Jayne Sheehan
Diane Gilworth
February 11, 2009
Agenda
11:00-11:10 – Jayne Sheehan, introductions, vulnerabilities- med management
11:10-11:20- CQI/Medication Management in Derm Surgery, Sheilah Janus, Dr. Daihung Do
11:20-11:30 – JC Readiness-updates Jayne Sheehan 11:30-12:00- Medication management-code carts,
Allison McHugh 12:00-12:20 – Policy & Procedure Subgroup Update
Sandy Hewitt 12:20-12:25 Tool box update, Lynne Brophy 12:25-12:30- Medication management reminders and
Chart Audit Update Diane Gilworth
Vulnerabilities-just a reminder Patient Rights
Patient and/or Family Involved in Decisions Health Care Proxy
Identifying /Involving in Care Informed Consent
Provision of Care Patient Education
Assessing Learning Needs Evaluating Comprehension
Pain Assessment/Reassessment ** Restraints
Timely Orders Ongoing Assessment
National Patient Safety Goals 2 Patient Identifiers
Administering Medications Collecting Blood Labeling Containers In Front of Patient
Write Down/Read Back Recording Calls to Floors/Units
Hand Offs – up to date and pertinent information with opportunity to ask questions
To/From Procedure and Test Areas Intra-Hospital Transfers
Medication Labeling Going to Gemba Transferring from original
container Detailed information on label
Medication Reconciliation ** Intra-hospital Transfers Outside Providers Patients
National Patient Safety Goals (Cont.) Anticoagulation Therapy
Process to implement an enterprise-wide Anticoag Therapy Program
Universal Protocol Operative / Procedural Area/ Bedside Verification of Side/Site/Procedure Marking of Site Time Out Immediately Before Procedure
Medical Staff Standards Bylaws Related Timeliness of Reappointments
Human Resources Decentralized Monitoring of Competencies Performance Evaluations Staffing Effectiveness Exercise 2008-09
Infection Control Use of PPE PPD Screening
Information Management (Medical Records Related) Aggregate Reports of Compliance Streaming
through HIM Committee Performance Improvement
Collecting/Analyzing/Using Data for Improvement
Staff Knowledge of Priorities
Going to Gemba…Go and See Genchi Genbutsu: One of the fundamentals of the
Toyota way. In short this means, “Go to the actual scene (genchi)
and confirm the actual happenings or things (genbutsu)”
“The record suggested that people got hurt not because they are stupid but because they found themselves in
circumstances in which it is easy to get hurt and hard to be safe”
Key Capabilities: Seeing problems as they occur Swarming & solving problems as they are seen Spreading new knowledge Leading by developing capabilities 1,2 & 3
LOCAL ANESTHETIC PREPARATION, STORAGE, TRANSPORT, AND
ADMINISTRATION POLICY
Dermatology- CQI project
Sheliah Janus, Daihung Do MD
Reviewing our ProgressJayne Sheehan
For Each Chapter•Key Concepts
•National Patient Safety Goals•Related Policies/Procedures
•Resources-on-line-staff
•Related sub-group activity
Ethics Rights-Resp
September 08
Provision of Care
October/November 08
Med Management
December 08
Safety/Disaster Management
January-09
Surveillance, Prevention of infection
February-09I
Improving Organizational Performance
March-09
Leadership
EC/R
Sub- Groups•Policy/Procedures•CQI/chart auditsScope of Practice•PACE Audits•License Verification•Anti-coagulation
On Line “Joint tool Box”ChaptersIntegrated learning
Power of the group
Content of our work
Sub-groups, -The “why and what”
CQI/scope of service, Lead - Jason Laviolette JC documents which will be reviewed during initial sessions-guide the survey process
PACE Audits, Lead - Stephanie Tarantino Reviewed unit based PACE audits/concordance with hospital wide PACE audits- measures to
make this data available to you in real time- JC requirement
License Verification, Lead Diane Gilworth JC standard- primary source documentation/central verification process- in place for all ambulatory
RN’s and NP’s
Policy/Procedure sub-group, Lead - Sandy Hewitt Re-organization of policies and procedures- tool boxes
Anticoagulation, Lead - Louise Mackisack JC standard and high risk medications.
Goal:
a) increased the number of engaged “experts” – integrated knowledge for all
b) Integrate knowledge of JC into everyday practice
Readiness PreparationJayne Sheehan
An Unscheduled JC Visit- your role
Clean sweep- “25 steps to a sweeping success” No food, drinks, clean corridors Staff –badges PACE RACE HIPPA Have a tracer patient in mind Code Carts- checked, locked MDs- everything you need to know about JC National patient safety goals
25 Steps to a Sweeping Success
Codes and Emergency Management of
MedicationsAllison McHugh
Policy and Procedure Subgroup Update
Sandy Hewitt
What is our Charter? Provide periodic and systematic review of P&Ps to
ensure they reflect current practice and comply with appropriate guidelines and mandates.
Determine what general P&Ps need modification for Ambulatory purposes.
Ensure standardization of those Ambulatory P&Ps specific to us. Ex: some HR policies.
Improve ease of access to P&Ps.
Locate Ambulatory’s P&Ps on the “Ambulatory Services” site on the portal. (Lynne’s Tool Kit)
Request of you……
We’ll be sending an e-mail requesting you to please tell us:
Which policies and procedures you refer to most frequently.
Which policies and procedures do you have trouble finding.
If there are policies and procedures you wish we had.
C. More to come
Tool Box
Lynne Brophy
Chart Audits-updates
Diane Gilworth
Good Better Best
Continue with present chart audits
Review your data and be prepared to discuss with the JC
Reformat questions for easier documentation
Clarify # of chart audits per unit
Define what it means to be compliant
Get data back to you in a timely manner
Create a new more clinicallyRelevant chart audit
Data is available real time- unit specific-CQI
Clinicians would do all Chart audits- MD’s, NP’s , RN’s.
Chart Audit Process 2009 and beyond
Ambulatory Unit
Date of Service
Medical record number
Attending physician (Last Name, First)
Patient Seen By (Last Name, First)
Reviewed by
Review date
Date of Birth (enter mm/dd/yyyy)
Ambulatory unit- drop down menu for all unitsAdd in # of charts to be done within a quarter- (based on unit specific parameters)
Data comes back to you in a timely manner
Proposed chart Audits 2009
Problem list is updated and reviewed (within last 12 months) Yes/No
Allergies are reviewed and updated (within last 12 months) Yes/No
Medication list is up to date (on a quarterly basis the medication reconciliation survey could be rolled into the chart audit to reduce the number of actual surveys done per unit)
Yes/NoSummary list is present- by 3rd visit-
this list included known and significant medical diagnosis and conditions, known significant operative and invasive procedures, known adverse and allergic drug reactions, know long term medications, including current prescriptions, over the counter drugs and herbal preparations. The list is quickly and easily available for practitioners.
Yes/NoConsent forms are present as applicable for invasive procedures. general consent includes a discussion of: a. the nature of the proposed care, treatment, services, medications, interventions, likelihood of achieving goals, reasonable alternatives, relevant risks and benefits, side effects related to alternatives, including possible results of not receiving any therapy, …..
Yes/No
Chart Audits
H & P is present ( need language to determine what counts as an H&P)
Yes/NoPain assessment is documented as appropriate
(would recommend standardizing pain assessment tools and if possible creating space within web OMR for direct documentation)(provide link to pain assessment tool)
Yes/No
Pain is reassessed at subsequent visits. A comprehensive pain assessment is conducted as appropriate to the patients condition and the scope of care, treatment, and services provided. (would recommend standard reassessment tools and standard template for documentation in Web OMR)(provide link to pain reassessment tool)
Yes/No Advanced directive is present-
new field in Web OMR (documentation indicates whether the patient has signed an advance directive)
Yes/No
Medication Management
Medication management policy/competency on line
Prohibited abbreviations (hand-out) Multi-dose vial- 28 days- pharmacy policy Refrigerator Alarms (change battery and
check green sticker) Medication questions –posted on portal
Refrigerator temperature ranges should be between 36 and 46 degrees Fahrenheit,
•if alarm sounds:Turn alarm off.Check to see if refrigerator is functioning properly.C all service response at: 617-632-0070.Call Pharmacy about interim medication storage.
It is necessary to reset the unit whenever a change is made to c / F temperature.
To reset the unit, use a pointed object to push the RESET button on the back of the unit.
Click mode to Lo to Hi, set Lo (36oF) Hi (40oF) turn alarm ON.Order back-up batteries replacement 1AA battery.
Refrigerator Alarms
Thank you
Jayne Sheehan
Diane Gilworth