3Vulnerabilities-just a reminder Patient RightsPatient and/or Family Involved in DecisionsHealth Care ProxyIdentifying /Involving in CareInformed ConsentProvision of CarePatient EducationAssessing Learning NeedsEvaluating ComprehensionPain Assessment/Reassessment **RestraintsTimely OrdersOngoing AssessmentNational Patient Safety Goals2 Patient IdentifiersAdministering MedicationsCollecting BloodLabeling Containers In Front of PatientWrite Down/Read BackRecording Calls to Floors/UnitsHand Offs – up to date and pertinent information with opportunity to ask questionsTo/From Procedure and Test AreasIntra-Hospital TransfersMedication LabelingGoing to GembaTransferring from original containerDetailed information on labelMedication Reconciliation **Intra-hospital TransfersOutside ProvidersPatientsNational Patient Safety Goals (Cont.)Anticoagulation TherapyProcess to implement an enterprise-wide Anticoag Therapy ProgramUniversal ProtocolOperative / Procedural Area/ BedsideVerification of Side/Site/ProcedureMarking of SiteTime Out Immediately Before ProcedureMedical Staff StandardsBylaws RelatedTimeliness of ReappointmentsHuman ResourcesDecentralized Monitoring of CompetenciesPerformance EvaluationsStaffing Effectiveness ExerciseInfection ControlUse of PPEPPD ScreeningInformation Management (Medical Records Related)Aggregate Reports of Compliance Streaming through HIM CommitteePerformance ImprovementCollecting/Analyzing/Using Data for ImprovementStaff Knowledge of Priorities
4Going to Gemba…Go and See Genchi Genbutsu: One of the fundamentals of the Toyota way.In short this means, “Go to the actual scene (genchi) and confirm the actual happenings or things (genbutsu)”“The record suggested that people got hurt not because they are stupid but because they found themselves in circumstances in which it is easy to get hurt and hard to be safe”Key Capabilities:Seeing problems as they occurSwarming & solving problems as they are seenSpreading new knowledgeLeading by developing capabilities 1,2 & 3
5Sheliah Janus, Daihung Do MD Dermatology- CQI projectLOCAL ANESTHETIC PREPARATION, STORAGE, TRANSPORT, AND ADMINISTRATION POLICYSheliah Janus, Daihung Do MD
8On Line “Joint tool Box” ChaptersContent of our workOn Line “Joint tool Box”Integrated learningFor Each ChapterKey ConceptsNational Patient Safety GoalsRelated Policies/ProceduresResources-on-line-staffRelated sub-group activityEthics Rights-RespSeptember 08Provision of CareOctober/November 08Med ManagementDecember 08Safety/Disaster ManagementJanuary-09Surveillance, Prevention of infectionFebruary-09IImproving Organizational PerformanceMarch-09LeadershipEC/RPower of the groupSub- GroupsPolicy/ProceduresCQI/chart auditsScope of PracticePACE AuditsLicense VerificationAnti-coagulation
9Sub-groups, -The “why and what” Goal:increased the number of engaged “experts” – integrated knowledge for allIntegrate knowledge of JC into everyday practiceCQI/scope of service, Lead - Jason LavioletteJC documents which will be reviewed during initial sessions-guide the survey processPACE Audits, Lead - Stephanie TarantinoReviewed unit based PACE audits/concordance with hospital wide PACE audits- measures to make this data available to you in real time- JC requirementLicense Verification, Lead Diane GilworthJC standard- primary source documentation/central verification process- in place for all ambulatory RN’s and NP’sPolicy/Procedure sub-group, Lead - Sandy HewittRe-organization of policies and procedures- tool boxesAnticoagulation, Lead - Louise MackisackJC standard and high risk medications.
11An Unscheduled JC Visit- your role Clean sweep- “25 steps to a sweeping success”No food, drinks, clean corridorsStaff –badgesPACERACEHIPPAHave a tracer patient in mindCode Carts- checked, lockedMDs- everything you need to know about JCNational patient safety goals
13Codes and Emergency Management of Medications Allison McHugh
14Policy and Procedure Subgroup Update Sandy Hewitt
15What is our Charter?Provide periodic and systematic review of P&Ps to ensure they reflect current practice and comply with appropriate guidelines and mandates.Determine what general P&Ps need modification for Ambulatory purposes.Ensure standardization of those Ambulatory P&Ps specific to us. Ex: some HR policies.Improve ease of access to P&Ps.Locate Ambulatory’s P&Ps on the “Ambulatory Services” site on the portal. (Lynne’s Tool Kit)
16Request of you……We’ll be sending an requesting you to please tell us:Which policies and procedures you refer to most frequently.Which policies and procedures do you have trouble finding.If there are policies and procedures you wish we had.
20Chart Audit Process 2009 and beyond BetterBestGoodCreate a new more clinicallyRelevant chart auditData is available real time- unit specific-CQIClinicians would do all Chart audits- MD’s, NP’s , RN’s.Continue with present chart auditsReview your data and be prepared to discuss with the JCReformat questions for easier documentationClarify # of chart audits per unitDefine what it means to be compliantGet data back to you in a timely manner
21Proposed chart Audits 2009 Data comes back to you in a timely manner Ambulatory UnitDate of ServiceMedical record numberAttending physician (Last Name, First)Patient Seen By (Last Name, First)Reviewed byReview dateDate of Birth (enter mm/dd/yyyy)Ambulatory unit- drop down menu for all unitsAdd in # of charts to be done within a quarter-(based on unit specific parameters)Data comes back to you in a timely manner
22Chart AuditsProblem list is updated and reviewed (within last 12 months) Yes/NoAllergies are reviewed and updated (within last 12 months) Yes/NoMedication list is up to date(on a quarterly basis the medication reconciliation survey could be rolled into the chart audit to reduce the number of actual surveys done per unit)Yes/NoSummary list is present- by 3rd visit-this list included known and significant medical diagnosis and conditions, known significant operative and invasive procedures, known adverse and allergic drug reactions, know long term medications, including current prescriptions, over the counter drugs and herbal preparations. The list is quickly and easily available for practitioners.Consent forms are present as applicable for invasive procedures.general consent includes a discussion of: a. the nature of the proposed care, treatment, services, medications, interventions, likelihood of achieving goals, reasonable alternatives, relevant risks and benefits, side effects related to alternatives, including possible results of not receiving any therapy, …..
23H & P is present( need language to determine what counts as an H&P) Yes/NoPain assessment is documented as appropriate(would recommend standardizing pain assessment tools and if possible creating space within web OMR for direct documentation)(provide link to pain assessment tool)Yes/NoPain is reassessed at subsequent visits.A comprehensive pain assessment is conducted as appropriate to the patients condition and the scope of care, treatment, and services provided. (would recommend standard reassessment tools and standard template for documentation in Web OMR)(provide link to pain reassessment tool)Advanced directive is present-new field in Web OMR (documentation indicates whether the patient has signed an advance directive) Yes/No
24Medication Management Medication management policy/competency on lineProhibited abbreviations (hand-out)Multi-dose vial- 28 days- pharmacy policyRefrigerator Alarms (change battery and check green sticker)Medication questions –posted on portal
27Refrigerator AlarmsRefrigerator temperature ranges should be between 36 and 46 degrees Fahrenheit,if alarm sounds:Turn alarm off.Check to see if refrigerator is functioning properly.C all service response at:Call Pharmacy about interim medication storage.It is necessary to reset the unit whenever a change is made to c / F temperature.To reset the unit, use a pointed object to push the RESET button on the back of the unit.Click mode to Lo to Hi, set Lo (36oF) Hi (40oF) turn alarm ON.Order back-up batteries replacement 1AA battery.