Transcript JACHO 2008 - Harvard University

Jayne Sheehan
Diane Gilworth
February 11, 2009
Agenda
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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
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Patient Rights
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Patient and/or Family Involved in Decisions
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Health Care Proxy
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Identifying /Involving in Care
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Informed Consent
Provision of Care
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Patient Education
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Assessing Learning Needs
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Evaluating Comprehension
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Pain Assessment/Reassessment **
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Restraints
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Timely Orders
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Ongoing Assessment
National Patient Safety Goals
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2 Patient Identifiers
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Administering Medications
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Collecting Blood
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Labeling Containers In Front of Patient
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Write Down/Read Back
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Recording Calls to Floors/Units
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Hand Offs – up to date and pertinent information with
opportunity to ask questions
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To/From Procedure and Test Areas
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Intra-Hospital Transfers
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Medication Labeling
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Going to Gemba
Transferring from original
container
Detailed information on label
Medication Reconciliation **
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Intra-hospital Transfers
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Outside Providers
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Patients
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National Patient Safety Goals (Cont.)
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Anticoagulation Therapy
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Process to implement an enterprise-wide
Anticoag Therapy Program
Universal Protocol
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Operative / Procedural Area/ Bedside
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Verification of Side/Site/Procedure
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Marking of Site
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Time Out Immediately Before Procedure
Medical Staff Standards
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Bylaws Related
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Timeliness of Reappointments
Human Resources
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Decentralized Monitoring of Competencies
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Performance Evaluations
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Staffing Effectiveness Exercise 2008-09
Infection Control
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Use of PPE
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PPD Screening
Information Management (Medical Records Related)
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Aggregate Reports of Compliance Streaming
through HIM Committee
Performance Improvement
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Collecting/Analyzing/Using Data for
Improvement
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Staff Knowledge of Priorities
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Going to Gemba…Go and See
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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”
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Key Capabilities:
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Seeing problems as they occur
Swarming & solving problems as they are seen
Spreading new knowledge
Leading by developing capabilities 1,2 & 3
Dermatology- CQI project
LOCAL ANESTHETIC PREPARATION, STORAGE,
TRANSPORT, AND ADMINISTRATION POLICY
Sheliah Janus, Daihung Do MD
Reviewing our
Progress
Jayne Sheehan
Chapters
Content of our work
On Line “Joint tool Box”
Integrated learning
Ethics Rights-Resp
Power of the group
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
For Each Chapter
•Key Concepts
•National Patient Safety Goals
•Related Policies/Procedures
•Resources
-on-line
-staff
•Related sub-group activity
Sub- Groups
•Policy/Procedures
•CQI/chart audits
Scope of Practice
•PACE Audits
•License Verification
•Anti-coagulation
Sub-groups, -The “why and what”
Goal:
a) increased the number of engaged “experts” – integrated
knowledge for all
b) Integrate knowledge of JC into everyday practice
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CQI/scope of service, Lead - Jason Laviolette
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PACE Audits, Lead - Stephanie Tarantino
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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
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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
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JC documents which will be reviewed during initial sessions-guide the survey process
Re-organization of policies and procedures- tool boxes
Anticoagulation, Lead - Louise Mackisack
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JC standard and high risk medications.
Readiness Preparation
Jayne Sheehan
An Unscheduled JC Visit- your role
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Clean sweep- “25 steps to a sweeping success”
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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
Medications
Allison McHugh
Policy and Procedure Subgroup
Update
Sandy Hewitt
What is our Charter?
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Provide periodic and systematic review of P&Ps to
ensure they reflect current practice and comply with
appropriate guidelines and mandates.
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Determine what general P&Ps need modification for
Ambulatory purposes.
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Ensure standardization of those Ambulatory P&Ps
specific to us. Ex: some HR policies.
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Improve ease of access to P&Ps.
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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:
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Which policies and procedures you refer to most
frequently.
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Which policies and procedures do you have
trouble finding.
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If there are policies and procedures you wish we
had.
C. More to come
Tool Box
Lynne Brophy
Chart Audits-updates
Diane Gilworth
Chart Audit Process 2009 and beyond
Good
Continue with
present chart
audits
Review your data
and be prepared to
discuss with the
JC
Better
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
Best
Create a new more
clinically
Relevant chart audit
Data is available real
time- unit specificCQI
Clinicians would do
all Chart auditsMD’s, NP’s , RN’s.
Proposed chart Audits 2009
Ambulatory Unit
Date of Service
Ambulatory unit- drop down
menu for all units
Add in # of charts to be done
within a quarter(based on unit specific
parameters)
Medical record number
Attending physician
(Last Name, First)
Patient Seen By (Last
Name, First)
Data comes
back to you in a
timely manner
Reviewed by
Review date
Date of Birth (enter
mm/dd/yyyy)
Chart Audits
Problem list is updated and reviewed (within last 12 months)
Allergies are reviewed and updated (within last 12 months)
Yes/No
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 visitthis 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/No
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, …..
Yes/No
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)
Yes/No
Advanced directive is presentnew field in Web OMR (documentation indicates whether the patient
has signed an advance directive)
Yes/No
Medication Management
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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 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: 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.
Thank you
Jayne Sheehan
Diane Gilworth