1. Jayne Sheehan Diane Gilworth TJC and CMS Update Ambulatory Monthly Meeting April 8, 2009

2. Agenda 11:00-11:30 – Jayne Sheehan – –CMS update Binder Documentation Process/Structure Visit outline – –JC updates – –Chart audits – – Competencies – – License renewal process – – PA and NP competencies – – Updates- tool box and PACE

3. CMS-binder 482.54(a) Organization 482.54(a) Organization Organization Chart (for your department) Organization Chart (for your department) Scope of Practice Scope of Practice Evacuation Plan Evacuation Plan Process Improvement/Quality Improvement Plans Process Improvement/Quality Improvement Plans Meeting Minutes (i.e., staff meetings, Practice Committee, QI Committee, etc.) Meeting Minutes (i.e., staff meetings, Practice Committee, QI Committee, etc.) Departmental Guidelines (specific to your area) Departmental Guidelines (specific to your area) 482.54(b) Personnel 482.54(b) Personnel Director of Department - Job Description Director of Department - Job Description Departmental Job Descriptions (include all non-physician job descriptions in your unit/department for each role, including Practice Manager and on down) Departmental Job Descriptions (include all non-physician job descriptions in your unit/department for each role, including Practice Manager and on down) RN Licensing - See Ambulatory Services Administrative Notebook RN Licensing - See Ambulatory Services Administrative Notebook NP Practice Guidelines and Core Competencies - See Ambulatory Services Administrative Notebook NP Practice Guidelines and Core Competencies - See Ambulatory Services Administrative Notebook Certifications required for your department - (list of certifications that your staff and level of staff need to have-include all certifications specific to your unit or positions, i.e., chemo certification, Trauma, BLS, ALCS, etc.) Certifications required for your department - (list of certifications that your staff and level of staff need to have-include all certifications specific to your unit or positions, i.e., chemo certification, Trauma, BLS, ALCS, etc.)

4. Vulnerabilities: Areas identified by Mock Survey 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 Transferring from original container Detailed information on label – –Medication Reconciliation ** Intra-hospital Transfers Outside Providers Patients National Patient Safety Goals (Cont.) 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 Medical Staff Standards  Bylaws Related  Timeliness of Reappointments Human Resources Human Resources  Decentralized Monitoring of Competencies  Performance Evaluations  Staffing Effectiveness Exercise 2008-09 Infection Control Infection Control  Use of PPE  PPD Screening Information Management (Medical Records Related) Information Management (Medical Records Related)  Aggregate Reports of Compliance Streaming through HIM Committee Performance Improvement Performance Improvement  Collecting/Analyzing/Using Data for Improvement  Staff Knowledge of Priorities

5. No Licensee is allowed to work until their license is renewed and verified by the Manager or an ACS/OneStaff Specialist Any Questions??

6. Review of Policy PM-12 Employee Licensure Verification It is the employee’s responsibility It is the employee’s responsibility –to keep his/her license, accreditation, certification and/or registration up to date. Failure of an employee to maintain current required documentation or failure to provide the department/division with the necessary documentation will be grounds for dismissal. Failure of an employee to maintain current required documentation or failure to provide the department/division with the necessary documentation will be grounds for dismissal. The monitoring and maintenance of current licenses, accreditation, certifications, and/or registration should be maintained in the employee’s departmental file. The monitoring and maintenance of current licenses, accreditation, certifications, and/or registration should be maintained in the employee’s departmental file.

7. RN/NP License Renewal Process Ambulatory Process Centralized Ambulatory Cost Centers (Departments) Ambulatory Cost Centers (Departments) –entered into OneStaff for License Tracking Purposes only. New Hire is entered into OneStaff’s Personnel Module New Hire is entered into OneStaff’s Personnel Module License tracking is entirely dependent: License tracking is entirely dependent: –upon the manager notifying the OneStaff/HR Specialist of each New Hire and terminations A list of Ambulatory Departments – A list of Ambulatory Departments – –handout for your updates Process: Process: –Copy of the License Renewal is printed from the Nursing Board’s website- before the license expirse –License Renewal information is entered into OneStaff and filed centrally by department name.

8. License Verification One Staff Stand Alone Module For Licenses Monthly report to all directors and managers Expired License Ambulatory Directors updates New hires Termination Sheila Goggin For discussion DEA/DPH ACLS/BLS HR Primary Source Verification Process

9. RN/NP/LPN Added to One Staff Personnel Module

12. November 30th, 2008 December Licenses Not Yet Renewed RN License Expiration Date License NumberDirector/Manager Ricci,Stephanie A12/10/2008265229Bourie,T. Sansone,Sarah E12/17/2008260694Bourie,T. Sleininger,Danielle M12/8/2008256990Campbell, J. Ninobla,Annalyn S12/17/2008253646Campbell, J. Robbins,Kristin W12/29/2008267463Campbell, J. Cahill,Allissa12/12/2008271986Clarke,D.

13. License Verification Sheila Goggin is sending out information for the RN’s and NP’s are you getting the information? ( licenses are renewed on even year) Sheila Goggin is sending out information for the RN’s and NP’s are you getting the information? ( licenses are renewed on even year) Sheila is printing out the license and keeping a hard copy for primary source verification Sheila is printing out the license and keeping a hard copy for primary source verification Should we Add Should we Add –Add in BLS,ACLS, DEA and DPH to central monitoring

14. Review of Policy PM-12 Employee Licensure Verification Decentralized Process Disciplines within the Medical Center that must be primary source verified Disciplines within the Medical Center that must be primary source verified –Dietitians/nutritionists –Audiologists/audiologist assistants –Speech pathologists/assistants –Optometrist –Pharmacist/Pharm tech –NP/RN, Nurse Midwife, nurse anesthetist, CNS, –OT/PT –Athletic trainer –Mental Health Counselor –Educational Psychologists –Rehabilitation Counselor –Respiratory Therapist –Perfusionists –Questions- contact HR directly

15. Remember Primary Source Verification Decentralized Process The department director is responsible for ensuring that The department director is responsible for ensuring that –primary source verification of the license is performed upon hire and at the time of renewal –Primary source verification provides evidence and written validation that the license is verified as current and is maintained.

16. Primary Source Verification Decentralized If the license has been renewed, If the license has been renewed, –print a copy of this license from the website on the day it is viewed ( see website examples in the policy) If the license has not yet been renewed by the expiration date, If the license has not yet been renewed by the expiration date, –the person performing the review must contact the licensing board directly to ascertain the status of the providers license/certification and must document using the Verbal Verification (see policy) Upon renewal, Upon renewal, –the posted renewal on the website must then be printed and filed in the personnel record, along with the verbal verification form

17. No Licensee is allowed to work until their license is renewed and verified by the Manager or /ACS/OneStaff Specialist Any Questions??

18. Best 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. Chart Audit Process 2009 and beyond

19. Chart Audit- Next Steps *Primary Care *Medical Specialty Practices *Surgical Specialty Practices Emergency Room *Ambulatory Procedure Based Audits 4 chart Audits in Development* All Other Practices

20. Core Elements Unit based- specific elements

21. Chart Audit- Next Steps Specialty based Work groups to evaluate the content of chart audits Editor of all templates-TBD Medical Specialty Practices Surgical Specialty practices Emergency Room Ambulatory Procedure Based Audits Primary Care Data reported to specialty based directors on monthly basis Data Evaluated and if changes are necessary-work with specialty based group to address Specialty Based Chart Audits

22. On-going work-updates Competencies- Competencies- –list of all competencies –Email PA/NP competencies, RX and MD review PACE updates- PACE updates- –drop down menu similar to chart audits to facilitate better data management-getting results back to you Tool Box- Tool Box- –patient rights and provision of care

23. Competencies

25. NP and PA Practice NP’s and PA’s – collaborative practice agreement (guidelines) Supervising MD Supervising and evaluating Guidelines must be reviewed and confirmed as in effect on an Annual basis Office of Professional Staff Affairs- Sends out a document to Supervising MD’s on an annual basis Prescription Review-currently no standard way of doing this Documentation of review with supervising physician [244 CMR 4.22(3)(a)] Schedule II drug (narcotics)- only after consolation with MD- documented review in 96 hours. Regulations do not specify number of rx to be review - usually a % every 90 days--- --- BIDMC proposed 10 per quarter Regulations do specify that needs to be face to face with subsequent documentation HCA working on standard process

26. HCA- DRAFT for Standardization of Prescription RX Standards: Review occurs at the end of each calendar quarter (i.e. March 31st, June 30th, September 30th, December 31st) Maximum number is 10 charts or based on patient visit volume Documentation of review with supervising physician [244 CMR 4.22(3)(a)] – –Face sheet defines number of initial prescriptions or changes in medication [105 CMR 700.003 (4)] – –Attach note/encounter that resulted in prescription – –Submit packet of face sheet and notes to supervising physician to be reviewed independently with follow up discussion with in 5-10 days from submission Face sheet of the prescription review for the previous four quarters will be submitted with the NPs yearly evaluation. Initial Schedule II prescriptions will be reviewed within 96 hours, either by verbal communication, forward progress note or chart review

27. HCA- DRAFT-FACE Sheet NURSE PRACTITIONER PRESCRIPTION AUDIT NURSE PRACTITIONER PRESCRIPTION AUDIT NURSE PRACTITIONER: NURSE PRACTITIONER: SUPERVISING PHYSICIAN: SUPERVISING PHYSICIAN: REVIEW PERIOD: REVIEW PERIOD: [ ] January – March, 2009 [ ] January – March, 2009 [ ] April – June, 2009 [ ] April – June, 2009 [ ] July – September, 2009 [ ] July – September, 2009 [ ] October – December, 2009 [ ] October – December, 2009 NUMBER OF RECORDS REVIEWED: ______________________________________ NUMBER OF RECORDS REVIEWED: ______________________________________ NUMBER OF INITIAL PRESCRIPTIONS: ___________________________________ NUMBER OF INITIAL PRESCRIPTIONS: ___________________________________ NUMBER OF DOSAGE CHANGES: ________________________________________ NUMBER OF DOSAGE CHANGES: ________________________________________ PROBLEMS/ ISSUES IDENTIFIED BY SUPERVISING MD: ___________________ PROBLEMS/ ISSUES IDENTIFIED BY SUPERVISING MD: ___________________ FEEDBACK/ EVALUATION: _____________________________________________ FEEDBACK/ EVALUATION: _____________________________________________ Signatures: ____________________________________, NPDate: _____________ Signatures: ____________________________________, NPDate: _____________ ____________________________________, MDDate: _____________ ____________________________________, MDDate: _____________ Performance manager *** 243 CMR- include a defined mechanism to monitor prescribing practices including documentation of review by the supervising MD at least every 3 months

28. Responsibilities Hiring department ensures that written collaborative agreements- current (resources, practice etc.) Hiring department ensures that written collaborative agreements- current (resources, practice etc.) Hiring department is responsible for annual review Hiring department is responsible for annual review Hiring department is responsible for documenting primary source license verification- which includes advanced practice certification. (centralized this process) Hiring department is responsible for documenting primary source license verification- which includes advanced practice certification. (centralized this process)

29. References: Collaborative Practice Guidelines Collaborative Practice Guidelines State of MASS reg- 243 CMR (Board of Regulation of Medicine) State of MASS reg- 243 CMR (Board of Regulation of Medicine) BIDMC Credentialing and Evaluation Process for Advance Practice Nurses- OPSA-22 BIDMC Credentialing and Evaluation Process for Advance Practice Nurses- OPSA-22 HCA- Advanced Practice Forum HCA- Advanced Practice Forum –Leah Mckinnon-Howe NP –Barbara Rosato NP

30. Location of all Medical Records- for your information

32. Thank you TJC and CMS Update Ambulatory Monthly Meeting April 8, 2009