SurgeryShopper Adds Immediate Jeopardy Standards and Inspection to its Onboarding/Vetting Processes
QUALITY & PATIENT SAFETY
SurgeryShopper™
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"Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of PATIENTS in its care at risk for serious injury, serious harm, serious impairment or death."
Key components that SurgeryShopper site inspections will determine if Immediate Jeopardy (IJ) exists include: 1) noncompliance, 2) serious adverse outcome or likely serious adverse outcome as a result of the noncompliance, and 3) need for immediate action to correct noncompliance and prevent occurring or recurring harm.
Key Components in Determining IJ Include:
• Noncompliance: An entity has failed to meet one or more federal health, safety, and/or quality regulations;
AND
• Serious Adverse Outcome or Likely Serious Adverse Outcome: As a result of the identified noncompliance, serious injury, serious harm, serious impairment or death has occurred, is occurring, or is likely to occur to one or more identified recipients at risk;
AND
Need for Immediate Action: The noncompliance creates a need for immediate corrective action by the provider/supplier to prevent serious injury, serious harm, serious impairment or death from occurring or recurring.
While most PPOs and other networks that offer price transparency and surgery prices online contract via email without ever setting foot in their listed providers' facilities, SurgeryShopper conducts onsite inspections for every facility listed in its network.
SurgeryShopper inspects every provider facility before it is added to our network.
Determining noncompliance requires SurgeryShopper’s site inspection team to gather enough evidence through observation, interview, and record review to support incidences of noncompliance, and to understand the extent, nature and scope of noncompliance, as well as the impact or likely impact of risk to others. Our inspectors identify and analyze noncompliance against all relevant regulations or tags.
For example, a power outage may have relatively minor consequences to the general population but in a health facility, an outtage has the potential to give rise to life-threatening consequences for ventilator-dependent patients if adequate contingencies are not in place.
Serious injury, serious harm, serious impairment or death are adverse outcomes which result in, or are likely to result in:
- death; or
- a significant decline in physical, mental, or psychosocial functioning, (that is not solely due to the normal progression of a disease or aging process); or
- loss of limb, or disfigurement; or
- avoidable pain that is excruciating, and more than transient; or
- other serious harm that creates life-threatening complications/conditions.
*NOTE: IJ does not require serious injury, harm, impairment or death to occur. It is enough that non-compliance makes serious injury, harm, impairment or death likely to occur to one or more recipients.
The table below provides a listing of examples of patient outcomes or facility staff action that may indicate immediate jeopardy. It isn’t necessary to identify that both a patient outcome and a staff/facility action has occurred to warrant further study. NOTE: This listing is neither an exhaustive list of possible IJs, nor does it contain all circumstances
which require further investigation by our site inspectors.
Abuse – Patient Outcome/Experience
- Non-consensual sexual contact e.g., unwanted intimate touching, sexual assault or battery
- Unexplained head and/or bodily trauma, facial injuries, or fractures
- Bruises around the breast or genital area; or unexplained bruising
- Fear of a person or place, of being left alone, of being in the dark, disturbed sleep, or nightmares
- Extreme changes in behavior, including aggressive or disruptive behavior
- Withdrawal, isolating self, feelings of guilt and shame, depression, crying, talk of suicide or attempts, elopement
Staff/Facility Action
- Staff threatening, intimidating, humiliating, or demeaning a patient(s)
- Staff to patient physical abuse
- Taking, sharing or posting of sexually explicit photographs of patients
- Rape, sodomy, or sexual assault of a patient
- Failure to investigate allegations of abuse or neglect; or to implement policies to prevent abuse
- Confinement in room or other area by blockade, device, or threat
Quality of Care/Quality of Life – Patient Outcome/Experience
- Unexpected Death due to facility noncompliance
- Withdrawal, isolating self, feelings of guilt and shame, depression, crying, talk of suicide or attempts, elopement
- Brain Damage that is avoidable and not solely due to normal progression of a disease or aging process
- Significant decline in physical, mental, or psychosocial functioning, that is avoidable and not solely due to the normal progression of a disease or aging process.
Examples may include, but are not limited to:
Observations of patients:
- Crying out for help or in pain;
- Appearing gaunt, or emaciated without a clinical rationale;
- Appearing somnolent or lethargic without a clinical rationale.
- Serious injury resulting from inadequate supervision, or failure to implement care plan, or follow physician orders
- Loss of limb
- Disfigurement
- Avoidable Excruciating Pain
- Sudden and/or unexpected onset of an acute significant decline given the patients’ current clinical status
- Sudden onset of unexpected somnolence or lethargy
- Avoidable stage III/IV pressure ulcer development
- Off-premises elopement
- Patients(s) found in unsafe location on-premises
- Choking
- Repeated falls with one or more serious injuries
- Sudden, unexpected onset of delirium, or other change in mental status
- Acute respiratory distress
Staff/Facility Action
- Inappropriate use of mechanical lifts
- Life threatening medication error or life-saving medications not provided
- Failure to honor one or more patients’ advance directives
- Failure to identify a significant change in condition in one or more patients
- Pattern of unanswered call-bells, or unanswered call bell resulting in serious harm to one or more patients
- Staffing numbers insufficient to provide basic care and services, or meet patients’ basic needs
- Discharge to destination or provider that is deemed unsafe, or inadequate to meet the patients’ immediate health and/or safety needs
- Staff untrained or without sufficient competencies to meet the health and/or safety needs of one or more patients
Infection Control – Patient Outcome/Experience
- Uncontrolled spread of a communicable disease or infection. Examples may include, but are not limited
to no evidence of:- Surveillance activities; or
- Immunization program for communicable diseases such as Influenza or Pneumonia;
- Needle-stick Exposure to infectious disease
Staff/Facility Action
Using the same needles, syringes and/or finger-stick devices for more than one patient
Environmental/Structural – Patient Outcome/Experience
- Chemical Burn
- 3rd Degree Burn
- Unintended exposure to unsafe chemicals, poisons, or radiological agents
- Exposure to excessive heat or cold
- Bed or Side-rail Entrapment
- Electrical Shock
Staff/Facility Action
- Vendors and/or Employees not being Paid
- Lack of, or inadequate emergency preparation. Examples may include, but are not limited to:
- Lack of potable water supply; or sufficient food
- Allowing temperatures to significantly raise or drop outside of 71 to 81 degrees.
