Jayne Sheehan

Diane Gilworth

February 11, 2009

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

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 2008-09

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

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

LOCAL ANESTHETIC PREPARATION, STORAGE, TRANSPORT, AND

ADMINISTRATION POLICY

Dermatology- CQI project

Sheliah Janus, Daihung Do MD

Reviewing our ProgressJayne Sheehan

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

Sub- Groups•Policy/Procedures•CQI/chart auditsScope of Practice•PACE Audits•License Verification•Anti-coagulation

On Line “Joint tool Box”ChaptersIntegrated learning

Power of the group

Content of our work

Sub-groups, -The “why and what”

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.

Goal:

a) increased the number of engaged “experts” – integrated knowledge for all

b) Integrate knowledge of JC into everyday practice

Readiness PreparationJayne Sheehan

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

25 Steps to a Sweeping Success

Codes and Emergency Management of

MedicationsAllison McHugh

Policy and Procedure Subgroup Update

Sandy Hewitt

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)

Request of you……

We’ll be sending an e-mail 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.

C. More to come

Tool Box

Lynne Brophy

Chart Audits-updates

Diane Gilworth

Good Better Best

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

Create a new more clinicallyRelevant 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

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 unitsAdd in # of charts to be done within a quarter- (based on unit specific parameters)

Data comes back to you in a timely manner

Proposed chart Audits 2009

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/NoSummary 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.

Yes/NoConsent 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, …..

Yes/No

Chart Audits

H & P is present ( need language to determine what counts as an H&P)

Yes/NoPain 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)

Yes/No Advanced directive is present-

new field in Web OMR (documentation indicates whether the patient has signed an advance directive)

Yes/No

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

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: 617-632-0070.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.

Refrigerator Alarms

Thank you

Jayne Sheehan

Diane Gilworth