joint commission 2010- 2011 update for hospital imaging ... · 19 the joint commission 2010-2011...
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Joint Commission 2010-2011 Update for Hospital Imaging Departments
Joint Commission 2010-2011 Update for Hospital
Imaging DepartmentsJudith M. Atkins, RN, MSN
www.mckennaconsulting.com304-988-1047
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The Joint Commission 2010-2011IMAGING
Patient Safety ApproachFunctional Standards
Proactive Risk Reduction Uniform Patient Care Processes
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The Joint Commission 2010-2011Chapters (Alphabetized)
Accreditation Participation Requirement (APR)Environment of Care (EC)Emergency Management (EM)Equipment Management (EQ) for HMEHuman Resources (HR)Infection Control (IC)
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011Chapters
Information Management (IM)Leadership (LD)Life Safety (LS)Medication Management (MM)Medical Staff (MS)National Patient Safety Goal (NPSG)Nursing (NR)
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The Joint Commission 2010-2011
ChaptersProvision of Care (PC)Performance Improvement (PI)Record of Care, Treatment and Services (RC)Rights and Responsibilities (RI)Transplant Safety (TS)Waived Testing (WT)
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CMS 2010-2011Conditions of Participation
CoP – Compliance with Federal, State and Local LawsCoP – Governing BodyCoP – Patients RightsCoP – Quality Assessment and Performance ImprovementCoP – Medical Record Services
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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CMS 2010-2011
Conditions of Participation continuedCoP – Pharmaceutical ServicesCoP – Radiologic ServicesCoP – Laboratory ServicesCoP – Food and Dietetic ServicesCoP – Utilization ReviewCoP – Physical Environment
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CMS 2010-2011
Conditions of Participation continuedCoP – Infection ControlCoP – Discharge PlanningCoP – Organ Tissue and Eye ProcurementCoP – Surgical ServicesCoP – Anesthesia ServicesCoP – Nuclear Medicine
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CMS 2010-2011
Conditions of Participation continuedCoP – Outpatient ServicesCoP – Emergency ServicesCoP – Rehabilitation ServicesCoP – Respiratory Services
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 UNANNOUNCED SURVEY
Prepare for the Next Patient –Not the Next Set of SurveyorsShouldn’t matter if TJC or CMS
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The Joint Commission 2010-2011 SURVEY PROCESS
Tracer Methodology
Sees Care and Services through the patients eyesBrings the surveyor to your various diagnostic areas based on the patient
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The Joint Commission 2010-2011 SURVEY PROCESS
Tracer MethodologyMeasures your systems and processes based on individual patients
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 FORMAT
Standard-The goal you are trying to reachElement of Performance-action step you need to take to reach the goal
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The Joint Commission 2010-2011 MEASUREMENT METHODOLOGY
A = All or nothing
C = Frequency Based Percentage/Occurrence
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The Joint Commission 2010-2011 SCORING
2 = Compliant 90-100% or 1 occurrence
1 = Partial 80-89% or 2 occurrences
0 = Non-Compliant Less than 80% or 3 occurrences
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011Lost Automatic deemed status with CMSProduced additional Elements of Performance to align with the Condition of ParticipationNo SupplementalsRFI’s direct and indirect
= Direct
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIES Rights, Responsibilities, & Ethics
Rights/Responsibilities Posted Patient gets Copy Confidentiality
Board in NuclearComputer Screens Sign in Sheets Registration Areas
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESRights, Responsibilities, & Ethics
Privacy Gowns
Security Personal Belongings
Complaint Process - Grievance
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESProvision of Care
Assessment Data & Information MRI Screening Screening/Assessment Special Procedures/Radiology Interventional Victims of Abuse
Non-inpatient proceduresHistory and Physical
Key Question-Criteria for Identifying Victims
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIES Education
Appropriate to Setting Pain
Restraints Competency for Removing/Replacing Not a Restraint if used During Procedure Monitoring
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESModerate Sedation
AssessmentMonitoringPhysician Oversight (Not Nursing)Post Anesthesia Visit – 48 hours
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIES
Diagnostic TestingPerformed as OrderedTimely MannerRelevant Information Prior to a Test
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIES
Resuscitation
Defibrillators (APR.01.02.01)Crash CartsTackle Boxes
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESLife Safety
Statement of Condition for Health Care OccupancyNPFA – National Fire Protection AssociationFire ExitsSmoke and Fire Doors – PropsPainted over tags
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESMedication Management
Contrast Media (Medication) Proper/Safe Storage- Warmers Orders Written Clearly/Transcribed Accurately Labeling – Injectors Security of MedicationsFirst Dose Review- Protocol Based when Radiology staff is giving – not appropriate if nurse given
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESMedication Management (Continued)
No High Concentrations of ElectrolytesNo Range Orders, No Blanket OrdersOrder driven from an L.I.P.In-house prep of radio-pharmaceuticals is done under the supervision of a pharmacist or MD or DO.
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIES
Medication Management (Continued) Medication errors, adverse drug reactions and medication incapability's reported “immediately” to attending
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIES
Emergency Medications Crash Cart Checks Age Appropriate Contrast Media Response Kits – controlled like crash carts
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESImproving Organizational Performance
Decreasing VariationsEmployee AwarenessSentinel EventsOver-Reads QCFMEA – Failure Mode and Effect Analysis (18 months)
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESLeadership
Same Standard of Care Key Question-Are Things Done the Same Way on Weekends?Integration Across the SystemContract for Outside Sources (Nuclear Med radiopharmaceuticals)
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESLeadership
Vendor Identification/requirements5 Pillars of LeadershipDoctor of Medicine or Osteopathy
Directs Anesthesia and Nuclear Medicine
Director of Radiology and NuclearRecommends qualifications to work as a tech in Radiology/Nuclear – must be approved by the Med Staff (not just directors, but the Med Exec or Medical Staff as a whole)
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESEnvironment of Care
Doors Propped Open BiomedStaff Awareness Cidex with Gludaraldehyde and without GludaraldehydeSafety rounds – find before and they find again – leadership issue
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESEnvironment of Care
Hot Lab Disaster Role Apron/Shields – inventory and consistencyLength of CordsOff Site IssuesManifest, permits
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESHuman Resources
Staffing Medical Staff Orientation- Vendor/ContractorCompetency
Patient Population Specific Performance Evaluations
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESHuman Resources (Continued)
Files Job Description with QualificationsLicense, Registration, Certification (Primary Source)Initial Assessment Ongoing Competency
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIES
Human Resources (Continued)Files
Patient Population Specific Performance Evaluations EducationHealth Screening
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIES
Information Management Confidentiality/PrivacySecurity
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESRecord of Care, Treatment and Services
Verbal OrdersPost Procedure Note-Can’t Be Documented Before the Procedure (APR.01.02.01)Key Question – Do You or Physicians Document Prior to Activities Actually Happening?
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESInfection Control
Hand HygieneCidex pHSterile SuppliesRefrigeratorsWarmers – temperature checks – dates on fluids-based on manufacturers recommendationGel (Based on your own risk assessment)Cleaning of hard objects –follow manufactures recommendations
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIESMedical Staff
Credentials Involvement in PI Peer ReviewFT or PT consulting radiologist supervises ionizing radiology services
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The Joint Commission 2010-2011 KEY FUNCTIONS & COMMON
DEFICIENCIES
Nursing An RN provides or supervises nursing services 24/7
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The Joint Commission 2010-2011 NATIONAL PATIENT SAFETY GOALS
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011NPSG Significant Changes
No new ones for 2010Retained as Goals
01.01.01 Two Identifiers01.03.01 Transfusion Identification02.03.01 Critical Results03.04.01 Label Medications03.05.01 Anticoagulant – changes
- Lab work not specified – now general
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The Joint Commission 2010-2011NPSG Significant Changes
Retained as Goals continued07.01.01 Hand Hygiene07.03.01 MDRO07.04.01 Central Line Infection-
changes-Deleted chlorahexidine-scientific, literature or evidence based practice
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The Joint Commission 2010-2011NPSG Significant Changes
Retained as Goals continued07.05.01 Surgical Site Infection-
changes-does not specify debilitories meet current scientific literature or evidence based practice
15.01.01 Suicide PreventionUniversal Protocol
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011
Entire Goal Integrated with Standard
02.02.01 Abbreviation03.03.01 Look Alike/Sound Alike09.02.01 Falls16.01.01 Early Response
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The Joint Commission 2010-2011
Deleted some requirements and Integrated with Standards
02.02.01 Read Back02.05.01 Hand Off Communication13.01.01 Patient Involvement
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The Joint Commission 2010-2011Deleted
Healthcare Associated Infection as a Sentinel Event
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011
Significant changes…Deletion of EP 1 from NPSG.01.01.01 on two identifiers:
When active patient involvement is not possible or the patient’s reliability is in question, the hospital will designate the caregiver responsible for identity verification.
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The Joint Commission 2010-2011Significant changes…
Burdensome to fieldTwo identifiers on armband more reliable than memory of third party staff memberNote contradicted intent of EP
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The Joint Commission 2010-2011
Significant changes…NPSG.02.02.01 on prohibited abbreviations moved to standards for all programs
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011Significant changes…
NPSG.02.03.01 addressing timely reporting of critical tests and critical results
Field considers confusing and burdensomeRevised to focus on critical test results (as defined by the HCO)
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The Joint Commission 2010-2011Significant changes…
NPSG.02.03.01 continued
Data collection requirements no longer prescriptiveApplies only to Hospital and Lab programs
Infrastructure not available in AmbulatoryNot a major safety concern in BHC, OME, and LTC
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The Joint Commission 2010-2011
Significant changes…NPSG.03.04.01 on labeling medications
EP 7 (which requires HCOs to retain medication vials until completion of procedure) deleted
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011
Significant changes…NPSG.03.04.01 continued
Further review of this goal is expected May be incorporated into MM chapterNeed for two individuals to verify labels under discussion
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The Joint Commission 2010-2011Significant changes…
NPSG.07.01.01 on hand hygiene Modifications are intended to reflect a more realistic approach
Existence of a programGoals and demonstrable efforts to improveNo observation of hand hygiene by surveyors
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The Joint Commission 2010-2011
Significant changes…NPSG.07.02.01 related to HAIs as a sentinel event
Deleted due to redundancy with sentinel event policy
Other HAI requirements were phased in for January 2010
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011
Significant changes…NPSG.16.01.01 related to recognition and response
Moved to standardsFocus is on process for recognition and response and not on a solution
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The Joint Commission 2010-2011
Universal ProtocolRetain focus on safetyMore achievableAddress Main Goals
Correct PatientCorrect SiteCorrect Procedures
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The Joint Commission 2010-2011UNIVERSAL PROTOCOL
Applies to all invasive proceduresReference to minimal risk deletedThree components can readily be incorporated in all sites
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011UNIVERSAL PROTOCOL
Pre-procedureReference to where and when removedTerm checklist changed to standardized list
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The Joint Commission 2010-2011UNIVERSAL PROTOCOL
Site MarkingSome modification for locationSite marking may be delegated
Permitted to participateFamiliar with the patientPresent during procedure
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The Joint Commission 2010-2011UNIVERSAL PROTOCOL
Qualified through residency program, orLicensed and performs duties requiring collaboration and supervisory agreements with LIPs (APRNs and PAs)
Joint Commission 2010-2011 Update for Hospital Imaging Departments
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The Joint Commission 2010-2011UNIVERSAL PROTOCOL
TimeoutPrior to incisionList of issues shortened
Correct PatientCorrect SiteCorrect Procedure
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ReferencesThe Joint Commission, 2010-2011 The Joint Commission on Accreditation of Healthcare Organizations, Department of Publications Joint Commission Resources, Oakbrook Terrace, Illinois, 2010-2011 http://www.jointcommission.org/patientsafety
CMS 42 Code of Federal Regulations 482http://www.access.gpo.gov/nara/cfr/waisidx_04/42
cfr482_04.html
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Thank [email protected]
McKenna ConsultingPost Office Box 3187Charleston, WV 25332
304-988-1047