Transcript JACHO 2008 - Harvard University

Ambulatory
Joint Commission
October 14, 2009
Agenda
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Chart Audit Updates
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Chart Audit Action Plan Grid
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PACE Audit Updates
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Announcements
Announcements:
o
Employee Safety Fair, Oct. 22nd - Kelly Orlando
o
BIDMC Bowl-a-Rama Hand Hygiene Incentive
Program; E&W cafeterias 12:00-1:30 (Oct. 21st22nd)
o
Reminder:
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Please write up your quality improvement initiatives
so that you’ll have them for the Silverman
Symposium.
Goals of Chart Audit

Use real time data to drive positive change;
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Provide meaningful data at the unit level and
rolled up for all of Ambulatory;
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Ensure regulatory compliance;
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Resolve any Joint Commission vulnerabilities;
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Meet Medical Center requirements.
What will stay the same….
 Number of charts reviewed is dependent on
the number of visits the day of the chart audit:

Clinics w/<30 visits/day
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Clinics w/31-100 visits/day = 10 charts

Clinics w/>100 visits/day
= 7 charts
= 20 charts
 It is always optional if for any reason a clinic
wants to review more than the required number
of charts.
What’s new with the chart
audit tool?
 A lot. Thank you for your meaningful input!
We’ve put it to good use and we think we have a
better tool.
 We’ve divided the tool into 4 sections:
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Patient demographics
Visit Information
Medical Record
Medication Reconciliation
 Provided clarifying explanations embedded in the
tool.
TJC: Elements of Performance for a
Summary List
1.
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3.
4.
A summary list is initiated for the patient by his or her third visit.
The patient’s summary list contains the following information:

Any significant medical diagnoses & conditions.

Any significant operative & invasive procedures

Any adverse or allergic drug reactions

Any current medications, over-the-counter medications &
herbal preparations
The patient’s summary list is updated whenever there is a
change in diagnoses, medications or allergies to medications,
and whenever a procedure is performed.
The summary list is readily available to practitioners who need
access to the information of patients who receive continuing
ambulatory care services in order to provide care, treatment,
and services.
Revised PACE Audits
 The PACE audit workgroup has revised the audit
form for ease of use.
 All questions are listed in the affirmative. This makes
it easier for us to compile your data in Performance
Manager.
 The sections to the assessment remain the same:
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Infection Control
Fire & Life Safety
Medication Management & Pharmacy
 We have a new methodology for applying to PACE
Audits.
The Self-Assessment Methodology
 You will conduct self-assessments monthly.
 Each month will focus on a different section of the audit
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tool, i.e. Medication Management.
Each quarter you will complete the whole assessment,
allowing time for correcting any items out of compliance.
For any item that is out of compliance, documentation of
corrective action, anticipated completion date and actual
completion date are required in the comments section.
You will receive a document providing instructions and
completion dates for entering data (by the 3rd week of
each month).
You will receive your data in the Ambulatory Joint
Commission folder.
The subgroup will report out aggregate data each month
at these meetings.
“ Outside Eyes” – Peer Review
 Outside Eyes is a LEAN term for using someone with
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some distance from the situation to help problem
solve.
Peer reviews should be treated as a “real survey.”
Three times per year, in Jan, May, and Sept, your unit
will be assessed by a peer from another unit.
Peer means a manager and a staff member from
each unit.
Using a staff member helps to train others in this
audit process.
The subgroup has yet to determine the pairing of
units. More on that next month!
Everyday 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.
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This consult can serve as “outside eyes” for your
survey readiness; again very much in the spirit of
LEAN.
E2 – Everybody/Every day