preparing for joint commission accreditation: ensuring success with medication management kurt a....

PREPARING FOR JOINT COMMISSION ACCREDITATION: ENSURING SUCCESS WITH MEDICATION MANAGEMENT

Kurt A. Patton, MS, R.Ph. former Executive Director Hospital Accreditation, Joint

Commission.

WHATS NEW I SHOULD WORRY ABOUT THIS YEAR?

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NEW STUFF FOR MM• CMS and their S&C letter re the retirement

of the 30 minute rule. • The One and Only Campaign. • CMS surveyor worksheet drafts and their

perspective on multidose vials in procedural settings

• New EP July 1 re formulary additions and populations served

• The bar is being raised on expectations

FREQUENT FLIERS

• Perpetually difficult issues that have been around for a long time that hospitals continue to struggle with.

• Fix them by being more intrusive/thorough/rigorous with peers in other departments, your staff and yourself.

• Perform “Mother in law” inspections

TJC PRIMER, 101• A elements, absolute performance

expectation or a policy mandate. You have it, or you don’t

• Bulleted A – you have to fulfill all bullets or it’s a failure

• C elements, 2 observations =RFI, but 90% can clear the RFI through clarification.

• D = documentation required

D FOR DOCUMENTATION• MM.01.01.01: The organization has a written policy that describes

that the following information about the patient is accessible to licensed independent practitioners and staff who participate in the management of the patient’s medications:- Age- Sex- Diagnoses- Allergies- Sensitivities- Current medications- Height and weight (when necessary)- Pregnancy and lactation information (when necessary)- Laboratory results (when necessary)- Any additional information required by the organization

D FOR DOCUMENTATION

• MM.01.01.03: The hospital identifies, in writing, its high-alert and hazardous medications. * – Everyone has the high alert list– The hazardous portion of this EP was added

several years ago, and frequently missed.

D FOR DOCUMENTATION• MM.01.02.01: The hospital develops a list

of look-alike/sound-alike medications it stores, dispenses, or administers.Note: One source of look-alike/sound-alike medications is The Institute for Safe Medication Practices – Gap here is often EP 3, annual review, or EP 2

actions to prevent interchange and a breakdown in some location, often pharmacy.

D FOR DOCUMENTATION• MM.02.01.01, 3 EP’S, seldom missed• Members of the medical staff, licensed independent

practitioners, pharmacists, and staff involved in ordering, dispensing, administering, and/or monitoring the effects of medications develop written criteria for determining which medications are available for dispensing or administering to patients.

• The hospital maintains a formulary, including medication strength and dosage.

• The hospital develops and approves written medication substitution protocols to be used in the event of a medication shortage or outage.

D FOR DOCUMENTATION• MM.03.01.01: The hospital has a written

policy addressing the control of medication between receipt by an individual health care provider and administration of the medication, including safe storage, handling, security, disposition, and return to storage.

• Often missed, huh? Get it and give it, right?

D FOR DOCUMENTATION

• MM.04.01.01: The hospital has a written policy that identifies the specific types of medication orders that it deems acceptable for use. – PRN qualifiers, range orders, titrations

• Scoring usually takes place at EP 13, the hospital implements its policies for medication orders.

MEDICATION ORDERS POLICY• PRN – must have an indication in the body of

the order, or by policy that is universally understood and always applied.

• Range orders – must be verbalized and implemented uniformly by all nursing staff in the organization. Advice: embed instructions in order and/or MAR.

• Titration – must have a start point, must have a therapeutic end point that is measureable


policy that defines the following: The required elements of a complete medication order.– Name of drug, dose, frequency, route, rate,

etc. – Most hospitals usually have this, breakdown is

performance at EP 13 again.


policy that defines the following: When indication for use is required on a medication order.– You are writing the policy, make it only for PRN

orders and antibiotics if you want.


policy that defines the following: The precautions for ordering medications with look-alike or sound-alike names.– What are you going to do differently to prevent

interchange of these LASA drugs?– WARNING: You must do what you say you are

going to do, don’t be too uniform and prescriptive.

D FOR DOCUMENTATION

• MM.04.01.01:The hospital has a written policy that defines the following: Actions to take when medication orders are incomplete, illegible, or unclear. – Usually everyone has this, but the failure to

take action is very common. Be especially careful with PACU and ICU.

D FOR DOCUMENTATION

• MM.04.01.01: The hospital defines, in writing, the circumstances for which weight-based dosing is required for pediatric populations.

D FOR DOCUMENTATION

• MM.05.01.17: The hospital has a written policy describing how it will retrieve and handle medications within the hospital that are recalled or discontinued for safety reasons by the manufacturer or the U.S. Food and Drug Administration (FDA).– Everybody does it, but not everybody has a

written policy.

D FOR DOCUMENTATION

• MM.06.01.01: The hospital defines, in writing, licensed independent practitioners and the clinical staff disciplines that are authorized to administer medication, with or without supervision, in accordance with law and regulation. – Often missing, often to limited in detail. – CMS has made this more complex now.

D FOR DOCUMENTATION

• MM.06.01.03: If self-administration of medications is allowed, written processes that address training, supervision, and documentation guide the safe and accurate self-administration of medications or the administration of medications by a family member. – Make sure your policy does not conflict with what you do

in an infusion center, sleep lab or other outpatient setting.

D FOR DOCUMENTATION

• MM.06.01.05: The hospital has a written process addressing the use of investigational medications that includes review, approval, supervision, and monitoring.– Not usually an issue

D FOR DOCUMENTATION• MM.07.01.03: 2 EP’S: The hospital has a written

process to respond to actual or potential adverse drug events, significant adverse drug reactions, and medication errors.

• The hospital has a written process addressing prescriber notification in the event of an adverse drug event, significant adverse drug reaction, or medication error.– Where would a surveyor see this documented?

MOST FREQUENT MISTAKES

• We can permit range orders because the Joint Commission doesn’t say they are prohibited.

• Our nurses know how to sort through therapeutic duplication.

• CPOE fixes everything• The nurses will just have to learn to date

the multidose vials correctly

MOST FREQUENT MISTAKES• I think that area, those meds are secure

enough, don’t worry about it. • I can only control what takes place in the

pharmacy.• I’m not sure what that EP means, but I don’t

think its applicable to our hospital.• Only pharmacists, nurses and physicians are

authorized to have access to medications.

THE MOST FREQUENTLY SCORED MM STANDARD 31%

• MM.03.01.01– There are many facets, 11 EP’s– EP’s 2, 3, 6 and 8 cause most of the problems• (Refrigerators, warmers), security lapses, expired

meds• Have you looked at radiology, OR, ED and pharmacy

to look at warmed products. • TJC published a “booster pack” just for this one standard

several years ago. – This is where they changed to BUD

MEDICATION STORAGE AND TEMPERATURE CONTROL

• You use paper logs, or you use electronic sensor monitoring for refrigerators. – Performance lapses with paper logs, missing days– Failure to document actions taken when the temperature is

out of range. Paper and electronic– Failure to include pharmacy in actions taken– Failure to implement a system for 5 day operations– Failure to know how to use the system for 5 day operations.– Turning off alarms, knowledge deficits on zeroing out

recorded highs• Did you know you had performance lapses, why not, or

why wasn’t it corrected?

MEDICATION STORAGE AND TEMPERATURE CONTROL

• Failure to consider warmers, not knowing what is being warmed and who is warming medications.

• Failure to use manufacturers advice for warmed medication max temp and duration

• Failure to implement the expiration dating system for warmed products.

• Failure to recognize contrast is a medication• Failure to recognize special requirements for

vaccines

TEMPERATURE CONTROL• Remote sensor monitoring can help– Do you have the capability to print a

retrospective log– Do you have the capability to print actions

taken– Implement a mandatory system for

documenting actions taken– Trace these capabilities just like a surveyor

PROBLEM 2, SAME STANDARD, MEDICATION SECURITY

• Policy and actual process must be consistent.• “We only allow nurses, physicians,

pharmacists and respiratory therapists to have access to medications”. – What about radiology technicians?– What about materials management staff?– What about central supply staff?– What about clean utility rooms used to store IV

bags?

MEDICATION SECURITY DRILL DOWN• Go to radiology: how many different cabinets, how

many different rooms have contrast? Is the warmer locked? Are these rooms/cabinets locked or open to all staff and visitors who are present?

• Go to clinical units, ED, OR, central stores, materials management: Where are IV’s stored, who has access and who delivers supplies?

• How are crash carts replenished?• Are the crash carts stored in observed locations or on

dead end corridors near an exit?• Are secure, limited access areas like OR, really

secure? What about housekeeping and maintenance staff? Weekends?

SECURITY OF MEDICATIONS POLICY• Joint Commission and CMS permit concept of secure by

observation, but it has to be real. • If your surveyor can wander without challenge its not

secure. • Joint Commission and CMS don’t mandate which staff may

have access. Some state regulations may, but not TJC/CMS. • Write policy loosely reflecting actual processes, not rigidly

reflecting a desired practice that does not exist. • We need to create a new mindset of practicality• Look at pneumatic tubes and crash carts. Document risk

assessment when doubtful

EXPIRATION DATE CONTROL, STILL MM.03.01.01

• Pharmacy staff inspect the official storage locations: Joint Commission surveyors look in unofficial locations. – open every drawer and every cupboard, even when there should

not be any medications stored there.– Go with the department head to every room, just like a surveyor– GI lab, endo, trauma, anesthesia carts, ambulatory Tx rooms

• Multi-dose vial expiration system– Use BUD date 28 days in the future, not date opened– Check your system pre-survey to determine if it works. If not,

change it. Its not going to get better during survey. – Consider expiration dating from day of dispensing

• Anesthesia carts – Do they have partial vials and syringes pre-drawn that should have been labeled with an EXP?

SECOND MOST FREQUENTLY SCORED MM STANDARD MM.04.01.01

• 14 EP’s, Chief problems: clarity of range orders and prn indications on orders. All performance lapses scored at EP 13. C, 90%

• Any range order, 5-10 mg must have absolute clarity, and reproducibility among staff. – Only way to succeed is to make the selection of dose

part of the order. – If you think policy and training is an acceptable

alternative, conduct tracer interviews.

HAVE YOU GIVEN PEOPLE THE TOOLS THEY NEED TO BE COMPLIANT?

• NPSG.03.04.01 labeling medications and solutions during procedures. – Go to ED, ICU, GI lab, Ambulatory procedure

rooms- do they have sterile labels for minor procedures?

– Look for the silver color Mayo stand, ask how it is used and prepared for a procedure.

– Are there any mental reminders about labeling, consent, time out, don’t forget to label everything

• Yes, it still applies to 1 drug and sterile water

EMERGENCY MEDICATIONS MM.03.01.03

• Are they accessible without risk of tampering or theft? If in doubt, risk assess and document

• EP 3, Whenever possible, emergency medications are available in unit dose, age specific, and ready to administer forms.

• Broselow carts, tapes or other systems: Do they use standardized concentrations or infinitely variable concentrations? Have you searched for old tapes and old instructions? 2002 too old, 2007A glucagon error

• If your instructions and your training call for a pediatric concentration, you MUST have it or change the instructions.

STERILE PRODUCT PREPARATION, MM.05.01.07

• Does the pharmacy prepare all sterile infusions except in emergent situations or short stability? Elastomeric pumps too?

• Do you do this for infusion center and all outpatient locations?

• How are you preparing radiopharmaceuticals and does pharmacy or a physician supervise off hours compounding?

• Do you monitor performance of clinical contractors of specialty prescriptions?

PREPARING FOR SURVEY• Day one patient tracers may uncover MM

issues. Find out what was found. • Prepare for MM system tracer. “Here is what

we were doing to prevent what you saw”. We were aware, we were on top of it.

• Joint Commission views MM issues anywhere in the organization as under your purview.

• Don’t describe your area of responsibility as less than whole organization.

MM SYSTEM TRACER• Reserve a room, but be ready to walk around

also. • Have nursing and medical staff representatives

present. • Consider rehearsal, filter out those staff that will

be a liability• Come prepared to talk positively and

affirmatively about the good work you do. • If the surveyor lets you, keep talking about the

great work you do.

MEDICATION RECONCILIATION• 1 standard, 5 C EP’s not being scored as often as

the old one• Problems exist in EP 3: Compare the medication

information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies. – Is continue, discontinue, change clear that decisions

were made and not errors? – Who in your hospital has a documented competency

to conduct this medrec analysis?

ONE AND ONLY CAMPAIGN

• One needle, one syringe, one patient• If staff use something as multidose, make sure

the FDA told you it was multidose. Contrast, IV bags, irrigating fluids, lidocaine and sterile water vials.

• Be cautious with the use of insulin pens• Consider using multidose vials in procedural

settings as single dose only. CMS and AORN

CMS AND TJC ARE MORE CLOSELY ALIGNED

• Keep up with the SOM/Interpretive Guidelines, it can change how standards are evaluated without seeing something new from TJC.

PREPARATION OF DRUGS TAG A-0405

• The 30 minute rule is gone, but the replacement is complex.

• Medical staff must approve the P+P for medication administration.

• P+P must identify the disciplines authorized to administer medications and the categories of medication they may administer. E.g oral, IV, IM, inhaled

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Training for those administering medications must include equipment, devices, special procedures and or techniques required.

P+P must address the required components of training and what can be provided via orientation vs. additional or ongoing training and what requires a documented competency.

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Timing of med administration:1. ID meds not eligible for scheduled dosing times

Stats, first dose, one time, time sequenced, PRN2. ID meds eligible for scheduled dosing times

BID, TID, ETC

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• 3. Further divide your meds eligible for scheduled dosing time into:– Time critical, e.g. antibiotics, anticoag, insulin,

anticonvulsants, analgesics immunosupressives, RX less than q4hThese may be given +/- 1 hr

– Non Time Critical, e.g. daily, weekly, monthly. These may be given +/- 2 hr

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• P+P must address what to do with missed doses and what is a med error.

• Evaluate your timing policies for QAPI• May adopt standing orders but include well

defined criteria for use and get practitioner sign off after use. – Monitor correct use of standing orders also

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PREPARATION OF DRUGS TAG A-0405, SURVEY PROCEDURES

• Verify the hospital has P+P for:– Meds not eligible for scheduled times– Meds eligible and time critical– Meds eligible and not time critical

• Verify windows do not exceed 1 hr for time critical, 2 hr for not time critical, or 4 hr for not time critical (daily’s or longer).

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PREPARATION OF DRUGS TAG A-0405, SURVEY PROCEDURES

• Ask to see one or more standing orders and evidence of training, periodic evaluation of the use of the standing order including adherence to policy.

• Interview nursing staff. Are they familiar with P+P for standing orders and are they following?

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QUESTIONS?

• [email protected]

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preparing for joint commission accreditation: ensuring success with medication management kurt a....

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