Sharing Singapore's experience: The Joint Commission International accreditation of a psychiatric hospital

INTRODUCTION

Hospital accreditation is usually a voluntary, self and peer assessment process used to gauge a hospital's level of performance in relation to a set of requirements (standards) and to identify and implement ways to continuously improve its quality and safety of care. International hospitals may pursue accreditation by way of the Joint Commission International (JCI), the international branch of the Joint Commission (JC), the largest accreditor of health care organizations in the United States. The clinical services provided, such as patient tracer activities, open and closed medical record review, direct observation of patient care processes and interview of patients, are subject to a comprehensive evaluation against all JCI standards.¹

INSTITUTE OF MENTAL HEALTH, SINGAPORE

The Institute of Mental Health (IMH) a 2,000 bed acute, tertiary psychiatric hospital in Singapore was the first mental health institution in Asia to receive the highly coveted JCI accreditation in 2005 and thereafter in 2008 and 2011. IMH offers a comprehensive range of psychiatric services for children, adolescents, adults and the elderly supported by various departments, such as medical affairs, psychology, nursing, pharmacy, occupational therapy, case management and medical social work.² IMH will be preparing for their fourth on-site JCI accreditation in 2014, which encompasses a rigorous week-long audit by an international survey team generally comprised of a physician, nurse, and administrator.

JCI STANDARDS AND ITS MEASURABLE ELEMENTS FOR THE DEPARTMENT OF PHARMACY

The survey process measures standards compliance throughout the organization, and the accreditation decision is based on the overall compliance of the organization. The standards are grouped by those functions related to providing patient care (Patient Centered Standards), and those related to providing a safe, effective and well-managed organization (Health Care Organization Management Standards). Medication Management and Use (MMU) is one of the Patient Centered Standards that generally falls under the responsibility of the pharmacy department, and Measureable Elements are a list of requirements to be in full compliance with the standard. MMU encompasses the systems and processes the organization uses and applies the principles of effective process design, implementation, and continuous improvement to the selecting, procuring, storing, ordering/prescribing, transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring of medications.³ Presently, there are no specific standards set for hospital-based inpatient psychiatric services by JCI. Table 1 compares the applicable standards for hospitals for JC and JCI. ³⁴

Table 1: A Comparison of Joint Commission and Joint Commission International Standards ³⁴

View Fullscreen

Unlike general hospitals, establishments such as IMH, comprised of over 50 acute and chronic long-stay wards with a maximum bed capacity of 40 beds per ward, need to consider several variations of the standard hospital accreditation. As IMH is a specialized psychiatric institution, there are numerous barriers to being successfully accredited as a ‘hospital’. For example, there is no extensive drug formulary to treat medical illnesses and there are no surgical facilities and intensive care units within the premises. Thus, the pharmacy department has to establish policies concerning procurement of required non-formulary medications (from external sources with minimum delay, if necessary) or alternatively, to help organize patient transfer to a general hospital in a medical emergency. This article will briefly summarize the organization's medication management processes and successful measures undertaken to meet the challenges of a JCI hospital accreditation.

ORGANIZATION AND MANAGEMENT

To ensure effective and efficient medication management, there is a plan or policy that identifies how medications are used throughout the hospital. For example, according to the organization's policy, when the pharmacy is closed, medications are managed by emergency room personnel. Limited quantities of the most commonly used medications are kept in the emergency room to be dispensed by a registered nurse. An off-site, on-call pharmacist is available for any medication related queries by staff or patients. Effective medication management includes a yearly systems review of all parts of the organization. This review consists of medication management on both an inpatient and outpatient basis and assesses medication use in specialized units such as the high-dependency care unit, electroconvulsive therapy unit, addictions, forensic, child, geriatric, intellectual disability wards and long-term care units.

SELECTION AND PROCUREMENT

IMH Pharmacy and Therapeutics Committee (P&T) maintains and monitors the IMH Formulary as well as the use of medications in the hospital. The Committee reviews the full list of drugs annually, including slow moving and obsolete items, guided by an established set of criteria before making a decision to remove the item from the formulary. It also takes into consideration Singapore's Standard Drug List, a national list of drugs that are to be used as first-line agents and which are subsidized for citizens, into its decision making process.⁵ Inclusion of standard drugs in the formulary is of significance as it is a list of clinically relevant and cost effective drugs essential for the management of common diseases.

For drugs newly added to the formulary, P&T conducts a review 6–12 months after the introduction to monitor appropriateness of indication, prescribing patterns, and unanticipated adverse events with the new drug. The JCI surveyor will look for information obtained from the Adverse Drug Reaction (ADR) national database, physician's feedback and reasons quoted by the physician or pharmacist during a drug refund process due to an ADR. Medication costs are refunded if a patient returns the medications with a corresponding memo from the physician indicating an ADR or a lack of efficacy.

There is also a procedure to approve and procure required medications and nutritional items not stocked in IMH on an ad-hoc basis. The pharmacist in charge of the patient will screen the medication order and suggest an alternative drug or evaluate feasibility of access to the drug by obtaining the drug from another pharmacy, determining the quantity to supply, and assessing affordability by the patient. To educate hospital staff in the process of procurement of non-formulary items, this information is shared during routine physician and nursing orientations conducted by the pharmacy department. Newly hired pharmacy staff are educated regarding the medication procurement process during the department induction program.

There is an established system and actions that are taken by the purchasing office to manage the availability of a drug before the stock is depleted. The JCI surveyor will review the pharmacy correspondence with the drug manufacturer and the vendor and assess the methods in place to inform the physicians of drug shortages. Physicians will be informed of a situation via email by the P&T committee and are recommended to restrict initiation of the medication and/or convert patients to other alternatives. If necessary, the P&T committee will develop approved drug substitution protocols.

STORAGE

True to its Southeast Asian location, Singapore is characterized by a hot and humid climate all year round. With an average room temperature well above 80°F, medications are required to be stored properly and safely under conditions suitable for product stability as specified by manufacturers. Most items recommended to be kept at ‘room temperature’ in the US need to be kept in a cooler, air-conditioned environment in Singapore. The pharmacy department ensures that regular temperature monitoring is done in the wards and clinic treatment rooms, and periodically updates the list of items that require refrigeration. Vaccines that are temperature sensitive and require round-the-clock temperature monitoring will only be kept in the pharmacy store. The pharmacy store is a lockable, air-conditioned drug storage facility connected to a 24-hour emergency power supply. Access to the pharmacy store is restricted to authorized pharmacy personnel only.

All medication storage areas in the wards are inspected quarterly by pharmacists to ensure proper storage, temperature monitoring, dispensing of controlled drugs (CD) and controlled psychotropic drugs (CPD) and their recordkeeping. CD (e.g., methylphenidate) and CPD (e.g., benzodiazepines, phenobarbital) are the equivalent of US Schedule II and IV controlled drugs, respectively. Due to frequent requests and use of CD and CPD in the psychiatric population, several of these items are kept in the ward as ‘ward stock’. Several policies are drafted to accurately account for these items according to local laws guided by the Medicines Act, Misuse of Drugs Act and the Poisons Act.⁶ In fact, JCI measurable elements of storage of medications are steered by over 20 policies that have been developed and implemented by IMH. For example, detailed instructions are written for policies such as: (1) goods received and stored by the pharmacy store, (2) issue, transfer and return of pharmaceuticals, (3) disposal of expired or deteriorated goods, (4) monitoring of the expiration date of drugs, (5) receiving and dispensing of CD and CPD, (6) reporting of breakage, wastage or loss of CD and CPD, (7) medication recalls, (8) handling of drug samples, (9) handling of high alert medications, (10) distribution, storage and accountability of investigational products or devices, (11) handling of patient own medications in the ward, and (12) checking of the emergency drug kit (E-Kit), trolley and equipment.

IMH list of High Alert Medications (HAM) was established by the P&T based on the institutions' data on medication errors and near misses, sentinel events and with reference to the list of HAM from the Institute of Safe Medication Practices. Access to HAM is controlled and only supplied from the pharmacy when there is a request. A pharmacist will review the order prior to supply and any unused product is returned back to the pharmacy. Specific HAM can only be kept in the ward if the usage is sufficiently high and when immediate administration is necessary for emergency and resuscitation purposes or to avert an adverse outcome. HAM kept as ward stock, where possible, have only one type or strength available in order to avoid medication errors. Containers for HAM are affixed with the cautionary label “HIGH ALERT MEDICATION”. A cautionary bright orange label “NOT for IV BOLUS” will be pasted on the individual packaging of concentrated electrolytes listed as HAM. HAM orders shall be reviewed and verified by a pharmacist or a physician before administration unless it is to be administered immediately for emergency and resuscitation purposes.

Being a specialized psychiatric hospital, all IMH wards and clinics are equipped with emergency medications stored in a portable E-Kit for easy accessibility. JCI standards require that emergency medications are available, monitored and safe when stored out of the pharmacy. A policy defines how emergency medications are stored, maintained and protected from theft and loss. All E-Kits are sealed with a serial lock and the pharmacy store keeps track of and sends out email notification reminders for items in the E-Kit that are expiring at least 2 weeks before their expiration dates. Any E-Kit seal that is broken for usage is returned to the pharmacy store for replenishment. Items used are verifiable via the electronic medication administration record. The nursing department has a related policy in place to check for the expiration dates of items in the E-Kit and the serial lock daily and to ensure items in the emergency trolley and equipment are in functioning condition.

Policies and procedures should also address the destruction of medications known to be expired, outdated, or deteriorated and to prevent the diversion of those. Should there be a recall by the manufacturer or the Health Sciences Authority of Singapore, there is a system in place to retrieve medications dispensed. At IMH, all medication movement is tracked by a purchasing and inventory management computer system and a policy guided by the Storage and Monitoring of Expiry Date of Drugs. Expired, deteriorated and returned goods are disposed of by methods outlined in the Guidelines for the Disposal of Pharmaceutical Waste. There are also work instructions in place to dispose of CD/CPDs and patient own medications.

There are several quality and patient safety initiatives employed when medications are stored in the pharmacy and in the ward setting. Separation of Look-Alike-Sound-Alike drugs, Tallman lettering, color-coded and bolded labels for drug names prone to errors, a colored sticker for items expiring soon, and a High-Alert medication sticker are some of the initiatives implemented.

ORDERING AND TRANSCRIBING

As in any hospital, there are policies and procedures to guide the safe prescribing, ordering and transcribing of medications. All prescriptions for inpatients and outpatients are prescribed through the electronic prescription system or by a legible, written order in the event of a system interruption. No verbal or telephone orders are allowed except during medical emergencies and resuscitations. All incoming new physicians are trained in correct prescribing and transcribing practices and adherence to elements of a complete order. The use of dangerous abbreviations, symbols and dose designations are avoided by posting a list of High-Risk Abbreviations and Symbols in every consultation room, patient treatment room and by the computers. IMH strives for 100% medication reconciliation to be performed by a pharmacist within 24-hours of admission, and by a pharmacist or a nurse at the point of discharge.

Only those permitted by the organization and by relevant licensure shall prescribe or order medications. A process is in place to limit, when appropriate, the prescribing practices of individuals. There are some prescription restrictions that must be adhered to, depending on the prescribing physician's level of training and specialization. For example, methadone prescribing is limited to physicians who are Registrar level and above (psychiatrists listed in the specialist register of the Singapore Medical Council) and practicing in the Department of Addiction Medicine.

Those permitted to prescribe and order medications are known to all who dispense and administer medications. A process is in place to contact the individual who prescribed the medication when questions arise. All physicians' signatures and photos are captured for identification and verification of physicians authorized to prescribe at IMH. This list is modified periodically to update any incoming or outgoing physicians.

PREPARING AND DISPENSING

A licensed pharmacist, or in the absence of a pharmacist, a trained professional (a physician), reviews each prescription or medication order for appropriateness prior to dispensing and administration. Those who review medication orders are shown competent to do so by education, training or by demonstrated competency in the review process. Staff education, qualifications and training is assessed by obtaining primary source verification prior to employment. Pharmacy staff competency is assessed at the point of recruitment via an induction checklist and thereafter continually via a competency assessment checklist. Having attained at least a 70% passing mark on a written assessment of pharmacotherapeutic knowledge, monthly workload reports, and the number of medication related errors are all deliberated at the annual performance review for pharmacists.

A system is used to dispense medications in the right dose to the right patient at the right time. Computer software used to cross-check drug interactions are updated quarterly and patient drug allergy reports are updated at midnight.

Most medications are dispensed in ready-to-administer form to minimize opportunities for error during administration and there is a uniform dispensing and distribution system from all pharmacy locations including satellite pharmacies within the hospital. There are work instructions that define the actions and responsibilities of the pharmacy store personnel in issuing, replenishing, transferring, returning of pharmaceuticals and handling of E-Kits. Drug samples are delivered to and kept in the pharmacy, segregated from other medications with their inventory monitored, recorded and tracked. The pharmacy controls the availability and the use of drug samples. Clinic patients are dispensed samples from the pharmacy after producing a signed prescription.

ADMINISTRATION

A directorial standard defines the actions and responsibilities of the physician and the registered nurse who are authorized in the administration of medications. It also includes the actions and responsibilities of an enrolled nurse (an assistant nurse supervised by a registered nurse) in the administration of topical medications for the eyes, ears, nose and skin. The process for preparation and supervision of oral medications by a registered nurse for self-administration by patients in the rehabilitation wards are also incorporated into the standards.

Established procedures have been created for handling a patient's own medications brought to the hospital, and actions and responsibilities of personnel handling those medications until the time of discharge. Patient own medications should be identifiable, properly labeled, and neither deteriorated (no discoloration or change in appearance) nor expired. When CD and CPD are administered, it should be recorded accordingly and witnessed by another registered nurse.

When administering medications, the patient's identity is verified correctly using two identifiers: by asking the patient their name and hospital registration number (HRN) and checking those against the patient's wrist tag and/or in the event the wrist tag is missing, matching the patients face with the patient's photograph. Before the medication is administered, the patient's wrist tag or the barcode on patient's photo is scanned.

Trained and competency-assessed nurses, pharmacy technicians, intern pharmacists or pharmacists counsel all patients at the initiation of a new medication and for subsequent administrations or clinic visits. Due to the nature of the illness, counseling of medications given is mandatory, unless otherwise declined by the patient or caregiver.

MONITORING

Physicians, nurses, pharmacists and other health care practitioners work together to monitor medication effects on patients and to evaluate the patient for adverse effects. Inpatient medication records are reviewed to ensure there is an appropriate indication for each drug prescribed, medical problems are addressed, and medications are administered on time. Pharmacists attempt their best to review 100% of all new medications ordered before the first dose is administered, such that an intervention can be performed appropriately and in a timely manner. Nurses closely monitor the patient's reaction to the first dose of a new medication to identify any allergic responses, unanticipated adverse events, fall risk, as well as the likely therapeutic response.

The organization has established a protocol for reporting and recording an ADR to medications and other alternative medicinal substances within 24 hours of detection. Medications newly added to the formulary are monitored for appropriateness of use, efficacy, drug allergies and ADRs. The P&T secretary compiles and collates statistics on a quarterly basis and may use this information for formulation of a drug use policy for drugs that are of high risk and for educational purposes. ADR reports are submitted electronically or manually using a form to the Pharmacovigilance Unit of Health Sciences Authority of Singapore, for contribution to the national database of ADRs.

For drugs with a narrow therapeutic index, changes in the brand used are avoided as much as possible. If a brand change is essential, the bioequivalent new brand is introduced to physicians and nurses and informed that they are to monitor for responses to therapy and adverse events. Surveillance monitoring for adverse events will be carried out within one year post substitution.

Medication errors, including near misses during prescribing, preparing, dispensing and administration, are reported electronically by any person and are monitored and reviewed quarterly by the P&T committee to improve the medication management process. Information of incidents reported will require a root cause analysis to be performed. Several patient safety workshops, continuing education lectures and small group events as a part of staff training are conducted throughout the year. The staff are educated on the method of reporting errors and empowered and advised of the importance of reporting as a process of improving the organization's quality and patient safety measures.

CONCLUSION

The main advantages of JCI standards are creating a culture for the reduction of safety risk to patients and improving quality of care within an organization. By undergoing repeated accreditations, IMH continually strives to improve patient care processes. In doing so, IMH gains public trust and is able to use the accreditation status as a tool to attract patients and staff. A JCI-accredited institution assures the quality of service provided by the institution is of internationally recognized standards. IMH is now in a position to compete globally with like institutions envisioning to be a tertiary center of excellence and a global leader in mental healthcare.

Medications are an important component in the treatment and management of many diseases and conditions. Their proper management, which often is the obligation of the institution's pharmacy department, is vital to eliminate any potential harm to a patient. JCI accreditations have identified certain standards to encourage hospitals to develop an effective and safe medication management system. This should be an accountable system monitoring the facility's compliance with the expectations of JCI standards. Working towards JCI standards can be a challenging, but rewarding experience to all involved in demonstrating that the healthcare facility has a visible commitment towards improving safety and quality of patient care.