{"id":3965,"date":"2021-11-03T15:01:39","date_gmt":"2021-11-03T15:01:39","guid":{"rendered":"https:\/\/thedacare.org\/provider-portal\/?p=3965"},"modified":"2021-11-03T15:01:39","modified_gmt":"2021-11-03T15:01:39","slug":"upcoming-regulatory-activities","status":"publish","type":"post","link":"https:\/\/thedacare.org\/provider-portal\/2021\/11\/03\/upcoming-regulatory-activities\/","title":{"rendered":"Upcoming Regulatory Activities"},"content":{"rendered":"\n<p>ThedaCare Regional Medical Centers \u2013Neenah (December) and Appleton (end of January 2022) are in the window for their triennial accreditation surveys.&nbsp; ThedaCare Medical Center Shawano is due by May 2022.<\/p>\n\n\n\n<p>During the surveys, the surveyors will be interacting with staff, providers and patients.&nbsp; A tracer methodology is utilized by the surveyors which traces patients through all points of their stay (ED, OR, PACU, ICU, Surgical Services to discharge).&nbsp; The surveyors are looking at hand-overs between departments as well as hand-over\/communication between team members.<\/p>\n\n\n\n<p>Other areas of focus for surveyors include:<\/p>\n\n\n\n<ol class=\"wp-block-list\" type=\"1\"><li>Placement of Orders in the EMR.&nbsp; Providers <strong>should not<\/strong> be giving orders via secure chat.&nbsp;<\/li><li>Medication Orders in general.&nbsp; Two areas of focus are:<ol start=\"1\" type=\"a\"><li>Therapeutic Duplication- multiple pain medications without specific directions. <em>Ex. 2 medications ordered for \u201csevere\u201d pain, but no instruction on which one to use first. State of WI licensing for nurses does not allow them to pick one over the other.&nbsp; The provider must indicate!<\/em>&nbsp;<\/li><li>PRN medications without an indication listed.&nbsp; We have worked hard to incorporate in the order sets indications for the most commonly ordered PRN medications.&nbsp; Even if medication only has one indication, it must be listed in the order.&nbsp; <em>Ex. Medications for constipation need to have indication listed, and if one or more is ordered would need instructions.&nbsp; For example, give fleets enema for constipation unresolved form Bisacodyl Suppository.<\/em><\/li><\/ol><\/li><li>Timing of History and Physicals, Operative Reports, Procedural Notes and Discharge Summaries.&nbsp;<\/li><li>Informed Consent process \u2013 prior to any procedure, surgery or blood transfusions.&nbsp;<\/li><li>Advanced Care Planning and presence of Advanced Directives.<\/li><li>Provider Consultations being conducted within timeframes outlined in policy.&nbsp;<\/li><\/ol>\n\n\n\n<p>If you have any questions regarding the upcoming surveys, please reach out to the unit managers for clarification or email <a href=\"mailto:michelle.bastian@thedacare.org\">michelle.bastian@thedacare.org<\/a><\/p>\n\n\n\n<p>Thank you<\/p>\n\n\n\n<p>Mbonu Ikezuagu, MD, FACP, CPE<\/p>\n\n\n\n<p>Chief Quality Officer, ThedaCare<\/p>\n\n\n\n<p><a href=\"mailto:Mbonu.ikezuagu@thedacare.org\">Mbonu.ikezuagu@thedacare.org<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>ThedaCare Regional Medical Centers \u2013Neenah (December) and Appleton (end of January 2022) are in the window for their triennial accreditation&#8230;<\/p>\n","protected":false},"author":98,"featured_media":3909,"comment_status":"closed","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[8],"tags":[],"class_list":["post-3965","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-quality"],"jetpack_featured_media_url":"https:\/\/thedacare.org\/provider-portal\/wp-content\/uploads\/sites\/3\/2021\/10\/thedacare-logo.jpg","jetpack_sharing_enabled":true,"medium_card_thumbnail":"<img width=\"320\" height=\"180\" src=\"https:\/\/thedacare.org\/provider-portal\/wp-content\/uploads\/sites\/3\/2021\/10\/thedacare-logo.jpg?w=320&amp;h=180&amp;crop=1\" class=\"attachment-medium-card size-medium-card wp-post-image\" alt=\"\" decoding=\"async\" loading=\"lazy\" \/>","post_categories":[{"term_id":8,"name":"Quality","slug":"quality","term_group":0,"term_taxonomy_id":8,"taxonomy":"category","description":"","parent":0,"count":3,"filter":"raw","cat_ID":8,"category_count":3,"category_description":"","cat_name":"Quality","category_nicename":"quality","category_parent":0}],"_links":{"self":[{"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/posts\/3965","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/users\/98"}],"replies":[{"embeddable":true,"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/comments?post=3965"}],"version-history":[{"count":1,"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/posts\/3965\/revisions"}],"predecessor-version":[{"id":3966,"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/posts\/3965\/revisions\/3966"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/media\/3909"}],"wp:attachment":[{"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/media?parent=3965"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/categories?post=3965"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/thedacare.org\/provider-portal\/wp-json\/wp\/v2\/tags?post=3965"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}