Preparing for Joint Commission compliance: Are you in the loop?


Lee Murdaugh, RPh, PhD

Accreditation and Medication Safety
Innovative Delivery Solutions
Cardinal Health

Robert Jordin, RPh

Accreditation and Medication Safety
Innovative Delivery Solutions
Cardinal Health

Cardinal Health's top hospital pharmacy accreditation experts led an indispensable, two-hour presentation at the 2013 American Society of Health System Pharmacists (ASHP) Midyear Clinical Meeting. The meeting is the world's largest gathering of pharmacists, drawing more than 20,000 pharmacy professionals.

The popular session - which focused on how to prepare for an audit from The Joint Commission – often attracts a standing-room crowd. Speakers included three Cardinal Health accreditation experts who authored ASHP's Assuring Continuous Compliance with Joint Commission Standards: A Pharmacy Guide, a 469-page reference book on the topic.

Here, we hear from two of the four Cardinal Health experts who will speak on accreditation: Lee B. Murdaugh, RPh., PhD, and Robert C. Jordin, RPh. Both are directors of Accreditation and Medication Safety at Cardinal Health Innovation Delivery Solutions.

Q: Why is this presentation so popular, year after year?

Murdaugh: Many directors of pharmacy are overwhelmed with immediate duties and need a quick overview of what's happening in accreditation.

Jordin: We have the advantage of managing many hospital pharmacies and assisting many more through the accreditation process, so we have our finger on the pulse of what's happening in accreditation.

Q: What new issues might come up in an accreditation survey?

Jordin: The traditional issues - storage and security of medication, the way orders are written and so forth - remain crucial. But The Joint Commission is looking beyond the four walls of the pharmacy today. For example, The Joint Commission is looking closely at emergency medication carts stored on floors that are not active 24/7.

Murdaugh: Directors of pharmacy need to think broadly and focus on a wide range of issues. Compounding is getting more attention because of the highly publicized problems in Massachusetts. Hospitals are not exempt from increased scrutiny. How samples are handled is also a concern of The Joint Commission.

Q: Why does a director of pharmacy need to spend so much time beyond the pharmacy walls?

Murdaugh: Hospitals are diversifying. By expanding to outpatient settings - clinics, dialysis centers, free-standing ambulatory settings - the transitions of care become much more challenging. The director of pharmacy has to worry not just about medication management inside the hospital. The continuity of care needs to extend outside the hospital -- to follow-ups at out-patient clinics or maybe home health care.

If directors of pharmacy haven't gotten out of the pharmacy much in the past, they will in the future. Best practices for medication can fall through the cracks outside of the pharmacy walls, yet the same standards apply across transitions.

Q: Any suggestions for ensuring transitions of care meet Joint Commission standards?

Jordin: Lee hit the nail on the head. A DOP needs good interpersonal relationships and leadership skills. You have to build a rapport with nursing, radiology, surgery and beyond. A director of pharmacy has to educate and make others stakeholders in good medication management.

Q: Can you give an example of an "outside the pharmacy" issue that might affect a hospital's accreditation?

Jordin: We see a lot of medication orders that contain multiple medications being ordered for the same indication. These kinds of orders must include objective parameters. For instance, an order sheet that contains morphine and Vicodin every four hours as needed for pain needs to have directions provided by the physician telling the nurse when to use which. It must not be left up to the nurse to decide. This kind of attention to detail matters because individualized care is one of the core principles of patient safety.

Murdaugh: The medical literature contains examples of mistakes made with PRN medication orders that did not include an indication. We find change is more palatable when you can explain "why." It's incumbent on directors of pharmacy to educate.

Q: Why is accreditation so important?

Murdaugh: The standards are all about patient care. You should want to be in compliance at all times, not just in the three or four months before a survey. The process should be continuous.

Jordin: You can't let your guard down for a moment or rest on your laurels. You may have had a good survey three years ago or last year, but you can't let your foot off the pedal. In the past, almost all accreditation visits were unannounced. Today, you have a general idea, but it's not specific. We had one survey start unexpectedly three months early and, honestly, that's a good thing. Your hospital should be in a constant state of readiness.

Q: How can the accreditation process help hospital pharmacies?

Murdaugh: In today's environment, when so much emphasis is on cost, top administrators who hold the purse strings may not want to spend the money for a particular pharmacy improvement. The accreditation process can help a director explain why something is important.

Jordin: It could be a capital expense or staffing. Starting in 2004, new requirements were put in place for safely preparing compounded sterile products. This required major revisions to the sterile preparation room, yet you still find people dragging their feet on implementing the needed changes because of the renovation costs. Accreditation can help change this, for the better.