Presented by:Jayne SheehanSandra HewittLouise Mackisack

Ambulatory Joint Commission Meeting July 15, 2009

Agenda Overview of the Ambulatory Joint Commission

structure Reorganization of work groups

Recent Accomplishments/Actions since CMS Work of CMS Debriefing Group

Demo of TJC Folder Policies and Procedures 101 What’s New with Competencies The New and Improved Chart Audit Revisions to PACE Audits Resumption of Mock Joint Commission Surveys

Recent AccomplishmentsAs a result of our mock TJC and CMS surveys we have made great strides! We now have:

Reorganization of the TJC Team, including the addition of David Clough to Lead one of our work groups.

The Ambulatory Joint Commission Folder on the S:/drive

S:\Ambulatory Joint Commission

CMS Debriefing Document also on the S:/drive

S:\Ambulatory Joint Commission\CMS - AMBULATORY AND EMERGENCY SERVICES MASTER DOCUMENT

An ad hoc CMS team that has worked to provide resolution to potential vulnerabilities;

Parts of today’s presentation have come from our work within the CMS document. The Leads for each area are identified to address any further questions.

New Work Group Organization

OPS Council

Policies,Procedures & Guidelines

Pace Audits/Mock Surveys

CQI Projects(not active yet)

Competencies

TJC Facilitators Group

TJC Ambulatory Directors

and Managers Group

Reorganization of Work Groups

Work Group Membership Policy, Procedures & Guidelines:

Beatrice Ford Lynne Brophy Chris Healey Sandra Hewitt Richard Johnston Menrika Louis Christine Lynch Dan Nadworny

Competencies: Louise Mackisack Brigitte Bowen-Benitich Lynne Brophy Holly Dowling Maureen Mamet Heather Wathey Annie Whatmough Jan Woodruff

PACE Audits/Mock Surveys: David Clough

Laura Allen Jo-Ann Barletta Emily Cherecwich Linda Dicenzo Sandra Hewitt Kelly Orlando Eileen Rose

CQI – Process Improvement

Ambulatory Joint Commission Folder (live demo)

We want you to use this folder where you can find:

• Generic Job Descriptionso Unit specific JDs need to be developed and put in the folder as well.o Job description template in folder.

• Ambulatory Specific Guidelineso We are adding guidelines as we create them.

o These guidelines will be housed in this folder, until the Ambulatory Services Guidelines manual goes live on the PPGD site.

o Guideline Templates in folder – clinical area/department and administrative

• Medication Reconciliation Audit Results*• Chart Audits*• CMS Debriefing Document*• Scope of Service w/Org Charts• Generic MA Training Manual*• Staff Competencies Information*

Please notify Lynne when you make updates.

We’ll let you know when we make changes as well.

*More on these topics later

Ambulatory Policies, Procedures &Guidelines (Leads: B. Ford; L. Brophy; S. Hewitt)

Nomenclature for Organizational PPGDs

Medical Center Wide: o The BIDMC Policy Manual is the Source of Truth. o Ambulatory has very few specific policies and has

primarily Guidelines.

Interdepartmental: apply to more than one department, but are not Medical Center wide.

o Exs: we use lab, radiology, pharmacy manuals for PPGDs within ambulatory.

Intradepartmental: apply to one department only.

Areas of Concern Can’t find P&Ps:

• Training: working to include in Orientations• Cheat Sheet: available right on the portal• Ambulatory Services Guidelines: will house Ambulatory

modifications found within Who to Contact with Policy Questions *

• Sponsor/Requestor/Ambulatory Work Group How do you learn of New Policies?*

• Communication• On Portal

P&Ps not specific enough for ambulatory setting*

Resource Staff for Content Expertise in PPGD Development (ADM-01)

Name: Area of Expertise:• Ken Sands, MD, Sr. VP MD Licensing Board/Leadership• Patricia Folcarelli, RN, PhD, Director Patient Safety• Kathy Murray, Director Process Improvement/TJC• Kim Sulmonte, RN, Director Patient Care Services/PI• Gary Schweon, Director Environmental Health & Safety• Catherine Mahoney, Assoc. Counsel Legal Counsel• Anne Marie Jarvey, Director Accreditations/Facility Licensure• Frank Rosen, Specialist Regulatory/Medical Staff• Shawna Butler, Specialist Risk Management/Adverse

Events • Gerry Abrahamian, Director Medical Records Management• Judy Bieber, Director Human Resources/ER• Leon Goldman, Admin. Officer Business Conduct• Sharon Wright, MD, Director Infection Control• Rosemary Kennedy, Director Radiation Safety• Meg Femino, Director Emergency/Disaster

Preparation

Information on each PolicyBeth Israel Deaconess Medical Center BIDMC Manual

Title: Drug Sample Management Number: CP-11

Purpose: To describe how drug samples are managed within the medical center

Vice President Sponsor: Kenneth Sands, MD, MPH, Sr. Vice President, Health Care Quality and Director, Silverman Institute for Health Care Quality and Safety

Responsible Person: Francis P. Mitrano, RPh MS Title: Director of Pharmacy(sometimes listed as Requestor)

Approved By: Operations Council: 2/2/09 Eric Buehrens, Chief Operating Officer

P&T: 01/14/09 James Heffernan, MD David Feinbloom, MD P&T Co-Chairs, P&T CommitteeOriginal Date Approved: 10/01Revisions: 6/04, 11/05, 11/08 Next Review Date: 2/2012

Accessing P&Ps on the Portal

Conducting a Search on the Portal

You can view any policy or policy manual in two ways: You can view an entire manual by clicking on its title as listed

on the portal. Typing key words into the Search box and then clicking on the

manual as it is listed.

To conduct a PPGD search, type key words into the Search box which would be reasonable to assume would be contained in the policy.

If a search doesn’t return anything useful try shortening the search phrase.

Punctuation is generally ignored (so capitalization is irrelevant)

If you have any questions, contact Professional Staff Affairs Office at: 7-1917

Quick “How to” Conduct a Google Search(live demo)

How do I keep updated regarding changes to PPGDs?

Relevant PPGDs are reviewed at Departmental/ Division Meetings and/or e-mailed and documented that they have been shared with all staff. Ambulatory learns of them at Leadership

VPs, Directors and Managers communicate PPGD changes that impact your work.

This meeting is an important vehicle for communicating PPGD changes.

Also, as PPGDs are updated there is a website link on the General Portal that will have the monthly updates.

Who can help you with PPGDs?

Should you have questions with respect to interpretation, finding a policy, etc., contact a member of the Ambulatory work group.

Your questions help the work group to identify areas that may need guidelines for our use.

The work of the ambulatory group is to ensure updates and to develop ambulatory specific guidelines.

Ambulatory P&P Work Group has made it a point to be involved with Medical Center policy revisions and updates by being a part of the PPGD oversight committee.

Competencies How did we get to this?…regulatory plus pulse

check (literally) Two fold – Support Staff and NP/PA Training Manual developed for Medical

Assistants, Practice Assistants, Practice Representatives and Phlebotomists – Authored by Maureen Mamet, RN in partnership with Heather Wathey Practice Coordinator HCA

Standardized and placed on the shared drive Expectation: each area updates with specific

unit based skills

Competencies

The core competencies match to the job description

Training check list developed from the Training Manual materials – Maureen Mamet, RN, Jan Woodruff, RN, Brigitte Bowen-Benitich, Heather Wathey

Competencies Requirements with inclusion of the HR expectations developed and links added– Annie Whatmough, Holly Dowling, Lynne Brophy

Tracking document also developed

Competencies

Competencies Expectation:

All support staff in the MA, PA, PR and Phlebotomy positions will complete formal skills training and demonstrate they have completed/met all competency requirements

How do we get there? Skills Training

Jan Woodruff, RN and Heather Wathey from HCA will do the training for Ambulatory in the following manner:

Competencies

Train the Trainer: Nine departments with a RN and lead MA have sent

their representatives to a 4 hour training Eleven Departments are being scheduled for train the

trainer and 4 for MAs. 26 have not responded yet. The expectation is the representatives will train all their

staff by September “Oddments”:

These classes are for all the remaining Ambulatory MA, PA, PR and phlebotomy staff without department based trainers

Competencies

The next series of classes are scheduled for 2 Sessions each day – AM and PM:

Tuesday August 11 Wednesday August 12 Thursday August 13 (Lexington)

Tuesday August 18 Wednesday August 19 Thursday August 20

Competencies

Outstanding Issues to be resolved: Formalizing the requirements for temps

Competencies

Nurse Practitioners and Physicians Assistants APN Forum – Co-chairs: Jayne Sheehan, APN, Leah

McKinnon-Howe, APN, and Barbara Rosato, APN

Work completed: Practice Guidelines Competencies Supervising physician responsibilities Competency Requirement Checklist (with links) Prescription Audits

Competencies

Competencies

Outstanding Issue- to be resolved this month: Linking with credentialing Supervising physician and performance

evaluations loop Billing Standardization –inpatient and outpatient,

BIDMC and HMFP Standardized Performance Evaluation

Competencies

Clinical Nurses Competency Requirements Developed and on the

shared drive – S:\Ambulatory Joint Commission\STAFF

COMPETENCY INFORMATION Performance Evaluations – Signature required by a

Nurse Manager and in the absence of a nurse manager Jayne will co-sign.

BLS/ACLS – Sheila Goggin is tracking. HR notifies Sheila of the new hires and BLS/ACLS status. Job Descriptions will be updated requiring all CN have

BLS and if not within 60 days of hire

Competencies

Clinical Nurses and NP/PA License Tracking Sheila Goggin is keeping a centralized list Sheila’s list is dependant upon us notifying

her when we hire. OneStaff is not the trigger for this list.

Chart Audit (Leads: S. Hewitt/L. Brophy)

Not fully meeting the intent of chart audits; Conducted audits, didn’t see the results by

unit and/or aggregate for all of Ambulatory; Hard to make a plan of action; Unit specificity lacking; Two separate audits: chart and med

reconciliation.

Past Concerns:

Goals of Chart Audit Use data to drive positive change in real time;

Provide meaningful data for Ambulatory and allow unit specificity where needed;

Ensure regulatory compliance;

Meet Medical Center requirements.

What about Medication Reconciliation? Medication reconciliation auditing will be

integrated with chart auditing; Combined audits will be unannounced each

month; We will use the med reconciliation methodology

regarding number of charts reviewed, adjusted for a monthly process:

Clinics w/<30 visits/day = 7 charts

Clinics w/31-100 visits/day = 10 charts

Clinics w/>100 visits/day = 20 charts

New Chart Audit QuestionsStandardized Department name – Pick menu not free text

New Chart Audit Questions

New Chart Audit Questions

Performance Manager Download

Results will be downloaded from Performance Manager to Excel;

For the generic chart audit, we will tabulate results and graph them by: unit; and aggregate for ambulatory.

For those who want to have unit specific criteria: Lynne will work with you to load your criteria; You will be responsible for tabulating your unit specific

results; Lynne will train you to work with your data.

Department%

ComplianceIssues/

ConcernsPlanned

Interventions/Action Plan

Expected Date of

Completion

Feedback Provided

Y/N

Provider

Initials &

Date

Staff Responsible

Eye Unit 80% POC Wording needs to indicate that provider discussed and educated patient.

8/20/09 Y JA

8/20/09

K. Jordan

Eye Unit 90% Med Rec

List not updated

9/7/09 Y FB

8/20/09

K. Jordan

AMBUALTORY SERVICES CHART AUDIT ACTION PLAN GRIDDATE ______________

•Each unit will update Action Plan monthly and provide review quarterly.

•Utilize this Plan as a QI tool.

•Verification will continue to ensure appropriate auditing practices.

•We will continue to report Medication Reconciliation results to HCQ.

New Chart Audit Start-up Roll out of the new integrated chart audit will begin in August. By Monday July 20th, supply Lynne via email the name of

your clinics/departments for the drop down pick option (#1 on survey)

We will want the name of your auditor(s) for providing any training that might be needed and to give feedback if indicated. If you have a separate person downloading unit specific data, we will need that name as well.

You will receive an e-mail with start up information which will include: Step-by-step instructions; Explanation where indicated as to how to satisfy each

criterion; Reference to P&Ps or any other information source; Who to contact with questions.

PACE Audits The PACE audit form is under revision by the

work group.

Information will be recorded within Performance Manager and results will be provided to you similar to chart audit results.

You will receive actionable real time data.

We are in the process of revising the schedule for conducting self-audits and mock surveys.

Anticipate new audit will be available for September.

Mock TJC Surveys We will resume mock surveys on the units to

ensure Every Day Readiness. Goal is to help staff to comfortably and

reliably respond to a Joint Commission surveyor on a range of topics.

Here are some sample questions:Q: What is the single most important measure to prevent the transmission of

organisms?

A: Hand hygiene

Q: Who is your floor marshal for emergency evacuation?

A. Name of person