Review for Required Monitors

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Review for Required Monitors The Joint Commission Hospital Accreditation Manual, 2009 Medicare Conditions of Participation, Hospitals Update: February 2009 Indicator / Monitor Restraint, Medical (non-specific requirement. For example, prevalence, use of various methods, etc., however, specific requirements about data collection, measurement, data display, evaluation and actions) [PC.03.02.11 EPs.1-11] Restraint, Behavioral, in behavioral health care environment only (specific data elements: data collection, measurement, data display, evaluation and actions required) [PC.03.03.31 EP.2, 6, 7, 8, 9,10] Seclusion. Must be measured in all areas (specific data elements: data collection, measurement, data display, evaluation and actions) required for behavioral health care setting [PC.03.03.31 EP.2, 6, 7, 8, 9,10] Behavior management and treatment [PI.01.01.01. EP.12] Critical value / result reporting, from availability to practitioner [PSG 02.03.01 EP.5] Critical test processing, from order to result [PSG 02.03.01 EP5] Clinical practice guidelines, practitioner variation (if guidelines are used) [LD.04.04.02 EP.5] A A A A 2009 The Greeley Company, A Division of HCPro, Inc. 1

Appropriateness of clinical practice patterns and significant departures from established patterns of practice [MS.05.05.05.01 EP.7 and EP.8] Anticoagulation program data [PSG.03.05.01 EP.9 / MM.08.01.01 EP.1-9] Prevention of Multi-Drug Resistant Organism data [PSG 07.03.01 EP 9]*effective 2010 Prevention of Central Line Associated Blood Stream Infection data [PSG 07.04.01 EP 9]*effective 2010 Prevention of Surgical Site Infection data [PSG 07.05.01 EP 9 & 10]*effective 2010 Utility and effectiveness of the Rapid Response program [PSG 16.01.01 EP.7] Cardiopulmonary arrest rate [PSG 16.01.01. EP 6/PI01.01.01 EP 11] Respiratory arrest rate [PSG 16.01.01. EP 6/PI01.01.01 EP 11] Resuscitation outcomes [PI.01.01.01 EP.11, LD. 04.04.01, EP. 2] Mortality rate [PSG 16.01.01. EP 6] Patient satisfaction [PI.01.01.01 EP.16] Culture of safety [LD.03.01.01 EPs.1 & 2] A 2009 The Greeley Company, A Division of HCPro, Inc. 2

Patient safety data with annual reporting to the governing body [MS.05.01.01 EP.11, LD.04.04.05 EP.13] Sentinel event data [MS.05.05.01 EP.10, PI.03.01.01 EPs 1-4] Blood and blood product use [PI.01.01.01 EP.7, MS.05.01.01 EP.5] Operative and other invasive procedures [PI.01.01.01 EP.4 MS.05.01.01 EP 6, LD. 04.04.01 EP. 2] Medication management, non-specific, usually includes medication errors, adverse drug reactions and other risk points based on an evaluation of the medication management system. [PI.01.01.01 EP.15 &15/MM.08.01.01 EP. 1-9] Medication use [PI.03.01.01 EP.1-4/MS.05.01.01 EP.4] Serious adverse drug events [PI.01.01.01 EP.15] Significant medication errors [PI.01.01.01 EP 14] Confirmed transfusion reactions [PI.01.01.01 EP 8] Infection control surveillance and reporting [IC.03.01.01 EP.3] Quality control [WT.04.01.01 EP 1-5] Use of developed criteria for Autopsies [MS.05.01.01 EP.9] 2009 The Greeley Company, A Division of HCPro, Inc. 3

Organ procurement effectiveness [PI.02.01.01 EP.7] ORX indicators [APR 04.01.01 EP.11] Grievance data (for example, frequency, type, individual issues) [42CFR 482.13(a)(2) (Interpretive Guideline)] [RI. 01.07.01 EP.4 & 17] Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use [PI.01.01.01 EP.6] Major discrepancies between preoperative and postoperative diagnosis [PI.01.01.01 EP.5] Information received from / reported to the hospital s Quality Improvement Organization [42CFR 482.21(b)(1)] LD.04.04.01 EP.6 Performance Improvement Projects 42CFR 482.21(d) LD.04.04.01 EP. 5-7 Environmental occurrences, [EC.04.01.01 EP 1] and related EPs: injuries to pts or others, EP.3, occupational illnesses EP.4, property damage EP.5, security incidents EP.6, hazardous materials / waste spills / exposures EP.8, fire-safety management problems EP.9, equipmentmanagement problems EP.10, utilities systems management problems EP.11 Opportunities to improve the environment of care [EC.01.01.01 EP.1] 2009 The Greeley Company, A Division of HCPro, Inc. 4

Monitors for each environment of care plan: safety, security, hazardous materials and waste, emergency management, fire safety, medical equipment, and utilities [EC.04.01.01 EP.1] Human resource indicators (e.g. hours per patient day, overtime, agency use) [PI.04.01.01 EP.4] Quality of history and physical examinations [MS.03.01.01 EP.7] Medical Assessment and Treatment of patients [MS.05.01.01 EP 2, PI.03.01.01 EP 1-4] Concurrent medical records indicators, including readability / legibility and other factors [RC.01.04.01 EP 1, MS.05.01.03 EP.3] Medical records delinquency rate [RC.01.04.01 EP 3 & 4, MS.05.01.03 EP.3 ] Available supply of patient bed space [LD.04.03.11 EP.5] Service Efficiency [LD.04.03.11 EP 5] Falls incidence, severity and fall-related injuries (implied) [PSG 09.02.01 EP.6] Sentinel Events [LD.04.04.05 EP.11, PI.03.01.01, EP1] Monitors for the risk reduction strategies employed as a result of a sentinel event root cause analysis. [LD.04.04.05 EP.13] Monitors for the effectiveness of redesigned processes as a result of failure mode effects analyses (FMEA). [LD.04.04.05 EP.10] A 2009 The Greeley Company, A Division of HCPro, Inc. 5

Performance of contract services. (Indicators are not necessarily required, but some form of evaluation against established expectations must be documented). [LD.04.03.09 EP. 4-6] Staffing Effectiveness Indicators [PI.04.04.01 EP.1-10] 2009 The Greeley Company, A Division of HCPro, Inc. 6

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