Pioneers Memorial Hospital
Physician Reference Guide
For The Joint Commission
2010
Pioneers
Physician
Be
Prepared
1
TABLE OF CONTENTS
MEDICAL STAFF ................................................................................................................................................................... 3
PROFESSIONAL PRACTICE EVALUATION ................................................................................................................................... 3
WHAT IS FPPE?........................................................................................................................................................................ 3
WHAT IS OPPE? ...................................................................................................................................................................... 4
COMPETENCY AND THE SIX (6) DIMENSIONS OF PERFORMANCE ............................................................................................ 5
CONSULTATIONS ...................................................................................................................................................................... 6
BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY ............................................................................................................... 7
PATIENT RIGHTS ................................................................................................................................................................... 8
PATIENT & FAMILY COMPLAINTS .............................................................................................................................................. 8
PRIVACY AND SECURITY ........................................................................................................................................................... 8
PATIENT SAFETY.................................................................................................................................................................... 8
2010 NATIONAL PATIENT SAFETY GOALS ................................................................................................................................ 9
INCIDENT REPORTING ............................................................................................................................................................. 11
SENTINEL EVENTS .................................................................................................................................................................... 11
ROOT CAUSE ANALYSIS (RCA)............................................................................................................................................. 11
FMEA .................................................................................................................................................................................... 11
DISCLOSURE OF UNANTICIPATED OUTCOMES ........................................................................................................................ 12
TIME OUT................................................................................................................................................................................ 12
UNAPPROVED ABBREVIATIONS............................................................................................................................................... 13
CRITICAL VALUES ................................................................................................................................................................... 15
HAND WASHING .................................................................................................................................................................... 15
PERFORMANCE IMPROVEMENT..................................................................................................................................... 16
2009 HOSPITAL WIDE PERFORMANCE IMPROVEMENT PROJECTS ........................................................................................... 16
INFORMED CONSENT ....................................................................................................................................................... 17
MEDICAL RECORD DOCUMENTATION REQUIREMENTS............................................................................................ 18
VERBAL ORDERS AND DATE/TIME/SIGN ................................................................................................................................ 18
LEGIBLE .................................................................................................................................................................................. 18
ENVIRONMENT OF CARE OVERVIEW............................................................................................................................ 19
PHYSICIAN BE PREPARED – KNOW THOSE CODES.................................................................................................................. 20
CORE MEASURES............................................................................................................................................................... 21
2
Medical Staff
Professional Practice Evaluation
Concept: Gather data as physician uses privileges
FPPE – Focused Professional Practice Evaluation
OPPE – Ongoing Professional Practice Evaluation
What is FPPE?
In 2007, The Joint Commission (TJC) published a new evaluation requirement that took effect January 1, 2008.
Known as Focused Professional Practice Evaluation (FPPE), it requires that hospitals subject practitioners to a
period of focused observation of their clinical performance as a means to determining their current, privilegespecific competence when the hospital has no firsthand knowledge to otherwise make such a determination.
FPPE is therefore required for new applicants to the medical staff as well as for existing practitioners requesting
additional privileges. FPPE ends when a practitioner’s competency is established, providing the basis for
continuous review and ongoing professional practice evaluation (OPPE).
Focused Professional Practice Evaluation (FPPE)
FFPE is required when an organization lacks information regarding physician performance, and it generally
occurs under three circumstances:
• The practitioner is not yet a medical staff member
• The practitioner has not yet performed the procedure for which he or she seeks
privileges at your organization in the past
• There is a concern regarding the practitioner’s current competency, either due
to data from OPPE or because the practitioner has not used the privilege for
an extend period of time
FPPE data may include:
• Personal interaction with the practitioner by the proctor
• Detailed medical record review by the proctor
• Interviews of hospital staff interacting with the practitioner
• Surveys of hospital staff interacting with the practitioner
• Chart audits by non-medical staff personnel based on medical staff defined criteria for initial appointees
The data obtained by the proctor will be recorded in the proctoring form approved by each specialty to
structure the proctoring data for consistency and inter-rater reliability.
3
What Is OPPE?
The term “Ongoing Professional Practice Evaluation” (OPPE) has been defined to encompass the entire process
described above. Every physician will be subjected to the OPPE process on a continuous basis with periodic
reports being generated.
OPPE moves the review process from every two years, at time of reappointment, to every eight (8) months, to
allow for performance improvement. And, when necessary, refer on for FPPE (focused professional practice
evaluation).
Each of these indicators will be tied to one or more of the six core competencies listed on the following page.
OPPE data may include:
• Routine chart audits by non-medical staff personnel for important clinical functions
• Data abstracted for external comparative databases used to evaluate current medical staff
Members
• Incident reports
• Findings of cases identified for review by medical staff peer review committees
• Electronic claims data used to evaluate current medical staff members
• Patient satisfaction surveys
4
Competency and the Six (6) Dimensions of Performance
Measures the six core competencies to comply with FPPE and OPPE. It’s all about competence:
Starting in January 2008, every medical staff in the United States will have to collect physician specific data
regarding the six core competencies as defined by the JC, the American Board of Medical Specialties (ABMS)
and the Accreditation Council for Graduate Medical Education (ACGME). These are the same six core
competencies that we are already using to rate every resident. Detailed descriptions of how to use these core
competencies and the data elements that can be used are currently on the ACGME and ABMS websites.
The six core competencies and a brief description are:
Patient Care:
Practitioners are expected to provide patient care that is compassionate, appropriate, and effective for the
promotion of health, prevention of illness, treatment of disease, and care at the end of life.
Medical/Clinical Knowledge:
Practitioners are expected to demonstrate knowledge of established and evolving biomedical, clinical, and
social sciences, and the application of their knowledge to patient care and the education of others.
Practice-Based Learning and Improvement
Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and
improve patient care practices.
Interpersonal & Communication Skills:
Practitioners are expected to demonstrate interpersonal and communication skills that enable them to
establish and maintain professional relationships with patients, families, and other members of health care
teams.
Professionalism:
Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional
development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward
their patients, their profession, and society. (The Joint Commission considers diversity to include race, culture,
gender, religion, ethnic background, sexual preference, mental capacity, and physical disability.)
System-Based Practice:
Practitioners are expected to demonstrate both an understanding of the contexts and systems in which health
care is provided, and the ability to apply this knowledge to improve and optimize health care.
5
Consultations
Request for Consultations.
Requests for consultation must include the physician or specialty requested and the reason for the consultation.
Direct communication from the attending physician to the consulting physician is required or Consultation
Request Form is filled out. This is extremely important to assure that physician’s questions can be answered.
Recommended Consultations. Except in an emergency, consultation is recommended in the following
instances:
•
Where the diagnosis is obscure after ordinary diagnostic procedures have been completed.
•
Where there is doubt as to the choice of therapeutic measures to be used.
•
In unusually complicated situations where specific skills of other Physicians may be needed.
•
In instances where the patient exhibits severe psychiatric symptoms.
•
When pelvic surgery is contemplated in the presence of a confirmed pregnancy.
•
When requested by the patient or a surrogate decision-maker.
•
When required by the Medical Staff or Hospital rules.
Required Consultations
A consultation is required when the Clinical Service Chief or Chief of Staff determines that a patient will benefit
from such consultation. Such consultation shall be required only after the Clinical Service Chief or Chief
of Staff has discussed the situation with the patient’s attending physician.
If a nurse has any reason to doubt or question the care provided any patient or believes that consultation is
needed and has not been obtained, he or she may call this to the attention of his or her supervisor, who
in turn may refer the matter to the appropriate Clinical Service Chief. The Clinical Service Chief may
then, in appropriate circumstances, require a consultation, after conferring with the patient’s attending
physician.
A Medical Staff member may be required by the Medical Executive Committee to have consultations on all or
some of his or her cases. In such situations, the Medical Staff member shall be responsible for informing
the assigned consultants of each admission and for arranging for timely consultation.
Required Report
The written or dictated consultant reports must contain at least the following elements, as appropriate:
Review of history and medical record;
Summary of physical findings;
Diagnostic impression, and;
Recommendations for treatment.
6
Behaviors That Undermine a Culture of Safety
Intimidating and disruptive behaviors can:
foster medical errors,
contribute to poor patient satisfaction and to preventable adverse outcomes,
increase the cost of care,
cause qualified clinicians, administrators and managers to seek new positions in more professional
environments.
Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work
environment. To assure quality and to promote a culture of safety, health care organizations must address the
problem of behaviors that threaten the performance of the health care team.
Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well
as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes
during routine activities.
Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power.
Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending
language or voice intonation; and impatience with questions.
Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.
All intimidating and disruptive behaviors are unprofessional and should not be tolerated.
Final Note:
The above behavior traits can be displayed by any member of the healthcare organization.
If you are experiencing this type of behavior from any member of the hospital staff or medical staff, please
contact the Medical Staff Office.
7
Patient Rights
Each patient has basic rights which are posted in both English and Spanish within PMHD units for patient's and
family’s reference. Inpatients are also given a copy of these rights at the time of admission.
Patient & Family Complaints
Patient/family complaints and grievances may be registered through Patient Relations at PMHD, or through the
area where interaction/care takes place. Complaints should be documented and forwarded to Patient
Relations.
Privacy and Security
Patients are entitled to be treated in a secure environment and must be offered privacy in terms of the
personal space and all communications regarding their medical care.
Patient Safety
The Patient Safety Program is designed to decrease medical errors, improve systems to prevent adverse events,
and encourage open reporting of events related to patient care.
The Patient Safety and Quality Council at PMHD provide expertise, review data, and set priorities for enhancing
patient safety. All physicians are encouraged to attend this bimonthly meeting.
Bill Railsback, Director of Quality and Lab, is the PMHD Patient Safety Officer.
8
2010 National Patient Safety Goals
The purpose of the Joint Commission’s National Patient Safety Goals is to promote specific improvements in
patient safety. The goals highlight problematic areas in health care and describe evidence and expert-based
solutions to these problems. Recognizing that a sound system design is intrinsic to the delivery of safe, high
quality health care, the goals focus on system-wide solutions wherever possible.
Goal 1
Improve the accuracy of patient identification
NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment, or services.
NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification.
Goal 2
Improve the effectiveness of communication among caregivers
NPSG.02.03.01: Report critical results of test and diagnostic procedure on a timely basis.
Goal 3
Improve the safety of using medications
NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in
perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups and
basins.
NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.
Goal 7
Reduce the risk of health care-associated infections
NPSG.07.01.01: Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines
or World Health Organization (WHO) hand hygiene guidelines.
NPSG.07.03.01: Implement evidence-based practices to prevent health care-associated infections due to
multiple drug-resistant organisms n acute care hospitals.
NPSG.07.04.01: Implement evidence-based practices to prevent central line-associated bloodstream
infections.
NPSG.07.05.01: Implement evidence-based practices for preventing surgical site infections.
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Goal 8
Accurately and completely reconcile medications across the continuum of care
NPSG.08.01.01: A process for comparing the patient’s current medications with those ordered for the patient
while under the care of the hospital.
NPSG.08.02.01: When a patient is referred to or transferred from one hospital to another, the complete and
reconciled list of medication is communicated to the next provider of service, and the communication is
documented. Alternatively, when a patient leaves the hospital’s care to go directly to his or her home, the
complete and reconciled list of medications is provided to the patient’s known primary care provider, the
original referring provider, or a known next provider of services.
NPSG.08.03.01: When a patient leaves the hospital’s care a complete and reconciled list of the patient’s
medications is provided directly to the patient, and as needed, the family, and the list is explained to the
patient and/or family.
NPSG.08.04.01: In settings where medications are used minimally, or prescribed for a short duration, modified
medication reconciliation processes are performed.
Goal 15
The organization identifies safety risks inherent in its patient population
NPSG.15.01.01: Identifies patients at risk for suicide. Note: This requirement only applies to psychiatric hospitals
and patients being treated for emotional or behavioral disorders in general hospitals.
Universal Protocol
Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery TM
UP.01.01.01: Conduct a pre-procedure verification process.
UP.01.02.01: Mark the procedure site.
UP.01.03.01: A time-out is performed before the procedure.
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Incident Reporting
All events related to clinical care that involves harm to the patient or the potential for harm should be reported
using the PMHD Quality Review Report. A report should be completed on any error involving a patient, any
near miss patient related event, any significant clinical event even if it is not an error and any systems problem
that adversely affects your work.
Examples of reportable events may include: medication errors, transfusion reactions, complications from
procedures, code blue, communication issues, AMA, and clinical management issues.
All incident reporting is handled by the Risk Manager, Juana Gonzales.
Sentinel Events
• An unexpected occurrence involving the death, serious physical or psychological injury or risk thereof,
specifically including loss of limb or function. • When a sentinel event is identified, a team will be analysis
assembled to perform a root cause and develop an action plan for improving practice and process
• Notify PMHD Risk Management and Quality Management whenever a sentinel event occurs.
Root Cause Analysis (RCA)
An RCA is a reactive approach to an actual event or near miss that has already occurred.
• Identifies the “fundamental” reasons for the event
• Asks why, what and how rather than who
• Identifies process improvements that will prevent reoccurrence
Note: this is covered in the Policy: Sentinel Event
FMEA
Do you know what a Failure Modes & Effects Analysis (FMEA) is?
It is a proactive analysis of a process to identify potential system failures.
Do you know what FMEAs Pioneers has performed?
2010 – Continued with 2009 FMEA
2009 – Continued with 2008 FMEA
2008 – Medication Reconciliation & Critical Values
2007
Blood Administration & Patient Flow
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Disclosure of Unanticipated Outcomes
• An Unanticipated Outcome is an outcome that differs significantly from what the practitioner or patient
expected. This is not necessarily the result of an error.
• Disclosure of unanticipated outcomes to patients, and when appropriate their families, is required and should
be done by the responsible licensed independent
practitioner in a timely manner.
• Medical record documentation should include: a factual explanation of the outcome; measures taken to
correct the outcome; physician’s recommendations in response to the outcome; any other type of assistance
the patient may need; questions raised by the patient and response by the physician and the date, time,
location and person’s present at the discussions.
Time Out
Final Verification Process: prior to start of any surgical or invasive procedure- All participants take “time out” to
confirm
• correct patient
• correct procedure,
• correct site
• readiness of team.
Hot Tip: Remember “time out” is required before ANY invasive procedure-this may be a chest tube placement,
amniocentesis, lumbar puncture, etc.
Note: Please refer to the Policy: Universal Protocol/Universal Precaution – verification of Correct Site for
Invasive or Surgical Procedure(s)
Patient Safety.
12
Unapproved Abbreviations
Do NOT use unacceptable abbreviations within the medical record. PMHD have developed a list of
abbreviations that are not to be used in any handwritten patient care communications.
Hot Tip: The communications where the unacceptable abbreviations can not be used can be pharmacy
orders, progress notes, operative reports, etc.
Please See Matrix on Following Page
13
Pioneers Memorial Hospital
Official “Do Not Use” List
ITEM ABBREVIATION
1. U (for unit)
2. IU (for International unit)
3. Q.D.
4. Q.O.D.
5. Trailing Zero (X.0 mg)
[Note: Prohibited only for
medication-related
notations];
POTENTIAL PROBLEM
Mistaken as zero, four or cc
Mistaken as IV (intravenous)
or 10 (ten)
(Latin abbreviation for once
daily and every other day)
Mistaken for each other.
The
period after the Q can be
mistaken for an “I” and the
“O” can be mistaken for “I”.
PREFERRED TERM
Write “unit”
Write “International unit”
Write “daily” and “every
other day”
Decimal point is missed
Never write a zero by itself
after a decimal point (X
mg),
and always use a zero
before
a decimal point (0.X mg).
7. MS
8. MSO4
9. MgSO4
Confused for one another.
Can mean morphine sulfate
or magnesium sulfate.
Write “morphine sulfate” or
“magnesium sulfate”
Write “morphine sulfate” or
“magnesium sulfate
AZT
HCI
HCT
MTX
TAC
Confused for azathioprine
Confused for potassium
chloride
Confused for
hydrochlorothiazide
Confused for mitoxantrone
Confused for tetracaine,
adrenalin, cocaine
Mistaken for mg (milligrams)
Resulting in ten-fold dosing
overdose
6. Lack of Leading Zero (.X
mg)
10. µg
(for microgram)
11. PT
12. o.d. or OD
13. Per os, AS
14. Apothecary symbols for
fluid ounces, drams, minims
Intended for either
Prothrombin time or Physical
therapy.
Intended as once daily but
can be misinterpreted as
"right eye" (OD- oculus
dexter)
Intended as orally but can
be mistaken for OS (left
eye) or AS (left ear)
Symbol for fluid ounces
misread for "3", drams
misread for "grain or gram"
and minim misread as "mL"
Write out name of
medication
Write “mcg”
Write Protime or physical
therapy.
Use "daily"
Use "orally"
Use metric system
14
Critical Values
One focus of the National Patient Safety Goals is communication among caregivers. There is a specific goal
that states we will measure, assess and, if appropriate, take action to improve the timeliness of reporting, and
the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
•
To meet this requirement, the Policy: Critical Value Protocol was developed. This policy may be referenced in
the Pioneers Key Policies Reference Guide.
Failure Mode and Effects Analysis (FMEA)
• Proactive approach focused on high risk processes so future problems can be prevented
• Assumes failures will occur, and that it is possible to minimize the probability and ill effects of failures
• The Joint Commission requires an annual selection of a “high risk process” to be analyzed, redesigned and
monitored.
Hand Washing
Two million people each year become ill as a result of a hospital-acquired infection. Proper hand hygiene is
critical to the prevention of these infections - which contribute to the death of nearly 90,000 hospital patients
per year and $4.5 billion in medical expenses.
You may not realize you have germs on your hands!
Nurses, doctors and other healthcare workers can contaminate their hands by
doing simple tasks, including:
· taking a patient’s blood
pressure or pulse;
· assisting patients with mobility;
· touching the patient’s gown
or bed sheets; and
· touching equipment, including bedside rails, over bed tables, IV pumps.
The photo shows a blood agar plate 24 hrs after an ICU nurse placed her hand on plate”
15
Performance Improvement
2009 Hospital Wide Performance Improvement Projects
1. Improving Core Measure Outcomes – Gina Parker
•
CHF – Merridee Moshier
•
PNE – Merridee Moshier
•
AMI – Robyn
•
SCIP – Connie Smith
•
HOP – Gina Parker/Robyn Atadero?
•
Pregnancy Related – Barbara Deol
•
Pediatric Asthma – Barbara Deol
Atadero
2. Decreasing Decubitus/Pressure Ulcers – Merridee Moshier
3. Improving Pain Management – Barbara Deol
4. Improving NPSG Compliance – Gina Parker
5. Improving Hand washing Compliance- Bill Railsback
6. Improving Patient Flow – Robyn Atadero
Physician participation is encouraged and your participation is greatly appreciated.
16
Advance Directives
An Advance Directive (AD) is a legal document specifying the patient’s wishes for care if he or she is unable to
make decisions for them.
• All inpatients over the age of 18 and able to give informed consent are to be offered information and an
opportunity to complete an Advance Directive.
• The physician is responsible for knowing what is in the AD and to include this information in the plan of care.
• There are two main types of Advance Directive
• A Living Will is completed by the patient to inform their physician about the desires related to their
care in the event that the patient is not able to actively participate in the decision making process
• A Durable Power of Attorney for Health Care (“DPAHC”) allows a person to designate another
individual (and two alternates) to make health care decisions for them in the event that they are not
able to make decisions for themselves. The DPAHC also contains a section in which the patient can
make their wishes known in advance
• When a patient has an advance directive and undergoes an operative or invasive procedure requiring
sedation, if the wishes of the patient (e.g. to not be resuscitated) are to be suspended in order to recover the
patient from the
sedation, this must be discussed explicitly with the patient or surrogate and noted in the patient’s chart
Informed Consent
Informed consent occurs when a patient accepts or rejects a medical intervention willingly and without
coercion. Informed consent can only occur when the patient fully understands the nature of the intervention
and its risks and benefits, as well as the alternatives with their risks and benefits. The major elements in informed
consent are understanding by the patient and that it is signed voluntarily.
Prior to performing any surgical or invasive procedures (except emergencies) or procedures/tests requiring
Moderate Sedation in either the Hospital or Clinic settings, the physician is responsible for obtaining the
patient’s informed
consent. The physician must provide to the patient:
• A description of the procedure or treatment
• Potential problems related to recuperation
• The medically significant benefits and risks involved
• Any alternative treatment options and their risks and benefits
• The name of the person or persons who will carry out the procedure or treatment
• What is likely to happen if the patient decides not to have the procedure or treatment.
The consent form must be completed and present in the patient’s chart
prior to the surgery or procedure.
17
Medical Record Documentation Requirements
Medical Staff members are required to:
• Complete all medical record documentation within 14 days of discharge, including Discharge Summaries.
• Complete History/Physicals within 24 hours of admission and prior to surgery
• Write/dictate Operative/Procedure Reports immediately after the surgery or procedure
Verbal Orders and Date/Time/Sign
o
Must be written down and read back to the physician and
o
Must be limited to urgent/emergent situations and
o
Must be signed by the physician within 24 hours
Legible
o
All entries must be legible and complete
• Date, time, write name and discipline, and sign all orders and documentation, including progress notes (we
strongly encourage the inclusion of your dictation
number)
• Time the following using a 24 hour clock: orders, postop note, medication administration, forms that include a
time element, restraint application and removal, anesthesia note immediately prior to induction and others
when indicated
• Do not use unapproved abbreviations or symbols in any patient care documentation
• Handwrite or dictate a clinic note within 24 hours of the encounter
• Document telephone calls and telephone consultations in the medical record
• Errors should be corrected by lining out the mistake with a single line and writing the correction above. The
original author of the documentation should date and initial corrections
• Send the original, signed copy of the documentation to the medical records department within 24 hours of
completion for scanning.
• Maintain a summary/problem list on all outpatients seen at least three times by a primary care physician.
• Send a copy of the signed research consent form to medical records for scanning for patients participating in
a research study.
• Medical student entries must be counter-signed by a licensed supervising physician before implementation
• Document adverse/allergic reactions to medications
• Blood Transfusion consent includes Paul Gann Act requirements
• Consents are completed for all surgical/invasive procedures and for use of anesthesia/sedation including
risks, benefits, alternatives discussed with patient.
18
Environment of Care Overview
A safe, functional, and effective environment for patients, staff members, and other individuals in the hospital is
crucial to providing care and achieving good outcomes. Effective management of the environment of care
includes using processes and activities to reduce and control environmental hazards and risk, prevent
accidents and injuries, and maintain safe conditions for patients, visitors, and staff.
Code Red - Fire
RACE
PASS
(Use of fire extinguisher)
R – Rescue
A – Alarm
C – Confine
E – Extinguish/Evacuate
P - Pull
A - Aim
S - Squeeze
S – Sweep
Evacuation of Patients
1st
Priority – patient where fire started
2nd
Priority – ambulatory
3rd
Priority – bedridden
Caring for Inmates
Do:
1.
2.
3.
4.
5.
Instruct inmate regarding care.
Ask to be called by your first name and profession.
Communicate in a professional manner relevant to nursing care only.
Monitor and remove unnecessary medical equipment.
Stay away from inmate patient areas if not involve in their care.
Don’t:
1.
2.
3.
4.
5.
Block the officers’ view of the inmate at any time.
Have personal contact unless medically ordered.
Have loose items in your pockets.
Acknowledge or reveal presence of inmate patients.
Make telephone calls or mail anything for inmate patients.
19
Physician Be Prepared – Know Those Codes
Code Blue
Medical Emergency
Code Red
Fire
Code Grey
Security/Violence
Code Orange
Hazardous Material Release
Code Pink
Child Abduction
Code Yellow
Trauma
Code Triage
Disaster Plan Activation
Dial 4444 and advise hospital operator of exact location
Codes
Physician
Be
Prepared
20
Core Measures
PMHD adheres to a set of care processes called Core Measures, which were developed by
The Joint Commission to improve the quality of health care by implementing a national,
standardized performance measurement system.
The Core Measures were derived largely from a set of quality indicators defined by the
Centers for Medicare and Medicaid Services (CMS).
They have been shown to reduce the risk of complications, prevent recurrences and
otherwise treat the majority of patients who come to a hospital for treatment of a condition
or illness.
Core Measures help hospitals improve the quality of patient care by focusing on the actual
results of care.
Core Measure Performance
You Are Part of the Team
Getting to Green
21
What is the core measure selection and reporting?
Hospitals are required to select four (4) and gather data and report. PMHD selected:
HF
PNEU
AMI
SCIP
Measures related to heart failure care
Measures related to pneumonia care
Measures related to heart attack care
Measures related to surgical care improvement project
The core measure score is based on the hospital quality measures and shows the
percentage of patients who received the recommended care for all of the measures that
they were eligible to receive.
Are there other core measures?
The below core measures are not reported publicly but data is being gathered
PR
CAC
HOP
Pregnancy Related
Children’s Asthma Care
Hospital Outpatient Services
·Acute Myocardial Infarction
·Chest pain
·Surgery
What are the MDs and nursing staff’s role in core measures?
Use of order sets by MDs guarantees that all diagnostic and treatment components of each
measure set are completed and documented at a precise time.
Nursing staff must also ensure that these orders are carried out and documented at the right
time on the right document.
Remember, no documentation means no intervention was done and negative scores are
given to set measures.
What does it mean to receive high scores on core measures?
The goal is 100% in our core measure compliance.
This means that patients with core measure diagnoses were given timely and appropriate
care on all elements. Our scores are publicly reported as well as for all hospitals in the
surrounding area. The goal of core measures is to have evidence-based care for our patients
because it’s the right thing to do! Getting the recommended care means patients are more
likely to have better outcomes.
22
Core Measure Set
Heart Failure (HF)
Measures:
Smoking status, council smoking cessation
Left Ventricular Systolic function (ECHO)
o Can document results of past Echo as long as Left Ventricular Function is addressed or
document of echo planned after discharge
ACEI/ARB at discharge for Ejection Fraction <40% or documentation of moderate dysfunction
If meds are not ordered, Physicians must document reason why
All six discharge instruction elements
o activity level
o diet
o discharge medications
o follow‐up appointment
o weight monitoring
o what to do if symptoms worsen
At Admission
Physician Responsibility
Order LVS function (ECHO) during
admission, document past results or
plan to perform after discharge,
must include Left Ventricular Systolic
function either Ejection Fraction or
Narrative
Nurse Responsibility
Document smoking status and
smoking cessation
o
If the patient has smoked in the
past year then the patient must
have smoking cessation
counseling
23
At Discharge
Physician Responsibility
Order ACEI/ARB at discharge for
Ejection Fraction < 40% or narrative
description of moderate to severe
dysfunction; reason for not
prescribing could be documented
anytime during the admission
o
Nurse Responsibility
The patients medication must be
completely reconciled at discharge
o
Must document reason for
not prescribing both except
in cases of worsening renal
failure, hypotension,
hyperkalemia, renal artery
stenosis, angioedema
Look at home medications
and active medications,
clarify discharge meds with
physician if there is
uncertainty
All six discharge instruction must be
documented on the discharge form
and/or Affinity charting
o
o
o
o
o
o
activity level
diet
discharge medications
follow‐up appointment
weight monitoring
what to do if symptoms
worsen
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Core Measure Set
Pneumonia (PNEU)
Measures:
Smoking status, council smoking cessation
Blood cultures prior to antibiotics
Antibiotic within 6 hours
Correct Antibiotic selection for Community Acquired Pneumonia
Influenza vaccine status/administration
Pneumococcal vaccine status/administration
At Admission
Physician Responsibility
Correct antibiotic selection per
pneumonia pathway
Nurse Responsibility
Ensure antibiotic selection follows
recommended guidelines on
pneumonia pathway
Document influenza and
pneumococcal vaccine status
o You may need to call the
patient’s primary Physician or
family to get complete
information
o Check Clinical Circumstances
in Affinity, document status in
Affinity at admission and
discharge, check the patient’s
old chart
o Documentation of past
influenza only counts for THIS
season, NOT past seasons
Order blood cultures within 24 hours
for patients being admitted ICU
Draw blood cultures before antibiotic
Order blood cultures before
antibiotic administration
Antibiotics to be administered
within 6 hours of arrival not from the
time the patient is seen by MD
Use pneumonia pathway for
community and healthcare
acquired pneumonia
Administer antibiotic within 6 hours of
arrival
Document smoking status and
smoking cessation
If the patient has smoked in the past year
then the patient must have smoking
cessation counseling
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At Discharge
Physician Responsibility
Order pneumococcal and
influenza vaccine as appropriate
Nurse Responsibility
Ensure vaccine status is completed
either in Affinity or the screening
form, follow screening form for both
pneumococcal and influenza
criteria
Offer pneumococcal vaccine year
round
Offer influenza vaccine if OctoberMarch
A patient can refuse, just document
refusal
Ensure the influenza vaccine was
administered this season if
documentation is for past
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Core Measure Set
Acute Myocardial Infarction - AMI
Measures:
Smoking status, council smoking cessation
Aspirin within 24 hours of arrival
Fibrinolosis within 30 minutes of arrival
Left Ventricular Systolic function (ECHO)
Can document results of past Echo as long as Left Ventricular Function is addressed
Aspirin at discharge
Beta Blocker at discharge
ACEI/ARB at discharge for Ejection Fraction <40% or documentation of moderate dysfunction
If meds are not ordered, Physicians must document reason why
At Admission
Physician Responsibility
Aspirin within 24 hour of arrival or for
not ordering
Nurse Responsibility
Ensure Aspirin is ordered within 24
hours of arrival or have MD document
reason for not ordering
Order LVS function (ECHO) during
admission, document past results or
plan to perform after discharge,
must include Left Ventricular Systolic
function either Ejection Fraction or
Narrative
Ensure ECHO is ordered or
documentation of previous ECHO
result; the result must include the Left
Ventricular Systolic function (Ejection
Fracture) or a narrative, i.e. Moderate
Left Ventricular Systolic function
Fibrinolosis within 30 minutes of
arrival
o Not 30 from the time the MD
sees the patient
If the patient has smoked in the past
year then the patient must have
smoking cessation counseling
Document smoking status and
smoking cessation
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At Discharge
Physician Responsibility
Nurse Responsibility
Order ASA and Beta Blocker at
discharge or document reason for
not prescribing; reason for not
prescribing could be documented
anytime during the admission
Ensure Aspirin and Beta Blocker are
ordered at discharge
Order ACEI/ARB at discharge for
Ejection Fraction < 40% or narrative
description of moderate to severe
dysfunction; reason for not
prescribing could be documented
anytime during the admission
Ensure ACEI/ARB is ordered at
discharge for an Ejection Fraction
of <40% or narrative description of
moderate to severe dysfunction
o
Must document reason for
not prescribing both except
in cases of worsening renal
failure, hypotension,
hyperkalemia, renal artery
stenosis, angioedema
If ASA, Beta Blocker, ACEI/ARB are
not ordered the physician must
document why
If ASA, Beta Blocker, ACEI/ARB are
not ordered the physician must
document why
The patients medication must be
completely reconciled at discharge
o
Look at home medications
and active medications,
clarify discharge meds with
physician if there is
uncertainty
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Core Measure Set
Surgical Care Improvement Project(SCIP)
Measures:
Prophylactic antibiotic ordered and administered is per recommended guidelines for
particular surgery
Antibiotic administered within 1 hour of surgery cut time
Prophylactic antibiotics are stopped within 24 hours of surgery cut time
Appropriate form of hair removal
Immediate normothermia post surgery
Urinary catheter removed on POD 1 or POD 2
Beta Blocker prior to admission and peri-operatively
VTE (DVT) prophylaxis ordered
VTE (DVT) prophylaxis applied within 24 after surgery cut time
Pre-OP
Physician Responsibility
Pre-op
o Appropriate selection of
prophylactic antibiotic for
required surgery
o Start antibiotic within 1 hour
of incision (2 hours for
quinilones or Vancomycin)
o D/C order for foley by POD 1
or POD 2
o Maintain normothermia
during surgery
o Order or continue Beta
Blocker 24 hours before
surgery cut time, peri- or
intra-operatively or during
recover time
o Documentation VTE (DTV)
prophylaxis is ordered and
applied before 24 hours post
op
o
Nurse Responsibility
Pre-op
o Administer antibiotic within 1
hour of incision, 2 hours if
administering a quinilone or
Vancomycin
o Ensure hair removal is clipped
or a depilatory is used NEVER
SHAVED
o When a Beta Blocker is a
routine home medication there
is documentation of
administration 24 hours prior to
surgery cut time, during surgery
or while in recovery room
o Documentation supports VTE
(DVT) prophylaxis is ordered
and applied
o
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Post Op
Physician Responsibility
Post-op
o Stop prophylactic
antibiotics within 24 hours
of surgery cut time
o Ensure normothermia perioperatively
o D/C urinary catheter on
POD 1 or POD 2
o Order Beta Blocker during
recovery period if it is the
patients routine home
medication
o VTE (DVT) prophylaxis is
ordered
Nurse Responsibility
Post-op
o Remind physicians to stop
antibiotics within 24 hours
of surgery cut time if no
documentation of post op
infection
o Post op temperature is
normal immediately after
surgery, documentation
supports hypothermia
o Urinary catheter is
removed on POD1 or POD
2 unless there is
documentation to
continue
o Ensure Beta Blocker is
administer in recovery
room if it is routine home
medication
o Documentation support
VTE (DVT) prophylaxis is
ordered and applied post
operatively
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To:
PMHD Medical Staff
From: Lee Harrison, CPCS, CPMSM, CHC
Director of Medical Staff Services, Compliance and Privacy
My intent in developing the Physician Reference Guide is to provide you with an overview of key processes and
policies that relate to The Joint Commission. Please take the time to familiarize yourself with these.
Should you have any questions, or need further clarification, please give me a call.
Always happy to help.
Phone:
760-351-3507
Email:
[email protected]
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