Top FAQs Slides Sept 30

7/25/2019 Top FAQs Slides Sept 30

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Top FAQs

Hospital AccreditationSeptember 30, 2015

Donna Tiberi ,RN, BS, HA

Standards !nterpretation "Accreditation ana#er


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Objectives

Review of actual HFAPs

frequently asked questions (FAQs)

Increase awareness and

understanding of Acute Carestandard co!liance

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PLEASE NOTE

All Allied Healt" Professional

requireents "ave #een deletedfro C"a!ter $ and are now

located in C"a!ter % & 'edical

ta*

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FAQs +e t"oug"t it would "el!ful to review frequently asked questions

su#itted #y "os!itals to !rovide clari,cation*

-ften ties accreditation organi.ations are told t"at t"ere isinconsistency wit" t"eir FAQ res!onses* -rgani.ations re!ort t"att"ey ask t"e sae questions/ #ut receive dierent answers* 0"iscan #e true* However/ one reason w"y FAQs are answered dierentlyis #ecause questions were !"rased dierently* Its not uncoonfor organi.ations to call in to A-s any ties or su#it t"e saequestion ulti!le ties for t"e sae issue* 1ven one word canc"ange t"e answer2

Its i!ortant to ree#er t"at #ased on "ow a question is writtenor asked will deterine "ow our tandards Inter!retationde!artent will res!ond to your question*

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01.00.07Governing Body es!onsibi"ities

Q3 0"e Acute Care standard (45*44*46)

requires t"at t"e governing #oard#ylaws address t"e res!onsi#ilities fort"e !"ysical !lant* I do not understand"ow to i!leent t"is* 7o I need a

stateent in t"e #ylaws t"at s!eak tow"at our current !rocess entails8

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01.00.07Governing Body

es!onsibi"itiesAns#er$0"e #ylaws of t"e governing #ody ust state t"at t"e governing #ody isres!onsi#le for t"e 9!rovision for t"e adequacy of t"e !"ysical !lant*9 0"isstateent esta#lis"es t"e role and res!onsi#ilities of t"e governing #ody toensure a safe environent for !atients/ visitors/ and sta*

It is t"e res!onsi#ility of t"e governing #ody to review safety re!orts/ins!ections/ and ot"er re!orts of t"e !"ysical condition and take correctiveaction/ including t"e release of funds as necessary*

:e sure t"e coittee inutes at eac" level/ es!ecially t"e governing#ody/ re;ect t"e review of t"ese re!orts and any corrective actions taken

as indicated*

0"e


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. .&tegories E"igib"e /or

A!!oint+entid"eve" Pr&ctitioners

Q3 0"e Acute Care standard states t"att"e nu#er of allied "ealt"!rofessionals t"at ay #e su!ervised#y a single !"ysician is liited in soestates*

+"ere can I ,nd t"e ratio so t"at I awit"in t"e state liitations8

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. . &tegories E"igib"e /or A!!oint+ent

S,!ervision o/ A""ied 2e&"t%Pr&ctitionersAns#er$

=ou ay refer to your state>s Advanced ?ursePractice Act and t"e P"ysician Assistant Practice

Act to identify w"et"er t"ere is a liit*


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10.01.0-3n/or+&tion in edic&"

ecordsQ3 0"e Acute Care standard (54*45*4$)states t"at !arts of t"e edical record t"at

are t"e res!onsi#ility of t"e !"ysician ust#e aut"enticated #y t"e !"ysician*

0"e standard also sti!ulated t"at it is u! tot"e institution to de,ne t"e rules @regulations for aut"enticationdelegation*Are all "istory @ !"ysicals (H@Ps) su#Bect tocosignature8

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ecordsAns#er$'edical sta !olicies identify t"ose !ortions of t"e edicalrecord/ if any/ t"at ay #e delegated to a non!"ysician!ractitioner* 'edical sta !olicy/ consistent wit" tate law de,nes30"e !ortions of t"e edical record t"at ay #e delegated to non!"ysician !ractitioners/ suc" as3

'edical History

P"ysical 1Daination

Progress ?otes

-!erative Re!ort

7isc"arge uary

0"e requireents for cosignature andor aut"entication/ consistent wit"

tate law for non!"ysician !ractitioners/ es!ecially3

?urse Practitioners

P"ysician Assistants

Certi,ed Registered ?urse Anest"etists (CR?A)

Certi,ed ?urse 'idwifes

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0(.01.14e5,ired A!!"ic&tion &nd e&!!"ic&tion$

3n/or+&tion to be evie#edri+in&" B&c6gro,nd %ec6s

Q3 +"at ty!e of criinal #ackground c"ecks are required to

run on e!loyees8 Per Indiana state law/ we are required too#tain liited criinal #ackground "istory*

+e are not o#taining3 5) social security traceE $) countycriinal c"eck for all counties livedE %) ultistate/ ultiBurisdiction searc"E and ) all G4 states seD oender registries*

7uring our last survey/ we were not cited #ut were questioneda#out our searc"es* 0"e surveyor entioned t"at statewidesearc"es are !ulled dierently t"an ultistate searc"es*

Are our current searc"es acce!ta#le8

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3n/or+&tion to be evie#ed

Ans#er$

HFAP is not !rescri!tive* Criinal #ackgroundc"ecks is often a state requireent and variesgreatly/ state to state* 0"ere are any ty!es ofsearc"es to consider* =our "uan resourcesde!artent s"ould develo! t"is !olicy in colla#orationwit" t"e legal de!artent*

0"e "os!ital will conduct criinal #ackgroundinvestigations #ased on inforation !rovided in t"ea!!lication or as required #y federal and stateregulations

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0(.01.14e5,ired A!!"ic&tion &nd

e&!!"ic&tion$ 3n/or+&tion to beevie#ed

'contin,ed )

0"e "os!ital will conduct criinal #ackground c"ecksas allowed #y tate law for all !otential new "ires

0"is !olicy s"ould esta#lis" "ow eDtensive t"ecriinal #ackground c"eck will #e in ters of3

0"e nu#er of years to #e searc"ed

+"et"er t"e searc" will #e liited to your state or #eyond* oefacilities "ave i!leented ,nger!rinting for new e!loyees/ #ut

again t"is is not an HFAP requireent

Certain states "ave ore eDtensive requireents for t"ose e!loyedin nursing "oes/ #e"avioral "ealt" or ental "ealt" facilities

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0(.01.14e5,ired A!!"ic&tion &nd

e&!!"ic&tion

Q3 1!loyent veri,cation fro forere!loyers "as #een increasingly dicultand a tie consuing task* +e wouldlike to know w"at ot"er eans wouldeet t"e standard8

+e currently conduct skills c"ecklists onclinical sta and all new "ires "ave a#ackground c"eck*

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0(.01.14e5,ired A!!"ic&tion&nd

e&!!"ic&tionAns#er$+e would suggest develo!ing a !olicy in colla#oration wit" yourlegal de!artent outlining your !rocess for o#taining referenceinforation*

0"is !olicy s"ould s!ecify t"e nu#er of atte!ts t"at will #e ade

to o#tain references* Per"a!s you will ail two requests and send at"ird as 9certi,ed ail*9

0"e !olicy s"ould also outline docuentation eD!ectations/ e*g*/9?o res!onse received fro letter ailed on uly 5/ DDDD* econdletter ailed to DDDD on uly 56/ DDDD*9

=our facility ay also consider t"e use of electronic eans torequest t"is inforation* For soe facilities/ t"is "as #een aneective eans used #y t"e 'edical ta ocers to o#tainreferences in a tiely anner*

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3n/or+&tion to be evie#ed'contin,ed)

Ans#er$

At tie of survey/ your facility s"ould #ea#le to s!eak to t"e requireents

esta#lis"ed #y your state and #e a#le toeD!lain your !olicy @ !rocedures*

0"e "os!ital ust #e a#le to s!eak to t"ea!!lication request inforation regardingany criinal "istory

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0(.01.1Te+!or&ry Privi"eges

Q3 +"at are t"e standardrequireents for assigningte!orary !rivileges to a

!"ysician8

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Ans#er$It is not !eritted to grant te!orary!rivileges until suc" tie as t"e a!!ointent orrea!!ointent !rocess can #e co!leted*

All a!!licants requesting !rivileges ust got"roug" t"e entire credentialing and !rivileging!rocess for a!!roval*

For t"ose t"at cannot wait/ t"is eans t"at anad "oc or 'edical 1Decutive Coitteeeeting s"ould #e sc"eduled sooner t"an!lanned*

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'contin,ed)

Ans#er$

0"e edical sta #ylaws s"ould clearly de,ne t"e !rocess for grantingte!orary !rivileges* -f course/ your edical sta ay !refer to wait untilall % references #efore t"e a!!lication is su#itted to t"e c"iefde!artent

c"air and C1-* 0e!orary !rivileges s"ould #e te!orary and tieliited*Ina!!ro!riate granting of te!orary !rivileges could #e a violation of t"eAcute Care standard (4%*45*5$) Jnifor A!!lication of 'e#ers"i! Criteria)t"at requires a unifor a!!lication of e#ers"i! criteria* It is not!eritted to grant te!orary !rivileges until suc" tie as t"e a!!ointentor rea!!ointent !rocess can #e co!leted* Please review t"e Acute Care

standard (4%*45*5K) for additional inforation*

All a!!licants requesting !rivileges m$st #o t%ro$#% t%e entirecredentialin# and pri&ile#in# process 'or appro&al( For t"ose t"atcannot wait/ t"is eans t"at &n &d %oc or edic&" E8ec,tiveo++ittee +eeting s%o,"d be sc%ed,"ed sooner t%&n !"&nned.

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09.00.04o+!etency

Q3 Can you !rovide a

descri!tion of t"e sco!e of!ractice for Licensed Practical?urses (LP?s)8

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09.00.04o+!etency

Ans#er$

0"e sco!e of !ractice for LP?s is de,nedt"roug" your facility>s !olicies @ !roceduresand in accordance wit" your state law*

0"e Bo# descri!tions ust re;ect t"e sco!eof !ractice and "ow t"is individual willfunction wit"in your organi.ation/ includingsu!ervision requireents in certain settings ofcare*

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09.00.04ode B",e

Q3 Is t"ere a requireent for

conducting a ock Code :lue(eergency code) eDercise8

0"ere is a requireent for ,re/#ut not sure a#out Code :lue*

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09.00.04o+!etency

ode B",eAns#er$HFAP standards are not !rescri!tive* 0"ere is no standard t"ats!eaks to "os!ital codes* However/ t"e Acute Care standard

(4*44*4G) s!eaks to sta co!etency !er "os!ital !olicy*

ta ust #e quali,ed and co!etent to !erfor t"eir dutiesas assigned* Conducting a ock 9Code :lue9 ay #e oneeDa!le your facility "as de,ned as a !olicy to ensure staco!etence via !ractice*

If sta is required to #e certi,ed in Advanced CardiovascularLife u!!ort (ACL)/ Pediatric Advanced Life u!!ort (PAL)/ :asicLife u!!ort (:L)/ etc*/ t"e sta ust also aintain certi,cation

every t#o ye&rs &s re5,ired !er certi:c&tion.Again/ t"ere isno HFAP requireent for conducting a ock Code :lue*

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09.00.0;Ev&",&tion o/ o+!etence

Q3 0"e Acute Care standard (4*44*4M)indicated t"at co!etence evaluations

s"ould #e at least on an annual #asis*-ur organi.ation is considering a c"angein t"e tieline/ #ut will aintain on anannual #asis* +it" t"is c"ange/ soeevaluations ay #e earlier or later t"ant"e last evaluation* Is t"is acce!ta#le8

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Ans#er$

=es/ suc" !ro!osed c"anges would #e

acce!ta#le* However/ #e sure toeoriali.e your !lan and t"e details of allc"anges*

Also/ #e sure to docuent t"ese c"angesin your Leaders"i! eeting inutes*

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Q3 -ur leaders"i! sta is consideringallowing Cat" La# 0ec"nicians to insertPeri!"erally Inserted Central Cat"eters(or PICC lines)*

Is t"ere a standard requireent a#outw"o s"ould #e inserting intravenouslines8

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Ans#er$=our facility de,nes t"e duties and res!onsi#ilities of eac"disci!line t"roug" a Bo# descri!tion*

0"e Acute Care standard (4*44*4M) requires t"at sta ust #e

co!etent in knowledge/ skills and a#ility to !erfor t"eirres!onsi#ilities*

0"ere ust #e an o#Bective !rocess !erfored at de,ned intervalsfor assessing and evaluating t"e co!etence of all e!loyees*

As long as your sta "ave co!leted a!!ro!riate training and!assed co!etency assessents/ sta ay !erfor !rocedures orservices wit"in t"eir sco!e of !ractice and in accordance wit""os!ital !olicy/ state law @ regulations*

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09.00.10Ne# E+!"oyee Orient&tion r&!!ing* Stor&ge o/*< ?istrib,tion o/ Steri"e E5,i!+ent < S,!!"ies

Q3 Is t"ere a standard t"at

address storage of sterileinstruents8

+"at is t"e recoendedte!erature for all sterilestorage areas8

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07.0-.09Pre!&ring* Asse+b"ing* >r&!!ing* Stor&ge o/* s entire care during "is"er in!atient

or out!atient treatent*

0"e edical record ust containinforation to Bustify adission/ continued

"os!itali.ation/ su!!ort t"e diagnosis/ anddescri#e t"e !atient>s !rogress and res!onseto edications and treatent services*

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. .3n/or+&tion in edic&"

ecords

Q3 7oes HFAP recogni.e t"ea#ility of idlevel !ractitioners/

suc" as P"ysician Assistants(PAs)/ to cosign for !"ysicians

t"at "ave delegated t"e!erforance of edical serviceto t"is individual8

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10.01.0-3n/or+&tion in edic&" ecords

Ans#er$@es HFAP recogni.es t"e a#ility of idlevel!ractitioners cosign for !"ysicians*

'edical sta !olicies identify t"ose !ortions of t"e edical record/

if any/ t"at ay #e delegated to a non!"ysician !ractitioner*

Jnder standard 54*45* 4$ it states t"at t"e 'edical sta !olicy/consistent wit" tate law de,nes t"e !ortions of t"e edical recordt"at ay #e delegated to non!"ysician !ractitioners/ suc" as3

'edical History

P"ysical 1Daination Progress ?otes

-!erative Re!ort

7isc"arge uary

Also refer to standard %4*44*54 History @ P"ysical*

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ecords'contin,ed)

Ans#er$

0"e requireents for cosignature andoraut"entication/ ust #e consistent wit" tate law fornon!"ysician !ractitioners/ es!ecially3

?urse Practitioners

P"ysician Assistants

Certi,ed Registered ?urse Anest"etists (CR?A)

Certi,ed ?urse 'idwifes

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10.01.04Pre!rinted Orders* Order Sets

< Protoco"s

Q3 In regards to t"e Acute Care

standard (54*45*4G)/ ite %/w"at is t"e required frequencyfor reviewing !re!rintedorders/ order sets and!rotocols8

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10.01.04Pre!rinted Orders* Order Sets

< Protoco"sAns#er$

All edication standing orders or routine !rotocolsare su#Bect to &nn,&" revie# &ndor revision

A"" !rotoco"s &nd !r&ctice g,ide"ines for!atient care ust #e reviewed on an &nn,&" b&sisto ensure all inforation is u!todate wit" current

!ractice guidelines* 0"e 'edical standing ordersand !rotocols are to #e reviewed #y t"e !rofessionaledical sta via its coittee structure

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10.01.1?isc%&rge S,++&ry

Q3 Is it a requireent to

"ave a list (or te!late) ofw"at to include in a

disc"arge suary8

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10.01.1?isc%&rge S,++&ry

Ans#er$=our facility s"ould "ave a !olicy a!!roved #y t"e edical sta t"atoutlines t"e eD!ectations for t"e disc"arge suary/ includingtieliness for co!letion and content* Please refer to t"e Acute Carestandard (54*45*5K) 7isc"arge uary/ for t"e entire requireent*0"e edical records ust contain a disc"arge suary wit" outcoeof "os!itali.ation/ dis!osition of case/ and !rovisions for followu! care*

0"e disc"arge suary requireent would include out!atientrecords* For eDa!le3

5* 0"e outcoe of t"e treatent/ !rocedures/ or surgery

$* 0"e dis!osition of t"e case

%* Provisions for followu! care for an out!atient surgery !atient or aneergency de!artent !atient w"o was not aditted or transferred toanot"er "os!ital

7isc"arge suaries ust #e co!leted wit"in 6 days of disc"arge*0"e edical record ust #e co!leted wit" in %4 days*

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14.01.0(o+!"&ints &nd Griev&nces

Q3 If t"e governing #ody "as

delegated t"e !rocess forresolution of co!laints andgrievances to a coittee or

de!artent/ does t"at coitteeor de!artent need to re!ort #ackto t"e governing #ody8

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14.01.0(P&tient Griev&nces

Ans#er$=es/ t"e coittee for co!laintsgrievances would need tore!ort #ack to t"e governing #ody* Counication re!orting s"ouldalways go u! to all leaders"i! levels*

Please ree#er t"at t"e "os!ital>s governing #ody is res!onsi#le

for t"e eective o!eration of t"e grievance !rocess* 0"is includest"e "os!ital>s co!liance wit" all of t"e C' grievance !rocessrequireents*

A written co!laint is always considered a grievance andinforation o#tained fro !atient satisfaction surveys usually does

not eet t"e de,nition of a grievance*

7ata collected regarding !atient grievances/ as well as ot"erco!laints ust #e incor!orated in t"e "os!ital>s QualityAssessent and Perforance I!roveent (QAPI) Progra*

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1.00.10onscio,s Sed&tion

Q3 +"en !erforingconscious sedation/ t"e nurse

!roviding t"e sedation is alsoonitoring t"e !atient ands"ould not #e t"e circulatingnurse* Is t"is correct8

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48/69

1.00.10oder&te Sed&tion$ Assisting >it%

t%e Proced,reAns#er$=es/ t"is is correct* tandard 5K*44*54 states t"at t"e !roceduralist s"all"ave an assistant assigned w"enever oderate sedation is adinisteredE t"isassistant ay #e anot"er !"ysician/ R?/ LP?LS?/ or tec"nician*

0"e +onitoring R? ay #e counted as t"e 9R? !lanning and su!ervising

nursing careT for t"e !atient*D$rin# s$r&e* t%e s$r&e*ors ill re&ie to determine t%at polic*re/$ires moderate sedation cases to %a&e a minim$m o' to 2 sta

one 1 to monitor

one 1 to assist t%e p%*sician

0"e nurse adinistering sedation cannot #e t"e nurse assisting wit" t"e!rocedure or #e t"e circulating nurse in t"e roo*

Please review t"e Acute Care standard (5K*44*4K 'oderate edation) foradditional inforation

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1;.00.1(Q,&"i:ed Personne"

Q3 +"at stang

quali,cations are requiredto assist and !rovide

oderate sedation during a#ronc"osco!y8

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1 . .1Q,&"i:ed Personne" St&C

Q,&"i:c&tionso+!etencyAns#er$=our edical sta will need to de,ne t"e quali,cations for sta t"at can assist wit"

!atients receiving oderate sedation*

Hos!itals are eD!ected to regularly reassess sta co!etency and to !rovide!eriodic training needed to kee! sta skills u!todate*

0"e "os!ital ust docuent training co!letion dates and evidence of satisfactoryco!etence*

ta t"at co!lete training #ut cannot deonstrate satisfactory co!etence ustnot #e !eritted to use radiologic equi!ent andor adinister !rocedures

0"e quali,cations s"ould #e written in eit"er t"e Bo# descri!tion or a!!roved !olicy*It is recoended t"at t"e education de!artent !re!are a training !rogra wit" a!osttest to ensure co!etency* :ot" training !rogra and !osttest ust #e

su#itted to t"e director of anest"esia for a!!roval* =ou ay review t"e Acute Carestandards (5M*44*5%$4*44*465G*4$*%4) for additional inforation*

T%e Associ&tion o/ !eriO!er&tive egistered N,rses 'AON) is a valua#leresource and ay oer eDa!les3 '%tt!s$###.&orn.orged,c&tionc,rric,",+con:denceb&sedD"e&rning+oder&teDsed&tion.&s!8). A"so* t%e A+eric&n Society o/ Anest%esio"ogists'ASA) #ebsite !rovides g,ide"ines re"&tive to +oder&te sed&tion.

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-4.01.0(Sec,rity o/ edic&tions

Q3 -ur cras" cart and -ni

edication syste is located in analcove #y t"e nurses> station* 7ot"ey "ave to #e #e"ind locked

doors8

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-4.01.0(Sec,rity o/ edic&tions

Ans#er$

0"e cras" cart and -ni edication systeust #e aintained in an area t"at allows for

sucient sta trac to notice anyoneatte!ting to access cart w"en not aut"ori.ed*

ta ust #e a#le to view t"e cart fro t"estation or ;oor area* It is recoended t"at

your facility conduct a risk assessent todeterine !otential unaut"ori.ed access to t"ecart*

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53/69

(0.00.04S,rgic&" Privi"eges

Q3 7oes a "os!ital

e!loyed First Assist needto #e credentialed and

!rivileged8

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54/69

(0.00.04S,rgic&" Privi"eges* N :rst

&ssist&ntsAns#er$@es* t%e :rst &ssist&nt +,st be credenti&"ed &nd !rivi"eged* #%et%ere+!"oyed by t%e %os!it&"* & !%ysici&n or ot%er entity* or & contr&cted!rovider.

0"e First Assist/ also known as Certi,ed urgical First Assistant CFA)

'ust #e considered a edical !rofessional w"o assists surgeons during surgeries*

0"e !ractitioner is individually credentialed #ased on t"eir own individualquali,cations* =ou ay wis" to refer to t"e Acute Care anual standard (%4*44*4G)for ore detail on Allied Healt" Practitioner categories* If t"e "os!ital utili.es R?First Assistants/ surgical PA/ or ot"er non'77- surgical assistants/ t"e "os!italust esta#lis" criteria/ quali,cations and a credentialing !rocess to grant s!eci,c

!rivileges to individual !ractitioners #ased on eac" individual !ractitionersco!liance wit" t"e !rivilegingcredentialing criteria and in accordance wit"Federal and tate laws and regulations* 0"is would include surgical services tasksconducted #y t"ese !ractitioners w"ile under t"e su!ervision of an '77-*

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Q3 7oes "os!itale!loyed

urgical Assistants andurgical 0ec"nicians need to#e credentialed t"roug" t"eedical sta !rocess8

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Ans#er$=our facility ay c"oose to use eit"er t"e edical sta or "uanresources de!artent !rocess in accordance wit" federal and state laws @regulations* =our facility ust3

Have edical sta a!!roved quali,cations t"at details t"e eD!ectations regardingeducation/ training/ eD!erience/ certi,cationlicense as a!!ro!riate to t"e !osition*

Have edical sta a!!roved !rivileges t"at detail t"e surgical tasks t"at area!!ro!riate for t"e !osition* 0"is ay #e in t"e for of eit"er a Bo# descri!tion or listof !rivileges*

Have a !rocess to credentialvalidate t"e quali,cations of t"e individual/ includingeducation/ training/ eD!erience/ certi,cationlicense as a!!ro!riate to t"e !osition*

Have a !rocess for t"e ongoing evaluation of co!etency of t"e individual* "ouldyour facility deterine t"ese individuals are to go t"roug" t"e edical stacredentialing !rocess/ t"ey ust follow t"e sae !rocedures as t"e edical sta!ersonnel*

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contin,edAns#er$Credentialing and !rivileging criteria requireents a!!ly to all categories of!ractitioners utili.ed in t"e facility* 0"e granting of surgical !rivileges is a function ofgovernance u!on t"e recoendation of t"e Professional 'edical ta* Initial andrevised renewed !rivileges are co!ied to t"e surgical services*

Requireents a!!ly to all categories of !ractitioners utili.ed in t"e facility* 0"e grantingof surgical !rivileges is a function of governance u!on t"e recoendation of t"e

Professional 'edical ta* Initial and revised renewed !rivileges are co!ied to t"esurgical services

If t"e "os!ital utili.es R? First Assistants/ surgical PA/ or ot"er non'77- surgicalassistants/ t"e "os!ital ust esta#lis" criteria/ quali,cations and a credentialing !rocessto grant s!eci,c !rivileges to individual !ractitioners #ased on eac" individual!ractitioners co!liance wit" t"e !rivilegingcredentialing criteria and in accordance wit"Federal and tate laws and regulations* 0"is would include surgical services tasksconducted #y t"ese !ractitioners w"ile under t"e su!ervision of an '77-*

+"en !ractitioners w"ose sco!e of !ractice for conducting surgical !rocedures requirest"e direct su!ervision of an '77- surgeon/ t"e ter Usu!ervisionT would ean t"esu!ervising '77- surgeon is !resent in t"e sae roo/ working wit" t"e sae !atient*

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. .


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. .ondition o/ P&rtici!&tion$

edic&" Le&ders%i! /or Anest%esi&

Services

Q3 +e were infored t"at

"os!itals will #e cited for not"aving an Anest"esia RescueCa!acity !olicy* +"at needs to#e included in t"is !olicy forco!liance8

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(0.01.00


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(0.01.00ondition o/ P&rtici!&tion$

edic&" Le&ders%i! /or Anest%esi&

ServicesAns#er$

0"e "os!ital ust deonstrate t"at its eergency services areintegrated into its ot"er de!artents* 0"e integration ust #esuc" t"at t"e "os!ital can iediately ake availa#le t"e fulleDtent of its !atient care resources to assess and rendera!!ro!riate care for an eergency !atient*

A /&ci"ity +,st be &b"e to res!ond to &ny "i/e t%re&tening

!&tient e+ergency b&sed on %os!it&" services !rovided in&ccord&nce #it% t%eir !&tient !o!,"&tion 'i.e.* neon&t&"*!edi&trics* &d,"ts etc.).

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. . diti / P ti i ti


60/69

. .ondition o/ P&rtici!&tion$

edic&" Le&ders%i! /or Anest%esi&Services

contin,edAns#er$esc,e &!&city$ :ecause t"e level of sedation of a !atient receivinganest"esia services is a continuu/ it is not always !ossi#le to !redict "ow

an individual !atient will res!ond* Furt"er/ no clear #oundary eDists #etweensoe of t"ese services* Hence/ "os!itals ust ensure t"at !rocedures are in!lace to rescue !atients w"ose level of sedation #ecoes dee!er t"an

initially intended/ for eDa!le/ !atients w"o inadvertently enter a state of

7ee! edationAnalgesia w"en 'oderate edation was intended*

esc,e fro a dee!er level of sedation t"an intended requires anintervention #y a !ractitioner wit" eD!ertise in airway anageent andadvanced life su!!ort*

0"e quali,ed !ractitioner corrects adverse !"ysiologic consequences of t"e

dee!ert"an intended level of sedation and returns t"e !atient to t"eoriginally intended level of sedation* (Rescue ca!acity is not only required asan essential co!onent of anest"esia services/ #ut is also consistent wit"

t"e requireents*

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(0 01 0(


61/69

(0.01.0(oder&te Sed&tion

Q30"e Acute Care standard (%4*45*4%) liits!rivileges only to a list of !roviders t"at canadinister dee! sedation*

In our eergency de!artent (17)/ t"e!"ysicians are credentialed to give dee!sedation and to su!ervise* -ur registerednurses are also trained to give IS dee!

sedation in unusual circustances* Is t"is!ractice acce!ta#le8

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(0.01.0(


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(0.01.0(oder&te Sed&tion

'onscio,s Sed&tion)

Ans#er$0"e Acute Care standard (%4*45*4%) requires t"at anest"esia is furnis"edin a wellorgani.ed anner and liited to quali,ed individuals*Anest"esia services ust #e delivered in a anner t"at is consistentwit" t"e needs and t"e resources of t"e "os!ital*

"ould your facility deterine/ as a!!ro!riate/ to adinister IS dee! sedation int"e 17 or areas ot"er t"an surgery/ t"e 17 !"ysicians ust #e granted !rivilegesa!!roved #y t"e edical eDecutive coittee and t"e governing #ody* 0"e 17!"ysician requesting t"is !rivilege ust deonstrate co!etency*

0"e credentials coittee/ wit" in!ut fro t"e director of anest"esia/ isres!onsi#le to deterine t"e training requireents and t"e et"od to #e used to

evaluate co!etency*

Facilities will de,ne co!etency/ training requireents/ and et"ods toevaluate all sta t"at is !eritted to adinister sedation of any ty!e*

Co!etency is to #e reassessed wit" eac" rea!!ointent*

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E+!"oyee Ed,c&tion Fi"e


63/69

E+!"oyee Ed,c&tion Fi"eetention

Q3 How long s"ould we kee!

educational records on staeducation requireents/

e*g*/ education on restraintsor CPR8

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E+!"oyee Ed,c&tion Fi"e


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E+!"oyee Ed,c&tion Fi"eetention

Ans#er$HFAP "as no standard regarding t"e lengt" of tie for saving t"ese sta education,les* =ou ay want to seek direction fro your facility>s Risk 'anageent andor legalcounsel regarding t"e !referred !ractice* =ou ay also wis" to contact your state to

o#tain additional inforation as soe states ay "ave retention requireents* =ouay wis" to review Civil Rig"ts Act of 5MN and FLA se #elow3

Jnder t"e Civil Rig"ts Act of 5MN/ 0itle SII/ and t"e A7A/ e!loyers wit" at least,fteen e!loyees ust retain a!!lications and ot"er !ersonnel records relating to"ires/ re"ires/ tests used in e!loyent/ !rootion/ transfers/ deotions/ selection fortraining/ layo/ recall/ terinations of disc"arge/ for one year fro aking t"e recordor taking t"e !ersonnel action* ee ore at3 %tt!$cor!or&te.:nd".co+%,+&nreso,rcest%e%o#"ong+,ste+!"oyersret&ine+!"oyeerecords.%t+"st%&s%.tFnv9QFG.d!,/

$45G Jnder t"e FLA/ t"e recordkee!ing requireents are eit"er two years or t"reeyears de!ending on t"e ty!e of record involved3 ee ore at3%tt!$cor!or&te.:nd".co+%,+&nreso,rcest%e%o#"ong+,ste+!"oyersret&ine+!"oyeerecords.%t+"st%&s%.tFnv9QFG.d!,/

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?irect Access L

Q3 7oes HFAP "ave state

s!eci,c guidelines for statest"at allow direct access

(wit"out a !"ysicianorder)to !"ysical t"era!y8

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?irect P&tient Access L

Ans#er$HFAP will survey to ensure co!liance to state law @regulations for !"ysical t"era!y access*

oe states do not allow direct access and require a

!"ysician>s order/ !lan/ and signature to !roceed wit"treatent

oe states allow for u! to $5 days of care wit"insco!e of P0 !ractice guidelines to !rovide services#efore o#taining !"ysician order and signatures*

=ou ay wis" to refer to t"e following we#site3 $45G%tt!$###.&!t&.org,!"o&dedFi"esAPTAorgAdvoc&cySt&te3ss,es?irectDAccess?irectAccessbySt&te.!d/. ' !"e&se revie# (1.00.11 Orders /orO,t!&tient Services).

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onitoring End Tid&" O-

Q3 Is t"ere a requireentfor onitoring 1nd 0idalC-$ levels during

oderate sedation8

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onitoring End Tid&" O-

Ans#er$HFAP standards are not !rescri!tiveE "owever/ yourfacility is required to follow currentASA AmericanSociet* o' Anest%esiolo#ists !ractice guidelines to

ensure !atient care is delivered in a safe and eectiveanner*

=ou ay wis" to review t"e ASA g,ide"ines and ot"er

inforation at3###.&s&%5.orgFore+bersSt&nd&rdsG,ide"ines&ndSt&te+ents.&s!8

###.ncbi.n"+.ni%.gov!+c&rtic"esP(1=714(H

###.dre+ed.co++edic&"De5,i!+entDne#s+eetne#&s&st&nd&rds#it%#&ve"ineto,c%+onitors

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QIEST3ONSJ

Please submit questions to:

Donna Tiberi

Standard nter!retation

Dtiberi"#$a!%or&

or

in$o"#$a!%or&

or

Please 'all 312(202(8073

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