News from Executive Briefings #6: Category A vs. C Elements of Performance

Pat Adamski repeated Joint Commission’s intent to have A elements of performance relate to policies and processes and have C elements of performance reflect actual practice. She indicated that this should be reflected in all standards, including the safety goals.

Our review shows a very high number of category A safety goals related to actual practice. We intend to bring these discrepencies to Pat’s attention in the near future.

News from Executive Briefings #5: Reminder … Baseline Culture Survey Due Soon

Pat Adamski reminds us that the new Leadership Chapter requires the completion of a baseline assessment of the culture of safety by January 1, 2009. The time frame for reassessment is open, meaning the findings and actions will determine when a second look is appropriate. She also reminds us that a validated tool is available at http://www.ahrq.gov/qual/hospculture/.

Thank you Pat!

News from Executive Briefings #4: All Safety Goals to be Reconsidered in ‘09

Dr. Angood announced this intention to review the effectiveness and appropriateness of the National Patient Safety Goals over the next year. Our advice: look for your opportunity to participate.

News from Executive Briefings #3: Questions About FAQs

Dr. Angood apologized for the tardy June 28, 2008 release of the FAQs for the goals that became effective on January 1, 2008. Angood explained that the delay was due to the redesign of the FAQ process. He did not address the three-month delay between their development and their publication (from March to June). [more]

News from Executive Briefings #2: Documentation of Time Out

In the Chicago session of Hospital Executive Briefings, Dr. Peter Angood, the Joint Commission’s Vice President and Chief Medication Safety Officer, indicated that only minimal documentation is required for the time out and the use of a check list prior to transporting the patient from the preparation area to the procedure room. For example, the hospital must document that the time out occurred, but need not go into the details as to what was said or who was involved.

CAUTION: Verbal representations are often not worth the paper they are written on. Ask for and wait for a written response (e.g. FAQ) before changing anything big.

News from Executive Briefings #1: “D”s Will Not Change

Although there may be some errors, the “D”s [indicating that documentation is required] for the new standards will remain as written in the current version of the manual according to Dr. Robert Wise, Vice President for the Division of Standards and Survey Methods for the Joint Commission. Although he acknowledges that there may be errors, Dr. Wise committed that, until they change, documentation is not required unless there is a Circle D logo in the accreditation manual.

We will be preparing a list of those things where, although one would think that documentation may be a good thing, it apparently won’t be required. Stay tuned.

No Shortage of Category “A” EPs Based on Performance

When the Standards Improvement Initiative was rolled out recently by Joint Commission the official stance was that Category A elements of performance primarily required a process and that requirements for the execution of that process were relegated to related Category C EPs with 90% being full compliance. Official presentations added that there were some issues where a Category A EP might pertain to implementation, but these were very few and primarily due to an underlying regulatory requirement. Well, sad to say, that doesn’t seem to be the case. [more]

What’s in Your Warmer?

Many times surveyors site hospitals under the Medication Management Standard MM.2.20 under either EP 2 (medications are stored under suitable conditions for stability) or EP 9 (medications are accurately labeled with contents, expiration dates and warnings) when IV contrast or other IV fluids are found in a fluid warmer with expired dates or without dates of expiration listed. Sometimes (although not as frequently as one would think), the joint commission is correct in rendering the citation when fluids are warmed, with the increased temperature accelerating the expiration date, and the hospital has not indicated the accelerated date, or, has done so and the date has expired without removal of the fluid from the warmer. HOWEVER, often hospitals are inviting trouble with their own policies on warmed fluids or contrast media. Not all contrast media accelerates its expiration date when warmed. The same is true for some IV fluids. The key is to review the manufacturer’s recommendations for storage which includes warming of fluids and other temperature information. If the manufacturer’s recommendations (insert pamphlet) do not discuss warming or cooling of the fluid or contrast, there is no reason to believe warming or cooling would alter the stability or accelerate the expiration date. In these instances, the [more]

Recover From Your Addiction to Long Policies

There are truly only a handful of policies that consistently get organizations into trouble with regulators. This is usually because these key policies go into unnecessary detail or, because a surveyor told us we “had to,” we painted ourselves into a nice little corner. We urge you to break the habit now. Much like other 12-step programs, the first step is to admit you have a policy problem. [more]

Hand Hygiene Tip #2: Count Opportunities, Not Observations

Tip #1 (posted last week) urged you to formally adopt the CDC rather than the WHO hand hygiene guidelines. In this tip, we will offer a few pointers about how to count hand hygiene compliance.

How many opportunities are there in the following scenario? A care giver dons gloves, touches the patient’s intact skin, removes gloves, moves the IV stand to a new position and leaves the room. Was it A: 1 opportunity, B: 2 opportunities, C: 3 opportunities, or D: 4 opportunities? … I’ll wait while you read this again. Ready? OK … the correct answer is B … 2 opportunities: 1. before contact with the patient and 2. after removing the gloves. What about after touching the IV pole? This is a category II recommendation by CDC and not required (if you’ve chosen CDC over WHO). What about before leaving the room? No one actually requires that. [more]