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									#226 – Consults: Kill or
       Be Killed
                                      Harold D. Bonds, MT (ASCP) SC
                                                  G. V. Montgomery VAMC
                                                    Jackson, Mississippi
                                                  Sheri Kreuz, RD, MBA
                                                      SDS, Clin2 Team
                                                     Salt Lake City OIFO
 Additional Information provided by:
                  Pamela Johnson                       Mary Montufar                      Ann Narciso
              Clinical Applications Coordinator    Clinical Applications Coordinator   Clinical Applications Coordinator
              Richmond VAMC                        Palo Alto VAMC                      Palo Alto VAMC
                    #226 – Consults: Kill or Be Killed


• Goals:
  – Identify uses of the Consult Tracking
    Package
    • Administrative Use for Lodger/Hoptel Services
    • Disease Management for improving patient
      outcomes.
  – Scheduling-Consult Package linkage issues
    • Go over current Remedy Tickets
    • Provide feedback from sites using the linkage
  – Survival: Don’t be Killed by Consults
  – Consult Monitoring Strategies
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            #226 – Consults: Kill or Be Killed


• LEARNING OBJECTIVES:
 – 1. Distinguish unique innovations within
   consult package
 – 2. Evaluate for application at any site
 – 3. Discuss lessons learned related to
   Consult/Scheduling interface
 – 4. Discuss Consult Monitoring Strategies



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       #226 – Consults: Kill or Be Killed


• Utilizing the Consult
 Tracking Package for
    Tracking Hoptel
        Resources
   Harold D. Bonds, MT (ASCP) SC


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• Goals:
  – Provide control over the Hoptel bed program
    availability, budget, and staffing.
  – Provide a mechanism for tracking Hoptel
    services availability, budget and staffing by
    data management.
  – Create a process for approval of Hoptel
    service utilization electronically within the
    patient record using a team approach.

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• Objective: Better utilization of the Hoptel
  bed resources for availability, tracking,
  and cost containment using the Quality
  Management process for performance
  improvement of Plan, Study (Do), Check
  Act.




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               #226 – Consults: Kill or Be Killed


• Plan:
  – Formulate a process to achieve the goals of
    Hoptel bed program availability, budget, and
    staffing by utilizing the Consult Package
    along with the Text Integration Utilities and
    Scheduling Packages.




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  Routing slip for Hoptel approval of patients from another VA facility receiving
  treatment at the G. V. (Sonny) Montgomery Veterans Affairs Medical Center.
Treatment being provided:
      ________ Radiation Therapy Only:
      ________ Radiation Therapy and Chemotherapy combined:

Date of First Appointment: _________________________________________________

Expected Date of Completion (if known): ______________________________________

Date routed to Social Work Services: _________________________________________

Bed Service Chief Approval/Disapproval: (Only required if patient is to require inpatient care)
      Approved: ________
      Disapproved: ________

MAS Service Chief Approval/Disapproval:
     Approved: ________
     Disapproved: ________


Additional Patient Information may be found in the consult for the requested services.
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             #226 – Consults: Kill or Be Killed


• Create a consult request in CPRS for the
  Hoptel program with required information
  in a template format for requesting a
  patient be considered for the Hoptel
  program.




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• Create a progress note for answering the
  Hoptel consult that is blank in the Text
  Integration Package. (accomplished on
  12/26/02)




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• Create templates located in the shared
  templates section of CPRS for the
  services involved to use in answering the
  consult. Each service attaches an
  addendum to the original note for
  completion of the process.




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• Create a clinic called “HOPTEL” for
  scheduling the patients into the Hoptel
  program.




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• Consult template created and checked to
  ensure it is working properly.
  • Template approved by the Chief Executive
    Nurse and attached to the consult.
  • Quick order created for the consult.
  • All components working properly.

• Teams were created for the each service.

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• Progress note title created under the
  Consult Document Class. Templates
  created for the Nursing Intravenous
  Access Team, Patient Information
  Management Service (formerly Medical
  Administration Service), and Social Work.
  Templates and progress note checked to
  ensure working properly to answer the
  consult.
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• Request for creation of a new clinic called
  “HOPTEL” submitted to MAS for creation.
  [Sometimes the patient is scheduled for
  treatment for 6-12 weeks. Appointments
  to be entered each day separately.




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• Set a target date for completion of the
  process.
• Train personnel in utilization of process.
• Memo from Chief of Staff to Medical Staff
  regarding how and when to request the
  consult.



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FY OCT           NOV         DEC          JAN         FEB          MAR       APR        MAY          JUN         JUL          AUG        SEP

2002 $ 10,070.22 $ 7,499.10 $ 7,749.07 $ 7,784.78 $ 7,177.71 $ 9,748.83 $ 10,141.70 $ 10,784.42 $ 13,676.93 $ 14,533.97 $ 17,140.84 $ 17,140.84


2003 $ 12,232.11 $ 12,677.05 $ 18,283.52 $ 10,748.71 $ 6,391.39 $ 6,642.06 $ 6,427.80 $ 6,642.06 $ 6,427.80 $ 6,642.06 $ 6,642.06 $ 6,427.80


2004 $ 6,642.06 $ 6,427.80 $ 6,642.06 $ 6,642.06 $ 6,213.54 $ 15,498.14 $ 14,998.20 $ 15,498.14 $ 14,998.20 $ 11,070.10 $ 12,462.79 $ 12,355.66


2005 $ 9,998.80 $ 12,962.73 $ 11,070.10 $ 12,391.37 $ 10,641.58 $ 11,070.10 $ 10,713.00 $ 11,141.52 $ 10,713.00 $ 12,074.70 $ 11,932.80 $ 11,547.00


2006 $ 11,931.90 $ 11,547.00 $ 11,931.90 $ 11,931.90 $ 10,777.20 $ 11,931.90 $ 11,547.00 $ 11,931.90 $ 11,547.00 $ 11,931.90 $ 11,931.90 $ 11,547.00


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2007 $ 11,931.90 $ 11,547.00 $ 14,318.28 $ 14,318.28 $ 12,932.64
   #226 – Consults: Kill or Be Killed



Management of
 Home Oxygen
   Patients
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• Goal:
  Provide insight into how G. V.
  Montgomery VAMC manages patients on
  Home Oxygen through CPRS electronic
  documentation from the initial request
  through the different disciplines to the
  outcome of the patients.


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                     #226 – Consults: Kill or Be Killed


•   Flow Map the current process
    – Initial Request (Consult) to Pulmonary Services
    – Pulmonologist answers consult identifying Respiratory Therapist
      in Home Oxygen Service as additional signer
    – Respiratory Therapists carry Home Oxygen equipment to
      Patient home and sets up.
    – All documentation is recorded on paper (Locally created forms;
      not filed in Medical Record)
    – Missed follow up in Pulmonary
    – Prescription tracking process manually kept in MS Excel
      Spreadsheet
    – Lack of patient compliance with policies/prescription
    – Lack of Equipment tracking/usage/cost (Prosthetics Package
      usage)
    – Patient Safety Issues
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                #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendation #1 - Clinical Provider
    Involvement
    • Explain the process for requesting Home Oxygen
      for a patient utilizing the Consult package and the
      approval process by the Pulmonary Physicians
    • Home Oxygen Request (Pulmonary) consult.
    • Consult note duplicating the Home Oxygen
      consult entered by the Pulmonologist.

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               #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendation #1 - Clinical Provider
    Involvement
    • Respiratory Therapist Setup and Monitoring of
      Home Oxygen Usage




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               #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendation #2 – Standardized
    Annual Renewal Process
    • Ensure Home Oxygen Prescription is entered into
      the Prosthetics Package
    • Run Monthly Reports for Prescription expirations
    • Ensure follow up appointments for Home Oxygen
      patients


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               #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendation #3 – Monitoring Home
    Oxygen Patients
    • CPRS documentation
      – Inpatient Education for Home Oxygen use and safety




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• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendation #3 – Monitoring Home
    Oxygen Patients
    • CPRS documentation
      – Inpatient Education for Home Oxygen use and safety
      – Initial Home Oxygen Set up




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• Create a Home Oxygen Request to be
  entered into the Prosthetic Package for
  equipment set up on patient.
  – Select CONSULT MANAGEMENT OPTION
     • Select COPY PROSTHETIC REQUEST
       – Select HOME OXYGEN REQUEST
          » Enter EQUIPMENT (RESPIRATORY) as the name
             to add.




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              #226 – Consults: Kill or Be Killed


• Create a dialog template to attach to the
  request in CPRS and attach to the
  request.




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               #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendation #3 – Monitoring Home
    Oxygen Patients
    • CPRS documentation
      – Inpatient Education for Home Oxygen use and safety
      – Initial Home Oxygen Set up
      – Follow Up Home Oxygen visits




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                #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendation #3 – Monitoring Home
    Oxygen Patients
    • CPRS documentation
      –   Inpatient Education for Home Oxygen use and safety
      –   Initial Home Oxygen Set up
      –   Follow Up Home Oxygen visits
      –   Home Oxygen Ventilator Patients



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                #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendation #3 – Monitoring Home
    Oxygen Patients
    • CPRS documentation
      –   Inpatient Education for Home Oxygen use and safety
      –   Initial Home Oxygen Set up
      –   Follow Up Home Oxygen visits
      –   Home Oxygen Ventilator Patients
      –   Home Safety Inspections

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                #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendation #3 – Monitoring Home
    Oxygen Patients
    • CPRS documentation
      –   Inpatient Education for Home Oxygen use and safety
      –   Initial Home Oxygen Set up
      –   Follow Up Home Oxygen visits
      –   Home Oxygen Ventilator Patients
      –   Home Safety Inspections
      –   Home Visit Patient Safety Education
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                #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendations #2, 4, and 7 –
    Patient Compliance and Safety
    • JCAHO Patient Safety Goals
       – Verify all JCAHO Patient Safety Goals are met
       – Document in CPRS the verification of JCAHO Patient
         Safety Goals




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                #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendations #2, 4, and 7 –
    Patient Compliance and Safety
    • Patient declines re-evaluation
    • Patient non-compliant with prescription
    • Patient non-compliant with safety guidelines
       – Compliance with VHA Directive 2006-021 – Reducing
         Fire Risks in patients with Home Oxygen
          » CPRS Clinical Warning Note posting for all patients
             using Home Oxygen
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                #226 – Consults: Kill or Be Killed


• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendations #2, 4, and 7 –
    Patient Compliance and Safety
    • Patient declines re-evaluation
    • Patient non-compliant with prescription
    • Patient non-compliant with safety guidelines
       – Compliance with VHA Directive 2006-021 – Reducing
         Fire Risks in patients with Home Oxygen
          » CPRS Clinical Warning Note posting for all patients
             using Home Oxygen
          » CPRS Patient Record Flag for non-compliant
             patients with directive and signed agreement
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• National Leadership Board (NLB) Home
  Oxygen Program recommendations
  – NLB Recommendations #5 and 6
    • Develop Home Oxygen Advisory Board
    • Define Home Oxygen Advisory Board
      Membership responsibilities




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                          #226 – Consults: Kill or Be Killed
                             HOME   CARE    ADVISORY   BOARD



1.  FUNCTION:   The Home Care Advisory Board will function as an
interdisciplinary board in an advisory capacity to the Chief of Staff to
ensure implementation, development, maintenance, and clinical oversight
of all Home Care Programs.  Specific responsibilities include the
following:

    A.  Ensuring coordination         and integration among           the   home care service
entities to establish policy,         maintain quality care           and   patient safety,
and provide for the necessary         resources.

    B.  Ensuring the home       care services provided through               the medical
center are comprehensive,       coordinated, and accessible to               meet the needs
its beneficiaries.

    C.  Ensuring that home care            services are coordinated          to    eliminate
fragmentation, gaps in service,            and duplication of care.

    D.    Tracking and     trending   the    resolution   of    clinical     issues      brought
before   the board.

    E.  Ensuring the       home care entities act        upon   any    reports      and/or
recommendations from       authorized agencies.

2.   MEMBERSHIP:

     Home Based Primary Care Medical Director, Co-Chairperson
     Staff Pulmonologist, Co-Chairperson
     Chief, Pharmacy Service
     Chief, Prosthetics & Sensory Aid Service
     Chief, Acquisition & Material Management Service
     Administrative Assistant to Chief, Nursing Service
     Administrative Assistant to Chief of Staff
     Community Health Nurse
     Coordinator, Home Based Primary Care
     Coordinator, Homemaker/Home Health Aid
     Coordinator, Home Oxygen Program
     Supervisor, Social Work
     Coordinator, Physical Medicine & Rehabilitation Service
     Contracting Representative
     Quality Management Consultant
     MAS Fee Basis Clerk

3.  REPORTING:  Minutes of the         Home Care Advisory        Board      will    be
prepared and forwarded to ECMS         for approval.

4.   MEETINGS:     The   Interdisciplinary      Board   will    meet   monthly      at   11:00   a.m.

5.   REFERENCES:    None


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• Policy regarding reducing/eliminating
  smoking with use of Home Oxygen




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REDUCING SMOKING FIRE HAZARD WITH OXYGEN TREATMENT


1. PURPOSE: The purpose of this memorandum is to establish policy and procedure, and to provide a process for reducing the
    fire hazard of smoking when oxygen treatment is expected at the G. V. (Sonny) Montgomery VA Medical Center. This
    guideline provides the minimum requirements for reducing the fire hazard of smoking when oxygen treatment is expected,
    and reinforces the VHA policy of smoking cessation and control.

2. POLICY: It is the policy of this medical center that, whenever oxygen treatment is being delivered, access to smoking
    materials must be restricted; patients who smoke must be offered nicotine replacement therapy or other alternatives; and all
    smoking must be prohibited in the vicinity of oxygen delivery equipment.

3. DEFINITIONS: High-risk Patients: High-risk patients are patients who exhibit unsafe clinical or behavioral traits involving
    oxygen and smoking, such as:
     - Attempting to hide their smoking materials or activities from staff;
     - Having a history of non-compliance with smoking rules; or
    - Smoking in a patient sleeping room or other areas designed as non-smoking areas.
4. RESPONSIBILITY:
    A. Center Director: Overall direction to ensure implementation and compliance with this policy, in accordance with VHA
    Directive 2006-021, Reducing the Fire Hazard of Smoking When Oxygen Treatment Is Expected.
    B. Chief of Staff: General supervision of the clinics and wards and oversight of policy implementation as it relates to clinical
    staff.
    C. Chief, Nursing Service, or Designee: General supervision of the clinics and wards and oversight of policy implementation
    as it relates to nursing staff and the Home Oxygen Program staff.




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                                 #226 – Consults: Kill or Be Killed

D. Office of Quality Management:

       (1) Ensures appropriate tracking of reported incidents involving patients who have a close call or
confirmed adverse event related to smoking.

        (2) Ensures that each incident is reported to the prescribing clinician and to the appropriate
committee: Home Care Advisory Board for Home Oxygen Therapy; Environment of Care Committee for any
incidents occurring at the medical center.

E. Chair, Environment of Care Committee: Ensures that appropriate tracking and action is taken as
appropriate in compliance with this policy.

F. Chair, Home Care Advisory Board: Ensures that appropriate tracking and action is taken as appropriate in
compliance with this policy.

G. Respiratory Therapists: Ensures that the patient and/or the patient's surrogate have been informed of the
terms regarding safe administration of oxygen therapy when therapy is initiated and agree to comply with
terms stated.

H. Facility Management Service: Ensures that signs are posted in smoking areas that oxygen is not allowed.

I. Front-Line Staff: Reporting as appropriate all close calls and adverse events related to patients smoking
while oxygen is in use.


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5. PROCEDURE:

  A. Inpatient

    (1) In all patient care settings on the facility grounds, smoking is prohibited in patient sleeping rooms and all
   areas designated as non-smoking areas.

    (2) Oxygen cylinders and other oxygen delivery equipment are not permitted within smoking shelters.

    (3) Patients who smoke must be offered nicotine replacement therapy (e.g., patch, gum, lozenges) to treat
   nicotine withdrawal, or other smoking cessation intervention alternatives must be offered. A clinical reminder
   will be added to the patient record to verify whether they accepted or refused. NOTE: Guidance on nicotine
   replacement therapy (NRT) is available from the VHA Office of Public Health Care Group (13B) through their
   "Medications for Management of Tobacco Dependence." (See Attachment A)

    (4) A fire-assessment is conducted for all new oxygen therapy inpatients who smoke, and a reassessment is
   conducted when renewing an oxygen prescription or at any time there is a significant change in the patient's
   oxygen therapy set-up (e.g., transfer to a different ward or unit).

    (5) For those patients who are determined to be high-risk patients, a clinical interdisciplinary team reviews
   each case involving a high-risk patient who is prescribed oxygen in order to determine appropriate restricted
   environmental or clinical requirements. The high-risk patient is assigned a sleeping room that is:

   a. Fully equipped with Quick Response (QR) fire sprinklers;
   b. Provided with standard response fire sprinklers and smoke detection (e. g., system or battery powered); or
   c. Located as close to the nursing station as practical to increase the level of monitoring and supervision.
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 (6) Patients, family members, and visitors of these high-risk patients must be instructed by staff
 that smoking materials may not be brought into the facility. Family members and visitors are to be
 requested to acknowledge that they understand this requirement by signing a locally developed
 fire and oxygen hazard awareness form. (See Attachment B)

 (7) All patients who fail to comply with oxygen therapy and smoking safety guidelines are referred
 to their clinical interdisciplinary team or the facility Ethics Consultation Service for review, as
 appropriate, to determine continued oxygen therapy, and how such therapy will be provided in
 ongoing care. NOTE: A flag will be placed in CPRS to identify those patients who are considered
 high-risk patients.

B. Outpatient

 (1) In all patient care settings on the facility grounds, smoking is prohibited in all areas designated
 as non-smoking areas.

 (2) Oxygen cylinders and other oxygen delivery equipment are not permitted within smoking
 shelters and signs will be posted.

 (3) Patients who need portable oxygen tank exchange while in the hospital must have an order
 placed in CPRS, requesting the tank. (See Attachment C)




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  (4) Patients who smoke must be offered nicotine replacement therapy (e.g., patch, gum, lozenges) to treat
  nicotine withdrawal, or other smoking cessation intervention alternatives must be offered. A clinical
  reminder will be added to the patient record to verify rather they accepted or refused. NOTE: Guidance on
  nicotine replacement therapy (NRT) is available from the VHA Office of Public Health Care Group (13B)
  through their "Medications for Management of Tobacco Dependence." (See Attachment A)

  (5) All patients who fail to comply with oxygen therapy and smoking safety guidelines are referred to the
  Home Care Advisory Board for review to determine appropriateness of continued oxygen therapy, and how
  such therapy will be provided in ongoing care. NOTE: A flag will be placed in our system to identify those
  patients who are considered high-risk patients.

C. Home Care

  (1) A consult for Home Oxygen must be placed in CPRS by the ordering provider.

  (2) Upon approval of home oxygen through the Home Oxygen Consult, the Home Oxygen Respiratory
  Therapist will assess the patient's smoking status. If the patient smokes, the patient and/or family member
  must sign the No Smoking with Oxygen Contract. (See Attachment B).

  (3) Patients requesting multiple oxygen exchange must have an order for multiple exchange and these must
  be exchanged through the Home Oxygen Program. Patients who smoke will receive additional education
  prior to the exchange.

  (4) A fire-assessment is conducted for all new oxygen therapy patients who smoke, and a reassessment is
  conducted when renewing an oxygen prescription or at any time there is a significant change in the patient's
  oxygen therapy set-up.

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(5) The educational materials will be provided upon initial delivery and every six months thereafter at a
minimum.

(6) The patient's home environments will be assessed for smoke alarms. If no smoke alarms, the patient
and/or family will be instructed to obtain a smoke alarm and place the working alarm in the home. However, if
a patient or family member smokes and does not have a smoke alarm, one will be issued with instructions for
utilization in the home. Patients and family will be advised to test smoke alarm monthly.

(7) Education and orientation will be provided to each patient and other family members who smoke in the
dwelling regarding the hazards of smoking while oxygen is being administered.

(8) High-risk home oxygen patients and/or family members must sign the No Smoking with Oxygen Contract.
(See Attachment B)

(9) Any home oxygen orders sent to private vendors will include high-risk for smoking while oxygen is in use.

(10) Home Care Respiratory Therapists will complete initial assessment and do a 30-day follow-up phone call
to assess compliance with smoking and home oxygen use. Patient will be seen in Home Oxygen Clinic
within 3 months for follow-up of compliance and annually thereafter at minimum.

(11) Incidents, where patients are reported as non-compliant with the guidelines set forth in the education
and orientation material and/or whose behavior poses a risk of self harm or harm to others, are documented
and reported to the Home Oxygen Coordinator, or designee. Home Oxygen Coordinator, or designee, must
report non-compliant behavior to the patient's provider, or appropriate designee, who must counsel the
patient and/or patient's surrogate of the potential risks associated with such activity and potential
consequences of continued activity. NOTE: A flag will be placed in CPRS to identify those patients who are
considered high-risk patients.
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   (12) When there is potential of identified conflict between the patient's right to smoke and/or the patient's
   continued smoking while using oxygen and the risk of harm to self or others, the provider(s) or others are to
   utilize an interdisciplinary review process, or request an Ethics Consultation, to address and resolve the
   situation.

   (13) All patients who fail to comply with oxygen therapy and smoking safety guidelines are referred to an
   interdisciplinary clinical committee or the facility Ethics Consultation Service, as appropriate, for review to
   determine continued oxygen therapy and how such therapy will be provided in ongoing care.

6. REPORTING REQUIREMENTS:

  A. VA Form 10-71 (586), Patient Incident/Adverse Event Report (PIR) will be completed involving patients
   receiving oxygen therapy who have close calls or confirmed adverse events related to smoking, in
   accordance with Center Policy Memorandum A-11Q-31, Patient Safety Improvement Program.

  B. Each PIR will be forwarded to the Office of Quality Management. The Office of Quality Management will
   report on significant events or ongoing trends related to Smoking and Oxygen Use to the Environment of Care
   Committee.

  C. A flag will be placed in the medical record of all patients determined to be High-Risk. The note attached to
   the flag will document any close calls or confirmed adverse events related to smoking and oxygen use.

ATTACHMENTS:          (A) Medications for Management of Tobacco Dependence
                      (B) No Smoking with Oxygen Contract
                      (C) Home Oxygen Tank Exchange Order


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REFERENCES:
    Veterans Health Administration (VHA) Patient Safety Alert dated January 6, 2005,
  Fire Response and Planning at:
  http://vaww.ncps.med.va.gov/Guidelines/alerts/FireResponseAlert.pdf
    Joint Commission on Accreditation of Healthcare Organizations, Environment of
  Care Standards, EC. 1.30
    VHA National Ethics Teleconference Call, October 23, 2001, Home Oxygen for
  Patients Who Smoke: Prescription versus Proscription at:
  http://vaww1.va.gov/vhaethics/download/Transcripts/EthicsHotlineCall10.23.01.doc
    VHA Prosthetic Clinical Management Program (PCMP); Clinical Practice
  Recommendations
    Home Use of Supplemental Oxygen, Draft and dated January 11, 2005;
  Department of Veterans Health Administration.
    JCAHO Standards; Understanding Clinical Respiratory Services for 2004.
    VHA Directive 2003-035, Smoke Free Policy for VA Health Care Facilities, dated
  July 1, 2003;
    VHA Directive 2003-042, National Smoking and Tobacco Use Cessation Program,
  dated August 6, 2003;
    VHA Directive 2006-021, Reducing the Fire Hazard of Smoking when Oxygen
  Treatment is Expected, dated May 1, 2006.

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Attachment   B



                           G. V. (SONNY) MONTGOMERY VAMC
                          NO SMOKING WITH OXYGEN CONTRACT


I__________________________ agree not to smoke near or when I am using
my oxygen.  I understand the risks associated with smoking and oxygen
use.
If I smoke near or when I am using my oxygen, I will give up the use of
oxygen. I agree to contact the appropriate medical center staff to
report any such actions. I understand that my oxygen therapy will be
discontinued and only reinstated after a successful smoking cessation
program.

I have   received safety instructions   on   the   use   of   oxygen   and   understand
how to   use oxygen safely.



_____________________                         _______________________
Signature of Patient                          Social Security Number

As a family member or caregiver of above patient, I understand the
safety issues associated with oxygen use and the risks involved in
smoking near or with oxygen.  I agree to report to the appropriate
medical center staff any violations of smoking with oxygen.

______________________                        _______________________
Signature                                     Relationship
Family Member/Caregiver


____________________                          _______________________
Signature of Witness                          Printed Name of Witness



Date:______________




                                                                                    72
                                           #226 – Consults: Kill or Be Killed
                                     Attachment C

                      GUIDELINES FOR OXYGEN TANK EXCHANGE

- For patients needing a portable oxygen exchange tank while in the Medical Center, the primary provider will enter an order for
      Single Tank Exchange.

- The Single Tank Exchange (Respiratory) order will be listed under text orders. The provider must enter justification for the
     exchange, verification of the patient's current oxygen order and if this is a VA or non-VA home oxygen patient.

- The Single Tank Exchange order will be sent to the Respiratory Department and the provider will be directed to page Respiratory
     for the oxygen exchange.

- Respiratory Therapists will issue the oxygen tank and document the issued tank's serial number and the returned tank's serial
     number.

- If the patient requested or has need for multiple oxygen tanks, the order for the multiple tanks will be entered under orders
       (Multiple Oxygen Tanks, Home Oxygen) and the Home Oxygen Respiratory Therapists will be paged (altered to the request)
       and the tanks will be issued from the warehouse.

- Patients enrolled in the VA Home Oxygen Program will have a posting in CPRS to identity these patients.

- Patients who smoke will be re-educated regarding risk associated with smoking and oxygen use during each tank exchange by
      Respiratory.

- Patients who are at risk for home oxygen due to smoking non-compliance will have their records flagged in CPRS as a warning
      not to issue home oxygen.



                                                                                                                             73
                                       #226 – Consults: Kill or Be Killed
                                 Attachment C (continued)
HOME OXYGEN SINGLE TANK EXCHANGE ORDER
(Completed by ordering provider)
VA Home Oxygen:___
Non-VA Home Oxygen:___
    Who is providing oxygen:_____________________

Patient's current home oxygen order:
                ___Liter flow
                ___Duration
                ___Route

Justification:    ___Tank is empty
                  ___Requires additional tank volume due to travel
                  ___Tank is mal-functioning
Smoking Status:
   Current Smoker:
   Education regarding not smoking with oxygen reinforced.
   Non-Smoker:

(Completed by Respiratory Therapy)
Tank Issued, Serial Number:_____________

Tank Retuned, Serial Number:__________

                                                                     74
                                    #226 – Consults: Kill or Be Killed
                                      Attachment C (continued)
HOME OXYGEN MULTIPLE TANK EXCHANGE ORDER
(Must be enrolled in VA Home Oxygen Program with Current Home Oxygen Orders)

(Completed by ordering provider)
Request ____ portable tank exchange

Justification:      ___Travel Time exceeds number of portable tanks issued
                 ___Patient missed home visit via Home Oxygen RT
                 ___Tanks mal-functioning

___Patient and/or family members verbalized understanding of risks
associated with transporting and storing portable oxygen tanks.
___Patient and/or family member have safe identified storage area for
portable tanks.

___Smoking Status:
   Current Smoker:
   Education regarding not smoking with oxygen reinforced.
   Non-Smoker:

(Completed by Home Oxygen Respiratory Therapist)
Tank Issued, Serial Number:_____________

Tank Returned
      Not Applicable:_________
      Serial Number:__________

                                                                               75
              #226 – Consults: Kill or Be Killed


• Statistics for Home Oxygen patients with
  improvements in patient outcomes.
  – Provide statistical data to show improved
    compliance, decreased cost and improved
    outcome for Home Oxygen Patients.




                                                76
                          #226 – Consults: Kill or Be Killed

               Number of Home Oxygen Cylinders Rented/Refilled Monthly
                                     FY 2005
             1000
                    936
              900
              800
                           754
              700
Number




              600
                                  553
              500                                                         475          475
                                               425    433   450
              400                                                  375
              300                                                               260
                                                                                                300
                                        245
              200
              100
                0
                      4




           pr 5



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                                              Month
              The number of Home Oxygen tanks rented/refilled per month has decreased by 68%.
                                                                                                 77
                          #226 – Consults: Kill or Be Killed


                          Cost of Renting/Refilling Home Oxygen Tanks
                                            FY 2005
       $6,000


                 $5,148
       $5,000

                          $4,147
       $4,000
Cost




       $3,000                      $3,042
                                                            $2,382   $2,475               $2,613             $2,613

       $2,000                                      $2,338                       $2,063
                                                                                                                      $1,650
                                            $1,348                                                  $1,430
       $1,000


          $0                                                     5
                      4




                                                        5




                                                                                                       5
                                               5




                                                                                                                5
                                  05




                                                                                  05
                                                                          5
                      4
            4




                                                                                              5
                    -0




                                                                                                     -0
                                                                -0


                                                                        -0
                                                      -0
                                            -0




                                                                                                             -0
                                                                                           l-0
                   -0
         -0




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                 ov




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                                                                                                  A
                                                                     M


                                                            Month
Cost of Renting/Refilling Home Oxygen Tanks per month has dropped 49% since October 2004.

                                                                                                                          78
             #226 – Consults: Kill or Be Killed


• 67 of 101 Chronic Obstructive Pulmonary
  Disease patients on Home Oxygen were
  hospitalized less than 2 times during a 6
  year period.
• 83 of 101 have been hospitalized less
  than 4 times in 6 years.



                                           79
 CONSULT/SCHEDULING LINK –
update since Summer 2006 Release

        Sheri Kreuz, RD, MBA
          SDS, Clin2 Team
         Salt Lake City OIFO
                     Objectives

• Discuss issues with Service Consults
  Schedule-Management Report
• Discuss a few process issues
• Discuss Remedy Tickets
• Mention E3R(s)
• Discuss CPRS v27
  Enhancements/Initiatives related to
  Consults

                                         81
            Service Consults Schedule-
               Management Report
               [GMRC RPT SD SCH-MGT CONSULTS]




• STATUSES Prior to New Report
  – PENDING
  – ACTIVE
  – SCHEDULED
  – INCOMPLETE
  – DISCONTINUED
  – CANCELLED
  – COMPLETED

                                                82
              Service Consults Schedule-
                 Management Report
                        [GMRC RPT SD SCH-MGT CONSULTS]

• AFTER
                    2  Active, By Admin
                 202 Active, Can By Clinic
                 239 Active, Can By Patient
                 160 Active, No-Show
                 297 Active, Edit Resubmit
                   4 Active, IFC
                 277 Active, Manually
                 263 Incomplete
                5593 Pending
                  10 Pending, EWL
                 665 Sch, Linked, Ck'd Out
                3171 Scheduled, Linked
                  60 Sch, Not Linked now
                   5 Schedule, IFC
                 970 Sch, Never Linked
          ----------
               11918 Total OPEN consults

                2129 Cancelled
               27208 Completed
                1261 Discontinued
          ----------
               30598 Total CLOSED consults

          ==========                                     83
            42516 GRAND TOTAL
              Service Consults Schedule-
                 Management Report
                 [GMRC RPT SD SCH-MGT CONSULTS]




• Sch. Not Linked now – History of consult
  being linked to an appointment; consult
  later marked SCHEDULED manually
• Scheduled, Linked – Consult currently
  linked to an appointment
• Sch. Never Linked – Consult marked
  SCHEDULED manually with no history of
  being linked to an appointment
                                                  84
           REPORT STATUS ISSUES (con’t)

• Sch, Linked, Ck’d Out – consult complete
  but no note for either of these reasons
  – Incorrect note title completed
  – Incomplete note – awaiting provider signature




                                                85
                NO SHOW ISSUE

• Consults linked to an appointment where
  patient is a NO SHOW
• Consult status changes from
  SCHEDULED to ACTIVE
• Reprint Consult to prevent being lost
• Auto-Rebook – currently allows a dc’d
  consult to be changed back to Scheduled


                                            86
              CANCELLATION ISSUE

• CANCELLED consult can be attached to
  an appointment when:
  – Service allowed appointment to be made for
    the consult
  – Patient was a NO SHOW for the appointment
  – Service CANCELLED the consult less than 6
    months ago




                                             87
             CANCELLATION ISSUE (con’t)

• Consult Status History
  –   PENDING
  –   SCHEDULED (LINKED using interface)
  –   NO-SHOWED
  –   CANCELLED
• All other consults in a CANCELLED status are
  NOT allowed to be linked to an appointment.
• Any consult that was cancelled initially (never
  SCHEDULED) by the service will NOT be
  displayed to link to an appointment.


                                                    88
                                          REMEDY TICKETs
                                            159382 (174399,184547)
                                        Procedure Name = Service Name




Will this appointment be for a CONSULT/PROCEDURE? YES//

Please select from the list of consult(s), press 0 for none.

TWENTY,PATIENT

# Service                  Sending Provider Request Date Cons # Reqst Type
------------------------------------------------------------------------------------------------------
1.                         VEHU,ZERO                06/27/07@06:57 1070 Procedure




                                                                                                         89
        REMEDY TICKET – 168769 Report Not
                  Consistent

• GMRC RPT SD SCH-MGT CONSULTS
• If service is a GROUPER and contains
  other GROUPER service(s), the sub-
  grouper service(s) do not print.
• User would need to know to run the report
  on the sub-GROUPER service(s).
• Fix will be made to compile all services
  related to user’s selection
• No patch designated yet/no timeframe

                                          90
              REMEDY TICKET – 174855
                 Unscheduled Visits




• Unscheduled Visit action in Appt Mgt does
  not prompt to link to a consult
• Can’t discuss the appropriateness of using
  Unscheduled Visit but the ticket has been
  submitted and sent to Tier 3.


                                           91
                  Other Issues/Uses

• Some sites are using the GMRC/SD link to
  schedule patients for pick up of prosthetics
  items.
• Electronic Wait List (EWL) patients:
  – Leave consult in pending status (PENDING,
    EWL)
  – Manually receive w/comment indicating pt on
    EWL (ACTIVE, EWL)
  – Schedule via CPRS (SCHEDULE, EWL)


                                                  92
                  CPRS V27 CONSULT
               ENHANCEMENTS/INITIATIVES

• Reference
   – NSR 20051008
• Add Desired Date to Consult Software
   – Add earliest and latest desired dates to the
     Consults and Interfacility Consults software
     packages to monitor the electronic closure of
     consults in CPRS.

*Dependent on Consults patch and possibly Health
  Summary patch


                                                     93
              CPRS V27 CONSULT
           ENHANCEMENTS/INITIATIVES



• PSI-04-012 (Part 4): Consults completed
  without viewing reason for consult
  – Added right-click option to note editing menu
    to display details of consult being completed
    while editing a consults-titled note
• 508 Compliance – CPRS/consults (in
  addition to Reminders, EFs, Orders)


                                                94
Monitoring for Performance Improvement


      Harold D. Bonds, MT (ASCP) SC
         Health Systems Specialist
         G. V. Montgomery VAMC
                Jackson, MS
           #226 – Consults: Kill or Be Killed
               Monitoring for Performance improvement



•    Data for Monitoring may be collected from
     several sources:
    – VistA Consult Package Reporting Options
    – Care Management Query Tool
    – VistA Fileman templates (requires some
       programming knowledge for obtaining
       information from the files)




                                                        96
              #226 – Consults: Kill or Be Killed
                   Monitoring for Performance improvement


VistA System Consult Tracking Reports option:

–     ST   Completion Time Statistics
–     PC   Service Consults Pending Resolution
–     SH    Service Consults Schedule-Management Report
–     CC   Service Consults Completed
–     CP   Service Consults Completed or Pending Resolution
–     IFC Interfacility (IFC) Requests
–     IP   Interfacility (IFC) Requests By Patient
–     IR   Interfacility (IFC) Requests by Remote Ordering Provider
–     NU   Service Consults with Consults Numbers
–     PI   Print Interfacility (IFC) Requests
–     PL   Print Consults by Provider, Location, or Procedure
–     PM   Consult Performance Monitor Report
–     PR   Print Service Consults by Status
–     SC   Service Consults By Status
–     TS   Print Completion Time Statistics Report
                                                                      97
           #226 – Consults: Kill or Be Killed
                 Monitoring for Performance improvement


VistA System Consult Tracking Reports option:
– SH Service Consults Schedule-Management Report
    • Benefits of this option are:
        – Status of the consults:
        – Service Connection Percentage (Priority Scheduling)
        – Total consult numbers at a single glance
        – Patient appointment linked with consult
    • Pitfalls of this option:
        – Ordering Provider not listed
        – Reason for Request not indicated
        – Completion, Cancellation, and Discontinued data not
           available

                                                                98
                    #226 – Consults: Kill or Be Killed
                            Monitoring for Performance improvement

Service Consults By Status            Jun 14, 2007@15:01:02    Page:    1 of     1
Service: Urology
SUMMARY From: 04/01/07 To 04/30/07                                      06/14/07
==================================================================================
        12 Active, Can By Clinic
        14 Active, Can By Patient
        14 Active, No-Show
         1 Incomplete
        17 Pending
        37 Sch, Linked, Ck'd Out
         9 Scheduled, Linked
         3 Sch, Never Linked
----------
       107 Total OPEN consults

        22   Cancelled
       137   Completed
         8   Discontinued
----------
       167   Total CLOSED consults

==========
       274   GRAND TOTAL

                                                                             99
                         #226 – Consults: Kill or Be Killed
                                 Monitoring for Performance improvement


 Urology 04/01/07 - 04/30/07
                       Consult                                Clinic              Appointment  Stop
Status                 Date    SC  L4         Patient          Appointment        Date/time    Code
===================================================================================================
Active, Can By Clinic 04-03-07 10% 0001 CPRS,PATIENTONE
Active, Can By Clinic 04-03-07     0002 CPRS,PATIENTTWO
Active, Can By Clinic 04-04-07 0%  0003 CPRS,PATIENTTHREE
Active, Can By Clinic 04-07-07 20% 0004 CPRS,PATIENTFOUR
Active, Can By Clinic 04-09-07     0005 CPRS,PATIENTFIVE
Active, Can By Clinic 04-11-07     0006 CPRS,PATIENTSIX
Active, Can By Clinic 04-12-07     0007 CPRS,PATIENTSEVEN
Active, Can By Clinic 04-18-07 50% 0008 CPRS,PATIENTEIGHT
Active, Can By Clinic 04-18-07     0009 CPRS,PATIENTNINE
Active, Can By Clinic 04-19-07     0010 CPRS,PATIENTTEN
Active, Can By Clinic 04-19-07     0011 CPRS,PATIENTELEVEN
Active, Can By Clinic 04-24-07     0012 CPRS,PATIENTTWELVE
Active, Can By Patient04-02-07     0013 CPRS,PATIENTTHIRTEEN
Active, Can By Patient04-02-07 30% 0014 CPRS,PATIENTFOURTEEN
Active, Can By Patient04-03-07     0015 CPRS,PATIENTFIFTEEN
Active, Can By Patient04-04-07     0016 CPRS,PATIENTSIXTEEN
Active, Can By Patient04-05-07     0017 CPRS,PATIENTSEVENTEEN
Active, Can By Patient04-12-07 80% 0018 CPRS,PATIENTEIGHTEEN
Active, No-Show        04-02-07    0019 CPRS,PATIENTNINETEEN
Active, No-Show        04-09-07    0020 CPRS,PATIENTTWENTY
Active, No-Show        04-10-07    0021 CPRS,PATIENTTWENTYONE
Active, No-Show        04-10-07    0022 CPRS,PATIENTTWENTYTWO
Incomplete             04-26-07    0023 CPRS,PATIENTTWENTYTHREE
                                                                                            100
                          #226 – Consults: Kill or Be Killed
                                   Monitoring for Performance improvement


Urology 04/01/07 - 04/30/07
                          Consult                                      Clinic       Appointment   Stop
Status                    Date     SC      L4     Patient              Appointment  Date/time     Code
=================================================================================================
Pending                    04-05-07 100% 0024 CPRS,PATIENTTWENTYFOUR
Pending                   04-09-07 30% 0025 CPRS,PATIENTTWENTYFIVE
Pending                   04-09-07        0026 CPRS,PATIENTTWENTYSIX
Sch, Linked, Ck'd Out 04-02-07           0027 CPRS,PATIENTTWENTYSEVEN GU-PROSTATE ONC 05-08-07 @ 14:00 414
Sch, Linked, Ck'd Out 04-03-07 0%        0028 CPRS,PATIENTTWENTYEIGHT GU CYSTO/CYSTOG 05-02-07 @ 08:30 414
Sch, Linked, Ck'd Out 04-03-07 70% 0029 CPRS,PATIENTTWENTYNINE         GU-UROLOGY       05-16-07 @ 11:45 414
Scheduled, Linked 04-02-07 40%          0030 CPRS,PATIENTTHIRTY        GU-UROLOGY       06-15-07 @ 10:30 414
Scheduled, Linked 04-02-07              0031 CPRS,PATIENTTHIRTYONE     GU-UROLOGY      06-20-07 @ 10:15 414
Scheduled, Linked 04-03-07              0032 CPRS,PATIENTTHIRTYTWO     GU-UROLOGY      06-15-07 @ 09:00 414
Sch, Never Linked 04-02-07              0033 CPRS,PATIENTTHIRTYTHREE
Sch, Never Linked 04-25-07              0034 CPRS,PATIENTTHIRTYFOUR
Sch, Never Linked 04-27-07 10%          0035 CPRS,PATIENTTHIRTYFIVE




                                                                                                   101
           #226 – Consults: Kill or Be Killed
                  Monitoring for Performance improvement


VistA System Consult Tracking Reports option:
– IFC      Interfacility (IFC) Requests
    • Benefits of this option:
       – List consults by Requesting or Consulting facility
       – List status of consults by Requesting or Consulting facility
       – Provides totals for each consult service by facility and overall
         totals by facility
       – Provides basic status of consults
   • Pitfalls of this option:
       – Does not indicate Ordering Provider
       – Does not indicate Reason for Request
       – Does not indicate Completion, Cancellation, or Discontinue
         data
       – No appointment data not available
                                                                            102
#226 – Consults: Kill or Be Killed
   Monitoring for Performance improvement




                                            103
                 #226 – Consults: Kill or Be Killed
                      Monitoring for Performance improvement
To Service Brachytherapy Total Requests Discont.                     13
To Service Brachytherapy Total Requests Completed                    93
To Service Brachytherapy Total Requests Pending                       1
To Service Brachytherapy Total Requests Scheduled                     4
To Service Brachytherapy Total Requests Incomplete                    1
To Service Brachytherapy Total Requests Cancelled                     6
Total Requests Pending Resolution To Service Brachytherapy            6
Total Requests To Service Brachytherapy @ VAMCFIVE                    2
Total Requests To Service Brachytherapy @ VAMCTHREE                  34
Mean Days Completed To Service Brachytherapy @ VAMCTHREE             40
Total Requests To Service Brachytherapy @ VAMCSEVEN                   3
Mean Days Completed To Service Brachytherapy @ VAMCSEVEN             26
Total Requests To Service Brachytherapy @ VAMCFOUR                   31
Mean Days Completed To Service Brachytherapy @ VAMCFOUR              22
Total Requests To Service Brachytherapy @ VAMCTWO                    13
Mean Days Completed To Service Brachytherapy @ VAMCTWO               33
Total Requests To Service Brachytherapy @ VAMCONE                    22
Mean Days Completed To Service Brachytherapy @ VAMCONE               16
Total Requests To Service Brachytherapy @ VAMCSIX                     5
Mean Days Completed To Service Brachytherapy @ VAMCSIX               10
Total Requests To Service Brachytherapy @ VAMCEIGHT                   8
Mean Days Completed To Service Brachytherapy @ VAMCEIGHT             28
Mean Days Completed To Service Brachytherapy                         27
Total Requests To Service Brachytherapy                              118
                                                               104
           #226 – Consults: Kill or Be Killed
                  Monitoring for Performance improvement

VistA System Consult Tracking Reports option:

– PL      Print Consults by Provider, Location, or Procedure
   • Benefits of this option:
       – Consult Statistics by Ordering Provider, Location or Procedure
           » Individually
           » System wide
   • Pitfalls of this option:
       – Reason for Request not indicated
       – Completion, Cancellation, or Discontinue data not available
       – No appointment data not available




                                                                       105
#226 – Consults: Kill or Be Killed
   Monitoring for Performance improvement




                                            106
                     #226 – Consults: Kill or Be Killed
                             Monitoring for Performance improvement


Consult# Req Date Ordering Provider           Location To Service           Patient SSN Status Procedure
  854454 23-Jan-07 CPRSREMOTE,PROVIDERFIVE    BILOXI VAMC Urology                       c
  858708 29-Jan-07 CPRSREMOTE,PROVIDERFIVE    BILOXI VAMC Urology                       s
  892416 11-Apr-07 CPRSREMOTE,PROVIDERFIVE    BILOXI VAMC Urology                       s
  891268 12-Apr-07 CPRSREMOTE,PROVIDERFIVE    BILOXI VAMC Urology                       c
  854207 22-Jan-07 CPRSREMOTE,PROVIDERTHREE   BILOXI VAMC Oncology                      c
  886279 29-Mar-07 CPRSREMOTE,PROVIDERTHREE   BILOXI VAMC Oncology                      c
  853309 22-Jan-07 CPRSREMOTE,PROVIDERTHREE   BILOXI VAMC Radiation Therapy             c
  878268 17-Mar-07 CPRSREMOTE,PROVIDERTHREE   BILOXI VAMC Radiation Therapy             dc
  882240 29-Mar-07 CPRSREMOTE,PROVIDERTHREE   BILOXI VAMC Radiation Therapy             s
                                                                                                  107
           #226 – Consults: Kill or Be Killed
                  Monitoring for Performance improvement

VistA System Consult Tracking Reports option:

– PM      Consult Performance Monitor Report
   • Benefit of this option:
       – Gives Consult Completion Statistics with Percentages
   • Pitfalls of this option:
       – No Individual consult information available
       – No appointment data available




                                                                108
             #226 – Consults: Kill or Be Killed
                     Monitoring for Performance improvement

VistA System Consult Tracking Reports option:

– PR          Print Service Consults by Status
   • Benefits of this option:
        – Allows each status to be reviewed/printed separately or together
        – Provides numbers of consults in each status
        – Provides patient information with ordering location
   • Pitfalls of this option:
        –   No Ordering provider information
        –   No Reason for Request available
        –   No Completion, Cancellation, or Discontinue data available
        –   No Appointment data available




                                                                             109
                              #226 – Consults: Kill or Be Killed
                                        Monitoring for Performance improvement

Consult/Request By Status               FROM: May 01, 2006 TO: May 31, 2006
 Number St Last Action                Req Dt Patient Name               Patient Location

SERVICE: Urology
 760020 x CANCELLED                   05/31/06 CPRSpatient,O. (1111)     CPRSclinic One
 759955 x CANCELLED                   05/31/06 CPRSpatient,T. (2222)     CPRSclinic Two
 759939 x CANCELLED                   05/31/06 CPRSpatient,T. (3333)     CPRSclinic Three
 759689 x CANCELLED                   05/31/06 CPRSpatient,F. (4444)     CPRSclinic Four
 759576 x CANCELLED                   05/31/06 CPRSpatient,F. (5555)     CPRSclinic Five
 759500 x ADDED COMMENT               05/31/06 CPRSpatient,S. (6666)     CPRSclinic Six
 759377 x CANCELLED                   05/30/06 CPRSpatient,S. (7766)     CPRSclinic Seven
 759372 x CANCELLED                   05/30/06 CPRSpatient,E. (8888)     CPRSclinic Eight
 759176 x CANCELLED                   05/30/06 CPRSpatient,N. (9999)     CPRSclinic Nine
 759153 x CANCELLED                   05/30/06 CPRSpatient,T. (1010)     CPRSclinic Ten
 758738 x CANCELLED                   05/26/06 CPRSpatient,E. (1111)     CPRSclinic Eleven
 758883 x CANCELLED                   05/26/06 CPRSpatient,T. (1212)     CPRSclinic Twelve
 758628 x CANCELLED                   05/26/06 CPRSpatient,T. (1313)     CPRSclinic Thirteen
 758161 x CANCELLED                   05/25/06 CPRSpatient,F. (1414)     CPRSclinic Fourteen
 758057 x CANCELLED                   05/25/06 CPRSpatient,F. (1515)     CPRSclinic Fifteen
 757938 x CANCELLED                   05/25/06 CPRSpatient,S. (1616)     CPRSclinic Sixteen
 757385 x CANCELLED                   05/24/06 CPRSpatient,S. (1717)     CPRSclinic Seventeen
 756934 x CANCELLED                   05/23/06 CPRSpatient,E. (1818)     CPRSclinic Eighteen
 756754 x CANCELLED                   05/22/06 CPRSpatient,N. (1919)     CPRSclinic Nineteen
 756305 x CANCELLED                   05/22/06 CPRSpatient,T. (2020)     CPRSclinic Twenty
 756166 x CANCELLED                   05/20/06 CPRSpatient,T. (2121)     CPRSclinic Twentyone

To Service Urology Total Requests Cancelled   21

                                                                                                110
             #226 – Consults: Kill or Be Killed
                  Monitoring for Performance improvement


•   VistA System Consult Tracking Options:
    –   There is no one option in the VistA Consult
        Package that will provide all the information that
        may be obtained from all five of the reporting
        options described.
    –   There is not an option in the VistA Consult
        Package that will provide the Reason for
        Request
    –   There is not an option in the VistA Consult
        Package that will provide the Completion,
        Cancellation or Discontinued consult
        information.
                                                           111
             #226 – Consults: Kill or Be Killed
                  Monitoring for Performance improvement


• Consult cancellation reasons can be retrieved by two
  methods:
   – Manually looking at each patient’s Electronic Medical
     Record from a list generated with one of the VistA
     Consult Tracking Options.
   – Searching and printing the cancelled consults with the
     reason for cancellation from the consult files.




                                                           112
             #226 – Consults: Kill or Be Killed
                  Monitoring for Performance improvement


• Consult completion information can be retrieved by two
  methods:
   – Manually looking at each patient’s Electronic Medical
     Record from a list generated with one of the VistA
     Consult Tracking Options.
   – Searching and printing a list of the completed
     consults from the consult files with the associated
     results field populated.




                                                           113
                #226 – Consults: Kill or Be Killed
                       Monitoring for Performance improvement


• Care Management Query Tool:
   – Benefits:
     • Provides report with differing criteria defined by user:
           –   Consult Service
           –   Ordering Provider
           –   Ordering Location
           –   Date Range
           –   Directly exportable report to Microsoft Excel Spreadsheet
  – Pitfalls:
     •   Requires specific patient list for search
     •   No Appointment data available
     •   No Reason for Request
     •   No Completion, Cancellation, or Discontinue data available
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                        #226 – Consults: Kill or Be Killed
                                    Monitoring for Performance improvement

CPRS,PATIENTONE      1/3/2007 14:56 CPRS,PROVIDERONE     Pharmacokinetics Cons Bedside                                         cancelled
CPRS,PATIENTONE                     CPRS,PROVIDERTWO     Physical Medicine & Rehabilitation Service Cons Consultant's Choice   delayed
CPRS,PATIENTTWO                     CPRS,PROVIDERTHREE   Physical Medicine & Rehabilitation Service Cons Consultant's Choice   lapsed
CPRS,PATIENTTWO                     CPRS,PROVIDERTHREE   PHARMACY FALL RISK ASSESSMENT Cons Bedside                            lapsed
CPRS,PATIENTTWO     2/27/2007 13:19 CPRS,PROVIDERFOUR    Interdisc PU Team Cons Consultant's Choice                            complete
CPRS,PATIENTTWO      6/1/2007 11:14 CPRS,PROVIDERFIVE    TRAUMATIC BRAIN INJURY (LOCAL) Cons Consultant's Choice               cancelled
CPRS,PATIENTTWO      6/1/2007 11:19 CPRS,PROVIDERFIVE    INTERDISC PU TEAM Cons Consultant's Choice                            complete
CPRS,PATIENTTWO      6/1/2007 11:23 CPRS,PROVIDERFIVE    PM&RS Speech Pathology Cons Consultant's Choice                       active
CPRS,PATIENTTHREE    3/15/2007 9:40 CPRS,PROVIDERSIX     Dermatology Cons Consultant's Choice                                  complete
CPRS,PATIENTFOUR    1/19/2007 13:45 CPRS,PROVIDERSEVEN   Podiatry Cons Consultant's Choice                                     discontinued
CPRS,PATIENTFOUR     4/6/2007 11:03 CPRS,PROVIDERSEVEN   OEF/OIF VETERAN REFERRAL Cons Consultant's Choice                     discontinued
CPRS,PATIENTFOUR    4/19/2007 10:00 CPRS,PROVIDERSEVEN   OEF/OIF VETERAN REFERRAL Cons Consultant's Choice                     complete
CPRS,PATIENTFOUR    5/23/2007 14:13 CPRS,PROVIDEREIGHT   Cardiology Cons Consultant's Choice                                   discontinued
                                                                                                                                 115
     Questions???

Please write your questions on the 3 x 5
              cards provided
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