Ambulatory Joint Commission Meeting July 15, 2009

1. Ambulatory Joint Commission Meeting July 15, 2009 Presented by: Jayne Sheehan Sandra Hewitt Louise Mackisack

2. Agenda • Overview of the Ambulatory Joint Commission structure • Reorganization of work groups • Recent Accomplishments/Actions since CMS • Work of CMS Debriefing Group • Demo of TJC Folder • Policies and Procedures 101 • What’s New with Competencies • The New and Improved Chart Audit • Revisions to PACE Audits • Resumption of Mock Joint Commission Surveys

3. Recent Accomplishments As a result of our mock TJC and CMS surveys we have made great strides! We now have: • Reorganization of the TJC Team, including the addition of David Clough to Lead one of our work groups. • The Ambulatory Joint Commission Folder on the S:/drive • S:\Ambulatory Joint Commission • CMS Debriefing Document also on the S:/drive • S:\Ambulatory Joint Commission\CMS - AMBULATORY AND EMERGENCY SERVICES MASTER DOCUMENT • An ad hoc CMS team that has worked to provide resolution to potential vulnerabilities; • Parts of today’s presentation have come from our work within the CMS document. The Leads for each area are identified to address any further questions.

4. New Work Group Organization Reorganization of Work Groups

5. Policy, Procedures & Guidelines: Beatrice Ford Lynne Brophy Chris Healey Sandra Hewitt Richard Johnston Menrika Louis Christine Lynch Dan Nadworny Competencies: Louise Mackisack Brigitte Bowen-Benitich Lynne Brophy Holly Dowling Maureen Mamet Heather Wathey Annie Whatmough Jan Woodruff PACE Audits/Mock Surveys: David Clough Laura Allen Jo-Ann Barletta Emily Cherecwich Linda Dicenzo Sandra Hewitt Kelly Orlando Eileen Rose CQI – Process Improvement Work Group Membership

6. Ambulatory Joint Commission Folder (live demo) We want you to use this folder where you can find: • Generic Job Descriptions • Unit specific JDs need to be developed and put in the folder as well. • Job description template in folder. • Ambulatory Specific Guidelines • We are adding guidelines as we create them. • These guidelines will be housed in this folder, until the Ambulatory Services Guidelines manual goes live on the PPGD site. • Guideline Templates in folder – clinical area/department and administrative • Medication Reconciliation Audit Results* • Chart Audits* • CMS Debriefing Document* • Scope of Service w/Org Charts • Generic MA Training Manual* • Staff Competencies Information* Please notify Lynne when you make updates. We’ll let you know whenwe make changes as well. *More on these topics later

7. Ambulatory Policies, Procedures &Guidelines(Leads: B. Ford; L. Brophy; S. Hewitt) Nomenclaturefor Organizational PPGDs • Medical Center Wide: • The BIDMC Policy Manual is the Source of Truth. • Ambulatory has very few specific policies and has primarily Guidelines. • Interdepartmental: apply to more than one department, but are not Medical Center wide. • Exs: we use lab, radiology, pharmacy manuals for PPGDs within ambulatory. • Intradepartmental: apply to one department only.

8. Areas of Concern • Can’t find P&Ps: • Training: working to include in Orientations • CheatSheet: available right on the portal • Ambulatory Services Guidelines: will house Ambulatory modifications found within • Who to Contact with Policy Questions * • Sponsor/Requestor/Ambulatory Work Group • How do you learn of New Policies?* • Communication • On Portal • P&Ps not specific enough for ambulatory setting*

9. Resource Staff for Content Expertise in PPGD Development (ADM-01) Name:Area of Expertise: • Ken Sands, MD, Sr. VP MD Licensing Board/Leadership • Patricia Folcarelli, RN, PhD, Director Patient Safety • Kathy Murray, Director Process Improvement/TJC • Kim Sulmonte, RN, Director Patient Care Services/PI • Gary Schweon, Director Environmental Health & Safety • Catherine Mahoney, Assoc. Counsel Legal Counsel • Anne Marie Jarvey, Director Accreditations/Facility Licensure • Frank Rosen, Specialist Regulatory/Medical Staff • Shawna Butler, Specialist Risk Management/Adverse Events • Gerry Abrahamian, Director Medical Records Management • Judy Bieber, Director Human Resources/ER • Leon Goldman, Admin. Officer Business Conduct • Sharon Wright, MD, Director Infection Control • Rosemary Kennedy, Director Radiation Safety • Meg Femino, Director Emergency/Disaster Preparation

10. Information on each Policy Beth Israel Deaconess Medical Center BIDMC Manual Title: Drug Sample Management Number: CP-11 Purpose: To describe how drug samples are managed within the medical center Vice President Sponsor: Kenneth Sands, MD, MPH, Sr. Vice President, Health Care Quality and Director, Silverman Institute for Health Care Quality and Safety Responsible Person: Francis P. Mitrano, RPh MS Title: Director of Pharmacy (sometimes listed as Requestor) Approved By: Operations Council: 2/2/09 Eric Buehrens, Chief Operating Officer P&T: 01/14/09 James Heffernan, MD David Feinbloom, MD P&T Co-Chairs, P&T Committee Original Date Approved: 10/01 Revisions: 6/04, 11/05, 11/08 Next Review Date: 2/2012

11. Accessing P&Ps on the Portal

12. Conducting a Search on the Portal

13. Quick “How to” Conduct a Google Search (live demo) • You can view any policy or policy manual in two ways: • You can view an entire manual by clicking on its title as listed on the portal. • Typing key words into the Search box and then clicking on the manual as it is listed. • To conduct a PPGD search, type key words into the Search box which would be reasonable to assume would be contained in the policy. • If a search doesn’t return anything useful try shortening the search phrase. • Punctuation is generally ignored (so capitalization is irrelevant) • If you have any questions, contact Professional Staff Affairs Office at: 7-1917

14. How do I keep updated regarding changes to PPGDs? • Relevant PPGDs are reviewed at Departmental/ Division Meetings and/or e-mailed and documented that they have been shared with all staff. • Ambulatory learns of them at Leadership • VPs, Directors and Managers communicate PPGD changes that impact your work. • This meeting is an important vehicle for communicating PPGD changes. • Also, as PPGDs are updated there is a website link on the General Portal that will have the monthly updates.

15. Who can help you with PPGDs? • Should you have questions with respect to interpretation, finding a policy, etc., contact a member of the Ambulatory work group. • Your questions help the work group to identify areas that may need guidelines for our use. • The work of the ambulatory group is to ensure updates and to develop ambulatory specific guidelines. • Ambulatory P&P Work Group has made it a point to be involved with Medical Center policy revisions and updates by being a part of the PPGD oversight committee.

16. Competencies • How did we get to this?…regulatory plus pulse check (literally) • Two fold – Support Staff and NP/PA • Training Manual developed for Medical Assistants, Practice Assistants, Practice Representatives and Phlebotomists – Authored by Maureen Mamet, RN in partnership with Heather Wathey Practice Coordinator HCA • Standardized and placed on the shared drive • Expectation: each area updates with specific unit based skills

17. Competencies • The core competencies match to the job description • Training check list developed from the Training Manual materials – Maureen Mamet, RN, Jan Woodruff, RN, Brigitte Bowen-Benitich, Heather Wathey • Competencies Requirements with inclusion of the HR expectations developed and links added– Annie Whatmough, Holly Dowling, Lynne Brophy • Tracking document also developed

18. Competencies

19. Competencies • Expectation: • All support staff in the MA, PA, PR and Phlebotomy positions will complete formal skills training and demonstrate they have completed/met all competency requirements • How do we get there? • Skills Training • Jan Woodruff, RN and Heather Wathey from HCA will do the training for Ambulatory in the following manner:

20. Competencies • Train the Trainer: • Nine departments with a RN and lead MA have sent their representatives to a 4 hour training • Eleven Departments are being scheduled for train the trainer and 4 for MAs. 26 have not responded yet. • The expectation is the representatives will train all their staff by September • “Oddments”: • These classes are for all the remaining Ambulatory MA, PA, PR and phlebotomy staff without department based trainers

21. Competencies • The next series of classes are scheduled for 2 Sessions each day – AM and PM: • Tuesday August 11 • Wednesday August 12 • Thursday August 13 (Lexington) • Tuesday August 18 • Wednesday August 19 • Thursday August 20

22. Competencies • Outstanding Issues to be resolved: • Formalizing the requirements for temps

23. Competencies • Nurse Practitioners and Physicians Assistants • APN Forum – Co-chairs: Jayne Sheehan, APN, Leah McKinnon-Howe, APN, and Barbara Rosato, APN • Work completed: • Practice Guidelines • Competencies • Supervising physician responsibilities • Competency Requirement Checklist (with links) • Prescription Audits

24. Competencies

25. Competencies • Outstanding Issue- to be resolved this month: • Linking with credentialing • Supervising physician and performance evaluations loop • Billing • Standardization –inpatient and outpatient, BIDMC and HMFP • Standardized Performance Evaluation

26. Competencies • Clinical Nurses • Competency Requirements Developed and on the shared drive – S:\Ambulatory Joint Commission\STAFF COMPETENCY INFORMATION • Performance Evaluations – Signature required by a Nurse Manager and in the absence of a nurse manager Jayne will co-sign. • BLS/ACLS – Sheila Goggin is tracking. HR notifies Sheila of the new hires and BLS/ACLS status. • Job Descriptions will be updated requiring all CN have BLS and if not within 60 days of hire

27. Competencies • Clinical Nurses and NP/PA License Tracking • Sheila Goggin is keeping a centralized list • Sheila’s list is dependant upon us notifying her when we hire. • OneStaff is not the trigger for this list.

28. Chart Audit (Leads: S. Hewitt/L. Brophy) Past Concerns: • Not fully meeting the intent of chart audits; • Conducted audits, didn’t see the results by unit and/or aggregate for all of Ambulatory; • Hard to make a plan of action; • Unit specificity lacking; • Two separate audits: chart and med reconciliation.

29. Goals of Chart Audit • Use data to drive positive change in real time; • Provide meaningful data for Ambulatory and allow unit specificity where needed; • Ensure regulatory compliance; • Meet Medical Center requirements.

30. What about Medication Reconciliation? • Medication reconciliationauditing will be integrated with chart auditing; • Combined 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

31. Standardized Department name – Pick menu not free text New Chart Audit Questions

32. New Chart Audit Questions

33. New Chart Audit Questions

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. • 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.

35. 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.

36. New Chart Audit Start-up • Roll out of the new integrated chart audit will begin in August. • By Monday July 20th, supply Lynne via email the name of your clinics/departments for the drop down pick option (#1 on survey) • We will want the name of your auditor(s) for providing any training that might be needed and to give feedback if indicated. 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.

37. PACE Audits • The PACE audit form is under revision by the work group. • Information will be recorded within Performance Manager and results will be provided to you similar to chart audit results. • 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.

38. Mock TJC Surveys • We will resume mock surveys on the units to ensure Every Day Readiness. • Goal is to help staff to comfortably and reliably respond to a Joint Commission surveyor 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