Jayne SheehanDiane Gilworth

TJC Ambulatory Monthly TJC Ambulatory Monthly MeetingMeeting

March 11, 2009March 11, 2009

AgendaAgenda

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 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 Vulnerabilities: Areas identified by Mock SurveySurvey

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

National Patient Safety Goals (Cont.)National Patient Safety Goals (Cont.) Anticoagulation TherapyAnticoagulation Therapy

Process to implement an enterprise-Process to implement an enterprise-wide Anticoag Therapy Programwide Anticoag Therapy Program

Universal ProtocolUniversal Protocol Operative / Procedural Area/ BedsideOperative / Procedural Area/ Bedside Verification of Side/Site/ProcedureVerification of Side/Site/Procedure Marking of SiteMarking of Site Time Out Immediately Before Time Out Immediately Before

ProcedureProcedure Medical Staff StandardsMedical Staff Standards

Bylaws RelatedBylaws Related Timeliness of ReappointmentsTimeliness of Reappointments

Human Resources Human Resources Decentralized Monitoring of CompetenciesDecentralized Monitoring of Competencies Performance EvaluationsPerformance Evaluations Staffing Effectiveness Exercise 2008-09Staffing Effectiveness Exercise 2008-09

Infection ControlInfection Control Use of PPEUse of PPE PPD ScreeningPPD Screening

Information Management (Medical Records Information Management (Medical Records Related)Related)

Aggregate Reports of Compliance Aggregate Reports of Compliance Streaming through HIM CommitteeStreaming through HIM Committee

Performance ImprovementPerformance Improvement Collecting/Analyzing/Using Data for Collecting/Analyzing/Using Data for

ImprovementImprovement Staff Knowledge of PrioritiesStaff Knowledge of Priorities

Special Thanks to : Special Thanks to :

“Early Risers” (Kim/Kirsten) Public Safety Ambassadors Admissions Facilitator Service Response Food Services Service Response Telecommunications Information Systems Communications Human Resources TJC Facilitators

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 Assessing The Notification/Logistics PlansNotification/Logistics Plans

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 Assessing with ‘Fresh Eyes’Eyes’

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 Where Are We After the Past 2 Days? 2 Days?

Best in Class

Internal State of Disaster

Good Program,

“tweaking” needed

Much Work to be Done Systems/Processes

The Themes of Findings The Themes of Findings 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……The Particulars……

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……The Particulars……

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 Next Steps

Vetting through the Clinical Operations Group Vetting through the Clinical Operations Group for for – Policy ChangesPolicy Changes– Process ImprovementsProcess Improvements– Development of Resources/SupportsDevelopment of Resources/Supports

Work Plans and Actions will be defined over Work Plans and Actions will be defined over the course of the next few monthsthe course of the next few months

TJC SpecificsTJC Specifics

Celebrating our success and Celebrating our success and learning from our opportunitieslearning from our opportunities– Yolanda Milliman-RichardYolanda Milliman-Richard– Janet Lewis, Janet Lewis, – Sheliah JanusSheliah Janus– Kerry BrownKerry Brown

Mock Survey ReviewMock Survey Review

Focus of the survey in your areaFocus of the survey in your area– what did the surveyor ask, any surprises, any area in what did the surveyor ask, any surprises, any area in

which you felt unprepared? which you felt unprepared? Did the sweep documents helpDid the sweep documents help

– are there any additional things we should be doing to are there any additional things we should be doing to help your staff prepare/help you? help your staff prepare/help you?

Nursing/MD responseNursing/MD response to the surveyor to the surveyor – ((in all cases the staff were superb and were able to in all cases the staff were superb and were able to

really articulate the care processesreally articulate the care processes)- can we improve )- can we improve this? this?

Suggested areas for improvementSuggested areas for improvement– did the survey find anything that surprised you?  did the survey find anything that surprised you? 

What would you changeWhat would you change– as a result of the survey as a result of the survey

Jayne SheehanJayne SheehanDiane GilworthDiane Gilworth

Thank YouThank You

March 11, 2009March 11, 2009