TJC Compliance Challenges

November 2011 - Vol. 8 No. 11 - Page #4

Q&A with Darryl Rich, PharmD, MBA,
FASHP Surveyor, The Joint Commission


Pharmacy Purchasing & Products: What changes can hospital pharmacy practitioners expect from TJC in 2012?
Darryl Rich: At this point, there are no expected changes in medication management (MM) standards interpretation or structure, or for any of the medication-related national patient safety goals (NPSGs) for 2012. Now, there are effectively only two NPSGs related to medications—medication reconciliation and anticoagulation management—and we just resumed scoring medication reconciliation in July of this year. 

PP&P: How has TJC’s approach to medication reconciliation changed in the last year?
Rich: Medication reconciliation scoring originally was suspended because the goals were considered too prescriptive and too difficult for organizations to achieve, so TJC rewrote them to allow more flexibility. As a result, the NPSG was simplified into MM.03.06.01, while still retaining the goals of what is expected from medication reconciliation. In the past, the expansive NPSG 8 covered medication reconciliation and there were several subheadings with numerous elements of performance (EP) under each one. This has been streamlined into a single NPSG with only five EP (see Table 2).

Given the more streamlined nature of the standard, it is likely that any hospital that originally had a system in place for medication reconciliation—and continued to follow it during the moratorium—will meet the new requirements. While certain outpatient and diagnostic areas, such as ambulatory surgery or outpatient radiology, are allowed to have a different approach than the rest of the hospital, the main point is that the standard requires facilities to define their medication reconciliation policy in writing and to follow that policy. What we have seen upon inspection is that a number of organizations have a policy indicating all areas will perform a complete medication reconciliation with dose route, frequency, etc, but in practice, they are not performing these actions in non-24 hour settings. Simply put, the hospital must follow its own policies, and while I have not seen many issues with this standard on recent surveys, we do not have enough hard data yet to determine overall improvement. 

PP&P: What trends are you seeing with the NPSG for anticoagulation management?
Rich: Hospitals have been performing well in this area, as only 1.3% of facilities have been scored for issues related to anticoagulation management. Most commonly, this area is scored when a facility does not have a written protocol for the different types of anticoagulants. In looking at the NPSG for anticoagulation therapy, the actual element of performance is EP 2, which directs facilities to use written, approved protocols for initiation and maintenance of anticoagulation therapy—namely, heparin, low molecular weight heparin, and warfarin. In many cases, a facility will only perform pharmacist monitoring of international normalized ratios (INRs), whereas TJC requires a dosing protocol be in place and followed, regardless of who is dosing it—physician or pharmacist. 

PP&P: What issues were most prevalent during 2011 surveys?
Rich: As would be expected, issues found on surveys throughout the year are shared among surveyors. So, on a team of six surveyors, if one surveyor notes an issue, then the other five members of that team will likely carry it through to their subsequent tracers to check for trending. Among the larger issues that arose this year were those related to therapeutic duplication. For example, we found certain pharmacies were dispensing multiple narcotics or multiple antiemetics as PRN without clear definition as to when to use one product over another. These issues were scored as a lack of review for therapeutic duplication. This was probably the biggest issue with MM standard 05.01.01. Ultimately, it was less an issue of pharmacies not catching these mistakes, rather it was that they were unaware any action was necessary.

It is worth noting here that likely our number one ongoing issue involves incomplete or illegible medication orders. For example, an order may come in to titrate propofol but no parameters or no initial rate is listed and pharmacy has been letting this go. In my experience those organizations that have an electronic medical record or CPOE—particularly if they have both—do much better in terms of standards compliance on surveys, as these systems generally address issues involving incomplete or illegible orders. Further to this, our most frequent, non-pharmacy issue is dating and timing of physicians orders, so by automating the process through CPOE, these steps happen automatically.

PP&P: Were there additional issues of note in 2011?
Rich: Another area of concern falls under standard MM.03.01.01—failure to store medications according to manufacturer requirements (see Table 1). We have seen a few trends with specific products that are not being stored properly, including lorazepam syringes, which the manufacturer requires to be refrigerated, but are often stored at room temperature. Conversely, magnesium citrate, which manufacturers require storing at room temperature, is commonly stored under refrigeration. In another example, opened IV bulk packages used for multiple doses of contrast are required to be stored in an aseptic area after opening, but this does not always occur. In many instances, pharmacy is simply not reviewing the package insert and instead relies on information gleaned from a reference book or an article. Nonetheless, CMS requires that the manufacturer’s recommendations be followed, and while some groups, including ASHP and ISMP, are working with CMS to change the sources for storage guidance, as of now, this is the rule we have to score by.

Click here to view a larger version of this Table

We have also seen issues with frozen products in that there is such a wide range of temperature requirements, some of which do not overlap, so facilities can be left needing two different freezers to maintain the appropriate range of temperatures. There have also been situations where the manufacturer changed the temperature requirements on the package insert, but never alerted their customers to the change. It is important to check the manufacturers’ temperature requirements on a regular basis to avoid having a problem during an inspection. 

Further to this, medication security remains a problem. TJC requires that all drugs be kept in a secure area, and we commonly see issues specific to medication cart storage. Many practitioners assume that if a medication cart is locked, it constitutes security, but that does not follow the CMS interpretation of medication security, which indicates that the medication cart must also be stored in a secure area, such as a locked medication room. 

PP&P: Have you seen progress in the management of contrast agents?
Rich: In most cases, contrast agents fall under the purview of radiology, but as a medication, we do expect compliance to the medication management standards. Of course, whenever anything is scored under the medication management standards, regardless of where it is in the hospital, it is often the director of pharmacy who is ultimately responsible.

That being said, medication use in radiology has improved, but it is still a problematic area. The same could be said for nuclear medicine where new products are being released making it even more challenging. For instance, there is a new radiopharmaceutical that is also a controlled substance—DaTscan, which is used to diagnose Parkinsonian syndromes. It is important that pharmacy, radiology, and nuclear medicine work together to be sure medications are properly managed outside of the pharmacy. 

PP&P: What areas demonstrated the greatest improvement in 2011 and which remained challenging? 
Rich: There has been significant progress in managing expiration dating for multi-dose vials. Pharmacist review of orders also increased and we are definitely seeing improvement in the labeling of medications during surgical procedures, which—although this occurs outside of the pharmacy—is still a medication issue. Despite this good news, I have noticed that some pharmacies are not aware that TJC requires facilities to have a list of high alert medications and attendant policies to manage these products. This requirement changed a couple years ago to include a list of hazardous medications in use in addition to having policies for managing them and it appears that many practitioners missed that distinction.

Medication preparation continues to provide challenges, particularly when sterile IVs are being prepared outside of the pharmacy. This practice is allowed in urgent situations, but in doing so, nursing must have a functionally separate area on the unit in which to prepare the IV dose, and few facilities have this. The area does not need to be a hood or other engineering control, rather it simply needs to be clean, functionally separate, and dedicated solely to IV preparation.

PP&P: At what point do national patient safety goals become medication management standards and do certain standards fall out of use?
Rich: Our aim is always to move goals into standards as organizations improve their compliance. As compliance rates increase, we can turn our focus to current and projected issues. A key goal for the Joint Commission is to streamline the standards and ensure they are all evidence-based. To enable this, we have eliminated many requirements and we continue to focus on identifying those evidence-based practices that are key to achieving safety and quality.

We also have come to realize that there is no such thing as a single, definitive best practice; rather, depending on the cause of the problem, there may be many different approaches that can lead to improved quality and safety. It is key to pinpoint the cause of any problem, as this will vary from hospital to hospital, and then focus on fixing your specific deficiencies. 

PP&P: What resources are available for facilities preparing for TJC inspections?
Rich: There are a few resources available—two of which are available only to TJC accredited organizations. One is a leading practice database that accredited facilities can access through their dedicated TJC intranet site and look at any standard to see what TJC deems a leading practice to meet that standard. That database is growing daily, so it is a good idea to check it regularly. The second resource is called a BoosterPak and of those currently available, the only medication-related one is for the medication storage standard—MM.03.01.01. This pack of information offers detailed, frequently asked questions and answers, gives the background of the standard, and offers a more comprehensive view on achieving compliance. This is also available through each facility’s TJC intranet site called Joint Commission Connect. 

The official electronic newsletter, Perspectives, should be available via the hospital’s coordinator for the Joint Commission. These individuals should be key resources for pharmacy directors to keep in contact with because they receive information straight from TJC and if that person is not sharing it, then the pharmacy director needs to reach out and request it. 

For general resources available to any facility, TJC has frequently asked questions about standards posted on its Web site— It also is a good idea to talk with colleagues who have been through a recent survey to learn from their experiences. There are various email forums or listservs available to address specific issues related to automation and operations. Networking in this capacity can provide great education on the survey process.

Darryl Rich, PharmD, MBA, FASHP, is a surveyor for TJC in the hospital, home care, and ambulatory accreditation programs. In addition, he works for the Standards Interpretation Group serving as an internal resource for TJC related to pharmacy and medication management. Darryl received his PharmD from the University of California at San Francisco and his MBA in health care management from Bryant University in Rhode Island.





Table 2. NPSG.03.06.01Maintain and communicate accurate medication information for the individual served.




Elements of Performance for NPSG.03.06.01

1. Obtain and/or update information on the medications the individual served is currently taking. This information is documented in a list or other format that is useful to those who manage medications.
Note 1: The organization obtains the individual’s medication information during the first contact. The information is updated when the individual’s medications change.
Note 2: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications. 
Note 3: It is often difficult to obtain complete information on current medications from the individual served. A good faith effort to obtain this information from the individual and/or other sources will be considered as meeting the intent of the EP.

2. Define the types of medication information (for example, name, dose, route, frequency, purpose) to be collected in non-24-hour settings based on situations of individuals served and characteristics of different settings.

3. For organizations that prescribe medications: Compare the medication information the individual served brought to the organization with the medications ordered for the individual by the organization in order to identify and resolve discrepancies. 
Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified staff member, identified by the organization, does the comparison. (See also HR.01.06.01, EP 1)

4. For organizations that prescribe medications: Provide the individual served (or family as needed) with written information on the medications the individual should be taking at the end of the encounter (for example, name, dose, route, frequency, purpose). 
Note: When the only additional medications prescribed are for a short duration, the medication information the organization provides includes only those medications. For more information about communications to other providers of care when the patient is discharged or transferred, refer to Standard CTS.06.02.05.

5. For organizations that prescribe medications: Explain the importance of managing medication information to the individual served.
Note: Examples include instructing the individual served to give a list to his or her primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations. (For information on education of the individual served, refer to Standard CTS.04.01.03.)

Effective July 1, 2011 © 2011 The Joint Commission


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