Performance Improvement
List 3 activities monitored as part of the Capstone PI Program
What are:
Call Metrics
OnCall response time
Med errors, Near Misses
Complaints
Satisfaction (patient, provider, employee)
Medical Records
Incidents
Infections (patients, employees)
Unscheduled hospitalizations
Catheter complications
Pump malfunctions
Billing and Coding errors
The New Patient Packet provides teaching on what topics?
List 2 and give examples
Emergency preparedness
Infection control
Complaint process and to whom a complaint may be made.
How to contact the pharmacy, How to contact pharmacy after hours
How to get information about billing
What to do if there is a problem (recall, error, ADE...)
Information about the medication and disease state (in some cases)
The compliance officer should be contacted if:
Include 2 examples -
What are:
Any type of fraud, waste, abuse, harassment, code of conduct violation
Where are the safety data sheets located?
Give an example of a product that we should have a SDS for?
What part of the safety data sheet is most important for the pharmacy team?
IN SHAREPOINT is not a complete answer :D
SharePoint> Regulatory and Compliance > MSDS Sheets
Any cleaning product or hazardous material
The first aid section is the most important section
The Aseptic technique competency
Aseptic Manipulation (medias, surface samples, GFT) annually for RPH, Every 6 months for techs
Cleaning and Disinfection
Garbing and Hand Hygiene
All tracked and documented in Simplifi and Connecteam
Name of members of the Governing Body (Day to Day leadership)
Brad, Aaron, Kevn, Gregg, Kendra, Diane, Tara
How often does the PI committee meet?
What is quarterly
Tools / process used to communicate with a patient that is non-verbal or deaf
What is Florida Relay service. Call 711 to access FL relay. The service will provide sign language interpreters for patients
Capstone Compliance Program (what is it)
What is the compliance program is:
Handling of any type of Fraud, waste and abuse
Is reviewed annually and updated. The annual compliance plan is updated annually and put into a Connecteam course for employees to complete
All employees must complete trainings annually on the compliance program
Includes the code of conduct
Offers guidelines for employee behavior
Describe your contingency plan if medication storage conditions fail (refrigerator) or the pharmacy uninhabitable
What is
Determine cause
Move medications to a different refrigerator / start up generator
Secure building / try to salvage meds / contact sister pharmacy
Annual trainings required by ACHC
What are: Compliance, Complaints, Hazardous Materials/OSHA, worker safety, patient rights and responsibilities, cultural diversity, Emergency preparedness, Ethics, Communication barrier, Infection control
Negative outcomes that must be reported to ACHC.
How long do you have to report these
Loss of a payer contract
Exclusion from Medicare / Medicaid
FDA 483
Legal action
Fine > 15K
Must be reported within 30 day
What is your role / responsibility in PI
What is to share ideas for improving processes or activities to improve the overall quality of patient care and employee satisfaction
What information do you provide the patient regarding confidentiality?
Notice of Privacy Practices in New Patient Packet and on Website.
Confidentiality is reviewed with patient by intake with admission agreement and signature authority form
Describe your recall policy
What is
When the pharmacy is notified of a recall the warehouse team will check for the recalled item in inventory
Remove any in inventory and put in the quarantine bin
If patient level recall - Run report in CareTend or Vital Books to see if provided to a patient. If so, contact patient and provider and replace meds/supplies
How do we educate patients on the DMEPOS Standards?
What is the New Patient Packet, a copy is also on the Capstone Website
An evaluation of your ability to perform your job is conducted?
What is the annual performance evaluation
Items that you must notify ACHC about
Change in ownership
Change in address
Change in CEO
Change in leadership
Notify within 30 days
When is a corrective action plan needed
When we do not meet our goal for a quality metric for more than 1 consecutive quarter.
How do we educate patients on the CMS Supplier Standards
What is the DMEPOS standards. These are provided in English and Spanish in the welcome packet. Once the website if finalized, these will be published on the website
Describe how you ensure the medication arrives to the patient's home in a safe and effective manner
What is
Boxes are sealed with tamper evident tape Temperature verification testing is done on all shipping containers, delivery methods and temperature extremes.
Each person responsible for packing the product will do an annual observation competency. An observation for each packout will be conducted annually
What components are included in your Infection Control and TB Surveillance Program
What are Infection control trainings, TB trainings through Central Line, TB Prevalence data for 2022 and 2023. Infection (patient and employee) monitoring. Hand hygiene techniques. Vital Care TB plan
The infection control process includes the following:
What is-
Employee infection form
Patient infection monitoring / Catheter infections
Hand hygiene in clean room
Return to work process
Hand Hygiene observed for nurses in AIC
Cleaning in the AIC before and after patient care
TB prevalence data, TB exposure plan
What is your role in the budgeting process
No formal role (Brad maintains) but if capital expenditures, requests can be made through direct manager
What quality assurance activities are reported to and reviewed by the PI committee
Quality assurance activities include:
Review of the clean room certification report, missing tasks in Simplifi, surface sample results, completion of clean room competencies (when applicable), Out of spec reading (consistently) related to temp or humidity in any designated area
How do we document that the patient received their New Patient packet
Documented that we provided the New Patient Packet on the initial delivery ticket (which is checked by the pharmacist) and the patient signs for the delivery / or have Fed Ex documentation of the delivery
Guidelines for clean room certification
What is the Certification and Recertification of Sterile Compounding Areas Policy.
The compounding room must be certified every 6 months
Air sampling, surface sampling, air velocity, air pressure verification, smoke samples, HEPA and prefilter testing
ACHC requires a clinician be available to patients 24 hours a day / 7 days a week. Describe how Capstone does this
What is our after hours policy. IVR turned on after hours. Patient can choose to leave a message or speak to someone. Call transferred to Always on Call. Always on Call contacts the after hours pharmacist.
How are you educated on emergency planning and how often is the education reviewed?
An annual training on emergency planning is required. Education occurs as part of the Vital Care annual trainings through Central Line.
Each pharmacy has a Emergency plan that is also reviewed annually.
A disaster drill is conducted annually (usually as a tabletop drill) with leadership. The results are reviewed with all staff and presented at the PI meeting along with a discussion of any improvements required based on the results of the drill.
How are suspected abuse or neglect situations handled?
What type of abuse
Who do you report it to
In a situation where abuse is suspected, the employee should contact their manager. The manager will review the situation and determine the appropriate action. Nurses and pharmacists should review with DON, DOP, Compliance officer.
In FLA there is a specific hotline number that nurses are required to contact. This is in the Orlando Intro Letter that is sent with the New Patient Packet.