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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 The team uses at least two client identifiers before providing any service or procedure (major) Things to Consider 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 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 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 There is documented evidence of ongoing, effective training on infusion pumps. Things to Consider 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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