Transcript March 11, 2009 Agenda and Master Presentation

Jayne Sheehan
Diane Gilworth
TJC Ambulatory Monthly Meeting
March 11, 2009
Agenda
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11:00-11:30 – Jayne Sheehan,
– TJC mock survey overview- celebrating our
success and learning from the opportunities
11:30-12:15
– TJC specifics – Success Opportunities for
Improvement
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Yolanda Millman-Richard
Janet Lewis
Sheilah Janus
Kerry Brown
12:15-12:30 Bill Pyne
– Updates on Ambulatory code cart exchange
Vulnerabilities: Areas identified by Mock Survey
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Patient Rights
– Patient and/or Family Involved in Decisions
– Health Care Proxy
 Identifying /Involving in Care
– Informed Consent
Provision of Care
– Patient Education
 Assessing Learning Needs
 Evaluating Comprehension
– Pain Assessment/Reassessment **
– Restraints
 Timely Orders
 Ongoing Assessment
National Patient Safety Goals
– 2 Patient Identifiers
 Administering Medications
 Collecting Blood
 Labeling Containers In Front of Patient
– Write Down/Read Back
 Recording Calls to Floors/Units
– Hand Offs – up to date and pertinent
information with opportunity to ask questions
 To/From Procedure and Test Areas
 Intra-Hospital Transfers
– Medication Labeling
 Transferring from original container
 Detailed information on label
– Medication Reconciliation **
 Intra-hospital Transfers
 Outside Providers
 Patients
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National Patient Safety Goals (Cont.)
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Anticoagulation Therapy
 Process to implement an enterprise-wide
Anticoag Therapy Program
Universal Protocol
 Operative / Procedural Area/ Bedside
 Verification of Side/Site/Procedure
 Marking of Site
 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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Special Thanks to :
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“Early Risers” (Kim/Kirsten)
Public Safety
Ambassadors
Admissions Facilitator
Service Response
Food Services
Service Response
Telecommunications
Information Systems
Communications
Human Resources
TJC Facilitators
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Escorts to the “Surveyors”
Staff from the following areas:
– ED
– CC6A
– Perioperative Services
– Digestive Disease Center
– Farr 2
– Interventional Radiology
– Pain Clinic
– Chest Disease Center
– Stoneman 6
– Labor/Delivery
– Feldberg 6
– Deaconess 4
Assessing The
Notification/Logistics Plans
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Paging for Assembly
– Senior Leaders Greet Survey Team at 9am
Individual Communication Networks Activated
– Patient Care Services
– Ambulatory /ED Services
Meeting/Work Rooms Secured
TJC ‘Communication Center’ Operationalized
– Community Wide Email /Greeting Announcement
– Ongoing Updates re: Focus and Findings via the
TJC Public Calendar
Assessing with ‘Fresh Eyes’
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Visits to Interventional Procedure Areas
 GI, Interventional Radiology, CDC, Pain
Clinic
Inpatient/ED Patient Tracer
Perioperative Patient Tracer
OB Patient Tracer
Ambulatory Clinic Patient Tracer
Medical Record Documentation
HR Record Reviews
Where Are We After the Past
2 Days?
Internal
State of
Disaster
Much Work to be Done
Systems/Processes
Good Program,
“tweaking” needed
Best in
Class
The Themes of Findings
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Policy Related
– Complex: Opportunity to weed and focus on standards before setting
the bar toward best practice
– Multiple Source Documents: Opportunity to Consolidate
– Staff Awareness was inconsistent
Lack of Specificity re: Accountability
– Seen in Med Rec Process (Inpatient)
– Assessment of Patients
Documentation Gaps/Complexity
– Omitted / Disjointed Content
– Multiple Source Documents for same subject
– Difficult to Navigate
– Doesn’t always reflect care processes
– Forms don’t prompt for process steps
Inconsistency with ‘Universal Protocol’
– Varying approaches, tools and checklists in OR, OB, Procedure Areas
The Particulars……
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Documentation
– Flow of Content
 (Assessment  Problem List  Care Plan  Goals)
– Completion
 Post Procedure Documentation
 Timing/Dating/Authentication
 Consent for Procedure/Intervention
 Patient Education
– Audit Processes
 what is looked at/how are results shared and used for
PI
Medication Reconciliation (Inpatient)
Restraints = Immobilization in the ICUs
The Particulars……
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Medication Management
– Emergency Medication
Storage/Availability/Surveillance/Disposal
– Staff Education re: Look Alike/Sound Alike and High Risk
Meds
Labeling
– Blood Draw Labeling in presence of patient
– Specimen Labeling
– Medication Syringe Labeling process
Universal Protocol
Critical Tests/Critical Result Reporting
– Staff Awareness of Process
– Measures of Success - 12months Order Result
Next Steps
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Vetting through the Clinical Operations Group for
– Policy Changes
– Process Improvements
– Development of Resources/Supports
Work Plans and Actions will be defined over the
course of the next few months
TJC Specifics
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Celebrating our success and learning
from our opportunities
– Yolanda Milliman-Richard
– Janet Lewis,
– Sheliah Janus
– Kerry Brown
Mock Survey Review
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Focus of the survey in your area
– what did the surveyor ask, any surprises, any area in which you
felt unprepared?
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Did the sweep documents help
– are there any additional things we should be doing to help your
staff prepare/help you?
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Nursing/MD response to the surveyor
– (in all cases the staff were superb and were able to really
articulate the care processes)- can we improve this?
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Suggested areas for improvement
– did the survey find anything that surprised you?
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What would you change
– as a result of the survey
Jayne Sheehan
Diane Gilworth
Thank You
March 11, 2009