1. Jayne Sheehan Diane Gilworth February 11, 2009

2. Agenda
11:00-11:10 – Jayne Sheehan, introductions, vulnerabilities- med management
11:10-11:20- CQI/Medication Management in Derm Surgery, Sheilah Janus, Dr. Daihung Do
11:20-11:30 – JC Readiness-updates Jayne Sheehan
11:30-12:00- Medication management-code carts, Allison McHugh
12:00-12:20 – Policy & Procedure Subgroup Update Sandy Hewitt
12:20-12:25 Tool box update, Lynne Brophy
12:25-12:30- Medication management reminders and Chart Audit Update Diane Gilworth

3. Vulnerabilities-just a reminder
Patient Rights
Patient and/or Family Involved in Decisions
Health Care Proxy
Identifying /Involving in Care
Informed Consent
Provision of Care
Patient Education
Assessing Learning Needs
Evaluating Comprehension
Pain Assessment/Reassessment **
Restraints
Timely Orders
Ongoing Assessment
National Patient Safety Goals
2 Patient Identifiers
Administering Medications
Collecting Blood
Labeling Containers In Front of Patient
Write Down/Read Back
Recording Calls to Floors/Units
Hand Offs – up to date and pertinent information with opportunity to ask questions
To/From Procedure and Test Areas
Intra-Hospital Transfers
Medication Labeling
Going to Gemba
Transferring from original container
Detailed information on label
Medication Reconciliation **
Intra-hospital Transfers
Outside Providers
Patients
National Patient Safety Goals (Cont.)
Anticoagulation Therapy
Process to implement an enterprise-wide Anticoag Therapy Program
Universal Protocol
Operative / Procedural Area/ Bedside
Verification of Side/Site/Procedure
Marking of Site
Time Out Immediately Before Procedure
Medical Staff Standards
Bylaws Related
Timeliness of Reappointments
Human Resources
Decentralized Monitoring of Competencies
Performance Evaluations
Staffing Effectiveness Exercise
Infection Control
Use of PPE
PPD Screening
Information Management (Medical Records Related)
Aggregate Reports of Compliance Streaming through HIM Committee
Performance Improvement
Collecting/Analyzing/Using Data for Improvement
Staff Knowledge of Priorities

4. Going 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 occur
Swarming & solving problems as they are seen
Spreading new knowledge
Leading by developing capabilities 1,2 & 3

5. Sheliah Janus, Daihung Do MD
Dermatology- CQI project
LOCAL ANESTHETIC PREPARATION, STORAGE, TRANSPORT, AND ADMINISTRATION POLICY
Sheliah Janus, Daihung Do MD

7. Reviewing our Progress
Jayne Sheehan

8. On Line “Joint tool Box”
Chapters
Content of our work
On Line “Joint tool Box”
Integrated learning
For Each Chapter
Key Concepts
National Patient Safety Goals
Related Policies/Procedures
Resources
-on-line
-staff
Related sub-group activity
Ethics Rights-Resp
September 08
Provision of Care
October/November 08
Med Management
December 08
Safety/Disaster Management
January-09
Surveillance, Prevention of infection
February-09I
Improving Organizational Performance
March-09
Leadership
EC/R
Power of the group
Sub- Groups
Policy/Procedures
CQI/chart audits
Scope of Practice
PACE Audits
License Verification
Anti-coagulation

9. Sub-groups, -The “why and what”
Goal:
increased the number of engaged “experts” – integrated knowledge for all
Integrate knowledge of JC into everyday practice
CQI/scope of service, Lead - Jason Laviolette
JC documents which will be reviewed during initial sessions-guide the survey process
PACE Audits, Lead - Stephanie Tarantino
Reviewed unit based PACE audits/concordance with hospital wide PACE audits- measures to make this data available to you in real time- JC requirement
License Verification, Lead Diane Gilworth
JC standard- primary source documentation/central verification process- in place for all ambulatory RN’s and NP’s
Policy/Procedure sub-group, Lead - Sandy Hewitt
Re-organization of policies and procedures- tool boxes
Anticoagulation, Lead - Louise Mackisack
JC standard and high risk medications.

10. Readiness Preparation Jayne Sheehan

11. An Unscheduled JC Visit- your role
Clean sweep- “25 steps to a sweeping success”
No food, drinks, clean corridors
Staff –badges
PACE
RACE
HIPPA
Have a tracer patient in mind
Code Carts- checked, locked
MDs- everything you need to know about JC
National patient safety goals

12. 25 Steps to a Sweeping Success

13. Codes and Emergency Management of Medications
Allison McHugh

14. Policy and Procedure Subgroup Update Sandy Hewitt

15. What 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)

16. Request 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.

17. C. More to come

18. Tool Box
Lynne Brophy

19. Chart Audits-updates Diane Gilworth

20. Chart Audit Process 2009 and beyond
Better
Best
Good
Create a new more clinically
Relevant chart audit
Data is available real time- unit specific-CQI
Clinicians would do all Chart audits- MD’s, NP’s , RN’s.
Continue with present chart audits
Review your data and be prepared to discuss with the JC
Reformat questions for easier documentation
Clarify # of chart audits per unit
Define what it means to be compliant
Get data back to you in a timely manner

21. Proposed chart Audits 2009 Data comes back to you in a timely manner
Ambulatory Unit
Date of Service
Medical record number
Attending physician (Last Name, First)
Patient Seen By (Last Name, First)
Reviewed by
Review date
Date of Birth (enter mm/dd/yyyy)
Ambulatory unit- drop down menu for all units
Add in # of charts to be done within a quarter-
(based on unit specific parameters)
Data comes back to you in a timely manner

22. Chart Audits
Problem list is updated and reviewed (within last 12 months) Yes/No
Allergies are reviewed and updated (within last 12 months) Yes/No
Medication 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/No
Summary 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, …..

23. H & P is present
( need language to determine what counts as an H&P) Yes/No
Pain 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/No
Pain 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

24. Medication Management
Medication management policy/competency on line
Prohibited abbreviations (hand-out)
Multi-dose vial- 28 days- pharmacy policy
Refrigerator Alarms (change battery and check green sticker)
Medication questions –posted on portal

27. Refrigerator Alarms
Refrigerator 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.

28. Thank you Jayne Sheehan Diane Gilworth