Title: PREPARING FOR JOINT COMMISSION ACCREDITATION: ENSURING SUCCESS WITH MEDICATION MANAGEMENT
1PREPARING FOR JOINT COMMISSION ACCREDITATION
ENSURING SUCCESS WITH MEDICATION MANAGEMENT
- Kurt A. Patton, MS, R.Ph. former Executive
Director Hospital Accreditation, Joint
Commission.
2WHATS NEW I SHOULD WORRY ABOUT THIS YEAR?
3NEW 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
4FREQUENT 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
5TJC 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
6D 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
7D 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.
8D 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.
9D 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.
10D 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?
11D 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.
12MEDICATION 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
13D 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.
14D 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.
15D 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.
16D 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.
17D FOR DOCUMENTATION
- MM.04.01.01 The hospital defines, in writing,
the circumstances for which weight-based dosing
is required for pediatric populations.
18D 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.
19D 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.
20D 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.
21D 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
22D 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?
23MOST 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
24MOST 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.
25THE 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
26MEDICATION 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?
27MEDICATION 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
28TEMPERATURE 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
29PROBLEM 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?
30MEDICATION 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?
31SECURITY 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
32EXPIRATION 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?
33SECOND 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.
34HAVE 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
35EMERGENCY 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.
36STERILE 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?
37PREPARING 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.
38MM 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.
39MEDICATION 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?
40ONE 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
41CMS 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.
42PREPARATION 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
43PREPARATION 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.
44PREPARATION 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
45PREPARATION 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
46PREPARATION 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
47PREPARATION 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).
48PREPARATION 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?
49 QUESTIONS?