Guidelines are established as tools to enhance patient care; however, translating guidelines can be difficult. Diana Scott, RN, MHA, CPHQ, senior director of accreditation services at Vizient, and Carma Herring, RN, MS, OCN®, from the John Stoddard Cancer Center, discussed mandates from the Joint Commission and Centers for Medicare and Medicaid Services (CMS), as well as tips for using guidelines and being compliant during a session at the 42nd Annual Congress in Denver, CO.

Scott kicked off the session by asking, “What is guiding your actions? Of course, it is patient safety and quality and clinical outcomes.”

She discussed updates from the Joint Commission, which changed its scoring methods to focus more on patient risk. It now has a zero-defect approach like CMS, because the Joint Commission and CMS are now beginning to agree on outcomes.

She said the top 10 challenging standards from the Joint Commission are:

  1. Safe, functional environment
  2. Infections associated with medical equipment, devices, and supplies
  3. Utility systems
  4. Maintaining means of egress
  5. Maintaining systems for extinguishing fires
  6. Provision of care based on orders and in accordance with law and regulation
  7. Maintain buildings to protect from smoke and fire
  8. Building and fire protection features that are designed and maintained to minimize the effect of fire, smoke, and heat
  9. Mange risks related to hazardous materials and waste
  10. Complete and accurate medical records for each patient

Scott also discussed informed consent and that it is “more than getting a signature.” Nurses face barriers to communication, including health literacy and cultural difference. As an example, she pointed out that providing an interpreter for the patient is federal law, so it is important to be aware of the requirements.

She also detailed medication management, particularly in times of transition of care. Contributing factors to medication errors and adverse events include poor or lack of medication reconciliation, complex medication regimens, high-risk treatments, elderly patient population, limited English proficiency, and patients and family who receive unclear or conflicting information. Strategies to improve medication management include involving pharmacists when possible, assessing risks at the receiving setting, and educating patients and family members. In addition, make sure medication orders are clear and accurate by using preprinted and electronic standing orders, order sets, and protocols.

Other areas Scott touched on were hazardous waste and medications, implicit bias, and antimicrobial stewardship. She asked the audience to consider how their organizations handle these areas of interest and how they can be improved.

She concluded by discussing leadership involvement and pushing staff education. The ultimate education goal is to ask, “Did they get it?” Is the staff implementing what was communicated in educational initiatives? “This is the real measure of education,” she noted.

Ms. Herring, a representative for and the only nurse on the Commission on Cancer (CoC), continued the session by defining guidelines, policies, standards, and procedures that lead to patient quality of care. Standards assign quantifiable measures with desired outcomes. Guidelines indicate or outline policy or conduct and how to act in a given situation, but are not mandatory. Policy is a course or principle of action adopted or proposed by the government, party, business, or individual. Procedures are established or official ways of getting a policy done.

In the United States, 1,500 hospitals are accredited by the CoC, and 70% of patients with cancer are treated at CoC-accredited hospitals. Being CoC accredited can affect patient outcomes, improve the environment and visibility of cancer programs, and enhance collaboration across the oncology community (including professionals, advocates, payers, and the government), Herring noted.

She discussed preparing for a CoC survey or visit. For administrative personnel, system policies should be updated and in place, a mock survey could be conducted to discover potential issues, and education should be provided for the management staff. For frontline management, update floor policies, adhere to general policies, and document staff competencies. For bedside staff, know where to find policies and procedures and adhere to them.

Herring also provided tips for ongoing compliance:

  • Be aware of previous survey findings observed on your unit or department.
  • Consider periodic monitoring of any standards compliance issues observed in your unit.
  • Surveyor’s interview follows the course of care, treatment, and the services provided.
  • Be familiar with locating patient care information in your medical record.
  • Evaluate the interconnection between disciplines, departments, and services.

Herring noted three patient-oriented standards that are “good goals, but difficult to meet”: survivorship, psychological distress screening, and patient navigation. She pointed out that you do not need to hire a nurse navigator; you just need to have a navigator process. “Document, document, document!” she advised.

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