I n t e g r i t y - S e r v i c e - E x c e l l e n c e Air Force Pharmacy New JCAHO/Inspection...
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Transcript of I n t e g r i t y - S e r v i c e - E x c e l l e n c e Air Force Pharmacy New JCAHO/Inspection...
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Air Force Pharmacy
New JCAHO/Inspection Standards – P&T
Implications & Critical Elements of Design
Phil L. Samples, Col(s), USAF, BSCBSPhr, MS, PharmD., BCNSP
Associate Director, Biomedical Sciences CorpsAssociate Corps Chief for Pharmacy, BSC
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Overview
Membership Issues
Requirements in policy
Specific JCAHO issues
Implications of DoDI/AFAA
Strategies for Success
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Pharmacy & Therapeutics Directives
AF – controlled by AFI 44-102 Medical staff function Must meet minimum 4 times per year Membership is prescribed
JCAHO – does not prescribe the make up but will survey to your policy
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Functions
Mandatory (AF) Functions Reviews policies, acquisition and use of medications
within the facility
Reviews medication errors (from ALL sources)
Reviews Adverse Drug Reactions (ADRs)
Evaluates clinical data on new medications and preparations for use at the MTF
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Membership
Members – WHY? 2 physicians 1 dentist 1 pharmacist 1 nurse The Chief of Medical Logistics
Remember, JCAHO – does not prescribe the make up but will survey to your policy
Possible additions – Resource manager, other interested parties (be careful, the committee can become too cumbersome and difficult to achieve quorum)
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
JCAHO Implications and Issues
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Periodic Performance Review
Review all standards and identify areas for improvement to include National Patient Safety Goals (NPSG)
Develop plan of action for deficiencies Deficiency identified in an Element of Performance
(EP) designated with an “M” must identify measure of success
Phone conference with JCAHO to approve plan Measure of Success will be reviewed during survey
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Plan of Action
Describe planned action for each Element of Performance (EP) marked as partial or insufficient compliance
For each EP where a measure of success is required describe: What will bring standard into compliance How action will result in improvement How will you know – measurable objective criteria,
performance improvement (PI) data, inspection, interviews
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Definition of Medication
DRASTIC CHANGE! Medications Include – standards apply to all of these
Prescription Drugs Diagnostic & contrast agents
OTC Drugs Respiratory treatments
Sample Drugs Parenteral Nutrition
Herbal remedies Blood derivatives
Vitamins Intravenous solutions
Vaccines Any drug designated by the FDA as a drug
Radioactive meds
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Definition of Medication
What is NOT included:
Enteral Nutrition Products Oxygen Other medical gases
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Safe Medication Management
Safe Medication Management
Patient Specific Information –MM.1.10
Selection & Procurement Storage Ordering & Transcribing
MM.2.10 MM.2.20, 2.30, 2.40 MM.3.10, 3.20
Preparing & Dispensing Administration Monitoring
MM.4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8 MM.5.10, 5.20 MM.6.10, 6.20
Special Case
High Risk Medications
MM.7.10, 7.20, 7.30, 7.40
Evaluation – MM.8.10
Six Critical Processes
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Selection & Procurement MM.2.10
Criteria for addition and deletion to formulary Must include propensity for medication errors, abuse
potential and sentinel events MUST be able to monitor med PRIOR to addition (e.g. new lab
or radiographic procedure) ANNUAL review of meds based on emerging data
Black box warning Process to approve & procure meds not on formulary
Orders for non-formulary meds must be approved by an abbreviated process
Process for handling medication shortages Communication with staff, developed substitutes,
education about protocols, obtaining during disaster
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Selection & Procurement MM.2.10
Compliance tips Document process in P&T Minutes Document evidence of sound alike, look alike
potential Excellent sources – USP and ISMP
Document ability to monitor Antibiotic sensitivity Anticoagulant monitoring Appropriate equipment in treatment area
Develop abbreviated procedure for non-formulary approval
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Proper and Safe Storage MM.2.20
P & T Considerations should document issues concerning consequences of storage Only approved meds are stocked and/or stored Segregation of look-alike, sound alike meds Medication concentrations are standardized NO, repeat NO, concentrated electrolytes in patient
care areas (example of exception – perfusionist in cardiac surgery)
Meds in most ready-to-use form
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
NPSG Specific Requirements of P&T
Unapproved abbreviation list must include U (for units) IU (for international units) Q.D. (for once daily) Q.O.D. (for every other day) Trailing zero (e.g. 3.0mg) Lack of leading zero (e.g., .3mg) MS or MSO4 (for morphine sulfate or magnesium
sulfate) MgSO4 (for magnesium sulfate)
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Unapproved abbreviations (con’t) Must include 3 new items not on mandatory list by 1
Apr 04 Will include electronic and print media by 2005
NPSG Specific Requirements of P&T
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Monitoring MM.6.10, 6.20
Develop and document strategy to monitor the first few doses of a medication new to the patient
Aggregate and analyze data ADR MUE/DUE/AUE
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
High Risk Medications MM.7
P&T must identify high-risk medications Document safety steps taken in each area of
medication use system
Tips Approve and publish list of high-risk medications Develop grid (see next slide)
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
High Risk Medications MM.7
Medication/Drug Class
Selection/
Procurement
Storage Ordering/
Transcribing
Preparing/
Monitoring
Administration Monitoring
Chemo-therapy
Neuro-muscular
Blockers
Cardio-
Plegic
Solutions
ETC, ETC
Specific Agents –Warfarin, etc
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Evaluation MM.8.10
Evaluate literature and document actions ISMP Patient Safety Alerts or USP – good sources of
data Review internal data for trends or other issues
regarding medication safety Good sources - ADR and MUEs
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Successful Hints for the P&T
Sub-committees (depending on facility size) New drug requests MUEs
Write liberal policies wherever possible Must meet at least 4 times per year
Ensure medical staff buy in Select thought leaders to serve
Properly vet your minutes through the commander, either directly or through Exec Committee (CC is ultimate authority for obligation of funds)
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Successful Hints for the P&T
Detailed Minutes (OPEN: Jul 03, ECD: 12/03, OPR: CMO, OCR: SGA) Enough detail to allow a new person to understand Refer to higher committee when needed
Mark compliance issues in minutes Note in margin Group together
Documentation of Physician involvement
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Keys to Successful Survey
Clean and organized Secure all medications – pharmacy MUST control all
medications in all areas Concentrate on Problematic Areas (crash carts,
anesthesia, etc.) Emphasize Safe Use of Medications – NPSG! Develop Good P&T Minutes Demonstrate Competence Customize Policies and Procedures Educate and rehearse Take credit for improvements and positive outcomes
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
I n t e g r i t y - S e r v i c e - E x c e l l e n c e