Download Required Organizational Practices Resources for

Required Organizational Practices
Resources for 2015
ROPs
TWO CLIENT IDENTIFIERS
The team uses at least two client
identifiers before providing any
service or procedure.
Tests for Compliance
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The team uses at least two client
identifiers before providing any service
or procedure (major)
Things to Consider
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Is staff aware of the Patient Identification policy
and its requirements?
What processes do you have in place in your
specific program area to educate staff on this
patient safety measure:
o Orientation
o In-services
o Posters
How does staff educate patients about how and
why we include them in the verification process?
What processes do you have in place to validate
that patients are being appropriately identified?
Do you share audit results with staff?
What improvement activities have been
implemented as a result of audit findings?
Available Resources
Patient Identification Policy.pdf
Newborn Identification Policy.pdf
GNCH NURSING_PROCEDURE Patient Identification.pdf
Audit tools
Observation record
Staff Interview
version 4 May 7 2012.pdf
Questions version 4 May 8 2012.pdf
Poster
Expect to Check
poster.pdf
ROPs
MEDICATION
RECONCILIATION AT CARE
TRANSITIONS
Acute Care Services
With the involvement of the
client, family, or caregiver (as
appropriate), the team generates
a Best Possible Medication
History (BPMH) and uses it to
reconcile client medications at
transitions of care.
Tests for Compliance
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Upon or prior to admission, the team
generates and documents a Best
Possible Medication History (BPMH),
with the involvement of the client,
family, or caregiver (and others, as
appropriate).
The team uses the BPMH to generate
admission medication orders OR
compares the Best Possible Medication
History (BPMH) with current medication
orders and identifies, resolves, and
documents any medication
discrepancies.
A current medication list is retained in
the client record.
The prescriber uses the Best Possible
Medication History (BPMH) and the
current medication orders to generate
transfer or discharge medication orders.
The team provides the client,
community-based health care provider,
and community pharmacy (as
appropriate) with a complete list of
medications the client should be taking
following discharge.
Things to Consider
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Is staff familiar with the MedRec process?
If MedRec is not fully implemented on your unit
are staff aware of the roll out plan?
What is in place to educate staff about the
MedRec process?
Are staff familiar with where and how to access
resources?
What processes are in place to report, resolve,
document and discuss errors
Are forms filled out completely and
appropriately?
Is there a clear process on your unit to ensure
the BPMH and current medication list follows the
patient to the next level of care including
discharge
What processes are in place to validate the
MedRec process?
How are audit results shared with staff?
What improvement initiatives have occurred as a
result of audit findings?
Available Resources
MedRec on CompassionNet
 What is MedRec
 What’s In It For Me
 Accreditation Canada Information
 MedRec Champion resources
 MedRec on Admission resources
 MedRec at Transfer Resources
 MedRec at Discharge Resources
 MedRec Admission Auditing Resources
ROPs
INFUSION PUMPS TRAINING
The organization provides
ongoing, effective training for
service providers on all infusion
pumps.
Tests for Compliance
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There is documented evidence of
ongoing, effective training on infusion
pumps.
Things to Consider
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Staff must be trained on all infusion pumps
(includes PCA pumps).
Enteral feeding pumps are no longer included in
the ROP (however standardized training on the
use of these pumps is important).
What process are in place to educate all staff
(new hires and casual):
o Orientation
o Ongoing certification
Are checklists used to ensure consistency?
Surveyors may request to see evidence of how
managers and / or educators validate that all
staff have received the appropriate education.
How do you determine that the education you
have provided is effective?
What processes are in place to address infusion
pump incidents, data library updates etc.?
Have improvements been made based on RLS
data or feedback?
Available Resources
When to Use an Infusion Pump
Infusion Pump Education Module
Sample Checklists:
M:\MarkDocs\Staff M:\MarkDocs\Staff M:\MarkDocs\Staff
Education&Certification\Certification
Education&Certification\Certification
Days\Medfusion
Education&Certification\Certification
Certification
Days\Pump
Checklist.pdf
Certification
Days\Infusion
Hands On.pd
Pu
M:\MarkDocs\Staff
Education&Certification\Certification Days\Instructor cards for Smart Pump.pdf
ROPs
INFORMATION TRANSFER
The team transfers information
effectively among service
providers at transition points.
Tests for Compliance
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The team has established mechanisms
for timely and accurate transfer of
information at transition points.
The team uses the established
mechanisms to transfer information.
Things to Consider
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Have you identified all handover points for your
area?
Does your area have a standardized consistent
process that staff follows for each transition
point?
Does your area have a written guideline for the
process that staff is to use?
How are staff orientated to the process and tools
used on your unit?
Does your unit use standardized tools (e.g.
SBAR, CHAT, ISOBAR, checklists, transfer
forms, Kardex)?
Is information transferred in a timely manner?
How do you validate that the process is adhered
to?
Do you follow up with any RLS incidents that are
related to information transfer?
Have any changes been made to improve
current processes?
Have you ever communicated with partners who
receive the information you provide to ensure
they are receiving the information they need for
continuity of care?
How do you include the patient/family when
communicating information at transfer or
discharge?
Available Resources
Transfer of Information Accountability Policy
Internal Transfer Report
GNCH and MCH Women's Health Inpatient Transfer Policy.pdf
Transfer from L&D to Antepartum
L&D transfer to Postpartum
MCH Patient Transfer Policy
Frequently Asked Questions Document
FAQs.pdf
ROPs
SAFE SURGERY CHECKLIST
The team uses a safe surgery
checklist to confirm safety steps
are completed for a surgical
procedure.
Tests for Compliance
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The team has agreed on a three-phase
checklist to be used in the operating
room.
The team uses the checklist for every
surgical procedure
The team has developed a process for
ongoing monitoring of compliance with
the checklist.
The team evaluates the use of the
checklist and shares results with staff
and service providers.
The team uses results of the evaluation
to improve the implementation of and
expand the use of the checklist.
Things to Consider
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Are staff aware of and do they understand the
policy and use of the checklist?
What processes are in place to education staff
(including physicians) on the appropriate use of
the checklist?
What processes are in place to validate that the
checklist is being used and completed
appropriately?
Have any improvement opportunities been
identified to enhance appropriate use of the
checklist?
Available Resources
Safe Surgical Checklist Policy
SSC Link to Videos
PowerPoint Education Module
2013
Powerpoint.pptx
SSC User Manual
AHS Safe Surgery
Checklist User Manual v4.pdf
Covenant Health SSC
vii-b-240_Covenant_
Health_Safe_Surgery_Checklist.pdf
Auditing Information
SSC Observational
Auditor
Audit Sample Size_Covenant
FAQ_18June2014.pdf
breakdown_2014-15.pdf
ROPs
FALLS PREVENTION
STRATEGY
The team implements and
evaluates a falls prevention
strategy to minimize client injury
from falls.
Tests for Compliance
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The team implements a falls prevention
strategy.
The strategy identifies the populations
at risk for falls.
The strategy addresses the specific
needs of the populations at risk for falls.
The team establishes measures to
evaluate the falls prevention strategy on
an ongoing basis.
The team uses the evaluation
information to make improvements to its
falls prevention strategy.
Things to Consider
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What processes are in place on your unit to
assess a patients risk for falls on admission and
on an ongoing basis?
How is staff educated about falls prevention on
your unit?
How do you include patients and families in the
conversation about falls risk and prevention?
How do you determine that appropriate
interventions are in place to reduce the risk of
falls?
Is staff clear of all steps to follow when a patient
falls?
Are post falls huddles occurring consistently on
your unit (the surveyors may ask to see post fall
huddle documentation)?
Does your unit use the available RLS data to
analyze fall trends on your unit?
What processes are in place on your unit to
validate that falls risk assessments and
interventions are appropriately being completed?
How is staff made aware of the number of falls
occurring on your unit?
What improvement activities have occurred on
your unit as a result of information/data obtained
about falls in your area (change in admission
practice, improved RLS reporting etc.)?
Available Resources
Falls Prevention & Risk Reduction Policy
Neonatal Falls Mitigation Strategy
Women's Health Falls Mitigation Strategy
Patient Information/Falls
ROPs
CLIENT AND FAMILY ROLE IN
SAFETY
The team informs and educates
clients and families in writing and
verbally about the client and
family’s role in promoting safety.
Tests for Compliance
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The team develops written and verbal
information for clients and families
about their role in promoting safety.
The team provides written and verbal
information to clients and families about
their role in promoting safety.
Things to Consider
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What information about patient safety is provided
to patients on your unit?
How is patient safety information reviewed with
patients and their families?
How do you know that patient safety information
has been reviewed with patients and families –
what is the process for documentation?
What type of education have staff received to
ensure they are educating patients and families
about important patient safety information
appropriately?
What processes are in place on your unit to
validate that patient safety information is being
provided to all patients?
Surveyors will talk to patients/families and ask
about the information that has been provided and
discussed.
Available Resources
Your role in care brochure
Your role in care.pdf
Site Specific Patient Handbooks (MCH Example)
Site Specific Patient
Handbook.pdf
ROPs
PRESSURE ULCER
PREVENTION
The team assesses each client’s
risk for developing a pressure
ulcer and implements
interventions to prevent pressure
ulcer development.
Tests for Compliance
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The team conducts an initial pressure
ulcer risk assessment at admission,
using a validated, standardized risk
assessment tool.
The team reassesses each client for
risk of developing pressure ulcers at
regular intervals, and with significant
change in client status.
The team implements documented
protocols and procedures based on
best practice guidelines to prevent the
development of pressure ulcers, which
may include interventions to: prevent
skin breakdown; minimize pressure,
shear, and friction; reposition; manage
moisture; optimize nutrition and
hydration; and enhance mobility and
activity.
The team supports education for health
care providers, clients, and families or
caregivers on the risk factors and
strategies for the prevention of pressure
ulcers.
The team has a system in place to
measure the effectiveness of pressure
ulcer prevention strategies, and uses
results to make improvements.
Things to Consider
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Based on your patient population what risk
assessment tool is used on your unit?
How do you educate staff on your unit about the
tool used (at orientation and ongoing)?
Where is the information documented on the
patient chart?
How is this information communicated among
team members?
What process is in place on your unit to reassess
patients?
What protocols are in place to prevent pressure
ulcers for at risk patients?
How do you communicate to patients/families
strategies for pressure ulcer prevention?
How do you document the information that is
provided to patients and families?
How do you validate that the tools are being
completed appropriately?
What processes are in place to collect data about
pressure ulcer rates on your unit?
Have any improvement strategies been
implemented as a result of pressure ulcer trends
on your unit?
Available Resources
Pressure Ulcer Assessment and Prevention
Standards of Practice
Pressure Ulcer Prevention - Heels
Wound Management Edmonton Continuing Care Centres
Quality Assurance
Skin Surveys GNCH Med.doc
ROPs
SUICIDE PREVENTION
The team assesses and monitors
clients for risk of suicide.
Tests for Compliance
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The team identifies clients at risk of
suicide.
The team assesses each client for risk
of suicide at regular intervals, or as
needs change.
The team addresses the immediate
safety needs of clients who are
identified as being at risk of suicide.
The team identifies treatment and
monitoring strategies to ensure client
safety.
The team documents the
implementation of the treatment and
monitoring strategies in the client’s
health record.
Things to Consider
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Is all staff (including physicians) aware of current
policies and guidelines?
Does staff know where/how to access
information?
What type of education do staff receive about
suicide prevention at orientation?
What ongoing education is provided to staff and
physicians?
Are there consistent practices in place on your
unit to address patients who have been identified
at risk?
Are treatment and monitoring strategies clearly
documented in the patients chart?
Can staff easily locate the treatment and
monitoring information? (surveyors may look for
how this information is communicated among
staff)
What audit strategies are in place to ensure that
risk assessments and checklists are completed
appropriately?
Are audit results shared with staff?
Have any improvement strategies been
implemented based on results of audits?
Available Resources
Suicide Risk Assessment and Management
Environmental Risk Assessment MH P&P
Template (Veteran’s Affairs; new facility); Sample: Post
Inspection Report
tms-amh-checklist-en 2014 Environment
vironment-ahs-adaptation.pdf
Scan.pdf
Observation Levels
Search of Patient Property
Inpatient Attempted Suicide
Inpatient Death by Suicide
ROPs
VENOUS
THROMBOEMBOLISM (VTE)
PROPHYLAXIS
The team identifies medical and
surgical clients at risk of venous
thromboembolism (deep vein
thrombosis and pulmonary
embolism) and provides
appropriate thromboprophylaxis.
*NOTE: This ROP is not a
requirement for pediatric
hospitals. The ROP applies to
clients 18 years of age or older.
Tests for Compliance
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The organization has a written
thromboprophylaxis policy or guideline.
The team identifies clients at risk for
venous thromboembolism (VTE), [(deep
vein thrombosis (DVT) and pulmonary
embolism (PE)] and provides
appropriate evidence-based, VTE
prophylaxis.
The team establishes measures for
appropriate thromboprophylaxis, audits
implementation of appropriate
Thromboprophylaxis, and uses this
information to make improvements to
their services.
The team identifies major orthopaedic
surgery clients (hip and knee
replacements, hip fracture surgery) who
require post-discharge prophylaxis and
has a mechanism in place to provide
appropriate post-discharge prophylaxis
to such clients.
The team provides information to health
professionals and clients about the risks
of VTE and how to prevent it.
Things to Consider
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Is staff aware of the policy and practice support
documents?
What processes are in place to educate staff
about VTE risk assessment?
Does staff know where to access resources and
information on VTE?
What processes are in place to ensure all
patients are assessed on admission and with any
change in condition?
What processes are in place to flag the
prescribing practitioner that prophylaxis orders
have not been completed?
How are patients/families educated about VTE
risk on your unit?
What processes are in place to validate that risk
assessments on being completed as required on
your unit?
How are audit results shared with staff (including
physicians) on your unit?
Are any improvement initiatives underway as a
result of the audit information?
Available Resources
VTE Resources on CompassionNet
 Covenant Health Policy and Practice Guideline
 VTE Preprinted Care Order Set
 Frequently Asked Questions Document
 3 step process for prevention of VTE
 Pocket Card/poster for Pharmacological Options
 Education Modules on CliC and CompassionNet
 Patient Information Brochure
 One Page Information Sheet
 Audit Legend
 Audit Tool
 Information on Mechanical Prophylaxis
 Presentation by Dr. Elizabeth Mackay, Dr. Bruce
Ritchie and Dr. Bill Geerts