TJC & CMS Update 2017 Kimberly Merritt, MHA, BSN, CNOR, GRCP, - PowerPoint PPT Presentation

TJC & CMS Update 2017 Kimberly Merritt, MHA, BSN, CNOR, GRCP, HACP Jill Ryan, CPHQ, HACP

2 Disclosures • Courtemanche & Associates is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. • Continuing Education Contact Hours will be awarded upon full attendance of the program and receipt of the participant course evaluations. In order to receive CE credit hours for your participation in the session, the electronic evaluation feedback form must be completed within 2 weeks of the educational activity. • The planners and presenters for this session are: Sharon Dills, MSN, RN, HACP, GRCP Kimberly Merritt, MHA, BSN, CNOR, GRCP, HACP and Jill Ryan, CPHQ, HACP • The planners and presenters noted above have disclosed no influencing relationships or commercial support relating to this activity. • Participation in an accredited activity does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with this activity. • Courtemanche & Associates does not discuss any products for use for a purpose other than that for which they were approved by the Food and Drug Association.

3 Session Outline • Accreditation & Regulatory Compliance – The Foundation for Patient Safety • TJC Survey Process Updates • TJC Top Scoring Findings & Strategies for Success

4 Session Objectives • At the conclusion of the session, learner will be able to: • Identify at least one impact of TJC’s SAFER Matrix TM methodology • Identify at least one frequently scored standard and one strategy to achieve sustained compliance

5 Accreditation & Regulatory Compliance: The Foundation for Patient Safety

6 Highlights of the Patient Safety Journey 2017 2013 “High‐Reliability Health 2009 Care: Getting There from 1999 IOM Report Here” “Patient Safety at Ten: Unmistakable Progress, “To Err Is Human: Troubling Gaps” Building a Safer Healthcare System” Estimates between NAHQ Publishes 44,000 and 98,000 HQ Essentials: hospital deaths Competencies for annually due to the Healthcare medical errors Quality Professional In follow‐up to his C+ rating in 2004, Wachter Chassin and Loeb identify This report is widely gives the industry a B‐ actions leaders can take to regarded as the One of the six for safety efforts. create more highly reliable precipitator of the patient competencies is Patient healthcare organizations safety movement. Safety.

7 Reducing Risk

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9 Impact of A&R Compliance on Care JAMA Internal Medicine Study • Significant decrease in 30‐day mortality rate for admissions during TJC survey weeks • Greatest impact – major teaching hospitals What do we think about that?

One Organization’s Experience 10

11 TJC Survey Process Journey 2010s • Requirements associated with risk – direct and indirect impact Today • Survey process more robust • TJC required to participate in CMS 1990s deemed status application process 1980s • • Survey results in a % score Patient Safety Systems chapter • “Agenda for Change” Siloed approach – requirements by • Survey process focuses on cross‐ department department functioning Survey process focused on meetings, document and medical record 2000s Survey activity focused on review. risk, leadership involvement in creating • and modeling culture of “Shared Visions New Pathways” safety and sustaining • Standards & survey process change focused on integrated systems SAFERMatrix TM and functions TJC founding in 1950s to provide voluntary accreditation. Initial • Survey results based on members – ACS, ACP, AHA, AMA, thresholds Canadian Medical Association • Tracer methodology

12 TJC Survey Process Updates

13 TJC’s Project REFRESH Quick Recap • Enhancements to pre/intra/post survey process • Review of standards and EPs • Post survey process – clarifications and ESC • Process for healthcare organizations with Preliminary Denial of Accreditation (PDA02) Decisions • SAFER Matrix TM

14 TJC’s Project REFRESH Still Underway • Still underway • Accreditation report – coming soon • PDF and Excel versions • User‐friendly views • Effectiveness of follow‐up surveys • SIG support during survey • Intracycle monitoring • Engaging physician leadership • And more

15 Review of Standards/EPs • Methodology • Eliminate duplication and redundancy or implicit in another EP • Allow for organization discretion in defining policy, procedure • Reduce requirements addressed by law and regulation • Eliminate requirements for things already embedded in operations Take‐Away – Gone but not forgotten – often embed/scored at other EPs

PDA02 – Repeat Findings, Trends, 16 Patterns • Optional clarification – within 10 days • Plan of correction – 10 days from clarification being waived or completed • Typically condition‐level deficiencies – within 45 days • PDA validation survey – within 60 days • Accreditation with follow‐up survey – typically 4‐6 months • Must participate in intracycle monitoring • Following survey around 18 month mark • Touchpoint discussions with TJC COO and/or CMO

17 ESC Timeline – High Level • Report posted within 10 days • Clarification (optional) within 10 business days • If Condition Level Deficiencies – survey within 45 days • Recommend having corrective actions in place at 30 days with ESC drafted • If Time Limited Waiver needed (LS RFIs) – recommend submitting by 30 days • All ESC due at 60 days • If Accreditation with Follow‐up Survey – timeframe varies

18 ESC Content Revised & More Robust • Assigning accountability • Who is ultimately responsible • Leadership involvement (if red or dark orange on SAFER) • Who and how involved • Correcting the non‐compliance • Preventive analysis (if red or dark orange) • What actions have been taken and when • Ensuring sustained compliance • What procedures/activities put in place to monitor compliance? • Frequency of that monitoring • What data will be collected? • Where and how often will data be reported

SAFER Matrix TM 19 TJC Hospital Executive Briefings, 10/5/2017

TJC’s Top Clinical Findings 20 January – June 2017 – TJC Hospital Executive Briefings, October 5, 2017 Standard Issue Percent of Hospitals Scored Non‐compliant IC.02.02.01 Cleaning, disinfection, sterilization 70% RC.01.01.01 Content of medical record – dating/timing 57% PC.02.01.03 Implementing current orders 57% IC.02.01.01 Infection control surveillance 52% MM.04.01.01 Medication orders – meet requirements 49% MM.03.01.01 Medication storage and security 48% PC.01.03.01 Care planning 45% PC.02.02.03 Food and nutrition services 42% PC.02.01.11 Resuscitation equipment/supplies 38% PC.01.02.03 Assessment and reassessment 31%

TJC’s Top Physical Environment 21 January – June 2017 – TJC Hospital Executive Briefings, October 5, 2017 Standard Issue Percent of Hospitals Scored Non‐compliant LS.02.01.35 Managing fire extinguishing systems 86% LS.02.01.30 Maintaining building and fire protection 74% features EC.02.05.01 Maintaining utility systems (includes air 73% pressure, temperature, humidity) EC.02.06.01 Maintains safe environment 68% LS.02.01.10 Building and fire general requirements 66% EC.02.02.01 Hazardous materials 62% LS.02.01.20 Egress issues 60% EC.02.05.05 Managing equipment 60% EC.02.03.03 Fire drills 47% EC.02.05.09 Cylinder storage/handling 35% EC.02.03.05 Fire alarm and sprinkler testing 16% requirements, etc.

22 Immediate Threat to Life (ITL) • Ligature and Suicide Risks • Findings in APR, LD, EC, HR, NPSG, PC • High Level Disinfection & Sterilization • Findings in IC, LD, HR, EC • Nationally, ligature/suicide risk is a focus of every survey • 70% of ITL decisions were related to HLD/Sterilization first half of 2017

23 High Risk (Red) Findings • Infection Prevention • Air pressure relationships (outside of OR) • Cleaning, disinfection, sterilization • Environment of Care • Air pressure relationships (in OR) • Availability of emergency equipment • Safe, suitable conditions • Management of medical equipment • Management of hazardous materials

24 High Risk (Red) Findings • Infection Prevention • Air pressure relationships (outside of OR) • Cleaning, disinfection, sterilization • Environment of Care • Air pressure relationships (in OR) • Availability of emergency equipment • Safe, suitable conditions • Management of medical equipment • Management of hazardous materials

25 High Risk (Red) Findings • Provision of Care • Following most recent orders (usually related to meds) • H&P not timely • Restraint assessments • Patient Rights • DNR documentation (ambiguous/incomplete) • Leadership • Failure to comply with COPs

26 Moderate Risk (Dark Orange) Findings • Human Resources • Staff competencies • Defined • Timely • Based on job responsibilities • Life Safety • Availability of fire extinguishing features • Documentation of testing requirements