2Agenda Medication Management Presentation TJC Survey Trends Presented by: May Adra, Pharm.D., Medication Safety CoordinatorTJC Survey TrendsPresented by: Kathy Murray, Director of Process ImprovementMock Surveys on Ambulatory UnitsPresented by: Sandra HewittPace Audit UpdatePresented by: Kevin HartCQI UpdatesPresented by: Menrika LouisMedication and Solution LabelingUniversal Protocol Poster Roll-outChart AuditsPresented by: Sandra Hewitt/Lynne Brophy
3Ambulatory Mock Surveys First of all thanks to all of you! You were welcoming, responsive and your staff did a wonderful job!The team of surveyors enjoyed the opportunity to interact with you and to meet your staff.Learning took place on both sides of the equation.Here are the members of the survey team:Kevin Hart Linda LentzSandra Hewitt Stephenie LouxSheilah Janus Daniel McTigueRoseAnne Joaquin
4The Broad ThemesFinding: Most staff were not comfortable in responding to questions.Most staff members are knowledgeable;Need more experience expressing themselves.Recommendation: Try to create more opportunities for them to express themselves on these topics. Perhaps role playing at staff meetings?
5Terminology Finding: Staff did not always recognize terms such as: Time outStandard of careScope of ServiceRecommendations:Let staff know that they can always ask for a clarification on a question or say they don’t know but can find out.When training staff, help them understand concepts as well as familiarize them with some common terminology.
6Process ImprovementFinding: When prompted with “what have you done to make things better on your unit?” staff were able to describe PI projects.Recommendations:Try posting your PI projects on your units to help remind staff of projects.Have them be comfortable describing those things that impact what they do.
7Emergency ProtocolsFinding: Congratulations, staff know their evacuation plans, but they were uncertain about:Who is their Fire Marshal;Tended to skip the “R” in RACE;Had trouble with PASS for extinguisher use.Recommendation: Review with staff or post Policy EC-36: Fire Response, “Code Red Procedure.
8Familiarity with the Portal Finding: Staff are well prepared to say that they can find answers on the portal, but when taken to a computer, were not able to demonstrate their ability to find what they need.Recommendations: Common items to be able to find on the portal are:Policies and proceduresPatient education materialsMSDSEmergency phone numbersProhibited abbreviationsEmployee Resources
9Scope of ServiceFinding: Staff should be comfortable in responding to “what happens on this unit?”Recommendations: Review Scope of Service with your staff, emphasizing:Type of clinic/providersType of services offered, i.e. phlebotomy, consultations, post-op visits, procedures, etc.How many procedure/exam rooms on unitWhere the waiting area isType of staffingHours of operation
10CompetenciesFinding: Everyone should be familiar with how they were oriented to their roles on the unit and how they are tested on what they do.Recommendations:Review competencies with staff, have them be able to speak to when they are tested and how they get assistance when needed.Be able to produce documentation of competencies for your staff (should be on the S:drive).
11Office of Business Conduct Finding: Staff were not always aware of how to call in ethical concerns, anonymously if so desired.Recommendations:Please instruct staff that they can always call the Office of Business Conduct, confidentially, without fear of retribution at (617)They can call anonymously at (888) if that feels more comfortable.Staff should be able to find OBC on the portal under Employee Resources.
12Health Care ProxyFinding: Not everyone was familiar with what a HCP is.Recommendations:Staff should be able to give a basic description;Tell where to find HCPs on their unit;Know what to do with an HCP should a patient bring one with them to the practice.
13A few other things….. Badges above the waist and face forward. Make sure you have enough Emergency Response Quick References available on your unit.Have record of preventive maintenance for equipment:Microscopes need PM 2x/year.Also, physicians who use microscopes need to either have it as part of the clinical training or identified in their delineation of privileges.Make sure you have the updated version of consent forms with space for signature, date and time for both provider and patient.
14Additional survey visits? We’ve been asked back to some units.If you’re interested in having a team member return, please me.I will work with the team to arrange for your visit.If you have a particular area in which you would like us to focus, let me know that as well.
15The New & Improved Pace Audit What’s New?What’s the Process?What’s the Benefit?
16What’s New? Pace Audit Tool Consists of 12 sections. Monthly sections will be identified in the tool by date. A monthly schedule will be provided.Audits are due by the 21st of each month. Full Audit due in May.Results“Outside Eyes” “Outside Eyes is a Peer review. Every 4th month a full survey will be done with help of two colleagues from a different unit
18What’s the Process?Tool is completed monthly with “yes,” “no” or “N/A”“Yes” being the goal;“No” raises red flag for action!Corrective action plans are necessary for all “no” answers;Space is allotted at the end of each section for action plans/comments.
19What’s the Benefit? You will now have access to your results; Results will be posted on the S:Drive Ambulatory Joint Commission folder/Pace Audit subfolder;As with chart audits, results will be available by individual units and in the aggregate for Ambulatory and ED;We will be able to trend areas of strength and vulnerabilities.
20What’s next…….. Excellence in practice for our patients Success for Joint CommissionOngoing efforts for improvement
21Lastly!The Audit Team is here to support and assist you with any questions or concerns;We will also diligently monitor results for 100% compliance;We need YOU, to make this audit successful!
22Revised Medication and Solution Labeling Policy CP-32 Correct way…Labels show type of medication or substance including strengthVery few changes.Reorganized to clearly state exception to labeling requirement.Key points to policy:Labeling is requiredWhen Medication or solution is transferred from its original packaging to another containerandpreparer it is different than the administrator.and / oris used non-continuously. (ex. is set down for intended re-use during the procedure)Labeling is not requiredWhen Solution is immediately prepared and administered in full by the same person.Online training is available at:What’s wrong with this picture?
23Universal Protocol (CP-33) Preventing Wrong Site, Wrong Procedure, and Wrong Person SurgeryAddress missing information or discrepancies before starting the procedure.Use a standardized list to verify the availability of items for the procedure.Mark the site when there is more than one possible location for the procedureThe procedure is not started until all questions or concerns are resolved.During the time-out, the immediate team members agree, at a minimum, on these three things:
27Lynne Updates Speak Up™ brochures will be ready by end of week to be picked up in Shapiro 245Computer privacy screenssent corrected measurement and quantity info back to Office Depot/3M Reps and will get quotes by end of weekOnce quotes received Jayne will work with Eric for fundingEmergency Response Quick Reference (aka flipchart). Each flipchart is $19.75 & you will be invoiced, no PO is needed to place the order. Login: BIDMCPassword: flipcharts1