The abbreviated self assessment

49 Pages·2012·0.68 MB·English

Instructions
It is important for each hospital or ambulatory site in a multihospital or ambulatory system to complete the self
assessment individually.
1. Establish an interdisciplinary team consisting of, or The team leader should provide copies of the self
similar to, the following: assessment tool, FAQs and Key Definitions to all
team members for review before the first meeting.
• Senior administration representative In the electronic version, FAQ information and Key
• Chief medical officer Definitions can be accessed by hovering over the
• Nurse executive FAQ icon or the defined item (shown in small capital
• Director of pharmacy letters).
• Chief information officer
• Clinical information technology specialist 3. Verify your demographic information.
• Medication safety officer/manager Before the first team meeting, the team leader
• Risk management and quality improvement should review and verify the responses in the
professionals demographics section with the administration of the
• At least two staff nurses working in oncology care hospital/ambulatory organization/practice setting as
areas discussed in the FAQs.
• At least two staff oncology pharmacists (one
clinical and one distribution) 4. Convene the team.
• At least one active oncology staff physician. During the assessment meetings, ensure that
each team member can view either a hardcopy or
It is helpful to appoint a team leader to coordinate electronic version of the self assessment. There are
the process. Other practitioners and staff (e.g., a couple of options for completing the assessment:
biomedical personnel, certified nurse practitioners,
receptionists) may need to join the core team for • Option 1: Print hardcopies of the self assessment
evaluation of certain sections of the self assessment. to share with team members, manually complete
the demographic information, and fill in your
Your team should be provided with sufficient time choice (A through E, or Not Applicable [N/A])
to complete the self assessment and be charged for each self assessment item. Once completed,
with the responsibility to evaluate, accurately and submit your information online at:
honestly, the current status of medication practices http://mssa.ismp-canada.org/oncology.
as they relate to oncology in your facility. Because • Option 2: Use the online self assessment form to
medication use is a complex, interdisciplinary view at team meetings, complete the demographic
process, the value and accuracy of the self information, and enter your choice (A through E,
assessment is significantly reduced if it is completed or Not Applicable [N/A]) for each self assessment
by a single individual or discipline involved in item, saving your username/password-protected
oncology medication use. Based on participant document at the end of each meeting. (Please
feedback from prior self assessments, we anticipate see Step 8 for information regarding accessing
that it will take three team meetings of approximately the online self assessment form and obtaining a
1 to 2 hours each to complete this self assessment. username and password.)
2. Read and review the self assessment in its entirety, 5. Discuss each core characteristic and evaluate the
including the instructions, Key Definitions, and organization’s/practice setting’s current success
Frequently Asked Questions (FAQs) before beginning with implementing the self assessment items within
the assessment process. that core.
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Instructions (continued)
As necessary, investigate and verify the level of the components of the item have been fully
implementation with other healthcare practitioners implemented in only some or all areas of the
and staff outside your core assessment team. When organization, your self assessment choice should
a consensus on the level of implementation for each be D.
self assessment item has been reached, select the • For self assessment items with an option of
appropriate checkbox (A through E, or Not Applicable “Not Applicable” (N/A): Select “Not Applicable”
[N/A]), using the following scoring key and guidelines: (N/A) only if the item does not correspond to
any services you provide in your organization/
Scoring Key practice setting. N/A responses are scored the
A. There has been no activity to implement this item. same as answering B (This item has been formally
B. This item has been formally discussed and discussed and considered, but it has not been
considered, but it has not been implemented. implemented).
C. This item has been partially implemented in the
organization for some or all areas, patients, drugs, 6. Repeat the process outlined in Step 5 for all self
and/or staff. assessment items.
D. This item is fully implemented in the organization
for some or all areas, patients, drugs, and/or staff. 7. If you have questions: Refer to the FAQs and Key
E. This item is fully implemented throughout the Definitions – these are directly linked in the online
organization for all patients, drugs, and/or staff. form and identified in the PDF version via an
N/A. (Not applicable) will be available as an option FAQ icon or use of small capitals font for the Key
for specific questions. Definitions.
Organizations may want to consider assigning an For additional questions, contact ISMP at
individual to record any discussion generated around [email protected] or call 001 215 947
each self assessment item and the rationale behind 7797 from 9 am – 5 pm (Eastern Daylight-Saving
the selected choice. This information, meant for Time). If you are experiencing technical difficulties
internal use only, can assist the team when reviewing with the online assessment portal, contact ISMP
scores for individual items or reassessing your Canada at: [email protected].
organization at a later date and will provide insight
into why the choice selected for each self assessment 8. To submit your final completed assessment or to use
item was chosen. Option 2 to complete the assessment, go to http://
mssa.ismp-canada.org/oncology, and click on the
Scoring Guidelines link to register.
• For all self assessment items: Self assessment
items refer to chemotherapy/biotherapy medications See the next section, Instructions for Entering and
prescribed, dispensed, and administered to all Submitting Information to ISMP/ISMP Canada, for
inpatients and outpatients for both the treatment of further information about obtaining a username and
oncology and non-oncology disease processes (e.g., password, entering your information, and submitting
methotrexate for rheumatoid arthritis or psoriasis). your completed assessment.
• For all self assessment items: Choice of E
(full implementation) is appropriate only if all 9. Once you have entered and submitted your
components are present in all areas of the information online, you will be prompted to print a
organization, for all patients, all medications, report which will summarize your results. This is
and followed by all staff. If only one or some of explained in detail in the next section.
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Instructions for Entering and Submitting Information to ISMP/ISMP Canada
1. To access the oncology self assessment webpage. You can maneuver through the tool by using the
dark blue tabs at the top of the screen that relate
From any computer with Internet capability, go to: to each section (Demographics, I, II, III, etc.). You
http://mssa.ismp-canada.org/oncology to access can also move from section to section by using
the 2012 ISMP International Medication Safety the “Next Section” or “Previous Section” tabs
Self Assessment® for Oncology webpage. This that appear at the bottom right of the screen.
webpage will provide all the links you need to print • Saving data: You can click on the “Save” button
and view the assessment, register, complete the self at the bottom left of the screen any time after
assessment, submit your information, and view data has been entered. You can always go back
your results. and edit your responses and click the save button
again to update your information. To exit the
2. To register. online form, click on the “Logout” button found
at the top right of the page. In order to return to
Once the assessment webpage has been accessed, your saved information, you will need to go to the
you will see two blue boxes at the top of the page; homepage and click the “Existing User Login”
one for “New User Registration” and the other for box, and then enter your username/password.
“Existing User Login.” To register, click on the “New • Check MSSA for Errors: You can click on this
User Registration” box to open the registration button (located near the “Save” button at the
page. You will be prompted to select a username bottom left) at any time to see which items in the
and password. You then have the option to provide demographics section have not been answered
an email address to be used only if necessary or which other sections are incomplete. If all the
for password recovery. You have a further option items in the section have been answered, a green
to provide your full contact information so that check mark will appear next to the section tab at
information can be retrieved by ISMP in the the top of the screen.
event that you lose your login details. If you have
not provided your email address or full contact 4. To submit your completed assessment.
information, ensure you record your username
and password, and keep them in a safe place. Your Once all the items have been answered and saved,
username/password is required to: a message box will pop up telling you, “The MSSA is
• Enter your information into the online self now complete. Do you want to submit the results to
assessment form; ISMP Canada?” You can click OK to submit your self
• Save your entered information and return to assessment responses or Cancel to go back to the
the online form at a later time to complete the tool.
assessment;
• Submit your completed self assessment to ISMP; • If you select OK: Your responses will be submitted
and – you will NOT be able to make any changes to
• View and print a report of your self assessment your information if you select OK.
with scoring once it has been submitted. • If you select Cancel: Your responses will be
saved, but you can still go back and make
3. To enter assessment information. changes. You can even log out and log back in to
make changes.
• Entering data: Once you are logged in, you can • If you saved your changes and did not submit your
start entering data and saving your responses. results, the Check MSSA for Errors button will say
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Instructions for Entering and Submitting Information to ISMP/ISMP Canada
(continued)
Submit MSSA results unless you make changes. If Explanation of Scores
you do not make any changes, click on that button The assessment items have been scored as follows:
to submit your responses. If you make changes
and save them, the pop up box will come up again A. Score = 0
telling you the assessment is complete and will There has been no activity to implement
ask if you want to submit your results. this item.
B. Score = 1
5. To generate your report.
This item has been formally discussed
and considered, but it has not been
Once you have submitted your completed self
implemented.
assessment, a message box will appear stating that
C. Score = 2
the MSSA has been finalized. At this point you can
This item has been partially implemented
view your responses but you will not be able to make
in the organization for some or all areas,
any changes.
patients, drugs, and/or staff.
You will be prompted to print a report of your D. Score = 3
submitted self assessment with your answers and This item is fully implemented in the
numerical scores for each of the self assessment organization for some or all areas,
items, subtotals for each of the core characteristics patients, drugs, and/or staff.
and key elements, and a total score for the entire
E. Score = 4
self assessment. Note that the scored report will be
This item is fully implemented throughout
approximately 20 pages in length.
the organization for all patients, drugs,
and/or staff.
If you have not supplied your email or full contact
N/A. Score = 1
information to obtain a lost or forgotten username/
(Not applicable)
password, ensure that this report and your
username/password are maintained in a safe
location so you can compare your organization’s/
practice setting’s findings with aggregate data from
similar sites when it is available, or to use your
results to compare against future results of your
organization.
At any time after submitting your information, you
can enter your username/password to view and/or
print your self assessment report. However, you will
not be able to make any changes to the information
you originally submitted.
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Instructions for Entering and Submitting Information to ISMP/ISMP Canada
(continued)
Access to Comparative Reports Security and Protection of
Self Assessment Information Submitted
Shortly following the final submission date of to ISMP/ISMP Canada
the 2012 ISMP International Medication Safety
Self Assessment® for Oncology, ISMP and ISMP All information submitted to ISMP and ISMP Canada
Canada will prepare and make available to those is maintained in a secure database maintained
organizations that participated, a Preliminary solely by ISMP Canada. The application does not
Aggregate Results workbook with comparative allow viewing of data or demographic information
reports of the level of medication safety practices associated with individual assessment information.
based on the data submitted. Access to these All information is contextually de-identified, and
aggregate comparative reports will be available the demographics and submitted results will be
using the same password you used when entering used only for aggregate data reports. Usernames/
and submitting your information. In addition, further passwords required for submitting information to
analysis of the data will be completed, and the ISMP are self-selected by the organization/practice
results will be submitted for publication in a peer- setting participating in the self assessment. Access
reviewed journal. to any contact information voluntarily provided by the
organization (i.e., email address for lost or misplaced
password only) is restricted to a small number
of ISMP Canada personnel and confidentiality is
assured.
In addition to the usual high standard of
confidentiality associated with any information
submitted to ISMP and ISMP Canada, we would
also like to remind participants that ISMP is a
federally certified patient safety organization (PSO)
in the United States. If self assessment information
is collected within the hospital’s patient safety
evaluation system and submitted to ISMP as
patient safety work product, the information is
granted protection from discovery in connection
with a federal, state, or local civil, administrative, or
disciplinary proceeding. No contract with ISMP is
required for this legal protection. Further guidelines
regarding submitting information to ISMP as a PSO
can be found at:
www.ismp.org/docs/PSOguidelines.pdf.
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Demographics
FAQ - Please see the FAQs for information about completing the demographic information.
1a. Country 4. Please estimate your organization’s/practice
setting’s oncology patient population.
__________________________________________________ ____ % - Age 18 or less
____ % - Age 19 - 64
1b. Province/State/Region/Territory ____ % - Age 65 and over
__________________________________________________ 5. Are you an academic or university organization/
practice setting (e.g., do you have a medical school
2. Please check the one category that best describes affiliation)?
the location of your organization/practice setting. Yes
Urban No

(a population of approximately 50,000 or more)
Rural 6. What is the form of ownership or funding for the

(a population less than 50,000) organization/practice setting?
(select all that apply)
3. Describe your organization/practice setting(s). Public (government or military)
(If you have multiple practice settings, please Private for-profit
complete a separate assessment for each setting Private not-for-profit/charitable
that follows different procedures/processes for
oncology medications.) FAQ 7. Is your organization/practice setting part of a
Inpatient larger healthcare system with common ownership
3a. Total beds and/or governance?
Less than 100 Yes
100 to 299 No
300 to 499
500 and over 8. Is your organization/practice setting a nationally/
3b. Percent oncology provincially/state designated cancer center in
Less than 25% your country?
25% to 49% Yes
50% to 74% 8a. If multiple sites, how many are designated?
75% to 100% 1
Outpatient 2
3c. Total chairs/beds 3
Less than 10 4
10 to 19 5
20 to 49 6
50 and over 7
3d. Percent oncology 8
Less than 25% 9
25% to 49% 10
50% to 74% More than 10
75% to 100% No
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Demographics (continued)
9. What is the average number of chemotherapy/ 12. Does your organization/practice setting undergo
biotherapy doses administered per month at your specialty certification/accreditation for oncology
organization/practice setting? FAQ from an external review agency (e.g., World Health
Less than 249 Organization [WHO], National Cancer Institute [NCI],
250 - 999 Det Norske Veritas [DNV])?
1000 - 2999 Yes
3000 and over No
10. Which of the following cancer treatments does your 13. Has your organization/practice setting adopted
organization/practice setting provide? chemotherapy/biotherapy safety standards
(select all that apply) or guidelines from recognized professional
Alternative cancer therapies (e.g., homeopathic, organizations (e.g., World Health Organization
naturopathic, accupuncture) [WHO], International Society of Oncology Pharmacy
Blood and marrow transplants Practitioners [ISOPP], American Society of Clinical
Cancer vaccines Oncology/Oncology Nursing Society [ASCO/ONS],
Chemoembolization (venous occlusion therapy) Clinical Oncological Society of Australia [COSA],
Heated chemotherapy/biotherapy (hyperthermia) Accreditation Canada, Canadian Association of
High dose chemotherapy/biotherapy Nurses in Oncology [CANO-ACIO], other national
Home care chemotherapy/biotherapy professional/accrediting organizations)?
Intramuscular chemotherapy/biotherapy Yes
Intraoperative chemotherapy/biotherapy No
(e.g., isolated limb perfusions)
Intraperitoneal chemotherapy/biotherapy 14. What percentage of your professional staff is
Intrathecal chemotherapy/biotherapy oncology trained/certified through an external
(e.g., lumbar puncture, Ommaya reservoir) accreditation/certification organization?
Intravenous chemotherapy/biotherapy a. Pharmacists
Investigational chemotherapy/biotherapy None
Oral chemotherapy/biotherapy 1% - 25%
Radiolabeled chemotherapy/biotherapy 26% - 50%
Special procedures 51% - 75%
(e.g., cystoscopic procedures, intraocular) 76% +
Subcutaneous chemotherapy/biotherapy b. Pharmacy Technicians
Other ________________________________________ None
1% - 25%
11. Does your organization/practice setting participate 26% - 50%
in oncology-based research? 51% - 75%
Yes 76% +
No
[Question continued on next page]
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Demographics (continued)
c. Physicians 17. Who is authorized to check the final
None chemotherapy/biotherapy product before it
1% - 25% leaves the preparation area?
26% - 50% (select all that apply)
51% - 75% Pharmacists
76% + Pharmacy Technicians
d. Registered Nurses Physicians
None Registered Nurses
1% - 25% Other ________________________________________
26% - 50%
51% - 75% 18. Do you have computerized prescriber order
76% + entry (CPOE)?
e. Other __________________________________________ Yes
None No
1% - 25%
26% - 50% 19. How many standardized chemotherapy/biotherapy
51% - 75% order sets (electronic and/or pre-printed) does your
76% + organization/practice setting have available to
guide prescribing?
15. Does your organization/practice setting provide None
mandatory internal staff training/certification in 1 to 49
oncology prior to providing oncology patient care? 50 to 249
Yes 250 to 499
15a. For which healthcare practitioners? 500 or more
(select all that apply)
Pharmacists 20. Spectrophotometry or similar chemical analysis
Pharmacy Technicians technology is used for end-product testing to
Physicians verify the contents (active ingredients and/
Registered Nurses or concentration) of chemotherapy/biotherapy
Other ____________________________________ compounding/admixture prior to dispensing.
No Yes
No
16. Who prepares chemotherapy/biotherapy for your
organization/practice setting?
(select all that apply)
Pharmacists
Pharmacy Technicians
Physicians
Registered Nurses
Outsourced commercial compounding pharmacy
Other ________________________________________
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Demographics (continued)
21. Do you belong to a group purchasing/group service 22. Has your organization completed an ISMP
organization (GPO/GSO)? Medication Safety Self Assessment® for Hospitals?
Yes Yes
21a. Select country 22a. What year(s) did you complete
Canada the assessment?
21a i. Which Organizations? (select all that apply)
(select all that apply) 2012
Alberta Purchasing Connection (APC) 2011
Approvisionnement Montreal 2010
HealthPRO 2009
Medbuy 2008
Saskatchewan Association of 2007
Health Organizations (SAHO) 2006
Other ______________________ 2005
USA 2004
21a ii. Which Organizations? 2003
(select all that apply) 2002
Amerinet 2001
Broadlane 2000
Consorta No
Department of Defense
HCA (Hospital Corporation of America) 23. If you have received a code from ISMP or ISMP
MedAssets Canada to segregate your information as part of a
ION (International Oncology Network) collaborative, please insert it below. If you do not
Onmark, McKesson Specialty have a code, please leave blank. (optional) FAQ
Care Solutions
Premier __________________________________________________
US Oncology
Veteran’s Affairs
Provista/Novation
UHC/Novation (University Health
System Consortium)
VHA/Novation
Other __________________________
Other ______________________________
No
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A No activity to implement
B Formally considered, but not implemented
C Partially implemented in some or all areas
I. PATIENT INFORMATION D Fully implemented in some areas
E Fully implemented throughout
A B C D E
Core Characteristic #1
Essential patient information is obtained, readily available in useful form, and considered when prescribing,
dosing, scheduling, dispensing, administering, and monitoring chemotherapy, biotherapy, and treatment-
related drugs.
1 A structured process is in place to collect and verify the patient’s first
and last name, age or date of birth, and medical record number or
other unique identifier.
2 A structured process is in place to collect and document in a
designated location the cancer diagnosis including stage and
therapeutic goal (e.g., curative, palliative), comorbid and/or chronic
conditions (e.g., hypertension, diabetes, renal or liver impairment,
pregnancy, lactation), and performance status (general well-being)
based on standardized scale (e.g., Karnofsky scale or Eastern
Cooperative Oncology Group [ECOG] http://en.wikipedia.org/wiki/
Performance_status#Karnofsky_scoring).
3 Chemotherapy/biotherapy orders cannot be processed until the
patient’s allergies (e.g., drug, food, contrast media) and associated
reactions have been identified, documented, and reviewed.
4 Chemotherapy/biotherapy orders cannot be processed until
the patient’s adverse drug reaction history has been identified,
documented, and reviewed.
5 A structured process is in place to collect and document in a
designated location the patient’s current immunization status.
6 At the first encounter of each treatment cycle, a structured process
is in place to obtain a list of current medications (including over-
the-counter drugs, vitamins, herbals, recreational drugs, and
homeopathic drugs) that the patient has been taking prior to the
encounter and this list is compared with the medications prescribed
for the current encounter and at any further transition of care.
7 A structured process is in place to collect and document in a
designated location the patient’s current (actual) height and weight
in metric units.
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