While the month of December is often spent focusing on the holidays and time spent with Family and Loved ones, the end of December is often a time when we focus on reorganizing ourselves in preparation for the New Year both from a personal and work perspective.
To help you along from a work perspective, below is our list of Top 20 “To Do’s” for 2020:
1. Assemble your multi-disciplinary team to research, develop and implement your organization’s Maternal Hemorrhage Identification & Response Program. Consider using the resources posted on AWHONN’s page at https://www.awhonn.org/page/PPH
2. Review the Omnibus Reduction Act 2019. Assemble a multi-disciplinary team to review the latest changes to the patient discharge process and take action to achieve compliance. CMS Resource Page: https://www.cms.gov/newsroom/fact-sheets/omnibus-burden-reduction-conditions-participation-final-rule-cms-3346-f
3. Ensure that your facilities management team has all of the EC and LS documents ready for survey. Access the Life Safety & Environment of Care Document List and Review Tool that is available to you within The Joint Commission Survey Activity Guide and cross check your documents to the list. https://www.jointcommission.org/assets/1/6/LS_EC_Tool_LSC_2012.pdf
4. Review your Hand Hygiene compliance efforts. Are you monitoring compliance? If so, what are your trends? Do your staff understand the impact of poor hand hygiene compliance? Get a test kit and see if your staff are washing their hands effectively. Check out the Joint Commission resources at https://www.jointcommission.org/topics/hai_hand_hygiene.aspx
5. Ensure your Life-Safety/Facilities team is using The Joint Commission Fire Drill Matrix to track your fire drills. The matrix is available in the Survey Activity Guide that is available on the TJC website or by clicking here: https://www.jointcommission.org/assets/1/6/Fire_Drill_Matrix.xls
6. Make certain your Antibiotic Stewardship Program is addressing your ambulatory care locations. Consider posting the CDC signage available at: https://www.cdc.gov/antibiotic-use/community/pdfs/aaw/cdc-au-wait-room-poster-11×17-p.pdf or https://www.cdc.gov/antibiotic-use/community/pdfs/aaw/au_can-i-feel-better-without-antibioticsinfographic_8_5x5_5_4_508.pdf or visit the CDC website for additional options.
7. Review your high-level disinfection practices. Are you following the principles listed in the Joint Commission HLD BoosterPak? Are your staff following manufacturer’s Instructions for Use for instrument cleaning, use of disinfectants (including PPE) and equipment? Are logs reflective of accurate documentation? Are brushes used and stored appropriately? Transport of contaminated instruments in leakproof and puncture resistant containers? https://www.jointcommission.org/assets/1/6/TJC_HLD_BoosterPak.pdf
8. Ensure your staff are following the manufacturer’s Instruction for Use (IFU) in cleaning your medical equipment and devices. Create a binder with the IFU’s and ensure your staff know how to clean and where the resource can be accessed for reference. Consider how you are documenting staff training/competency in cleaning medical equipment. Now is a good time to have each department review their IFU’s for all equipment to ensure they are following and adhering to the most current version.
9. Conduct a tracer on the use of Personal Protective Equipment. Observe the routine use of PPE, then ask staff questions. How do you know what PPE to wear? Demonstrate to me how you would don it? How to do you remove it? When do you remove it? Where do you place it after use? Consider using the great training posters available on the CDC website https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
10. Conduct a sweep of all carts, trays, caddies, cabinets, drawers and other areas where medical supplies are stored for expired items. Are there any items that are not part of your normal inventory that may expire before they are used? When is the last time your par levels for supplies were reviewed? Adjust your supply storage to reduce overhead, free up space and reduce the risk for expired supplies.
11. Monitor the Federal Register for CMS’ Final Rule regarding Co-Located Hospitals. Follow up to QSO 19-13 (May 3, 2019 publication): https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-19-13-Hospital.pdf
12. Monitor the Federal Register for publication of the final changes to the Stark Law. http://starklaw.org/
13. Verify all maintenance, testing and inspections have been completed (fire doors, fire alarm system, utility systems, etc.) Fire Doors: https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=80
Fire Alarm Systems: https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=72
14. Ensure staff have received their annual required Emergency Management training – specific to organizations. FEMA training catalog: https://www.firstrespondertraining.gov/frts/npccatalog?catalog=EMI
FEMA Independent Study Program listing: https://training.fema.gov/is/crslist.aspx
15. Conduct your 2020 annual Life Safety Compliance Assessment. Access the Joint Commission EC portal for resources at: https://www.jointcommission.org/topics/the_physical_environment.aspx
16. Ensure your organization’s policy on Sentinel Events is up to date. Joint Commission released changes to Sentinel Event Definitions effective Jan 1, 2020. Check the November edition of Joint Commission Perspectives or review our On The Radar message here: https://courtemanche-assocs.com/sentinel-event-definitions-change/
17. Complete your 2020 HVA and Vulnerable Patient Population assessment. FEMA resources located at https://www.fema.gov/hazard-identification-and-risk-assessment
18. Conduct a sweep of your spaces for equipment requiring repair or disposal. Work with your organization to remove these from areas of patient care. Consolidate and clean up storage of administrative materials. Organize storage and reduce clutter.
19. Review your falls rate. Are you doing enough to reduce falls? Check out resources on fall reduction from The Joint Commission at: https://www.centerfortransforminghealthcare.org/what-we-offer/targeted-solutions-tool/preventing-falls-tst
20. Review your organizations compliance with NPSG.03.05.01 (National Patient Safety Goal for Anticoagulant Therapy) that became active in July 2019. https://www.jointcommission.org/assets/1/18/NPSG_03.05.01_Resources.pdf
Happy Holiday’s from the staff at Courtemanche and Associates! We wish you a safe and productive New Year and look forward to serving you in 2020!
