Download continuous readiness review (crr) – team leaders

CONTINUOUS READINESS REVIEW (CRR) – TEAM LEADERS


Team Leaders rotate every 1-2 years
Expectations include:
 Attend quarterly debriefing sessions to identify common positives/opportunities for
improvement and priority focus areas hospital-wide - to be lead by Accreditation
Coordinator
 Lead teams on monthly process reviews
 Data collected, as assigned, and forwarded to Accreditation Coordinator
 Be content experts on assigned content
Assigned Content
Goal 01.01.01 and 01.03.01 – Improve the accuracy of patient
identification
Goal 02.01.01 and 02.02.01– Improving the effectiveness of
communication among caregivers
02.01.01 – Read back orders
02.02.01 – Non-approved abbreviations
Goal 02.03.01 and 02.05.01 – Improving the effectiveness of
communication among caregivers
02.03.01 – Critical tests/results
02.05.01 – Hand-off communication
Goal 03.03.01 and 03.04.01 – Improve the safety of using medications
03.03.01 – Look-alike/sound-alike drugs
03.04.01 – Label medications on/off the sterile field
Goal 03.05.01 - Anticoagulant therapy
Goal 07.01.01 – Reduce the risk of health care-associated infections
Goal 07.03.01 – Implement evidence-based practices to prevent health careassociated infections due to multi drug-resistant organisms in acute care
hospitals
Goal 07.04.01 – Implement best practices or evidence-based guidelines to
prevent central line-associated bloodstream infections
Goal 07.05.01 – Implement best practices for preventing surgical site
infections
Goal 08.01.01, 08.02.01, 08.03.04 and 08.04.01 – Accurately and
completely reconcile medications across the continuum of care
08.01.01 – Comparing patient’s current medications to those ordered while
under the care of the organization
08.02.01 – When patient is referred to or transferred from one hospital to
another, the complete and reconciled list of medications is communicated to
the next provider of services, and communication is documented
08.03.01 – When a patient leaves the hospital’s care, a complete and
Team Leader
Director, Business
Systems
Director, Laboratory
Assistant Director,
Diagnostic Imaging
Director, Neonatal
Services
Clinical Manager,
Pharmacy
Clinical Coordinator,
Children’s Hospital
Clinical Staff
Development
Specialist
Director,
Women/Infant
Health
reconciled list of patient’s medications are provided directly to the patient and,
as needed, the family, and the list is explained to the patient and/or family
08.04.01 – In settings where medications are used minimally or prescribed
for a short duration, modified medication reconciliation processes are
performed
Goal 09.02.01 – Reduce the risk of patient harm resulting from falls
Goal 13.01.01 – Encourage patients’ involvement in their own care as a patient
safety strategy
Goal 15.01.01 – The organization identifies safety risks inherent in its patient
population – suicide assessment
Goal 16.01.01 – Improve recognition and response to changes in a patient’s
condition
Universal Protocol:
UP01.01.01, UP01.02.01, and UP01.03.01
UP01.01.01 – Conduct a pre-procedure verification process
UP01.02.01 – Mark the procedure site
UP01.03.01 – A time-out is performed immediately prior to starting
procedures
Pain Management
Patient Tracer – utilize tracer methodology and trace a patient type
Supervisor, Physical
Medicine and
Rehabilitation
Senior Coordinator,
Business Systems
Clinical Coordinator,
Behavioral Health
Director, Adult
Critical Care
Clinical Coordinator,
Surgical Services
Assistant Director,
Women/Infant
Health
Director, Nursing
Resource Unit /
House Supervisors
CONTINUOUS READINESS REVIEW (CRR) – TEAM PARTICIPANTS


Will be assigned to a team and rotate quarterly
Must attend 75% of all CRRs
Team
#
1
Clinical Coordinator, Adult
Critical Care
2
Quality Specialist
3
Quality Specialist
4
5
6
7
Administrative Director,
Heart Hospital
Assistant Director,
Emergency Services
Administrative Director,
Children’s Hospital
Director, Emergency Services
/ Emergency Management
Supervisor, Diagnostic
Imaging
Supervisor, Diagnostic
Imaging
Assistant Director, Human
Resources
Clinical Coordinator,
Women/Infant Health
Clinical Coordinator,
Medical/Surgical/Oncology
Nursing Director, Behavioral
Health
Quality Specialist
Chief Operating Officer
Director, Behavioral Health
Marketing
Director, Customer Focus
Programs
Director, Wound Care Center
Assistant Director, Pharmacy
Resource Coordinator,
Quality Management
Chief Executive Officer,
Behavioral Health
Director, Physical Medicine /
Rehabilitation
Assistant Director, Food and
Nutrition Services
Charge Nurse, Nursing
Resource Unit
Director, Respiratory Care
Services
Clinical Coordinator, Heart
Hospital
Supervisor, Diagnostic
Imaging
8
Chief Nursing Officer
Assistant Director,
Respiratory Care Services
9
Director, Surgical Services
Chief Medical Officer
Assistant Director,
Medical/Surgical/Oncology
Assistant Director, JO Wyatt
Clinic
Operations Supervisor,
Surgical Services
Director, Outpatient
Cardiology Services
Assistant Director, Adult
Critical Care Services
Director, Inpatient Cardiology
Services
Director, JO Wyatt Clinic
Pharmacy
Director,
Medical/Surgical/Oncology
Director, Patient/Family
Services
Assistant Director, Surgical
Services
10
11
12
13
14
15
Director, Clinical Services
Administrator, JO Wyatt
Clinic
Patient / Family Advocate
Infection Control Specialist
ENVIRNOMENT OF CARE CONTINUOUS READINESS REVIEW (CRR) – TEAM MEMBERS


All areas are to be surveyed / toured at least twice / year
Notify Department Director in advance so that he/she may be involved in inspection
Life Safety
Management
Infection
Control
Environmental
Security
Management
Hazardous
Materials
Team One
Leader:
Occupational
Health Nurse
Clinical Staff
Development
Specialist
Director, Managed
Care Contracts
Chief Executive
Officer
Director,
Environmental
Service
Team Two
Manager, Workers
Compensation
Epidemiology
Coordinator
Leader:
Director,
Financial
Management
Manager, Trauma
and Emergency
Management
Chief Financial
Officer
Team Three
Director, Health
Information
Management
Associate
Administrator
Director,
Information
Systems
Leader:
Supervisor,
Plant
Engineering
Director, Materials
Management
Team Four
Supervisor,
Security
Director, Human
Resources /
Education
Director, Food and
Nutrition Services
Leader:
Director, Plant
Engineering
Director,
Marketing /
Corporate
Communications