#5 p andpdevelopmentaccreditationclarkbash

Comprehensive Contact The Faculty
Policy & Procedure
Manual Rebecca Clark-Bash
Development: R. EEGEP T., CNIM, CLTM, F.ASNM
Foundations for
IONM Lab Knowledge Plus, Inc
Accreditation: P.O. Box 356
Joint Commission Lincolnshire, Il 60069
ABRET LAB-NIOM ABNMP
Phone: 815.341.0791
E-mail: opcal@aol.com

REBECCA J. CLARK-BASH, R. EEGEP T, CNIM, CLTM,F.ASNM SLIDE 2

Disclosure & Attestation Disclaimer
• Rebecca Clark-Bash is an • Medical policy and policy
electroneurodiagnostic
educator. specific to the monitoring
• As such, she receives team may vary by:
payment for educational & – State
consulting services. – Practitioner (MD, RN, CNIM)
• Currently there are no – Procedure.
royalty bearing
relationships between • This presentation should not
Rebecca, her spouse and a replace legal consult
corporate entity outside of
these educational &
program building services.

Policy & Procedure:
Session Content Core Content
• IONM Policy & Procedure Manual Core Content A well-written, comprehensive Policy &
• IONM Lab Accreditation & P & P Requirements: Procedure Manual is the laboratory's or IONM
– ABRET LAB-NIOM programs single most effective management tool
– ABNMP - and its most neglected one.
– Joint Commission

Policy & Procedure: Policy & Procedure:
Core Content Core Content
• Create an Action Plan-Core Content
Done the right way, written policies and procedures: – State its purpose or intent
– Explain how it is related to the overall management system
• Promote teamwork and improve human relations. – Clarify its scope
• Promote clarity, consistency, and continuity of – Provide any definitions that will help clarify the document
– Detail any controls that must be applied
performance and management decisions. – Explain how authority has been divided and distributed
• Establish approved, measurable standards of – List the responsibilities and tasks that should be performed
performance for competent practice – Identify who is responsible for performing the task
– Describe the task

• IMPROVE PATIENT CARE –
–
Specify how and when the tasks should be performed
List any materials and supplies that must be used
– List any tools and equipment that must be used
– Review the document properties and control

Document Control Content

Contact List

Glossary

Document Recommendations Document Recommendations
• Function • Function
• A comprehensive Employee Manual protects your
• An Employee Manual is a organization.
summary of your company´s • An Employee Manual describes the behavior that is
policies and procedures expected of your company´s employees.
regarding staff. • It also describes unacceptable behavior, such as
harassment or use of company equipment for personal
• It contains information business, and outlines the consequences of such
about, expected behavior, behavior.
benefits, and policies that • An Employee Manual addresses issues before they
become problems.
affect employment.

Other Documents Document Control

Create an Employee Manual Create an Employee Manual

Document Recommendations Document Contents
• Joint Commission Resources Consultant:
IONM Employee Manual – “Avoid extensive detail”

Policy & Procedure:
Document Contents Policy & Procedure:
• Hospital Compliance Officer:
Document Contents
– “Every detail at point-of-care must be defined” What is our MISSION?
Which directive is most consistent
with this mission?

Document Contents Document Recommendations
Rogue • Function
– Serves to establish the method to insure the patient
Monitorist receives the highest level of expertise and clinical
expertise from the healthcare team
– The method should be derived from evidence-based
No one should information
be delivering – Provides critical information regarding a path for
patient care decision making when standard
service protocols cannot be followed.

“Their Way”

Contents – First Rule – Golden Rule Contents – Second Rule

Have a Policy & Procedure Make certain all employees
Manual. own a copy & follow the
“I think my copy is
policies.
on my desk
somewhere.”

Contents – Second Rule Contents – Third Rule

Have a POLICY to insure When policies are not or
employees know the cannot be followed,
POLICY document the reason in
the case record.

• Contents – Basic Core Policies: Informed Consent
Pre-Op Holding Area – First in the late 1950's.
– Based in the tort of battery, under which liability is
• Surgeons order for monitoring imposed for unpermitted touching.
– Archive & retrieval procedure – Though battery claims occasionally occur when
treatment is provided without consent, most
consent cases generally center around whether the
consent was "informed", i.e., whether the patient
was given sufficient information to make a
decision regarding his or her body and health care.
– Because informed consent claims, unlike battery
claims, are based in negligence, they generally are
covered by liability insurance.

• Contents – Basic Core Policies: • Contents – Basic Core Policies: Informed Consent
– Informed Consent • In the communications process, the individual
• This communications process is both an ethical providing the monitoring , should disclose and
discuss with the patient:
obligation and a legal requirement spelled out in – The nature and purpose of intraoperative monitoring
statutes and case law in all 50 states – The risks and benefits of monitoring
– Alternatives (regardless of their cost or the extent to
which the treatment options are covered by health
insurance);
– The risks and benefits of the alternative; and
– The risks and benefits of not receiving or undergoing a
treatment or procedure.

Contents – Basic Core Policies: Informed Consent Who may obtain the patient’s informed
• Who may obtain the patient’s informed consent;
• Which procedures require informed consent;
consent?
• The circumstances under which surgery is considered an emergency, and may
be undertaken without an informed consent;
• The circumstances when a patient’s representative, rather than the patient, Liability for not telling the
may give informed consent for a surgery;
• The content of the informed consent form and instructions for completing it; patient all the risks of the
• The process used to obtain informed consent, including how informed surgery, and for not getting
consent is to be documented in the medical record;
• Mechanisms that ensure that the informed consent form is properly executed
and is in the patient’s medical record prior to the surgery (except in the case
truly informed consent, rests
of emergency surgery); and with the physician.
• If the informed consent process and informed consent form are obtained
outside the hospital, how the properly executed informed consent form is
incorporated into the patient’s medical record prior to the surgery.
SUPREME COURT OF NEBRASKA, 1997

Who may obtain the patient’s informed • Patient Informed Consent
consent?
Sample Policy …..Except in emergencies
The MONITORIST is not responsible for
providing the information necessary for
informed consent to the patient or
health care proxy agent. The
MONITORISTS role is both as a
witness and as a patient advocate.
(borrowed for NY State Nursing position statement)

• Contents – Basic Core Policies: Documentation
• What is mandated to be documented? • What is documented from the case?
• Frequency of documentation? – Blood Pressure? Where monitored?
– By the time events turn south, it is too late to – MAP?
retract the documentation footpath. – Core Temp? Where monitored?
• What is the required format? – Cerebral Oximetry, TCD..other monitoring not
– Iso= 1 managed by the IONM team
– Iso= 1 % MAC – Urine output?
– Gas = > 1 MAC – Blood loss?

• Contents – Basic Core • Procedure Notes
Policies: Documentation – To document or not to document?
• UNITS!!!! – Standardize comments
– Iso: 1 • Sc. In at L5, LR RSST Ndata
– Is that a MAC or a %
– Is that end tidal
concentration?


DOCUMENTATION DOCUMENTATION
• Chat Windows • DOCUMENT
– Is the Chat window saved? – Complications
– What is the protocol for action? – Challenges
– Are vital case details entered in the chat? • Internet down
• Internet up
10:03 I told him AGAIN!!!!
10:05 We golfing later?
10:07 You there????

• Where is the DATA??? DOCUMENTATION
• Data Archive
8:30 Record I – Frequency
8:32 Record II – Backup
– Paper documentation – Archive & Link

8:57 Record III


DOCUMENTATION DOCUMENTATION
• Initial and date edits to case record.
Never edit case
records after the
end of the case.

Hand Off Policy
DOCUMENTATION
• What is
• Surgeon Communication communicated?
• Document everything said to the surgeon and • What is documented?
the replyresponse
• “Surgeon informed…surgeon acknowledged.”

• Time Out Policy • Surgeon Communication
• Neurophysiology – Standardize method among
staff
Time Out – I lost my:
• P37
• Cortical
• Subcortical
• Brainstem
• MEPs
• And my favorite…

METHOD
• Surgeon Communication • Site method reference
– I lost my uppers
• ACNS Guidelines
• ASNM Position Statements
• Peer reviewed lit.
– Pubmed.org

Calibration Calibration
• Amplifier • Head Phones & Inserts
• Method • Method
• Frequency • Frequency
• Archived Record • Archived Record
• Hippa Documentation • Hippa Documentation

Calibration
• Chassis Leakage • Format
• Method
• Frequency
• Archived Record
• Hippa Documentation

• Updates • Staff Orientation
– Reviewed on a regular basis and documented • Policy for ANNUAL
– Always when a new procedure is added to service review of competency to
examine staff knowledge
of P & P

• Staffing Model Joint Commission
– Joint Commission The primary mission is to continuously improve the
– ABRET LAB-NIOM safety and quality of care provided to the public
– ABNMP through the provision of healthcare accreditation
and related services.

Simply,
“Create a Culture of Safety”

Joint Commission HIPPA
• Competency management
• Health Insurance Privacy &
• Assessments performed by a qualified individual
Portability Act.
• Applies to ALL staff
• Insure your staff is trained
• FT & PT Employees
YEARLY
• CONTRACTED STAFF!
• Document this training
• Volunteers!
• Document this competency.

Types of Accreditation Requirements For Accreditation
ABRET IONM Lab Accreditation www.abret.org
• Physician “Supervisor”
– Remote Real-Time Access of M.D. or D.O.
– Medical Specialty not specified
73 Labs Three Tiered Model-Components:
• Monitoring Staff Currently
Accredited • Technical
– Provided direct care to patient in surgery • Professional
• Medical

Requirements For Accreditation Requirements For Accreditation
Three Tiered Model- Technical Components: Three Tiered Model- Professional Component:
• Supervision of a CNIM credentialed technologist may be by a • Must be provided by an intra-operative neurophysiologist with
professional intra-operativeneurophysiologist either on-site, or extensive experience in IONM at least to the level required for
via a real-time on-line connection. DABNM certification.
•Technologists not practicing under the personal supervision of • Non-physician intra-operative neurophysiologists must be
an intra-operative neurophysiologist require the CNIM certified by the ABNM.
credential and may provide only waveform descriptions to the • Physician intra-operative neurophysiologists must be certified
surgeon. by the ABNM, ABEM, ABCN, or hold the added qualification in
clinical neurophysiology of the ABPN

Requirements For Accreditation Requirements For Accreditation
Three Tiered Model - Medical Component:
• Must be provided by a physician intra-operative
neurophysiologist.
•This physician must be licensed in the state in which the
surgery is taking place, and the degree of involvement is to be
determined for each case according to the skills of the team and
surgeon as well as the type of case, modalities monitored and
local and state regulations.
Currently No Accredited
Programs

MISSION IMPOSSIBLE?

QUESTIONS?

#5 p andpdevelopmentaccreditationclarkbash

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