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Webinar: USP <800>: Hazardous Drug Compliance and Safety in 2018

Presented on: 1:00-2:30 p.m. EST, Monday, October 30, 2017  

Presented by: Patricia C. Kienle, RPh, MPA, FASHP

Level of Program: IntermediateHCPro Webcast Icon

Who should listen: Accreditation specialists, regulatory officers, safety officers, pharmacists, and any healthcare staff who work with hazardous drugs

Registration: https://hcmarketplace.com/usp-800-drug-compliance-safety-2018 

Summary: Making drugs is risky business, even when it’s done in hospital pharmacies. From the person carrying the chemicals from the loading bay to the person doing the actual mixing, improper exposure to hazardous medication compounding substances can have lasting and devastating health effects.

On December 1, 2019, the U.S. Pharmacopeial Convention’s (USP) Chapter <800> will become fully enforceable by regulators. This chapter addresses the physical environment and equipment needed to maintain sterility and protect the 8 million healthcare workers potentially exposed to hazardous vapors and particles each year. USP is expected to be adopted by many regulators and accreditors, such as state pharmacy boards and The Joint Commission.

 

Join expert speaker Patricia C. Kienle, RPh, MPA, FASHP, for this 90-minute webinar, as she dives into the different types of hazardous drugs and the requirements for compliance. Kienle will also teach participants how to perform an Assessment of Risk and how to stay safe when handling hazardous drugs.

 

Registration is still open, sign up now!

 

 

George Mills is leaving The Joint Commission

The Joint Commission confirmed Thursday afternoon that a key figure in standards interpretation for the healthcare accrediting organization will be departing this fall.

George Mills, MBA, FASHE, CEM, CHFM, CHSP, who has served as director of the organization’s engineering department for the past six years, will leave his post effective October 9. Mills has been with The Joint Commission for 14 years.

“During his tenure he has served as an advocate for healthcare organizations as they strive to improve the quality and safety of their physical environments,” a spokesperson for The Joint Commission said in an email.

The confirmation came after HCPro’s resident hospital safety expert, Steve MacArthur, safety consultant for The Greeley Company, blogged Thursday on murmurings of an impending Mills exit. The Joint Commission also confirmed MacArthur’s report that John D. Maurer, SASHE, CHFM, CHSP, will take over as acting director of engineering on an interim basis.

“I don’t anticipate that this will engender a significant change in how business will be conducted, including the practical administration of the Life Safety portion of the accreditation survey process,” MacArthur wrote, noting that he has always found Maurer to be “thoughtful, helpful, and equitable.”

Beginning October 9, Maurer will serve as acting director while a search for Mills’ successor is undertaken, the spokesperson said. Mills declined Thursday to comment on his forthcoming departure, and Maurer could not be reached.

 

Crucial accreditation deadlines on the horizon for pain management and emergency preparedness

Time is running out to meet the new emergency management (EM) Conditions of Participation (CoP) and The Joint Commission’s revised pain management standards. The EM Interpretive Guidelines go into effect on November 15 while the pain management standards go into effect January 1.

Emergency management

The new EM CoPs fill gaps CMS’ previous regulations by compelling hospitals to communicate and coordinate their emergency plans with other healthcare organizations and government agencies. They also require regular emergency preparedness training with staff and disaster contingency planning.

Steve MacArthur, a safety consultant at The Greeley Company, pointed out that a lot of the new requirements include things that hospitals should have already been doing.

“While this rule is new to the ‘marketplace,’ there are really no new concepts contained therein,” he says. “This may provide some guidance for CMS surveyors as they drill down on organizational preparedness activities. But none of this is groundbreaking or in any way representative of a change in how hospitals have done, and will continue to do, business. [It’s] just another set of official ‘eyes’ looking through the compliance microscope.”

Pain management

The Joint Commission prepublished its new pain management standards back in June. The accreditor said it used the revision to address disparities between its standards and what the literature recommended. Some of the changes include:

•    Enabling clinician access to prescription drug monitoring program databases

•    Performance improvement activities focusing on pain assessment and management to increase the safety and quality for patients

•    Identifying the leader or leadership team responsible for pain management and safe opioid prescribing

•    Involving patients in developing their treatment plans and setting realistic expectations and measurable goals

•    Identifying and monitoring high-risk patients as a way to promote safe opioid use

Facilities should assign teams to research best practices in pain management, get the medical staff working on revising protocols and deter¬mining how to gather data on pain management effectiveness, and alert your information technology and electronic health records experts that they will be needed.

The annual fire and smoke door testing requirements will also be due by January 2018.

Fire and smoke: CMS clarifies which doors must be inspected annually

After pushback, federal officials backed away from their claim that smoke barrier doors must be inspected and tested annually.

More than three weeks after a well-publicized compliance deadline passed, CMS announced Friday that the deadline would be pushed back nearly six months, giving facilities until New Year’s Day 2018 to comply with an annual testing requirement for certain doors.

David Wright, director of the CMS Survey and Certification Group, made the announcement in a memo to state survey agency directors. He acknowledged that there had been a fair amount of confusion concerning the change, and he offered some pretty consequential clarifications that could affect whether the new requirement applies to your facility at all.

“[C]onsidering the level of reported misunderstanding of this requirement, CMS has extended the compliance date for this requirement by six months,” Wright wrote.

Within the National Fire Protection Association’s (NFPA) 2012 Life Safety Code® (LSC), which CMS adopted last year, there is a requirement that fire doors and smoke barrier doors be tested annually. Officials with CMS had taken the position that the new requirement applies to healthcare occupancies; that position, however, was met with pushback.

A petition objecting to the CMS position was discussed at length in June by members of the NFPA Healthcare Interpretations Task Force (HITF), says Brad Keyes, CHSP, owner of Keyes Life Safety Compliance. That petition objected to the notion that the LSC specifically requires annual inspections of smoke barrier doors in healthcare occupancies.

“The HITF members did discuss the issue and agreed that healthcare occupancies were exempt from complying with section 7.2.1.15.2 … because the healthcare occupancies did not specifically require compliance with that section,” Keyes says in an email.

The committee decided to table its decision on the matter to give CMS an opportunity to review its position, as it did, Keyes says.

“I am pleased that the system worked in favor for the many hospitals that are certified by the Federal agency,” he adds.

Although the LSC does include provisions requiring annual inspections of smoke barrier doors and fire doors alike, section 7.2.1.15.1 states that these standards apply only where required by Chapters 11–43. Since the chapters governing healthcare occupancies make no direct reference to Section 7.2.1.15.1, the door inspection provisions do not apply to healthcare occupancies, Wright acknowledged in his memo.

Based on that conclusion, Wright spells out a few key takeaways:

  1. Fire doors. In healthcare occupancies, all fire door assemblies must be inspected and tested annually in healthcare occupancies, based on section 8.3.3.1 of the 2012 LSC, which applies to all occupancies.
  2. Smoke barrier doors. Non-rated doors (including smoke barrier doors and corridor doors to patient care rooms) aren’t subject to the annual inspection and testing requirements, but they “should be routinely inspected as part of the facility maintenance program.”
  3. Deadline. The compliance deadline has been pushed back from July 6, 2017, to January 1, 2018.
  4. Citations. Any LSC deficiencies related to annual fire door inspections should be cited under K211—Means of Egress—General.

But what if a healthcare organization was already cited at some point during the three-week gap between the original compliance date and the clarifying memo (July 6–28) for a failure to conduct an annual test of its smoke doors? Multiple CMS representatives did not respond to requests for an answer. Keyes says CMS has been a stickler in the past, holding that a finding cannot be removed once it is written on a survey report.

“There was an accreditation organization [AO] that used to allow findings to be removed from their survey report if the hospital could demonstrate compliance at the time of the survey,” Keyes says. “CMS has said that the AOs may no longer remove findings, even if the hospital was compliant at the time of the survey.”

The Joint Commission stated in the July edition of Perspectives that it requires annual testing for fire door and smoke door assemblies alike, despite acknowledging that the healthcare occupancy chapters don’t cite section 7.2.1.15 specifically. (To support the requirement, The Joint Commission noted that Section 18/19.2.2.2.1 references section 7.2.1, and cited a belief that the annual tests are beneficial.)

Keyes adds a word of caution: “The AOs are not locked into complying with everything CMS says or does. The AOs may have standards that exceed what CMS requires.”

That means the guidance in Wright’s memo might not trickle down to the AOs and state agencies that conduct surveys at your facilities, especially considering how widely advertised the original compliance date has been.

“So, I suspect many of the AOs will keep the start date at July 5, 2017, since they are already enforcing that,” Keyes says.

With that in mind, he recommends that all healthcare facilities have their fire doors tested as soon as possible, rather than waiting until the new deadline—because another authority having jurisdiction might keep to the stricter timeline.

Joint Commission revises Medication Management EPs

The Joint Commission has revised Medication Management elements of performance (EP) for several of its programs. The changes will go into effect on January 1, 2018 and will impact hospitals, ambulatory care, behavioral care, home care, nursing care centers, critical access hospitals, and office-based practices accredited by The Joint Commission. The revisions will require organizations to:

•    Record the date and time of any medication administered in the patient’s clinical record.
•    Implement a policy to provide emergency backup for essential medication dispensing equipment and for essential refrigeration for medications.
•    Have a written policy addressing the control of medications between when they are received by a provider and given to a patient. Those policies should now include what to do for the “wasting of medications.”
•    Implement a policy describing the types of medication overrides for automatic dispensing cabinets that will be reviewed for appropriateness and the frequency.

The revisions vary depending on the program.

Uniqueness is not unique

Editor’s Note: This is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

With all the regulatory and reimbursement changes occurring in our industry at an ever-increasing rate, one thing is for certain: Your organization is not unique.

When speaking to organizations, I often hear things like, “Well, we don’t have the resources that the university hospital has” from community hospitals and then the university hospitals will say things like, “We aren’t as nimble as those community hospitals.” It’s frustrating and ultimately self-defeating. It creates a semi-plausible excuse that permits low performance, and it must be stopped.

I see it in everything from patient experience, core measures, throughput, and profitability. “We are unique,” “Our patients are sicker,” “Our payer mix is bad,” “We have more psych patients,” “We have more beds,” and the list goes on and on.

The reality is that all hospitals are facing the same issues at the same time and those that are top performing do not allow themselves to take this mindset. Simply put, none of our organizations is unique.

Imagine if we took that same mentality when it came to treating patients. If clinicians second-guessed every cardiac rhythm that came across a monitor, think of the conversations between cardiologists. “Maybe ventricular fibrillation is good for this patient. I mean it’s not like he looks like the last guy who had it.” It is an absurd example that makes my point.

Hospitals can argue about the metrics and the systems in place for a millennium, doctors can debate the efficacy of the data points and whether things are “good measure” and that is healthy. However, the reality is just because you don’t like it doesn’t mean you are allowed to not do it or succumb to the idea that it is an impossible goal based solely on the fact that “your hospital is different.”

The metrics in healthcare are to create as level a playing field as there can be while trying to ensure high-quality care at reasonable or decreasing costs. Is it perfect? No, it is not, but it’s a start and part of the calling of being in medicine.

Clinicians don’t come to work expecting to provide bad care. In all my experience, I have never met a clinician that had that motive. The excuses come when compared to similar organizations and not performing well. The excuses come from everywhere rather than focusing on the core issue of poor performance.

Top-performing entities move through the Kübler-Ross 5 stages of grief faster and focus on the acceptance. Once that happens and the organization gets past its uniqueness, true organizational change can begin.

When dealing with an issue that causes your organization to lament how different it is to the standard, try these techniques. Allow the leaders an unadulterated complain fest. It’s a period of time not to last more than a day where complaining and feeling sorry for yourself is encouraged, get it all out on the table. It’s unfair, they don’t like us, and so on. Get all the negativity out in one moment of time. Grieving is natural and needs to happen. People in organizations need to feel like they are being heard and empathized with.

Next, require all the leaders to come up with short action plans that will move the organization forward. It does not have to be a total change in how you do business, but it starts the momentum going in the correct direction. This is not easy, and requires a substantial amount of effort. It shifts the energy in a positive direction and is the first essential step toward making a positive difference. Finally, reward and recognize people and departments making the gains, and the ones that are putting forth a strong effort.

The data is never perfect. There will always be concerns about percentiles, and comparative measures for everything we do in healthcare. Accepting it and focusing on the care each patient receives every time is the single most powerful curative tool an organization has in its armory. Doing the right thing, the right way, for the right reasons will always be correct, regardless of what the metric is.

Editor’s note: Patrick Pianezza, MHA, has worked with the Studer Group and Johns Hopkins Hospital. In his most recent role, Pianezza’s work drove organizational performance in Hospital Consumer Assessment of Healthcare Providers and Systems. to an all-time hospital best in the 90th percentile. He can be reached at ppianezza@gmail.com.

Maintaining security during a Joint Commission survey

Facilities often have questions when surveyors come to visit. Some of the most frequently asked questions involve security and confidentiality, how to make sure surveyors see what they need to without violating hospital safety. In the July issue of Perspectives, The Joint Commission answered some of the most frequent questions.

Access to Computer Systems: Surveyors will sign security agreements with the facility in order to receive a user ID and password to access a computer system (for example, in order to review policies and medical records) if the facility requires it.

Confidentiality Agreements: If a facility wants surveyors to sign a confidentiality agreement, then that agreement has to be sent to the Joint Commission Central Office for review before the survey.

That said, asking surveyors or reviewers to sign an agreement is unnecessary, according to The Joint Commission. Accreditation and certification contracts, plus the Business Associate Agreement between The Joint Commission and the facility, already bind individual surveyors and reviewers to confidentiality.

Security Sign-In: If a facility requires visitors to sign into the building as part of the organization’s regular security process then surveyors will sign in too. In lieu of asking to copy a surveyor’s driver’s license, Joint Commission badge, or any other form of ID, facilities should refer to surveyors’ pictures and biographies on the Joint Commission Connect™ secure extranet site.

Videotaping Survey Activities: Videotaping or recording any part of a survey or review, including the exit conference is forbidden.

Joint Commission: Six EPs deleted for Critical Access Hospitals

Later this year The Joint Commission will delete six elements of performance (EPs) from the Distinct Part Unit (DPU) standards for Critical Access Hospitals. The accreditor says this will streamline the standards and the changes go into effect on September 24, 2017.

The deleted EPs are from the Medical Staff, Leadership, and Rights and Responsibilities of the Individual chapters. You can read all six standards at the Joint Commission website. Those with questions can contact Laura Smith, MA, Joint Commission project director at lsmith@jointcommission.org.

https://www.jointcommission.org/standards_information/prepublication_standards.aspx

The Focused Standards Assessment tool goes temporarily offline in July

The Focused Standards Assessment (FSA) tool on The Joint Commission’s Intracycle Monitoring (ICM) Profile will be taken offline from June 30, (5:00 PM Central Time) through  July 10 (9:00 PM CT)

The FSA is an interactive standards self-assessment tool for facilities that lists the standards applicable to each organization’s accredited programs and services. An extension due date will be set to Monday, July 24, 2017 for facilities with an ICM submission date between July 1 and July 10.

https://www.jointcommission.org/facts_about_the_intracycle_monitoring_process/

Joint Commission Updates on HAI-related National Patient Safety Goal on HAIs

The Joint Commission has revised several of its requirements for National Patient Safety Goal (NPSG) 7, which focuses on the issue of healthcare-associated infections (HAI). The revisions go into effect on January 1, 2018, and apply to hospitals, critical access hospitals (CAH), and nursing care centers (NCC).

NPSG 07.03.01: Multidrug-resistant organisms (MDRO)

•    NCCs are now expected to follow the MDRO NPSG.07.03.01. Nursing homes experience a high rate of MDROs such as methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). This was particularly concerning because nursing home patients were bringing MDROs to hospitals and vice versa.
•    The Joint Commission is adding a new infection, carbapenem-resistant enterobacteriaceae (CRE) to NPSG.07.03.01. This change applies to hospitals, CAH, and NCCs.

NPSG 07.04.01: Central line-associated bloodstream infections (CLABSI)

•    The EPs for the NPSG 07.04.01 have been reordered.
•    EP 11 was revised to specify the use of chlorhexidine for antiseptic skin preparation.
•    For both NPSG 07.03.01 and NPSG 07.04.01, facilities are now allowed to determine how frequently they need to re-educate staff and licensed independent practitioners on MDROs and CLABSIs.