Accreditation Professional Orientation Certificate Program ...

Accreditation Professional Orientation Certificate Program Webinar # 3Establishing the Structure and Ensuring Support

Faculty and disclosure

Ahnna Parker, MSN, RN-BC, CICAccreditation [email protected]

Accreditation Professional Orientation Program │ Confidential Information2

Ahnna Parker does not have any relevant financial or nonfinancial relationships to disclose.

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Accreditation Orientation Program Certificate Learning Objectives Webinar #3• State the fundamental requirements of the CMS hospital and critical access CoPs

• Explain how to engage operational partners and content experts within an organization to ensure CPR and optimize effectiveness as accreditation professionals

• Recognize resources available through collaboration and networking with other member accreditation professionals.

• Demonstrate teamwork among participants


Accreditation Insights & ReadinessBuilding a continuous accreditation compliance process and team

4 Accreditation Professional Orientation Program │ Confidential Information

Establishing a continuous accreditation compliance processFunctional chapters / CMS conditions of participation


Success Strategies

Tools for assessing risk, identifying

issues, mitigating and sustaining

improvement.

Utilize existing organizational

systems, structures and

processes to keep issues at the

forefrontWhat committee’s /

groups focus on these requirements?

Identify operational partner(s)

Who has operational

responsibility for the

requirement?

Prioritize critical issues

Which issues have you assessed and

identified as critical? Which critical issues have been identified

in the field?

Structure


Continuous accreditation compliance process

Environment of Care (EC) and Life Safety (LS)


Critical priorities

Existing organizational

approach

Operational partner

Intent of requirements: promotion of safe, functional and supportive environment

Continuous accreditation compliance process Environment of Care (EC) and Life Safety (LS) components (addressed in more detail in Module #5)


• Safety and security• Smoking• Hazardous materials and waste• Medical equipment• Utilities management• Construction

Environment of Care (EC)

• Life safety code: electronic-statement of conditions (e-SOC)

• Building maintenance program• Fire safety• Egress: doors, clutter, exits, stairs

Life Safety (LS)


Environment of care (EC) operational partners

Directors of: - Facilities- Biomedical Maintenance- Hospital Safety- Security- Infection Prevention

COO or executive responsible for the physical plant

Environment of care (EC) – focused listVentilation in critical / non-critical spaces• Critical - OR, Central Sterile Processing,

Procedure Rooms and similar areas• Non-critical – soiled utility rooms, clean

utility rooms, and similar areasEyewash station location and maintenanceBiomedical Maintenance Up-to-dateIdentification and control of security sensitive areasGenerator Testing


Environment of care – foundational documents

Critical air pressure relationships test logsWater management program policy and documentation of activitiesEyewash station weekly test logsEmergency power generator test logsBiomedical maintenance preventative maintenance recordsLogs and actions taken for reported safety and security issues


Environment of care (EC) strategies for success

Be prepared for the document review. This activity can take two hours or more to review and typically includes both review of life safety and environment of care documentation requirements.

Ensure the documents are organized and easily accessible.

Environmental rounding to all care sites.

Resource Tool: Life Safety and Environment of Care document list andreview tool


Life safety (LS)

Basic building information (BBI): • Validation of square footage• Declaration of building occupancies

(hospital, ambulatory, business) • Description of the fire protection features

(sprinklers, fire alarm systems, etc.)• Inaccuracies impact survey length and

types of surveyors assigned



Life safety (LS) operational partners

Directors of: - Facilities- Safety

COO or executive responsible for the physical plantEnvironment of Care CommitteeLife Safety Engineer

Life safety (LS) – foundational documents

All Testing Documents – Automatic door closure, fire alarm audio chimes, visual strobes, pull stations, battery powered egress lighting, and much more!

Time Limited Waiver - Effective August 1, 2016, all life safety deficiencies cited during surveys will need to be corrected within 60 days. If the issue will need greater than 60 days to resolve, the hospital will need to request a Time Limited Waiver (TLW) or equivalency from their CMS regional office by routing the request through TJC


Life safety (LS) strategies for success

Be prepared for the document review. This activity can take two hours or more to review and typically includes both review of life safety and environment of care documentation requirements.

Ensure the documents are organized and easily accessible.

If this slide appears to be the same as seen for Environment of Care, it is! This must be very important! EC-LS are very tightly linked.

Resource Tool: Building Tour Guidance



Emergency Management (EM)


Critical priorities


approach

Operational partner

Intent of requirements: plan for emergencies to prevent disruption of safe patient care and services


Emergency management (EM) operational partners

Disaster Planner or equivalentEmergency Department:

- Nurse Manager- Medical Director

COO or executive responsible for the physical plant


Emergency Management• Emergency operations plan (EOP)• Phases of emergency: mitigation, preparedness, response and recovery

• Requirements: communication, resources, safety and security, staff responsibilities, utilities, patient care support

• Other key components:–Disaster privileging–2 exercises per year


Emergency management strategies for successEnsure the EOP plan is current and available.

Be prepared to discuss any actual events or drills.

Have the after-action reports available for review.

Ensure any weaknesses in the plan as identified during after-action review are incorporated into the EOP.

Resource Tool: CMS Emergency Preparedness Template


Continuous accreditation compliance process Information Management (IM)


Critical priorities


approach

Operational partner

Overview: a well-planned system meets the external and internal information needs of the

organization with efficiency and accuracy


Information management (IM) operational partners

Directors of:- Healthcare Informatics- Information Technology

Medical Records ManagerHIPAA Compliance Officer


Information Management (IM)•Planning – managing information•Providing – health information, knowledge – based information

•Protecting – integrity, security and privacy

•Monitoring data


Information management strategies for successWhat are some examples of challenges in your organization related to information management?

• Health Insurance Portability and Accountability Act (HIPAA)• Electronic system downtime• Paper versus electronic health record (EHR) Corrections• Use of templates in the EMR• Copy-forward

Resource Tool: Health Information Policy Checklist



Infection Prevention and Control (IC)


Critical priorities


approach

Operational partner

Overview: prevention and reduction of acquiring and transmitting infections


Infection control (IC) operational partners

Director of Infection Prevention and ControlDirector of Sterile ProcessingDirector of Environmental ServicesInfectious Disease Physician

Continuous accreditation compliance process Infection Prevention and Control (IC or IPC)

Requirements:• Appointed individual responsible for IPC program

• Program resources (access to information, education, equipment, supplies

• IPC Plan (overarching description of all aspects of program)

• IPC Annual Risk Assessment

• IPC Annual Goals (measurable)

• IPC Surveillance Plan/Calendar reflecting all IPC activities


Continuous accreditation compliance process Infection Prevention and Control (IC or IPC)Requirements continued:• Infectious Disease Outbreak Management Plan

• Community Coordination

• Hand Hygiene Program (may be included in IPC Plan)

• Influenza Vaccine Program (may be included in IPC Plan)

• High level and low-level disinfection

• Antimicrobial Stewardship Program

• IPC Committee (may be incorporated into another organizational committee, i.e. Safety Committee) Minutes


Infection control (IC) strategies for success• Be prepared to produce and discuss the Infection Prevention and Control (IPC) Risk

Assessment (be sure to include risks from all areas of the hospital and any hospital associated entities [billed under hospital’s CCN number], i.e. ASCs, Clinics, Sleep Centers, other Ambulatory Sites).

• Know where all Instrument Sterilization and High Level Disinfection (HLD) occurs in your system, including hospital based ambulatory sites. Surveyors will most likely want to visit those sites to assess compliance with Manufacturer’s Instructions for Use in processing instruments/equipment and in maintaining/documenting management of all associated equipment (sterilizers, autoclaves, automated scope processors).

• Be aware that non-compliance with Manufacturer’s Instructions for Use associated with sterilization and/or high-level disinfection of equipment is a major cause of serious survey findings that will automatically generate follow up surveys.

Resource Tool: CMS Infection Prevention WorksheetAccreditation Professional Orientation Program │ Confidential Information29

Continuous accreditation compliance process Transplant Safety (TS)

(TS Chapter includes Tissue Management Standards)


Critical priorities


approach

Operational partner

Overview: The standards in this chapter focus on the development and implementation of policies and procedures associated with Organ Transplants AND Tissue Management.


Transplant safety (TS) operational partners

Director of Operating RoomMaterials ManagerLead OR Circulator RN

Continuous accreditation compliance process: Transplant safety (TS)


Identifying, reporting

and taking action when

adverse events occur

Bidirectional traceability

Preparation and final

disposition of organs

and tissues

Tissue storage

Donating and

procuring organs and

tissues

Transplant safety (TS) strategies for success

• If you perform organ transplants in your hospital and/or Ambulatory Surgery Center, review the “Transplant” Standards at the beginning of the Transplant Safety Chapter with your Operational Partners to ensure your organization is in compliance.

• Regarding “Tissue, to determine if a product is a tissue, go into the Transplant Safety Chapter of the Joint Commission Manual and review the list of tissues included there. If you use ANY tissues on that list, then all of those applicable Standards and Elements of Performance apply.

• Have policies and procedures readily available.

• Transplant and Tissue tracers usually occur as part of the OR Tracer

• When the Surveyor is ready to trace transplants/tissues, have the Operation Partners present to walk the Surveyor through the process and assist with the associated closed record review.


Transplant safety (TS) strategies for success (continued)• In a binder, have a current copy of FDA licensure for each Tissue Bank utilized by your facility.

Does your state require licensure of Tissue Banks in addition to FDA requirements? If so, have the current state licensure documentation for each Tissue Bank utilized.

• Is Breast Milk identified as a “tissue” in your state? If so, breast milk management will have to include all applicable tissue documentation elements.

• Surveyors will review processes and documentation compliance for transplants and/or implantable tissue through a closed record review.

• Be prepared to answer the question: How can all tissues be traced from the tissue bank to the patient AND/OR from the patient back to the Tissue Bank?

Resource Tool: Tissue Management / Bidirectional Tissue TracerAccreditation Professional Orientation Program │ Confidential Information35


Waived Testing (WT)


Critical priorities


approach

Operational partner

Overview: Waived testing is the most common and most basic complexity level of lab testing performed by caregivers at the patient bedside or point of care. The standards outline the requirements for performance and ensuring accuracy of those tests, which often provide the basis for medical decisions.


Waived testing (WT) operational partners

Director of Laboratory ServicesLab Manager for Waived Testing (in hospital and affiliated off-site entities; i.e. ASC, Clinics)Clinical Managers for affiliated off-site entities

Lab tests and waived testing (WT)“Test results that are used to assess a patient condition or make a clinical decision about a patient are governed by the federal regulations know as the Clinical Laboratory Improvement Amendments of 1988 (CLIA ‘88).

CLIA ‘88 classifies lab tests into four complexity levels:• High complexity• Moderate complexity• Provider-performed microscopy (PPM) procedures (a subset of moderate complexity)• Waived Testing

The high, moderate, and PPM levels, otherwise called nonwaived testing, have specific and detailed requirements regarding personnel qualifications, quality assurance, quality control and other systems and are performed in the hospital lab. Waived Testing…has a few requirements and is less stringent than the requirements for nonwaived testing.” (Joint Commission Waived Testing Standards, HAS 2020)


Waived testing (WT) specifically• When a patient performs a test on him or herself (blood glucose testing) using their own meter

cleared by the FDA for home use, the action is NOT regulated.

• Testing performed by staff on patients is an activity regulated by CLIA ’88

• Waived testing is the most common complexity level performed by caregivers at the patient bedside or point-of-care (vs. in the lab)

• The list of lab tests designated as CLIA Waived is constantly changing, so one must check to ensure that a lab test performed at the beside in fact “CLIA Waived.” One must check the United States FDA, CMS or CDC for the most up-to-date information on test categorization and complete CLIA ‘88 requirements. Example: Some tests that are performed in an I-STAT machine are CLIA Waived and other tests that are performed on the same I-STAT machine are NOT CLIA Waived.


Continuous accreditation compliance process Waived Testing (WT)• Have the Current CLIA Waived Testing Certificate• Have waived testing policies and procedures for each waived test performed; available to staff• Maintain consistent and complete documentation of quality controls performed per MIFUs for

each test • Ensure competencies – minimum of two of the following methods must be documented for each

team member performing a test at orientation and annually- Performance of a test on a blind specimen - Periodic observation of routine work by the supervisor or qualified designee - Monitoring of each user’s quality control performance - Use of a written test specific to the test assessed

• Validate and document Physician performed microscopy competencies (if applicable)


Continuous patient readiness process Waived testing


Program policies and procedures

Consistent/ complete quality

controlsCompetency –two methods

Maintenance of records

Inventory and approval

process


Waived testing (WT) strategies for success

• Have current copies of CLIA Waived Testing Certificate(s) available to share with Surveyor

• Have staff members’ initial and annual competencies readily available during the Human Resources Staff Personnel File reviews

• Know that as Surveyors perform patient tracers throughout the hospital, they will inspect Waived Testing equipment, processes, and logs in each area.

• Ensure that glucometers do not have traces of blood on them and that cleaning procedures exactly follow Manufacturer’s Instructions for Use; use the cleaning wipes designated by the manufacturer.

Resource: CLIA WebsiteAccreditation Professional Orientation Program │ Confidential Information42

Be proactiveAn accreditation professional is a facilitator and resource for many. The accreditation professional is NOT a one person show.

Engage the appropriate “operational partners” or some call it “chapter champions” for each chapter of regulatory standards.

Make rounds with “operational partners” or “chapter champions” on a scheduled and regular basis

Keep your sights on the patient

Improve patient safety

No surprises

Thoughtful process change


Questions or comments


Interactive Activity


Next steps

1. Complete evaluation

2. Stay connected –• Network Members - register for Fundamental and Advanced

webinar series and encourage operational partners to listen in to pertinent webinars

• Attend Vizient conferences to stay up to date with trends and requirements

• Connect with the colleagues during the course• Connect with your Vizient faculty


This information is proprietary and highly confidential. Any unauthorized dissemination, distribution or copying is strictly prohibited. Any violation of this prohibition may be subject to penalties and recourse under the law. Copyright 2018 Vizient, Inc. All rights reserved.

Contact: Diana Scott, Associate VP, Accreditation Advisory Services, [email protected] Webb, Accreditation Director, [email protected]



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