Embed Size (px)
Citation preview
4/8/2016
1
Top Deficiencies and Top Code 15 Incidents
SANDRA JONES, CASC, CPHRM, LHRM, CHCQM, FHFMA
PATRICIA KACZMAREK, BHSC., MSHL, RN
1
Top 10 State Licensing Tags (M Tags)Health Tag Title Top Total
M0050 Medical Records 1 13M0041 Surveil, Prevent & Control Of Infection 2 11M0031 Nursing Service 3 9M0007 Organized Medical Staff 4 8M0426 Patient Safety Officer And Committee 5 7M0412 Incident Reporting System ‐ Reports 6 6M0003 Governing Body 7 5M0410 RM Program ‐ Incident Reporting System 8 5M0051 Physical Plant Maintenance 9 4M0059 Quality Assessment & Improvement 10 4
2
4/8/2016
2
Top 10 CMS Certification Tags (Q Tags)
Health Tag Title Top Total
Q0181 Administration of Drugs 1 29Q0240 Form and Content of Record 2 24Q0241 Sanitary Environment 3 21Q0266 Discharge Order 4 18Q0267 Discharge with Responsible Adult 5 13Q0184 Written Order of Administration of Drugs 6 11Q0262 Admission and Pre‐Surgical Assessment 7 11Q0242 Ongoing Infection Control Program 8 10Q0240 Maintaining Infection Control Program 9 9Q0101 Physical Environment 10 7
3
Top 10 CMS National 2015Health Tag Title Number
Q0241 Sanitary Environment 394Q0181 Administration of Drugs 342Q0242 Infection Control Program 286Q0162 Form and Content of Record 220Q0101 Physical Environment 181Q0141 Organization and Staffing 153Q0221 Notice of Rights 138Q0261 Admission Assessment 133Q0043 Disaster Preparedness Plan 119Q0104 Safety from Fire 119
4
4/8/2016
3
Top 10 State Life Safety Code Tag (K Tags)LSC Tag Title Top Total
K0147 Electrical Safety 1 75K0144 Generator Maintenance & Testing 2 41K0046 Life Safety Code Standard 3 33K0315 Emergency Management Plan 4 24K0316 Generator ‐ Fuel Testing 5 23K0322 Sprinkler System 6 22K0076 Life Safety Code Standard 7 20K0051 Program Standards 8 19K0328 Fire Alarm Testing 9 19K0325 Afss & Standpipe‐Inspect, Test, & Maintain 10 18
5
Top Federal LSC Tags (K Tags)
LSC Tag Title Top Total
K0147 Electrical Safety 1 14K0046 Generator Maintenance & Testing 2 9K0144 Life Safety Code Standard 3 6K0048 Emergency Management Plan 4 5K0051 Generator ‐ Fuel Testing 5 5K0064 Sprinkler System 6 4K0050 Life Safety Code Standard 7 3K0067 Program Standards 8 3K0072 Fire Alarm Testing 9 3K0076 Afss & Standpipe‐Inspect, Test, & Maintain 10 3
6
4/8/2016
4
M0050-Medical Records
Physician orders for medications
Documentation of medications given
H&P within 30 days and updated on date of service
Discharge with a responsible adult companion
Physician order for discharge
Surgeon ordering a transfer to hospital (not only anesthesiologist)
7
M0041-Infection Control
Appointment of and education of infection control leader
Incorporated into QAPI
Following manufacturer’s instruction for use
Hand hygiene practices
Use of PPE
Cleaning of equipment, instruments
High level disinfection and sterilization
8
4/8/2016
5
M0031-Nursing Service
RN circulator
Appointment RN in charge of Nursing Services
RN in PACU plus another person
Verification of licenses
9
M0007-Organized Medical Staff
Credentialed and privileged, biennial review reappointment
Current licensing verified
Approval by governing body of appointment and privileges
Review of policies and activities for infection control, pharmacy, quality, medical necessity, discharge practices
10
4/8/2016
6
M0426-Patient Safety Officer and Committee Appointment of patient safety officer
Appointment of non‐employee, non‐contracted staff, non‐medical staff member to committee
Activities of committee in patient safety measures
11
M0412-Incident Reporting System -Reports Physician notified and physician recommendations, if
any
List of all persons involved directly and witnesses
Name, signature and position of person completing reports, date and time of completion
12
4/8/2016
7
M0003-Governing Body
Governing body membership, medical staff bylaws
Approval of medical staff and AHP appointments and privileges, approval of scope of procedures
Appointments to positions
Be responsible for oversight of QAPI, environment
Meetings held, minutes recorded
13
M0410-RM - Incident Reporting System Timeliness of reporting by staff to risk manager or
designee
Duty of all providers, agents, and employees to report
Staff knowledge of process
Contents of report: Patient’s name, diagnosis, date, location … IDC‐10‐CM
14
4/8/2016
8
Top 10 CMS Certification Tags (Q Tags)
Health Tag Title Top Total
Q0181 Administration of Drugs 1 29Q0240 Form and Content of Record 2 24Q0241 Sanitary Environment 3 21Q0266 Discharge Order 4 18Q0267 Discharge with Responsible Adult 5 13Q0184 Written Order of Administration of Drugs 6 11Q0262 Admission and Pre‐Surgical Assessment 7 11Q0242 Ongoing Infection Control Program 8 10Q0240 Maintaining Infection Control Program 9 9Q0101 Physical Environment 10 7
15
Life Safety Code
Hospital grade extension cords, reduced tripping hazards
Generator testing, logs, battery powered lights
Emergency management plan, annual review by AHJs
Fuel testing
Sprinkler system installation, testing, maintenance
Medical gas safety, secured tanks
Fire alarm testing, signal panels, pull stations
Sprinkler and standpipe systems maintained and checked
16
4/8/2016
9
Plan of Correction (POC)
Action taken to correct each specific deficiency
Description of how actions will improve the process that led to deficiency cited
Procedure for implementing the corrective actions
Completion date for correction of each deficiency
Monitoring and tracking procedures to ensure the POC is effective
Title of person responsible for implementing the POC
17
POC
How will you fix it,
How you will implement it,
When
How you will know you fixed it
Who is responsible for fixing it and monitoring it
18
4/8/2016
10
QAPI
Problem identified
How will you fix it
How will you implement
How will you check that it worked
Who will do it and to whom will it be reported
19
POC
Include◦ New policy, worksheet, log
◦ Educational materials and sign in sheets
◦ Monitoring plan
◦ If you have already “fixed it”, include your monitoring that shows it is fixed.◦ Statement from maintenance, picture of repair
◦ Copy of surveillance worksheet, e.g.
◦ Statistical statement: 20 observations, 20 compliance = 100%
20
4/8/2016
11
POC
How long can I take to submit my POC?
How much do I commit to do?
Can I change my POC if it did not work?
What will be a desk review versus a re‐visit?
How many days do I have to make the correction?
21
Questions?
22
4/8/2016
12
Code 15 Reports
QUARTERLY REPORTS
23
24
4/8/2016
13
25
26
4/8/2016
14
27
Code 15 Reporting
Page 9, FSASC Risk Management and Related Regulations, Third Edition
The term “adverse incident” means an event over which health care personnel could exercise control.
28
4/8/2016
15
Code 15 Reporting
Death of patient two days post op
Scenarios:◦ Transfer from ASC to hospital◦ Patient admitted to hospital from home◦ Patient pronounced dead at house
29
Code 15 Reporting
Patient having regional block on right side. Needle inserted in left side. No medication administered.
Patient having pain procedure, radio frequency ablation, using electrical currents produced by radio waves to heat nerve tissue and decrease pain signals. Needles inserted in left side. Procedure stopped since needles should have been inserted in right side.
30
4/8/2016
16
Code 15
Patient had cataract lens inserted that was 20.5 diopter. Immediately recognized that it should have been 25.0 diopter. Lens 20.5 removed and 25.0 inserted. Patient never left O.R.
Same scenario. Patient was in PACU when wrong lens noted and returned to O.R. to have correct lens inserted.
Patient was discharged and wrong lens insertion discovered on post op visit. New procedure occurs to change lens.
Patient was discharged, wrong lens inserted, vision O.K. with eye glasses. No change of lens.
31
Root Cause Analysis
What happened? ◦ Details, details, details
Why did it happen?◦ People◦ Equipment◦ Environmental factors◦ Information factors◦ Communication◦ Policy, procedure, practices
32
4/8/2016
17
Scenario 1
The patient signed a consent to have the right side. The surgery was scheduled and planned for the left side.
What?
Why?
33
Scenario 2
Patient died three days after surgery. Spoke with family. Patient took more meds than prescribed for post surgery pain.
What?
Why?
34
4/8/2016
18
Scenario 3
Patient was discharged home. Complained of pain and blood discharge following colonoscopy.
When to emergency department. Admitted for perforation and had surgery.
What?
Why?
35
Scenario 4
Patient post op visit, vision worse than expected.
Wrong lens implanted
What?
Why?
36
4/8/2016
19
Analysis
Failure Modes and Effects Analysis
http://app.ihi.org/Workspace/tools/fmea/AllTools.aspx#21◦ Analysis of what can go wrong
◦ Reports written by other health care organizations◦ DVT Prevention
◦ Crash Cart Use, Access, Training
◦ SSI risk reduction
37
RCA vs FMEA
Root Cause Analysis: What was cause(s) of event?
FMEA: What could cause an event?◦ Can this be a risk assessment?
◦ Is this the start of a QAPI project?
38
4/8/2016
20
Risk Management Design
1. Identification
2. Analysis
3. Plan and Implement
4. Monitor
5. Respond
39
Resources
http://www.jcrinc.com/root‐cause‐analysis‐in‐health‐care‐tools‐and‐techniques‐5th‐edition/
40
4/8/2016
21
Resources
http://www.stratishealth.org/index.html
https://www.stratishealth.org/documents/MN_AE_Health_Events_Measurement_Guide.pdf
http://www.health.state.mn.us/patientsafety/toolkit/
http://www.patientsafety.va.gov/professionals/onthejob/rca.asp
http://patientsafetyauthority.org/Pages/Default.aspx
41
Questions
42
