Jayne Sheehan Diane Gilworth February 11, 2009

1. Jayne Sheehan Diane Gilworth February 11, 2009

2. Agenda • 11:00-11:10 – Jayne Sheehan, introductions, vulnerabilities- med management • 11:10-11:20- CQI/Medication Management in Derm Surgery, Sheilah Janus, Dr. Daihung Do • 11:20-11:30 – JC Readiness-updates Jayne Sheehan • 11:30-12:00- Medication management-code carts, Allison McHugh • 12:00-12:20 – Policy & Procedure Subgroup Update Sandy Hewitt • 12:20-12:25 Tool box update, Lynne Brophy • 12:25-12:30- Medication management reminders and Chart Audit Update Diane Gilworth

3. Vulnerabilities-just a reminder Patient Rights Patient and/or Family Involved in Decisions Health Care Proxy Identifying /Involving in Care Informed Consent Provision of Care Patient Education Assessing Learning Needs Evaluating Comprehension Pain Assessment/Reassessment ** Restraints Timely Orders Ongoing Assessment National Patient Safety Goals 2 Patient Identifiers Administering Medications Collecting Blood Labeling Containers In Front of Patient Write Down/Read Back Recording Calls to Floors/Units Hand Offs – up to date and pertinent information with opportunity to ask questions To/From Procedure and Test Areas Intra-Hospital Transfers Medication Labeling Going to Gemba Transferring from original container Detailed information on label Medication Reconciliation ** Intra-hospital Transfers Outside Providers Patients National Patient Safety Goals (Cont.) Anticoagulation Therapy Process to implement an enterprise-wide Anticoag Therapy Program Universal Protocol Operative / Procedural Area/ Bedside Verification of Side/Site/Procedure Marking of Site Time Out Immediately Before Procedure Medical Staff Standards Bylaws Related Timeliness of Reappointments Human Resources Decentralized Monitoring of Competencies Performance Evaluations Staffing Effectiveness Exercise 2008-09 Infection Control Use of PPE PPD Screening Information Management (Medical Records Related) Aggregate Reports of Compliance Streaming through HIM Committee Performance Improvement Collecting/Analyzing/Using Data for Improvement Staff Knowledge of Priorities

4. Going to Gemba…Go and See • Genchi Genbutsu: One of the fundamentals of the Toyota way. • In short this means, “Go to the actual scene (genchi) and confirm the actual happenings or things (genbutsu)” “The record suggested that people got hurt not because they are stupid but because they found themselves in circumstances in which it is easy to get hurt and hard to be safe” • Key Capabilities: • Seeing problems as they occur • Swarming & solving problems as they are seen • Spreading new knowledge • Leading by developing capabilities 1,2 & 3

5. Dermatology- CQI project LOCAL ANESTHETIC PREPARATION, STORAGE, TRANSPORT, AND ADMINISTRATION POLICY Sheliah Janus, Daihung Do MD

7. Reviewing our Progress Jayne Sheehan

8. Chapters Content of our work On Line “Joint tool Box” Integrated learning • For Each Chapter • Key Concepts • National Patient Safety Goals • Related Policies/Procedures • Resources • -on-line • -staff • Related sub-group activity Ethics Rights-Resp September 08 Provision of Care October/November 08 Med Management December 08 Safety/Disaster Management January-09 Surveillance, Prevention of infection February-09I Improving Organizational Performance March-09 Leadership EC/R Power of the group • Sub- Groups • Policy/Procedures • CQI/chart audits • Scope of Practice • PACE Audits • License Verification • Anti-coagulation

9. Sub-groups, -The “why and what” • Goal: • increased the number of engaged “experts” – integrated knowledge for all • Integrate knowledge of JC into everyday practice • CQI/scope of service, Lead - Jason Laviolette • JC documents which will be reviewed during initial sessions-guide the survey process • PACE Audits, Lead - Stephanie Tarantino • Reviewed unit based PACE audits/concordance with hospital wide PACE audits- measures to make this data available to you in real time- JC requirement • License Verification, Lead Diane Gilworth • JC standard- primary source documentation/central verification process- in place for all ambulatory RN’s and NP’s • Policy/Procedure sub-group, Lead - Sandy Hewitt • Re-organization of policies and procedures- tool boxes • Anticoagulation, Lead - Louise Mackisack • JC standard and high risk medications.

10. Readiness PreparationJayne Sheehan

11. An Unscheduled JC Visit- your role • Clean sweep- “25 steps to a sweeping success” • No food, drinks, clean corridors • Staff –badges • PACE • RACE • HIPPA • Have a tracer patient in mind • Code Carts- checked, locked • MDs- everything you need to know about JC • National patient safety goals

12. 25 Steps to a Sweeping Success

13. Codes and Emergency Management of Medications Allison McHugh

14. Policy and Procedure Subgroup Update Sandy Hewitt

15. What is our Charter? • Provide periodic and systematic review of P&Ps to ensure they reflect current practice and comply with appropriate guidelines and mandates. • Determine what general P&Ps need modification for Ambulatory purposes. • Ensure standardization of those Ambulatory P&Ps specific to us. Ex: some HR policies. • Improve ease of access to P&Ps. • Locate Ambulatory’s P&Ps on the “Ambulatory Services” site on the portal. (Lynne’s Tool Kit)

16. Request of you…… We’ll be sending an e-mail requesting you to please tell us: • Which policies and procedures you refer to most frequently. • Which policies and procedures do you have trouble finding. • If there are policies and procedures you wish we had.

17. C. More to come

18. Tool Box Lynne Brophy

19. Chart Audits-updates Diane Gilworth

20. Chart Audit Process 2009 and beyond Better Best Good Create a new more clinically Relevant chart audit Data is available real time- unit specific-CQI Clinicians would do all Chart audits- MD’s, NP’s , RN’s. Continue with present chart audits Review your data and be prepared to discuss with the JC Reformat questions for easier documentation Clarify # of chart audits per unit Define what it means to be compliant Get data back to you in a timely manner

21. Chart Audit Proposed chart Audits 2009 Ambulatory unit- drop down menu for all units Add in # of charts to be done within a quarter- (based on unit specificparameters) Data comes back to you in a timely manner

22. Chart Audits • Problem list is updated and reviewed (within last 12 months) Yes/No • Allergiesare reviewed and updated (within last 12 months) Yes/No • Medication list is up to date • (on a quarterly basis the medication reconciliation survey could be rolled into the chart audit to reduce the number of actual surveys done per unit) • Yes/No • Summary list is present- by 3rd visit- • this list included known and significant medical diagnosis and conditions, known significant operative and invasive procedures, known adverse and allergic drug reactions, know long term medications, including current prescriptions, over the counter drugs and herbal preparations. The list is quickly and easily available for practitioners. • Yes/No • Consent forms are present as applicable for invasive procedures. • general consent includes a discussion of: a. the nature of the proposed care, treatment, services, medications, interventions, likelihood of achieving goals, reasonable alternatives, relevant risks and benefits, side effects related to alternatives, including possible results of not receiving any therapy, ….. • Yes/No

23. H & P is present • ( need language to determine what counts as an H&P) Yes/No • Pain assessment is documented as appropriate • (would recommend standardizing pain assessment tools and if possible creating space within web OMR for direct documentation) • (provide link to pain assessment tool) • Yes/No • Pain is reassessed at subsequent visits. • A comprehensive pain assessment is conducted as appropriate to the patients condition and the scope of care, treatment, and services provided. (would recommend standard reassessment tools and standard template for documentation in Web OMR) • (provide link to pain reassessment tool) • Yes/No • Advanced directive is present- • new field in Web OMR (documentation indicates whether the patient has signed an advance directive) Yes/No

24. Medication Management • Medication management policy/competency on line • Prohibited abbreviations (hand-out) • Multi-dose vial- 28 days- pharmacy policy • Refrigerator Alarms (change battery and check green sticker) • Medication questions –posted on portal

27. Refrigerator Alarms • Refrigerator temperature ranges should be between 36 and 46 degrees Fahrenheit, • if alarm sounds: • Turn alarm off. • Check to see if refrigerator is functioning properly. • C all service response at: 617-632-0070. • Call Pharmacy about interim medication storage. • It is necessary to reset the unit whenever a change is made to c / F temperature. • To reset the unit, use a pointed object to push the RESET button on the back of the unit. • Click mode to Lo to Hi, set Lo (36oF) Hi (40oF) turn alarm ON. • Order back-up batteries replacement 1AA battery.

28. Thank you Jayne Sheehan Diane Gilworth