Transcript Jayne Sheehan Diane Gilworth

Jayne Sheehan
Diane Gilworth
TJC and CMS Update
Ambulatory Monthly Meeting
April 8, 2009
Agenda
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11:00-11:30 – Jayne Sheehan
– CMS update
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Binder Documentation
Process/Structure
Visit outline
JC updates
Chart audits
Competencies
License renewal process
PA and NP competencies
Updates- tool box and PACE
CMS-binder
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482.54(a) Organization
Organization Chart (for your department)
Scope of Practice
Evacuation Plan
Process Improvement/Quality Improvement Plans
Meeting Minutes (i.e., staff meetings, Practice Committee, QI Committee, etc.)
Departmental Guidelines (specific to your area)
482.54(b) Personnel
Director of Department - Job Description
Departmental Job Descriptions (include all non-physician job descriptions in your
unit/department for each role, including Practice Manager and on down)
RN Licensing - See Ambulatory Services Administrative Notebook
NP Practice Guidelines and Core Competencies - See Ambulatory Services Administrative
Notebook
Certifications required for your department - (list of certifications that your staff and level
of staff need to have-include all certifications specific to your unit or positions, i.e.,
chemo certification, Trauma, BLS, ALCS, etc.)
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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No Licensee is allowed to work until their
license is renewed and verified by the
Manager or an ACS/OneStaff Specialist
Any Questions??
Review of Policy PM-12
Employee Licensure Verification
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It is the employee’s responsibility
– to keep his/her license, accreditation, certification and/or
registration up to date.
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Failure of an employee to maintain current
required documentation or failure to provide the
department/division with the necessary
documentation will be grounds for dismissal.
The monitoring and maintenance of current
licenses, accreditation, certifications, and/or
registration should be maintained in the
employee’s departmental file.
RN/NP License Renewal Process
Ambulatory Process
Centralized
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Ambulatory Cost Centers (Departments)
– entered into OneStaff for License Tracking Purposes only.
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New Hire is entered into OneStaff’s Personnel Module
License tracking is entirely dependent:
– upon the manager notifying the OneStaff/HR Specialist of each
New Hire and terminations
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A list of Ambulatory Departments –
– handout for your updates
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Process:
– Copy of the License Renewal is printed from the Nursing Board’s
website- before the license expirse
– License Renewal information is entered into OneStaff and filed
centrally by department name.
License Verification
Ambulatory Directors updates
•New hires
•Termination
Primary Source
Verification Process
One Staff
HR
Stand Alone Module
For Licenses
Sheila Goggin
For discussion
DEA/DPH
ACLS/BLS
Monthly report to all
directors and
managers
Expired License
RN/NP/LPN Added to One
Staff Personnel Module
November 30th, 2008
December Licenses Not Yet Renewed
RN
License
Expiration Date
License
Number
Director/Manager
Ricci,Stephanie A
12/10/2008
265229
Bourie,T.
Sansone,Sarah E
12/17/2008
260694
Bourie,T.
12/8/2008
256990
Campbell, J.
Ninobla,Annalyn S
12/17/2008
253646
Campbell, J.
Robbins,Kristin W
12/29/2008
267463
Campbell, J.
Cahill,Allissa
12/12/2008
271986
Clarke,D.
Sleininger,Danielle M
License Verification
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Sheila Goggin is sending out information for
the RN’s and NP’s are you getting the
information? (licenses are renewed on even year)
Sheila is printing out the license and
keeping a hard copy for primary source
verification
Should we Add
– Add in BLS,ACLS, DEA and DPH to central
monitoring
Review of Policy PM-12
Employee Licensure Verification
Decentralized Process
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Disciplines within the Medical Center that must be primary
source verified
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Dietitians/nutritionists
Audiologists/audiologist assistants
Speech pathologists/assistants
Optometrist
Pharmacist/Pharm tech
NP/RN, Nurse Midwife, nurse anesthetist, CNS,
OT/PT
Athletic trainer
Mental Health Counselor
Educational Psychologists
Rehabilitation Counselor
Respiratory Therapist
Perfusionists
– Questions- contact HR directly
Remember
Primary Source Verification
Decentralized Process
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The department director is responsible
for ensuring that
– primary source verification of the license is
performed upon hire and at the time of
renewal
– Primary source verification provides evidence
and written validation that the license is verified
as current and is maintained.
Primary Source Verification
Decentralized
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If the license has been renewed,
– print a copy of this license from the website on the day it
is viewed (see website examples in the policy)
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If the license has not yet been renewed by
the expiration date,
– the person performing the review must contact the
licensing board directly to ascertain the status of the
providers license/certification and must document using
the Verbal Verification (see policy)
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Upon renewal,
– the posted renewal on the website must then be printed
and filed in the personnel record, along with the verbal
verification form
No Licensee is allowed to work until their
license is renewed and verified by the
Manager or /ACS/OneStaff Specialist
Any Questions??
Chart Audit Process 2009 and beyond
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 Audit- Next Steps
4 chart Audits in Development*
*Primary Care
*Ambulatory Procedure Based Audits
*Surgical Specialty Practices
*Medical Specialty Practices
All Other Practices
Emergency Room
Core Elements
Unit based- specific elements
Chart Audit- Next Steps
Specialty Based Chart Audits
Medical
Primary
Care
Specialty
Practices
Surgical
Ambulatory
Specialty Emergency
Procedure
Based Audits practices Room
•Specialty based
Work groups to
evaluate the
content of chart
audits
•Editor of all
templates-TBD
Data reported to specialty based directors on monthly basis
Data Evaluated and if changes are necessary-work
with specialty based group to address
On-going work-updates
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Competencies– list of all competencies
– Email PA/NP competencies, RX and MD review
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PACE updates– drop down menu similar to chart audits to
facilitate better data management-getting results
back to you
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Tool Box– patient rights and provision of care
Competencies
NP and PA Practice
NP’s and PA’s –
collaborative practice
agreement (guidelines)
Supervising MD
Supervising and evaluating
Guidelines must be reviewed
and confirmed as in effect on an
Annual basis
Office of Professional Staff
AffairsSends out a document to
Supervising MD’s on an annual
basis
Prescription Review-currently
no standard way of doing this
Documentation of review with supervising
physician [244 CMR 4.22(3)(a)]
Schedule II drug (narcotics)- only after
consolation with MD- documented review
in 96 hours.
•Regulations do not specify number of rx
to be review - usually a % every 90 days----- BIDMC proposed 10 per quarter
•Regulations do specify that needs to be
face to face with subsequent
documentation
•HCA working on standard process
HCA- DRAFT for Standardization of
Prescription RX
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Standards:
Review occurs at the end of each calendar quarter (i.e. March 31st,
June 30th, September 30th, December 31st)
Maximum number is 10 charts or based on patient visit volume
Documentation of review with supervising physician [244 CMR
4.22(3)(a)]
– Face sheet defines number of initial prescriptions or changes in
medication [105 CMR 700.003 (4)]
– Attach note/encounter that resulted in prescription
– Submit packet of face sheet and notes to supervising physician to be
reviewed independently with follow up discussion with in 5-10 days from
submission
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Face sheet of the prescription review for the previous four quarters
will be submitted with the NPs yearly evaluation.
Initial Schedule II prescriptions will be reviewed within 96 hours,
either by verbal communication, forward progress note or chart
review
HCA- DRAFT-FACE Sheet
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NURSE PRACTITIONER PRESCRIPTION AUDIT
NURSE PRACTITIONER:
SUPERVISING PHYSICIAN:
REVIEW PERIOD:
Performance
[ ] January – March, 2009
manager
[ ] April – June, 2009
[ ] July – September, 2009
[ ] October – December, 2009
NUMBER OF RECORDS REVIEWED: ______________________________________
NUMBER OF INITIAL PRESCRIPTIONS: ___________________________________
NUMBER OF DOSAGE CHANGES: ________________________________________
PROBLEMS/ ISSUES IDENTIFIED BY SUPERVISING MD: ___________________
FEEDBACK/ EVALUATION: _____________________________________________
Signatures: ____________________________________, NP
Date: _____________
____________________________________, MD
Date: _____________
*** 243 CMR- include a defined mechanism to monitor prescribing practices
including documentation of review by the supervising MD at least every 3 months
Responsibilities
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Hiring department ensures that written
collaborative agreements- current
(resources, practice etc.)
Hiring department is responsible for annual
review
Hiring department is responsible for
documenting primary source license
verification- which includes advanced
practice certification. (centralized this
process)
References:
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Collaborative Practice Guidelines
State of MASS reg- 243 CMR (Board of
Regulation of Medicine)
BIDMC Credentialing and Evaluation Process
for Advance Practice Nurses- OPSA-22
HCA- Advanced Practice Forum
– Leah Mckinnon-Howe NP
– Barbara Rosato NP
Location of all Medical
Records- for your information
Thank you
TJC and CMS Update
Ambulatory Monthly Meeting
April 8, 2009