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http://www.jcrinc.com July 2017 Volume 15 Issue 7 TheSource TM For Joint Commission Compliance Strategies For Subscription Information, Call 877-223-6866 Inside 2 5 Sure-Fire Methods: Ensuring That Resuscitation Services Are Available Throughout the Hospital 4 Tracer Methodology 101: Medication Management System Tracer in a Hospital- Based Anticoagulation Clinic 9 Medication Management Compliance Data for Hospitals, Full Year 2016 10 Benchmark: Unde rstanding 2017 Performance Measure Reporting Requirements Spotlight on Success Mercy Virtual Innovates Telehealth M ercy Virtual is a health care organization that provides telehealth services to patients in health care facilities. In October 2015 Mercy opened its Virtual Care Center, the first and only facility of its kind. The four-story, 125,000-square- foot building is the cornerstone of Mercy’s virtual care program and serves as a center for developing and delivering telehealth. Mercy designed the Virtual Care Center to provide patient-centered care, advance technological innovations, and identify opportunities to make care more accessible, more affordable, and more comprehensive. Mercy collaborates with bedside clinicians, primary providers, and specialists to maximize patient data in real time to support timely diagnoses and interventions. Mercy’s work demonstrates the ways that health care organizations can leverage technology to support patient care, treatment, and services. (continued on page 13) The Mercy Virtual Care Center. Photo courtesy of Mercy Virtual NEW WAY to access your online subscription!

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[email protected] R esuscitation services are a fundamental component of health care. Ensuring that hospital staff have ready access to these services throughout the facility can make the difference between a patient’s life and death. The Joint Commission’s Provision of Care, Treatment, and Services (PC) Standard PC.02.01.11 requires that resuscitation services are available throughout the hospital. Specifically, this standard’s elements of performance indicate criteria for making resuscitation services available. ( See “Related Requirements” on page 3.) Standard PC.02.01.11 was among the top 20 most cited for hospitals during 2016, with 33% of surveyed hospitals noncompliant. One factor contributing to the high rate of noncompliance with this standard is the infrequent need for such services in some units of the hospital. Eric R. Brown, MD, PhD, FACOG, FACS, CHCQM, CJCP, physician consultant at Joint Commission Resources, says, “In some areas of a hospital, the use of resuscitation services may be a rare event, and this can unintentionally foster a degree of complacency. In the midst of their competing responsibilities, staff may overlook processes to check that their equipment and supplies are up to date and functioning.” This deficiency can be mitigated not only with improved staff education, Brown says, but also S ure -F ire M ethodS Ensuring That Resuscitation Services Are Available Throughout the Hospital In addition to providing resuscitation services and ensuring the necessary equipment is available, staff must also receive training on how and when to provide resuscitation services. We’ve got a new address! Joint Commission Resources (JCR) is excited to announce that we have streamlined access to The Source on the JCR website at www.jcrinc.com.

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www.jcrinc.com July 2017 The Source 3 by considering effective ways to monitor services across the hospita l.Managing resuscitation services requires a range of elements to work effectively—which can include carts, equipment, and other necessary supplies or medications, as well as a hospitalwide process for managing these resources.

“Carts will have medications, supplies, and equipment that need to be checked regularly for their function and whether they are within their expiration dates,” explains Stephen F. Knoll, CRNA, MA, associate director in the Standards Interpretation Group at The Joint Commission. “The Joint Commission does not prescribe what needs to be on these carts nor does it mandate any particular frequency for checking carts, but it will expect that hospitals will follow their own documented policies and procedures and have included items on the cart that fit within the relevant and appropriate professional association’s guidelines and according to manufacturer’s guidelines.” When determining when and how to monitor any relevant supplies or equipment, Knoll recommends using a considered approach: “Determining what to use should be based on a risk assessment, including the manufacturers’ recommendations for checking equipment such as def ibrillators,” he stresses. Brown and Knoll recommend the following strategies for improving compliance with Standard PC.02.01.11:

1 Go back to basics. When you are uncertain about the effectiveness of resuscitation services in your facility, both Brown and Knoll recommend that you go back to the basics to assess compliance. For example, do a walk-through of the facility; check how well staff are adhering to policies, protocols, or procedures; and assess how well staff understand these processes and requirements. “Hospitals can and should have a system in place that enables them to check and verify that they are ensuring that resuscitation services are available in the hospital,” emphasizes Knoll. “The Joint Commission is not prescriptive about what system or process is followed, as long as there is a set policy or procedure in place, which the hospital follows.” When gaps in compliance are identified, hospitals should review and modify their approach to ensure improved compliance. 2 Consider a range of approaches. The goal is to optimize and simplify your methods to ensure that resuscitation services are available and used appropriately. Organizations can consider evaluating their existing processes and systems to identify further efficiencies or opportunities for improvement.

For example, use a sealed-tray crash cart to enable consistent access to equipment and medication.

Research conducted in 2014 at a large, urban hospital in the United Kingdom found that the use of a standardized process to maintain resuscitation crash carts improved readiness. The research team evaluated whether an intervention using a sealed-tray system and a related database would improve compliance with the hospital’s policy. The researchers found a sustained and significant improvement in staff access to resuscitation equipment. 1 Another example of adapting an existing process is to engage a wider range of staff to help monitor resuscitation services in their area. Brown points to an example of a small team in each area of the hospital in which each individual monitors certain components of a crash cart, rather than a single individual responsible for checking the entire cart. 3 Implement staff training and provide information at the right time and for the right reasons. Staff education and training are critical to effectively managing resuscitative services. “Accountability (continued on page 15) Standard PC.02.01.11 Resuscitation services are available throughout the hospital.

Elements of Per formance for PC.02.01.11 1. Resuscitation services are provided to the patient according to the hospital’s policies, procedures, or protocols.

2. Resuscitation equipment is available for use based on the needs of the population served.

Note: For example, if the hospital has a pediatric population, pediatric resuscitation equipment should be available. ( See also EC.02.04.03, EP 2) 4. An evidence-based training program(s) is used to train staff to recognize the need for and use of resuscitation equipment and techniques.

Related Requirements Helpful resources:

The Joint Commission’s Quick Safety Issue 32 (April 2017), “Crash-Cart Preparedness.” https://www .jointcommission.org/assets/1/23/Quick_Safety _Issue_32_20171.PDF 2015 American Heart Association Guidelines for CPR and ECC. https://eccguidelines.heart.org/index .php/circulation/cpr-ecc-guidelines-2/ www.jcrinc.comJuly 2017 4 The Source M edication management in a hospital setting requires a systematic approach to reduce the risk of adverse medication errors. Certain medications, while providing necessary therapeutic treatment, require additional monitoring due to their potential risk of harm to patients if misused or handled incorrectly. This is particularly true in the case of anticoagulation therapy, and a number of its associated medications such as heparin or warfarin.

Anticoagulation therapy provides a critical treatment for a number of conditions, including the following: • Atrial f ibrillation • Valve replacement • Deep vein thrombosis • Pulmonary embolism With a growing and aging population, the effective management of hospital-based anticoagulation clinics requires a standardized approach that is also adaptable to meet patient needs. While The Joint Commission’s Medication Management (MM) standards contain requirements that apply to anticoagulation therapy, The Joint Commission specifically addresses this issue at National Patient Safety Goal (NPSG) NPSG.03.05.01 , which requires health care organizations to reduce the likelihood of patient harm associated with the use of anticoagulant therapy. ( See “Related Requirements” on page 5.) High-Risk Medication “Anticoagulation therapy medications are high-risk drugs and can pose serious risk to patients if they are not properly managed,” explains Jeannell Mansur, RPh, PharmD, FASHP, FSMSO, CJCP, principal consultant for Medication Safety at Joint Commission Resources. “There can often be complexities in determining the appropriate dose, which requires careful and competent oversight and close monitoring and the need for patient adherence to the prescriber’s instructions for using the medications. A standardized dosing approach can be successfully used, but all patients are not able to be managed on such standardized p r o t o c o l s .” Mansur further states: “By employing a standardized approach, a clinic can help reduce the chance of significant adverse events that patients might experience in relation to the successful treatment and management of their anticoagulation therapy. But there must be sufficient expertise to also know when a tailored approach is needed to optimize response to therapy” Joyce Webb, RN, BSN, MBA, CMPE, project director, Department of Standards and Survey Methods at The Joint Commission, explains that a robust system of oversight, verifications, and monitoring is critical to preventing harm in a hospital-based anticoagulation clinic: “Because of the nature of anticoagulation therapy, you want to make sure that there are fail-safe systems to ensure the correct dose and that the monitoring protocols are followed,” she explains.

In addition, Webb emphasizes that patients undergoing anticoagulation therapy need to receive sufficient education to support safe care and patient compliance as part of the overall system.

t racer M ethodology Medication Management System Tracer in a Hospital-Based Anticoagulation Clinic Effective medication management is essential to preventing patient harm.

www.jcrinc.com July 2017 The Source 5 Patient education is vital to an effective anticoagulation therapy program. Patient education could include face-to- face interaction with a qualified professional who works closely with patients. This can help them understand the risks involved with anticoagulation therapy, the importance of compliance with treatment plans, as well as the necessary precautions, such as drug-food interactions and regular International Normalized Ratio (INR) monitoring, as applicable. An organized system to monitor anticoagulation therapy helps prevent errors that can lead to patient harm.

“A clinic benefits from having a monitoring system specific to anticoagulation therapy, where its functionality has been shaped around that clinic’s particular needs,” explains Webb.

Organizations should consider implementing the following system components: • Ensure easy access to information on potential food or drug interactions.

• Track and follow up on patient visits and document patient compliance.

• Support patient education.

• Display graphics of patient lab values, progress toward treatment goals, and other essential information.

Mansur also recommends that those who manage anticoagulation therapy are well trained, and competency is confirmed. ”Effective staff training and competency assessment are critical,” she notes. Mansur adds that the organization should confirm that staff, in the role they are assuming in the clinic, are working within the scope of their licensure. Handy tool: The Institute for Safe Medication Practices provides useful guidance and educational tools relating to anticoagulation therapy at http://w w w.ismp.org/tools /anticoagulantTherapy.asp .

The Scenario This mock tracer was conducted in an anticoagulation clinic located in a large medical center in a suburban community in the Pacific Northwest. The activity took place during a wider medication management system tracer during the organization’s on-site accreditation survey. The clinic was located within the hospital and saw patients who required regular monitoring. The surveyor met with the clinic director, one of its registered nurses, and the hospital’s pharmacy director.

Learning about systems and processes to oversee anticoagulation therapy. The surveyor first wanted to explore how the clinic managed its therapy practices and who had oversight responsibility for its function within the (continued on page 6) NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

Elements of Per formance for NPSG.03.05.01 1. Use only oral unit-dose products, prefilled syringes, or premixed infusion bags when these types of products are available.

Note: For pediatric patients, prefilled syringe products should be used only if specifically designed for children.

2. Use approved protocols for the initiation and maintenance of anticoagulant therapy.

3. Before starting a patient on war farin, assess the patient’s baseline coagulation status; for all patients receiving warfarin therapy, use a current International Normalized Ratio (INR) to adjust this therapy. The baseline status and current INR are documented in the medical record.

Note: The patient’s baseline coagulation status can be assessed in a number of ways, including through a laboratory test or by identifying risk factors such as age, weight, bleeding tendency, and genetic factors.

4. Use authoritative resources to manage potential food and drug interactions for patients receiving warfarin.

5. When heparin is administered intravenously and continuously, use programmable pumps in order to provide consistent and accurate dosing.

6. A written policy addresses baseline and ongoing laboratory tests that are required for anticoagulants.

7. Provide education regarding anticoagulant therapy to prescribers, staff, patients, and families. Patient /family education includes the following:

• The importance of follow-up monitoring • Compliance • Drug-food interactions • The potential for adverse drug reactions and interactions 8. Evaluate anticoagulation safety practices, take action to improve practices, and measure the effectiveness of those actions in a time frame determined by the organization.

Related Requirements www.jcrinc.comJuly 2017 6 The Source hospital. [1, 2, 3] The pharmacy director explained that she had overall medication management oversight responsibility for the hospital, but that the clinic’s function was specifically managed by the clinic director. The effective provision of medication management was also supported by the hospital’s patient safety officer and patient safety leadership, in collaboration with pharmacy leadership, engaged in regular monitoring of the policies and procedures relating to medication management. [4] The team explained that the clinic had its own medication management documentation procedures, which included a written policy for baseline and ongoing laboratory tests, a policy regarding patient information, a written process for the storage and handling of medication and point-of-care-testing devices, and a list of high-alert medications. [5] All of these were examined by the sur veyor.The surveyor then wanted to explore what kinds of medication management processes were in place within the clinic, including processes to determine staff competency to perform INR point-of-care testing devices. [6] The surveyor discussed these with the team while reviewing a patient’s record, which included the documentation for INRs from visits to the clinic. [7] The patient had been attending the clinic for the previous seven months following an admission to the hospital for heart surgery. The surveyor was able to determine that the patient’s visits and treatment were appropriately monitored and documented—including any related follow-up for when the patient missed an appointment. What the surveyor was not able to determine from the documentation, however, was whether or not there had been suitable education provided for the patient. [8, 9] Upon discussion, the surveyor was able to confirm that the clinic had a written policy for documenting specific education provided, but it had just not been documented in the patient’s record. The surveyor also explored what mechanisms the clinic had in place to monitor and assess the effectiveness of their anticoagulation therapy program. [10] Improving patient education going forward. The group discussed reviewing the patient education provision within the clinic to ensure that it was appropriate and suitable for the needs of the clinic and its patients. They also discussed improving their approach to staff training and education in these areas to ensure that staff understood the processes and policies to support patient education and engagement. [11] Sample Questions The following represent some questions that could be asked during a tracer. Use them as a starting point to plan your own tracers.

1. Please describe your systems to manage anticoagulation therapy in your hospital-based clinics.

2. Who is actually directing the therapy of these anticoagulation medications? How have you conf irmed that staff are working within their scope of practice?

3. Who has oversight responsibility for the clinic? How is this documented and communicated?

4. Please describe your policies that relate to anticoagulation therapy within the clinic.

5. What are your processes to store and handle the medications and equipment used within the clinic?

How are these monitored?

6. What are your day-to-day practices within the clinic?

7. How do you manage patient visits, monitoring, documentation, and patient education practices?

8. What kind of patient education and support do you provide in your clinic? How is this monitored? Who is responsible for providing patient education?

9. How do you assess and review the effectiveness of your patient education and engagement provision?

10. How do you assess the effectiveness of your anticoagulation clinic? What metrics are collected and what have you identified to be opportunities for improvement?

11. What staff training and education do you provide in relation to anticoagulation therapy? TS Tracer Methodology 101 (continued from page 5) 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 July 2017 The Source 7 Tracer Question(s)Relevant Standard(s) Person(s) Asked Please describe your systems to manage anticoagulation therapy in your hospital- based clinics. Compliant?If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date Tracer Question(s) Relevant Standard(s) Person(s) Asked Who is actually directing the therapy of these anticoagulation medications? How have you confirmed that staff are working within their scope of practice? Compliant? If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date Mock Tracer Form Medication Management System Tracer in a Hospital-Based Anticoagulation Clinic* Organization Department Unit Date of Tracer Time of Tracer Tracer Topic Type of Tracer Individual System Program High-Risk Environment of Care Life Safety Code ® Tracer Team Patient Record # (if applicable) Documents Reviewed x Tracer Question(s) Relevant Standard(s) Person(s) Asked Who has oversight responsibility for the clinic? How is this documented and communicated? Compliant?If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date Tracer Question(s) Relevant Standard(s) Person(s) Asked Please describe your policies that relate to anticoagulation therapy within the clinic. Compliant?If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date (continued on page 8) * For the full version of this tool, please see the electronic issue of this newsletter.

www.jcrinc.comJuly 2017 8 The Source Tracer Question(s)Relevant Standard(s) Person(s) Asked What kind of patient education and support do you provide in your clinic? How is this monitored? Who is responsible for providing patient eduction? Compliant?If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date Tracer Question(s) Relevant Standard(s) Person(s) Asked What are your processes to store and handle the medications and equipment used within the clinic? How are these monitored? Compliant?If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date Tracer Question(s) Relevant Standard(s) Person(s) Asked What are your day-to-day practices within the clinic? Compliant?If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date Tracer Question(s) Relevant Standard(s) Person(s) Asked How do you manage patient visits, monitoring, documentation, and patient education practices? Compliant?If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date Tracer Methodology 101 (continued from page 7) www.jcrinc.com July 2017 The Source 9 T he table below shows the percentage of hospitals that were found noncompliant with each Medication Management (MM) standard, as well as medication- related National Patient Safety Goals (NPSGs). Medication management is an important component in the palliative, symptomatic, and curative treatment of many diseases and conditions. However, medications are also capable of causing great harm if the incorrect dose or medication is inadvertently administered to a patient. To eliminate any potential harm that could be caused by medications, hospitals need to develop an effective and safe medication management system. The “Medication Management” (MM) chapter addresses critical processes, including those undertaken by the hospital and those provided through contracted pharmacy services. However, the specifics of the medication management system used by the hospital can vary depending on the care, treatment, and services it provides. Not all hospitals will implement all of the medication processes. Effective and safe medication management also involves multiple services and disciplines working closely together. The MM standards address activities involving various individuals within an organization’s medication management system, such as licensed independent practitioners and staff. T S Medication Management Compliance Data for Hospitals, Full Year 2016 Standard Number Standard % Noncompliant MM.01.01.01 The hospital plans its medication management processes. 0.00 MM.01.01.03 The hospital safely manages high-alert and hazardous medications. 3.26 MM.01.02.01 The hospital addresses the safe use of look-alike/sound-alike medications. 2.08 MM.02.01.01 The hospital selects and procures medications. 0.42 MM.03.01.01 The hospital safely stores medications. 32.06 MM.03.01.03 The hospital safely manages emergency medications. 3.05 MM.03.01.05 The hospital safely controls medications brought into the hospital by patients, their families, or licensed independent practitioners. 0.21 MM.04.01.01 Medication orders are clear and accurate. 35.18 MM.05.01.01 A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital. 10.76 MM.05.01.07 The hospital safely prepares medications. 6.66 MM.05.01.09 Medications are labeled. 3.33 MM.05.01.11 The hospital safely dispenses medications. 2.08 MM.05.01.13 The hospital safely obtains medications when the pharmacy is closed. 0.14 MM.05.01.17 The hospital follows a process to retrieve recalled or discontinued medications. 0.21 MM.05.01.19 The hospital safely manages returned medications. 0.76 MM.06.01.01 The hospital safely administers medications. 1.04 MM.06.01.03 Self-administered medications are administered safely and accurately.

Note: The term self-administered medication(s) may refer to medications administered by a family member. 0.21 MM.06.01.05 The hospital safely manages investigational medications. 0.07 MM.07.01.03 The hospital responds to actual or potential adverse drug events, significant adverse drug reactions, and medication errors. 1.11 MM.08.01.01 The hospital evaluates the effectiveness of its medication management system.

Note: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information) 1.67 NPSG.03.04.01 Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.

Note: Medication containers include syringes, medicine cups, and basins. 10.5 NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

Note: This requirement applies only to hospitals that provide anticoagulant therapy and/or long-term anticoagulation prophylaxis (for example, atrial fibrillation) where the clinical expectation is that the patient’s laboratory values for coagulation will remain outside normal values. This requirement does not apply to routine situations in which short-term prophylactic anticoagulation is used for venous thrombo-embolism prevention (for example, related to procedures or hospitalization) and the clinical expectation is that the patient’s laboratory values for coagulation will remain within, or close to, normal values. 0.5% NPSG.03.06.01 Maintain and communicate accurate patient medication information. 4.3% www.jcrinc.comJuly 2017 10 The Source T he health care industry is constantly changing, and health care organizations must adapt to achieve and maintain high-quality patient care. The Joint Commission is no exception, leading its accredited organizations toward high-reliability quality of care. One example of this is its revised requirements for reporting on performance measures, which went into effect January 1, 2017. Hospital Accreditation Program Requirements The following changes apply to performance measure data collected in 2017 by organizations accredited under the Hospital Accreditation Program. The measure set reporting requirement has been eliminated for 2017. Instead, hospitals will select and report on individual measures. Those measures for most hospitals will be a blend of chart-abstracted measures and electronic clinical quality measures (eCQMs) ( see the box on page 12).

Most hospitals must select and report data on the following: • Five required chart-abstracted measures, as applicable to the services provided and patient populations served by the hospital ( see Fig u re 1, right) • Four additional chart-abstracted perinatal care measures if the hospital has at least 300 live births for the year ( see Fi g u r e 1) • Six of 13 available eCQMs, as applicable to the Understanding 2017 Performance Measure Reporting Requirements Benchmark Chart-Abstracted Measures Organizations must report data on the following measures:

Emergency Department (ED) ED-1 ED-2 Perinatal Care (PC) PC-01* Venous Thromboembolism (VTE) VTE-6 Influenza Immunization (IMM) IMM-2 Perinatal Care (PC) If ≥ 300 live births for the year, the organization must also report on the following 4 measures:

• PC-02 • PC-03 • PC-04 • PC-05 Electronic Clinical Quality Measures (eCQMs) Organizations must report on six of the following eCQMs:

Acute Myocardial Infarction (AMI) eAMI-8a Children’s Asthma Care (CAC) eCAC-3 Emergency Department (ED) eED-1 eED-2 ePC-01 ePC-05 Stroke (STK) eSTK-2 eSTK-3 eSTK-5 eSTK-6 Venous Thromboembolism (VTE) eVTE-1 eVTE-2 Early Hearing Detection and Intervention (EHDI) eEHDI-1a Figure 1: Measures for Hospital Accreditation Program www.jcrinc.com July 2017 The Source 11 services provided and patient populations served by the hospital Chart-abstracted measure data will continue to be reported to The Joint Commission on a quarterly basis, while eCQM data will be reported annually and are due at The Joint Commission no later than March 15, 2018. These are the minimum requirements for 2017.

Hospitals may choose to report data on additional chart- abstracted measures and eCQMs. If a hospital does not provide a service or serve a population addressed by any one of the chart-abstracted measures, it will not be required to report on an alternative measure(s). However, the hospital is free to report on an alternative measure(s) if it wishes. If a hospital is unable to identify six eCQMs from The Joint Commission’s list, it will be required to report on as many eCQMs as are relevant to its services provided and populations served. Hospitals with Modified Requirements Certain types of hospitals have slightly different requirements for 2017. Critical access hospitals and small hospitals (those with an average daily census of 10 or fewer inpatients) must report on a total of six measures, as applicable to the services provided and patient populations served. They may be all chart-abstracted measures, all eCQMs, or any combination of Joint Commission chart-abstracted measures and Joint Commission eCQMs ( see Figure 2, below). Critical access and small hospitals continue to be exempt from the vendor requirement to report data. Freestanding psychiatric hospitals must report data on four hospital-based inpatient psychiatric services (HBIPS) chart-abstracted measures: • H BI P S -1 • H BI PS -2 • HBIPS -3 • H BI PS -5 Hospitals that have an inpatient psychiatric unit, or that maintain a separate site as a psychiatric hospital that is accredited under the main hospital, may report on any HBIPS measure if they choose to do so. However, there is no 2017 requirement that these organizations must report on HBIPS measures. ORY X® performance measure reporting requirements remain suspended for freestanding children’s hospitals , long term acute care hospitals , and inpatient rehabilitation facilities . Important Notes Regarding CMS Requirements The Joint Commission continues to remain as closely aligned as possible with the Centers for Medicare & Medicaid Services (CMS) on measures the two organizations have in common.

First, The Joint Commission has not adopted the CMS Figure 2: Measures for Critical Access Hospitals and Small Hospitals Organizations must report on six of the following measures, or any combination of chart-abstracted measures and electronic clinical quality measures (eCQMs):

Joint Commission Chart-Abstracted Measures Joint Commission eCQMs ED-1, ED-2 eAMI-8a PC-01, PC-02, PC-03, PC-04, PC-05 eCAC-3 VTE-6 eED-1, eED-2 IMM-2 ePC-01, ePC-05 HBIPS-1, HBIPS-2, HBIPS 3, HBIPS 5 eSTK-2, eSTK-3, eSTK-5, eSTK-6 TOB-1, TOB-2, TOB-3 eVTE-1, eVTE-2 SUB-1, SUB-2, SUB-3 eEHDI-1a OP-18, OP-20, OP-21, OP-23 (continued on page 12) Key: ED: Emergency department, PC: Perinatal care, VTE: Venous thromboembolism, Influenza Immunization: IMM, HBIPS:

Hospital-based inpatient psychiatric Services, TOB: Tobacco treatment, SUB: Substance abuse, OP: Hospital outpatient department, AMI: Acute myocardial infarction, CAC: Children’s asthma care, ED: Emergency Department, PC: Perinatal care, STK:

Stroke, VTE: Venous thromboembolism, EHDI: Early Hearing Detection and Intervention www.jcrinc.comJuly 2017 12 The Source sepsis management bundle measure (SEP-1) for 2017. This is a chart-abstracted measure that must be reported to CMS.

The Joint Commission will not accept data on the SEP-1 measure.Second, The Joint Commission requires reporting on 6 of 13 eCQMs, while CMS requires reporting on 8 of 15 eCQMs. The Joint Commission has not included two of the CMS stroke eCQMs. This decision was made because The Joint Commission feels that the measures in question have become “check box” measures. In other words, compliance on those measures has become so much a part of regular operations and processes that their value as performance improvement tools is diminished. Finally, in the recently released April fiscal year 2018 Inpatient Prospective Payment System (IPPS) proposed rule, CMS has proposed modifying its reporting requirements for 2017. These proposed changes would decrease the number of eCQMs and calendar quarters on which hospitals would be required to report data. Specifically, hospitals would be required to: • Select and report on six of the available eCQMs included under the Hospital Inpatient Quality Reporting Program (a reduction of two measures from the original eight required under the previously finalized IPPS rule) • Report on any two calendar quarters of data for 2017 (reduced from one full calendar year of data required under the previously approved IPPS final r u le) How to Ensure Compliance Compliance with The Joint Commission’s new ORY X requirements for 2017 does not appear to be challenging for most organizations, according to Sharon Sprenger, MPA, RHIA, CPHQ, associate director, Measurement Coordination and Outreach, Division of Healthcare Quality Evaluation, at The Joint Commission. Earlier this year, accredited organizations made their 2017 ORY X selections using the ORY X Measure Selection (OMS) application on their Joint Commission Connect ™ extranet sites. The OMS application is now closed to external users. Sprenger says, “Should CMS enact its proposed changes to 2017 eCQM reporting requirements when it releases its final rule later this summer, The Joint Commission will take time to review it before deciding whether or not we will make any changes to our own 2017 reporting requirements.” Pioneers in Quality The Joint Commission’s ORY X performance measure reporting requirements for 2017 place more emphasis than before on the use of eCQMs. The movement from paper-based measures to electronic-based measures can be challenging. One resource to help organizations make the transition to eCQMs is The Joint Commission’s Pioneers in Quality program. Sprenger encourages organizations to access the Pioneers in Quality program’s many resources through its portal at https://w w w.jointcommission.org/topics/pioneers_in_quality .aspx . Among its valuable components are the following:

• eCQM e-alerts notif y organizations of new material as it is added.

• Pioneers in Quality Advisory Panel guides The Joint Commission in its development of eCQM– related resources and support for its accredited organizations.

• 2017 Pioneers in Quality Proven Practices Collection allows organizations to submit their eCQM success stories for recognition and to serve as a guide for others seeking similar success.

“The Pioneers in Quality portal is an excellent place to find all sorts of valuable tools, resources, and information about eCQMs,” says Sprenger.

Looking Ahead The changes described in this article affect data being collected in 2017, which will be reported to The Joint Commission during 2017 and 2018. As of this writing, the measure data reporting requirements for 2018 data have not been determined, but will be forthcoming. “Organizations can look for The Joint Commission’s 2018 ORY X performance measure reporting requirements in early fall of 2017,” Sprenger explains. “Organizations that have questions regarding their 2017 ORY X requirements, or that have questions regarding their current measure selections, should contact The Joint Commission at HCOORY [email protected] or call 630-792-5085” T S Benchmark (continued from page 11) Key Terms Chart-abstracted measures are those for which sources for abstraction can be paper, electronic, structured or unstructured allowable values. The eCQMs only use structured data that is electronically documented.

www.jcrinc.com July 2017 The Source 13 Not Your Average Telehealth Mercy Virtual Care Center is unlike any other health care organization. There are no patients and no exam rooms. Its 600-plus employees use custom-designed computer apps, high-resolution cameras and displays, advanced hardware and software, and cutting-edge telecommunications systems to provide care for patients in seven states.According to Randall Moore, MD, MBA, president of Mercy Virtual, this is beyond what most people think of as telehealth. “Seeing a doctor from your smartphone or iPad, or consulting a specialist in another city—that’s simply making routine care more convenient,” he says. “While that’s certainly valuable, we are doing more.” Mercy Virtual uses a combination of analytics, machine learning, and different forms of connectivity to deliver both historically hospital-based services in the home and enhance care provided at other facilities. Providers working in the Virtual Care Center’s 160 clinical stations have access to electronic medical records (EMRs), mobile monitoring devices, and other data in real time. Further, customized software overlays the EMR system to analyze data in ways that support specialized care. For example, Mercy Virtual has a telesepsis program.

The program involves the use of the organization’s software to analyze patient data and reports specific metrics to specialists in recognizing and treating sepsis. These individuals use alerts to quickly identify patients who are showing signs of sepsis. Some EMRs have systems designed to alert staff to potential sepsis in a patient. However, Moore explains, sepsis alerts are prone to false positives. This can lead to alert fatigue for on-site nurses and may, in turn, result in care being delayed. “Our telesepsis program sorts through the alerts and finds the cases that require immediate action,” says Moore. “We then alert the bedside staff. When they get an alert from us, they know it’s time to act.” Because of this collaboration, antibiotic infusions can begin within minutes instead of potentially hours. Moore emphasizes that telehealth is not synonymous with technology. “Technology is only the tool we use to achieve our goals,” he says. “We are trying to transform health care into a progressively seamless experience for patients and providers, while redefining quality and value in terms of what the patient actually wants.” Closing the Gaps Mercy Virtual encompasses a variety of programs, from intensive care unit (ICU) monitoring and telestroke services to chronic disease management. These services are provided by teams of physicians, nurses, and other staff who work in and outside of the Virtual Care Center building. The teams work with each other as well as on-site care providers to provide a continuous care experience for each patient.

For example, a patient who presents at the emergency department at a remote hospital may need to be transported by ambulance to another facility, where he or she is admitted into the ICU. This process involves several geographic locations and handoffs between departments and organizations. Mercy Virtual staff will be part of the care team from the beginning and, through the use of Bluetooth-enabled devices and secure telecom systems, follow the patient along the entire continuum of care. Also, transitioning a patient among different care teams at the Virtual Care Center means those teams can collaborate and coordinate care to reduce risks. “We are closing gaps and making the typical transitions of care disappear,” Moore says. Proactive Care Mercy Virtual’s provision of care is proactive, rather than reactive. “The power of virtual care,” Moore explains, “is the ability to provide truly patient-centered care that focuses quality, safety, and value on what the patient wants. Patients with chronic diseases, for example, are able to stay in their homes and maintain normal routines and comforts.” Spotlight on Success (continued from page 1) (continued on page 14) Telemedicine services can enable some patients to receive care in their homes that they otherwise would need to receive in a hospital or other health care facility.

www.jcrinc.comJuly 2017 14 The Source One example is Naomi, an 87-year-old patient who had multiple ICU visits for advanced lung and colon cancers and other health issues. According to Moore, Naomi had 13 hospitalizations in two years. She wanted to spend as much of her remaining time at home, playing bingo on Tuesday nights and otherwise living as normal and comfortable a life as possible. Mercy Virtual was able to provide that for her.

Through its remote monitoring systems, staff noticed signs of deterioration in Naomi’s condition in real time and alerted care team members in the field who intervened before hospitalization became necessary. Under Mercy Virtual’s care, Naomi lived at home for 10 months, missing bingo only once, before her care was transitioned to home hospice providers. During that time, she had only one hospitalization. “Naomi is just one example of the improved quality and value we can provide our patients with chronic disease,” Moore says. “Also, our teleICU program has seen about 35% fewer expected deaths—that’s 1,200 patients—and a similar reduction in average length of stay.” At Mercy Virtual, the goal is to identify and treat problems before they require a hospital visit. “We think of hospitalization as a system failure for someone with a chronic disease,” Moore says. “If people like Naomi can live the majority of their lives outside the hospital, shouldn’t we be directing more effort to making that possible for more people?” Redefining Quality and Value Due to the unique nature of Mercy Virtual’s care, treatment, and services, the organization approaches quality, safety, and value from a different perspective than traditional health care providers do. According to Moore, by identifying needs earlier, and intervening sooner, the patient’s health care team can reduce the likelihood that a patient may need hospitalization. “In addition to measuring how well we perform during a patient’s hospitalization,” Moore suggests, “we might also measure how well we avoid hospitalization in the f irst place.” Moore shares the story of one stroke patient as an example of how virtual care can improve care. A man presented at a remote facility with symptoms of an acute stroke. According to Moore, a patient in that area normally would not have been able to receive the clot dissolution analysis and medications to reverse the stroke. However, through the telestroke program, a stroke specialist was able to assess the patient within 10 minutes of his presentation; and within 45 minutes the patient was identified as a candidate for the clot dissolution protocol.

Because of the speed enabled by Mercy Virtual’s telestroke program, the patient received treatment in time to be released without the sequela of a stroke. “This patient would have received excellent stroke care at the hospital,” Moore asserts, “but because we were able act quickly and reverse the stroke, he never needed to.” Maintaining Compliance Despite the differences between Mercy Virtual and traditional practices, Moore does not see any real differences in how they maintain continuous compliance with Joint Commission standards. “We don’t think of it as virtual care,” he says. “It’s simply care. It’s not a separate entity, and so it doesn’t need special consideration when it comes to safety and compliance.” Credentialing and Privileging Telemedicine providers must meet the same criteria for credentialing and privileging as any other practitioner. In The Joint Commission’s Ambulatory Health Care Accreditation Program, Human Resources (HR) Standard HR.02.01.03 (“The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.”) addresses telehealth specifically in several of its EPs.

These requirements are particularly relevant because Mercy Virtual provides only telehealth. However, like the rest of its services, the credentialing and privileging procedures are an augmentation of traditional practices. They follow the same criteria as any other health care organization using the same resources for verification and so on.

There is an added layer, though. All staff members who work in the Virtual Care Center were already privileged and credentialed in their respective setting.

When they move to virtual care, they become part of the care team at all the hospitals that contract with them. Therefore, those practitioners are privileged and credentialed according to those hospitals’ criteria as well.

In addition, Mercy Virtual uses additional criteria to ensure that its staff is knowledgeable about providing virtual care and using the technology. Spotlight on Success (continued from page 13) www.jcrinc.com July 2017 The Source 15 The Source TM Editorial Advisory Board Steve Anderson, RN, MBA, CJCP Senior Director, Clinical Improvement and Patient Safety Vizient, Inc.

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 Executive Director for Medicare Strategy and Operations 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 Senior Advisor for Nursing Leadership Jonas Center for Nursing Excellence Moore describes three areas in which Mercy Virtual’s practices align with The Joint Commission’s mission and vision: • Improving the patient’s experience and health • Improving the health of the populations served • Providing high-quality care at a lower cost Further, Moore explains that virtual care can improve patient safety and quality of care by reducing provider burnout. One area that organizations often wrestle with when it comes to telehealth is the issue of credentialing and privileging. The sidebar on page 14 describes how Mercy Virtual approaches this essential process. “Intervening earlier decreases the net health care needs of the patient while providing better outcomes and satisfaction,” he explains. “This directly affects the frontline staff who provide the care.” Moore emphasizes that Mercy Virtual and other leaders in virtual care will need to work with The Joint Commission to evaluate compliance with the standards from a virtual care perspective. This includes the evaluation of quality and safety as preventing the need for hospitalization and other traditional care. T S is critical for a health care organization aiming to deliver safe, high- quality care,” explains Brown. “Staff need to be trained and mentored to understand the underlying principles as to why having reliable resuscitation services across the hospital is essential.” Brown adds that after they are engaged and empowered to carry out policies or protocols, staff are more likely to hold themselves accountable for compliance. 4 Ensure that resuscitation services are appropriate to the area and population in question. Knoll points out that not all areas of the hospital will require the same approach to resuscitation services and related equipment. Ensuring that a hospital has the correct equipment appropriate to the specific area is an important element that hospitals need to consider. This includes using published national professional association guidelines (specific to certain areas of practice) as a guide for what should be made available in certain areas, such as in the postoperative recovery area. ( See “Helpful Resources” on page 3). These guidelines, including any manufacturer’s documentation for specific equipment or supplies, should also help determine what is appropriate for a particular setting. Knoll advises that when hospitals opt to use other population-specific supplies— such as the Broselow Tape in the pediatric setting—they should ensure that it is correct and up-to-date based on clinical or practice guidelines. 5 Integrate into your other existing preparedness activities . Consider including a review of resuscitation services and related equipment as part of the hospital’s overall preparedness activities, similar to preparing for an influx of patients or an extended power outage. T S Reference 1. Davies M, et al. A simple solution for improving reliability of cardi\ ac arrest equipment provision in hospital. Resuscitation. 2014 Nov;85(11):1523–1526.

5 Sure-Fire Methods (continued from page 3) July 2017 Volume 15, Issue 7, July 2017 Send address corrections to:

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www.jcrinc.com www.jcrinc.com www.jcrinc.com www.jcrinc.com www.jcrinc.com The Source 17 Medication Management System Tracer in a Hospital-Based Anticoagulation Clinic continued from page 8 Tracer Question(s)Relevant Standard(s) Person(s) Asked How do you assess the effectiveness of your anticoagulation clinic? What metrics are collected and what have you identified to be opportunities for improvement? Compliant? If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date Tracer Question(s) Relevant Standard(s) Person(s) Asked How do you assess and review the effectiveness of your patient education and engagement provision? Compliant?If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date Tracer Question(s) Relevant Standard(s) Person(s) Asked What staff training and education do you provide in relation to anticoagulation therapy? Compliant?If insufficient compliance: Immediate Threat to Life Yes Likelihood to Harm High No Moderate Not scored Low Not applicable Limited PatternWidespread Scope of Noncompliance Evidence of Compliance Plan of Action Due Date www.jcrinc.comJuly 2017