Lessons Learned from a Recent TJC Survey

OR Manager WebinarJohn R. Rosing, MHA, FACHEVice President and Principal

Patton Healthcare ConsultingJune 28, 2012

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H&P and Update • An H&P is done no more than 30 days prior to

admission or within 24 hours of admission. • If the H&P is done anytime in the 30 days prior to

admission you update it within 24 hours of admission, or prior to an invasive procedure on the day of the procedure, whichever comes first.– Must document: the patient was examined, and the H&P

was reviewed - CMS mandate– In EMR – use a SmartText: e.g., .no changes or .changes

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Informed Consent

• Physician responsibility• Paper form needs date and time for all signatures• Form may include potential use of blood• Process includes discussion of likelihood of desired

outcome• Anesthesia consent is usually in anesthesia record• Sedation consent is on presedation assessment• RN confirms patient understanding, advocate

Document Operative & High Risk Procedures (RC.02.01.03)

H&P in record before procedure (EP 3) Post op/post procedure report is dictated

before transfer to next level (EP 5) (Unless a post op/post procedure note is

entered immediately [see EP 7], if so, report may be written or dictated per policy)

The post operative/procedure report includes: name of LIPs, procedure name and description, findings, EBL, specimens, post op diagnosis (EP 6 - Top Scorer)

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Document Operative & High Risk Procedures (RC.02.01.03)

If report is delayed, an immediate post procedure note is entered and includes LIP, assistants, procedure(s) performed and finding(s), ANY EBL, ANY specimens, Post op diagnosis (EP 7 top scorer). Check your policy.

Medical record includes the LIP release order or approved DC criteria (EP 9)

Medical record includes the use of DC criteria/pt readiness (EP10)

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CMS/TJC Anesthesia 1/11 Changes

• Postanesthesia assessment must occur (and be documented) within 48 hours of recovery.

• May be based on data collected by a nurse (as in the case of SDS where discharge is by RN using criteria approved by the medical staff.)

• No requirement for an LIP postsedation assessment.

• All entries to medical record are dated/timed

Medication Orders

• Preprocedure meds and testing by protocol is now permitted with qualifications

• Cannot sign post-operative anesthesia or surgical orders pre-operatively

• Got away with it on paper; could fudge or omit the time and not be noticed

• CPOE captures the time automatically• Must pend and go back in and sign

Medication Orders

• Intraprocedure verbal orders need to be countersigned by LIP

• On paper – sign the OR flow sheet/ MAR• eFlow Sheet or eMAR and goes to LIP inbox

for electronic signature• Caution: Verbal orders require read-back to

ensure understanding. E.g., “2 and 50”

Medication/Fluid Integrity

• IV bag fluids and Irrigation bottle fluids• Cannot exceed 104 degrees F• Wise to record a daily temp reading• IV bag in outer pouch: 14 days, – label with new, “do not use beyond” date

• Irrigation bottle fluids: 72 hours, – label with new, “do not use beyond” date

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Label All Medications(NPSG.03.04.01)

Label all meds on and off the sterile field.• All products, including sterile water/saline,

disinfectants in a basin must be labeled.• The safety goal includes bedside procedures as

well as IR, cath lab, Out Patient• Unlabeled refuse may be cited• There is no acceptable alternative to labels• Its an A element of performance

Time Out (UP.01.03.01)

The final verification process must be conducted in the location where the procedure will be done, just before starting the procedure

Cath, Endo, ASC, AMB, IR, bedside, etc.Compare two identifiers on the arm band (if

visible) against the medical record, OR select one of the following three options…

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Time Out and 2 identifiersThree Options

• Two team members confirm patient ID upon arrival in the procedure suite using two identifiers.

• One of the two team members remains with the patient during the entire pre-procedure process.

• During the final time out, this team member confirms patient ID. OR• Two team members ID patient upon arrival in procedure suite as previously

described. • Two patient identifiers are written on white board in procedure room and

confirmed by the two team members. • During final time out, the team confirms patient ID against information on

white board. OR• Place a patient ID on an exposed extremity – alternate wrist or either ankle. • Reference the two identifiers on this ID band during the final time out.

Environment/Crisis

• No equipment blocking fire alarm pull boxes, fire extinguishers, electric breaker panels, medical gas shut-off valve boxes.

• Airway fire prevention and response drills, study best practices

• Laser Safety• Malignant Hyperthermia

Reduce Risk of Infection

• Surveyors will observe staff as they process dirty equipment

• Surveyors will check manufacturer instructions for use (IFU) for three things: the device/instrument, the sterilizer itself, and the packaging (i.e., blue wrap or flash pan.)

• Check your policy, check staff understand and follow both. Create a recipe book

• Will observe proper use of PPE

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Laryngoscope Blades• Clean and (at least) high level disinfect them per

manufacturer instructions for use• Store in manner that prevents recontamination• One blade per Zip-Lock bag if HLD, or • Peal pouch if steam• Consistent practice throughout the hospital• Testing light source?

– Hand hygiene and/or use gloves– Place back into Zip-lock bag or peal pouch– Battery expiration dates!

High Level Disinfection - Scopes

• Follow manufacture recommendations• E.g., glutaraldehyde or OPA MEC test strips– Date when opened– QC run on a positive and negative solution– Requires 6 strips right from the start– Document the strip QC– MEC testing prior to each load, document QC

Separation of Clean/Dirty

• Scrutiny of scope cleaning room to determine if flow/practice prevents cross-contamination

• Key: remove HLD scopes from sterilizer only when no other dirty scopes are in the room

• Flawless QC and load record documentation• Proper PPE

Scope Storage

• Rinse with sterile water or potable water and 70% alcohol, then forced-air dry

• Hang in a positive pressure vented cabinet• Avoid tip dragging on base (avoid rack sag)• Avoid cross-contamination (adjacent sink??)• 30 day shelf life? (August 2011 OR Manager)• Never store in foam mold in hard case

Consistent Practice

• How many TEE probes exist in the hospital?• How many nasogastric scopes? Where???• In each area – are decontamination, testing,

QC, HLD processing, load record-keeping steps performed consistently???

• Exact concentrations, soak times, handling• Inventoried by Biomed/Clinical Engineering

Sterile Processing Tour

• Attire: donned at the hospital, changed daily• Red line – no one enters without proper

attire• No artificial nails, nail polish, jewelry, watch• Head AND facial hair covered at all times• In Decontamination: liquid-resistant garb,

heavy-duty gloves, eye protections• WASH HANDS WHEN FINISHED

Immediate Use Sterilization• Important that staff can speak to the process without

using the term “flash”• Follow manufacturer recommendations for sterilizer,

pack, instruments, CI, BI• Covered containers even in sub-sterile• “A sterilized item intended for immediate use is not stored for

future use, nor held from one case to another.”• “Instrument inventories should be sufficient to meet anticipated

surgical volume and permit the time to complete all critical elements of reprocessing.”

• Submit data to PI Committee /leadership to justify purchase

SPD Facility

• Easily cleaned walls, floors and ceiling• Daily housekeeping• No exposed pipes, etc. that collect dust• Maintain neg/pos pressure by keeping doors and

windows closed; test pressures monthly• Sinks available for hand washing• Eye wash within 10 second travel time; single action

lever, tepid water temperature to allow 15 minute flush time

Temperature, Humidity, Storage

• Monitor and record daily• Temp 68-73 in clean area of department• Temp 60-65 in decontamination • Humidity 30-60% in work areas• Humidity not > than 70% in sterile storage• 18 inch, 6 inch, 2 inch, solid lower shelf

Loaner Equipment

• Clear policy and procedure, penalties for noncompliance; ripe for short-cuts

• Mandate 48 hour lead-time???• Follow manufacture recommendations• Staff should blow whistle if uncertain

Tissue Management TS.03.01.01

– EP 1 Assign responsibility for tissue– EP 2 Policy for acquisition, receipt, storage, issuance– EP 3 Confirm FDA registration, have current paperwork– EP 4 Spread process throughout hospital– EP 5 Use manufacturer instructions for transporting,

handling, storing and using tissue (verify that vendor keeps records per lot # in event of RCA)

– EP 6 document receipt of tissue(TS.03.02.01 EPs 3 &6)– EP 7 at receipt, package integrity and temp control is

verified (TS.03.02.01 EP 6)

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TS.03.01.01 Continued

– EP 8 Daily record of temperature for ambient, refrigerated, frozen, or liquid nitrogen (TS.03.02.01 EP 5)

– EP 9 Continuous monitoring for refrigerated, frozen, or liquid nitrogen

– EP 10 Functional 24/7 alarm for refrigerated, frozen, or liquid nitrogen

– EP 11 If you are a tissue supplier, you need FDA registration.

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TS.03.02.01

– EP 1 Bi-directional tracing including discarded (FAQ ‘10)– EP 2 Written materials/instructions to prepare or

process (FAQ TJC)– EP 3 date/time/name of staff involved at receipt/

acceptance, preparation, and issuance.

“During tracer activities, it was found that the organization had not been recording times at the following points: 1. Receipt at the warehouse which was located off site; 2. Receipt by the surgical personnel upon arrival to OR; 3. Time placed in refrigerator or freezer, and 4. Time removed from the refrigerator or freezer.”

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TS.03.02.01• EP 4 document in MR tissue type and unique identifier• EP 5 retain records on temperatures, outdated

procedures, manuals, and publications for 10 years (TS.03.01.01 EP 2 & 8)

• EP 6 records on distribution, transplantation, disposition, or expiration for 10 years– Name of supplier– Original numeric/alphanumeric donor and lot– Name of recipient and final disposition– The expiration dates of all tissue (TS.03.01.01 EP 6&7)

• EP 7 complete tissue cards and return to supplier

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TS.03.02.01 (con’t)

TS.03.03.01 (all are “A” EPs) – EP 1 written procedure to investigate adverse

events, disease transmission or complication– EP 2 conduct investigation – EP 3 report to supplier ASAP– EP 4 sequester compromised tissue or tissue

implicated by a supplier – EP 5 inform patients

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Questions???

JohnRosing@PattonHC.com262-242-3631

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