Ambulatory Joint Commission Meeting August 12, 2009

1. Ambulatory Joint Commission Meeting August 12, 2009 Presented by: The CMS Debriefing Workgroup

2. 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

3. 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

4. Do you feel like you’re drowning some days? You have colleagues and systems to keep your heads above water!!

5. 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!

6. 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.

7. 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.

8. 3 Categories of Auditing How 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. • 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. • This consult can serve as “outside eyes” for your survey readiness; very much in the spirit of LEAN. E2 – Everybody/Every day

9. 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.

10. Confidentiality • Destruction of patient information • Use of shredders: • Location should be at front desk & consult rooms; • Ordering information in CMS document. • Charts and patient information: • Veiled or turned in chart racks. • Computer screens: • Need protection; • Screen cover ordering information from Office Depot is in the CMS document.

11. Clinic Findings(Lead: Amalia Gonzalez) • Expired Meds • Require constant vigilance; • Use monthly check list - refer to EOC – 1; • Pharmacy policy #03-07-07 gives guidance for drug storage. • Inspection by: • Pharmacy monthly – for high volume drug use/storage areas. • PACE rounds every 6 months – for low volume drug use/storage areas.

12. Monthly Supply Checklist

13. 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.

14. 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.

15. Sample Medication Log

16. 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.

17. Code Cart Concerns CMS & JCAHO concern: It was not clear that we had a STANDARDway to assure that NO items in the code cart are expiredat 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 thedefibrillator 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!

18. Refrigerator Temps & Alarms • Refrigerators used for medications only: check temperature & alarms • Temperature must meet Nat’l Institute of Standard and Technology Guidelines. • Daily, at opening of clinic, assigned staff checks unit and determines if it is within the acceptable temperature range. • If outside normal temperature range, call Service Response. • Temperature is to be recorded daily on the monthly Refrigerator and Freezer Temperature Log, • Refrigerator logs are at the end of #ASM-4, Medication Fridge Temp Policy. • Tracked on PACE audit MM8-12

19. Tracking # of Patients in Clinic • CMS asked, “How do you track the number of patients in your clinic?” • Answer:you can use: • The ccc CAS report • The ccc check-in report * ED uses their dashboard,which can be printed from any computer.

20. Hmm, I seem to be staying afloat! Boy, who said this was going to be tough?

21. 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.

22. 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: • Processing infectious waste is extremely expensive; • Only infectious waste should be placed in the designated receptacles; • All other waste should be discarded as solid waste; • A standard list will be created for all units. • Policy reference is EC - 59

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

30. 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: • Important meeting content is recorded. • There is a recognized standard and method for documentation and communication. • 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.

31. Did you say chart audit?? I’m all ears!

32. 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.

33. 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

34. 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.

36. 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.

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