FLORIDA ORTHOPEDIC RISK PURCHASING GROUP
Patient Safety Premium Credit Program
PHASE I: SELF-ASSESSMENT
CONFIDENTIAL
Policy Number:
Practice Name:
Address:
Contact Person:
Phone:
E-Mail:
Number of practice sites:
Average daily patient census:
Average number of surgical procedures per week:
List 5 most prevalent procedures performed in past 12 mos.
Physicians
Advanced Practice
Providers
Employees
Contracted
Practitioners
Locum Tenens
Employees
Orthopedic
Surgeons
RNs
LPNs
Podiatrists
MAs
PAs
NPs
Orthopedic
Techs
Approximate # of cases
Physical
Therapists
X-Ray
Techs
Other Clinical Staff
Other
Non-Clinical Staff
Full Time
Part Time
1
LEGEND
Failure to meet criteria has resulted in claims or patient harm– Correction within 3 months
is recommended.
Failure to meet criteria contributes to patient harm or claims. Correction within 6 months
is recommended.
Important for patient safety risk mitigation – Correction within 12 months is recommended.
PHASE I INSTRUCTIONS:
Please indicate whether criteria are consistently met or
inconsistently met by placing a checkmark in the appropriate column. Use the comment
column to identify areas that you would like to discuss with your risk manager or to provide
additional insight into your office protocols pertaining to the criteria. The recommendations
listed below each section are offered as guidance. Please complete all applicable sections or
place “N/A” in the comment section. You may use one assessment tool for the practice;
however, please note any variances between practitioners in the “Comments” section. Upon
completion please return to: sstrickland@thedoctors.com.
1 - DIAGNOSTIC TRACKING
M = Met
I = Inconsistently completed/implemented
1. A diagnostic tracking system is fully established to
include:
1.1. A process for reconciling diagnostics ordered with
results received.
1.2. By proactive tracking and action taken if
diagnostic results not received timely.
1.3. The process is not dependent on passively
waiting for receipt of diagnostic reports or on a
return appointment by the patient.
1.4. There is evidence to indicate practitioner review
of all diagnostic results prior to reports being
placed in the chart (permanent section of EHR, if
utilized).
1.5. A process exists for notifying patients of all
diagnostic results, including those that are
normal. Validation of notification is evidenced in
the medical record.
M
I
Comments:
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
2
1.6. When there are abnormal diagnostic findings and
the patient cannot be reached by telephone, an
alternative procedure for patient notification is
established. Validation of alternative notification
and patient plan of care is evidenced in the
medical record.
1.7. When panic values are received, a process for
immediate patient notification is established.
Such notification and a patient plan of care are
evidenced in the medical record.
☐ ☐
☐ ☐
1 - DIAGNOSTIC TESTING RECOMMENDATIONS
An established diagnostic tracking system will enhance patient care by ensuring that ordered
diagnostics are completed, results received timely, and patient follow-up is initiated. An
effective process will reduce the likelihood of missed results while reducing patient harm and
ultimately avoiding a liability claim.
Process improvement strategies:
(1.1/1.3) Assign specific personnel to proactively manage outstanding diagnostic results.
(1.1/1.2) Develop & utilize an outstanding tracking log. As an alternative, or to accompany the log,
consider use of an alpha system retaining copies of outstanding requisitions in the file until results
reconciled.
(1.4) Require practitioner to review of all results prior to filing in the medical record. Practitioner
initials and date of review is a primary method while alternative methods for the EHR may be
used.
(1.4) Include documentation of physician instructions/direction to staff for applicable result
management.
(1.5) Communicate all diagnostic results, including normal results to the patient. This can be
completed by telephone call by office personnel.
(1.5) As an adjunct to telephone calls, utilize a standard letter for notification of normal results.
(1.5) Encourage patients to call the office for results if not notified within reasonable time period.
(1.6/1.7) For abnormal results, it is recommended that a licensed practitioner notify the patient.
(1.6) Require documentation of a plan of care/staff instructions based on practitioner review, as
applicable.
(1.6) Document patient non-compliance with plan of care.
3
(1.6/1.7) Develop a contingency for notifying patients of abnormal results, including panic values
when unable to reach by telephone. This could include notifying the person listed as authorized to
receive medical information and lastly the emergency contact listed.
(1.6/1.7) Include contingencies for physician review and patient notification and care (when
applicable) when the primary practitioner is unavailable.
Consider random or scheduled medical reviews to monitor the diagnostic tracking process.
Use of EHR functions may provide automation for some steps in the process. (Do not rely on
individual physician alert inboxes for tracking outstanding results).
Additional information:
http://www.thedoctors.com/groups/public/@tdc/@web/documents/print_pdf/con_id_004096.pdf.
2 - APPOINTMENT MANAGEMENT
M = Met
I = Inconsistently completed/implemented
M
1. The appointment management system includes
tracking and follow-up of important appointments,
including post-op, post procedure, post hospital
discharge, post- consultation and specialty specific
follow-up. Tracking is evidenced in the electronic
scheduling module.
☐ ☐
2. Missed appointments (no-shows and cancellations
without immediate re-appointment) are reviewed by a
licensed practitioner for re-appointment disposition.
Validation of the missed appointment, review, and
action taken are evidenced in the medical record or
as an alternative, the electronic scheduling module
(Practice Management Module).
☐ ☐
3. Post-operative infections are monitored and analyzed
for possible causes and necessary interventions.
I
Comments:
☐ ☐
4
2 - APPOINTMENT MANAGEMENT RECOMMENDATIONS
(2) Communicate to the physician of missed appointments that are not immediately re-scheduled
for staff instruction on re-appointment disposition, including documentation of such instruction and
follow-up based on instruction.
(2) Document in the scheduling module and/or the medical record of all efforts regarding
appointment management as well as for evidence of non-compliance.
Review of non-compliance with the patient including documentation of discussion about the health
consequences of continued noncompliance. Consider using the AskMe3© to ensure patient
comprehension.
(2) Note all actions and keep copies of all letters sent to the patient in the patient’s medical
record.
(1) For preventive care appointment reminders, establish a “recall” process for notifying patients
of time-sensitive tests such as Mammograms, cholesterol screening, PSA testing, etc.
(3) Reminder tool suggestions include: automated reminder software, postcard mailings, and
phone calls.
(2) Provide patients with education materials to increase awareness and enhance likelihood of
completing such testing or return appointment for examination.
3 - PATIENT INFORMATION
M = Met
I = Inconsistently completed/implemented
1. The patient completes a written history form or the
history in a patient interview is entered into the
medical record at the initial visit.
2. The history form is periodically updated with the
patient and updated in the medical record.
3. DVT assessment for all patients having hip/knee
arthroplasty is performed.
4. The orthopedic surgeon adheres to the site marking
and time-out procedure used in the operative
facilities.
M
I
☐
☐
☐
☐
☐
☐
☐
☐
Comments
5
5. Patients who have undergone rehab (a series of
physical therapy/occupational therapy/rehab
treatment modalities) are not discharged from the
practice until they are seen and evaluated by their
physician.
☐
☐
3 – PATIENT INFORMATION RECOMMENDATIONS
A complete patient history is essential to providing safe patient care. An organized template
containing all needed information will assist in provision of care. Such information is useful
for all subsequent care, including diagnosis, plan of care, medication regimen, and further
understanding of patient’s own health history.
Process Improvement Strategies:
(1) Utilize a patient generated history form that contains all needed past and present medical,
surgical, social, medication, and other information based on specialty, including:
 Patient demographics/emergency contact information.
 Current problem/reason for visit.
 Medical conditions, including pregnancy, past operations, hospital admissions and
recurrent problems.
 Personal and family health history.
 Allergies to medications and other (i.e., dietary or environmental).
 Current medications.
 Immunization history.
 Personal habits (smoking, tobacco, exercise, safety such as seat belt use, alcohol).
 Environmental/occupational hazards.
(1) Questions should be brief as to allow for patient understanding.
(1) Include patient signature and date lines on form as evidence as patient completion.
(1) Include practitioner signature and date lines as evidence of review.
(1) Review of completed forms by front line staff directly with the patient prior to physician exam
can enhance completion of critical history while assisting the physician in subsequent patient
interface based on a completed form.
(2) Establish a timeframe for patients to complete a new patient information packet. Consider
annually for full form completion while reviewing the initial form at each visit. This can be a simple
review and Q&A of asking the patient, “Has anything you’ve written on your history form changed
since your last visit” with emphasis on medications, hospitalizations, illnesses, not already known
to the practitioner.
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4 - TELEPHONE COMMUNICATION
M = Met
I = Inconsistently completed/implemented
M
I
1. There is an established system for telephone
communication that includes tracking,
documentation, relay and practitioner response to
relevant in-coming telephone calls.
☐
☐
2. There is an established system for after hour
telephone communication that includes tracking,
documentation, and relay and practitioner response
to after-hours telephone calls.
☐
☐
3. The system is used when the following occur:
3.1. Prescribing of changing medications.
3.2. Making a diagnosis.
3.3. Directing treatment.
3.4. Directing patient to another practitioner or
facility.
☐
☐
☐
☐
☐
☐
☐
☐
4. The documentation reflects a standardized
communication process including,
4.1. Full name and DOB of caller, if patient.
4.2. Nature of the call.
4.3. Disposition provided by staff, by whom.
4.4. Physician review and instructions for patient, if
applicable.
4.5. Follow-up taken based on instructions, if
applicable.
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
5. Written protocols are esblished for front office/nonlicensed personnel for responding to patients as
developed by practitioners.
☐
☐
Comments:
7
4 – TELEPHONE COMMUNICATIONS RECOMMENDATIONS
Telephone calls are an essential part of communication within an office setting. A
standardized process will ensure information is managed fully while maintaining effective
documentation in the process. Written procedures must be established for non-licensed staff
managing phone calls. Documenting after-hour phone calls is often missed, but as important
as documenting office hour calls.
Process improvement strategies:
(1) Establish use of a standardized format for managing and documenting in-coming telephone
calls. Ensure all staff members use the same process to reduce the likelihood of incomplete
follow-up of calls and missed patient care.
(1/3) Include complete documentation of the telephone call as evidence of care and treatment.
(1/3/4) Use of a pre-defined call sheet/call log that is patient specific can be useful to fulfill the
standard. To be effective a patient specific call sheet should include:
 Full name and Date of Birth of patient.
 The caller if different from patient.
 Nature of the call.
 Disposition provided by staff, by whom.
 Physician review and instructions for patient, if applicable.
 Follow-up taken based on instructions, if applicable.
 Date and time call received/ Date and time call made.
After hour calls
(2) Establish a process that ensures documentation of after-hour telephone calls.
(2) Use of various tools can assist in compliance.
(2) Use of a note pad used to enter relevant information for later entry into the medical record
(next business day in most cases).
(2) Use of dictation using transcription service for entry in the medical record.
(2) Use of office voicemail immediately following the call for entry in the medical record.
(2) Use of answering service information about calls put through to the on call practitioner. Office
staff can approach the on call practitioner the morning after call and make notes about the calls
received, to include the symptoms reported and the advice given.
Written Protocols
(5) Given the limited professional education, unlicensed medical assistants and licensed practical
nurses should not provide medical advice to patients without practitioner intervention or
consultation.
8
(5) Establish written protocols outlining specifically what medical assistants may say to patients
when managing certain types of calls.
(5) Otherwise, defer all patient telephone calls where medical advice is requested to a registered
nurse, nurse practitioner, physician assistant or physician.
(5) Medical assistants and licensed practical nurses can obtain the basic information from a
patient during a call, such as name, medications the patient is taking, allergies and substance of
the patient’s question.
(5) The medical assistant or licensed practical nurse can follow up with the patient as to the advice
or recommended care provided by the practitioner and document the contact into the medical
record.
5 - MEDICATIONS
M = Met
I = Inconsistently completed/implemented
M
I
1. There is a medication list in the medical record to
include:
1.1. Prescribed medications.
1.2. OTC.
☐ ☐
Vitamins, herbals, and supplements.
☐ ☐
1.3.
Comments:
☐ ☐
☐ ☐
2. The list is updated at every visit.
☐ ☐
3. The list is in a prominent and easily found location.
4. Allergies are indicated on all records in a
conspicuous fashion with NKA as
appropriate.
☐ ☐
5. Pain management treatment plans include
objective measures of success, such as
documenting the level of pain during each
encounter rarely acceptable.
☐ ☐
9
6. A written policy is in place or acute pain
management to include:
6.11 Physician only prescribes schedule II
medications.
6.12 Strict oversight as to appropriate duration of
narcotic use for acute pain management.
6.13 No premature refills, no after-hour refills as a
rule.
☐ ☐
☐ ☐
☐ ☐
6.14 Patient education to include dangers of
combining narcotics with alcohol, street drugs,
other medications without doctor’s advice.
6.15 Referral of patients who need chronic pain
management to a chronic pain management clinic.
Strict policy prohibiting management of chronic
pain patients who have been dismissed from
chronic pain clinics.
7.1 Chronic Pain Management Practice is directed
with written policies and procedures, not limited
to, but including:
a. Establishment of medical/surgical
appropriateness.
b. Negotiation of Opioid Contract with strict
enforcement.
c. Compliance with Florida Administrative codes.
☐ ☐
☐ ☐
☐ ☐
☐ ☐
5 – MEDICATIONS RECOMMENDATIONS
Process improvement strategies:
(1) As part of the patient generated history, ensure the form contains a medication and allergy
section as outlined in section 4 (patient information). Ensure herbals and over-the-counter (OTC)
medications are included.
(1) As part of verification, actively review completed medication and allergy history with the patient
directly along with other patient history. Blank spaces should be a trigger to further clarify if the
patient is taking any medications and if he/she has drug/food allergies. Request the patient fill in
the blanks if applicable. No known allergies (NKA) should be specified rather than the space left
blank.
10
(1/3/4) To continue the medication reconciliation process, translate patient generated
medication/allergy history to an office generated medication list. The list should include all
medications currently taken, not those prescribed only by the practitioner seeing the patient.
Allergies should also be prominently located on the medication sheet/template. This section can
then be used as the master reference for listed allergies.
(2/3) To ensure an accurate and current medication list, review medication/allergy history at each
visit. Update the list as needed. Documentation of such review at each visit can be completed by a
pre-defined check box on the medication page. This step can be completed by someone other
than the practitioner prior to exam.
(2/4) Consider providing a printed list of current medications with allergies to the patient at each
visit and ask that they bring the list with them with updates to each visit. This can be used as a
medication reconciliation reference.
6 – MEDICAL RECORD
Section 6 - Standard: Medical Record
M = Met
I = Inconsistently completed/implemented
Type of Medical Record:
☐ Paper
☐ Combined/Hybrid
EHR System:
☐Advanced Data Systems
☐ AdvancedMD
☐ Allscripts
☐ AthenaHealth
☐ eClinicalWorks
M
I
Comments:
Are you satisfied with your EHR?
☐ Yes
☐ No
List any shortcomings:
☐ Electronic
☐ eMDs
☐ GE Centricity
☐ NextGen
☐ Practice Fusion
☐ SoapWare
☐Other
☐ ☐
1. For paper records, the chart is legible.
☐ ☐
2. Corrections to the records are completed accurately.
3. A DVT assessment is documented in the medical
record.
4. Documentation of each visit includes:
a) Chief complaint/purpose of visit and HPI, as
indicated.
☐ ☐
☐ ☐
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b) Review of Systems and status of chronic
conditions, as indicated.
c) Review of Histories, as indicated.
☐ ☐
☐ ☐
d) Review of tests/consultants.
☐ ☐
e) Diagnosis or impression.
☐ ☐
f) Plan of care, interventions, treatments, or
prescriptions given.
☐ ☐
g) Patient’s response to and compliance with
interventions or treatments.
☐ ☐
i) Verbal and written discharge instructions.
☐ ☐
☐ ☐
j) Follow-up plan.
Number of records reviewed (3 to 5 per physician recommended):
6 – MEDICAL RECORDS RECOMMENDATIONS
A complete, accurate, and legible medical record provides the entire healthcare team with
understandable and readable information, such that, a correct plan of care can be generated
without delays. Outside organization/external reviewers will view the record favorably.
Corrections and other revisions to existing entries must be standardized across the
healthcare organization to prevent loss of information while maintaining the integrity of the
medical record.
Process Improvement Strategies:
Illegibility:
(1) As an adjunct to illegibility that is unable to be rectified, consider use of dictated entries.
(1) Use of checklists is another option where frequently gathered data can be indicated with
minimal writing, reducing the impact of legibility issues.
(5) The use of scribes is another method to aid in documentation.
Corrections:
(6) Establish a standardized process for making entry corrections in the medical record. Educate
all staff and practitioners to further ensure a standardized process is followed. A written procedure
can act as a resource for staff/practitioner review.
(2) For paper charts – Avoid obliterations, erasures, and scratch outs.
Consider use of a strikethrough with initials and date to indicate as an incorrect entry. If
applicable, follow this with a correct entry.
12
(2) For the paper chart -- If an entry has been identified as an error after subsequent
documentation has occurred or much time has passed, consider an addendum specifying what
entry was entered in error followed by the corrected entry.
(3) For the EHR - Avoid deletions, and other steps that render the original entry unreadable.
Changes made to entries during the same charting session (prior to signing
off/authenticating/finalizing the entry) do not require indication as an error and correction.
(3) For the HER - Consider use of an “addendum” to make corrections when identified after
signing off/authenticating/finalizing the entry.
(2/3) Consider administrative review of intended charting prior to of all high-risk situation charting
involving corrections, late entries, addendums, and amendments.
(4) Implement a documentation template, checklist, or guidelines to prompt physicians and other
care providers to document: chief complaint or reason for visit, review of systems, review of
histories, as indicated, clinical findings, diagnoses or impressions, review of diagnostics and/or
referrals, plan of care including interventions, treatments, or prescriptions or samples given;
patient’s response and compliance, instructions provided, and follow-up plan of care, including
follow-up visit recommendations. Encourage physicians to utilize the standardized documentation
template, checklists, or guidelines to document patient encounters. Audit charts periodically to
ensure compliance with documentation requirements.
7 - INFORMED CONSENT
M = Met
I = Inconsistently completed/implemented
1. An appropriate informed consent document is
present
M
I
☐ ☐
2. The informed consent discussion (risks, benefits,
alternatives and patient expectations) is
documented.
☐ ☐
3. When a patient refuses recommended therapy the
discussion with the patient is documented in the
medical record
☐ ☐
4. Specific written informed consents are obtained for
off-label use of drugs or medical equipment.
Comments:
☐ ☐
13
7 – INFORMED CONSENT RECOMMENDATIONS
Informed consent is required for all invasive and complex procedures. An effective process
includes not only practitioner to patient discussion(s) and education but also evidence of
such discussion. A written document signed by the patient is further evidence of the patient’s
informed decision to proceed or not proceed (consent to refusal) with the recommended
therapy. To ensure consent forms are well written while ensuring all aspects of documentation
are evidenced in the medical record, consider review of specialty specific informed consent
forms via The Doctors Company website link:
http://www.thedoctors.com/KnowledgeCenter/PatientSafety/InformedConsent/index.htm
Process improvement strategies:
(1) Identify procedures that require informed consent and take inventory that specific forms are
available. This includes not only the informed consent forms, but education materials such as
brochures, video clips, and/or education sheets and other materials as identified as useful in
teaching. Evidence of providing such education should be documented in the medical record.
(2) Ensure practitioners (this cannot be delegated in most instances) conduct a meaningful
informed consent discussion by having a dialogue (more than once in many cases) with the
patient (and/or legal representative/family member) about proposed treatment recommendations.
Include in the discussion, risks and benefits, alternatives, and risks of refusal. This information
must be communicated in terms a patient can understand.
 An Interpreter may be necessary for LEP patients while assistance may also be needed for
hearing impaired/visually impaired individuals.
(3) Ensure documentation of the informed consent discussion is completed by the practitioner.
This can be made as a separate entry in a progress note or as evidenced on the informed consent
document that contains a risks/benefits statement including physician signature and date. See
Essential Elements of Effective Informed Consent (short video)
http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/index.htm?sub=14
(4) Informed Refusal should also be documented in the medical record including the signature of
the patient indicating refusal (see sample informed refusal form in link below). The written
documentation should include the key risks in not proceeding with the test or treatment.
8 - RADIOLOGY SERVICES
M = Met
I = Inconsistently completed/implemented
1. Interpretations and reports are supplied in a timely
manner.
M
I
Comments:
☐ ☐
☐ ☐
2. Radiologist provides consultation and over reads.
14
3. Reports are labeled and dated and placed in the
medical records after physician review.
4. Mechanism is in place to notify physicians and
patients of discrepancies in film interpretation.
☐ ☐
☐ ☐
8 – RADIOLOGY SERVICES RECOMMENDATIONS
Providing diagnostic services can create considerable risk for a medical practice, in that
without accurate diagnostic data, the physician’s ability to reach a reliable diagnostic
conclusion may be compromised.
Process Improvement Strategies
(1) Assign responsibility and oversight of all radiology procedures to a properly trained and
qualified physician. Responsibilities of the director include development and implementation of an
operations manual, establishment and documentation of a quality control program, performance
reviews including competency testing, documentation of the preventive maintenance and service
of all equipment, maintenance and follow-up of diagnostic tracking, and compliance with safety
mandates. The Director must ensure interpretations and reports are received timely and that
orders for procedures are appropriate, including radiology/oncology orders. Implement a tracking
and follow-up system to ensure that all radiology reports are completed and the results received in
a timely manner. Most radiology reports should be available within 2 - 14 days after completion.
The system should include a mechanism to identify delinquent reports. An effective system will
include monitoring and tracking of all pending reports through receipt and review by the physician,
initialing to indicate physician review, and appropriate follow-up and discussion with the patient in
a timely manner. Patient notification and any follow-up recommendations should be documented.
(2) Enlist a radiologist to over-read any questionable diagnostic results and provide radiology
consultation.
(3) Implement a policy regarding filing radiology reports that includes a requirement that only
reports that indicate physician review are attached to the medical record and that patient
notification has been completed and documented.
(4) Implement a mechanism to notify patients of discrepancies in the initial interpretation. Utilize a
Performance Improvement program to monitor compliance. Review a percentage of charts
(such as high frequency or problem prone radiology procedures) to determine detection and
follow-up of discrepancies.
15
9 - OFFICE-BASED PROCEDURES
M = Met
I = Inconsistently completed/implemented
1. Ambulatory surgery or invasive procedures should
comply with all appropriate federal, state, and
private regulatory standards with respect to physical
facility, equipment and staffing requirements:
(1) “Options” notice is posted.
M
I
Comments:
☐ ☐
(2) Appropriate level of emergency equipment is
available and monitored.
☐ ☐
(3) Appropriate level of monitoring equipment is
utilized.
☐ ☐
(4) Transfer agreement with near-by hospital is
enacted.
☐ ☐
2. Invasive procedures are not performed in the office
for which the physician does not have hospitalprivileges.
☐ ☐
3. The physician performing office procedures when
more than local anesthesia is provided is ACLS
trained.
☐ ☐
4. A CPR trained professional staff member dedicated
to monitoring the patient is used when providing
more than supplemented local anesthesia.
☐ ☐
5. Monitoring, when providing more than
supplemented local anesthesia includes pulse
oximetry.
☐ ☐
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6. Procedures are documented, including “time-out” to
identify patient, procedure, site, medications given,
intraoperative monitoring, and post-procedure and
discharge status and instructions.
☐ ☐
☐ ☐
7. Written discharge instructions are given to the
patient and the responsible adult caregiver.
8. Follow-up telephone calls are made to patients
within 24 hours of a procedure.
☐ ☐
9. Sterilization procedures follow manufacturers’
guidelines/infection control standards.
☐ ☐
a) Sterile supplies are dated and checked.
☐ ☐
☐ ☐
10. Single use items are not cleaned and reused.
9 – OFFICE–BASED PROCEDURES RECOMMENDATIONS
Of the top allegations involving surgical claims in the office, respiratory failure and airway
obstruction, due to over-sedation and/or failure to monitor and treat the patient are listed
among the most frequent and severe. Providing appropriate levels and numbers of staff
helps ensure patients are monitored appropriately so that prompt interventions can correct
any respiratory or airway difficulties. Florida Administrative Code 64B8-9.009 Standard of
Care for Office Surgery delineates requirements for performing office based procedures based
on the complexity of the procedure. Staff numbers, training and preparation, monitoring
equipment, and resuscitative medications and equipment vary according the level of
procedure performed. (Hyperlink to Florida Administrative Code 64B8-9.009: - Standard of
Care for Office Surgery : 64B8-9.009 : Standard of Care for Office Surgery - Florida
Administrative Rules, Law, Code, Register - FAC, FAR, eRulemaking)
1) Ensure that appropriate staffing is available and trained to monitor the patient (vital signs, level
of consciousness, procedure tolerance, pharmacological indications of agents used, and
emergency interventions) and assist with the surgical procedure. Level and numbers of staff
assistants vary according to the level of procedure being performed.
Provide formal clinical training for the staff nurses who will monitor the conscious sedation
patients, including, but not limited to, pharmacology and emergency intervention, as well as
routine monitoring, interpretation, and documentation.
17
Post appropriate notice in the reception area and on consent forms for Level II and III surgery
providers.
Maintain emergency response medications, supplies and equipment appropriate to the level of
procedures. The emergency supplies should be maintained in a central, easily accessible location
and the contents, including medication expiration dates, should be monitored periodically. Train
staff members and physicians in the location and use of the emergency response kit and in
providing cardiopulmonary resuscitation.
Ensure that adequate equipment for oxygen administration and suction are set up for each
recovering patient.
Ensure that appropriate monitoring equipment is provided for each post-operative patient,
including, but not limited to, pulse oximeter, BP, cardiac monitor.
Maintain a transfer agreement with the nearest hospital with emergency facilities.
2) Maintain credentialing files for physicians performing in-office procedures. Grant physicians
privileges to perform only those procedures granted in hospital privileging practices. Avoid
allowing physicians to perform procedures for which they are not credentialed.
3) Ensure physicians using more than local anesthesia maintain current ACLS certification.
Provide annual ACLS training and conduct periodic emergency drills.
4) Ensure that all clinical staff members maintain current BLS certification. Conduct mock
emergency drills.
5) Ensure that appropriate staffing is available and trained to monitor the patient (vital signs, level
of consciousness, procedure tolerance, pharmacological indications of agents used, and
emergency interventions) and assist with the surgical procedure. Level and numbers of staff
assistants vary according to the level of procedure being performed. Pulse oximetry monitoring is
be utilized if greater than local anesthesia is administered. Provide formal clinical training for the
staff nurses who will monitor the conscious sedation patients, including, but not limited to,
pharmacology and emergency intervention, as well as routine monitoring, interpretation, and
documentation.
6) Implement a checklist to document the “time out” and universal protocol for avoiding surgical
error. Utilize an active process to confirm patient identity, the planned procedure, the site or side
of the procedure (as indicated), completed accurate consent and documentation, and correctly
displayed images. Document medications given, intraoperative monitoring and post-procedure
and discharge status and care instructions provided.
7) Provide a copy of written discharge instructions, including medication and post-operative care
regimens, activities, cautions, hydration/nutrition recommendations, reportable signs and
symptoms, and follow-up visit. These instructions should be reviewed with and available to both
the patient and the responsible adult caregiver.
8) Implement a policy to telephone post-procedure patients within 24 hours of the procedure.
Document patient status with reference to pain, operative site, mobility, nutrition/hydration,
elimination, and patient concerns. Include a section of the post-operative/discharge note to
document the findings of the post-procedure call.
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9) Develop and implement step-by-step procedures for steam and cold sterilization processes.
Include the manufacturer’s recommendations in developing these guidelines. Include also
preventive maintenance and testing procedures. Post procedures in a easily accessible location.
10) Train staff members in sterilization procedures and in asepsis protocols, including handling
and disposal of contaminated supplies and equipment and disposal of singe use items.
11) Monitor the expiration dates and integrity of sterile supplies. Discard items past the expiration
date and/or with a breach in packaging integrity.
Additional patient safety or risk management concerns or questions:
Thank you for completing Phase I – Self Assessment of the FORPG/The Doctors Company
Patient Safety Premium Credit Program. Upon review by a physician in the practice, please
return the completed assessment to sstrickland@thedoctors.com. The Doctors Company will
notify the contact person you have listed below to review the status of the assessment.
NOTE: To complete Phase II and qualify for the Patient Safety Premium Credit Program,
please complete the on-demand webinar component “Managing Orthopedic Risks” located at
www.orthorpg.com .
Date of Submission:
Survey Completed by:
Physician Reviewer:
Contact Person:
Phone:
E-mail:
The comments and recommendations in this report are meant to be advisory only as loss
prevention measures and should not be construed as legal advice or a standard of care; nor do
they ensure a successful outcome. They are provided for your discussion and consideration as a
. means to improve patient safety. Any changes in policies or procedures should be implemented
only with the appropriate approvals within your organization. The ultimate decision regarding the
appropriateness of any treatment must be made by each healthcare provider in light of all
circumstances prevailing in the individual situation and in accordance with the laws of the
jurisdiction in which the care is rendered.
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