epic bca/downtime manual houston methodist hospital system

© 2016 Houston Methodist Hospital (all rights reserved). This material may not be copied, modified or distributed without the express prior written approval of Houston Methodist Hospital.

Epic BCA/Downtime Manual

Houston Methodist Hospital System

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Contents Purpose ................................................................................................................................. 3

Summary ............................................................................................................................... 3

Downtime Scenarios ............................................................................................................. 4

Downtime and Recovery Notification ..................................................................................... 7

Communicating During Downtime ....................................................................................... 10

Downtime Kits ..................................................................................................................... 11

Before Planned Downtime ................................................................................................... 11

During Downtime ................................................................................................................. 12

Downtime Check List ........................................................................................................... 13

Downtime Reports ............................................................................................................... 14

Downtime PCs in your Department ...................................................................................... 16

Nursing Downtime Procedures ............................................................................................ 16

Recovery Procedure ............................................................................................................ 18

Appendix 1: How to access SRO ......................................................................................... 25

Appendix 2: How to access BCA Web ................................................................................. 26

Appendix 3: How to access BCA PCs ................................................................................. 28

Appendix 4: Ongoing Testing Required by Application Team .............................................. 29

Drill 1: Introduction to BCA/Downtime Support Resources ............................................... 29

Drill 2: Use Shadow Read Only (SRO) (Scenario 1) ........................................................ 30

Drill 3: Use BCA Web (Scenario 2) .................................................................................. 30

Drill 4: Use BCA PCs (Scenario 3) ................................................................................... 30

Appendix 5: Pharmacy Downtime Manual ........................................................................... 33

Appendix 6: Patient Access Downtime Manual .................................................................... 35

Appendix 7: Surgical Downtime Manual .............................................................................. 43

Appendix 8: Inpatient Downtime Manual.............................................................................. 55

Appendix 9: Emergency Department Downtime Manual ...................................................... 63

Appendix 10: Lab Downtime Manual ................................................................................... 71

Appendix 11: HOD Downtime Manual ................................................................................. 73

Appendix 12: Ambulatory Downtime Manual ....................................................................... 79

Appendix 13: Radiology Downtime Manual ......................................................................... 87

Appendix 14: Cardiology Downtime Manual ........................................................................ 91

Appendix 15: Rehabilitation Services Downtime Manual ..................................................... 92

Appendix 16: Food and Nutrition Services Downtime Manual ............................................. 98

Appendix 17: Health Information Management (HIM) ........................................................ 103

Appendix 18: Billing ........................................................................................................... 104

Appendix 19: Definitions, Acronyms and Abbreviations…………………………………...…105

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Background Information Purpose

The purpose of the Epic BCA/Downtime Manual is to define both the necessary process and computer functions required to maintain patient care activities during downtime and to outline the recovery process. The manual outlines how clinicians will process and handle information during downtimes and transition back to full functionality of Epic systems.

Clinicians reference the downtime manual when Epic is unavailable due to any scheduled and unscheduled downtimes. Clinicians are expected to follow a detailed process for capturing and recording data on appropriate forms and entering that data into Epic during the recovery period.

Clinicians need to be familiar with their downtime kits. The downtime kits contain relevant paperwork to be used in the event of a scheduled or unscheduled Epic downtime.

Scheduled downtimes due to system upgrades or “fixes” will be coordinated at times when

patient care is least impacted.

Summary

The manual describes the process that clinicians will follow when there is an interruption to

the department due to a power outage, computer downtime, or other technical interference

(i.e. Citrix outage).

This manual is structured in three parts:

1. Downtime Preparation: Outlines the key information required to prepare for a

scheduled or unscheduled downtime.

2. During Downtime: Outlines clinical and revenue cycle downtime procedures

when the system is unavailable.

3. After Downtime: Outlines clinical and revenue cycle downtime procedures while the

system is in recovery.

The manual outlines how to determine specific downtime levels based on the sub‐

workflows and detailed scenarios from action through recovery, when the downtime is

complete.

Hospital wide communication protocols are outlined in the Houston Methodist IT

Continuity Escalation Plan.

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Downtime Scenarios There are three types of downtime scenarios which use different BCA tools.

Scenario # Network/SRO Status Tool(s) available to view patient data

1 SRO up Wide Area Network up Local Area Network up

SRO (Supports Read Only)

BCA‐Web

BCA‐PC

2 Wide Area Network down Local Area Network Up

BCA‐ Web

BCA‐PC

3 Wide Area Network down Local Area Network down

BCA‐PC

4 Data Center Access down BCA‐PC

Scenario 1: Use SRO ‐ Networks is up, Epic is down and Supports Read Only (SRO) is available

Scenario 1 Instructions:

Instructions Screenshot

How to log into SRO:

Log into the SRO environment. This allows clinicians to navigate Epic Hyperspace in a similar way; however it prevents clinicians from entering any new information into the system.

READ ONLY

Holly Hall, TX Data Center

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Use your Epic Hyperspace username and password.

Upon login, these are indications that you are in a Read-Only environment (SRO).

Record downtime events on paper forms which are available in your downtime kits.

Keep paper forms until information is recovered into the system.

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Holly Hall, TX Data Center

Scenario 2‐4: Use BCA Web or BCA PC – All other scenarios

Hospital/Clinic

Local Area Network

Wide Area Network

BCA PC

Scenarios 2‐4 Instructions:


How to log into BCA Web:

Access BCA Web from the desktop icon or from the following link: https://epiclbebcawprod.houstonmethodist.org/BCAWeb-8.2/prelogin.html

BCA WEB

Login using your Epic Hyperspace user name and password.

Select your Department/Unit from the Folder List.

Print necessary reports.

Record downtime events on paper forms which are available in your downtime kits.

Keep paper forms until information is recovered into Epic.

*If BCA Web is not available, please use BCA PC.

How to log into your BCA PC:

Identify your BCA PC. This device has a label that reads “Epic BCA Downtime Device”.

https://epiclbebcawprod.houstonmethodist.org/BCAWeb-8.2/prelogin.html


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Log into BCA Printing using the icon on the desktop.

Use your Epic Hyperspace username and password.

Select reports to print critical patient information.

Downtime and Recovery Notification Type of Downtime Communication Plan

Scheduled Downtime

Users will be notified in advance of the planned downtime event via email. These email notifications/flyers can be printed by management/supervisors and posted to visible bulletin boards in staff areas and may include in staff huddles.

IT will phone Operations Administrators/Administrative Coordinators/Centralized Billing Office at affected facility/facilities 1 hour prior to scheduled downtime as a reminder of impending downtime.

Operations Administrators/Administrative Coordinators/Centralized Billing Office will utilize in-house pagers/phone communication to notify units/departments of impending downtime.

Recovery

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Type of Downtime Communication Plan

IT will notify Operations Administrators/Administrative Coordinators/Centralized Billing Office that the system has been restored and that ADT areas will brought online first.

IT will notify ADT areas that they may initiate census/downtime event reconciliation.

ADT areas will notify IT when they have completed census/downtime event reconciliation.

IT will notify Operations Administrators/Administrative Coordinators/Centralized Billing Office that ADT reconciliation has been completed and all other users will now be brought online.

IT will notify end users via email that the system has been restored, ADT events have been reconciled, and recovery procedures/data entry can be initiated.

Operations Administrators/Administrative Coordinators/Centralized Billing Office will utilize in-house pagers/phone communication to notify units/departments that the system has been restored, ADT events have been reconciled, and recovery procedures/data entry can be initiated.

IT will utilize Everbridge alert to Management level Distribution list that system has been restored.

Pharmacy will notify each department as appropriate when Medication Order Reconciliation is complete.

Unscheduled (Small Scale)

Downtime

Users will notify Help Desk of system interruption.

Help Desk/IT will assess/identify problem.

IT will notify managers/supervisors of affected areas to initiate downtime procedures.

Recovery






Operations Administrators/Administrative Coordinators/Centralized Billing Office will utilize in-house

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pagers/phone communication to notify units/departments that the system has been restored, ADT events have been reconciled, and recovery procedures/data entry can be initiated.



Unscheduled (Large Scale)

Downtime

Users will notify Help Desk of system interruption.

Help Desk/IT will assess/identify problem.

IT will notify Operations Administrators/Administrative Coordinators/Centralized Billing Office of downtime.

IT will utilize Everbridge alert to management level distribution list to notify that the system is down and to initiate downtime procedures.

IT will notify users via email to initiate downtime procedures.

o Code White email script: “The [Epic] system is down. Estimated

length of downtime is XXX (if known). Initiate downtime procedures. Access clinical data using XXX (SRO, BCA-PC, BCA-Web).

Operations Administrators/Administrative Coordinators/Centralized Billing Office will utilize in-house pagers/phone communication/overhead to notify units/departments of unscheduled downtime and initiation of downtime procedures.

o Code White overhead page script: “May I Have Your Attention, please? Code

White Downtime.” Recovery






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o Code White email script: “The [Epic] system is restored. Initiate

recovery procedures.

Operations Administrators/Administrative Coordinators/Centralized Billing Office will utilize in-house pagers/phone communication to notify units/departments that the system has been restored, ADT events have been reconciled, and recovery procedures/data entry can be initiated.

o Code White overhead page script: “Code White Downtime All Clear.”



Communicating During Downtime Department Communication

Pharmacy Written orders will be scanned/faxed to Pharmacy

Medications not in PYXIS will be delivered to units via pneumatic tube or courier

Laboratory Utilize Downtime Lab Requisition Forms with labeled specimens

STATs and Critical Values will be called to unit by Laboratory, all other results will be scanned to unit or sent by pneumatic tube

Radiology Fax order and call department

Nutrition Fax order and call department

Therapies (PT/OT/SP) Contact the department via telephone

Respiratory Call/Overhead page/or use pager system/wireless communication device (ex. Vocera) to notify therapist assigned to unit

o HMWB, HMSJ, and HMSL also can fax to respiratory department, but should still follow with phone call or page to therapist

Patient Access Services- ADT (Admission/Discharge/Transfer)

Admission

ED/Admitting Physician will make a bed request using the phone to the Clinical Bed Coordinator/Administrative Coordinator

Clinical Bed Coordinator/Administrative Coordinator will fill out ADT Downtime Event Form and fax to Patient Access Services

Clinical Bed Coordinator/Administrative Coordinator will notify ED staff and receiving inpatient unit of patient bed assignment

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Transfer

Inpatient clinical staff will fill out ADT Downtime Event Form and fax to Clinical Bed Coordinator/Administrative Coordinator and Patient Access Services

Clinical Bed Coordinator/Administrative Coordinator will notify transferring and receiving departments of patient bed assignment

Discharge

Inpatient clinical staff will fill out ADT Downtime Event Form and fax to Clinical Bed Coordinator/Administrative Coordinator and Patient Access Services

Downtime Kits Every department will create and maintain an Epic downtime kit. The downtime kit should contain the following:

o Facility Phone Numbers list

o Downtime policy/procedure documentation

o Downtime checklist

o Blank labels

The following blank forms and other information will be in the downtime kit:

Nursing Documentation forms (Flowsheet Records)

Blank MAR forms

Blank Physician order forms

Blank Progress Notes

Downtime Event forms

Requisition Slips

Department specific order sets and forms Pharmacies should have blank labels on hand prior to any downtime. In the event of a planned downtime, the blank label supply should be checked and if necessary, use the Custom Label activity to print blank Med and IV labels.

All Areas/Departments have created their own Downtime Kits. Each department’s kits have necessary paper forms and access to instructions to support clinicians to provide patient care.

Before Scheduled Downtime Enter Orders: Orders, Ancillary procedures and Labs to be completed during

downtime should be entered in Electronic Medical Record (EMR) before downtime begins.

Organize Downtime Forms: Downtime forms are located in the Downtime Kits. During scheduled downtimes, prepare any needed forms before downtime begins.

Coordinate Patient Labels: Place patient labels on downtime paper forms including

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each page of the paper flow sheet if needed.

During Downtime This section provides information about what to do during a downtime. This includes:

1. Downtime Checklist: Easy to access information for clinicians.

2. Downtime Reports.

3. Downtime PCs.

4. Downtime Procedures (see the appendix for specific departmental information).

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Downtime Check List

☐ Communicate that downtime procedures are in effect to other clinicians.

☐ Identify your Downtime kits and BCA PC.

☐ Assess the Downtime level based on the availability of SRO, BCA Web and/or BCA PCs.

☐ Follow Downtime Procedures based on the Downtime Level (see below).

Downtime Type

LEVEL 1 Scheduled

Access SRO *Minimal Paper

Charting

LEVEL 2 Unscheduled

Access BCA Web &/or BCA Computer & Printer *Start Paper Charting Immediately

Tool to access Epic information

Supports Read Only (SRO)

BCA Web and/or BCA PC

Instructions Log into the SRO environment

READ ONLY Use your Epic Hyperspace username and password Access read‐only version of Epic Record downtime events on paper forms Keep paper forms until information is recovered.

From any workstation: Open the BCA Web icon or enter the following URL into internet browser:

BCA WEB

https://epiclbebcawprod.houstonmethodist.org/BCAWeb-8.2/prelogin.html Log in using your Epic Hyperspace user name and password. Print the appropriate reports. Record downtime events on paper forms Keep paper forms until information is recovered *If BCA Web is not available, locate your BCA PC:

Identify your Downtime Workstation and log into the BCA Printing icon

Login using your Epic Hyperspace username and password



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Print the appropriate reports.

☐ Print patient labels and put labels on patient forms

☐ Distribute/make available downtime forms

☐ Create/update patient paper chart

☐ Begin the recovery process (see page 18)

☐ Once system is back up notify clinicians to return to normal operations

☐ Collect all documentation for Health Information Management (HIM)/Medical Records to scan into the medical record (see the full recovery procedure on page 18)

Downtime Reports Departments Report Name Report Description

Patient Access Census Shows basic information about patients in the hospital, such as date of birth, admission time, and attending provider

Ambulatory Clinics

Clinical Summary Shows clinical data for each patient, including active orders, recent results, and vitals.

Daily Appointment Report (DAR)

Shows information about upcoming appointments within a department for use during a downtime

Emergency Departments

Census Shows basic information about patients in the hospital, such as date of birth, admission time, and attending provider

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Departments Report Name Report Description

Medical Administration Report (MAR)

Provides medication administration information about a patient during a downtime.

Clinical Summary

Shows clinical data for each patient, including active orders, recent results, and vitals.

Lab Census Shows basic information about patients in the hospital, such as date of birth, admission time, and attending provider

HOD DAR Shows information about upcoming appointments

within a department for use during a downtime


Medical Administration Report (MAR)


Inpatient Medical Administration Report (MAR)




Surgical Master Daily Schedule

Shows all of the scheduled cases for the day

Pick List Provides case information about the patient, including supplies for surgery, drugs, instructions, etc.

Preference Cards Provides case‐neutral information about surgeons' preference cards.


MAR Provides medication administration information about a patient during a downtime.

Anesthesia Record

Shows anesthesia records in which the patient hasn't been marked Ready for Procedure.

Pharmacy Rx Med Profile Shows patient‐specific medication information, such as relevant results, allergies, and all medications


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Departments Report Name Report Description

Rx MAR Provides medication administration information about a patient during a downtime.

Rx Cart Fill Full by Dept.

Shows information for orders that are dispensing from a cart.

Downtime PCs in Your Department

Every department has an allocated downtime workstation. These computers are identified with a sticker that reads-Epic BCA Downtime Device.

Nursing Downtime Procedures

Documentation: 1. Print necessary Downtime Reports from BCA Web or BCA Downtime PCs as appropriate

(Clinical Summary, MAR, etc.). Retrieve appropriate documentation, order, and requisition

forms from Downtime Kits.

2. Document Assessments, Interventions, Plan of Care, I&O’s, IV’s, IV Titration, and Vital Signs

on the paper flow sheet.

3. All new orders are placed either on blank Physician Order forms or pre-printed Order Sets

found in Downtime Kits and placed in the order section of the Downtime Clinical Summary in

patient paper chart.

4. Document medication administrations on paper MAR report as outlined in next section. For

new patients, use blank MAR forms found in the Downtime Kit.

Medication Administration:

1. For patients that have an electronic medication profile, Medication Administration Record

(MAR) reports will be printed from BCA Web or BCA PCs.

2. For new patients and/or patients without an electronic med profile, use blank MARs found in

Downtime Kits.

3. Update paper Medication Profiles with new medication orders received since the time of

printing and throughout the downtime. For medication schedules use standard administration

times.

a) Transcribe new orders onto the paper Medication profile & administration schedules in

the designated time column. (Include comments and/or end times if specified.)

b) Mark discontinued meds by writing “Discontinued” next to the entry and crossing out the

medication name using a single line through the medication entry. Initial, date, and time

entry.

c) If a medication is changed, discontinue the original order as above, and transcribe the

new order as a new medication entry.

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4. Perform manual verifications of the 7 rights of medication administration during each

administration; Right patient, right medication, right dose, right route, right time, right

monitoring, and right documentation.

Orders:

1. Continue to fax/tube written medication orders to Pharmacy with patient information,

including location. Medication order processing should not be affected.

2. Use manual requisition forms for other orders.

a) LAB/Transfusion Services Orders

i. For labs not entered in Epic, send specimen with a patient label and completed

downtime Laboratory Requisition form(s). Lab requisition forms must have patient

name, MR #, account #, physician and patient location.

ii. Fax/tube copy of written order and blood requisition form for new blood transfusion

orders to Blood Bank. Blood Bank will call the unit when blood products are ready for

pickup.

iii. All samples must have collector’s and witness’s initials, collection date and time on

the label.

b) Patient Care Supply‐ Call Central Supply/Supply Chain for patient supply/equipment

requests.

c) Radiology Orders‐ Fax order and call department for Radiology, CT, MRI, Angiography

orders.

3. For other ancillary orders please call or page the specific departments (PT/OT/ST, RT, Case

Manager, Social Worker, Chaplain, etc.)

4. For Diet Orders ‐ Call/fax order to Food and Nutrition Services.

Test Results:

1. Radiology reports & images will be available on the PACS system ONLY.

2. Lab results will be faxed/tubed to units. Critical values will be phoned to the units.

3. Document Glucose‐meter results on the paper flow sheet.

4. For other results‐ call the appropriate department.

Automated Dispensing Cabinets (ADC… i.e. Pyxis)

New medication orders or changes will not cross into the Automated Dispensing Cabinet (ADC).

ADCs will be placed on critical override to allow access to medications. Manually add new patients

into cabinet for override dispensing.

ADT‐ Admit/Discharge/Transfer: For Admission call Patient Access Services.

Clinicians need to track transfers and discharges on the ADT Downtime Event Form and fax

completed forms to Patient Access Services.

Refer to steps in Appendix 8: Inpatient Downtime Manual for admission /discharge/transfer

procedures.

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After Downtime (Recovery): This section outlines the steps clinicians should take once the system has been recovered.

Recovery Procedure

IT/H

elp

De

skIn

terf

ace

sA

DT

En

d U

se

rsH

IM

Downtime Recovery Workflow

Start

IT Communicate to Interface Team that Epic is back up

from a downtime IT Communicate to ADT that

interfaces are on

ADT Registration Follow process for getting ADT reconciled. Use downtime MRN

and CSN where needed

Interfaces Team Send messages to Epic and

communicate to IT

ADT RegistrationCommunicate to IT that all

admission/discharge/transfers are entered

ITCommunicate to all end users

that Epic is now available

End UsersComplete reconciliation of

pertinent data based on policy and length of downtime

End UsersReconcile MAR once Pharmacy reconciles medication orders

End UsersEnter note in patient chart

that patient was seen during downtime

End UsersContinue care as usual

HIMCollect paper documents and

scan into medical record

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Recovery Procedure / Tasks

Step Detail Responsible

IT/Helpdesk Communicate to ADT and Interfaces that Epic is back up.

Once ADT and Interfaces are reconciled, IT/Helpdesk communicates to users that Epic is now available.

IT/Help Desk

ADT Follow process for getting admissions reconciled. Use downtime MRNs and CSNs where needed.

Communicate to IT/Helpdesk that ADT is

reconciled.

ADT Registration

Interfaces Interface engine releases queued

messages to Epic and communicate to

IT/Helpdesk when complete.

Lab and Radiology orders/results are received in Epic

Interfaces Team

End users Other users complete reconciliation of

pertinent data based on policy and length of

downtime.

Reconcile MAR once pharmacy reconciles

medication orders.

Enter Epic Downtime Event Note for all

patients in the facility during downtime.

Clinicians

HIM Collect paper forms and scan into Epic HIM

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After Epic Downtime

DO NOT resume documentation in Epic until instructed even if Epic appears to be back

online. A “CODE WHITE ALL CLEAR” will be initiated when EMR is all clear and ready to use.

(Instructions will be sent when system is ready & stable)

Upon Resuming Documentation in Epic:


1 Verify the census (ensure that patients are in correct room and bed). Transfers and discharges need to be entered by Patient Access Services using ADT Downtime Event Form.

Nursing Patient Access

2 Enter in Epic all non‐medication orders (ancillary consultations, nursing activities, etc.) 1. The following departments will be entering orders sent

with manual requisition slips; Radiology, Laboratory and Non‐Invasive Cardiology. Respiratory orders will be entered in Epic by designated Respiratory Therapist. a) Downtime orders must be acknowledged after

verification in the electronic system. 2. Prior to resuming documentation of meds in Epic, you must

verify the electronic Medication Administration Record (MAR). A. Confirm new medication orders and schedules in Epic’s

MAR (highlighted items) against the Physician Orders & paper MAR.

B. Discrepancies in order entry and/or future schedules must be communicated to Pharmacy for corrections prior to confirming the order.

C. Orders must be acknowledged after verification in computer.

D. Medication Administration: Nursing will keep the original paper orders in the chart until the patient is discharged. Then they will be scanned into the medical record by HIM staff.

Nursing

3 Before removing medication schedules generated during downtime, verify administration of dose and document against the schedules with the appropriate reason.

Nursing

4 Documentation forms used during the downtime will become a Nursing

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permanent part of the medical record. Place forms in the designated section of the chart and discard interim reports (Clinical Summary, etc.) in the confidential recycle bin.

5 In Epic- Add Downtime Documentation o Open Vitals flowsheet o Select Add Rows o Search for and add the Downtime Documentation

flowsheet group to the flowsheet. o Document “Downtime Begin” and “Downtime End”

times in the flowsheet rows that now appear at the top of the flowsheet.

Nursing

6 Intravenous Medication Reconciliation Instructions o Reconciliation is the process of updating and

documenting IV bags and/or continuous infusions following an interruption in computer documentation. IVs should be reconciled after a downtime for the accurate documentation of intake and output.

I. During Downtime:

a) Document IV bags and the corresponding IV intake volume on the paper flow sheet.

b) Continue to hang IV bags in the correct sequence while on paper.

II. After Downtime: Update IVs in Epic.

a) End bags that were completed or stopped during computer downtime. (Verify remaining volume prior to ending bags)

b) Scan current bags into the system to resume computer documentation. Note: Make sure to adjust the volume of each bag to the actual remaining volume upon resuming online documentation.

c) If a bag previously hung is still infusing, update the remaining volume.

Nursing

7 Post –Downtime Recovery: Once the system becomes available, clinically required data will be entered into Epic System. Paper documentation created during downtime will be placed in the patient’s chart.

Nursing

8 Essential Data – ADT must reconcile patients’ locations into the system and make sure that MRNs are resolved.

Patient Access

9 Downtime Event Note: All patients system wide will need the Nursing

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following event note completed in order to satisfy regulatory compliance:

A. From the Notes Activity, select “Create Note” and enter a note type of “Downtime Event Note”.

B. Create a downtime event note using Downtime Event Note SmartText

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Documentation Recovery

For all existing patients, update the patient chart based on any events that happened during downtime.

High Priority Critical Elements for Inpatient

Downtime ≤ 1 hour

Downtime 1-3 hours

Downtime > 3 hours Entering

User

Height/Weight

Enter all Nursing

Allergies

Lines/Drains/Airways

Isolation and Infection Flags

Code Status

FYI Flags

Pregnancy Status

Medication Orders

Use the “Transcribed from paper” mode, enter orders into Epic: Enter all medication orders

Pharmacist

Medication Administration

Enter all (**do not enter until Pharmacy communicates that they have

finished recovering orders**) Nursing

Non-Medication Orders

Enter all Nursing non-medication orders including future labs, diet, activity, ancillary consults, etc. (Do not enter orders for

medications or performed labs)

Nursing

Respiratory Orders Enter all Respiratory non-medication orders Respiratory

Imaging Orders Enter all orders performed during downtime to reconcile exams Radiology

Problem List Enter all Provider

Inpatient Admission Data Sets

Downtime ≤ 1 hour

Downtime 1-3 hours


User

Prior to Admission Meds

Enter all

Enter all for patients admitted during the downtime

Nursing Patient (head-to-toe) Assessment

Enter all for patients admitted during the downtime

Fall risk Initial assessment for all patients admitted during the downtime Braden scale

Inpatient-other critical data

Downtime ≤ 1 hour

Downtime 1-3 hours


User

Vitals

Enter all

One set per shift or if pertinent others occur Device integration units-do not back enter-the data will file when the system comes back up

Nurse

Intake/Output I & O shift totals Nurse

Blood Administration Enter all Nurse

Vent settings Enter last settings Respiratory

Care plan Enter all Nurse

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Notes Scan in Scan

Code Documentation Scan in (TBD medication entry) Scan

Discharge Instructions Scan in Scan

Ancillary Clinical Services

Downtime ≤ 1 hour

Downtime 1-3 hours


User

PT/OT/SLP/Evaluation and Re-Evaluation

Enter all

Enter last assessment PT, OT,

SLP,

PT/OT/SLP/Treatment Plan

Enter all PT, OT,

SLP

Oncology/Ambulatory

Clinical Services

Downtime ≤ 1 hour

Downtime 1-3 hours


User

Oncology - Any manipulation of the Treatment Plan or Therapy Plan, including: completing treatment day, dose changes, and schedule change.

Enter all

Nurse

Oncology - Cancer Staging (new or revised)

Enter all

Provider

Oncology/Ambulatory - final lab results from non-Houston Methodist labs

Enter all

Nurse

Oncology/Ambulatory - any new items or updates that are pushed to MyChart: problem list, med list, allergies, immunizations, preventative care/health maintenance, test results, history, vital signs

Enter all

Nurse

Oncology/Ambulatory - MyChart activation code generation for new patient or proxy

Enter all

Nurse

Problem List Enter all Provider

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Appendix: Appendix 1: How to access the Support Read Only (SRO) environment Use this approach if Epic Hyperspace is not available (i.e. Scheduled Downtime)

Staff log into any workstation on their unit.

Find the SRO icon located on the desktop. This icon will be pointed to the SRO environment.

READ ONLY

Login using your Epic Hyperspace User ID and Password

Navigate SRO the same way you would using Hyperspace. Record downtime events on paper and keep in the patient’s chart until the system has been recovered.

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Appendix 2: How to access BCA Web Use this approach if Epic Hyperspace and Shadow Read Only (SRO) is not available (i.e. Unscheduled Downtime)

Access BCA Web using the BCA Web icon on the desktop or

use the URL listed below from any browser.


BCA WEB

Log‐in with your network ID and password.

Navigate to your Department/Unit folder from the list.

Select your report from the list.


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View or print appropriate reports.

Within the Folder List, the following reports may be available (Clinical Summary, MAR, DAR, Scheduled Orders, Census (see page 14 for a complete list by department)).

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Appendix 3: How to access BCA PCs Use this approach in all other scenarios

BCA PCs should be used if SRO and BCA Web are not available.

Epic Downtime Reports: Print out applicable downtime reports. Reports should have a copy that is immediately filed into the patient’s paper record (if appropriate). Follow this procedure to access the BCA reports:


Log on to the BCA workstation. Use your domain login information for access to the workstation

Double click the BCA Reports icon on the

desktop

For username/password enter in your Epic Hyperspace login information

Once logged in, user will be able to select reports and print

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Appendix 4: BCA Readiness Required by Application Team

Initial Training:

Training will also be provided as part of the standard curriculum.

Ongoing Drills: It is recommended that quarterly BCA drills are scheduled and are incorporated as part of the scheduled Disaster Drills. This process will be jointly coordinated by the following groups.

Component Lead Contact

BCA PCs Network Tech Analyst IT Infrastructure

BCA Reports Application System Analyst IT – ClinDoc, OpTime, ASAP, Willow, Ambulatory, Beaker and HODs.

BCA Drills Facility Nurse Champions Denise Martin

BCA Policies and Procedures Nurse Managers HMHS – All Entities

The purpose of downtime drills is to educate clinicians of what resources they have available during different scenarios of downtime.

Drill 1: Introduction to BCA/Downtime Support Resources The purpose of this drill is to ensure clinicians are aware of downtime equipment and resources; and that they are properly deployed in their department.

Step 1: Locate your BCA/Downtime PC:

The BCA PC should have a sticker labeled “Epic BCA Downtime Device” on the top. The PC should also have a sticker identifying the device name on it such as “1D3PRE_DT13”.

Step 2: Locate the BCA/Downtime Printer:

The BCA Printer should have a sticker labeled “Epic BCA Downtime Device” on the top. The printer should also have a sticker identifying the device name on it such as “1D3PACU_LJ02”. The printer will also be connected to the BCA/Downtime PC by a USB Plug.

Step 3: Locate the Epic Support Read‐Only icon and the Downtime Printing icon: These icons should be on your desktop, the icons will be used depending upon the scenario during downtime.

30

READ ONLY

Step 4: Locate your downtime kits: This may be a binder, cart, box, etc. The kits should contain the Downtime Procedure Manual, paper forms to use during downtime, and any other necessary forms that your department/unit will need if Epic is down.

Drill 2: Use Support Read Only (SRO) (Scenario 1)

The purpose of this drill is to educate clinicians on an alternate way of using Hyperspace during a downtime. Step 1: Log into Epic Read Only (SRO): This can be located on any PC desktop or Workstation on Wheels (WOW).

The shadow read‐only icon will enable you to view Epic in read‐only.

READ ONLY Step 2: Navigate through SRO like Hyperspace: No new information can be entered but you can review any information on patients that was previously entered in Epic before it went down.

Drill 3: Use BCA Web (Scenario 2) The purpose of this drill is to educate clinicians of an alternate option of getting patient information if the SRO application is unavailable.

Step 1: Begin Downtime Procedures: Explain what and overhead page of “Code White” signals. Step 2: Go to BCA Web: Click on the BCA Web icon or enter the URL into a browser.


BCA WEB

Step 3: Log into BCA Web: The login page for BCA Web will come up and you will enter you normal login information.

Step 4: Review Patient Reports: Navigate through the folders to find your Department/Unit

Folder. Once the reports come up you can find the patients in your department/unit and view/print reports as needed.


31

Drill 4: Use BCA PCs (Scenario 3) The purpose of this drill is to educate clinicians on an alternate option of getting patient information if SRO and BCA Web are both unavailable.

Step 1: Begin Downtime Procedures: Explain what and overhead page of “Code White” signals. Step 2: Find the BCA/Downtime PC

The BCA PC should have a sticker labeled “Epic BCA Downtime Device” on the top. The PC should also have a sticker identifying the device name on it such as “1D3PRE_DT13”.

Step 3: Log into the BCA Printing Icon: Look on the desktop for the “BCA Printing” icon, this icon will allow you to print the same reports that you get from BCA Web. Use your normal login information to get into Downtime Printing.

Step 4: Find Patient Reports Needed: Once logged into “BCA Printing” the Reports Screen appears. Here you can filter by Department, Location, PC and Report Type Tags. You can view all patient reports and choose the ones you would like printed.

32

Possible other drills include:

A) Test IT Communication Plan The purpose of this drill is to educate clinicians on the proper steps of communicating with IT during a downtime to ensure proper patient care.

B) Recovery

33

Appendix 5: Pharmacy Downtime Manual

BCA PCs and Downtime Reports

Site Location BCA Name Department Reports

HMH HMH PHARMACY (DB1-002 Central Pharmacy Office)

1DB1PHAR_BCA Willow Pharmacy RX Profile, Pharmacy RX MAR, Census

HMH HMH Fondren ICU RX Satellite

1F3PHAR_BCA Willow Pharmacy RX Profile, Pharmacy RX MAR, Census

HMH HMH RX OPC 22 Satellite

1OPC22PHAR_BCA

Willow Pharmacy RX Profile, Pharmacy RX MAR, Census

HMH HMH Fondren RX OR Satellite

1FANE_DT01 Willow Pharmacy RX Profile, Pharmacy RX MAR, Census

HMH HMH Main OR RX Satellite

1M3OR_DT02 Willow Pharmacy RX Profile, Pharmacy RX MAR, Census


1OP19SURG_DT10 Willow Pharmacy RX Profile, Pharmacy RX MAR, Census


TBD Willow Pharmacy RX Profile, Pharmacy RX MAR, Census

34

Pharmacy Department Downtime Workflow

Pharmacy Procedure / Tasks ‐ ALL


Downtime

Communicate that department is in downtime period.

Is SRO available?

– Yes: Log into the SRO environment and use the

read‐ only mode of Epic to view relevant patient data.

– No: Proceed to the next step. – Are BCA web available?

o No: Identify your BCA PC to access the reports.

o Yes: Use BCA web to access report.

o Is the length of the downtime short? Yes: Print off required reports

(Rx MAR, Rx Profile and Census Report).

No: Print all required reports (Rx MAR, Rx Profile and Census Report).

– Receive new orders by fax and provide first

doses. – Put labels on medication with patient MRN

and information (DOB) – Record what has been sent on paper. – Keep all paper forms until the system has

recovered.

Pharmacy

Leader

Pharmacist

35

Appendix 6: Patient Access Downtime Manual


Site Location BCA Name Department Reports needed

HMH HMH ADMITTING

1M1PAS_DT10

ADT ADT Downtime Census,

ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH ANATOMICAL PATH

1M3LAB_DT27 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH ENDOVASCULAR

1M2AOD_DT21

ADT ADT Downtime Census,

ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH MAIN RAD IMAGING

1M2IMG_DT02 1M2RAD_DT15

ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH MAIN 3NW AOD 1M3AOD_DT41 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH MAIN ED 1M1EDEMS ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH APEC 1OP22RAD_DT34

1OP22RAD_DT45


HMH HMH MAIN BREAST CENTER

1SM7BRCT_DT60 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH OP TREATMENT 1WP11NS_DT03 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH KIRBY BREAST CENTR

1KB1IMG_DT17 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

36


HMH HMH VOSSED 1VO1ED_DT09 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH KIRBY ED 1KE1ED_DT31 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH PEARLAND ED 1PL1ED_DT15 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH CANCER CTR ANNEX

1AX1RONC_DT07

1AX1RONC_B


HMH HMH Admin TBD ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH Transplant 1OP26TPC_DT34

1SM12TPC_DT193

1OP26TPC_DT30

1SM12TPC_DT104


HMH OPC 18 TBD ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH Jones 10 1J10NS_DT14 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH OPC 2 TBD ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH Smith 5 TBD ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH ORTHO HMH SM 2600 TBD ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

37


HMH HMH West Houston Imaging

5KI1IMG_DT20

5KI1IMG_DT10


HMH HMH BED & PT MGMT 1D4CSCH_DT10 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH OPC 21 1OP21CANC_DT73 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH BMT IP 1M8SENS_DT10

1M8NENS_DT03

1M8PHAR_DT04


HMH HMH BMT OP 1M8SWNS_DT24 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH MAIN 8NW 1M8NWNS_DT20 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH Main 9 TBD ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH International Services

1ST5INTL_DT04 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH Telecom/Operators

1D2TELCOM_DT15 ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

HMH HMH Volunteer Services

TBD ADT ADT Downtime Census, ADT Downtime Event Form, ADT Downtime Event Log

38

Patient Access Department Downtime Workflow

HM Patient Access Downtime Workflow

Do

wnt

ime

Reg

istr

atio

nA

dm

it

Patient Access Communicate that department is in downtime period

Patient Access Use BCA Web

Is BCA Web available?

Epic is down

RegistrationUse existing MRN/CSN. Use ADT downtime registration

form to capture patient information.

RegistrationUse the ADT

Downtime Event Form and Log to

capture the event information

Registration

Assign patient a downtime MRN/CSN, use ADT

downtime registration form to capture patient

information.

Patient AccessPrint necessary census reports and downtime event forms from BCA

workstation

No

Is this a new patient?

No

Yes

Yes

RegistrationProvide patient with consent

forms for signing. Place all forms in patient chart

RegistrationRecord dates and

times for every event on the ADT Downtime Event

Form and Log

RegistrationRefer patient to appropriate area – Lab, Radiology, etc.

Does the patient need to be admitted?

Yes

No

RegistrationIdentify a bed and

call transport, record the event in the ADT Downtime Event Form and Log

End

39

Patient Access (ADT) Procedure / Tasks – ALL


Downtime Communicate that the department is in a downtime scenario.

Is the SRO available?

– Yes: Log into the SRO environment to view relevant patient information.

o Use necessary forms to record clinical, charge and time information.

o Keep paper copies in the patient chart until the system has been recovered.

– No: Are BCA PCs available? o Yes: Use your Epic Hyperspace

username and password. o No: Log into BCA Web and use your

Epic username and password. – Print BCA Reports (Downtime Census and

Scheduling Reports) from the BCA workstations. – Print necessary forms from the BCA

workstations and start using ADT Downtime Event Log to record events.

Patient Access Registration

Registration Is this a new patient?

– No: Use existing MRN/CSN, MRNs and CSNs will be displayed in the existing Census Report. Use ADT Downtime Registration Form to capture patient information and events.

– Yes: Assign patient a downtime MRN and CSN. Use ADT Downtime Event Form to capture patient information.

– Use the ADT Downtime Event Log to capture event information.

Patient Access Registration

40


Admissions Does the patient need to be admitted?

No: Refer the patient to the appropriate area(s) (Surgery, Transport, Lab, Radiology, etc.).

Yes:

o Provide patient with forms for signing; place forms in patient chart.

o Call Clinical Bed Coordinator/Administrative Coordinator to identify a bed.

o Call transport and record the event using the Downtime Event Form and Log

o Move the patient to the identified bed

o Provide clinicians with patient chart

Make sure that dates and times of every event are recorded on the ADT Downtime Event Form and ADT Downtime Event Log

Registration

Downtime Patient Station When Epic is brought back up, any admission information needs to be entered via downtime patient station. This admission information will be entered into the system prior to being available to other users. After the admission information is input via patient station, the discharge and transfer information will be completed. After all ADT information is completed, the system will be returned to normal operation and all users will be permitted to log on. To use downtime patient station, click on the downtime patient station button on the toolbar. Do not use the ED track board, as there is no way to input downtime CSNs or MRNs via the track board.

41

Downtime patient station looks the same as regular patient station except this will bring up the box seen below after you click on new ED arrival. Enter the MRN previously created or use the downtime MRN. , Click accept. (It is possible that the MRN was established earlier, and therefore you do not have a downtime MRN, but you do have a downtime CSN.)

42

When you click on arrive, you will see this dialog box. Enter the downtime CSN that was assigned during downtime (from your hand written event log).

That’s it! Now everything else is entered in the usual fashion.

43

Appendix 7: Surgical Downtime Manual



HMH

APEC 1OP22RAD_DT34 1OP22RAD_DT45

OpTime

Master Daily Schedule

HMH

HMH Centralized Scheduler

1KN1PAS_DT59 1KN1PAS_DT70 1KN1PAS_A

OpTime

Master Daily Schedule

HMH

D3 Pre

1D3PRE_DT13 1DPRE_DT13

OpTime

Master Daily Sched, Clinical Summary, MAR, Case Log

HMH

D3OR

1D4OR_DT10

OpTesia

Master Daily Sched, Pick List, Pref Cards, Clinical/Anesthesia

Summary, MAR, Case Log

HMH

D3PACU

1D3PACU_DT25

OpTesia

Master Daily Sched, MAR, Clinical Summary, Anesthesia

Summary

HMH

Main Pre

1M3PREOP_D10

OpTime


HMH

Main OR

1M3OR_DT02

OpTesia



HMH

Main PACU

TBD

OpTesia


Summary

HMH

D6OR

1D6OR_DT06

OpTesia



HMH

D6PACU

1D6PACU_DT07

OpTesia


Summary

HMH

Fondren Pre

TBD

OpTime


HMH

Fondren OR

1F3ANE_DT01

OpTesia



HMH

OPC Pre

TBD

OpTime


HMH

OPHTH OR

TBD

OpTesia



HMH

OTO OR

TBD

OpTesia Master Daily Sched, Pick List,

Pref Cards, Clinical/Anesthesia Summary, MAR, Case Log

HMH

OPC PACU

TBD

OpTesia


Summary

44


HMH

OPC 18 Pre

TBD

OpTime


HMH

OPC18 OR

TBD

OpTesia



HMH

OPC18 PACU

TBD

OpTesia


Summary, MAR, Case Log HMH

OPC 19 Pre

1OP19PRE_DT40

OpTime


HMH

OPC 19 OR

1OP19SURG_DT10

OpTesia



HMH

OPC19 PACU

1OPC19PACU_DT41

OpTesia


Summary

HMH

HMH ENDO

1SM6GI_DT05

OpTesia



45

Downtime Central Scheduling Workflow Sc

he

du

ling

– E

xisti

ng

Ap

po

intm

en

t R

eq

ue

stSc

he

du

ling

– N

ew

Ap

po

intm

en

t R

eq

ue

stSu

rgic

al C

ase

Sc

he

du

ling

Downtime Surgical Workflow

Start

Scheduler Staff: Communicates – EPIC is down &

department is in downtime period

Is this during business hours?

Refer to Surgical policies and procedures

NO

Scheduler print Schedule Request Log and keeps

paper copies until system has been recovered.

End

Scheduler prints Master Daily Schedule report

from downtime workstation

Prints Schedule

Request Log,

Fax a copy of DAR

for PAT, MDS – PRE/

OR/PACU.

Prints latest schedule

for the day – SPD/

Materials for

procedures that day.

Is SRO available?

Scheduler logs into SRO Environment to patient scheudle

YES

NO

YES

Start

Refer schedule request to the OR

Charge Nurse

NO

End

During Recovery, all

scheduled

procedures need to

be logged in EPIC


Record the request on the schedule

request logYES

Scheduler schedules new appointment

manually based on the print out copy

Fax confirmation of appointment to original

requestor

OR Scheduler – logs in SRO & use read-only mode of EPIC to

view relevant patient data

OR SCHEDULER

communicates

downtime to all

surgical department

staff & immediately

begin downtime

procedure

Is SRO Availble?StartIs the BCA Web

Available?

OR SCHEDULER

communicates

downtime to all

surgical department

staff & immediately

begin downtime

procedure

YESNO

OR Scheduler – logs in BCA PC

OR Scheduler – receives surgery request by phone

or fax

YESNO

Is surgery within the next 24

hours?

OR Scheduler – schedules procedure manually base

on availability. During recovery – need to enter all

data to EPIC

NO

OR Charge NURSE receives

scheduling request by phone

and record surgery and book

on availability. OR Scheduler

can schedule procedure with

Charge RNs approval.

Include list of operation,

surgeon , room time, special

needs and allergies.

End

SPD/Materials – prints off preference card/pick list

from the BCA workstations and prepare equipment.

46

Downtime Central Scheduling Workflow


Existing Appointment Request

Communicate that Epic is down and department is in downtime period.


No: Refer to the surgical policies and procedures.

Yes: Is SRO available?

Yes: Log into the SRO environment to patient schedule.

o Print schedule request log. o Keep paper copies until system

has been recovered.

No: Log in to BCA web and print DAR and Clinicians Daily Schedule from downtime workstation using Epic Hyperspace user name and password.

o Print schedule request log. o Fax a copy of the DAR and daily

schedule to PAT clinic and Preop/ OR and PACU department for any changes on schedule for the next day which is an end of day process providing latest copy of schedule.

o Print out preference cards, pick list and schedule for SPD and materials for procedures that day.

Scheduler

New Appointment Request

Is this elective surgery?

Yes: Record the request on the schedule request log.

o Schedule new appointments manually

o Fax confirmation of the appointment to the original requestor via orders now.

No: Refer schedule request to the OR Charge Nurse

Scheduler

47


Downtime (Scheduling)

Communicate downtime to Surgical Department

clinicians and immediately begin downtime

procedures.

Is SRO available?

Yes: Log into SRO using any PC. Record all events on paper.

No: Is BCA Web available?

o Yes: Log into BCA web using any PC. Choose your device and print relevant reports. Record all events on paper.

o No: Find your BCA PC and log in using your Epic Hyperspace user name and password. Print relevant reports. Record downtime events on paper.

Print paper copies of forms or get forms from the Downtime Binder. Receive surgery requests by phone or by fax.

Is surgery within the next 24 hours?

Yes: Connect directly to OR Charge Nurse.

No: Connect to Central Scheduling.

Central Scheduling:

Print BCA Reports (case log summary and master

daily schedule) from the BCA workstations.

Print off and fax preference cards and schedule to

SPD and OR Clinical. Include list of operations,

surgeons, room, time, special needs and

allergies.

OR Charge Desk:

Receive schedule by phone or fax.

OR Charge record surgery request and book

based on availability.

Include list of operations, surgeons, rooms, time,

special needs, and allergies.

SPD/Materials:

Print off preference cards/pick list from the BCA

workstations and pick lists and prepare

equipment.

Central Scheduling

SPD

Materials

OR Charge

Unit Clerk

48

Downtime Surgical Department Workflow A

DM

ITTI

NG

PR

E –

OP D

ep

art

me

nt

INTR

AO

P D

ep

art

me

nt

PA

CU

/Re

co

ve

ry D

ep

art

me

nt

AO

D/P

ha

se 2

Downtime Surgical Workflow

Start

Unit Clerks communicates

downtime to all surgical dept staff &

downtime procedure begins

IS SRO available?

Unit Clerk prints Master Daily schedule, labels for

that day. Registers patients on the MDS &

record pt’s time of arrival

Unit Clerks verify

patient’s info from

intake chart and

walks pt over to AOD/

Preop and puts all

forms in patient’s

paper file

Is SRO available?

Staff puts patient in preop room & does

inventory of pt’s belongings

Clinical Staff – create

lab/radiology/BB

requisition order and

send paper request

form with specimen to

lab and/or patient to

radiology

Clinical Staff uses periop nursing Bo document pt

info, patient time of arrival and provide

patient with labeled band.

Clinical Staff – gathers info on health history, fall

risks, skin, meds, allergies, NPO and

performs POC testing if necessary

Does patient require radiology/lab/blood bank

orders?

YES

Intra RN –

completes PREOP

Checklist for

patient. Use periop

downtime nursing

record to document

relevant findings

and record follow

up orders

Intra RN – Documents “In

Room time”, time out,

incision time, positioning and

skin condition. Use printed

forms to fill out relevant

implants(if any), charges and

supplies. Use pronted forms/

labels to submit any

specimen to pathology/lab.

Is BCA Web Available?

NO

YES

Unit Clerk finds the BCA PC and Logs in

NO

To AOD?Preop Area

To AOD?Preop Area

Start

Anesthesia Staff – follows anesthesia

downtime procedures

Clinical staff starts pt’s IV and finishes PREOP

documentation

Clinical Staff sends patient to OR department

NO

Clinical Staff sends patient to OR department

Intra Clinical Staff –

pulls preference

card for procedure

Start

Intra RN – saves

copy of implant

used and additional

supply items used

for charges.

Document patient

tracking events.

Intra RN –

Document “Out of

Room” time and

send patient to

recovery, drop off

patient to recovery

with the intra-op

sheets.

Drop off patient to PACU

PACU process

patient through

recovery including

physician orders

(Surgeon and

Anesthesia orders).

Documents in

flowsheet.

PACU RN Contract

house supervisor

by phoneto identify

a bed and transport

to department

Drop off patient to PACU

PACU RN receives

patient and record

Time of Arrival

Start

PACU RN –

prepares patient for

admission to floor

Transport patient from

a surgical department

to inpatient unit,

marking to bed

assigned bed, room

and floor

Move patient to next level of care (floor/

ICU

Is the patient inpatient?

YES

Transport patient to

AOD/Phase 2 or

Day Surgery and

mark out of PACU.

PACU staff takes

note of time

NO

Move patient to AOD/Day Surgeyr

or Phase 2

Clinical staff cares for patient

till patient meets discharge

criteria, If not – physician

writes admission/o

Clinical Staff

receives patient in

department and

document data on

downtime periop

nursing

documentation

form. Marks patient

in Phase 2

Start

Clinical Staff –

documents

discharge criteria

met, prepares

discharge forms

and provides any

additional

educational

Patient /guardian

signs discharge

form, copy of which

stays in h

Move patient to AOD/Day Surgeyr

or Phase 2

Does the patient meet discharge

criteria?NO

END

YES

49

Surgical Departments Procedures


Admitting

Unit Clerk/Secretary

Communicate downtime to surgical department clinicians and immediately begin downtime procedures.

Is SRO available?

Yes: Log into SRO to navigate similar to how you would use Epic. Record all events on paper forms.

No: Is BCA web available? o Yes: Log into BCA Web using your Epic

Hyperspace user name and password. Print all necessary reports and record events on paper forms.

o No: Identify your BCA PC and print necessary reports. Record events on paper forms.

Unit Clerk

Pre‐Op

Registration:

Register patients on the master daily schedule and record time of

Arrival.

Verify patient information from intake charts and on

case log

Summary.

Walk patient over to the AOD/Pre-Op Department.

Put completed forms in the patient’s paper file.

Unit Clerks:

Put patient in pre‐op room.

Do an inventory of patient’s belongings. Clinicians:

Use perioperative nursing admission record to document patient information.

Verifies patient information.

Records time of arrival. Use Patient Arrival Log.

Provides a patient band.

Gathers the following patient information:

o Health history taken by nurse

o Assess for fall risk

o Assess skin

o Meds reconciliation

o Confirms allergies and nil per os (NPO) (fasting)

o Draws labs, urine and pregnancy test, as

required.

Surgeon:

50


Marks patient updates the H&P.

Does the patient have an implanted cardiac device?

Yes: Follow the implanted cardiac process.

No: Proceed to the next step.

Does the patient require lab/transfusion orders?

Yes: Clinicians – Create lab and/or radiology requisition order and send paper form with patient to lab.

No: Clinicians – Send patient to OR department.

Anesthesia Clinicians:

Follow the anesthesia downtime procedures, including anesthesia consent forms.

Pre-Op Clinicians:

Start patient’s IV.

Intra ‐Op

Intra-Op Clinicians:

Print appropriate preference cards.

Complete the pre‐operations check list for patients using forms from the BCA workstation.

Take patient to the OR

Record the time the patient arrives in the OR using OR timesheet.

Position patient appropriately for surgery

Use current intra‐ops nursing records to document

relevant findings and record any follow‐up orders.

Use printed forms to fill out Main OR charge sheet, Operating Room Misc. Charges, and any other relevant charge sheets including implants.

Record the time out of the OR using OR timesheet.

Put forms in patient chart copy of charges should stay in

unit for keying in during recovery phase.

Use printed forms and labels to submit any specimen for

testing.

Prepare the patient to hand off to recovery.

Drop patient off at recovery and record the time.

Drop off patient documentation,

specimens and intra‐op sheets.

Clinicians

51


Recovery

Post Anesthesia Care Unit (PACU) clinicians:

Receives patient post op.

Record the arrival time.

Process the patient through recovery and process any physician orders.

Is this day surgery?

Yes: PACU Registration:

Does the patient meet discharge criteria?

Yes: PACU Registration submits PACU time, charge, supplies and nursing forms.

o PACU Registration: Prepare discharge forms and provides any additional education material as required.

o Patient signs discharge forms.

o Patient is moved to Phase 2 – AOD Department.

No: PACU clinicians: o Contact House Supervisor by

phone to identify a bed and transport department.

o Prepare patient for admission/transfer. o Move patient from surgical department to

inpatient care unit

PACU (Clinicians)

52

Downtime Pre‐Admission Testing (PAT) Workflow P

re-A

dm

issi

on

Te

stin

g (

PA

T)

Pre-Admission Testing (PAT) Workflow

Start

PAT Registration Staff – communicate downtime to all staff

in the department and immediately

downtime procedure begins

Is SRO available?

PAT Registration Staff pronts off schedule and

relevant forms and stickers

PAT staff finds the BCA PC and Logs in

PAT Staff logs into the SRO

environment & user read only mode of

EPIC to view relevant patient data

Is BCA Web Available?

PAT Staff – Identify which patients need clinic visits VS PAT

Screening Calls

Does patient require clinic

visit?PAT Staff – Phones patients and record

answers to the general

questionnaire. All paper copies.

NO

PAT Staff -Phones patient and register/schedule for clinic

visit

PAT Staff – Record registration staff on the PAT log and completes the

consultation. Fulls out paper copies of any required lab, radiology and or

specimen forms

YES

PAT Staff – Discharge patient

End

PAT Procedures


Downtime

Communicate downtime to surgical department clinicians and immediately begin downtime procedures.

Is SRO available?

Yes: Log into SRO to navigate similar to how you would use Epic. Record all events on paper forms.

No: Is BCA web available? o Yes: Log into BCA Web using your Epic

Hyperspace user name and password. Print all necessary reports and record events on paper forms.

o No: Identify your BCA PC and print necessary reports. Record events on paper forms.

Use PAT forms (including patient registration, consent forms, etc.). You can print them off of the BCA workstation or you can find them in the downtime binder

Identify which patients need clinic visit versus phone calls.

Does patient require clinic visits? o Yes: PAT Registration phone

patients and register for clinic visit. PAT Registration:

Record registration on the PAT log.

Complete the consultation and fill out paper copies of any required lab, radiology and/or specimen forms.

Discharge patient.

PAT Registration

53


o No: PAT Clinical phone patients and record answers to the general questionnaire. Put paper copies in the patient’s chart.

Downtime Surgical Charges

Op

tim

e C

ha

rge

s

Downtime Surgical Charges Workflow

Start

Clinical Staff – Records Level of

Care and all charges on paper superbill/fee slips/implants

used.

Clinical Staff – Record orders in superbill

Clinical Staff – Submit all orders/

facesheets

Unit Clerks communicates downtime to all

surgical dept staff & downtime procedure

begins

End

Downtime Surgical Charges Procedures


Downtime

Clinicians:

Record the level of care and charges on the bill/fee slips, copy of charges should be kept in unit.

Record orders on bill.

Submit orders/fee sheets.

Copy of implants used in procedure should be kept for billing purposes.

Clinicians

54

Anesthesia Department Downtime Workflow

Anesthesia Department Downtime Workflow

AN

ESTH

ESIA

De

pa

rtm

en

t

Start

End

Document PACU

handoff on

anesthesia form

and staff patient

transfer out of

PACU

Has the patient been marked

ready for surgery?

Anesthesia Staff – Use pre-anesthesia evaluation form &

Event report

Anesthesia Clinical Staff – prints episode report,

Event report and Optime Master Daily Schedule

and use BCA anesthesia record form

Transfer patient to PACU

Anesthesia Clinical Staff – Record all information using the Episode report

Clinical Staff communicates that the

department is in downtime and begins

procedures immediately

Anesthesia Staff – user paper

Physician Orders as required and

Anesthesia record

PRE YES

NO

INTRA

PACU

Anesthesia Procedure Tasks-ALL


Pre‐Anesthesia

Communicate that the department is in a downtime and immediately begin downtime procedures.

Print the BCA Reports (Episode Reports, Event Reports and OpTime Master Daily Schedule) from the BCA workstations.

Has the patient been marked for surgery?

No: Use Pre‐Anesthesia Evaluation Form and Event Report.

Yes: Record information using the Episode Report. o Use paper copies of physician order sets as

required.

Anesthesia Registration

Post Anesthesia Care Unit

Has the patient been transferred to PACU?

Yes: Use the PACU Care Record to record information.

Clinicians

Recovery Process

Copy of preference cards used for supplies and for billing purposes will remain intact and stored in a designated area to be entered by designated person once the system has been restored data should be entered into EPIC.

Staff responsible for transcribing the record/documents into EPIC data that drives billing – i.e. event times, in/out of OR, PACU times, etc.

Nurse(s) will have the option to verify information entered into Epic for Accuracy.

Completed paper chart will be sent to HIM for

Staff Nurse

Data Entry Personnel

Nurse Auditor

55


document scanning purposes.

Downtime kits are to be returned to nurse’s station on each unit and the unit clerk/nurses are responsible to replenish used forms.

Appendix 8: Inpatient Downtime Manual



HMH HMH ALKEK 7 1AL7NS_DT13 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH ALKEK 8 1AL8NS_DT13 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH BMT IP 1M8SENS_DT10

1M8PHAR_DT04

1M8NENS_DT03

IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH WP IP REHAB 10 1WP10NS_DT19 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH WP IP REHAB 9 1WP9NS_DT15 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH DUNN 10E 1D10ENS_DT07 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH DUNN 10W 1D10WNS_DT14 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH DUNN 4W 1D4WNS_DT20

1D4WNS_DT14








56


HMH HMH DUNN ICU 1D3SICU_DT45

1D3SICU_DT48


HMH HMH FONDREN 11 1F11NS_DT12 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH CONF HRT FAILURE 1F11NS_DT28 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH FONDREN 12 1F12NS_DT11 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH FONDREN CCU 1F10CCU_DT02

1F10CCU_DT13


HMH HMH FONDREN ICU 1F3ICU_DT12

1F3ICU_DT08


HMH HMH JONES 10 1J10NS_DT11 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary


HMH HMH JONES 9 1J9NS_DT10

1J9NS_DT13


HMH HMH M6SW 1M6SWNS_DT17 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH MAIN 4NW 1M4NWNS_DT16 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH MAIN 4SW 1M4SWNS_DT10 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH MAIN 5 1M5NWNS_DT09 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary


HMH HMH MAIN 7N PSYCH 1M7NWNS_DT18 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH MAIN 7SW 1M7SWNS_DT16

1M7PHAR_DT11



HMH HMH FONDREN MICU 1F2ICU_DT43 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH NEURO ICU 1M4NICU_DT21 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH SNF 1WP8NS_DT19 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

HMH HMH NURSERY LEVEL ii 1M6NSRY_DT08 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

57



HMH HMH OBS UNIT M3SW 1M3SWNS_DT14 IP Clinical Summary, MAR, Respiratory Therapy Clinical Summary

58

Inpatient Downtime Workflow

Inpatient Downtime Workflow

Clin

ical

Be

d

Coo

rdin

ato

r/A

dm

inis

trat

ive

Coo

rdin

ato

r

Inp

atie

nt

New

Pat

ien

tD

isch

arge

HIM

Downtime

Start

Charge Nurse/Manager/US

Communicate that the department

should begin downtime procedures

Is SRO available?

Yes

Inpatient StaffLog into the SRO

environment to view relevant patient

information

Inpatient StaffRetrieve necessary

forms from Downtime Kit to

record clinical data/place orders

Inpatient StaffKeep paper copies until system has been recovered

End

NoIs BCA Web available?

Yes

Inpatient StaffPrint BCA Reports (Census, Clinical Summary, MAR)

Inpatient StaffRetrieve necessary

downtime documents and

forms from Downtime Kits

Inpatient StaffPlace all forms in

patient paper chart

Is this a direct admit?

No

Inpatient StaffIdentify the BCA PC

and print BCA Reports (Census, Clinical Summary,

MAR)

Patient AccessProvide inpatient

unit with downtime MRN and necessary consent and patient

forms

Yes

ED/Surgery/HODSubmit a patient bed request by phone or fax to

Clinical Bed Coordinator/

Administrative Coordinator



Reference the Bed Board Log Form

Clinical Bed Coordinator/Administrative Coordinator

Assign patient’s bed and notify charge nurse by phone or page.

Complete Downtime Event Form and fax to Patient Access

Services

Clinical StaffComplete necessary

clinical documentation and

handoff report

Clinical StaffPlace all forms in

patient paper chart

Clinical StaffTransport patient to

appropriate department

Clinical StaffComplete all

necessary forms and place in patient

paper chart

Is this patient being

discharged?

No

Clinical StaffComplete all

necessary forms and place in patient

paper chart

Yes

Clinical StaffPrint discharge

instructions. Print patient education

from BCA workstation via

kramesondemand

Clinical StaffDischarge patient

Unit Secretary

Update Department Log. Fill out Downtime Event Form and fax to

Patient Access Services and Clinical Bed Coordinator/Administrative

Coordinator



Update Bed Board Log Form

Unit SecretaryCollect all paper

downtime forms to be scanned by HIM

End

HIMScan paper

downtime forms into Epic

59

Inpatient Procedure / Tasks ‐ Step Detail Responsible

Inpatient Unit Communicate that the department is in downtime period. Is SRO available?

Yes: Log into the SRO environment to view relevant patient data.

No: Is BCA Web available? o Yes: Log into BCA web to print

necessary reports. Retrieve necessary forms from

Downtime Kit to record clinical data/place orders.

Keep paper copies until system has been recovered

o No: Identify the BCA PC and print BCA Reports (Census, Clinical Summary, MAR)

Retrieve necessary forms from Downtime Kit to record clinical data/place orders.

Place forms in the patient paper chart.

Is the patient a direct admit?

Yes: Patient Access to provide Inpatient Unit with downtime MRN and necessary consent and patient forms.

No: Submit a Patient Bed Request by phone or fax to Clinical Bed Coordinator.

Charge Nurse Unit Secretary

Clinical Bed Coordinator/ Administrative Coordinator

Reference the Bed Board Log Form.

Assign patient’s bed and notify charge nurse by page or phone.

Inpatient Staff notifies the Clinical Bed Coordinator/Administrative Coordinator and updates the Bed Department Log and fills out the ADT downtime event form. Fax downtime event form to Patient Access Services

Clinical Bed Coordinator/ Administrative Coordinator

New Patient Complete the necessary clinical documentation and handoff report.

Place forms in the patient’s paper chart.

Transport patient to the appropriate department.

Clinicians

Patient Discharge

Complete necessary clinical documentation. Is the patient being discharged?

Yes: Print patient education from kramesondemand.com. If the network is not available, physicians can access discharge

Clinicians

60


instruction forms from the Downtime Kit. o Notify Clinical Bed

Coordinator/Administrative Coordinator and complete the ADT Downtime Event Form.

o Fax ADT Downtime Event Form to Patient Access Services.

o Discharge patient.

No: Complete necessary clinical documentation and place in patient’s chart.

Recovery IT will notify users via email/overhead page (Code White All Clear) when system is up and recovery process may begin.

o DO NOT reconcile MAR until your unit/department is notified by Pharmacy that medication order reconciliation is complete.

o Refer to detailed Recovery Procedure on page 18.

Clinicians

HIM Collect paper forms and scan into Epic HIM

61

Inpatient/ADT Downtime Communication Workflow

ADT Communication Workflow

Dis

cha

rge

Ad

mit

tin

gT

ran

sfe

r

Downtime

Start

End

Patient needs to be admitted

ED/Surgery/HODSubmit a patient bed request by phone or fax to



Clinical Bed Coordinator/Administrative Coordinator

Assign patient’s bed and notify charge nurse by phone or page.

Complete Downtime Event Form and fax to Patient Access

Services

Patient Access Services

Receives Downtime Event Form and

updates Downtime Event Log

Patient Access Services

Add patient to Patient List Report

StartPatient is ready for

discharge

IP Clinical Staff/Unit Secretary

Fill out downtime event form

End


Fax form to Clinical Bed Coordinator/

Administrative Coordinator and Patient Access

Services

StartIs this a facility to facility transfer?


Fill out downtime event form


Fax form to Clinical Bed Coordinator/

Administrative Coordinator and Patient Access

Services

Refer to Admit and Discharge steps as

outlined above

EndNo

Yes


Admission ED/Surgery/HOD makes a bed request by phone to the Clinical Bed Coordinator/Administrative Coordinator.

Clinical Bed Coordinator/Administrative Coordinator fills out ADT Event Form and faxes it to Patient Access Services.

Patient Access Services receives the faxed form and records the information from the form on the ADT Downtime Event Log.

ED/Surgery/HOD

Discharge IP Clinicians complete the ADT Downtime Event Form.

IP Clinicians fax form to Clinical Bed

IP Clinical Staff/ Unit Secretary

62


Coordinator/Administrative Coordinator and Patient Access Services.

Patient Access Services receives the faxed form and records the information from the form on the ADT Downtime Event Log.

Transfer Is this a facility to facility transfer?

Yes: Refer to Admit and Discharge steps as outlined above.

o Patient Access Services receives the faxed form and records the information from the form on the Downtime Event Log.

No: IP Clinicians fill out ADT Event Form and fax to Clinical Bed Coordinator/Administrative Coordinator and Patient Access Services.

IP Clinical Staff/ Unit Secretary

63

Appendix 9: Emergency Department Downtime Manual

BCA PCs and Downtime

Reports


HMH HMH Main ED 1M1EDEMS ASAP Clinical Summary, MAR, Census

HMH HMH VOSS ED 5VO1ED_DT16 ASAP Clinical Summary, MAR, Census

HMH HMH KIRBY ED 1KE1ED_DT21 ASAP Clinical Summary, MAR, Census

HMH HMH PEARLAND ED 1PL1ED_DT18 ASAP Clinical Summary, MAR, Census

64

Downtime Workflow (if Epic is down)

65

Procedure / Tasks ‐


ED Admission

Communicate to all staff that downtime is in effect and immediately begin downtime procedures.

Is SRO available?

o Yes: Registration log into the SRO environment and use the read‐only mode of Epic to view relevant data.

o No: Is BCA web available? Yes: Log into BCA Web from

any PC. Print clinical summary, census report and labels for patients.

No: Identify you BCA PC and print clinical summary, census report and labels for patients.

Put patient labels on every form.

Create or add to soft charts for existing patients.

Distribute forms to physicians and nurses.

Is it a new patient?

Yes: Did the patient arrive by ambulance?

o No: Proceed to triage section. o Yes: Primary Nurse record patient

information on the ambulance intake record.

Registration registers patients via arrival log.

Create paper chart with ADT downtime event form and labels and pass to Unit Clerk.

Document using the arrival logs. o No: Registration registers patients

using the arrival log. Use ADT downtime event form. Print labels. Create paper chart with ADT

downtime event form and labels to pass to Unit Clerk.

Document via arrival logs.

o Unit Clerks put patient labels on every

form.

o Distribute forms to clinicians.

Registration

Unit Clerk

66


Triage Primary Nurse initiates the Emergency Services Record form

Primary Nurse

Primary Assessment

Primary Nurse

Complete the secondary nursing assessment and the nurse initiated orders (NIO) form

ED Physician

Use the Emergency Services Record form

Does the patient require lab work?

Yes: Unit Clerk completes the Lab Request Form with specimen and send to the Lab.

o Send specimen to Lab via Tube.

o Lab results are reported by fax. o Check the fax machine regularly and

put results into the patient’s paper chart. o Call Lab for results (if results not

received by 30 minutes).

No: Does the patient require radiology? o Yes: Unit Clerk uses the radiology

computer downtime request form. Send radiology request via phone or

fax. Abnormal radiology requests are

reported by phone or fax. Check the fax machine regularly

and put results into the patient’s paper chart.

Call Radiology for results (if results not received by 30 minutes).

o No: Proceed to secondary assessment.

Information to be put in patient’s paper chart. Orders to be communicated with a Unit Clerk.

Additional specialized forms to be printed from the BCA workstation.

Primary

Nurse ED

Physician

Unit

Secretary

Primary Nurse complete: Clinicians

– Nursing Care Record, Unit Secretary Secondary Assessment

– ED Clinical Record, – Progress Record, and – Epic Downtime Form – Vitals as required.

Pharmacy

ED Physician complete:

67


– ED Clinical Order,

– Subsequent ED provider orders and – Physician Orders as required. Physician orders will be located on the downtime workstation and on the intranet. Information to be put in patient’s paper chart. Orders to be communicated with a Unit Clerk. Additional specialized forms to be printed from the BCA workstation. Communicate with the Unit Clerk for the form to be printed and put in the patient soft chart. Physician order sets and other forms will be located on the downtime workstation and on the intranet.

Pharmacy Clinicians

– For pharmacy orders that cannot be fulfilled in ED.

Send medication orders to pharmacy department

by fax.

– Pharmacy to review in case of dosage questions. Pharmacy to receive request by phone.

Clinicians

Laboratory For laboratory requests use the Lab Requisition Form.

– Orders to be communicated with a Unit Clerk. – Reference table below to provide sufficient

patient information. Keep orders and results in patient paper chart.

Clinicians Unit Secretary

Discharge/Admit/ Transfer

Is the patient ready for discharge?

– Yes: ED Physician/Primary Nurse will print emergency discharge instructions and ED discharge form from the downtime BCA workstation.

o Complete ED Charge Sheets.

– No: Does the patient need to be admitted? o Yes: ED Physician makes a bed request

using the phone to call House Supervisors/Bed Control.

o Fill out the Inter Facility Transfer Form. o House Supervisors/Bed Control fills out the

ADT event form and sent to ADT.

o Complete ED Charge Sheets.

– Send completed patient forms to HIM for scanning.

Once patient admitted/transferred photocopy the forms. Keep the originals in the ED and pass on the copies of the patient paper chart to the appropriate department.

– Send ED Chart copy with patient.

ED

Physician

Hospitalist

Unit Clerks

House Supervisor / Patient Access

68


– Send original orders and EKG results with patient. Send chart with patient when patient is being admitted or

transferred

Charges Use new charge sheets to capture relevant billing information. Keep original in patient paper chart and send to HIM

Billing

HIM

Downtime Patient Station When Epic is brought back up, any admission information needs to be entered via downtime patient station. This admission information will be entered into the system prior to being available to other users. After the admission information is input via patient station, the discharge and transfer information will be completed. After all ADT information is completed, the system will be returned to normal operation and all users will be permitted to log on. To use downtime patient station, click on the downtime patient station button on the toolbar. Do not use the ED track board, as there is no way to input downtime CSNs or MRNs via the track board.

Downtime patient station looks the same as regular patient station except this will bring up the box seen below after you click on new ED arrival. Enter the MRN previously created or use the downtime MRN. Click accept. (It is possible that the MRN was established earlier, and therefore you do not have a downtime MRN, but you do have a downtime CSN.)

69

When you click on arrive, you will see this dialog box. Enter the downtime CSN that was assigned during downtime (from your hand written event log).

70

That’s it! Now everything else is entered in the usual fashion.

71

Appendix 10: Lab Downtime

Manual BCA PCs and Downtime

Reports


HMH HMH LAB 1D2LAB_DT28 Laboratory Medicine Census

HMH HMH MAIN 5 PATHOLOGY LAB

MCM560_DT02

Laboratory Medicine Census

HMH HMH BLOOD BANK

1D2BBANK_DT02

Laboratory Medicine Census

72

Lab Downtime Workflow

Inpatient Lab Downtime Workflow

Inp

ati

en

t La

b S

taff

Downtime

Start

Lab Staff Communicate that

the department should begin

downtime

procedures

Is SRO available?

Yes

Lab StaffLog into the SRO


information

Lab StaffRetrieve necessary

forms from Downtime Kit to

record clinical data/place orders

Lab StaffKeep paper copies until system has been recovered

End


Yes

Lab StaffPrint BCA Reports (Census, Clinical Summary, MAR)

Lab StaffRetrieve necessary



Lab StaffFile all forms

accordingly per department procedures

No

Lab StaffIdentify the BCA PC

and print BCA Reports (Census, Clinical Summary,

MAR)

Lab Staff Reconcile all lab

orders post downtime

End

Procedure / Tasks –

Lab should have preprinted sample labels with instrument IDs in their downtime kits.


Downtime

Communicate that Epic is down and department is in downtime period.

Is SRO available?


No: Is BCA Web available? o Yes: Log into BCA web to print

necessary BCA reports. o No: Identify your downtime PC

and print necessary BCA reports

Retrieve necessary forms from Downtime Kit.

Keep paper copies until system has been recovered.

Reconcile all lab orders post downtime.

Inpatient Staff

73

Appendix 11: HOD Downtime

Manual BCA PCs and Downtime

Reports

Site Location BCA Name Department

Reports needed

HMH HMH HEART TRANSPLT

1OP26TPC_DT34

1SM12TPC_DT193

1OP26TPC_DT30 1SM12TPC_DT104

HOD Clinical Summary, MAR, DAR

HMH HMH LIVER TRANSPLT

1OP26TPC_DT34

1SM12TPC_DT193



HMH HMH LUNG TRANSPLT

1OP26TPC_DT34

1SM12TPC_DT193



HMH HMH PANCREAS TRANSP

1OP26TPC_DT34

1SM12TPC_DT193

1OP26TPC_DT30

1SM12TPC_DT104


HMH HMH RENAL TRANSPLT

1OP26TPC_DT34

1SM12TPC_DT193

1OP26TPC_DT30

1SM12TPC_DT104


HMH HMH WH

TRANSPLANT

TBD HOD Clinical Summary, MAR, DAR

HMH HMH SL

TRANSPLANT


HMH HMH LUBBOCK TRANSPLANT


HMH HMH SPEECH OP JONES

TBD HOD Clinical Summary, DAR

HMH HMH SPEECH OP SUNSET

1SS6IM_DT12 HOD Clinical Summary, DAR

HMH HMH VASC ACCESS TEAM

1M2PICC_DT01 1M2EV_DT02


HMH HMH L&D PROCEDURES


HMH HMH

NEUROPHYSIOL

OGY

1M4NENS_DT07


HMH HMH RESP

CARE PFT

1OP22PUL_DT06


74

HOD Downtime Workflow ‐ P

ati

en

t In

take

Ch

ec

k In

Do

wn

tim

eP

rovid

er

Vis

itC

he

ck O

ut

Reco

ve

ry

HOD Department Downtime Workflow

Start

Check In/Registration: Communicate

Downtime to all staff and begin

downtime procedures

Is SRO available?Is BCA Web available?

Patient access:Log into BCA Web

Patient access:Log into the SRO


information

Patient access:Identify the BCA PC

and login.

Check In/Registration: Daily: Print Department

Appointment Report (DAR), Clinical

Summary, and MAR

Y

N

N

Y

Check In/Registration:

Record patient’s status as arrived on

the Department Appointment Report

(DAR)


Collect Payment if required and record

in daily cash log

New Patient?


Patient complete new patient packet

Photocopy patient identification and insurance

Place non-clinical forms in designated areas for scanning

Put clinical forms, clinical downtime report in patient chart and place in

designated area for clinical staff


Patient completes required forms per visit type

Put clinical forms, clinical downtime report in patient chart and place in

designated area for clinical staff


Notify clinical staff of patient arrival

Y

N

Clinical Staff:Verify patient name and obtain intake

information on downtime encounter form, including any vital signs, history (allergies,

medications) that are pertinent to department and specialty

Clinical Staff:Notify provider of patient ready status

Provider:Document relevant

findings or notes

Provider:Document

assessment and plan

Provider:Document

Medications, Lab/Radiology, Referrals

Provider:Record any follow-

up orders on downtime

encounter form

Provider:Charges: indicate level of care and diagnosis, orders,

other charges

Provider:Provider signs the

completed downtime

encounter form

Clinical Staff:Collect patient’s completed forms

Check Out/Registration:

Collect payment (if not collected at

check in) and record in daily cash log

Follow up appointment?


Record follow up appointment

information. This will be used to

contact patient for scheduling once the system is available


Record completion of appointment on


(DAR)

Clinical Staff:Open the encounter and enter discrete data from the downtime encounter form, including orders,

LOS/CPT codes

Check In/Registration: Check in patient on the schedule. Record any co

payments received. Schedule any follow up

appointments

Clinical Staff:Scan paper forms to the

encounter

Clinical Staff:Notify provider to close

encounterEnd

N

Y

75

Procedure / Tasks ‐ Step Detail Responsible

Downtime Communicate downtime to all ambulatory clinic staff, immediately begin downtime procedures

Is SRO available?

Yes: Log into SRO using your Epic Hyperspace user name and password.

No: Is BCA web available? o Yes: Log in using

your Epic Hyperspace user name and password.

o No: Identify your BCA PC.

Print clinical summary and DAR report for that day.

Clinic Manager

Call Processing / Scheduling

1. Patient calls will be recorded on downtime phone log, including:

1. Patient Name

2. DOB

3. Return phone number

4. Reason for call

5. Contact name and relationship

6. Provider name

7. Call recipient

2. Call processor determines the reason for the call:

Is the reason for the

call due to an urgent

medical need?

Yes:

c. Call processor transfers the call to appropriate clinician, as per clinic protocol.

d. Clinician

documents call

with patient on

downtime phone

log.

No:

e. Call processor

records reason for

Front Desk

76


call on downtime

phone log.

f. Call processor

routes message to

appropriate staff

for follow‐up per

clinic policy.

No: Is patient requesting an appointment? a) Call processor informs patient that

scheduling systems are down and they will be contacted to schedule an appointment as soon as systems are restored.

b) Call processor enters patient information on downtime phone log. If the patient’s prefers, they may also call back at a later time.

3. Call processor will place

phone logs in designated

place for recovery process.

Check In 1. Record the patient’s arrival time on printed

DAR.

2. Collect payment, if required. Record payment on DAR.

3. Is patient a new patient?

Yes:

a) Ask the patient to complete a new patient packet.

b) Copy patient identification and insurance cards (if copiers are functional).

c) Place non‐clinical forms in designated area for scanning.

d) Collect clinical forms, clinical downtime report and place in designated area for clinical staff pick‐up.

No:

a) Request the patient complete required forms for specific visit type.

b) Place clinical forms, clinical downtime report in designated area for clinical staff pick up.

Check In/Registration

77


4. Notify clinical staff of patient arrival per clinic policy (i.e. light system, phone call etc.)

Patient Intake

1. Obtain intake information on the downtime encounter form per clinic policy. This could include:

a) Verify patient name

b) History (allergies, medications, etc.)

c) Vital signs

2. Notify provider of patient ready status per clinic policy (i.e. forms placed in door etc.)

Clinical Staff

Provider Visit

1. Document relevant findings or notes for patient on downtime encounter form

2. Document the assessment and plan: a) Medication orders:

i. Provider writes order on prescription pad. ii. Clinical staff copies prescription and places

with patient’s forms. b) Lab and Radiology orders:

i. Provider completes paper requisition/order form.

ii. Clinic staff records two patient identifiers (patient name and SSN or DOB) on requisition/order form.

iii. Is the procedure performed in‐clinic? Yes:

a) Clinical staff notifies lab or radiology technician of pending order, per clinic decision.

b) Lab or radiology results are sent to the ordering provider for review.

No: a) Clinical staff faxes requisition/order

to performing location, or gives to patient to present upon arrival at performing location.

c) Referral orders: i. Provider records referral on the downtime

referral form. ii. A copy of the referral form is provided to the

designated staff to complete referral, per clinic policy.

iii. Place completed referral form with patient’s clinical forms.

iv. Fax/phone referral.

3. Patient follow‐up:

Provider Clinical Staff

78


a) Provider records any follow‐up orders on downtime encounter form.

4. Charges:

a) Provider indicates level of service and any other charges on downtime encounter form.

b) Provider records diagnoses and orders on downtime encounter form.

5. Provider signs the completed forms.

6. All clinical documentation associated with patient visit is retained by clinical staff

7. All other documents are delivered to the appropriate personnel.

Check Out Check Out/Registration staff collects payment if not collected at check in and records on daily cash collection log, if applicable.

1. Is a follow‐up appointment needed? Yes:

a) Check Out/Registration staff records follow‐ up appointment on schedule request log.

b) Check Out/Registration staff notifies patient they will be contacted for scheduling as soon

as the system is available. No:

a) Record completion of appointment on DAR. 2. Check Out/Registration staff notes completion of

appointment on printed DAR. 3. Check Out/Registration staff places documents in

designated location for recovery procedure.

Check Out/Registration Staff

Recovery Check In/ Registration: 1. Check in patient on the schedule. 2. Record any copayments received. 3. Schedule any follow up appointments. 4. Send copayment receipt to patient if necessary.

Clinical Staff:

1. Open the encounter and enter discrete data from the downtime encounter form, including orders, LOS, CPT codes.

2. Scan paper forms to the encounter. 3. Notify provider to close encounter.

Check In/ Clinical Staff

79

Appendix 12: Ambulatory Downtime Manual


Site Location BCA Name Department Reports Needed

HMH INT MED HMH ST 1130

1ST11MPCG_DT20

1ST11MPCG_LT15

Ambulatory DAR, Clinical Summary

HMH INT MED HMH ST 1950

1ST19IM_DT24 Ambulatory DAR, Clinical Summary

HMH URO HMH ST 2100

1SM22OB_DT10

1SM22OB_DT05


HMH HMH HEALTH INFO MGMT

1ST5MREC_DT05 Ambulatory DAR, Clinical Summary

HMWB MPCG Centralized Call Center

3HG5MPCG_LT02 3HG5MPCG_LT03


HMWB FAM MED WB WCP 390

3SP3MPCG_LT06 3RM2MPCG_LT02


HMWB FAM MED WB WCP 400

3SP4MPCG_LT17 Ambulatory DAR, Clinical Summary

HMWB INT MED WB WCP 400

3SP4MPCG_LT17 Ambulatory DAR, Clinical Summary

HMWB URO WB WCP 400

3SP4UR_LT05 Ambulatory DAR, Clinical Summary

Baytown FAM MED BAYTOWN 201

4AX2MPCG_LT09 Ambulatory DAR, Clinical Summary

Cypress FAM MED CYPRESS 200

3RM2MPCG_LT04 Ambulatory DAR, Clinical Summary

Harris Co FAM MED HARRIS CO 970

1HC2MPCG_LT01 Ambulatory DAR, Clinical Summary

Heights FAM MED HEIGHTS

1HE2MPCG_LT05 Ambulatory DAR, Clinical Summary

Memorial FAM MED MEMORIAL 155

1SF1MPCG_LT15 Ambulatory DAR, Clinical Summary

MONT FAM MED MONTG 100

8RM2MPCG_LT01 8RM2MPCG_LT01


MT BELV INT MED MT BELV 600

4MB1MPCG_C Ambulatory DAR, Clinical Summary

HMSL FAM MED SL MOB3 400

2M34FAM_DT47 2M34FAM_DT16


HMSL INT MED SWEETWTR

2M34FAM_DT16 Ambulatory DAR, Clinical Summary

80


210

Spring FAM MED SPRING FQ

3RM1MPCG_LT08 Ambulatory DAR, Clinical Summary

HMSTJ FAM MED ST JOHN 412

6B14PHYS_LT04 Ambulatory DAR, Clinical Summary

HMSTJ INT MED ST JOHN 412

6B14PHYS_LT04 Ambulatory DAR, Clinical Summary

HMW URO WH MOB2 325

5B23UR_DT08 Ambulatory DAR, Clinical Summary

HMW URO GYN WH MOB1 350

5B23UR_DT08 Ambulatory DAR, Clinical Summary

West U FAM MED WEST U 200

1BS2MPCG_LT12 Ambulatory DAR, Clinical Summary

West U INT MED WEST U 200

1BS2MPCG_LT12 Ambulatory DAR, Clinical Summary

Spring FAM MED STERLING RDG

8RM1MPCG_LT09


Spring INT MED STERL RDG A

8RM1MPCG_LT09


Missouri City FAM MED SIENNA 110

2FM3FAM_LT02


HMSJ URO SAN JAC 211

4P12SPG_DT02


Bellaire FAM MED BELLAIRE 175

1BL1MPCG_LT13


Bellaire INT MED BELLAIRE 175

1BL1MPCG_LT13


HMWB ENDO WB WCP 400

3SP4END_LT05


HMSJ URO SAN JAC 211

5B13OB_DT07


HMH HMH SUNSET MARKETING

SSCALCTR_DT04


Baytown INT MED MT BELV 600

4MB1MPCG_LT04


Baytown FAM MED MT BELV 600

4MB1MPCG_LT04


81


Conroe FAM MED LEAGUE LINE

TBD Ambulatory DAR, Clinical Summary

Pearland FAM MED PEARLAND 200


Pearland INT MED PEARLAND 200


Houston FAM MED EL CMNO RL


HMSTJ ENDO ST JOHN 302


Texas City ENDO TX CITY 200


HMSTJ INT MED ST JOHN 302


Webster FAM MED WEBSTER


Sugarland FAM MED RIVERST 105


Sugarland INT MED RIVERST 105


82

Ambulatory P

ati

en

t In

take

Ch

ec

k In

Do

wn

tim

eP

rovid

er

Vis

itC

he

ck O

ut

Reco

ve

ry

Ambulatory Department Downtime WorkflowPrimary Application: EpicCare Ambulatory

Secondary Application: Care Everywhere, MyChart

Start

Check In/Registration: Communicate

Downtime to all staff and begin

downtime procedures

Is SRO available?Is BCA Web available?

Patient access:Log into BCA Web

Patient access:Log into the SRO


information

Patient access:Identify the BCA PC

and login.

Check In/Registration: Daily: Print Department

Appointment Report (DAR) and clinical downtime report

Y

N

N

Y


Record patient’s status as arrived on


(DAR)


Collect Payment if required and record

in daily cash log

New Patient?


Patient complete new patient packet

Photocopy patient identification and insurance

Place non-clinical forms in designated areas for scanning

Collect clinical forms, clinical downtime report and place in designated area

for clinical staff


Patient completes required forms per visit type

Put clinical forms, clinical downtime report and place in designated area for

clinical staff


Notify clinical staff of patient arrival

Y

N

Clinical Staff:Verify patient name and obtain intake

information on downtime encounter form, including any vital signs, history (allergies,

medications) that are pertinent to department and specialty

Clinical Staff:Notify provider of patient ready status

Provider:Document relevant

findings or notes

Provider:Document

assessment and plan

Provider:Document

Medications, Lab/Radiology, Referrals

Provider:Record any follow-

up orders on downtime

encounter form

Provider:Charges: indicate level of care and diagnosis, orders,

other charges

Provider:Provider signs the

completed downtime

encounter form

Clinical Staff:Collect patient’s completed forms


Collect payment (if not collected at

check in) and record in daily cash log

Follow up appointment?


Record follow up appointment

information. This will be used to

contact patient for scheduling once the system is available


Record completion of appointment on


(DAR)

Clinical Staff:Open the encounter and enter discrete data from the downtime encounter form, including orders,

LOS/CPT codes

Check In/Registration: Check in patient on the schedule. Record any co

payments received. Schedule any follow up

appointments

Clinical Staff:Scan paper forms to the

encounter

Clinical Staff:Notify provider to close

encounterEnd

N

Y

83

Procedure / Tasks ‐ ALL Step Detail Responsible

Downtime Communicate downtime to all ambulatory clinic staff, immediately begin downtime procedures

Is SRO available?

Yes: Log into SRO using your Epic Hyperspace user name and password.

No: Is BCA web available? o Yes: Log in using

your Epic Hyperspace user name and password.

o No: Identify your BCA PC.

Print clinical summary and DAR report for that day.

Clinic Manager

Call Processing / Scheduling

3. Patient calls will be recorded on downtime phone log, including:

8. Patient Name

9. DOB

10. Return phone number

11. Reason for call

12. Contact name and relationship

13. Provider name

14. Call recipient

4. Call processor determines the reason for the call:

Is the reason for the call due to an urgent medical need?

Yes:

Call processor transfers the call to appropriate

clinician, as per clinic protocol

Clinician documents call with patient on

downtime phone log

No:

Call processor records reason for call on

downtime phone log.

Call processor routes message to appropriate

staff for follow- up per clinic policy

Is patient requesting an appointment? Yes:

Front Desk

84


Call processor informs patient that scheduling systems are down and they will be contacted to schedule an appointment as soon as systems are restored.

Call processor enters patient information on downtime phone log. If the patient’s prefers, they may also call back at a later time.

3. Call processor will place phone logs in designated place for recovery process.

Check In 1. Record the patient’s arrival time on printed DAR. 2. Collect payment, if required. Record payment on

DAR. 3. Is patient a new patient?

Yes:

Ask the patient to complete a new patient packet.

Copy patient identification and insurance cards (if copiers are functional).

Place non‐clinical forms in designated area for scanning.

Collect clinical forms, clinical downtime report and place in designated area for clinical staff pick‐up.

No:

v. Request the patient complete required forms for specific visit type.

vi. Place clinical forms, clinical downtime report in designated area for clinical staff pick up.

4. Notify clinical staff of patient arrival per clinic policy

(i.e. light system, phone call etc.)

Check In/Registration

Patient Intake

3. Obtain intake information on the downtime encounter form per clinic policy. This could include:

e. Verify patient name

f. History (allergies, medications, etc.)

g. Vital signs

Notify provider of patient ready status per clinic policy (i.e. forms placed in door etc.)

Clinical Staff

Provider Visit

1. Document relevant findings or notes for patient on downtime encounter form

2. Document the assessment and plan:

a. Medication orders:

i. Provider writes order on prescription pad.

ii. Clinical staff copies prescription and

Provider/Clinical Staff

85


places with patient’s forms.

b. Lab and Radiology orders:

i. Provider completes paper requisition/order

form.

ii. Clinic staff records two patient identifiers

(patient name and SSN or DOB) on

requisition/order form.

iii. Is the procedure performed in‐clinic?

Yes:

Clinical staff notifies lab or radiology

technician of pending order, per clinic

decision.

Lab or radiology results are sent to the

ordering provider for review.

No:

Clinical staff faxes requisition/order to performing location, or gives to patient to present upon arrival at performing location.

c. Referral Orders i. Provider records referral on the downtime

referral form. ii. A copy of the referral form is provided to

the designated staff to complete referral, per clinic policy.

iii. Place completed referral form with patient’s clinical forms.

iv. Fax/phone referral. 3. Patient follow-up:

Provider records any follow‐up orders on downtime encounter form.

4. Charges:

Provider indicates level of service and

any other charges on downtime

encounter form.

Provider records diagnoses and orders on

downtime encounter form.

5. Provider signs the completed forms.

6. All clinical documentation associated with patient

visit is retained by clinical staff.

7. All other documents are delivered to the

appropriate personnel.

86


Check Out Check Out/Registration staff collects payment if not collected at check in and records on daily cash collection log, if applicable.

1. Is a follow‐up appointment needed? Yes:

a. Check Out/Registration staff records

follow‐ up appointment on schedule request log.

b. Check Out/Registration staff notifies patient they will be contacted for scheduling as soon as the system is available.

No: a. Record completion of appointment on

DAR. 2. Check Out/Registration staff notes completion of

appointment on printed DAR. 3. 3. Check Out/Registration staff places

documents in designated location for recovery procedure.

Check Out/Registration Staff

Recovery Check In/ Registration: 5. Check in patient on the schedule. 6. Record any copayments received. 7. Schedule any follow up appointments. 8. Send copayment receipt to patient if necessary.

Clinical Staff:

4. Open the encounter and enter discrete data from the downtime encounter form, including orders, LOS, CPT codes.

5. Scan paper forms to the encounter. 6. Notify provider to close encounter.

Check In/Clinical Staff

87

Appendix 13: Radiology Downtime Manual


HMH HMH MAIN RAD IMAGING

1M2IMG_DT02

1M2RAD_DT15

Radiology Department appointment reports & Schedule Orders Report

HMH HMH Main US 1D2CT_DT05


HMH HMH Main CT (D2) 1D2CT_DT02


HMH HMH Main CT (ER-(1st

floor- M161)

1M1EDEMS Radiology Department appointment reports & Schedule Orders Report

HMH HMH Main MRI (B1) 1MB1IMG_DT01


HMH HMH Main Nuclear Medicine

TBD Radiology Department appointment reports & Schedule Orders Report

HMH HMH Main Breast Center TBD Radiology Department appointment reports & Schedule Orders Report

HMH HMH ENDOVASCULAR

1M2AOD_DT21


HMH HMH ENDOVASCULAR PACU

1M2EV_DT02

1M2PICC_DT01


88

HMH HMH OPC RAD IMG

1OP17RAD_DT07


HMH HMH OPC US

1OP17US_DT01


HMH HMH OPC CT

HMH OPC CT

1OP17NS_DT01


HMH HMH OPC MRI 1OP16IMG_DT01 Radiology Department appointment reports & Schedule Orders Report

HMH HMH OPC NUC MED

OP17NM_DT07


HMH HMH OPC Endovascular TBD Radiology Department appointment reports & Schedule Orders Report

HMH HMH KIRBY BREAST CENTR

1KB1IMG_DT17

Radiology Department appointment reports

HMH HMH KIRBY ED (HMH Kirby ED IMG)

1KE1ED_DT31

NPI951FBD

ASAP (?)

Radiology

Department appointment reports & Schedule Orders Report

HMH HMH VOSS ED (HMH Voss ED IMG)

1KB1IMG_DT17

ASAP (?)

Radiology

Department appointment reports & Schedule Orders Report

HMH HMH WEST HOUSTON IMG

5KI1IMG_DT20

5KI1IMG_DT10

Radiology Department appointment reports

HMH HMH PEARLAND ED (HMH Pearland ED IMG)

1PL1ED_DT18

ASAP (?)

Radiology

Department appointment reports &

89

Schedule Orders Report

HMH HMH XR NRG TBD Radiology Schedule Orders Report

Procedure / Tasks ‐ ALL

Radiology Downtime Workflow

Tech

no

logi

stR

adio

logi

st

Communicate that Epic is down and department is in downtime period

Log into the SRO environment and use the read-only model of Epic to


Log into BCA Web and print necessary reports (DAR and SO

reports)

Use radiology downtime

requisition form/report

Receive imaging requests by fax or paper copy from

ordering departments

IS BCA Web available?

Is SRO available?Epic is down

Reads exams in RIS/PACS

Dictate exam in powerscribe: results

interface to PACS

Phone ordering provider or patients

care team per critical results policy

Maintains downtime log to reconcile

completed exams when EPIC is

restored ensuring reports available in

EPIC

Is this an a new order?

Is this an abnormal finding?

Record request on downtime paper log

Complete the downtime log with pertinent patient information/keep

paper copy of imaging order

Print any necessary reports (DAR and SO

reports) from BCA PC workstations

Yes

No

Yes

No

Yes

No

Downtime documentation is complete; exams

and medications are reconciled in patients chart

No

yes

Performs exam and sends to PACS

Is RIS IC Down?

No

Yes

Primary Application: RadiantSecondary Application: None


Downtime Facilitate any downtime phone calls and faxes to the associated departments

Imaging Clerical Staff

90


Downtime 1. Communicate that the department is in downtime period.

Is SRO available?


No: Is BCA Web available? • Yes: Log into BCA Web to print

necessary reports (DAR, and SO reports).

• No: Identify your downtime BCA PC and print necessary reports (DAR, and SO reports).

2. Use the downtime requisition forms and reports. 3. Review imaging faxes and paper orders received from ordering departments.

Is this a new order? • Yes: Record new order on the

downtime log. • No: Place labels on the

downtime log and complete any additional information. Retain a copy of the physician order form.

4. Perform exam and send to PACS.

Technologist

Downtime Is RIC IC down? (interim workflow until last go-live)

Yes:

No: Read exams in RIS IC/PACS. Dictate exam in Powerscribe. Results interface to PACS.

Is this an abnormal exam?

Yes: Phone ordering provider or patient’s care team per critical results policy.

No: Technologist will maintain a downtime log and reconcile exams when Epic is recovered.

Radiologist

Recovery Reconcile downtime log when Epic is recovered to ensure completed exam reports are available.

Technologist

91

Appendix 14: Cardiology Downtime Manual


HMH HMH CARDIO NUC MED

1MB1NMED_DT07 Cardiology Department Appointment Report (DAR) & Schedule Orders Report (SO)

HMH HMH CARDIO

VASCULAR

1F9CARD_DT76 Cardiology Department Appointment Report (DAR) & Schedule Orders Report (SO)

HMH HMH CARDIO DIAG

OPC

1MB1IMG_DT02 Cardiology Department Appointment Report (DAR) & Schedule Orders Report (SO)

HMH HMH CARDIO MRI

OPC

1OP16IMG_DT01 Cardiology Department Appointment Report (DAR) & Schedule Orders Report (SO)

HMH HMH CATH LAB 1AL10CATH_DT05 Cardiology Department Appointment Report (DAR) & Schedule Orders Report (SO)

92

Procedure / Tasks ‐ ALL

Cardiology Downtime Workflow

Tech

no

logi

stC

ard

iolo

gist

Communicate that Epic is down and department is in downtime period

Log into the SRO environment and use the read-only model of Epic to


Log into BCA and print necessary

reports (DAR and SO reports)

Use downtime requisition form/

report

Receive imaging requests by fax or paper copy from

ordering departments

IS BCA Web available?

Is SRO available?Epic is down

Read exams in Ancillary systems

Report signed in ancillary system,

results interface to Epic

Phone ordering provider or patients

care team per critical results policy

Maintains downtime log to reconcile

completed exams when EPIC is

restored ensuring reports available in

EPIC

Is this an a new order?

Is this an abnormal finding?

Record request on downtime paper log

Puts labels on downtime log and

complete other per pertinent patient information/keep

paper copy of imaging order

Print any necessary reports (DAR and SO

reports) from BCA workstations

Yes

No

Yes

No

Yes

No

Downtime documentation transcribed into

relevant sections of chart. Exams and

medications reconciled in patients chart

No

Yes

Performs exam and sends to ancillary

system

Is the ancillary system down?

No

Documents procedure

completely in paper downtime forms

Yes


Downtime Facilitate any downtime phone calls and faxes to the associated departments

Imaging Clerical Staff

Downtime 1. Communicate that the department is in downtime period.

Is SRO available?


No: Is BCA Web available? • Yes: Log into BCA Web to print

necessary reports (DAR, and SO reports).

• No: Identify your downtime BCA PC and print necessary reports (DAR, and SO reports).

2. Use the downtime requisition forms and

Technologist

93


reports. 3. Review imaging faxes and paper orders received from ordering departments.

Is this a new order? • Yes: Record new order on the

downtime log. • No: Place labels on the

downtime log and complete any additional information. Retain a copy of the physician order form.

4. Perform exam and send to ancillary systems.

Downtime Are the ancillary systems also down?

Yes: Is this STAT? o Yes: Read on modality. o No: Interpret after systems are

restored.

No: Create report for exam in ancillary systems. Sign the study in the ancillary system. Results interface to epic, will be available when Epic is restored.

Is this an abnormal exam?

Yes: Phone ordering provider or patient’s care team per critical results policy.

No: Technologist will maintain a downtime log and reconcile exams when Epic is recovered.

Cardiologist

Recovery Reconcile downtime log when Epic is recovered to ensure completed exam reports are available.

Technologist

94

Appendix 15: Rehabilitation Services Downtime Manual

BCA PCs and Downtime Reports Site Location BCA Name Department Reports Needed

HMH HMH WP IP REHAB 10 1WP10NS_DT19 Rehabilitation Services

Patient Summary

HMH HMH WP IP REHAB 9 1WP9NS_DT16 Rehabilitation Services

Patient Summary

HMH HMH PT OT REHAB 1M1PTOT_DT10 Rehabilitation Services

Patient Summary

HMH HMH ACUTE SPEECH 1N2SPCH_DT01 Rehabilitation Services

Patient Summary

95

Rehabilitation Services Department Downtime Workflow

Rehabilitation Services Downtime Workflow

New

Ref

erra

lsD

ow

nti

me

Do

cum

enta

tio

nR

eco

very

HIM

Downtime

Start

Charge Therapist/Manager/US


should begin downtime

procedures.

Is SRO available?

Yes


Log into the SRO environment to view

relevant patient information.


Retrieve necessary forms from

Downtime Kit.


Keep paper copies until system has been recovered.

End


Yes


Print BCA Reports (PT/OT/SP Therapy Patient Summary).


Retrieve necessary downtime

documents and forms from

Downtime Kits.

No


Identify the BCA PC and print BCA

Reports (PT/OT/SP Therapy Patient

Summary).

TherapistVerify current patients have

evaluation and plan of care prior to

treatment.

TherapistPlace all paper

forms in patient chart.

Therapist/ManagerDocumentation will be scanned in. Enter

charges.


Collect all paper downtime forms to be scanned by HIM.

End

HIMScan paper

downtime forms into Epic.

Charge Therapist/Manager/USRecord new

referrals received via phone.

TherapistVerify written order and review patient

chart prior to treatment.


Notify therapists of new referrals.

TherapistComplete all

documentation on paper forms/

progress notes.

Is documentation being transcribed during same

shift as care was performed?

TherapistEnter

documentation and charges as you

normally would.

Yes

NoTherapist/Manager

Enter Downtime Event Note.

96

Rehabilitation Services Procedure / Tasks – ALL Step Detail Responsible

Downtime Communicate that the department is in downtime period. Is SRO available?



Yes: Log into BCA web to print necessary reports.

o Retrieve necessary forms from Downtime Kit to record clinical data.

o Keep paper copies until system has been recovered.

No: Identify the BCA PC and print BCA Reports (Patient Summary)


o Place forms in the patient paper chart.

Charge Therapist Manager Unit Secretary

New Referrals New referrals will be received via telephone and recorded by discipline by the Charge Therapist/Manager/Unit Secretary. Each referral recorded will include the time the call was received, the name of the patient, DOB, location and patient account number. On weekends or when no secretary is present, the referrals will be recorded on the department answering machine and logged every hour until end of shift in the manner described above.

New referrals will be seen per department policy.

All staff should verify written order and review paper progress notes from other disciplines (MD, RN, SW), prior to rendering patient care.

Charge Therapist Manager Unit Secretary

Documentation Complete documentation on paper forms or blank notes

Therapists

Recovery Reconcile patient lists with Epic.

Transcribe downtime documentation into Epic. o Is documentation transcription being

performed before the end of the shift in which the care occurred?

Yes: Enter documentation and charges as you normally would, modifying time rows to reflect the time that care was performed.

No: Documentation will be scanned into Epic by HIM. Enter charges for care performed using

Therapists Managers

97


the “Flowsheet Charges” section. Modify time and date rows to reflect the time that care was performed.

Using the Notes Activity, enter Downtime Event Note indicating length of downtime and location of downtime documentation:

HIM Collect paper forms and scan into Epic. HIM

98

Appendix 16: Food and Nutrition Services Downtime Manual

BCA PCs and Downtime Reports Site Location BCA Name Department Reports Needed

HMH HMH NUTRITION 1MB1FNS_DT04 Nutrition Dietary Report

Food and Nutrition Services Department Downtime Workflow

Food and Nutrition Services Downtime Workflow

Ord

ers

Do

wn

tim

eD

ocu

me

nta

tio

nR

eco

very

HIM

Downtime

Start

FNS Call Center/Diet Office Staff


should begin downtime procedures

Is SRO available?

Yes


Log into the SRO environment to view

relevant patient information


Retrieve necessary forms from

Downtime Kit


Keep paper copies until system has been recovered

End


Yes

FNS Call Center/Diet Office Staff/Patient Services LeadershipPrint BCA Reports (Dietary Report)

FNS Call Center/Diet Office Staff/Patient Services LeadershipRetrieve necessary



No

FNS Call Center/Diet Office Staff/Patient Services LeadershipIdentify the BCA PC

and print BCA Reports (Dietary

Report)

Clinical Nutrition Staff

Document complete note on a blank

progress note form


Place all paper forms in patient

chart


Enter Downtime Event Note

USCollect all paper


End

HIMScan paper



Record new orders received via phone/fax/downtime order sheets on downtime

record

Host/HostessReview downtime

report and downtime order

sheet for changes prior to passing

meals


Enter any new orders or changes in

diet orders into CBORD

Host/HostessCollect any

downtime order sheets from patient

care units

Patient Services Leadership

Review downtime procedure with

host/hostess and provide copies of downtime order

sheets and guidlines


Verify new orders, changes in diet

orders, and nourishment

requests were entered into CBORD


Enter critical, pertinent info from

paper documentation into

Epic

99

Food and Nutrition Services Procedure / Tasks – ALL Step Detail Responsible

Downtime Communicate that the department is in downtime period.

Notification that the Epic system is down o The FNS Call Center/Diet Office will notify

the following individuals and groups of individuals that the system is down:

FNS administration Patient Services Leadership Team Dietitians Dietetic Technicians Hosts / Hostesses

Alpha numeric notification: o HMH- The following notification is to be

sent: “Epic system down. Implement downtime procedure. Host/hostess report to Call Center”.

The notification above is to be sent as an alpha numeric page to the following individuals and groupings in the wireless paging system:

FNS Administration (grouping) FNS Dietitians (grouping) FNS Patient Services Leadership

(individuals on duty) FNS Hosts / Hostesses (each one

listed in wireless paging system) o Other entities- The following notification

is to be sent: “Epic system down. Implement downtime procedure. Host/hostess report to Diet Office”.

In addition to above, the notification is also to be communicated verbally to the Patient Services leadership team on duty.

Is SRO available?



Yes: Log into BCA web to print necessary reports.


o Keep paper copies until system has been

FNS Call Center/Diet Office Staff Patient Services Leadership

100


recovered.

No: Identify the BCA PC and print BCA Reports (Dietary Report)


Responsibilities of Patient Services leadership on duty:

Assure that all FNS Call Center/Diet Office phones are staffed and have FNS Downtime Record Sheets to record messages.

o If necessary, reassign employees to cover the phones.

o Provide each call center station with sufficient copies of FNS Downtime Record Sheets.

o Review downtime procedures with staff.

Verify that the notification of downtime reached the appropriate individuals.

Review the downtime procedure with host/hostesses and provide them with copies of the following to be distributed to nursing:

o FNS Downtime Guidelines o FNS Downtime Order Sheets

Orders Host / Hostess’s responsibilities:

For each patient care unit (PCU) assigned, pick up copies of:

o FNS Downtime Guidelines o FNS Downtime Order Sheets

Review guidelines with nursing staff (especially the unit secretary).

o All diet changes, nutrition consults and other FNS requests are to be called into FNS Call Center/Diet Office.

HMH (713) 441-2500 HMW (832) 522-1200 HMWB (281) 737-1355 (fax) HMSL HMSJ (281) 428-4441 HMSTC (281) 599-4356 (fax) HMSTJ

o In addition to calling in the orders, the order is to be written on the FNS Downtime Order Sheet.

Before passing meals, nourishments, etc., review the FNS Downtime Order Sheet for changes.

FNS Call Center/Diet Office responsibilities:

Host/Hostess

101


Record each call on the FNS Downtime Record sheet.

Follow-through with each order: o For diet changes, allergies, etc., enter the

updated information into CBORD. o Initiate the order as appropriate, e.g.,

send diet order to kitchen. o Page clinical staff as appropriate, e.g.,

nutrition consult requests. o Page formula clerk as appropriate, e.g.,

new formula orders or changes.

Handling of Enteral Nutritional Formulas:

Using the most current formula list, update the formula list as changes are received.

If formula labels were not generated prior to system going down, hand-write the formula labels.

Prior to distributing formulas, check the FNS Downtime Order sheet on each patient care unit.

Clinical Nutrition staff responsibilities related to food service:

Dietitians provide assistance as needed to the Host/Hostesses on their patient care units.

Dietitians review with nursing the FNS Downtime Guidelines (as back up communication).

Documentation Documentation by clinical nutrition staff:

Documentation during downtime: o Document complete note on a blank

“progress note” form in the progress note section of the paper chart.

o Use the heading “Nutrition” and document the date and time in the left margin.

o All medical record entries should be written legibly in blue or black ink.

o Include signature, title, credentials (RD) to complete documentation. Pager number is optional.

o If an error in documentation is made, the error should be lightly scored through, via a single line, signed and dated.

o Liquid paper and labels are not to be used to cover incorrect or revise documentation. List date, time, and initial next to correction.


Recovery Recovery Documentation by clinical nutrition staff:

Enter critical, pertinent info from hand written


102


“progress note” into Epic as a “late entry due to system down”.

Decision to repeat excerpts of manual documentation to be decided on an individual patient case basis, staffing needs, prioritization, etc.

After Epic restored, enter reference to handwritten documentation using Downtime Event Note in Notes Activity:

Reconciliation of orders When Epic has been restored:

Host / hostesses are to bring the FNS Downtime Order Sheets to the FNS Call Center/Diet Office.

The FNS Call Center/Diet Office is to verify that changes in diet orders, nourishment requests, etc. were entered into CBORD using the:

o FNS Downtime Order Sheets from the patient care units

o FNS Downtime Record sheets

The FNS Call Center/Diet Office will verify that nutrition consult requests were received by the dietitian or dietetic technician.

Retention and disposal of FNS Downtime Order Sheets and FNS Downtime Record Sheets

Retain the sheets in a secure location within FNS Call Center/Diet Office for 3 weeks

After 3 weeks, dispose of sheets via approved recycle bins for confidential information.

Host/Hostess Call Center/Diet Office Staff

HIM Collect paper forms from patient chart on unit and scan into Epic

HIM

103

Appendix 17: Health Information Management (HIM)

HIM Downtime Workflow

HIM Downtime Workflow

Dow

ntim

eR

eco

very

HIM

Downtime

Clinical StaffComplete necessary

clinical documentation

using paper downtime forms

Clinical StaffPlace all forms in

patient paper chart

Is downtime greater than 3

hours?

No

Clinical StaffTranscribe clinical

documentation into Epic

Yes

Clinical StaffTranscribe required documentation into

Epic. Any documentation that

is not transcribed remains in paper

chart.

Unit SecretaryCollect all paper


End

HIMScan paper


End

HIM Procedure / Tasks – ALL Step Detail Responsible

Downtime Complete necessary clinical documentation using department specific downtime forms found in each unit’s Downtime Kit and place in patient’s chart.

Clinicians

Recovery Is downtime greater than 3 hours?

No: Transcribe downtime clinical documentation

into Epic and resume clinical documentation in

Epic.

Yes:

o Transcribe required downtime

documentation into Epic (refer to for

detailed list of items to be transcribed vs.

scanned based on length of downtime)

and resume clinical documentation in

Epic.

o Collect all paper forms to be scanned by

HIM

Clinicians/Unit Secretary

Recovery Is downtime greater than 3 hours?

Yes: Retrieve/receive downtime documents and scan into patient’s medical record.

HIM

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Appendix 18: Billing

Billing Downtime Workflow

Billing Downtime Workflow

Do

wn

tim

eR

eco

very

Downtime

Billing StaffDocument all

transactions on paper and hold until system is recovered

Billing StaffInput data and

documentation that transpired during

downtime.

End

Billing StaffHold any corrections

that are normally done electronically

Billing StaffDivert incoming calls

to message. Suspend outgoing

phone calls.

Billing Procedure / Tasks – ALL Step Detail Responsible

Downtime All transactions will be documented on paper including money collection and held until Epic is recovered.

Any corrections that are normally done will be held until system performance can be resumed.

Incoming phone calls will be diverted to message.

Outgoing phone calls will be suspended.

Billing Staff

Recovery Input data and documentation that transpired

during downtime.

Billing Staff

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Appendix 19: Definitions, Acronyms, and Abbreviations ADT: Admission, Discharge, Transfer

ADS: Automated Dispensing Systems

BCA: Business Continuity Access. Epic defines BCA as the process of maintaining continuity of

clinical information from the Epic system during downtime situations.

BCA PC: Business Continuity Access via PC

CSN: Contact Serial Number

Downtime: Refers to a time when a computer system is not functional. The level of the downtime

determines what and how much information is processed manually. A Level 1 (see below)

Downtime should be assumed until it is announced otherwise.

Epic: Electronic repository for clinical patient information.

Epic BCA web: When access to Epic Hyperspace (Citrix) is down, but the local area network

(LAN) is still available, BCA Web is an application that can be opened from any workstation and

gives access to standard downtime reports (the same ones available on BCA workstations). It is

NOT read‐only access to Epic Hyperspace.

Epic BCA (downtime) workstations (BCA PC): A dedicated Epic workstation that is on a secure

electrical network (emergency power) that contains periodically updated Epic patient reports. It

must be attached directly to a printer (not networked) that is also powered by an emergency

power source.

Primary and Secondary Server Failure is defined as a period when both the primary and

secondary servers have failed.

HIPAA: Health Insurance Portability and Accountability Act.

HOD: Hospital Outpatient Department

Interface Down: Data communication between two interfaced systems is not functional.

IT: Information Technology

LAN: Local area network.

Network Failure: The network is unavailable.

Downtime workstation can be used to view and /or print reports to provide orders and

other clinical data. The orders and clinical data are current up to the time the batch report

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was run in the system.

Downtime workstation reports are available on inpatient units.

MRN: Medical Record Number

OR: Operating room.

PACU: Post anesthetic care unit

PAS: Patient Access Services

PAT: Pre‐admission testing

Scheduled downtime: A planned event occurs when ITS closes access to the computer system

for the purpose of maintaining or updating the software or hardware. The duration of this type of

downtime is usually known and communicated beforehand, and typically occurs after hours.

SRO: Supports Read‐Only access to the Epic system. The look and feel is the same as the

normal Epic Hyperspace, however ambulatory clinic clinicians cannot “write” any data to the

shadow server. Please note that the information is only as current as the last copy from the

production (PRD) environment to the SRO environment.

Terminal or Printer Failure: An unexpected failure of one piece of equipment. If this occurs,

please use another piece of equipment until it can be fixed or replaced.

Unscheduled downtime: An unplanned event usually occurring as a result of network, power, or

system failure. The duration of this downtime is usually unknown.

US: Hospital unit secretaries/clerks

WAN: Wide area network