Jayne Sheehan Diane Gilworth

1. Jayne SheehanDiane Gilworth TJC Ambulatory Monthly Meeting March 11, 2009

2. Agenda • 11:00-11:30 – Jayne Sheehan, • TJC mock survey overview- celebrating our success and learning from the opportunities • 11:30-12:15 • TJC specifics – Success Opportunities for Improvement • Yolanda Millman-Richard • Janet Lewis • Sheilah Janus • Kerry Brown • 12:15-12:30 Bill Pyne • Updates on Ambulatory code cart exchange

3. 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 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 Vulnerabilities: Areas identified by Mock Survey

4. “Early Risers” (Kim/Kirsten) Public Safety Ambassadors Admissions Facilitator Service Response Food Services Service Response Telecommunications Information Systems Communications Human Resources TJC Facilitators Escorts to the “Surveyors” Staff from the following areas: ED CC6A Perioperative Services Digestive Disease Center Farr 2 Interventional Radiology Pain Clinic Chest Disease Center Stoneman 6 Labor/Delivery Feldberg 6 Deaconess 4 Special Thanks to :

5. Assessing The Notification/Logistics Plans • Paging for Assembly • Senior Leaders Greet Survey Team at 9am • Individual Communication Networks Activated • Patient Care Services • Ambulatory /ED Services • Meeting/Work Rooms Secured • TJC ‘Communication Center’ Operationalized • Community Wide Email /Greeting Announcement • Ongoing Updates re: Focus and Findings via the TJC Public Calendar

6. Assessing with ‘Fresh Eyes’ • Visits to Interventional Procedure Areas • GI, Interventional Radiology, CDC, Pain Clinic • Inpatient/ED Patient Tracer • Perioperative Patient Tracer • OB Patient Tracer • Ambulatory Clinic Patient Tracer • Medical Record Documentation • HR Record Reviews

7. Where Are We After the Past 2 Days? Internal State of Disaster Good Program, “tweaking” needed Best in Class Much Work to be Done Systems/Processes

8. The Themes of Findings • Policy Related • Complex: Opportunity to weed and focus on standards before setting the bar toward best practice • Multiple Source Documents: Opportunity to Consolidate • Staff Awareness was inconsistent • Lack of Specificity re: Accountability • Seen in Med Rec Process (Inpatient) • Assessment of Patients • Documentation Gaps/Complexity • Omitted / Disjointed Content • Multiple Source Documents for same subject • Difficult to Navigate • Doesn’t always reflect care processes • Forms don’t prompt for process steps • Inconsistency with ‘Universal Protocol’ • Varying approaches, tools and checklists in OR, OB, Procedure Areas

9. The Particulars…… • Documentation • Flow of Content • (Assessment  Problem List  Care Plan  Goals) • Completion • Post Procedure Documentation • Timing/Dating/Authentication • Consent for Procedure/Intervention • Patient Education • Audit Processes • what is looked at/how are results shared and used for PI • Medication Reconciliation (Inpatient) • Restraints = Immobilization in the ICUs

10. The Particulars…… • Medication Management • Emergency Medication Storage/Availability/Surveillance/Disposal • Staff Education re: Look Alike/Sound Alike and High Risk Meds • Labeling • Blood Draw Labeling in presence of patient • Specimen Labeling • Medication Syringe Labeling process • Universal Protocol • Critical Tests/Critical Result Reporting • Staff Awareness of Process • Measures of Success - 12months Order Result

11. Next Steps • Vetting through the Clinical Operations Group for • Policy Changes • Process Improvements • Development of Resources/Supports • Work Plans and Actions will be defined over the course of the next few months

12. TJC Specifics • Celebrating our success and learning from our opportunities • Yolanda Milliman-Richard • Janet Lewis, • Sheliah Janus • Kerry Brown

13. Mock Survey Review • Focus of the survey in your area • what did the surveyor ask, any surprises, any area in which you felt unprepared? • Did the sweep documents help • are there any additional things we should be doing to help your staff prepare/help you? • Nursing/MD response to the surveyor • (in all cases the staff were superb and were able to really articulate the care processes)- can we improve this? • Suggested areas for improvement • did the survey find anything that surprised you?  • What would you change • as a result of the survey

14. Jayne SheehanDiane Gilworth Thank You March 11, 2009