Medicare Fire drill (revised 5/9/2011)
1. Hospital Administration or Quality office to Page: Transplant Administrator
2. HOSPITAL Administration will Secure Entrance Conference Location
3. Ann Marie/Irma to clean, secure and hand signage in 11th Floor Break Room
4. Irene (Irma backup)
a. Alert Ann Marie & Irma to activate command center switch (clean 11, post signs,
switch Ann Marie desk for the week with Jennifer or into 1145)
b. Grab Medicare NOTEBOOK
c. Send email message to entire team (#1) SEE (n) for additional cc’s needed
d. Call those on ‘critical list’ to make sure they read email/are aware CMS onsite
e. Clear all appointments from Jennifer’s calendar for current week and next
f. Clear your calendar for retrieving/providing items as they are requested by CMS
g. Remind Jennifer to breathe (several times!)
h. Collect and label each list from Margie/Jose to place in NOTEBOOK (tabs 1-5, 8-9 )
i. Collect from Shannon list of inpatients to place in NOTEBOOK (tab 6)
j. Collect from S. Vidal list weeks’ outpatient clinic schedule NOTEBOOK (tab 7)
k. Collect from Rod or backup the OR records (“PICES” sheets showing the ABO
double check) of all current inpatients- place in folder (not in NOTEBOOK)
l. Bring NOTEBOOK to Jennifer once filled
m. Be on standby to make copies of each ‘list’ once auditors have made selections
n. Transplant List Email should be cc to the following (* include assistants)
1.
Michael
2.
Mickey
3.
Michelle
4.
Tim
5.
Mickey
6.
Allen
7.
Noel (HOSPITAL OR)
8.
Erica (HOSPITAL OR)
o. Critical Calls – to alert them CMS has arrived- emails will provide further
information
1. Terrie
2. Patricia
3. Rhonda
4. Margie
5. Michael
6. Shannon
7. Tim
8. Luis
9. Debbie
i. Call Donna to call/text (be on standby/check UT emails)
1. Glen
2.
3.
4.
5.
6.
7.
8.
Kenneth
Greg
Bob
Jose
Chuck
Kermit
Juan
ii. Call CT Surgery to text message or page
1. Scott
p. As Medicare Audit is underway, there will be a “Wall of Requests” in your office,
when there is a request- I will ask you to be the gatekeeper for the information.
Basically, one of the lead coordinators will point out the person, who can get the
information, you call them to gather the information which they will bring to you to
deliver to the supervisor. You will keep a running list of the name-MRN-supervisor
who is asking and what/when it was delivered to the supervisor.
5. Margie primary (Jose backup)
a. Print All Lists Currently maintained from list of onsite items requested (requests
may be different, this was from another transplant center)
b. Coordinate with Michelle office –access to Sunrise, PICES (same systems UNOS
needed for availability)
c. Look to clear calendar for yourself or Jose to ensure availability to CMS for next 5
days
6. Inpatient: Shannon (back up Darnell)
a. Bring list of all TICU/TTele inpatients to Irene – flag each as pre/post/non tx
b. Audit all recently transplanted charts with inpatient audit tool
i. Ensure Every chart with current note** of evidence of
1. Complete surgical consent
2. ABO at recovery (OR will be pulling at receipt)
3. education,
4. discharge planning,
5. multidisciplinary rounds,
6. pharmacy interaction,
7. social work interaction if applicable,
8. dietary note
**If any disciplines involved, but evidence not documented in sunrise
page to notify need progress note asap
ii. Inform bedside nurses to alert recently transplanted inpatients patients and
families of presence of Medicare to audit our program and they may be
asked questions about their experiences with us
c. Shannon will aid auditors all week, if in town. If not in town, Darnell to assist as
needed but will focus primarily on patient care
7. Tricia primary (Vanessa backup)
a. Identify each liver transplant inpatient and outpatient on lists Irene provided
b. Delegate your own clinical work so that you are able to focus whole week on
administrative
c. Have immediate meeting with entire liver team (include Tambi)
i. Distribute chart audit tool to each coordinator and divide inpatient and
outpatients equally among them. Audit pretransplant portion of those
charts asap
ii. Keep in mind any “fresh” liver transplants inpatient will be the MOST
audited, recent transplants outpatient or inpatient will be next likely to be
audited
iii. Any evaluations due to be seen in clinic during the week will be audited
iv. Review location of all policy and procedures (S drive)
v. Remember that any pediatrics case in last 3 years cab be audited too
vi. Review Questions for Coordinators with your team
Transplant Coordinator Interview Guide for Organ Transplant
1. What are your responsibilities as a transplant coordinator?
2. Describe the complete evaluation process for organ transplant.
3. What are the patient screening criteria for the transplant program are these
selection criteria followed?
4. Do you have a regular schedule or process for communicating with the dialysis
facilities that are serving patients on the waiting list? [Applies to kidney-only and
kidney/pancreas programs]
5. Who is responsible for monitoring changes to the clinical information of the
patients on your transplant program’s waiting list and updating UNET with any
changes?
6. What are your responsibilities for patient education, pre-op, post-op?
7. Describe the informed consent process. When does this process start and when
does this process end? What is your direct role in this process? (This question is
focusing on the entire process of informed consent, not a document signature prior
to surgery.)
8. How do you determine a patient is competent for self-care at home? What are your
discharge criteria for organ transplant patients?
9. What role do you play in staff education and how often?
10. Describe in detail your role on the multidisciplinary transplant team.
11. Have there been any instances when a transplant was unable to be performed
because a transplant surgeon or physician was not available?
12. Please describe how inpatient dialysis services are available if needed. [Applies to
kidney-only and kidney/pancreas programs]
If applicable, New Employee Interview Guide:
1. Please explain your preceptor or supervision structure for your training for the first
3 months of your employment and training process.
2. Discuss your first 3 months working in the transplant program:
Did you have a preceptor?
What role did he/she serve?
What training did you receive?
What supervision did you have?
8. Terrie primary (Mike back up)
a. Identify each kidney transplant inpatient and outpatient on lists Irene provided
b. Delegate your own clinical work so that you are able to focus whole week on
administrative
c. Have immediate meeting with entire kidney team (include Mary)
i. Distribute chart audit tool to each coordinator and divide inpatient and
outpatients equally among them. Audit pretransplant portion of those
charts asap
ii. Keep in mind any “fresh” kidney transplants inpatient will be the MOST
audited, recent transplants outpatient or inpatient will be next likely to be
audited
iii. Any evaluations due to be seen in clinic during the week will be audited
iv. Review location of all policy and procedures (S drive)
v. Remember that any pediatrics case in last 3 years cab be audited too
vi. Review Questions for Coordinators with your team
Transplant Coordinator Interview Guide for Organ Transplant
1. What are your responsibilities as a transplant coordinator?
2. Describe the complete evaluation process for organ transplant.
3. What are the patient screening criteria for the transplant program are these selection
criteria followed?
4. Do you have a regular schedule or process for communicating with the dialysis
facilities that are serving patients on the waiting list? [Applies to kidney-only and
kidney/pancreas programs]
5. Who is responsible for monitoring changes to the clinical information of the patients
on your transplant program’s waiting list and updating UNET with any changes?
6. What are your responsibilities for patient education, pre-op, post-op?
7. Describe the informed consent process. When does this process start and when does
this process end? What is your direct role in this process? (This question is focusing on
the entire process of informed consent, not a document signature prior to surgery.)
8. How do you determine a patient is competent for self-care at home? What are your
discharge criteria for organ transplant patients?
9. What role do you play in staff education and how often?
10. Describe in detail your role on the multidisciplinary transplant team.
11. Have there been any instances when a transplant was unable to be performed because a
transplant surgeon or physician was not available?
12. Please describe how inpatient dialysis services are available if needed. [Applies to
kidney-only and kidney/pancreas programs]
If applicable, New Employee Interview Guide:
3. Please explain your preceptor or supervision structure for your training for the first 3
months of your employment and training process.
4. Discuss your first 3 months working in the transplant program:
Did you have a preceptor?
What role did he/she serve?
What training did you receive?
What supervision did you have?
9. Michael
a. Hold immediate brief team meeting on units
b. Inpatient transplant patients will be primary target (and the staff caring for those
patients)
c. Inform bedside nurses to alert recently transplanted inpatients patients and
families of presence of Medicare to audit our program and they may be asked
questions about their experiences with us
d. Assess your work schedules for periods of not being available and have identified
backups
i. Inpatient coordinators will be using chart audit tool to audit these patients
ii. Keep in mind any “fresh” transplants inpatient will be the MOST audited,
recent transplants who may be inpatient will be next likely to be audited
iii. Review and feel comfortable with location of all policy and procedures in
notebooks and HOSPITAL intranet
iv. Review Questions for Staff Nurses with your team
Staff Nurse Interview Guide for Organ Transplant
1. What are your responsibilities as a staff nurse for the organ transplant patient and the organ
donor patient?
2. What specialized training did you receive prior to caring for an organ transplant recipient?
3. What type of continuing training is provided for you?
4. What paperwork do you receive when a patient is admitted?
5. How does the multidisciplinary team develop an on-going plan of care for the organ
transplant recipient and how often is that plan updated, how often does the patient
participate?
6. How does the multidisciplinary team develop an on-going care plan for the organ
transplant donor and how often is this updated, is this care provided by a different team?
How often does the patient participate? What is your role with the living donor advocate if
applicable?
7. What do you teach patients about post-hospitalization follow-up, medications and side
effects of medications, reportable signs and symptoms of infection and rejection? What do
you teach patients about contacting the doctor(s) if they experience certain symptoms?
8. Describe in detail your role on the multidisciplinary transplant team.
9. Have there been any instances when a transplant was unable to be performed because a
transplant surgeon or physician was not available?
If applicable, New Employee Interview Guide:
1. Please explain your preceptor or supervision structure for your training for the first 3
months of your employment and training process.
2. Discuss your first 3 months working in the transplant program:
Did you have a preceptor?
What role did he/she serve?
What training did you receive?
What supervision did you have?
10. Rhonda primary (Martha backup)
a. Hold immediate brief team meeting (include Tamara)
b. Identify each lung transplant inpatient and outpatient on lists Irene provided
c. Delegate your own clinical work so that you are able to focus whole week on
administrative
i. if one of you is out, Tamara will serve as backup
d. Using the chart audit tool divide inpatient and outpatients between you and
Martha. Audit pretransplant portion of those charts asap
e. Keep in mind any “fresh” lung transplants inpatient will be the MOST audited,
recent transplants outpatient or inpatient will be next likely to be audited
f. Any evaluations due to be seen in clinic will be audited
g. Review and feel comfortable with location of all policy and procedures on S drive
h. Review Questions for Coordinators with your team
Transplant Coordinator Interview Guide for Organ Transplant
1. What are your responsibilities as a transplant coordinator?
2. Describe the complete evaluation process for organ transplant.
3. What are the patient screening criteria for the transplant program are these selection criteria
followed?
4. Do you have a regular schedule or process for communicating with the dialysis facilities
that are serving patients on the waiting list? [Applies to kidney-only and kidney/pancreas
programs]
5. Who is responsible for monitoring changes to the clinical information of the patients on
your transplant program’s waiting list and updating UNET with any changes?
6. What are your responsibilities for patient education, pre-op, post-op?
7. Describe the informed consent process. When does this process start and when does this
process end? What is your direct role in this process? (This question is focusing on the
entire process of informed consent, not a document signature prior to surgery.)
8. How do you determine a patient is competent for self-care at home? What are your
discharge criteria for organ transplant patients?
9. What role do you play in staff education and how often?
10. Describe in detail your role on the multidisciplinary transplant team.
11. Have there been any instances when a transplant was unable to be performed because a
transplant surgeon or physician was not available?
12. Please describe how inpatient dialysis services are available if needed. [Applies to kidneyonly and kidney/pancreas programs]
11. Rod primary (Misty or Deb Backup)
a. Identify each fresh transplant inpatient and outpatient on lists Irene will be
gathering
b. You may need to delegate your own clinical/call responsibilities work so that you
are able to focus whole week on administrative
c. Work with OR to Audit any fresh transplant inpatient charts asap for
1. ABO double check prior to implantation,
2. Living donor ABO check prior to recovery
3. Recoveries off site evidence of ABO check prior to recovery in
recipients medical record
ii. Go ahead and have OR print the PICES sheet showing the ABO double
check for these patients and bring to Irene
d. Review and feel comfortable with location of all policy and procedures on S drive
e. Audit Vessel Log for daily Temp Checks and overall compliance
12. Elizabeth (Cindy back up)
a. Identify each fresh transplant inpatient and outpatient on lists Irene provided
b. If you have provided education on these patients ensure you have documented
this in sunrise
c. Alert Irene by email if you will not be available- you will be scheduled to be
interviewed
d. Review the questions you will be asked.
1. What are your responsibilities as a Transplant Social Work?
2. Please discuss any initial or ongoing training you received regarding the
transplantation process, or working with transplant recipients and living
donors.
3. Describe your role in evaluation and follow-up of your recommendations of
recipients and living organ donor patients.
4. Describe your responsibilities and participation in the multi-disciplinary
team.
5. Are there social work screening criteria used in the transplant program
evaluation, are these selection criteria followed?
6. What are your responsibilities for patient education, pre-op, post-op?
7. What are your discharge criteria for organ transplant patients?
8. What role do you play in staff education and how often?
13. Pam /Heather
a. Identify each fresh transplant inpatient and outpatient on lists Irene provided
b. If you have provided education on these patients ensure you have documented
this in sunrise
c. Alert Irene by email if you will not be available- you will be scheduled to be
interviewed
d. Review the questions you will be asked.
1. What are your responsibilities as a Transplant Pharmacist?
2. Please discuss any initial or ongoing training you received regarding the
transplantation process, or working with transplant recipients and living
donors.
3. Describe your role in evaluation and follow-up of organ transplant and
organ donor patients.
4. Describe your responsibilities and participation in the multi-disciplinary
team.
5. Are there pharmacological screening criteria used in the transplant
program evaluation, are these selection criteria followed?
6. How are the medications updated on the patient profile, how is this
communicated and verified by the transplant team. How are medication
changes and updates communicated to the transplant or donor patient pre
and post procedure?
7. What are your responsibilities for patient education, pre-op, post-op?
8. What are your discharge criteria for organ transplant patients?
9. What role do you play in staff education and how often?
Team Email #1: as soon as possible after arrival (call Transplant
Administrator on cell to fill in blanks)
CMS has arrived for our unannounced Transplant Center audit. We have ____
surveyors and we expect them to be onsite for ______ days.
They are auditing our lung, kidney, and liver, living donor and pancreas programs.
A “command center” has been set up in the 11th floor transplant break room. Jennifer
Milton will be present with the surveyors in this location as will the pre-transplant
lead coordinators, Margie and Shannon.
11th floor staff. We apologize profusely for the inconvenience but for this week,
please utilize the 8th floor clinic break room to store your food and have breaks.
Please utilize the copier in the clinic unless you urgently need to use the copier on 11.
Please minimize your trips for office supplies and mail to the best of your ability to
reduce the traffic in/out of the command center.
Ann Marie will sit _______________ during the week and the mail cart for deliveries
will be there as well.
-Location of all Transplant Policies & Procedures is in the S drive
We will communicate findings via email as the day progresses to keep you alerted as
to what areas are being audited and of any findings, key questions or concerns the
auditors may have noted.
Team Email #2: after entrance conference(call tansplant administrator
on cell to fill in blanks)
As you likely heard the CMS audit entrance conference has concluded and the survey
is underway- the following are the key points.
The CMS team has reviewed key outcomes data before they arrived today.
In data reporting (CMS requires 95% compliance) our lung program had
(_________) liver had (__________) and kidney had (_____________.)
In volumes requirements (CMS requires an annual volume of 10 transplants) none of
our programs were cited.
CMS informed us to expect:
1.
2.
3.
PLEASE REMEMBER TO:
1. Make sure you are adhering to Dress Code, Name Badge, and Environment of
Care requirements
2. Cheer & Encourage ‘Reviewers’
3. When asked, scour records for missing information
4. Listen out for and plan to attend the exit conference
5. Avoid 11th floor break room – make plans to use 8 or 12
Routine Team Email Updates: At the start of each day & The end of
each day
The CMS team is well underway in our audit. Just wanted to provide all of you with
an update. I also want to thank you all for running, retrieving and covering as needed
with not the slightest compromise in patients care.
Currently, there are in several areas:
1.
2.
3.
They have noted we:
1.
2.
3.
Please be sure to
1.
2.