December

TheSource
December 2014 Volume 12 Issue 12
TM
For Joint Commission Compliance Strategies
Effectively Engaging Staff in Patient Safety
Reporting Systems
A
robust reporting system for patient safety events is
essential to improving quality and safety in hospitals.
When staff report patient safety issues or process failures, the
hospital is able to identify problems and solutions, implement
sustainable improvements, and disseminate the lessons learned.
A reporting system is required within a hospital by Joint
Commission Leadership (LD) Standard LD.04.04.05, EP 6,
which states, “The leaders provide and encourage the use of
systems for blame-free internal reporting of a system or process
failure, or the results of a proactive risk assessment.”
Engaging medical staff (many of whom may be working
in the hospital under contract) in reporting systems has been
an ongoing challenge for many hospitals. It’s often difficult
to foster buy-in on reporting because staff may fear being
reprimanded or singled out for reporting a mistake they’ve
made. In some instances a staff member may report a process
Inside
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4
7
(continued on page 11)
5 Sure-Fire Methods:
Complying with PC.02.01.03 for Home Care
Tracer Methodology 101:
Patient Flow Tracer in a Level I Trauma Center
CMS:
New Provision of Care, Treatment, and Services
Requirements to Align with CMS Swing Bed
When an organization has an effective safety culture,
staff feel comfortable reporting patient safety events.
0
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5
1
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Certified Joint Commission Professional:
Focus on the “Nursing” Chapter
Perspectives on Patient Safety:
Clostridium difficile Infections Rising in the United States
Benchmark:
The Keys of Excellence: The 2014 Top Performers on
Key Quality Measures® Program
Requirements
http://www.jcrinc.com
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Sure-Fire
Methods
The Joint Commission: The SourceTM
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2 The Source
Complying with
PC.02.01.03 for Home
Care
T
he complexity of
providing care,
treatment, or services when
multiple organizations
are involved requires an
interdisciplinary collaborative
approach and a mutual
effort to coordinate care in
a manner that is conducive
to optimal patient outcomes.
Joint Commission Provision
of Care, Treatment, and
Services (PC) Standard
PC.02.01.03 requires that
Careful communication and coordination is essential
home care organizations
to safe patient care when multiple providers are
provide care, treatment,
involved.
or services in accordance
with orders or prescriptions, as required by law and regulation (see “Related
Requirements” on page 3 for the entire standard). During the first half of 2014,
41% of surveyed home care organizations were found to be noncompliant with
this standard.
According to Kathy Clark, MSN, RN, associate project director, Department
of Standards and Survey methods, The Joint Commission, one of the biggest
reasons that organizations are being cited for noncompliance with Standard
PC.02.01.03 is that care is being provided before the orders are received. “What
often happens is that the home care nurse goes out and evaluates the patient and
writes up the plan of care, but for whatever reason, the orders don’t come back
from the physician until care has already started. In some cases, it’s just a matter
of the physician not getting the orders back in a timely manner. In other cases, the
home care agency hasn’t been notified as to who will be taking over the patient’s
care, so they don’t know who to contact for orders.”
Edward Smith, RN, MSN, associate director, Standards Interpretation Group,
The Joint Commission, says that another reason organizations are struggling to
comply with Standard PC.02.01.03 is that the patient’s orders are not up-to-date.
“Components of the plan of care are being removed or added as patient care
evolves, and the orders aren’t being updated,” he says.
Organizations are also having difficulty complying with Standard
PC.02.01.03 because orders are not always being followed as they are written. “A
lot of times, this has to do with the frequency of visits,” says Clark. “The order
might say they are supposed to visit three times a week, and they may only visit
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Related Requirements
Standard PC.02.01.03 for Home Care
The organization provides care, treatment, or services in
accordance with orders or prescriptions, as required by law
and regulation.
Elements of Performance for PC.02.01.03
1. Prior to providing care, the organization obtains or renews
orders (verbal or written) from a licensed independent
practitioner in accordance with professional standards of
practice and law and regulation.
2. For home health agencies that elect to use The Joint
Commission deemed status option: The organization
obtains physician orders for therapy services, including
the specific procedures, modalities, and the amount,
frequency, and duration of their use.
3. The organization consults with the prescribing physician
as needed to confirm the physician’s order(s).
4. The organization reviews orders and prescriptions for
appropriateness and accuracy before providing care,
treatment, or services.
5. Prior to implementing an order or prescription, staff
obtain answers to any questions that exist. (See also
MM.05.01.01, EP 11)
6. For DMEPOS suppliers serving Medicare
beneficiaries: The organization recommends any
necessary changes, refinements, or additional
evaluations to the prescribed equipment, supplies, and
services.
7. The organization provides care, treatment, or services
using the most recent patient order(s).
8. For home health agencies that elect to use The Joint
Commission deemed status option: The organization
two times one week, and there’s no note in the chart as to
why the visit was missed or that the physician was notified.”
Smith adds, “Things sometimes get overlooked because
staff members fail to rely on the orders as they are written.
They’ve been out to the home three or four times, and they
feel like they know what to do. So they provide care, write
a note, and walk out the door without reviewing the plan of
care.”
Clark and Smith offer the following five strategies to
help home care organizations to better comply with Standard
PC.02.01.03:
Know your referral sources. “Develop a relationship
with your referral sources and let them know what
you need from them when a patient is referred to your
organization,” says Clark. “Make sure your referral
paperwork includes a place for them to include which
physician will be responsible for follow-up. Whoever
is receiving the referrals at your organization should
also be assertive enough to call and ask if they’re not
1
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9. 10.
11.
12.
16.
20.
follows physician orders when administering medications
and treatments.
For home health agencies and hospices that elect
to use The Joint Commission deemed status option:
The home health aide or hospice aide provides services
that are ordered by the physician in the plan of care,
consistent with the aide’s training, and that the aide is
permitted to perform under state law.
For DMEPOS suppliers serving Medicare
beneficiaries: The organization provides all medical
equipment and supplies to serve a medical purpose
covered under the Medicare program and may require the
physician to collaborate and coordinate clinical services
with other health care professionals (for example,
providers of orthotics and prosthetics; occupational,
physical, and respiratory therapists; and pedorthists).
The organization confirms that the item delivered to the
patient is consistent with the prescribing physician’s order.
For custom orthotics and prosthetics services: The
organization confirms that the implementation plan is
consistent with the prescribing physician’s dispensing
order and/or the written plan of care and that it is in
accordance with Medicare rules.
For hospices that elect to use The Joint Commission
deemed status option: Hospice aides report changes
in the patient’s medical, nursing, rehabilitative, and social
needs to a registered nurse, as the changes relate to the
plan of care and quality assessment and performance
and improvement activities.
Before taking action on a verbal order or verbal report of
a critical test result, staff uses a record and “read back”
process to verify the information.
getting all of the information they need for a smooth
transition.”
Reeducate the staff. “Reconnect the dots between
the plan of care and the staff’s actions in the home,”
Smith says. “Staff needs to know that the plan of care
isn’t just something they need to complete to meet a
requirement; it’s a tool for providing care. Make sure
staff also knows that they need to review the plan of
care before they go into the home and again before
they leave. While in the home, they need to touch
on everything that’s already in the plan and decide if
there’s anything that should be added or changed.”
Clark adds, “Education should also include therapists,
since they are also contributing to the plan of care.”
Supervise visits. “Create a schedule that allows
you to go out with staff and watch the care they are
providing in the home,” says Smith. “Look at the
plan of care and make sure the care being provided is
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3
December 2014
(continued on page 19)
The Source 3
Tracer
Methodology
Patient Flow Tracer in a Level I Trauma Center
B
reakdowns in effective patient flow can impact patient
safety and the quality of care, treatment, and services.
When a hospital effectively manages its systemwide processes
for patient flow it can minimize delays. During an on-site
accreditation survey, surveyors will conduct patient flow
tracers to understand and follow a hospital’s own processes
and to learn if there are any vulnerabilities in the system.
They will also check to see if the hospital has built in
processes to monitor and mitigate any patient flow problems.
“The patient flow standard applies to all types of
hospital settings—all hospitals need to ensure their
patient flow processes are effective,” emphasizes Cynthia
Leslie, APRN, BC, MSN, associate director in The Joint
Commission’s Standard Interpretation Group.
The patient flow standard (Leadership [LD] Standard
LD.04.03.11) has a three-fold goal:
1. Hospital leadership ensures that it relies on data and
measures to effectively manage patient flow.
2. Any flow issues that present in the emergency
department (ED) are managed throughout the
hospital.
3. The safety risks presented by issues such as patient
boarding are suitably managed.
Patient flow is covered in the leadership standards
because of the impact that leadership has on the culture,
expectations, and successful performance of the hospital
itself. Leaders’ active support and oversight are critical to
effective patient flow, as so many areas of the hospital need
to be involved, stresses Leslie.
A team approach can help achieve effective patient
flow, Leslie says. She recommends using a broad approach
to selecting members of the team. EDs have often been
viewed as causing the bulk of patient flow problems. And
yet, while the ED may be where a patient flow problem
manifests itself, the problems do not always originate there.
For example, delays in discharge planning or housekeeping
problems could impact admission rates from the ED.
Having a team approach to studying and responding to such
issues takes patient flow beyond the ED alone to focus on
hospitalwide risk factors. As a result, a patient flow response
team should be comprised of more than ED staff alone,
4 The Source
Poor patient flow can lead to delays in treatment and to patient
harm.
Leslie emphasizes. While clinical staff such as patient safety,
nursing, and medical staff are often critical to the team,
nonclinical hospital services have a role to play as well.
Facilities, cleaning, or transport staff should participate, she
notes, to ensure that critical details such as bed availability,
staffing issues, or facilities vulnerabilities are taken into
consideration. Discharge planning and case management
staff should also be represented on the team to provide input
into communication issues and possible delays caused by
external factors and agencies.
Leslie recommends that hospitals also look at the flow
of patients based on data from across the entire organisation.
“Not only should you look at data from the emergency
department, but also at surgical procedures, readmission
rates, discharge planning, case management, physician
involvement, and so on—any data which can potentially
impact patient care,” she adds.
In 2012 The Joint Commission undertook a review
of its patient flow standard and added new elements of
performance (EPs), primarily aimed at ensuring that there
is a process in place to manage and mitigate any patient
boarding in the ED (EP 6) and to ensure that effective
December 2014
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systems are in place to support and manage boarded
psychiatric patients (EP 9). Both of these new EPs went into
effect on January 1, 2014.
Boarding can put patients at increased risk due to care
delays, and it can put added pressure on staff. It can also
point to a systemic hospitalwide problem with patient flow.
Patients presenting in the ED with psychiatric
emergencies can face particular vulnerabilities if boarded.
Ensuring that the needs of ED–boarded psychiatric patients
are appropriately and safely accommodated requires that
the ED has clear lines of communication with a hospital’s
psychiatric unit, explains Leslie. By ensuring that all of the
necessary services and staff are communicating, hospitals
can both speed up and ease the boarding process for
potentially vulnerable patients.
During a tracer focused on patient flow, surveyors
will consider what elements of the patient flow process
are in place and how well the hospital follows its own set
process, paying particular attention to issues of leadership
involvement, communication, staff training, and data
collection. Patient flow teams can conduct their own tracers
by conducting rounds or by tracing a boarded patient to
determine how effective their process is and where there
are vulnerabilities in their system. Conducting tracers at
particularly busy times of day can help reveal issues more
readily as well.
The Scenario
This tracer took place in a 300-bed Level 1 trauma center
in an urban community in the southwestern United States.
During the course of the survey, the surveyor noted long
wait times in the ED, including seven patients boarded
in the ED while waiting for inpatient beds to become
available. The surveyor also noted that three incoming
ambulances had been diverted to other hospitals. Two of the
seven patients boarded in the ED were psychiatric patients
reporting suicidal ideation. The surveyor began a tracer
focusing on patient flow in the hospital.
Exploring processes to manage patient flow. The
surveyor looked closely at the hospital’s process to manage
patient flow with members of its leadership team and with
staff identified as being involved in patient flow activities.
[1, 2, 3] During the tracer, the surveyor met with the ED
director, quality improvement director, ICU charge nurse,
and psychiatric department charge nurse. She also looked at
how staff were involved in the patient flow team, what data
they collect on patient flow, and how processes are put in
place, particularly for improvements to patient flow. [4, 5, 6]
Examining patient flow in relation to boarding and
psychiatric patients. The surveyor opted to further study
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Tips for Success from Other
Hospitals
In its work to improve patient flow, the Urgent
Matters Learning Network II (LNII) created a toolkit
for hospitals. The following are a few example
strategies from the toolkit:
•
Bedside Triage and Registration: Patients are
placed in beds immediately and registered and
seen by providers as staff becomes available. This
eliminates bottlenecks within the ED and reduces
wait times for patients.
•
Comprehensive Diversion Reduction Plan: One
hospitals developed a comprehensive plan to
improve efficiency of hospital discharges.
•
ED Scribes: Scribes work with physicians as they
see patients to record information electronically in
real time, allowing physicians to spend their time
with patients rather than entering information.
•
Emergency Department Follow-Up Office: A highly
specialized team of registered nurses and clerks
inform patients about diagnostic tests completed
after discharge, communicate with primary care
and other community providers, and field calls
from patients who have questions or concerns
after leaving the hospital.
•
Improved Treatment of Asthma: One hospital
created a multidisciplinary team to develop an
improved protocol for asthma patients in the ED to
prevent return ED visits and reduce hospital length
of stay.
Source: George Washington University School of Medicine and Health
Sciences. Urgent Matters Toolkit. Accessed Nov 7, 2014. http://smhs
.gwu.edu/urgentmatters/toolkit/985888.
patient flow by visiting key areas of the hospital, including
the ED and the inpatient behavioral unit, to speak with staff
about their experiences with boarding, particularly in the
case of specific populations. [7, 8] She noted that although
the ED was boarding patients, processes were in place to
admit and move the patients at the earliest point available,
and specialist nurses from the psychiatric unit had been to
the ED to assess the two patients identified with suicide
ideation. She also saw that the hospital had set a four-hour
boarding time limit, during which the team collected data
to measure levels of success. She noted that the hospital had
December 2014
(continued on page 6)
The Source 5
Tracer Methodology 101
(continued from page 5)
generally been successful since they began collecting data six
months earlier.
Moving forward. The surveyor asked if the team
had determined what hospitalwide factors were resulting
in increased numbers of boarded patients in the ED.
The quality improvement director noted that they had
determined delays in available inpatient beds were being
caused by the discharge and case management planning
processes. The director indicated that the team was already
discussing a project to improve the discharge planning
process, as well as a hospitalwide effort to reduce ED wait
times.
Sample Questions
The following represent some questions that could be asked
during a tracer. Use them as a starting point to plan your
own tracers.
1. Please describe your own process to manage patient
flow in the hospital.
2. Who is responsible for the patient flow function?
3. Which staff are involved in conferring on patient flow?
How do you train and educate staff on patient flow?
4. What oversight structure (such as a team or committee)
do you have in place? How is this monitored and
reported back to leadership?
5. What data collection processes do you have in place to
track and monitor patient flow?
6. If a modification needs to be made to your patient flow
process, how is that done? Who documents it?
7. What processes do you have in place to manage and
respond to boarding? Do your processes include a time
limit on boarding?
8. What is your process to handle patient flow regarding
psychiatric patients? TS
Mock Tracer Tracking Worksheet:
Patient Flow Tracer in a Level I Trauma Center
Use this worksheet to record notes and areas of concern that you identify while conducting your organization’s mock tracers. This information
can be used to highlight a good practice or to determine issues that may require further follow-up. Checking “yes” or “no” indicates whether
the staff member interviewed during the tracer answered the question correctly. An incorrect answer should always receive comments or
recommendations for follow-up.
Tracer Team Member: ___________________________ Tracer Patient or Medical Record: ____________________________
Staff Interviewed: ________________________________________________________________________________________
Unit or Department Where Tracer Was Conducted: _____________________________________________________________
CORRECT
ANSWER
TRACER QUESTIONS
INCORRECT
ANSWER
FOLLOWCOMMENTS
UP NEEDED OR NOTES
1. Please describe your own process to manage patient flow in
the hospital.
2. Who is responsible for the patient flow function?
3. Which staff are involved in conferring on patient flow? How do
you train and educate staff on patient flow?
4. What oversight structure (such as a team or committee) do
you have in place? How is this monitored and reported back
to leadership?
5. What data collection processes do you have in place to track
and monitor patient flow?
6. If a modification needs to be made to your patient flow
process, how is that done? Who documents it?
7. What processes do you have in place to manage and respond
to boarding? Do your processess include a time limit on
boarding?
8. What is your process to handle patient flow regarding
psychiatric patients?
6 The Source
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Provision of Care, Treatment,
C New
M and Services Requirements to Align
S with CMS Swing Bed Requirements
I
n May 2012 the Centers for Medicare & Medicaid
Services (CMS) published changes to the Medicare
Conditions of Participation (CoPs) for hospitals in a
final rule entitled Medicare and Medicaid Programs;
Regulatory Provisions to Promote Program Efficiency,
Transparency, and Burden Reduction; Part II.1 In response
to these regulatory changes, The Joint Commission has
revised its Provision of Care, Treatment, and Services (PC)
standards for hospitals and critical access hospitals to realign
Joint Commission requirements with the revised CMS
requirements. In addition, rehabilitation and psychiatric
distinct part units in critical access hospitals are required
to comply with the hospital CoPs. For both programs,
Joint Commission standards have been revised to clarify
the requirements for when a practitioner who is not on the
medical staff orders outpatient services (under Standard
PC.02.01.03, EP 1) and medical staff structure for
multihospital systems (under the Medical Staff standards).
A report of all the changes associated with the CMS burden
reduction rule is available on The Joint Commission’s
website at http://www.jointcommission.org/assets/1/6
/HAP_Burden_Reduction_Aug2014.pdf.
Several requirements have been added that are related to
the use of swing beds for long term care. Due to the revised
requirements, swing beds will now be included in Joint
Commission surveys for hospitals that use Joint Commission
accreditation for deemed status purposes, for hospitals that
use long term care swing beds.
Following are the swing bed–related revisions (shown in
underlined text) to the PC chapter, as well as strategies for
compliance.
Revised Requirement: Standard PC.01.02.09
The hospital assesses the patient who may be a victim of
possible abuse and neglect.
Elements of Performance for PC.01.02.09
8. For hospitals that use Joint Commission
accreditation for deemed status purposes and have
swing beds used for long term care: The hospital
reports to the state nurse aide registry or licensing
authorities any knowledge it has of any actions taken by
a court of law against an employee that would indicate
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The revised requirements are designed to provide guidance on
the safe and effective use of swing beds for long term care.
unfitness for service as a nurse aide or other facility
staff. (See also RI.01.06.03, EP 3)
Compliance Strategies
“Joint Commission standards require that hospitals do
background checks on potential employees, so anything
relevant that is uncovered during those background checks
should be reported,” says John Herringer, RN, associate
director, Standards Interpretation Group, The Joint
Commission. “Also, if a nurse’s aide asks for a day off to
go to court, you’d want to investigate the charges so you’d
know whether or not a conviction would be relevant to the
care being provided.”
December 2014
(continued on page 8)
The Source 7
CMS
(continued from page 7)
“If a hospital does become aware of any court actions that
would indicate a nurse’s aide may be unfit for service, there
needs to be a defined internal process as to who’s responsible
for reporting to the nurse aide registry,” says Teresa Hamblin,
RN, MS, consultant, Joint Commission Resources. “Also,
where will it be documented? All of this information should
be part of a comprehensive abuse prevention policy.”
Revised Requirement: Standard PC.02.01.03
The hospital provides care, treatment, and services as
ordered or prescribed, and in accordance with law and
regulation.
Elements of Performance for PC.02.01.03
1. For hospitals that use Joint Commission accreditation
for deemed status purposes: Prior to providing care,
treatment, and services, the hospital obtains or renews
orders (verbal or written) from a licensed independent
practitioner or other practitioner in accordance with
professional standards of practice; law and regulation;
hospital policies; and medical staff bylaws, rules, and
regulations.*
Note: Outpatient services may be ordered by a practitioner
not appointed to the medical staff as long as he or she meets
the following:
• Responsible for the care of the patient
• Licensed in the state where he or she provides care to
the patient
• Acting within his or her scope of practice under state
law
• Authorized in accordance with state law and policies
adopted by the medical staff and approved by the
governing body to order the applicable outpatient
services
Compliance Strategies
“It’s very common for a practitioner to order a test or a
treatment and for the patient to take that order to a hospital
that’s closer to home or to where they work,” says Herringer.
“In that case, the hospital that’s doing the test or procedure
doesn’t have to credential or privilege the practitioner who
wrote the order, but they do have to make sure they’re
licensed.”
“The bylaws need to be updated to reflect who is eligible
to write orders, the verification process for when orders come
in, and where this will all be documented,” Hamblin says.
* For law and regulation guidance pertaining to those responsible for
the care of the patient, refer to 42 CFR 482.12(c).
8 The Source
Revised Requirement: Standard PC.02.02.01
The hospital coordinates the patient’s care, treatment, and
services based on the patient’s needs.
Elements of Performance for PC.02.02.01
8. For hospitals that use Joint Commission
accreditation for deemed status purposes and have
swing beds used for long term care: The hospital
provides activity services directly or through referral for
ambulatory and non-ambulatory residents at various
functional levels.
9. For hospitals that use Joint Commission accreditation
for deemed status purposes and have swing beds
used for long term care: The hospital provides services
(directly or through referral) to facilitate family support,
social work, nursing care, dental care, rehabilitation,
primary physician care, or discharge.
12.For hospitals that use Joint Commission
accreditation for deemed status purposes and have
swing beds used for long term care: The hospital
provides 24-hour emergency dental services directly or
through arrangement with an external provider.
Compliance Strategies
According to Melissa Hager, BSN, RN, consultant, Joint
Commission Resources, the activities provided under EP
8 should be based on individual preferences. “Conduct an
activities assessment and see what types of activities the
resident normally enjoys on a daily basis,” she says.
“With the possible exception of dental care, most of the
services mentioned in EP 9 can be directly provided by the
hospital,” Hager says. “Policies should be clear about what
will be provided by the hospital and what will be provided
through referral or contracted services; provision of these
services should be reflected in the record.”
“Swing beds are a long-standing concept in critical
access hospitals, so this isn’t new to them,” says Herringer.
“But acute-care hospitals may not normally offer dental
services except in trauma cases, so they’ll have to determine
how they’re going to provide these services.”
“If you don’t have 24-hour dental care in house, you
need to have a contract with an outside referral source,”
Hager says. “If there’s no contract, it will be difficult to show
that you have 24-hour service available.”
Revised Requirement: Standard PC.02.02.09
For hospitals that use Joint Commission accreditation
for deemed status purposes and have swing beds used
for long term care: Residents participate in social and
recreational activities according to their abilities and
interests.
December 2014
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Elements of Performance for PC.02.02.09
1. For hospitals that use Joint Commission accreditation
for deemed status purposes and have swing beds
used for long term care: The hospital offers residents a
variety of social and recreational activities according to
their abilities and interests.
3. For hospitals that use Joint Commission accreditation
for deemed status purposes and have swing beds
used for long term care: The hospital helps residents to
participate in social and recreational activities according
to their abilities and interests.
Compliance Strategies
“If you don’t have an activities director, appoint someone
who is qualified to do an assessment that incorporates
patient interests and takes into account cognitive abilities,”
says Hager. “A standardized assessment tool with a checklist
and room for a narrative assessment at the end would be
helpful. After you’ve completed your assessments, put
together an activities calendar to inform the residents what
activities are currently available and what is upcoming.”
“For residents who can’t go somewhere to participate in
activities, you have to bring the activities to them,” Herringer
says. “For example, someone could go to the room and play
cards with them if that’s something they like to do.”
Revised Requirement: Standard PC.04.01.03
The hospital discharges or transfers the patient based on his
or her assessed needs and the organization’s ability to meet
those needs.
Elements of Performance for PC.04.01.03
5. For hospitals that use Joint Commission accreditation
for deemed status purposes and have swing beds
used for long term care: Except when specified in the
CoP from 42 CFR 483.12(a)(5)(ii), the written notice of
transfer or discharge required under paragraph 42 CFR
483.12(a)(4) must be made by the hospital at least 30
days before the resident is transferred or discharged.
Note: Notice may be made as soon as is practical before
transfer or discharge when the safety of the individuals
in the facility would be endangered; the health of the
individuals in the facility would be endangered; the
resident’s health improves sufficiently to allow a more
immediate transfer or discharge, and immediate transfer or
discharge is required by the resident’s urgent medical needs;
or a resident has not resided in the facility for 30 days.
6. For hospitals that use Joint Commission accreditation
for deemed status purposes and have swing beds used
for long term care: The written notice before transfer
or discharge specified in the CoP from 42 CFR
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483.12(a)(4) includes the following:
• The reason for transfer or discharge
• The effective date of transfer or discharge
• The location to which the resident is transferred or
discharged
• A statement that the resident has the right to appeal
the action to the state
• The name, address, and telephone number of the
state’s long term care ombudsman
• For a resident who is developmentally disabled,
the mailing address and telephone number of the
agency responsible for the protection and advocacy,
established under Part C of the Developmental
Disabilities Assistance and Bill of Rights Act
• For a resident who is mentally ill, the mailing
address and telephone number of the agency
responsible for the protection and advocacy,
established under the Protection and Advocacy for
Mentally Ill Individuals Act
Compliance Strategies
“Many health and also social issues are involved in
transferring or discharging a resident, so you need to give
people plenty of time to come to terms with what’s available
and what their responsibilities are going to be,” says Herringer.
“Develop a discharge notification process that’s
consistent with these regulations,” Hamblin says. “The
process should include documentation requirements so you
can show that the process is being followed.
“All of these requirements should be incorporated
into your transfer and discharge policy,” says Hamblin.
“It might be helpful to develop a checklist or some other
form of standardized documentation to help staff meet the
requirements.”
Revised Requirement: Standard PC.04.01.07
For hospitals that use Joint Commission accreditation
for deemed status purposes and have swing beds used for
long term care: Residents are not transferred or discharged
from the hospital unless they meet specific criteria, in
accordance with law and regulation.
Elements of Performance for PC.04.01.07
1. For hospitals that use Joint Commission accreditation
for deemed status purposes and have swing beds used
for long term care: The hospital transfers or discharges
residents only when at least one of the following
conditions is met:
• The resident’s health has improved to the point
December 2014
(continued on page 19)
The Source 9
CJCP
™
Certified
Joint Commission Professional
™
Focus on the “Nursing” Chapter
I
n January 2013, Joint Commission Resources (JCR)
launched its credential for accreditation professionals—
Certified Joint Commission Professional (CJCP®). Upcoming
testing dates will occur in January 2015, April 2015, and July
2015.
To help candidates prepare for the CJCP examination
and understand what to expect, this column features sample
questions similar to those that appear on the examination.
The answer key on page 14 provides the context for the correct
answer. All of the CJCP examination questions are multiple
choice, offering three possible choices from which you should
pick the BEST answer. Also, the examination does not have any
true/false questions or include any answers that are “All of the
above” or “None of the above.” Please note the questions that
follow are NOT actual examination questions; they are simply
indicative of the types of questions a candidate may see on the
exam. For more information on CJCP, or other products to help
you prepare for the exam, such as live events, workbooks, or
online education learning modules, visit http://www.jcrinc.com
/cjcp-certification/. You may also email questions directly to
[email protected].
About the “Nursing” Chapter
The Nursing (NR) standards primarily address the role of
the nurse executive, the leader for nursing staff in a hospital.
Many of the standards in this chapter are linked to the
“Leadership” (LD) chapter to clearly reflect the leadership
role of the nurse executive.
The nurse executive is largely accountable for the most
substantial patient care workforce of the hospital. Nurse
executives routinely assume oversight responsibility for
the provision of safe, effective, high-quality nursing care
throughout the hospital; development, presentation, and
management of the nursing services’ portion of the hospital’s
budget; work team productivity; consumer satisfaction
activities; and staff retention efforts.
To effectively fulfill this ever expanding role, today’s
nurse executive demonstrates expertise in a range of areas
(for example, strategic planning, negotiating, budgeting,
marketing, trend variance analysis, information technology)
in addition to demonstrating extensive knowledge of the
current complexities of the health care industry.
10 The Source
Sample Questions
1
Which of the following criteria are hospitals NOT
required to consider when appointing a nurse
executive?
a.The scope and complexity of the nursing care
needs of the major patient population(s) served by
the hospital
b.The availability of nursing and administrative
staff and services needed to assist the nurse
executive in the execution of responsibilities
c.Prior involvement in patient safety events,
including sentinel events
For hospitals that use Joint Commission
accreditation for deemed status purposes: A
registered nurse assigns the nursing care for each
patient to other nursing personnel in accordance
with which of the following?
a.The patient’s needs and the qualifications and
competence of the nursing staff available
b.The patient’s needs, the qualifications and
competence of the nursing staff available, and the
patient’s preferences
c.The patient’s needs, the qualifications and
competence of the nursing staff available, and
nurse seniority within the hospital
Which of the following is the nurse executive
required to coordinate?
a.The credentialing and privileging of nursing staff
b.Development of hospitalwide plans to provide
nursing care, treatment, and services
c.Programs to recognize nursing staff for
exceptional performance
2
3
December 2014
(See Answer Key on page 14.)
www.jcrinc.com
Effectively Engaging Staff
(continued from page 1)
error he or she has witnessed, but leadership fails to take
any action to fix the problem. To create a quality reporting
system, it is vital that staff feel comfortable reporting
situations without reprisal and know that leadership takes
reporting seriously. To do this, a robust organizational safety
culture must be in place.1
Culture Club
Increasingly, evidence links safety culture to improved
patient care and a safer work environment. Creating this
culture of safety often means making a shift in the way staff
view their health care organization and their roles within it.
This challenge often begins at the top.
“Leadership has to set the bar so the organization
understands patient-related harm. They need to own
the issue,” says Ronald Wyatt, MD, medical director of
the Division of Healthcare Improvement at The Joint
Commission. “One of the best ways we can understand
patient-related harm is if we know about it in a timely
fashion. It has to be reported. Then it has to be acted upon
so we can ensure improvement over time.”
Wyatt says that the creation of a safety culture requires
engagement of the next level of leadership–physicians,
physician leaders, unit managers, and division heads.
However, engaging physicians in improvement initiatives can
be difficult for health care organizations. Hospital leaders
have typically tackled performance improvement with help
from their administrative, nursing, and other clinical staff,
but exclude physicians. However, without their engagement,
safety improvement efforts can have trouble getting off
the ground and will be difficult to sustain. If organization
leadership can show physicians that new processes will give
them more time and make patients safer, then they may be
more likely to support improvements.1
Peter Fleischut, MD, associate chief innovation officer
for New York-Presbyterian Hospital, cautions that it’s also
important to focus on the frontline of nurses, physician
assistants, information technology (IT) professionals, quality
and patient safety officers. “Giving front line staff a voice
and a way to align initiatives and priorities with senior
leadership is an essential component. It’s vital to not get
too complicated and focus on one or two key initiatives,
especially when it comes to residents’ time. If they aren’t
overwhelmed they can really push the needle on those
issues.”
Wyatt says it’s important to have a small group who
will champion the effort and be fully engaged, with an
understanding of the part reporting has to play in a safety
culture. Being fully engaged with this awareness means the
www.jcrinc.com
“
Leadership has to set the bar so
the organization understands
patient-related harm. They
need to own the issue.
Ronald Wyatt, MD
”
Medical Director of the Division of Healthcare
Improvement at The Joint Commission
reporting process needs to be communicated in a way that is
not punitive.
For medical staff to embrace reporting they can’t fear it.
They need to know leadership is focused on improvement,
not penalties. “Make it clear that reporting is voluntary,
anonymous (if possible), and nonpunitive. Then guarantee
that action will be taken,” says Wyatt. “It’s not enough to
have a reporting system that you spend millions of dollars
on, it’s how it’s going to be used. That has to be clearly
communicated down to the front lines.”
Reporting Process
The process for reporting should be specified in detail,
including the items to be reported and to whom the report
should be made. Reports should include the name of the
reporter, the names of the individuals involved, the date
and time of the incident, a description of the incident, and
the names of any witnesses.2 Providing anonymity to the
reporter may not always be possible. The details of any
report should be made known to the individuals involved
in the patient safety event, and the patient safety specialist
(or equivalent personnel) will likely need to consult both
sides.
An organization should always respond to reports
seriously and send a report about follow-up actions to the
person who made the report. Publicizing the response to
the health care staff is also important. Without mentioning
names, making an abstract of the case and the outcome
available demonstrates accountability and commitment
from leadership.2 This demonstrates to staff that leaders
take reports seriously and that reporting can lead to positive
change.
After a reporting system has been created and the intent
and process has been made clear to staff, it’s important to
continue monitoring that system and the reports. Has there
been a reporting increase in one unit or a decrease in another
unit? Wyatt says that may be a signal of system vulnerability.
“If you have a unit that is a big reporter of events in one
quarter, and then in another quarter they are not, then
you want to understand why that is. Look at the data to
December 2014
(continued on page 12)
The Source 11
Effectively Engaging Staff
Defining Safety Culture
(continued from page 11)
understand where your reports are coming from, what’s
being reported, and continue to go back to understand what
the system is trying to say. Signals require a rapid response in
order to mitigate risk and identify vulnerability. This makes
the organization more resilient.”
Transparency and Accountability
Wyatt says that a positive outlook on reporting can
be transmitted through internal channels, executive
walkarounds, huddles, or department meetings. Providing
this kind of transparency helps to break down the barriers
in reporting. A transparent organization does not try to hide
errors. Instead it acknowledges that mistakes do occur and
that it’s important to fix systems that might cause them.
Openly discussing and analyzing issues, errors, and risks with
frontline staff, medical staff, patients, families, and the public
helps to make the environment more conducive to sharing
information and reporting problems.1 “A great example is
Cincinnati Children’s Hospital, where they have morning
leadership huddles that are actually videotaped. They are
broadcast throughout the facility and show unit leaders
discussing what happened last night. They openly report
that and share it with the organization,” Wyatt says.
Transparency also comes in the form of rewarding those
who come forward and report a near miss, a close call, or
unsafe condition. Wyatt says that even the reporter directly
involved in the event should be rewarded for speaking up.
“It will probably surprise people how little a reward it takes,”
Wyatt says. “In some cases it’s just a ‘thank you very much
for reporting.’”
Wyatt says that in military health care facilities coins
are often given out as rewards for reporting injuries, and
that system has spilled over into some other organizations.
Other facilities may offer different incentives like gift cards
or a cup of coffee. “You can get so far with just those simple
things. Most people don’t understand that,” Wyatt says. “I
think that sometimes we make it more complicated than it
needs to be. People like to be acknowledged for doing what’s
right.”
When people are recognized for doing the right
thing, it is often surprising how fast that information is
communicated across a facility. But Wyatt stresses it’s
important to make sure everyone in the organization realizes
the reason for reporting is to improve safety. At the same
time if an organization decides, that there is a blame-worthy
event (such as negligence, criminal behavior, or substance
abuse), those issues must also be addressed in an active way.
“As best you can, communicate that fact out to staff so then
you start to build a culture where there is psychological
12 The Source
Defining safety culture can often be complex, but in
its simplest form it is a health care environment in
which everyone’s nonnegotiable goal is optimal, safe
care. In addition, the following conditions should be
present:1
• No one is hesitant to voice a concern about a
patient because it is psychologically safe to do
so.
• There is a simple model of accountability that
clearly differentiates “unsafe” individuals from
competent, conscientious individuals who
“fall victim to” system errors. People need to
know they’re safe before they’re going to be
comfortable talking about errors, near misses,
and system failures.
•There is a continual focus on identifying and
mitigating sources of risks and hazards.
• When individuals do voice concerns, they know
they will be treated with respect, and leadership
will address their concerns and take action.
• After leaders have taken action or looked into
the matter, they will close the loop and provide
feedback to the person who raised the concern.
safety. If you do, people won’t just bury their heads in the
sand,” Wyatt says. “If they see something, they will say
something. That’s where you want to get to.”
Achieving the level of accountability Wyatt envisions
will enable an organization to balance learning and
discipline. It’s important that organizations look objectively
at errors and make it clear to staff what to expect when an
error occurs and how they will be held accountable. This
accountability system is important because people will
make mistakes, no matter how skilled or experienced. Given
the constant distractions in the health care environment,
as well as stress and fatigue, it’s easy to see how staff
may overestimate their abilities and underestimate their
limitations.1 How an organization reacts to the errors that
will occur makes a world of difference.
“Accountability has to go from the top down and
bottom up,” Wyatt says. “You flatten out that hierarchy,
and then you start to approach the kind of culture you
want to have to decrease harm and error.” Wyatt says that
he always remembers a story his mentor told him. While
attending at Boston Children’s Hospital, a physician was
December 2014
www.jcrinc.com
about to examine a patient when someone in the room said,
“You can’t do that here.” He turned around to the face the
speaker and asked, “What are you talking about?” And the
housekeeper said, “We wash our hands here before we touch
patients.”
“That’s a housekeeper talking to a senior, academic
attending physician specializing in infectious diseases
at Boston Children’s,” Wyatt says. “[At that hospital],
leadership told staff to do that. They let everyone know that
they are important and have a role to play in preventing
patient-related harm and error.”
Creating a culture in which a housekeeper is
comfortable correcting an attending physician admittedly
takes time. But Wyatt points out that just saying it takes
times is not an excuse. “A leader that’s interested in a
learning organization and a culture of safety isn’t going to
say it will take us five years to get there. He will say, ‘The
time is now. We don’t want to hurt anyone. Our goal is zero,
and you are a valuable part of that.’”
When an organization has engaged leadership that’s
visible, staff start to believe in the culture. Patients also start
to believe it. Today there are organizations that ask patients
and their family members to go on walkarounds with the
health care team (and sometimes top organizational leaders),
so they can learn from them. Performing these types of
multidisciplinary rounds offers a health care organization
a fresh perspective on safety and can help the team to
be more proactive rather than reactionary. Typically, the
hospital bedside is the optimal location for these rounds,
which should take place at least twice a day at shift changes.
Within these rounds, teams should discuss care for each
patient.1
“We want patients engaged in changing the culture. We
want patients’ families involved in teaching us. What are the
things you see that we don’t see?” Wyatt adds.
A multidisciplinary approach is something that
New York-Presbyterian Hospital is familiar with. “We
wanted to engage the residents that are on the front
lines, dealing with the patients,” Fleischut says. “We put
together a multidisciplinary council of all the residents—
nurses, physician assistants, IT professionals, quality and
patient safety officers—so they would have a voice in the
organization, and also the organization, through the hospital,
would have a voice through the frontline staff. It was a twoway communication that helped create the culture.”
Team Training and Respect
Ensuring that a strong safety culture continues means
continuous team training and communication, supported
by leadership in clinical units. Along with multidisciplinary
sessions, education on team behaviors, communication
strategies, and structures for communication using relatable
scenarios are good methods. It’s important to also have staff
practice using the behaviors and strategies.2
Effective team training in safety requires an environment
of psychological safety in which everyone is comfortable
voicing an opinion. Creating a culture of respect in health care
is part of the larger challenge of creating a culture of safety. A
culture of respect requires an organization and its leaders to
develop methods for responding to disrespectful behavior and
to actively prevent it from occurring.2
Wyatt says that disrespectful behavior can render
ineffective any safety culture strategies an organization may
have. “At most organizations, around 20% of the medical
staff are habitually disrespectful people. Leadership has to be
willing to step in and have the courage to say, ‘No. Not here.
Not in our culture.’”
The culture that engaged leaders do want is a
transparent one, free of fear and full of cooperation, in
which everyone feels they can actively discuss safety
concerns. By effectively demonstrating engagement and
giving medical staff a stake in improving safety for patients,
leaders can strengthen commitment and make reporting a
seamless part of the culture. TS
References
1.Leonard M, et al., editors. The Essential Guide for Patient Safety Officers,
2nd ed. Oak Brook, IL: Joint Commission Resources, 2013.
2.Leape LL, et al. Perspective: A culture of respect, part 2: Creating a culture of respect. Acad Med. 2012 Jul;87(7):853–858.
Share Your Success
Are you or your organization working on a project or policy that will improve patient safety,
increase standards compliance, or advance performance measurement efforts?
If you have an article, tool, or policy you would like to submit for potential publication in The SourceTM
or an idea for a case study, please send us an e-mail at [email protected].
www.jcrinc.com
December 2014
The Source 13
CJCP
(continued from page 10)
Answer Key
1
The correct answer is c. The hospital is not required
to consider any past involvement in patient safety
events or sentinel events. Standard NR.01.02.01
states, “The nurse executive is a licensed professional
registered nurse qualified by advanced education and
management experience.” Elements of performance
(EPs) 4–7 of that standard require that hospitals
should consider the following when appointing a
nurse executive:
• The education and experience required for peer
leadership positions.
• The hospital’s scope of services and complexity
and the position’s authority and responsibility.
• The scope and complexity of the nursing care
needs of the major patient population(s) served
by the hospital.
• The availability of nursing and administrative
staff and services needed to assist the nurse
executive in the execution of responsibilities.
The correct answer is a. According to Standard
NR.02.01.03, EP 8, a registered nurse is required
to assign the nursing care for each patient to other
nursing personnel in accordance with the patient’s
needs and the qualifications and competence of the
nursing staff available. Answer b is incorrect because
the standard does not require the nurse executive to
2
consider patient preferences. Answer c is incorrect
because the standard does not require the nurse
executive to consider staff seniority.
The correct answer is b. Standard NR.02.01.01,
EP 1, requires the nurse executive to coordinate the
development of hospitalwide plans to provide nursing
care, treatment, and services. NR.02.01.01, EPs 2–6, also
require the nurse executive to direct the following:
• The development of hospitalwide programs,
policies, and procedures that address how
nursing care needs of the patient population are
assessed, met, and evaluated.
• The development of an effective, ongoing
program to measure, analyze, and improve the
quality of nursing care, treatment, and services.
• The implementation of hospitalwide plans to
provide nursing care, treatment, and services.
• The implementation of hospitalwide programs,
policies, and procedures that address how
nursing care needs of the patient population are
assessed, met, and evaluated.
• The implementation of an effective, ongoing
program to measure, analyze, and improve the
quality of nursing care, treatment, and services.
3
NR.02.01.01 does not require the nurse executive to
coordinate credentialing and privileging or staff
recognition programs. TS
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Don’t forget to sign up for the “New Issue” alert!
14 The Source
December 2014
www.jcrinc.com
Perspectives on Patient Safety Top 5 in the News
Clostridium difficile Infections
Rising in the United States
T
he number of Clostridium difficile (C. diff.) infections in US hospitals nearly doubled
between 2001 and 2010, according to a study of 2.2 million C. diff. cases. The study
appeared in the October 2014 issue of the American Journal of Infection Control.1 During
that period, rates of C. diff. infection (CDI) among hospitalized adults rose from 4.5 to
8.2 CDI discharges per 1,000 total adult hospital discharges. The study also found no
significant improvement in patient mortality rates or hospital lengths of stay.
Of the 2.2 million adult C. diff. cases included in the study, 33% had a principal
diagnosis of C. diff.; 67% were classified as secondary C. diff., meaning that infection was
not the primary reason they were hospitalized. Approximately 7.1% (154,184 patients) died
during the study period.1
The study found that C. diff. rates peaked in 2008 and began to decline slightly
in 2010, possibly as a result of improved infection prevention and control practices or
increased antibiotic stewardship.1
According to the Centers for Disease Control and Prevention (CDC), C. diff. is the
most common bacteria responsible for causing health care–associated infections in US
hospitals. Antibiotic stewardship is critical to reducing the incidence of infection. This
illness causes approximately 14,000 deaths annually in the United States. Reducing the use
of high-risk, broad-spectrum antibiotics by 30% could lower CDI by 26%, according to
CDC estimates.2
According to a 2013 survey conducted by the Association for Professionals in Infection
Control and Epidemiology (APIC), 60% of US hospitals had implemented antibiotic
stewardship programs by 2013, up from 52% in 2010.2 The White House recently
announced a new executive order and National Strategy for Combating Antibiotic-Resistant
Bacteria, which emphasizes the need for antibiotic stewardship programs to help clinicians
improve prescribing practices.3
Resources for health care organizations on antibiotic stewardship are available from a
number of infection prevention and control and patient safety organizations, including the
following:
• APIC: http://www.apic.org/Professional-Practice/Practice-Resources
/Antimicrobial-Stewardship
• CDC: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements
.html
• Infectious Diseases Society of America: http://www.idsociety.org/stewardship
_policy/
• Joint Commission Resources: http://www.jointcommission.org/assets/1/18
/Antibiotic_stewardship.pdf TS
References
1.Reveles KR, et al. The rise in Clostridium difficile infection incidence among hospitalized adults in the
United States: 2001-2010. Am J Infect Control. 2014 Oct; 42(10):1028–1032.
2.Association for Professionals in Infection Control and Epidemiology. 2013 Clostridium difficile
Infection (CDI) Pace of Progress Survey. Mar 2013. Accessed Nov 7, 2014. http://www.apic.org
/Resource_/TinyMceFileManager/APIC_SurveyFinal.pdf.
3.White House. National Strategy for Combating Antibiotic-Resistant Bacteria. Sep 2014. Accessed
Nov 7, 2014. http://www.whitehouse.gov/sites/default/files/docs/carb_national_strategy.pdf.
www.jcrinc.com
December 2014
C
DC: New Guidelines for Ebola
Infection Prevention The US Centers
for Disease Control and Prevention (CDC) has
released a set of new guidelines for infection
prevention and control practices in possible
Ebola cases. The guidelines include provisions
for personal protective equipment, patient
evaluation, handling human remains, laboratory
safety, and the environment of care. The
guidelines are available at http://www.cdc.gov/
vhf/ebola/hcp/index.html.
A
llergic Reaction Toolkit for the
Emergency Department More than
200,000 patients visit emergency departments
(EDs) for food allergy reactions. Food Allergy
Research & Education and the American
College of Emergency Physicians recently
released a toolkit to help ED patients
treated for an allergic reaction manage their
condition after discharge. The Anaphylaxis
Toolkit can be downloaded for free at
www.AllergicReactionToolkit.com. It includes
an emergency care plan, epinephrine autoinjector prescription reminder, reminder to
follow up with an allergist, and tools and
resources for parents, teens, and adults.
M
RSA Down 72% in VA ICUs A
Department of Veterans Affairs (VA)
initiative reduced methicillin-resistant
Staphylococcus aureus infections (MRSA)
by 72% in VA hospital intensive care units
and 66% in other VA hospital units between
2007 and 2012, the department announced
in October. VA’s MRSA prevention practices
include patient screening programs; contact
precautions for patients with MRSA;
strategically placed hand hygiene reminders
and hand sanitizer stations; and a dedicated
employee at each medical center to monitor
compliance, train staff, and work with patients
and families.
A
dverse Events Contribute to Staff
Burnout Nurses involved in adverse
events are often considered “second victims”
due to the emotional harms they experience.
A study published online on August 21 by the
Journal for Nursing Care Quality found that
nurses who participated in preventable adverse
events had higher levels of burnout, but peer or
physician support following events appeared to
have a protective effect.
R
educing Patient ID Errors in Radiology
A recent study found that health care
organizations can prevent and/or identify
patient identification errors by including a pointof-care facial photograph with portable chest
radiographs. The study appeared in the August
2014 issue of the journal Academic Radiology.
The Source 15
Benchmark
The Keys of Excellence: The 2014 Top Performer
on Key Quality Measures® Program
I
n November, The Joint Commission announced the
hospitals that earned recognition in the Top Performer
on Key Quality Measures® program. These hospitals
demonstrated consistently excellent performance on
evidence-based process of care measures. This is the fourth
consecutive year for the program.
To be named a Top Performer, a hospital must meet
three criteria. First, it must achieve at least a 95% composite
rate, which is an aggregation of all reported accountability
measures, including those with fewer than 30 reported
cases. Second, it must achieve at least a 95% rate for each
individual accountability measure that has a sample size
of 30 or more cases. The third criteria is core measure
set designation. The hospital must have at least one core
measure set that has a core measure set composite rate
≥ 95% (based on the rate obtained from the combined
12 calendar months of data), and all applicable individual
accountability measures with a rate that is ≥ 95% (based on
the rate obtained from the combined 12 calendar months of
data).
No special applications are required; all hospitals that
submit performance data to The Joint Commission through
the ORYX® are automatically eligible for recognition.
Measure set data must be reported for a minimum of 12
months to be included in the calculation. Data used to
determine the 2014 Top Performer hospitals were reported
from January 2013 through December 2013. These data
included 44 accountability measures in 10 core measure sets,
including the following:
• Acute myocardial infarction (AMI)
• Heart failure (HF)
• Pneumonia (PN)
• Surgical Care Improvement Project (SCIP)
• Immunization (IMM)
• Children’s asthma care (CAC)
• Hospital-based inpatient psychiatric services
(HBIPS)
• Stroke (STK)
• Venous thromboembolism (VTE)
• Perinatal care (PC)
Program Results and Analysis
In 2014, 3,326 hospitals were eligible for Top Performer
recognition. Of those, 1,224 hospitals (about 37%) met or
surpassed the required 95%/95% threshold, an increase
of more than 11% over last year’s program. There were
44 hospitals that received recognition for more than the
required four core sets, an increase of 144% over the
previous year (18 hospitals in 2012). (See Table 1, below, for
some overall trends in the program since its debut in 2011.)
The Top Performer program, now in its fourth year,
has steadily grown from 406 recognized hospitals in 2011
to 1,224 in 2014 (see Figure 1 on page 17). There were 147
hospitals that achieved recognition all four years (2013,
2012, 2011, and 2010). The number of hospitals achieving
recognition in any three consecutive years was 314, in any
Table 1. Trends in the Top Performer Program
2010 to 2013 data years
2010
2011
2012
Number of accountability measures
23
43
40
44
Number of measure sets
5
8
9
10
3,000
3,376
3,346
3,326
Number of Top Performer hospitals
406
620
1,099
1,224
Number of “on track” hospitals
362
583
673
718
Number of eligible hospitals
16 The Source
December 2014
2013
www.jcrinc.com
two consecutive years, 712. In 2014, 397 hospitals are being
recognized as Top Performer hospitals for the first time.
Of the 3,326 eligible hospitals, 718 (about 21.5%) were
identified as being “on track” for recognition, having missed
qualifying by only one measure. Also, 387 hospitals that
achieved Top Performer status in 2013 did not achieve it in
2014.
Academic medical centers and critical access hospitals
are also eligible for the Top Performer program. In 2014, 37
academic medical centers achieved this recognition. This
represents an increase of 54% over the previous year (24
hospitals). Of the 150 critical access hospitals eligible for
recognition, 57 were named Top Performer hospitals.
There are 2014 Top Performer hospitals in all 50
states, plus Washington, DC, and Puerto Rico. Florida
had the most Top Performer hospitals (107), followed by
California (97), and Texas (96). (See Table 2 on page 18 for
demographic details.)
Analysis of Measures
According to the performance data submitted in 2013, some
measures were more problematic than others—meaning
those measures had the highest number of hospitals failing
to achieve the 95% performance rate threshold for the Top
Performer program. The most problematic measure was in
Figure 1. Increase in Top
Performer Hospitals in 2010,
2011, 2012,
Increase and
in Top 2013
Performer hospitals
in 2010, 2011, 2012, and 2013
1,300
1,224
1,200
1,099
1,000
800
620
600
400
406
200
0
2010
2011
© Copyright, The Joint Commission
2012
2013
“
Of the 3,326 eligible hospitals,
718 (about 21.5%) were identified
as being “on track” for recognition,
having missed qualifying by only
one measure. Also, 387 hospitals
that achieved Top Performer
status in 2013 did not achieve
it in 2014.
”
the pneumonia set (antibiotics to non-ICU patients)—477
hospitals had a performance rate below 95% for this
measure. The second most problematic measure was from
the surgical care set (urinary catheter removed), with 376
hospitals reporting less than a 95% performance rate.
The Joint Commission’s expansion of measure reporting
requirements, which took effect January 1, 2014, had no
impact on the hospital’s ability to be recognized in 2014.
This is because the 2014 recognition was based on data
reported in 2013—before the new measure sets were added
to the requirements. However, the changes may affect a
hospital’s ability to be recognized in 2015, because that will
be based on data collected in 2014.
Advantages of the Top Performer
Program
The Top Performer program has proven valuable for hospitals
as both a performance improvement tool and a public
relations opportunity.
It is important to note the differences between the Top
Performer on Key Quality Measures program and other ratings
programs. Unlike the Top Performer program, others may use
ratings systems that offer a subjective view of performance.
Some factor in subjective data such as physician survey;
others may use a sliding scale.
By providing a more accurate representation of a
hospital’s actual performance excellence, the Top Performer
program eliminates bias by relying solely on objective,
quantifiable performance data that are submitted by the
hospitals themselves. The measures used to determine
recognition are commonly accepted, evidence-based
processes of care measures that are common to all hospitals,
regardless of their size or focus. Also, because these measures
evaluate a hospital’s use of processes, they are not susceptible
to the difficulty in determining cause that can occur
when outcomes are used as a basis for evaluation. Another
advantage of the Top Performer program is that it is based
on data that organizations collect themselves throughout the
year. This means a hospital can assess its own performance
(continued on page 18)
www.jcrinc.com
December 2014
The Source 17
Benchmark
(continued from page 17)
and know ahead of time whether it is meeting the 95%/95%
thresholds. The specificity of the measures is another
strength of the program, because it allows hospitals to target
areas for improvement, particularly if a hospital has narrowly
missed recognition. Encouraging improvement is, after all,
the underlying goal of the Top Performer program.
Hospitals achieving Top Performer status receive a letter
and certificate of recognition, along with a communications
toolkit to help promote the achievement both internally and
to the media. Top Performer hospitals are also recognized in
the Improving America’s Hospitals annual report, on The Joint
Commission’s Quality Check™ site, in publications such as
Perspectives and The Source, and on The Joint Commission’s
website.
Questions about the Top Performer program should be
sent via e-mail to topperformersprogram@jointcommission
.org. TS
Table 2. 2014 Top Performer Demographic Data
Based on data reported in 2013
Demographic Category
2013 Count
(# out of 1,224 total)
2013 Percentage
(% out of 1,224 total)
Rural
293
23.9
Urban
931
76.1
For profit
377
30.8
Not for profit
709
57.9
Governmental
138
11.3
< 100 beds
372
30.4
100–299 beds
577
47.1
300+ beds
275
22.5
86
7.0
1,138
93.0
CAH
57
4.7
HAP
1,167
95.3
Northeast
179
14.6
Midwest
304
24.8
South
519
42.4
West
220
18.0
2
0.2
Rural Status
Owner Status
Bed Size Category
Teaching Status
Teaching
Nonteaching
Program
Region
Outside U.S.
KEY:
CAH: Critical Access Hospital
HAP: Hospital Accreditation Program
AMC: Academic Medical Center
AMC
Yes
37
3.0
No
1,187
97.0
18 The Source
December 2014
www.jcrinc.com
The SourceTM
Editorial Advisory Board
5 Surefire Methods
(continued from page 3)
consistent with the orders. This can be done as part of regular supervisory
visits.”
Develop a process for “missed visits.” “You need to have a process in
place for what staff should do when a visit is missed,” Clark says. “The
process should include how missed visits will be documented and how the
physician will be notified. Some organizations have a ‘missed visit’ form that
includes a place to document the date and time of the missed visit, why the
visit was missed, and whether the physician was notified by fax, e-mail, or
telephone. Alternatively, staff could just make a note in the chart that the
visit was missed and why, and how the physician was notified. It doesn’t
matter how you do it as long as you have a process and staff know what
they are supposed to do.”
Conduct mock tracers. “Look at the patient from the point of admission to
the point of discharge, focusing on the development of and compliance with
orders,” says Smith. “Conduct periodic audits and include an ongoing
review of the plan of care. Place the orders on the left and the clinical notes
on the right and do a crosswalk to make sure they all match so that there
are no notes that are not reflected in the orders and vice versa.” TS
4
5
(continued from page 9)
•
•
•
•
Dale W. Bratzler, DO, MPH
Professor and Associate Dean
University of Oklahoma Health Sciences Center,
College of Public Health
Elizabeth Brown, RHIA, CPHQ, CJCP
Lead CSR Consultant
Joint Commission Resources
Diane Storer Brown, PhD, RN, CPHQ,
FNAHQ, FAAN
Strategic Leader, Hospital Accreditation
Programs
Kaiser Permanente, Northern California
Hedy Cohen, RN, MS
Clinical Consulting Nurse
Institute for Safe Medication Practices
Mary G. George, MD, MSPH, FACS, FAHA
Medical Officer, Division for Heart Disease and
Stroke Prevention, NCCDPHP
US Centers for Disease Control and Prevention
Betty Gwaltney, RN, MBA, CPHQ, CJCP
System Manager, Survey Support
Providence Health & Services
Robert S. Lagasse, MD
Professor of Anesthesiology and
Director, Quality Management &
Perioperative Safety
Yale University School of Medicine
CMS
•
Steve Anderson, RN, MBA, CJCP
Senior Director, Clinical Improvement and
Patient Safety
VHA Pacific Northwest
where he or she no longer needs the hospital’s services.
The transfer or discharge is necessary for the resident’s benefit or if the
hospital cannot meet the resident’s needs.
The health or safety of the resident is endangered by remaining in the
hospital.
The hospital has provided the resident, who has not paid for his or her
stay, with reasonable notice of transfer or discharge, as defined by the
hospital and in accordance with law and regulation.
The hospital ceases operation.
The resident leaves against medical advice and signs a form stating that
his or her action runs contrary to medical advice.
Ana Pujols McKee, MD
Executive Vice President and
Chief Medical Officer
The Joint Commission &
Joint Commission Resources
David S. Nilasena MD, MSPH, MS
Chief Medical Officer, Region VI
US Centers for Medicare & Medicaid Services
Cathy Rick, RN, NEA-BC, FACHE, FAAN
Chief Nursing Officer
US Department of Veterans Affairs
Compliance Strategies
“You need to have clear documentation as to why a resident is being transferred or
discharged,” Hamblin says. “If it’s being done for the benefit of the patient, how will
the patient benefit? If you can’t meet the resident’s needs, why not? Also, what did
you do to try to meet the resident’s needs? All of this needs to be documented.” TS
References
1.US Department of Health & Human Services, Centers for Medicare & Medicaid Services. 42
CFR Parts 413, 416, 440 et al. Medicare and Medicaid Programs; Regulatory Provisions to
Promote Program Efficiency, Transparency, and Burden Reduction; Part II; Final Rule. May 12,
2014. Accessed Nov 7, 2014. http://www.gpo.gov/fdsys/pkg/FR-2014-05-12/pdf/2014-10687.pdf.
December 2014
The Source 19
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