AMP with FSA
Jeanette Snell, RN, MSN
Clinical Advisor
© Joint Commission Resources
Step-by-Step Guide
to Implementing AMP in your Organization
Step 1-Developing Teams
Identify individuals requiring AMP access.
Identify user roles in your organization.
Complete user assignments.
Implement AMP across your organization.
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Objectives:
Understanding User Roles
 Staff Member (Individual)
 Staff Member (Team Coordinator)
 Program Administrator
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 Site Manager
– First tier of access
– Able to view all EP’s and documentation
– Able to add/edit documentation for
assigned EP’s only
– Enter an individual score
– Low volume of EP’s assigned
– Multiple staff members per each EP
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Staff Member Role
– Staff Member level of access
– Able to view all EP’s and documentation
– Able to add/edit documentation for assigned
EP’s only
– Enter a preliminary score
– Typically assigned an entire chapter
– Ability to assign tasks
– One team coordinator allowed per EP
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Staff Member Role-Team Coordinator
– Higher level of access
– View and score all EP’s (No assignment)
– Responsible for entering the final score
– Scoring
• Score each EP independently
• Score EP’s in bulk
• Accept Team Coordinators’ scores
– No Administrative functionality
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Site Manager Role
Program Administrator Role
Highest level of access
View and score all EP’s (No assignment)
Responsible for entering the final score
Scoring
• Score each EP independently
• Score EP’s in bulk
• Accept Team Coordinators’ scores
– Assign users/access
– License maintenance
– Site Setup and Password/Email setup
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Collaboration among User Roles
Program
Administrator
Site
Manager
HR Chapter
Team
Coordinator
Staff
Member
HR.01.01.01 EP
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Staff
Member
Staff
Member
HR.01.02.07 EP
1,2,5
HR.01.01.01 EP
2
Team
Coordinator
Staff
Member
MM.07.01.03
EP 1-6
MM Chapter
Staff
Member
MM.07.01.03
EP 1-6
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Site
Manager
Role
Pros
Cons
Staff Member
-Deploy responsibility
-Allows input from many individuals in
organization (Individual scores)
-Accountability
-Additional level of scoring
-Additional assignments
Team Coordinator
-Chapter responsibility
-Allows one individual to review
individual scores
-Enter preliminary score
-Convert preliminary score to final score
-Additional level of scoring
Site Manager
-May enter final score
-Assist program administrator/team
coordinator
-Useful for systems
-Additional level if individual
facility
-Everyone can document on all
EP’s when only this level is used
(can overwrite each others data)
Program Administrator
Required
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Accreditation Manager Plus
Team Development
Complete Team Development Tool
(Role, Title, Name, Email)
The following slides offer suggestions for team
members arranged by Chapter of the CAMH
***Please note that Joint Commission does not require use of all AMP roles
These are ideas to assist you in compliance efforts.***
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or team structure as proposed in this toolkit.
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Team Development Tool
Assigning Users
Accreditation Participation Requirements
 Vital to accreditation
 Tend to be clear cut requirements
 Noncompliance is very evident
 Typically assigned to JC liaison or program
 Leadership involvement if noncompliance
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administrator.
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What is the culture of your organization?
What is the size of your organization?
Who is responsible for accreditation?
Who is responsible for compliance?
Who is responsible for scoring?
What is the level of comfort?
How will you utilize the functionality in
AMP?
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Accreditation Culture
Assigning Users
Environment of Care
– Facilities Director/staff
– Security Director/staff
– Lab Director/staff
– Pharmacy Director/staff
– Biomedical Engineering
– Peri-operative Director/staff
– End users
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 Proposed team members include:
Assigning Users
Emergency Management
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Emergency Management leader
Administration
Medical Staff
Emergency Dept Director/ Staff
Infection Prevention and Control Coordinator
Facilities/Safety/Security Director
Utilities Director
Nutritional Services Director
Lab Director
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 Proposed team members include:
Assigning Users
Human Resources
 Human Resources Director/staff
 Employee Educator
 Nurse Educator
 Director of Volunteers
 Employee health nurse
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 Those responsible for competency assessment
Assigning Users
Infection Prevention
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Infection Prevention
Microbiologist
Nurse Managers/Nursing Staff
Facilities/Engineering
Peri-operative Services
Central Supply/Sterile Processing
Employee Health Nurse
Environmental Services
Department Managers
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 Possible team members include:
Assigning Users
Information Management/Record of Care
 Possible team members include:
CIO
HIM Director
Performance Improvement Staff
Medical Staff Representative/CMO
Nursing Representative/CNO
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Assigning Users
Leadership
 Conflict of Interest
 Communication
 Culture of Safety
 Contracts
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 Conflict Resolution
Assigning Users
Life safety
 Possible team members:
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– Facilities Director
– Safety/Security Director
– Engineering
– Department managers
Assigning Users
Medication Management
 Possible team members:
Pharmacy Director/staff
Nurse managers/staff
Medical Staff representative
P&T Chair
Director of Outpatient Services/clinic staff
Radiology Director/staff
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Assigning Users
Medical Staff
 Possible team members:
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– CMO
– Medical Staff Office representatives
– Credentials Chair
– Medical Staff Leadership
Assigning Users
NPSG
 Possible team members include:
Nurse Managers/staff (include MS/ICU/ED)
Lab Director/Blood bank staff
Anesthesia personnel
Peri-operative Services Director
Pharmacy Director
Radiology Staff
Outpatient staff
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Assigning Users
Nursing
 Consider the following:
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– Education and Experience
– Access to policies and procedures
– Developing standards of care
– Implementing standards of care
– Implement staffing plan
– Oversight for all nursing care
Assigning Users
Patient Rights and Organizational Ethics
– Administrative representative
– Legal Counsel/Risk Manager
– Patient Relations
– Patient Advocate
– Social Worker
– Nursing representatives
– Outpatient representative
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 Potential Team members include:
Assigning Users
Provision of Care
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CNO
Nursing Administration
Staff Nurses
Pharmacy Director
Anesthesia Personnel
Behavioral Health (if applicable)
Multidisciplinary Team Members
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 Possible team members:
Assigning Users
Performance Improvement
 Possible team members might include:
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– Quality Improvement personnel
– Department Directors
– Medical Staff Leaders
– Administration
Assigning Users
Tissue
 Peri-operative Services Director
 Wound Center Director
 Lab Director
 Tissue Officer (if required by law)
 Tissue Management personnel
 Nursing representatives
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 Materials Management personnel
Assigning Users
Waived Testing
– Lab Director or designee
– Staff Educator/Competency
Assessment
– Nurse Managers/staff
– Outpatient Services
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 Potential team members include:
Quick Review
 Staff member***
 View/Edit -My assignments (Individual score)
 View all EP’s
 Team Coordinator***
 View/Edit -My assignments (Preliminary score)
 Review individual scores/assign preliminary score
 Can document on all EP’s (no assignment)
 Score each EP/score bulk/accept preliminary scores as final
***Can only document on EP’s in their assignment
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 Site Manager/Program Administrator
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Questions?
Customer Support
Technical Issues
(Customer Support)
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Call: 888-527-9255
Email: support@jcrinc.com