January 13, 2010

Ambulatory Joint Commission

Agenda Chart Audit Results and Action Planning

Presented by: Sandra Hewitt, Lynne Brophy

Ambulatory CQI Committee Update Presented by: Sandra Hewitt

PACE Audit Committee Update Presented by: Sandra Hewitt

Results - Dashboard

N = 23 categories

Criteria 28-Oct 3-Sep Comments>90% Compliance 15 14 Good!

Improved 11 Good!Stayed the same 5 Okay

Dropped 7 Not so goodImmediate action 4 4 Compelling

Data Comparisons

73%73%

85%

61% 63%

75%

45%

25%

75% 74%79%

85%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Time OutDocumented

Ops/ProcNoted

Consent Timed Updated Medlist to pt

Chart Audit Vulnerabilities

3-Sep

28-OctGoal

Chart Audit Action Planning Each audited area is required to complete an action

plan grid.

Criteria below 75% compliance need action plans.

I am pulling together a subgroup to focus on systems issues that can have a positive impact on aggregate results and reduce vulnerabilities.

Please let me know if you’re interested in working as part of this group. We especially need representation from procedural areas, as well as areas from the Department of Medicine.

Work Group Organization

OPS Council

Policies,Procedures & Guidelines

CQI Projects PACE Audits

TJC Facilitators Group

TJC Ambulatory Directors

and Managers Group

Chart Audit Focused Group

New

Charge of CQI To meet TJC standards and regulatory

agency directives for quality care and patient safety.

To identify areas within Ambulatory/ED where we can: Effect positive change and Reinforce best practices.

.

Scope of CQI Promote knowledge and tools for everyday

readiness. Develop a systematic approach for reducing

ambulatory and ED vulnerabilities by: Overseeing a workgroup that monitors chart audit results and

assists in the resolution of common systems issues.

Assessing risk by establishing a method for f/u on incident reporting/call outs.

Standardizing critical hand-offs.

Improving our communication methods particularly regarding change.

Sharing Best Practices among TJC team members.

Survey staff on units to add to their comfort level and expertise in responding TJC surveyors.

Ambulatory CQI Subcommittee

Membership:

Lead: Menrika LouisMary Beth Bahren

Toby Grooms

Sandra Hewitt

Jason Laviolette

Dan Nadworny

Ann Stathakis

Linda Trainor

Follow up on PACE Audits

We have had delays in getting our PACE audit tool revised.

The PACE group met with Gary Schweon and Frank Rosen to discuss the following topics:

Compare their new tool with ours; o There is room for collaboration in our audit tools.

Share our new methodology for self-audits; Internal PACE surveys using “outside eyes”

Internal PACE Surveys Gary and his team overwhelmingly support an internal

Ambulatory and ED survey process;

They recognize that their surveys are only 2X per year and that there is room for more surveillance and follow up on corrective actions could be more timely;

We also discussed that there are additional topics (Patient Care/Patient Safety) not included in the EOC that we may want to examine either through PACE or the CQI committee’s unit questions of staff;

Additionally, we agreed that the “outside eyes” concept not only helps managers but also serves as a means of educating staff.

Revised PACE Audit Methodology Monthly self-assessments;

One section a month/complete audit per quarter: Infection Control Fire & Life Safety Medication Management & Pharmacy

We may need to adjust our first audits to get a full 2nd quarter of data.

Peer reviews will be every 4 months and will be coordinated with Gary’s team schedule.