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Pharmacist Input Increases With New JCAHO Surveys

Donna Young

The amount of pharmacy "face time" during onsite surveying under the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO's) redesigned accreditation process—Shared Visions-New Pathways, which includes new medication management standards—is dramatically different than in previous surveys, said Rich Paoletti, director of pharmacy services for Crozer-Keystone Health System in Springfield, Pennsylvania.

As part of the accreditation process, JCAHO is using a "tracer" methodology in which the care of a patient is tracked throughout the health system.

Before the new accreditation process was implemented in January, surveyors generally scheduled visits to the pharmacy and typically met with pharmacy managers to review policies and procedures and discuss JCAHO's expectations of the facility, and they had little interaction with pharmacy staff, Paoletti said.

But when his facility was surveyed in early February under the new standards, he said, surveyors made multiple trips to the pharmacy and interacted frequently with pharmacy staff and pharmacists on patient care units.

"They were really not concerned with administrator or leadership input," Paoletti said. "They were more concerned with staff input and what the staff said."

JCAHO has shifted emphasis away from survey preparation and scoring to focusing the process on continuous compliance with standards to ensure safe, high-quality health care services, he explained.

If JCAHO issues a finding or recommendation, a facility has 90 days to respond with a plan of action.

Melanie D. Wolfe, coordinator of education and practice development at St. Luke's Hospital, a Mayo Clinic facility in Jacksonville, Florida, said the use of the tracer methodology to track medication and data use is an improvement over JCAHO's previous accreditation process.

St. Luke's ambulatory care clinic was surveyed in late January.

"The overall experience with the tracer process seemed to be more conducive to the surveyor really understanding what you do rather than sitting around the table and just answering questions, telling them what they want to know," Wolfe said.

Through the tracing process, surveyors "got to see the process in place" and practitioners were able to demonstrate that they were following policies and procedures, she added.

"My experience was a positive one," Wolfe said.

Richard Demers, assistant hospital director and pharmacy director at the Hospital of the University of Pennsylvania in Philadelphia, said that JCAHO's use of the tracer methodology provides pharmacy a "more fair assessment of the way you provide your service to the hospital."

Demer's facility was surveyed in late February.

"I think it's easier for [surveyors] to tease out whether you're doing the things that you should be doing to provide patient care," he said. "If you're not doing things [correctly], it's going to show with this. I think the staff feels better because . . . they saw a surveyor and they were able to tell them what they do and they get approval that what they're doing is a good thing. I think it's a better assessment. It's not easier; it's better."

Pharmacists at Innovis Health in Fargo, North Dakota, found the tracer methodology process to be "more valuable" to the hospital and surveyors in determining if clinicians were following policies and procedures and providing safe and thorough care to patients, said clinical pharmacist Curt Trowbridge.

"It's a lot better than going through pages and pages of policies and procedures like we used to do," he said.

Abbreviations. The use of unacceptable or do-not-use abbreviations was a high concern of surveyors during the five-day survey process at Paoletti's health system, he said.

As part of the National Patient Safety Goals, institutions should standardize abbreviations, acronyms, and symbols and must develop a list of abbreviations, acronyms, and symbols not to use in clinical communications.

JCAHO issued a list of nine do-not-use abbreviations last fall.

During the onsite survey, Paoletti said, surveyors not only reviewed medical charts and records to identify the use of inappropriate abbreviations, but they "actually looked on our storage shelves and our bins to see if we were using inappropriate abbreviations" in the pharmacy.

"I wasn't really expecting that," Paoletti confessed.

If a surveyor discovered an unacceptable abbreviation on an order, he said, the JCAHO team member would ask a pharmacist about what steps he or she would take to clarify the abbreviation before dispensing the medication.

Under JCAHO's medication management standards, orders that contain an unacceptable abbreviation should be considered invalid until the abbreviation's intended meaning is clarified.

Julie Bubach, clinical pharmacist at Innovis Health, stressed that JCAHO strictly enforces its standards about unapproved abbreviations.

"When they say they want compliance, they do want compliance," she said.

Bob Schultz, clinical pharmacist and Innovis interim pharmacy director, said his pharmacy established a system to track the use of unacceptable abbreviations, which generates a "feedback" letter to the health care professional who used the inappropriate abbreviation.

The letter identifies the unapproved abbreviation, when and where it was used, why it was inappropriate, and the correct abbreviation that should be used, he said.

Schultz submits a monthly report to the health system's performance improvement and medication safety committees about unapproved abbreviation use to "show where and if we are making improvement."

It has been difficult for some health professionals who have for many years used abbreviations, now determined to be inappropriate by JCAHO, to change their actions, said Demers.

"I don't know how you can take a physician who has been practicing for 35 years, trained to use these abbreviations, then all of a sudden say that tomorrow you have to stop and expect them to do it 100% of the time. That actually to me produces as much of a communication problem as you're resolving, theoretically," he said.

David M. Kile, director of pharmacy and respiratory care services at Ellis Hospital in Schenectady, New York, said that his facility made "concentrated efforts" to address use of unacceptable abbreviations, including having nurses contact prescribers each time an inappropriate abbreviation was used in orders or medical records.

"We were able to get the use of prohibited abbreviations down to 7% of total medication orders," he said.

But two surveyors during the onsite survey at his facility found some unacceptable abbreviations in patient medical records, Kile admitted.

Ellis Hospital was surveyed in late January, he said, and because his facility provides contracted pharmacy services to an adjacent rehabilitation facility, Sunnyview Hospital, he also participated in that institution's survey process in February.

Wolfe said that surveyors paid close attention to how her facility stored high-risk medications, including potassium chloride, magnesium, and other electrolyte products.

They were particularly concerned with the storage and security of high-risk drugs on crash carts and how those carts are secured and restocked.

Another medication management standard that health systems should be prepared to comply with is JCAHO's requirement to have a documented diagnosis, indication, or condition for each medication order, Kile noted.

When a surveyor could not identify an indication, condition, or diagnosis in a patient's records, including radiology and laboratory test results, for an antimicrobial that had been administered to the patient, the surveyor visited the pharmacy to ask why the product had been dispensed.

"It kind of put us on the spot, but it never did result in a particular recommendation from them," Kile said.

He attributed the lack of a recommendation to the fact that the new survey process is a learning experience for surveyors.

During the onsite surveys, he said, surveyors showed a lot more interest in automated systems and other technologies than in previous years.

Kile attributed surveyors' increased interest to his pharmacy's McKesson Robot Rx—a centralized robotic drug distribution system that automates the storage, dispensing, return, restocking, and crediting of bar-coded, unit dose inpatient medications—to JCAHO's new medication management standards and the emphasis on the patient safety goals.

Janet A. Silvester, pharmacy director at Martha Jefferson Hospital in Charlottesville, Virginia, said that, during the onsite visit at her institution, surveyors also expressed interest in her pharmacy's Robot Rx system and the hospital's McKesson AcuDose-Rx decentralized medication dispensing cabinets in the emergency department.

JCAHO surveyed Martha Jefferson Hospital's acute care facility, outpatient physician practices, and home health services in mid-March, Silvester said.

Surveyors were particularly interested in how the pharmacy stored look-alike and sound-alike drug products, she said.

But, she added, she was almost disappointed that the surveyors did not "probe a little more" than they did, and described the overall experience as "painless."