Jayne Sheehan Diane Gilworth TJC and CMS Update Ambulatory Monthly Meeting April 8, 2009.

Jayne SheehanJayne SheehanDiane GilworthDiane Gilworth

TJC and CMS UpdateTJC and CMS UpdateAmbulatory Monthly MeetingAmbulatory Monthly MeetingApril 8, 2009April 8, 2009

AgendaAgenda

11:00-11:30 – Jayne Sheehan– CMS update

Binder Documentation Process/Structure Visit outline

– JC updates– Chart audits– Competencies– License renewal process– PA and NP competencies– Updates- tool box and PACE

CMS-binder CMS-binder

482.54(a) Organization482.54(a) Organization Organization Chart Organization Chart (for your department)(for your department) Scope of PracticeScope of Practice Evacuation PlanEvacuation Plan Process Improvement/Quality Improvement PlansProcess Improvement/Quality Improvement Plans Meeting Minutes Meeting Minutes (i.e., staff meetings, Practice Committee, QI Committee, (i.e., staff meetings, Practice Committee, QI Committee,

etc.)etc.) Departmental Guidelines (Departmental Guidelines (specific to your area)specific to your area)

482.54(b) Personnel482.54(b) Personnel Director of Department - Job DescriptionDirector of Department - Job Description Departmental Job Descriptions Departmental Job Descriptions (include all non-physician job descriptions in (include all non-physician job descriptions in

your unit/department for each role, including Practice Manager and on down)your unit/department for each role, including Practice Manager and on down) RN Licensing - RN Licensing - See Ambulatory Services Administrative NotebookSee Ambulatory Services Administrative Notebook NP Practice Guidelines and Core Competencies - NP Practice Guidelines and Core Competencies - See Ambulatory Services See Ambulatory Services

Administrative NotebookAdministrative Notebook Certifications required for your department - Certifications required for your department - ((list of certifications that your list of certifications that your

staff and level of staff need to have-staff and level of staff need to have-include all certifications specific to your include all certifications specific to your unit or positions, i.e., chemo certificationunit or positions, i.e., chemo certification, , Trauma, BLS, ALCS, etc.)Trauma, BLS, ALCS, etc.)

Vulnerabilities: Areas identified by Mock Vulnerabilities: Areas identified by Mock SurveySurvey

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.)National Patient Safety Goals (Cont.) Anticoagulation TherapyAnticoagulation Therapy

Process to implement an enterprise-Process to implement an enterprise-wide Anticoag Therapy Programwide Anticoag Therapy Program

Universal ProtocolUniversal Protocol Operative / Procedural Area/ BedsideOperative / Procedural Area/ Bedside Verification of Side/Site/ProcedureVerification of Side/Site/Procedure Marking of SiteMarking of Site Time Out Immediately Before Time Out Immediately Before

ProcedureProcedure Medical Staff StandardsMedical Staff Standards

Bylaws RelatedBylaws Related Timeliness of ReappointmentsTimeliness of Reappointments

Human Resources Human Resources Decentralized Monitoring of CompetenciesDecentralized Monitoring of Competencies Performance EvaluationsPerformance Evaluations Staffing Effectiveness Exercise 2008-09Staffing Effectiveness Exercise 2008-09

Infection ControlInfection Control Use of PPEUse of PPE PPD ScreeningPPD Screening

Information Management (Medical Records Information Management (Medical Records Related)Related)

Aggregate Reports of Compliance Aggregate Reports of Compliance Streaming through HIM CommitteeStreaming through HIM Committee

Performance ImprovementPerformance Improvement Collecting/Analyzing/Using Data for Collecting/Analyzing/Using Data for

ImprovementImprovement Staff Knowledge of PrioritiesStaff Knowledge of Priorities

No Licensee is allowed to work until No Licensee is allowed to work until their license is renewed and verified their license is renewed and verified by the Manager or an ACS/OneStaff by the Manager or an ACS/OneStaff SpecialistSpecialist

Any Questions??Any Questions??

Review of Policy PM-12Review of Policy PM-12Employee Licensure Employee Licensure VerificationVerification It is the It is the employee’s responsibilityemployee’s responsibility

– to keep his/her license, accreditation, certification to keep his/her license, accreditation, certification and/or registration up to date.and/or registration up to date.

Failure of an employee to maintain currentFailure of an employee to maintain current required documentation or failure to provide the required documentation or failure to provide the department/division with the necessary department/division with the necessary documentation will be documentation will be grounds for dismissalgrounds for dismissal..

The monitoring and maintenance of current The monitoring and maintenance of current licenses, accreditation, certifications, and/or licenses, accreditation, certifications, and/or registration should be registration should be maintained in the maintained in the employee’s departmental file.employee’s departmental file.

RN/NP License Renewal Process RN/NP License Renewal Process Ambulatory Process Ambulatory Process

CentralizedCentralized Ambulatory Cost Centers (Departments) Ambulatory Cost Centers (Departments)

– entered into OneStaff for License Tracking Purposes onlyentered into OneStaff for License Tracking Purposes only.. New Hire is entered into New Hire is entered into OneStaff’s Personnel ModuleOneStaff’s Personnel Module License tracking is entirely dependent:License tracking is entirely dependent:

– upon the manager notifying the OneStaff/HR Specialist of upon the manager notifying the OneStaff/HR Specialist of each New Hire and terminationseach New Hire and terminations

A list of Ambulatory Departments – A list of Ambulatory Departments – – handout for your updateshandout for your updates

Process:Process:– Copy of the License Renewal is printed from the Nursing Copy of the License Renewal is printed from the Nursing

Board’s website- before the license expirseBoard’s website- before the license expirse– License Renewal information is entered into OneStaff and License Renewal information is entered into OneStaff and

filed centrally by department name.filed centrally by department name.

License VerificationLicense Verification

One StaffStand Alone Module

For Licenses

Monthly report to all directors and managers

Expired License

Ambulatory Directors updates•New hires•Termination

Sheila Goggin

For discussionDEA/DPHACLS/BLS

HR

Primary SourceVerification Process

RN/NP/LPN Added to RN/NP/LPN Added to One Staff Personnel One Staff Personnel ModuleModule

November 30th, 2008

December Licenses Not Yet Renewed

RNLicense Expiration Date

License Number Director/Manager

Ricci,Stephanie A 12/10/2008 265229 Bourie,T.

Sansone,Sarah E 12/17/2008 260694 Bourie,T.

Sleininger,Danielle M 12/8/2008 256990 Campbell, J.

Ninobla,Annalyn S 12/17/2008 253646 Campbell, J.

Robbins,Kristin W 12/29/2008 267463 Campbell, J.

Cahill,Allissa 12/12/2008 271986 Clarke,D.

License VerificationLicense Verification

Sheila Goggin is sending out information Sheila Goggin is sending out information for the RN’s and NP’s are you getting for the RN’s and NP’s are you getting the information? (the information? (licenses are renewed on even licenses are renewed on even year)year)

Sheila is printing out the license and Sheila is printing out the license and keeping a hard copy for keeping a hard copy for primary primary source verificationsource verification

Should we AddShould we Add– Add in BLS,ACLS, DEA and DPH to central Add in BLS,ACLS, DEA and DPH to central

monitoringmonitoring

Review of Policy PM-12Review of Policy PM-12Employee Licensure Employee Licensure

VerificationVerificationDecentralized ProcessDecentralized Process

Disciplines within the Medical Center that must be primary Disciplines within the Medical Center that must be primary source verifiedsource verified– Dietitians/nutritionistsDietitians/nutritionists– Audiologists/audiologist assistantsAudiologists/audiologist assistants– Speech pathologists/assistantsSpeech pathologists/assistants– OptometristOptometrist– Pharmacist/Pharm techPharmacist/Pharm tech– NP/RN, Nurse Midwife, nurse anesthetist, CNS, NP/RN, Nurse Midwife, nurse anesthetist, CNS, – OT/PTOT/PT– Athletic trainerAthletic trainer– Mental Health CounselorMental Health Counselor– Educational PsychologistsEducational Psychologists– Rehabilitation CounselorRehabilitation Counselor– Respiratory TherapistRespiratory Therapist– PerfusionistsPerfusionists

– Questions- contact HR directlyQuestions- contact HR directly

RememberRememberPrimary Source VerificationPrimary Source Verification

Decentralized ProcessDecentralized Process The The department directordepartment director is is

responsible for ensuring that responsible for ensuring that – primary source verification of the license is primary source verification of the license is

performed performed upon hire and at the time of upon hire and at the time of renewalrenewal

– Primary source verification provides Primary source verification provides evidence and written validation that the evidence and written validation that the license is verified as current and is license is verified as current and is maintained.maintained.

Primary Source Primary Source VerificationVerificationDecentralizedDecentralized If the license has been renewedIf the license has been renewed, ,

– print a copy of this license from the website on the print a copy of this license from the website on the day it is viewed (day it is viewed (see website examples in the policy)see website examples in the policy)

If the license has not yet been renewed If the license has not yet been renewed by the expiration dateby the expiration date, , – the person performing the review must contact the the person performing the review must contact the

licensing board directly to ascertain the status of licensing board directly to ascertain the status of the providers license/certification and must the providers license/certification and must document using the Verbal Verification (see policy)document using the Verbal Verification (see policy)

Upon renewalUpon renewal, , – the posted renewal on the website must then be the posted renewal on the website must then be

printed and filed in the personnel record, along printed and filed in the personnel record, along with the verbal verification formwith the verbal verification form

No Licensee is allowed to work until No Licensee is allowed to work until their license is renewed and verified their license is renewed and verified by the Manager or /ACS/OneStaff by the Manager or /ACS/OneStaff SpecialistSpecialist

Any Questions??Any Questions??

Best

Create a new more clinicallyRelevant chart audit

Data is available real time- unit specific-CQI

Clinicians would do all Chart audits- MD’s, NP’s , RN’s.

Chart Audit Process 2009 and beyond

Chart Audit- Next Chart Audit- Next StepsSteps

*Primary Care

*Medical Specialty Practices

*Surgical Specialty Practices

Emergency Room

*Ambulatory Procedure Based Audits

4 chart Audits in Development*

All Other Practices

Core Elements

Unit based- specific elements

Chart Audit- Next Chart Audit- Next StepsSteps

•Specialty based Work groups to evaluate the content of chart audits

•Editor of all templates-TBD

Medical

Specialty

Practices

Surgical

Specialty

practices

Emergency

Room

Ambulatory Procedure Based Audits

PrimaryCare

Data reported to specialty based directors on monthly basis

Data Evaluated and if changes are necessary-work with specialty based group to address

Specialty Based Chart Audits

On-going work-On-going work-updatesupdates Competencies- Competencies-

– list of all competencieslist of all competencies– Email PA/NP competencies, RX and MD Email PA/NP competencies, RX and MD

review review PACE updates- PACE updates-

– drop down menu similar to chart audits to drop down menu similar to chart audits to facilitate better data management-getting facilitate better data management-getting results back to youresults back to you

Tool Box-Tool Box-– patient rights and provision of carepatient rights and provision of care

CompetenciesCompetencies

NP and PA PracticeNP and PA Practice

NP’s and PA’s – collaborative practice agreement (guidelines)

Supervising MDSupervising and evaluatingGuidelines must be reviewed and confirmed as in effect on anAnnual basis

Office of Professional Staff Affairs-

Sends out a document to Supervising MD’s on an annual basis

Prescription Review-currently no standard way of doing thisDocumentation of review with supervising physician [244 CMR 4.22(3)(a)]Schedule II drug (narcotics)- only after consolation with MD- documented review in 96 hours.

•Regulations do not specify number of rx to be review - usually a % every 90 days------ BIDMC proposed 10 per quarter•Regulations do specify that needs to be face to face with subsequent documentation

•HCA working on standard process

HCA- HCA- DRAFTDRAFT for for Standardization of Prescription Standardization of Prescription

RXRX Standards: Review occurs at the end of each calendar quarter (i.e. March

31st, June 30th, September 30th, December 31st) Maximum number is 10 charts or based on patient visit

volume Documentation of review with supervising physician [244

CMR 4.22(3)(a)]– Face sheet defines number of initial prescriptions or changes in

medication [105 CMR 700.003 (4)]– Attach note/encounter that resulted in prescription– Submit packet of face sheet and notes to supervising physician to

be reviewed independently with follow up discussion with in 5-10 days from submission

Face sheet of the prescription review for the previous four quarters will be submitted with the NPs yearly evaluation.

Initial Schedule II prescriptions will be reviewed within 96 hours, either by verbal communication, forward progress note or chart review

HCA- DRAFT-FACE HCA- DRAFT-FACE SheetSheet NURSE PRACTITIONER PRESCRIPTION AUDITNURSE PRACTITIONER PRESCRIPTION AUDIT NURSE PRACTITIONER:NURSE PRACTITIONER: SUPERVISING PHYSICIAN:SUPERVISING PHYSICIAN: REVIEW PERIOD:REVIEW PERIOD: [ ] [ ] January – March, 2009January – March, 2009 [ ] [ ] April – June, 2009April – June, 2009 [ ] [ ] July – September, 2009July – September, 2009 [ ] [ ] October – December, 2009October – December, 2009 NUMBER OF RECORDS REVIEWED: ______________________________________NUMBER OF RECORDS REVIEWED: ______________________________________ NUMBER OF INITIAL PRESCRIPTIONS: ___________________________________NUMBER OF INITIAL PRESCRIPTIONS: ___________________________________ NUMBER OF DOSAGE CHANGES: ________________________________________NUMBER OF DOSAGE CHANGES: ________________________________________ PROBLEMS/ ISSUES IDENTIFIED BY SUPERVISING MD: ___________________PROBLEMS/ ISSUES IDENTIFIED BY SUPERVISING MD: ___________________ FEEDBACK/ EVALUATION: _____________________________________________FEEDBACK/ EVALUATION: _____________________________________________ Signatures: ____________________________________, NPSignatures: ____________________________________, NP Date: Date:

__________________________ ____________________________________, MD____________________________________, MD Date: Date:

__________________________

Performance manager

*** 243 CMR- include a defined mechanism to monitor prescribing practices including documentation of review by the supervising MD at least every 3 months

ResponsibilitiesResponsibilities

Hiring department ensures that written Hiring department ensures that written collaborative agreements- current collaborative agreements- current (resources, practice etc.)(resources, practice etc.)

Hiring department is responsible for Hiring department is responsible for annual reviewannual review

Hiring department is responsible for Hiring department is responsible for documenting primary source license documenting primary source license verification- which includes advanced verification- which includes advanced practice certification. (practice certification. (centralized this centralized this process)process)

References:References:

Collaborative Practice GuidelinesCollaborative Practice Guidelines State of MASS reg- 243 CMR (Board of State of MASS reg- 243 CMR (Board of

Regulation of Medicine)Regulation of Medicine) BIDMC Credentialing and Evaluation BIDMC Credentialing and Evaluation

Process for Advance Practice Nurses- Process for Advance Practice Nurses- OPSA-22OPSA-22

HCA- Advanced Practice ForumHCA- Advanced Practice Forum– Leah Mckinnon-Howe NPLeah Mckinnon-Howe NP– Barbara Rosato NPBarbara Rosato NP

Location of all Medical Location of all Medical Records- for your Records- for your informationinformation

Thank youThank you

TJC and CMS UpdateTJC and CMS UpdateAmbulatory Monthly MeetingAmbulatory Monthly MeetingApril 8, 2009April 8, 2009