Proactive study standard trips up 27% of agencies

Use FMEA process to meet standard

(Editor's note: This is the second of a two-part series that discusses the most challenging Joint Commission standards for home health agencies. Last month the top two challenges, standards for which agencies are cited 28% of the time, were discussed along with tips for compliance. This month, five more challenging standards are discussed.)

Home health managers are very aware of the need to conduct performance improvement projects, but 27% of home health agencies surveyed in 2006 by The Joint Commission did not have an ongoing program for proactive identification or resolution of potential adverse events.

"Standard PI.3.20 requires an organization to proactively review a high-risk process once a year to identify potential risks to the patient," says Carol Mooney, RN, MSN, senior association director of the standards interpretation group for The Joint Commission. While agencies do have performance improvement studies or committees in place to review processes once a problem has occurred, the key to complying with this standard is to choose a process or issue for which your agency has not experienced any problems to date, she explains.

The best approach to meet this standard's requirements is to use a failure mode evaluation analysis (FMEA), which requires identification of the process to be studied and a dissection of all the steps involved in the process, says Mooney. Flowchart every step, and question every step of the process to identify points at which a failure to protect patient safety might occur, she says. The next step is to prioritize the failure points to highlight the failures that would be critical to the patient. "Once the failure points are identified, solutions that eliminate or reduce the process failures must be implemented; then the agency must test the success of the changes," she adds.

Topics for a proactive study could include patient falls, home oxygen fires, medication errors, or a new service that is offered by the agency, says Mooney. Ideas for topics can come from sentinel event alerts by The Joint Commission, safety issues identified by other organizations in the industry, or suggestions from clinical staff and managers, she adds.

Mooney also recommends that home care managers focus on very specific processes that can easily be identified, such as proper use of certain equipment including patient lifts. Keeping a narrow focus enables an agency to thoroughly evaluate the process in a way that results in meaningful information and improvements, she adds.

The challenge that most agencies face in complying with this standard is the difficulty identifying a topic that represents a high risk to patient safety and the challenge of producing a flowchart that describes the failure points, says Mooney. "Documentation for this process includes the flowchart, minutes of FMEA committee meetings that report the study findings and implementation of changes, and documentation of the assessment form to evaluate the changes," she points out.

Not all FMEAs result in major process changes, points out Mooney. "If the study is performed and no major risks are identified, that is fine as long as the FMEA process was followed," she adds.

Document phone orders

An 18% non-compliance rate for providing care, treatment, and services according to a physician's order (PC.5.20) may sound terrible, but the reality is that most agencies cited for this standard are not documenting physicians' phone orders, says Mooney. "There is a lot of documentation required and sometimes the phone order is a basic, simple change to the treatment plan, but it is essential that any change be documented," she points out.

Improper hand hygiene still shocks some surveyors, admits Mooney. Fourteen percent of agencies surveyed in 2006 were cited for non-compliance with National Patient Safety Goal 7 that requires agencies to reduce the risk of health care-associated infections. With hand hygiene an important part of any infection control program, Mooney points out the need for continuous re-education of staff members. "Sometimes the lack of knowledge is due to staff turnover but often it is due to a need for better education," she says. Without continuous reminders, staff members can easily lapse into old habits and neglect to soap and rinse hands for a minimum of 15 seconds or to wash hands between patients, even if gloves are used, she adds. (To see the Centers for Disease Control and Prevention hand hygiene guidelines, go to

"I also suggest that supervisors reinforce education by observing staff members' hand hygiene practices on visits and include these observations as part of employee evaluations," Mooney says.

Conducting drills to test emergency management procedures (EC.4.20) also proved to be a challenge for 14% of home health agencies. "One fire drill a year is not enough to meet this standard," says Mooney. Although fire drills are important and should be conducted, in order to meet EC.4.20, the agency must participate in or conduct its own mock scenario of an emergency, she explains. "If an agency is hospital-based, the manager needs to make sure that the home care staff are involved in the hospital's emergency drill," she adds. This doesn't always happen, she adds.

Because many communities conduct community-based drills that involve police, fire, and local health care organizations, the agency can meet the standard by participating in the drill, says Mooney. "After the drill, the agency should critique its performance and develop recommendations for improvement if needed," she adds.

Goal 8 of the National Patient Safety Goals, which calls for the accurate and complete reconciliation of medications across the continuum of care, was a problem for 13% of the agencies surveyed. "Nurses should get a complete list of medications by talking with the patient, the family, the hospital if the patient was referred after a hospital stay, and the patient's physician," says Mooney. "It is also a good idea to ask the patient if medications are kept in different places in the home so the nurse can look for them." Because home care patients take a number of medications that may be changed frequently, a home care nurse should always ask if the patient has seen a physician since the last home care visit, or if any medications have changed since the last visit, she suggests. A copy of the most up-to-date list developed during home care should be given to the patient's family upon discharge. "The list should also be given to the next provider, whether that is a nursing home, or the patient's primary physician," she says. "Never assume that the physician knows what medications the patient is taking," she adds.

Overall, home health agencies are doing well in their surveys, says Mooney. The switch to an unannounced survey process has not affected agencies' ability to be survey-ready, she says. "Home health agencies have had unannounced surveys by state agencies for years, so the switch to unannounced Joint Commission surveys was not a problem for them," she explains.

One tip that Mooney offers to help agencies be sure that the surveyor is well prepared is to ensure that your application information is correct. "Agencies should review their application to make sure they delete discontinued services, add new services, or correct any other information about the agency that may have changed," she says. "If the surveyor has updated information, the survey will go more smoothly."


For more information on Joint Commission standards, contact:

  • Joint Commission Standards Interpretation Group, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. Phone: (630) 792-5900. Web: To submit a question by e-mail, under "Standards," click on "Standards FAQs." Select "Click here to go to the Standards Online Question Submission Form."
  • The Institute for Healthcare Improvement web site includes a section on medication reconciliation review, including samples of a reconciliation tracking tool and a medication reconciliation flow sheet. Go to, click on "topics" on left navigational bar, choose "patient safety," then choose "medication systems." Under "medication systems," click on "tools," then choose "medication reconciliation" to see a list of forms and tools that can be used for medication reconciliation.