Archive for April, 2009
AHAP giveaway announcement–our final winner
And the final winner in our AHAP Conference registration giveaway: Marina Isaac of Mount Sinai Hospital & Schwab Rehabilitation Hospital in Chicago, IL!
We’re looking forward to seeing all of our winners at this year’s conference! Thanks to all of the members who participated in this fantastic contest–we were incredibly impressed with the turnout and with the quality of information being shared week to week.
Update to yesterday’s contest entry
After receiving several requests, we wanted to share the progress report Edward mentioned in his tip yesterday. It is downloadable at the link below.
combined-core-measures-progress-notechf
Also, he has offered to to share similar documents on pneumonia and AMI. Please feel free to contact me at mphillion@hcpro.com if you’re interested!
Thanks for the great tip, Edward. And just a reminder to all our members–tomorrow’s the last day to enter for our free AHAP conference giveaway. Entries can be submitted right up until noon tomorrow. We’ll announce a winner by the end of the day.
Contest entry: Physician progress note
Our latest AHAP conference giveaway entry comes from Edward Chilcote, LVN, CPHQ, HACP, QA/PI coordinator at Tri-City Regional Medical Center. Edward writes:
Through interdisciplinary collaboration we devised a “Core Measures” physician progress note that combines the documentation requirements for CHF, and the documentation requirements for CC’s and MCC’s.
This improved communication between Physicians, Medical Records, Case Managers, Nurses and Coders.
This assisted us to achieve an even higher standard of care, and improve the documentation necessary to abstract CC’s and any MCC’s as it relates to CHF.
The revision provided our facility with both; Clinical and Financial outcomes.
Only two days left to enter! Our final drawing will take place this Friday, April 24th.
This week’s winner!
This week’s free registration for the 2009 AHAP Conference goes to:
Sandra J. Anaya RN of Tri-City Regional Medical Center!
Congratulations, Sandra. And remember, there’s still one more chance to win–we’ll draw a final winner at random on Friday, April 24th. We’ll accept entries to the contest up until 12 noon EST on Friday.
Last minute contest entry
The latest contest entry snuck in just under the wire–11:57 a.m. arrival time! This great tip is accompanied by two sample documents linked below, and comes to us from
Marina Isaac, MHA, manager of continual survey readiness at Mount Sinai Hospital & Schwab Rehabilitation Hospital, Chicago. Marina writes:
As part of our Continual Survey Readiness program, we place an emphasis on the National Patient Safety Goals from the moment any caregiver starts working with our organization and throughout the duration of employment. During new employee orientation, caregivers are introduced and informed about the significance of NPSGs. That is also when employees receive a Survey Readiness Handbook, which includes the NPSGs and outlines general information that they are encouraged to refer to and keep on them at all times. 2009 NPSG posters are located throughout the hospital. Departmental quality dashboards and mock tracers collect data related to our current compliance levels related to these standards. These dashboards then roll up to form the Hospital Quality Dashboard which is consistently presented to the Board. Currently, we are in the process of creating an organizational NSPG dashboard.
Occasionally, task forces and committees are formed to address particular NPSGs. For example, one task recently worked together on updating our policies for Universal Protocol. The hospitals’ Invasive Procedure Site Marking and Time Out Policy was amended, a Pre-procedural and Surgery Checklist was modified to model after the WHO Surgical Safety Checklist, and the time out sticker was revised. See attached. Similarly, we take action for other NPSGs, as appropriate. Thus, a continual emphasis is placed on the National Patient Safety Goals, which enforces that they are a priority for our organization.
Thanks for the entry. Marina. We’ll be announcing this week’s winner in just a few hours. And remember, only one more week left to win–we’ll draw our last winning contestant next Friday, April 24th!
Contest entry: Safety preparedness
Our latest contest entry in our AHAP 2009 conference registration giveaway comes from Sandra J. Anaya RN, of Tri-City Regional Medical Center. Sandra writes:
As a part of our safety preparedness program we have placed “quick reference” guides on all units in the form of a wall-mounted flip chart that staff can use to remind them of key safety procedures that need to be carried out for different types of disaster.
We have updated them to include information about emergency management planning, the Incident Command Center, and how the Command Center is activated. We have found that during any type of survey, when staff may be nervous, they can walk over to the flip chart and share the information with surveyors. The charts are also beneficial when orienting temporary agency personnel.
And the winner is…
We just held this week’s random drawing for a free registration for the upcoming AHAP Conference, and the winner is:
Michael Neiman, senior director of accreditation with Thomas Jefferson University Hospitals in Philadelphia, PA! Michael has entered several tips since the start of the contest–be sure to check them out, along with all of the entries so far, below.
We’ll draw the next winner a week from today–be sure to check back to see if you’re the winner! And if you haven’t entered yet, there’s still two more weeks to win, so send those tips, tools, or survey stories in soon!
Contest entry: Mini-handbook
The latest tip comes from Michael Neiman, senior director of accreditation with Thomas Jefferson University Hospitals in Philadelphia, PA. Michael writes:
We create a mini-handbook every year called Q and A for staff which fits in pocket for a reference guide. It includes HR, IC, Patient Safety, PI, Patient Rights, Privacy and Safety. These are given out to all new employees and staff every year. Staff find these education and valuable.
Contest entry: Survey experience
Our latest entry into our free AHAP giveaway comes from Karen A. Beck, CPHQ, quality manager at Sacred Heart Visiting Nurses & Hospice. She writes:
We were surprised the first week of February when TJC surveyors showed up at our hospital. We are a hospital based agency that provides home health and hospice services. We were not totally unprepared, though. I had been working from the Survey Activity Guide using the Preliminary Information sheet provided in this document. I compiled all of our information and had it housed in a binder ready on my bookshelf.
I also had the most current measure of success data I informed our management team and quality nurse of it’s location in the event I was not available. Our plan included assigning specific personnel to be responsible for running current patient lists and serving as “gophers” for any requests. As soon as the call arrived from the hospital accreditation coordinator we put our plan into action.
All the information we needed to get our surveyor started was readily available. This was not always the case in the past where we were scrambling to pull information together.
Revised revisions receive scoring guidelines
Those of us who stopped by the Joint Commission’s Standards landing page today received a bit of a shock–a bolded notice that additional updates had been made to the revised standards and EPs released on March 26. When the initial shock wore off, though, it turned out to be good news–the standards and EPs were not revised (again), but rather, the PDF had been updated to include (drum roll please) scoring guidelines! This much-awaited announcement indicates which standards are A versus C, where all the “circle M’s” and “circle D’s” are.
You can find the latest PDF of revisions here.
Keep in mind there’s no guarantees that we won’t see additional revisions leading up to July 1–the Joint Commission’s deeming authority application is still in process and we could, potentially see more changes.
