As we come to the close of 2023, and ready ourselves for an exciting 2024, the consulting team at
Courtemanche & Associates wanted to provide you with our list of 12 “ To Do’s” in 2024!
Top 12 for 2024
1. Evaluate your Health Equity and Disparities Program
Review your organizational assessment and the specific areas identified by your organization where opportunity for improvement exists. Assess your progress with your 2023 action plans and determine if you have had a positive impact. Be certain to plan additional actions for 2024. Use this evaluation as the foundation for your annual stakeholders report.
2. Review and Update your Survey Execution Plan
With the changes that were made to comply with CMS expectations, organizations should review their plan and adjust them to ensure a smooth process. Remember, no pre-survey notification, no blackout dates, and on-site surveys in response to complaints will mean your organizational plan will need to change.
3. USP 797 Gap Assessment
The final version of USP 797 was released in mid-2023, and TJC has published and posted its crosswalk for compliance expectations on its website. Use the crosswalk to determine where your organizational gaps exist and make modifications to ensure compliance.
4. Review your Competency Assessment Program
The Joint Commission Glossary contains definitions of education, training, and competency. Review your competency program to ensure that when you say you are assessing competency, you really are assessing the application of the SKILLS needed to complete the task. Consider revisiting the competency assessment process that was used during the Pandemic and ensure that the competency of staff recruited during the Pandemic was adequately assessed.
5. Review of your Live Plants Policy in the Patient Care Area
It is important to remember that immunocompromised patients have a higher likelihood of developing an infection than healthy individuals and may be vulnerable when exposed to live plants and soil. Review your live plant policy to determine if your patients are at risk. Consider these precautions that can be implemented in the patient-care setting, especially if there are immunocompromised patients:
- Limiting flower and plant care to staff with no direct patient contact
- Advising healthcare staff to wear gloves when handling plants
- Washing hands after handling plants
- Changing vase water every two days and discharging the water into a sink outside the immediate patient environment
- Cleaning and disinfecting the vases after use
6. Evaluate Inspection of Surgical Instrumentation
Ensuring that all instruments are inspected before sterilization is important for protecting the patient and the life of the instrumentation. Checking and inspecting all reuseable instruments for things such as rust, pitting, discoloration, retained bioburden, sharpness, smooth operation, loose, damaged or corroded connectors, overall instrument functionality and sharpness is essential to patient safety. Following the Manufacturer’s instructions for use and cleaning procedures is vital to ensure patient safety and prevent infection.
7. Review Rounding for Patient Safety
It is important to round in your organization to stay abreast of patient safety and regulatory issues in all areas of the facility. Review your current rounding practice to ensure you are evaluating all patient care areas consistently. Review rounding data to determine trends of opportunities. Ensure you evaluate for opportunities in the environment, quality and performance improvement, patient safety, and regulatory
compliance.
8. Point of Use Cleaning (POU) Evaluation
Point of Use cleaning is required before transporting contaminated instrumentation from the OR, procedure rooms, nursing units, or departments. Evaluate your current practices to determine if your practice is aligned with policy and evidence-based practice. This should include removing visible bioburden (blood, bone, etc.) from the instrument, keeping the instrument wet by spraying the instruments with an enzymatic spray/gel at the point of use (or using a water-soaked towel), and transporting them in a leak-proof, puncture-proof container with a biohazard sticker on it.
9. Instructions for Use (IFU)
IFUs are essential to provide staff information on how to operate, maintain, and clean medical equipment. Evaluate if your staff have access to the IFU for equipment they use or are in charge of managing. Is the IFU current? Do staff know how to access their IFUs?
10. Surgical Fire Risk
Fires during surgical procedures still occur despite advances in fire prevention. There is a recommittal by accrediting organizations in evaluating surgical fire risk prevention. Evaluate your current posture in your prevention efforts. Ensure your policy is in place and up to date. Are staff evaluated on their prevention practices (fire risk assessments, drying times for flammable antiseptics, safe use of cautery and heat sources)? Are staff evaluated on surgical fire response, including evacuation? Are all areas at risk participating in risk prevention and response?
11. Workplace Violence
Workplace violence in healthcare facilities continues to be a persistent issue. It’s important for organizations to evaluate their practices and incident data to determine
how to address their own risks. Consider the following as part of your evaluation:
- What does your annual analysis of workplace violence incidents indicate as risks for your organization?
- Have you developed a mitigation plan based on these risks?
- Have you communicated risks and prevention efforts to your staff?
- Have you evaluated your staff's perception of personal safety from workplace violence, and what does the data show?
12. Tissue Transplant Safety
The management of transplantable tissues is critical. Evaluate your current practice for monitoring temperatures of tissue storage. Are there gaps in measures? Are there unaddressed excursions of temperature from acceptable ranges? Ensure your temperature logs are accessible if requested by the survey team. Are your thermometers and refrigerators/freezers maintained and calibrated per the manufacturer’s instructions for use? Are your tissue logs complete with all required information, including identification of diluents in the event of a recall? Are all documentation elements present to support the bi-directional tracing of tissue/diluent to the patient?
Happy Holidays
From the staff at Courtemanche and Associates: We wish you a safe holiday and a productive New Year and look forward to serving you in 2024
To learn more about Regulatory & Accreditation updates contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
