June 2018 PHC Newsletter

by dawnconrey
Patton Healthcare Consultants

Accreditation – Compliance – Patient Safety

June 2018

Inside This Issue

  • Perspectives
    • Leadership Session – Be Prepared for Changes
    • SAFER™ Matrix Placement Under Review – # RFIs Still Important
    • Not to Miss – New APR Requires You to Notify TJC if You Lose Deeming
    • Action Item: Exacting Competency Requirements for USP797 Listed
    • Changes to Ligature Scoring and an OSHA Reporting Requirement
    • Pediatric Hospitals to Get Experienced Specialized TJC Teams
    • Intracycle Monitoring (ICM) Calls Suspended by TJC
  • EC News
    • Active Shooter
    • Suggestions for Sprinkler Pipe – Avoid Common Findings
  • Quick Safety
    • Action Item – Ensure you have a Continuity of Operations Plan
  • CMS Update

June 2018 PHC Newsletter


Leadership Session – Be Prepared for Changes:

The lead article in the June edition of Perspectives discusses an important change effective this month in the survey process for the leadership session. That’s not a lot of notice for hospitals, but for those of you who read our March 2017 issue of this newsletter when we discussed future implications of Sentinel Event 57 we predicted this change was on the horizon. In addition, CAS consulting clients who began using our 2018 Leadership System Tracer tool should be well versed in this new content. Effective immediately TJC is requiring your most recent safety culture survey results to be included with your day one documents. TJC indicates that surveyors may want to review this document even before the opening conference, so be prepared to have that available immediately upon their arrival. They also indicate that surveyors may ask for audiovisual arrangements to be made so that they can show the Joint Commission’s video entitled: “Leading the Way to Zero”. If this cannot be done, surveyors can show it on their tablets.

More importantly Joint Commission will be more critically evaluating what is done and the results relative to the culture of safety survey. They have identified 3 specific leadership standards that will be explored and 6 specific elements of performance that will be evaluated. TJC has identified questions about the culture of safety that will be directed to leaders, and other questions that will be directed to staff. Ideally you would like your responses to these questions to be, “yes we do,”, “yes we have” and “yes, here is what we did.”

The type of issues surveyors may ask of leaders will include:

  • How do you assess the culture of safety and what tool do you use? Bear in mind, the most frequent mistake we hear in response to this question is a discussion about employee engagement and the percent response rate. The culture of safety can be integrated with an engagement survey, but more often it is the stand-alone AHRQ survey that is used to assess the culture.
  • Do you include cultural improvement goals for the leaders or middle management?
  • Is the board involved in setting expectations or improving the safety culture?
  • Do you use internal or external benchmarks? Here is a good opportunity to discuss your own improvements over time or subsequent surveys, and in comparison, to other organizations using the same tool.
  • What quality improvement projects have you conducted to improve your scores on the culture of safety survey?
  • Do you have a uniform code of conduct that is used for behavioral issues for all physicians and staff? Are the disciplinary procedures equitable and transparent?
  • What process do you have for reporting near miss errors or close calls that did not reach the patient?
  • In the event of a harm event how do you determine it is a blameless error or a blame worthy error?

In addition to the need for leadership to be able to describe what they have done, (talk the talk) Joint Commission will be asking staff what they have seen done, (walk the walk). These staff directed questions may include:

  • Have you ever completed a culture of safety survey, have you seen the results and does your supervisor discuss the results with you?
  • Does your hospital have a formal mechanism for reporting intimidating behavior and would you feel comfortable reporting such behavior?
  • When an error occurs, do you have confidence that your leadership will take an appropriate look at how the system or process is accountable vs an individual?
  • What process do you have for reporting close calls?
  • Does leadership conduct root cause analysis of any close calls that are reported?

We believe these changes announced by TJC could be significant. The leadership session is something TJC has tried to improve over many years, and they have noticed a lack of scoring on the 3 standards and 6 EP’s discussed in this article. During consultation visits we often note a lack of readiness to discuss the culture of safety results and a lack of awareness at a staff level, so this may take some effort to be prepared.

 SAFER™ Matrix Placement Under Review – # RFIs Still Important:

Perspectives has another article on improving the reliability and consistency of their surveys, in particular use of the SAFER Matrix. They have identified inconsistency among surveyors in how they assess findings using this tool. They are attempting to evaluate individual surveyor patterns in an effort to improve consistency. We would not ordinarily discuss this type of issue in our newsletter, however it is important that organizations not get too annoyed by placement of findings in the SAFER Matrix. We frequently encounter hospitals that want to clarify placement on the matrix while accepting the finding, however we have learned that TJC itself is not that enamored with its own tool, nor does it appear to be using it to differentiate accreditation status. The total number of findings, the number of COP’s out and repeat findings seem to be greater influencers.

Not to Miss – New APR Requires You Notify TJC if You Lose Deeming:

Perspectives also announces a new APR 01.03.01, EP 2 that takes place effective July 1, 2018. Many readers may remember the Wall Street Journal article last year critical of TJC for continuing to show organizations where deemed status has been removed as fully accredited and out of synch with what CMS is showing. Part of that disparity was TJC not hearing from CMS when they make these decisions. Well, this new APR will take care of this. As of July 1, if you have a CMS survey and CMS temporarily removes deemed status, requiring clearance by the state agency you will have to notify TJC. The EP states that when you receive such notice from CMS you must immediately notify TJC. The term immediately is not defined, but it is your best interest to do it that same day. TJC indicates that it will not perform routine resurveys if your deemed status has been removed. CMS in their memo QSO 18-12 issued January 12, 2018 stated that: “No accreditation decisions or recommendations made by an AO based on a Medicare accreditation survey conducted while a supplier or provider is under state agency jurisdiction will be accepted by CMS.” If the Joint Commission does not hear about this deemed status removal and the surveyors show up at your door, and then hear about it, you will be charged for the survey, but it will not be completed. If they conduct the survey because you did not inform them, it sounds like CMS will not accept the results and you will have to go through another survey after deemed status is returned. The Joint Commission asks that you notify your Account Executive via email should you receive this notice from CMS. We would suggest that you keep a copy of your email readily available in the event a survey gets scheduled and there is any potential dispute about billing.

Action Item: Exacting Competency Requirements for USP797 Listed:

The other major news this month is the column entitled Consistent Interpretation. This column reinforces the warning we have been providing about Joint Commission applying the exacting details of USP Chapter 797 in the survey process even though there are no new standards that say this. In this article TJC provides 3 detailed examples of competency validation requirements required for sterile compounding.

The first example is competencies required of staff that will perform sterile compounding. In this example the hospital required a didactic test but did not establish a passing score for that test. TJC states the organization must identify a passing score on such a test. In addition, there must be an observational component to the competency for sterile compounding which will include proper adherence to hand washing and garbing. There must also be an outcome competency, in this case a media fill test and gloved fingertip sampling. Lastly, staff who prepare hazardous sterile compounds must have an additional competency assessment verifying compliance with those processes for self-protection.

The second competency issue described is interesting. The standard is HR.01.06.01, EP 3 that requires staff to be deemed competent by someone with the educational background, experience and knowledge related to the skills being assessed. In this case, they describe the staff assigned to clean the sterile non-hazardous or hazardous medication compounding area. Joint Commission points out that the evaluator for this competency must be the compounding supervisor, not the EVS manager.

The third example TJC discusses is that staff who will prepare sterile compounds must be assessed as competent before they may prepare any sterile products for patient use. Specifically, TJC states that they must pass the:

  • didactic exam
  • visual observation of hand hygiene
  • visual observation of garbing and use of PPE
  • media fill test
  • gloved fingertip testing X 3
  • and it prepares hazardous sterile compounds additional competencies for that function.

The most important take away from this is to know and be prepared for a thorough evaluation of USP Chapter 797 next time TJC arrives at your door. Your pharmacy directors should undertake a thorough review of all requirements in USP Chapter 797 and self-assess to identify areas which may need improvement prior to your next survey. We would encourage readers to obtain and use either the Medication Compounding Certification standards or the Home Care Medication Compounding chapter. These tools provide more useable EP level detail of the requirements in USP Chapter 797 that are scattered throughout a long narrative document.

Changes to Ligature Scoring and an OSHA Reporting Requirement:

There are also 4 simple announcements in Perspectives this month. The first is that ligature hazards will no longer be scored against the physical environment but instead against the patient’s rights COP. The second is a reminder that OSHA is expecting your calendar year 2017 employee injury reports to be electronically submitted by July 1 this year. Next year the due date for the 2018 reports will be March 2, 2019.

Pediatric Hospitals to Get Experienced Specialized TJC Teams:

TJC also announced that pediatric hospitals will have experienced pediatric physicians and nurses assigned to the survey. We assume this is welcome news to these hospitals to have surveyors more familiar with the unique services and needs of pediatric patients. In addition, general hospitals with inpatient pediatric services will have these specialized surveyors assigned providing at least 2 of the following criteria are met:

  1. The hospital has a separate ED for pediatrics staff by pediatric practitioners
  2. The hospital has a level III or IV neonatal ICU
  3. The hospital has an ADC in inpatient pediatrics of 6 or more

Intracycle Monitoring (ICM) Calls Suspended by TJC:

Lastly, TJC announced they are suspending their ICM calls for most organizations at this time. We don’t believe there will be much push back in the industry as these calls were perceived by some as more burdensome rather than enlightening. There is a small subset of hospitals that were in PDA 02 status that will have to continue with the calls for now.


Active Shooter:

While this is not a subject any of us would like to focus on, it is becoming a recurring event in too many locations. The lead article in this month’s edition discusses an active shooter event at a hospital and provides their advice to help you prepare. There is also an extensive list of resources you can reference as you conduct your preparation. These references include the Joint Commission’s emergency management resources page, which has resources beyond just the active shooter situation. These are highlighted in EC News in the article following the one on active shooter. This particular hospital learned that their code silver alert was not clear enough and universally understood so they have decided to abandon that term and just use the plain language: “active shooter/violence with weapon.” They also identified that they had the ability to lock down units, but it required an intervention by security staff who may not be immediately available. They have now added a mechanism for nursing staff and managers on the unit to manually lock those doors.

 Suggestions for Sprinkler Pipe – Avoid Common Findings:

There is also an article detailed EP level scoring for LS.02.01.35 which was scored noncompliant in 86% of surveys in 2017. As anticipated, the number 1 most frequently scored EP is the one about extraneous materials being tied to or touching sprinkler pipe above the ceiling. This is a chronic issue for hospitals with contractors and vendors running IT cable, where they conveniently tie it to the sprinkler pipe. Far too often hospitals fix that area cited by TJC during survey but don’t expand beyond that location to find out other areas of the hospital with the same problem. You really need a 2-pronged strategy, the first to prevent the creation of new problems by having an inspection process above the ceiling after each vendor completes their work. The second is a long-term inspection and correction process for all areas of the hospital, to learn how many of the same flaw you have and get them fixed.

Quick Safety:

Action Item –  Ensure you have a Continuity of Operations Plan:

Joint Commission published a new issue of their Quick Safety Newsletter this past month on emergency management and the continuity of operations plan. This was a new EM requirement added for CMS in EM.02.01.01, EP 12 that we have seen scored noncompliant in too many hospitals thus far in 2018. It would appear that many organizations did not write this plan or perhaps did not know what to write in this plan. The terminology CMS used sounds too similar to the emergency operations plan hospitals already had, but one component of the continuity of operations plan that was not as detailed in the EOP is succession planning for key leaders. There should also be delegation of authority to those successors so that they are authorized to carry out essential functions for the hospital. This issue of Quick Safety is a good tool to use to create your continuity of operations plan if you did not write it last fall.

CMS Update:

There were no new QSO memos issued to the hospital industry this past month.

Consultant Corner

We wish you all a wonderful and safe summer!

Thank you,

Jennifer Cowel, RN MHSA

Kurt Patton, MS RPh

John Rosing, MHA

Mary Cesare-Murphy, PhD