March 10, 2010 Ambulatory Joint Commission

Agenda  Comments on Count-down to Survey Discussion  Chart audit results and what we’re doing about them… Presented by: Sandra Hewitt  Updates on Medication Reconciliation and Universal Protocol Presented by: Charmaine Massey and Sandra Hewitt  Ambulatory CQI Committee Update Presented by: Menrika Louis  Waiting Room Patient Information Posting Standards Presented by: Sandra Hewitt  New PACE Audit Tool & our results from 2/10/10 Presented by: Gary Schweon  Mock Surveys on ambulatory units Presented by: Sandra Hewitt

Count down to survey! Anniversary survey date is 7/27/2010. If you have any specific questions or concerns, please feel free to contact me and if it’s something I can’t help you with, I’ll work to connect you with the appropriate person(s).

What if The Joint Commission showed up tomorrow?  Sweep cards  No food and drink in clinical areas  Badges above the waist and facing forward  HIPAA enforced - Computer screens not visible - Patient information not in view  Code Carts – checked and locked  Have a tracer patient in mind  Hand hygiene  Anyone need Sweep Cards? It’s the way to sweeping success and a calm demeanor.

Chart Audit Results for November

Chart audit results

Chart Audit Subgroup Membership Lynne BrophyJason Laviolette Linda DicenzoJanet Lewis Sandra HewittNancy Richter Courtney IvesCarol Slowley

Chart Audit Subgroup Work Reviewing what constitutes invasive procedures in Ambulatory/ED and when consents are needed. Consent forms will be replaced with corrected version with space for physician and patient to both time and date their signatures. (Updated version now available only in English; info next slide.) Inventoried where signed consents are stored. More on that process later. Addressing time out procedures. (Will be reviewed under updates on Universal Protocol).

Updated Consent Forms English version only can be ordered direct ship by contacting: Nancy at S&A Paramount (800) x 32.

Medication Reconciliation Update: Enhancement in the Works Charmaine Massey Significant NPSG Updates

Medication Reconciliation Viewed as critical to safety by key stakeholders; Organizations continue to struggle with implementation; Currently under evaluation and refinement; While organizations will still be surveyed for this requirement, findings will not factor in the accreditation decision (effective 1/1/09). Changes to be announced in Implement revisions for January 2011.

Hand Hygiene  Modifications are intended to reflect a more realistic approach;  Need to demonstrate: - the existence of a program - goals and efforts to improve  Goal does not need to be 90%  No more observation to find 3 instances of no hand washing.

Universal Protocol Updates

Pre-procedure verification The “checklist” has become a “standardized” list; Not necessary to document that standardized list was used for each patient; TJC will observe practice, interview staff and look for postings or cards regarding a standardized list. We will be developing posters to put in exam rooms.

Site marking If there is no debate regarding location, then we DON’T have to mark, unless deemed valuable. LIP accountable for procedure should mark site, most frequently the provider performing the procedure. A Resident/PA/NP can act on behalf of LIP in LIMITED situations only.

Time Out To be conducted at some time prior to incision. List of issues was shortened to focus on correct patient, correct site, correct procedure.

CQI Committee Updates Menrika Louis

Ambulance Transfers from Ambulatory Clinics Problem / Questions: Is there a standardized process for patients in ambulatory clinics to be transferred to the Emergency Department? What process is being followed? Does the process provide safe transfer for the patient and does it follow the NPSG’s related to hand-offs? Are we providing the Emergency Department with the pertinent information they need, this includes but is not limited: allergies, last meds given, Code status if any and precautions? Clinic Observations Findings: * Transfer processes varied. Provider used online call-in to the ED. Ambulance unable to find patient location. Not all appropriate staffs were alerted of the transfer. Provider was not always available for hand-off to EMTs. Med lists, facesheets were printed and provided to the EMTs. ED Observations: Information needed at ED Triage differs from treating clinician in ED. *Observations of patient transfers from various ambulatory clinics to the ED were done over a period of one week.)

Ambulance Transfers from Ambulatory Clinics ANALYSIS Despite the different types of clinics and support staff, there is need for a standardized, streamlined process for transferring patients from Ambulatory Clinics to the Emergency Department. RECOMMENDATIONS Change the ED online call-in to trigger the input of more information from the provider. Clear outline of what preparations are expected when patients are being transferred to the ED. Roles/expectations should be defined for participants (Medical Assistants, Registered Nurse, Provider (MD/NP). Communication plan to ensure unit awareness of EMTs’ impending arrival. Proper hand-off is needed at every point of transfer.

Waiting Room Patient Information Posting Standards

Goals: Ensure that all necessary information is posted in waiting rooms. Establish standard language and appearance of information. Create a less confusing presentation for patients.

Criteria: Required Information Healthcare Proxy Transparency Info on Delays Patient Rights Infection Control Signage Medicare Rights Copay Signage Notice of privacy Practices Booklets Hand-washing Notice Wait Sign (if waiting >15 minutes) TJC Brochure on physician visits

Physician Visit Brochures Speak Up™ brochures are available in English and Spanish at: SpeakUp/

Criteria: Presentation Information easy to find Presented by subject matter Clear and prominent signage indicating where to find the information Cell phone signage tasteful and in multiple languages Standard TV instructions Good display rack design Labeling of sections within display rack Current specialty specific information Posting kept to a reasonable limit and in proper frame/laminate sleeve