Pilot Agencies CQI Recommendations

UP.01.03.01 requires a time-out before the start of the procedure. The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are missing from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a unique form which will be used to document

The electronic medical record system (EMR) serves many purposes in an emergency for the patient, physicians, and hospitals involved in the diagnosis and care during an emergency.

Each year in the United States approximately 114 million people visit their local Emergency Department (ED), and 16 million of these patients arrive by Emergency Medical Services (EMS). (Board et al.) Health care in America has moved from an individual, fee-for-service health care system, towards a more integrated healthcare system i.e., The Affordable Care Act (ACA), which is a government controlled healthcare system, and is set up to be a value-based payment system. The ACA will expand and transform the roles of EMS within the healthcare system. EMS’s ability to survive and thrive in this new era of healthcare, will revolve, in part, on its ability to articulate its value to healthcare providers, healthcare organizations, hospital systems, and payers, as well as patients and family members. (Smith) EMS can thrive in the future, if it embraces change. John F. Kennedy had this to say about change, “Change is the law of life. And those who look only to the past or present are certain to miss the future.” (BrainyQuote) In order for EMS to thrive in the changes that the future is bringing, it must: focus on mobile integrated healthcare, be data driven in their clinical practices. There are three other areas that will be discussed at length, EMS agencies should be actively pursuing a community paramedicine program, EMS using remote telemedicine and EMS moving towards a value-based payment system.

The RN/ Case Managers and Triage Nurses will increase their compliance of filling out incident reports that are being filled out by 10% within the next 3 months. The nurses will fill these out for patient falls, infections and injuries in order to be compliant with our Quality Assurance Goals.

The Medical Record Management System your office implements is only as good as the ease of

For example, a hospital-wide policy can be made making it mandatory for all critical results to be documented and reported within the hour. Attestations can be put in place for all hospital staff to sign, holding them responsible if policies are not followed. Another suggestion would be to have all critical results reported to two sources, for example the patient’s nurse and charge nurse, to increase the likelihood of rapid documentation. The point of the corrective actions is to ensure that each staff member knows what they are responsible for. For example, laboratory staff knows to document the critical values and alert the appropriate nurse or charge nurse, the nurse or charge nurse knows to document the critical lab values or test result and to alert the ordering physician, the ordering physician knows to discuss a treatment plan with the patient and to document appropriately in the chart, etc. The point is, every staff member has a role to play in assisting the hospital in becoming one hundred percent compliant. This corrective action plan holds each staff member accountable. Those who do not comply can easily be tracked and disciplined by their supervisor.

I have learned the process of how the infection control data is reported not only to the Quality Department but also to other State and Government Agencies. The information is highly sensitive and contain patient specific information as well as non-publicly reported data. The Quality Coordinators extract this information from other data reporting systems such as QCentrix and ThreaDoc.

This Stage 1 started from 2011-2012, its objective dealt with data capture and sharing, these sheets are providing these services to assist professionals and hospitals understand the requirements of each objective and demonstrate meaningful use success. This stage also allows qualified providers to receive their payment after fulfilling nine core objectives and one public health objective. The second stage of the Meaningful Use is Stage 2 started in 2014; it dealt with the advanced clinical processes. This Stage introduces new aims and measures, as well as higher entries; it also required health care providers to prolong EHR capabilities to a greater portion of their patient populations. The last stage of the Meaningful Use is Stage 3, this Stage it still in a building phase. Its objective will be focusing on improving quality, safety, efficiency, and leading to improved outcomes. Even though the details of this program have not been finalized, Meaningful Use Stage 3 will work to make the program easier to understand. It will provide the professionals (EPs) and hospitals the ability to exchange and use information between electronic health records, and improve patient outcomes. Based on the current timeline, healthcare providers have the choice to begin Stage 3 Meaningful Use in 2017 but are not permitted to use it until

This affects the delivery of healthcare in that the information needed by providers, physicians, medical staff, and the patients themselves, may not be delivered correctly, timely, and of course securely. Various systems will be discussed and each how they affect healthcare delivery, in particular Electronic Health Record (EHR), Electronic Medical Records (EMR) and Computerized Physician Order Entry (CPOE) (also sometimes referred to as Computerized Provider Order Entry).

2-B. The recommendation for Time-Out to be incorporated into the electronic medical records assumes the hospital is using an EMR. Even so, it will take co-operation with the medical records staff at the minimum and perhaps the IT department. 6 months may be too soon. At the minimum, a progress report will be due in 6 months and a new due date

With the partial electronic medical record system, budgeting for full EMR integration is a key priority that will allow Creekside to capture

In any continuous quality improvement effort, measurement is the key element (Sollecito, & Johnson, 2013). “Measurement and statistical analysis are used to assess the impact of an improvement effort” (Sollecito & Johnson, 2013). To Measure the impact of the program, the hospital utilized a departmental quality improvement assessment with a scoring matrix for self-assessment (McLaughlin, et. al., 2012). The scoring matrix consisted of five category ratings which each department head had to complete. Univer4sal Charting and Resource Utilization were also used for measurement (McLaughlin, et. al., 2012).

How can EMR’s improve the nursing process now and in the future? Having had the op-portunity to perform my clinicals in three different Emergency Departments in the past two years and being exposed to both the positive and negative to both paper and paperless medical records Training new nurses is vital for an accurate EMR. Bober, M., & Boonstra, J.

Besides the disadvantages of (EMR)’s the advantages pose great benefits to patient care and efficiency. The greater use of electronic medical records or health records can reduce wait times, of seeing doctors or waiting for test results. All staff would need to cohesively work out the technical challenges and software data. With sophisticated IT

Communication is the key to relating in all environments. When communication lines are broken, it makes take in jobs and personal relationship suffer. In medical environment communication is key in running hospital, nursing home and community care providers. With technology our communication has advanced because now we have electronic medical records. Electronic medical records are a way of providing the medical staff and insurance on the patient health information and insurance coverage. As stated by About.com, “This also provide the doctors away to for individual patients, access to good care becomes easier and safer when