Ambulatory Joint Commission

1. Ambulatory Joint Commission April 14, 2010

2. Agenda Updates on: • Health Care Proxy Presented by: Stephen O’Neill • Ambulatory Policies and Procedures Presented by: Beatrice Ford • Mock Surveys on ambulatory units Presented by: Sandra Hewitt • Chart Audits Presented by: Sandra Hewitt/Lynne Brophy • Waiting Room Patient Information Posting Standards Presented by: Sandra Hewitt • Review of CMS Document Presented by: Sandra Hewitt

3. Advance DirectivesHealth Care ProxiesWhat? Who? Where? Steve O’Neill, LICSW, BCD, JD Social Work Manager for Psychiatry, Primary Care and Infectious Disease Associate Director, Ethics Support Service Division of Medical Ethics, HMS

4. What is New? New HCP Form to go with Q/A Form On-Line Access via BIDMC Web for our Patients and their Significant Others Spanish, Russian, Portuguese and Chinese Translations available now. More to come. Use old stock first before going to new ones.

5. AD? HCP? Last night, my wife and I were sitting in the living room and I said to her, "I never want to live in a vegetative state, dependent on some machine and fluids from a bottle. If that ever happens, just pull the Plug." She got up, unplugged the TV, and then threw out my beer. ……………......

6. WHO….does what, and where? CCC Registration field on AD’s………..same OMR Face Sheet……..Health Care Proxy field- to be done by Clinicians and/or some Non-clinician who have access Health Care Proxy forms……..send to Medical Records with patient’s unit number Questions………..refer patient/other to hard copy or BIDMC web HCP + Q/A……..or Social Work, Pastoral Care, or Ethics Support Service

7. Additional Questions Training: ALL staff………………. --On-Site --Ethics Liaison Program --HMS

8. Ambulatory P&P: Refrigerator & Freezer Temperatures Guideline Revision • Two key changes: • Freezer temperature has been changed to comply with both the Pharmacy and Pathology refrigerator and freezer temperature guidelines. • The acceptable range for refrigerator temperatures is between 2–8 degrees C or 36 to 46 degrees F unless otherwise noted on the refrigerator. • The acceptable range for freezer temperature is between – 18 degrees C or colder or –4 degrees F or colder unless otherwise noted on the freezer. • Links have been added to both the Pharmacy and the Department of Pathology’s policies for reference. • Please be sure you are maintaining your refrigerator and freezer temperature log. The updated guideline will soon be available in the Ambulatory Services Manual on the portal.

9. Mock Surveys • Two different mock surveys at this time: • Ambulatory Mock Survey Team is going to units to ask staff questions. • These surveys will continue through the end of April. • Staff are doing well. Managers are getting feedback. • Please check your wall mounted Cal-stats as outdated ones have been found. • Greeley consultant has been engaged to perform an unannounced assessment. • This survey started yesterday. • We will have a punch list of actions to bring us into a better state of readiness for an actual survey. • Here are some initial findings.

10. Some feedback – Procedural Units • A surveyor will want to see the processing of a patient from the beginning to end. • Have staff able to articulate the elements of a time out; how and when it is performed. • Be able to provide to a surveyor: • the consent form • pre-procedure assessment • documentation of pre- and post-procedure vitals • post-procedure note • Staff should be able to articulate a standard practice and not respond with how a particular provider wants things done for his/her patients. There needs to be a standard of care and all patients need to receive the same level of care at BIDMC. There is always room to surpass our standard, but we must ensure that all patients receive our standard.

11. Some feedback • Microscopes: need competencies for providers who use them. • Doors with signage saying they need to be closed, be sure they are closed. • Equipment cleaning between uses. All equipment needs to be cleaned even if kept in a doctor’s exam room. • Health care proxies: it is not clear when looking at a patient’s record in OMR when “no” is selected if that means no healthcare proxy or patient hasn’t been asked. • Be ready to identify those elements of a problem list.

12. Some feedback • Credentials for your providers: be able to access them on your units. • Call lights: test response time. Ensure that the light is properly identified for location; not room 222, but more specific if you can, like the function of the room, “back waiting area.” • Multi-dose vials are good for 28 days not 30. • Labeling: No more than one medication or solution is labeled at one time. Be sure staff can explain this method when asked. • Looking into whether some vials are single patient or single day use (~ normal saline and topical anesthetics).

13. Chart Audit Results

14. Actions on Chart Audit Results

15. Time-out Recalculated Impact of understanding the difference between a “NO” response and N/A was compliance in the 70’s vs in the 90’s.

16. New Chart Audit • We are going back to February 22nd for the next chart audit. • This audit will serve as a baseline, except in the case of “time outs,” which will be responded to with the new understanding. • The audit after this one will then show impact of the actions we have taken on: • Consent form timed • Updated medication list

17. Waiting Room Patient Information Posting Standards

18. Goals: • Ensure that we meet regulatory standards by providing all necessary information in waiting rooms. • Establish standard language and appearance of information. • Create a less confusing presentation for patients.

20. Criteria: Required Information

22. Physician Visit Brochures Speak Up™ brochures are available in English and Spanish at: http://www.jointcommission.org/PatientSafety/SpeakUp/

23. Information easy to find Presented by subject matter Clear and prominent signage indicating where to find the information Cell phone signage tasteful and in multiple languages Standard TV instructions Good display rack design Labeling of sections within display rack Current specialty specific information Posting kept to a reasonable limit and in proper frame/laminate sleeve Criteria: Presentation

24. Informal Survey • Transparency information about delays was outdated on every unit visited. • Specialty specific information was old. • Over time we will standardize signage such as wait time, hand hygiene, telephone use, etc. • The “Go ahead and ask” signage is an inpatient initiative and is not best for our outpatient areas. • Display racks needed attention. • We’d like to recommend that you use your CoC to “own” your patient information postings.

34. TJC Items • "What MDs Need to Know for TJC”, 2010 version is now available. • For past Right Way Every Day fact sheets http://home.caregroup.org/templatesnew/links/cat_out.asp?pageid=8754 • I’ll send the links for both in an e-mail • Excellent information to share with staff http://home.caregroup.org/templatesnew/departments/BID/JCAHO_Survey/uploaded_documents/What%20MDs%20Need%20to%20Know%20Trifold.pdf

35. Record Retention ADM-26: Attachment B Record Retention & Disposition Schedule A. Patient Care A1. Patient Care Records A2. Clinical Laboratory Services: Records A3. Clinical Laboratory Services: Specimens & Samples A4. Clinical Trials A5. HIPAA Privacy & Security Compliance B. Human Resources B1. Personnel Files B2. Other HR Files C. E-mail

36. Record Retention (Lab) • Requirement for retaining quality control logs • worksheets, • QC, • QA, • Proficiency Testing • Preventive Maintenance records • State supersedes CLIA and CAP at 4 years.

37. Items from CMS • Be sure your CMS books are up-to-date • Meeting minutes • Job descriptions • Competencies • Be sure that we have all start dates for NPs so that you will be in alignment with our new policy for their performance evaluations

38. Lynne Updates • Computer privacy screens • Sweep cards • They are available and HERE today! • #12 Should read: “Sharps containers no more than ¾ filled.” • 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