Demystifying The Joint Commission Requirements Paul Arnstein, RN, PhD, FAAN Clinical Nurse Specialist for Pain Relief Director: MGH Cares About Pain Relief Massachusetts General Hospital Financial Disclosures 2010 2011 Advisory Board Consultation Ortho McNeil Covidien Projects receiving unrestricted educational grants Ortho McNeil PriCara Purdue Pharma LP Other Consulting Nurse Practitioner Healthcare Foundation Book: Clinical Coach for Effective Pain Management F.A. Davis My Personal Journey: Understanding the Joint Commission Orderly Polish everything Nursing Student Safety punch list R.N. Endless to do lists Nursing Director Best appearances in preparation for visit Policies Charts Personnel Hallways 1
ASPMN sends a Liaison Belinda Puetz, ASPMN Executive Director convinced JCAHO in 2005 they needed a Pain Management Nurse Transitions from JCAHO to The Joint Commission Bully Pulpit Gotcha mentality Aware of common problems Prescriptive solutions Shared visions, new pathways Each organization is unique Serve different populations Access to different resources Enduring, meaningful change JCAHO Takes on Pain 15% Americans major trauma/surgery pain (45 million) 35% Adults have chronic pain (>116 million) More than diabetes, heart disease & cancer combined Pain related disorders increasingly prevalent 50% of inpatients/outpatients have pain 30% patients give hospital low marks for pain control Untreated/undertreated pain still common CDC(2007) Fast Facts A-Z @ CDC.gov Ries et al (2008). SEER Cancer Statistics Review IOM (2011) Martin BI, et al. (2008). Back/Neck Problems. JAMA, 299 CDC (2008). Targeting Arthritis: @cdc.gov Jha et al. (2008) [HCAHPS] NEJM, 359 (18):1921-31 National Center for Health Statistics (2006), Special Feature on Pain 2
Standards justified Pain Standards added (2000): Pain is carefully assessed & treated promptly Pain assessment lapses risk for untreated pain Reassessment lapses linked to sentinel events First foray into Evidence based practice Intent to succeed where AHCPR failed Policy Push to Improve Pain Care AHCPR genesis AHCPR guidelines 1, 9, 10, 14 (1992 4) Year 2000, JC Standards integrated Focus: Quality, standardization, & safety Medicare / Medicaid CoP followed suit Military Pain Care Acts of 2008, 2010 Affordable Care Act (2010) / IOM report(2011) Myths about TJC pain standards Pain as a conspiracy by Pharma Pain as the 5th vital sign Assessment all non verbal patients w/ FLACC Timing of reassessments Prohibition of nursing judgment To select from ordered prn drugs To dose by a range orders 3
JCAHO Focus in 2005 ~perpetuated myths Very standards focused Not clear Not consistently interpreted NPSGs examined but not integrated The Talk and the Walk not in sync More prescriptive than consultative Senior leadership unaware of what surveyors said to create & perpetuate myths e.g. Assessing non verbal & range orders OSH Case: Mr. Abe Sessonumberg 27 y/o Male for I&D cyst on 12/24 Cried inconsolably post op Aggressive morphine use, periods of apnea ICU morphine titrated to FLACC scores Ventilator dependent Eventual switch & revelation Were standards met for this patient? Did the patient receive the best possible pain treatment? JCAHO response (Range Order & Nonverbal Assessment remediation) In Defense of Range Orders Permit flexibility & rapid response to patient needs Professional judgment is allowed ~based on : Vital signs Age Level of consciousness/alertness Patient condition Co morbidities Other medications Anticipated illness trajectory Target symptom severity Patient response pattern matters 4
Safe, Prudent Approaches Range narrow enough to be safe Range wide enough to provide flexibility Start with the lowest dose in the ordered range Unless assessment indicates need for higher dose If symptoms are not relieved, Additional doses within range may be given Total amount <not to exceed maximum dose Rolling clock notion of limit Order refinement to increase or decrease dose Standards interpretation confusion Does every patient (inpatient & outpatient need to be screened/assessed for pain)? Yes Why does the FLACC need to be used in populations it was never validated for? It doesn t What do surveyors want for range orders? Clear indication Consistent interpretation Decision making within scope of practice Joint Commission priority 2006 08 To improve the quality & safety of care New survey method New scoring Reorganized, reworded all standards Emphasis on Direct Impact items, for example: Anesthesia and Sedation Pain Assessment and Reassessment Emergency Medication availability High Alert Medications (including SALAD) Healthcare Associated Infections 5
TJC Standards: Respect right to pain control & train professionals Rights and Responsibility: RI.01.01.01 (EP8) Organization respects patient s right to pain management Human Resources: HR.01.04.01 (EP4) Provides orientation to staff on assessing / managing pain Medical Staff Chapter : MS.03.01.03 (EP2) Hospital educates all LIPs on assessing & managing pain* *LIPs = licensed independent practitioners TJC Standards: Assess, Treat, Reassess & Document Pain PC.01.02.07 Identification & treatment of pain is a key part of care. Expectation: patients will be asked about pain, and when present services will be provided accordingly. Elements of Performance: 1. Conduct a comprehensive assessment consistent with scope of care, treatment, services & patient s condition 2. Assesses pain in an age and ability appropriate manner 3. Reassess & respond to pain based on hospital criteria 4. Either treat pain or refer the patient for treatment TJC Standards: Assesses & Reassess Patient s Pain PC.01.02.01 Patient needs must be reassessed throughout the course of care, treatment and services. EP1: Reassessment includes effectiveness and side effects DEFINE WHEN EP2: When in depth pain assessments are performed 6
New! 2012 Standard: Pediatrics PC.01.02.07 Hospital assesses and manages pain EP2 The hospital involves the family, when appropriate, in identifying signs of pain. PROCEDURAL PAIN REQUIREMENT EP6: In order to reduce stress and pain related to procedures, the hospital intervenes before the procedure using pharmacologic and non pharmacologic (comfort) measures. TJC Standards: Patient Education PC.02.03.01 Hospital provides patient education based on each patient s needs and abilities. EP10: Information on safe, effective use of medications Discussion of pain, the risk for pain, the importance of effective pain management, the pain assessment process and methods for pain management. TJC Standards: Care after procedures requiring moderate or deep sedation or anesthesia PC.03.01.07 Sedation and anesthesia in any setting for any purpose, by any route EP2: Monitors the patient s physiological status, mental status and pain level at a frequency and intensity consistent with the potential effects of the procedure &/or sedation or anesthesia administered. 7
Related Standards MM.01.01.03. (2%) (C)* Managing high alert medications MM.02.01.01. (<1%) (A)* Standardized concentrations of drips (A) Annual review of formulary drugs for safety/efficacy MM.03.01.01. (34%) (C) Storage per manufacturer recommendations. (A) Controlled drug storage per law and regulation (A) Medication security (C) Medication handling when in possession of staff (C)* Revised expiration dating of multi dose vials (C)* Most ready to administer form stored on unit Pain related MM Standards MM.04.01.01. Medication orders are clear & accurate EP1 has a written policy that identifies the specific type of medication orders that it deems acceptable for use. (Range orders, titration/taper orders etc) The hospital policy defines: Required elements of a complete medication order When indication for use is required Precautions for ordering LASA drugs Actions to take when medication orders are incomplete, illegible or unclear. The hospital implements it policies for medication orders MM.05.01.01 A pharmacist reviews all orders to be dispensed All medication orders are reviewed for EP5. Existing or potential interactions between the medication ordered and current medications EP6 appropriateness EP8 reviewed for therapeutic duplication. EP9 other contraindications.. all concerns, issues, or questions are clarified with the individual prescriber before dispensing. 8
Additional Pain Clinic Issues NPSG 03.04.01 Labeling all medications, medication containers, and other solutions on/off sterile field. UP.01.01.01 Pre procedure verification process. UP.01.02.01 Mark the procedure site UP.01.02.01 Time out immediately prior to starting the procedure Non Compliance in 2010 Standard Practice Non-Compliance PC.02.01.03 Home Care PC.01.02.03 MM.04.01.01 PC.8.10 (BehavHe) NPSG.03.04. 01 (amb) Provide treatment per (Rx) order [Scope] Assess and reassess according to defined time frames Medication orders are clear & accurate All patients are assessed for pain Label all meds on & off sterile field w/procedure 34% 31% Hospital 23% CriticAcces 19% LTC 28% 11% 16% 2009 2010 New TJC Philosophy Move away from Gotcha mentality Convergence and synergy Work together to find high quality, reliable, safe care Find real life solutions to common problems Provide a national voice for advocacy & support Change survey to relationship based approach 1 point person, knows your issues, provides guidance Booster packs, training webinars, conference calls More consultative than interventional 9
2011 Transformed to the new TJC Standards are just one leverage point Partner with organizations with similar goals Focus on real life issues that make a difference Accountability Culture of Safety / Trust Robust Process Improvement Highly reliable, evidence based care Communication and leadership Focus on routine processes that routinely fail The Joint Commission Mission Mission: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Vision: All people always experience the safest, highest quality, best value health care across all settings. There s a growing alignment between the Walk and the Talk Strategic Approach Improved Accreditation Process Customer service training Focus to better understand your organization not theirs Proactive calls, webinars, conference calls, social media Move toward relationship based model Support tools Booster packs Targeted solutions tools Leading practices Frequent touch points Ongoing data transfer Intra cycle monitoring 10
Improve TJC processes Use Robust Process Improvement (DMAIC) methods Define Measure Analyze Improve Control Address field staff needs Surveyor consistency More robust than Plan Do Check Act interpreting regulations & standards Advance programs & Disease specific certification CMS Deeming Status conflicts Much discussion Most EP s Have to meet Conditions of Participation CoP s outdated & not evidence based TJC has gone light on many CMS fought back Ongoing negotiations with CMS, some progress Those standards sometimes carry caveat May get Deemed Status Deficiency Not Conditional Re accreditation Status Will require a revisit Accountability Need Accountability and Highly Reliable Solutions Airlines as a model If they failed like HC More than a crash each day Leadership must commit to a O quality failure goal 11
Build a Culture of Safety Balance learning from isolated, small, human errors with accountability for blameworthy errors. Make changes, take action as appropriate Without differentiating the two, lose trust Trust to safely report concerns without repercussions Trust action will be taken Intimidating behaviors undermine culture of safety Condescending language, unreturned calls, impatience Occurs with all roll groups Evolution of Quality Improvement Publish it (passive diffusion) Hope they will change Read it for them (clinical practice guidelines) Hope they will become enlightened TQM / CQI / system redesign it (industrial style) Hope they will improve Hope. Next stop high reliability High Reliability Solutions Highly effective process improvement Find and fix problems before harm occurs When harm does occur, analyze with stakeholders Root Cause Analysis Failure Modes and Effects Analysis (FMEA) Build skills: Identifying hazards Using tools of highly reliable, sustainable improvement e.g. six sigma, lean, etc. Create ways (e.g. dashboards) to monitor proactively 12
R 3 Reports (e.g. Revised Patient Communication std) Requirement, Rationale, Reference Required (new standards 2012): Hospital effectively Communicates with patients when providing care Medical record reflects treatment and services Promotes patient rights Defines qualifications of interpreters Rationale Change in CMS Conditions of Participation requirement Changes in Federal Regulations (Limited English Proficiency) Changes in Research (Health literacy, ethnic/cultural, GLBT) References (25 cited) Measurement is the key: Slippery slope of evidence Needs to be accurate, timely and meaningful Some measurements required by all organizations Some selected based on RPI goals New way of calculating standards Press Release September 2011 Achieve >90% on >85% of composite EPs = accredited Achieve >95% on all standards = Top Performer status 2011 Accreditation categories Preliminary Accreditation Accredited Accredited with follow up Replaces provisional accreditation Follow up ~ 30 days to 6 months Contingent Accreditation Replaces Conditional Accreditation (30 day F/u) Preliminary Denial of Accreditation Denial of Accreditation 13
Moving towards Support for Integration of Care: Physical and Behavioral Health Addiction and mental health care Prevention and early detection Focus on transitions in care Pre hospital and post discharge 2011 2012 What to expect Second generation tracers More questions asked more drill down Focus on high risk processes that affect care Clinical procedures (surgery or interventions) & competency Blood & medications Patterns of M & M, and length of stay Use of consultants the appropriate treatment team Cleaning equipment, HH & infection control Staff/LIP training on assessing & managing pain 14
Strategic Surveillance System (S3) Quarterly data transfer + past survey data ID problems ORYX core measure data HCAHPS (Hospital Consumer Assessment of Healthcare Providers) data Complaint and sentinel event information Tool aides in drill down & clarifies expectations How TJC defines the priority focus area Benchmark against national and state comparison Trend the focus area over the last eight quarters. Targeting solutions to root cause Rapidly building a database available to accredited organizations to help solve problems between visits Each unique facility has unique issues Can learn from leading practices library Can use a targeted solution developed by others who successfully solved similar problems Will not affect accreditation unless an Immediate Threat to Life noted during survey No effort to find or fix obvious root causes 15
Root Cause of: 80% Serious Errors #1 Cause of Sentinel Events Transfer-related malpractice Permanent Disability from errors 11% due to communication 6% due to professional skill level 16
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Standardize Hardwire System Allow Opportunities to Question Reinforce Quality & Measurement Educate and Coach Our Challenge (move our agenda forward): Link suboptimal pain control (& improper detox) to: Culture of Safety Trust, accountability Patient Satisfaction Required education of patients & professionals Communication breakdowns Then use RPI methods to Better understand current state Improve professional practice 18
Thank you for the privilege to serve as your liaison to TJC 19