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
2018 Joint Commission UpdateCHS Pharmacy Education Series
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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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.
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2018 Joint Commission UpdateCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 4
2018 Joint Commission Update
PATRICIA C. KIENLE, RPH, MPA, FASHP
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 6
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
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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
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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Medication Orders
Big issue: clarity Differentiate
Order Sets Protocols Standing Orders
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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It’s Not Just Critical Care …
Imaging Including Nuclear Medicine
Dialysis Obstetrics Any area where these type of orders are
used
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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Storage of Medications
Secure
Integrity ProtectedSafe
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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Anti-Diversion Strategies
ASHP Guidelines on Preventing Diversion of Controlled Substances
Published in AJHP 2017
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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Compounding
CMS Conditions of Participation USP Chapters State Board inspections
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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Immediate Use
For urgent use Not convenience
Not scheduled cases Distance from compounding site doesn’t
matter
Clean, uncluttered, functionally separate area for preparation
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Mixing on Patient Care Units
What do your areas look like?
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2018 Joint Commission UpdateCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 17
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
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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
2018 Joint Commission UpdateCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 18
… 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
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Emergency Medication Containers
Code carts Malignant hyperthermia carts/kits Reaction kits Anything you define as an emergency supply Anything marked “emergency” or similar
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Consistency of Policy and Procedures
Seal Log List of contents Overseen by pharmacy
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NEW Broselow Tape
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Antimicrobial Stewardship
Required members of oversight committee Infectious disease physician
Infection preventionist Pharmacist Practitioner
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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
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Tracers
List the key elements Develop a form Use it to trace processes Compare
Standards Policies What actually happens
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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2018 MEDICATION MANAGEMENT UPDATE
Tackling Our Problems To
Resolve Them
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
ProCE, Inc.www.ProCE.com 23
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
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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)
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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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
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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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)
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2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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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
2018 Joint Commission UpdateCHS Pharmacy Education Series
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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
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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)
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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
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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
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