May 12, 2010

Ambulatory Joint Commission

Agenda Medication Management Presentation

Presented by: May Adra, Pharm.D., Medication Safety Coordinator

TJC Survey Trends Presented by: Kathy Murray, Director of Process Improvement

Mock Surveys on Ambulatory Units Presented by: Sandra Hewitt

Pace Audit UpdatePresented by: Kevin Hart

CQI Updates Presented by: Menrika Louis

o Medication and Solution Labelingo Universal Protocol Poster Roll-out

Chart AuditsPresented by: Sandra Hewitt/Lynne Brophy

Ambulatory Mock Surveys First of all thanks to all of you! You were welcoming,

responsive and your staff did a wonderful job!

The team of surveyors enjoyed the opportunity to interact with you and to meet your staff.

Learning took place on both sides of the equation.

Here are the members of the survey team:

Kevin Hart Linda Lentz

Sandra Hewitt Stephenie Loux

Sheilah Janus Daniel McTigue

RoseAnne Joaquin

The Broad Themes

Finding: Most staff were not comfortable in responding to questions.o Most staff members are knowledgeable;o Need more experience expressing themselves.

Recommendation: Try to create more opportunities for them to express themselves on these topics. Perhaps role playing at staff meetings?

Terminology Finding: Staff did not always recognize terms

such as:o Time outo Standard of careo Scope of Service

Recommendations: o Let staff know that they can always ask for a

clarification on a question or say they don’t know but can find out.

o When training staff, help them understand concepts as well as familiarize them with some common terminology.

Process Improvement Finding: When prompted with “what have

you done to make things better on your unit?” staff were able to describe PI projects.

Recommendations: o Try posting your PI projects on your units to

help remind staff of projects.o Have them be comfortable describing those

things that impact what they do.

Emergency Protocols Finding: Congratulations, staff know their

evacuation plans, but they were uncertain about: o Who is their Fire Marshal;o Tended to skip the “R” in RACE;o Had trouble with PASS for extinguisher use.

Recommendation: Review with staff or post Policy EC-36: Fire Response, “Code Red Procedure.

Familiarity with the Portal Finding: Staff are well prepared to say that they can

find answers on the portal, but when taken to a computer, were not able to demonstrate their ability to find what they need.

Recommendations: Common items to be able to find on the portal are:o Policies and procedureso Patient education materialso MSDSo Emergency phone numberso Prohibited abbreviationso Employee Resources

Scope of Service Finding: Staff should be comfortable in responding

to “what happens on this unit?” Recommendations: Review Scope of Service with

your staff, emphasizing:o Type of clinic/providerso Type of services offered, i.e. phlebotomy,

consultations, post-op visits, procedures, etc.o How many procedure/exam rooms on unito Where the waiting area iso Type of staffingo Hours of operation

Competencies Finding: Everyone should be familiar with

how they were oriented to their roles on the unit and how they are tested on what they do.

Recommendations: o Review competencies with staff, have them be

able to speak to when they are tested and how they get assistance when needed.

o Be able to produce documentation of competencies for your staff (should be on the S:drive).

Office of Business Conduct Finding: Staff were not always aware of how

to call in ethical concerns, anonymously if so desired.

Recommendations: o Please instruct staff that they can always call

the Office of Business Conduct, confidentially, without fear of retribution at (617) 667-1897.

o They can call anonymously at (888)753-6533 if that feels more comfortable.

o Staff should be able to find OBC on the portal under Employee Resources.

Health Care Proxy Finding: Not everyone was familiar with what

a HCP is. Recommendations:

o Staff should be able to give a basic description;

o Tell where to find HCPs on their unit;o Know what to do with an HCP should a patient

bring one with them to the practice.

A few other things….. Badges above the waist and face forward.

Make sure you have enough Emergency Response Quick References available on your unit.

Have record of preventive maintenance for equipment:

o Microscopes need PM 2x/year.o Also, physicians who use microscopes need to either have it as part

of the clinical training or identified in their delineation of privileges.

Make sure you have the updated version of consent forms with space for signature, date and time for both provider and patient.

Additional survey visits?

We’ve been asked back to some units. If you’re interested in having a team member

return, please e-mail me. I will work with the team to arrange for your

visit. If you have a particular area in which you

would like us to focus, let me know that as well.

The New & Improved Pace Audit What’s New?

What’s the Process?

What’s the Benefit?

What’s New?

Pace Audit Tool Consists of 12 sections. Monthly sections will be

identified in the tool by date. A monthly schedule will be provided.

Audits are due by the 21st of each month. Full Audit due in May.

Results “Outside Eyes” “Outside Eyes is a Peer review.

Every 4th month a full survey will be done with help of two colleagues from a different unit

What’s the Process?

Tool is completed monthly with “yes,” “no” or “N/A” o “Yes” being the goal; o “No” raises red flag for action!

Corrective action plans are necessary for all “no” answers;

Space is allotted at the end of each section for action plans/comments.

What’s the Benefit?

You will now have access to your results; Results will be posted on the S:Drive

Ambulatory Joint Commission folder/Pace Audit subfolder;

As with chart audits, results will be available by individual units and in the aggregate for Ambulatory and ED;

We will be able to trend areas of strength and vulnerabilities.

What’s next……..

Excellence in practice for our patients

Success for Joint Commission

Ongoing efforts for improvement

Lastly! The Audit Team is here to support and assist

you with any questions or concerns;

We will also diligently monitor results for 100% compliance;

We need YOU, to make this audit successful!

Revised Medication and Solution Labeling Policy CP-32

Correct way…Correct way…Labels show type of medication or substance including strength

What’s wrong What’s wrong with this picture?with this picture?

Very few changes. Reorganized to clearly state exception to

labeling requirement.

Key points to policy:

Labeling is required When Medication or solution is

transferred from its original packaging to another container

and preparer it is different than the

administrator.

and / or is used non-continuously. (ex. is set

down for intended re-use during the procedure)

Labeling is not required When Solution is immediately

prepared and administered in full by the same person.

Online training is available at:

http://research.bidmc.harvard.edu/education/MedicationLabeling_files/frame.htm

Universal Protocol (CP-33)

•Address missing information or discrepancies before starting

the procedure.•Use a standardized list to

verify the availability of items for the procedure.

Mark the site when there is more than one possible location for

the procedure

•The procedure is not started until all questions or

concerns are resolved.•During the time-out, the

immediate team members agree, at a minimum, on these

three things:

Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery

Chart Audit ResultsFeb. 22nd

Lynne Updates Speak Up™ brochures

will be ready by end of week to be picked up in Shapiro 245

Computer privacy screens

sent corrected measurement and quantity info back to Office Depot/3M Reps and will get quotes by end of week

Once quotes received Jayne will work with Eric for funding

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