HCPro.com - Accreditation Monthly

The Joint Commission Back to Closed Record Review?

Thu, 12 Nov 2009 13:30:00 GMT

Have you heard that the Joint Commission survey will again be doing closed record review? For hospitals with deemed status, CMS is requesting The Joint Commission to review records at a rate of 10% of the average daily census or a minimum of 30 records (20 for small hospitals) during the survey process. If The Joint Commission does not review the required number of records during the open record tracer review, the surveyors will ask to review additional open and closed records. We've already had two clients that have had this happen.

What does this mean for you? You can expect that Joint Commission surveyors will pretty much sit in a room (from what the clients say) and review the records. This gives them more opportunities to find RFIs. Some of the additional vulnerabilities of reviewing the closed record include:

Review of the appropriateness of the discharge summary
Discharge teaching
Unmet goals from the care plan are addressed at discharge
Medication reconciliation at discharge (although not scored this year)
Authentication of verbal/telephone orders within 48 hours (or state statute requirement)
Completeness of the medical record

The Joint Commission is not moving away from the tracer method—it is committed to that survey process—it simply has to meet the required number of records as stipulated by CMS.

We will wait and see how this affects the survey findings in the months to come!

Blanket Warmers, What Is Safe?

Wed, 21 Oct 2009 13:30:00 GMT

When completing readiness assessments, I have noticed much disparity in the temperature of blanket warmers from hospital to hospital and from warmer to warmer in the same hospital. I have also noticed that staff members cannot speak to the "safe" temperature range, and often, the safe range or upper limit is not posted, nor is there a policy readily available.

Safe temperature ranges for blanket and fluid warmers are most commonly published by ECRI Institute, and until recently, it set the "safe" temperature limit for blanket warmers at 110°F (43°C). This temperature was recommended because solutions were often warmed in the same cabinets as blankets, and the lower temperature eliminated the serious burn risk presented by excessively heated solutions.¹ This year, ECRI revised the recommended temperature for blanket warmers to 130°F (54°C).

Manufacturers vary in their temperature recommendations and often do not agree with ECRI.

Recommendation:
Organizations should engage in a thoughtful process that includes research of recommended temperatures. Research can include a Web search, as well as manufacturer recommendations. The organization should then develop a policy for blanket warmer and fluid temperatures that will be used throughout the organization regardless of the manufacturer. Be sure to post the temperature range on all blanket warmers and instruct staff members on the procedure.

¹Health Devices, July 2009 www.ecri.org

Problem Lists - What is Required?

Tue, 15 Sep 2009 13:30:00 GMT

When on-site assessing ambulatory care for standard compliance, I am often asked about what is required for a problem list (now called summary lists).

The intent of the summary list is to provide a quick reference of needed critical information about a patient in order to provide optimal and safe care. Many patients travel from clinic to clinic or provider to provider, and if the critical information is not easily available, it may be missed when making decisions about care and treatment. The list generally includes:

Newly identified and chronic diagnoses
Procedures performed
Allergies and drug interactions
Medications taken (medication reconciliation)

When Required
A summary list must be initiated anywhere in the ambulatory setting by the third visit. Each clinic provider would then update the list as necessary.

When not Required
According to the Joint Commission FAQ dated August 5, 2009, "A summary list is not required in settings where patients present with a known diagnosis and receive one-time predetermined care (e.g., ambulatory surgery, diagnostic imaging services)."

Process
Hospitals with multiple ambulatory care settings should decide who is responsible for initiating the summary list and how the lists will be made available to providers as needed. I have seen both manual and computerized summary lists.

The Joint Commission also cautions, "…should the organization allow each outpatient setting to initiate and maintain its own summary list, the organization increases the risk of not having the most current patient information available to each area."

This is a challenging process for ambulatory care settings where each clinic maintains its own record for patients with multiple visits, such as wound clinic, pain clinic, and physical therapy. In these circumstances, there needs to be a centralized summary list that can be accessed at each visit and updated as needed.

Policies: Say What You Do and Do What You Say

Wed, 26 Aug 2009 13:30:00 GMT

There is sometimes a tendency to want to write everything down in great detail, but more may not be better when it comes to writing policies. Organizations often receive Joint Commission RFIs due to language in their own policies. Consider the following guidelines for writing policies.

Q: Do we need this policy?
A: A policy is needed if:

It is specifically required by an accrediting or regulatory body (e.g., Joint Commission, CARF, CAP, DHR, or CMS).
Specific guidelines are needed to direct decision-making or completion of an activity or function (particularly high-risk, low-volume activities).
There is a widespread and repeated problem and pattern of actions that are inconsistent with the institution's values. Even then, there should be a period of questioning whether the problem is best addressed by a policy or through some other intervention.

Q: What are the characteristics of an ideal policy?
A: The ideal policy will:

Be brief and include only the information needed to convey the key message or steps
Reflect what will be done, not what the organization hopes will happen
Follow the natural flow of the process to enhance compliance
"Say what we do and do what we say"
Avoid requirements that are more extensive than regulatory or accreditation standards
Be developed with input from those who are impacted by the policy (staff members, other departments, physicians, etc.)
Not conflict with system policies

Q: What are some specific policy-writing tips?
A: For starters:

Keep sentences short (average of 10–12 words)
Use clear, concise, easy-to-understand language
Use the active voice (e.g., "assess the following" instead of "the patient will be assessed")
Be consistent with verb tense throughout
Whenever possible, link attachments to online forms on the intranet
Exclude the following documentation in the body of the policy:
- Staff education material (consider alternatives such as CBLs, PowerPoint presentations, or competency checklists)
- Forms and instructions
- Flow charts
- Communication to a specific department regarding an infrequent occurrence

Remember, policies are ineffective if they are over-engineered or too wordy. Policies are not meant to be all-encompassing or a substitute for individual judgment and training.

More from the March 2009 Joint Commission Changes: Anesthesia

Tue, 14 Jul 2009 13:30:00 GMT

Many of the published March 2009 changes were made to align with CMS' Conditions of Participation (CoP). However, when looking at the CMS definition of anesthesia, it does not include sedation. The Joint Commission standard (PC.03.01.01) states, "The standards for sedation and anesthesia care" which then goes on to specify "general, spinal, region, deep, and moderate sedation." Therefore, it is assumed that the following standards will include sedation, but as is often the case, uncertainty remains.

PC.03.01.03 states that a pre-anesthesia evaluation must be completed within 48 hours prior to the procedure requiring anesthesia.

PC.03.01.07 states that a post-anesthesia evaluation must be completed and documented no later than 48 hours following a procedure requiring anesthesia.

Points to remember:

Both evaluations must be performed by an individual with privileges to administer anesthesia
There is no specification in the standard as to how soon after the procedure the post-anesthesia evaluation can be performed

To achieve compliance, we recommend that you:

Build pre- and post-anesthesia evaluations into your documentation process
Design an anesthesia evaluation form that includes the pre- and post-anesthesia evaluations
Educate your anesthesia providers and monitor compliance with the standard

Joint Commission and CMS Alignment: Restraint Management

Tue, 09 Jun 2009 13:30:00 GMT

Before tracers, restraint was one of the most frequently cited requirements for improvement (RFI), formerly known as a "Type 1" recommendation. Since The Joint Commission recently made significant changes to align more closely to CMS' Conditions of Participation, we have a hunch restraint citations may make it back to the top 10 list.

The March update replaces the January update published by The Joint Commission. Be sure you have that information, available on the agency's Web site.

The following is a summary of the direct impact elements of performance (EP). All direct impact requirements for this subject are Category A.

EP.03.05.01 focuses on the indications for each episode of restraint, including discontinuation of restraint at the earliest possible time.
EP.03.05.03, EP.1 requires the use of safe techniques to restrain patients according to hospital policies and procedures.
Suggestion: Implement a well-designed education program that aligns practice across the organization. Provide documentation/competencies of the education. Remember that the medical staff needs restraint education as well. This can be an abbreviated educational document provided to physicians. Don't forget about security guards or other non-licensed personnel that observe patients in restraints or assist with the application of restraints. EP.03.05.05, EP.5 applies only to restraint used for the management of violent or self-destructive behavior. It requires an in-person evaluation by the physician at least every 24 hours. Remember, EP 4 defines the age specific time-limited orders.
EP.03.05.05, EP.6 requires renewal of medical (non violent) restraint according to hospital policy. A single instance of a missing order could generate a direct impact RFI.
Suggestion: Consider the use of protocol orders with specific criteria for discontinuation. There is no longer a requirement that orders be renewed each calendar day, but you must follow your policy.
EP.03.05.11, EP.1 requires a face-to-face evaluation of violent or self-destructive patients by a responsible physician or an appropriately trained RN or physician assistant (PA) within one hour of the application of the restraint/seclusion.
Suggestion: Ensure that all RNs who staff the emergency department or the behavioral healthcare unit have documented training and competencies in evaluating violent or self-destructive patients.
EP.03.05.11, EP.2 requires a nurse or PA who performs the one-hour face-to-face evaluation of violent or self-destructive patients to consult with the responsible physician as soon as possible after initiation of restraint.
EP.03.05.11, EP.3 specifies the content of the one-hour evaluation of violent patients.
Suggestion: Hard code this documentation into forms or computer templates. Include the four required components of the face-to-face evaluation defined in EP3.
EP.03.05.13, EP.1 requires the continuous observation of patients who are simultaneously restrained and secluded.

There are plenty of other requirements to worry about. But we suggest starting here, with the Category A direct impact requirements.

The Joint Commission and Telemedicine: The Final Word?

Wed, 13 May 2009 13:30:00 GMT

In the April issue, we discussed the potential changes to The Joint Commission's position on credentialing telemedicine physicians. At that time, we recommended that you do not change your credentialing practices until The Joint Commission clarifies its position. Below is the information we have to date.

In November, The Joint Commission released a change to MS.13.01.01, which went along with CMS' position on telemedicine, stating that all physicians need to be credentialed and privileged at the originating site¹. However, in the January and March releases, The Joint Commission deleted this change and reverted back to its original position that hospitals may choose to rely on the credentialing and privileging of the distant site² for interpretive services such as radiological interpretation.

It appears that for now, The Joint Commission is holding firm on the option that the hospital may rely on the distant site for credentialing if that site is Joint Commission–accredited, the physician is granted privileges for the services provided, and the originating site has evidence of internal review of the practitioner's performance of the services rendered. The Joint Commission also acknowledges the difference between its standard and the CMS regulation and alerts hospitals that they may be vulnerable to a CMS citation if they choose the JC option.

¹Originating site: where the patient is located
²Distant site: where the LIP providing the service is located

Hold Off on Credentialing Changes

Thu, 16 Apr 2009 13:30:00 GMT

There are two versions of the 2009 CMS changes made by The Joint Commission: the version that was e-mailed on January 6, and the version currently posted on The Joint Commission Web site. (It took us a very long time to find the posted version. It's not under Standards, but under What's New. Go figure!)

The bottom line is that the changes to MS.13.01.01 that were in the January 6 e-mail are not on the Web. Are the changes to MS.13.01.01 in? Are they out? Are they under discussion? We've asked The Joint Commission, but they have not yet responded.

In the meantime, do not make any changes to the way you credential or privilege remote diagnostic-only practitioners! Wait for clarity from Oakbrook Terrace.

Joint Commission Changes to Align with CMS

Wed, 11 Mar 2009 13:30:00 GMT

On January 6, The Joint Commission announced the addition of 165 new elements of performance (EP) for hospitals that use Joint Commission accreditation for deemed status purposes. The intent is to more closely align the standards with CMS' Conditions of Participation. The majority of the new EPs have little effect on existing processes. Approximately 35% will require a change in practice. I will mention a few select standards that do have an impact and what that means to your organization. I recommend that you review all 165 EPs to see how they affect your organization.

HR.01.02.01, EP 19: If blood transfusions and intravenous medications are administered by staff other than doctors of medicine or osteopathy, the staff members have special training for this duty.
Impact: Maintain documentation of training and competencies for staff members administering blood and IV medications.

MS.13.01.01, EP 1: All licensed independent practitioners who are responsible for the patient's care, treatment and services via telemedicine link are credentialed and privileged to do so at the originating site according to standards MS.06.01.03 through MS.06.01.16.
Impact: This now requires Nighthawk and similar contractors to be fully credentialed by the hospital.

NR.02.03.01, EP 11: A registered nurse supervises and evaluates the nursing care of each patient.
Impact: The RN scope of practice should include the oversight of patients assigned to LPNs and other non-RN nursing staff. Nursing staff should be able to articulate this practice.

PC.03.01.07, EP 7: A post-anesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services.
Impact: It is unclear how The Joint Commission will interpret this, because unlike CMS, The Joint Commission has an "expansive" definition of anesthesia services. At a minimum, there should be a post-anesthesia note for all inpatient post-op patients receiving anesthesia.

PC.03.05.03, EP 2: The use of restraint or seclusion is in accordance with a written modification to the patient's plan of care.
Impact: This requirement has not existed in Joint Commission requirements.

PC.03.05.05, EP 1: A physician or other authorized LIP primarily responsible for the care of the patient's ongoing care orders the use of restraint or seclusion in accordance with hospital policy and law and regulation.
Impact: This eliminates the "12-hour rule" to get an order for medical restraints. The following is from the CMS interpretive guidelines:… in (these) emergency application situations, the order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied. The failure to immediately obtain an order is viewed as the application of restraint or seclusion without an order.

PC.03.05.05, EP 3: The attending physician is consulted as soon as possible, in accordance with hospital policy, if he or she did not order the restraint or seclusion.
Impact: This should be part of your hospital policy and the notification documented in the medical record.

PC.03.05.09, EP 2: Physicians and other LIPs authorized to order restraint or seclusion (through hospital policy in accordance with law and regulation) have working knowledge of the hospital policy regarding the use of restraint and seclusion.
Impact: This imposes a training burden for the general medical staff.

RC.01.01.01, EP 19: All entries in the medical record, including all orders, are timed.
Impact: The Joint Commission, until now, only required medical record entries to be dated.

RC.02.03.07, EP 4: Verbal orders are authenticated within the timeframe specified by law and regulation. If there is no State law that designates a specific timeframe, the verbal orders are authenticated within 48 hours.
Impact: New for The Joint Commission. (Although not stipulated, if the authentication is not dated and timed, it is not possible to determine whether the 48-hour time frame was met.)

RC.02.03.07, EP 6: Documentation of verbal orders includes the time the verbal order was received.
Impact: New for the Joint Commission

RI.01.07.01
EP 1: The hospital establishes a complaint and grievance resolution process.

EP 2: The hospital informs the patient and his or her family about the complaint and grievance resolution process.

EP 4: The hospital reviews and, when possible, resolves complaints and grievances from the patient and his or her family.

EP 6: The hospital acknowledges receipt of a complaint or grievance that the hospital recognizes as significant and notifies the patient of follow-up to the complaint or grievance.

EP 7: The hospital provides the patient with the phone number and address needed to file a complaint or grievance with the relevant state authority. (See also MS.09.01.01, EP 1)

EP 10: The hospital allows the patient to voice complaints or grievances and recommend changes freely without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care.

EP 17: The governing body reviews and resolves grievances unless it delegates this responsibility, in writing, to a grievance committee.

EP 18: In its resolution of grievances, the hospital provides the individual with a written notice of its decision, which contains the following:

The name of the hospital contact person
The steps taken on behalf of the individual to investigate the grievance
The results of the process
The date of completion of the grievance process

EP 19: The process for resolving grievances includes a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the Quality Improvement Organization (QIO).

EP 20: The governing body approves the complaint and grievance resolution process.
Impact:These standards are new to the Joint Commission but not CMS. The hospital must now have a procedure, approved by and overseen by the governing body. It will be necessary to track the steps of the process.

Most hospitals already follow these new Joint Commission standards if they receive Medicare and Medicaid reimbursement for services. However, this is a good time to review current policies and practice to be sure the standards are met.

CMS Pushes for More Joint Commission Changes

Tue, 10 Feb 2009 13:30:00 GMT

The Joint Commission must for the first time meet CMS expectations to maintain its Medicare deeming authority. This has triggered significant changes, since the current Joint Commission standards and survey processes do not match CMS standards and survey processes. The first wave of change was the 300 or so new elements of performance that took effect January 1, 2009. These changes were made on the fly—without the typical pause for comments from the field—and bring the Joint Commission standards in better alignment with the Medicare Conditions of Participation. We expect more changes in the next few months.

The Joint Commission will attempt to better define its Immediate Threat to Life trigger for preliminary denial of accreditation.
The Joint Commission must define which standards or elements of performance trigger a Medicare condition-level finding.
The Joint Commission must define what it will do when it encounters a condition-level finding.
We also expect the survey process to change to a more CMS-like tracer. The Joint Commission's tracer methodology was based on the CMS survey methods for long-term care facilities. However, the Joint Commission process does not focus on particular problem-prone issues. We expect that future tracers will focus on patients in restraint and emergency department transfers.

The next few months should be fascinating.

About the author: Mr. Bud Pate serves as vice president for content and development at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. He is a nationally recognized expert in patient flow and hospital and health system regulation and accreditation, with more than 25 years of experience in high-profile problem solving.

The Future of the Building Maintenance Program

Tue, 13 Jan 2009 21:00:00 GMT

The concept for the Building Maintenance Program (BMP) began in 1998, as described in an American Society on Healthcare Engineering (ASHE) technical paper, which The Joint Commission eventually adopted as part of the life safety assessment under section EC.5.20, EP 1, part A6J. The plan called for a systematic and routine inspection of key elements of life safety in hospitals' facilities. If a hospital could demonstrate at least 95% compliance with life safety features by documenting the inspections, The Joint Commission would agree that those particular features of life safety were in compliance. This meant a surveyor would not cite the hospital for noncompliance of smoke barrier penetrations, corridor door latching, exit sign illumination, etc., if the BMP documentation indicated the sampling to be at least 95% compliant. It proved to be a terrific advantage for facility directors in hospitals.

However, due to pressure from other authorities, The Joint Commission has decided to eliminate all scoring advantages associated with the BMP beginning January 1, 2009. Surveyors will no longer grant immunity for life safety deficiencies even if the hospital can demonstrate 95% compliance. The expectation now is that all hospitals must comply with the Life Safety Code® (LSC) 100% of the time. Even with this turn of events, I strongly encourage hospitals that have a BMP to continue using it, and hospitals that do not have a BMP to seriously consider starting such a program.

The reason is simple: The BMP is a wonderful tool for assessing the building's compliance with life safety standards. It provides a routine inspection of key elements and will uncover any deficiencies, which either can be resolved immediately or placed on the Plan For Improvement (PFI) section of the electronic Statement of Conditions. This systematic approach to management, once implemented, can easily be supervised via the hospital's computerized maintenance management system.

I believe hospitals need all the help they can get when it comes to life safety assessments. My observations as a LSC surveyor for The Joint Commission indicated hospitals are poorly prepared in this area—and are never as prepared as they think they are. If you would like assistance on starting a BMP at your own facility, please consider The Greeley Company. We would be glad to help.

If you have any questions or comments regarding this information, please feel free to contact me at 815/629-2240 or 815/742-4367.

Thank you.

Brad Keyes, CHSP
Consultant
The Greeley Company

Proctoring/FPPE (Focused Professional Practice Evaluation)

Tue, 09 Dec 2008 13:30:00 GMT

In traveling from hospital to hospital, I find that the FPPE process is one that is a challenge to comprehend, design, and implement. The lack of an FPPE process is also more consistently cited by The Joint Commission surveyor. It is my hope that the following article will help clarify what is needed and how to begin the process.

A good FPPE process allows a medical staff to bridge the gap between having no firsthand knowledge of a practitioner's competency to one in which we have sufficient information as to allow monitoring of ongoing competency by a peer review process. The FPPE policy should ensure achievement of that goal.

Note: Practitioners requesting membership but not exercising specific privileges do not need to be proctored. This includes your no-volume physicians.

FPPE applies in two cases

When a hospital must confirm competence of a practitioner who is new to the organization (for the purpose of granting privileges). A period of FPPE must be implemented for all initially requested privileges. For practitioners who do not currently have privileges or a track record at the hospital, the medical staff must define the circumstances that require monitoring and evaluation of a practitioner's performance.
For situations in which a concern is identified in regard to the competency or ability to provide care by a practitioner who is not new to the organization. This includes the following circumstances:
- A known practitioner requests a new privilege that he or she was not previously granted.
- When questions arise about whether a practitioner can continue to provide safe, high-quality care. In these cases, the medical staff must develop criteria that address when such a review will be triggered. (I often see this included in the medical staff peer review policy. If that is the case, it does not need to be discussed in the FPPE process.)

Performance monitoring process
The performance monitoring process should identify:

The criteria to be used for performance monitoring>
The method used for establishing a monitoring plan specific to the requested privilege(s)
The method used to determine how long the performance monitoring will last
Circumstances that require monitoring by an external source

Methods
Typically, all or some of the following are identified as FPPE monitoring methods:

Prospective proctoring: Presentation of cases with planned treatment outlined for the proctor's treatment concurrence, review of case documentation for treatment concurrence, or completion of a written or oral examination or case simulation.
Concurrent proctoring: Direct observation of the procedure being performed or medical management either through observation of practitioner interactions with patients and staff members or review of clinical history and physical and review of treatment orders during the patient's hospital stay.
Retrospective evaluation: Review of the case record after care has been completed. May also involve interviews of personnel directly involved in the care of the patient.

FPPE leads to OPPE
As stated above, FPPE is a focused evaluation process to confirm an individual practitioner's current competence at the time new privileges are granted, either at initial appointment or as a current member of the medical staff. In addition to specialty-specific issues, proctoring will address the six general competencies of physician performance. Often, these are the same as identified in your ongoing professional practice evaluation (OPPE) but on a more frequent review—either prospective, concurrent, or retrospective. The six general competencies are:

Patient care
Medical knowledge
Practice-based learning and improvement
Interpersonal and communication skills
Professionalism
Systems-based practice

Medical staff oversight
Your process should include oversight responsibility. Identify which group in the medical staff will have primary oversight of this program (e.g., credentials committee, department chairs, MEC, or other).

Medical staff proctors
Identify the criteria for choosing a proctor.

Data sources and reporting
As stated above, FPPE and OPPE data are often the same information, but what distinguishes FPPE is more frequent and intense monitoring. Data sources often include:

Routine chart audits by non-medical staff personnel for important clinical functions
Identified procedural or care process documentation review by the proctor
Data abstracted for external comparative databases used to evaluate current medical staff members
Incident reports
Findings of cases identified for review by medical staff peer review committees
Electronic claims data used to evaluate current medical staff members
Patient satisfaction surveys

Finally, identify the method by which the analyzed data are reported along with recommendations. Most often, the endpoint will be when competency is established so FPPE can be ended and OPPE or the regular monitoring process can take over. The end point needs to be clearly identified in the policy.

2009 Universal Protocol FAQs . . . finally here

Fri, 14 Nov 2008 13:00:00 GMT

I'm sure you have all been waiting with bated breath for the 2009 Universal Protocol (UP) FAQs. Seldom have I seen such confusion or lack of clarity around a standard. I'll discuss some of the more controversial or less understood points. You can find the full FAQs at www.jointcommission.com.

What procedures fall within the scope?
The definition has not changed: "All operative and other invasive procedures that expose patients to more than minimal risk."

The FAQs provide some clarity around the phrase "puncture or incision of the skin, insertion of an instrument, or insertion of foreign material into the body." The FAQs state that "…certain routine ‘minor’ procedures" such as the following, are NOT within the scope of the protocol:

Venipuncture
Peripheral intervenous line placement
Insertion of a nasogastric tube
Urinary catheter placement
ECT
Closed reduction
Radiation oncology
Lithotripsy (this does have laterality, but the stone is visualized during the procedure)
Dialysis (except insertion of the dialysis catheter)

Examples of procedures that ARE covered by the UP include:

PICC line
Central line insertion
Chest tubes and other similar types of common procedures

The FAQs go on to state that "each organization is expected to clearly define those procedures that fall within the protocol". Although this statement references the term "procedures," it seems that they could be defined in groups, such as "all procedures performed in the OR suite", "all procedures performed in special procedure areas", etc rather than a list of individual procedures. Procedures done at the bedside require some thought and some decision as to what puts the patient at "more than minimal risk".

Is a preprocedure checklist now required?
Yes, and it needs to be completed PRIOR to moving the patient into the OR or procedure room. The checklist should include:

All relevant documents present
Blood products, if ordered
Implants
Special equipment

If the staff in the preprocedure area do not have access to some of the information (e.g., blood, special equipment, implants), the organization would be expected to implement a communication process between the two areas ensuring the required elements are available and ready for use. They go on to say: "In those unusual circumstances when this verification cannot be performed during the preop verification process, the confirmation may be done at the time out … this should be based on individual circumstances, and should not be routine practice."

Must all procedures be marked?
The intent of site marking has not changed. It still must be performed for laterality, levels, and multiples. The mark must be visible after prepping and draping, etc. Exemptions to site marking include:

Midline, single organ procedures
Endoscopies without laterality
When there is no predetermined insertion site such as cardiac catheterization and other interventional procedures

If the site cannot be marked, will not be visible after draping, or the patient refuses site marking, an alternative process must be clearly identified (such as a wristband with description of site, a mark on the same side as the procedure, etc). This needs to be defined in the policy.

Time Out
You may have noted some contradictions about time outs.

On one hand, the FAQ requires one, and only one, time out for most surgeries: either before anesthesia, or after anesthesia and prior to incision. On the other hand, the FAQ seems to require two time outs when a spinal or regional block is involved: prior to the block, and again prior to incision. (hmmmm …?)
On one hand the FAQ indicates that only one time out is necessary when the same team will perform all portions of a multipart procedure. On the other hand it requires a separate time out when the various parts of the procedure require separate consent forms.

The bottom line: "Each organization defines under which situations the time out is required to be performed prior to anesthesia or when it is preferable to do so immediately prior to the procedure/incision; or when flexibility may be considered …". One way to interpret this is to ask "does the anesthesia have laterality where an error could be made?" Also, the proceduralist may not be present during the anesthesia, therefore, define who is responsible to conduct the timeout? (Anesthesia staff introducing the anesthesia and procedural assistants seems reasonable).

Documentation
All aspects of the universal protocol must now be documented (UP.01.03.01 EP.6). However, some parts of the protocol do not lend themselves to documentation, such as verification of the procedure during scheduling or a checklist that is on a wallboard instead of a form.

Take the Pain Out of Pain Reassessments in Three Steps

Tue, 07 Oct 2008 16:23:00 GMT

The problem
Most hospitals have an 80% intrinsic rate of compliance with their pain reassessment policy. This is usually good enough to meet 2008 expectations, but it will not be nearly good enough for 2009 (90% will be the minimum level of performance). The challenge is that the bedside nurse has no reason to go back to the chart when he or she determines that a pain medication has been effective. If another dose is needed, no problem: The nurse is in the chart for the follow-up dose of medications anyway. If another dose is not needed, however, the nurse is not inclined to revisit the chart just to document that all is well—it just isn't natural.

The solution
Step 1: Separate pain management from pain assessment. Take your requirements for assessment and reassessment of pain out of your pain management policy. In fact, make your pain management policy one sentence: "Patients in this organization shall have the right to effective pain management" (RI.01.01.01, EP.8). The rest of the material on effective pain management should be in the form of educational material for clinical personnel. Effective pain management is a journey, not a destination, so educate, educate, educate. But don't require specific pain management steps: patients are individuals, and managing their pain will be individualized accordingly.

Step 2: Simplify pain assessment requirements. The Joint Commission requires that there be a policy for patients who may need a more in depth assessment of pain (PC.01.02.01, EP.2); there be a comprehensive initial pain assessment that is consistent with the organization's scope of care, treatment, and services and the patient's condition. (PC.01.02.07, EP.1); clinical personnel reassess and respond to the patient's pain according to reassessment criteria (PC.01.02.07, EP.3); and age- and condition- appropriate assessment methods be used (PC.01.02.07, EP.2).

Consider the following:

If you have a trigger for a more in-depth assessment, put it in a generic initial assessment and screening policy; keep it out of your pain policy. (Reflect what's already happening, don't make up something new.)
Mention the pain scales to be used in the policy, but keep the details of the various scales out of your policy. Leave the details to your education documents.
Do not specify a scale for nonverbal adults. No reliable scale exists (remember, FLACC is for infants, not adults).
Allow documentation of "patient sleeping," "resting comfortably," and similar observations in lieu of a pain scale at the time of the post intervention reassessment.
Make the details of the comprehensive initial assessment vague. Leave it to "location, intensity, and nature." Put the details in the forms for the various settings (emergency departments can therefore be appropriately different from inpatient and procedural areas).
Only require pain assessments in the general ambulatory setting for patients complaining of pain and allow the provider's note to suffice for the pain assessment.
Remember our general rule: No policy should be over 1.5 pages in length.

Step 3: Allow end-of-shift documentation. Although the policy should specify that the reassessment should take place within a clinically appropriate time frame (e.g., within a half hour of intravenous doses or within an hour of an oral dose), the documentation of this reassessment may be deferred until the end of the shift. This then allows a number of options for documentation (which is the subject for our other Stop the Madness articles and approaches for easing nursing's documentation burden).

Update from Executive Briefings #8: RFI Trends

Thu, 11 Sep 2008 15:12:00 GMT

Pat Adamski reported the following "Problem Standards" from the results of surveys conducted in 2007 and the first quarter of 2008.

EC.5.20: Life Safety Code (LSC). 2007 RFI rate: 29%; 2008 RFI rate: 45%. The increasing rate of LSC RFIs is attributed to additions to the number of surveys including a LSC specialist.

IM.6.50. Verbal orders not authenticated. 2007 RFI rate: 25%; 2008 RFI rate: 35%. At present, a single unsigned telephone order is an RFI (category A). The good news is that this issue will become a category C element of performance in 2009.

MM.2.20. Medication storage. 2007 RFI rate: 43%; 2008 RFI rate: 31%. This issue includes expired medications and medication refrigerators that are not monitored or are out of range. This issue will also move from a category A (100%) to a category C (90%) requirement.

EC.5.40. Testing of LSC devices. 2007 RFI rate: 18%; 2008 RFI rate: 30%. The increase in RFI rate probably reflects an increase in LSC engineer survey participation. Sometimes, this is merely a few missed issues or missing documentation, and the issue can be easily clarified or corrected. However, this can lead to preliminary denial of accreditation (PDA) due to immediate threat if there are significant lapses and if interim life safety measures have not been implemented. It is recommended that compliance with this issue be tacked through to the leadership level.

IM.6.10. Complete medical record. 2007 RFI rate: 26%; 2008 RFI rate: 24%. Findings tend to fall into the general area of a complete medical record and the issue of dating and authentication of medical record entries. Although CMS requires that entries be timed, The Joint Commission does not. However, The Joint Commission will survey to your policy, so if you require timing, so will they.

HR.1.20. Primary source verification. 2007 RFI rate: 15%; 2008 RFI rate: 18%. One-hundred percent compliance with this issue will continue to be required in 2009.

MM.3.20 2007 Noncompliance with medication order policies. 2007 RFI rate: 20%; 2008 RFI rate: 16%. This will remain a category C element of performance. In our experience, a hospital's intrinsic rate of compliance is about 93%, meaning that clarification rather than correction should be considered.

PC.8.10: Assessment and reassessment of pain. 2007 RFI rate: 15%; 2008 RFI rate: 16%. A large part of noncompliance with PC.8.10 is unrealistic policies for reassessing pain. We've posted several sample policies and approaches in our Center's documents library, but the bottom line is: Don't paint yourself into a corner.

EC.7.40: Emergency power generation. 2007 RFI rate: 8%; 2008 RFI rate: 16%. This is another issue in which the effect of an extra LSC surveyor can be clearly seen. Issues with emergency power generation can also lead to immediate accreditation problems due to imminent threat to patient welfare.

PC.13.20: Pre-sedation assessment. 2007 RFI rate: 18%; 2008 RFI rate: 15%. These issues can usually be traced back to requiring too much documentation. To address this, simply remember that less is more and to standardize your forms.

EC.7.50: Medical gasses. 2007 RFI rate: 6%; 2008 RFI rate: 14%. Our friendly neighborhood LSC specialists are at work again. The specter of imminent jeopardy arises when it comes to alarms being shut off.

Open Shafts in Mechanical Rooms

Tue, 12 Aug 2008 16:24:00 GMT

This month’s article was written by Brad Keyes, CHSP, a consultant at The Greeley Company.

I recently observed an open shaft in a mechanical room at a client’s hospital. The mechanical room was located in the penthouse, which housed an air-handler and elevator equipment. The vertical shaft extended more than four floors below and was used for ventilation ductwork, steam and chilled water pipes, and communication wires.

The Life Safety Code permits an open shaft in a mechanical room, as long as the room has a use related to the purpose of the shaft. The mechanical room also has to be separated from the rest of the building by appropriate fire-rated walls. (See LSC 8.2.5.3, 2000 edition.)

The problem that I saw was that this mechanical room, which didn’t have fossil fuel–fired equipment, had other items stored in it, including a separate storage room. With the constant problem that hospitals face of too little storage for too much stuff, the use of a mechanical room for storage is a common situation.

I wrote to the Standards Interpretation Group (SIG) at The Joint Commission and specifically asked if the following items were allowed to be stored in this situation:

Cardboard boxes of filters
Medical equipment, televisions, computer servers
A separate room used for storage

Its answer was clear:

Only one change of air filters is allowed in any mechanical room
All storage must be confined with appropriately constructed barriers
Any use of the mechanical room not primary to the function of the vertical shaft must be separated by appropriate constructed barriers

My recommendation is to inspect your mechanical rooms, especially the penthouse rooms, although open shafts in mechanical rooms can be found on the lower floors, and follow these suggestions:

Leave only one set of filters for the air-handling equipment in that room; remove all others. Always keep new air filters clean in the boxes they came in or inside plastic bags. This is an infection control issue.
Remove all items that are stored in mechanical rooms that are not related to the purpose of the shaft. Spare electric motors, drive shims, replacement belts, etc., are considered related to the purpose of the room. Televisions, computer servers, plumbing supplies, and medical equipment are not.
Check the fire rating on any barriers separating a storage room from the mechanical room. The walls will need to be two-hour fire-rated if the shaft extends four or more floors, or one-hour fire-rated if the shaft extends three or fewer floors. The door will need to be fire-rated and must be fitted with positive latching and a closure. Look for unsealed penetrations in those walls also.

Finally, if you have no other place for storage and you want to continue to utilize the mechanical rooms for that purpose, you will have to construct storage rooms with appropriate fire-rated barriers. This is an expensive proposition, but it may be your best choice. Also, keep in mind that fire-rated storage cabinets are considered the same thing as fire-rated rooms. So consider using fire-rated cabinets for your smaller storage needs.

If you have any questions or comments regarding this information, please feel free to contact me at 815/629-2240 or 815/742-4367.

New Medical Staff Models & Credentialing Challenges

Tue, 22 Jul 2008 14:36:00 GMT

Dear Greeley Medical Staff Institute Member:

You are processing an application for a candidate new to your medical staff. As part of the application, the candidate lists being a member of the ABC Medical Center medical staff. You write to the ABC medical staff office (MSO) for a reference and get a "good standing" letter. What the candidate didn't tell you is he was let go from the group holding the exclusive contract at ABC for hospitalist services because of suspected impairment and patterns of disruptive behavior. Since the contract was handled outside the ABC MSO, it had no knowledge of what occurred and why he was terminated because the problem did not go through the process outlined in the medical staff bylaws for investigation or due process. What to do?

In the May column, Rick Sheff addressed the question "Is the old medical staff model dead?" In August, our coauthored new book, The Greeley Guide to New Medical Staff Models: Contemporary Solutions for Today's Physician-Hospital Relationship Challenges, will be released. Through our consulting and research, at least 17 medical staff models were identified. Traditionally, independent physicians made up the majority of medical staff members in most community-based hospitals. More and more, however, hospitals are utilizing employment agreements and exclusive contracts with physicians. In fact, such models are increasing exponentially in some organizations.

These employment and exclusive contract agreements often have "termination with cause" clauses, but just as many have provisions for termination without cause requiring only notification within a specified number of days. Normally, what you see in these agreements with the individual physicians is that if the group or the individual is terminated, they automatically waive their right to a fair hearing and due process under the medical staff bylaws. Hospital privileges are often tied to the agreement and are forfeited if the agreement is terminated. What happens if an employed or exclusive contract physician shows evidence or is suspected of having a problem? One scenario is that should a physician prove to be incompetent, disruptive, or impaired, the agreement is terminated and thus the administrative burden of dealing with this issue through a lengthy and costly medical staff can be obviated. Such problems will never be the subject of the medical staff process for investigation, fair hearing, or appeal as required in the medical staff bylaws. Further, impaired physicians may never receive the evaluation and referral for help to a physician health program as required by The Joint Commission's standard MS.4.80.

Given these changes, the challenge for medical staff professionals and medical staff credentials committees is getting the information needed to make the best possible decision about a candidate new to the staff. Consider the following ten practices as strategies to meet this challenge:

Always remember that credentialing has no master other than the patient.
The burden is on the applicant to provide all the information you deem necessary. Do not process an application until you have all the information you need. No exceptions.
Do not make:
1. Information errors: Undiscovered information existed that could have been known and would have affected a credentialing decision (practices four through ten address this concern)
2. Decision errors: The necessary information was known, but leaders made the wrong decision
Use all sources to obtain the information you need. Pick up the phone, do a Google search, and expand your field of inquiry as outlined in practice five below. Remember, verbally releasing or obtaining information still requires that you receive written information in a timely manner as backup documentation for the credentialing file.
An emerging best practice is to identify not only where the physician held privileges but who employed them — hospital, exclusive contract group, or another group practice. In many hospitals, physician employment and contract issues do not reside in the MSO; indeed, the MSO might be the last to know that the physician was terminated, particularly if the medical staff due process for investigation, fair hearing, and appeal was never activated. The burden on the applicant is to provide the information as to who in the organization can specifically address any issues that occurred under the employment or contracted agreement. Don't act on the application without it.
Have the applicant sign an "absolute" release waiver that helps diminish the chance of a defamation lawsuit.
Ask and answer specific questions. The principle here is there should be a specific question in writing and then an answer to that specific question.
Allow responding hospitals or individuals serving as references to answer all questions on the reference form with "yes," "no," or "prefer not to comment." If the latter is checked, go back to practice seven and ask the specific questions that require an answer.
Consider neutral letters as red flags. Suppose you are credentialing a new applicant to your medical staff who indicated previous affiliation with Community Hospital. In response to a request for information, you get a letter that the physician was on staff from such and such date to such and such date, the so-called "name-rank-serial number" letter. In the May Kadlec reversal, the federal court upheld a Louisiana hospital's action of providing a neutral letter that was factually correct but incomplete. Although this ruling is still on appeal and only applies to Louisiana, the question becomes: Is this just a hospital's standard operating procedure to send a form letter or does this now become a potential red flag that damaging information is being withheld? Once again, the burden on the applicant is to provide independent verification of information indicating the presence or absence of a problem.
Expand your list of potential red flags and have a low threshold for red flags to be investigated. Consider the following:

Resignation as partner from a group
Ending an employment arrangement with a healthcare facility
Any gaps in CV, particularly with employment or medical staff membership
Moved significant distances or has moved a lot during his or her professional career
Change of specialties
Requesting fewer privileges than normally granted under a core privileging system
Gaps in insurance coverage, change in carriers, or reduction in coverage
Professional liability history
Reference letters are neutral
Category ratings are "poor," "fair," or "average"
Responses from hospitals and/or employers simply give dates of service or very limited information (as in Kadlec, it was factually correct but still misleading and incomplete)

Now more than ever, strong medical and healthcare leadership is required to do the right thing, ensure patient safety, and help physicians be the best they can be. The Greeley Company Medical Staff Institute is your partner in helping to ensure physician success, hospital success, and quality care for your community.

If you have any questions about the Greeley Medical Staff Institute or your membership benefits, please contact Debbie Barreira, Client Relations Manager, at dbarreira@greeley.com or 888/749-3054 Ext. 3126.

Until next time, be the best you can be.

William K. Cors, MD, MMM, FACPE, CMSL
Vice President of Medical Staff Services
Senior Consultant
The Greeley Company

New 2009 National Patient Safety Goals

Tue, 08 Jul 2008 15:34:00 GMT

On June 17, The Joint Commission announced the new National Patient Safety Goals (NPSG) for 2009. Several changes and additions have been built into the 2008 NPSGs. Multiple drug–resistant organisms (MDRO), central line–associated bloodstream infections, and surgical site infections are additions to Goal #7: reduce the risk of healthcare-associated infections. These new changes should not come as a surprise to healthcare workers due to the recent national emphasis on MRSA, bloodstream infections, and surgical site infections. If your facility has been following the Institute for Healthcare Improvement’s programs, which were introduced several years ago, you will have already been working on these and be one step ahead of the others. Similar to the 2008 anticoagulation and rapid response NPSGs, these new changes will be phased in during 2009.

The following addresses only new NPSGs or those goals with new elements of performance.

NPSG.01.01.01 EP.1: Two identifiers—new element of performance

Patient identification must include the active participation of the patient, and, when needed, the family. The goal states: “When active patient involvement is not possible or the patient’s reliability is in question, the hospital will designate the caregiver responsible for identity verification.”

NPSG.01.03.01: Blood transfusions—new goal

Before initiating a blood or blood component transfusion, the patient is matched to the blood component during a two-personverification process:

Two patient identifiers are used
One person must be the person administering the transfusion
The second person must be qualified to administer blood components
When two persons are not available, an automated identity technology (e.g., bar coding) may be used in place of the second individual

NPSG.07.03.01: Multiple drug–resistant organisms)—new goal

Implement evidence-based practices to prevent healthcare-associated infections due to MDROs. One-year phase-in period.

2009

April 1: Leadership assigns responsibility for development and oversight
July 1: Work plan that identifies resources, accountabilities, and timeline for implementation
October 1: Pilot testing for at least one clinical unit is under way

By January 2010:

Elements of performance fully implemented
Implementation of a risk assessment
Based on the results of the risk assessment, provide:
1. Initial and annual education to caregivers
2. Patient and family education to those patients who are infected or colonized with MDRO
A surveillance program for MDROs, including monitoring of MDRO outcomes, data analysis, and reporting to key stakeholders
Implementation of risk reduction strategies, including a laboratory-based alert system to identify new patients with MDRO

NPSG.07.04.01: Central line–associated blood stream infections—new goal

A process for surveillance for central line–associated blood stream infections. The phase-in is the same as NPSG.07.03.01: Multiple drug–resistant organisms, with the changes as follows:

3. b. Provide patient and family education about central line–associated bloodstream infection prevention prior to the insertion of the central line

By January 2010:

Implementation of policies and procedures aimed at preventing central line–associated bloodstream infections
A checklist and standardized protocol for line insertion
Avoidance of using the femoral vein as a line site for adults
Using an all-inclusive standardized supply kit for central line insertion
Protocol for maximum sterile barrier, the use of chlorhexidine-based skin antiseptic, and a protocol to disinfect hubs and injection ports before accessing ports
Process to evaluate all central venous catheters routinely and remove nonessential catheters

NPSG.07.05.01: Surgical site infections—new goal

The phase-in is the same as MDRO and central line–associated bloodstream infection, with the changes as follows:

By January 2010

This goal establishes specific interventions for prevention of surgical site infections and includes:

Staff education
Education of patients, and families (as appropriate), who are undergoing a surgical procedure
Risk assessment
Policies and procedures aimed at the prevention of SSI
Implementation of evidence-based guidelines for antimicrobial agents
Guidelines for hair removal to include clippers and depilatories
Measurement of surgical site infection data and prevention outcome measures and reporting to key stakeholders

NPSG.08.01.01: Medication reconciliation—new expectations

EP.1 now specifically requires dose, route, and frequency. This does not seem to be required for outpatient setting and the emergency department for short-term drug use (see NPSG.08.04.01).

EP.2 requires comparisons against the list of current medications as each new medication is ordered.

EP.3: Discrepancies are reconciled and documented.

EP.4: There must be communication among providers related to the up-to-date reconciliation list whenever there is a transfer within the hospital. This communication must be documented. There is also language about such communication during handoffs from one caregiver to another, but it is not clear whether this handoff must now be documented.

NPSG.08.02.01: Communication of reconciliation list—new expectations

This version seems to revert to sending the list to the patient’s primary care provider, next provider, or referring physician. This may be given to the patient only if short-duration medications are to be taken after discharge (see NPSG.08.04.01).There is also a new requirement related to transfers: The next provider must be given information about how to obtain clarification on the list.

NPSG.08.03.01: Patient education—new expectations

This issue used to be addressed under NPSG #8B but is now its own standard. When the patient leaves the hospital’s care, the current list of reconciled medications is provided to the patient and their family as needed. This interaction must be documented.

NPSG.08.04.01: Minimal use/short-duration medication reconciliation

It seems that dose, route, and frequency are not required for the current medication list in some settings (e.g., the emergency department, outpatient surgery, radiology, or ambulatory care). EP.2 requires the creation of a short-term medications list. The complete medication reconciliation process is used when there is a new or changed long-term medication. This essentially gives more guidance for the outpatient setting.

NPSG.13.01.01: Patient involvement in safety—existing goal, new elements of performance

EP.2 There must now be documented education about hand hygiene, respiratory hygiene practices, and contact precautions according to the patient’s condition and within 24-48 hours of admission. Comprehension is evaluated. This pertains to patients and families.

EP.3 goes on to require additional education for surgical patients to include measures that will be taken to prevent adverse events in surgery e.g., patient identification, prevention of surgical site infections. Patient’s understanding must be documented.

UP.01.01.01: Universal Protocol/procedure verification—existing requirement with new expectations

EP.2 now requires the use of a pre-procedure checklist when the patient moves from the pre-procedure setting. This will be a change for endoscopy, catheterization laboratories, and invasive radiology.

UP.01.02.01: Universal Protocol: Site marking—new/clarified expectations

EP.1: Site marking: This now pertains to all procedures involving incision or percutaneous puncture.

EP.2 is more specific about the site is marked prior to moving the patient to the procedure area and with the patient’s participation if possible.

UP.01.03.01 Universal Protocol: Timeout—new expectations

EP.5: The timeout must now include consent, the need to administer antibiotics or fluids for irrigation purposes, and “safety precautions based on patient history or medication use.”

EP.6 now requires that all components of the Universal Protocol are documented, not just the timeout (as in current requirements).

We recommend getting a jump on the new NPSGs as soon as possible; don’t wait until December before introducing them to your facility. Several of these changes will take time and effort to affect compliance before next year.

OR temperature and humidity reading logs

Tue, 10 Jun 2008 14:48:00 GMT

We have heard that Joint Commission surveyors are requesting to review logs of temperature and humidity readings of all operating room suites and recovery room areas. Since the Environment of Care standards do not require the logging of such readings, it may be confusing why the surveyors are requesting to look at them. An examination of the Environment of Care standards will guide you in the event a surveyor asks to examine these logs.

EC.8.10, EP 7 states that “Ventilation provides for acceptable levels of temperature and humidity and eliminates odors.” The Joint Commission does not prescribe how your organization meets this requirement, but it would expect that you have an analysis or an assessment that shaped the decision as to the acceptable levels of temperature and humidity in your facility. Frequent monitoring of the temperature and humidity is certainly one method of meeting this requirement.

This monitoring may be accomplished through the Building Automation System (BAS), which may automatically record readings on a periodic basis or have alarms programmed to actuate when the temperature or humidity exceeds the minimum or maximum set points.

Monitoring may also be accomplished through manually reading the thermostat and humidistat in each room on a periodic basis, such as prior to a procedure. A written process stating that a staff member will contact engineering when the temperature and humidity readings are beyond the minimum or maximum set points is adequate for a manual system.

So, what should the temperature and humidity levels be set at? The Joint Commission does not prescribe those set points, but would expect that you follow industry standards or state licensing requirements. Organizations need to define what parameters they will follow. In addition to your state requirements, check with the Association of periOperative Registered Nurses, the American Institute of Architects, and the U.S. Department of Health and Human Services.

EC.7.10, EP 16 states that “The hospital designs, installs, and maintains ventilation equipment to provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies for ventilation systems serving areas specially designed to control airborne contaminants (such as biological agents, gases, fumes, and dust).” Again, The Joint Commission does not prescribe how you meet this requirement, but you should have an assessment or test results from an air balancing report calculating the appropriate air exchange rates. Nor does The Joint Commission state what the air exchange rates should be, but it expects you to follow your state licensing requirements or an industry standard, such as the American Society of Heating, Refrigeration, and Air-Conditioning Engineers, which has many recommendations for air exchange rates.

A Joint Commission surveyor may ask to see temperature and humidity logs to determine compliance with these two EC standards. Logs are not required, but they are an indication of compliance. You may be able to demonstrate compliance by other means, such as proof of following the state licensing requirements and adherence to industry standards. The frequency of any reading is solely up to you. CAUTION: Be careful what your policies state. If the policy says you will make temperature and humidity readings prior to each procedure, then The Joint Commission can and will hold you to that policy and logs will be much more important for proof of compliance with your policy.

If you have any questions or comments regarding this information, please feel free to contact Brad Keyes, CHSP, Consultant for The Greeley Company, at 815/629-2240 or 815/742-4367.

Pain Reassessments-They're a Pain

Tue, 13 May 2008 15:42:00 GMT

This month's article was written by Bud Pate, REHS, and Lisa Eddy, RN, CPHQ, senior consultants at The Greeley Company.

The Greeley Company is receiving more requests for assistance with post Joint Commission accreditation survey clarification work. One of the most frequent requirements for improvement is for pain reassessments. Many hospitals are cited for failure to conduct a reassessment after pain intervention. However, it isn’t that organizations aren’t reassessing pain, it’s that they aren’t documenting the pain reassessment.

Follow your policy
This core issue is emerging as one of policy versus practice. The Joint Commission (formerly JCAHO) rightly will cite a hospital for failure to reassess the patient’s pain in accordance with the hospital’s own policy. It is not uncommon for hospitals to “hold their own feet to the fire” by an overly stringent pain management policy that requires reassessment of pain post-intervention in an unrealistic time period. The Joint Commission under the “Provision of Care” chapter, standard PC.8.10 elements of performance (EP) 3 requires regular reassessment according to hospital-established criteria. There is no hard and fast Joint Commission rule for pain reassessments. These can be done as the hospital defines.

Make your policy realistic
We suggest you revise your policy to align with real-life practice and not put difficult-to-accomplish time frames in your policy for pain reassessment. For example, it is almost impossible for a busy med-surg nurse caring for multiple patients with complex needs, to reassess a pain medication administered intravenously and then document that reassessment within 20 minutes, as some polices require. We suggest a more flexible approach that moves the nurse toward the bedside and away from superfluous documentation. For example, rather than requiring pain reassessments concurrently, why not require a pain reassessment for the presence and intensity of pain at least once every 12 hours for inpatients and extended-stay outpatients and following any intervention intended to lessen the patient’s pain (e.g., administration of pain medications, application of cold packs, repositioning). Reassessment (post-intervention) should take place within a clinically appropriate time frame, such as within a one-to two hour time frame for the administration of oral medications or within one hour of the administration of intramuscular or IV pain medications.

Educate your patients
But don’t forget your pain policy must be complemented by a plan for ongoing pain education (which is required under RI.2.160 EP.1). It is this education document that will specify the how to complete clinically appropriate reassessments.