Avoid most common areas of noncompliance with tips from The Joint Commission and AAAHC
Half of ambulatory organizations undergoing accreditation by The Joint Commission are out of compliance with the standard on credentialing and privileging (HR.02.01.03). The biggest reason? Noncompliance with Element of Performance (EP) 3, which requires the organization to document training specific to the privileges being requested.
"What they're doing wrong is they're not using primary sources," says Michael Kulczycki, executive director if the Ambulatory Health Care Accreditation Program at The Joint Commission. Ambulatory organizations may mistakenly accept a copy, rather than looking directly on the web, for example, to obtain a certificate of completion or confirm an educational degree. The prime source documentation must be in the credentialing file.
Also, EP15 specifies that when you're granting initial privileges to a licensed independent practitioner (MD or DO, for example), you must review that practitioner's information at the National Practitioner Data Bank (http://www.npdb-hipdb.hrsa.gov). Providers must review the data bank when renewing privileges also, Kulczycki says. Also, once the organization has reviewed the data bank, the leaders must evaluate whether they are going to grant privileges, he says.
The Accreditation Association for Ambulatory Health Care (AAAHC) says organization frequently neglect to tell physicians that the privileges are time-limited, says Steven Gunderson, DO, chief exececutive officer and medical director of the Rockford (IL) Ambulatory Surgery Center. Gunderson is a AAAHC surveyor and a member of the AAAHC Accreditation Committee. Organizations usually give surgical privileges for two or three years, depending on what their state allows, Gunderson says. "What we find is that they give privileges, they send a letter saying you're on staff,' but they don't know the privileges are for a limited time and they have to reapply." That information must be in the letter or in the governing minutes, he says.
Consider these other suggestions for complying with problematic standards:
• Safely store medications.
Medication must be stored in accordance with manufacturer recommendations, which means that if refrigerator storage is required, the facility must comply, Kulczycki says. Alarms and records that the refrigerator has maintained the proper temperature also are essential elements.
Also, medication on the anesthesia cart must be properly labeled, not expired, and, depending on the type of medication, appropriately controlled (locked as needed) and monitored, he says. However, surveyed organizations often find that although medications might have been checked by several persons, there is often a "Joint Commission moment" when the surveyor pulls out the one container of medication that's expired. To avoid this problem, change the person who reviews the medications from time to time.
"If you have clinical person monitoring the medication storage area, to mix it up for one month, pull someone from the front business office, tell them what to look for, and have them do a mock tracer in areas," Kulczycki says. "A fresh set of eyes will bring new perspective."
• Reduce the risk of infections associated with medical equipment.
Noncompliance in this area often can be attributed to surface cleaning of low-level infectious areas, sterilization or spore testing in high-level areas, or expired sterile supplies, Kulczycki says.
"This one in particular is an example that the organization is doing the steps, but maybe the person doing the cleaning doesn't know the specific," Kulczycki says.
For example, the sterilizing solution might require a contact period of a set number of minutes, and the person doing the cleaning might be wiping off the solution right away. The problem sometimes can be traced to supply ordering, Kulczycki says. Members of the staff might change solutions, but they didn't review how the new solution affects the sterilization process in place or train the staff.
• Include detailed allergy documentation in a specific place in every record.
Don't list only the items patients are allergic to, but also list the symptoms they develop.
"For example, the record shows they're allergic to penicillin, but it doesn't say what happens," Gunderson says. "Do they have a rash? Do they go into anaphylactic shock? That's part of the medical record." Such information is essential if, for example, a patient goes into cardiac arrest and has to be transferred to a hospital. "You can't ask the patient," Gunderson says.
• Have a list of look-alike, sound-alike medications.
There should be some mechanisms for the pharmacy to have identified look-alike, sound-alike drugs, Gunderson says. "You don't necessarily have to have a policy, but that's helpful," he says. You should make all staff aware that some drugs look alike and sound alike, and tell them how the facility addresses this potential problem. For example, the facility might choose to segregate those drugs in the pharmacy and the medication cart so it's not easy to grab the wrong drug.
• Avoid the "ventriloquist act."
Educate your staff about the accreditation process, Gunderson says. "It's distressing when you ask, `Have you been involved in the QI process,' and they look like a deer caught in the headlights," he says. "They don't even know what QI is."
Tell your staff what the survey process is about and what to expect in the survey, Gunderson says. At his facility, the leaders put together a newsletter for staff that, on one side of the page, lists standards and, on the other side of page, tells staff members how their facility complies with the standards. "We give examples so staff become familiar with every chapter we will be surveyed on, at least some aspect," Gunderson says. [To see a copy of a newsletter from Gunderson's facility, access the online issue of Same-Day Surgery. For assistance, contact customer service at firstname.lastname@example.org or (800) 688-2421.
When Joint Commission surveyors are doing patient tracers, they often talk to staff persons who perform activities such as infection control and sterilization. The administrator or quality coordinator is allowed to accompany the surveyor during those discussions. However, "we want to hear form the person doing the job, not the person supervising them or who has a coordination relationship to that area to step in and say, "this is what they're supposed to do," Kulczycki says. Sometimes the supervisor is behind the surveyor mouthing what the staff member should say, he says. "Often, the caregiver knows the answer, and they're perfectly comfortable talking to the surveyor," Kulczycki says.
It's usually the supervisor making the staff worker anxious, not the surveyor, he says. "Surveyors are skilled at making staff comfortable by saying, "Tell me the story about what you did with the patient."
10 Elements of a QI Study
Source: Accreditation Association for Ambulatory Health Care.
Are you failing to address these problem areas?
AAAHC surveyor shares top problems with compliance
What's the one area that outpatient surgery programs often have accreditation problems ? QI studies, says Steven Gunderson, DO, chief executive officer and medical director of the Rockford (IL) Ambulatory Surgery Center. Gunderson is a AAAHC surveyor and a member of the AAAHC Accreditation Committee.
"That seems to be an issue almost anywhere you go," Gunderson says.
The Accreditation Association for Ambulatory Health Care (AAAHC) requires review of the QI program annually. "Make sure it's addressing those issues you're trying to improve upon and it's doing an adequate job," Gunderson says. There are other areas, including bylaws and patient rights and responsibilities, that are required by AAAHC to be reviewed annually, Gunderson says. The Joint Commission has an element of performance (LD.04.04.05, EP 13) that says at least annually, the leaders provide governance with written reports on all system or process failures, number and type of sentinel events, and all actions taken to improve safety. Make a grid to track the items, and mark off items as you review them, Gunderson advises. (See sample grid with the March 2012 online issue of SDS Accreditation Update.)
Another problem area is that AAAHC requires your QI project include 10 elements, specified in the standards. (See box, right.) "It's in the handbook, but I'm surprised how many times people leave out one of the 10 elements in their study," Gunderson says. If your facility prefers to use another QI methodology, then do 1-2 studies in a three-year accreditation period using the 10 steps, he says. "You'll have a happy surveyor," Gunderson says. "People tend to get upset when you don't use those 10 elements." The Joint Commission doesn't specify the content of QI studies, but it does have a performance improvement standard (PI.01.01.01) and elements of performance identifying expected and suggested data collection.
Another problem occurs when facilities neglect to purchase a new accreditation handbook, he says. "A lot of times they think we were surveyed three years ago and did OK, so I'll stick with the book I had then and not spend money for a new book,'" Gunderson says. Over three years, many standards are modified or changed, and some chapters are eliminated or combined. "You don't know what you don't know because you didn't obtain the handbook," Gunderson says.
Facilities also frequently fail to perform a self-assessment, he says. "You should start way ahead of the survey, especially if you're Medicare-surveyed because you have no date, you just have an idea" of when the survey will be, Gunderson says. At his center, about halfway through the three-year accreditation survey period, the leaders start preparing by performing a self-assessment with the most recent handbook. "If you do the self-assessment, you can find out if you have problems with certain standards, then work to correct those problems before the survey occurs," Gunderson says.
These compliance issues aren't "rocket science," he says. "Plan ahead, do the self-assessment, understand the standards, and you won't have any problems."
TJC, hospitals identify best measures to prevent SSIs
Working with 17 accredited hospitals to test and trial surgical site infection (SSI) prevention measures, The Joint Commission (TJC) recently issued an implementation guide for its national patient safety goal for hospitals, ambulatory organizations, and office-based surgery on SSIs (NPSG.07.05.01).1
The guide is based on the results from TJC's "SSI Change Project," which focused on identifying effective practices for preventing SSIs. Overall, 23 measures were identified that resulted in at least a 30% reduction in SSI rates for one surgical procedure for at least one year in the participating hospitals.
Surveyors will not be enforcing the specific practices outlined in the document, says Kelly Podgorny, DNP, RN, project director in TJC's Division of Healthcare Quality Evaluation and one of the principal authors of the guide.
The Centers for Medicare and Medicaid Services is beginning to refuse covering the cost of additional care related to some SSIs, including orthopedic procedures. While advances have been made in infection control practices, improved operating room ventilation, sterilization methods, barriers, surgical technique, and availability of antimicrobial prophylaxis, SSIs remain a substantial cause of morbidity and have an associated mortality rate of 3%, the Centers for Disease Control and Prevention reports. Of those fatal infections, 75% could be attributed directly to acquiring an SSI, the CDC notes.2
In the TJC guideline, many facilities cited the benefit of having a multidisciplinary SSI team that was responsible for project planning, implementation, and evaluation. Team members included infection preventionists, surgical staff, nurses, surgeons, anesthesia practitioners, pharmacists, and epidemiologists.
The three pediatric hospitals participating in the project determined there was a dearth of pediatric-focused evidence-based practices to reduce SSIs. The pediatric hospitals developed strategies that should be useful for other pediatric settings targeting SSIs.
"We thought that this was an important and unexpected outcome of the SSI Change Project," Podgorny says. "Each pediatric hospital discussed strategies to deal with this barrier and those are addressed and described in the implementation guide."
St. Christopher's Hospital for Children in Philadelphia developed a bundle for pediatric patients that includes a specific focus on postoperative prevention and surveillance after discharge. St. Christopher's implemented the bundle of interventions in February 2011 for spinal fusion surgery patients. "Since then, the hospital has had a 76% reduction in SSI rates and bundle compliance has remained at 100%," The Joint Commission states in the guide. The St. Christopher's pediatric SSI bundle includes a post-op nursing standard of care; designated nursing units for high-risk procedure patients (e.g., spinal fusion surgery); specific dressings and post-op protocols; a nursing teach-back; surgery-specific educational tool for patients and parents; products needed for home care, including how to meet the needs of low socioeconomic families; and early, consistent, scheduled, post-discharge follow-up with the surgeon for early identification of any infection.
- Joint Commission. The Joint Commission's Implementation Guide for NPSG.07.05.01 on Surgical Site Infections: The SSI Change Project 2013; Available at: http://ow.ly/m58iD.
- Centers for Disease Control and Prevention. April 2013 CDC/NHSN Protocol Corrections, Clarification, and Additions. Available at: http://ow.ly/m65zB.