Ambulatory Joint Commission

1. Ambulatory Joint Commission May 12, 2010

2. 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 Update Presented by: Kevin Hart • CQI Updates Presented by: Menrika Louis • Medication and Solution Labeling • Universal Protocol Poster Roll-out • Chart Audits Presented by: Sandra Hewitt/Lynne Brophy

3. 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

4. The Broad Themes • Finding: Most staff were not comfortable in responding to questions. • Most staff members are knowledgeable; • 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?

5. Terminology • Finding: Staff did not always recognize terms such as: • Time out • Standard of care • Scope of Service • Recommendations: • Let staff know that they can always ask for a clarification on a question or say they don’t know but can find out. • When training staff, help them understand concepts as well as familiarize them with some common terminology.

6. 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: • Try posting your PI projects on your units to help remind staff of projects. • Have them be comfortable describing those things that impact what they do.

7. Emergency Protocols • Finding: Congratulations, staff know their evacuation plans, but they were uncertain about: • Who is their Fire Marshal; • Tended to skip the “R” in RACE; • Had trouble with PASS for extinguisher use. • Recommendation: Review with staff or post Policy EC-36: Fire Response, “Code Red Procedure.

8. 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: • Policies and procedures • Patient education materials • MSDS • Emergency phone numbers • Prohibited abbreviations • Employee Resources

9. 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: • Type of clinic/providers • Type of services offered, i.e. phlebotomy, consultations, post-op visits, procedures, etc. • How many procedure/exam rooms on unit • Where the waiting area is • Type of staffing • Hours of operation

10. 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: • Review competencies with staff, have them be able to speak to when they are tested and how they get assistance when needed. • Be able to produce documentation of competencies for your staff (should be on the S:drive).

11. Office of Business Conduct • Finding: Staff were not always aware of how to call in ethical concerns, anonymously if so desired. • Recommendations: • Please instruct staff that they can always call the Office of Business Conduct, confidentially, without fear of retribution at (617) 667-1897. • They can call anonymously at (888)753-6533 if that feels more comfortable. • Staff should be able to find OBC on the portal under Employee Resources.

12. Health Care Proxy • Finding: Not everyone was familiar with what a HCP is. • Recommendations: • Staff should be able to give a basic description; • Tell where to find HCPs on their unit; • Know what to do with an HCP should a patient bring one with them to the practice.

13. 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: • Microscopes need PM 2x/year. • 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.

14. 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.

15. The New & Improved Pace Audit • What’s New? • What’s the Process? • What’s the Benefit?

16. 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

18. What’s the Process? • Tool is completed monthly with “yes,” “no” or “N/A” • “Yes” being the goal; • “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.

19. 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.

20. What’s next…….. • Excellence in practice for our patients • Success for Joint Commission • Ongoing efforts for improvement

21. 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!

22. Revised Medication and Solution Labeling Policy CP-32 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 Correct way… Labels show type of medication or substance including strength What’s wrong with this picture?

23. Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery 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:

24. Chart Audit Results Feb. 22nd

27. 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