© joint commission resources amp with fsa step-by-step guide to implementing amp in your...
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AMP with FSA
Step-by-Step Guide
to Implementing AMP in your Organization
Step 1-Developing Teams
Jeanette Snell, RN, MSN
Clinical Advisor
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Objectives:Identify individuals requiring AMP access.
Identify user roles in your organization.
Complete user assignments.
Implement AMP across your organization.
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Understanding User Roles
Staff Member (Individual)
Staff Member (Team Coordinator)
Site Manager
Program Administrator
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Staff Member Role
– First tier of access– Able to view all EP’s and documentation– Able to add/edit documentation for
assigned EP’s only– Enter an individual score– Low volume of EP’s assigned– Multiple staff members per each EP
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Staff Member Role-Team Coordinator
– Staff Member level of access – Able to view all EP’s and documentation– Able to add/edit documentation for assigned
EP’s only– Enter a preliminary score– Typically assigned an entire chapter– Ability to assign tasks– One team coordinator allowed per EP
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Site Manager Role
– Higher level of access– View and score all EP’s (No assignment)– Responsible for entering the final score– Scoring
• Score each EP independently• Score EP’s in bulk• Accept Team Coordinators’ scores
– No Administrative functionality
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Program Administrator Role
– Highest level of access– View and score all EP’s (No assignment)– Responsible for entering the final score– Scoring
• Score each EP independently• Score EP’s in bulk• Accept Team Coordinators’ scores
– Assign users/access– License maintenance– Site Setup and Password/Email setup
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Collaboration among User Roles
TeamCoordinator
TeamCoordinator
StaffMember
StaffMember
StaffMember
StaffMember
StaffMember
SiteManager
HR Chapter
HR.01.01.01 EP 2
HR.01.02.07 EP 1,2,5
HR.01.01.01 EP 2 MM.07.01.03
EP 1-6
MM Chapter
MM.07.01.03 EP 1-6
SiteManager
Program Administrator
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Accreditation Manager Plus
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Role Pros Cons
Staff Member -Deploy responsibility-Allows input from many individuals in organization (Individual scores)-Accountability
-Additional level of scoring-Additional assignments
Team Coordinator -Chapter responsibility-Allows one individual to review individual scores-Enter preliminary score-Convert preliminary score to final score
-Additional level of scoring
Site Manager -May enter final score-Assist program administrator/team coordinator-Useful for systems
-Additional level if individual facility-Everyone can document on all EP’s when only this level is used(can overwrite each others data)
Program Administrator Required
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Team Development
Complete Team Development Tool
(Role, Title, Name, Email)
The following slides offer suggestions for team
members arranged by Chapter of the CAMH
***Please note that Joint Commission does not require use of all AMP roles
or team structure as proposed in this toolkit.
These are ideas to assist you in compliance efforts.***
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Team Development Tool
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Assigning UsersAccreditation Participation Requirements
Vital to accreditation
Tend to be clear cut requirements
Noncompliance is very evident
Typically assigned to JC liaison or program
administrator.
Leadership involvement if noncompliance
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Accreditation Culture
What is the culture of your organization? What is the size of your organization? Who is responsible for accreditation? Who is responsible for compliance? Who is responsible for scoring? What is the level of comfort? How will you utilize the functionality in
AMP?
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Assigning UsersEnvironment of Care
Proposed team members include:– Facilities Director/staff– Security Director/staff– Lab Director/staff– Pharmacy Director/staff– Biomedical Engineering– Peri-operative Director/staff– End users
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Assigning UsersEmergency Management
Proposed team members include:– Emergency Management leader– Administration– Medical Staff– Emergency Dept Director/ Staff– Infection Prevention and Control Coordinator– Facilities/Safety/Security Director– Utilities Director– Nutritional Services Director– Lab Director
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Assigning Users Human Resources
Human Resources Director/staff
Employee Educator
Nurse Educator
Director of Volunteers
Employee health nurse
Those responsible for competency assessment
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Assigning UsersInfection Prevention
Possible team members include:– Infection Prevention– Microbiologist– Nurse Managers/Nursing Staff– Facilities/Engineering– Peri-operative Services– Central Supply/Sterile Processing– Employee Health Nurse– Environmental Services– Department Managers
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Assigning UsersInformation Management/Record of Care
Possible team members include:– CIO– HIM Director– Performance Improvement Staff– Medical Staff Representative/CMO– Nursing Representative/CNO
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Assigning UsersLeadership
Conflict of Interest
Communication
Culture of Safety
Conflict Resolution
Contracts
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Assigning UsersLife safety
Possible team members:– Facilities Director– Safety/Security Director– Engineering– Department managers
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Assigning UsersMedication Management
Possible team members:– Pharmacy Director/staff– Nurse managers/staff– Medical Staff representative– P&T Chair– Director of Outpatient Services/clinic staff– Radiology Director/staff
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Assigning UsersMedical Staff
Possible team members:– CMO– Medical Staff Office representatives– Credentials Chair– Medical Staff Leadership
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Assigning UsersNPSG
Possible team members include:– Nurse Managers/staff (include MS/ICU/ED)– Lab Director/Blood bank staff– Anesthesia personnel– Peri-operative Services Director– Pharmacy Director– Radiology Staff– Outpatient staff
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Assigning Users Nursing
Consider the following:– Education and Experience– Access to policies and procedures– Developing standards of care– Implementing standards of care– Implement staffing plan– Oversight for all nursing care
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Assigning Users Patient Rights and Organizational Ethics
Potential Team members include:– Administrative representative– Legal Counsel/Risk Manager– Patient Relations– Patient Advocate– Social Worker– Nursing representatives– Outpatient representative
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Assigning UsersProvision of Care
Possible team members:– CNO– Nursing Administration– Staff Nurses– Pharmacy Director– Anesthesia Personnel– Behavioral Health (if applicable)– Multidisciplinary Team Members
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Assigning UsersPerformance Improvement
Possible team members might include:– Quality Improvement personnel– Department Directors– Medical Staff Leaders– Administration
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Assigning UsersTissue
Peri-operative Services Director
Wound Center Director
Lab Director
Tissue Officer (if required by law)
Tissue Management personnel
Materials Management personnel
Nursing representatives
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Assigning Users Waived Testing
Potential team members include:– Lab Director or designee– Staff Educator/Competency
Assessment– Nurse Managers/staff– Outpatient Services
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Quick Review
Staff member*** View/Edit -My assignments (Individual score) View all EP’s
Team Coordinator*** View/Edit -My assignments (Preliminary score) Review individual scores/assign preliminary score
Site Manager/Program Administrator Can document on all EP’s (no assignment) Score each EP/score bulk/accept preliminary scores as final
***Can only document on EP’s in their assignment
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Questions?
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Customer Support
Technical Issues
(Customer Support)
Call: 888-527-9255
Email: [email protected]
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