Transcript January 14, 2009 Agenda and Master Presentation

Jayne Sheehan
Diane Gilworth
January 14, 2009
Agenda
11:-00-11:15
Vision and future of Joint Commission Readiness Program- Jayne Sheehan
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Unscheduled visit
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JC Calendar in Outlook
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NSPG cards distributed
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FAQ to staff
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Scope of Service-due on shared drive
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CQI / Silverman Posters
11:15-11:45
Ambulatory Joint Commission Portal Page - Lynne Brophy/Diane Gilworth
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Tool box review
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Discussion/feedback
11:45-12:15
Safety - Meg Femino
12:15-12:30
Chart audits - 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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Transferring from original container
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Detailed information on label
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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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An Unscheduled JC Visit
Readiness Preparation
An Unscheduled JC Visit
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BIDMC will be notified no later than 7:30am that the Joint
Commission is scheduled to visit.
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Facilitators will l be notified via page shortly there after with a
message that reads: "TJC has arrived, begin preparations for
survey"
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Facilitators will be begin notification process to your managers
and staff and also begin any preparations for the survey.
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During the survey, you will receive on-going pages with
updates regarding best guesses on locations of the surveyors
and any other information that is deemed relevant.
Check your TJC calendar for updates
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TJC Calendar of events
Directions to Add TJC Survey Calendar to Favorites:
For Easy Viewing
1. Go to Outlook Calendar
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Locate Folder Tab
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On left hand side at the bottom
If it is not there:
Select “GO” at the top menu
Scroll to folders (A new Screen will pop up)
3. Click the + sign next to Public Folders
4. Click the + sign All Public Folders
5. Scroll until TJC Survey Calendar Icon- Click on the Icon
6. Select OK
7. The Calendar should now pop up on your screen
8. On left hand side of the calendar the folders list should still appear
9. Under Public Folders: locate TJC Survey Calendar
10. Right Click
11. Select Add to favorites
12. Select Add in pop up window
13. Go back to your own calendar- TJC Survey Calendar should be listed
14. Check box for side by side viewing
*If the TJC Survey Calendar tab does not appear- repeat steps 9-14*
FAQ to share with
your staff
Joint Commission Questions for staff discussion
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Share the
FAQ with
your staff
What is “code red”?
Code phrase for a fire emergency.
Why do corridors need to be clear of equipment and clutter?
Corridor storage creates a fire hazard, an evacuation hazard
and a trip/fall hazard.
How do you access the inventory of patient education materials on the
portal?
Go to Patient Education; click on the BIDMC fact sheets and instructions.
Name several protective devices or equipment available for use to prevent
accidental exposure to blood born pathogens.
Gowns, gloves, goggles, face shields, safety needles and sharps, sharps
containers, biohazard bags.
What is the single most important measure to prevent the transmission of
organisms?
Hand hygiene
Who is responsible for performance improvement?
Everyone
What do you do if you identify an area for performance improvement?
Discuss it with your manager.
Where would you find and file an incident report for patient/visit incidents?
In CCC, under “utility” option
Share the
emergency
plan with
your staff
REMINDERS
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Scope of Practice – due on Shared Drive

CQI / Silverman Institute Posters
Tool Box
Lynne Brophy
Diane Gilworth
Safety
Meg Femino
Chart Audits
Diane Gilworth
Current State Chart Audits
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.
Chart Audits- Best
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Problem list is updated and reviewed (within last 12 months)
Allergies are reviewed and updated (within last 12 months)
Medication list is up to date
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Summary list is present- by 3rd visit
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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.
Consent forms are present as applicable for invasive procedures. general
consent includes a discussion of:
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(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)
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,
when indicated any limitations on the confidentiality of information learned about the
patient) this should be standard in all consent forms
H & P is present
Chart Audits- Best
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Pain assessment is documented as appropriate
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Pain is reassessed at subsequent visits.
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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)
Advanced directive is present
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(would recommend standardizing pain assessment tools and
if possible creating space within web OMR for direct
documentation)
new field in Web OMR (documentation indicates whether the
patient has signed an advance directive)
There are additional standards specific to
operative/high risk procedures which may pertain to
derm surgery and endoscopy and others where procedures
and or conscious sedation is being used.
Chart Audits- Best
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Emergency Department patients- chart contains the following
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Time and means of arrival
Whether patient left against medical advice
Conclusions of termination of treatment-final disposition, condition
and instructions for follow up
Copy of record is available to practitioner or medical organization
providing follow-up care, treatment and services.
Hospital communicates appropriate information to any organization
or provider
The information shared contains- reason for transfer or discharge,
patients physical and psychological status, summary or care,
treatment and services provided
Community resources or referrals provided to the patient.
Thank you
Jayne Sheehan