Jeanell Mansur from Joint Commission Resources shared some great insights and tips for preparing for upcoming Joint Commission surveys. Her top two takeaways for hospitals were: “Get ready for new Antimicrobial Stewardship standards and Medication Security/Controlled Substance handling standards by conducting a comprehensive gap analysis and program reviews against the standards.” Visante offers support for both of these areas should organizations desire an external review of their programs.

More highlights from the Joint Commission Resources Review include:

  • Deletion of the old scoring methodology with Direct/Indirect findings along with A & C categories. The old scoring methodology has been replaced with the Survey Analysis for Evaluating Risk (SAFER) matrix. SAFER provides a visual representation of survey findings with risk on the Y axis moving from Low to Moderate to High, and frequency on the X axis moving from Limited to Pattern to Widespread.
  • Response time for corrections has now been standardized to 60 days.
  • If High Risk standards are cited or Moderate Risk + Pattern, the plan of correction must now include how Leadership is included in the process and how the organization will ensure their changes are effective and sustainable.
  • MM 04.01.01 Medication Orders is now the most frequently cited standard at 33.5%. Failure to clarify orders and inconsistency in interpreting range and titration orders are frequent points of failure. Titrations are also a major area of focus with required elements for clarification specified.
  • Texting orders are NOT allowed as of December 2016. This holds true even if the computer order system is down.
  • MM 03.01.01 Medication Storage & Security is the second most frequent area for citation at 31.4%. Dating of vials is a frequent problem with organizations dating the vial when it was opened instead of the required date for when it expires.
  • Multi-Dose Vials are an issue. If an MDV is used when an SDV is available that will be cited.
  • Drug security in OR’s is an issue. OR’s not in use with unsecured drugs present will be cited.
  • MM 05.01.01 Pharmacy Review of Orders – be careful of multiple-choice orders with no clear delineation of when to use one drug vs. another such as post-op pain meds or oncology nausea/vomiting orders.
  • TJC is looking for areas that don’t have pharmacy reviewing orders but should. A common approach is to ask which Automated Dispensing Cabinets (ADC) are not profiled leading them to areas like PACU and Procedure areas.
  • Override processes for ADCs should be regularly reviewed and approved.
  • Auto Verification of orders is a practice that TJC does not approve of outside of areas such as ED and will cite this.
  • MM 05.01.07 Pharmacy Preparation of IV Solutions. TJC wants ALL sterile compounding done in the pharmacy with the exception of emergency situations or very short dated drugs. This includes hospitals that don’t offer 24-hour services – they will be pushed toward options such as pre-mixes.
  • It was noted that while CMS has taken a position prohibiting the use of syringes drawn up in the OR beyond 1 hour, TJC is not scoring this at the present time.
  • USP 795 and 797. For organizations requesting the voluntary Joint Commission certification of their sterile compounding program all elements of USP 795/797 will be surveyed. For regular TJC surveys, they will not score these elements unless the organization has indicated they are USP 795/797 compliant and then all elements are “fair game” for review.
  • TJC is not presently surveying against the upcoming USP 800 standards but they are paying special attention to chemotherapy in their review of sterile compounding operations.

Anticipated TJC Changes Coming in July

  • Automated dispensing equipment and medication refrigerators will be required to be on the emergency power system.
  • Behavioral Health is being added to the standards for hazardous medication handling.

Survey Tips

  • Make sure all pharmacy & personnel licenses are current.
  • Have a policy in place to address having clerks or students that have access to medication areas if this is the situation.
  • Check the security of the pharmacy, e.g., cameras, alarms, motion detectors, etc.
  • Make sure eye wash equipment is tested and documented weekly.
  • Make sure everyone knows how to use the fire control systems.
  • Make sure any pharmacy equipment has been validated by bioengineering and has a regular maintenance schedule.
  • While high alert and Look Alike Sound Alike warning are used regularly on the nursing units these should also be present in the pharmacy.
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