Written plans strengthen patient care quality
They provide framework for QI strategies
Many written plans are required by the Joint Commission’s standards. But these plans are also important to a hospital from a business standpoint. A written plan helps to clarify and focus the organization’s attention on important patient care and administrative processes. It also provides a logical framework within which physicians and staff can develop and pursue improvement strategies. Lastly, a written plan serves as a basis for discussion with various stakeholders.
Preparation of comprehensive plans that meet Joint Commission requirements will not guarantee improved patient care, but lack of a sound plan will, almost certainly, invite failure.
In the two previous columns, 10 of the plans required by the Joint Commission’s standards were described. This month, the remaining three are detailed.
Utilization review plan
The Medicare Hospital Conditions of Partici-pation still require hospitals to have a written utilization review plan, although the need for such a plan is not specifically spelled out in the Joint Commission’s standards. The utilization review plan should contain:
• a confidentiality policy which applies to all utilization management activities;
• a conflict of interest policy, in relation to all utilization management activities;
• description of the process or mechanisms by which one evaluates and communicates, at a minimum:
— appropriateness and medical necessity of admission;
— appropriateness and medical necessity of continued stay;
— appropriateness and timeliness of clinical services;
— problems or areas of concern revealed through utilization review activities;
— hospital-specific length of stay norms;
— criteria used in the review process;
— effectiveness of the discharge planning process;
— flow of information and reporting process.
Information management plan (IM.1)
The information management plan of the organization must be leadership-driven and describe how all types of information (manual and automated) are maintained. The mechanisms for security, confidentiality, and integrity of information must be described. One component of the plan should be a needs assessment that covers what data and systems are necessary and relevant to:
• type, structure, size, and complexity;
• needs of information users;
• planning;
• research and education;
• data set parity and data connectivity;
• internal and external transmission;
• reporting needs over time;
• continuous performance improvement;
• comparisons with past performance and external comparisons;
• support of customer and supplier relationships;
• enhancement of cost effectiveness;
• enhancement of work flow;
• support of clinical and administrative decision making.
Other considerations in the needs assessment include: What technology is appropriate and affordable? Does the organization plan to expand or redesign services? What long-range plans may affect the information needs of the organization?
Include in the information management plan a data inventory which summarizes what data are collected, where the data are maintained, the form of the data (manual or automated), how long the data have been collected and stored, availability of data dictionaries, methods of accessing information, reporting capabilities, and key contact people.
Environment of care plan (EC.1.3 - EC.1.9)
The activities related to managing the environment of care can all be put into separate sections in one "Environment of Care" plan, or they can be maintained as separate plans. An individual must be named to direct all environment of care activities. Since 1995, the Joint Commission has also required facilities to complete a statement of conditions (SOC) in preparation for the survey. The SOC has four parts: (1) introduction and instructions; (2) basic building information; (3) life safety assessment; and (4) plan for improvement. The SOC should cover every building in the organization, including ambulatory services. The heart of the SOC are parts 3 and 4 ,which detail the results of the organizationwide safety assessment, what deficiencies were identified, and plans for corrective actions.
Listed below are the activities that must be addressed under the broad environment of care function and a brief description of what should be included in the plan. Each of these plans, whether integrated into an overall environment of care plan or documented separately, should contain a performance standard which relates to an improvement target and how this target will be achieved. Surveyors will expect to see work in progress toward achieving the targets in each of the environment of care activities (e.g., goals, measurement, data collection, and headway toward improvement):
• Emergency preparedness (internal and external).
The organization should detail the recovery plans that are in place for internal and external events that might compromise services. For example, if a flood were to occur in the pharmacy, how would patient medication services be continued? The process for drills, testing, and inspection procedures must also be spelled out in this plan. The organization should strive to design an efficient prevention system and hospitalwide attitude of readiness for a wide range of disasters that (it is hoped) will never occur.
• Hazardous materials.
The exposure of health care workers to harmful chemicals such as formaldehyde; hazardous materials such as mercury; infectious substances such as blood; or biohazardous waste such as radionuclides — is a necessary part of the job.
However, it is the hospital’s responsibility to see that no worker or patient is harmed by such exposures and to see that the natural environment is not harmed either. The hazardous materials plan should describe the types and whereabouts of hazardous materials in the organization, how hazardous waste is managed, and how exposures are to be handled. An inventory of hazardous materials should be maintained by individual departments, and there should be a defined process for periodically updating these inventories.
• Medical equipment.
This plan must address how medical equipment is kept in proper working order. Be sure to include an inventory of all equipment in the organization and how often maintenance and safety checks are conducted. User competencies should also be addressed. Define how competencies are maintained for all medical equipment. An area of special focus is maintenance of competencies for high-risk equipment or equipment that is infrequently used, e.g., pediatric defibrillators. The plan should also address the process used by the organization to report medical equipment and product problems to the Food and Drug Administration.
• Life safety.
This plan should include a description of how the organization minimizes the risk of a fire and maximizes its ability to control one should it occur through a variety of engineering specifications and administrative duties. The plan should include the mechanisms by which managers and staff are made familiar with fire prevention techniques as well as the location of fire alarms, extinguishers, exits, and smoke barriers and how to respond.
In the area of fire prevention, the organization should also have an established nonsmoking policy. It is acceptable to allow exceptions to the policy if authorized by the patient’s licensed independent practitioner, however, the criteria for such exceptions should be approved by the medical staff.
• Security.
In 1995, the Joint Commission increased its emphasis on security plans. The organization’s security plan should describe the mechanisms used to prevent child abductions, theft, drugs, and violent behavior, and methods for training physicians and staff. The goal is to provide a low-risk, secure environment across all health care settings.
• Safety management.
This plan must address all the items in the intent statement of the standard, including management of grounds and equipment, risk assessment for other hazards, compliance with OHSA standards, and annual evaluation for effectiveness. Be sure to document how risks are identified (e.g., safety rounds, findings from accident and injury investigations, product recalls, etc.) and how such risks are investigated and resolved.
• Utilities management.
The plan should describe the process for maintaining utility systems and procedures for handling a system failure. The organization must have a systematic process for ensuring that utilities — water, electrical, telecommunications, air handling, medical gases, computers, etc. — are properly constructed and maintained so as not to pose a risk to patients should a utility system fail.
The preparation of patient care and administrative plans is not the end result. The successful implementation of that plan is the ultimate goal.
However, a well-written plan will demonstrate to the Joint Commission that careful consideration has been given to activities. Most importantly, each plan provides a framework for ensuring quality patient care in the organization.
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