SDS Accreditation Update

Joint Commission, AAAHC report most common problems with compliance

One of the most challenging areas for hospitals and ambulatory organizations undergoing accreditation is meeting National Patient Safety Goal (NPSG) 02.03.01 requiring organizations to improve the timeliness of reporting and receipt of critical tests and critical results and values. In the first half of 2009, 38% of hospitals and 21% of ambulatory organizations failed to comply with this goal. (For more information on hospital noncompliance, see story, below.)

"We want the organization to make sure they have a process in place where they are reporting critical test results in a timely manner, depending on their baselines, and have an appropriate timeframe to get the critical test results to the practitioner to act on," says Pat Adamski, RN, MS, MBA, director of the Standards Interpretation Group and The Office of Quality Monitoring, The Joint Commission. "They need to have a methodology to evaluate the process, to see how well they're doing and make improvements as they see are needed," Adamski says.

Organizations are now required to list only critical tests that will necessitate a call to practitioners when results are abnormal. For 2010, the organization must define what are considered critical results and diagnostic procedures. The focus is on critical results and not the test.

Another common area of compliance problems is credentialing and privileging, according to accreditation sources. In fact, in the first half of 2009, 45% of ambulatory organizations failed to comply with HR.02.01.03, which says the organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.

"Credentialing is one of those things that ambulatory organizations tend not to be as thorough about as a hospital would," Adamski says. "They don't go through all the steps to obtain all they need to require credentialing and privileges. There's a lack of a comprehensive process."

An official with the Accreditation Association for Ambulatory Health Care (AAAHC) also have noticed compliance problems in this area. "It's not only verification, but privileging also is an issue," says Michon Villanueva, AAAHC assistant director of accreditation services.

Another issue is adherence to an organization's own credentialing and privileging processes, Villanueva says. "The privileging is not consistent with the services provided in the organization, or the providers are not being privileged for specific procedures," she says.

Here are some other common noncompliance areas for ambulatory organizations with Joint Commission standards:

MM.03.01.01 The organization safely stores medications; 27% failed to comply in the first half of 2009.

"This is usually related to medications not being in a secure environment — being left out where patients or families could potentially have access," Adamski says.

Also, it's important to store medications according to manufacturers' recommendations, she says. "Some will need to be refrigerated at the appropriate temperature," Adamski says. "Others should be at room temperature."

Where ambulatory organizations have difficulty is when they are closed on weekends and don't have mechanisms to ensure the refrigerator maintains its temperature over the weekend, she says. All facilities with refrigerated medications should have a thermometer that records temperatures, Adamski says. "On Monday, they can eyeball it to make sure the temperature was OK on the weekend," she says. "They don't have to worry about whether medications are still viable."

UP.01.03.01 A timeout is performed immediately prior to starting procedures; 24% lacked compliance in the first half of 2009.

The biggest issue is lack of participation by the full team, Adamski says. "Some participate, and some aren't engaged in the process," she says. Anesthesiologists should be included, some providers suggest.

The Joint Commission simplified the Universal Protocol for 2010, Adamski says. "Because of the difficulty engaging some of the participants in the process, we've gone back to the basic: verifying a minimum of the right patient, right procedure, and right side in timeout," she says. Also verify the correct implant or lens, providers suggest.

Additionally, organizations must ensure the timeout is documented, Adamski says.

WT.05.01.01 The organization maintains records for waived testing; 21% failed to comply in the first half of 2009.

"Sometimes ambulatory areas aren't as diligent about maintaining records," Adamski says.

Hospitals have problems with egress corridors

Top noncompliance areas reported

Close to half (45%) of hospitals accredited by The Joint Commission failed to meet standard LS.02.01.20, which says the hospital maintains the integrity of the means of egress.

The standard is part of compliance with the NPFA 101 Life Safety Code. Typically, hallways are blocked by supplies or carts, says Pat Adamski, RN, MS, MBA, director of the Standards Interpretation Group and The Office of Quality Monitoring, The Joint Commission. Surgery areas are particularly vulnerable to blocking exits, she says.

The Joint Commission has moved the Life Safety Code requirements to their own chapter, she says. This allows organizations to become more familiar with the Life Safety Code and better educate staff, Adamski says.

"We are talking about the health and well-being of staff and patients," she says. "If you can't get through an egress corridor, you may not be able to evacuate during a fire."

Here are additional compliance problems for hospitals:

LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat; 43% failed to comply in the first half of 2009.

Fire and smoke doors are a significant problem, Adamski says. "If you're working in hospitals or ambulatory clinics, and the fire alarms go off, the fire doors automatically close," she says. "If something keeps one of those doors from closing, and it compromises the smoke chambers, etc., often staff notice, but do they pick up phone and call? No, they just close the doors instead of saying, 'the automatic closer doesn't work.'"

Doors also might fail due to being held open by illegal doorstops or other items, some sources say. Also, a door might lack a seal, they say.

Educate members of your staff that they can have a significant impact, Adamski says. "If they let someone know, someone can fix it," she says. "The next time you have a fire drill or alarm, it will be fixed and automatically close."

EC.02.03.05 The hospital maintains fire safety equipment and fire safety building features; 38% of hospitals failed to comply in the first half of 2009.

Making sure the fire alarms, sprinklers, portable fire extinguishers, and hamper switches are inspected, tested, and maintained, Adamski says. Many organizations use outside vendors for these tasks, she says. "Make sure the process to share results or outcomes of inspections and testing goes up chain of command," Adamski says. "If there are resources needed to make repairs, make sure those resources are released."

RC.02.03.07 Qualified staff receive and record verbal orders; 40% of hospitals failed to comply in the first half of 2009.

The Centers for Medicare & Medicaid Services (CMS) requires that verbal orders be authenticated within 48 hours, unless state laws allow more time, Adamski says. "A chronic problem in organization is making sure if you have a phone or verbal order from a doctor or licensed independent practitioners, that they come back and sign off on the order within 48 hours," she says.