feb 18 2015 chs webinar combined …s3.proce.com/res/pdf/chs/chs2015febhandout.pdf · 2015 pharmacy...

2015 Joint Commission UpdateCHS Pharmacy Education Series

ProCE, Inc.www.ProCE.com 1

2015 Pharmacy Education Series

February 18, 20152015 J i t C i i U d t2015 Joint Commission Update

Featured Speaker:

Patricia C. Kienle, RPh, MPA, FASHPDirector, Accreditation and Medication SafetyCardinal Health Innovative Delivery Solutions

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Submission of an online evaluation is the only way to obtain CE credit

Online Evaluation, Self-Assessmentand CE Credit

Submission of an online evaluation is the only way to obtain CE credit for this webinar

Go to www.ProCE.com/CHSRx Webinar attendees will also receive an email with a direct link to the

web page Print your CE statement of completion online

– Credit for live or enduring only

Deadline: March 20, 2015( l bl h )

2

CPE Monitor (applicable to pharmacists)– CE information automatically uploaded to NABP/CPE Monitor within 1 to 2

weeks of the completion of the self‐assessment and evaluation

Event Code

Code will be provided at the end of today’s activity



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February 18, 20152015 Joint Commission Update

Featured Speaker:

Patricia C. Kienle, RPh, MPA, FASHPDirector, Accreditation and Medication SafetyCardinal Health Innovative Delivery Solutions

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It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Ms. Kienle has served as a consultant/speaker for BD, is a stockholder and employee of Cardinal Health, and is an elected member of the USP Compounding Expert Committee, but is not speaking in that capacity or as a representative of USP. Ms. Moran has no relevant commercial and/or financial relationships to disclose.

Please note: The opinions expressed in this activity should not be construed as those of the CME/CE provider. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature.

CE Activity Information & Accreditation

ProCE, Inc. (Pharmacist CE)

– 2.0 contact hours

Funding:This activity is self‐funded through CHSPSC

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This activity is self funded through CHSPSC.



2015 JOINT

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COMMISSION UPDATE

P i i C Ki l RPh MPA FASHPPatricia C. Kienle, RPh, MPA, FASHP

Director, Accreditation and Medication Safety

Cardinal Health Innovative Delivery Solutions

[email protected]

Disclosure

• Patricia Kienle is an employee and stockholder of Cardinal Health

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Cardinal Health

• Patricia Kienle is an elected member of the USP Compounding Expert Committee, but is not speaking in that capacity or as a representative of USP



Objectives

• Identify the top non-compliant medication-related issues found during accreditation surveys

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issues found during accreditation surveys• State the one new Medication Management Element of Performance added to Joint Commission standards in 2014

• Distinguish the difference between protocols and order sets

• Describe the key accreditation issues related to single-use containers

• State the key question surveyors ask staff concerning refrigerator temperatures

• Identify three things that you can improve the next day you are at work

Patti’s Wish

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next day you are at work



CMS AND ACCREDITATION ORGANIZATIONS

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Laws, Regs, and Standards

• RegulationsFederal

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• Federal

• State

• Accreditation• Joint Commission

• AOA’s HFAP

DNV GL Healthcare• DNV-GL Healthcare

• CIHQ

• Ambulatory accreditation organizations

• Best Practices



CMS Hospital Conditions of Participation

• Revision 122

S t b 26 2014

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• September 26, 2014

• http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

• Conditions and Interpretive Guidelines are blsurveyable

• Survey Procedures provide information to surveyors

• New information is in RED

Updated CoP Information in 2014

• For information only – not to be cited

S f ti i

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• Scope of practice issues

• Non-physician prescribers

• Medical staff bylaws



Keep Current References

• CMS Conditions of Participation

St t l ti

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• State regulations• General Hospital regulations

• State Board of Pharmacy

• Accreditation standards

• Medical Staff bylaws

Medication Use System

Plan

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Plan

Evaluate



NEW FOCUS AREAS

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Areas of Focus

• Sample medications

A t bilit f di h ti l

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• Accountability for radiopharmaceuticals

• Clinical alarm systems

• Enteral tubing connectors

• ISMP Targeted Medication Safety Practices



Sample Medications

MM Standards with Sample Medication Requirements

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Requirements

MM.01.01.01 MM.05.01.09

MM.01.01.03 MM.05.01.11

MM.01.02.01 MM.05.01.17

MM.02.01.01 MM.05.01.19

MM.03.01.01 MM.07.01.01

MM.03.01.05 MM.07.01.03

MM.04.01.01 MM.08.01.01

Accountability for Radiopharmaceuticals

• New JC Element of Performance

MM 03 01 01 Th h it l f l t

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• MM.03.01.01: The hospital safely stores medications

• EP 24: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains records of the receipt and disposition of radiopharmaceuticalsdisposition of radiopharmaceuticals



Clinical Alarm Systems

• National Patient Safety Goal spans 2014 and 2015

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2015

• 2015 requirements• Continue issues prioritized during 2014

• Complete policies and procedures that address specifics listed in the NPSG• Operationp

• Predictability

• Alarm settings

• Educate practitioners

Enteral Tubing Connectors

• Enteral connectors changing from Luer-Lock to route specific small bore connectors

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route-specific small bore connectors

• www.StayConnected2014.org



ISMP Targeted Medication Safety Best Practices for Hospitals

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Best Practice

1 Vinca alkaloids dispensed only in minibags1 Vinca alkaloids dispensed only in minibags

2a Oral methotrexate default set to weekly

2b A pharmacist counsels every patient discharged on weeklymetrotrexate

3a Patient weights are expressed only in metric units

3b All scales for weighing patients are set and measure only in metric units

4 Nursing does not need to measure any oral liquid dose; all are provided in cups or oral syringes

5 Oral liquid measuring devices only display metric scale

6 No glacial acetic acid is available in the hospital

TOP NON-COMPLIANT STANDARDS

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Top Med Non-Compliant StandardsStandard % Non-Compliant

MM.03.01.01 Medication Storage 32%

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MM.03.01.01 Medication Storage 32%

MM.04.01.01 Medication Orders 24%

MM.05.01.01 Pharmacist Review of Orders 20%

NPSG.03.04.01 Labeling in Procedures 12%

NPSG.03.06.01 Medication Reconciliation 6%

MM.05.01.07 Medication Preparation 5%

MM 05 01 08 Medication Labeling 4%MM.05.01.08 Medication Labeling 4%

MM.01.02.01 Look- and Sound-Alike Meds 3%

MM.01.01.03 High-Alert/Hazardous Meds 3%

MEDICATION STORAGE

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Medication Storage

Security

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Security

Safety

Integrity

Medication Security

• Policy – who is authorized to access medications?

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medications?

• How timely is the removal of access to Automated Dispensing Cabinets and other locked medication areas once an employee leaves?

• Do you have a parallel process to remove access for personnel credentialed through the medicalfor personnel credentialed through the medical staff (not employees)?



Medication Safety

• ISMP Targeted Medication Safety Best

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Medication Safety Best Practices for Hospitals

• 2014-2015 time frame

• Six targets

Dispensing Vinca Alkaloids

• Vinca alkaloid oncology agents

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agents• Vincristine• Vinblastine• Vinorelbine

• Fatal when inadvertently administered intrathecally

• Best Practice: administer only as a piggyback IV



Oral Methotrexate

• Non-oncology dose of oral methotrexate is dosed weekly

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dosed weekly

• Patients need to be familiar with frequency and risk of errors

• Best Practice• Default frequency in computers should be set to eeklto weekly

• All patients prescribed weekly methotrexate need to be counseled by a pharmacist

Patient Weights in Metric

• What’s the conversion between pounds and

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between pounds and kilograms?

• What’s the most common error?

• Best PracticeM ti t i ht i• Measure patient weights in kg only

• Set scales to metric



Dispensing Oral Liquids

• Doses should be ready-to use

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to-use

• What errors could occur if liquids are dispensed in bulk bottles?

• Best PracticeU it d• Unit-dose cups

• Oral syringes

Metric Oral Dosing Devices

• Some oral syringes have multiple marking

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multiple marking• mL

• Teaspoonful

• Minim

• Best Practice: use i ith lsyringes or cups with only

metric marking



Eliminate Glacial Acetic Acid

• Glacial acetic acid = 99.5%

Vi 5%

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• Vinegar = 5%

• Otic use = 2%

• Irrigation = 0.25%

• Best Practice: remove and safely discard glacial acetic acid

Integrity of Medications

• In date

St d t t t

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• Stored at proper temperature• Refrigerators

• Freezers

• Warmers

• Biggest issue = refrigerator temperature logs• Complete

• Staff knows what to do when the temperature is out of range



CDC Single-Use Containers

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www.cdc.gov/injectionsafety/CDCposition-SingleUseVial.html

CDC Multiple-Dose Vials

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www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html



MEDICATION ORDERS

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Medication Orders

• Types of orders allowed

C i t ith li

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• Consistency with policy

• Order sets

• Standing orders

• Protocols



What’s the Difference?

• Order sets / preprinted orders• Activated by signature of Licensed Independent

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• Activated by signature of Licensed Independent Practitioner

• Protocols• May be some situations where they are initiated by non-

LIP under pre-defined circumstances

All i l f di l t ff CNO d• All require approval of medical staff, CNO, and pharmacy

• All must use nationally-accepted or evidence-based guidelines

ORDER REVIEW

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When Might Review Not Occur?

• Urgent patient needs

LIP t th b d id

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• LIP at the bedside• ED – OK if the physician is available in the department

• Imaging – OK for contrast administration under protocol

• Areas of focus in surveysN fil d ADC• Non-profiled ADC areas• Monitoring overrides

• Nuclear medicine procedures

• Off-site clinics that are part of hospital survey

MEDICATION LABELING

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Labeling

• Pharmacy and Nursing areasMM 05 01 09

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• MM.05.01.09

• Procedural areas• NPSG.03.04.01

• All medications must be labeledO l ti d d i di t l• Only exception: drawn up and immediately administered by the same person

• Standardized throughout the health system

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MED RECONCILIATION

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Medication Reconciliation

• What is the problem?

H fi it?

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• How can we fix it?

• Do electronic systems help?

• How knowledgeable are patients?



PREPARING MEDICATIONS

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Sterile Preps Mixed by Pharmacy

• Includes procedural areas

OR

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• OR• Antibiotic irrigations

• Other mixtures

• Nuclear Medicine• Sincalide

D b t i• Dobutamine



HIGH-ALERT AND HAZARDOUS DRUGS

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High-Alert Medications

• List reviewed

St ff f f t d

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• Staff aware of safety procedures

• High-Alert

• Look- and Sound-Alike medications

• Consistent practice and labeling throughout the health system



Hazardous Medications

• MM – NIOSH-hazardousHazardous to personnel

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• Hazardous to personnel

• EC – EPA-hazards• Hazardous to the environment

What are the Regulations?

• Hazard Drugs – Handling in Healthcare Settings

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in Healthcare Settings

• Applies to both sterile and nonsterile compounding

• Proposed USP <800>• Federally-enforceable

regulationregulation

• State regulations• Enforcement



Hazardous Drug Definition

• CarcinogensG t i

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• Genotoxins• Teratogens• Reproductive toxins• Organ toxicity at low doses• Structure or toxicity similar to drugs classified as hazardous

NIOSH 2014 List of Hazardous Drugs

• Antineoplastic

N ti l ti

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• Non-antineoplastic

• Reproductive hazard only

• www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf



Entity-Exempt Dosage Forms

• All drugs you handle on the NIOSH list are hazards

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hazards

• You may choose to review the non-antineoplastic and reproductive hazard only HDs to exempt some dosage forms

• You need to identify alternative containment strategies and/or work practicesstrategies and/or work practices

• Annual review required

• If you don’t choose an alternative approach, all HDs must be handled with all details in <800>

Administering HDs

• Requires Supplemental Engineering Controls

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Photo courtesy of BD



MEDICATION MANAGEMENT UPDATE

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MANAGEMENT UPDATE

Tackling Our ProblemsOur Problems

and

Resolving Them

Program Objectives• Identify the most problematic Medication Management

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Medication Management standards in 2014 for CHS facilities

• Outline areas of focus and issues to be addressed for each of those identified problematic standardseach of those identified problematic standards

• Discuss actions to resolve the issues and enhance compliance to the identified problematic standards



Most Problematic MM Standards - 2014

The majority of our RFIs were cited at:

• MM.03.01.01- relates to safe storage of

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medications in compliance with law, regulation and manufacturer’s guidelines (EPs 2-8 & 18)

• MM.04.01.01- relates to clear, complete and accurate medication orders to enhance communication between all participants in the medication management process (EP 1 3 6 9 13 d 15)(EPs 1, 3, 6-9, 13 and 15)

• MM.05.01.01- relates to the pharmacist’s review of the appropriateness of medication orders for medications that are to be dispensed in the hospital (EPs 1, 8, 13)

Historical Perspective

2012 2013 2014

• Over the past 3 year accreditation cycle all

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2012 2013 2014

MM.03.01.01 all EPs

7 20 29

MM.04.01.01 all EPs

13 36 7

MM 05 01 01 ll EP

accreditation cycle, all three of these standards have been problematic for our facilities

• While there has been dramatic improvement in

MM.05.01.01 all EPs

9 6 28the outcomes for MM.04.01.01, that is not true for the other two standards



MM.03.01.01 – Areas for Focus

• Special storage conditions• Medications in warming cabinets

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Medications in warming cabinets

• Refrigerated medications

• Monitoring conditions 24/7

• Expired medications• Dating multidose containers upon opening

• Expired medications that remain accessible for administration

• Securing medications from unauthorized access• Locking storage areas v. continuous supervision

• Disposal of controlled substances

• Temperature logs with temperatures recorded out of acceptable range

Improving MM.03.01.01 Outcomes• Ensure your written policy on medication storage

addresses all elements of storage

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g• Locking v. constant supervision• Who may access the locked areas • The circumstances under which they may have access

• Educate staff to revise expiration dates of medications stored in a warming cabinet- follow the manufacturer’s guidelines!Review refrigerator temperature logs and provide• Review refrigerator temperature logs and provide refresher training when out of range temperatures are recorded without appropriate actions being documented

• Ensure that Crash Carts are visible at all times, especially if stored in occupied ED rooms



MM.04.01.01 – Areas of Focus• Incomplete medication orders

• Order lacks any of the parameters required by policy (i.e. route of administration, frequency of dosing, etc.)

• Order includes prohibited abbreviations

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Order includes prohibited abbreviations• Not clarified with prescriber prior to medication being

dispensed

• Therapeutic duplication• Orders lack selection criteria to guide administration• Involves preprinted order sets as well as orders

generated by an individual provider• Not clarified with prescriber prior to medication being

dispensed

• Titration orders• Lacks specific criteria for titration (dose, clinical parameters)• Not clarified with prescriber prior to medication being dispensed

• Sedation orders• Lacks sedation goal and/or dosing parameters• Not clarified with prescriber prior to medication being dispensed

Improving MM.04.01.01 Outcomes

• Educate and re-educate all clinical staff involved in the medication management process on all requirements of

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medication management process on all requirements of a complete order

• Review preprinted order sets to ensure only complete, accurate orders are included

• Monitor the clarification process to ensure incomplete, inaccurate orders are clarified with the prescriber prior to dispensing the medicationdispensing the medication

• Monitor troublesome types of orders (titration, sedation) to ensure criteria for use are included and followed• Provide feedback to prescribers (OPPE?) and those who

administer medications on the monitoring results you obtain



MM.05.01.01 – Areas of Focus• Pharmacist’s review of orders

• Orders faxed from physician’s office and implemented ith t h i t’ i

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without pharmacist’s review• PACU orders not transmitted for pharmacist’s review• Preprinted order sets and protocols

• Clarifying orders• Incomplete, inaccurate orders not

clarified before dispensing• All issues not clarified with prescriber

before dispensing• Confusion over nursing v. pharmacy

role in clarification process

Improving MM.05.01.01 Outcomes

• Educate and re-educate all clinical staff involved in the medication management process on the need for

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medication management process on the need for pharmacist’s review of orders

• Review preprinted order sets and protocols with a critical eye to determine any potential unresolved therapeutic duplication issues

• Work with clinicians who administer medications to promote understanding of the clarification processpromote understanding of the clarification process • Orders should be written correctly from the beginning

• Ideally, nursing can clarify at the time of issuance

• But, remember the final responsibility for clarification rests with the dispensing pharmacist



If you resolve these issues…

You can be certain of a happy survey

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outcome!

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U d t C tU d t C t PhPhUpdate on Current Update on Current Pharmacy Pharmacy Initiatives and StrategiesInitiatives and Strategies

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Robert Fink, Pharm.D., M.B.A., FASHP, FACHE, BCNSP, BCPS

Chief Pharmacy Executive

Community Health Systems

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feb 18 2015 chs webinar combined …s3.proce.com/res/pdf/chs/chs2015febhandout.pdf · 2015 pharmacy...

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