Transcript August 12, 2009 Agenda and Master Presentation

Ambulatory Joint
Commission Meeting
August 12, 2009
Presented by:
The CMS Debriefing Workgroup
Recap Last Meeting

Overview of the Ambulatory Joint
Commission structure
 Reorganization of work groups
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Demo of Ambulatory Joint Commission
Folder

Policies and Procedures 101
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What’s New with Competencies
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The New and Improved Chart Audit
Today’s Agenda – Where we left off
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Revisions to PACE Audits
Resumption of Mock Joint Commission Surveys
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Patients Rights and Confidentiality (Menrika)
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Clinic Findings (Amalia)
Infection Control (Lynne)
Life Safety
New Ambulatory Guideline on Meeting Minutes
Update on Chart Audit
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Do you feel like you’re drowning some days?
You have
colleagues and
systems to keep
your heads
above water!!
The Goal of this Presentation…
 Inform you of concerns that were raised during the
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CMS Survey;
Help you find resource documents (such as the
Amb & Emergency Services CMS Debrief Master
Doc in the Amb JC Folder on the S:Drive);
Let you know what systems are in place to help you
navigate CMS/TJC requirements;
Ensure you know the activities and teams we have
in place;
Give you contacts should you still have questions;
Give Lynne a break!!!
You know a lot of this content, however, we all need to
have the same knowledge base!
Ambulatory PACE Audits
(Lead: D. Clough)
 The PACE audit form is under revision by the
Ambulatory PACE work group.
 You will record data within Performance Manager
and will receive results similar to those from chart
audits.
 You will receive actionable real time data!
 We are in the process of revising the schedule
for conducting self-audits and mock surveys.
 Anticipate new audit will be available for
September.
Mock TJC Surveys
 The PACE audit team will resume mock surveys within
Ambulatory to ensure Every Day Readiness.
 Goal is to help staff to comfortably and reliably respond
to Joint Commission surveyors on a range of topics.
 Here are some sample questions:
Q: What is the single most important measure to prevent
the transmission of organisms?
A: Hand hygiene
Q: Who is your floor marshal for emergency evacuation?
A. Name of person
 “Surveyors” will also spot check PACE audit criteria while
on the unit.
3 Categories of Auditing
How are they different?
 Self-auditing: this is a tool to help you manage your unit’s
compliance. Results will be provided to you on Performance
Manager and you will be able to take corrective actions when
indicated.
 Ambulatory Mock Surveys: These surveys are conducted to
help you and your staff prepare for a surveyor’s visit to your unit
and will be conducted in the same manner.
 Health Care Quality Every Day Readiness Surveys: This type
of survey is a consult.
o You request facilitators to come to you and help you
problem-solve around Joint Commission standards that may
be giving you a challenge in achieving full compliance.
o This consult can serve as “outside eyes” for your survey
readiness; very much in the spirit of LEAN.
E2 – Everybody/Every day
Patient Rights
(Lead: Menrika Louis)
 Concerns: Patient Rights & Healthcare Proxies
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The most updated versions are not always
available on units;
Lack a clear understanding of communication of
updates;
Not all languages are available in waiting areas;
Ordering information is available within the
CMS document in the Ambulatory Joint
Commission folder;
Space and storage is problematic on some units
and needs to be addressed.
Confidentiality
 Destruction of patient information
 Use of shredders:
o
o
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Charts and patient information:
o
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Location should be at front desk & consult rooms;
Ordering information in CMS document.
Veiled or turned in chart racks.
Computer screens:
o
o
Need protection;
Screen cover ordering information from Office
Depot is in the CMS document.
Clinic Findings
(Lead: Amalia Gonzalez)
 Expired Meds
o Require constant vigilance;
o Use monthly check list - refer to EOC – 1;
o Pharmacy policy #03-07-07 gives guidance
for drug storage.
o Inspection by:
 Pharmacy monthly – for high volume drug
use/storage areas.
 PACE rounds every 6 months – for low volume
drug use/storage areas.
Monthly Supply Checklist
(INSERT DEPARTMENT): Monthly Supply Checklist
Exam Rooms
Supply Cart
(top & drawers)
Shelves/Cabinets
Counter tops
# of Items
Discarded
# of Items
Restocked
Drug Sample Management
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Drug samples are ALLOWED but we must follow
policy CP - 11.
Units must have logs and a sign-out process.
Samples must be stored in a secure area;
accessible only to authorized individuals.
Samples distributed to patients must be labeled
in accordance with state regulations, i.e. patient
info, dosing and manufacturer and lot number,
etc.
Rationale: you are dispensing drugs, therefore
you must comply with the state regulations
related to this activity.
Tracking & Inspection of Samples
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Drug samples are tracked through various
means:
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Questions on PACE self assessment tool;
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Emphasis on samples during mock surveys;
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Pharmacy inspection of unit’s sample
program;
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Medication logs FAX’d to Pharmacy monthly;
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The log is found at the end of CP-11.
Sample Medication Log
Moderate Sedation
 During the CMS visit we were asked, “During the
administration of IVMS, can the nurse/monitor be
involved with helping the physician?”
 Answer: The nurse should have no other significant
responsibilities that would compromise her ability to
monitor the patient, BUT the nurse MAY perform
minor, interruptible tasks.
 Policy for moderate sedation is CP – 03.
 For those clinics that use moderate sedation, Janet
Lewis is an excellent resource.
Code Cart Concerns
CMS & JCAHO concern: It was not clear that we had a
STANDARD way to assure that NO items in the code cart are
expired at any given time.
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During the monthly audit, use the inventory sheet as a guide
to verify that items that should be present are actually present
and if not, contact distribution or clinical engineering as
appropriate.
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When you complete the monthly audit, all items are checked
for expiration.
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Check the clinical stickers on both the defibrillator and suction
machine. (PM valid through __/__/__) Call clinical
engineering for out-of-date stickers or any malfunctions.
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Check that the needle stick box is only ½ full.
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Remember: there are daily, weekly and monthly checks!
Refrigerator Temps & Alarms
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Refrigerators used for medications only: check
temperature & alarms
o Temperature must meet Nat’l Institute of Standard and
Technology Guidelines.
o Daily, at opening of clinic, assigned staff checks unit and
determines if it is within the acceptable temperature
range.
o If outside normal temperature range, call Service
Response.
o Temperature is to be recorded daily on the monthly
Refrigerator and Freezer Temperature Log,
o Refrigerator logs are at the end of #ASM-4, Medication
Fridge Temp Policy.
o Tracked on PACE audit MM8-12
Tracking # of Patients in Clinic
 CMS asked, “How do you track the
number of patients in your clinic?”
 Answer: you can use:
1.
2.
*
The ccc CAS report
The ccc check-in report
ED uses their dashboard, which can be
printed from any computer.
Hmm, I seem to be staying afloat!
Boy, who
said this was
going to be
tough?
Infection Control
(L. Brophy)
 Hand Hygiene
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Pump in/Pump out!!
Measure on PACE audit;
Observations of hand hygiene will be an emphasis on
Mock Surveys;
Ensure portable Calstat containers in exam rooms;
No Calstat units should be mounted over electrical
outlets;
The resolution of other Calstat wall mount units is still
in the planning stages.
Biohazard Waste & Receptacles
 What should be placed in these receptacles?
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Anything visibly saturated with blood or body fluids.
 What should NOT be placed?
Dry
band-aid;
Tubing attached to an IV bag.
Although it is important to segregate all biohazard waste:
o Processing infectious waste is extremely expensive;
o
Only infectious waste should be placed in the designated
receptacles;
o
All other waste should be discarded as solid waste;
o
A standard list will be created for all units.
o
Policy reference is EC - 59
Sharp Containers
 Sharp Waste is defined as:
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All needles, IV catheters, syringes (note: syringes are
considered a sharp with or without a needle attached) and
sharp medical instruments (e.g. scalpel blades, suture
needles, disposable razors).
 Call when containers are ½ full! (Be sure to check the
container on the Code Carts.)
 EVS evening shift checks containers daily.
 Contacts: Mark Leonard (East); Scott Tripp (West).
 For daytime emptying contact: Service Response.
 Again, policy reference is EC - 59.
Medical Equipment Cleaning
 Equipment cleaning policy: IC ES15
 High frequency shared medical equipment requires
cleaning both before and after patient use:
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Wipe down equipment with ready to use Steris
Germicidal Surface Wipes (red top). When indicated,
gloves should be worn to protect against blood and
body fluids.
 Examples of High Frequency Shared Medical Equipment:
portable blood pressure cuff, glucometer, pulse oximeter,
portable doppler, bladder scanner, portable thermometer,
EKG machine.
 Other minor equipment: need guideline addendum to
equipment cleaning policy.
Cleaning – Utility Rooms
 EVS evening shift is responsible for cleaning
clean/dirty utility rooms:
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Floor care
Wall spotting
Dusting
Remove medical waste
 EVS does not transport dirty instruments or
other equipment left in the room.
And even more Cleaning……
 Exam Rooms: EVS cleans daily in evening.
 Exam tables: EVS should clean any
permanent non-clinical equipment daily.
 Managers should work with individual EVS
staff to ensure that cleaning is being
performed as outlined.
Personal Protective Equipment
 New policy is in the approval process.
 There will be an online mandatory training
once the policy is passed.
 Training will be part
of the annual mandatory
education process.
Life Safety
(Lead: D. Clough)
 No propping open doors:
 If door is not working properly, contact Service
Response and obtain a work order.
 Space heaters: Gone!!
 Stairwells and hallways:
 NO STORAGE.
 Taped off areas need review by Lean Team.
Guideline on Meeting Minutes
 We had lots of agendas for CMS….. Not minutes.
 Purpose of Guideline: To establish a method of
documentation and communication within a meeting
group, ensuring that:
1.
2.
3.
Important meeting content is recorded.
There is a recognized standard and method for
documentation and communication.
All members are informed of progress toward
achieving the group’s charter, progress to date and
accountabilities for further actions.
 All routine meetings such as staff meetings, committee
meetings, and special interest groups, require a formal
record of meetings.
 Guideline currently can be found on the S: drive Ambulatory Services/Ambulatory Policies.
Did you say
chart audit??
I’m all ears!
New Chart Audit Start-up
 Roll out of the new integrated chart audit will begin this month!
 Please make sure you supplied Lynne via email the name of
your clinics/departments for the drop down pick option (#1
on survey)
 You also should have provided the name of your auditor(s).
 If you have a separate person downloading unit specific data,
we will need that name as well.
 You will receive an e-mail with start up information which will
include:
 Step-by-step instructions;
 Explanation where indicated as to how to satisfy each
criterion;
 Reference to P&Ps or any other information source;
 Who to contact with questions.
New Chart Audit
(Leads: S. Hewitt/L. Brophy)
 Link to audit tool will be sent to each
manager/director, with instructions on how to access
 Combined chart and med rec audits will be
unannounced each month;
 We will use the med reconciliation methodology
regarding number of charts reviewed, adjusted for a
monthly process:
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Clinics w/<30 visits/day
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Clinics w/31-100 visits/day = 10 charts
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Clinics w/>100 visits/day
= 7 charts
= 20 charts
Performance Manager Download
 Results will be downloaded from Performance Manager to
Excel;
 For the generic chart audit, we will tabulate results and graph
them by:
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unit; and
aggregate for Ambulatory
graphs will be placed on the shared drive (Ambulatory Joint
Commission) for ease of access
Email will be sent out when they are ready for reviewing
 For those who want to have unit specific criteria:
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Lynne will work with you to load your criteria;
You will be responsible for tabulating your unit specific
results;
Lynne will train you to work with your data.
AMBUALTORY SERVICES
CHART AUDIT ACTION PLAN GRID
DATE ______________
Department
%
Compliance
Issues/
Concerns
Planned
Interventions/
Action Plan
Expected
Date of
Completion
Feedback
Provided
Y/N
Provider
Initials &
Date
Staff
Responsible
Eye Unit
80%
POC
Wording
needs to
indicate that
provider
discussed
and educated
patient.
8/20/09
Y
JA
8/20/09
K. Jordan
Eye Unit
90%
Med
Rec
List not
updated
9/7/09
Y
FB
8/20/09
K. Jordan
•Each unit will update Action Plan monthly and provide review quarterly.
•Utilize this Plan as a QI tool.
•Verification will continue to ensure appropriate auditing practices.
•We will continue to report Medication Reconciliation results to HCQ.
With a little help from one another, we’ll all
keep our heads above water!!