April 14, 2010

Ambulatory Joint Commission

AgendaUpdates on:

Health Care Proxy Presented by: Stephen O’Neill

Ambulatory Policies and ProceduresPresented by: Beatrice Ford

Mock Surveys on ambulatory units Presented by: Sandra Hewitt

Chart AuditsPresented by: Sandra Hewitt/Lynne Brophy

Waiting Room Patient Information Posting Standards Presented by: Sandra Hewitt

Review of CMS DocumentPresented by: Sandra Hewitt

Advance DirectivesHealth Care Proxies

What? Who? Where?

Steve O’Neill, LICSW, BCD, JDSocial Work Manager for Psychiatry, Primary Care

and Infectious DiseaseAssociate Director, Ethics Support Service

Division of Medical Ethics, HMS

What is New?

New HCP Form to go with Q/A Form

On-Line Access via BIDMC Web for our Patients and their Significant Others

Spanish, Russian, Portuguese and Chinese Translations available now. More to come.

Use old stock first before going to new ones.

AD? HCP?

Last night, my wife and I were sitting in the living room and I said to her,

"I never want to live in a vegetative state, dependent on some machine and fluids from a bottle. If that ever happens, just pull the Plug."

She got up, unplugged the TV, and then threw out my beer. ……………......

WHO….does what, and where? CCC Registration field on AD’s………..same OMR Face Sheet……..Health Care Proxy

field- to be done by Clinicians and/or some Non-clinician who have access

Health Care Proxy forms……..send to Medical Records with patient’s unit number

Questions………..refer patient/other to hard copy or BIDMC web HCP + Q/A……..or Social Work, Pastoral Care, or Ethics Support Service

Additional Questions

Training: ALL staff……………….

--On-Site

--Ethics Liaison Program

--HMS

Ambulatory P&P: Refrigerator & Freezer Temperatures Guideline Revision

Two key changes:- Freezer temperature has been changed to comply with both

the Pharmacy and Pathology refrigerator and freezer temperature guidelines.

The acceptable range for refrigerator temperatures is between 2–8 degrees C or 36 to 46 degrees F unless otherwise noted on the refrigerator.

The acceptable range for freezer temperature is between – 18 degrees C or colder or –4 degrees F or colder unless otherwise noted on the freezer.

- Links have been added to both the Pharmacy and the Department of Pathology’s policies for reference.

Please be sure you are maintaining your refrigerator and freezer temperature log.

The updated guideline will soon be available in the Ambulatory Services Manual on the portal.

Mock Surveys Two different mock surveys at this time:

o Ambulatory Mock Survey Team is going to units to ask staff questions.

o These surveys will continue through the end of April.o Staff are doing well. Managers are getting feedback.o Please check your wall mounted Cal-stats as outdated ones

have been found.o Greeley consultant has been engaged to perform an

unannounced assessment.o This survey started yesterday.o We will have a punch list of actions to bring us into a better

state of readiness for an actual survey.o Here are some initial findings.

Some feedback – Procedural Units A surveyor will want to see the processing of a patient from the

beginning to end. Have staff able to articulate the elements of a time out; how and

when it is performed. Be able to provide to a surveyor:

- the consent form

- pre-procedure assessment

- documentation of pre- and post-procedure vitals

- post-procedure note Staff should be able to articulate a standard practice and not

respond with how a particular provider wants things done for his/her patients. There needs to be a standard of care and all patients need to receive the same level of care at BIDMC. There is always room to surpass our standard, but we must ensure that all patients receive our standard.

Some feedback Microscopes: need competencies for providers who

use them. Doors with signage saying they need to be closed, be

sure they are closed. Equipment cleaning between uses. All equipment

needs to be cleaned even if kept in a doctor’s exam room.

Health care proxies: it is not clear when looking at a patient’s record in OMR when “no” is selected if that means no healthcare proxy or patient hasn’t been asked.

Be ready to identify those elements of a problem list.

Some feedback Credentials for your providers: be able to access

them on your units. Call lights: test response time. Ensure that the light

is properly identified for location; not room 222, but more specific if you can, like the function of the room, “back waiting area.”

Multi-dose vials are good for 28 days not 30. Labeling: No more than one medication or solution is

labeled at one time. Be sure staff can explain this method when asked.

Looking into whether some vials are single patient or single day use (~ normal saline and topical anesthetics).

Chart Audit Results

Actions on Chart Audit ResultsIssue Action

Time out documented New calculations

Problem list/note includes known op & invasive procedures

Subgroup of Web OMR Advisory Committee is completing work on the problem list; let’s focus on whether an entry from the audit has been made if appropriate.

Consent form is timed(location of consent forms)

New forms available in English at Office Depot; other languages later this week.

Updated medication list given to pt at end of visit

OMR enhancement: Option in OMR to document that the pt declined copy of updated med list; reflected in OMRA option in CCC so you can see when auditing.

Time-out Recalculated

Name: Aggregate Data Audit Date: November 17, 2010

Criterion

% ComplianceGoal/ Improvement

for next Quarter Issues/Concerns

Planned Interventions/Action

Plans75% or less

Time out documented

94.20%Time out required before start of an invasive procedure

Address methods for improvement at chart audit subgroup

Impact of understanding the difference between a “NO” response and N/A was compliance in the 70’s vs in the 90’s.

New Chart Audit

We are going back to February 22nd for the next chart audit.

This audit will serve as a baseline, except in the case of “time outs,” which will be responded to with the new understanding.

The audit after this one will then show impact of the actions we have taken on:

- Consent form timed

- Updated medication list

Waiting Room Patient Information Posting Standards

Goals:

Ensure that we meet regulatory standards by providing all necessary information in waiting rooms.

Establish standard language and appearance of information.

Create a less confusing presentation for patients.

Criteria: Required Information

Healthcare Proxy Transparency Info on Delays*

Patient Rights Infection Control Signage*

Medicare Rights Co-pay Signage

Notice of privacy Practices Booklets

Hand-washing Notice*

Wait Sign (if waiting >15 minutes)

TJC Brochure on physician visits

Physician Visit Brochures

Speak Up™ brochures are available in English and Spanish at:

http://www.jointcommission.org/PatientSafety/SpeakUp/

Criteria: Presentation Information easy to find

Presented by subject matter

Clear and prominent signage indicating where to find the information

Cell phone signage tasteful and in multiple languages

Standard TV instructions

Good display rack design

Labeling of sections within display rack

Current specialty specific information

Posting kept to a reasonable limit and in proper frame/laminate sleeve

Informal Survey

Transparency information about delays was outdated on every unit visited.

Specialty specific information was old. Over time we will standardize signage such as wait

time, hand hygiene, telephone use, etc. The “Go ahead and ask” signage is an inpatient

initiative and is not best for our outpatient areas. Display racks needed attention. We’d like to recommend that you use your CoC to

“own” your patient information postings.

TJC Items

"What MDs Need to Know for TJC”, 2010 version is now available.

For past Right Way Every Day fact sheetshttp://

home.caregroup.org/templatesnew/links/cat_out.asp?pageid=8754

- I’ll send the links for both in an e-mail- Excellent information to share with staff

http://home.caregroup.org/templatesnew/departments/BID/JCAHO_Survey/uploaded_documents/What%20MDs%20Need%20to%20Know%20Trifold.pdf

Record Retention

ADM-26: Attachment BRecord Retention & Disposition ScheduleA. Patient CareA1. Patient Care RecordsA2. Clinical Laboratory Services: RecordsA3. Clinical Laboratory Services: Specimens & SamplesA4. Clinical TrialsA5. HIPAA Privacy & Security ComplianceB. Human ResourcesB1. Personnel FilesB2. Other HR FilesC. E-mail

Record Retention (Lab)

Requirement for retaining quality control logs- worksheets, - QC,- QA, - Proficiency Testing- Preventive Maintenance records

State supersedes CLIA and CAP at 4 years.

Items from CMS

Be sure your CMS books are up-to-date- Meeting minutes- Job descriptions- Competencies

Be sure that we have all start dates for NPs so that you will be in alignment with our new policy for their performance evaluations

Lynne Updates Computer privacy screens Sweep cards

- They are available and HERE today!- #12 Should read: “Sharps containers no more than ¾

filled.” Emergency Response Quick Reference (aka flipchart). 

Each flipchart is $19.75 & you will be invoiced, no PO is needed to place the order.  http://www.mmpbrookline.com/customer_portal/

Login: BIDMC

Password: flipcharts1