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2 Welcome! Agenda Advanced Practice OverviewBack to Agenda Agenda Advanced Practice Overview Professionalism and Collaborations Credentialing and Privileging Tennessee Guidelines for Practice Prescribing in Tennessse Vanderbilt Guidelines for Practice National Guidelines for Practice FPPE/OPPE Orientation Packet and Checklist Office of Advanced Practice Virtual Tour I will be going over overview and we will introduce other speakers to you throughout the day

3 Advanced Practice OverviewBack to Agenda Advanced Practice Overview

4 History 2005: less than 100 APRNs at VanderbiltOffice of Advanced Practice began as virtual center within Vanderbilt School of Nursing Numbers continue to expand (850+) NP/CNS: ~600 CRNAs: ~160 CNMs: ~45 CNS: ~20 PAs: ~37

5 History Vanderbilt one of the largest NP populationsAPRNs & PAs comprise 1/3 of Vanderbilt providers. The MD to APP ratio is 2:1 Evolved role reflects: Privileged providers Appropriate scope of practice Collaborative practice model Quantifiable practice outcomes Talk about quantifiable practice outcomes: LOS studies, pediatric sedation work, models of practice, transplant database, inpatient metrics, clinic APPs learning and administering new treatments (pain, gen surg)

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7 Magnet Hospital “ . . person, place, object, or situation that exert attraction” Commitment, quality, & excellence in nursing Awarded by American Nurses Credentialing Center (ANCC) 6% of US hospitals designated

8 Professional Practice ModelEvidence based practice Quality, safety, service Professionalism and Leadership Integrated Technology Professionalism…speak to relationships and representing yourself; respecting your team; working collaboratively Leadership: providing more opportunities through work groups, committees, leadership tracts. Integrated Tech: EMR, IMPAX, Mobile Apps, Data Collection, Data Warehouse

9 Essential Model ComponentsTransformational Leadership Structural Empowerment Exemplary Professional Practice New Knowledge, Innovations & Improvements Outcomes Transformational Leadership: Adaptive leadership is referred to as 'transformational'; under it, environments of shared responsibilities that influence new ways of knowing are created. Transformational leadership motivates followers by appealing to higher ideas and moral values, where the leader has a deep set of internal values and ideas. This leads to followers acting to sustain the greater good, rather than their own interests, and supportive environments where responsibility is shared Structural Empowerment: involved in shared governance and decision making structures and processes to establish standards of practice and address opportunities for improvement. Nurse leaders serve on decision making bodies that address excellence in patient care and the safe, efficient, and effective operation of the organization. The flow of information and decision-making is multidirectional among profession nurses at the bedside, leadership, interprofessional teams, and the chief nursing officer Exemplary Professional Practice: Grounded in collaboration…evidenced by effective and efficient care services, interprofessional collaboration, and high-quality patient outcomes. Partner with patients, families, support systems, and interprofessional teams to positively impact patient care and outcomes. Interprofessional team members include but are not limited to personnel from medicine, pharmacy, nutrition, rehabilitation, social work, psychology, and other professions that collaborate to ensure a comprehensive plan of care. Collegial working relationships within and among the disciplines are valued and promoted by the organization’s leadership and its employees. The achievement of exemplary professional practice is grounded in a culture of safety, quality monitoring, and quality improvement. New Knowledge/innovations: Processes such as LEAN can be applied to think of more efficient ways to get patients throughout the continuum of care. Use GI Lap as example…led by APN Outcomes: T2, Urology (dec LOS, pathways), MICU

10 Shared Governance Model“A commitment to others to have an active voice and participation in improving practice in collaboration leaders.” Supports Principles of: Decentralized decision making, Shared accountability, Partnerships to deliver. APPs and leader collaboration

11 Advanced Practice CommitteesAdvanced Practice Council – Meets quarterly Advanced Practice Standards Professional Development/Grand Rounds AP Leadership Board INVITED TO PARTICIPATE!!! Committees are open; Boards are by invitation APN Clinical Grand Rounds – NPs demanding ground rounds, may want to consider speaking when develop expertise. Trauma Services: T1 – ICU; T2 – Teaching Unit with Residents; T3 NP service, post stepdown to discharge

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13 Professionalism, Collaboration & TeamworkBack to Agenda Professionalism, Collaboration & Teamwork

14 Building Relationships: NursingInvest in development Devote equal energy/time CREDO behaviors (Orientation Handbook p.5) Service is highest priority Communicate effectively Professional self-conduct Committed to my colleagues Maintain self-awareness Many times divert energies to developing relationships with physician colleagues. Treat them with respect. When NP loses cool with RN or speak disrespectfully, then that is reported. Please embrace professionalism. We understand your work, pressures associated with it. Example: Busy service, put in feeding tube. Returns in 2 hours and finds no feeding tube. Why? RN – “I don’t know how”. NP – “What do you mean you don’t know how?” New RN now in tears. Keep your antenna up! Lead by example….use giving bath as example (Laurie) Some nurses on the inpatient side will want you to “prove” yourself. Just be consistent and professional…you will gain their respect and trust much easier than forcing it.

15 Building Relationships: PhysicianPromote trust & credibility Integrated into care Continuous presence Increase knowledge & expertise Look at relationships you have with attendings. Once you build up trust and credibility with physicians you are more integrated due to continuity – consistent physical and emotional presence. More integrated than residents who rotate through. Have great opportunity to build up content of cutting edge knowledge. Most APRNs will find themselves orienting and supporting house staff. See this as a opportunity to develop relationships with future attendings.

16 Collaboration “. . joint & cooperative, integrates individual perspectives & expertise of team members” (Resnick & Bonner, 2003, p. 344) Enhances empowerment Increases job effectiveness & satisfaction Associated with improvements in: Patient outcomes Healthcare costs Decision making Look at relationships you have with attendings. Once you build up trust and credibility with physicians you are more integrated due to continuity – consistent physical and emotional presence. More integrated than residents who rotate through. Have great opportunity to build up content of cutting edge knowledge. Most APRNs will find themselves orienting and supporting house staff. See this as a opportunity to develop relationships with future attendings. Working together leads to collaborations in new ways of practice, research, and better outcomes. You will be invited to work groups because you work well with others and contribute in a team environment.

17 Good & Bad Teamwork https://www.youtube.com/watch?v=ftPOy4yUGMQ

18 APRN/PA Patient Care Center (PCC), Hospital or AreaName Title CRNA/VPEC Brent Dunworth Associate Director/ Chief CRNA MEDICINE Jane Case Assistant Director NEUROSCIENCES Briana Witherspoon OBGYN - DEPT Angela Wilson-Liverman Division Director SURGERY (and TRAUMA/OrthoTrauma/Pain) Billy Cameron TRANSPLANT Jerita Payne VCH Acute and Critical Care Michelle Terrell VCH Acute and Outpatient Care Jill Kinch VHVI Tiffany Street VICC Jennifer Mitchell OBGYN-SON MIDWIFERY & SON CLINICS Pam Jones Sr. Associate Dean Community Partnerships PSYCHIATRY Molly Butler OCCUPATIONAL HEALTH Catherine Qian Clinical Manager ORTHOPAEDICS Mary Duvanich/Jonathan Riggs Administrative Director/Team Lead ED Emily Evans Team Lead

19 Which is the following does NOT describe a Magnet designated facility?Committed to quality and excellence in nursing Awarded by Centers for Medicare/Medicaid (CMS) Only 6% of US hospitals have designation Awarded by American Nurses Credentialing Center (ANCC)

20 Which of the following describesthe culture of shared governance:Advocacy of active voice Commitment to active participation Improving practice through collaboration All of the above

21 All of the following are true regarding collaboration except:Includes perspectives & expertise of team members Enhances empowerment Decreases job satisfaction Is associated with improved patient outcomes

22 Credentialing & PrivilegingBack to Agenda Credentialing & Privileging

23 Process Flow Advanced Practice Credentialing and Privileging ProcessOrientation Handbook pp.14-15

24 Credentialing & Privileging FormsOne Packet Core Privileges Days to prepare file for committee Reappointment Application Every 2 years Advanced Practice Non-Core Privileges When applying for procedural privileges Orientation Handbook p.17-15

25 Credentialing & Privileging (cont’d)Delineation of Privileges (DOP): Clinical privileges granted based upon scope of practice and competencies Notice and Formulary: (BON requirement) drug categories removed, more streamlined Process must be completed within 120 days Review Medical Staff Bylaws/Rules/Regulations RN experience does NOT expand your NP scope NPDB checks for malpractice, criminal background, disciplinary actions Notice and Formulary – serves as notice to Board that you are starting or changing practice. It is your responsibility to keep information in Notice and Formulary up to date which in turn keeps your Practitioner Profile up-to-date. Do not check antineoplastics unless you are in a setting in which this is appropriate. Oxytocics – again not unless applicable to setting The Credentialing/Privileging Process Must complete application for acquisition of ONE PACKET. Credentialing – you are a licensed provider in good standing and are competent. Privileging – you have to request clinical privileges and based upon credentialing piece you are granted clinical privileging. Initially request CORE – taken from CORE COMPETENCIES for nurse practitioners. TJC states that all providers must demonstrate competency. Core Privileges noted in ONE PACKET. For procedures will have special privileges – adult and pediatric – refer to MASTER LIST – list can not be altered; new additions must be approved by Medical Executive exam. PATCH – apply for moderate sedation. PLASTICS – suturing. Privileges renewed q 2 years. Apply for NPI – keep confirmation letter safe. Contents of ONE Packet then goes to PSS where everything needs to be primary source verified. One page asks about self-disclosure. If answered “Yes”, don’t need to write an essay but you must fully disclose. If in the verification process, something is found and failure to disclose is seen as fraudulent and process halts. Once verification is complete then packet goes to Joint Practice Committee (which is a peer review process). If no concerns then packet are taken to next step (if greater than 50% pediatrics) then goes to Children. Next step is Executive Medical Board – occurs once per month – only this entity can grant privileges. All committee reviews occur within a 2 week period monthly. In the meantime you are in a protected role, known as “orientation” and used B of N rules for new NP graduates which facilitates acclimation to new NP role. Cannot prescribe independently and all notes need to be countersigned. Payers recognize Vanderbilt’s credentialing and privileging processes. Enrolled with payors 1 x monthly. Then switched on in the EPIC system and status will be changed in Star Panel (if you were a RN and now an APP). Three companies do not enroll NPs: Cigna, United, Aetna. If you see a patient with one of these insurances you will be a servicing provider but bill would be submitted under physician. There has to be a good reasons why NPs are not billing. Global period – 90 day period there is nothing to bill for. EX. if seeing mostly post-op patients then there would be nothing to bill for. Always have to be on the lookout for missed billing opportunities especially if NPs are trying to justify and validate added-value.

26 Privileges Core: granted when competency verified after committee review Joint Practice VUH/VCH Credentialing Committee Medical Center Medical Board

27 Core Privileges

28 Privileges (cont’d) Non-Core/Specialized/Procedural:Given only after procedural competency demonstrated After competency threshold met, MD/preceptor presence not necessary Medical necessary Volume supported

29 Privileges (cont’d) Master Procedural List: used for DOP; can only be altered upon committee review Procedural Log Assures ongoing competency Tracks & validates procedures completed Star Panel’s Procedural Notes De-identified log to PSS q 2 yrs for reappointment

30 Advanced Procedure PrivilegesApplication for Advanced Procedure Privileges requested by APN Leader obtained from Provider Support Services (PSS) collaboratively completed w/ APN leader and/or supervising physician returned to PSS Orientation Handbook pp.39-40

31 Can submit for additional privileges in January, July & OctoberMust provide application with signatures and procedure log indicating supervised training procedures High Risk requiring separate application Colposcopy Privileges Moderate Sedation Privileges Neonatal Circumcision Privileges Nitrous Oxide Administration

32 Additional Privileges

33 Additional Privileges

34 Credentialing Committee ProcessJoint Practice Committee Peer Review VCH Credentials Committee VUMC Credentials Committee Medical Center Medical Board Final approval Privileges activated as provider

35 Billing Providers Must be member of Vanderbilt Medical Group (VMG) Professional Staff Faculty status prerequisite to membership Credentialing & Privileging process permits payer enrollment Exceptions: Cigna, United, Aetna C& P process permits payor enrollment with VMG Contracted and Government payors Shared visit: has to be MD involvement (hands on) with documentation AEB significant portion of note completed (POC, decision making, completed PE). Service Provider vs billing provider – may use when NP unable to bill to payor who does not recognize APP

36 Privileges (cont’d) Professional InsuranceCoverage thru Vanderbilt self-insured trust 5.5 aggregate PSS reviews malpractice history (NPDB, carrier) Evidence of previous coverage Collaborative practice critical Claims: failure to diagnose consult/refer 1 M incident and 5.5 M/aggregate is typical coverage Core privileges – entry level proficiencies (every patient everyday). Examples: H & P, Diagnose, order/interpret lab/tests, prescribe, POC) Vanderbilt is self-insured. Current coverage is thru Vanderbilt self-insured trust. Insured for up to 5.5 aggregate. Asks for name of previous insurance carriers as PSS is looking for 5 years history. By virtue of caring your own insurance, will complicate with too many attorneys. No telling what kind of attorney you may get. Vanderbilt invests enough resources to adequately protect NPs. CAPNAH keeps abreast of malpractice climate – most in family practice and OB; incidents center around failure to dx and failure to confer – therefore emphasize and encourage collaborative practice. Allegations: failure to diagnose or delay in diagnosis of infection/abscess, sepsis and cancer; failure to timely and/or order appropriate treatment, improper technique or negligent performance of a treatment/test; improper or untimely management of an aging services resident, medial patient or medical complication; failure to recognize contraindication or adverse interaction among meds or improper prescribing/management of anticoagulant.

37 Provisional Status To be in provisional status you must:Have completed educational requirements Be board certified Be in process of state licensure Be in process of credentialing and privileging Not represent yourself as NP, CNM, CRNA Work under direct supervision Follow ANA, State, Specialty organization and practice/discipline specific guidelines.

38 Provisional Status Tennessee State BON Guidelineshttps://tn.gov/assets/entities/health/attachments/Position_Statement_Booklet.pdf (Orientation Handbook p. 13) *Review handout in packet VUMC Guidelines RN or staff badge (as opposed to the dark blue badge) RN access to star panel Cannot diagnose, treat, prescribe Sign documents as trainee (cannot indicate NP, PA, CRNA, CNM until C&P)

39 Until Privileges Received100% chart review by supervising physician/preceptor No prescribing Input orders under supervision Direct care appropriate with physician/preceptor’s presence

40 Until Privileges Received (cont’d)Perform procedures under supervision May not render independent clinical decisions, diagnoses, or prescriptions May not bill for services May not enroll with payers Use BON guidelines for the new graduate NP. OAP website Guidelines for New APN Graduate

41 Reporting Changes in Status to the Board of NursingAccording to the Nurse Practice Act, any nurse who knows of any health care provider's incompetent, unethical or illegal practice MUST report that information through proper channels. The only two (2) proper channels to report nurses are: The Board of Nursing, via Health Related Boards Investigations, or The Tennessee Nurses Professional Assistance Program. Source: NURSING TENNESSEE CODE UNANNOTATED TITLE 63, CHAPTER 7 Current as of January 13, 2010

42 Credentialed Providers are Required to Report Change in Status to Credentials Committee

43 Update the Conflict Disclosure SystemAbide by the conflict of interest and commitment policies and standards; Fully disclose any professional and relevant personal activities, at least annually, or when a potential conflict arises; Remedy conflict situations or comply with any management or monitoring plan prescribed; Remain aware of the potential for conflicts; Take the initiative to manage, disclose, or resolve conflict situations as appropriate.

44 The One Packet has how many days to be prepared for committee review?

45 Until privileges are received, the APP must:Have 100% of charts reviewed by supervising MD/preceptor B. Perform all procedures under supervision Not render independent clinical decisions, diagnoses, or prescriptions D. All of above

46 After receiving an initial C&P appointment, APPs are reviewed for reappointment every:1 year 2 years 3 years 4 years

47 After receiving an initial faculty appointment, APPs are reviewed for reappointment every:1 year 2 years 3 years 4 years

48 State of Tennessee GuidelinesBack to Agenda State of Tennessee Guidelines

49 Governing Rules and RegulationsPractice governed by: NPs: BME and B of N PAs: BME Critical to review Board R & R Note regulatory/legislative climate (state/national) NPs only provider governed by two boards. Become familiar with B of N and BME Rules and Regulation. Rules written back in the 80s and don’t reflect role of evolution. They are regulations and we must comply and therefore must adapt. PAs governed by BME. BME can’t change rules and regulations without consent of B of N. Stay intune with regulatory/legislative climate due to changes in state and national.

50 State Guidelines Tennessee Board of NursingReview BON handout in packet Tennessee Department of Health – Physician Assistants Tennessee Board of Medical Examiners Rules and Regulations Review BME handout in packet

51 Clinical Supervision RequirementsCLINICAL SUPERVISION REQUIREMENTS. It is the intent of these rules to maximize the collaborative practice of certified nurse practitioners and supervising physicians in a manner consistent with quality health care delivery. (1) A supervising physician, certified nurse practitioner or a substitute supervising physician must possess a current, unencumbered license to practice in the state of Tennessee. (2) Supervision does not require the continuous and constant presence of the supervising physician; however, the supervising physician must be available for consultation at all times or shall make arrangements for a substitute physician to be available. (3) A supervising physician and/or substitute supervising physician shall have experience and/or expertise in the same area of medicine as the certified nurse practitioner.

52 Supervision Requirements – Chart Review20% chart review by supervising MD BME does not specify chart content IP Admission and discharge notes w/ countersignature OP process practice-designated Physical presence of MD NOT required Protocols are written guidelines of medical management Some APRNs will already have protocols established in clinical areas. Protocols don’t apply to CRNA’s – look at BME rules. Protocols need to be reviewed and signed every 2 years. Protocols must be immediately readily available for review within area of clinical practice.

53 Protocols Protocols are mandated by the Tennessee Board of Medical Examiners (Chapter , Tennessee Board of Medical Examiners Rules and Regulations) and are defined as written guidelines for medical management.  (http://state.tn.us/sos/rules/0880/ pdf) Shall be jointly developed and approved by the supervising physician and nurse practitioner; Shall outline and cover the applicable standard of care; Shall be reviewed and updated biennially; Shall be maintained at the practice site; Shall account for all protocol drugs by appropriate formulary; Shall be specific to the population seen; Shall be dated and signed; and Copies of protocols and formularies shall be maintained at the practice site and shall be made available upon request for inspection by the respective boards. Orientation Handbook pp.36-38

54 Protocol Overview Protocol Warehouse https://int.vanderbilt.edu/vumc/CAPNAH/APSC/APRNprotocolswarehouse/default.aspx Access provided by Office of Advanced Practice Attaches to service line’s protocols Template for compilation: protocol, procedure, and reference Orientation Handbook pp.36-38

55 Protocols Protocols are maintained on the OAP Sharepoint Site at:  https://int.vanderbilt.edu/vumc/CAPNAH/APSC/APRNprotocolswarehouse/default.aspx Protocol Learning Module Protocol Template Procedure Template Protocol/Procedure Template for Reference Text Writing Guidelines EBM Resource Toolbox Orientation Handbook pp.36-38

56 Practice Template

57 Procedure Template

58 Reference Text Template

59 State Guidelines Tennessee Rules and Regulations for Physician Assistants Licensure Verification Mandatory Practitioner Profile

60 License Verification/Status & Update Practitioner Profilehttps://health.state.tn.us/Licensure/default.aspx APN Contact: / Nursing : Fax:

61 State Guidelines Application for APN License  Application for PA License  Application for PA Supervising Physician

62 Notice & Formulary for Certificate of Fitness to Prescribe

63 Drug Enforcement Administration (DEA)https:///www.deadiversion.usdoj.gov/webforms/validateLogin.jsp

64 National Provider Identification (NPI) https://nppes. cms. hhs

65 TN Prescription Safety ActAPN/PA Notice and Formulary Tennessehttp://tn.gov/assets/entities/health/attachments/PH-3625.pdf e Prescription Safety Act 2012 TN BON CS Continuing Education Requirement Chronic Pain Guidelines

66 Tennessee Bill 396 BON Reminder SB 676At each renewal must present 2 continuing education credits on controlled substance Reminder of supervising MD in CSMD SB 676 2 hours of continuing education bienally Must include education on opioids, benzodiazepines, barbiturates, carisoprodol Tennessee Bill 396 No more than 30-day non-refillable Must write from formulary

67 State Guidelines Controlled Substance Monitoring Databasehttps://www.tncsmd.com/Login.aspx?ReturnUrl=%2fdefault.aspx Entering Physician Driver’s License   Controlled Substance Monitoring Database FAQ

68 Controlled Substance Monitoring Database (CSMD)Register with CSMD All providers with DEA who prescribe CS Provide direct care to TN patients more than 15 days/year Register w/in 30 days of initial DEA registration Check CSMD before prescribing: new course of opioids and/or benzodiazepines & at least annually for ongoing treatment FAQs https://www.tn.gov/health/article/CSMD-faq Delegated access: a licensed HCP & 2 other persons per practitioner Report variances with actual knowledge Register! Access through CAPNAH site As of January 1, 2013 all providers were required to register with CSDM. As of April 1, 2013, – database must be checked prior to prescription of opiods or benzodiazepines. Law allows 2 unlicensed and 1 licensed delegate. Refer to CAPNAH website At this time, do not recommend inclusion in chart unless measures are in place to assure strict confidentiality. Information within database is under more scrutiny than HIPPA. Exception rules to check database: Directly administered to patient, Hospice, Post-op pain x 2 days of surgery performed in licensed facility, Veteran. Definitely check is giving 30 day supply! Department of Health has posted form for providers to support reporting process. When in doubt, consult with supervising MD

69 CSMD Checking Exceptions for Prescribing ProvidersHospice patient Quantity prescribed/dispensed doesn’t exceed amount needed for single, 7 day treatment w/o RF Medical specialty patients deemed low abuse potential Direct administration to hospital/NH patients Licensed veterinarians for non-humans

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71 More on Prescribing in TennesseeBack to Agenda More on Prescribing in Tennessee

72 States Painkiller Prescriptions per 100 People

73 Rates of Opioid-Related Overdose Death Tennessee and United States, 1999–2010Rate per 100,000 population There has been an increase in prescription opioid use in the United States since 1990s. This graph depicts the rates of opioid-related overdose deaths by year for Tennessee (in green) and the US (in red), from 1999 through 2010. On the y axis are the rates of opioid overdose death per 100,000 population. The rates of opioid related overdose deaths increased in Tennessee from 1999 through 2002, but mirrored the national rates. Since 2003, however, the opioid overdose death rates in Tennessee have increased at a faster rate than rates nationwide. Source: Tennessee Department of Health – Vital Statistics, NCHS Data Brief

74 Opioid Prescription Rates by County- TN, 2007The next 5 slides are a visual representation of the increasing opioid prescription rates in Tennessee by county of residence. The lightest pink color represents rates less than 105 prescriptions per 100 population, and brightest red represents rates above 140 prescriptions per 100 population. This slide shows prescription rates for 2007. The number of counties with higher prescription rates increased… CLICK

75 Opioid Prescription Rates by County- TN, 2011And in 2011. This is a widespread, statewide problem.

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77 Source: Centers for Disease Control

78 Prescriptive AuthorityRespect granted authority DO NOT provide for friends and family Patient relationship a must AEB H & P, diagnosis, plan, available for FU. Be professional, respectful, and direct Refer to packet B of N R & R. On Website Prerequisites to prescribing (Adv Prac, R & R, BON R & R, pg 6, Paragraph 1 & 2) Be careful as they may impose prescription restrictions. Don’t go off the reservation and avoid having to do damage control. Narcotic prescribing – Experienced NP approached by staff member desiring RF on Xanax as could not get to PC. Rx prescribed with instructions to tell PC that she had prescribed. NP could not go into record as was not provider of record and could not due HIPPA concerns. Many months went by. Patient seen by PCP at OHO. PCP check database and noted that patient had been refilling medication monthly with 60 versus 30 tabs. NP now having to clear name from criminal activity, undergoing discipline by B of N. DO NOT PUT YOURSELF IN THIS POSITION. With great sensitivity, do not self-prescribe as pharmacists are watching. Unfortunate that NPs are under such scrutiny but this is current day practice. Antidepressant – may be hesitant to go to see a physician for treatment due to fear of judgment.

79 Prescriptive Authority (cont.)Varies by state - TN BON/BME R & R Controlled drug prescribing (II-V) Protocol and Formulary Collaborating physician/designee info VUMC – 100% review of CS Rxs

80 Electronic PrescribingMany health care clinics and hospitals have transitioned to e-Prescribing. Can reduce errors; however, NEVER rely solely on the computer software to do your vigilance for you!

81 The “Rights” of Prescription WritingRight patient Right drug Right dose (strength per unit dose) Right dosage schedule, dosing interval, times of day Right route of administration Right date Right number of refills Right duration of treatment Right to informed consent Right to refuse treatment Right to be knowledgeable

82 Universal Components of a PrescriptionPrescriber’s Printed Name and Address DEA # Patient Name Date Drug, Dose, Units, Route, Frequency Quantity to Dispense Indication* Refill information No Substitution Signature (*dispense as written or substitution allowed)

83 *Indication Drug indication is useful, not only to reduce potential filling errors, but to improve patient knowledge of their medications. Pharmacy law only allows labeling for what is written on the prescription If the prescriber didn’t say what it is for, then it shouldn’t be on the label.

84 Rx (please print) Lisinopril 20mg #30 Sig: 1 tablet by mouth dailyJohn Brown AGPCNP-BC Karen Jones MD 136 Wright Way Nashville, TN DEA # Name: John A. Smith Address 123 Meadow Lane, Nashville, TN Date 08/23/2013 Rx (please print) Lisinopril 20mg #30 Sig: 1 tablet by mouth daily Indication: for blood pressure Dispense as written Substitution allowed ____________________________ _____John Brown_____________ REFILL TIMES PRN NR LABEL

85 Name of Drug Avoid handwriting errors that may impair interpretationExamples: Lamisil (antifungal) vs. Lamictal (anticonvulsant) Epogen (RBCs) vs. EpiPen (severe allergy) MS04 vs. MgS04 should ALWAYS be written out as “Morphine sulfate” or “Magnesium sulfate”

86 Decimal Points ALWAYS LEAD, NEVER TRAIL!0.25 mg (correct) versus .25 mg (Incorrect) Can “lose” the decimal and be read as “25 mg” 1 mg (correct) versus 1.0 mg (Incorrect) Can be misread to be “10 mg”

87 Write it Out Levothyroxine (synthetic T4) prescribed in “μg” amounts.May see people write it as either “mcg” or “μg” Both can be misread as “mg” WRITE IT OUT = “100 micrograms” OR WRITE IT IN MILLIGRAMS = 0.1 mg Insulin and diabetes Dispensed in units (u) WRITE OUT “units”

88 Institutional GuidelinesBack to Agenda Institutional Guidelines

89 Institutional GuidelinesVUMC Nursing Bylaws  https://vanderbilt.policytech.com/dotNet/documents/?docid=3422&mode=view Vanderbilt Medical Group (VMG) Bylaws (billing providers) https://vanderbilt.policytech.com/dotNet/documents/?docid=2272&mode=view VUMC Medical Staff Bylaws  https://vanderbilt.policytech.com/dotNet/documents/?docid=3597&mode=view VUMC Policies https://vanderbilt.policytech.com/

90 Faculty and Staff Staff Faculty Faculty Manual Vacation Leave programsRetirement Disciplinary action Appointment/Reappointment Resignation Compensation models Tuition Human Resources Vacation and sick leave Retirement Disciplinary action Resignation Compensation models What’s the same? Same: OPPE/FPPE and Insurance, Medical Director, APN Leader, PCC, Recruitment

91 Tuition Benefits Staff Full Status FacultyAudit/enroll courses 1 course/semester = 3/yr (1 Semester = Fall, Spr, Summer) 3 credit hrs/4 hrs w lab 47% tuition discount Faculty Manual: Part IV, Chapter 3, Section E Consult with Dept Chair or Division Director Another accredited University w coursework relevant, enhancing to current skill set https://hr.mc.vanderbilt.edu/benefits/tuition.php Self - 70% tuition reimbursement Contingent upon evidence of completion with a “C” or better Eligible semester 3 months after hire Consult with supervisor Spouse/Partner – 47% tuition reimbursement 1 course/semester Children – 55% tuition discount, 8 semesters, eligible 5 yrs post hire HR – Tuition Benefit https://hr.mc.vanderbilt.edu/benefits/tuition.php HR – Employee Tuition FAQs https://hr.mc.vanderbilt.edu/policies/faq-employee-tuition.php

92 Compliance Modules VUMC Faculty Compliance Moduleshttps://medschool.vanderbilt.edu/faculty/foto VUMC Staff Compliance Modules https://webapp.mis.vanderbilt.edu/compliance

93 The Joint Commission National Patient Safety GoalsVanderbilt Joint Commission Handbook Recent Site Visit

94 Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms. “Trailing zeros” maybe used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report sizes of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

95 Clinical DocumentationDocumentation Standards for Clinicians Complete, accurate EHR supports safe care Timeliness requirements Within 24 hours of admission or consultation Prior to any operation or procedure Within 72 hours of discharge Daily for IP progress notes Within 4 business days for OP progress notes Delinquent = incomplete > 14 days post IP discharge or OP encounter. Incomplete > 28 days = automatic suspension of privileges https://vanderbilt.policytech.com/dotNet/documents/?docid=7716

96 Shared Visits Split/Shared Encounter: Encounter between MD & NPNot applicable to medical students, nurses, residents Not applicable to consultations, procedures or critical care services Service must be medically necessary. Service must be within scope of practice/licensure of NP. NP service & MD service may occur jointly or at independent times on same day calendar day. Both must complete a face to face encounter in order to bill as a shared/split visit. Both NP & MD should document what each personally performed. Total documentation by both NP & MD should support the level of service reported.

97 Incident to EncountersMedicare Incident To Criteria: MD must personally perform the initial service & remain actively involved in the course of treatment MD must be present in the office suite and perform a face to face encounter. MD is delegating work to the NP MD and NP must be in the same specialty. Incident To applies to the office/clinic setting (not applicable in the hospital setting) Cannot be used when: Seeing new patients Seeing established patients with new problems Physician not physically present in office suite Physician not performing face to face encounter

98 Learning Management System

99 People Finder

100 People Finder

101 Back to Agenda National Guidelines

102 APRN Consensus Model Uniform model of regulation for advanced practiceDesigned to align licensure, accreditation, certification, education (LACE) Consensual title for advanced practice: APRN (TN – APN) 4 roles: 6 populations: Across continuum, Adult-Gero Primary/Acute; Pediatric Primary/Acute; Neonatal, Psychiatric, Women’s health/gender related

103 APRN Consensus Model (cont’d)

104 APRN Consensus Model (cont’d)Enables practicing to full extent of education and licensure Uniformity eases mobility among states, benefits APRN and enhances patient care Credential is legal tag; demonstrates successful acquisition of board certification. “What Do you Know About the Consensus Model?”

105 Specialty Practice (cont’d)If signing title documents, use board granted credentials Some payors withhold payment if certification doesn’t match practice Professional/Personal Responsibility to assure LICENSE/CERTIFICATIONS CURRENT 90 day warning from PSS prior to expiration (certifications, license) New By TN BON: Renewal of Certificate and Demonstration of Competency. Maintain national certification AND complete 1 CEU to address controlled substance prescribing practices through an approved provider by certifying board.

106 American Nurses Credentialing Center (ANCC)

107 Professional Practice EvaluationBack to Agenda FPPE/OPPE Professional Practice Evaluation

108 Professional Practice EvaluationJoint Commission Standards MS and MS

109 The Joint Commission Ongoing Professional Practice Evaluation (OPPE), MS To move from cyclical to continuous evaluation of a practitioner's performance to identify practice trends that impact quality, patient safety and determine whether a practitioner is competent to maintain existing privileges or needs referral for a focused review. Focused Professional Practice Evaluation (FPPE), MS To verify competency, when applying for new privileges (ie. new hire) and whenever questions arise regarding the practitioner's professional performance.

110 Focused Professional Practice Evaluation (FPPE)A period of focused review (JC standard MS ). Clearly defined performance monitoring process Time or volume limited Consistently implemented Assigned proctor, usually a peer Outlined plan for improvement Orientation Handbook p.43

111 When is an FPPE performed?When a practitioner has the credentials to suggest competence, but additional information or a period of evaluation is needed to confirm competence in the organization’s setting. Implemented for all newly requested privileges Practitioners new to the organization Existing practitioners applying for new privileges When practice issues are identified that affect the provision of safe, high-quality patient care Triggered from an ongoing evaluation or clinical practice trends Triggered by a single incident or sentinel event

112 How can we measure FPPE? Chart reviewMonitoring clinical practice patterns Simulation Peer Review (Internal and/or External) Discussions with other individuals involved in patient care Direct Observation

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115 Ongoing Professional Practice Evaluation (OPPE)To move away from the procedural, cyclical process in which practitioners are evaluated when privileges are initially granted and every 2 years thereafter. To continuously evaluate a practitioner’s performance To identify professional practice trends that impact on quality of care and patient safety. To decide whether a practitioner is competent to maintain existing privileges or needs referral for FPPE Orientation Handbook p.43

116 What is OPPE? Clearly defined quality review process to evaluate each practitioner’s practice. Type of data collected may be general but also must include data that is determined by individual departments and be individual practice specific Can include both subjective and objective data Must occur more than once a year, usually every 6-8 months

117 Types of Data Qualitative Quantitative Professionalism BehaviorInvolvement/Commitment to Practice Leadership Communication Patients/Families Health Care Team Oral/Written Tools Questionnaires Surveys Evaluation forms Discussions Direct observance Confidential reporting methods Chart audits Performance Indicators Blood transfusion patterns Ventilator days Hand hygiene Protocol adherence Outcomes Data Length of stay Readmission rates Nosocomial infection rates Technical performance Complication rates Frequency of procedures performed Performance indicators (protocol, time out) Tools Dashboards Scorecards Graphs Reports Checklists

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119 What is Competency? Professionalism Patient CareNeurocritical care Trauma Glucose management Surgical ICU Cardiology arrhythmia Inpatient medicine Cardiothoracic ICU Medical ICU Hematology Professionalism Patient Care Interpersonal communications Medical/Clinical knowledge Systems based practice Practice based learning and improvement Scientific Foundation Leadership Quality Practice Inquiry Technology and Information Literacy Policy Health Delivery Systems Ethics Independent Practice

120 To practice a sample OPPE, please scan this code or go to this link: https://redcap.vanderbilt.edu/surveys/?s=N3XJ7N8WTR https://redcap.Vanderbilt.edu/surveys/?s=N3XJ7N8WTR Orientation Handbook p.49

121 Orientation Handbook p.49

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123 Practice-Specific Quality IndicatorsNP RBC Utilization NP Service O/E LOS NP Unit O/E LOS NP Discharges by noon NP Readmissions CLABSI CAUTI Hand hygiene Practice specific metrics for clinical practice standards and processes

124 Professional Practice Evaluation?Which of the following is NOT true regarding Professional Practice Evaluation? A. OPPE occurs every 6 months (April & October) B. FPPE verifies competence for a newly hired APRN/PA C. FPPE does not use direct observation as a means to evaluate competency D. FPPE is reactivated when questions arise regarding an established practitioner’s performance

125 Per VUMC policy, all of the following pertain to timely documentation except: A. Supports safe & accurate care B. Must be completed within 24 hours of admission or consultation C. Is not required prior to any operation or procedure D. If incomplete >28 days, results in automatic suspension of privileges

126 When comparing staff and faculty , which of the following is NOT a shared commonality? A. Have an AP leader for support B. Required to give 4 months notice C. Undergo FPPE and OPPE D. Receive malpractice insurance via VUMC’s self-insured trust

127 Which of the following is true regarding APP supervision?A. Requires 10% chart review B. Requires physical presence at all times C. Requires collaborative creation of evidence-based protocols D. Requires 50% review of all CS prescriptions

128 Office of Advanced Practice Virtual Tour

129 Orientation Packet and ChecklistBack to Agenda Certificate of Completion Congratulations!!! Orientation Packet and Checklist Click to download the Orientation Handbook and Orientation Checklist

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