OCCUPATIONAL MEDICINE PROGRAM ASSESSMENT (OMPA) IMPLEMENTATION & SUSTAINMENT GUIDE FY 2014

Transcription

1 OCCUPATIONAL MEDICINE PROGRAM ASSESSMENT (OMPA) IMPLEMENTATION & SUSTAINMENT GUIDE FY 2014

2 INTRODUCTION 1. Requirement. To comply with requirements of OPNAVINST series, the Bureau of Medicine and Surgery (BUMED) has developed the assessment method titled Occupational Medicine Program Assessment (OMPA). The development of the assessment tools are on-going and are completed as a collaborative effort between the Navy Medicine Regions (East and West) and the Navy and Marine Corps Public Health Center (NMCPHC). Changes from previous years implementation have been made that have resulted in major program improvements and functions. 2. Purpose. The purpose of the OMPA is to conduct a non-punitive, continual, and systematic self-assessment of each Occupational Medicine program and to identify program strengths and weaknesses and support Process Improvement Plans (PIP). Clinic performance should conform to program goals and mandated requirements in order to reduce work-related risk, improve worker health, prevent premature disability and mortality, facilitate a rapid and safe return to work, provide superior services for all health care rendered and improve staff environment. The Program Status Dashboard key is intended to provide a color-coded (green-amber-red) picture of each OM program to aid nurses and Consultants in program improvement measures. 3. Goal. The goal of this OMPA Program is to standardize the requirements, assessment, and measures of success across all US Navy s Occupational Medicine programs regardless of their location. Ultimate implementation and changes made to this program for a local command or clinic is at the discretion and/approval from the cognizant Regional OM Program Manager. 4. Process. There are 4 parts to this process (overview is provided on the following page): PART I -- Select applicable and current Occupational Medicine (OM) programs for selfassessment via the OMPA Checklist/Status tool. PART II -- Conduct self-assessment program review utilizing pre-approved OMPA sheets or other Regional OM Program Manager approved methods to collect data to support and validate each programs status. New sheets are being developed and will posted to the BUMED SharePoint program as they become available Forms/AllItems.aspx NOTE: To access BUMED SharePoint you must select your certificate on your CAC badge. PART III -- Develop Process Improvement Plans (PIP) as needed for any program(s) with status icon of amber or red. PART IV-- Report and brief command, regional, and other leadership levels on overall OM program successes/challenges via approved scoring grid and other presentation tools.

3 Identify applicable programs using the OMPA Checklist/Status Tool Include any programs that are unique to your location Review and complete the OMPA tool (if available) or other approved method on each applicable program selected on the checklist. Program Deficiencies Identified? Yes Document comments for noted program deficiencies in the section provided on the applicable OMPA tool or other assessment method. No Assess each program using the criteria defined on the OMPA tools or by using the information contained in this guide. Status of amber or red? No Yes Develop detailed Performance Improvement Plan (PIP) for each program with amber or red status icons. Maintain updates as directed. Enter each program status icon onto the combined OMPA Checklist/Status tool. Establish a schedule for re-assessment (at least annually or as directed by local program manager or Regional Nurse Complete the Process: Brief Command Leadership (DH, Dir, XO, and CO) for resource and support at least annually

4 PART I Select programs for review OMPA PROGRAM CHECKLIST/STATUS TOOL Using the OMPA Program Checklist/Status Tool provided at the beginning of the current FY, select all of those programs that represent the services provided by your OM clinic or facility. o All applicable programs must be reviewed at least annually. o If there is no available pre-approved OMPA tool for a program you choose, please enter the name of your program for review into one of the available empty boxes. Program suggestions may be offered as options to select in the form of a drop-down list, but all entries may be typed as you elect. Save your completed OMPA Program Checklist/Status Tool to a file on your computer to provide to your local command OM Consultant or Regional OM Program Manager and to use as part of your validation tools for this program PART II Conduct self-assessments to collect and validate data to support your score OMPA Self-Assessment Tools are designed to provide a concise standardized summary of each program based upon the specific program Federal, DOD, and Navy statutes, regulations, instructions, and guidance in a specific easy to use format. Additional OMPA Self-Assessment Tools are under construction for applicable programs as quickly as possible. o Previous tools no longer available: Program 08 Occupational Health Overview (deleted) Program 18 Hearing Conservation Program (HCP) o Currently available pre-approved sheets include: Program 02 Responsibilities per OPNAVINST series Program 03 Staffing per OPNAVINST series Program 06 Training Program 09 Worksite Visits and Inspections Program 23 Ergonomics Program (Medical Components) Program 28 Bloodborne Pathogens Surveillance Program Program 29 Reproductive Hazard Medical Surveillance Program Program 33 Latex Medical Surveillance Program Program 42 Tuberculosis Screening Program Program 43 General Certification Exam Program Program 44 General Surveillance Exam Program Program 47 Cadmium Medical Surveillance Program Program 50 OM Records Management Program

5 o If no program tool is available for the program you are assessing please contact your local OM Consultant or Regional OM Program Manager for the appropriate method required for review. You are required to maintain all supplemental documents such as record audits, checklists, and databases that validate your responses on each tool. You may also need to present these during an assist visit or inspection. SPECIFIC PROGRAM TOOLS with PIP UPDATES Standardized format and approved questions from all Navy Medicine Regional OM Program Managers. More sheets may be added a varying intervals. If there is no pre-approved program sheet for use, refer to your local OM Consultant or Regional OM Program Manager for assessment requirements. o Definitions of the purpose and goal of the program identified. o A listing of required references (with hyperlinks as available) that defines or describes the program requirements. o Specific target questions that establish and validate OM clinic compliance with the required references. o Some questions with OPNAV or Navy Medicine specific formulas may be automatically programmed for ease of use. o Compliance criteria that more clearly defines program quality using color-coded icons. o Available space to provide Performance Improvement Plan (PIP) updates. o Instructions for saving the document to your own files. o Easy to use Print features o Program Improvement Plan (PIP) section for initial implementation and updates for programs with a score of amber or red. PART III Program successes and Process Improvement Plans (PIP) development COMPLIANCE STATUS DETERMINATION Each OMPA tool will take compile and average of the selected responses throughout the assessment and assign it a value based on the descriptions below: Note the additional PIP and/or assist visit requirements listed in the grid above for scores of amber or red.

6 PROGRAM IMPROVEMENT PLANS (PIP) Program Improvement Plans (PIPs) are more detailed than the OMPA tools and establish specific goals for your individual clinic s program needs or deficiencies. o Sample Plans for Improvement may be requested from your local OM Consultant or your Regional OM Program Manager. o Your Command may already have a prescribed format that is used locally at your command in additional to this PIP format. Check with the responsible department Quality Management, Risk Management or Performance Improvement Coordinator within your facility for details or requirements. o PIPs should include: Specific taskings and goals including time lines and re-assessment dates Equipment purchases and Training or staffing needs Any other necessary requirement to support the improvement to your program Each OM clinic or facility should follow the guidance provided by the local OM Consultant or Regional OM Program Manager to establish a follow up schedule for PIP updates (bimonthly, quarterly, etc.) Follow-up reports are submitted as directed by the local OM Consultant or Regional OM Program Manager. RE-ASSESSMENT SCHEDULE All programs must be reviewed at least annually or as directed. The local OM Consultants or Regional OM Program Managers will establish criteria for more frequent reviews (semi-annual, quarterly, etc.) which may be based on : o Program (Self-Assessment) Scores of amber or red o Specific program target needs o Program of special interest or high visibility at the activity o Navy-Wide Regional or BUMED review recommendation PART IV Report and brief leadership on program status ANNUAL COMMAND LEADERSHIP BRIEFING Annually the OMPA is to be briefed to your command leadership. o This briefing provides the opportunity to inform the command of the strengths and weaknesses of the OM program and Program Improvement Plans.

7 o This is the time to identify any needed support or resources needed for successful program improvement. o Briefing should include: Overall program score Highlights of the program Successes and challenges (with recommendations for improvements) Status of any PIPs The briefing specifics of this can be determined at the MTF level but should include the OM Department Head, the Director and CO or XO. o Some Commands also chose to include the Environment of Care Committee in this briefing. ADDITIONAL INFORMATION and SUGGESTIONS Remember to make your self-assessment specific to your local area and population. You may need to add references or resources (example: MOUs/ISSAs, contractor agreements, Foreign National regulations and requirements, etc ) to make your self- assessment complete. Be sure to save a copy of each tool upon updating the information to better show your progress. Remember to keep all documents that validate your response and status icons (medical record audit trails, program checklists, program databases, etc.) for review by the Regional Nurse or IG. Consider assembling OMPA in 3-ring binders to store any required documents or logs. o If you choose electronic storage methods, be prepared to print copies for review or inspection upon request. Questions, concerns, and/or problems with content or validation should be directed to your local OM Consultant or Regional OM Program Manager. Questions, concerns, or problems with technical form processing and/or format should be forwarded via to: denise.mullins@med.navy.mil Suggestions for improvements or enhancements may be forwarded to any Regional OM Program Manager or denise.mullins@med.navy.mil