Protocols

I would like to know how organizations support the use of clinical protocols -

* What is your approval and implementation process?

* What clinical scenarios are in protocol format?

* What kind of format is used, i.e., flow charts or physician order set format?

* What disciplines are using clinical protocols in your organizations?

Thanks.

Denise R. Linder, MSN, RN
Director Patient Care Systems
BryanLGH Medical Center
402.481.8073 - phone


Comments

  • edited July 2016
    We approve protocols through the medical staff committee process. We put them in pre-printed order format. The protocol can then be initiated by a verbal order and the protocol order form signed same as a verbal order. We only use protocols that will fit into an "if this, then that" form of decision making. Used for mostly for medication regimens, e.g., insulin.

    Susan L. Cresswell, MHA, CPHQ
    Director, Quality Resources
    Providence Medford Medical Center
    1111 Crater Lake Avenue
    Medford, Oregon 97504
    (541) 732-5098
  • edited July 2016
    We follow pretty much the same process as below





    We are all angels with only one wing; we can only fly while embracing
    one another.



    Jane Zachrich, RN. MSN

    Chief Nursing Officer, VP Patient Services

    Community Memorial Hospital

    phone: 419-542-5567

    fax: 419-542-6506

    jzachrich@cmhosp.com

  • sorry, we do not perform preop or surgery at this facility. cj

    *Carol Johnston,* APRN, PMH, BC
    Director Performance Improvement
    Clifton T. Perkins Hospital Center
    8450 Dorsey Run Rd
    Jessup, MD 20794
    410-724-3188
    carol.johnston@maryland.gov





    On Wed, Oct 19, 2016 at 1:32 PM, Maureen Casey wrote:

    > Hello,
    > My preadmission testing department would like to use a protocol for which
    > preop tests to order based on patient age, comorbidities, and surgical
    > procedure. The protocol has been developed in collaboration with Surgery
    > and Anesthesia. The question is whether the protocol needs to be signed by
    > the surgeon and placed in the patient's chart. I believe the CMS regs
    > require that both be done, but would like input from the group.
    >
    > Thanks,
    >
    > Maureen Casey,MBA, RN, CPHQ
    > Director, Performance Improvement
    > Kent County Memorial Hospital
    > Warwick, RI 02886
    > ---
    > JCAHO-WATCH is a free service sponsored by DecisionHealth. JCAHO-Watch is
    > 100% independent and is in no way affiliated with the Joint Commission on
    > Accreditation of Healthcare Organizations, the trademark holder of JCAHO
    > and Joint Commission.
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    > You are currently subscribed to jcaho-watch as:carol.johnston@maryland.gov.
    > To unsubscribe send a blank email to leave-2795728-23985758.
    > 317f75ae7269c6c8fc19700539535721@lyris.ucg.com
    >

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  • We were cited for this issue during a recent survey. Even though we had an order to initiate the protocol, the TJC survey team said the protocol also had to be signed. They were adamant. We pled our case during special issue resolution, but to no avail.

    We submitted it for clarification and were rejected. During a TJC follow up survey, we asked a different surveyor and he couldn’t believe we were cited for this. He encouraged us to call the SIG. We called the SIG last week and they relented, saying we didn’t explain our process to them clearly enough.

    In the interim, I submitted a question about this to the CMS version of the SIG. Haven’t gotten a response yet.
    ------------------------------------------------------------------------------------------------------------------------------------------------
    On Wed, Oct 19, 2016 at 1:32 PM, Maureen Casey wrote:
    Hello,
    My preadmission testing department would like to use a protocol for which preop tests to order based on patient age, comorbidities, and surgical procedure. The protocol has been developed in collaboration with Surgery and Anesthesia. The question is whether the protocol needs to be signed by the surgeon and placed in the patient's chart. I believe the CMS regs require that both be done, but would like input from the group.

    Thanks,

    Maureen Casey,MBA, RN, CPHQ
    Director, Performance Improvement
    Kent County Memorial Hospital
    Warwick, RI 02886
    ---
    JCAHO-WATCH is a free service sponsored by DecisionHealth. JCAHO-Watch is 100% independent and is in no way affiliated with the Joint Commission on Accreditation of Healthcare Organizations, the trademark holder of JCAHO and Joint Commission.
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  • The law is clear.
    Everything except pneumococcal and influenza vaccines need a LIP signature, date and time

    From: Maxey, Lisa [mailto:lmaxey@wkhs.com]
    Sent: Wednesday, October 19, 2016 2:19 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols

    We were cited for this issue during a recent survey. Even though we had an order to initiate the protocol, the TJC survey team said the protocol also had to be signed. They were adamant. We pled our case during special issue resolution, but to no avail.

    We submitted it for clarification and were rejected. During a TJC follow up survey, we asked a different surveyor and he couldn’t believe we were cited for this. He encouraged us to call the SIG. We called the SIG last week and they relented, saying we didn’t explain our process to them clearly enough.

    In the interim, I submitted a question about this to the CMS version of the SIG. Haven’t gotten a response yet.
    ------------------------------------------------------------------------------------------------------------------------------------------------
    On Wed, Oct 19, 2016 at 1:32 PM, Maureen Casey wrote:
    Hello,
    My preadmission testing department would like to use a protocol for which preop tests to order based on patient age, comorbidities, and surgical procedure. The protocol has been developed in collaboration with Surgery and Anesthesia. The question is whether the protocol needs to be signed by the surgeon and placed in the patient's chart. I believe the CMS regs require that both be done, but would like input from the group.

    Thanks,

    Maureen Casey,MBA, RN, CPHQ
    Director, Performance Improvement
    Kent County Memorial Hospital
    Warwick, RI 02886
    ---
    JCAHO-WATCH is a free service sponsored by DecisionHealth. JCAHO-Watch is 100% independent and is in no way affiliated with the Joint Commission on Accreditation of Healthcare Organizations, the trademark holder of JCAHO and Joint Commission.
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    This message and attachment(s), if any, is intended for the sole use of the individual and/or entity
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  • Unless you have an order to initiate the approved protocol.

    From: Deborah Krejci [mailto:dkrejci@comhs.org]
    Sent: Wednesday, October 19, 2016 4:13 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols

    The law is clear.
    Everything except pneumococcal and influenza vaccines need a LIP signature, date and time

    From: Maxey, Lisa [mailto:lmaxey@wkhs.com]
    Sent: Wednesday, October 19, 2016 2:19 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols

    We were cited for this issue during a recent survey. Even though we had an order to initiate the protocol, the TJC survey team said the protocol also had to be signed. They were adamant. We pled our case during special issue resolution, but to no avail.

    We submitted it for clarification and were rejected. During a TJC follow up survey, we asked a different surveyor and he couldn’t believe we were cited for this. He encouraged us to call the SIG. We called the SIG last week and they relented, saying we didn’t explain our process to them clearly enough.

    In the interim, I submitted a question about this to the CMS version of the SIG. Haven’t gotten a response yet.
    ------------------------------------------------------------------------------------------------------------------------------------------------
    On Wed, Oct 19, 2016 at 1:32 PM, Maureen Casey wrote:
    Hello,
    My preadmission testing department would like to use a protocol for which preop tests to order based on patient age, comorbidities, and surgical procedure. The protocol has been developed in collaboration with Surgery and Anesthesia. The question is whether the protocol needs to be signed by the surgeon and placed in the patient's chart. I believe the CMS regs require that both be done, but would like input from the group.

    Thanks,

    Maureen Casey,MBA, RN, CPHQ
    Director, Performance Improvement
    Kent County Memorial Hospital
    Warwick, RI 02886
    ---
    JCAHO-WATCH is a free service sponsored by DecisionHealth. JCAHO-Watch is 100% independent and is in no way affiliated with the Joint Commission on Accreditation of Healthcare Organizations, the trademark holder of JCAHO and Joint Commission.
    To access the web interface, go to http://www.decisionhealth.com/jcaho-watch and enter your e-mail address. Click on the My Account tab and then the Advanced tab to set or change your password. Click on the Essentials tab and Membership Type to set the way you want to access list messages. To read messages on the web interface only, set Membership Type to “no mail.” To see the archive of past messages, click on the Messages tab and the Show More button. To view the chat forum, click on the Conference tab. To unsubscribe, click on the My Forums tab.
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    ---

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  • Even protocols must be signed off on.
    Not necessarily before initiation,(ie emergency protocols) but as soon as feasible

    From: Maxey, Lisa [mailto:lmaxey@wkhs.com]
    Sent: Wednesday, October 19, 2016 4:17 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols

    Unless you have an order to initiate the approved protocol.

    From: Deborah Krejci [mailto:dkrejci@comhs.org]
    Sent: Wednesday, October 19, 2016 4:13 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols

    The law is clear.
    Everything except pneumococcal and influenza vaccines need a LIP signature, date and time

    From: Maxey, Lisa [mailto:lmaxey@wkhs.com]
    Sent: Wednesday, October 19, 2016 2:19 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols

    We were cited for this issue during a recent survey. Even though we had an order to initiate the protocol, the TJC survey team said the protocol also had to be signed. They were adamant. We pled our case during special issue resolution, but to no avail.

    We submitted it for clarification and were rejected. During a TJC follow up survey, we asked a different surveyor and he couldn’t believe we were cited for this. He encouraged us to call the SIG. We called the SIG last week and they relented, saying we didn’t explain our process to them clearly enough.

    In the interim, I submitted a question about this to the CMS version of the SIG. Haven’t gotten a response yet.
    ------------------------------------------------------------------------------------------------------------------------------------------------
    On Wed, Oct 19, 2016 at 1:32 PM, Maureen Casey wrote:
    Hello,
    My preadmission testing department would like to use a protocol for which preop tests to order based on patient age, comorbidities, and surgical procedure. The protocol has been developed in collaboration with Surgery and Anesthesia. The question is whether the protocol needs to be signed by the surgeon and placed in the patient's chart. I believe the CMS regs require that both be done, but would like input from the group.

    Thanks,

    Maureen Casey,MBA, RN, CPHQ
    Director, Performance Improvement
    Kent County Memorial Hospital
    Warwick, RI 02886
    ---
    JCAHO-WATCH is a free service sponsored by DecisionHealth. JCAHO-Watch is 100% independent and is in no way affiliated with the Joint Commission on Accreditation of Healthcare Organizations, the trademark holder of JCAHO and Joint Commission.
    To access the web interface, go to http://www.decisionhealth.com/jcaho-watch and enter your e-mail address. Click on the My Account tab and then the Advanced tab to set or change your password. Click on the Essentials tab and Membership Type to set the way you want to access list messages. To read messages on the web interface only, set Membership Type to “no mail.” To see the archive of past messages, click on the Messages tab and the Show More button. To view the chat forum, click on the Conference tab. To unsubscribe, click on the My Forums tab.
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    ---

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    To access the web interface, go to http://www.decisionhealth.com/jcaho-watch and enter your e-mail address. Click on the My Account tab and then the Advanced tab to set or change your password. Click on the Essentials tab and Membership Type to set the way you want to access list messages. To read messages on the web interface only, set Membership Type to �no mail.� To see the archive of past messages, click on the Messages tab and the Show More button. To view the chat forum, click on the Conference tab. To unsubscribe, click on the My Forums tab.

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    ---

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    ---

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  • I have talked to CMS about this issue three times. It is not enough just to have an order that is signed that mentions the protocol. For example, the ED has a trauma protocol and it has 20 things such as tetanus, IV, monitor, etc. You can’t just have an order that says trauma protocol. The detailed orders can’t just be housed somewhere out on the system. The order for the trauma protocol would list the 20 things then be signed by the provider.



    In your example, the protocol would need to be in the chart and signed by the provider.



    In emergency situations, the protocol could be approved by MEC (and by nursing and pharmacy leadership) and the nurse can initiate the emergency protocol and then have the provider sign off the order. The patient is having chest pain radiating down his left arm and diaphoresis and is short of breath. The nurse puts him on the monitor, puts in an IV, calls for an EKG etc. The nurse writes down the order and the ED physician or provider signs it off.



    CMS has standing orders and protocols in 4 different tags numbers: 405, 406, 450, and 457. Tag 457 is the primary one and it is the medical record section. Much of what is in 457 came out of tag number 405.



    Sue Dill Calloway RN Esq.

    AD, BA, BSN, MSN, JD

    CPHRM, CCMSCP

    President

    Patient Safety and Healthcare Consulting and Education

    5447 Fawnbrook Lane

    Dublin, Ohio 43017



    614 791-1468

    sdill1@columbus.rr.com



    From: Maxey, Lisa [mailto:lmaxey@wkhs.com]
    Sent: Wednesday, October 19, 2016 3:19 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols



    We were cited for this issue during a recent survey. Even though we had an order to initiate the protocol, the TJC survey team said the protocol also had to be signed. They were adamant. We pled our case during special issue resolution, but to no avail.



    We submitted it for clarification and were rejected. During a TJC follow up survey, we asked a different surveyor and he couldn’t believe we were cited for this. He encouraged us to call the SIG. We called the SIG last week and they relented, saying we didn’t explain our process to them clearly enough.



    In the interim, I submitted a question about this to the CMS version of the SIG. Haven’t gotten a response yet.


    ------------------------------------------------------------------------------------------------------------------------------------------------

    On Wed, Oct 19, 2016 at 1:32 PM, Maureen Casey wrote:

    Hello,
    My preadmission testing department would like to use a protocol for which preop tests to order based on patient age, comorbidities, and surgical procedure. The protocol has been developed in collaboration with Surgery and Anesthesia. The question is whether the protocol needs to be signed by the surgeon and placed in the patient's chart. I believe the CMS regs require that both be done, but would like input from the group.

    Thanks,

    Maureen Casey,MBA, RN, CPHQ
    Director, Performance Improvement
    Kent County Memorial Hospital
    Warwick, RI 02886
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  • We have an order and a copy of said protocol is on the chart.

    From: Sue Dill [mailto:sdill1@columbus.rr.com]
    Sent: Wednesday, October 19, 2016 4:24 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols

    I have talked to CMS about this issue three times. It is not enough just to have an order that is signed that mentions the protocol. For example, the ED has a trauma protocol and it has 20 things such as tetanus, IV, monitor, etc. You can’t just have an order that says trauma protocol. The detailed orders can’t just be housed somewhere out on the system. The order for the trauma protocol would list the 20 things then be signed by the provider.

    In your example, the protocol would need to be in the chart and signed by the provider.

    In emergency situations, the protocol could be approved by MEC (and by nursing and pharmacy leadership) and the nurse can initiate the emergency protocol and then have the provider sign off the order. The patient is having chest pain radiating down his left arm and diaphoresis and is short of breath. The nurse puts him on the monitor, puts in an IV, calls for an EKG etc. The nurse writes down the order and the ED physician or provider signs it off.

    CMS has standing orders and protocols in 4 different tags numbers: 405, 406, 450, and 457. Tag 457 is the primary one and it is the medical record section. Much of what is in 457 came out of tag number 405.

    Sue Dill Calloway RN Esq.
    AD, BA, BSN, MSN, JD
    CPHRM, CCMSCP
    President
    Patient Safety and Healthcare Consulting and Education
    5447 Fawnbrook Lane
    Dublin, Ohio 43017

    614 791-1468
    sdill1@columbus.rr.com

    From: Maxey, Lisa [mailto:lmaxey@wkhs.com]
    Sent: Wednesday, October 19, 2016 3:19 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols

    We were cited for this issue during a recent survey. Even though we had an order to initiate the protocol, the TJC survey team said the protocol also had to be signed. They were adamant. We pled our case during special issue resolution, but to no avail.

    We submitted it for clarification and were rejected. During a TJC follow up survey, we asked a different surveyor and he couldn’t believe we were cited for this. He encouraged us to call the SIG. We called the SIG last week and they relented, saying we didn’t explain our process to them clearly enough.

    In the interim, I submitted a question about this to the CMS version of the SIG. Haven’t gotten a response yet.
    ------------------------------------------------------------------------------------------------------------------------------------------------
    On Wed, Oct 19, 2016 at 1:32 PM, Maureen Casey wrote:
    Hello,
    My preadmission testing department would like to use a protocol for which preop tests to order based on patient age, comorbidities, and surgical procedure. The protocol has been developed in collaboration with Surgery and Anesthesia. The question is whether the protocol needs to be signed by the surgeon and placed in the patient's chart. I believe the CMS regs require that both be done, but would like input from the group.

    Thanks,

    Maureen Casey,MBA, RN, CPHQ
    Director, Performance Improvement
    Kent County Memorial Hospital
    Warwick, RI 02886
    ---
    JCAHO-WATCH is a free service sponsored by DecisionHealth. JCAHO-Watch is 100% independent and is in no way affiliated with the Joint Commission on Accreditation of Healthcare Organizations, the trademark holder of JCAHO and Joint Commission.
    To access the web interface, go to http://www.decisionhealth.com/jcaho-watch and enter your e-mail address. Click on the My Account tab and then the Advanced tab to set or change your password. Click on the Essentials tab and Membership Type to set the way you want to access list messages. To read messages on the web interface only, set Membership Type to “no mail.” To see the archive of past messages, click on the Messages tab and the Show More button. To view the chat forum, click on the Conference tab. To unsubscribe, click on the My Forums tab.
    You are currently subscribed to jcaho-watch as:carol.johnston@maryland.gov. To unsubscribe send a blank email to leave-2795728-23985758.317f75ae7269c6c8fc19700539535721@lyris.ucg.com


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    ---

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  • Sue et al, 
    Are you saying that the entire protocol order needs to live in the chart? Or just the order to initiate and the subsequent acted on orders? 
    For example: 
    - Can you have an order to get a CT of the head with contrast per protocol signed by the provider in the chart

    - The appropriately approved protocol decision tree on how staff knows how much to contrast to give (based on age, kidney function etc) outside of the record (e.g. another software system hyperlinked, or stored in the organization)

    - Then the dose of contrast administered (signed per protocol) in the record


    The only thing that would not be in the medical record is the dosing decision tree; however you would be able to show what protocol you used at the time of administration. Also, on ROI you would be able to see a protocol was ordered and what was administered? I use the radiology example because this seems to be a recent area of focus. 
    Let me know your thoughts- has anyone been cited and or successfully utilized this strategy? It makes the annual review more plausible. 
    Thank you, 
    Mitch Gesinger RN, MSN Director of Accreditation

    On Thursday, October 20, 2016 8:25 AM, "Maxey, Lisa" wrote:


    We have an order and a copy of said protocol is on the chart.   From: Sue Dill [mailto:sdill1@columbus.rr.com]
    Sent: Wednesday, October 19, 2016 4:24 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols   I have talked to CMS about this issue three times. It is not enough just to have an order that is signed that mentions the protocol. For example, the ED has a trauma protocol and it has 20 things such as tetanus, IV, monitor, etc. You can’t just have an order that says trauma protocol. The  detailed orders can’t just be housed somewhere out on the system. The order for the trauma protocol would list the 20 things then be signed by the provider.   In your example, the protocol would need to be in the chart and signed by the provider.   In emergency situations, the protocol could be approved by MEC (and by nursing and pharmacy leadership) and the nurse can initiate the emergency protocol and then have the provider sign off the order. The patient is having chest pain radiating down his left arm and diaphoresis and is short of breath. The nurse puts him on the monitor, puts in an IV, calls for an EKG etc. The nurse writes down the order and the ED physician or provider signs it off.   CMS has standing orders and protocols in 4 different tags numbers: 405, 406, 450, and 457. Tag 457 is the primary one and it is the medical record section. Much of what is in 457 came out of tag number 405.   Sue Dill Calloway RN Esq. AD, BA, BSN, MSN, JD CPHRM, CCMSCP President Patient Safety and Healthcare Consulting and Education 5447 Fawnbrook Lane Dublin, Ohio 43017   614 791-1468 sdill1@columbus.rr.com   From: Maxey, Lisa [mailto:lmaxey@wkhs.com]
    Sent: Wednesday, October 19, 2016 3:19 PM
    To: Multiple recipients of list JCAHO-WATCH
    Subject: RE: [jcaho-watch] Protocols   We were cited for this issue during a recent survey.  Even though we had an order to initiate the protocol, the TJC survey team said the protocol also had to be signed.  They were adamant. We pled our case during special issue resolution, but to no avail.   We submitted it for clarification and were rejected.  During a TJC follow up survey, we asked a different surveyor and he couldn’t believe we were cited for this.  He encouraged us to call the SIG.  We called the SIG last week and they relented, saying we didn’t explain our process to them clearly enough.   In the interim, I submitted a question about this to the CMS version of the SIG.  Haven’t gotten a response yet.
    ------------------------------------------------------------------------------------------------------------------------------------------------ On Wed, Oct 19, 2016 at 1:32 PM, Maureen Casey wrote: Hello,
    My preadmission testing department would like to use a protocol for which preop tests to order based on patient age, comorbidities, and surgical procedure.  The protocol has been developed in collaboration with Surgery and Anesthesia.  The question is whether the protocol needs to be signed by the surgeon and placed in the patient's chart.  I believe the CMS regs require that both be done, but would like input from the group.

    Thanks,

    Maureen Casey,MBA, RN, CPHQ
    Director, Performance Improvement
    Kent County Memorial Hospital
    Warwick, RI 02886
    ---
    JCAHO-WATCH is a free service sponsored by DecisionHealth. JCAHO-Watch is 100% independent and is in no way affiliated with the Joint Commission on Accreditation of Healthcare Organizations, the trademark holder of JCAHO and Joint Commission.
    To access the web interface, go to http://www.decisionhealth.com/jcaho-watch and enter your e-mail address. Click on the My Account tab and then the Advanced tab to set or change your password. Click on the Essentials tab and Membership Type to set the way you want to access list messages. To read messages on the web interface only, set Membership Type to “no mail.”  To see the archive of past messages, click on the Messages tab and the Show More button. To view the chat forum, click on the Conference tab. To unsubscribe, click on the My Forums tab.
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