center application number: _30_____ (to be filled in by elso) web viewas a new word document, ......

This page is confidential for ELSO Administrative use only. All correspondence will be sent to both the Primary Contact and Medical Director.

Please read the Instructions Completely

Please choose which Award you are applying for:

( ) Center of Excellence The Center of Excellence Award is for Centers that are established and have invested time in developing their programs according to ELSO Guidelines. A minimum score must be achieved on the Excellence in Life Support application in order to be designated as a Center of Excellence.

$3,500 fee USD (International ELSO Centers in specific countries may be eligible for a discounted fee) 3 year Award Period Must be an ELSO member in good standing for at least 3 years Must have supported an average of 5 patients per year for the past 5 years Must have reported all patients to the ELSO registry Must complete all sections of the ELSO Award Application

( ) Center on the Path to Excellence These programs are on the Path to Excellence, but have not yet demonstrated the extraordinary achievement in all categories as required for the Center of Excellence Designation. These programs desire recognition for their adherence to the ELSO Guidelines in providing ECLS patient care and are working towards the requirements for designation as a Center of Excellence. A minimum score must be achieved on the application in order to be designated as a Center on the Path to Excellence.

$2,000 fee USD (International ELSO Centers in specific countries may be eligible for a discounted fee) 3 year Award Period Must be an ELSO member in good standing Must have reported all patients to the ELSO registry Only complete sections 1, 2, 3 and 4

Primary Application Contact Information

ELSO Center/Hospital Name: Insert here

Primary Contact Name: Insert here

Address: Insert here


City: Insert here State: Insert here Zip: Insert here

Country: Insert here

E-mail Address: Insert here

All inquiries regarding fees and submission direct to [email protected] _______________________________________________________________________________________________ELSO Award Application of 17 © 2016 Extracorporeal Life Support Organization

ELSO Award for Excellence in Life SupportApplication

2016

mailto:[email protected]

Medical Director Contact Information( ) Same as Primary Contact

Medical Director Contact Name: Insert here



City: Insert here State: Insert here Zip: Insert here

Country: Insert here

E-mail Address: Insert here

Your Initials and Signature Verify that you have:____ Read and Verify all of the information entered herein is correct and true.____ Read and Acknowledge the policies and procedures of the ELSO Award for Excellence in

Life Support.

Electronic Signature: Insert here

All inquiries regarding fees and application submission direct to [email protected]

All inquiries regarding the Award for Center of Excellence in Life Support or the Path to Excellence in Life Support direct to [email protected]

ELSO Award Application of 17 © 2016 Extracorporeal Life Support Organization


2016



To

receive the Award at the USA ELSO meeting:o Application period is through May 1. Applications received during this time period will be considered for the

Award of Excellence. The designation will be awarded at the USA ELSO conference, and will continue for a period of 3 years.

To receive the Award at EURO ELSO:o Application period is through March 1. Applications received during this time period will be considered for

the Award of Excellence. The designation will be awarded at the EURO ELSO conference, and will continue for a period of 3 years.

Save the application form on your computer as a new word document, using the title:

YourCenterELSOApplication.docx(Example: MillionDollarBabiesHospitalELSOApplication.docx)

Please read the entire application before beginning the application. The application questions are designed to allow each center to describe in detail the important aspects of their ECMO program. It is not necessary to provide additional elements in answers that do not request additional information.

Please read the policies and procedures before beginning the application. It is a requirement that the Center read and acknowledges that they are aware of the policies and procedures prior to submission of the application.

When examples of projects, processes, or initiatives are requested, specific examples should only be used once. For instance, the same example may not be used for both a quality initiative and a best practice journey. If examples are repeated, only one question will be given credit. The other will automatically be scored as a “does not meet”.

Use spell check and grammar check. It may be helpful to compose answers in a word processing program and copy/paste into the document.

Remove all identifiers in the application. The city, institution, staff names, or other identifiers should not be used in answering questions. All attachments should have center-specific headings & information removed or blacked out. Applications will be returned if they are not de-identified.

International centers should assure fluency of English. Centers may choose to complete the application in their native language. Google Translator or a similar application may be used once the application is complete to translate to English.

The following supporting documentation is required to be attached at the time of application submission. Missing supporting documentation will result in not meeting the standards of those questions. Attachments should be de-identified with center-specific headings and content blacked out or removed. Additional documentation may be included within the body of the application.

o Download ELSO Excellence in Life Support Documentso ELSO Award for Excellence in Life Support Equipment and Resource Questionnaire o Agenda for the most recent ECMO Training Courseo Initial water drill checklist or simulation scenarioo Recent annual written testo Recent continuing education water drill checklist or simulation scenario

Submit completed application and all required attachments electronically to [email protected]

Submit check or credit card payment. See payment form for details. (download ELSO Excellence in Life Support Documents. All inquiries regarding fees and application submission direct to [email protected]

Direct all inquiries regarding the Award for Center of Excellence in Life Support or the Path to Excellence in Life Support to [email protected]



2016

Instructions



http://www.elso.org/Excellence/ApplicationSupportDocuments.aspx




Center Application Number: (To be filled in by ELSO)

1. Systems FocusProvide generalized background information about your institution.

1.1 Has your center been a member of the Extracorporeal Life Support Organization (ELSO) for at least 3years? How many patients have been supported with ECLS at your center per year in the last 5 years? Count each patient once. (List patients/year and any variances)

For Path of Excellence Applications, please note if you have had patients and in which populations, or mark as Not Applicable.

2011 2012 2013 2014 2015NeonatePediatric

AdultTotal ECMO

Patients

Insert additional information here.

1.2 Are there any patients in your institution on extracorporeal life support (specifically a pump with an oxygenator) that are not reported to the registry and why?

Insert answer here.

1.3 Check all of your specialty services available on a 24-hour/day on-call basis? (Describe plan for any services not available)

☐ Cardiology ☐ General surgery☐ Cardiovascular surgery ☐ Neonatology☐ Anesthesiology ☐ Neurosurgery☐ Interventional Radiology ☐ Genetics☐ Biomedical Engineering ☐ Social Work☐ Neurology ☐ Nephrology☐ Critical Care Specialist ☐ Pulmonology☐ Hospitalist ☐ Hematology/Oncology☐ Infectious Disease ☐ Gastroenterology☐ Other:

Insert additional information here. ELSO Award Application of 17 © 2016 Extracorporeal Life Support Organization


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1.4 Check available support services and/or consultants that are available (Describe plan for any services and/or consultants not available)

☐ Blood gas laboratory ☐ Chemistry and hematology laboratory☐ Blood Bank ☐ Pharmacy ☐ Cardiovascular operating room with

cardiopulmonary bypass capabilities☐ Radiology including cranial ultrasound and CAT scan

☐ Occupational and/or Physical Therapy ☐ Developmental/rehabilitation Specialist☐ Nutritionist ☐ Pastoral Care☐ Interpreter services

Insert additional information here.

1.5 Outline available inter-hospital transport services for patients on ECLS. If you do not provide ECLS transport services, please detail your plan for transporting patients on ECLS to or from your center in case of emergent need.

Insert answer here.

1.6 Describe the ECLS Medical Director position responsible for the overall operation of the Center.

Provide medical specialty:

Insert answer here.

Outline specifics of the scope of Directors responsibilities:

Insert answer here.

1.7 Describe the ECLS Coordinator position responsibilities in your institution.

Provide description of specialty:

Insert answer here.

Outline specifics of the scope of Coordinators responsibilities:

Insert answer here.



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2. Environmental FocusProvide information about your facility and equipment available for ECLS. Please assure that you have completed the ELSO Equipment and Disposable Resource questionnaire.

2.1 Describe in detail all units/areas in the institution where ECLS is provided. (Include each patient population cared for)

Insert answer here.

2.2 Describe the general availability of your back-up equipment and components, and their location in relation to your ECLS patient.

Insert answer here.

2.3 Discuss your plans for equipment and staff utilization in the event that your center exceeds your normal and usual number of ECLS beds/pumps (increased census).

Insert answer here.



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3. Workforce FocusFor this application, “ECLS Specialist” refers to the individual your center designates to care for the ECLS circuit.

3.1 Describe the pre-requisites required to apply to be an ECLS Specialist. (Must include Specialty/discipline. Include past experience, skills assessments, certifications, etc.)

Insert answer here.

3.2 What is your staffing model for your ECMO patients? (Check all that apply)

1 Specialist per pump, patient has a dedicated nurse 1:1 1 Specialist per pump, patient’s nurse may have 1 or more other patients 1 Specialist for 2 pumps, patients have a dedicated nurse 1:1 1 Specialist for 2 pumps, patient’s nurse may have 1 or more patients Single caregiver model (ECLS specialist is also the patient’s nurse) Other (describe below)

Insert answer here.

3.3 Who provides primary medical management of the ECLS patient? (Include all individual ECLS populations described in 1.1)

Insert answer here.

3.4 What written and electronic materials and clinical expertise are available 24/7 to the ECLS Specialists for ECLS pump and patient management troubleshooting?

Insert answer here.

3.5 Who performs ECLS priming and how do you provide 24/7 coverage for priming?

Insert answer here.



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3.6 Highly stressful events are common during an ECMO run. These events may overwhelm individual staff members and their ability to cope. Staff debriefing processes are defined as programs available for staff where they are able to discuss events or situations, receive support, and learn coping skills. Describe your staff debriefing process that occurs after critical stressful incidents.

Insert answer here.

3.7 Moral distress is the physical or emotional suffering that is experienced when an individual staff member knows the right thing to do, but constraints make it nearly impossible to pursue the right course of action. How do you provide interventions for individuals in these situations? How do you prevent or mitigate the moral distress that staff may experience when caring for critically ill patients on ECLS?

Insert answer here.



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4. Knowledge ManagementProvide ECLS Team training and competencies.

4.1 Detail your institution’s initial physician credentialing process for ECLS. Include all attendings, fellows, and residents who care for ECLS patients. Include courses, mentoring, minimum patient requirements etc.

Insert answer here.

4.2 What annual continuing education and training is required for physicians, including attendings, fellows and residents, to maintain credentials to care for an ECLS patient? Include courses, water drills/simulations, minimum patient requirements etc.

Insert answer here.

4.3 What specific ECLS training is required for advanced practice nurses or physician assistants who manage ECLS patients? Include initial and continuing education.

Insert answer here.

4.4 Explain your centers’ initial training program for future ECLS Specialists. Specifically, how do you meet these ELSO Guidelines? Address all four questions regarding guidelines for credit.

a. Describe 24 – 36 hours Didactic Sessions (attach class agenda):

Insert answer here

b. Describe your Water Drill and/or Simulation sessions used to teach basic circuit and emergency management skills (attach a water drill checklist or scenario):

Insert answer here

Question continued on next page:



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c. Describe 16 – 32 hours of Bedside Training Sessions:

Insert answer here.

d. Describe Final Exam and process (must include minimum passing requirements):

Insert answer here.

4.5 What is your continuing education and competency program for the ECLS Specialist? Specifically, how do you meet these ELSO Guidelines? Address all four questions regarding guidelines for credit.

a. Describe all Formal Team Meetings: (must include agenda details, frequency, education, attendance records and attendance requirements):

Insert answer here

b. Describe your Water Drill and/or Simulation sessions used to assess competency (attach a water drill checklist or scenario)

.Insert answer here

c. Describe Annual Examination process (attach recent annual exam):

Insert answer here.

d. Describe quarterly pump time requirements:

Insert answer here.

4.6 Describe your policy regarding an ECLS Specialist who does not meet continuing education requirements. (must include all continuing education components as described above in question 4.5)

Insert answer here.



2016

4.7 Describe your educational program for bedside nurses to care for an ECLS patient.

Insert answer here.

4.8 What initial priming education and water drill training are required to be a primer? Include courses, water drills/simulations, minimum patient requirements etc.

Insert answer here.

4.9 Explain your annual continuing education and competency required for ECLS primers. Include courses, water drills/simulations, minimum patient requirements etc.

Insert answer here.

Application for the Silver Level (Path to Excellence), Stop Here



2016

5. Quality FocusProvide continuous quality improvement activities.

5.1 How does your center maintain knowledge of current ECLS practice? How do you incorporate that new knowledge into your Centers’ clinical practice? Answer all three questions for credit.

a. Describe how you stay current with the latest advances/research/techniques:

Insert answer here.

b. How do you communicate this knowledge with your team?

Insert answer here.

c. Give a specific example demonstrating how your center implemented a recentadvance/research/technique into policy OR procedure OR standards, OR best practice development and initiation. This example must represent work conducted within the last 2 years.

Develop your answer with the advance/research/technique you wanted to implement, how you incorporated it into your practice and contextually within your ECLS program. Include the evidence that shows you successfully implemented the advance/research/technique into practice and how it improved patient care or outcomes.

Insert answer here.

5.2 Workforce management includes topics such as initial education and training, or continuing education. The term “Best Practice” refers to processes and policies that generally produce exceptional results. Best practices may involve the innovative uses of resources, staff, and technology. What new best practice related to workforce management was implemented in your ECLS center in the last 2 years?

Relate a specific example related to the development and initiation of a process specific to workforce management OR education OR training, OR continuing education within your ECLS program in the last 2 years. Describe the need you identified for this new best practice and how it was developed, initiated, and evaluated for effectiveness.

Insert answer here.



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5.3 The value of care we give our patients can be improved by reducing costs, increasing work efficiency, reducing waste, optimizing the use of resources, promoting family centered care or improving patient outcomes. What initiative have you implemented in your ECLS program to improve the value of the care you deliver to the patient or family?

Give a specific example related to a process that improved the value of care delivered to a patient or family within the last 2 years. The example should be complete and relevant to increasing the value of care.

Insert answer here.

5.4 List all ECLS related conferences attended by one or more of your team within the last two years. (ELSO, Keystone, SEECMO, EURO ELSO, etc.) Maintain anonymity by listing the individuals by role (coordinator, director, etc.)

Describe the personnel who attend each of the above conferences:

Insert answer here.

Additionally, list any ELSO committees that individuals from your institution actively participate on:

Insert answer here.



2016

6. Process OptimizationProvide outcome reviews and developmentally focused care.

6.1 Illustrate your Centers’ Morbidity and Mortality Review process. Describe a recent review of a case that includes a major complication or death that was discussed with ECLS team members.

Detail your M&M process, including how you incorporate all ECLS team members (physicians, specialists, perfusion, etc.) into this process:

Insert answer here

Give a specific example of a recent patient that was presented at an M&M within the last 2 years. Include personnel present, discussion, analysis, and conclusions that may have arisen from the M&M:

Insert answer here

6.2 The ELSO Registry provides specific reports to each center to assist in comparing center outcomes to the aggregate international outcomes. Discuss how you review the ELSO Registry data reports and how you utilize the ELSO Registry data reports in your centers’ practice.

Describe your process for reviewing and comparing your ELSO center specific patient data, including outcomes and complications:

Insert answer here.

Give a specific example of how the ELSO Registry data specifically has impacted patient care or driven practice changes within the last two years. Describe the entire process -from identifying the need for data through the change implementation.

Insert answer here.



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6.3 Benchmarking is the process of measuring your own performance against the performance of industry leaders. Utilizing information obtained through benchmarking to improve processes, procedures, and treatment strategies shows a commitment to excellence and improving patient care outcomes. Discuss your center’s benchmarking process. How has it influenced your ECLS Program to adapt best practices to increase an aspect of performance within your Program?

Detail your benchmarking process:

Insert answer here.

Give a specific example of the development or the revision of a process that can be directly related to Benchmarking a process in the last 2 years. Describe the need you identified for this process change and how benchmarking was used. Must include data to show the improvement in the process:

Insert answer here.

6.4 Specify your process for monitoring ECLS patient anticoagulation.

Describe the testing structure, protocol, tools or algorithms used for patient anticoagulation management:

Insert answer here.



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7. Patient &Family FocusProvide family education and participation in care.

7.1 Give a detailed explanation of the educational materials you provide to the family of the ECLS patient.

Insert answer here.

7.2 Family centered care recognizes the vital role families play in ensuring the health and well-being of infants, children, adolescents and family members of all ages. Describe how your center incorporates the family/caregiver into the daily care of the patient on ECLS

How do you include family in the daily care of the patient?

Insert answer here.

How do you provide appropriate activity/developmental care for each ECLS patient population listed in question 1.1? For those awake and responsive patients, how do you include them in self-care activities?

Insert answer here.

7.3 ECLS patients are often awake and responsive, and may require long ECLS runs. Families are presented with statistics, facts and unknown prognoses for their loved ones. How do you address the potential distress and suffering that may occur in your families and/or patients with the real probability of death or unpredictable outcomes on ECLS?

Insert answer here.

7.4 How do you follow-up your patients to see what their outcomes are? Describe your medical follow-up plans for each of your ECLS patient population listed in question 1.1.

Insert answer here.

END OF APPLICATION



2016