An inside look at JCAHO ambulatory care surveys

Joint Commission surveyor tells you how to prepare

While there are numerous business decisions to ponder if your home infusion company considers opening an ambulatory care suite, you won’t want to overlook one: accreditation.

By opening such a suite, you’ve also opened the ambulatory care can of worms that leaves you open to survey under some new standards from the Joint Commission on Accreditation of Healthcare Organizations.

It’s not all bad news when it comes to preparing for a Joint Commission survey of your ambulatory care site, says Steve Olsen, PharmD, an intermittent Joint Commission surveyor for home care, ambulatory care, and long-term care pharmacy. Olsen also is a consultant for JCAHO’s not-for-profit consultant subsidiary, Quality Healthcare Resources.

As a home infusion agency, you’ll likely be able to ignore a big chunk of the ambulatory care standards, depending on the services you provide.

"This is the same set of standards that we would survey an ambulatory surgical center under, so go through and make a screening of the standards that obviously don’t apply," recommends Olsen. "I’d imagine close to 20% wouldn’t apply."

Two sections you can likely ignore are those on anesthesia and abuse and neglect. Unless you’re anesthetizing patients, you can skip those standards. The same goes for the abuse and neglect section. Your agency must be able to spot potential abuse. However, unless your agency treats victims of abuse and neglect, you can skip the treatment portion of the standards.

"In home care there’s only the expectation that somebody be able to screen for abuse and neglect, and if they detect that, they do the appropriate reporting," he says. "The standards go on to talk about active treatment, but they only apply if you’re in the business of actively treating patients that have been abused or neglected. You don’t want to read the standards and say, ‘You mean I’ve got to start treating these people?’"

And now the bad news

Once you’ve sorted through the standards and weeded out those that don’t apply, that still leaves upwards of 80% that do apply. Here are six common problematic areas Olsen finds during his ambulatory care site surveys:

1. Storage and documentation.

For home infusion agencies, many of the problematic areas for home care transfer directly to problems in ambulatory care. For example, if compounding is being done on site, the standards are the same as in home care. The same can be said for standards such as storing drugs and recording expiration dates.

However, there are components that are unique to ambulatory care.

"There’s an expectation that there be a routine process for checking to see that medications are not out of date," notes Olsen. In addition, you should have a system in place to track down medications that are recalled. In his eight years of surveying, he’s seen just one method that cuts the mustard.

"The only way I’ve seen is the recording of lot numbers," he says. "The standards don’t require the recording of lot numbers in language, but you’ve got to be able to match the manufacturer to the patient, and there’s only one way to do that."

Olsen says that for ambulatory care, you’ve got to include medication samples in this process. Another problematic area is that of expiration dates for medications. Be sure you have a process in place to check the expiration dates of any medications you have on site.

2. Care site.

This is an area that many home infusion agencies are unfamiliar with. Olsen says it’s important to realize that you now have to consider patient safety in your office.

"The additional component you bring in with an ambulatory infusion suite as opposed to just home care is now you’ve got patients in the building, and there’s a whole different expectation in the standards now that you’ve got patients in there," he notes.

For example, needles, drugs, and syringes must be locked in storage. Unlike a home infusion office, you now have to worry about patients having access to supplies. Another is oxygen bottles, which must be strapped down.

"If you have a mild tremor in Southern California and one of the bottles falls and the nozzle is knocked off, it’s like a torpedo," says Olsen. "It will go through three or four walls in a building."

3. Fire safety.

This area is also different because now patients are going to be on site. Olsen notes that fire drills must be held quarterly in an ambulatory building center, whereas home care agencies are only required to evaluate their fire safety program annually. Also, while sprinklers are not required, if your site has sprinklers, you cannot store anything within 18 inches of the ceiling.

Fire extinguishers must be tested annually and inspected quarterly, as opposed to inspected annually for home care agencies.

Staff must educate every patient as to what to do in case of a fire, and there must be two exit signs in two different areas from the patient care site. That way if one exit is blocked there is an alternate site to safety. The exit signs also must be internally or externally lit at all times, as must the "path of egress." The latter may not require expensive lighting systems, though.

"The first thing to look at is if there is enough natural light if you’re only open during the day," says Olsen. If not, rather than installing an expensive light system, he recommends installing plug-in rechargeable flashlights. If there is a problem, they can be unplugged and used to guide patients out of the building.

It’s important to note that last year the Joint Commission actually reduced its standards regarding requirements for fire safety.

"After July of 1996, the Joint Commission doesn’t require compliance with the life safety code for business occupancy," says Olsen. "The life safety code is what a hospital or surgical center would have to comply with. It talks about the fire ratings of walls, doors, and even the surface of the wallpaper."

JCAHO saw it was not necessary to hold ambulatory care sites to such standards when it realized that previous studies showed that no patient treated in an ambulatory setting had ever been killed or injured due to a fire.

Before you wipe the sweat from your brow and breathe a bit easier, be forewarned that you may inadvertently subject yourself to the standard, depending on the patients you treat and the drugs you administer in your ambulatory suite.

"If you cause the patient to lose their ability to navigate in the fire and you didn’t have adequate staff to get them out of there," you could be subject to the life safety code. Olsen says that some chemotherapeutic pre-med protocols can leave a patient semi-comatose and unable to see themselves to safety in case of a fire.

"If you’ve got four of those patients and only two nurses, how are two nurses going to evacuate those four semi-comatose patients?" he asks. If you’re dealing with such patients, you’d be wise to call the Joint Commission and see how many such patients you can handle at one time. (See related story on the Joint Commission, at right.)

4. Handicap access.

Now that patients are coming to you rather than you going to them, you’ve got to cater your building appropriately. JCAHO looks for compliance with the Americans with Disabilities Act (ADA). Olsen says to consider the following:

• adequately marked handicap parking spaces;

• proper lighting in the parking lot if you are open at night (Olsen notes this area does not come under the ADA, but he checks to ensure patient and staff safety);

• wheelchair access ramps;

• vertical signs indicating handicap parking spaces;

• posted hours of operation, along with notification on the outside of your building of an emergency number.

"In home care, you give that information to the patient during admission so they know how to get a hold of you after hours," says Olsen. "For these folks, you’re going to give them an admissions packet, but they could come to your office on a weekend or after hours and may not remember how to get a hold of you."

Entrance doors must be at least 30 - inches wide.

If an entrance does not meet the requirements, don’t call in the hard hats just yet. A little ingenuity can save your agency time and money.

"For one organization the doors to the bathroom were too small," says Olsen. "But on the second floor — and there was an elevator up to the second floor — they had an arrangement with a dentist who had a handicap access bathroom that the ambulatory infusion center’s patients could use that restroom, and that was OK."

Exposed hot water pipes underneath sinks must be wrapped.

"If you’re in a wheelchair and roll up under the sink . . . " says Olsen.

Use a call system in the bathroom and in the infusion site.

"I’ve seen everything from sophisticated intercoms to cowbells," says Olsen. Regardless of what you use, though, your staff had better know to respond.

"If you have a call system in the bathroom and I push it, somebody had better come," says Olsen.

5. Infection control.

The key here is to consider everything that involves where patients come and go. For example, will you protect the chair and change the protection between every patient or wipe down the chair between each patient? You also have to wipe down the tables, polls, IV equipment, even the remote control to a TV or VCR if the patient has access to it. And don’t forget any toys you make available to children. You’d better have a system on how those are cleaned.

6. Equipment maintenance.

In home care, JCAHO requires "routine maintenance procedures" be performed on an infusion device between each patient.

"That’s because the home environment is not very well controlled; the dog can knock the pump over, or during the delivery process the equipment can get knocked around," says Olsen.

For your ambulatory care site equipment, there’s no need to test equipment between every patient. Olsen says "routine maintenance" is still required, but surveyors are typically lenient regarding the frequency of this. Note that abiding by the preventive maintenance according to the manufacturer’s recommendations is still required.