Top 10 Accreditation Violations and How to Avoid Them

Oops—Top 10 Accreditation Violations & How to Avoid Them Linda McSmith, RN, LRM Assistant Vice President of Risk Management and Client Services ® Top 10 (11) Joint Commission Recommendations  Accreditation Preparation Do..s     Keep manual updated Keep staff informed and educated on the process Communication skills Focus on process  Patient care  Infection control  Medication management  Human resources  Patient rights  Environment of care TOP TEN LIST – NUMBER 11  Goal 2, Requirement 2B (16%) Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008 TOP TEN LIST – NUMBER 11  List of unapproved abbreviations  Process to monitor what abbreviations are being used  Trending of the information and the process used to create change TOP TEN LIST – NUMBER 10  Goal 2, Requirement 2C (16%) Measure, assess, and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008 TOP TEN LIST – NUMBER 10  Identification of what a “Critical Test” means in your organization  Policy to state how “Critical Tests” results are communicated to the provider  Policy that identifies the time limits for the communication of the results to the provider  Documentation on when and how the communication with the provider took place TOP TEN LIST – NUMBER 9 • HR.4.10 (17%) There is a process for ensuring the competence of all practitioners permitted by law and the organization to practice independently. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008 TOP TEN LIST – NUMBER 9  Documentation of the credentialing process  Verification of identity by documenting the observation of a government issued ID  Primary source verification documented  Verification of competency  Training  Privileges at other organizations  Heath status verification  License verification TOP TEN LIST – NUMBER 8 • Goal 3, Requirement 3C (18%) Identify and, at a minimum, annually review a list of lookalike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Reference: Reference: THE JOINT COMMISSION PERSPECTIVES February 2008 TOP TEN LIST – NUMBER 8  Identify list of look-alike/sound-alike drugs in the organization  Identify how your organization can differentiate the identities of the medications through bold face, color, and/or tall man letters, for the parts of the names that are different (e.g., hydrOXYzine, hydrALAzine)  http://www.jointcommission.org/NR/rdonlyres/C92AAB3FA9BD-431C-8628-11DD2D1D53CC/0/LASA.pdf  Maintain awareness of look-alike and sound-alike drug names as published by various safety agencies TOP TEN LIST – NUMBER 8  Whenever possible, determine the purpose of the medication before dispensing or administering the medication  Accept verbal or telephone orders only when truly necessary  Encourage staff to read back all orders, spell the product name, and state its indication  Consider the possibility of name confusion when adding a new product to the formulary  Encourage reporting of errors and potentially hazardous conditions with look and sound-alike product names and use the information to establish priorities for error reduction TOP TEN LIST – NUMBER 7  EC.4.10 (17%) The organization addresses emergency management. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008  Conduct a Hazard Vulnerability Analysis  Know your organizational role in the community  Maintain a written Emergency Plan  Preparedness  Response  Recovery TOP TEN LIST – NUMBER 6  MM.2.20 (22%) Medications are properly and safely stored. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008  Maintain Formulary, approve it annually by the Board  Process to add medications to the formulary between approvals  Maintain proper storage of medications TOP TEN LIST – NUMBER 6  Policy on what your process is from receiving medications through the administration of the medications  Proper access rights to medications  Controlled substances are stored to prevent diversion and according to state and federal laws and regulations  Control the storage of RX pads TOP TEN LIST – NUMBER 5  Universal Protocol 1, Requirement 1C (20%) Conduct a “time-out” immediately before starting the procedure as described in the Universal Protocol. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008 TOP TEN LIST – NUMBER 5  http://www.jointcommission.org/NR/rdonlyres/E3C600EB043B-4E86-B04E-CA4A89AD5433/0/universal_protocol.pdf  Pre-operative verification process  Ensure that all of the relevant documents and studies are available prior to the start of the procedure and that they have been reviewed and are consistent with each other and with the patient’s expectations and with the team’s understanding of the intended patient, procedure, site, and as applicable, any implants. Missing information or discrepancies must be addressed before starting the procedure  Process begins with the gathering and verification of information, continuing through all settings and interventions involved in the preoperative preparation of the patient, up to and including the “time out” just before the start of the procedure TOP TEN LIST – NUMBER 5  “Time out” immediately before starting the procedure  To conduct a final verification of the correct patient, procedure, site and, as applicable, implants  Active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a “fail-safe” mode, i.e., the procedure is not started until any questions or concerns are resolved  Marking the operative site  To identify unambiguously the intended site of incision or insertion  For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (as in spinal procedures), the intended site must be marked such that the mark will be visible after the patient has been prepped and draped Reference Joint Commission - Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™© Copyright 2003 TOP TEN LIST – NUMBER 4  HR.4.20 (22%) Individuals permitted by law and the organization to practice independently are granted clinical privileges. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008 TOP TEN LIST – NUMBER 4 Entity specific delineation of privileges Training verification Peer recommendation Leadership (Board) evaluation of requested privileges  Challenges to licensure, relinquishments of licensure or termination from medical staff memberships  Evaluation of professional liability actions resulting in final judgment actions against applicant  Notification to practitioner in writing of decision  A qualified anesthesiologist or qualified physician administers anesthetics     TOP TEN LIST – NUMBER 3 PC.16.10 (24%) The director named on the CLIA certificate establishes policies and procedures that define the context in which waived test results are used in patient care, treatment, and services. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008 TOP TEN LIST – NUMBER 3  http://www.fda.gov/cdrh/clia/cliawaived.html  http://www.cms.hhs.gov/clia/  Director determines with the Board what tests your organization will perform  Use of the results are consistent with policies and procedures and manufacturer’s recommendations  Reference ranges must be documented with results  Policies and procedures TOP TEN LIST – NUMBER 2 PI.3.20 (26%) An ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients is defined and implemented. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008 TOP TEN LIST – NUMBER 2          http://www.jointcommission.org/PatientSafety/fmeca.htm Annually, select high risk process to analyze Describe process Determine where it can break down Identify the possible effects of the break down Prioritize the possible failures Determine the root cause Redesign the process Test the redesign and monitor for sustained compliance to the change in process TOP TEN LIST – NUMBER 1  Requirement 8B (28%) A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. Reference: THE JOINT COMMISSION PERSPECTIVES February 2008 Oops—Top 10 Accreditation Violations & How to Avoid Them Thank You