2018 Pharmacy Education - ProCEs3.proce.com/res/pdf/CHS2018Feb21Handout.pdf · 2018 Pharmacy...

2018 Joint Commission UpdateCHS Pharmacy Education Series

ProCE, Inc.www.ProCE.com 1

2018 Pharmacy Education Series

February 21, 20182018 Joint Commission Update

Featured Speakers:

Patricia C. Kienle, RPh, MPA, FASHP Jacqueline E. Moran, RN, CPHQDirector, Accreditation & Medication Safety Senior Director of Survey ManagementCardinal Health Innovative Delivery Solutions Community Health Systems

Lisa Stefanov, RN, MSN, CPHQDirector of Survey ManagementCommunity Health Systems

Submission of an online post‐test and evaluation is the only way to obtain CE credit for this webinar

Go to www.ProCE.com/CHSRx

Print your CE statement of completion online

– Credit for live or enduring (not both)

Deadline: March 23, 2018

Pharmacists and Pharmacy Technicians: CE credit uploaded to CPE Monitor

– User must complete the “claim credit” step

Online Evaluation, Self-Assessmentand CE Credit

Attendance Code

Code will be provided at the end of today’s activity 2



How to Ask a Question

Locate menu bar on your computer desktop

Click orange arrow button to open menu box

Type question into question box

Click Send

Do not close menu box

– This will disconnect you

from the Webcast

Please submit questions throughout

presentation

Click No!

Click

Enter question

3

Accessing PDF Handout Click the hyperlink that is

located directly above the question box

Do not close menu box

– This will disconnect you

from the Webcast

No!

Clickhyperlink

4



2018 Pharmacy Education Series

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. Ms. Kienle is an employee and stockholder of Cardinal Health, has served as an author for ASHP, is a committee member for USP, and is a speaker for Critical Point. Ms. Moranhas no relevant commercial or financial relationships to disclose. Ms. Stefanov has no relevant commercial 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.

February 21, 20182018 Joint Commission Update

Featured Speakers:

Patricia C. Kienle, RPh, MPA, FASHP Jacqueline E. Moran, RN, CPHQDirector, Accreditation & Medication Safety Senior Director of Survey ManagementCardinal Health Innovative Delivery Solutions Community Health Systems

Lisa Stefanov, RN, MSN, CPHQDirector of Survey ManagementCommunity Health Systems

5

CE Activity Information & Accreditation

ProCE, Inc. (Pharmacist and Pharmacy Technician CE)This CE activity is jointly provided by ProCE, Inc. and CHSPSC, LLC. ProCE is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE Universal Activity Number 0221‐9999‐18‐080‐L03‐P/T has been assigned to this knowledge‐based live CE activity (initial release date 2‐21‐18). This CE activity is approved for 2.0 contact hours (0.2 CEU) in states that recognize ACPE providers. This CE activity is provided at no cost to participants. Successful completion of the online post‐test and evaluation at www.ProCE.com/CHSRx is required to receive CE credit. CE credit will be uploaded to NABP/CPE Monitor. No partial credit will be given.

Funding:This activity is self‐funded through CHSPSC.

6



2018 Joint Commission Update

PATRICIA C. KIENLE, RPH, MPA, FASHP

7

Disclosure

Patricia Kienle is an employee of Cardinal Health She is a member of the USP Compounding Expert

Committee, but this presentation is not affiliated with or endorsed by USP

8



Learning Objectives -Pharmacists

State the top four types of non-compliant medication issues

Identify the medication-related contracted services that require leadership approval

Explain the difference among protocols, order sets, and standing orders

State the top five citations identified during compounding certifications

Cite the pharmacy-related issues in the Antibiotic Stewardship standards

9

Learning Objectives -Technicians

State the three criteria for storage of medications State the type of expectations a hospital should have

when using outsourced compounders Explain the difference among protocols, order sets,

and standing orders State the top five citations identified during

compounding certifications

10



CMS Conditions of Participation

Regulatory requirements are based on the Centers for Medicare and Medicaid Services Hospital Conditions of Participation

Available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf §482.25 Pharmaceutical Services

Joint Commission and AOA/HFAP are “deemed” by CMS for hospital certification

11

Most Challenging HFAP Standards

Standard Topic TJC Standards01.01.23 Contractor Quality

MonitoringContracted Clinical Services

03.01.01 Medical Staff Bylaws Medication Management07.01.01 Infection Control Sterile Compounding12.00.03 Medical Errors and

Adverse EventsMedication Errors, ADRs, and Incompatibilities

16.01.01 Preparation and Administration of Drugs

Medication Management

2017 HFAP Quality Report12



Most Challenging MM Standards

Standard Topic % Non-CompliantMM.04.01.01 Med Orders 49%MM.03.01.01 Med Storage 48%MM.05.01.01 Review of Orders 15%MM.05.01.07 Safe Med Preparation 14%NPSG.03.04.01 Med Labeling 9%MM.05.01.09 Med Labeling 3%MM.03.01.03 Emergency Meds 8%NPSG.03.06.01 Med Reconciliation 7%

The Source, November 2017 13

Environment of Care

Emergency power Backup

Essential medication equipment Refrigeration

14



Medication Orders

Big issue: clarity Differentiate

Order Sets Protocols Standing Orders

15

What’s the Difference?

Type of Document Description

Order Set List from which a practitioner can choose

Protocol Treatment plan for patient who meets the criteria

Standing Order Order(s) that may be initiated prior to LIP assessment if the patient meets certain criteria

16



The Big Problem: EP 13

One element of performance causes the most citations MM.04.01.01, EP 13: The hospital implements its

policies for medication orders

Problems: Unclear and incomplete Range orders Titration orders

17

Approval

CMS Conditions of Participation Approval by medical staff committee,

pharmacy, and nursing

Review and update and defined frequency Must be consistent with national guidelines

18



It’s Not Just Critical Care …

Imaging Including Nuclear Medicine

Dialysis Obstetrics Any area where these type of orders are

used

19

Be Sure to Include …

Orders must be part of the patient’s medical record Avoid opportunities for therapeutic duplication Be sure titrate orders are clear

20



Storage of Medications

Secure

Integrity ProtectedSafe

21

Controlled Substances

Security and control of containers as they move through the organization Patient care areas

Procedural areas Storage of full containers

Waste disposal systems that deactivate drug substances

22



Control Between Dispensing and Administration

Updated EP 4 in MM.03.01.01 Control … including safe storage, handling,

wasting, security, disposition, and return to storage

Define specifics in policy All controlled substances must have wastage

documented

23

Anti-Diversion Strategies

ASHP Guidelines on Preventing Diversion of Controlled Substances

Published in AJHP 2017

24



Common Storage Issues

Insulin and other multiple dose vials Follow CDC Safe Practices

https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html

Refrigerators, freezers, and warmers Temperature monitoring

Action when out of range

25

Review of Orders

ADC overrides: NEW MM.08.01.01, EP 16 Effective January 1, 2018 When automatic dispensing cabinets (ADCs) are

used, the hospital has a policy that describes the types of medication overrides that will be reviewed for appropriateness and the frequency of the reviews 100% review of overrides is not required

Review all overrides for valid order

26



Compounding

CMS Conditions of Participation USP Chapters State Board inspections

27

CMS Survey Letter - 2015

Pharmaceutical Services: Revisions … made to CoP to bring them into alignment with current accepted standards of practice including: accepted professional pharmacy principles, including United States Pharmacopeia (USP) standards; compounding of medications, particularly compounded sterile preparations (CSPs); determining beyond-use dates (BUDs) …

Preparing CSPs Outside of the Pharmacy: … clarify that hospitals must ensure staff adherence to accepted standards of practice in those limited instances when CSPs may be prepared outside of the pharmacy

28



Contracted Services

CMS §482.12(e) LD.04.03.09 Care, treatment and services provided

through contractual agreement are provided safely and effectively

Leadership Approves all contractual agreements Monitors contractual services Establishes and communicates expectations Takes action to improve services that don’t meet

expectations29

Contracted Clinical Services

Nuclear pharmacy Remote order entry Medication Therapy Management (MTM) services Compounding pharmacy services Pharmacy management Any other clinical service outsourced to outside vendor

30



Immediate Use

For urgent use Not convenience

Not scheduled cases Distance from compounding site doesn’t

matter

Clean, uncluttered, functionally separate area for preparation

31

Mixing on Patient Care Units

What do your areas look like?

32



TJC Compounding Certification

Hospital accreditation MM.05.01.07 Home Care accreditation Medication

Compounding standard as of January 1, 2018

Certification differs from accreditation Compounding certification

Michigan

Organizations approved by Board of Pharmacy

33

Top Non-Compliant Compounding Standards …

Standard % Non-CompliantMDCS.01 Work practices and environment consistent

with low-medium-, and high-risk levels60%

MDCS.08 Written policies and procedures for environmental quality control

47%

MDCS.12 Hand hygiene 47%MDCS.13 Staff follow cleaning and disinfecting

practices47%

MDCS.10 Integrity of the compounding area, handling CSPs, and use of protective equipment

41%

The Joint Commission Perspectives, September 201734



… Top Non-Compliant Compounding Standards

Standard % Non-CompliantMDCED.05 Education and training in aseptic technique

includes demonstration of competency33%

MDCGR.02 Definition of compounding staff responsibilities 30%

MDCSN.03 Policies and procedures for hazardous compounding

22%

MDCGR.01 Leaders responsible for safety and quality of care

15%

MDCED.04 Education and training includes equipment competency

15%

MDCS.03 Manipulation, workflow, and storage of single-and multiple-dose vials

15%35

Labeling

36



Emergency Medication Containers

Code carts Malignant hyperthermia carts/kits Reaction kits Anything you define as an emergency supply Anything marked “emergency” or similar

37

Consistency of Policy and Procedures

Seal Log List of contents Overseen by pharmacy

38



NEW Broselow Tape

39

Antimicrobial Stewardship

Required members of oversight committee Infectious disease physician

Infection preventionist Pharmacist Practitioner

40



Pain Management

Not MM standards Leadership – individual or team Medical Staff – participation Provision of Care – define criteria and provide

patient education Performance Improvement – data, analysis, and

monitoring

41

Tracers

List the key elements Develop a form Use it to trace processes Compare

Standards Policies What actually happens

42



2018 MEDICATION MANAGEMENT UPDATE

Tackling Our Problems To

Resolve Them

43

Program ObjectivesBy the end of this presentation, attendees will be able to:

• Identify our most common TJC citations related to medications and their management

• Articulate successful strategies to address citations

44



Historical Perspective• In January 2017, TJC dramatically changed the survey process rendering numerical comparisons with prior years meaningless• Each single observation is cited and may be cited at

multiple chapters/standards

• Historically, our most frequently cited medication-related standards are: MM.03.01.01, MM.04.01.01 and MM.05.01.01

• For 2017, our most frequently cited medication-related standards are MM.03.01.01, MM.04.01.01 and PC.02.01.03

45

MM.03.01.01

• Outlines the requirements for safe storage of medications in compliance with law, regulation and manufacturer’s guidelines (EPs 2-9 & 18)

46



MM.03.01.01 – Areas of Focus• Preventing unauthorized access to meds

• Locking cabinets

• Mobile carts not being observed

• Special storage conditions• Medications/contrast media in

warming cabinets

• Refrigerated medications

• Monitoring conditions 24/7

• Temperatures out of acceptable range without recorded actions

47

MM.03.01.01 - Areas of Focus

• Expired medications• Dating multidose containers upon opening

• Expired medications that remain accessible for administration

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

48



Improving MM.03.01.01 Outcomes

• Educate staff to revise expiration dates of medications stored in a warming cabinet

• Follow the manufacturer’s guidelines!

• Post manufacturer’s guidelines at the storage location

• Review refrigerator temperature logs routinely

• Provide refresher training when out of range temperatures are recorded without appropriate actions being documented

49

MM.04.01.01

• Outlines requirements to have clear, complete and accurate medication orders in order to enhance communication between all participants in the medication management process (EPs 1-14 and 21)

50



MM.04.01.01 – Areas of Focus• Incomplete medication orders

• Incomplete titration orders

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

• Not clarified with prescriber prior to medication being dispensed

• Medication orders not found in the patient record• Undocumented verbal orders

• Missing full protocols

51

MM.04.01.01- Areas of Focus

• Unresolved therapeutic duplication• 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 orders• 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 52



Improving MM.04.01.01 Outcomes• Establish process for clarification – is it nursing or pharmacy?

• Educate and re-educate all clinical staff on all requirements of a complete order & clarification process

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

• Monitor problematic orders (titration, sedation) to ensure completeness and provide feedback to prescribers (OPPE?) and those who administer medications on the monitoring results you obtain

53

PC.02.01.03

• Outlines the requirement to provide care, including medication administration, in compliance with the most current orders from a licensed independent practitioner; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations. (EPs 1, 7 and 20)

54



PC.02.01.03 – Areas of Focus• Titration orders not followed as written

• Sedation orders

• Pitocin orders

• Pain Meds not given as ordered

• Medication given without an order • Pharmacy changed order without completing clarification

• Med ordered for one indication but given for another

• Referenced protocol not on medical record

• Order set with all pre-checked orders, no evidence physician deleted inappropriate orders

55

Improving PC.02.01.03 Outcomes

• Educate all providers and staff of the need to have current, appropriate medication orders for any medication administered

• Re-educate staff on the potential impact of administering medications without an LIP order

• Review records to ensure any order to follow a protocol results in a copy of the full protocol being added to the record

• Monitor, then close the feedback loop to ensure all staff are aware of needs to improve

56



Resolve these issues…

To ensure a successful survey outcome!

57

58

2018 Pharmacy Education - ProCEs3.proce.com/res/pdf/CHS2018Feb21Handout.pdf · 2018 Pharmacy...

Documents

Transcript of 2018 Pharmacy Education - ProCEs3.proce.com/res/pdf/CHS2018Feb21Handout.pdf · 2018 Pharmacy...