Self Assessment For Oncology - Ismp

IntroductionThe 2012 ISMP International Medication Safety Self Assessment for Oncology was developed by the Institutefor Safe Medication Practices (ISMP) and the Institute for Safe Medication Practices Canada (ISMP Canada),through a grant from the International Society of Oncology Pharmacy Practitioners (ISOPP) to help hospitals,ambulatory care centers, and office practice settings throughout the world evaluate oncology medicationsafety. Chemotherapy and biotherapy agents used in cancer treatment are considered to be “high-alert” drugswhich are more likely to cause patient harm when involved in an error. The self assessment is designed toheighten awareness of the distinguishing characteristics of a safe medication system, with a specific focus onmanagement of chemotherapy, biotherapy, and treatment-related drugs.The self assessment is divided into ISMP’s Key Elements of the Medication Use SystemTM. Each of the ten keyelements significantly influences safe medication use and is further defined by one or more core characteristics.Each core characteristic contains individual self assessment items to help you evaluate your success withachieving each core characteristic.The 2012 ISMP International Medication Safety Self Assessment for Oncology and its components arecopyrighted by ISMP and ISMP Canada and may not be used in whole or in part for any other purpose or by anyother entity except for the self assessment of medication systems by organizations/practice settings as part oftheir ongoing quality improvement activities. The aggregate results of this assessment will be used for researchand educational purposes only.ISMP and ISMP Canada are not standard setting organizations. As such, the self assessment items in thisdocument are not purported to represent a minimum standard of practice and should not be considered as such.In fact, some of the self assessment items represent innovative practices and system enhancements that arenot widely implemented in most organizations/practice settings today. However, their value in reducing errors isgrounded in scientific research and/or expert analysis of medication errors and their causes.mssa.ismp-canada.org/oncologyCopyright 2012 Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada. All Rights Reserved.7

InstructionsIt is important for each hospital or ambulatory site in a multihospital or ambulatory system to complete the selfassessment individually.1. Establish an interdisciplinary team consisting of, orsimilar to, the following: Senior administration representativeChief medical officerNurse executiveDirector of pharmacyChief information officerClinical information technology specialistMedication safety officer/managerRisk management and quality improvementprofessionals At least two staff nurses working in oncology careareas At least two staff oncology pharmacists (oneclinical and one distribution) At least one active oncology staff physician.It is helpful to appoint a team leader to coordinatethe process. Other practitioners and staff (e.g.,biomedical personnel, certified nurse practitioners,receptionists) may need to join the core team forevaluation of certain sections of the self assessment.The team leader should provide copies of the selfassessment tool, FAQs and Key Definitions to allteam members for review before the first meeting.In the electronic version, FAQ information and KeyDefinitions can be accessed by hovering over theFAQ icon or the defined item (shown in small capitalletters).3. Verify your demographic information.Before the first team meeting, the team leadershould review and verify the responses in thedemographics section with the administration of thehospital/ambulatory organization/practice setting asdiscussed in the FAQs.4. Convene the team.During the assessment meetings, ensure thateach team member can view either a hardcopy orelectronic version of the self assessment. There area couple of options for completing the assessment:Your team should be provided with sufficient timeto complete the self assessment and be chargedwith the responsibility to evaluate, accurately andhonestly, the current status of medication practicesas they relate to oncology in your facility. Becausemedication use is a complex, interdisciplinaryprocess, the value and accuracy of the selfassessment is significantly reduced if it is completedby a single individual or discipline involved inoncology medication use. Based on participantfeedback from prior self assessments, we anticipatethat it will take three team meetings of approximately1 to 2 hours each to complete this self assessment. Option 1: Print hardcopies of the self assessmentto share with team members, manually completethe demographic information, and fill in yourchoice (A through E, or Not Applicable [N/A])for each self assessment item. Once completed,submit your information online at:http://mssa.ismp-canada.org/oncology. Option 2: Use the online self assessment form toview at team meetings, complete the demographicinformation, and enter your choice (A through E,or Not Applicable [N/A]) for each self assessmentitem, saving your username/password-protecteddocument at the end of each meeting. (Pleasesee Step 8 for information regarding accessingthe online self assessment form and obtaining ausername and password.)2. Read and review the self assessment in its entirety,including the instructions, Key Definitions, andFrequently Asked Questions (FAQs) before beginningthe assessment process.5. Discuss each core characteristic and evaluate theorganization’s/practice setting’s current successwith implementing the self assessment items withinthat core.mssa.ismp-canada.org/oncologyCopyright 2012 Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada. All Rights Reserved.8

Instructions (continued)As necessary, investigate and verify the level ofimplementation with other healthcare practitionersand staff outside your core assessment team. Whena consensus on the level of implementation for eachself assessment item has been reached, select theappropriate checkbox (A through E, or Not Applicable[N/A]), using the following scoring key and guidelines:Scoring KeyA. There has been no activity to implement this item.B. This item has been formally discussed andconsidered, but it has not been implemented.C. This item has been partially implemented in theorganization for some or all areas, patients, drugs,and/or staff.D. This item is fully implemented in the organizationfor some or all areas, patients, drugs, and/or staff.E. This item is fully implemented throughout theorganization for all patients, drugs, and/or staff.N/A. (Not applicable) will be available as an optionfor specific questions.Organizations may want to consider assigning anindividual to record any discussion generated aroundeach self assessment item and the rationale behindthe selected choice. This information, meant forinternal use only, can assist the team when reviewingscores for individual items or reassessing yourorganization at a later date and will provide insightinto why the choice selected for each self assessmentitem was chosen.Scoring Guidelines For all self assessment items: Self assessmentitems refer to chemotherapy/biotherapy medicationsprescribed, dispensed, and administered to allinpatients and outpatients for both the treatment ofoncology and non-oncology disease processes (e.g.,methotrexate for rheumatoid arthritis or psoriasis). For all self assessment items: Choice of E(full implementation) is appropriate only if allcomponents are present in all areas of theorganization, for all patients, all medications,and followed by all staff. If only one or some ofmssa.ismp-canada.org/oncologythe components of the item have been fullyimplemented in only some or all areas of theorganization, your self assessment choice shouldbe D. For self assessment items with an option of“Not Applicable” (N/A): Select “Not Applicable”(N/A) only if the item does not correspond toany services you provide in your organization/practice setting. N/A responses are scored thesame as answering B (This item has been formallydiscussed and considered, but it has not beenimplemented).6. Repeat the process outlined in Step 5 for all selfassessment items.7. If you have questions: Refer to the FAQs and KeyDefinitions – these are directly linked in the onlineform and identified in the PDF version via anFAQ icon or use of small capitals font for the KeyDefinitions.For additional questions, contact ISMP atoncselfassessment@ismp.org or call 001 215 9477797 from 9 am – 5 pm (Eastern Daylight-SavingTime). If you are experiencing technical difficultieswith the online assessment portal, contact ISMPCanada at: mssa@ismp-canada.org.8. To submit your final completed assessment or to useOption 2 to complete the assessment, go to http://mssa.ismp-canada.org/oncology, and click on thelink to register.See the next section, Instructions for Entering andSubmitting Information to ISMP/ISMP Canada, forfurther information about obtaining a username andpassword, entering your information, and submittingyour completed assessment.9. Once you have entered and submitted yourinformation online, you will be prompted to print areport which will summarize your results. This isexplained in detail in the next section.Copyright 2012 Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada. All Rights Reserved.9

Instructions for Entering and Submitting Information to ISMP/ISMP Canada1. To access the oncology self assessment webpage.From any computer with Internet capability, go to:http://mssa.ismp-canada.org/oncology to accessthe 2012 ISMP International Medication SafetySelf Assessment for Oncology webpage. Thiswebpage will provide all the links you need to printand view the assessment, register, complete the selfassessment, submit your information, and viewyour results.2. To register.Once the assessment webpage has been accessed,you will see two blue boxes at the top of the page;one for “New User Registration” and the other for“Existing User Login.” To register, click on the “NewUser Registration” box to open the registrationpage. You will be prompted to select a usernameand password. You then have the option to providean email address to be used only if necessaryfor password recovery. You have a further optionto provide your full contact information so thatinformation can be retrieved by ISMP in theevent that you lose your login details. If you havenot provided your email address or full contactinformation, ensure you record your usernameand password, and keep them in a safe place. Yourusername/password is required to: Enter your information into the online selfassessment form; Save your entered information and return tothe online form at a later time to complete theassessment; Submit your completed self assessment to ISMP;and View and print a report of your self assessmentwith scoring once it has been submitted.3. To enter assessment information. Entering data: Once you are logged in, you canstart entering data and saving your responses.mssa.ismp-canada.org/oncologyYou can maneuver through the tool by using thedark blue tabs at the top of the screen that relateto each section (Demographics, I, II, III, etc.). Youcan also move from section to section by usingthe “Next Section” or “Previous Section” tabsthat appear at the bottom right of the screen. Saving data: You can click on the “Save” buttonat the bottom left of the screen any time afterdata has been entered. You can always go backand edit your responses and click the save buttonagain to update your information. To exit theonline form, click on the “Logout” button foundat the top right of the page. In order to return toyour saved information, you will need to go to thehomepage and click the “Existing User Login”box, and then enter your username/password. Check MSSA for Errors: You can click on thisbutton (located near the “Save” button at thebottom left) at any time to see which items in thedemographics section have not been answeredor which other sections are incomplete. If all theitems in the section have been answered, a greencheck mark will appear next to the section tab atthe top of the screen.4. To submit your completed assessment.Once all the items have been answered and saved,a message box will pop up telling you, “The MSSA isnow complete. Do you want to submit the results toISMP Canada?” You can click OK to submit your selfassessment responses or Cancel to go back to thetool. If you select OK: Your responses will be submitted– you will NOT be able to make any changes toyour information if you select OK. If you select Cancel: Your responses will besaved, but you can still go back and makechanges. You can even log out and log back in tomake changes. If you saved your changes and did not submit yourresults, the Check MSSA for Errors button will sayCopyright 2012 Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada. All Rights Reserved.10

Instructions for Entering and Submitting Information to ISMP/ISMP Canada(continued)Submit MSSA results unless you make changes. Ifyou do not make any changes, click on that buttonto submit your responses. If you make changesand save them, the pop up box will come up againtelling you the assessment is complete and willask if you want to submit your results.5. To generate your report.Once you have submitted your completed selfassessment, a message box will appear stating thatthe MSSA has been finalized. At this point you canview your responses but you will not be able to makeany changes.You will be prompted to print a report of yoursubmitted self assessment with your answers andnumerical scores for each of the self assessmentitems, subtotals for each of the core characteristicsand key elements, and a total score for the entireself assessment. Note that the scored report will beapproximately 20 pages in length.If you have not supplied your email or full contactinformation to obtain a lost or forgotten username/password, ensure that this report and yourusername/password are maintained in a safelocation so you can compare your organization’s/practice setting’s findings with aggregate data fromsimilar sites when it is available, or to use yourresults to compare against future results of yourorganization.Explanation of ScoresThe assessment items have been scored as follows:A. Score 0There has been no activity to implementthis item.B. Score 1This item has been formally discussedand considered, but it has not beenimplemented.C. Score 2This item has been partially implementedin the organization for some or all areas,patients, drugs, and/or staff.D. Score 3This item is fully implemented in theorganization for some or all areas,patients, drugs, and/or staff.E. Score 4This item is fully implemented throughoutthe organization for all patients, drugs,and/or staff.N/A. Score 1(Not applicable)At any time after submitting your information, youcan enter your username/password to view and/orprint your self assessment report. However, you willnot be able to make any changes to the informationyou originally submitted.mssa.ismp-canada.org/oncologyCopyright 2012 Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada. All Rights Reserved.11

Instructions for Entering and Submitting Information to ISMP/ISMP Canada(continued)Access to Comparative ReportsShortly following the final submission date ofthe 2012 ISMP International Medication SafetySelf Assessment for Oncology, ISMP and ISMPCanada will prepare and make available to thoseorganizations that participated, a PreliminaryAggregate Results workbook with comparativereports of the level of medication safety practicesbased on the data submitted. Access to theseaggregate comparative reports will be availableusing the same password you used when enteringand submitting your information. In addition, furtheranalysis of the data will be completed, and theresults will be submitted for publication in a peerreviewed journal.Security and Protection ofSelf Assessment Information Submittedto ISMP/ISMP CanadaAll information submitted to ISMP and ISMP Canadais maintained in a secure database maintainedsolely by ISMP Canada. The application does notallow viewing of data or demographic informationassociated with individual assessment information.All information is contextually de-identified, andthe demographics and submitted results will beused only for aggregate data reports. Usernames/passwords required for submitting information toISMP are self-selected by the organization/practicesetting participating in the self assessment. Accessto any contact information voluntarily provided by theorganization (i.e., email address for lost or misplacedpassword only) is restricted to a small numberof ISMP Canada personnel and confidentiality isassured.In addition to the usual high standard ofconfidentiality associated with any informationsubmitted to ISMP and ISMP Canada, we wouldalso like to remind participants that ISMP is afederally certified patient safety organization (PSO)in the United States. If self assessment informationis collected within the hospital’s patient safetyevaluation system and submitted to ISMP aspatient safety work product, the information isgranted protection from discovery in connectionwith a federal, state, or local civil, administrative, ordisciplinary proceeding. No contract with ISMP isrequired for this legal protection. Further guidelinesregarding submitting information to ISMP as a PSOcan be found anada.org/oncologyCopyright 2012 Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada. All Rights Reserved.12

DemographicsFAQ - Please see the FAQs for information about completing the demographic information.1a. Country1b. Province/State/Region/Territory2. Please check the one category that best describesthe location of your organization/practice setting.Urban(a population of approximately 50,000 or more)Rural(a population less than 50,000)3. Describe your organization/practice setting(s).(If you have multiple practice settings, pleasecomplete a separate assessment for each settingthat follows different procedures/processes foroncology medications.) FAQInpatient3a. Total bedsLess than 100100 to 299300 to 499500 and over3b. Percent oncologyLess than 25%25% to 49%50% to 74%75% to 100%Outpatient3c. Total chairs/bedsLess than 1010 to 1920 to 4950 and over3d. Percent oncologyLess than 25%25% to 49%50% to 74%75% to 100%mssa.ismp-canada.org/oncology4. Please estimate your organization’s/practicesetting’s oncology patient population.% - Age 18 or less% - Ag

for Oncology for hospitals, clinics, and office practice settings that offer oncology services. This project was made possible through a grant from the International Society of Oncology Pharmacy . (ISOPP), the American Society of Clinical Oncology (ASCO), and the