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Services
Tools & Solutions
Conference
Topics
Announced!
Join us in
Philadelphia, May
16-17 for our 2012
Annual Conference
"Developing a
Culture of Change:
The Picture of
Compliance".
The topics for this
year's conference
will cover:
CMS CoPs
Environment of
Care & Life Safety
Tracer Activity
Patient-Provider
Communication
Testimonials
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January 30, 2012
Struggling With How to Manage Your IC
Calendar?
By: Jill Ryan, HACP
Organizations often struggle with the planning, monitoring and
evaluation requirements related to infection prevention and
control requirements. These activities are vital to the integrity
of an organization’s infection control program. A breakdown in
the process cannot only lead to RFIs during survey, but much
more importantly, to compromises in the program resulting in
patient safety issues. Organizations that follow a planned,
consistent approach to these activities demonstrate a
commitment to reducing risk from healthcare acquired
infections and to the well-being of hospital staff, LIPs and
visitors. The following outlines a suggested annual calendar of
activities that can be amended to meet the needs and timeline
of any organization.
Calendar
Month
January
Fiscal Year
Month
st
1 month
February
2 month
March
End of 1
Quarter
th
4 Month
Care Planning
Meaningful Use
Register now to
receive the early
bird discount at
$549/person!
About C&A
April
nd
st
Activity
Annual review and update of Infection Control
Plan
Effectiveness of prior year goals and
implementation of activities
Development of current year goals
based on identified risks and factors
outlined in IC.01.04.01 (and last year’s
results)
Review and updating of infection prevention
and control activities
Quarterly analysis of surveillance activities,
hand hygiene practice, outbreaks, etc.
Review and updating of infection and
prevention policies and procedures
New
Publication!
C&A has developed
the CMS ESRD
Compliance
Forecaster to aid
your organization in
tracking compliance
with CMS' CfC
requirements for
End Stage Renal
Disease facilities!
Finally, your
organization can
have a simple
method for tracking
compliance with all
of the ESRD CfCs in
one convenient
electronic
document!
Get yours today!
th
May
5 Month
June
July
End of 2
Quarter
th
7 Month
August
8 Month
September
End of 3
Quarter
th
10
Month
th
11
Month
Fiscal Year
End
October
November
December
nd
th
rd
Updating/Affirmation of identification of
person with clinical authority for infection
prevention and control program (assuring
“Letter of Authority” is present in the
employee or Medical Staff member’s file)
Quarterly analysis of surveillance activities,
hand hygiene practice, outbreaks, etc.
Review of allocation of resources to support
infection prevention and control initiatives
Updating and implementation of flu vaccine
program
Quarterly analysis of surveillance activities,
hand hygiene practice, outbreaks, etc.
Annual IC education (in conjunction with
International Infection Prevention Week)
Report flu vaccination rate; analysis of reasons
for LIP and staff declination of vaccine
Risk assessment based on patient population,
care, treatment and services, surveillance
activities and past year’s data
Were You Aware?
1. We’re starting off the New Year with an old topic! With
continued focus on infection prevention and control, a
few reminders:
a) Be sure that appropriate staff can speak to the
process for monitoring temperature, humidity,
air exchanges and any other key environmental
factors and that documentation of such
monitoring is available. Items to consider:
i.
Temperature of kitchen dishwashers
ii.
Temperature & humidity in surgical
settings
iii.
Air exchanges in central processing areas
b) Laryngoscope blades are to be sterilized or
processed using high-level disinfection. They
then must be packaged in some way to maintain
integrity.
c) Check out the article in this edition of C&A
e-News for an annual IC planning calendar!
2. Some revisions to the TJC accreditation requirements
have recently been published. See the pre-publication
standards for:
a) LD.03.01.01 which broadens the culture of safety
requirements to include “behaviors that
undermine a culture of safety.”
b) MM.02.01.01 requiring organizations to consider
“populations served” when selecting and
procuring medications
c) Under the Ambulatory Health Care Accreditation
program, see new requirements related to
patient notices, for ambulatory surgical centers
using TJC for deemed status.
3. Hospitals seeking TJC Advanced Certification for
Palliative Care may be eligible for a grant from the
LIVESTRONG® foundation. See this link to TJC’s website
for more information.
4. C&A has updated its resource to provide a summary of
topics requiring education for hospital staff members
and LIPs. We hope you will enjoy this useful resource!
Were You Aware 2012 Recap
Maintaining a Patient-Safe Environment
According to the Centers for Disease Control and Prevention,
one out of twenty hospitalized patients will have a hospitalacquired infection. The estimated financial impact on US
hospitals ranges from $28 billion to $45 billion (with a "b")
dollars annually! The link between appropriate maintenance of
the physical environment and the provision of clinical care is
key to infection prevention. Join our March 19th webinar to
learn how to integrate environmental and infection prevention
rounds and tracer activity and engage non-clinical and clinical
staff in identifying and managing associated patient safety
risks.
Contact us at (704) 573-4535 or [email protected] for more information!
Courtemanche & Associates
Charlotte, NC | Parsippany, NJ
Phone 704-573-4535 | Fax 704-573-4538
[email protected] | www.courtemanche-assocs.com
Services
Tools & Solutions
What's New?
What's Scoring?
How Can We Fix
It!?
Testimonials
C&A E-Newsletter
About C&A
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February 29, 2012
Believe it or not, the
end of the first quarter
of 2012 is drawing
near! What are we
seeing in organizations
that have been
surveyed in the last
few months?
Will 2012 trends differ
from those we saw in
2011? What are
organizations doing to
comply with the new
patient-provider
communication and
visitation
requirements? What
documents are
surveyors really
reviewing?
Join us for our April
16th webinar,
"What's New? What's
Scoring? How Can We
Fix it?" to get the
answers to these, and
many more, questions!
For more information
and to register, visit
www.courtemancheassocs.com,
Have You Registered Yet?
You won't want to miss out on our 2012 Annual Conference
hosted in Philadelphia, PA on May 16th - 17th! The topics for
this year's conference cover CMS CoPs, Environment of Care &
Life Safety, Tracer Activity, Patient Provider Communication,
Care Planning and Meaningful Use!
Ann Scott Blouin, Executive Vice President for the Division of
Accreditation and Certification Operations at The Joint
Commission, will be this year's keynote speaker! We will also
have an interactive session directly with Joint Commission to
navigate through the new TJC E-Application!
Sign up now!
Early Bird Rate is still available!
contact us at
[email protected] or call us
at (704) 573-4535.
Developing "Plans" That Meet Regulatory
Requirements - A Quick Primer
By: Nancy McLean, RN, BSN, MSHA, NHA, HACP
We Want to Hear
From You!
C&A prides itself on
delivering accurate and
relevant information to
the healthcare
industry. As we are
constantly trying to
improve our
newsletter, we ask
that you take 5
minutes to complete
the online survey
below.
Your responses will
help us to address any
issues that you may
have as well as to
better design our enewsletter to meet
your needs.
Click Here to take
the 5 minute
survey!
To meet regulatory and accreditation requirements,
organizations must develop and implement several plans and
perform annual, or as needed, evaluations of their
effectiveness.
Plans requiring an annual review include the five Environment
of Care plans (that can be incorporated into one overall
Environmental or Safety Plan):
Safety and Security
Hazardous Materials and Wastes
Fire Safety
Medical Equipment
Utilities Management
In addition to these, The Joint Commission also requires plans
in the following areas:
Emergency Operations with a twice a year drill and
evaluation
Infection Prevention and Control that is evaluated
annually
Capital expenditure plan updated annually
The appropriate chapters in The Joint Commission’s
Comprehensive Accreditation Manual for Hospitals (2012) list
the specific requirements for each plan.
Commonalities among the processes for developing and
evaluating plans include:
Assigned responsibility for oversight
Development of related policies and procedures using
evidence-based practices in their development
Completion of a risk assessment
Development of measurable goals based on the results
of the risk assessment
Prioritization of the measurable goals selected
Measuring and assessing the effectiveness of the plan in
meeting the prioritized goals
Leadership input and approval on the recommended
priorities and final plan
While each hospital may take a different approach to this
planning and evaluation function, based on organizational
structure, here are some helpful hints to assure a robust
process.
Completion of the annual risk assessment includes a review of
data and progress made toward the prior year’s goals. To
assure a process that demonstrates compliance with
requirements and is meaningful to operations, the review of
data should be accomplished through easy-to-view graphs or
by other statistical methods easy to understand. It is
recommended that these graphs be incorporated into the final
evaluation of the year’s plan and provide a picture of whether
of not goals were achieved.
The evaluation of the prior year’s plan can be a separate
document included in the appropriate committee meeting
minutes or it can be incorporated into the coming year’s plan.
It is important to review the data from the prior year to
determine whether goals were achieved at the levels specified.
Goals that were achieved and have a track record for
sustainability can be dropped. Goals that were not achieved
need to be examined closely to determine if they should be
carried into the next year’s plan. To assure compliance to the
requirement it would be prudent to report the progress toward
goals to the Performance Improvement Committee (or the
organization’s equivalent committee) on a scheduled basis,
monthly or quarterly.
Remember that selected goals should be approved by the
appropriate committee and senior leaders of the organization.
The goals should also be shared with the departmental staff
affected by the goals and those that can influence the
achievement of the goals.
In addition to the plans outlined above, “as needed”
evaluations are required for plans that address:
Utilization Review (if not in a binding review agreement
with a Quality Improvement Organization (QIO))
Managing internal and external information and
interruptions in the information (IT) process
Provision of nursing care and nurse staffing
Quality control plans for Waived Tests evaluated as
needed
Creating an annual organizational calendar can help assure that
these plans are updated and evaluated as necessary.
Were You Aware?
1. CMS has provided clarification and revised interpretive
guidance on the issue of orders for rehabilitation and
other outpatient services. In its Survey & Certification
Memo dated February 17, 2012, CMS clarified that it is
not its intent to limit those permitted to order or make
referrals for such services only to practitioners
credentialed and privileged by the organization. As is
fully outlined in the S&C Memo, orders for outpatient
services can be accepted from non-credentialed LIPs as
long as the hospital has a process for assuring the
orderer is licensed in the state and practicing within
their scope. This process needs to be defined in policy
and approved by the governing body.
2. The Joint Commission has launched its new EApplication. In addition to the improvements made to
the E-App, TJC is also requiring organizations to update
their applications at 9, 18 and 27 months post-survey.
Organizations are reminded that they must also still
meet the requirements under APR.01.03.01 and report
any “changes in ownership, control, location, capacity or
services offered” within 30 days of the change.
3. Just a reminder that the tracking and logging
requirements for tissue and transplant products begins
at the point of entry into the hospital. So, if those
products are received by the Receiving Department as
they arrive on the loading dock before being transported
to the responsible department, the tracking process
begins with Receiving. That would include verification of
package integrity and required temperature monitoring
as applicable.
4. Hospital organizations acquiring physician practices are
encouraged to consider the regulatory implications in
the initial stages of that process. If the physician
practice will meet TJC’s organizational and functional
criteria for survey applicability under the hospital, then
the practice must meet accreditation requirements.
This is often a challenge for previously independent
physician offices. Issues including the physical
environment of the practice, infection control practices,
medical record content and responsibilities of
professional and support staff should be reviewed.
(2012). Be compliance-ready: what to consider when
acquiring a physician practice. Journal of Healthcare
Management, 57(1), 12-16.
5. Patient identification is starting to re-emerge as a hot
topic for organizations. Issues include staff being
unable to articulate the organization’s designated
identifiers, not using the identification process, not
labeling specimens in the presence of the patient. This
might be an area where a “mini-tracer” can identify
circumstances related to non-compliance so that
process improvements can be made.
2012 Were You Aware Recap
Courtemanche & Associates
Charlotte, NC | Parsippany, NJ
Phone 704-573-4535 | Fax 704-573-4538
[email protected] | www.courtemanche-assocs.com
Services
Tools & Solutions
Early Bird Ends
Next Week!
You won’t want to
miss out on our
2012 Annual
Conference hosted
in Philadelphia on
May 16th & 17th!
Ann Scott Blouin,
Executive Vice
President for the
Division of
Accreditation and
Certification
Operations at The
Joint Commission
will be this year's
keynote speaker!
We will also have an
exciting, interactive
session directly with
Joint Commission to
navigate through
the new TJC EApplication!
Sign Up Now! The
Early Bird Rate ends
April 5th!
Click Here to view
the 2012
Conference
Brochure!
Testimonials
C&A E-Newsletter
About C&A
Contact
March 30, 2012
It Could Happen To You...
C&A is excited to present "It Could Happen to You,"
hypothetical case studies for you to solve. These are scenarios
that could happen during your next survey, during the postsurvey process, or any average day. We have dramatized a
situation to seek your reaction and input. So, take a moment,
review the case, and provide us with your opinion on the
scenario, because it could happen to you!
We want to hear from you ... send us your thoughts and
comments at [email protected]. We will
share your insights in our next issue!
"The Case of the Care Before the Patient"
Was Mary Right or Over-Reacting?
Mary is at the command center and it's
the first day of her Joint Commission
(TJC) survey. The surveyor is tracing
patients in the Perioperative area when
Mary receives a call from a surveyor
escort (SE) alerting her to a potential
problem. The SE told Mary that while
the surveyor was in pre-op, medical
records were reviewed for patients
coming in for procedures later that day
who had not yet arrived.
The surveyor reviewed three medical records for patients, and
saw documentation in one record that the immediate preanesthesia assessment was completed before the patient
arrived in the area. The surveyor asked if this happens often
and the OR staff said, "We never saw it before." Staff tried to
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Publications!
C&A has developed
the CMS ESRD
Compliance
Forecaster & the
CMS LTC
Compliance
Forecaster to assist
your organization
with its ongoing
compliance with
CMS CoPs and
CfCs!
These electronic
workbooks are
organized with
individual
worksheets for each
ESRD CfC and LTC
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find the anethesiologist completing the documentation, but he
was already in surgery with a patient.
When the SE alerted Mary about this, thoughts of falsification
loomed in her head. She had heard that documenting care
before it occurs could be viewed as pre-charting the course of
care or falsification, and might invoke an Accreditation
Participation Rule (APR). Mary also knew that the leadership
had taken a firm stance on this and that policies and
procedures were in place for medical record documentation and
to hold people accountable when performance was
unacceptable.
Mary quickly reviews the APR and learns that this could invoke
an automatic decision rule for Preliminary Denial of
Accreditation. Mary, realizing that this could end the survey,
immediately calls the anesthesiologist of record to find out why
the record was completed before the patient arrived. The
anesthesiologist angrily explained that he had four surgeries
back to back; he had reviewed the patient history and knew
there would be no problem, so he filled in the paperwork. Big
deal! He also reminded Mary that he had an excellent record
with this hospital, and that she had no right to question him on
this one incident. The anesthesiologist then threatened to call
leadership to complain about Mary and the trouble she caused
him.
Now, Mary is in a quandary about how to address this issue
with TJC and mitigate scoring this APR. Mary realizes that she
needs to inform leadership about the potential of an adverse
outcome and enlist their support in explaining what happened
to TJC, but she is not sure how to go about it.
Could the situation be avoided? How?
Should Mary have called the anesthesiologist?
What would you do?
We want to hear from you… send us your thoughts and
comments at [email protected]. We will
share your insights in our next issue!
Editor’s Note: “It Could Happen to You” scenarios are inspired
by true stories, but are changed to sharpen the dilemmas
involved in order to present a specific issue and evoke dialogue
among our readers. The names of the characters, organizations
and locations are fictional and are not to be confused with real
people or places.
Were You Aware?
1. The Centers for Medicare & Medicaid Services has
released its Financial Report for FY2011. The report
is quite detailed and contains over 35 pages related to
CMS’ oversight of accreditation organizations. While
C&A will incorporate key information into its future
newsletters and educational offerings, here are several
interesting highlights:
a. TJC offers the most accreditation programs (6);
AOA/HFAP offers 3; all other accrediting
organizations offer 2 or less. Three accrediting
organizations provided deemed status to
hospitals in FY2010: TJC (3,841 facilities),
AOA/HFAP (186 facilities); DNV (117 facilities).
b. 85% of hospitals are “deemed” through
accreditation by an accrediting organization with
15% “non-deemed” and surveyed by the State
Agency for compliance with CMS COPs.
c. CMS validates the work of accrediting
organizations through two types of validation
surveys – sample validation and focused or forcause surveys. Three percent (3%) of hospitals
experienced a validation survey in FY2010.
d. The hospital disparity rate (missed ConditionLevel findings) between accrediting organization
findings and State Agency (surveying for CMS)
findings continues. Here’s a snapshot:
i.
All Accrediting Organizations (FY2010):
1. Overall disparity = 38%
2. Physical Environment disparity =
31%
3. Health disparity = 17%
ii.
Overall Disparity Rate by Accrediting
Organization (FY2008-2010):
1. AOA/HFAP = 80%
2. DNV = 43%
3. TJC = 34%
e. After Physical Environment, the disparity has
been found most frequently in the following
COPs: Governing Body, Infection Control, Quality
Assurance, Nursing Services, Food/Dietetic and
Surgical Services.
2. Practitioners granted initial or new clinical privileges
must undergo focused professional practice evaluation
(FPPE) at that hospital to assure competency.
Additionally, any triggered evaluation (issue-based)
FPPE must also be performed at the organization. This
assures that FPPE is conducted within the physical
environment, using the equipment and resources
available, where care is to be provided. Some
organizations have sought to use evaluation data from
other hospitals to meet this requirement. That would
not meet the intent of this standard.
3. Hospitals, especially those within larger healthcare
systems, are encouraged to review any affiliated
ambulatory settings, physician practices, etc. that either
fall under the hospital’s accreditation application or
might be perceived as belonging to the hospital. These
affiliated entities are not always involved in ongoing
accreditation readiness and survey preparation activities
and often do not meet requirements. Begin by assuring
that related entities do, indeed, meet TJC’s criteria for
inclusion in survey (see the Organizational & Functional
Integration Criteria in the Accreditation Process chapter
of the TJC manual). Once inclusion in the survey
process has been confirmed, consider the following:
a. Are clinical and administrative activities
integrated with the hospital – i.e., are policies
and procedures consistently implemented?
b. Are applicable credentialing and privileging
processes implemented?
c. Have staff been oriented and trained for their
specific roles and care setting? Are competencies
assessed?
d. Are any contracted services defined,
performance expectations identified and
evaluations conducted?
e. Do key planning activities, i.e., emergency
management, environment of care, infection
prevention and control, involve the ambulatory
and/or offsite locations?
Were You Aware 2012 Recap
Courtemanche & Associates
Charlotte, NC | Denville, NJ
P: 704-573-4535 | F: 704-573-4538
[email protected] | www.courtemanche-assocs.com
Services
Tools & Solutions
In the News!
Congratulations to
Senior Consultant,
Nancy McLean,
RN, BSN, MSHA,
NHA, who was
selected to speak at
the North Texas
Association for
Healthcare
Quality's 2012
Annual
Conference!
Ms. McLean spoke
on "Quality as
Defined by
Regulations &
Standards" which
provided insights
necessary to
become more
knowledgeable in
the role quality
plays in healthcare.
In the News!
Congratulations to
Senior Consultant,
Sharon Dills, MSN,
RN, HACP, who was
selected to speak at
the Maryland
Health
Information
Management
Association's
2012 Annual
Meeting!
Testimonials
About C&A
C&A E-Newsletter
Contact
May 7, 2012
Conclusion: It Could Happen To You...
"The Case of the Care Before the Patient"
Was Mary Right or Over-Reacting?
about it.
As you may remember from last
month's edition of C&A e-News, we
left Mary in a quandary about how to
address this issue with TJC and mitigate
scoring this APR. Mary realized that she
needed to inform leadership about the
potential of an adverse outcome during
their TJC survey and enlist their support
in explaining what happened to their
surveyors, but she is not sure how to go
We asked for your thoughts and insights on how you would
address this situation and those responses came pouring in!
Thanks to everyone who responded! Great job!
Here are just a few thoughts from our readers:
“In this situation I’d have the anesthesiologist review the preanesthesia assessment at the arrival for pre-op and document
another note. I think it was appropriate to speak with the
anesthesiologist” – Sue
“In our organization, I would have been able to discuss it with
our VP of Risk Management and Accreditation and he would
inform our Chief Medical Officer and/or the CEO. I would have
asked one of them to speak with the Anesthesiologist”
– Jennifer
Ms. Dills spoke on
"TJC & CMS
Requirements and
the Electronic
Health Record"
which provided
insights into how
the electronic health
record can assist
with regulatory
compliance.
See You in
Philly!
We are excited to
host our 2012
Annual Conference
"Developing a
Culture of Change:
A Picture of
Compliance" in
Philadelphia, May
16-17th!
Keynote Speaker,
Ann Scott Blouin,
Executive Vice
President for the
Division of
Accreditation and
Certification
Operations at The
Joint Commission
will be speaking on
"Developing a
Culture of
Continuous
Improvement
Toward High
Reliability".
We look forward to
seeing everyone
there!
“This situation can be avoided by having “hard stops” in place for
patient safety.” – Julie
“In my opinion, the situation should be faced head-on at all
levels.” – Judy
“I think speaking with anesthesia was not the best solution due
to the high stress of dealing with the surgical cases at the time
and not really having a plan of action due to not discussing the
issue with leadership first. “ - Susan
“The situation could possibly have been avoided if the present
leadership had refreshed the medical staff and reviewed the
policies all ready in place prior to the survey.” – Tanna
In Conclusion:
In the end Mary and her leadership team were able to persuade
The Joint Commission survey team that this was not an
acceptable practice in the organization, that policies and
procedures existed to guide medical record documentation, that
the Chief of Anesthesia had already counseled the
anesthesiologist, and explained that focused professional practice
evaluation procedures were instituted to monitor this provider’s
pre-anesthesia assessment documentation for the next two
weeks to assure appropriate documentation. Mary and the
executive team were able to convey that the leadership had the
right structures in place to guide practice, hold people
accountable, and that the organization takes action when
individuals do not follow those guidelines.
The Joint Commission surveyor scored this under LD.04.01.05,
EP 4 (staff are held accountable), rather than under
APR.01.02.01, which addresses issues of inaccurate information
or falsification, and could have resulted in a preliminary denial of
accreditation.
References
The Joint Commission Comprehensive Accreditation Manual for
Hospitals, 2012:
LD.04.01.05: The hospital effectively manages its programs,
services, sites, or departments.
EP4: Staff are held accountable for their responsibilities.
APR.01.02.01: The hospital provides accurate information
throughout the accreditation process.
EP1: The hospital provides accurate information throughout the
accreditation process. (See also APR.01.01.01, EP 1)
Note 1: Information may be received in the following ways:
Provided verbally
Obtained through direct observation by, or in an interview
or any other type of communication with, a Joint
Commission employee
Derived from documents supplied by the hospital to The
Joint Commission
Submitted electronically by the hospital through a
performance measurement system to The Joint
Commission
Note 2: For the purpose of this requirement, falsification is
defined as the fabrication, in whole or in part, of any information
provided by an applicant or accredited organization to The Joint
Commission. This includes redrafting, reformatting, or deleting
document content. However, the organization may submit
supporting material that explains the original information
submitted to The Joint Commission. These additional materials
must be properly identified, dated, and accompanied by the
original documents.
Look at a future edition of C&A e-News for our Next Case
Study:
“Is it Clutter or Not? That is the Question!”
Developing "Care Plans" That Guide Patient
Care & Meet the Standards & Regulations
By: Nancy McLean, RN, BSN, MSHA, NHA, HACP
Both The Joint Commission and the Centers for Medicare and
Medicaid Services (CMS) require that organizations develop
patient care plans to meet the assessed need of the patient. CMS
specifically requires that there be "nursing care plans" that guide
patient care from the nursing perspective and "rehabilitation care
plans" that guide all rehabilitation disciplines in providing care
and treatment. There are also separate, specific requirements for
pain, restraints and/or seclusion and discharge planning.
Regardless of the discipline developing or contributing to the care
plan, or the topic of the care plan, all care plans are divided into
four distinct parts:
Measurable patient goals
Timeframe for achieving goals
Interventions planned to assist in goal achievement
Evaluation of progress toward goals
Review of current electronic health record (EHR) designs often
demonstrate confusion between patient-specific measurable goals
and staff-specific interventions used to assist in meeting the
goals. Distinguishing between the two is easy if the person
completing the care plan asks the question, “Is this what a staff
member would do to assist the patient?” If the answer to the
question is, “Yes,” then it is an intervention and not a patientcentered goal. It is also recommended that in developing goals,
the goal statement begins with, “The patient will…” This
statement clearly marks this as a patient-specific goal. When
selecting from a computerized menu of applicable care plan
actions, these words are often not included. A simple mental
check of mentally saying, “The patient will,” before an action on
the menu will assist in distinguishing goals from staff
interventions.
Remember that the patient’s goals must be measurable within
defined timeframes. This requires selecting a timeframe. Not all
goals are for the length of stay. An example of this would be in
the case of a patient admitted with severe pain from a fractured
hip but scheduled for ORIF. A goal of, “The patient’s pain will be
controlled prior to surgery with intravenous pain medication”
might be documented. Both TJC and CMS require reassessment
of the patient’s needs if the condition changes and updating the
care plan based on the reassessed needs. Reassessment of this
patient’s pain after the procedure would be appropriate. The
reassessment should include whether the pain goal should be
extended or if a change to oral analgesics would be more
appropriate. If you are in the process of designing an EHR or
have the ability to revise the EHR consider grouping patient goals
separately from staff interventions.
Finally, consider the requirement to “evaluate progress toward
goals.” Can you create a pop-up of patient-specific goals every
time the notes are accessed as a reminder to address patient
progress or can the software automatically transfer goals to a
table that triggers a required assessment, (similar to how most
systems input information on restraints).
Remember that both CMS and TJC have basically the same
requirements and consider the care plan an vital tool in managing
the patient’s care and a important part of the medical record.
Were You Aware?
1. Over the last several months, CMS has published some
updates to the Interpretive Guidelines for hospitals.
Those (and all) Survey & Certification Memos can be found
on the Policies & Memos to State Regions page on CMS’
website. Highlights of updates published in the last few
months include:
A. Medication Administration (482.23(c) and (c)(1);
S&C-12-05-Hospital Memo dated 11/18/11)
i.
Timing of Medication Administration
a. Removed reference to “30-minute
rule”
b. Hospitals must establish policies re:
timing of medication administration
and address specific circumstances
outlined in the CMS memorandum
c. Evaluation of medication
administration timing policies
ii.
Standing Orders – Defining policy re: S&C
memo 10/24/2008
a. Policies must address use of standing
orders involving medication
administration and include the
process for development, approval,
monitoring, initiation, authentication,
etc. of standing orders
b. Patient-specific orders must be
initiated by an LIP
c. Specific criteria for initiation of
standing orders
d. i.e., Specific clinical situation – Rapid
response scenario
e. Must assure professional staff are
practicing within scope of practice
B. Hospital Equipment Maintenance Requirements
(482.41(c)(2) – S&C-12-07-Hospitals dated
12/2/2011)
i.
Allows alternate equipment maintenance
schedules in certain circumstances
a. Must be based on maintenance
strategies and an evidence-based
assessment process
b. Cannot be adjusted for equipment
critical to patient health & safety
(i.e., life support, resuscitation
equipment)
c. Maintenance methods cannot be
adjusted
C. Life Safety Code – Waiver Instructions (S&C-1221-LSC, dated 3/9/2012)
i.
Allows hospitals & nursing homes to request
waivers (without need to demonstrate
ii.
undue hardship) to allow them to use the
2012 LSC (rather than 2000) related only
to:
a. LSC 18/19.2.3 – Means of Egress –
Wheeled equipment & fixed furniture
b. LSC 18/19.3.2.5 – Cooking Facilities
– Allow certain alternative type of
kitchen cooking requirements
c. LSC 18/19.5.2 – HVAC – Allow direct
vent gas fireplaces in patient
sleeping rooms; solid fuel burning
fireplaces in other areas
d. LSC 18/19.7.5 – Furnishings,
Mattresses, Decorations – Allow
combustible decorations on walls,
doors, ceilings
C&A Note: We have not yet seen how this
process will be handled/determined by CMS,
State Agencies & TJC. More to come!
D. Requirements for Orders for Outpatient Services
(482.56(b), 482.57(b) – S&C-12-17-Hospitals
dated February 17, 2012)
i.
Rehab, Respiratory (& other) Outpatient
Orders
ii.
Does NOT require the physician to be
credentialed or privileged by the hospital
iii.
DOES require that the ordering practitioner:
iv.
Be responsible for the care of the patient
v.
Be licensed in state/jurisdiction where
he/she sees the patient
vi.
Is practicing within scope of license
vii.
DOES require board-approved policy
E. Patient Privacy & Medical Record Confidentiality
(482.13(c)(1), 482.13(d)(1), 482.24(b)(3) – S&C12-18-Hospitals dated 3/2/2012)
i.
Consistent with HIPAA requirements to limit
incidental uses & disclosures, i.e., using
dividers and space where confidential
information is discussed, limiting access to
areas where white boards display patient
information, etc.
ii.
Also addresses access to, and release of,
medical records
2. TJC is now provides a mobile (via smartphone) notification
of onsite survey activity! Organization contacts can sign
up via their TJC Extranet site.
Were You Aware Recap
Tracer Workshop: Procedural Areas A Focus on
Consent, Sterilization and Anesthesia
You already know that TJC surveyors focus on procedural areas
and operating rooms so they may make multiple visits to these
areas – prepare your staff and physicians. You probably also
know that surveyors must visit 100% of anesthetizing areas.
Let’s face it, there are so many interesting items to survey –
anesthesia, infection control, medication administration and
safety, sterilization, staff competency, humidity, vendors,
documentation, well the list just never ends. And, we can’t forget
site marking and time outs. Even though these items have been
required for years, organizations continue to struggle with
ongoing compliance in many or all of these areas and the RFIs
come easy. Many times staff don’t feel comfortable or well
informed about what to look for in these areas.
Join us on June 18th for our webinar on tracing in procedural
areas. This presentation will provide a tracer example and give
staff tips on how to survey for compliance.
Contact us at (704) 573-4535 or [email protected] for more information!
Courtemanche & Associates
Charlotte, NC | Denville, NJ
P: 704-573-4535 | F: 704-573-4538
[email protected] | www.courtemanche-assocs.com
Services
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Ongoing
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ReadinessSOAR to Success,
Electronic
Workbook has
been updated with
the new 2012 Joint
Commission
Standards!
This valuable tool
can help you quickly
and easily find the
standards and
scoring information
you need. It puts
the latest
accreditation
requirements,
policies and
procedures at your
fingertips and
includes scoring
information at every
element of
performance.
The SOAR to
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Workbook also
comes in the
following editions:
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June 28, 2012
It Could Happen To You...
C&A is excited to present "It Could Happen to You,"
hypothetical case studies for you to solve. These are scenarios
that could happen during your next survey, during the postsurvey process, or any average day. We have dramatized a
situation to seek your reaction and input. So, take a moment,
review the case, and provide us with your opinion on the
scenario, because it could happen to you!
We want to hear from you! Send us your thoughts and
comments at [email protected]. We will share
your insights in our next issue!
"Is It Clutter or Not?"
That is the Question!
The Life Safety Surveyor was
conducting the building tour on 4 West.
As they walked through the patient
care unit, he observed 4 isolation carts,
an emergency cart, 3 linen hampers, 6
computers on wheels, a housekeeping
cart, 2 beds, 2 bedside tables, three
chairs, and two carts full of traction
supplies.
Tim, the manager on 4 West, was shocked to see the surveyor
and Armand, the Safety Officer, walk on the unit. The surveyor
took one look at the corridor and started writing something
down. Armand started scowling as he looked around the unit.
He thought Tim knew that you couldn’t store this stuff in the
corridor and now it was too late to fix it. The surveyor said,
“Let’s go to 3 West.” And, they left the unit without further
explanation.
Hospital, Critical
Access Hospital,
Behavioral Health,
Ambulatory, Long
Term Care and
Home Care.
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"Building a
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on July 23rd!
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miss out on this
valuable education
session that shows
it's more than a plan
on paper!
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Today!
(704) 573-4535
[email protected]
After the surveyor left, Tim called Gina, the survey coordinator
and said, “I think we’re in trouble. The surveyor was just here,
saw lots of stuff in my corridor and started writing it all down.
He never asked for an explanation and now they are on the
way to 3 West.” Gina starts to sweat. She knows that not only
could this be scored as corridor clutter, but she has also heard
whispering about life safety issues being scored as an
immediate threat to life. What should Gina do? Should this be
scored as clutter or immediate threat to life? Can this be
avoided?
Corridor Clutter Revisited... Again!
By: Marty Piepoli, MSW, LISW/CP, HACP
Most organizations, especially those built before the turn of the
last century, have had multiple challenges with storage and
assuring clear and unobstructed access through corridors to
exits. Over the past several years, Maintaining the Means of
Egress (LS.02.01.20, EP13), has been scored in the Top 10 of
annual TJC findings. Challenged with the task of maintaining
fire safety each day, organizations have employed Environment
of Care rounding teams, focused strategies during fire drills for
clear corridor access, determined how to use dead-end
corridors and constructed storage alcoves in order to comply
with Means of Egress expectations.
CMS and TJC currently recognize Life Safety Code (LSC) 101,
2000 edition. Sections 19.2.3 & 7.3 address the Means of
Egress. Since 2004, CMS has provided several Survey &
Certification Letters (S & C) in order to address exceptions to
the LSC specifically related to corridor clutter. CMS issued S&C
LSC-10-18 in May, 2010 (excerpt below) revising guidance on
what could be permitted in corridors:
Allowance for wall mounted computers and other items to
be wall-mounted in corridors as long as they do not project
out more than 6 inches from the corridor wall or conflict
with other sections of the Life Safety Code; projections shall
not exceed a length of 36 inches, shall be separated by at
least 48 inches from other projections, shall be installed at
least 40 inches or greater above the floor, and shall only be
installed in corridors that are at least 6 feet in width.
Projections shall be permitted on either side of the corridor.
Placement of items associated with the use of these wall
mounted pieces of equipment such as chairs, tables,
cabinets, carts, etc. in the corridor, which would reduce
corridor to less than the required width, are not
permitted when not in use. An item is considered “not in
use” if it is left unattended or is not moved for more than
30 minutes. In addition, corridor wall alteration to reduce
the projection of a wall-mounted item is prohibited if it
reduces the protective requirements of the wall.
Items such as linen carts, medication carts, and janitorial
equipment would not be included in these exclusions.
Infection control supply cabinets outside of a specific room
are allowed in the corridor while precautions are in force for
that room. Crash carts are allowed in the corridor for quick
access in an emergency.
Despite the guidance, clutter continued to be an issue for
hospitals and was addressed by the revised 2012 edition of
LSC101 which has not yet been adopted by CMS. However, in
order to provide some relief related to this ongoing challenge,
CMS issued an S&C Letter 12-21 on March 9, 2012 providing
Instructions Concerning Waivers of Specific Requirements of
the 2012 Edition of the National Fire Protection Association
(NFPA) 101, the Life Safety Code (LSC), in Health Care
Facilities. This guidance addresses exceptions for both the
nursing home and acute care hospital settings. CMS will
consider a waiver to allow uses that meet the requirements
found in the 2012 edition:
LSC sections 18/19.2.3 Capacity of Means of Egress and
more specifically the requirements at 18/19.2.3.4 which
allow, under certain circumstances, projections into the
means of egress corridor width for wheeled equipment and
fixed furniture.
CMS will consider a waiver to allow the use of the
requirements found at LSC section 18/19.7.5 Furnishings,
Mattresses, and Decorations including sections 18/19.7.5.6
which allow the installation of combustible decorations on
walls, doors and ceilings.
Previous guidance concerning “not in use” criteria found in
S&C-10-18-LSC is still applicable.
What does this mean for your organization today?
In considering whether or not to apply for a waiver as
outlined above, start with a review of the 2012 edition of
the LSC101 to assess your organization’s ability to comply
with the new exceptions noted related to egress, corridor
storage and wall-coverings. Seek input from your Facilities
Leadership, Architect, or Physical Engineer. Also, you may
want to seek the guidance of your local Authority Having
Jurisdiction (fire marshal) in determining the information
needed for the waiver.
Follow CMS guidelines for submitting a waiver to your CMS
regional office.
Also submit a Traditional Equivalency request to The Joint
Commission detailing the request, the related LSC
requirement and how the organization meets the
expectations of that requirement.
In conclusion, it is important to note that organizations cannot
simply adopt these practices. Both CMS and TJC require formal
submission, and subsequent approval, of a request to comply
with these less restrictive corridor requirements.
Sources:
CMS S & C Letter 10-18-LSC issued May 14, 2010Revision of S&C-04-41 dated August 12, 2004, Corridor
Width & Corridor Mounted Computer Touch Screens in
Health Care Facilities
CMS S & C Letter 12-21-LSC issued March 9, 2012Instructions Concerning Waivers of Specific
Requirements of the 2012 Edition of the National Fire
Protection Association (NFPA) 101, the Life Safety Code
(LSC), in Health Care Facilities
The Joint Commission Comprehensive Accreditation
Manual for Hospitals, 2012
The Joint Commission Perspectives, June, 2012
LSC 101, 2000 edition, LSC101, 2012 edition
Were You Aware?
CMS has CMS has published revisions to the Conditions of
Participation related to several key areas. These revisions were
published in the Federal Register on May 16, 2012 and include:
Governing Body – 482.12 – Allow multi-hospital systems
to have one governing body
Will allow one governing body to oversee multiple
hospitals in a multi-hospital system.
Added a requirement for a member, or members, of the
hospital’s medical staff to be included on the governing
body as a means of ensuring communication and
coordination between a single governing body and the
medicals staffs of individual hospitals in the system.
Patient Rights – 482.13 – Revise report requirement for
deaths that occur when patient is only in soft two-point
soft wrist restraints
Replacing the requirement that hospitals must report
deaths that occur while a patient is only in soft, 2-point
wrist restraints with a requirement that hospitals must
enter specific information in the patient’s chart and
maintain a log (or other system) of all such deaths.
Log is internal to the hospital but must be made
available to CMS upon request and must include patient’
name, DOB, DOD, name of attending or other LIP,
medical record number and primary diagnosis.
Medical Staff – 482.22 – Privileges can be granted to
those not on the medical staff and clarification around
language for privileging non-physician staff
Broadened the concept of “medical staff” to allow for
inclusion of other practitioners as eligible candidates for
the medical staff with hospital privileges to practice in
the hospital in accordance with State law.
All practitioners will function under the rules of the
medical staff. This change will clearly permit hospitals to
allow other practitioners (e.g. APRNs, PAs, pharmacists)
to perform all functions within their scope of practice.
Requiring that the medical staff must examine the
credentials of all eligible candidates (as defined by the
governing body) and then make recommendations for
privileges and medical staff membership to the
governing body.
Medical Staff – 482.22 – Including podiatrists in list of
those permitted to assume medical staff leadership
This change will allow podiatrists to assume a new
leadership role within hospitals, if hospitals so choose.
Nursing Services – 482.23 – Allow an integrated,
interdisciplinary plan of care & provision for patient selfadministration of medications (with parameters)
Will allow hospitals the option of having a stand-alone
nursing care plan or a single interdisciplinary care plan
that addresses nursing and other disciplines.
Allow hospitals to have an optional program for
patient(s)/support person(s) on self-administration of
appropriate medications. The program must address the
safe and accurate administration of specified
medications; ensure a process for medication security;
address self-administration training and supervision;
and document medication self-administration.
Nursing Services – 482.23 – Minor changes related to
blood transfusions/IV
Eliminated the requirement for non-physician personnel
to have special training in administering blood
transfusions & intravenous medications and have
revised the requirement to clarify that those who
administer blood transfusions and intravenous
medications do so in accordance with State law and
approved medical staff policies and procedures.
Nursing Services – 482.23 – Broadening those from who
RNs are permitted to act on drug/biological orders (i.e.,
APRNs, PAs, PharmDs)
Allowing for drugs & biologicals to be prepared and
administered on the orders of practitioners (other than a
doctor), in accordance with hospital policy and State
law, and have also allowed orders for drugs & biologicals
to be documented and signed by practitioners (other
than a doctor), in accordance with hospital policy and
State law.
Medical Record Services – 482.24 – Broadening
permitted use of standing orders to include not only
emergency response situations but also ED and Post-op
and defining the parameters for development, approval
and use, including criteria for initiation, standing orders
and protocols
Will allow hospitals the flexibility to use standing orders
and have added a requirement for medical staff,
nursing, and pharmacy to approve written and
electronic standing orders, order sets, and protocols.
Requires that orders & protocols must be based on
nationally recognized and evidence-based guidelines
and recommendations.
Still does NOT allow nurse-initiated orders (except
influenza & pneumococcal) without physician order.
Medical Record Services – 482.24 – Removal of 48 hour
timeframe for authentication and continued allowance
for “another practitioner responsible for care” to sign off
on verbal orders
Eliminated the requirement for authentication of verbal
orders within 48-hours and have deferred to applicable
State law to establish authentication timeframes.
Made permanent the previous temporary requirement
that all orders, including verbal orders, must be dated,
timed, and authenticated by either the ordering
practitioner or another practitioner who is responsible
for the care of the patient and who is authorized to write
orders by hospital policy in accordance with State law.
Infection Control Services – 482.42 – Removal of the
need for a separate infection control log
Eliminated the obsolete requirement for a hospital to
maintain an infection control log.
Hospitals are already required to monitor infections and
do so through various surveillance methods including
electronic systems.
Outpatient Services – 482.54 – Removal of the
requirement that one, singular individual have
responsibility for all outpatient services, allowing more
than one leader to have responsibility
Removed the burdensome and outdated requirement for
a single Director of Outpatient Services position that
oversees all outpatient departments in a hospital.
Hospitals already have separate directors for individual
outpatient departments, so having a single overall
Director position is duplicative and unnecessary.
Transplant Center – 482.92 – Reducing unnecessary
duplication of blood type verification processes
Eliminated a duplicative requirement for an organ
recovery team that is working for the transplant center
to conduct a “blood type and other vital data
verification” before organ recovery when the recipient is
known.
The verification will continue to be completed at two
other times in the transplant process.
The full detail of these revisions can be found at:
http://www.gpo.gov/fdsys/pkg/FR-2012-0516/html/2012-11548.htm
Were You Aware 2012 Recap
Courtemanche & Associates
Charlotte, NC | Denville, NJ
P: 704-573-4535 | F: 704-573-4538
[email protected] | www.courtemanche-assocs.com
Services
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Congrats!
Congratulations to
Christine Candio,
Chief Executive
Officer at Inova
Alexandria
Hospital in Fairfax,
VA, for receiving the
2012 Brava!
Women Business
Achievement
Award by
Washington
SmartCEO
magazine!
Testimonials
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July 30, 2012
Conclusion: It Could Happen To You...
"Is It Clutter or Not?"
That is the Question!
As you may recall from last month's
edition of C&A e-News, Gina, the survey
coordinator, was concerned about a
potential survey finding on 4 West. Tim, the
unit manager, had seen the Life Safety
surveyor taking notes about "clutter" he
observed in the corridor. The LS surveyor
was now on his way to 3 West.
This award honors
women business
leaders who
We asked for your thoughts on how Gina
combine their
should have handled this situation. Thank you for all your
irrepressible
responses, we appreciate the feedback!
entrepreneurial
spirit with a passion
for giving back to Here are two responses that echo the thoughts of others:
the community.
Tamara contributed:
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There's still time to
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Accountability
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on August 20th!
“First, Gina should call 3 West immediately and have someone
ensure hallways are clear before surveyor arrives.
Second, Gina or Tim should have someone move unused items out
of the corridors on 4W and possibly the surveyor will be back and
notice it is gone according to the 30 minute rule. If at all possible,
everything should be on one side of the corridor for safety.
Isolation carts are permitted as long as in use next to patient
room
Emergency (crash carts) are permitted
Linen hampers are best in the dirty utility rooms
You won’t want to
miss out on this
valuable education
session that focuses
on how to build
processes that
support compliance
in your
organization!
Contact Us
Today!
Computers should be in use, otherwise stored in an area not
considered a corridor
The housekeeping cart should be in use or kept in a
“housekeeping closet”
The 2 beds, 2 tables, 3 chairs and traction carts should not
be in the hallway longer than 30 minutes, and should be
moved to another location. Hopefully, they were sitting
there waiting for transport.”
And Judy shared:
“First, Gina should notify 3 West immediately of impending surveyor
entry & have them move anything that is blocking exits or that
(704) 573-4535 cannot be justified as being in place for actual immediate use. In
info@courtemanche- addition, a general confidential, urgent message to all department
assocs.com
managers should be issued to quick sweep their units for such
issues and correct immediately.
Publication
Spotlight
Next, manager on 4 West should write down items viewed in hall &
start mental justification process for himself using TJC allowable
guidelines. Some items can be explained but probably not all. This
would be damage control. Should also find unit education records
that cover TJC guidelines on hallway use & criteria for equipment
C&A's Score
placement in hallways, to show attempts to educate staff. Should
Ongoing
also find any environmental rounds on unit that support appropriate
Accreditation
hallway findings if available. This info should be presented during
Readinessexit interview by Gina and/or unit manager on that day wrap up
SOAR to Success, session or at least on exit interview, as a rebuttal. Finally, this unit
should clean itself up as much as possible immediately and stay
Electronic
that way until survey conclusion, hoping that surveyor will
Workbook has
accidently pass thru there again!
been updated with
the new
Finally, safety officer, unit manager and survey coordinator should
2012/2013 Joint be prepared for rebuttal comments when surveyor findings are
Commission
presented, in a non-confrontational manner but with the intent to
Standards!
try to explain the finding and support any validity to equipment
This valuable tool
can help you quickly
and easily find the
standards and
scoring information
you need. It puts
the latest
accreditation
requirements,
policies and
procedures at your
fingertips and
includes scoring
presence that might exist. A prayer service for leniency and
understanding prior to discussion with the surveyor would be in
order!”
In Conclusion:
Now was not the time to panic! Gina composed herself and quickly
took control. She contacted the unit manager on 3 West and
advised that the LS surveyor was on his way and that he had
concerns about corridor clutter. The 3 West manager indicated
sweeps had already been done, but she’d double
check to be sure the corridor was in appropriate order! Gina then
asked the survey Command Center to send an email to all
information at every managers reminding them of the need to maintain means of egress
and noting that the only items not in immediate use that are
element of
permitted to be in corridors are: isolation and chemotherapy carts
performance.
(when associated with patients) and emergency carts. Finally, yet
all within a matter of two minutes, Gina called Tim and asked if he
Click Here to
needed assistance in locating appropriate storage places for the
Order Now!
equipment that had been on his unit. Setting Gina’s mind at ease,
Tim advised that task was already well underway!
The survey blitz team were sent on rounds to assure that corridors
and stairwells were clear from obstructions and reported back to the
Command Center that all areas looked to be in good shape!
In the end, the Life Safety surveyor, having found no other
concerns related to means of egress, scored a Requirement for
Improvement (RFI) under LS.02.01.20, EP13. Included in the
organization’s Evidence of Standards Compliance for this finding
was development and implementation of a “Means of Egress” policy
& education on the importance of maintaining clear corridors to
assure safe, expeditious evacuation in the event of smoke or fire
conditions.
References:
The Joint Commission Comprehensive Accreditation Manual
for Hospitals, 2012
LS.02.01.20: The hospital maintains the integrity of the
means of egress.
o EP13: Exits, exit accesses and exit discharges are
clear of obstructions or impediments to the public
way, such as clutter (for example, equipment, carts,
furniture), construction material, and snow and ice.
(For full text and any exceptions, refer to NFPA 1012000: 7.1.10.1).
Coaching Staff in a Healthcare Setting - Part 1
By: Nancy McLean, RN, BSN, MSHA, NHA, HACP
Several years ago, the buzz words, "blame free," were suggested as
a foundation for an organizational culture that would lead to
improved patient safety and quality. However, there are times when
blame free does not address the inappropriate behaviors we may be
faced with, such as, theft, medication diversion, abuse, etc. We
now recognize that a "just culture" is more appropriate. Just like the
change from "blame free" to "just culture," healthcare organizations
should consider a change from the approaches of disciplinary action,
corrective action and disciplinary process to "coaching." Coaching
supports the philosophy of a "just culture." Coaching implies
"team".
Hundreds of books and thousands of articles have been written on
the concept of “team.” Teams require a coach or coaches. In the
healthcare setting, work teams are rarely formalized and nurtured
by the leadership of the organization. Informal teams often develop
in healthcare based on work flow and work load without the
guidance or support of a coach. These teams are often singledisciplinary though we continue to hear requirements that are
dependent on multidisciplinary or interdisciplinary concepts. These
teams are often short-lived – the staff come together to tackle a
specific problem or situation and then return to their individual
issues and priorities. There is no coach to assure the team stays
together. Development of a team culture in healthcare starts with
leadership support of a coaching philosophy. Leaders can begin the
process by turning discipline into coaching.
Coaching begins with identification of the coach and team members
that will comprise the “team.” The team then jointly establishes the
team goals. Two things bring a team together: a common enemy or
common goals. When a common enemy is the foundation for team
cohesiveness, the team is short lived. The team breaks apart when
the enemy is defeated. When common goals are a foundation for a
team, the team stays together to achieve goals and build new goals
based on past achievements. The coach must assure:
Team members know their positions on the team
Team members know and understand the value of all
positions
Individual team members understand how their position
contribute to the overall success of the team The team
develops realistic measurable, common goals
The team has the education, support and resources to help
meet the goals
The coach routinely provides the team with feedback on their
progress toward meeting the agreed upon goals and
celebrates with the team as they score each touchdown
Healthcare organizations can lay the foundation for a team
philosophy by:
Establishing common goals that each employee understands
their role in helping to achieve
Developing a philosophy of coaching for achievement of the
goals
Coaching begins with jointly establishing and documenting
performance goals, targets and deadlines with the employee. It
proceeds with routine review of the progress toward goals and
targets. It includes the exploration of reasons that goals are not
being met and revised targets or deadlines, when necessary. It
encourages acceptance or responsibility for the employees own
performance. It assists the employee in self-reflection related to the
right job and right organization for them. It replaces the disciplinary
process, not so much as to the flow of the process, but as to the
punitive sound and philosophy.
Ultimately an organizational philosophy of coaching leads to
employee commitment and dedication, reduced turnover, increased
job satisfaction, and improved performance resulting in
improvement in care and treatment provided and winning teams.
Go team!
Look for Coaching Part 2 in an upcoming edition of C&A e-News!
Click here to learn more about coaching for regulatory success!
References:
Team climate, intention to leave and turnover among
hospital employees: Prospective cohort study, 2007, Mika
Kivimäki, Anna Vanhala, Jaana Pentti, Hannakaisa
Länsisalmi, Marianna Virtanen, Marko Elovainio and Jussi
Vahtera http://www.thomasgroup.com/eLibrary/IndustryInsights/Healthcare-and-Life-Sciences/NursingRetention.aspx
Nursing Retention. © 2012 Thomas Group, Inc. All rights
reserved
Were You Aware?
1. Late Breaking News: On July 13th, the CDC published an
article related to two recent outbreaks of staphylococcus
aureus infections. Investigation revealed both outbreaks related
to the use of single-dose vial (SDV) medications for more than
one patient. These two outbreaks involved a total of ten patients
who required treatment.
Administering drugs from one SDV to multiple patients without
adhering to USP 797 Compounding Sterile Preparations is NOT
ACCEPTABLE. Both the CDC and CMS (see reference links below)
require that organizations using SDVs for multiple
patients adhere strictly to infection control practices and USP
797 Sterile Compounding Guidelines for repackaging and
storage. Organizations must be aware of the following broad
expectations:
Single dose vials (SDVs) are intended for single use, and
are labeled as such, because they typically lack
antimicrobial preservatives
The use of SDVs for multiple patients increases the risk
of infection transmission
SVDs that are repackaged under USP 797 Sterile
Compounding Guidelines consistent with aseptic
conditions and stored consistent with USP 797 and
manufacturer guidelines is permissible
USP 797 requires specific conditions, trained and
qualified staff, ISO Class 5 conditions for air quality, ISO
class 7 buffer zone, proper attire and controls
Medications are repackaged properly
Repackaged medications are labeled properly with
correct name, concentration, volume, route, beyond
use date and storage conditions
For additional information on the safe use of SDVs:
http://www.cms.gov/Medicare/Provider-EnrollmentandCertification/SurveyCertificationGenInfo/Downloads/S
urvey-and-Cert-Letter-12-35.pdf
http://www.cdc.gov/injectionsafety/cdcpositionsingleusevial.html
2. Summer is the time to unwind, refresh and get energized! It’s
also time to be sure that your organization has implemented any
changes promulgated by regulatory and accrediting
organizations during the year and has a process in place to
address upcoming changes. Some helpful hints for staying on
top of all those changes:
Frequently review TJC’s website
(http://www.jointcommission.org) and “The Joint
Commission Perspectives” for new and updated FAQs,
pre-publication standards and proposed standards that
are in field review. Some recent updates include:
 Updated (July) FAQs related to the Human
Resources requirements for unlicensed persons
serving as scribes and responsibilities for nonlicensed, non-employee individuals in the
organization. Note that both of these FAQs are
further clarifications of FAQs issued earlier this
year.
 Revisions to the patient flow requirements to
assure that organizations address potential safety
issues related to boarding both medical and
behavioral health patients awaiting placement.
 Revisions to emergency management exercise
requirements for home care settings.
 A “loosening up” of the requirement for quality
control checks for waived testing.
Check the CMS website regularly for changes to the
State Operations Manual, Appendix A (Interpretive
Guidelines) and outlined in Survey & Certification
Memoranda. See the May/June edition of C&A eNews for recent changes.
For new or revised requirements that are effective in 612 months, establish work teams to assess current state,
identify gaps related to new requirements, strategize
solutions and create the plan and timeline for
implementation. For example, for the patient flow
requirements, consider a team comprised of ED, BH,
Quality & Ancillary representatives. And, most
importantly, don’t forget the medical staff!
3. Were you aware . . . that you can easily avoid a potential
Situational Decision Rule and Accreditation with Follow-up
Survey result with a simple policy update?
LS.01.02.01, EP3 requires that organizations have a
written Interim Life Safety Measure (ILSM) policy that
addresses situations when the organization cannot
immediately address Life Safety Code deficiencies –
either due to construction, renovation or other factors.
The policy must include criteria for evaluating the extent
of ILSM to be implemented.
Many organizations have policies that only address LSC
deficiencies related to construction and/or do not contain
evaluation criteria.
Take a few moments to review your ILSM policy & make
the necessary adjustments to the procedure and practice.
Were You Aware Recap
Courtemanche & Associates
Charlotte, NC | Denville, NJ
P: 704-573-4535 | F: 704-573-4538
[email protected] | www.courtemanche-assocs.com
Services
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Enjoy the Last
Days of
Summer!
Testimonials
C&A E-Newsletter
About C&A
Contact
August 27, 2012
It Could Happen To You...
C&A is excited to present "It Could Happen to You,"
hypothetical case studies for you to solve. These are scenarios
that could happen during your next survey, during the postsurvey process or any average day. We have dramatized a
situation to seek your reaction and input. So, take a moment,
review the
is month's cases and provide us with your opinion (a simple
yes/no) on the scenario, because it could happen to you!
There's Still
Time!
There's still a few
spots left to register
for the "TJC
Update: The Latest
on Executive
Briefings" webinar
on September 24th!
You won't want to
miss out on this
valuable education
session that focuses
on the latest
standards and
survey process
changes!
Contact Us Today!
(704) 573-4535
[email protected]
We want to hear from you! Send us your thoughts and
comments at [email protected]. We will
share your insights in our next
issue!
"It's All in the Way You
Label It"
Scenario 1:
It was 2:30 p.m. and Ronda, RN had
prepped all medications and solutions
for Mrs. Tructon’s hip surgery. Each
was labeled with the medication name, the strength, quantity,
dosage amount, and expiration time. The surgery proceeded
and was going a bit longer than had been anticipated. It was
time for Ronda to go to off duty. Betty, the nurse replacing
Ronda, came into the room as the procedure continued. Ronda
thanked Betty for relieving her, indicated that everything was
in order and that “all the solutions are already out for you” and
left the room.
If a Joint Commission surveyor had observed this exchange,
would there have been an RFI?
Coming Soon!
Be on the lookout for
the launch of C&A's
all new leadership
series LEAD: Lead,
Explore, Achieve,
Develop!
This essential
leadership series
uses your
organizational
concepts to provide
the tools to get
started while
acquainting new,
existing and soon to
be leaders in their
changing roles and
responsibilities.
More information
coming soon!
Scenario 2:
Ms. Mercy was Ms. Mercy was in her room just before she was
scheduled to go into surgery for a hip replacement. Mary, Ms.
Mercy’s nurse, was preparing the antibiotic that Ms. Mercy was
to receive before her procedure. Mary drew up the appropriate
medication and did not label it as she was going directly to the
patient’s bedside. Just then, Ms. Mercy’s family entered the
room to wish the patient well. Giving them a moment of
privacy, Mary left the room for just a moment, spoke to her
colleague at the nurse’s station & returned to Ms. Mercy’s
bedside to administer the medication.
If a Joint Commission surveyor had been onsite would Mary
have been scored?
Remember to send us your thoughts and comments at
[email protected]. We will share your
insights in our next issue!
The Latest on the EC & LS Front
By: Marty Piepoli, LISW/CP, HACP
"What's the current buzz" in the physical environment related
to the day to day operations in your healthcare organization?
Well, the 49th American Society for Healthcare Engineering
(ASHE) Annual Conference, held in July, sought to discuss the
current buzz in facilities management. With the largest
attendance on record, the program's theme of "Dealing With
and Managing Through Change" was very appropriate.
Some of the many topics during the conference were designed
to provide insight and education for the more than 11,000
members across the country representing 2,500 hospitals.
Dialogue and discussion ranged from the approval of LSC 101,
2012 for future adoption by CMS, discussion around creating
uniformed life safety codes via the International Codes
Commission, educational how to’s for managing your
departments more effectively, a TJC update, basics of the life
safety code and “Why Hospitals Should Fly,” a great closing
plenary session by John Nance, one of the founding members
of the National Patient Safety Foundation (NPSF).
With several topics of interest regarding the environment, I
thought focusing on the key points made by The Joint
Commission’s George Mills, Director, Department of
Engineering, would be of special interest. The session began
with disclosure of the top scoring Environment of Care and Life
Safety standards that continue to be a concern for
organization’s to manage. George was quick to point out that
these findings have continued to find their way into the top 10
for several years.
LS.02.01.20—56%: Maintaining egress
o Emphasis on what is permitted in the
corridors
o Proper use of dead-end corridors that are
<50 sg.ft. for stored items
o Importance of “Suite Designations” on the
organization’s life safety drawings
o Using legends to denote fire and smoke
barrier rated walls
LS.02.01.10—52%: Building & fire protection
features designed/maintained to minimize the
effects of fire, smoke, and heat
o Beware of EP’s 5 & 9 pertaining to latching
and penetrations
o Consider including the doors as part of a
Building Maintenance Program to assist with
ongoing surveillance of the facility
LS.02.01.30—45%: Providing & maintaining building
features to protect individuals from the hazards of
fire and smoke
o Of interest, how organizations define
hazardous storage locations and
corresponding aspects of proper smoke
barrier protection
EC.02.03.05—40%: Maintaining fire safety
equipment & fire safety building features
o Noted documentation as the number one
reason for additional Life Safety Surveyor
time
o Discussed how vendors should be working
with you to mitigate differences related to
devices under NFPA72 and NFPA25 for fire
alarm and sprinkler testing
o Referenced LD.04.01.05 to demonstrate how
accountability for oversight is demonstrated
LS.02.01.35—31%: Providing & maintaining systems
for extinguishing fires
o Second consecutive year in the top 10
scoring standards with focus on the 18”
storage rule
o
o
Grease-producing cooking devices with
extinguishing systems activating properly
Bundles of cable lying on top of fire
suppression risers, not attached to a bracket
or through some type of easy-pass system
Mills provided the formula for determining how many Life
Safety Surveyor (LSS) days an organization would receive: two
surveyor days for all organizations and more than two based on
the combination of >1.5 million sq.ft. of patient care space and
more than three buildings on the campus. Facilities managers
should be sure to confer internally with accreditation leaders
and the TJC Account Executive regarding LSS days. The LSS
will focus intently on EC.02.03.05, EC.02.05.07 and
EC.02.05.09 during the document review to assure compliance
with feature of fire safety equipment, generator testing and
medical gas testing. He added that the Life Safety Surveyors
are part of the survey team for smaller hospitals and Critical
Access hospitals and will conduct the EC and EM sessions for
these settings and as directed by the Team Leader in other
settings.
Additional points of interest addressed during this session
included the need for risk assessment to determine where you
are place eye wash stations, emphasis on temperature and
humidity in procedural and sterile areas citing the ASHRAE
ventilation guidelines. George added that with the increased
emphasis on infection control, surveyors are looking for
chipped or bubbling paint and wall board as well as positivenegative pressure relationships. George also addressed the
CMS S & C Letter of March 9, 2012 regarding application for a
waiver to utilize certain aspects of the new Life Safety Code
101, 2012 edition. He addressed the five areas of the new code
and noted that TJC will grant Traditional Equivalencies for these
aspects of the new code. He did point out, however, that CMS
approaches this reactively and that in all likelihood a facility
would be cited at the CMS/State level and then use the waiver
request as part of the plan of correction.
The ASHE conference was jam-packed with information to
provide facility managers with tools and strategies to manage
an ever- changing healthcare environment. Facilities
management integrates the need to clearly define the life cycle
of a system and the return on investment for a project or new
capital infrastructure expense. Both new and seasoned facility
managers must be equipped with the knowledge and tools to
not only manage the day to day operations, but implement
sound financial approaches as well.
Resources:
o
Presentations provided at 49th Annual Conference,
American Society for Healthcare Engineering, July 1618, 2012
o
The Joint Commission Comprehensive Accreditation
Manual for Hospitals, 2012
o
www.cms.gov
Courtemanche & Associates
Charlotte, NC | Denville, NJ
P: 704-573-4535 | F: 704-573-4538
[email protected] | www.courtemanche-assocs.com
12/ 5/ 12
C&A Newslet t er - Sept em ber
Services
Tools & Solutions
Well Wishes!
Please join us in
sending well wishes
to Lauren Hannan,
Education & Client
Relations
Coordinator, as she
pursues an exciting
new career
opportunity. We
thank Lauren for her
many contributions
to the company
over the last two
years and wish her
the best of luck in
all future endeavors!
If you have any
questions regarding
any educational
concerns, please
feel free to call us
at 704-573-4535.
Don't Miss Out
on C&A's 2013
TJC & CMS
Webinar
Series!
Register on or
before December
7th to receive the
early bird rate!
The 2013 TJC &
CMS Webinar series
focuses on the
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Testimonials
C&A E-Newsletter
About C&A
Contact
September 27, 2012
Conclusion: It Could Happen To You...
"It's All in the Way You
Label It"
As you may recall from last month's
edition of C&A e-News, we had two
scenarios which involved medication
labeling. Our first scenario, opened
with Ronda, an RN, preparing a
patient's medications for surgery and was getting ready to leave
her shift. In our second scenario Mary was getting ready to
administer medications to a patient at their bedside.
In each scenario we invited you to respond to our poll asking if
a Joint Commission surveyor had been onsite would the scenario
been scored. We appreciated the outstanding feedback to our
poll.
Check out the responses. They may surprise you....
Read More
Coaching in a Healthcare Setting - Part 2
By: Nancy McLean, RN, BSN, MSHA, NHA, HACP
In a prior article we discussed how a healthcare culture based
on coaching and team concepts can lead improvement in care
and treatment provided. These same concepts can apply to the
organization's role in assuring physician competence. In 2009
the Joint Commission published the Medical Staff standards
requiring the hospital to develop methods of evaluating
physician practice in focused situations and on an ongoing
basis.
This formalized oversight of the Medical Staff member's
1/ 2
12/ 5/ 12
C&A Newslet t er - Sept em ber
"how to" of
regulatory and
accreditation
compliance while
keeping you up to
date on the latest
accreditation and
regulatory news,
changing
standards, and
best practices
for compliance
throughout the
year!
Click Here to view
the entire brochure
complete with
dates,
topics & more
information!
individual performance was initially met with hesitation, with
some organizations taking up to 18 months to implement the
requirements. Three years later there is still confusion,
hesitation and strong reaction from some Medical Staff members
as to the degree of required performance monitoring and what is
being monitored. Executive leaders are also mentioning the
reaction of the physicians when presented with...
Read More
Were You Aware?
Sentinel Event #49: Safe use of opioids in hospitals
On August 8, 2012, TJC published Sentinel Event
#49 regarding the use of opioids in hospitals. While
many believe that the use and administration of
opioids is safe in a hospital setting because of
frequency of use and ongoing monitoring...
Pain assessments and pain goals...
are often not effective? Working with hospital
organizations, we often have conversations (ok
sometimes heated debates) related to the subject
of pain. Typically, these conversations revolve
around...
Read More
Courtemanche & Associates
Charlotte, NC | Denville, NJ
P: 704-573-4535 | F: 704-573-4538
[email protected] | www.courtemanche-assocs.com
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Andrea Marsh
Courtemanche & Associates [[email protected]] on behalf of
Courtemanche & Associates [[email protected]]
Friday, November 30, 2012 10:53 AM
[email protected]
C&A Newsletter - November 2012
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Subject:
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2013 Annual
Conference
Testimonials
C&A E-Newsletter
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November 30, 2012
Registration
Now Open!
Conclusion: It Could Happen To You... April 30th - May
1st
Chicago Renaissance
Downtown,
Chicago, IL
C&A's most exciting
conference to date!
Stay up to date on
all the latest trends
in accreditation
and regulatory
compliance,
in addition this
conference will offer
a real "hands on"
approach providing
you with tools that
will help your
organization stay
compliant
throughout the
year.
Click here to view
the brochure or Call
us (704) 573-4535
to find out how to
register!
ʺThe Right Patientʺ As you may recall from last month's
edition of C&A e-News, we presented
a case study which involved proper
patient identification. Our scenario,
opened with Ben, a six year old boy
who was in the hospital awaiting his
tonsillectomy. Jeremy the nurse had come into Ben's room to
make final preparations for the surgery. Jeremy needed to
confirm the patient's identity.
For this scenario we invited you to respond to our poll asking if
Jeremy had followed appropriate procedures to make sure that
he indeed had the right patient. We appreciated the
outstanding feedback to our poll.
Check out the responses. They may surprise you...
Read More
Endoscopy Equipment Processing Room Requirements In April, 2012, EC News, distributed by Joint Commission
Resources, addressed Endoscopy Equipment Processing Room
1
Early Bird Rates Ending Soon!
There is still time to
register for
C&A's 2013
Webinar Series.
This series not only
keeps you current
with the latest
TJC/CMS trends, it
also offers practical
solutions for
everyday regulatory
compliance issues.
Early Bird Rates
end on Dec. 7th, so
be sure to send in
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details soon.
Click Here to
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more!
Requirements regarding air flow and negative pressure which
provided guidelines for Gastrointestinal Endoscopy rooms. This
same article referenced the 2010 Facilities Guidelines Institute
(FGI) for design and construction of health care facilities,
section 3.9 and The Joint Commission relevant standards.
Although this article...
Read More
Were You Aware?
- Lack of documentation leads to RFIs
According to TJC survey results, 40% of all hospital surveys
completed in 2011 and the first half of 2012 received an RFI in
standard EC.02.03.05, which relates to documentation. This
standard requires documentation for approximately 20 different
tests of fire safety and alarm systems. One of the reasons for
the high RFI rate is....
- ECRI Releases Top 10 Health Technology Hazards
for 2013
It seems like almost every day there is some new technology
being created or introduced to make healthcare work easier;
however...
Read More
Irene, Sandy, Snowfall, Flooding, Power Loss, LEAD Lead, Explore,
Achieve, Develop
Create a culture of
compliance every
day by empowering
your entire
organization.
This C&A Leadership
training program is
available to
organizations in
many different
formats to best fit
your style and
budget.
Click Here Are just a few of the issues that every healthcare organization
considers in assuring that the Emergency Operations Plan
(EOP) is up to date. With the recent devastating impact left by
hurricane Sandy organizations are taking a very hard look at
the structure of their EOP and are asking if the plan will really
work. Now is a good time to review your current EOP plans.
Join us on January 14th from 11:00am - 12:15pm, for C&A's
first webinar for the 2013 series: "Emergency Management
Planning, Drilling, Critiquing: Tips on Assuring a
Manageable Yet Comprehensive Emergency Operations
Plan." This important webinar will address aspects specific to
an all-hazards approach to emergency management to assure
that your organization doesn't have a paper product, but an EM
Plan that actually works.
Click Here to Register
2