| C
= Competency. You must complete
all these competencies by your annual evaluation |
Self-Assessment |
Clinical
Skill Competency |
| |
P |
R |
N |
Validated
Date
Signature |
| C
I. Maintains established organizational and departmental
policies and procedures, objectives, performance improvement
program, safety, environmental and infection control standards,
and patient standards. |
|
|
|
|
| A.
Adheres to all policies and procedures of the organization |
P |
R |
N |
|
|
1. Locates policy and procedure books |
P |
R |
N |
|
|
2. Demonstrates knowledge and appropriate use of telehealth
specific policies and procedures |
P |
R |
N |
|
| B.
Performs safe lifesaving, emergency preparedness, and
environment of care procedures according to hospital/department
procedures/policies |
|
|
|
|
|
1. Maintains BLS/heart saver certification |
P |
R |
N |
|
|
2. Demonstrates/verbalizes appropriate response(s) to
code/emergency situations |
P |
R
|
N
|
|
| A.
Verbalizes correct responses to: |
|
|
|
|
|
1) cardiac arrest |
P |
R |
N |
|
|
2) fire |
P |
R |
N |
|
|
3) bomb |
P |
R |
N |
|
|
4) disaster |
P |
R |
N |
|
|
5) evacuation |
P |
R |
N |
|
|
6) manpower |
P |
R |
N |
|
|
7) tornado warning |
P |
R |
N |
|
| B.
Reviews safety manual annually |
P |
R |
N |
|
| C.
Demonstrates/verbalizes appropriate procedures to use
when handling hazardous materials/wastes |
P |
R |
N |
|
| C
II. Collaborates with other telehealth personnel
to assure successful consultations. |
|
|
|
|
| A.
Completes Telemedicine Intake form. |
P |
R |
N |
|
| B.
Assures appropriate physician credentialing prior to consult. |
P |
R |
N |
|
| C.
Notifies telehealth coordinator and outlying/consulting
physician of request for telemedicine consultation. |
P |
R |
N |
|
| D.
Schedules video conference equipment and room. |
P |
R |
N |
|
| E.
Confirms date, time, transmission, equipment needed, and
staff needs with all clinicians, technical staff, involved
with the consult and the family. |
P |
R |
N |
|
| C
III. Operates telemedicine/video conference equipment
and assists as ordered by the physician during consults
as clinic and programming needs dictate. |
|
|
|
|
| A.
Assures operation and connectivity. |
|
|
|
|
| 1.
Identifies risks and safety factors and demonstrates knowledge,
set-up, correct use, handling, maintenance and trouble
shooting of video conference and peripheral equipment. |
P |
R |
N |
|
|
a. Operates the camera |
P |
R |
N |
|
|
b. Establishes camera pre-sets |
P |
R |
N |
|
|
c. Operates peripheral equipment |
P |
R |
N |
|
| B.
Presents patient to consulting physician(s) as ordered. |
P |
R |
N |
|
| C.
Demonstrates/verbalizes appropriate action to take in
case of a system/utility/transmission failure. |
P |
R |
N |
|
| 1.
Check LCD display to determine if lines are activated. |
P |
R |
N |
|
|
a. If "down" or "out of service" reboot IMUX or disconnect/reconnect
transmission line(s). Redial. |
P |
R |
N |
|
|
b. If "idle" or "ready", reboot main equipment switch.
Redial. |
P |
R |
N |
|
| 2.
Check equipment to assure all cables area connected securely. |
P |
R |
N |
|
| 3.
If above is not successful, contact MGH telehealth staff
or technical consultant for assistance. |
P |
R |
N |
|
| 4.
Reschedule at alternate site/time as situation warrants. |
P |
R |
N |
|
| 5.
Refer patient to the Emergency Department or local physician
as indicated. |
P |
R |
N |
|
| D.
Maintains knowledge of Safe Medical Device Act and reports
as appropriate |
P |
R |
N |
|
| C
IV. Maintains a safe, comfortable, private, confidential,
and therapeutic environment for patients/families
in accordance with hospital standards. |
|
|
|
|
| A.
Maintains confidentiality/privacy of patient and family
by: |
|
|
|
|
|
1. Discussing patient information only with others involved
in the patient's care |
P |
R |
N |
|
|
2. Placing shades over window(s) |
P |
R |
N |
|
|
3. Placing monitors out of view from doors/windows |
P |
R |
N |
|
|
4. Destroying written information used for patient care
that is not a part of the patient record. |
P |
R |
N |
|
| B.
Introduces all personnel at each site in video conference,
identifying their role. |
P |
R |
N |
|
| C.
Monitors and controls the environment |
P |
R |
N |
|
|
1. Regulates temperature as indicated |
P |
R |
N |
|
|
2. Adheres to electrical safety policies and procedures |
P |
R |
N |
|
| D.
Demonstrates appropriate use of methods to prevent the
spread of infection |
P |
R |
N |
|
|
1. Demonstrates correct handwashing technique |
P |
R |
N |
|
|
2. Uses appropriate infection control safety precautions |
P |
R |
N |
|
| A.
Use of gloves when appropriate |
P |
R |
N |
|
| B.
Use of mask when appropriate |
P |
R |
N |
|
| 3.
Demonstrates awareness and implementation of various isolation
precautions |
P |
R |
N |
|
| A.
Standard precautions |
P |
R |
N |
|
| B.
Airborne |
P |
R |
N |
|
| C.
Contact |
P |
R |
N |
|
| D.
Droplet |
P |
R |
N |
|
| E.
Neutropenic |
P |
R |
N |
|
| E.
Verbalizes understanding of blood borne pathogen exposure
plan |
P |
R |
N |
|
| F.
Collaborates with infection control practitioner when
indicated. |
P |
R |
N |
|
| C
IV. Responsible for the
creation, storage, maintenance, and release of medical
records. |
|
|
|
|
| A.
Assures appropriate charting by documenting |
|
|
|
|
|
1. Type of telemedicine consult |
P |
R |
N |
|
|
2. Participants at all sites |
P |
R |
N |
|
|
3. Transmission speed |
P |
R |
N |
|
|
4. Any procedures done or ordered |
P |
R |
N |
|
|
5. Who is responsible for follow up care if any |
P |
R |
N |
|
|
6. Patient/family teaching |
P |
R |
N |
|
| B.
Obtains copy of the consulting (outlying) physician's
dictated report of the telemedicine consult for patient's
medical record as indicated. |
P |
R |
N |
|
| C.
Handles/Stores medical record in a confidential manner. |
P |
R |
N |
|
| D.
Obtains release of medical record as indicated. |
P |
R |
N |
|
| C
V. Assures that patient
and significant other are informed regarding the video
system, capabilities, and the process that will take place
to include the risks and benefits of telemedicine. Assures
that informed consents are obtained. |
|
|
|
|
| A.
Respects patient rights |
|
|
|
|
|
1. Demonstrates awareness of the individual rights of
the patient regarding cultural, religious, and ethical
values. |
P |
R |
N |
|
|
2. Verbalizes understanding of functions of hospital ethics
mechanism |
P |
R |
N |
|
|
3. Explains telemedicine process to patient/family prior
to the video conference, to include the risks and benefits
of telemedicine |
P |
R |
N |
|
|
4. Informs patient/family that they have the right to
stop the video conference at any time and ask to see their
physician in person. |
P |
R |
N |
|
|
5. Obtains consent for telemedicine prior to the video
conference. |
P |
R |
N |
|
| F.
Obtains consent for taping for all video taped consults. |
P |
R |
N |
|
| C
VI. Assists in the data
collection, evaluation, reporting, and performance improvement
activities as they apply to telehealth. |
|
|
|
|
| A.
Uses standardized tools to log and report video conference
activity. |
P |
R |
N |
|
| B.
Uses standardized tools to collect evaluation data. |
P |
R |
N |
|
| C.
Communicates with MGH telehealth staff regarding utilization. |
P |
R |
N |
|
| D.
Communicates with administration regarding VCS/Telemedicine
usage and reports. |
P |
R |
N |
|
| E.
Provides other data and information on VCS/Telemedicine
usage as requested for grant related reports and system
evaluation. |
P |
R |
N |
|
| C
VII. Enhances professional growth and development
through participation in educational programs, current
literature, and inservices |
|
|
|
|
| A.
Attends telehealth coordinator meetings |
P |
R |
N |
|
| B.
Updates telemedicine knowledge by reading circulated literature |
P |
R |
N |
|
| C
VIII. Performs other duties as assigned or requested. |
P |
R |
N |
|