Transcript Adventure Works 2006 Sales Proposal

Annual Pharmacy Conference
SOARS Findings
Ravella Gooden-Dickinson
SOARS Program Coordinator
March 27, 2008
SOARS Mission
Assist VHA Medical Facilities
in being ready for any
internal or external review.
Goal is to provide optimal
services every day!
SCOPE OF REVIEW
Cleanliness
Safety
Patient Safety
Patient
Rights
Resident
Supervision
Seamless
Transition
Oxygen
Management
Patient Tracers
Moderate
Sedation
SPD
Infection
Control
Medication
Management
Improvement
Personnel
Suitability
Privileging
Training
Pressure Ulcers
Information
Management
Long Term
Care
Waits and
Delays
MH Risks
OR Safety
Equipment
Contracts
Data Analysis
Waits and
Delays
Performance
Emergency
Mgmt
What We’ll Cover Today
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SOARS Status Update
SOARS Findings
OIG Findings and reviews
“The Common Threads”
Where do we go from here
Questions and answers
STATUS UPDATE
• Started in 2003
• To date, completed 178 total visits. 138 initial
visits at all VHA medical facilities and Health
Care System and completed 40 triennial visits.
• 250 Internal Consultants and 30 Leaders
• Developed 42 assessment guides in
collaboration with Program Offices
• Changed in July, 2006 to compulsory visits with
comprehensive written reports
STATUS UPDATE
Continued
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Conduct 6 Audio Training Conferences per
year
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Produced 2 Training Film – “Pharmacy
Assessment” and “SPD Assessment”
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Added new clinical focus: “tracers”
OIG Pharmacy Reviews
o Review of VA Medical Facility Compliance with
Controls over Prescription Drugs (05-00877-17)
o Audit of VA's Consolidated Mail Outpatient
Pharmacies (CMOP - 06)
o Pharmacy Operations. (07)
o Management of Selected Prescription and OTC
Medications (08)
FY 07 OIG CAP Findings
(30 facilities)
• Strengthen QM processes to accurately
reconcile medications during admission,
transfer, & discharge
• Improve compliance w/ monitoring for
medication expiration dates
• Improve QM processes in PT safety,
medication management, & clinic access
FY 07 OIG CAP Findings
(30 facilities)
• Ensure unattended medication carts are locked
• Improve compliance w/ medication refrigerator
temperature monitoring
• Achieve full compliance with Medication
Reconciliation requirements
MEDICATION MANAGEMENT
(SOARS Trended Findings)
• Significant Concerns:
 Unsecured medications
 Medication Reconciliation Processes
• Continuing Concerns:
 Storage and labeling of medications
 Inconsistent and continuous medication
refrigeration monitoring
 USP 797 compliance
• The Weak Link:
 The UnAnnounced Inspection Program
More SOARS Findings
• Multi-use vial dating and outdated medications in
general
• Patient Safety Goal #6- Sound alike Look alike
drug identification (usually seen in Pharmacy, not
always on ward)
• Vault and/or Pharmacy Security - Ensure that
either the police or pharmacy print lists for
analysis of people entering the vault and off hours
pharmacy(24/7) on a random basis frequently.
• Update local policies to reflect current national
requirements for in/outpatient pharmacy
…Continued SOARS Findings
• Unannounced Inspection Program:
 Not analyzing data or trending findings
 Predictable inspections
 Clear documentation of resolution of
discrepancies
 Proper medication dispensing
/documentation/provider ordering (many
facilities beginning to utilize nurses in nonclinical roles to conduct record reviews)
OIG reports…”drug thefts…diverted controlled
substance and record altering…stealing pain
medication…”
Not Fixed but Improved
• Drugs held for Destruction
• Follow-up on deficiencies noted in Annual Police
or other reviews
• Proper ordering and receiving of controlled
substances by Pharmacy
• Methadone Clinic Oversight
• Drills for the movement of emergency Pharmacy
Caches
Item
JC
SOARS OIG CAP
(64 visits) (49 visits) (36 visits)
NPSG
Med Recon
53%
48%
17%
6%
94%
80%
CS Mgmt/Insp
Med
Mgmt/Sec
Med Sec
24/7 Refrig
Dating
8%
91%
17%
80%
98%
67%
22%
14%
11%
6%
3%
82%
61%
54%
14
Item
JC
SOARS OIG CAP
(64 visits) (49 visits) (36 visits)
Outdates
12%
3%
35%
Proper
31%
6%
Dispensing*
*New specific monitor in SOARS starting in
10/07
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SOARS Program Goals
• Standardization of visits (2 – FT Leaders)
• Increase involvement of VISNs and Program
Offices
• Improve skills of consultants and leaders
(training videos)
• Stay Ahead…..be proactive vs. reactive
• Promote “Continuous Readiness”!
Questions?
THANKS to our SOARS Consultants!
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Ron Boneberg
Sharon Castle
Roy Coakley
Maria Favale
Mario Franchi
David Gray
Barbara Ko
Randy Koontz
John Lowe
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Ron Lovly
Pat Minard
Sampath Narayana
Eric Richards
Bernadette Brown
Michelle Shank
Mark Slagle
Fred Soetje
Mick Weiss