1. Jayne Sheehan Diane Gilworth TJC Ambulatory Monthly Meeting March 11, 2009

2. Agenda 11:00-11:30 – Jayne Sheehan, – –TJC mock survey overview- celebrating our success and learning from the opportunities 11:30-12:15 – –TJC specifics – Success Opportunities for Improvement Yolanda Millman-Richard Janet Lewis Sheilah Janus Kerry Brown 12:15-12:30 Bill Pyne – –Updates on Ambulatory code cart exchange

3. Vulnerabilities: Areas identified by Mock Survey Patient Rights – –Patient and/or Family Involved in Decisions – –Health Care Proxy Identifying /Involving in Care – –Informed Consent Provision of Care – –Patient Education Assessing Learning Needs Evaluating Comprehension – –Pain Assessment/Reassessment ** – –Restraints Timely Orders Ongoing Assessment National Patient Safety Goals – –2 Patient Identifiers Administering Medications Collecting Blood Labeling Containers In Front of Patient – –Write Down/Read Back Recording Calls to Floors/Units – –Hand Offs – up to date and pertinent information with opportunity to ask questions To/From Procedure and Test Areas Intra-Hospital Transfers – –Medication Labeling Transferring from original container Detailed information on label – –Medication Reconciliation ** Intra-hospital Transfers Outside Providers Patients National Patient Safety Goals (Cont.) National Patient Safety Goals (Cont.)  Anticoagulation Therapy Process to implement an enterprise-wide Anticoag Therapy Program  Universal Protocol Operative / Procedural Area/ Bedside Verification of Side/Site/Procedure Marking of Site Time Out Immediately Before Procedure Medical Staff Standards Medical Staff Standards  Bylaws Related  Timeliness of Reappointments Human Resources Human Resources  Decentralized Monitoring of Competencies  Performance Evaluations  Staffing Effectiveness Exercise 2008-09 Infection Control Infection Control  Use of PPE  PPD Screening Information Management (Medical Records Related) Information Management (Medical Records Related)  Aggregate Reports of Compliance Streaming through HIM Committee Performance Improvement Performance Improvement  Collecting/Analyzing/Using Data for Improvement  Staff Knowledge of Priorities

4. Special Thanks to : “Early Risers” (Kim/Kirsten) Public Safety Ambassadors Admissions Facilitator Service Response Food Services Service Response Telecommunications Information Systems Communications Human Resources TJC Facilitators Escorts to the “Surveyors” Staff from the following areas: –ED –CC6A –Perioperative Services –Digestive Disease Center –Farr 2 –Interventional Radiology –Pain Clinic –Chest Disease Center –Stoneman 6 –Labor/Delivery –Feldberg 6 –Deaconess 4

5. Assessing The Notification/Logistics Plans Paging for Assembly – –Senior Leaders Greet Survey Team at 9am Individual Communication Networks Activated – –Patient Care Services – –Ambulatory /ED Services Meeting/Work Rooms Secured TJC ‘Communication Center’ Operationalized – –Community Wide Email /Greeting Announcement – –Ongoing Updates re: Focus and Findings via the TJC Public Calendar

6. Assessing with ‘Fresh Eyes’ Visits to Interventional Procedure Areas   GI, Interventional Radiology, CDC, Pain Clinic Inpatient/ED Patient Tracer Perioperative Patient Tracer OB Patient Tracer Ambulatory Clinic Patient Tracer Medical Record Documentation HR Record Reviews

7. Where Are We After the Past 2 Days? Best in Class Internal State of Disaster Good Program, “tweaking” needed Much Work to be Done Systems/Processes

8. The Themes of Findings Policy Related – –Complex: Opportunity to weed and focus on standards before setting the bar toward best practice – –Multiple Source Documents: Opportunity to Consolidate – –Staff Awareness was inconsistent Lack of Specificity re: Accountability – –Seen in Med Rec Process (Inpatient) – –Assessment of Patients Documentation Gaps/Complexity – –Omitted / Disjointed Content – –Multiple Source Documents for same subject – –Difficult to Navigate – –Doesn’t always reflect care processes – –Forms don’t prompt for process steps Inconsistency with ‘Universal Protocol’ – –Varying approaches, tools and checklists in OR, OB, Procedure Areas

9. The Particulars…… Documentation – –Flow of Content (Assessment  Problem List  Care Plan  Goals) – –Completion Post Procedure Documentation Timing/Dating/Authentication Consent for Procedure/Intervention Patient Education – –Audit Processes what is looked at/how are results shared and used for PI Medication Reconciliation (Inpatient) Restraints = Immobilization in the ICUs

10. The Particulars…… Medication Management – –Emergency Medication Storage/Availability/Surveillance/Disposal – –Staff Education re: Look Alike/Sound Alike and High Risk Meds Labeling – –Blood Draw Labeling in presence of patient – –Specimen Labeling – –Medication Syringe Labeling process Universal Protocol Critical Tests/Critical Result Reporting – –Staff Awareness of Process – –Measures of Success - 12months Order  Result

11. Next Steps Vetting through the Clinical Operations Group for Vetting through the Clinical Operations Group for –Policy Changes –Process Improvements –Development of Resources/Supports Work Plans and Actions will be defined over the course of the next few months Work Plans and Actions will be defined over the course of the next few months

12. TJC Specifics Celebrating our success and learning from our opportunities Celebrating our success and learning from our opportunities –Yolanda Milliman-Richard –Janet Lewis, –Sheliah Janus –Kerry Brown

13. Mock Survey Review Focus of the survey in your area Focus of the survey in your area –what did the surveyor ask, any surprises, any area in which you felt unprepared? Did the sweep documents help Did the sweep documents help –are there any additional things we should be doing to help your staff prepare/help you? Nursing/MD response to the surveyor Nursing/MD response to the surveyor –(in all cases the staff were superb and were able to really articulate the care processes)- can we improve this? Suggested areas for improvement Suggested areas for improvement –did the survey find anything that surprised you? –did the survey find anything that surprised you? What would you change What would you change –as a result of the survey

14. Jayne Sheehan Diane Gilworth Thank You March 11, 2009