JCAHO: What's the big deal?

Discussion in 'Pharmacy' started by Sparda29, Jan 14, 2014.

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  1. Sparda29

    Sparda29 En Taro Adun Gold Donor 7+ Year Member

    Can someone explain to me what's the big deal with JCAHO? Everyone at my hospital has their panties up their asses running around trying to tidy things up. How does this affect pharmacy? Director has us looking in medication bins for expireds and things placed in the wrong bin, is an inspector really gonna look through that?

    They are also quizzing us stuff like fire safety, no tape on the walls, no papers everywhere, ID badges above the waist. What's the big deal? Any administration people on here care to shed a light on this?

    How does this involve a staff pharmacist? I mean, if they start to ask me questions, can't I just tell them I'm busy and to bother someone else?

    We had a mock survey last year and when the DOP found out they were coming around he told one of the staff pharmacists to go to lunch since this pharmacist has a tendency to make inappropriate gestures and jokes (that we in the pharmacy are used to and cool with).
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  3. rxlea

    rxlea Almost a unicorn Moderator Emeritus 7+ Year Member

    It's a big deal to be accredited by the joint commission especially now with health care reform- meaningful use and performance standards are tied to reimbursement.

    I think I read somewhere that some states may require an institution to be accredited by this type of organization in the future.

    They will go to every single department. Sometimes there is a calendar of when they will visit you but in my experience (and I've been around for two surveys at two different institutions), they like to surprise you. Everything, and I mean everything, they see will go into their reports. Then they have these meetings with the department heads to discuss things like risk reduction, medication errors, etc.

    They'll want to see how you prevent errors or adverse events. They'll want to see the workings of your EMRs, drug distribution, safety protocols...everything. Even how your bins are colored to distinguish high risk medications and whether you have tall man lettering.

    It has everything to do with pharmacy practice.
    Last edited: Jan 14, 2014
    TLAD123 likes this.
  4. xiphoid2010

    xiphoid2010 7+ Year Member

    Aug 23, 2007
    Loss of accreditation means you won't get paid by CMS. Hello soup kitchen! Isn't that reason enough alone?
  5. TLAD123

    TLAD123 2+ Year Member

    Are you saying you're a hospital pharmacist and don't know what the joint commission is? How is this possible?

    Joint commission accreditation determines amount of CMS reimbursement. Your pharmacy's scores directly affect this. Everything from following laws and policies, to patient satisfaction. They're very stringent at the Joint commission (no longer called JCAHO) on their rules and the government basically wants any reason to give you less money (not necessarily true, but they don't want to fund non compliant hospitals).
  6. All4MyDaughter

    All4MyDaughter SDN Mommystrator Moderator Emeritus Lifetime Donor 10+ Year Member

    Time to take a shot, folks.
  7. Sparda29

    Sparda29 En Taro Adun Gold Donor 7+ Year Member

    I know what it is. I don't get why I need to be up to speed on what they are doing? Rather than just ignoring them and letting them go around and checking for what they need to check? Is it true that they don't like return meds/discharge patient meds being bunched up in buckets, as opposed to being put back into the bins?
  8. rxlea

    rxlea Almost a unicorn Moderator Emeritus 7+ Year Member

    This brought the lulz
  9. TLAD123

    TLAD123 2+ Year Member

    I suppose not - maybe some directors' jobs are too close to the line and want to make sure everything goes as perfectly as possible? I guess it depends on the situation. I'm not sure on what exactly they like/don't like - as I'm still a pharm student and haven't experienced an evaluation in person, so no help there, sorry.

  10. All4MyDaughter

    All4MyDaughter SDN Mommystrator Moderator Emeritus Lifetime Donor 10+ Year Member

    I think the fact that you don't know what the standards are highlights the need for you to know about this to do your job. No organization can maintain accreditation if the people doing the work don't understand how to stay in compliance with accreditation standards.
    TLAD123 likes this.
  11. WVUPharm2007

    WVUPharm2007 "Bubs Depot!" 10+ Year Member

    Dress like Waldo. If anyone asks you anything, say you are a candystriper.
    Aznfarmerboi likes this.
  12. Sparda29

    Sparda29 En Taro Adun Gold Donor 7+ Year Member

    Chances are they'll probably show up in the morning so I won't even be there when it happens.
  13. opinionfree

    opinionfree 2+ Year Member

    Apr 17, 2013
    Here is where those sniper rifles could come in handy...

    Son, please stop trying to shake the tree so violently. I can't begin to put a % on the inane tasks we are required to perform in the pharmacy, as well you know. This joint commission stuff is very important (everything for poor people must be top shelf) and being nothing more than a cog in the wheel, just do whatever they tell you to do.

    When I wish to flex my manhood against the corporate machine, I wear the exact same unbelievably, unfashionable neck tie everyday. It's my male equivalent of a 'Norma Ray' moment.
  14. mustang sally

    mustang sally 10+ Year Member

    Feb 22, 2007
    The middle of nowhere
    Best to lay low during the survey and say as little as possible. Anything you say can and will be held against you.

    The techs scatted like rats from a sinking ship during our survey. Unable to escape the pharmacy with some lame made-up task like a tech, I diligently pretended to be doing something super important at my desk.

    Hopefully your DOP isn't the type to get too stressed out about Joint. But if he is, just grin and bear it and wait for it to be over.
  15. type b pharmD

    type b pharmD 7+ Year Member

    Feb 24, 2009
    Im not a joint commission expert, but have been through 2 inspections in my time. . The following has been my experience..

    The inspectors pickiness or vindictiveness may depend on if your department is low hanging fruit..

    Every dept has to meet the minimum standards .. but whether joint commission goes over you with a fine toothed comb may depend more on the hospital as a whole..

    Example.. my first joint commission audit.. pharmacy was basically barely in compliance.. we literally were cleaning up the final red flags while jc was standing waiting for us to open the pharmacy door. Well after all of that, they spent about 5 minutes total in the pharmacy and basically just signed us off with no more than a cursory look.

    Issue was, the hospital had so many problems with nursing, environmental services, and patient reported satisfaction type things. . Joint commission reps spent all their time basically dinging away points from these departments to bring our score to either the minimum or to remediation level.. they didnt really care about the pharmacy.

    If your hospital always gets excellent scores whether its hcahps , 5 star, or jcaho , then they will fine tooth comb everything to see if you deserve thay reimbursement. . If other departments are doing great, chances are pharmacy is going to be a target

    So i guess my point is, it depends on your hospital's overall performance and reputation, as well as results of past inspections. Maybe your director is in hot water due to failing or nearly failing in the past.

    Sparda-specific advice: lay low
  16. StellargalS

    StellargalS lollipop! POP!

    Sparda you are a gem. :rofl:ASHP would be shocked! Pllllllllllllllllllllllllllll
    You'll probably be running the place in a couple of years. :highfive:
    Here! Here! :caution: To Sparda!:clap::bow::soexcited::claps:
  17. rxlea

    rxlea Almost a unicorn Moderator Emeritus 7+ Year Member

    Lay low and if possible don't send or ask nurses to send handwritten faxes (I don't know your workflow though). They don't like that. Speaking from experience.
  18. knight on horse

    knight on horse 2+ Year Member

    Jul 1, 2013
    There will be two sides to this - the echo, shadow of the old America, and that of the new

    These new standards sound great, and hospitals should be audited. That is the first part, the ghost of old America

    The second part is the wave of the future, the new America. The way of the Third World. These inspectors, these regulatory agencies will line their fat pockets and threaten you with fines

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