# Presentation: 069617

## 109H – The Road to Readiness: A Comprehensive Guide

- Shirley Simons RN, MSN, CPHQ
- Chief Quality Officer
- VA Nebraska-Western Iowa HCS

## 109H – Road Map to Readiness

- Please,
- No questions during the presentation.
- Questions written on the 3X5 card will be answered at the conclusion of the presentation.
- For questions not answered,
- the question and the answer will be available on the web.

## 109H – Road Map to Readiness

- If you get lost, raise your hand

- There are room assistants to help you.

**Notes:**
This is fast-paced presentation as I will try to move through the documents just as a surveyor does during the survey process.  Don’t hesitate to raise your hand if you need assistance.  We learn in many ways and we help each other along the path of learning.

## 109H – Road Map to Readiness

- At the end of the presentation, participants will be able to:
- Demonstrate their ability to navigate through a patient’s clinical record
- Describe tools in CPRS to search for data
- Recognize applicability of tracer methodology in conducting health care inspections
- Formulate process improvement plans to update front line staff in navigation techniques

**Notes:**
Our experience with Joint Commission in 2003 as a pilot site for the tracer methodology was a wake-up call for us that nursing staff needed to be more proficient with navigation in CPRS.  After that survey we began our efforts to work with the nursing staff to help them improve their CPRS skills.  As we continued to do tracer activities, we could see their skill and confidence increasing over time.  We did better during out survey in 2004 and the nursing staff were really strong during our survey in April of this year.  They did a great job of navigating through the record and answering the questions of the surveyors.  Although we all have staff that might not be really comfortable with CPRS we can all improve if we put our minds to it! 

## 109H – Road Map to Readiness

- Priority Focus Process (PFP)
- Priority Focus Areas (PFA)
- Process, system, or structure that significantly impacts the quality & safety of care
- Clinical Service Groups (CSG)
- Categories of patients/residents/clients or service for which data are collected

## 109H – Road Map to Readiness

- Assessment & care/services
- Communication
- Credentialed Practitioners
- Equipment Use
- Infection Control
- Information Management
- Medication Management

- Organizational Structure
- Orientation & Training
- Rights & Ethics
- Physical Environment
- Quality Improvement
- Patient Safety
- Staffing

- Priority Focus Areas

## 109H – Road Map to Readiness

- Examples of Clinical Service Groups
- Cardiology
- Internal Medicine
- Urology
- General Surgery
- Dialysis
- Behavioral Health
- Long Term Care
- Residential Care

## 109H – Road Map to Readiness

- The Tracer Process
- Readiness Tool
- Focuses on Care/Service to Patient
- Involves Front Line Staff
- Moves Back in Time

## 109H – Road Map to Readiness

- Tracer Elements
- Choose a patient to trace
- PFA/CSG
- Following a specific topic (NPSG, Medication Management)
- Work with the nurse providing care to the patient
- Front line staff
- Surveyor is observer
- 30-60 minutes with the front line care staff

## 109H – Road Map to Readiness

**CPRS Log In**
- Access Code:  	##VEHU
- Verify code:  	VEHU##
- Signature code:  	VEHU##
- 		## = your student number

## 109H – Road Map to Readiness

**Universal Protocol (UP1)**
- Conducted in a location where the procedure will be completed just before starting the procedure
- Involves the entire operative team, uses active communication and includes at least:
- Correct patient identity
- Correct side and site
- Agreement on the procedure to be done
- Correct patient position
- Availability of implants or special equipment, if appropriate
- The process is documented

## 109H – Road Map to Readiness

- Hand-off Communication
- Hand-offs for your patient
- Surgical Evaluation Unit to Surgery
- Surgery to the inpatient unit
- Shift to shift during the inpatient stay

## 109H – Road Map to Readiness

- Use of Data For Improvement
- Current Data Collected
- Model for Improvement (e.g. PDSA)
- Examples of Improvement Driven by the Data
- Critical test results to ordering provider
- Documentation of pain medication effectiveness
- VHA Performance Measures
- Discharge Teaching for CHF Patients
- Timeliness of EKG & Troponin for Patients with Chest Pain in the ER
- Know the examples for your department

## 109H – Road Map to Readiness

- Summary
- Find out how your facility is using the tracer process for readiness
- Volunteer to be involved
- Focus on the patient/resident/client
- Build sound processes
- Be Continually Ready!

## 109H – Road Map to Readiness

- QUESTIONS