thp regulatory readiness 2011 - framework (2011!11!02)
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THP Regulatory Readiness 2011
Continuous Readiness Strategy
Part I Steering Committee: Senior Leadership
Provides direction and oversight as the steering committee, maintains momentum
Participated in selection of chapter champions (not senior staff) and strategy coordinator
Regularly meets face-to-face with chapter champions to discuss and address barriers
Identifies opportunities for improvement from reported data
Follows-up on results of corrective action plans
Celebrates chapter champions and team members
Responsible for embedding / sustaining quality and safety improvements
Senior Leader Title Senior Leader NamePresidentVice President and Chief Quality Officer
Vice President & Chief Financial OfficerAdministrative Director Planning,Development & Ambulatory CareAdministrative Director Physician ServicesAdministrative Director Human ResourcesSenior Vice President & Chief OperatingOfficerVice President & Chief Nursing Officer
Senior Leadership Defines:
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Part II Standards Compliance
Joint Commission Chapter Champions
Establish and select one chapter champion for each chapter
Responsible and accountable for compliance to chapter standards
Champions choose team members to assist in the review of standards and elements of
performance (EPs); each team member accepts 1 3 standards, depending upon extent ofstandard
Team members assist in the review and auditing of EPs / Measures of Success (MOS); team
members are sought from all departments and from all levels
Communicate list of these staff to coordinator / senior leadership for acknowledgement and
recognition
Chapter Abbreviation Chapter Champion
Accreditation ParticipationRequirements
APR
Environment of Care ECEmergency Management EMHuman Resources HRInfection Prevention & Control ICLeadership LDLife Safety LSMedication Management MMMedical Staff MSN ti l P ti t S f t G l NPSG
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard ChapterChampion / Plan
Team Members
Accreditation
ParticipationRequirements
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /Plan
Committee /Team Members
Environment of Care
Life Safety Plan Mark Anderson
Tod Nutt
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Human Resources
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Infection Prevention &
Control
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
InformationManagement
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Leadership
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Life Safety
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter
Champion / Plan
Team Members
MedicationManagement
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Medical Staff
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Goal Chapter Champion /
Plan
Team Members
National Patient SafetyGoals
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Nursing
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Provision of Care,Treatment & Services
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Provision of Care,Treatment & Services
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Improvement
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Record of Care,
Treatment & Services
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /Plan
Team Members
Rights & Responsibilitiesof the Individual
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /Plan
Team Members
Transplant Safety
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Chapter Standard Chapter Champion /
Plan
Team Members
Waived Testing
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Part II Standards Compliance
Strategy Coordinator Director, Quality
Develops Guidelines for Chapter Champions, including:
Define roles of coordinator, chapter champion, team member
Define responsibilities and accountabilities of each
Define time frames / expectations for frequency of meetings of each group
Develop tools for collecting data Develop tools for reporting data
Develop time frames for submission of data
Establish frequency and type of data reporting
o Weekly reports to SLT
o Weekly reports to chapter champions
o Monthly reports to department directors
o Monthly reports to medical staff leadership Organize and provide to chapter champions a packet of the aforementioned information,
including an instruction guide for implementation of strategy
Communicate to hospital staff the strategy / plan for continuous readiness and compliance
to quality and safety standards, roles, responsibilities and accountabilities of chapter
champions and team and the need for staff participation in teams.
Oversight for development of tracer activities.
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
Part III Tracer Activity
Tracer Activity as a Component of Ongoing Readiness
Establish and implement tracer training for staff Director, Quality
Establish a person / process to facilitate oversight of tracer activities Director, Quality
Create tools to be used for tracing in each department
Identify local unit / department based management responsible for conducting tracers ineach department
Track tracer activities
Review tracer tools
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity andReporting Schedule
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THPresby Dallas Regulatory Readiness 2011 Tracer Activity and Reporting Schedule
Unit Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecBUILDING A
OR & CENTRAL STERILE
PROCESSINGA-3 L & DA-4 POST PARTUM & NBNA-5 ONCOLOGY & M/S
BUILDING BDAY SURGERYPACUCATH LABB-3 HIGH RISK OBB-4 PEDIATRICSB-5 TELEMETRY & M/S
BUILDING CEMERGENCY ROOMC-2 CCUC-3 NICUC-4 POST PARTUMC-5 TELEMETRY & STEPDOWNC-6 M/S
C-7 BARIATRICS & M/SC-8 ORTHOPAEDICSOTHER PATIENT CARE AREASARTSLABORATORYOUTPATIENT THERAPYRADIOLOGY (THP)SEAY BEHAVIORAL HEALTHWOUND CARE CENTER
OTHER DEPARTMENTSHUMAN RESOURCESMEDICAL STAFF SERVICESENVIRONMENT OF CARE
ROUNDS
MEDICATION MANAGEMENTINFECTION PREVENTION &
CONTROLFOOD & NUTRITION SERVICESPHARMACYPEDIATRIC IMAGINGWOMENS DIAGNOSTIC CENTERFRISCO REHAB CENTERQUALITY, PATIENT SAFETY &
RISK
Key: T = Tracer Activity Performed R = Report tracer outcomes / staff competency to Regulatory Readiness
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