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http://www.jcrinc.com August 2015 Volume 13 Issue 8 TheSource TM For Joint Commission Compliance Strategies For Subscription Information, Call 800-746-6578 Inside 2 5 Sure-Fire Methods: Feeding Individuals Receiving Behavioral Health Care 4 Tracer Methodology 101: Individual Tracer in an Eating Disorder Treatment Center 7 Certified Joint Commission Professional: Focus on the “Transplant Safety” Chapter 11 Perspectives on Patient Safety: CDC: Tuberculosis at an All-Time Low in the United States 12 Patient Safety Toolbox: Indwelling Catheter Performance Checklist Medication Management Countering Drug Diversion P rescription drug abuse is one of the fastest growing heath care problems in the United States. It has affected so many patients, families, health care workers, and hospitals across the nation that the US Centers for Disease Control and Prevention (CDC) has formally labeled the problem an “epidemic.” 1 According to the CDC’s latest data, drug overdose was the leading cause of injury death in 2013. There were 43,982 drug overdose deaths in the United States in 2013. More than half of those deaths (22,767) were related to prescription drugs, and 71% involved opioid painkillers. 2 ( See figure 1 on page 8.) A major driver of the prescription drug abuse crisis is drug diversion, which occurs when prescription medicines are obtained or used illegally. The problem of drug diversion is complex, often making it difficult to prevent. Patients can become addicted to medication, some people pose as patients to obtain prescriptions drugs, and in many cases, health Health care organizations nationwide are struggling to prevent medication diversion. (continued on page 8) 2 The Source The Joint Commission: The Source TM Executive Editor: Jim Parker Associate Director, Publications: Helen M. Fry, MA Senior Project Manager: Allison Reese Associate Director, Production: Johanna Harris Executive Director, Publications: Catherine Chopp Hinckley, PhD Contributing Writers: Julie Henry, RN; Laden Cockshut, PhD; Markisan Naso Subscription Information:

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© 2015 The Joint Commission. No part of this publication may be reproduced or transmitted in any form or by any means without written permission. B ehavioral health care organizations that provide nutrition services are responsible for ensuring that food is safely prepared and distributed and that they are adhering to individual nutritional requirements. Joint Commission Care, Treatment, and Services (CTS) Standard CTS.04.03.33 requires that organizations providing food services have a process for preparing and/or distributing food and nutrition products ( see “Related Requirements” on page 3 for the entire standard). In 2014 this was one of the most challenging standards for organizations accredited under The Joint Commission’s Behavioral Health Care Accreditation Program, with 17% of organizations surveyed found to be noncompliant. According to Merlin Wessels, LCSW, associate director, Standards Interpretation Group, The Joint Commission, one of the biggest reasons behavioral health care organizations are being cited for noncompliance with Standard CTS.04.03.33 is that they fail to watch for expiration dates and dispose of food when it is expired. “Food that is opened but not consumed within that sitting is often not marked with a new expiration date,” Wessels says. “After the food has been opened, the expiration date becomes significantly less. It could be a matter of just a few days, depending on what type of food it is.” Many organizations are also not adequately monitoring temperatures for foods S ure -F ire M ethodS Feeding Individuals Receiving Behavioral Health Care Organizations that provide nutritional services must ensure that food pr\ ovided to individuals served has not expired and is properly stored and prepared.

www.jcrinc.com August 2015 The Source 3 that need to be refrigerated or frozen, and some are not meeting special dietary needs or cultural preferences.Wessels provides the following five strategies to help organizations to better comply with Standard CTS.04.03.33:

1 Develop a defined process for monitoring expiration dates. “The process should include rotating food so the older food can be used before the expiration date is up,” says Wessels. “When food is opened, it needs to be marked with a new expiration date, and someone needs to consistently monitor all nutrition products to make sure they’re being used or disposed of before they expire.” 2 Invest in a minimum/maximum thermometer with an alarm for refrigerators and freezers. “In a 24/7 setting, staff will be able to hear the alarm and take immediate action,” Wessels says. “In settings in which staff leaves the building on weekends or holidays, when they return to work, someone needs to be in charge of checking to see that the temperature stayed within the minimum/maximum range.” 3 Educate staff. “One of the things staff needs to know is how to set the appropriate temperature ranges on the alarm,” says Wessels. “They should also have an understanding of proper sanitation and storage techniques. And if you’re in a setting in which clients are learning to cook, staff should be trained in and consistently adhere to safety rules.” Tracy Collander, LCSW, executive director of Behavioral Health Care Accreditation, The Joint Commission, explains, “Clients should be managed by staff to adhere to safety rules while cooking, and staff need to oversee clients’ adherence to public health regulations while learning to cook.” 4 Incorporate nutrition screening into the pre- admission assessment. “Ask about cultural or religious preferences and dietary restrictions before you admit someone,” Wessels says. “If you can’t meet their needs, let the person know up front so they can decide if they’re willing to accept what you are able to offer or if another place might be a better fit for t h e m .” 5 Make sure staff is adhering to public health regulations . “You need to make sure that your prep area is sanitary and that food is being stored properly in sealed containers,” says Wessels. “Review public health regulations, which are determined by local jurisdiction, to make sure you’re in compliance.” T S Standard CTS.04.03.33 For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products.

Elements of Performance for CTS.04.03.33 1. For organizations providing food services: Food and nutrition products are provided to the individual served as appropriate to the care, treatment, or services being provided.

2. For organizations providing food services: Food and nutrition products are prepared under proper conditions of sanitation, temperature, light, moisture, ventilation, and security.

3. For organizations providing food services: Food and nutrition products are stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security. 4. For organizations providing food services: Cultural, religious, and ethnic food preferences of the individual served are honored when possible, unless contraindicated.

5. For organizations providing food services: Staff assist the individual served who requires help eating.

6. For organizations providing food services: Special diets and altered diet schedules are accommodated.

7. For organizations providing food services: Meals and snacks are served at times that are normal and appropriate for the age of the individual served.

8. For organizations providing food services: The organization assigns responsibility for preparing, storing, distributing, and administering food and nutrition therapy products.

9. For organizations providing food services: The dining areas used by individuals served are adequately supervised.

Related Requirements www.jcrinc.comAugust 2015 4 The Source C linically significant eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorders, affect 20 million women and 10 million men in the United States.

1 Eating disorders should not be ignored or taken lightly—more people die of anorexia nervosa than any other psychiatric disorder. 1 Behavioral health care organizations frequently care for individuals who experience eating disorders even if the setting does not specifically serve this population. However, this individual tracer scenario takes place at a residential eating disorder treatment center in the rural Pacific Northwest that is accredited by The Joint Commission under its Behavioral Health Care Accreditation Program. Applicable Standards Every tracer scenario will evoke a set of applicable standards. For example, this particular individual tracer focuses on standards related to children and youth services, assessment and screening, treatment plans, and outcomes. However, during your own mock tracers and actual surveys, certain clinical situations will point to other appropriate standards that are not specifically discussed here. During tracers, surveyors will assess compliance with any behavioral health care standards that apply to the given situation.

Children and Youth When organizations treat individuals who are under the age of legal majority (18 years), they must comply with Care, Treatment, and Services (CTS) Standards CTS.02.03.01 and CTS.02.03.03 , which require clinicians to assess the specific needs of children and youth, understand the developmental stages, coordinate family involvement throughout the screening and assessment process, and explain how the family is expected to help the individual achieve his or her goals. Furthermore, the treatment team must communicate with the individual’s educators to ensure educational continuity ( see Standard CTS.04.02.15 ).

Finally, clinicians must prove they are competent to provide services for children and youth and to understand their developmental stages ( see Human Resources Management [HR M] Standard HR M.01.06.05 ). Screening and Assessment Screening and assessing an individual who is receiving behavioral health services sets the foundation for the treatment plan, says Merlin Wessels, LCSW, associate director, Standards Interpretation Group, The Joint Commission. For example, if the treatment team does not know that an individual has experienced trauma in the form of physical or sexual abuse or has made plans for suicide, then significant gaps will exist in the individual’s treatment plan.

Standard CTS.02.01.03 requires organizations to screen individuals for various issues based on the needs of t racer M ethodology Individual Tracer in an Eating Disorder Treatment Center The Joint Commission in July 2015 announced the development of new standards for eating disorder treatment centers.

www.jcrinc.com August 2015 The Source 5 the population served and the organization’s policies. In addition, other Joint Commission behavioral health care accreditation standards require screenings for the following issues: • CTS.02.01.01 : Risk of imminent harm to self or others • National Patient Safety Goal (NPSG) Requ i rement N PSG .15.01.01 : Risk for suicide • CTS.02.01.06 : Physical status • CTS.02.01.09 : Physical pain • CTS.02.01.11 : Nutritional status • CTS.02.01.13 : Educational status • CTS.02.01.15 : Legal issues • CTS.02.01.17 : Vocational status • CTS.02.02.05 : Trauma, abuse, neglect, exploitation Treatment Plans and Outcomes After completing a thorough assessment and screening, the team will create a plan for the care, treatment, or services that ref lects the individual’s assessed needs, strengths, preferences, and goals ( see Standard CTS.03.01.03 ).

“Including the individual in planning and knowing their personal goals and strengths is key to the plan of care, treatment, or services,” says Peggy Lavin, LCSW, ACSW, senior associate director, Behavioral Health Care Accreditation Program, The Joint Commission. “Plans of care, treatment, or services should sound like what the individual wants.” Likewise, Elements of Performance 3 and 4 of Standard CTS.02.01.03 require clinicians to assess the individual’s and family’s perceptions about their needs, preferences, and goals for care, treatment, and services. Upon initiating a plan of care, treatment, or services, the team also decides how to monitor the individual’s progress toward achieving the agreed-upon goals and how to assess the individual’s strengths and outcomes based on the care, treatment, or services provided ( see Standard CTS.03.01.09 ).

“The Joint Commission is more focused on outcomes and progress,” says Lavin. For example, if one of the individual’s goals is to eat balanced meals without purging, the treatment team may use the individual’s progress on this goal as a measure of her progress toward achieving the goal.

Tracer Scenario This individual tracer follows a 17-year-old female in a residential eating disorder center after an intensive outpatient program (IOP) recommended a 24-hour treatment experience because the individual admitted to a staff member and other individuals served that she wished she were dead. The individual presents with symptoms of binge eating, vomiting after eating, laxative abuse, and thoughts of suicide. Currently, she is completing her first month of treatment with individual, group, and family therapy, art and music therapy, activity therapy, and cooking and nutritiona l classes. Children and Youth The surveyor gathers as many people from the individual’s treatment team to interview the group. First, she asks the social worker how the treatment team works with the individual’s high school to ensure educational continuity while she cannot attend school. The social worker says that she has received assignments from the individual’s last school attended. The center’s daily schedule allots several hours to complete homework with a tutor coming weekly from the public school.

The surveyor asks how the organization maintains competency records for each clinician who serves children and youth populations. The survey coordinator says they verify education, training, and experience of all the clinical staff as well as provide staff training to work with y o u t h . [1] Screenings and Assessments The surveyor asks members of the treatment team to describe the way they screen and assess individuals and how they know which screenings or assessments to perform. Each team member describes the screening and assessments he or she conducts. For example, the nurse explains the physical health status screening he performs and how he schedules a physical examination with the physician. The clinical social worker explains that, with her screenings, the individual affirmed her suicidal ideation and disclosed being sexually abused as a young child. The surveyor asks what the team’s next steps are after any screening shows significant findings. The nurse states that after his nutrition screening all individuals are referred to the clinical dietitian to perform a full nutrition assessment. All screening and assessment findings are documented in the clinical record for the rest of the treatment team to see. [2, 3] Thereafter, the surveyor speaks to the clinical dietician regarding the nutrition assessment. The dietitian reports that he assesses the individual’s beliefs, attitudes, and behaviors about food ( see Standard CTS.02.03.09 ) and then develops a plan to help change the individual’s behaviors toward food and monitors for future episodes of binge eating and purging ( see Standard CTS.04.02.17 ). (continued on page 6) www.jcrinc.comAugust 2015 6 The Source Treatment Plans and Outcomes The surveyor asks the psychiatrist, who conducted a mental health status evaluation, how she contributes to the treatment plan. The psychiatrist says that she is prescribing the individual an anti-depressant and monitoring her to see if the individual’s suicidal thoughts decrease throughout their weekly therapy sessions. The surveyor asks the treatment team how they communicate with each other about the treatment plan or find out how the individual is progressing with her goals ( see Standard CTS.04.01.01 ). The psychiatrist states that they have daily and weekly communication and use the clinical record to communicate with the team whenever the individual experiences a change, such as a response to a new intervention, the development of a new strength, or a set- back in progress toward goals. [4, 5] After talking with the individual’s treatment team, the surveyor introduces herself to the individual and her mother.

She asks the individual to describe her strengths and goals.

[6] The individual says that she competes on her high school Mock Tracer Tracking Worksheet: Individual Tracer in an Eating Disorder Treatment Center Use this worksheet to record notes and areas of concern that you identif\ y while conducting your organization’s mock tracers. This information can be used to highlight a good practice or to determine issues, which m\ ay require further follow-up.

Tracer Team Member: ___________________________ Tracer Patient or Medical Record: ____________________________ Staff Interviewed: _____________________________________________________________________________________\ ___ Unit or Department Where Tracer Was Conducted: _________________________\ ____________________________________ TRACER QUESTIONS Correct AnswerIncorrect Answer Follow-Up Needed Required Written Documentation Comments Or Notes Required Present 1. Can clinicians produce the competencies or credentials that prepare them to successfully care for the population served?

2. Are the screening and assessment findings documented within the clinical record?

3. Can the results of a screening trigger an additional assessment that is more comprehensive? How would a member of the treatment team communicate the need for this comprehensive assessment to the appropriate team member?

4. How does the treatment team communicate with each other regarding the treatment plan as well as updates to the treatment plan?

5. Does the treatment plan reflect the individual’s needs, strengths, preferences, and goals? Who contributes to the treatment plan?

6. How does the treatment team monitor the individual’s progress toward goals? What measure of a successful clinical outcome has been identified for individuals?

7. What strengths and outcomes does the treatment team expect to see for each individual? What happens if an individual is not meeting expected outcomes?

8. Are clinical records complete, accurate, and authenticated? Do they reflect the care, treatment, and services provided to the individual?

Tracer Methodology 101 (continued from page 5) (continued on page 15) www.jcrinc.com August 2015 The Source 7 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 October with additional dates in 2016. 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 12 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 w w w.jcrinc.com /cjcp-certif ication/ . You may also e-mail questions directly to [email protected]. About the “Transplant Safety” Chapter Transplantation of organs and tissues is sometimes the only option for treatment of a wide range of diseases. In the past decade, advances in transplantation have led to a greater success rate for transplanted organs and tissues. More and more people receive transplants every year, and more people are living longer after transplants. Transplantation is not free from risk. Transmission of infections from the donor to the recipient is a significant safety concern. With the increased numbers of organ and tissue transplants, the number of opportunities for transmission of infectious pathogens has also increased. The standards in this chapter focus on the development and implementation of policies and procedures for safe organ and tissue donation, procurement, and transplantation. Practice Questions 1 W hen is it unnecessary for a hospital to have a written agreement with a tissue bank or eye bank?

a. When the hospital does less than 12 tissue or eye transplants annually b. When the hospital has a written agreement with an organ procurement organization that also provides tissue and/or eye procurement services c. When the hospital uses Joint Commission accreditation for deemed status purposes 2 W hen requested, the hospital provides all data related to organ transplant to which of the following?

a. The Joint Commission Office of Quality and Patient Safety, the hospital’s designated organ procurement organization, the US Centers for Medicare & Medicaid Services b. The Organ Procurement and Transplantation Network, the hospital’s designated organ procurement organization, the US Centers for Medicare & Medicaid Services, the Scientific Registry c. The Organ Procurement and Transplantation Network, the hospital’s designated organ procurement organization, the Scientific Registry, US Department of Health and Human Services 3 The hospital retains tissue records for what length of time beyond the date of distribution, transplantation, disposition, or expiration of tissue (whichever is latest)?

a. 1 year b. 5 years c. 10 years (See Answer Key on page 12.) Focus on the “Transplant Safety” Chapter CJCP Certified Joint Commission Professional ® ™ www.jcrinc.comAugust 2015 8 The Source Medication Management (continued from page 1) care providers mastermind drug diversion schemes by writing unlawful prescriptions, falsifying documents, and mislabeling inventory. These providers can become addicted to the drugs they steal, or they end up selling them on the streets, or both.

Harmful Effects of Diversion Jeannell Mansur, PharmD, practice leader, medication safety, Joint Commission Resources, says that there are not a lot of eyes on the medication distribution process, so abuse doesn’t always become recognizable until a health care worker becomes addicted to drugs or to stealing them for illicit purposes. “By the time someone recognizes the signs, diversion has probably gone on a while and the person has just gotten more desperate and sloppy,” she says. When a health care provider reaches the desperation stage, it’s likely they have already done significant harm to patients. Substandard care, denial of essential pain medication for patients, and the risk of infection from injectable drugs that have been tampered with, are all possible effects of diversion. Substandard care can include not giving prescribed drugs to patients or giving them diluted versions of prescribed drugs. Both actions can result in unnecessary pain or anxiety for the patient. Contaminated substances that are used in place of a prescribed drug, such as unsterilized tap water or a different drug, can also increase patients’ risk for bloodborne infections, allergic reactions, and sepsis.

In addition to the effects of drug tampering, patients can be at risk when they are cared for by an impaired health care worker. Impairment could mean a health care worker who is addicted to drugs, or simply in a state of constant distraction. In other words, that provider will be more focused on getting his or her next hit or obtaining drugs to sell, than on patients’ needs. Whether it’s addiction to a substance or to the continual crime, a health care worker who diverts drugs is much more likely to make bad decisions or medication errors, which will almost certainly lead to patient injury. Diverting drugs can also harm the addicted health care worker both physically and emotionally. Along with the potential physical consequences of taking drugs improperly, the stress of obtaining drugs illegally, avoiding detection, and the huge risk to a health care worker’s professional career can cause emotional distress as well.

Figure 1. Drug Diversion www.jcrinc.com August 2015 The Source 9 Preventing Diversion Mansur says that many opportunities exist for health care workers to take and use medication for illicit purposes. Drug diversion can often be difficult to detect because the abusers know the systems they work in and are actively trying to cover their tracks. Many hospitals do have controlled processes, so it’s unlikely you’ll find easy evidence of diversion, such as medication counts being off. Abusers will instead try other methods of diversion that are harder to discover, “Such as saving a portion of a dose that you might have squirted down the drain of a sink for yourself,” Mansur says. “Or, taking a dose that is intended for a patient and giving them a normal saline.”Avoiding detection is also made easier because many health care workers are not even aware that drug diversion occurs in their workplace. To prevent diversion, health care organizations should educate staff about what the problem is, how to identify signs of possible diversion and addiction, how to keep medication secure, and how to properly respond if they witness diversion. Creating a comprehensive prevention program that provides clear procedures for tackling these diversion issues is a good way to start. “Policies should be developed that address all aspects of controlled substance process—from purchasing, distribution, removal, and administration, to wasting, policies on monitoring for diversion, reconciliation of discrepancies, to process for investigating suspected diversion to process for confirmed diversion to process for disclosing to patients and families if they have been affected by a diversion,” Mansur says. A solid backbone for diversion policies can be found in The Joint Commission’s Comprehensive Accreditation Manual for Hospitals, which includes standards that specifically reference ways of storing medication and controlled substances to minimize diversion. Medication Management (MM) Standard MM.03.01.01, for example, addresses how a hospital should safely stores medications. “This standard specifies that processes must be in place that minimize potential for diversion; making sure those who shouldn’t have access to medications don’t have access,” Mansur says.

( See “Related Requirements,” below for a list of applicable st a nd a rd s.) Medications must always be kept in secure areas, and controlled substances need to be locked up if they are not in the hands of a health care practitioner who is giving it to a patient. A good system should be in place for storing controlled substances when they aren’t being used. “This is a big issue in the operating room,” Mansur says. “At the end of a case the anesthesiologist needs to be very careful that they take any unused substances and secure them in storage, or waste those that have already been open so they are not accessible to unauthorized individuals. You want to make sure that you don’t have controlled substances o u t .” Mansur says that Joint Commission standards also direct organizations to set up a program that minimizes diversion. When Joint Commission surveyors visit accredited hospitals, they ask health care organizations how they monitor for diversion and what issues they might have. The surveyors will also look at how medication is dispensed and stored at a hospital (Standards MM.03.01.01 and MM.05.01.11 ) and search for evidence of discrepancies.

If discrepancies are found, they will ask about the correct procedure that should occur when that discrepancy is identified. It is important for hospitals to have proper procedures in place for handling those discrepancies. “Our standards always allow hospitals to define their own ways of doing things,” Mansur says. “But in the end it is about steps to mitigate diversion and steps to keep controlled substances locked.” Staff Education Is Critical To comply with Joint Commission standards, ongoing education should be a big part of the prevention program Ensuring compliance with the following Joint Commission standards can help organizations counter drug diversion:

• Standard MM.01.01.03: The hospital safely manages high-alert and hazardous medications.

• Standard MM.03.01.01: The hospital safely stores medications.

• Standard MM.05.01.11: The hospital safely dispenses medications. • Standard MM.05.01.13: The hospital safely obtains medications when the pharmacy is closed.

• Leadership (LD) Standard LD.03.01.01: Leaders create and maintain a culture of safety and quality throughout the hospital.

• Standard LD.04.04.05: The hospital has an organizationwide, integrated patient safety program within its performance improvement activities.

Related Requirements (continued on page 10) www.jcrinc.comAugust 2015 10 The Source effort. After staff understand the problem, how serious it is, and the importance of keeping medications out of the wrong hands, they must be instructed on how to identify signs of possible diversion and addiction. Warning signs typically include a change in an employee’s behavior. In order to prevent harm to patients, it’s vital that all health care workers be vigilant for signs of possible diversion. They also need to know how to engage the appropriate authorities.Mansur says that staff who work with someone abusing drugs are much more likely to notice that person acting oddly, than a manager is. It’s the staff who will witness the disposal of unused drugs, for example. So, it’s often up to staff to report any strange activity, even if it turns out to be something other than diversion. “Odd behavior doesn’t necessarily mean they are diverting, but it’s an opportunity to assess someone,” Mansur says. “Reporting is important, so that investigation can occur. Information should be treated confidentially, and appropriate authorities should be involved, such as professional licensing boards, DEA [US Drug Enforcement Agency], and law enforcement in the event that diversion is found.” It’s also a good idea to let staff know just how vulnerable they are to diversion and to give them information about the consequences that drug diversion can have on their lives and careers. They should be aware that the procedures for mitigating diversion are in place for good reason—to prevent patient harm, illnesses, and death. “It’s the elephant in the room, but it is one that needs to be addressed,” says Mansur. “I worked with a chairman of anesthesia who recognized that in the operating room world there was a steady f low of controlled substances and a lot of potential for abuse. Every year he would talk to his residents about this and how vulnerable they were, how they should be watching for signs, how important it is to be meticulous with accounting, and perform a proper witnessing of people who ask you to witness their dose wastage. Those are all aspects of education that proved beneficial.” Diversion is a serious, ongoing problem for the health care industry. Unfortunately, it’s a difficult battle because many offenders know how to manipulate the drug control systems and breach procedures to get what they want. “If you have access to controlled substances and you have a reason to be around them—taking care of patients who needs them, preparing controlled substance doses for patients, or administering them in an operating room—it is not difficult to divert,” Mansur says. “But, that sets up a whole chain of events. Abuse leads to addiction, and then you go down that very slippery path.” Health care organizations need to make sure staff are educated on diversion and help raise awareness. Health care providers must be vigilant and report problems to make a difference in the lives of patients and their coworkers. “I think we have to emphasize that the sooner [diversion] is addressed, the sooner those addicted can get help. And certainly there is patient safety to be concerned about. That should always be our first responsibility.” T S References 1. Centers for Disease Control and Prevention. Injury Prevention & Control: Prescription Drug Overdose: Understanding the Epidemic.

(Updated: Apr 30, 2015.) Accessed July 13, 2015. http://www.cdc.gov /drugoverdose/epidemic/index.html.

2. Centers for Disease Control and Prevention. Injury Prevention & Control: Prescription Drug Overdose: Prescription Drug Overdose Data. (Updated: Apr 30, 2015.) Accessed July 13, 2015. http://www .cdc.gov/drugoverdose/data/overdose.html. Medication Management (continued from page 9) It’s also a good idea to let staff know just how vulnerable they are to diversion and to give them information about the consequences that drug diversion can have on their lives and careers. “ ” 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 potent\ ial publication in The Source TM or an idea for a case study, please send us an e-mail at [email protected].

www.jcrinc.com August 2015 The Source 11 J oint Commission Launches New Certification Programs Effective July 1 The Joint Commission is accepting applications for two new certification programs. The Acute Stroke Ready Hospital Certification was developed in collaboration with the American Heart Association/American Stroke Association.

Acute Stroke Ready Hospital certification fulfills a community need within a stroke system of care. The second new program is Perinatal Care Certification, which is focused on achieving integrated, coordinated, patient-centered care for clinically uncomplicated pregnancies and births. S uicide-Risk Algorithm Could Help Prevent Patient Deaths A collaborative study conducted by the US Department of Veterans Affairs (VA) and the National Institute of Mental Health has resulted in an algorithm designed to identify patients who are most at risk for suicide. The study indicated that the algorithm proved more effective than other suicide screening methods used by the VA. The findings appear in the American Journal of Public Health, available online at http://ajph.aphapublications .org/doi/abs/10.2105/AJPH.2015.302737. ISMP: Children Need Greater Protection from Medication Errors A recent survey conducted by the Institute for Safe Medication Practices (ISMP) shows that many pediatric hospitals or general hospitals that treat pediatric patients are not complying with recognized practices to reduce medication errors. These include safety measures related to medication storage, orders, and pharmacist verification, and adoption of technology such as dose range checking software within computerized provider order entry systems. The complete findings appear in the June 4, 2015, issue of Medication Safety Alert!, http://www.ismp.org/newsletters /acutecare/showarticle.aspx?id=110.

N ational Patient Safety Foundation Issues Guidelines on Root Cause Analysis The National Patient Safety Foundation (NPSF), recently released guidelines developed to help health care organizations improve the way they investigate medical errors, adverse events, and near misses.

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm explains identified best practices for root cause analysis in health care.

A number of organizations, including The Joint Commission, contributed to the development of the guidelines. The guidelines are available at www.npsf.org/rca2. J ournal Article Examines Never Events The June 2015 issue of The Joint Commission Journal on Quality and Patient Safety features an article, “Never Events and the Quest to Reduce Preventable Harm.” Never events are events that should never occur in health care, including wrong-site surgeries, patient suicides, and other incidents. The article highlights how findings from adverse events, serious reportable events, sentinel events, and patient safety events can help play a role in reducing patient harm. Visit http://www.jcrinc .com/the-joint-commission-journal-on-quality-and -patient-safety/ for more information. T he US Centers for Disease Control and Prevention (CDC) recently reported that the incidence of tuberculosis (TB) has reached a historic low in the United States, with only 9,412 cases reported during 2014. Between 2013 and 2014 the rate of TB infection fell from 3.02 cases per 100,000 population to 295, a decline of 2.3%. Four states (California, Texas, New York, and Florida) account for more than half of all TB cases (51% or 4,795 cases).

The CDC estimates that infection prevention and control efforts throughout the United States helped prevent more than 200,000 TB infections since 1993.

However, some populations remain at risk. Although TB rates declined among most racial/ethnic groups, TB rates among racial/ethnic minorities were much higher than those of non-Hispanic Caucasians. Rates for people of Asian descent were 29 times higher than those of Caucasians, 17.9/100,000 compared to 0.6/100,000. Among African-Americans the rate of TB infection was 5.1/100,000, and Hispanics contract TB at a rate of 5.0/100,000. Asians experienced more TB cases than any other racial or ethnic group. Also at higher risk are individuals who were born outside the United States.

Despite declines in the rates of TB among both foreign-born and US-born individuals, the TB rate among foreign-born individuals (15.3/100,000) was 13 times higher than among US-born individuals. Among individuals with TB and a known place of birth, approximately 96% of Asians, 76% of Hispanics, 42% of blacks, and 23% of whites were foreign born. More than half (55%) of foreign- born TB patients originated from five countries: Mexico, the Philippines, India, Vietnam, and China. Other groups who are particularly vulnerable to TB include those who live with HIV and the homeless. Patients living with HIV tend to experience rapid progression of the disease and are more likely to die during treatment. Among the homeless, poor health care and crowded living situations (such as in shelters) increase the risk of transmission. T S Perspectives on Patient Safety CDC: Tuberculosis at an All-Time Low in the United States t op 5 in the News Figure. Tuberculosis (TB) in the United States Source: US Centers for Disease Control and Prevention.

www.jcrinc.comAugust 2015 12 The Source Answer Key 1 The correct answer is b. Transplant Safety (TS) Standard TS .01.01.01 requires hospitals, with the medical staff ’s participation, to develop and implement written policies and procedures for donating and procuring organs and tissues. Element of Performance (EP) 1 of that standard requires the hospital to have a written agreement with an organ procurement organization and follow its rules and regulations. EP 3 requires the hospital to also have a written agreement with at least one tissue bank and at least one eye bank to cooperate in retrieving, processing, preserving, storing, and distributing tissues and eyes. The second note to EP 3 indicates that when the hospital has a written agreement with an organ procurement organization that also provides tissue and/or eye procurement services it is not necessary for it to have separate agreements with a tissue bank or an eye bank. 2 The correct answer is c. Standard TS.02.01.01 , EP 2, requires the hospital to provide all data related to organ transplant to the Organ Procurement and Transplantation Network (established under section 372 of the Public Health Service Act), the Scientific Registry, or the hospital’s organ procurement organization, and, when requested by the office of the secretary, directly to the US Department of Health and Human Services. The standard does not require the hospital to provide all data to The Joint Commission or to the Centers for Medicare & Medicaid Services. 3 The correct answer is c. Standard TS.03.02.01 , EP 6, requires the hospital to retain tissue records for a minimum of 10 years beyond the date of distribution, transplantation, disposition, or expiration of tissue (whichever is latest). These records must include the following:

• The tissue supplier (for medical devices, this is the manufacturer) • The original numeric or alphanumeric donor and lot identif ication • The name(s) of the recipient(s) or the final disposition or each tissue • The expiration dates of all tissues TS CJCP (continued from page 7) U rinary tract infections (UTI) are the most common type of healthcare-associated infection reported to the US Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter. 1 Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. 1 Prolonged use of a urinary catheter is the most significant risk factor for these types of infections. Consequently, organizations should only use catheters when necessary and should remove them as soon as possible. The Joint Commission’s National Patient Safety Goal (NPSG) Requirement NPSG.07.06.01 requires accredited hospitals and critical access hospitals to implement evidence-based practices to prevent indwelling catheter- associated urinary tract infections (CAUTI). (Note that this requirement is not applicable to pediatric populations.) The checklist beginning on page 13 (published with permission of the Kentucky Department of Public Health) can help organizations ensure they are using catheters safety and effectively. Separate versions of the tool exist for female and male patients. The checklist for female patients appears in the electronic version of this newsletter. T S Reference 1. US Centers for Disease Control and Prevention. Catheter-associated urinary tract infections. Accessed Jul 17, 2015. http://www.cdc.gov /HAI/ca_uti/uti.html. Patient Safety Toolbox:

Indwelling Catheter Checklist www.jcrinc.com August 2015 The Source 13 Kentucky Department for Public Health – Healthcare Associated Infection Prevention Program INDWELLING URINARY CATHETERIZATION PERFORMANCE CHECKLIST FOR MALES NAME: __________________________________ POSITION: ____________________________ UNIT: _________________________________ __ The above named health care provider :

As of ______________, validated by: _____ __________________ _______________________ (D ate) ( Signature of evaluator) ________________________________________________________________________ ___. (Printed name) CRITICAL BEHAVIORS MET NOT MET COMMENTS 1. Assemble needed equipment for peri -bath and indwelling catheterization. Use the smallest catheter as possible . 2. Explain the purpose and necessity of the procedure to the resident. Introduce self. Maintain resident privacy. Keep resident warm. 3. Perform hand hygiene , don gloves. Perform peri -bath and d iscard disposable equipment. Cleanse peri area with soap and water . Wipe basin with disinfectant wipe after use. 4. Hand Hygiene. Follow Standard Precautions. 5. Position resident. 6. Open catheterization tray (maintain content sterility ). Use wrapper to m ake sterile field. Open edges away. 7. Place plastic -lined sheet under buttocks . Fold corners of sheet over hands to do this. 8. Don sterile gloves. 9. Place fenestrated drape over perineum. Do not contaminate gloves. 10. Arrange tray contents for use: a.Pour iodine solution over cotton balls b. Lift top tray and place onto sterile field c. Dispense lubricant onto tray d. Remove plastic shield from indwelling catheter and lubricate end of catheter No balloon check necessary before insertion. 11. Cleanse urethral meatus: a.Less-dominant hand: grasp penis at shaft , retracting foreskin if present .

b. Dominant hand: grasp iodine -saturated cotton ball with forceps. Cleanse in a circular motion start ing at the opening to the meatus to base of glans. Use as many cotton balls as necessary to cleanse penis down to base of the glans. K eep less -dominant hand in place for entire pro cedure. Checklist continued on the next page… Indw elling Urinary Catheterization- Male 1 | Page (continued on page 14) www.jcrinc.comAugust 2015 14 The Source Kentucky Department for Public Health – Healthcare Associated Infection Prevention Program CRITICAL BEHAVIORS MET NOT MET COMMENTS 12.Lift penis to position perpendicular to the resident’s body and apply light traction. Changes in angle or traction may help . Have resident take slow, deep breaths to focus the mind and relax the musculature. 13. Pick up catheter with dominant hand approximately 2 -3 inches from catheter tip. Place distal end in sterile tray. Do not force catheter. If resistance is met, stop, remove indwelling catheter and notify phy sician. 14. Gently insert the catheter into the meatus and advance to “Y” in catheter. Insert to “Y” to make sure that the balloon is past the prostate before inflating. 15. Inflate balloon with 10ml sterile water in balloon port. 16. Gently pull back catheter to position balloon at neck of bladder. Stop once any resistance is felt. 17. Place indwelling catheter bag below the level of the bladder. Do not curl tubing. Keep straight at all times. 18. Secure catheter with securement device. If necessary, clip skin hair for adhesion . Allow sufficient time for alcohol prep and skin protectant to dry. Secure c atheter with securement devic e, but not too tight. 19. Document date on securement device. Must be replaced every 7 days. 20. Discard dispo sable equi pment in Infectious Waste Trash. 21. Document intervention. Document size, resident toler ance, and description of urine. Document indwelling urinary catheter necessity on review form . ACTION PLAN _________________________________________________________________________ _____ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Date Action plan to be completed by: ____________________ Date Revalidation to be completed by: ___________________ Employee Signatur e: ____________________________________________________________ Supervisor/Designee Signature: _____________________________ Tit le: _________________ Reprints of this document are provided for informational purposes only. The Kentucky Department for Public Health is not responsible for the content of any reprinted materials and encourages all users to consult with their legal counsel regarding the adequacy for sample policies, procedures, and forms. For questions about the development of this form, please consult the Kentucky Department for Public Health, Healthcare -Associated Infection Prevention Program at http://chfs.ky.gov/dph/epi/hai/default.htm . Indwelling Urinary Catheterization- Male 2 | Page (continued on page 17 in the electronic version of this newsletter) www.jcrinc.com August 2015 The Source 15 The Source TM Editorial Advisory Board Steve Anderson, RN, MBA, CJCP Senior Director, Clinical Improvement and Patient Safety VHA Pacific Northwest 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 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 Tracer Methodology (continued from page 6) swimming team and gets good grades in her classes. She says that one of her goals in this program is to learn how to cook healthy meals. Even though the individual is taking cooking and nutrition classes, the surveyor cannot find the individual’s personal goal of learning to cook documented in the clinical record.

Moving Forward The surveyor meets with the treatment team again and reminds them to ensure that the individual’s goals are ref lected within the clinical record ( see Record of Care, Treatment, and Services [RC] Standard RC.02.01.01 ). “Surveyors should be able to look at the clinical record and verify the individual’s treatment plan,” says Wessels. [7, 8] Finally, the surveyor asks to review the job descriptions and competency files for the clinical social worker, nurse, psychiatrist, and clinical dietitian ( see Standards H R M .01.01.01 and HR M.01.06.01 ).

Sample Questions The following represent some questions that could be asked during an individual tracer. Use them as a starting point to plan your own tracers.

1. Can clinicians produce the competencies or credentials that prepare them to successfully care for the population served?

2. Are the screening and assessment findings documented within the clinical record?

4. How does the treatment team communicate with each other regarding the treatment plan as well as updates to the treatment plan?

5. Does the treatment plan ref lect the individual’s needs, strengths, preferences, and goals? Who contributes to the treatment plan?

6. How does the treatment team monitor the individual’s progress toward goals? What measure of a successful clinical outcome has been identified for individuals?

7. What strengths and outcomes does the treatment team expect to see for each individual? What happens if an individual is not meeting expected outcomes?

8. Are clinical records complete, accurate, and authenticated? Do they ref lect the care, treatment, and services provided to the individual? TS Reference 1. National Eating Disorders Association (NEDA): Get the Facts on Eating \ Disorders. Accessed Jul 15, 2015 http://www.nationaleatingdisorders.org/get-facts-eating-dis\ orders.

August 2015 Volume 13, Issue 8, August 2015 Send address corrections to:

The Joint Commission: The Source™ [email protected] or 877-223-6866 An affiliate of The Joint Commission 1515 W. 22nd Street, Suite 1300W Oak Brook, Illinois 60523 TS08 Home Care Executive Briefing September 2 Oak Brook, IL Hospital Executive Briefings September 10 Los Angeles, CA September 24 Rosemont, IL October 5 New York, NY Hospital CMS Basics September 11 Los Angeles, CA September 25 Rosemont, IL October 6 New York, NY CJCP Essentials Prep September 23 Rosemont, IL October 7 New York, NY 2015 Behavioral Health Care Conference October 15-16 Rosemont, IL Ambulator y Care Pre-Conference: Primar y Care Medical Home November 3 Rosemont, IL Ambulator y Care Conference November 4-5 Rosemont, IL Environment of Care Base Camp N o v e m b e r 1 0 -11 Lake Buena Vista, FL Exploring the Life Safety Chapter N ove m b e r 12-13 Lake Buena Vista, FL Joint Commission Resources FALL 2015 CONFERENCES & SEMINARS For more details and to register, please visit jcrinc.com or call JCR Customer Service at 877.223.6866.

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www.jcrinc.com The Source 17 Kentucky Department for Public Health – Healthcare Associated Infection Prevention Program INDWELLING URINARY CATHETERIZATION PERFORMANCE CHECKLIST FOR FEMALES NAME: __________________________________ POSITION: ____________________________ UNIT: _________________________________ __ The above named health care provider :

□ HAS MET all performance criteria (critical behaviors) identified below ; □ HAS NOT MET the performance criteria (critical behaviors) iden tified below with a checkmark () in “ NOT MET ” box. Refer to action plan. As of ______________, validated by: _____ __________________ _______________________ ( D ate) (Signature of evaluator) ________________________________________________________________________ ___. (Printed name) CRITICAL BEHAVIORS MET NOT MET COMMENTS 1. Assemble needed equipment for peri -bath and indwelling catheterization. Use the smallest catheter as possible . 2. Explain the purpose and necessity of the procedure to the resident. Introduce self . Maintain resident privacy. Keep resident warm. 3. Perform h and hygiene , don gloves. Perform peri -bath and d iscard disposable equipment. Cleanse peri area with soap and water. Wipe basin with disinfectant wipe after use. 4. Hand H ygiene . Follow Standard Precautions. 5. Position resident. 6. Open catheterization tray (maintain content sterility) . Use wrapper to m ake sterile field. Open edges away . 7. Place plastic -lined sheet under buttocks Fold corners of sheet over hands to do this . 8. Don sterile gloves. 9. Place fenestrated drape over perineum. Do not contaminate gloves. 10. Arrange tray contents for use: a. Pour iodine solution over cotton balls b. Lift top tray and place onto sterile field c. Dispense lubricant onto tray d. Remove plastic shield from indwelling catheter and lubricate end of catheter No balloon check necessary before insertion. 11. Cleanse urethral meatus: a.Less -dominant hand: separate labia and apply gentle traction upward. b. Dominant hand: grasp iodine saturated cotton ball with forceps . Wipe top to bottom of center, then out using a new cotton ball with each wipe. Must keep less -dominant hand in place for entire procedure and keep labia separated at all times. Checklist continued on the next page… Indwelling Urinary Catheterization- Female 1 | Page www.jcrinc.comAugust 2015 18 The Source Kentucky Department for Public Health – Healthcare Associated Infection Prevention Program CRITICAL BEHAVIORS MET NOT MET COMMENTS 12. Continue us ing less dominant hand to separate labia. Have resident take slow, deep breaths to focus the mind and relax musculature. 13. Pick up catheter with dominant hand approximately 2 -3 inches from catheter tip. Place distal end in sterile tray. 14. Gently insert the catheter into the meatus and advance until you see urine flow, and then advance another ½ - 1 inch. If the catheter is inserted into the vagina leave catheter in vagina and repeat steps 3 -12. Remove catheter from vagina after proper placement of urethral catheter. 15. Release labia and hold catheter in place while dominant hand inflates balloon with 10ml sterile water into balloon port. 16. Gently pull back catheter to position balloon at neck of bladde r. Stop once any resistance is felt. 17. Place indwelling catheter bag below the level of the bladder. Do not curl tubing. Keep straight at all times. 18.Secure catheter with securement device. If necessary, clip skin hair for adhesion . Allow sufficient time for alcohol prep and skin protectant to dry. Secure catheter with securement devic e, but not too tight. 19. Document date on securement device. Must be replaced every 7 days. 20. Discard disposable equipment in Infectious Waste Trash. 21.Document intervention. Document size, resident toler ance, and description of urine. Document indwelling urinary catheter necessity on review form . ACTION PLAN _________________________________________________________________________ _____ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Date Action plan to be completed by: ____________________ Date Revalidation to be completed by: ___________________ Employee Signatur e: ____________________________________________________________ Supervisor/Designee Signature: _____________________________ Tit le: _____________ ____ Reprints of this document are provided for informational purposes only. The Kentucky Department for Public Health is not responsible for the content of any reprinted materials and encourages all users to consult with their legal counsel regarding the adequacy for sample policies, procedures, and forms. For questions about the development of this form, please consult the Kentucky Department for Public Health, Healthcare -Associated Infection Prevention Program at http://chfs.ky.gov/dph/epi/hai/default.htm . Indwelling Urinary Catheterization-Female 2 | Page www.jcrinc.com August 2015