Download TOP 10 MOST FREQUENTLY SCORED STANDARDS

Lessons Learned from a
Recent TJC Survey
OR Manager Webinar
John R. Rosing, MHA, FACHE
Vice President and Principal
Patton Healthcare Consulting
June 28, 2012
1
H&P and Update
• An H&P is done no more than 30 days prior to
admission or within 24 hours of admission.
• If the H&P is done anytime in the 30 days prior to
admission you update it within 24 hours of
admission, or prior to an invasive procedure on the
day of the procedure, whichever comes first.
– Must document: the patient was examined, and the H&P
was reviewed - CMS mandate
– In EMR – use a SmartText: e.g., .no changes or .changes
2
Informed Consent
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Physician responsibility
Paper form needs date and time for all signatures
Form may include potential use of blood
Process includes discussion of likelihood of desired
outcome
• Anesthesia consent is usually in anesthesia record
• Sedation consent is on presedation assessment
• RN confirms patient understanding, advocate
Document Operative & High Risk Procedures
(RC.02.01.03)
 H&P in record before procedure (EP 3)
 Post op/post procedure report is dictated
before transfer to next level (EP 5)

(Unless a post op/post procedure note is
entered immediately [see EP 7], if so, report
may be written or dictated per policy)
 The post operative/procedure report
includes: name of LIPs, procedure name
and description, findings, EBL, specimens,
post op diagnosis (EP 6 - Top Scorer)
4
Document Operative & High Risk Procedures
(RC.02.01.03)
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If report is delayed, an immediate post
procedure note is entered and includes LIP,
assistants, procedure(s) performed and
finding(s), ANY EBL, ANY specimens, Post op
diagnosis (EP 7 top scorer). Check your policy.
Medical record includes the LIP release order or
approved DC criteria (EP 9)
Medical record includes the use of DC
criteria/pt readiness (EP10)
5
CMS/TJC Anesthesia 1/11 Changes
• Postanesthesia assessment must occur (and be
documented) within 48 hours of recovery.
• May be based on data collected by a nurse (as
in the case of SDS where discharge is by RN
using criteria approved by the medical staff.)
• No requirement for an LIP postsedation
assessment.
• All entries to medical record are dated/timed
Medication Orders
• Preprocedure meds and testing by protocol
is now permitted with qualifications
• Cannot sign post-operative anesthesia or
surgical orders pre-operatively
• Got away with it on paper; could fudge or
omit the time and not be noticed
• CPOE captures the time automatically
• Must pend and go back in and sign
Medication Orders
• Intraprocedure verbal orders need to be
countersigned by LIP
• On paper – sign the OR flow sheet/ MAR
• eFlow Sheet or eMAR and goes to LIP inbox
for electronic signature
• Caution: Verbal orders require read-back to
ensure understanding. E.g., “2 and 50”
Medication/Fluid Integrity
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IV bag fluids and Irrigation bottle fluids
Cannot exceed 104 degrees F
Wise to record a daily temp reading
IV bag in outer pouch: 14 days,
– label with new, “do not use beyond” date
• Irrigation bottle fluids: 72 hours,
– label with new, “do not use beyond” date
Label All Medications
(NPSG.03.04.01)
Label all meds on and off the sterile field.
• All products, including sterile water/saline,
disinfectants in a basin must be labeled.
• The safety goal includes bedside procedures as
well as IR, cath lab, Out Patient
• Unlabeled refuse may be cited
• There is no acceptable alternative to labels
• Its an A element of performance
10
Time Out
(UP.01.03.01)
The final verification process must be
conducted in the location where the
procedure will be done, just before starting
the procedure
Cath, Endo, ASC, AMB, IR, bedside, etc.
Compare two identifiers on the arm band (if
visible) against the medical record, OR
select one of the following three options…
11
Time Out and 2 identifiers
Three Options
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•
Two team members confirm patient ID upon arrival in the procedure suite
using two identifiers.
One of the two team members remains with the patient during the entire preprocedure process.
During the final time out, this team member confirms patient ID.
•
OR
• Two team members ID patient upon arrival in procedure suite as previously
described.
• Two patient identifiers are written on white board in procedure room and
confirmed by the two team members.
• During final time out, the team confirms patient ID against information on
white board.
OR
• Place a patient ID on an exposed extremity – alternate wrist or either ankle.
• Reference the two identifiers on this ID band during the final time out.
12
Environment/Crisis
• No equipment blocking fire alarm pull
boxes, fire extinguishers, electric
breaker panels, medical gas shut-off
valve boxes.
• Airway fire prevention and response
drills, study best practices
• Laser Safety
• Malignant Hyperthermia
Reduce Risk of Infection
• Surveyors will observe staff as they process dirty
equipment
• Surveyors will check manufacturer instructions
for use (IFU) for three things: the
device/instrument, the sterilizer itself, and the
packaging (i.e., blue wrap or flash pan.)
• Check your policy, check staff understand and
follow both. Create a recipe book
• Will observe proper use of PPE
14
Laryngoscope Blades
• Clean and (at least) high level disinfect them per
manufacturer instructions for use
• Store in manner that prevents recontamination
• One blade per Zip-Lock bag if HLD, or
• Peal pouch if steam
• Consistent practice throughout the hospital
• Testing light source?
– Hand hygiene and/or use gloves
– Place back into Zip-lock bag or peal pouch
– Battery expiration dates!
High Level Disinfection - Scopes
• Follow manufacture recommendations
• E.g., glutaraldehyde or OPA MEC test strips
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Date when opened
QC run on a positive and negative solution
Requires 6 strips right from the start
Document the strip QC
MEC testing prior to each load, document QC
Separation of Clean/Dirty
• Scrutiny of scope cleaning room to
determine if flow/practice prevents crosscontamination
• Key: remove HLD scopes from sterilizer only
when no other dirty scopes are in the room
• Flawless QC and load record documentation
• Proper PPE
Scope Storage
• Rinse with sterile water or potable water and
70% alcohol, then forced-air dry
• Hang in a positive pressure vented cabinet
• Avoid tip dragging on base (avoid rack sag)
• Avoid cross-contamination (adjacent sink??)
• 30 day shelf life? (August 2011 OR Manager)
• Never store in foam mold in hard case
Consistent Practice
• How many TEE probes exist in the hospital?
• How many nasogastric scopes? Where???
• In each area – are decontamination, testing,
QC, HLD processing, load record-keeping
steps performed consistently???
• Exact concentrations, soak times, handling
• Inventoried by Biomed/Clinical Engineering
Sterile Processing Tour
• Attire: donned at the hospital, changed daily
• Red line – no one enters without proper
attire
• No artificial nails, nail polish, jewelry, watch
• Head AND facial hair covered at all times
• In Decontamination: liquid-resistant garb,
heavy-duty gloves, eye protections
• WASH HANDS WHEN FINISHED
Immediate Use Sterilization
• Important that staff can speak to the process without
using the term “flash”
• Follow manufacturer recommendations for sterilizer,
pack, instruments, CI, BI
• Covered containers even in sub-sterile
• “A sterilized item intended for immediate use is not stored for
future use, nor held from one case to another.”
• “Instrument inventories should be sufficient to meet anticipated
surgical volume and permit the time to complete all critical
elements of reprocessing.”
• Submit data to PI Committee /leadership to justify purchase
SPD Facility
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Easily cleaned walls, floors and ceiling
Daily housekeeping
No exposed pipes, etc. that collect dust
Maintain neg/pos pressure by keeping doors and
windows closed; test pressures monthly
• Sinks available for hand washing
• Eye wash within 10 second travel time; single action
lever, tepid water temperature to allow 15 minute
flush time
Temperature, Humidity, Storage
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Monitor and record daily
Temp 68-73 in clean area of department
Temp 60-65 in decontamination
Humidity 30-60% in work areas
Humidity not > than 70% in sterile storage
18 inch, 6 inch, 2 inch, solid lower shelf
Loaner Equipment
• Clear policy and procedure, penalties for
noncompliance; ripe for short-cuts
• Mandate 48 hour lead-time???
• Follow manufacture recommendations
• Staff should blow whistle if uncertain
Tissue Management TS.03.01.01
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EP 1 Assign responsibility for tissue
EP 2 Policy for acquisition, receipt, storage, issuance
EP 3 Confirm FDA registration, have current paperwork
EP 4 Spread process throughout hospital
EP 5 Use manufacturer instructions for transporting,
handling, storing and using tissue (verify that vendor
keeps records per lot # in event of RCA)
– EP 6 document receipt of tissue(TS.03.02.01 EPs 3 &6)
– EP 7 at receipt, package integrity and temp control is
verified (TS.03.02.01 EP 6)
25
TS.03.01.01 Continued
– EP 8 Daily record of temperature for ambient,
refrigerated, frozen, or liquid nitrogen (TS.03.02.01 EP
5)
– EP 9 Continuous monitoring for refrigerated, frozen, or
liquid nitrogen
– EP 10 Functional 24/7 alarm for refrigerated, frozen, or
liquid nitrogen
– EP 11 If you are a tissue supplier, you need FDA
registration.
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TS.03.02.01
– EP 1 Bi-directional tracing including discarded (FAQ ‘10)
– EP 2 Written materials/instructions to prepare or
process (FAQ TJC)
– EP 3 date/time/name of staff involved at receipt/
acceptance, preparation, and issuance.
“During tracer activities, it was found that the organization had not been
recording times at the following points: 1. Receipt at the warehouse which
was located off site; 2. Receipt by the surgical personnel upon arrival to OR; 3.
Time placed in refrigerator or freezer, and 4. Time removed from the
refrigerator or freezer.”
27
TS.03.02.01
• EP 4 document in MR tissue type and unique identifier
• EP 5 retain records on temperatures, outdated
procedures, manuals, and publications for 10 years
(TS.03.01.01 EP 2 & 8)
• EP 6 records on distribution, transplantation,
disposition, or expiration for 10 years
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Name of supplier
Original numeric/alphanumeric donor and lot
Name of recipient and final disposition
The expiration dates of all tissue (TS.03.01.01 EP 6&7)
• EP 7 complete tissue cards and return to supplier
28
TS.03.02.01 (con’t)
TS.03.03.01 (all are “A” EPs)
– EP 1 written procedure to investigate adverse
events, disease transmission or complication
– EP 2 conduct investigation
– EP 3 report to supplier ASAP
– EP 4 sequester compromised tissue or tissue
implicated by a supplier
– EP 5 inform patients
29
Questions???
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