current smoker: education regarding not smoking with oxygen

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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

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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 Dont be Killed by Consults
• Consult Monitoring Strategies

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• 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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• 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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• 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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• 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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226 Consults Kill or Be Killed

• 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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• 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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• 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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• 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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• 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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• 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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• 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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226 Consults Kill or Be Killed
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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

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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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• 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
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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
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226 Consults Kill or Be Killed
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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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• 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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• 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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• 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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• 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 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.

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• 
  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

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• 
  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.

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• 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.

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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.

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CONSULT/SCHEDULING LINK update since Summer
2006 Release

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

81
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

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

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

83
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
42516 GRAND TOTAL
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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

85
REPORT STATUS ISSUES (cont)

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

86
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 dcd consult to
  be changed back to Scheduled

87
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

88
CANCELLATION ISSUE (cont)

• 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.

89
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_at_0657 1070 Procedure
90
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 users selection
• No patch designated yet/no timeframe

91
REMEDY TICKET 174855 Unscheduled Visits

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

92
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)

93
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

94
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)

95
Monitoring for Performance Improvement

• Harold D. Bonds, MT (ASCP) SC
• Health Systems Specialist
• G. V. Montgomery VAMC
• Jackson, MS

96
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)

97
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

98
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

99
226 Consults Kill or Be Killed Monitoring
for Performance improvement

• Service Consults By Status Jun 14,
  2007_at_150102 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
• ----------

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
• 
  
• 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

101
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 _at_ 1400 414
• Sch, Linked, Ck'd Out 04-03-07 0 0028
  CPRS,PATIENTTWENTYEIGHT GU CYSTO/CYSTOG
  05-02-07 _at_ 0830 414
• Sch, Linked, Ck'd Out 04-03-07 70 0029
  CPRS,PATIENTTWENTYNINE GU-UROLOGY
  05-16-07 _at_ 1145 414
• Scheduled, Linked 04-02-07 40 0030
  CPRS,PATIENTTHIRTY GU-UROLOGY
  06-15-07 _at_ 1030 414
• Scheduled, Linked 04-02-07 0031
  CPRS,PATIENTTHIRTYONE GU-UROLOGY
  06-20-07 _at_ 1015 414
• Scheduled, Linked 04-03-07 0032
  CPRS,PATIENTTHIRTYTWO GU-UROLOGY
  06-15-07 _at_ 0900 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

102
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

103
226 Consults Kill or Be Killed Monitoring
for Performance improvement
104
226 Consults Kill or Be Killed Monitoring
for Performance improvement
105
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

106
226 Consults Kill or Be Killed Monitoring
for Performance improvement
107
226 Consults Kill or Be Killed Monitoring
for Performance improvement
108
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

109
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

110
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

111
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.

112
226 Consults Kill or Be Killed Monitoring
for Performance improvement

• Consult cancellation reasons can be retrieved by
  two methods
• Manually looking at each patients 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.

113
226 Consults Kill or Be Killed Monitoring
for Performance improvement

• Consult completion information can be retrieved
  by two methods
• Manually looking at each patients 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.

114
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

115
226 Consults Kill or Be Killed Monitoring
for Performance improvement
116

• Questions???
• Please write your questions on the 3 x 5 cards
  provided