Presented by:The CMS Debriefing Workgroup

Ambulatory Joint Commission Meeting August 12, 2009

Recap Last Meeting

Overview of the Ambulatory Joint Commission structure Reorganization of work groups

Demo of Ambulatory Joint Commission Folder

Policies and Procedures 101

What’s New with Competencies

The New and Improved Chart Audit

Today’s Agenda – Where we left off Revisions to PACE Audits Resumption of Mock Joint Commission Surveys Patients Rights and Confidentiality (Menrika)

Clinic Findings (Amalia)

Infection Control (Lynne)

Life Safety New Ambulatory Guideline on Meeting Minutes Update on Chart Audit

Do you feel like you’re drowning some days?

You have colleagues

and systems to keep your heads above

water!!

The Goal of this Presentation… Inform you of concerns that were raised during the

CMS Survey; Help you find resource documents (such as the

Amb & Emergency Services CMS Debrief Master Doc in the Amb JC Folder on the S:Drive);

Let you know what systems are in place to help you navigate CMS/TJC requirements;

Ensure you know the activities and teams we have in place;

Give you contacts should you still have questions; Give Lynne a break!!!

You know a lot of this content, however, we all need to have the same knowledge base!

Ambulatory PACE Audits (Lead: D. Clough)

The PACE audit form is under revision by the Ambulatory PACE work group.

You will record data within Performance Manager and will receive results similar to those from chart audits.

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 The PACE audit team will resume mock surveys within

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

to Joint Commission surveyors 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 “Surveyors” will also spot check PACE audit criteria while

on the unit.

3 Categories of AuditingHow are they different? Self-auditing: this is a tool to help you manage your unit’s

compliance. Results will be provided to you on Performance Manager and you will be able to take corrective actions when indicated.

Ambulatory Mock Surveys: These surveys are conducted to help you and your staff prepare for a surveyor’s visit to your unit and will be conducted in the same manner.

Health Care Quality Every Day Readiness Surveys: This type of survey is a consult.

o You request facilitators to come to you and help you problem-solve around Joint Commission standards that may be giving you a challenge in achieving full compliance.

o This consult can serve as “outside eyes” for your survey readiness; very much in the spirit of LEAN.

E2 – Everybody/Every day

Patient Rights (Lead: Menrika Louis)

Concerns: Patient Rights & Healthcare Proxies The most updated versions are not always

available on units; Lack a clear understanding of communication of

updates; Not all languages are available in waiting areas; Ordering information is available within the

CMS document in the Ambulatory Joint Commission folder;

Space and storage is problematic on some units and needs to be addressed.

Confidentiality Destruction of patient information

Use of shredders: o Location should be at front desk & consult rooms; o Ordering information in CMS document.

Charts and patient information: o Veiled or turned in chart racks.

Computer screens:o Need protection;o Screen cover ordering information from Office

Depot is in the CMS document.

Clinic Findings (Lead: Amalia Gonzalez) Expired Medso Require constant vigilance;

o Use monthly check list - refer to EOC – 1;

o Pharmacy policy #03-07-07 gives guidance for drug storage.

o Inspection by: Pharmacy monthly – for high volume drug

use/storage areas.

PACE rounds every 6 months – for low volume drug use/storage areas.

Monthly Supply Checklist

 

(INSERT DEPARTMENT): Monthly Supply Checklist

Exam RoomsSupply Cart (top & drawers)

Shelves/Cabinets Counter tops# of Items Discarded

# of Items Restocked

          

          

          

          

          

          

Drug Sample Management Drug samples are ALLOWED but we must follow

policy CP - 11. Units must have logs and a sign-out process. Samples must be stored in a secure area;

accessible only to authorized individuals. Samples distributed to patients must be labeled

in accordance with state regulations, i.e. patient info, dosing and manufacturer and lot number, etc.

Rationale: you are dispensing drugs, therefore you must comply with the state regulations related to this activity.

Tracking & Inspection of Samples

Drug samples are tracked through various means:

Questions on PACE self assessment tool;

Emphasis on samples during mock surveys;

Pharmacy inspection of unit’s sample program;

Medication logs FAX’d to Pharmacy monthly;

The log is found at the end of CP-11.

Sample Medication Log

Moderate Sedation During the CMS visit we were asked, “During the

administration of IVMS, can the nurse/monitor be involved with helping the physician?”

Answer: The nurse should have no other significant responsibilities that would compromise her ability to monitor the patient, BUT the nurse MAY perform minor, interruptible tasks.

Policy for moderate sedation is CP – 03.

For those clinics that use moderate sedation, Janet Lewis is an excellent resource.

Code Cart ConcernsCMS & JCAHO concern: It was not clear that we had a STANDARD way to assure that NO items in the code cart are expired at any given time.

During the monthly audit, use the inventory sheet as a guide to verify that items that should be present are actually present and if not, contact distribution or clinical engineering as appropriate.

When you complete the monthly audit, all items are checked for expiration.

Check the clinical stickers on both the defibrillator and suction machine. (PM valid through __/__/__) Call clinical engineering for out-of-date stickers or any malfunctions.

Check that the needle stick box is only ½ full. Remember: there are daily, weekly and monthly checks!

Refrigerator Temps & Alarms Refrigerators used for medications only: check

temperature & alarmso Temperature must meet Nat’l Institute of Standard and

Technology Guidelines.o Daily, at opening of clinic, assigned staff checks unit and

determines if it is within the acceptable temperature range.

o If outside normal temperature range, call Service Response.

o Temperature is to be recorded daily on the monthly Refrigerator and Freezer Temperature Log,

o Refrigerator logs are at the end of #ASM-4, Medication Fridge Temp Policy.

o Tracked on PACE audit MM8-12

Tracking # of Patients in Clinic

CMS asked, “How do you track the number of patients in your clinic?”

Answer: you can use:1. The ccc CAS report

2. The ccc check-in report

* ED uses their dashboard, which can be printed from any computer.

Hmm, I seem to be staying afloat!

Boy, who said this

was going to be

tough?

Infection Control (L. Brophy)

Hand Hygiene Pump in/Pump out!! Measure on PACE audit; Observations of hand hygiene will be an emphasis on

Mock Surveys; Ensure portable Calstat containers in exam rooms; No Calstat units should be mounted over electrical

outlets; The resolution of other Calstat wall mount units is still

in the planning stages.

Biohazard Waste & Receptacles What should be placed in these receptacles?

Anything visibly saturated with blood or body fluids. What should NOT be placed?

Dry band-aid;Tubing attached to an IV bag.

Although it is important to segregate all biohazard waste:o Processing infectious waste is extremely expensive;

o Only infectious waste should be placed in the designated receptacles;

o All other waste should be discarded as solid waste;

o A standard list will be created for all units.

o Policy reference is EC - 59

Sharp Containers Sharp Waste is defined as:

All needles, IV catheters, syringes (note: syringes are considered a sharp with or without a needle attached) and sharp medical instruments (e.g. scalpel blades, suture needles, disposable razors).

Call when containers are ½ full! (Be sure to check the container on the Code Carts.)

EVS evening shift checks containers daily. Contacts: Mark Leonard (East); Scott Tripp (West). For daytime emptying contact: Service Response. Again, policy reference is EC - 59.

Medical Equipment Cleaning Equipment cleaning policy: IC ES15 High frequency shared medical equipment requires

cleaning both before and after patient use: Wipe down equipment with ready to use Steris

Germicidal Surface Wipes (red top). When indicated, gloves should be worn to protect against blood and body fluids.

Examples of High Frequency Shared Medical Equipment: portable blood pressure cuff, glucometer, pulse oximeter, portable doppler, bladder scanner, portable thermometer, EKG machine.

Other minor equipment: need guideline addendum to equipment cleaning policy.

Cleaning – Utility Rooms EVS evening shift is responsible for cleaning

clean/dirty utility rooms: Floor care Wall spotting Dusting Remove medical waste

EVS does not transport dirty instruments or other equipment left in the room.

And even more Cleaning……

Exam Rooms: EVS cleans daily in evening.

Exam tables: EVS should clean any permanent non-clinical equipment daily.

Managers should work with individual EVS staff to ensure that cleaning is being performed as outlined.

Personal Protective Equipment

New policy is in the approval process.

There will be an online mandatory training once the policy is passed.

Training will be part of the annual mandatory education process.

Life Safety (Lead: D. Clough)

No propping open doors: If door is not working properly, contact Service

Response and obtain a work order. Space heaters: Gone!!

Stairwells and hallways: NO STORAGE. Taped off areas need review by Lean Team.

Guideline on Meeting Minutes We had lots of agendas for CMS….. Not minutes. Purpose of Guideline: To establish a method of

documentation and communication within a meeting group, ensuring that:

1. Important meeting content is recorded.2. There is a recognized standard and method for

documentation and communication.3. All members are informed of progress toward

achieving the group’s charter, progress to date and accountabilities for further actions.

All routine meetings such as staff meetings, committee meetings, and special interest groups, require a formal record of meetings.

Guideline currently can be found on the S: drive - Ambulatory Services/Ambulatory Policies.

Did you say chart audit??

I’m all ears!

New Chart Audit Start-up Roll out of the new integrated chart audit will begin this month! Please make sure you supplied Lynne via email the name of

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

You also should have provided the name of your auditor(s).

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.

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

Link to audit tool will be sent to each manager/director, with instructions on how to access

Combined chart and med rec 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

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 graphs will be placed on the shared drive (Ambulatory Joint

Commission) for ease of access Email will be sent out when they are ready for reviewing

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.

With a little help from one another, we’ll all keep our heads above water!!