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The Joint Commission Medication Management Standards Update 2016CHS Pharmacy Education Series

ProCE, Inc.www.ProCE.com 1

2016 Pharmacy Education Series

March 16, 2016Th J i t C i i M di ti M t St d d U d t 2016The Joint Commission Medication Management Standards Update 2016

Featured Speaker:Jeannell M. Mansur, RPh, PharmD, FASHP, FSMSO, CJCPPrincipal Consultant, Medication Management and SafetyJoint Commission Resources/Joint Commission International

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2016 Pharmacy Education SeriesMarch 16, 2016

The Joint Commission Medication Management Standards Update 2016

Featured Speaker:Jeannell M. Mansur, RPh, PharmD, FASHP, FSMSO, CJCPPrincipal Consultant, Medication Management and SafetyJoint Commission Resources/Joint Commission International

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It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. All of today’s presenters have no relevant commercial and/or financial relationships to disclose.

Please note: The opinions expressed in this activity should not be construed as those of the CME/CE provider. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature.

CE Activity Information & Accreditation

ProCE, Inc. (Pharmacist CE)

– 2.0 contact hours

Funding:This activity is self‐funded through CHSPSC

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This activity is self funded through CHSPSC.



2016 Joint Commission Medication Management StandardsMedication Management Standards

Update

March 16, 2016

Jeannell Mansur, R.Ph., Pharm.D., FASHP, FSMSO, CJCP

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Jeannell Mansur, R.Ph., Pharm.D., FASHP, FSMSO, CJCP

Principal Consultant, Medication Management & Safety

Joint Commission Resources

[email protected]

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Learning Objectives

– Identify at least one key issue found on survey relating to the top four challenging medication management standardsmanagement standards

– List recommendations to assess and address opportunities to improve safety with the use of electronic medical records and computerized prescribing applications

– List recommendations for evaluating a medication ili ti ’ ff ti

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reconciliation program’s effectiveness

– Identify at least 2 key areas where medication reconciliation performance improvement initiatives are often beneficial

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MM.03.01.01 EP24 Radiopharmaceuticals

MM.03.01.01 EP24

A 24 F h it l th t J i t C i i A 24. For hospitals that use Joint Commission

accreditation for deemed status purposes: The

hospital maintains records of the receipt and disposition

of radiopharmaceuticals.

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(effective 7-2.14)

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Revision to Labeling Requirement NPSG.03.04.01 EP3

In perioperative and other procedural settings both on and

off the sterile field, medication or solution labels include the

following:

- Medication or solution name

- Strength

Amount of medication or solution containing

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- Amount of medication or solution containing medication (if not apparent from the container)

- Diluent name and volume (if not apparent from the container)

- Expiration date/time

(effective 1-1-15)10



Medication Samples and New Language by TJC

Announced December, 2013 Effective: July 1 2014 Effective: July 1, 2014“Note: This element of performance is also

applicable to sample medications” Accreditation Programs which have Sample

Medication requirements

H i l C i i l A H i l

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Hospital Critical Access Hospitals

Ambulatory Behavioral Health

Home Care Office Based Surgery

Applicable Standards for Sample Medications

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Recommended Strategies if You Allow Samples

– Policy (see sample checklist tool provided with your handout)with your handout)

– Who Dispenses?

– Labeling

– Playing the pharmacist.

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SEA 54: Safe Use of Health Information Technology

SEA 42: Safe implementation of Health Information

and Converging Technologies 2008and Converging Technologies- 2008

SEA 54: Safe Use of Health Information Technology-

March 31, 2015

120 sentinel events from Jan 2010- June 2013 –

health IT related

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health IT related

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8 Dimensions relating to Health IT performance

– Human factors interfaces with computer– Human factors interfaces with computer

– Workflow and communication

– Clinical content including decision support

– Internal organization policies and safety culture

– Performance issues relating to training and failure to follow procedures

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– Hardware/software

– Vendor and other external issues

– System measurements and monitoring

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Key areas for focus of activities to address

– Safety culture– Safety culture• Reporting

• Evaluating each adverse event for potential IT link

• Shared accountability between vendor and HCO

– Performance improvement• Downtime

• Standardized coded elements- allergies problem lists

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• Standardized coded elements- allergies, problem lists, diagnostic tests

• Extensive testing before go-live

• Training

• Order sets

• Forcing functions to mitigate wrong patient errors16




Key areas for focus of activities to address

– Performance improvement continued– Performance improvement continued…• Maximize use of EHR to order meds, tests, and

procedures

• Clinical oversight over delegated clinical tasks

• Provide patients with access to their electronic records

– Leadership• Chose vendors which interface easily and support

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Chose vendors which interface easily and support cognitive work of clinicians

• Involve front line staff in planning

• Examine workflows for failures points

• Make changes in a controlled fashion

• Use metrics to monitor performance17

Recommendations for SEAs

Published by the Joint Commission when significant

safety events occur to alert the fieldsafety events occur- to alert the field

Prescriptive recommendations

Your opportunity to look at your own processes

Key role for medication safety leader – SEAs that

interface medication processes

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interface medication processes

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Medication Management- Top Non-Compliant Standards/NPSGs for Hospitals (Jan-June, 2015)

Standard/NPSG % Non‐compliant

MM.03.01.01 Storage and Security of Meds 32%

MM.04.01.01 Medication Orders 25%

MM.05.01.01 Medication Order Review 18%

NPSG.03.04.01 Labeling in OR/procedures 9.9%

MM.05.01.07 Preparing medications 5.4 %

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NPSG.03.06.01 Reconciling Medications 4.3%

MM.01.01.03 High alert /Hazardous Meds 3.7%

MM.03.01.03 Emergency Medications 3.3%

MM.01.02.01 Look alike sound alike Med 3.1%19

MM.03.01.01 Medication Storage and Security

Problematic EPs:– EP 2: medications are stored according to manufacturer’sEP 2: medications are stored according to manufacturer s

recommendations– EP 3: all medications and biologicals are stored in secure areas

to prevent diversion and locked when necessary, in accordance with law and regulation

– Failure to address diversion– EP 6: the hospital prevents unauthorized individuals from

obtaining medications in accordance with law and regulation– EP 7: all products are labeled with contents, expiration date

(Bulk Packaging- Imaging)

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(Bulk Packaging Imaging)– EP 8: removes expired, damaged, and/or contaminated

meds/stores separately– EP 10: most ready to administer form or repackaged by

pharmacy (Bulk OTC)CoP Pharmaceutical Services 482.25

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Medication Orders- MM.04.01.01

Problematic EPs:

– EP 13: the hospital implements its policies for– EP 13: the hospital implements its policies for medication orders

Failure to clarify unclear, illegible and incomplete orders

Consistency in interpreting range orders

Lack of indication on PRN orders

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Lack of special precautions for ordering LASA medications

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Standing Orders/Protocols and Order Sets

MM.04.01.01 EP 15 Requirements clearly specified Medication orders initiated by RN prior to LIP

order requires approval by MD, RPH and CNO Developed using nationally recognized and

evidence based guidelines Regular review to determine continuing

usefulness and safety Dating, timing and authentication according to

l b l h i l li i

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law, bylaws or hospital policies

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Adjustment of Medications by non-LIPs Therapeutic substitution

Protocols

Non/off-protocol optimization

CMS considerations

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

New Credentialing and Privileging Resource Center

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Center http://www.ashp.org/menu/PracticePolicy/ResourceCenters/Credenti

aling-and-Privileging-Resource-Center

Pharmacist review of Medication Order MM.05.01.01

A pharmacist reviews the appropriateness of all

medication orders for medications to be dispensed in the

(cont’d)

medication orders for medications to be dispensed in the

hospital

– CoP Pharmaceutical Services 482.25(b)

– Problematic EPs:

• EP 1: pharmacist reviews all medication

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porders/prescriptions before dispensing/removing from floor stock or automated dispensing device

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Building a Better Override Assessment Process Override review process should assess

Urgency of situation or presence of LIP g y p“at bedside” Trends Medications Time of the day Users of override process

Presence of a medication order

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Barcode scanning of medications removed

Override rate

Multiple Choice Orders- Low Hanging Fruit

• Medication orders reviewed for:

–EP 7: therapeutic duplicationEP 7: therapeutic duplication

»Morphine 2 mg IV every 10 min PRN pain

»Tylenol #3 1 tablet every 4 hours PRN pain

• EP 11: after review all concerns issues

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• EP 11: after review, all concerns, issues, or questions are clarified with the individual prescriber before dispensing

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Auto-Verification: What is TJC position?

• Auto-verification is a process that is part of the functionality of some EMR vendors that yallows, depending on how it is set up by client, to allow access to medications without a pharmacist review

• Use of auto-verification in some settings where pharmacist review has been required

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• In conflict with MM.05.01.01 EP 1 and not an acceptable alternative to the required RPH review of order

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MM.05.01.07 Pharmacy Preparation of IV admixtures

Intent: To move IV admixture preparation out of the

nursing unitnursing unit

Consider where IV admixtures might be prepared

outside the pharmacy

Pharmacy should consider ways to make IV

admixtures available when needed without admixture by

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admixtures available when needed without admixture by

nurses

– These are not exceptions:

• Non 24/7 pharmacies; ORs; off-site clinics

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MM.03.01.03 Emergency Medications

• Determination of contents

• Process for ensuring availabilityProcess for ensuring availability• Replenishment

• Separate packaging of pediatric from adult medications in combined cart

• Ready to administer dosage forms

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MM.05.01.11 Safe dispensing of medications

Medications are dispensed in the most ready to Medications are dispensed in the most ready-to-

administer forms commercially available and, if feasible,

in unit doses that have been repackaged by the

pharmacy or licensed repackager. (also MM.03.01.01

EP10)

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EP10)

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High Alert Medication StrategiesMM.01.01.03

How have you defined these?

How have you defined strategies for reducing risk? How have you defined strategies for reducing risk?

How have you disseminated information about risks

and new processes

Recommendation: Address the specific risks of each

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Recommendation: Address the specific risks of each

high alert medication on your list

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Hazardous Medications Requirements are included in MM.01.01.03; EC.01.01.01,

EC.02.02.01, EC.04.01.01, as well as LD, LS, and EM

references

Need a list! (MM.01.01.03)

Defined by NIOSH - revised 2014

Strategies to protect those who come in contact– PPE– Other Primary engineering controls

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y g g– Processes– Training

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Look Alike Sound Alike Medication Strategies (MM.01.02.01)

Consider multiple concentrations of the same

medicationmedication

Have you defined policy on ordering LASAs?

Recommendation: Address display of LASA via

Tallman lettering, use of brands or indications; address

storage via restriction, separation, labeling

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storage via restriction, separation, labeling

Instruct on how TallMan lettering works

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Hot Labs-

– Hot labs• What is being done• What is being done

• Procedures

• Non-radiopharmaceuticals

• Medication storage–Storage and security of

R di h ti l J l 2012

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Radiopharmaceuticals, July 2012 Perspectives

– Inspection of medication storage

• Formulary – what is being purchased and used? 34



Medication Reconciliation: Focus on Quality

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NPSG.03.06.01Reconciling Medication Information

Components of the Revised Goal Collecting information on the home medications

– “Good faith” effort– Reconciliation with medications ordered in the

hospital Transfer of patient- and reconciliation of medications

– No longer specifically part of this NPSG– Update medications in medical record part of

RC.01.01.01 and RC.02.01.01

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RC.01.01.01 and RC.02.01.01 Discharge process

– Provide discharge medication information to patient– Added responsibility of patient to maintain list and

to communication to PCP– No requirement for the hospital to provide list to

next provider of care



NPSG.03.06.01Reconciling Medication Information

Components of the Revised Goal continued… Non-24 hour settingsg

– Must perform if changes in medications taken at home could occur; or if medications might be given during the encounter

– Organizations can define the medication information they require to be collected• Allows tailoring process for specific

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g p psettings

Points of Error in Medication Reconciliation©

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Performance Improvement Focus

The Quality of the Medication List

– Who should develop the list– Who should develop the list

– What can enhance the quality of the list• Software

• Claims data from community pharmacies

• Interviewing skills

• Training

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The Quality of the Reconciliation Process

– Clear delineation of accountability– Clear delineation of accountability• Auditing to confirm

– Involvement of a 2nd set of eyes to assist in problem identification

– Clinical decision support/tools

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The Development of the Home Medication List at

DischargeDischarge

– Clear display of in-hospital and admission home medications for consideration

– Additional expertise to address home meds not prescribed in house and potential issues with continuing

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– Resources to evaluate potential insurance issues with new medications prescribed

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Making sure the patient understands the medications

he/she will take at homehe/she will take at home

– Discharge teaching doesn’t start 15 minutes before discharge

– Assessment of patient needs, willingness to learn

– Use of supplemental tools to support understanding

– Teach-back method

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Teach back method

– Clear description of what medications are new, which are being changed or discontinued, and which are staying the same

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Medication-related Contracted Services

Outsourcing to compounding pharmacies

– TPNs other compounded sterile admixtures– TPNs, other compounded sterile admixtures

– Batch preparations

– Specialty custom products

These services provide care, treatment and services to

patients (direct patient care)

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Contracted Services Expectations:LD.04.03.09

Clinical leaders and medical staff have input as to

source for outsourced servicessource for outsourced services

Written description of scope and nature of outsourced

services in contract

Expectations for performance provided by hospital

according to defined measures provided to provider

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Performance is monitored

Steps taken to correct identified performance problems

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Joint Commission and Compounding

Survey process

State requirements State requirementshttp://www.criticalpoint.info/Statemap/story.html

Chemotherapy compounding EC.02.02.01 EP 9,10 Preventing exposure to

hazardous materials

EC 02 05 01 EP15 Appropriate pressures

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EC.02.05.01 EP15 Appropriate pressures

Joint Commission and Compounding

Changes in TJC processes Home Care in place Home Care- in place

Hospital- anticipated

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Antimicrobial Stewardship

Presidential Call to Action

CDC recommendations:

http://www.cdc.gov/vitalsigns/pdf/2015-08-vitalsigns.pdf

Joint Commission participation in White House Forum;

pledged commitment to promote antimicrobial

stewardship activities

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Field review for new standard on antimicrobial

stewardship completed- expect to see in 2016, to be

surveyed January, 2017

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Disclaimer

These slides are current as of February 28, 2016. The Joint Commission reserves the right to change the content of the information as appropriatecontent of the information, as appropriate.

These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

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These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or Joint Commission Resources.

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Questions

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2016 MEDICATION MANAGEMENT UPDATE

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MANAGEMENT UPDATE

Tackling Our Problems ToProblems To

Resolve Them



Program Objectives• Identify the most problematic Medication Management

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Medication Management standards in 2015 for our associated facilities

• Outline areas of focus and issues to be addressed for each of those identified problematic standardseach of those identified problematic standards

• Discuss actions to resolve the issues and enhance compliance to the identified problematic standards

Most Problematic MM Standards - 2015

The majority of our MM RFIs were cited at:

• MM.03.01.01- relates to safe storage of

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medications in compliance with law, regulation and manufacturer’s guidelines (EPs 2-8 & 18)

• MM.04.01.01- relates to clear, complete and accurate medication orders to enhance communication between all participants in the medication management process (EP 1 3 6 9 13 d 15)(EPs 1, 3, 6-9, 13 and 15)

• MM.05.01.01- relates to the pharmacist’s review of the appropriateness of medication orders for medications that are to be dispensed in the hospital (EPs 1, 8, 13)



Historical Perspective

2013 2014 2015

• Over the past 3 year accreditation cycle all

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2013 2014 2015

MM.03.01.01

20 29 17

MM.04.01.01

36 29 41

MM 05 01 01

accreditation cycle, all three of these standards have been problematic for our facilities

• While there has been dramatic improvement in

MM.05.01.01

1 22 8the outcomes for MM.03.01.01 and MM.05.01.01,but that is not true for MM.04.01.01

MM.03.01.01 – Areas of Focus• Special storage conditions

• Medications in warming cabinets

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• Refrigerated medications

• Monitoring conditions 24/7

• Temperature logs with temperatures out of acceptable range without recorded actions

S f• Securing medications from unauthorized access• Locking storage areas v. continuous supervision

• Disposal of controlled substances

• Securing prescription pads



MM.03.01.01 - Areas of Focus

• Expired medications

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• Dating multidose containers upon opening

• Expired medications that remain accessible for administration

• IV bags removed from overwraps or stored in warmers without revised expiration dates

Improving MM.03.01.01 Outcomes• Ensure your written policy on medication storage

addresses all elements of storage

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g• Locking v. constant supervision• Who may access the locked areas • The circumstances under which they may have access

• Educate staff to revise expiration dates of medications stored in a warming cabinet- follow the manufacturer’s guidelines!Review refrigerator temperature logs and provide• Review refrigerator temperature logs and provide refresher training when out of range temperatures are recorded without appropriate actions being documented

• Ensure that Crash Carts are visible at all times, especially if stored in occupied ED rooms



MM.04.01.01 – Areas of Focus• Incomplete medication orders

• Order lacks any of the parameters required by policy (i e route of administration frequency of dosing etc )

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(i.e. route of administration, frequency of dosing, etc.)• Order includes prohibited abbreviations• Weight-based dosing required but not done• Not clarified with prescriber prior to

medication being dispensed

• Blanket Resume Orders• Medication orders not found in the patient record• Undocumented verbal orders• Missing protocols

MM.04.01.01- Areas of Focus

• Unresolved therapeutic duplication• Orders lack selection criteria to guide administration

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• Orders lack selection criteria to guide administration• Involves preprinted order sets as well as orders

generated by an individual provider• Not clarified with prescriber prior to medication being

dispensed

• Titration and Sedation ordersL k ifi it i f tit ti (i iti l d/• Lack specific criteria for titration (initial and/or incremental doses, clinical parameters)

• Lack sedation goal and/or dosing parameters• Not clarified with prescriber prior to medication being

dispensed



Improving MM.04.01.01 Outcomes

• Educate and re-educate all clinical staff involved in the medication management process on all requirements of

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a complete order

• Review preprinted order sets to ensure only complete, accurate orders are included

• Monitor the clarification process to ensure incomplete, inaccurate orders are clarified with the prescriber prior to dispensing the medication

• Monitor troublesome types of orders (titration, sedation) to ensure criteria for use are included and followed• Provide feedback to prescribers (OPPE?) and those who

administer medications on the monitoring results you obtain

MM.05.01.01 – Areas of Focus• Pharmacist’s review of orders

• Orders faxed from physician’s office and implemented ith t h i t’ i

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without pharmacist’s review• PACU orders not transmitted for

pharmacist’s review• Preprinted order sets and protocols

• Clarifying orders• Incomplete, inaccurate orders not

clarified before dispensing• All issues not clarified with prescriber

before dispensing• Confusion over nursing v. pharmacy role in clarification

process



Improving MM.05.01.01 Outcomes

• Educate and re-educate all clinical staff involved in the medication management process on the need for

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medication management process on the need for pharmacist’s review of orders

• Review preprinted order sets and protocols with a critical eye to determine any potential unresolved therapeutic duplication issues

• Work with clinicians who administer medications to promote understanding of the clarification processpromote understanding of the clarification process • Orders should be written correctly from the beginning

• Ideally, nursing can clarify at the time of issuance

• But, remember the final responsibility for clarification rests with the dispensing pharmacist

Resolve these issues…

To ensure a successful survey outcome!

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U d t C tU d t C t PhPhUpdate on Current Update on Current Pharmacy Pharmacy Initiatives and StrategiesInitiatives and Strategies

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Jerry H. Reed, MS, RPh, FASCP, FASHP

Corporate Director, Pharmacy Operations

Community Health Systems



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A Checklist for Safe Use of Medication Samples

Proactively identify your organization’s approach to medication samples. If you decide to allow the use of medication samples, determine the following:

l For which types of patients? l On a trial basis or for chronic use? l Which medications? l Will you accept controlled substance medication samples?

Define control over medication samples. l Identify a secure location, with authorized access only. l Determine who will receive samples. l Determine who will log in samples. l Determine who will maintain the sample location, remove and properly dispose of

expired medications, and oversee recalled medications. l Review state laws to determine who is authorized to dispense sample medications

to the patient.

Review the list of allowed medication samples for compliance with the following:

l Look-alike, sound-alike medication process, if appropriate l High-alert or hazardous medication process, if appropriate l Applicability for weight-based dosing in pediatric patients

Include the following in the decision to provide a patient with a sample medication:

l Document in the patient’s medical record. l Properly label the sample. l Take steps to ensure no contraindications, interactions, duplications, or

patient-specific variables that might affect prescribing (check with the pharmacist). l Log dispensing in sample medication log book. l Provide information to the patient about the medication and its proper use. l Consider providing the patient with a prescription for subsequent refills, with

instructions.

Consider formalizing medication sample decisions for your practice site with a policy.

l Educate staff and pharmaceutical representatives on these policy decisions.

© Joint Commission Resources 2014.

2016 Pharmacy - ProCEs3.proce.com/res/pdf/CHS/CHS2016MarHandout.pdf · 2016 Pharmacy Education...

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