PREPARING FOR JOINT COMMISSION ACCREDITATION: ENSURING SUCCESS WITH MEDICATION MANAGEMENT

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PREPARING FOR JOINT COMMISSION ACCREDITATION
ENSURING SUCCESS WITH MEDICATION MANAGEMENT

• Kurt A. Patton, MS, R.Ph. former Executive
  Director Hospital Accreditation, Joint
  Commission.

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WHATS NEW I SHOULD WORRY ABOUT THIS YEAR?
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NEW STUFF FOR MM

• CMS and their SC letter re the retirement of the
  30 minute rule.
• The One and Only Campaign.
• CMS surveyor worksheet drafts and their
  perspective on multidose vials in procedural
  settings
• New EP July 1 re formulary additions and
  populations served
• The bar is being raised on expectations

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FREQUENT FLIERS

• Perpetually difficult issues that have been
  around for a long time that hospitals continue to
  struggle with.
• Fix them by being more intrusive/thorough/rigorous
  with peers in other departments, your staff and
  yourself.
• Perform Mother in law inspections

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TJC PRIMER, 101

• A elements, absolute performance expectation or a
  policy mandate. You have it, or you dont
• Bulleted A you have to fulfill all bullets or
  its a failure
• C elements, 2 observations RFI, but 90 can
  clear the RFI through clarification.
• D documentation required

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D FOR DOCUMENTATION

• MM.01.01.01 The organization has a written
  policy that describes that the following
  information about the patient is accessible to
  licensed independent practitioners and staff who
  participate in the management of the patients
  medications- Age- Sex- Diagnoses-
  Allergies- Sensitivities- Current medications-
  Height and weight (when necessary)- Pregnancy
  and lactation information (when necessary)-
  Laboratory results (when necessary)- Any
  additional information required by the
  organization

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D FOR DOCUMENTATION

• MM.01.01.03 The hospital identifies, in writing,
  its high-alert and hazardous medications.
• Everyone has the high alert list
• The hazardous portion of this EP was added
  several years ago, and frequently missed.

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D FOR DOCUMENTATION

• MM.01.02.01 The hospital develops a list of
  look-alike/sound-alike medications it stores,
  dispenses, or administers.Note One source of
  look-alike/sound-alike medications is The
  Institute for Safe Medication Practices
• Gap here is often EP 3, annual review, or EP 2
  actions to prevent interchange and a breakdown in
  some location, often pharmacy.

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D FOR DOCUMENTATION

• MM.02.01.01, 3 EPS, seldom missed
• Members of the medical staff, licensed
  independent practitioners, pharmacists, and staff
  involved in ordering, dispensing, administering,
  and/or monitoring the effects of medications
  develop written criteria for determining which
  medications are available for dispensing or
  administering to patients.
• The hospital maintains a formulary, including
  medication strength and dosage.
• The hospital develops and approves written
  medication substitution protocols to be used in
  the event of a medication shortage or outage.

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D FOR DOCUMENTATION

• MM.03.01.01 The hospital has a written policy
  addressing the control of medication between
  receipt by an individual health care provider and
  administration of the medication, including safe
  storage, handling, security, disposition, and
  return to storage.
• Often missed, huh? Get it and give it, right?

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D FOR DOCUMENTATION

• MM.04.01.01 The hospital has a written policy
  that identifies the specific types of medication
  orders that it deems acceptable for use.
• PRN qualifiers, range orders, titrations
• Scoring usually takes place at EP 13, the
  hospital implements its policies for medication
  orders.

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MEDICATION ORDERS POLICY

• PRN must have an indication in the body of the
  order, or by policy that is universally
  understood and always applied.
• Range orders must be verbalized and implemented
  uniformly by all nursing staff in the
  organization. Advice embed instructions in order
  and/or MAR.
• Titration must have a start point, must have a
  therapeutic end point that is measureable

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D FOR DOCUMENTATION

• MM.04.01.01 The hospital has a written policy
  that defines the following The required elements
  of a complete medication order.
• Name of drug, dose, frequency, route, rate, etc.
• Most hospitals usually have this, breakdown is
  performance at EP 13 again.

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D FOR DOCUMENTATION

• MM.04.01.01 The hospital has a written policy
  that defines the following When indication for
  use is required on a medication order.
• You are writing the policy, make it only for PRN
  orders and antibiotics if you want.

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D FOR DOCUMENTATION

• MM.04.01.01 The hospital has a written policy
  that defines the following The precautions for
  ordering medications with look-alike or
  sound-alike names.
• What are you going to do differently to prevent
  interchange of these LASA drugs?
• WARNING You must do what you say you are going
  to do, dont be too uniform and prescriptive.

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D FOR DOCUMENTATION

• MM.04.01.01The hospital has a written policy
  that defines the following Actions to take when
  medication orders are incomplete, illegible, or
  unclear.
• Usually everyone has this, but the failure to
  take action is very common. Be especially careful
  with PACU and ICU.

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D FOR DOCUMENTATION

• MM.04.01.01 The hospital defines, in writing,
  the circumstances for which weight-based dosing
  is required for pediatric populations.

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D FOR DOCUMENTATION

• MM.05.01.17 The hospital has a written policy
  describing how it will retrieve and handle
  medications within the hospital that are recalled
  or discontinued for safety reasons by the
  manufacturer or the U.S. Food and Drug
  Administration (FDA).
• Everybody does it, but not everybody has a
  written policy.

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D FOR DOCUMENTATION

• MM.06.01.01 The hospital defines, in writing,
  licensed independent practitioners and the
  clinical staff disciplines that are authorized to
  administer medication, with or without
  supervision, in accordance with law and
  regulation.
• Often missing, often to limited in detail.
• CMS has made this more complex now.

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D FOR DOCUMENTATION

• MM.06.01.03 If self-administration of
  medications is allowed, written processes that
  address training, supervision, and documentation
  guide the safe and accurate self-administration
  of medications or the administration of
  medications by a family member.
• Make sure your policy does not conflict with what
  you do in an infusion center, sleep lab or other
  outpatient setting.

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D FOR DOCUMENTATION

• MM.06.01.05 The hospital has a written process
  addressing the use of investigational medications
  that includes review, approval, supervision, and
  monitoring.
• Not usually an issue

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D FOR DOCUMENTATION

• MM.07.01.03 2 EPS The hospital has a written
  process to respond to actual or potential adverse
  drug events, significant adverse drug reactions,
  and medication errors.
• The hospital has a written process addressing
  prescriber notification in the event of an
  adverse drug event, significant adverse drug
  reaction, or medication error.
• Where would a surveyor see this documented?

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MOST FREQUENT MISTAKES

• We can permit range orders because the Joint
  Commission doesnt say they are prohibited.
• Our nurses know how to sort through therapeutic
  duplication.
• CPOE fixes everything
• The nurses will just have to learn to date the
  multidose vials correctly

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MOST FREQUENT MISTAKES

• I think that area, those meds are secure enough,
  dont worry about it.
• I can only control what takes place in the
  pharmacy.
• Im not sure what that EP means, but I dont
  think its applicable to our hospital.
• Only pharmacists, nurses and physicians are
  authorized to have access to medications.

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THE MOST FREQUENTLY SCORED MM STANDARD 31

• MM.03.01.01
• There are many facets, 11 EPs
• EPs 2, 3, 6 and 8 cause most of the problems
• (Refrigerators, warmers), security lapses,
  expired meds
• Have you looked at radiology, OR, ED and pharmacy
  to look at warmed products.
• TJC published a booster pack just for this one
  standard several years ago.
• This is where they changed to BUD

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MEDICATION STORAGE AND TEMPERATURE CONTROL

• You use paper logs, or you use electronic sensor
  monitoring for refrigerators.
• Performance lapses with paper logs, missing days
• Failure to document actions taken when the
  temperature is out of range. Paper and electronic
• Failure to include pharmacy in actions taken
• Failure to implement a system for 5 day
  operations
• Failure to know how to use the system for 5 day
  operations.
• Turning off alarms, knowledge deficits on zeroing
  out recorded highs
• Did you know you had performance lapses, why not,
  or why wasnt it corrected?

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MEDICATION STORAGE AND TEMPERATURE CONTROL

• Failure to consider warmers, not knowing what is
  being warmed and who is warming medications.
• Failure to use manufacturers advice for warmed
  medication max temp and duration
• Failure to implement the expiration dating system
  for warmed products.
• Failure to recognize contrast is a medication
• Failure to recognize special requirements for
  vaccines

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TEMPERATURE CONTROL

• Remote sensor monitoring can help
• Do you have the capability to print a
  retrospective log
• Do you have the capability to print actions taken
• Implement a mandatory system for documenting
  actions taken
• Trace these capabilities just like a surveyor

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PROBLEM 2, SAME STANDARD, MEDICATION SECURITY

• Policy and actual process must be consistent.
• We only allow nurses, physicians, pharmacists
  and respiratory therapists to have access to
  medications.
• What about radiology technicians?
• What about materials management staff?
• What about central supply staff?
• What about clean utility rooms used to store IV
  bags?

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MEDICATION SECURITY DRILL DOWN

• Go to radiology how many different cabinets, how
  many different rooms have contrast? Is the warmer
  locked? Are these rooms/cabinets locked or open
  to all staff and visitors who are present?
• Go to clinical units, ED, OR, central stores,
  materials management Where are IVs stored, who
  has access and who delivers supplies?
• How are crash carts replenished?
• Are the crash carts stored in observed locations
  or on dead end corridors near an exit?
• Are secure, limited access areas like OR, really
  secure? What about housekeeping and maintenance
  staff? Weekends?

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SECURITY OF MEDICATIONS POLICY

• Joint Commission and CMS permit concept of secure
  by observation, but it has to be real.
• If your surveyor can wander without challenge its
  not secure.
• Joint Commission and CMS dont mandate which
  staff may have access. Some state regulations
  may, but not TJC/CMS.
• Write policy loosely reflecting actual processes,
  not rigidly reflecting a desired practice that
  does not exist.
• We need to create a new mindset of practicality
• Look at pneumatic tubes and crash carts. Document
  risk assessment when doubtful

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EXPIRATION DATE CONTROL, STILL MM.03.01.01

• Pharmacy staff inspect the official storage
  locations Joint Commission surveyors look in
  unofficial locations.
• open every drawer and every cupboard, even when
  there should not be any medications stored there.
• Go with the department head to every room, just
  like a surveyor
• GI lab, endo, trauma, anesthesia carts,
  ambulatory Tx rooms
• Multi-dose vial expiration system
• Use BUD date 28 days in the future, not date
  opened
• Check your system pre-survey to determine if it
  works. If not, change it. Its not going to get
  better during survey.
• Consider expiration dating from day of dispensing
  
• Anesthesia carts Do they have partial vials and
  syringes pre-drawn that should have been labeled
  with an EXP?

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SECOND MOST FREQUENTLY SCORED MM STANDARD
MM.04.01.01

• 14 EPs, Chief problems clarity of range orders
  and prn indications on orders. All performance
  lapses scored at EP 13. C, 90
• Any range order, 5-10 mg must have absolute
  clarity, and reproducibility among staff.
• Only way to succeed is to make the selection of
  dose part of the order.
• If you think policy and training is an acceptable
  alternative, conduct tracer interviews.

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HAVE YOU GIVEN PEOPLE THE TOOLS THEY NEED TO BE
COMPLIANT?

• NPSG.03.04.01 labeling medications and solutions
  during procedures.
• Go to ED, ICU, GI lab, Ambulatory procedure
  rooms- do they have sterile labels for minor
  procedures?
• Look for the silver color Mayo stand, ask how it
  is used and prepared for a procedure.
• Are there any mental reminders about labeling,
  consent, time out, dont forget to label
  everything
• Yes, it still applies to 1 drug and sterile water

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EMERGENCY MEDICATIONS MM.03.01.03

• Are they accessible without risk of tampering or
  theft? If in doubt, risk assess and document
• EP 3, Whenever possible, emergency medications
  are available in unit dose, age specific, and
  ready to administer forms.
• Broselow carts, tapes or other systems Do they
  use standardized concentrations or infinitely
  variable concentrations? Have you searched for
  old tapes and old instructions? 2002 too old,
  2007A glucagon error
• If your instructions and your training call for a
  pediatric concentration, you MUST have it or
  change the instructions.

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STERILE PRODUCT PREPARATION, MM.05.01.07

• Does the pharmacy prepare all sterile infusions
  except in emergent situations or short stability?
  Elastomeric pumps too?
• Do you do this for infusion center and all
  outpatient locations?
• How are you preparing radiopharmaceuticals and
  does pharmacy or a physician supervise off hours
  compounding?
• Do you monitor performance of clinical
  contractors of specialty prescriptions?

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PREPARING FOR SURVEY

• Day one patient tracers may uncover MM issues.
  Find out what was found.
• Prepare for MM system tracer. Here is what we
  were doing to prevent what you saw. We were
  aware, we were on top of it.
• Joint Commission views MM issues anywhere in the
  organization as under your purview.
• Dont describe your area of responsibility as
  less than whole organization.

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MM SYSTEM TRACER

• Reserve a room, but be ready to walk around also.
  
• Have nursing and medical staff representatives
  present.
• Consider rehearsal, filter out those staff that
  will be a liability
• Come prepared to talk positively and
  affirmatively about the good work you do.
• If the surveyor lets you, keep talking about the
  great work you do.

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MEDICATION RECONCILIATION

• 1 standard, 5 C EPs not being scored as often as
  the old one
• Problems exist in EP 3 Compare the medication
  information the patient brought to the hospital
  with the medications ordered for the patient by
  the hospital in order to identify and resolve
  discrepancies.
• Is continue, discontinue, change clear that
  decisions were made and not errors?
• Who in your hospital has a documented competency
  to conduct this medrec analysis?

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ONE AND ONLY CAMPAIGN

• One needle, one syringe, one patient
• If staff use something as multidose, make sure
  the FDA told you it was multidose. Contrast, IV
  bags, irrigating fluids, lidocaine and sterile
  water vials.
• Be cautious with the use of insulin pens
• Consider using multidose vials in procedural
  settings as single dose only. CMS and AORN

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CMS AND TJC ARE MORE CLOSELY ALIGNED

• Keep up with the SOM/Interpretive Guidelines, it
  can change how standards are evaluated without
  seeing something new from TJC.

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PREPARATION OF DRUGS TAG A-0405

• The 30 minute rule is gone, but the replacement
  is complex.
• Medical staff must approve the PP for medication
  administration.
• PP must identify the disciplines authorized to
  administer medications and the categories of
  medication they may administer. E.g oral, IV, IM,
  inhaled

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PREPARATION OF DRUGS TAG A-0405

• Training for those administering medications must
  include equipment, devices, special procedures
  and or techniques required.
• PP must address the required components of
  training and what can be provided via orientation
  vs. additional or ongoing training and what
  requires a documented competency.

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PREPARATION OF DRUGS TAG A-0405

• Timing of med administration
• 1. ID meds not eligible for scheduled dosing
  times
• Stats, first dose, one time, time sequenced,
  PRN
• 2. ID meds eligible for scheduled dosing times
• BID, TID, ETC

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PREPARATION OF DRUGS TAG A-0405

• 3. Further divide your meds eligible for
  scheduled dosing time into
• Time critical, e.g. antibiotics, anticoag,
  insulin, anticonvulsants, analgesics
  immunosupressives, RX less than q4h
• These may be given /- 1 hr
• Non Time Critical, e.g. daily, weekly, monthly.
  These may be given /- 2 hr

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PREPARATION OF DRUGS TAG A-0405

• PP must address what to do with missed doses and
  what is a med error.
• Evaluate your timing policies for QAPI
• May adopt standing orders but include well
  defined criteria for use and get practitioner
  sign off after use.
• Monitor correct use of standing orders also

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PREPARATION OF DRUGS TAG A-0405, SURVEY PROCEDURES

• Verify the hospital has PP for
• Meds not eligible for scheduled times
• Meds eligible and time critical
• Meds eligible and not time critical
• Verify windows do not exceed 1 hr for time
  critical, 2 hr for not time critical, or 4 hr for
  not time critical (dailys or longer).

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PREPARATION OF DRUGS TAG A-0405, SURVEY PROCEDURES

• Ask to see one or more standing orders and
  evidence of training, periodic evaluation of the
  use of the standing order including adherence to
  policy.
• Interview nursing staff. Are they familiar with
  PP for standing orders and are they following?

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QUESTIONS?

• Kurt_at_Pattonhc.com