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Second in our series on TJC Survey Management Strategies

The TJC Medication Management Tracer has been part of the survey process for awhile. For this reason, some organizations underestimate its importance. Don’t make that mistake.

Safe medication management is a high focus area for TJC right now. Consequently, this session is more important than ever. So, what exactly is the Medication Management Tracer all about? And how do you prepare for it?

TJC Medication Management Tracer: Surveyor Focus

During this “system tracer,” the surveyors are analyzing your medication management processes. That means how you select, store, order, administer, and monitor medications.

Typically, the way surveyors do this is to trace the use of a specific medication during a tracer out on the unit. (If you administer any high risk medications such as insulin they’ll focus on one of those.) Then, they’ll hold a group session with your key leaders involved in the medication management process and pose questions about their observations. Some surveyors conduct this meeting in the pharmacy.

They may also ask questions about documents they reviewed in the Document Review session that relate to medication management such as your medication ordering policy. (For tips on preparing for the Document Review Session, see our recent post TJC Document Review Session: Survey Management Strategies.)

Who should Attend?

Attendees for the TJC Medication Management Tracer should be key leaders involved in oversight of organization-wide medication management processes. We recommend the Pharmacy Director, Chair of Pharmacy & Therapeutics Committee, Medical Director (or designee), Chief Nursing Officer (or designee.)

Tip: Make sure attendees for this session read the P&T Committee minutes you gave the surveyors for the Document Review. Surveyors often ask questions about topics they’ve noticed in the minutes.

High Focus Area: Antimicrobial Stewardship (AMS)

For hospitals, AMS is a high focus area. Surveyors expect to see you’ve put a team in place to develop an AMS program. They also want to see you’ve educated staff and licensed independent practitioners (LIPs) about AMS. And that you’ve developed AMS protocols.

We see surveyors scoring noncompliance for the following issues:

  • No evidence staff or LIPs were educated on AMS
  • AMS “teams” composed of only one person
  • No LIP on AMS team
  • Inactive AMS teams
  • No written document describing the AMS program
  • No AMS protocols or staff can’t describe the protocols

For guidance on these topics, see the TJC FAQs on AMS Education Requirements for Staff and LIPs and AMS Multi-disciplinary Team Requirements.

TJC Medication Management Tracer: Other Topics

In addition to tracing a medication and discussing AMS, surveyors are currently asking questions about the following processes:

  • Handling medication errors, adverse drug reactions, and medication incompatibilities
  • Reporting abuses and losses of controlled substances
  • Implementing preprinted order sets and protocols including development, approval, and periodic review

You should also expect surveyors to ask questions about things they observed about medication management during tracers. A Chief Nursing Offer recently related how this unfolded during their survey.

“When the Med Management interview started, the nurse surveyor rattled off a list of stuff she found out on the units. Like a nurse not using two identifiers when passing meds. And nurses not knowing about the 28 day expiration date for multi-dose vials. I wasn’t as prepared as I should’ve been for her questions. I thought the Med Management interview was just about things related to P&T Committee. I’ll know better in the future.”

Medication Management: Common Survey Findings

The most common Medication Management findings we see in psychiatric hospitals and BH organizations are the following:

  • Inconsistent monitoring of medication refrigerator temperatures
  • Not adhering to 28 day expiration date for multi-dose vials
  • No process for control of sample medications
  • Dorm style refrigerators used for vaccines
  • Unclear or ambiguous medication orders
  • Medication reconciliation not done according to policy
  • No documentation of competency for clients to self-administer medications

Survey Management Take-Aways

When doing your survey prep, don’t overlook the importance of the TJC Medication Management Tracer. Be prepared for surveyors to “pull the thread” from patient tracers and med room inspections into the Medication Management interview. Be ready to address the high risk areas we discussed in this article. With those strategies, you’ll minimize the number of findings you’ll get in the Medication Management chapter.

When do our mock surveys, we always include a robust Medication Management tracer. Clients tell us they were much better prepared for this session during their TJC survey and got through it with flying colors. That’s always nice to hear!