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Preparing Organizations:Related Joint Commission

Standards

Chicago, ILSeptember 14, 2004

R. Scott Altman, MD, MPH, MBAManaging Consultant, Joint Commission Resources

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Objectives of the Presentation

Discuss the related 2004 standards and the implications for ED operations

Recognize the impact of ED overcrowding on patient safety and outcomes of care

Discuss “issues” facing ED’s and possible strategies for improvement

Understand the intent of the draft ED Overcrowding standard and the elements of performance

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What is Wrong with this Picture?

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Related Standards

1. Right to TreatmentRI.2.10 and PC.15.20

2. Settings & ServicesLD.2.20, LD.3.30, LD.3.80, LD.4.40,

EC.8.10, RI.2.10, RI.2.60, and RI.2.130

3. Entry to ServicesPC.1.10 and PC.15.20

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Related Standards

4. Adequate StaffingLD.3.10, LD.3.70, HR.1.10, HR.1.20,

HR.1.30, and PI.2.30

5. Care, Treatment and ServicesPC.2.120, PC.2.130, PC.2.150, PC.4.10,

PC.5.60, PC.8.10, and IC.4.10

6. Uniformity of CareLD.3.20

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Related Standards

7. Timely Ancillary ServicesLD.2.20, LD.3.10, LD.3.30, PC.3.230, and

PC.5.60

8. Discharge or TransferPC.15.10 and PC.15.20

9. Emergency ManagementEC.4.10, HR.2.20, EC.4.20, and IC.6.10

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Related Standards

10. Continuous ImprovementPI.1.10, PI.2.20, PI.3.10, PI.3.20 and

LD.4.50

11. New StandardLD.10.11, LD.3.11, LD.3.15

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Issues:Right to Appropriate Treatment

Hospitals identify patients rights, then comply with the policy they develop Note hallway boarding issues, such as

confidentiality, privacy, security, hygiene, etc. Hospitals plan for patients needs to be met in

each step of the continuum, including the ED To the extent that it is felt that patients use

ED’s inappropriately, it is the hospitals responsibility to educate its staff, physicians, and patients on appropriate alternatives in their community.

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Right to Treatment

EMTALA Prudent Layperson

Not JCAHO

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Issues: Settings & Services

Leadership ensures that services are timely, effective, and efficient;

With adequate space, equipment, and resources;

In an environment that is safe, clean, comfortable, and well lit; and

maintain dignity, confidentiality, privacy, and security

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Issues: Entry to Services

Hospitals provide for referral, transfer, or discharge of patients to another level of care, health professional, or setting, based on the patient's assessed needs and the hospital's capability to provide the care.

Raises questions about accepting elective or direct admissions when the facility is full.

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Required admission and discharge criteria are very difficult to enforce

It is inconvenient to move patients in the middle of the night, and it can be politically difficult to require physicians to move their own patients to lower levels of care to open a bed for someone else’s patient

Issues: Entry to Services

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Data should show that during periods of peak utilization, criteria based movement of patients is enforced

Hospitals are required to do discharge planningTo create flexible capacity hospitals need to be

creativeUse or consideration of discharge lounges,

neighboring hotels, or similar flex space should be documented

Discharge planning can be done for the ED, not just in-patients

Issues: Entry to Services

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Issues: Adequate Staffing Hospitals must demonstrate that appropriate

physician, nursing, and ancillary staff are available and utilized to handle the need, recognizing that the “boarded” patients are in their most acute (highest staff demand) phase of in-patient care.

If staffing ratios are different between the ED and other units caring for patients of equivalent severity, the facility should have documentation demonstrating that the difference in staffing levels is safe and effective for both the patient and the staff.

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Issues:Care, Treatment, & Services

Initial and re-assessments are performed in the timeframe identified by the organization

The plan of care is individualized, timely, and limits the use of restraints or seclusion

Criteria based patient movement Pain is assessed and managed A hand hygiene program is in place All present challenges during overflow times

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Issues: Uniformity of Care

Patients in the ED should receive an equivalent level of care to that they would receive in an inpatient bed, be it Critical Care, Psychiatric, Pediatric, or Medical-Surgical

When the ED is used for overflow capacity, it must be done in a way that maximizes the uniformity of care, and patient safety.

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Issues: Timely Ancillary Services

The environment and culture should enable timely care, treatment, and services

Timely needs to be collaboratively agreed upon and measured as part of an organization-wide performance improvement effort

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Issues: Discharge or Transfer

Communication between the origin and the destination consists ofThe reason for transfer or dischargeThe patient’s physical and psychosocial statusA summary of care, treatment, and services

provided and progress toward goals Community resources or referrals provided to the

patient

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Emergency:A natural or man-made event that significantly

disrupts the environment of care;Eg: severe winds, storms or earthquakes

that significantly disrupts care, treatment, and services;Eg: loss of utilities

or that results in sudden, significantly changed or increased demands for the organization’s services.Eg: bioterrorist attack, building collapse, or plane

crash

Emergency Management

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EC.4.10The hospital addresses emergency

managementA hazard vulnerability analysis is conductedThe emergency management plan

comprehensively describes the hospital’s approach to internal and external emergencies

Hospital leaders including the medical staff are involved with the plan development

Emergency Management

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Hazard Vulnerability AnalysisEVENT PROBABILITY RISK PREPAREDNESS TOTAL

HIGH MED LOW NONE LIFE THREAT

HEALTH/ SAFETY

HIGH DISRUP-TION

MOD DISRUP-TION

LOW DISRUP-TION

POOR FAIR GOOD

SCORE 3 2 1 0 5 4 3 2 1 3 2 1 NATURAL EVENTS

Hurricane Tornado Severe Thunderstorm Snow fall Blizzard Ice Storm Earthquake Tidal Wave Temperature Extremes

Drought Flood, External Wild Fire Landslide Volcano Epidemic

©2000 American Society for Healthcare Engineering Developed by SBM Consulting, Ltd.

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Emergency Management

HR.2.20Staff, LIP’s, students and volunteers can

demonstrate their role relative to safety Can describe or demonstrate:

• Risks within the environment• Actions to eliminate, minimize, or report risks• Procedures to follow in the event of an incident• Reporting processes for common problems, failures,

and user errors

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Emergency Management

EC.4.20The hospital conducts drills regularly to test

emergency managementTwo drills annually, conducted at least four

months apart and no more than eight months apart

One must include an influx of simulated patientsOne must be communitywideThe communitywide drill can be tabletop

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Emergency Management

IC.6.10As part of emergency management activities,

the hospital prepares to respond to an influx, or the risk of an influx, of infections patients Including determining how it will keep abreast of

current information about the emergency of epidemics or new infections, and

how it will disseminate critical information to staff and practitioners

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Issues: Improving Organizational Performance

Hospitals collect data to monitor performanceStaff opinions, needs, perceptions of risks, and

suggestions for improving patient safety

Undesirable patterns or trends in performance are analyzed

Both include management of overcrowding

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11. Managing Patient Flow

Patient Flow, not ED Overcrowding Surveyed Beginning July 1, 2004 Scored Beginning January 1, 2005

(note: standard number change from LD.10.11 to LD.3.11, to LD.3.15)

No longer includes: “These temporary locations must be outside of the Emergency Department and in an appropriate patient care area.”

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Managing Patient Flow

LD.3.15The leaders develop and implement plans

to identify and mitigate impediments to efficient patient flow throughout the hospital

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Rationale of LD.3.15 Managing the flow of patients through their

care is essential to the prevention of patient crowdingA problem that can lead to lapses in patient

safety and quality of care Emergency Department is particularly

vulnerable to experiencing negative effects of inefficiency in the management of this process

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Rationale of LD.3.15 Emergency Departments have little control

over the volume and type of patient arrivals Most hospitals have lost the “surge

capacity” Improved management of processes can

ensure the wise use of limited resources and thereby reduce the risk to patients of negative outcomes Includes delays in the delivery of treatment,

care, or services

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Rationale of LD.3.15Leadership should identify all of the processes

critical to patient flow through the hospital system From the time patient arrives to discharge

Supporting processes are included if identified by leadership as impacting patient flow Diagnostic Communication Patient transportation procedures

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Elements of Performance (9)

1. Leaders assess patient flow issues within the organization, the impact on patient safety, and plan to mitigate that impact

2. Planning encompasses the delivery of appropriate and adequate care to admitted patients who must be held in temporary bed locations

Post anesthesia care units Emergency Department areas

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Elements of Performance

3. Leaders and medical staff share accountability to develop processes that support efficient patient flow

4. Planning includes the delivery of adequate care and services to those patients who are placed in overflow locations (corridors)

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Elements of Performance

5. Specific indicators are used to measure components of the patient flow process and components

Available supply of patient bed space Efficiency of patient care and treatment areas Safety of patient care and treatment areas Support service processes that impact patient flow

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Elements of Performance

6. Indicator results are available to those individuals who are accountable for processes that support patient flow

7. Indicator results are reported to leadership on a regular basis to support planning

Includes individuals who are accountable for processes that support patient flow

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Elements of Performance

8. Organization improves inefficient or unsafe processes identified by leadership as essential in the efficient movement of patients through the organization

9. Criteria are defined to guide decisions about initiating diversion

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Thank YouThank You