Description
Infection Prevention, Discharge Planning, Organ Procurement, Surgery, PACU, Anesthesia, Emergency Services, Outpatient, Rehab, and Respiratory
Objectives:-
- Discuss that CMS requires many policies in infection prevention and control
- Recall that patients referred to a post-acute care provider – PAC – must be given a list in writing of those available and this must be documented in the medical record
- Describe that all staff must be trained in the hospital’s policy on organ donation
- Recall that CMS has specific things that are required to be documented in the medical record regarding the post-anesthesia assessment
Infection Prevention and Control
- Infection preventionist responsibilities and role in the antibiotic stewardship program
- IP appointed by the board
- Policies and procedures required
- Mitigation of risks
- Duties and responsibilities of the leader of the Antibiotic Stewardship program
- Scope and complexity of the program
- Multi-hospital/Unified program
- Mandatory training
Discharge Planning
- Discharge planning worksheet
- Identification of patient needs
- Discharge planning and evaluation
- Information provided to the patient
- Discharge planning responsibility
- Identification of patients
- Transfers
- Referrals
- Self-care
- Timely discharge evaluation
- Discharge plan and self-care evaluation
Organ, Tissue, and Eye Procurement
- Policy requirements
- OPO agreement required
- Organ donation training
- Family notification
- OPO Notification one call rule
Surgical, PACU & Anesthesia Services
- Policies required
- Organized and staff service
- Surgical tasks and privileges
- Preventing OR fires
- H&P
- Consent
- OR register
- Operative report
- Required equipment
- PACU
- Anesthesia policies required
- Anesthesia and analgesia standards
- Pre- and post-anesthesia requirements
- Anesthesia organization and staffing
- State exemptions - CRNAs
- Documentation required
- Intra-operative anesthesia record
Outpatient Services and final changes
- Changes in accountability
- Policies and procedures
- Meeting needs of patients
- Outpatient orders
- Documentation of care given in the OP department
- Orders required
- Department director job description and responsibilities
Emergency Services
- Services must meet patient needs
- Following standards of practice
- Integrated into hospital PI
- Qualified medical director
- Policies required
- Training required
- Length of time to transport between departments
- EMAIL
Rehabilitation and Respiratory Services
- Integrated into QAPI
- Standards of care
- Qualified director
- Plan of care
- Scope of services
- Order needed
- Policies required
Who Should Attend?
- CEO’s
- COO’s
- Chief Nursing Officer
- Chief Medical Officer
- Quality Managers
- Consumer Advocate
- Nurse Educators
- Department directors
- All Nurses
- Risk Managers
- Hospital Legal Counsel
- Compliance Officers
- Joint Commission Liaison
- Director of Health Information
- Case Managers
- Pharmacists
- Social Workers
- Discharge Planners
- PI Coordinator
- Patient Safety Officer
- Patient Safety Committee
- Nurse Managers
- Outpatient Director
- Director of Rehab
- Dieticians
- Infection Control
- Medication Management Team
- Anesthesia and Surgery staff
- PACU Director
- Policy and Procedures Committee
- Respiratory Therapy Director
- Director of Radiology
- Infection Preventionist
- Pharmacist
- Pharmacy Director
