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March 10, 2010
Ambulatory Joint Commission
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Agenda Comments on Count-down to Survey
Discussion
Chart audit results and what we’re doing about them…Presented by: Sandra Hewitt
Updates on Medication Reconciliation and Universal Protocol Presented by: Charmaine Massey and Sandra Hewitt
Ambulatory CQI Committee Update Presented by: Menrika Louis
Waiting Room Patient Information Posting Standards Presented by: Sandra Hewitt
New PACE Audit Tool & our results from 2/10/10Presented by: Gary Schweon
Mock Surveys on ambulatory units Presented by: Sandra Hewitt
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Count down to survey!
Anniversary survey date is 7/27/2010.
If you have any specific questions or concerns, please feel free to contact me and if it’s something I can’t help you with, I’ll work to connect you with the appropriate person(s).
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What if The Joint Commissionshowed up tomorrow? Sweep cards
No food and drink in clinical areas Badges above the waist and facing forward HIPAA enforced
- Computer screens not visible- Patient information not in view
Code Carts – checked and locked Have a tracer patient in mind Hand hygiene
Anyone need Sweep Cards? It’s the way to sweeping success and a calm demeanor.
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Chart Audit Results for November
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Chart audit results
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Time OutDocumented
Ops/Proc Noted Consent Timed Updated Medlist to pt
Progress on Vulernabilities
3-Sep
28-Oct
17-Nov
Goal
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Chart Audit Subgroup
Membership
Lynne Brophy Jason Laviolette
Linda Dicenzo Janet Lewis
Sandra Hewitt Nancy Richter
Courtney Ives Carol Slowley
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Chart Audit Subgroup Work Reviewing what constitutes invasive procedures in
Ambulatory/ED and when consents are needed.
Consent forms will be replaced with corrected version with space for physician and patient to both time and date their signatures. (Updated version now available only in English; info next slide.)
Inventoried where signed consents are stored. More on that process later.
Addressing time out procedures. (Will be reviewed under updates on Universal Protocol).
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Updated Consent Forms
English version only can be ordered direct ship by contacting:
Nancy at S&A Paramount
(800) 582-2282 x 32.
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Medication Reconciliation Update:Enhancement in the Works
Charmaine Massey
Significant NPSG Updates
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Medication Reconciliation Viewed as critical to safety by key stakeholders;
Organizations continue to struggle with implementation;
Currently under evaluation and refinement;
While organizations will still be surveyed for this requirement, findings will not factor in the accreditation decision (effective 1/1/09).
Changes to be announced in 2010.
Implement revisions for January 2011.
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Hand Hygiene
Modifications are intended to reflect a more realistic approach;
Need to demonstrate:
- the existence of a program
- goals and efforts to improve
Goal does not need to be 90%
No more observation to find 3 instances of no hand washing.
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Universal Protocol Updates
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Pre-procedure verification
The “checklist” has become a “standardized” list;
Not necessary to document that standardized list was used for each patient;
TJC will observe practice, interview staff and look for postings or cards regarding a standardized list.
We will be developing posters to put in exam rooms.
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Site marking
If there is no debate regarding location, then we DON’T have to mark, unless deemed valuable.
LIP accountable for procedure should mark site, most frequently the provider performing the procedure.
A Resident/PA/NP can act on behalf of LIP in LIMITED situations only.
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Time Out To be conducted at some time prior to
incision.
List of issues was shortened to focus on correct patient, correct site, correct procedure.
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CQI Committee Updates
Menrika Louis
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Ambulance Transfers from Ambulatory Clinics
Problem / Questions: Is there a standardized process for
patients in ambulatory clinics to be transferred to the Emergency Department?
What process is being followed? Does the process provide safe transfer for the patient and does it follow the NPSG’s related to hand-offs?
Are we providing the Emergency Department with the pertinent information they need, this includes but is not limited: allergies, last meds given, Code status if any and precautions?
Clinic Observations Findings: *
Transfer processes varied. Provider used online call-in to the ED. Ambulance unable to find patient
location. Not all appropriate staffs were alerted
of the transfer. Provider was not always available for
hand-off to EMTs. Med lists, facesheets were printed and
provided to the EMTs.
ED Observations: Information needed at ED Triage
differs from treating clinician in ED.
*Observations of patient transfers from various ambulatory clinics to the ED were done over a period of one week.)
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Ambulance Transfers from Ambulatory Clinics
ANALYSIS
Despite the different types of clinics
and support staff, there is need for a
standardized, streamlined process for
transferring patients from Ambulatory
Clinics to the Emergency Department.
RECOMMENDATIONS Change the ED online call-in to
trigger the input of more information from the provider.
Clear outline of what preparations are expected when patients are being transferred to the ED.
Roles/expectations should be defined for participants (Medical Assistants, Registered Nurse, Provider (MD/NP).
Communication plan to ensure unit awareness of EMTs’ impending arrival.
Proper hand-off is needed at every point of transfer.
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Waiting Room Patient Information Posting Standards
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Goals:
Ensure that all necessary information is posted in waiting rooms.
Establish standard language and appearance of information.
Create a less confusing presentation for patients.
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Criteria: Required Information
Healthcare Proxy Transparency Info on Delays
Patient Rights Infection Control Signage
Medicare Rights Copay Signage
Notice of privacy Practices Booklets
Hand-washing Notice
Wait Sign (if waiting >15 minutes)
TJC Brochure on physician visits
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Physician Visit Brochures
Speak Up™ brochures are available in English and Spanish at:
http://www.jointcommission.org/PatientSafety/SpeakUp/
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Criteria: Presentation Information easy to find
Presented by subject matter
Clear and prominent signage indicating where to find the information
Cell phone signage tasteful and in multiple languages
Standard TV instructions
Good display rack design
Labeling of sections within display rack
Current specialty specific information
Posting kept to a reasonable limit and in proper frame/laminate sleeve
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