Jayne Sheehan Diane Gilworth January 14, 2009

1. Jayne Sheehan Diane Gilworth January 14, 2009

2. Agenda 11:-00-11:15 Vision and future of Joint Commission Readiness Program- Jayne Sheehan Unscheduled visit JC Calendar in Outlook NSPG cards distributed FAQ to staff Scope of Service-due on shared drive CQI / Silverman Posters 11:15-11:45 Ambulatory Joint Commission Portal Page - Lynne Brophy/Diane Gilworth Tool box review Discussion/feedback 11:45-12:15 Safety - Meg Femino 12:15-12:30 Chart audits - Diane Gilworth

3. Vulnerabilities-just a reminder 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.) Anticoagulation Therapy Process to implement an enterprise-wide Anticoag Therapy Program Universal Protocol Operative / Procedural Area/ Bedside Verification of Side/Site/Procedure Marking of Site Time Out Immediately Before Procedure Medical Staff Standards Bylaws Related Timeliness of Reappointments Human Resources Decentralized Monitoring of Competencies Performance Evaluations Staffing Effectiveness Exercise 2008-09 Infection Control Use of PPE PPD Screening Information Management (Medical Records Related) Aggregate Reports of Compliance Streaming through HIM Committee Performance Improvement Collecting/Analyzing/Using Data for Improvement Staff Knowledge of Priorities

4. An Unscheduled JC VisitReadiness Preparation

5. An Unscheduled JC Visit • BIDMC will be notified no later than 7:30am that the Joint Commission is scheduled to visit. • Facilitators will l be notified via page shortly there after with a message that reads: "TJC has arrived, begin preparations for survey" • Facilitators will be begin notification process to your managers and staff and also begin any preparations for the survey. • During the survey, you will receive on-going pages with updates regarding best guesses on locations of the surveyors and any other information that is deemed relevant. • Check your TJC calendar for updates

6. TJC Calendar of events Directions to Add TJC Survey Calendar to Favorites: For Easy Viewing 1.   Go to Outlook Calendar • Locate Folder Tab • On left hand side at the bottom • If it is not there: • Select “GO” at the top menu • Scroll to folders (A new Screen will pop up) 3.   Click the + sign next to Public Folders 4.   Click the + sign All Public Folders 5.   Scroll until TJC Survey CalendarIcon- Click on the Icon 6.   Select OK 7.   The Calendar should now pop up on your screen 8.   On left hand side of the calendar the folders list should still appear 9.   Under Public Folders: locate TJC Survey Calendar 10.  Right Click 11.  Select Add to favorites 12.  Select Add in pop up window 13.  Go back to your own calendar- TJC Survey Calendar should be listed 14.  Check box for side by side viewing *If the TJC Survey Calendar  tab does not appear- repeat steps 9-14*

7. FAQ to share with your staff

8. Share the FAQ with your staff • Joint Commission Questions for staff discussion • Q: What is “code red”? • A: Code phrase for a fire emergency. • Q: Why do corridors need to be clear of equipment and clutter? • A: Corridor storage creates a fire hazard, an evacuation hazard • and a trip/fall hazard. • Q: How do you access the inventory of patient education materials on the • portal? • A: Go to Patient Education; click on the BIDMC fact sheets and instructions. • Q: Name several protective devices or equipment available for use to prevent accidental exposure to blood born pathogens. • A: Gowns, gloves, goggles, face shields, safety needles and sharps, sharps containers, biohazard bags. • Q: What is the single most important measure to prevent the transmission of organisms? • A: Hand hygiene • Q: Who is responsible for performance improvement? • A: Everyone • Q: What do you do if you identify an area for performance improvement? • A: Discuss it with your manager. • Q: Where would you find and file an incident report for patient/visit incidents? • A: In CCC, under “utility” option

9. Share the emergency plan with your staff

10. REMINDERS • Scope of Practice – due on Shared Drive • CQI / Silverman Institute Posters

11. Tool Box Lynne Brophy Diane Gilworth

12. Safety Meg Femino

13. Chart Audits Diane Gilworth

14. Current State Chart Audits

15. Chart Audit Process 2009 and beyond Better Best Good Create a new more clinically Relevant chart audit Data is available real time- unit specific-CQI Clinicians would do all Chart audits- MD’s, NP’s , RN’s. Continue with present chart audits Review your data and be prepared to discuss with the JC Reformat questions for easier documentation Clarify # of chart audits per unit Define what it means to be compliant Get data back to you in a timely manner

16. Chart Audits- Best • Problem list is updated and reviewed (within last 12 months) • Allergies are reviewed and updated (within last 12 months) • Medication list is up to date • (on a quarterly basis the medication reconciliation survey could be rolled into the chart audit to reduce the number of actual surveys done per unit) • Summary list is present- by 3rd visit- • this list included known and significant medical diagnosis and conditions, known significant operative and invasive procedures, known adverse and allergic drug reactions, know long term medications, including current prescriptions, over the counter drugs and herbal preparations. The list is quickly and easily available for practitioners. • Consent forms are present as applicable for invasive procedures. general consent includes a discussion of: • a. the nature of the proposed care, treatment, services, medications, interventions, likelihood of achieving goals, reasonable alternatives, relevant risks and benefits, side effects related to alternatives, including possible results of not receiving any therapy, when indicated any limitations on the confidentiality of information learned about the patient) this should be standard in all consent forms • H & P is present

17. Chart Audits- Best • Pain assessment is documented as appropriate • (would recommend standardizing pain assessment tools and if possible creating space within web OMR for direct documentation) • Pain is reassessed at subsequent visits. • A comprehensive pain assessment is conducted as appropriate to the patients condition and the scope of care, treatment, and services provided. (would recommend standard reassessment tools and standard template for documentation in Web OMR) • Advanced directive is present- • new field in Web OMR (documentation indicates whether the patient has signed an advance directive) • There are additional standards specific to operative/high risk procedures which may pertain to derm surgery and endoscopy and others where procedures and or conscious sedation is being used.

18. Chart Audits- Best • Emergency Department patients- chart contains the following • Time and means of arrival • Whether patient left against medical advice • Conclusions of termination of treatment-final disposition, condition and instructions for follow up • Copy of record is available to practitioner or medical organization providing follow-up care, treatment and services. • Hospital communicates appropriate information to any organization or provider • The information shared contains- reason for transfer or discharge, patients physical and psychological status, summary or care, treatment and services provided • Community resources or referrals provided to the patient.

19. Thank you Jayne Sheehan