2018 Significant Changes to TJC Standards

2018 Significant Changes to TJC Standards

“Quick Check”

Overview / YES / NO / N/A
Documents-We have reviewed with Leadership and our readiness team the following process changes for 2018 TJC Survey

• Any Element of Performance with a D can not be clarified after survey. If an EP has a D it means you must have a Document to support Compliance. When the document is requested by the surveyor, it must be produced in a short time. Submitting later or the next day will not be counted. This becomes critical especially in the Environment of Care Chapter as all the testing has a D by it.

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Report Format-We have reported to the Leadership and our readiness team the new report format for TJC

• Excel Worksheet with findings
• A table of content to guide your review of the report
• Text for Standard and CMS separate to simplify the look of the report.

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Post Survey-Continuing Use of the Safer Matrix and extended Evidence of Standard Compliance report for Higher Risk and Higher Scope findings. The two additional requirements are Leadership Involvement and Prevention Analysis. All ESCs generated due to Requirements for Improvement are 60 days. Medicare issues did not change. You will still have a visit with 45 days for failing conditions. Immediate Threat is still 72 hours. /  /  / 
Life Safety Codes changed to NFPA 2012-Major changes to the overall codes for 2018. This program will cover the ones that impacted Environment of Care but the Life Safety Chapter will be covered later. /  /  / 
Tracers-The following tracers will be aggressive during 2018. We have notified our Leadership and readiness team. We have changed our internal tracer process:

• Cleaning, disinfecting and sterilization. This one causes a great number of conditions to fail under Infection Control and Surgical Services.
• Radiation Safety-Continuing emphasis on control of aprons, shields, dosimetry, radiation exposure control, CT requirements
• General Infection Control
• Management of medical gases-Compressed tanks, etc
• Management of Patients in Ambulatory Care
• Management of Ventilation; pressure gradients, sensors, inspections and reports

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Sessions-Same old same old FYI

• Opening Conference
• Leadership
• Medication Management
• Infection Prevention
• Data Management
• Environment of Care
• Life Safety
• Emergency Management
• Competency
• Credentials

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ISSUE/FINDING / YES / NO / N/A
Pain LD.04.03.13 Must be identified as a priority

• Establish a leader or leadership group
• Non-pharmacology pain treatment modalities available and listed in Pain Policy
• Education resources about pain and opioid addiction available to LIPs and Staff
• Opioid referral treatment programs identified and utilized
• You have facilitated the use of the Prescription Drug Monitoring Tools available in your state

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Pain PC.01.02.07 Screening, assessment, and reassessment

• Assessment policy for pain was reviewed for the following content:

• Screening for pain is included in the emergency department visits/admissions
• Treatment or referral
• When pain is present, it is included in the plan of care
• Patient is included in deciding expectations and measurable goals: methods to evaluate progress toward goals; and education on opioid and non-opioid prescriptions
• Safe use and storage and disposal of opioids if prescribed

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Pain PI.01.01.01, PI.02.01.01, and PI.03.01.01 Data collection, analysis and action includes:

• Types of interventions/effectiveness
• Analyzing data to identify areas to change
• Monitoring opioids (reversals, resp depression incidents, and duration/dose of opioid prescriptions
• Taking action to improve pain management is evident in PI documents

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Pain MS.05.01.01 Medical Staff Involvement in Pain Management

• The medical staff policies include their involvement in development of protocols and quality metrics and a review of pain management data

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Informed Consent RI.01.03.01

• The Informed Consent Policy was reviewed and revised as needed and includes:

• Specific care, treatment or service
• Circumstance that allow for exception to informed consent
• The process for obtaining
• Documentation requirements
• Surrogate decision maker
• A requirement for discussion of

• Proposed treatment and services
• Potential benefits, risks, side effects, likelihood of achieving goal, potential problems with recuperation
• Reasonable alternatives with risk benefits and side effects of the alternative

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Informed Consent for Research RI.01.03.05 includes:

• Info that helps patient to determine whether to participate or not
• That refusing will not jeopardize care
• Name of person providing info with date and time
• Patient’s right to privacy, confidentiality, and safety

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End of Life RI.01.05.01

• Policies on Advance Directives, withdrawing, and withholding address:

• Written information for patients
• Upon admission info on hospital’s approach for honoring
• Outpatients-Policy upon request or when warranted by care treatment and services
• Honor right to change
• Info to staff and LIPs relative to patients wishes

• When required by law or policy organ donation wishes are documented

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Complaint Resolution RI.01.07.01

• Complaint resolution policy was reviewed and includes

• Info to patient/families relative to complaints
• Governing Body is responsible unless it delegates responsibility in writing to a Complaint Resolution Committee

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Sign and hold orders MM.04.01.01

• Sign and hold order policy outlines the process and includes the requirement

• New prewritten (held) med orders and specific instructions from an LIP to administer meds to a patient in clearly defined circumstances that become active upon the release of the order on a specific date(s) and time(s).

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Automatic dispensing cabinet over-rides MM.08.01.01

• Policy defines the types of medication overrides that will be reviewed (100% review is not required)

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Control of Meds between receipt and administration MM.03.01.01

• Control of Meds policy includes

• Safe Storage
• Handling
• Wasting (NEW)
• Security
• Disposition
• Return to storage

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CT Exams-Qualifications to Perform HR.01.01.01

• The qualifications for CT Techs have been reviewed and include:
• Advances-Level certification by the American Registry of Radiologic Technologist (ARRT)

OR

• Nuclear Medicine Technology Certification Board (NMTCB) in completed tomography

OR have the following qualifications:

• State Licensure that permits them to perform diagnostic CT Exams and documented training on the provision of diagnostic CT exams

OR

• Registration and certification in radiography by ARRT and documented training on the provision of diagnostic CT exams

OR

• Certification in nuclear medicine technology by ARRT or NMTCB and documented training on the provision of diagnostic CT exams

(Note: Not applicable to dental Cone Beam CT or CT for Therapeutic radiation planning or delivery or for calculating attenuation coefficiency for nuclear med studies.) / 
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MDRO Education Staff and LIP NPSG.07.03.01

• We have reviewed our education processes to determine whether we should make a change from annual to periodic.

• We integrated the change into our policy.

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Central Line Education Staff and LIP NPSG.07.04.01

• We have reviewed our education processes to determine whether we should make a change from annual to periodic.

• We integrated the change into our policy.

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Respiratory Care-Fire Safety EC.02.01.03

• We have reviewed the appropriate Respiratory/Patient Care Policy and have added the appropriate language

• Smoking materials are removed from a patient receiving respiratory therapy
• If nasal cannula is delivering oxygen outside a patient room, no sources of ignition are within 1 feet
• When other oxygen delivery systems are used within a patients room, there are no sources of ignition with 15 feet
• Solid fuel burning appliances are not within the area of administration
• Non medical appliances with hot surfaces or sparking mechanisms not within site of intentional expulsion.

• We have educated the appropriate staff

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Fire Response Plan EC.02.03.01

• We have reviewed the Fire Response Plan and have included

• Requirement for periodic instruction of LIPs and staff on duties in the Plan, what we consider Periodic has been determined
• The requirement was coordinated with the education department

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Fire Hazards during Surgical Procedures EC.02.03.01

• We have developed a timeframe for periodic evaluation of Fire Risk during Surgical Procedures
• We have developed written procedures regarding hazards that could occur during Surgical Procedures including the use of flammable germicides or antiseptics
• We have defined in policy the requirements during the use of flammable germicides or antiseptics to include

• Non-flammable packaging
• Unit dose applicators

• Pre op Time Out verification includes
• Application site is dry prior to draping and use of surgical equipment
• Pooling of solution has not occurred or has been corrected
• Solution-soaked materials have been removed from the operating room prior to draping and use of surgical devices

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Quarterly Fire Drills EC.02.03.03

• Our Fire Drill policy for Quarterly Fire Drills was reviewed to include

• All required Quarterly Fire Drills are Unannounced

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Elevator Inspections EC.02.03.05

• Reviewed documentation for testing of Fire Fighter Response Elevators to assure it is scheduled

• Monthly
• Documented dates and results

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Labeling (permanent) of Equipment designated for Oxygen Enriched Environment EC.02.04.03

• We have identified the appropriate equipment and have checked the permanent labeling for the following requirements

• Oxygen-metering equipment, pressure-reducing regulators, humidifiers, and nebulizers are labeled with name of manufacturer or supplier.
• Oxygen-metering equipment and pressure reducing regulators are labeled "OXYGEN–USE NO OIL."
• Labels on flowmeters, pressure-reducing regulators, and oxygen-dispensing apparatuses designate the gases for which they are intended.
• Cylinders and containers are labeled in accordance with Compressed Gas Association (CGA) C-7.

Note: Color coding is not utilized as the primary method of determining cylinder or container contents. / 
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Hyperbaric Facilities EC.02.04.03

• All occupancies containing hyperbaric facilities have been reviewed and compared to

• NFPA99-2012;chapter 14
• Any changes have been implemented

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Anesthesia Apparatus testing and maintenance EC.02.04.03

• We have reviewed our testing and maintenance policies for anesthesia apparatus and have assured the following areas are being addressed

• The apparatus are tested at the final path to patient after any adjustment, modification, or repair
• Before the apparatus is returned to service each connection is checked to verify proper gas flow and an oxygen analyzer is used to verify oxygen concentration
• Areas designated for servicing of oxygen equipment are clean and free of oil, grease, or other flammables.

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Operating Rooms considered Wet Procedure Locations (based on a risk assessment) EC.02.05.01

• We have reviewed all locations with Operating Rooms and evaluated

• Compliance with Wet Procedure locations
• For ones that don’t comply we have completed a risk assessment to decide whether they need isolated power or ground-fault interrupters

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Categories of Electrical Distribution EC.02.05.01

• We have reviewed our Categories used for Electrical Distribution and match the following

• Category 1: Critical care rooms served by a Type 1 essential electrical system (EES) in which electrical system failure is likely to cause major injury or death to patients, including all rooms where electric life support equipment is required.
• Category 2: General care rooms served by a Type 1 or Type 2 EES in which electrical system failure is likely to cause minor injury to patients.
• Category 3: Basic care rooms in which electrical system failure is not likely to cause injury to patients. Patient care rooms are required to have a Type 3 EES where the life safety branch has an alternate source of power that will be effective for 1 1/2 hours.
  

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Hospital grade receptacles testing and protections EC.02.05.01

• We have reviewed our policy and practice related the receptacle testing in patient bed location and where deep sedation or general anesthesia is administered. It meets the testing requirement of

• after initial installation
• replacement
• servicing

• We have evaluated our electrical receptacles in pediatric locations (other than nurseries), bathrooms, play rooms, and activity rooms. They are:

• Listed tamper resistant or have a listed cover

• We have reviewed our electrical distribution to assure:

• Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking

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Power Strips EC.02.05.01

• We have reviewed our policy and practice on the use of power strips. It includes

• Used in a patient care vicinity only for components of movable electrical equipment and have been assembled by qualified personnel. Meets UL1363A or UL 60601-1
• Those used outside patient care vicinity but in patient care rooms, meet UL1363
• Those used in non-inpatient care rooms meet other UL standards

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Medical gases or vacuums used in general anesthesia (inhaled anesthetics) EC.02.05.01

• The valves, sensors, alarms and essential electrical systems have been evaluated for compliance for

• Zone valves immediately outside each anesthetizing location, readily accessible in an emergency, and arranged so one can be turned off and not affect others
• Alarm panels are installed to monitor all medical gases, medical surgical vacuum, and piped waste anesthetic gas disposal. Visual and audio sensors.
• Alarm sensors are installed on the source side of individual room zone valve box or on the pt use side of the individual zone valve box assembly.
• Essential electrical system critical branch supplies power for task illumination, fixed equipment, select receptacles and select circuits and the ventilation system

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Extension Cords EC.02.05.01

• We have evaluated our education on extension cords and have clearly established

• Extension cords cannot be substituted for fixed wiring in a building

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New Buildings with or requiring Life Safety Support (electromechanical or inhalation anesthetics) EC.02.05.03

• Will be designed and evaluated to assure

• they have illumination of means of egress, emergency lighting equipment, exit and directional signs supplied by the life safety branch of the electrical system

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Medication Dispensing Systems EC.02.05.03

• We have evaluated our emergency backup system for essential med dispensing

• and defined how emergency backup will happen and how dispensing will continue
• how refrigerated meds with have an emergency backup

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Flashlights or battery lamps EC.02.05.03 (if TJC is your deemed status)

• We have checked our areas not supplied by emergency power to check for

• Flashlight or battery lamp availability

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Line Isolation Monitors EC.02.05.05

• We have reviewed our testing policy to assure

• Line Isolation Monitors if installed are tested monthly
• Line Isolation Monitor Circuits with automated self-testing are tested at least annually
• All are tested after renovation or repair of the electric distribution system (documentation contains date, room, or area tested and results)

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Emergency lighting systems (egress), exits signs and task lighting EC.02.05.07

• Our monthly testing policy was reviewed to assure it includes

• Monthly functional testing of emergency lighting systems for egress, exit signs and task lighting for a minimum for 30 seconds
• Visual inspection of all other exit signs
• Annual functional testing for 1 ½ hours
• In deep or general anesthesia areas undergoing new construction, renovation or modernization the battery powered lighting is tested for 30 minutes

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Categories for medical air, surgical vacuum, waste anesthetic gas disposal and air supplies EC.02.05.09

• We have reviewed the current categories of systems in which failure is likely to cause major injury or death to assure they are categorized appropriately

• Category 1: likely to cause minor injury to patients
• Category 2: not likely to cause injury, but can cause discomfort
• Category 3: could cause major injury or death (general anesthesia not administered in a Category 3 medical gas system)

• Alarm systems comply with category 1-3 warning systems

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Oxygen Storage Labeling and Key Signs EC.02.05.09

• We have evaluated our Oxygen or Medical area locations to identify appropriate labeling and signage

• Only oxygen or medical air is labeled “Medical Gases: NO Smoking or Open Flame”
• Locations with other gases are labeled “Positive Pressure Gases: NO Smoking or Open Flames. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening”
• Cylinder Storage Room door or gate has a sign readable from 5 feet at a minimum includes the wording “CAUTION: OXIDIZING GAS(ES) STORED WITHIN. NO SMOKING”

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Gas cylinders EC.02.05.09

• We have reviewed our distribution policy to make sure it includes

• Cylinders are used in the order they are received from the supplier
• Only gas cylinders and reusable shipping containers and their accessories are stored in rooms containing central supply systems or gas cylinders

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Cylinders with integral pressure gauges EC.02.05.09

• We have reviewed our policy to assure that
• Threshold pressure considered empty has been established when the volume of stored gas is as follows:
• When more than 300 but less than 3,000 cubic feet, the storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited-combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2-hour fire protection rating.
• When less than 301 cubic feet in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in NFPA 99-2012: 11.6.2.

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Piped main medical gas valves and area shutoff valves EC.02.05.09

• We reviewed our labeling policy to include:

• Labeled by stencil or adhesive marker
• Name of the system and chemical symbol
• Color code
• Operating pressure if other than standard
• Intervals of 20 ft or less in every room on both sides of wall penetrations and on every story traversed by riser
• Piping not painted
• Shutoff valves identified with name or chemical symbol
• Shutoff valves labeled with room or area served and caution not to use except in emergency

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