1. © Joint Commission Resources AMP with FSA Step-by-Step Guide to Implementing AMP in your Organization Step 1-Developing Teams Jeanette Snell, RN, MSN Clinical Advisor

2. © Joint Commission Resources Objectives: Identify individuals requiring AMP access. Identify user roles in your organization. Complete user assignments. Implement AMP across your organization. 2

3. © Joint Commission Resources 3 Understanding User Roles  Staff Member (Individual)  Staff Member (Team Coordinator)  Site Manager  Program Administrator

4. © Joint Commission Resources Staff Member Role –First tier of access –Able to view all EP’s and documentation –Able to add/edit documentation for assigned EP’s only –Enter an individual score –Low volume of EP’s assigned –Multiple staff members per each EP 4

5. © Joint Commission Resources Staff Member Role-Team Coordinator –Staff Member level of access –Able to view all EP’s and documentation –Able to add/edit documentation for assigned EP’s only –Enter a preliminary score –Typically assigned an entire chapter –Ability to assign tasks –One team coordinator allowed per EP 5

6. © Joint Commission Resources Site Manager Role –Higher level of access –View and score all EP’s (No assignment) –Responsible for entering the final score –Scoring Score each EP independently Score EP’s in bulk Accept Team Coordinators’ scores –No Administrative functionality 6

7. © Joint Commission Resources Program Administrator Role –Highest level of access –View and score all EP’s (No assignment) –Responsible for entering the final score –Scoring Score each EP independently Score EP’s in bulk Accept Team Coordinators’ scores –Assign users/access –License maintenance –Site Setup and Password/Email setup 7

8. © Joint Commission Resources Collaboration among User Roles Team Coordinator Team Coordinator Staff Member Staff Member Staff Member Staff Member Staff Member Site Manager HR Chapter HR.01.01.01 EP 2 HR.01.02.07 EP 1,2,5 HR.01.01.01 EP 2 MM.07.01.03 EP 1-6 MM Chapter MM.07.01.03 EP 1-6 Site Manager Program Administrator 8

9. © Joint Commission Resources Accreditation Manager Plus 9 RoleProsCons Staff Member-Deploy responsibility -Allows input from many individuals in organization (Individual scores) -Accountability -Additional level of scoring -Additional assignments Team Coordinator-Chapter responsibility -Allows one individual to review individual scores -Enter preliminary score -Convert preliminary score to final score -Additional level of scoring Site Manager-May enter final score -Assist program administrator/team coordinator -Useful for systems -Additional level if individual facility -Everyone can document on all EP’s when only this level is used (can overwrite each others data) Program AdministratorRequired

10. © Joint Commission Resources Team Development Complete Team Development Tool (Role, Title, Name, Email) The following slides offer suggestions for team members arranged by Chapter of the CAMH ***Please note that Joint Commission does not require use of all AMP roles or team structure as proposed in this toolkit. These are ideas to assist you in compliance efforts.*** 10

11. © Joint Commission Resources Team Development Tool 11

12. © Joint Commission Resources Assigning Users Accreditation Participation Requirements  Vital to accreditation  Tend to be clear cut requirements  Noncompliance is very evident  Typically assigned to JC liaison or program administrator.  Leadership involvement if noncompliance 12

13. © Joint Commission Resources 13 Accreditation Culture  What is the culture of your organization?  What is the size of your organization?  Who is responsible for accreditation?  Who is responsible for compliance?  Who is responsible for scoring?  What is the level of comfort?  How will you utilize the functionality in AMP?

14. © Joint Commission Resources Assigning Users Environment of Care  Proposed team members include: –Facilities Director/staff –Security Director/staff –Lab Director/staff –Pharmacy Director/staff –Biomedical Engineering –Peri-operative Director/staff –End users 14

15. © Joint Commission Resources Assigning Users Emergency Management  Proposed team members include: –Emergency Management leader –Administration –Medical Staff –Emergency Dept Director/ Staff –Infection Prevention and Control Coordinator –Facilities/Safety/Security Director –Utilities Director –Nutritional Services Director –Lab Director 15

16. © Joint Commission Resources Assigning Users Human Resources  Human Resources Director/staff  Employee Educator  Nurse Educator  Director of Volunteers  Employee health nurse  Those responsible for competency assessment 16

17. © Joint Commission Resources Assigning Users Infection Prevention  Possible team members include: –Infection Prevention –Microbiologist –Nurse Managers/Nursing Staff –Facilities/Engineering –Peri-operative Services –Central Supply/Sterile Processing –Employee Health Nurse –Environmental Services –Department Managers 17

18. © Joint Commission Resources Assigning Users Information Management/Record of Care  Possible team members include: –CIO –HIM Director –Performance Improvement Staff –Medical Staff Representative/CMO –Nursing Representative/CNO 18

19. © Joint Commission Resources Assigning Users Leadership  Conflict of Interest  Communication  Culture of Safety  Conflict Resolution  Contracts 19

20. © Joint Commission Resources Assigning Users Life safety  Possible team members: –Facilities Director –Safety/Security Director –Engineering –Department managers 20

21. © Joint Commission Resources Assigning Users Medication Management  Possible team members: –Pharmacy Director/staff –Nurse managers/staff –Medical Staff representative –P&T Chair –Director of Outpatient Services/clinic staff –Radiology Director/staff 21

22. © Joint Commission Resources Assigning Users Medical Staff  Possible team members: –CMO –Medical Staff Office representatives –Credentials Chair –Medical Staff Leadership 22

23. © Joint Commission Resources Assigning Users NPSG  Possible team members include: –Nurse Managers/staff (include MS/ICU/ED) –Lab Director/Blood bank staff –Anesthesia personnel –Peri-operative Services Director –Pharmacy Director –Radiology Staff –Outpatient staff 23

24. © Joint Commission Resources Assigning Users Nursing  Consider the following: –Education and Experience –Access to policies and procedures –Developing standards of care –Implementing standards of care –Implement staffing plan –Oversight for all nursing care 24

25. © Joint Commission Resources Assigning Users Patient Rights and Organizational Ethics  Potential Team members include: –Administrative representative –Legal Counsel/Risk Manager –Patient Relations –Patient Advocate –Social Worker –Nursing representatives –Outpatient representative 25

26. © Joint Commission Resources Assigning Users Provision of Care  Possible team members: –CNO –Nursing Administration –Staff Nurses –Pharmacy Director –Anesthesia Personnel –Behavioral Health (if applicable) –Multidisciplinary Team Members 26

27. © Joint Commission Resources Assigning Users Performance Improvement  Possible team members might include: –Quality Improvement personnel –Department Directors –Medical Staff Leaders –Administration 27

28. © Joint Commission Resources Assigning Users Tissue  Peri-operative Services Director  Wound Center Director  Lab Director  Tissue Officer (if required by law)  Tissue Management personnel  Materials Management personnel  Nursing representatives 28

29. © Joint Commission Resources Assigning Users Waived Testing  Potential team members include: –Lab Director or designee –Staff Educator/Competency Assessment –Nurse Managers/staff –Outpatient Services 29

30. © Joint Commission Resources Quick Review  Staff member***  View/Edit -My assignments (Individual score)  View all EP’s  Team Coordinator***  View/Edit -My assignments (Preliminary score)  Review individual scores/assign preliminary score  Site Manager/Program Administrator  Can document on all EP’s (no assignment)  Score each EP/score bulk/accept preliminary scores as final ***Can only document on EP’s in their assignment 30

31. © Joint Commission Resources Questions?

32. © Joint Commission Resources Customer Support Technical Issues (Customer Support) Call: 888-527-9255 Email: support@jcrinc.comsupport@jcrinc.com 32