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Ambulatory Joint Commission

Ambulatory Joint Commission. January 13, 2010. Agenda. Chart Audit Results and Action Planning Presented by: Sandra Hewitt, Lynne Brophy Ambulatory CQI Committee Update Presented by: Sandra Hewitt PACE Audit Committee Update Presented by: Sandra Hewitt. Results - Dashboard.

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Ambulatory Joint Commission

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  1. Ambulatory Joint Commission January 13, 2010

  2. Agenda • Chart Audit Results and Action Planning Presented by: Sandra Hewitt, Lynne Brophy • Ambulatory CQI Committee Update Presented by: Sandra Hewitt • PACE Audit Committee Update Presented by: Sandra Hewitt

  3. Results - Dashboard N = 23 categories

  4. Data Comparisons

  5. Chart Audit Action Planning • Each audited area is required to complete an action plan grid. • Criteria below 75% compliance need action plans. • I am pulling together a subgroup to focus on systems issues that can have a positive impact on aggregate results and reduce vulnerabilities. • Please let me know if you’re interested in working as part of this group. We especially need representation from procedural areas, as well as areas from the Department of Medicine.

  6. Work Group Organization

  7. Charge of CQI • To meet TJC standards and regulatory agency directives for quality care and patient safety. • To identify areas within Ambulatory/ED where we can: • Effect positive change and • Reinforce best practices. .

  8. Scope of CQI • Promote knowledge and tools for everyday readiness. • Develop a systematic approach for reducing ambulatory and ED vulnerabilities by: • Overseeing a workgroup that monitors chart audit results and assists in the resolution of common systems issues. • Assessing risk by establishing a method for f/u on incident reporting/call outs. • Standardizing critical hand-offs. • Improving our communication methods particularly regarding change. • Sharing Best Practices among TJC team members. • Survey staff on units to add to their comfort level and expertise in responding TJC surveyors.

  9. Ambulatory CQI Subcommittee Membership: Lead: Menrika Louis Mary Beth Bahren Toby Grooms Sandra Hewitt Jason Laviolette Dan Nadworny Ann Stathakis Linda Trainor

  10. Follow up on PACE Audits • We have had delays in getting our PACE audit tool revised. • The PACE group met with Gary Schweon and Frank Rosen to discuss the following topics: • Compare their new tool with ours; • There is room for collaboration in our audit tools. • Share our new methodology for self-audits; • Internal PACE surveys using “outside eyes”

  11. Internal PACE Surveys • Gary and his team overwhelmingly support an internal Ambulatory and ED survey process; • They recognize that their surveys are only 2X per year and that there is room for more surveillance and follow up on corrective actions could be more timely; • We also discussed that there are additional topics (Patient Care/Patient Safety) not included in the EOC that we may want to examine either through PACE or the CQI committee’s unit questions of staff; • Additionally, we agreed that the “outside eyes” concept not only helps managers but also serves as a means of educating staff.

  12. Revised PACE Audit Methodology • Monthly self-assessments; • One section a month/complete audit per quarter: • Infection Control • Fire & Life Safety • Medication Management & Pharmacy • We may need to adjust our first audits to get a full 2nd quarter of data. • Peer reviews will be every 4 months and will be coordinated with Gary’s team schedule.

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