Comprehensive Contact The Faculty Policy & Procedure Manual Rebecca Clark-Bash Development: R. EEGEP T., CNIM, CLTM, F.ASNM Foundations for IONM Lab Knowledge Plus, Inc Accreditation: P.O. Box 356 Joint Commission Lincolnshire, Il 60069 ABRET LAB-NIOM ABNMP Phone: 815.341.0791 E-mail: email@example.comREBECCA J. CLARK-BASH, R. EEGEP T, CNIM, CLTM,F.ASNM SLIDE 2 Disclosure & Attestation Disclaimer• Rebecca Clark-Bash is an • Medical policy and policy electroneurodiagnostic educator. specific to the monitoring• As such, she receives team may vary by: payment for educational & – State consulting services. – Practitioner (MD, RN, CNIM)• Currently there are no – Procedure. royalty bearing relationships between • This presentation should not Rebecca, her spouse and a replace legal consult corporate entity outside of these educational & program building services.
Policy & Procedure: Session Content Core Content• IONM Policy & Procedure Manual Core Content A well-written, comprehensive Policy &• IONM Lab Accreditation & P & P Requirements: Procedure Manual is the laboratorys or IONM – ABRET LAB-NIOM programs single most effective management tool – ABNMP - and its most neglected one. – Joint Commission Policy & Procedure: Policy & Procedure: Core Content Core Content • Create an Action Plan-Core ContentDone the right way, written policies and procedures: – State its purpose or intent – Explain how it is related to the overall management system• Promote teamwork and improve human relations. – Clarify its scope• Promote clarity, consistency, and continuity of – Provide any definitions that will help clarify the document – Detail any controls that must be applied performance and management decisions. – Explain how authority has been divided and distributed• Establish approved, measurable standards of – List the responsibilities and tasks that should be performed performance for competent practice – Identify who is responsible for performing the task – Describe the task• IMPROVE PATIENT CARE – – Specify how and when the tasks should be performed List any materials and supplies that must be used – List any tools and equipment that must be used – Review the document properties and control
Policy & Procedure: Policy & Procedure: Document Control Content Contact List Glossary Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations• Function • Function • A comprehensive Employee Manual protects your• An Employee Manual is a organization. summary of your company´s • An Employee Manual describes the behavior that is policies and procedures expected of your company´s employees. regarding staff. • It also describes unacceptable behavior, such as harassment or use of company equipment for personal• It contains information business, and outlines the consequences of such about, expected behavior, behavior. benefits, and policies that • An Employee Manual addresses issues before they become problems. affect employment.
Policy & Procedure: Policy & Procedure: Other Documents Document Control Create an Employee Manual Create an Employee Manual Policy & Procedure: Policy & Procedure:Document Recommendations Document Contents • Joint Commission Resources Consultant: IONM Employee Manual – “Avoid extensive detail”
Policy & Procedure: Document Contents Policy & Procedure:• Hospital Compliance Officer: Document Contents – “Every detail at point-of-care must be defined” What is our MISSION? Which directive is most consistent with this mission? Policy & Procedure: Policy & Procedure: Document Contents Document Recommendations Rogue • Function – Serves to establish the method to insure the patient Monitorist receives the highest level of expertise and clinical expertise from the healthcare team – The method should be derived from evidence-based No one should information be delivering – Provides critical information regarding a path for patient care decision making when standard service protocols cannot be followed. “Their Way”
Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations Contents – First Rule – Golden Rule Contents – Second RuleHave a Policy & Procedure Make certain all employees Manual. own a copy & follow the “I think my copy is policies. on my desk somewhere.” Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations Contents – Second Rule Contents – Third RuleHave a POLICY to insure When policies are not or employees know the cannot be followed, POLICY document the reason in the case record.
Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations • Contents – Basic Core Policies: Informed Consent Pre-Op Holding Area – First in the late 1950s. – Based in the tort of battery, under which liability is • Surgeons order for monitoring imposed for unpermitted touching. – Archive & retrieval procedure – Though battery claims occasionally occur when treatment is provided without consent, most consent cases generally center around whether the consent was "informed", i.e., whether the patient was given sufficient information to make a decision regarding his or her body and health care. – Because informed consent claims, unlike battery claims, are based in negligence, they generally are covered by liability insurance. Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations• Contents – Basic Core Policies: • Contents – Basic Core Policies: Informed Consent – Informed Consent • In the communications process, the individual• This communications process is both an ethical providing the monitoring , should disclose and discuss with the patient: obligation and a legal requirement spelled out in – The nature and purpose of intraoperative monitoring statutes and case law in all 50 states – The risks and benefits of monitoring – Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance); – The risks and benefits of the alternative; and – The risks and benefits of not receiving or undergoing a treatment or procedure.
Policy & Procedure: Policy & Procedure: Document Recommendations Document RecommendationsContents – Basic Core Policies: Informed Consent Who may obtain the patient’s informed• Who may obtain the patient’s informed consent;• Which procedures require informed consent; consent?• The circumstances under which surgery is considered an emergency, and may be undertaken without an informed consent;• The circumstances when a patient’s representative, rather than the patient, Liability for not telling the may give informed consent for a surgery;• The content of the informed consent form and instructions for completing it; patient all the risks of the• The process used to obtain informed consent, including how informed surgery, and for not getting consent is to be documented in the medical record;• Mechanisms that ensure that the informed consent form is properly executed and is in the patient’s medical record prior to the surgery (except in the case truly informed consent, rests of emergency surgery); and with the physician.• If the informed consent process and informed consent form are obtained outside the hospital, how the properly executed informed consent form is incorporated into the patient’s medical record prior to the surgery. SUPREME COURT OF NEBRASKA, 1997 Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations Who may obtain the patient’s informed • Patient Informed Consent consent? Sample Policy …..Except in emergencies The MONITORIST is not responsible for providing the information necessary for informed consent to the patient or health care proxy agent. The MONITORISTS role is both as a witness and as a patient advocate. (borrowed for NY State Nursing position statement)
Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations • Contents – Basic Core Policies: Documentation • What is mandated to be documented? • What is documented from the case? • Frequency of documentation? – Blood Pressure? Where monitored? – By the time events turn south, it is too late to – MAP? retract the documentation footpath. – Core Temp? Where monitored? • What is the required format? – Cerebral Oximetry, TCD..other monitoring not – Iso= 1 managed by the IONM team – Iso= 1 % MAC – Urine output? – Gas = > 1 MAC – Blood loss? Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations• Contents – Basic Core • Procedure Notes Policies: Documentation – To document or not to document?• UNITS!!!! – Standardize comments – Iso: 1 • Sc. In at L5, LR RSST Ndata – Is that a MAC or a % – Is that end tidal concentration?
Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations DOCUMENTATION DOCUMENTATION • Chat Windows • DOCUMENT – Is the Chat window saved? – Complications – What is the protocol for action? – Challenges – Are vital case details entered in the chat? • Internet down • Internet up 10:03 I told him AGAIN!!!! 10:05 We golfing later? 10:07 You there???? Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations• Where is the DATA??? DOCUMENTATION • Data Archive 8:30 Record I – Frequency 8:32 Record II – Backup – Paper documentation – Archive & Link 8:57 Record III
Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations DOCUMENTATION DOCUMENTATION • Initial and date edits to case record. Never edit case records after the end of the case. Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations Hand Off Policy DOCUMENTATION • What is• Surgeon Communication communicated?• Document everything said to the surgeon and • What is documented? the replyresponse• “Surgeon informed…surgeon acknowledged.”
Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations• Time Out Policy • Surgeon Communication• Neurophysiology – Standardize method among staff Time Out – I lost my: • P37 • Cortical • Subcortical • Brainstem • MEPs • And my favorite… Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations METHOD• Surgeon Communication • Site method reference – I lost my uppers • ACNS Guidelines • ASNM Position Statements • Peer reviewed lit. – Pubmed.org
Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations Calibration Calibration• Amplifier • Head Phones & Inserts • Method • Method • Frequency • Frequency • Archived Record • Archived Record • Hippa Documentation • Hippa Documentation Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations Calibration• Chassis Leakage • Format • Method • Frequency • Archived Record • Hippa Documentation
Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations• Updates • Staff Orientation – Reviewed on a regular basis and documented • Policy for ANNUAL – Always when a new procedure is added to service review of competency to examine staff knowledge of P & P Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations • Staffing Model Joint Commission – Joint Commission The primary mission is to continuously improve the – ABRET LAB-NIOM safety and quality of care provided to the public – ABNMP through the provision of healthcare accreditation and related services. Simply, “Create a Culture of Safety”
Policy & Procedure: Policy & Procedure: Document Recommendations Document Recommendations Joint Commission HIPPA• Competency management • Health Insurance Privacy & • Assessments performed by a qualified individual Portability Act. • Applies to ALL staff • Insure your staff is trained • FT & PT Employees YEARLY • CONTRACTED STAFF! • Document this training • Volunteers! • Document this competency. Policy & Procedure: Policy & Procedure: Types of Accreditation Requirements For Accreditation ABRET IONM Lab Accreditation www.abret.org • Physician “Supervisor” – Remote Real-Time Access of M.D. or D.O. – Medical Specialty not specified 73 Labs Three Tiered Model-Components: • Monitoring Staff Currently Accredited • Technical – Provided direct care to patient in surgery • Professional • Medical
Policy & Procedure: Policy & Procedure: Requirements For Accreditation Requirements For AccreditationThree Tiered Model- Technical Components: Three Tiered Model- Professional Component:• Supervision of a CNIM credentialed technologist may be by a • Must be provided by an intra-operative neurophysiologist withprofessional intra-operativeneurophysiologist either on-site, or extensive experience in IONM at least to the level required forvia a real-time on-line connection. DABNM certification.•Technologists not practicing under the personal supervision of • Non-physician intra-operative neurophysiologists must bean intra-operative neurophysiologist require the CNIM certified by the ABNM.credential and may provide only waveform descriptions to the • Physician intra-operative neurophysiologists must be certifiedsurgeon. by the ABNM, ABEM, ABCN, or hold the added qualification in clinical neurophysiology of the ABPN Policy & Procedure: Policy & Procedure: Requirements For Accreditation Requirements For Accreditation Three Tiered Model - Medical Component: • Must be provided by a physician intra-operative neurophysiologist. •This physician must be licensed in the state in which the surgery is taking place, and the degree of involvement is to be determined for each case according to the skills of the team and surgeon as well as the type of case, modalities monitored and local and state regulations. Currently No Accredited Programs