On a professional level, the new year is a perfect time to renew your commitment to avoiding bad surveys. But New Year’s resolutions are hard to keep, right? Wrong! Although going to the gym at 4am seven days a week may be a resolution that eventually proves too hard to follow, this week we discuss some of the strategies your consultant pharmacist can suggest to help you keep your resolution to avoid poor survey outcomes.
At the recent Northeast Conference I discussed How Your Consultant Pharmacist Can Help You Achieve Survey Success. During my talk, I highlighted items commonly cited by certification and accreditation organizations. Although the list varies slightly depending on where you look or who you ask, the top cited survey issues are generally consistent from year to year.
What are some of the most commonly cited deficiencies?
Patient safety/safe injection practices:
Demonstrating safe injection practices, along with having a formal infection prevention and control program are both near the top of the list almost every year. Some specific practices cited include not labeling a multi-dose vial opened and drawn in a patient treatment area as a single patient vial; opening, dating, and saving multi-dose vials on anesthesia carts for future use; and splitting of single-dose vials. Additionally, not having an infection prevention and control policy that is based on nationally recognized guidelines or having the policy, but not following it.
Documentation:
Requirements for documentation appear throughout the standards and key documentation requirements are often incomplete or overlooked. The most noncompliance occurred in the areas of medication reconciliation and allergy documentation. This includes not providing patients with consistent discharge instructions and not having allergies properly defined and documented.
Credentialing and privileging:
The three most common issues with credentialing and privileging were, not conducting appropriate verification of provider qualifications, not following privileging protocol and not using peer reviews in the process of granting privileges.
How can you avoid deficiencies?
Patient Safety/Safe injection practices:
Any vial opened in a patient care area, becomes single patient only and should be handled accordingly. If you want to use multi-dose vials for multiple patients, they must be prepared in a segregated medication preparation area and labeled properly. Single dose vials, as the name implies, should be used for single doses only. When developing your infection control and prevention program, base it on nationally recognized guidelines such as the Centers for Disease Control (CDC).
Documentation:
Ensure you have a complete medication reconciliation process that includes providing each patient with a medication reconciliation form that is consistent with the facility documentation and includes any changes given upon discharge. Additionally, determine one consistent method for documenting allergies so that they are in a prominent and consistently defined location.
Credentialing and privileging:
First and foremost, follow your protocol. Perform timely primary and secondary source verifications. Document the privileges requested and granted, along with the specific time period for which they are granted. Perform peer review that goes beyond just the clinical record audit (e.g. infection rates, patient satisfaction results).
Although this list goes a long way in helping you keep your resolution, it is far from comprehensive. For help with these items or for a more detailed discussion on other topics you should be addressing, please contact us.
The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.
