THP Regulatory Readiness 2011 - FRAMEWORK (2011!11!02)

7/31/2019 THP Regulatory Readiness 2011 - FRAMEWORK (2011!11!02)

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THP Regulatory Readiness 2011

Continuous Readiness Strategy

Part I Steering Committee: Senior Leadership

Provides direction and oversight as the steering committee, maintains momentum

Participated in selection of chapter champions (not senior staff) and strategy coordinator

Regularly meets face-to-face with chapter champions to discuss and address barriers

Identifies opportunities for improvement from reported data

Follows-up on results of corrective action plans

Celebrates chapter champions and team members

Responsible for embedding / sustaining quality and safety improvements

Senior Leader Title Senior Leader NamePresidentVice President and Chief Quality Officer

Vice President & Chief Financial OfficerAdministrative Director Planning,Development & Ambulatory CareAdministrative Director Physician ServicesAdministrative Director Human ResourcesSenior Vice President & Chief OperatingOfficerVice President & Chief Nursing Officer

Senior Leadership Defines:


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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule

Part II Standards Compliance

Joint Commission Chapter Champions

Establish and select one chapter champion for each chapter

Responsible and accountable for compliance to chapter standards

Champions choose team members to assist in the review of standards and elements of

performance (EPs); each team member accepts 1 3 standards, depending upon extent ofstandard

Team members assist in the review and auditing of EPs / Measures of Success (MOS); team

members are sought from all departments and from all levels

Communicate list of these staff to coordinator / senior leadership for acknowledgement and

recognition

Chapter Abbreviation Chapter Champion

Accreditation ParticipationRequirements

APR

Environment of Care ECEmergency Management EMHuman Resources HRInfection Prevention & Control ICLeadership LDLife Safety LSMedication Management MMMedical Staff MSN ti l P ti t S f t G l NPSG


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Chapter Standard ChapterChampion / Plan

Team Members

Accreditation

ParticipationRequirements


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Chapter Standard Chapter Champion /Plan

Committee /Team Members

Environment of Care

Life Safety Plan Mark Anderson

Tod Nutt


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Chapter Standard Chapter Champion /

Plan

Team Members


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Plan

Team Members

Human Resources


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Plan

Team Members

Infection Prevention &

Control


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Plan

Team Members

InformationManagement


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Plan

Team Members

Leadership


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Plan

Team Members

Life Safety


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Chapter Standard Chapter

Champion / Plan

Team Members

MedicationManagement


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Plan

Team Members

Medical Staff


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Chapter Goal Chapter Champion /

Plan

Team Members

National Patient SafetyGoals


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Plan

Team Members

Nursing


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Plan

Team Members

Provision of Care,Treatment & Services


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Plan

Team Members

Provision of Care,Treatment & Services


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Improvement


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Plan

Team Members

Record of Care,

Treatment & Services


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Team Members

Rights & Responsibilitiesof the Individual


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Team Members

Transplant Safety


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Plan

Team Members

Waived Testing


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Part II Standards Compliance

Strategy Coordinator Director, Quality

Develops Guidelines for Chapter Champions, including:

Define roles of coordinator, chapter champion, team member

Define responsibilities and accountabilities of each

Define time frames / expectations for frequency of meetings of each group

Develop tools for collecting data Develop tools for reporting data

Develop time frames for submission of data

Establish frequency and type of data reporting

o Weekly reports to SLT

o Weekly reports to chapter champions

o Monthly reports to department directors

o Monthly reports to medical staff leadership Organize and provide to chapter champions a packet of the aforementioned information,

including an instruction guide for implementation of strategy

Communicate to hospital staff the strategy / plan for continuous readiness and compliance

to quality and safety standards, roles, responsibilities and accountabilities of chapter

champions and team and the need for staff participation in teams.

Oversight for development of tracer activities.


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Part III Tracer Activity

Tracer Activity as a Component of Ongoing Readiness

Establish and implement tracer training for staff Director, Quality

Establish a person / process to facilitate oversight of tracer activities Director, Quality

Create tools to be used for tracing in each department

Identify local unit / department based management responsible for conducting tracers ineach department

Track tracer activities

Review tracer tools


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THPresby Dallas Regulatory Readiness 2011 Tracer Activity and Reporting Schedule

Unit Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecBUILDING A

OR & CENTRAL STERILE

PROCESSINGA-3 L & DA-4 POST PARTUM & NBNA-5 ONCOLOGY & M/S

BUILDING BDAY SURGERYPACUCATH LABB-3 HIGH RISK OBB-4 PEDIATRICSB-5 TELEMETRY & M/S

BUILDING CEMERGENCY ROOMC-2 CCUC-3 NICUC-4 POST PARTUMC-5 TELEMETRY & STEPDOWNC-6 M/S

C-7 BARIATRICS & M/SC-8 ORTHOPAEDICSOTHER PATIENT CARE AREASARTSLABORATORYOUTPATIENT THERAPYRADIOLOGY (THP)SEAY BEHAVIORAL HEALTHWOUND CARE CENTER

OTHER DEPARTMENTSHUMAN RESOURCESMEDICAL STAFF SERVICESENVIRONMENT OF CARE

ROUNDS

MEDICATION MANAGEMENTINFECTION PREVENTION &

CONTROLFOOD & NUTRITION SERVICESPHARMACYPEDIATRIC IMAGINGWOMENS DIAGNOSTIC CENTERFRISCO REHAB CENTERQUALITY, PATIENT SAFETY &

RISK

Key: T = Tracer Activity Performed R = Report tracer outcomes / staff competency to Regulatory Readiness

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Documents

THP Regulatory Readiness 2011 - FRAMEWORK (2011!11!02)