October 14, 2009 Ambulatory Joint Commission

Agenda Chart Audit Updates Chart Audit Action Plan Grid PACE Audit Updates Announcements

Announcements: o Employee Safety Fair, Oct. 22 nd - Kelly Orlando o BIDMC Bowl-a-Rama Hand Hygiene Incentive Program; E&W cafeterias 12:00-1:30 (Oct. 21 st - 22 nd ) o Reminder: o Please write up your quality improvement initiatives so that you’ll have them for the Silverman Symposium.

Goals of Chart Audit Use real time data to drive positive change; Provide meaningful data at the unit level and rolled up for all of Ambulatory; Ensure regulatory compliance; Resolve any Joint Commission vulnerabilities; Meet Medical Center requirements.

What will stay the same…. Number of charts reviewed is dependent on the number of visits the day of the chart audit:  Clinics w/<30 visits/day = 7 charts  Clinics w/ visits/day = 10 charts  Clinics w/>100 visits/day = 20 charts It is always optional if for any reason a clinic wants to review more than the required number of charts.

What’s new with the chart audit tool? A lot. Thank you for your meaningful input! We’ve put it to good use and we think we have a better tool. We’ve divided the tool into 4 sections: o Patient demographics o Visit Information o Medical Record o Medication Reconciliation Provided clarifying explanations embedded in the tool.

TJC: Elements of Performance for a Summary List 1. A summary list is initiated for the patient by his or her third visit. 2. The patient’s summary list contains the following information:  Any significant medical diagnoses & conditions.  Any significant operative & invasive procedures  Any adverse or allergic drug reactions  Any current medications, over-the-counter medications & herbal preparations 3. The patient’s summary list is updated whenever there is a change in diagnoses, medications or allergies to medications, and whenever a procedure is performed. 4. The summary list is readily available to practitioners who need access to the information of patients who receive continuing ambulatory care services in order to provide care, treatment, and services.

Revised PACE Audits The PACE audit workgroup has revised the audit form for ease of use. All questions are listed in the affirmative. This makes it easier for us to compile your data in Performance Manager. The sections to the assessment remain the same:  Infection Control  Fire & Life Safety  Medication Management & Pharmacy We have a new methodology for applying to PACE Audits.

The Self-Assessment Methodology You will conduct self-assessments monthly. Each month will focus on a different section of the audit tool, i.e. Medication Management. Each quarter you will complete the whole assessment, allowing time for correcting any items out of compliance. For any item that is out of compliance, documentation of corrective action, anticipated completion date and actual completion date are required in the comments section. You will receive a document providing instructions and completion dates for entering data (by the 3 rd week of each month). You will receive your data in the Ambulatory Joint Commission folder. The subgroup will report out aggregate data each month at these meetings.

“ Outside Eyes” – Peer Review Outside Eyes is a LEAN term for using someone with some distance from the situation to help problem solve. Peer reviews should be treated as a “real survey.” Three times per year, in Jan, May, and Sept, your unit will be assessed by a peer from another unit. Peer means a manager and a staff member from each unit. Using a staff member helps to train others in this audit process. The subgroup has yet to determine the pairing of units. More on that next month!

Everyday Readiness Surveys This type of survey is a consult. o You request facilitators to come to you and help you problem-solve around Joint Commission standards that may be giving you a challenge in achieving full compliance. o This consult can serve as “outside eyes” for your survey readiness; again very much in the spirit of LEAN. E2 – Everybody/Every day