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Volume 2, Issue 1 A Publication of The Johns Hopkins Hospital Office of Medical Affairs November 2010
Joint Commission Follow-Up
As you know, we were recently surveyed by The Joint Commission and found to be deficient in several areas. As part of the follow-up to those deficiencies, several policies and system changes go into effect immediately. These changes must be incorporated into our practice immediately. To view actual policies and guidelines, place cursor over underlined word, hit “Ctrl,” left click, and “OK.” • ALWAYS reorder clinically-indicated restraints/seclusion during rounds and before the current order ends (newly revised by the end of the next calendar day for non-violent patients; see for violent patient parameters). • NEVER use prohibited abbreviations (e.g., U or q.d.) in written or electronic documentation • ALWAYS date and time all entries in the medical record. • ALWAYS label medications and solutions on and off the sterile field with drug name, strength, and amount (if not apparent from the container) immediately upon transferring from original packaging to another container. • ALWAYS assure direction is given for sequence of administration when ordering two PRN medications that are for the same indication (therapeutic duplication). An example would be promethazine and ondansetron – both ordered for nausea in the same patient (see new interpretatiin new appendix to Medication Administration Policy). • ALWAYS document a time-out prior to any operative or invasive procedure (including bedside If you have questions, please contact Susan Franklin, Director for Regulatory Affairs or Dana Moore, Assistant Director for Regulatory Affairs New Online Web Form for Reporting
Bloodborne Pathogen Exposures

Johns Hopkins University and Hospital Safety Policyrequires that any employee or staff member who sustains a bloodborne pathogen exposure report the
incident immediately. To facilitate reporting, medical staff members on the East Baltimore Campus may
utilize a new online web form which can be accessed atThe
goal of this web form is to provide another convenient mechanism for busy physicians to report
bloodborne pathogen exposures. After inputting the required information, the appropriate laboratory slips
will be generated to ascertain the HIV or Hepatitis C status of the source patient. Regardless of the HIV
or Hepatitis C status of the source patient, the “5-STIX” physician will contact the reporting individual to
discuss the results and appropriate follow-up. The web form is not intended to replace the “5-STIX”
Hotline which is available 24 hours per day for anyone desiring immediate assistance and counseling
about their exposure and treatment options.

If you have questions regarding the management of bloodborne pathogen exposures, please call 410-955-9213 or e-ma Central Line Insertion Care Checklist

The Central Line Insertion Care Checklist has been approved by the Medical Board to be a permanent
part of the patient’s medical record. Once completed, the checklist will be placed in the
“Operative/Invasive Procedures” tab of the medical chart. The Central Line Insertion Care Checklist
must be completed for each central line placed, including re-wires. Please discard all old checklists and
begin using the new checklist, which became effective November 1.
View the new Central Line Insertion Care Checklist by clicking (Ctrl + click, then “ok”)
The new form is available through Standard Register-Form # 15-480131000017 and will be placed in the
central line bundle kit. Until the current stock of central line bundles is depleted, please remove the old
checklist that is in the bundle and use the new one listed above.
Questions can be directed to Beverly Reynold or MiKaela Olsen
.
Sign, Date, and Time All Medical Record Entries
In August 2009, February 2010, and October 2010, Joint Commission surveyors identified “pervasive problems” with our documentation practices. Please help correct these problems by personally signing, dating, and timing every entry you make in the medical record. It is not acceptable practice for nurses to complete these items on behalf of physicians and may be interpreted as falsification of the medical record. The Joint Commission, Medicare, and JHH require that providers time, date, and sign all of their own medical record entries. The roll-out of Clinical Documentation in Eclipsys will address this problem by automatically dating and timing all entries. However, we must address our paper records deficiency until the roll-out is complete. Therefore, in addition to educating providers, we have implemented systematic audits of samples of inpatient and outpatient charts to monitor our progress. The audit results will be shared with the clinical departments. EPR Auto-Fax Update
As you know, all Discharge Summaries, Discharge Worksheets, and Structured Clinic Notes are automatically faxed to referring physicians, as long as the referring physician(s) name(s) has been collected upon admission or registration. In order to ensure that this same high level of faxing service is provided for unstructured clinic notes, we have made several changes. First, two Dictation Work Types of unstructured notes will now be automatically faxed when you sign the note: • #95 – Auto-fax Unstructured Outpatient Consult • #97 – Auto-fax Unstructured Outpatient Clinic Note No other Unstructured Work Types, other than those noted, are automatically faxed. Second, if for some reason there is no referring physician identified and you wish to include one, you can
select a referring physician from the CPD tab prior to signature and link that provider to the patient so
that faxing will occur.
Last, be aware that dictated names on the CC list are not faxed. You must link those providers using the
CPD tab noted above before signing the note. At this time, we are faxing over 11,000 notes per week and
hope we can effectively increase that number with your help.
How to add a referring physician link in EPR

• Open the document in Edit and click the CPD button. • Click to Add New / Search CPD button. • Key in last name of referring physician and then click Search button. A list will be returned. • Highlight name of referring physician from the list, and click Create Link. • Repeat or exit back to document edit. If the physician is not in the CPD, select Add New Physician, providing physician’s last, name, first name, address, and phone and fax numbers. The Office of Referring Physician Services will verify the information to ensure accuracy. This creates a referring link and adds the referring physician information to the document. Once the document is signed it will be sent for auto-faxing. Questions can be directed to Steve Mandell at Patient-Centered Care
As The Johns Hopkins Hospital continues to strive for excellence in patient care, teaching, and research, an emphasis on patient-centered care is imperative. To create an environment that embraces the participation of patients and families in the planning, delivery, and evaluation of their healthcare, we will convene an inaugural Patient and Family Centered Care Advisory Council in January, 2011. The development of the structure and processes for the Council, including the procedures for selection of members and agenda setting, began in the Spring of 2010. The Council will serve as a forum for information sharing among patients, families, and the healthcare team. Operational, financial, and strategic decisions that directly impact patients and families, and issues for which patient and family insight would be mutually beneficial for learning purposes, will be the focus. A leadership group with oversight from the Patient Safety Committee, Service Excellence, and Patient and Visitor Services will determine agenda items and coordinate membership. The Patient and Family Centered Care initiative will capitalize on bringing meaning and cultural change to the institution in order to provide the "patient-centered medicine" that the JHM mission expressly emphasizes. Please help us identify these Patient/Family Advisors for the Council. If you know of a patient who is interested in advocating for our patient population and providing input to better the patient experience, please contact Shereen Jahed or Mary Margaret Jacobs before December 15, 2010. Interpretation Services for Patients with Limited English Proficiency
Did you know that it is a Federal mandate for hospitals to provide interpretation services to patients with limited English proficiency (LEP)? Effective communication with LEP patients reduces the risks of patient safety-related incidents. At JHH, interpretation services provided by trained medical interpreters are available 24 hours a day, 7 days a week. Telephonic interpreting, available for more than 170 languages, is a great option for last-minute interpreter needs. Call 410-614-INTL (410-614-4685) to request an interpreter or to inquire information about the services. For additional information on language communication issues, see: • OnGuard article, “The Language of Safety,” • Change, “Translating Care: Interpreters Help Caregivers Overcome Language Barriers,” • Change, “Caring Perceptions: A Student Reflects on One Patient’s Experience,” • Change, “Dr. Roboto: The Emergency Department Tries out Patient Care through ‘Remote Risk Management Seminars
Physicians are required to attend a risk management seminar once every two years as part of the re-credentialing process. Seminars will be held in Hurd Hall on the following dates and times: Wednesday, December 8, 5:30 - 6:30 p.m. Wednesday, January 12, 5:30 - 6:30 p.m. Thursday, February 10, 12:00 - 1:00 p.m. Saturday, March 5, 11:00 a.m. – 12:00 p.m. Wednesday, April 13, 5:30 - 6:30 p.m. For additional information, contact the Legal Department at 410-955-7949. Redonda G. Miller, MD, MBA, Vice President, Medical Affairs Sharon Mears, Executive Assistant

Source: http://dcs.jhmi.edu/cvo/_MedStaffNews_Nov10.pdf