Ambulatory Joint
Commission Meeting
July 15, 2009
Presented by:
Jayne Sheehan
Sandra Hewitt
Louise Mackisack
Agenda

Overview of the Ambulatory Joint Commission
structure
 Reorganization of work groups

Recent Accomplishments/Actions since CMS
 Work of CMS Debriefing Group



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Demo of TJC Folder
Policies and Procedures 101
What’s New with Competencies
The New and Improved Chart Audit
Revisions to PACE Audits
Resumption of Mock Joint Commission Surveys
Recent Accomplishments
As a result of our mock TJC and CMS surveys we have made great
strides! We now have:
 Reorganization of the TJC Team, including the addition of
David Clough to Lead one of our work groups.

The Ambulatory Joint Commission Folder on the S:/drive


S:\Ambulatory Joint Commission
CMS Debriefing Document also on the S:/drive

S:\Ambulatory Joint Commission\CMS - AMBULATORY
AND EMERGENCY SERVICES MASTER DOCUMENT

An ad hoc CMS team that has worked to provide resolution to
potential vulnerabilities;

Parts of today’s presentation have come from our work within
the CMS document. The Leads for each area are identified to
address any further questions.
New Work Group Organization
OPS Council
TJC
Facilitators Group
Policies,
Procedures
& Guidelines
Competencies
TJC Ambulatory
Directors
and Managers
Group
Pace Audits/
Mock Surveys
Reorganization of Work Groups
CQI Projects
(not active yet)
Work Group Membership
 Policy, Procedures & Guidelines:
Beatrice Ford




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
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Lynne Brophy
Chris Healey
Sandra Hewitt
Richard Johnston
Menrika Louis
Christine Lynch
Dan Nadworny
 Competencies: Louise Mackisack







Brigitte Bowen-Benitich
Lynne Brophy
Holly Dowling
Maureen Mamet
Heather Wathey
Annie Whatmough
Jan Woodruff
 PACE Audits/Mock Surveys:
David Clough




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
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Laura Allen
Jo-Ann Barletta
Emily Cherecwich
Linda Dicenzo
Sandra Hewitt
Kelly Orlando
Eileen Rose
 CQI – Process Improvement
Ambulatory Joint Commission
Folder (live demo)
We want you to use this folder where you can find:
•
Generic Job Descriptions
o
o
•
Ambulatory Specific Guidelines
o
o
o
•
•
•
•
•
•
Unit specific JDs need to be developed and put in the folder as well.
Job description template in folder.
We are adding guidelines as we create them.
These guidelines will be housed in this folder, until the Ambulatory Services Guidelines
manual goes live on the PPGD site.
Guideline Templates in folder – clinical area/department and administrative
Medication Reconciliation Audit Results*
Chart Audits*
CMS Debriefing Document*
Scope of Service w/Org Charts
Generic MA Training Manual*
Staff Competencies Information*
Please notify Lynne when you make updates.
We’ll let you know when we make changes as well.
*More on these topics later
Ambulatory Policies, Procedures &
Guidelines (Leads: B. Ford; L. Brophy; S. Hewitt)
Nomenclature for Organizational PPGDs

Medical Center Wide:
o
o

The BIDMC Policy Manual is the Source of Truth.
Ambulatory has very few specific policies and has
primarily Guidelines.
Interdepartmental: apply to more than one
department, but are not Medical Center wide.
o

Exs: we use lab, radiology, pharmacy manuals for PPGDs
within ambulatory.
Intradepartmental: apply to one department
only.
Areas of Concern
 Can’t
•
•
•
Training: working to include in Orientations
Cheat Sheet: available right on the portal
Ambulatory Services Guidelines: will house Ambulatory
modifications found within
 Who
•
•
to Contact with Policy Questions *
Sponsor/Requestor/Ambulatory Work Group
 How
•
find P&Ps:
do you learn of New Policies?*
Communication
On Portal
 P&Ps
not specific enough for ambulatory setting*
Resource Staff for Content Expertise in
PPGD Development (ADM-01)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Name:
Ken Sands, MD, Sr. VP
Patricia Folcarelli, RN, PhD, Director
Kathy Murray, Director
Kim Sulmonte, RN, Director
Gary Schweon, Director
Catherine Mahoney, Assoc. Counsel
Anne Marie Jarvey, Director
Frank Rosen, Specialist
Shawna Butler, Specialist
Gerry Abrahamian, Director
Judy Bieber, Director
Leon Goldman, Admin. Officer
Sharon Wright, MD, Director
Rosemary Kennedy, Director
Meg Femino, Director
Area of Expertise:
MD Licensing Board/Leadership
Patient Safety
Process Improvement/TJC
Patient Care Services/PI
Environmental Health & Safety
Legal Counsel
Accreditations/Facility Licensure
Regulatory/Medical Staff
Risk Management/Adverse Events
Medical Records Management
Human Resources/ER
Business Conduct
Infection Control
Radiation Safety
Emergency/Disaster Preparation
Information on each Policy
Beth Israel Deaconess Medical Center BIDMC Manual
Title: Drug Sample Management Number: CP-11
Purpose: To describe how drug samples are managed within the medical
center
Vice President Sponsor: Kenneth Sands, MD, MPH, Sr. Vice President, Health
Care Quality and Director, Silverman Institute for Health Care Quality and Safety
Responsible Person: Francis P. Mitrano, RPh MS
(sometimes listed as Requestor)
Approved By:
Operations Council: 2/2/09
P&T: 01/14/09
Original Date Approved: 10/01
Revisions: 6/04, 11/05, 11/08
Next Review Date: 2/2012
Title: Director of Pharmacy
Eric Buehrens,
Chief Operating Officer
James Heffernan, MD
David Feinbloom, MD
P&T Co-Chairs, P&T Committee
Accessing P&Ps on the Portal
Conducting a Search on the Portal
Quick “How to” Conduct a Google Search
(live demo)
You can view any policy or policy manual in two ways:
 You can view an entire manual by clicking on its title as listed
on the portal.
 Typing key words into the Search box and then clicking on the
manual as it is listed.
 To conduct a PPGD search, type key words into the Search
box which would be reasonable to assume would be
contained in the policy.
 If a search doesn’t return anything useful try shortening the
search phrase.
 Punctuation is generally ignored (so capitalization is
irrelevant)
 If you have any questions, contact Professional Staff Affairs
Office at: 7-1917
How do I keep updated regarding
changes to PPGDs?
 Relevant PPGDs are reviewed at Departmental/
Division Meetings and/or e-mailed and documented
that they have been shared with all staff.
 Ambulatory learns of them at Leadership
 VPs, Directors and Managers communicate PPGD
changes that impact your work.

This meeting is an important vehicle for communicating
PPGD changes.
 Also, as PPGDs are updated there is a website
link on the General Portal that will have the
monthly updates.
Who can help you with PPGDs?

Should you have questions with respect to
interpretation, finding a policy, etc., contact a member
of the Ambulatory work group.
 Your questions help the work group to identify areas
that may need guidelines for our use.
 The work of the ambulatory group is to ensure
updates and to develop ambulatory specific
guidelines.
 Ambulatory P&P Work Group has made it a point to
be involved with Medical Center policy revisions and
updates by being a part of the PPGD oversight
committee.
Competencies



How did we get to this?…regulatory plus pulse
check (literally)
Two fold – Support Staff and NP/PA
Training Manual developed for Medical
Assistants, Practice Assistants, Practice
Representatives and Phlebotomists – Authored
by Maureen Mamet, RN in partnership with Heather Wathey
Practice Coordinator HCA


Standardized and placed on the shared drive
Expectation: each area updates with specific
unit based skills
Competencies
 The core competencies match to the job
description
 Training check list developed from the
Training Manual materials – Maureen Mamet, RN, Jan
Woodruff, RN, Brigitte Bowen-Benitich, Heather Wathey
 Competencies Requirements with inclusion of
the HR expectations developed and links
added– Annie Whatmough, Holly Dowling, Lynne Brophy
 Tracking document also developed
Competencies
Competencies
 Expectation:



All support staff in the MA, PA, PR and
Phlebotomy positions will complete formal
skills training and demonstrate they have
completed/met all competency requirements
How do we get there?
Skills Training

Jan Woodruff, RN and Heather Wathey from HCA
will do the training for Ambulatory in the following
manner:
Competencies
 Train the Trainer:
 Nine departments with a RN and lead MA have sent
their representatives to a 4 hour training
 Eleven Departments are being scheduled for train the
trainer and 4 for MAs. 26 have not responded yet.
 The expectation is the representatives will train all their
staff by September
 “Oddments”:
 These classes are for all the remaining Ambulatory
MA, PA, PR and phlebotomy staff without department
based trainers
Competencies
 The next series of classes are scheduled for
2 Sessions each day – AM and PM:





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Tuesday August 11
Wednesday August 12
Thursday August 13 (Lexington)
Tuesday August 18
Wednesday August 19
Thursday August 20
Competencies
 Outstanding Issues to be resolved:

Formalizing the requirements for temps
Competencies
 Nurse Practitioners and Physicians Assistants
 APN Forum – Co-chairs:
Jayne Sheehan, APN, Leah
McKinnon-Howe, APN, and Barbara Rosato, APN
 Work completed:

Practice Guidelines
Competencies
Supervising physician responsibilities

Competency Requirement Checklist (with links)

Prescription Audits


Competencies
Competencies
 Outstanding Issue- to be resolved this month:





Linking with credentialing
Supervising physician and performance
evaluations loop
Billing
Standardization –inpatient and outpatient,
BIDMC and HMFP
Standardized Performance Evaluation
Competencies
 Clinical Nurses
 Competency Requirements Developed and on the
shared drive – S:\Ambulatory Joint Commission\STAFF
COMPETENCY INFORMATION
 Performance Evaluations – Signature required by a
Nurse Manager and in the absence of a nurse
manager Jayne will co-sign.
 BLS/ACLS – Sheila Goggin is tracking. HR notifies
Sheila of the new hires and BLS/ACLS status.

Job Descriptions will be updated requiring all CN have
BLS and if not within 60 days of hire
Competencies
 Clinical Nurses and NP/PA License Tracking



Sheila Goggin is keeping a centralized list
Sheila’s list is dependant upon us notifying
her when we hire.
OneStaff is not the trigger for this list.
Chart Audit
(Leads: S. Hewitt/L. Brophy)
Past Concerns:





Not fully meeting the intent of chart audits;
Conducted audits, didn’t see the results by
unit and/or aggregate for all of Ambulatory;
Hard to make a plan of action;
Unit specificity lacking;
Two separate audits: chart and med
reconciliation.
Goals of Chart Audit

Use data to drive positive change in real time;

Provide meaningful data for Ambulatory and
allow unit specificity where needed;

Ensure regulatory compliance;

Meet Medical Center requirements.
What about Medication Reconciliation?
 Medication reconciliation auditing will be
integrated with chart auditing;
 Combined audits will be unannounced each
month;
 We will use the med reconciliation methodology
regarding number of charts reviewed, adjusted
for a monthly process:

Clinics w/<30 visits/day

Clinics w/31-100 visits/day = 10 charts

Clinics w/>100 visits/day
= 7 charts
= 20 charts
New Chart Audit Questions
Standardized Department
name – Pick menu not free
text
New Chart Audit Questions
New Chart Audit Questions
Performance Manager Download
 Results will be downloaded from Performance
Manager to Excel;
 For the generic chart audit, we will tabulate results
and graph them by:


unit; and
aggregate for ambulatory.
 For those who want to have unit specific criteria:
 Lynne will work with you to load your criteria;
 You will be responsible for tabulating your unit specific
results;
 Lynne will train you to work with your data.
AMBUALTORY SERVICES
CHART AUDIT ACTION PLAN GRID
DATE ______________
Department
%
Compliance
Issues/
Concerns
Planned
Interventions/
Action Plan
Expected
Date of
Completion
Feedback
Provided
Y/N
Provider
Initials &
Date
Staff
Responsible
Eye Unit
80%
POC
Wording
needs to
indicate that
provider
discussed
and educated
patient.
8/20/09
Y
JA
8/20/09
K. Jordan
Eye Unit
90%
Med
Rec
List not
updated
9/7/09
Y
FB
8/20/09
K. Jordan
•Each unit will update Action Plan monthly and provide review quarterly.
•Utilize this Plan as a QI tool.
•Verification will continue to ensure appropriate auditing practices.
•We will continue to report Medication Reconciliation results to HCQ.
New Chart Audit Start-up
 Roll out of the new integrated chart audit will begin in August.
 By Monday July 20th, supply Lynne via email the name of
your clinics/departments for the drop down pick option (#1
on survey)
 We will want the name of your auditor(s) for providing any
training that might be needed and to give feedback if indicated.
If you have a separate person downloading unit specific data,
we will need that name as well.
 You will receive an e-mail with start up information which will
include:
 Step-by-step instructions;
 Explanation where indicated as to how to satisfy each
criterion;
 Reference to P&Ps or any other information source;
 Who to contact with questions.
PACE Audits
 The PACE audit form is under revision by the
work group.
 Information will be recorded within Performance
Manager and results will be provided to you
similar to chart audit results.
 You will receive actionable real time data.
 We are in the process of revising the schedule
for conducting self-audits and mock surveys.
 Anticipate new audit will be available for
September.
Mock TJC Surveys
 We will resume mock surveys on the units to
ensure Every Day Readiness.
 Goal is to help staff to comfortably and
reliably respond to a Joint Commission
surveyor on a range of topics.
 Here are some sample questions:
Q: What is the single most important measure to prevent the transmission of
organisms?
A: Hand hygiene
Q: Who is your floor marshal for emergency evacuation?
A. Name of person