Volume 2024 | No. 2
SURVEYOR
PCAB COMPOUNDING
TCRX5-F
SECTION 5: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT TCRX5-D
Overview of the requirement:
Incidents, accidents, and complaints/grievances are tracked and trended at least quarterly as performance improvement activities. This includes data on infections and communicable diseases. This standard is evaluated using quarterly PI reports and incident/variance reports. In many cases, deficiencies were noted when patient and staff infections and illness were not reported or monitored for risk. Data is not consistently trended across time to look for patterns and improvement opportunities.
Overview of the requirement:
The PI Program includes activities with a goal and description of who, what, when, and how for each. Surveyors review documentation of performance improvement activities to evaluate compliance. Most deficiencies were cited for missing elements, particularly goals/thresholds, and plans of correction.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
26%
Frequency of citation:
25%
Examples of surveyor findings:
n The pharmacy lacks evidence of a written, effective, ongoing Performance Improvement (PI) Program. n Although the pharmacy had a Performance Improvement Program, it did not include: ٝ . Who is responsible for conducting PI activities? .A description of how data is gathered and organized. .Goals/thresholds or proposed plans of correction when goals/thresholds are not met. .Evidence of an activity/study as a component n The pharmacy lacks formal documentation of PI activities. Data is available but not analyzed and trended effectively. n Create a formal PI Program that includes the required activities, frequency of activities, who is responsible for conducting the activities, method of data collection, and who will receive the reports. n Add acceptable goals/thresholds to PI activity logs and create a standardized evaluation form to be used whenever an aspect of the PI Program fails to meet the goal/threshold. n Ensure each activity/study includes each of the required items, which can be done by using a template with clear places to add each of these items. A PI Program can be instrumental in an organization’s success. Don’t just include leadership; ask if any other personnel would be interested in participating with the PI Program. Staff members work daily in the organization’s environment and can bring valuable insight into the issues that arise and may have great suggestions on how to approach problem solving.
Examples of surveyor findings:
n Quarterly and annual PI reports were not in evidence. n The quarterly reports lack summarizing trends, patterns, and actions to decrease recurrence. n The pharmacy does not include data concerning reports of patient and staff infections as part of the overall Performance Improvement (PI) Plan. n Compare incident reports with quarterly reports to verify the monitoring of trends over time. n Include a component of infection prevention in your PI Program and quarterly/ annual reports. n Integrate an element of ongoing monitoring of processes that involve risks, such as an employee illness log. Document if personnel are following the infection control policy upon return to work. Monitor and report any patient and staff infections as part of the overall PI plan. Develop a method of voluntary self-reporting for employees. Individuals must report and be evaluated by the designated person(s) as to whether they have a personal risk of potentially contaminating the compounding environment and compounded preparations. The designated person(s) is responsible for evaluating whether to exclude these individuals from working in the compounding area before their condition has resolved.
Tips for compliance:
Tips for compliance:
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