Clinic-Protocol-Manual

Clinic Protocols
for Quality and

Risk
Management
Page intentionally left blank
2
STATEMENT OF APPROVAL
COMMUNITY HEALTH CENTER

QUALITY IMPROVEMENT MANUAL
Plan Approval – FY 2015-2016
This signifies that the Quality Improvement Plan for Community Health Center was reviewed and
approved by the Board of Directors as part of the overall annual grant application review process.
Approval Date: July 6, 2016
Medical Director: Danielle Darter, M.D.
QI Coordinator: Stephanie Bunch
Deputy Health Director/COO: Jennifer Greene, MPH
Health Director/CEO: Beth Lovette, RN, BSN, MPH
QI/QA Committee Board Members: Bob Edwards, Chairperson, Partners in Public Health
Erin Torres, Patient Board Member, Partners in Public Health
3
Page intentionally left blank
4
Table of Contents
STATEMENT OF APPROVAL
QUALITY IMPROVEMENT PLAN AND COMMITTEE DESCRIPTION
MEDICAL RECORDS
PROTOCOL FOR MID-LEVEL PROVIDERS
PATIENT SATISFACTION
PATIENT SATISFACTION SURVEY
PERINATAL LOG
IMMUNIZATIONS
PEDIATRIC DENTAL HYGIENE
GROWTH, DEVELOPMENT, AND ANEMIA SCREENING PROTOCOL
CERVICAL CANCER SCREEN PROTOCOL
DIABETES PROTOCOL
HYPERTENSION PROTOCOL
ASTHMA
NATIONAL ASTHMA EDUCATION AND PREVENTION PROGRAM:
DEPRESSION
Patient Health Questionnaire – PHQ-9
CARDIOVASCULAR DISEASE
CORONARY ARTERY DISEASE: LIPID THERAPY
ADULT WEIGHT SCREENING
TOBACCO USE SCREENING AND CESSATION INTERVENTION
COLORECTAL SCREENING
EMERGENCY PLANS AND PROCEDURES
ASSESSMENT OF PATIENTS POLICY
CONTINUITY OF CARE PLAN
CARE OF PATIENTS POLICIES
PATIENT SPECIFIC INFORMATION (MEDICAL RECORDS)
AGGREGATE DATA & INFORMATION
KNOWLEDGE BASED INFORMATION
COMPARATIVE DATA & INFORMATION
5
QUALITY IMPROVEMENT PLAN AND COMMITTEE DESCRIPTION
A. PURPOSE: To ensure quality of care and operations for the organization.
B. METHOD: A Quality Improvement Committee will oversee a comprehensive quality improvement plan,
which will be developed with the input from all personnel and will be implemented by all personnel.
C. THE QUALITY IMPROVEMENT COMMITTEE: The QI committee will meet on a quarterly basis or as
needed, and will be made up of permanent and rotating members. As much as is possible there will be a
representative from each clinical site on the QI committee.
Permanent Members:
Quality Improvement Coordinator (Chair)
Medical Director (Vice-Chair)
Director of Nursing
Practice Administrator
Rotating Members, minimum composition:
One nurse (MAs, LPNs, or dental assistant)

One secretary
The rotating members will serve a two-year term with no more than five members rotating off in any given
year. Other personnel may meet with the QI Committee as necessary when particular QI items are on the
agenda. For example, a member of the dental staff may meet with the QI committee when a dental audit
is presented. The rotating members will be personnel who have shown a commitment to quality patient
care and will be chosen by the QI committee.
The Quality Improvement Coordinator is designated as chair, and Medical Director as Vice-Chair, of the
QI committee and one of the two will report to the Board on a quarterly basis regarding QI activities.
D. QUALITY IMPROVEMENT PLAN: The QI plan will include QI items from the following areas in order
to ensure comprehensive quality of care and operations:
1. Clinical-Medical/Dental.
81717632. Credentialing/Continuing Medical Education
81717633. Safety
81717634. Ancillary services - laboratory, x-ray, EKG, etc.
81717635. Administrative/Clerical
81717636. Patient Satisfaction/Patient Rights & Responsibilities
E. AGENDA: The agenda of the QI committee will be determined by a schedule of audits and reviews
that will occur throughout the year in the various areas that the QI committee oversees. On a yearly
basis, the QI items will be reviewed by the QI committee and a plan for the coming year will be developed
with new items inserted and old items deleted, based on the needs of the organization.
6
F. THE QUALITY IMPROVEMENT PROCESS: The QI committee is responsible for general oversight of
the QI plan. Specifically, the QI committee makes sure that where there are deficiencies, corrective
action is taken and the deficiencies are followed up. However, the responsibility for the actual
implementation of the plan and implementation of corrective action will rest with personnel throughout the
organization whose job description includes that area of responsibility. For example: Implementation and
corrective action in clinical areas is the responsibility of the individual clinical supervisor, i.e., the physician
or dentist for the particular site.
G. SCOPE OF SERVICE: Scope of Service for this organization is fully described in the annual grant
application prepared for the Department of Health and Human Services. A list of required and optional
services provided by this Corporation is attached. In general, AppHealth considers itself as a primary
care organization. It is staffed by a provider base of a family practitioner and mid-level practitioners. The
provision of medical care consists of a full range of primary and preventive care services to all patients.
A list of these services is attached. Some centers provide more services than others, based on the
availability of equipment and trained staff. The Chief Medical Officer has courtesy hospital privileges at
Ashe Memorial Hospital, along with a formal arrangement in place where Hospitalists will admit and
provide inpatient services for our patients.
H. QUALITY IMPROVMENT METHODOLOGY
The Model for Improvement, developed by Associate in process Improvement provides a framework for
developing, testing, and implementing change, and it is a powerful tool for accelerating improvement. The
Model for Improvement is used to successfully improve care processes and outcomes.
What are we trying to accomplish? An organization's response to this question helps to clarify which
improvements it should target and their desired results.
How will we know that a change is an improvement? Actual improvement can only be proven through
measurement. A measureable outcome that demonstrates movement toward the desired result is
considered an improvement.
What changes can we make that will result in improvement? Improvement occurs only when a
change is implemented, but not all changes result in improvement. One way to identif y which change will
result in improvement is to test the change before implementing it.
7
The Plan-Do-Study-Act (PDSA) cycle that tests and implements a change. The PDSA cycle tests a
change by planning it, trying it, observing the results, and acting on what is learned. This is the scientific
method used for action-oriented learning.
The PDSA Cycle starts at the Plan stage. When a QI team o understands the nature of the current
problem, the process that underpins the problem, and has specific ideas about what would mitigate the
problem, it is ready to test changes to that process. The Plan stage helps the QI team to determine this
by working through a set of questions. Before changes are tested, the team should secure the buy -in of
those that will be affected. This ensures staff cooperation and results in an effective test of change.
Testing the change occurs during the Do stage. The QI team tests the change and collects the required
data to evaluate the change. In addition, any problems and observ ations during the test are documented.
In the Study stage, the QI team learns all it can from the data collected during the Do and considers if the
process was improved, objective for improvement and learning objectives. The responses derived from
the Study stage define the QI team's tasks for the Act stage.
The QI team may choose to start again with a new test cycle based on the analysis. If the problem is
unsolved, the team may return to the Plan stage to consider new options.
For most system changes in health care, multiple small tests of change are needed to improve one
system. The Model for Improvement is just one model that can be used to tailor the change to an
organization's system until the predicted improvement is achieved. The PDSA cycle helps an organization
to increase its ability to determine whether a change will have the desired outcome or if it should be
abandoned. For example, a change might be tried in one area of the organization, with one or more
individuals. As learning occurs, the test can be increased. If the test is successful, then the cycle is used
as a framework for implementing knowledge into practice.
Adapted from Institute for Healthcare Improvement
8
I. QUALITY IMPROVEMENT STRUCTURE
Commented [1]: Add Clinic QI to the FQHC block;

also include a communication line to QI
Commented [2]: Makes sense
9
RISK MANAGEMENT POLICY
PURPOSE: The purpose of this policy statement is to declare the basics of a risk management policy for
the organization to include those elements required for coverage of our clinicians under the Federal Tort
Claims Act (FTCA). Furthermore, it is the intention of this document to identify an individual(s) involved in
the risk management function(s) for this corporation, and to identify existing elements of a risk
management plan.
EXISTING ELEMENTS OF THE RISK MANAGEMENT PROGRAM:
1. Quality Improvement Plan- a Quality Improvement Plan is in place, is annually reviewed, and
a part of the on-going operations of this Corporation.
2. Quality Improvement Committee- a Quality Improvement Committee is in place, and is an
integral part of the on-going operations of this Corporation.
3. Credentialing- credentialing of providers that are part of the clinical staff of this organization is
accomplished in accordance with the appropriate sections of the Quality Improvement Plan.
4. Quality Improvement Coordinator- the Quality Improvement Coordinator is designated as the
Chairperson of the Quality Improvement Committee and as such works closely with the Risk
Manager to insure that the clinical aspects of the overall risk management program are
properly accomplished.
5. Insurance Review- the Risk Manager is charged with the responsibility of insuring that the
Corporation’s assets and individuals are properly insured on a continuing basis. This
includes annual reviews of leases, annual equipment audits, and reviews of the overall
insurance needs of all corporation personnel (from a business perspective).
6. Federal Tort Claims Act- The organization will apply to participate in the FTCA, in FY 16-17
following all procedures and meeting all requirements as requested.
CLINICAL STAFF SUPERVISION: Appalachian District Health Department has a formal clinical staff
organization as identified in its organizational chart. The clinical staff is under the direction of a Medical
Director. As such, the Medical Director is the supervisor of each member of the clinical staff. This
includes all physicians, dentists, and mid-level practitioners. The Medical Director reports directly to the
Executive Director/CEO.
10
MEDICAL RECORDS
GOAL: To maintain standardization and legibility of all AppHealth medical records. (Please see approved
policies regarding medical records policy #204, electronic health record #578, internet usuage policy
#829)
METHODS:
A. A patient record (medical or dental) will be prepared for each patient served by this
organization in Patagonia.
B. A standardized format will be used as noted below.
C. Periodic review of these records will be accomplished as part of the Quality Improvement
program.
D. EMR- As available, staff providers are required to enter their notes directly into the Electronic
Medical Record (EMR), in order to maintain them as organized and standardized as possible.
E. Compliance- Standardized, complete, and quality records are an integral portion of
the requirements of the contracts of each provider in the organization. As such,
performance is partially judged on these records.
F. All charts are standardized by the EMR, including the following sections:
a. Current Problems (diagnoses list)
b. Patient History (includes family history, patient history, social history and
procedure history)
c. Patient Prescriptions – Current Medications (medication list)
d. Encounters – All (all visits, chart messages, emails, consults, some reports,
past records)
e. Allergies (current medicine and food allergies)
f. Patient Flags (varied comments, not official part of medical record)
g. Results (results from lab work and imaging procedures)
h. Immunizations (found in NCIR)
G. Current Problems, Current Medications, History, Allergies and Immunizations will
be reviewed and kept current.
H. As a minimum, every patient visit will have an EMR entry, with a nurse entry, at
least one diagnosis regarding the current visit, and any medications prescribed.
I. Providers will finish notes within 72 hours of patient encounter.
J. Charts will be maintained continuously, with no charts left open and unsigned
longer than 30 days.
CHART REVIEWS:
Charts are pulled randomly.
QI review - Annually - 10 charts per full-time provider, 5 charts per part-time provider.
Peer Review - every 6 months, 6 charts per provider.
CMO Reviews - 10% of all mid-level charts.
ACCEPTABLE RATE OF COMPLIANCE:

EMR entry for every patient: 95%
Minimum information per entry: 85%
Problems, medications, allergies and immunizations kept current: 90%
11
PROTOCOL FOR MID-LEVEL PROVIDERS
The following diagnoses or suspected diagnoses should be triaged to the physicians for
evaluation. If the mid-level provider sees a patient that is suspected of having one of these
conditions, then immediate consultation with a physician is required. Consult can be made in
person or using phone, text or email as appropriate.
HEAD
Headache, severe and acute with fever or neurologic changes
Trauma with change in mental status or LOC
EYES
Chemical Exposure
Diplopia
Eye Pain, acute or severe
Foreign Body
Loss of vision, sudden
Trauma, severe
EARS
Fever with bloody discharge
Hearing Loss, sudden
Trauma
NOSE
Epistaxis, uncontrollable
Foreign body
THROAT
Inability to swallow
Pharyngitis with abscess
PULMONARY SYSTEM
Hemoptysis
Respiratory distress, moderate or severe
CARDIOVASCULAR
Abnormal pulse, symptomatic
Chest pain, acute with risk factors
Heart rate <40 or > 150
Pulseless, cold extremity
Syncope
GI
Acute abdomen
Choking
GI Bleeding, acute
Vomiting, protracted
12
GU
Hernia, incarcerated
Inability to void
Priapism
Scrotal pain, acute
GYN
Amenorrhea with severe abdominal pain
Ectopic pregnancy
PID with fever
Vaginal bleeding with pain or dizziness
MUSCULOSKELETAL
Compartment syndrome
Fracture or dislocation
NEUROLOGICAL
CVA
Dementia or confusion, acute
Loss of Consciousness
Meningitis
Mental status change, acute
Seizure, active
PSYCHIATIC
Abuse, suspected
Drug overdose
SKIN
Cellulitis, extensive or severe
ENDOCRINE
Hyperglycemia or hypoglycemia with symptoms
Thyrotoxicosis
MISC
Dehydration in pediatric patient or geriatric patient
Sepsis
Unstable patient
Anaphylaxis
Pain, severe
Fever in child less than 3 months of age
Site liability injury
13
PATIENT SATISFACTION
GOAL: To ensure that our patients needs and desires are met in a professional manner.
METHODS:
1. Patient Satisfaction Surveys are prepared by the Quality Improvement Committee to be
utilized as scheduled by the Committee. A sample is attached.
2. Patients will be encouraged to complete a survey with each office visit.
3. Results will be tallied by the individual centers and compiled by the Chair of the Quality
Improvement Committee for evaluation by the committee.
HOW OFTEN TO AUDIT: Ongoing, with monthly trending.
HOW MANY PATIENTS TO SURVEY: all patients
14
15
16
17
18
19
20
21
22
PERINATAL LOG
Problem: Failure of pregnant patients to obtain adequate prenatal care as reflected by entering into care
within the first trimester results in higher rates of infant mortality. Follow-up after delivery with a newborn
visit is an important tool in health education and disease prevention. A 6-8 week post-partum visit allows
screening for post-partum depression as well as an opportunity to start birth control.
Goal: To reduce preventable causes of death during infancy by providing adequate prenatal care and
appropriate newborn follow-up.
Methods:
1. Document pregnancy with a UCG when indicated. Positive results will be recorded in the
perinatal log.
2. Explain to the patient the importance of early prenatal care. Check with patient to see where
she would like to have OB care and explain the alternatives available. Within two weeks,
make an appointment for initial OB visit as soon as possible.
3. Indigent patients should be referred to the local health department where they can receive
information on WIC and Medicaid applications and free prenatal care.
4. Record in the prenatal log the date, Estimated Date of Confinement (EDC), Gs & Ps, and any
risk factors identified at intake..
5. Check the log monthly to verify and update documented information.
6. from patient where she plans to have her baby followed for health care after delivery and
record in log. This information may not be known at the initial visit, but should be entered in
the log at least two months before the EDC.
7. Arrange to have OB send verification of delivery and record date in log. If verification is not
received within three weeks after the EDC, contact patient.
8. After delivery is confirmed,record infant birth weight and send a reminder to the patient to
have baby evaluated within four weeks. Premature infants and infants that are breast feeding
should be evaluated in one week. Verify that newborn appointment has been kept with
designated provider indicated in log and record information in log.
9. After delivery is confirmed, verify post-partum appointment is scheduled and has been kept
and record in log.
How Often to Audit: Annually
How to Audit: Review the perinatal log since last audit to ensure completeness of all entries to include
date, EDC, Problem list, verification of delivery, planned pediatric visit with confirmation that appointment
kept. Any failures of patient compliance need documentation of attempt to correct the deficiency.
Acceptable Level of Compliance:
1. All entries in the log shall be up to date in 75% of the patients
2. Initial entry into OB care within the first trimester will be indicated in 50% of diagnosed
pregnancies.
3. Newborn follow-up within one week will be done in 50% of patients.
4. Post-partum follup within 2 weeks will be done in 50% of patients.
23
24
IMMUNIZATIONS
Purpose: To reduce morbidity and mortality from diseases that are preventable by
immunizations, namely: diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, H.
influenza, influenza, varicella, pneumococcal pneumonia and hepatitis. Influenza infection and
pneumococcal pneumonia are also important public health problems for adults in our service
area. Over 80% of the excess deaths from pneumonia and influenza in the United States occur
in persons 65 years or older, and a majority of these patients are not properly immunized.
Additionally, two thirds of all cases of tetanus each year occur in people over the age of 50.
Thus, vaccination against influenza, pneumococcal pneumonia and tetanus are an important
part of primary prevention for our adult patients, as well.
Goal: To provide or document adequate immunization for all pediatric, adolescent and adult
patients of AppHealth, according to the recommended schedule published by the CDC.
Method:
1. Provide on-site the following vaccines: DTaP, Hib, HepA, HepB, influenza, IPV, MMR, Td, Tdap,
meningococcal, varicella virus vaccine and pneumococcal vaccine.
2. Administer immunizations by the appropriate schedule as recommended by the CDC for children,
adolescents and adults.
3. Track all patients receiving primary immunizations at AppHealth for the intervals
determined by their age and immunization status at time of first AppHealth
immunization. Document that immunizations are received, or offered and refused, if
patient is deficient in immunizations.
4. Document immunization status of all patients who are active users, but select to receive
their immunizations elsewhere.
5. Verify pediatric patients’ immunization status at 12 months, 24 months, and 6 years old. Those
children who are found to be delinquent will have their immunization status rechecked in 6
months.
6. Check adolescent and adult patients’ immunization status annually, or at next visit if more than
one year has passed, based on the following:
Pneumococcal pneumonia vaccine: One time at 65 years or older, or re-vaccination if first
dose was 5 or more years ago, at age <65.
Influenza vaccine: Age 50 years or older, yearly from October – January.
Tetanus: Once at 11-12 years, then once every ten years.
7. Have in place a management plan to catch up on immunizations, if needed.
8. All vaccines are maintained in NCIR.
How Many Charts to Audit: 10 per FTE provider
Identify Charts: Random for ages 19-35 months, ages 11-18 years and age 65+. Patients will
have been seen within the last 6 months, had at least 3 visits to the office, and have been
patients for at least three months.

Immunizations up to date for 19-35 month-old patients, or a management plan in place if not up
to date: 85%
Immunizations up to date (HepB, MMR, Td) for 11-18 year old patients: 80%
Pneumococcal vaccine documented for patients age 65+: 80%
Influenza vaccine documented for patients age 50+: 80%
25
26
PEDIATRIC DENTAL HYGIENE
Problem: There is a high incidence of poor dental hygiene among children as reflected in numerous
referrals to the dental clinic.
Goal: To reduce dental decay in children
Methods:
1. Patient is identified as pediatric
2. Patient receives counseling re: the recommendation to refrain from giving a bottle at time of
bed, regular teeth brushing from the eruption of the first tooth and to supplement fluoride as
appropriate.
3. Counseling occurs at Well Child Care (WCC) visits, acute visits, or at intervals not to exceed
6 months until the age of two.
4. If the child lives in a non-fluoridated area, the water supply should be tested and then fluoride
supplementation should proceed as follows, based on concentration of fluoride contained in
the water:
Age of Child <0.3ppm 0.3-0.6ppm >0.6ppm

0 to 6 months None None None
6 months to 3 0.25 mg/d None None
years
3 to 6 years 0.50 mg/d 0.25 mg/d None
6 to 16 years 1.0 mg/d 0.50 mg/d None
5. All parents are encouraged to have the child’s first dental appointment soon after first
birthday.
6. Moderate to high risk patients will be referred directly to dentist, if possible.
7. Document that above recommendations are made. Use of EMR template item is adequate.
8. Apply fluoride varnish to all teeth surfaces when applicable. The purpose of applying fluoride
varnish is to prevent, retard, arrest, and/or reverse the process of cavity formation in Infants
and children with a moderate or high risk of developing cavities. Dental fluoride varnish is
start at 6 months and continues until age 3.5 every 6 months.
How Many Charts to Audit: 10 per provider
Identify Charts: Random screen of active patients aged 0-3 years (screen from time 0-2 years)

Documented counseling regarding BBTC and dental hygiene: 75%
Patients age 6 months to 16 years with fluoride assessment documented in the last year: 80%
Patients age 12 to 36 months with 1 or more documented fluoride varnish applications in the last year:
70%
27
GROWTH, DEVELOPMENT, AND ANEMIA SCREENING PROTOCOL
Goal: To adequately assess growth, nutrition, and development in pediatric population.
Objective: To identify, document, and manage problems with growth or developmental progress through
appropriately timed visits and screenings.
Screening Protocol: All children should be seen on a regular basis for the purposes of monitoring
growth and development and providing age appropriate screenings, immunizations, and anticipatory
guidance. All children seen for a well child visit should have:
1. Height, weight, BMI and head circumference (< 3 years of age) measured. This will be plotted
on a standardized growth chart in EMR.
2. Anemia screening once between the ages of 6 to 18 months.
3. Developmental assessment with evaluation of language, social, gross and fine motor
development using center tools (ASQ, MCHAT,HEADS,CRAFT,PHQ9)
Management Protocols:
1. Weight Assessment and Counseling - All children and adolescents aged 3 to 17 will have
a BMI percentile and counseling on nutrition and physical activity documented for the current
year.
2. Growth problem - Any child noted to have an abnormal growth pattern (<5% or >95% height
or weight, head circumference crossing 2 allobars) must have that growth pattern noted in the
chart and a management plan outlined. The management plan should be appropriate for the
abnormal pattern and may include dietary history, assessment of parental growth patterns,
social service evaluation, and nutritionist evaluation, referral to pediatrician or special
evaluation clinic. Monitoring of growth over time should also be evident.
3. Anemia - All children screened between 9 and 12 months. Children receive further screeing
through WIC. Children with a hematocrit <31% or hemoglobin <10.5g/dL should be identified
as anemic and a management plan should be outlined. Presumptive therapy with an
appropriate dose of supplemental iron and adequate follow-up should be instituted if dietary
history or blood smear support the diagnosis of iron-deficiency. Further evaluation should be
outlined if iron deficiency is not suggested by history or if no improvement is noted within two
months of iron replacement.
4. Developmental Delay - Children with delayed development, suggested on the basis of

screenings, should be further evaluated per the center’s protocol and available resources.
Options for further evaluation include referral to a pediatrician; developmental specialist or
developmental evaluation clinic; the local school district and/or CDSA. All children with
abnormalities in growth and development should have close follow-up and tracking as part of
the management plan.
Acceptable Level of Compliance: 80% of charts audited will be in compliance

Charts will be considered in compliance if:
1. There are adequate and regular measurements of height, weight, BMI and head
circumference (<3 years of age).
2. BMI percentile and counseling on nutrition and physical activity are documented for the
current year.
3. A hematocrit or hemoglobin is recorded in the chart.
4. Developmental screening is completed in the well child history and physical section of the
note.
28
5. A management plan must be in place for any abnormalities noted above.
Identify Charts: Randomized sampling of 5 charts per provider of pediatric patients who are age 18-24
months at the time of the review. Patients will have been seen within the last 6 months, had at least 3
visits to the office, and have been patients for at least three months. They will have had at least one well
child visit. Charts audited for immunizations may be used.
How Often to Audit: Once annually if the threshold is met. Repeat in 3-6 months if the threshold is not
met.
29
CERVICAL CANCER SCREEN PROTOCOL
Goal: To reduce the incidence of mortality secondary to undetected or delayed detection of cervical
cancer.
Objective: To promote women’s gynecological health and reduce the risk of mortality secondary to
undetected cervical carcinoma through implementation of Pap smear screening protocols.
Screening Protocol:
1. Regular Pap tests and gynecological exams recommended for all women starting at age 21.
2. Pap tests should be performed at an interval of every 3 years until age 30. If, at that point,
there are no risk factors for cervical cancer and the patient has had three consecutive normal
pap smears, then the test could be performed at an interval of every three to five years. Risk
factors for cervical cancer include:
a) Early onset of sexual intercourse
b) History of multiple sexual partners or partners with multiple partners
c) Low socioeconomic status
d) History of HPV genital infection
e) Previous cervical dysplasia or cancer
f) Tobacco use
3. Pap smears may be discontinued after age 65 years if patient has had two normal
consecutive Pap smears at least one year apart and chooses not to continue cervical cancer
screening.
4. Women who have had complete hysterectomies,( other than for cancer or cervical sparing),
do not need Pap tests but should have yearly breast exams and pelvic exams per the
provider’’s recommendations.
Management Protocols: Pap smears, HPV testing and follow up studies/referrals will be done following
the ASCCP Algorithms. Abnormal Pap smears, including those requiring colposcopy, should be recorded
and dated in the patient history and on the Problem List.

Documentation of a Pap smear in all females ages 21 years to 64 years per ASCCP guideline,
unless documented that the patient has had a hysterectomy or declines exam: 85%
The following will also be reviewed for compliance rate of 65%:

1. Pap smear is reviewed/signed by the provider.
2. Follow up of abnormal Pap smears is per protocol.
3. Diagnoses from abnormal Pap smears that require increased surveillance, colposcopy,
and/or referral are listed in the Patient History and on the Problem List.
4. If a patient refuses to have a Pap smear and this is documented, the chart shall be
considered in compliance.
5. If the patient receives Pap smears elsewhere and this fact is documented with the date of the
last Pap smear recorded, the chart will be considered in compliance.
Identify Charts: Randomized sampling of 5 charts per provider of adult female patients seen within the
previous six months who are between the ages of 21 and 64 years. Patients will have had at least 3 visits
to the office and have been patients for at least 3 months.
How Often to Audit: Once annually if the threshold is met. Repeat in 3-6 months if the threshold is not
met.
30
31
DIABETES PROTOCOL
Goal: To reduce unnecessary death and disability from diabetes.
Methods:
Newly Diagnosed people with diabetes will be seen by MD after initial diagnosis
1. Should have a complete physical examination and lab work-up to include a urinalysis,urine
micoralbumin, complete metabolic profile, fasting lipid panel and EKG if over 40 years of
age.
2. Dietary and lifestyle education, including self-management goals, should be given and
documented.
3. Refer to Diabetes Self Management Program/ Medical Nutrition Therapy.
4. Refer for a diabetic eye exam.
5. Should be started on a low dose ACE/ARB unless clinically contra-indicated
6. Follow-ups should be at least at 3 month intervals until glucose is stable, and should include
A1C if not done in past 3 months.
Established people with diabetes

1. Office visits every three to six months with a review of home blood sugar log. More frequent
visits if patient is symptomatic or abnormalities exist in lab tests.
2. Document foot exam and education of patient to do daily foot exam every routine visit..
3. All patients with diabetes will be on an ACE/ARB unless contraindicated.
4. Yearly fundoscopic exams.
5. Yearly microalbumin urine, repeat in 3 months if abnormal. Any patient with persistently
abnormal urine microalbumin with be referred to nephrology for further evaluation. If
possible, stop any diuretics after first abnormal microabumin.
6. HgbA1C done every 3-6 months depending on how well diabetes is controlled.
7. Exercise and diet education, including self-management goals, at least annually.
8. Target blood pressure to be less than 140/90
9. LDL level will be less than 100mg/dL, consider statin for all patients with diabetes. Check
fasting lipid profile at least once a year.
How Many Charts to Audit: 10 per FTE
Identify Charts: Random screen of people with diabetes who are active users.

Diabetes on Problem list: 90%.
Average HgbA1C <7%: 50%
Documented self-management counseling within the last year: 50%
BP controlled <140/90: 50%
LDL less than 100mg/dL: 50%
Yearly microalbumin: 50%
Dilated eye exam in past year: 50%
Comprehensive foot exam documented at all routine follow up appointments: 85%
32
HYPERTENSION PROTOCOL
Goal: To reduce unnecessary death and disability from uncontrolled high blood pressure.
Methods:
New Hypertensive Patients
1. Blood pressure measurement is made with a properly calibrated and validated instrument with
patient seated quietly for at least 5 minutes in a chair, with feet on the floor, and arm supported at
heart level. At least two measurements should be made. Two readings on separate days of
greater than 150/90 constitute diagnosis of hypertension.
2. Assess risk factors for CAD (family history, DM, cholesterol, smoking, obesity, exercise, alcohol).
3. Document education including low salt diet, weight loss, and exercise.
4. If patient is to be treated with medicines, document that hematocrit, creatinine, cholesterol,
urinalysis have been ordered or done within the last year.
5. Ensure that an EKG has been done within the last five years (if over 40 years of age).
6. If diuretics are to be used, document uric acid, potassium and glucose levels checked within the
previous year.
7. Reduce blood pressure to less than 150/90 for 70% of all patients within 3 months of initial visit.
8. If initial diastolic pressure is greater than 100, consider medical therapy at that time.
Chronic Hypertensive Patients:

1. If on medicines and stable 150/90 or less check blood pressure every 6 months with MD visit.
2. If not on medicines, check blood pressure at least yearly with MD visit.
3. Yearly urinalysis, creatinine, cholesterol (and potassium if on diuretic).
4. EKG every 5 years and fundoscopic exam at least every 2 years (if over 40 years of age).
5. Document patient education for every routine visit.
Identify Charts: Random screen of hypertensive patients who are active users.

Control of blood pressure 150/90 or less: 70%
Two blood pressure readings recorded in the last year: 90%
Document patient education with the last year: 70%
Use of aspirin or other antithrombotic agent if not contraindicated: 70%
33
ASTHMA
Goal: To reduce unnecessary morbidity and disability from uncontrolled asthma.
Methods:
1. Every asthma patient will be classified with the Classification of Asthma Severity scale, or the
Levels of Asthma Control scale.
2. Any patient that is classified with persistent asthma or uncontrolled will be put on the appropriate
anti-inflammatory medication to help prevent inflammation and asthma attacks.
3. Patients will be continually counseled on use of maintenance medications for persistent control of
symptoms vs. use of short-acting rescue medications for acute symptom relief.
4. Patients will be encouraged to notice, and further avoid environmental triggers like cigarette
smoke and other irritants.
Identify Charts: Random screen of asthma patients who are active users.

Percent of patients with severity and/or level of control assessment at last contact (phone or visit): 70%
Percent of patients with NHLBI classification of persistent asthma on anti-inflammatory medication: 70%
Documented self-management counseling within the last year: 70%
Number of symptom-free days in the past 2 weeks {14 – days (24hrs) of symptoms in last 2 weeks} : >10
days: 70%
34
NATIONAL ASTHMA EDUCATION AND PREVENTION PROGRAM:
Classification of Asthma Severity
Classification* Symptoms† Night symptoms Lung function
Step 1: mild Symptoms occurring twice a Symptoms occurring FEV1/FVC is 80% or

intermittent asthma week or less no more than twice a more of predicted
No symptoms and normal month
PEF between exacerbations PEF variability of less
Brief exacerbations (lasting a than 20%
few hours to days) with
variable intensity
Step 2: mild persistent Symptoms occurring more Symptoms occurring FEV1/FVC is 80% or
asthma than twice a week more than twice a more of predicted
Exacerbations may affect month
activity PEF variability of 20 to
30%
Step 3: moderate Daily symptoms Symptoms occurring FEV /FVC is greater
1
persistent asthma Daily use of inhaled short- more than once a than 60% but less than
acting beta agonist week 80% of predicted
Exacerbations affect activity
Exacerbations occur more PEF variability of greater
than twice a week and may than 30%
last for days
Step 4: severe Continual symptoms Frequent symptoms FEV1/FVC is 60% or less
persistent asthma Limited physical activity of predicted
Frequent exacerbations PEF variability of greater
than 30%
*The initial classification is based on the presence of certain clinical features before treatment. The presence
of one of the features of severity is sufficient to place a patient in that category. A patient should be assigned
to the most severe grade in which any feature occurs. The characteristics noted in this classification are
general and may overlap because asthma is highly variable. Furthermore, a patient's classification may
change over time.
†--Patients at any level of severity can have mild, moderate or severe exacerbations. Some patients with
intermittent asthma have severe and life-threatening exacerbations separated by long periods of normal lung
function and no symptoms.
35
Classification of Asthma Control
Classification of Asthma Control

Components of Control
Well-Controlled Not Very Poorly
Well-Controlled Controlled
Symptoms ≤2 days/week >2 days/week Throughout the day
Nighttime awakening ≤1x/month ≥2x/month ≥2x/week
Interference with normal

None Some limitation Extremely limited
activity
Impairment Short-acting beta2-agonist
use
≤2 days/week >2 days/week Several times per day
for symptom control (not
prevention of EIB)
>80% predicted/ 60−80% predicted/ <60% predicted/
● FEV1 or peak flow
personal best personal best personal best
● FEV1/FVC
>80% 75-80% <75%
0−1/year ≥2/year (see note)
Exacerbations
Consider severity and interval since last exacerbation
Progressive loss of lung

Evaluation requires long-term followup care
Risk function
Medication side effects can vary in intensity from none to very

Treatment-related adverse troublesome and worrisome. The level of intensity does not
effects correlate to specific levels of control but should be considered
in the overall assessment of risk.
Modified from the National Heart Lung and Blood Institute Clinical Practice Guidelines, Sect. 3, Component 1: Measures of
Assessment and Monitoring, http://www.nhlbi.nih.gov/guidelines/asthma/04_sec3_comp.pdf
*ACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma.
Key: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second.
Notes:
● The level of control is based on the most severe impairment or risk category. Assess impairment
domain by caregiver’s recall of previous 2–4 weeks. Symptom assessment for longer periods should
reflect a global assessment, such as inquiring whether the patient’s asthma is better or worse since
the last visit.
● At present, there are inadequate data to correspond frequencies of exacerbations with different levels
of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent ,
unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment
purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year
36
may be considered the same as patients who have not-well-controlled asthma, even in the absence
of impairment levels consistent with persistent asthma.
DEPRESSION
Problem: Depression is a very common and debilitating problem, seen in 5-13% of patient visits to
primary care providers.
Goal: To better identify and treat AppHealth patients who suffer from clinically significant depression
(CSD).
Methods:
1. All patients 13 years and older will be screened for depression with two simple questions(PHQ-2):
Have you lost interest or pleasure in things you usually like to do?
Have you felt sad, low, down, depressed or hopeless?
Yes to either question triggers completion of a PHQ-9 form and a more detailed investigation.
2. Recognize individuals at high risk for depression
• Chronic insomnia or fatigue
• Chronic pain
• Multiple or unexplained somatic complaints, “thick charts”
• Chronic medical illnesses (e.g., diabetes, arthritis)
• Acute cardiovascular events (myocardial infarction, stroke)
• Recent psychological or physical trauma
• Other psychiatric disorders
• Family history of mood disorder
3. Each patient with a PHQ 2 score > 0 will receive the Patient Health Questionnaire (PHQ-9).,
when possible. The PHQ-9 score will be obtained and documented.
4. Once depression is diagnosed, therapy can be initiated, whether it consists of psychotherapy,
medications,counseling or all three.
5. Suicide risk will be assessed regularly throughout the course of treatment, including consultation
with family and friends where appropriate. Agitation and suicide risk may increase early in
treatment. The following will be used to screen for suicide risk:
● Ask all depressed patients if they have thoughts of death or suicide, or if they feel
hopeless and feel that life is not worth living. Also ask if they have previously attempted
suicide.
● If the answer is yes, ask about plans for suicide. How much have they thought about
suicide? Have they thought about a method? Do they have access to material required
for suicide? Have they said goodbyes, written a note or given away things? What specific
conditions would precipitate suicide? What is stopping them from suicide?
● Assess risk factors for suicide:
Psychosocial - indeginous, male, advanced age, single or living alone
History - Prior suicide attempt, Family history of suicide, Family history of substance
abuse, history of abuse/neglect
Clinical/Diagnostic – hopelessness, psychosis, medical illness, substance abuse
● Consider emergency psychiatric consultation and treatment if:
– Suicidal thoughts are persistent
– The patient has a prior history of a suicide attempt or a current plan, or
– The patient has several risk factors for suicide
6. Patient will be seen in close follow-up (2-4 weeks) for re-evaluation.
7. Target length to be on antidepressant is 12 months, to minimize possibility of relapse.
37
38
How Often to Audit: Annually.
Identify Charts: Random screen of patients who are active users.

Percent of patients screened with PHQ-2: 70%
Percent of patients with positive PHQ-2 that have completed PHQ-9: 70%
39
Patient Health Questionnaire – PHQ-9
PATIENT NAME DATE
1. Over the last 2 weeks, how often have you been bothered by any of the following
problems?
Not at Several More than Nearly
all days half every day
(0) (1) (2) (3)
a) Little interest or pleasure in things.

b) Feeling down, depressed, or
hopeless.
c) Trouble falling asleep, sleeping too
much.
d) Feeling tired, or having little energy.
e) Poor appetite or overeating.
f) Feeling bad about yourself or that
you are a failure, or have let
yourself or your family down.
g) Trouble concentrating on things,
such as reading the newspaper or
watching TV.
h) Moving or speaking so slowly that
other people could have noticed; or
the opposite: being so fidgety or
restless that you have been moving
around more than usual.
i) Thoughts that you would be better
off dead or of hurting yourself in
some way.
2. If you checked off any problem on this questionnaire so far, how difficult have these
problems made it for you to do your work, take care of things at home, or get along
with other people?
□ Not difficult at all □ Somewhat difficult □ Very difficult □ Extremely difficult

TOTAL SCORE:
40
Instructions – How to Score the PHQ-9
Major depressive disorder is suggested if:

• Of the 9 items, 5 or more are checked as at least ‘more than half the days’
• Either item a. or b. is positive, that is, at least ‘more than half the days’
Other depressive syndrome is suggested if:

• Of the 9 items, a., b. or c. is checked as at least ‘more than half the days’
• Either item a. or b. is positive, that is, at least ‘more than half the days’
Also, PHQ-9 scores can be used to plan and monitor treatment. To score the instrument, tally
each response by the number value under the answer headings, (not at all=0, several days=1,
more than half the days=2, and nearly every day=3). Add the numbers together to total the
score on the bottom of the questionnaire. Interpret the score by using the guide listed below.
Guide for Interpreting PHQ-9 Scores
Score Action
0-4 The score suggests the patient may not need depression treatment
5-14 Mild major depressive disorder. Physician uses clinical judgment about treatment,
based on patient’s duration of symptoms and functional impairment.
15-19 Moderate major depressive disorder. Warrants treatment for depression, using
antidepressant, psychotherapy or a combination of treatment.
20 or higher Severe major depressive disorder. Warrants treatment with antidepressant, with or
without psychotherapy; follow frequently.
Functional Health Assessment

The instrument also includes a functional health assessment. This asks the patient how
emotional difficulties or problems impact work, things at home, or relationships with other
people. Patient responses can be one of four: Not difficult at all, Somewhat difficult, Very
difficult, Extremely difficult. The last two responses suggest that the patient’s functionality is
impaired. After treatment begins, functional status and number score can be measured to
assess patient improvement.
For further information on the PHQ-9:

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure.
J Gen Intern Med 2001;16: 606-613.
41
CARDIOVASCULAR DISEASE
Goal: To decrease morbidity and mortality associated with cardiovascular disease.
Objective: To identify and document cardiac risk factors, and initiate management as necessary to
prevent occurrence or recurrence of cardiac disease and injury.
Methods:
1. All adult patients (ages 20-64) should have in their chart documentation of a cardiovascular risk
assessment performed within the last four years. The assessment shall include the following:
● Family history (parents and siblings) of coronary artery disease.
● Screening question will be if any blood relative died suddenly from unexpected disease or had a
heart attack before the age of 55.
● Tobacco use
● Hypertension (BP>150/90 for 2 readings)
● Diabetes Melitis
● Elevated lipid levels, according to ATP III guidelines:
o LDL<100 for CAD or CAD-equivalent
o LDL<130 for 2 or more risk factors*
o LDL<160 for 1 or less risk factors*
*Risk factors: smoking, hypertension, diabetes, HDL<40, FH of significant CAD, men over 45,
women over 55
*Positive risk factor: HDL>=60mg/dL (cancels out one negative)
● Obesity - BMI>=30 (BMI = 705 x weight in pounds/height in inches squared)
2. Any positive answer for tobacco use, hypertension, diabetes, elevated cholesterol, or obesity should
be noted on the problem list.
3. Management plan will be documented for each of the identified risks as follows:
Cholesterol not known- advise to test
Hypercholesterolemia- diet instructions initially and consideration of medical treatment if LDL is
not adequately controlled after 3 months of lifestyle changes.
Diabetes - evaluate and treat per diabetes protocol
Obesity- diet and exercise program and dietitian referral
Hypertension- low salt diet and treatment per hypertension protocol
Smoking- counseled to stop smoking with or without withdrawal therapy
Inactivity- exercise program and instructions
Family history- N/A
Presence of CVD – aspirin therapy - 81mg to 325mg daily, blood pressure control, lipid levels
controlled, weight reduction
2 or more risk factors - if no contraindications, initiate aspirin therapy 81mg daily.
How Often to Audit: Annually.
Identify Charts: Random screen of adult patients who are active users.

Control of blood pressure under 150/90: 70%.
Documented patient education and counseling within the last 4 years: 70%
Use of aspirin or other antithrombotic agent for patients with CVD or at risk for CVD: 90%
Documented lipid panel in last year: 80%
42
LDL controlled to appropriate levels, as stated above: 60%
Weight reduction in last year (maximum weight in last 12 months minus last measured weight) for patients
with BMI>25: 30%
43
CORONARY ARTERY DISEASE: LIPID THERAPY
Goal: To decrease morbidity and mortality associated with coronary artery disease.
Objective: To identify patients with abnormal lipids and initiate interventions of lifestyle changes, diet,
exercise, weight loss and lipid lowering medication if indicated.
Methods:
1. All patients with documented Coronary Artery Disease should be on lipid therapy unless
contraindicated.
2.All adult patients should have annual lipid testing.
3. If lab values are abnormal, dyslipidemia will be noted in problem list, other CVD risk factors will be re -
evaluated, patient education and counseling will be documented annually.
4. If lifestyle changes do not result in adequate lowering of lipids, statin therapy will be initiated.
Identify Charts: Random screen of adult patients who are active users.

Percent of patients with Coronary Artery Disease on lipid therapy unless contraindicated: 70%
Percent of adult patients with annual lipid testing: 70%
Percent of adult patients with LDL > 100 with lifestyle counseling documented in the last year: 80%
Percent of adult patients with LDL > 100 despite lifestyle counseling on a statin: 70%
44
ADULT WEIGHT SCREENING
Goal: To identify adult patients who are over weight and have a written follow up plan to address
unhealthy weights. Obesity in adults increases risks for many other chronic diseases including diabetes,
hypertension, dyslipidemia and coronary artery disease. A 5 to 10 % reduction in weight can greatly
diminish rate of morbidity and mortality associated with obesity.
Methods:
1. All adult patients will have a BMI documented at each visit.
2. Adult patients identified with elevated BMI’s will be counselled about the importance of diet,
exercise, and weight loss.
3. Adult patients identified with obesity will have this diagnosis added to their problem list and be
referred for Medical Nutritional Therapy if appropriate.
4. Adult patients with obesity will have a follow up plan documented.
Identify Charts: Random screen of all adult patients.
Acceptable Levels of Compliance:

Percent of adult patients with BMI documented each visit: 90%
Percent of adult patients with elevated BMI with documented counseling: 70%
Percent of adult patients identified as obese have diagnosis added to their problem list: 70%
Percent of adult patients diagnosed with Obesity have documented follow up plan: 70%
45
TOBACCO USE SCREENING AND CESSATION INTERVENTION
Goal: To reduce morbidity and mortality from tobacco use. Tobacco use is the leading preventable
cause of death in the US. Stopping tobacco use can drastically improve outcomes in all diseases,
including COPD, heart disease,and ischemic vascular disease. Stopping smoking also decreases health
risks for maternity patients and children.
Methods:
1. All adult patients will be screened for tobacco use one or more times per year.
2. All adult patients who use tobacco will receive cessation counseling and be offered referral to NC QUIT
and medication.
3. All adult patients identified as using tobacco will have tobacco abuse added to their problem list.
Identify Charts: Random screen of all adult patients.

Percent of patients who have tobacco use updated in history: 70%
Percent of patients identified as using tobacco that received cessation counseling in the past year: 70%
Percent of patients identified as using tobacco that have tobacco abuse on their problem list: 70%
COLORECTAL SCREENING
46
Goal: Colorectal cancer almost always develops from precancerous polyps (abnormal growths) in
the colon or rectum. Screening tests can find precancerous polyps, so that they can be removed
before they turn into cancer. Screening tests can also find colorectal cancer early, when treatment
works best.
Methods:
1. Adult patients age 50 to 74 years of age will have appropriate screening for colorectal
cancer.
2. Appropriate screening for colorectal cancer will include either fecal occult blood test within 1
year or colonoscopy within 10 years.
How Many Charts to Audit: 10 per provideer
Identify Charts: Random screen of patients ages 50 to 74.
Acceptable Level of Compliance: 50%
47
EMERGENCY PLANS AND PROCEDURES
Emergency Codes
Overhead paged emergency color codes will be used to alert staff of situational emergencies that occur in
the agency.
Pa Situation
ge
Red Fire
Blue Medical Emergency
Grey Violence/Security Alert
Bro Severe Weather

wn
Pink Child Missing
Blac Bomb Threat

k
Ora Hazardous Material

nge Event/Bioterrorism
Bomb Threat
All bomb threats should be taken seriously.
When a bomb threat is called in, perform the following procedures:

● Remain calm
● Attempt to keep the caller on the line as long as possible. Ask him/her to repeat the message.
Record every word spoken by the person and use the bomb threat report to ask the necessary
questions of the caller. See Appendix A.
● Immediately after the caller hangs up, notify the immediate supervisor and make the appropriate
page for evacuation for a bomb threat.
○ Code Black
● Make the page 3 times slowly and clearly.
○ Code Black, Code Black, I repeat this is a Code Black
● Follow the evacuation procedures for fire response with the exception of the gathering location.
Ashe Health Department staff will meet behind the old hospital building in front of Mt. Jefferson
Child Development Center. Alleghany Health Department staff will meet at the Daymark
Recovery building. Watauga Health Department staff will meet in front of the Department of
Social Services Building.
● Employees should take all personal belongings with them. If a suspect item if found, the
employee may not return to the building until it is found clear.
● Notify 9-1-1 after staff have evacuated the building. The person who took the bomb threat call
should be the person to call 9-1-1 to give the operator the information you collected on the bomb
threat report. Alleghany staff will call from inside the Daymark Recovery building. Ashe staff will
call from inside the Mt. Jefferson Daycare Center building. Watauga staff will call from inside the
Department of Social Services building. Do not use cell phones or two way radios, as they
may set off the suspect device.
48
When a written threat is received, perform the following actions:
● Remain calm
● Avoid handling it unnecessarily in order to preserve possible fingerprint(s), handwriting or
typewriting, paper and postal marks. These will prove essential in tracing the threat and
identifying the writer.
● While written messages are usually associated with generalized threats and extortion attempts, a
written warning of a specific device may occasionally be received; it should never be ignored.
● Immediately after the caller hangs up, notify the immediate supervisor and make the appropriate
page for evacuation for a bomb threat.
○ Code Black
● Make the page 3 times slowly and clearly.
○ Code Black, Code Black, I repeat this is a Code Black
● Follow the evacuation procedures for fire response with the exception of the gathering location.
Ashe Health Department staff will meet behind the old hospital building in front of Mt. Jefferson
Child Development Center. Alleghany Health Department staff will meet at the Daymark
Recovery building. Watauga Health Department staff will meet in front of the Department of
Social Services Building.
● Employees should take all personal belongings with them. If a suspect item if found, the
employee may not return to the building until it is found clear.
● Notify 9-1-1 after staff has evacuated the building. The person who took the bomb threat call
should be the person to call 9-1-1 to give the operator the information you collected on the bomb
threat report. Alleghany staff will call from inside the Daymark Recovery building. Ashe staff will
call from inside the Mt. Jefferson Daycare Center building. Watauga staff will call from inside the
Department of Social Services building. Do not use cell phones or two way radios, as they
may set off the suspect device.
See Bomb Threat Report Form in Employee Safety Manual
Fire Emergency Response

Dry chemical Class ABC extinguishers are available in each health department building in all three
counties. This type of extinguisher is appropriate for use against fires that are made up of ordinary
combustibles (wood, paper textiles), flammable liquids and electrical equipment.
Alarm System
The Watauga County Health Department and Ashe School Based Health Center have alarm systems with
alarm pull stations. The Ashe School Based Health Center’s alarm system is tied to the Ashe County
Middle School’s alarm system. The Alleghany CAP-DA program is housed in the Blue Ridge
Development Center (BDC) in Sparta, NC. The Blue Ridge Development Center has alarm pull
stations. The Ashe County Health Department and Alleghany County Health Department does not
have automatic alarm pull stations due to the age of the building. If a fire is seen or suspected in the
Ashe or Alleghany County Health Departments, the lead secretary or back up secretary will go through
the building blowing a whistle to alert staff and patients to evacuate the building. The Ashe
Environmental Health building has smoke detectors.
If you discover a fire (see flames or smoke),

Use the RACE acronym as a reminder for a fire emergency response.
● Rescue: Remove anyone in immediate danger
● Alarm: Activate fire alarm pull station and dial 9-1-1 (If in Ashe or Alleghany, page “Code Red
and the location of the fire”, “Code Red and the location of the fire”, “Code Red and the location of
the fire” (THREE TIMES) over the intercom. If the intercom does not work, a whistle will be blown
throughout the building.
● Contain: Close doors to confine the fire
● Extinguish: Extinguish the fire, if safe to do so. Evacuate if instructed to do so.
49
Self-protective measures:
● If your clothes catch fire: Stop, Drop and Roll
● If the smoke is intense, drop to the floor and crawl
● If you are trapped in a room, place a wet towel or cloth under the door to prevent smoke from
entering
● Move to a safe location and close doors after ensuring that rooms have been evacuated
If you hear a fire alarm:

● NEVER assume the alarm is “just a drill”. Use every opportunity to practice and improve.
● Assist patients outside to the far end of the parking lot. Use the exit routes described later in this
section for different parts of each building
● The lead secretary will account for all patients and staff members
Use the fire extinguisher to put out a fire ONLY:

● AFTER the fire department has been notified and
● IF you have a way out and
● You can fight the fire with your back to the exit and
● You have the proper extinguisher, in good working order and
● You know how to use it
o To use a fire extinguisher, use the PASS acronym:
o Pull the safety pin
o Aim the stream at the base of the fire
o Squeeze the trigger handle together.
o Sweep the stream from side to side at the base of the fire.
If you are unsure of your ability to safely fight the fire or of the fire extinguisher’s capacity to contain the
fire, then confine the fire and leave the area immediately.
Evacuation
All employees should evacuate out of the building as quickly as possible. Each supervisor will take roll
call of each employee once everyone has evacuated the building.
All employees will follow the emergency exit diagrams in their current location for an exit route out of the
building. This means the closest exit to your current location. All employees at the Ashe County Health
Department and the Watauga County Health Department will meet in the front parking lot of each
building furthest away from the building. Employees at the Alleghany County Health Department will
meet in the side parking lot next to the health department. The Ashe School Based Health Center will
follow the evacuation plan and exit routes for the Ashe County Middle School.
Alleghany County Health Department Fire Response

● When a fire is discovered, page “Code Red and the location of the fire”, “Code Red and the
location of the fire”, “Code Red and the location of the fire.” If the intercom does not work, a
whistle will be blown throughout the building.
● All employees, patients and visitors will meet in the employee parking area for roll call.
Ashe County Health Department Fire Response

● When a fire is discovered, page “Code Red and the location of the fire”, “Code Red and the
location of the fire”, “Code Red and the location of the fire.” If the intercom does not work, a
● All employees, patients and visitors will meet in the employee parking area for roll call.
50
Watauga County Health Department Fire Drill Instructions
● Whoever discovers the fire will activate the nearest pull station.
● All staff and visitors will meet in the employee parking area for roll call.
Fire Drills
Fire Drills will be performed quarterly for each county health department. The School Based Health
Center will follow the schedule for the Ashe County Middle School. The Ashe Environmental Health
office is designated as a business, therefore, fire drills are not required by fire code.
Watauga County Health Department Fire Drill Instructions

· Call Security Central for Creekside Electronics, Inc. and tell them you need to put the Watauga
County Health Department’s fire alarm system on test. Tell them how long you expect the test to last:
Approximately 30 minutes. The number is: 1-800-438-4171
o Our account number is: 8120
o The receiver number is : PY
o The pass code is 1430
· Notify Boone dispatch that we are going to be doing a fire drill. The number is: (828) 262-4500
· Take the key from the system panel in the secretary’s office area, insert the key into a pull station,
open the door and push down the black lever to sound the fire alarm.
· Evacuate the building, timing how long it takes everyone to get out. The evaluator will stay in the
building about 3 minutes to make sure everyone is out.
· Reset the pull station by closing the door and turning the key.
· Go back to the Front Office area and insert the key in the panel box and turn the key. Press “Silence”.
Press “Acknowledge”. Then press “Reset”.
· Call “All Clear” and allow everyone to re-enter the building.
· Call Security Central for Creekside Electronics to put the health department “back on-line”.
· Call Boone Dispatch to notify them the drill is over.
Ashe County Health Department Fire Drill Instructions

· The employee that leads the drill will notify dispatch that we are going to be doing a fire drill. The
number is: (336) 846-5600
· The employee that leads the drill will then page “Code Red and the location of the fire”, “Code Red
and the location of the fire”, “Code Red and the location of the fire.” If the intercom does not work, a
· All employees, patients and visitors will meet in the employee parking area for roll call.
· Page and inform everyone “All Clear” and allow everyone to re-enter the building.
· Call dispatch to notify them the drill is over.
Alleghany County Health Department Fire Drill Instructions

· The employee that leads the drill will notify dispatch that we are going to be doing a fire drill. The
number is: (336) 372-4455
· The employee that leads the drill will then page “Code Red and the location of the fire”, “Code Red
and the location of the fire”, “Code Red and the location of the fire.” If the intercom does not work, a
· All employees, patients and visitors will meet in the employee parking area for roll call.
· Page and inform everyone “All Clear” and allow everyone to re-enter the building.
· Call dispatch to notify them the drill is over.
51
Hurricane Plan and Sheltering In Place
A hurricane is a tropical storm with winds at a constant speed of at least 74 miles per hour. The storm
itself can cover a circular area between 200 and 480 miles in diameter, last more than two weeks over
open water, and travel across the entire length of the Easter United States. Hurricane season is June
1 through November 30, with peak months being August and September. Unlike fires or tornadoes and
other severe weather emergencies, hurricanes are tracked for weeks before they make landfall. This
allows time to prepare for the storm.
Hurricane Plan Procedures

● Remain calm
● All employees and patients will be advised to shelter in place and gather in the center of the
building on the first floor (not a below ground floor), and close all doors and windows.
○ Page Code Brown and advise all employees, visitors and patients to shelter in place and
gather in the center of the building on the first floor (not a below ground floor), and close
all doors and windows.
● Gather essential disaster supplies (e.g., nonperishable food, bottled water, battery-powered
radios, first aid supplies, flashlights, batteries, duct tape, and plastic garbage bags if available) if
there is time
● Stay away from windows and doors and stay indoors until the storm is over.
Shelter in Place Guidelines

Not all emergencies require the evacuation of your building. During certain emergencies, authorities may
recommend citizens to “shelter in place”. This is a precaution aimed to keep you safe while remaining
indoors. Most likely you will only need to shelter in place for a few hours. Shelter in place is not the
same thing as going to a shelter in case of a storm.
● Shelter in place does not mean sealing off your entire office building or health care facility
● Shelter in place means taking refuge in your agency or whatever other building you are in. It is
preferable to take refuge in interior rooms, with a water supply, but with no or few window. If you
are told to shelter in place in your agency, follow the guidelines below.
In the event shelter in place is indicated, you should:

1. Notify your supervisor who will notify the Deputy Health Director.
2. The Deputy Health Director will give the ok to close the agency or parts of the agency. Close and
lock all windows, exterior doors, and any other openings to the outside.
3. If you are told there is danger of explosion, close the window shades, blinds or curtains.
4. Select interior rooms above the ground floor with the fewest windows or vents.
5. Avoid rooms with mechanical equipment like ventilation blowers or pipes because this equipment
may not be able to be sealed form the outside.
Keep People Safe

● If there are patients or visitors in the building, provide for their safety by asking them to stay, not
leave.
● Gather essential disaster supplies (e.g., nonperishable food, bottled water, water filters, battery-
powered radios, first aid supplies, flashlights, batteries, plastic garbage bags if available)
● Unless there is an imminent threat, ask staff, patients and visitors to call their emergency contact
to let them know where they are and that they are safe.
● Turn on call-forwarding or alternative telephone answering systems or services. Change the
recording to indicate that the office is closed.
● Continue listening to the radio or television until you are told all is safe or you are told to evacuate
in specific areas at greatest risk in your community.
Tornado Plan
52
A tornado is a violent storm with spiraling high-speed winds. The noise of a tornado has been
described as a roaring sound, like a train far away. Tornadoes often accompany severe thunderstorms
and are only one of many thunderstorm hazards.
Severe Thunderstorm WARNING:

A warning is issued when the National Weather Service expects thunderstorms with large hail and/or
damaging winds in excess of 57 miles per hour. Frequent lightening is likely and a tornado is possible.
Tornado WATCH:
A tornado watch is issued when the National Weather Service determines that the atmospheric conditions
are favorable for tornadoes to form, although none have yet been sighted. A “watch” is intended to
provide enough time, for those who need to set their plans in motion to do so.
Tornado WARNING:
A tornado warning is issued when a tornado has been sighted or is indicated by weather radar. Warnings
advise of a threat to life or property. IMMEDIATELY TAKE COVER IN A SAFE AREA AWAY FROM
OUTSIDE WINDOWS/DOORS, IN AN INTERIOR LOWEST LEVEL OF THE BUILDING.
Procedures if a Tornado Warning occurs:

● Remain calm
● All employees and patients will be advised to shelter in place and gather in the center of the
building on the first floor (or a below ground floor if available) and protect your head.
○ Page Code Brown and advise all employees, visitors and patients to shelter in place and
gather in the center of the building on the first floor and protect your head (Repeat three
times).
● Follow the above mentions shelter in place guidelines.
● Gather essential disaster supplies (e.g., nonperishable food, bottled water, water filters, battery -
powered radios, first aid supplies, flashlights, batteries, duct tape, and plastic garbage bags if
available) if there is time
● Stay away from windows and doors and stay indoors until the storm is over.
Protocol for Weather Drills and Weather Responses

Tornado
Drill: To enact a tornado drill, the employee leading the drill will page “This is only a drill. Code Brown, all
employees, visitors and patients should calmly shelter in place and gather in the center of the building
on the first floor and protect your head. When all is clear another page will be made. This is only a
drill.” (Repeat three times)
Response: To respond to a tornado warning page “Page Code Brown and advise all employees, visitors
and patients to shelter in place and gather in the center of the building on the first floor and protect
your head.” (Repeat three times)
Hurricane
Drill: To enact a Hurricane drill, the employee leading the drill will page “This is only a drill. Code Brown,
all employees, visitors and patients should calmly shelter in place and gather in the center of the
building on the first floor and protect your head. Stay away from windows and doors and stay inside
until the all clear is given. This is only a drill.” (Repeat three times)
53
Response: To respond to a hurricane warning page “Page Code Brown and advise all employees,
visitors and patients to shelter in place and gather in the center of the building on the first floor and
protect your head. Stay away from windows and doors and stay inside until the all clear is given.”
(Repeat three times)
Medical Emergencies
In the event of a medical emergency, use the Medical Emergency Code to alert other employees to help
and to report to the area.
Policy: Although AppHealthCare does not operate emergency rooms, it is our policy to identify and
respond to life threatening patient emergencies occurring in the office in a rapid, responsible and
professional manner. Our purpose is to stabilize the emergency patient.
Procedure:
The following procedures will be used to implement this policy:
1. "Code Blue" will be announced by the clinical staff member who discovers a patient emergency
has occurred. Patient will be placed flat on his/her back on the floor or on an exam table as
available.
2. Management SupportClerical staff will be assigned the following duties during a "Code Blue":
A. Notify EMS (911 or emergency number for each centers county) on Doctor or Nurse's
instruction, with patient information to include age, sex, condition, office address.
B. If patient is in public area of office, management supportclerk will escort other patients and
family members away from the emergency scene.
C. If a second Management Support staff memberclerk is available, they are responsible for
updating and assisting patient's family. If the second Management Support staff
memberclerk is not available, the recorder will assist the family when possible.
3. First medical professional on the scene, either nursing staff or provider, will assess patient and
begin BLS per protocol during a "Code Blue".
4. Other nursing or Management Supportclerical duties during "Code Blue":

A. The Management Supportclerk or second nurse will open the chart and document
emergency procedures to include patient history, code start time, medications administered,
procedures performed and code end time. A copy of this report plus patient's basic
demographic information will be made available to EMS.
B. Secondary nurse or Management Supportclerk will assist with BLS.
C. Secondary nurse will assist provider with advanced cardiac life support. As appropriate, run
EKG, start IV, and administer meds, on provider instruction.
D. Each site will determine who will be the recorder for their site. If the second nurse is the
recorder, Management Support the clerk will assist the first nurse with BLS and the second
nurse will record as well as assist the provider with ACLS. If Management Support the clerk
is the recorder, the second nurse will assist with BLS and ACLS.
54
5. The following additional procedures will be followed to insure that the office is prepared in the
event of a "Code Blue":
A. Nurses will monitor the crash box monthly for appropriate stocking and dating of medicines
and to insure that equipment and oxygen are in working order. Medical Director will advise
as to medicines and equipment necessary for the crash cart. The monthly crash box check
will be documented. Any discrepancies or problems will be reported to the Director of Risk
Management for action.
B. Clinical staff will maintain current CPR certification (BLS). Clerical staff is encouraged to
obtain CPR certification. Management will arrange and pay for classes each year. Providers
are encouraged to obtain and maintain advanced cardiac life support certification (ACLS).
C. Office manager phone numbers for each phone station to include numbers for EMS, police,
poison control and fire department. All centers are covered by 911.
D. The Director of Risk Management will arrange with each center staff a "Code Blue" drill to be
conducted annually. This will include review of emergency/disaster plans & policies. This will
be documented.
E. All new employees will be trained in "Code Blue" policies/procedures. This will be
documented also with emergency/disaster plans and policies.
55
ASSESSMENT OF PATIENTS POLICY
General: AppHealth assesses each incoming patient for his/her physical, psychological, social,
nutritional, and functional status to determine the need for care or treatment. Information from other
agencies or clinical settings is included in the initial patient assessment. Educational needs and the
capacity for home care are assessed so the center staff may arrange for appropriate training and/or
referrals.
The patient will be reassessed at each clinic visit for any changes from the initial assessment.
Progress or other changes made from one visit to the next in terms of the patient’s diagnosis, care
setting, desire for care, and response to care is noted in the medical record. The assessor will complete
or assist patient with completing the Health History Form during the first visit. When appropriate and with
the patient's approval, data from family or caregiver will be included. Initial assessment includes review
and integration of all available past medical history and records, if applicable. Any collaborative efforts
between departments, agencies, or care facilities will be clearly documented and delineated in the
medical record. The assessor will record relevant physical data that may include the following:
1. Laboratory findings
2. Allergies
3. Present medication usage
4. Activities of daily living
5. Nutritional status, if indicated
6. Patient mobility/functional status, if indicated
7. Alcohol and tobacco consumption
8. Past medical history and family medical history
9. Past hospitalizations/surgeries/invasive procedures
10. Review of systems
11. Wound location and duration
12. Temperature, pulse, respiration, blood pressure, BMI
13. Comfort level (pain threshold)
14. Evidence or suspicion of abuse
In the case of suspected abuse, staff is trained in the legal and procedural actions that must be
taken under such circumstances. Victims of alleged or suspected abuse and neglect are assessed with
the informed consent of the patient. All relevant staff is also trained in the federal, state, and/or local
statutes that apply to the collection of evidentiary material and the notification of authorities in suspected
abuse cases. Staff is familiar with local resources for referral of patient and family, to be utilized as
appropriate.
Non-physical assessment data include:
1. Patient diagnosis
2. Patient care setting
3. Patient’s desire for care
4. Patient’s response to care/care plan
5. Patient’s need for follow-up care
If a need for follow-up care is identified, the appropriate clinical staff develops a care plan, and follow-up
visits are scheduled. Center staff takes measures to communicate to the patient the importance of
keeping follow-up appointments.
Diagnostic Testing: The center provides for diagnostic testing as part of the patient assessment process.
When a center has X-ray, laboratory, and other diagnostic services on-site, these facilities are sufficient
56
for patient assessments, and are utilized as appropriate. If any or all of these facilities are not on-site,
contractual and procedural agreements with off-site laboratories and/or radiology providers are
established in writing, and the center provides the use of these services as part of patient assess ment.
The results of diagnostic tests are interpreted in a timely manner by qualified professionals, who
may be part of the center staff, or who are provided to the center by means of established and written
contract. Pathology examinations of tissue samples are reported to the center staff quickly and without
delay. All results of diagnostic testing are recorded in the patient medical record.
If the center maintains on-site laboratory facilities, these facilities are in compliance with federal
regulations, (CLIA-88). Documentation of compliance with federal regulations, and documentation that
testing provides the quality and accuracy to support clinical and medical decisions, is supplied by all in -
house or contracted referent facilities. See Lab Manual for details.
Assessment of Child and Adolescent Patients: Assessment of child or adolescent patients will be highly
individualized and will include evaluation during Well-Child visits and as indicated during sick visits of the
following:
1. Growth and development

2. Emotional needs
3. Cognitive status
4. Educational needs
5. Social needs
6. Daily activity needs
In addition, this center recognizes the need to be alert to suspicion or signs of abuse of its child
and adolescent patients. All staff members are trained in heightened alertness to vulnerable populations,
the recognition of signs of abuse, the criteria for identifying a victim of abuse, and the legal and
procedural actions which must be taken under such circumstances. Victims of alleged or suspected
abuse and neglect are assessed with the informed consent of the patient, parent, or legal guardian or
otherwise as provided by law. All relevant staff is also trained in the federal, state, and/or local statutes
that apply to the collection of evidentiary material and the notification of authorities in suspected abuse
cases. Staff is familiar with local resources for referral of patient and family, to be utilized as appropriate.
Prenatal and Postpartum Assessment: Prenatal and postpartum patients are seen and treated per
ACOG guidelines for prenatial and postpartum care. Care is transferred to the delivering physician at 37
weeks, sooner if patient is deemed beyond the scope of this practice.
Reassessment: Each patient will be reassessed at each clinic visit to determine appropriate progress, and
identify any changes from the initial assessment. If indicated, reassessment includes evaluation of the
patient's:
1. Diagnosis
2. Response to treatment
3. Knowledge of previous visit instruction
4. Areas of knowledge deficit
5. New illness/disease state
6. Wound condition, dressing usage and care needs
7. Signs and symptoms of complications
8. Continuing care needs
9. Nutritional status and needs
10. Comfort level
11. Compliance with treatment/care plan
57
If a significant change in the patient’s condition is detected upon reassessment, care plans are
adjusted accordingly, and timely reassessments are arranged. Mechanisms and policies are established
and utilized within the center to assure that care decisions are coordinated and appropriate throughout
the patient’s contact with the health center.
Potential Victims of Abuse and Neglect:
1. General
All health care providers have a responsibility to be alert to the indications given by patients that
they may be potentially victims of abuse or neglect. This responsibility embraces all patients, that is:
infants, children, victims of sexual assault, victims of spousal or partner abuse, and geriatric patients.
2. Criteria
The criterion listed below is a representative, but not exclusive list of indications that health care
provider should be alert to patient abuse systems.
● Child Abuse:
Physical Indications:
Lacerations
Bruises
Unexplained swelling
Unexplained broken bones
Significant unexplained weight loss
Behavioral Cues:
Nervous or inappropriate laughing or smiling
Crying
Sighing
Anxiety
Defensiveness, Anger
Lack of eye contact, or fearful eye contact
Minimizes seriousness of injuries
Reluctance to speak in the presence of a potential abuser
Verbal Cues
Talks about a "friend" who has been abused
Refers to a partner's "anger" or "temper"
Responds affirmatively to any of the following questions:
Have you been hit or harmed any time in the past year?
Have your parents ever destroyed things you cared about?
● Spousal or Partner Abuse:
Lacerations
Bruises
Injuries to the facial area
Behavioral Cues:
58
Crying
Sighing
Anxiety
Overly attentive, aggressive or defensive partner
Verbal Cues
Refers to a partner's "anger" or "temper"
Are you in a relationship with someone who hurts or
threatens you?
Has your partner ever destroyed things you cared about?
Has your partner ever forced you to have sex when you
did not want to?
● Sexual Assault
Lacerations
Bruises
Injuries to the vaginal area
Behavioral Cues:
Crying
Sighing
Anxiety
Verbal Cues
Are you in a relationship with someone who hurts or
threatens you?
Has your partner ever destroyed things you cared about?
Has your partner ever forced you to have sex when you
did not want to?
● Elder Abuse
Lacerations
Bruises
59
Any evidence of malnutrition
Behavioral Cues:
Crying
Sighing
Anxiety
Overly attentive, aggressive or defensive partner
Verbal Cues
Refers to an adult child's "anger" or "temper"
Are you ever hurt or threatened by a caregiver or close
relative?
Has your caregiver ever destroyed things you cared
about?
3. Action
In this healthcare organization all staff will be oriented to these criteria as part of the initial
employee orientation. All staff directly involved in the provision of healthcare services will receive periodic
updates regarding these criteria.
The reporting of abuse will be carried out in accordance with current law and regulation. The
organization will maintain a current list of referral agencies to assist patients and healthcare providers in
seeking appropriate assistance with issues of patient abuse or neglect.
60
CONTINUITY OF CARE PLAN
General: AppHealth Care provides general primary health care to members of the community. A
description of the scope of health care services is set forth in the Patient Information Brochure available
at the patient registration desk. The primary health care services are available for all age groups, for
persons of either sex, and include assessment and diagnostic services, treatment of acute and episodic
disorders, the management of chronic health conditions, referral for specialty health care services, and
patient health care education.
Initial assessment: New patients of the AppHealth Care will receive a comprehensive initial assessment
to ascertain the appropriateness of care available at the community health center.
The assessment of patient health care needs will include basic demographic information,
individual and family health history, a physical assessment, and as appropriate, the assessment of
nutritional needs, psycho-social needs, health education learning needs, and any other special needs
relevant to the provision of quality health care services.
A new patient, presenting for the first time with an urgent or episodic health care need will have
those factors assessed that are relevant to the immediate episode of care. By the third visit to the
community health center the remaining elements of the comprehensive assessment will be completed,
and a Health History Form initiated in the patient's health record.
Demographic information will be used to determine the payment status, and the third party payers
for the patient. It is the policy of the AppHealth Care that ability to pay will not be a factor in determining
eligibility to receive care. A sliding fee scale is available to all patients with an annual household income
at or below 200% of the federal poverty level.
The specific information to be obtained for all patients is described in the policies listed below:
Demographic & Payment Status Financial Policies

History & Physical Examination Assessment of Patients
Nutritional, Psycho-Social, & Learning Needs Assessment of Patients
Advance Directives Patient Rights
Referrals from an outside organization: Patients who are referred to AppHealth by an outside health care
or social service organization will be regarded as new patients, with the initial assessment expectations
those that are set forth above. With the written consent of the patient, relevant health and social history
data will be requested from the referring organization.
Referral to another health care organization: Patients whose health care needs exceed those that can be
provided by AppHealth Care, in terms of complexity and scope, will be referred to another health care
organization whose scope of care meets the needs of the patient. When requested, and authoriz ed in
writing by the patient, the findings of any health care assessment performed at AppHealth will be made
available to the organization to which the patient has been referred for care.
61
Criteria defining the appropriate care setting: The following elements will be utilized in making a
determination regarding the most appropriate care setting for the patient:
1. The scope of care available at AppHealthCare.

2. The patient's specific health care needs.
3. Payment status will not be a determining factor.
Patients who are being cared for on a regular basis at another health care facility will not be
eligible for limited health care services (such as laboratory tests only, or pharmacy services only), except
in unusual circumstances, and then only with the approval of the Medical Director.
Referral Protocols:Clinical protocols that detail the referral process should be followed by staff. These
include but are not limited to: AppHealthCare Referral Process; Policy 509 Referral Follow-Up Protocol;
Policy 204 Patient Records Management; Policy 570 After Hours Calls
Patient Transfers: Patient transfers arise from urgent health care needs and are distinguished from
routine referrals by the sense of medical urgency. Patient transfers are to be carried out in the following
manner:
1. Transfer is to be made by ambulance or EMS vans.

2. The hospital to which the patient is being transferred will be notified prior to the patient's
leaving AppHealth..
3. The patient's consent or the consent of an authorized patient surrogate will be obtained prior
to the transfer.
4. All relevant medical information will be assembled and transported with the patient.
5. When not accompanied by family members, AppHealth will make every effort to reach family
members and advise them of the transfer.
6. A follow-up telephone call will be made to confirm the patient's arrival at the hospital.
Referral Agreements: When referrals for specialty health care services, or any other related health care services,
develop in such a manner that a regular pattern can be discerned, AppHealth will seek to establish a referral
agreement with the other health care provider. Such an agreement will set forth the conditions for referral, the
procedures to be followed in transferring patient information and for the return of information related to the relevant
findings. In addition to the progress of treatment, the agreement may also set forth the arrangements for billing of the
services, matters related to medical malpractice liability, and such matters related to quality of care or accreditation
issues.
Denial of Care: Patients may be denied health care on the basis of several factors:
1. Patient care needs that are beyond the scope of services available at AppHealthCare (The
Clinical Program Services Policy should serve as an additional reference for any concerns
about patients with healthcare needs that require specialty care).
2. A pattern of significant non-compliance with health care instructions which, in the judgment of
the primary health care provider, jeopardize the health of the patient.
3. Failure to abide by health and safety requirements of AppHealthCare (non-smoking policy,
nontolerance for verbal or physical abuse of staff and other patients, etc.)
4. Other factors which make the continued provision of health care services inappropriate.
5. All patients who are denied care have a right to appeal this decision to the CEO by making a
request.
Patient Information Rack Cards and Welcome Letter: Patient Information is available at the registration
desk at each of AppHealth Care facilities. The brochures contain information regarding the scope of
services, the hours of operation and how to obtain assistance after hours, procedures for appointments,
62
applying for the sliding fee scale discount (including no one will be turned away for inability to pay) and for
walk-in services. Patient information will be available in English and Spanish
63
CARE OF PATIENTS POLICIES
General: This center operates according to an established and written set of patient care standards,
which addresses all aspects of patient care. Patient care plans are developed and performed by qualified
professionals in accordance with professional standards. All patients are monitored closely during and
after procedures are performed.
Determining Procedures: Patient care procedures are determined in part by assessment of the patient
as explicated in the Assessment of Patients policy. Also operative in determining appropriate procedures
is the review of the procedure’s potential risks and benefits. Once determined, patient care is performed
by a licensed, credentialed, and qualified professional as required by law and as stipulated by the
governing body. Patient care is carried out under satisfactory environmental conditions, (as described in
the Environment of Care Manual), and in accordance with Patient Rights and Organizational Ethics
Policies.
There is a process for periodic assessment of the appropriateness of the medical care that this
health center delivers. This process includes:
1. Professional peer review

2. Periodic chart audits
3. Patient satisfaction surveys
4. Review of Performance Improvement activities
5. Intensive assessment of significant negative outcomes
Informed Consent: Informed consent is the basis for a valid procedure permit. The physician will be
responsible for discussing with the patient and family the nature of the procedure and potential benefits,
risks, and potential complications. An informed consent form will be completed for all elective, invasive
procedures to include lesion and tumor removals and destructions, skin, cervical and endometrial
biopsies, placement of long acting reversable contraception, toenail removals and joint injections. As
dictated by the patient history, it may become necessary to obtain medical information from other
physicians or facilities. The medical record shall contain evidence of the patient's informed consent. See
Informed Consent at the end of this policy.
Medications/Pharmacy:
A. General:
All medications are dispensed by a qualified professional with adequate credentialing and
privileging as required by law. All medications are prescribed and dispensed according to applicable
federal, state, and local laws.
Medications are selected, prescribed, and dispensed by qualified professionals according to

organizational goals and in accordance with local, state, and federal law. Patient medication
information is always considered when prescribing, ordering, or dispensing medication. Medication
dispensing areas are kept clean and organized according to the policies described in Environment of
Care Policy Manual. Medication storage areas are kept locked.
B. Sample Medications -
1. SCOPE - This policy addresses practices and procedures for all sample medications
provided to patients of this organization. This includes any nutritional supplements provided
to pediatric or geriatric patients since these supplements are issued by lot numbers, and are
subject to recall.
64
2. RESPONSIBILITY - The Medical Director is responsible for all aspects of the sample
medications program of this organization.
3. CUSTODY - Sample medications are in the custody of the physicians or other health
providers to whom the pharmaceutical representatives have officially provided the samples in
accordance with state law and regulation. The custody of the medication remains the
responsibility of the physician to whom the medications were given.
4. SECURITY - All sample medications are stored in locked cabinets or closets. Keys to the
sample medications locked areas are provided only to those individuals that are authorized to
give the medications to patients on behalf of the physicians who have legal custody of the
medications.
5. INVENTORY - Appropriate inventory controls will be conducted to assure proper security,

storage, transportation and administration of sample medications. At least monthly, all
sample medication lockers will be inventoried to remove all out-dated medications. Out of
date medications will be discarded or disposed of in accordance with applicable state law and
regulation.
6. FORMULARY - Each physician will determine which sample medications he/she will accept.
The program will not accept medications solely on the preference of the pharmaceutical
representative. Consideration for the benefit to the center’s patients will be made in the
decision to accept sample medications. No narcotics or other controlled medications will be
accepted.
7. RECALL TRACKING - All sample medications provided to patients will be recorded to include
medication name, dosage and lot number. This will be done in the patient’s EMR chart, or on
a sample log-out tracking sheet. The pharmaceutical representative is responsible for
entering the name, lot number of the medications, expiration date and the date they were
provided to the organization on the appropriate recall-tracking sheet. Recall tracking sheets
will be maintained in each of the sample medication lockers.
8. ADVERSE DRUG REACTIONS - A record will be maintained of all adverse drug reactions
that are reported to the health center by patients who have received medications from the
health center. A summary of reported adverse drug reactions along with any corrective
action taken by the health center's medical staff will be reported to the Quality Improvement
Committee.
C. Emergency Medications
Emergency medications are located in a secure and easily accessed location and/or on the
emergency cart. Patient demographics determine the contents of emergency medication stores. The
exterior of the emergency cart is inspected daily. The emergency cart is locked with a serially
numbered breakaway lock. The number on this lock is inspected daily. A member of the nursing staff
monthly inspects the interior contents of the emergency cart. All records of inspection are maintained.
D. Multiple dose vials
Issue: Staff needs clear and consistent guidance regarding the procedures used to expired biologicals
contained in multiple dose vials.
Policy: To be followed as outlined below:

1. Appropriate sterile technique will be employed whenever multiple dose vials are entered.
65
2. Upon the initial draw from a multiple dose vial, the current date will be recorded on the vial
label.
3. If the vial contains medications to be used for infant or pediatric immunizations, the vial will
be considered expired 30 days after the date of the initial entry. The expired vial and its
contents will be disposed of in accordance with current approved practice.
4. If the vial contains other medications, the vial will be considered expired on the expiration
date given on the label by the manufacturer, provided there is no evidence of contamination.
5. If at any point appropriate sterile technique is compromised, the vial and its contents will be
considered expired and disposed of.
6. Should there be any physical or visual evidence of contamination the vial and its contents will
be considered expired and disposed of.
Pharmacy Services
Pharmacy services are provided by Halsey Drug located in Sparta and Peoples Drug located in West
Jefferson. These pharmacies are staffed by appropriately credentialed and licensed pharmacists and
staff, who follow all regulations and procedures as defined by local, state and federal law.
Laboratory Services
The following policies apply in the case of a laboratory which is designated by CLIA certification
as
a moderate complex laboratory solely equipped for the performance of routine laboratory testing or routine
diagnostic laboratory testing.
Laboratory facilities will comply with CLIA-88 regulations and any state or local statutes that may
apply. Procedures for infection control as outlined in the Environment of Care Policy Manual will be
followed, and records of quality control and compliance shall be maintained.
Specimen collection and specimen preservation shall be performed according to infection control
policies. Test performance shall be subject to quality control checks. Records of quality control shall be
maintained. A record of scheduled and regular instrument calibration, equipment performance
evaluation, and product quality control and evaluation are current and maintained.
All refrigerators which are used to contain specimens, reagents, and medicines are monitored
daily for appropriate temperatures in accordance with CLIA standards, (34°-40°F).
The mission of AppHealth laboratory is to maintain high standards of patient testing through an on-going
process designed to evaluate and monitor the quality of the total testing process, which includes general
systems, pre-analytical, analytical, and post analytical. This includes patient preparation and specimen
receipt, testing and test result reporting. Our Laboratory Quality Assessment program also includes
interaction with the patients, doctors, clinics, state and local government agencies and other laboratories.
The objective of this Quality Assessment Plan is to: Establish and follow written policies and procedures,
Assure the integrity of the specimen sample, Assure the accurate, reliable and prompt reporting of test
results, Monitor and evaluate quality control logs, Identify and correct problems, Identify needs, provide
training and other resources required to maintain competency and improve the skills of testing
personnel, Documentation of all aspects of quality assured services, and improve communication .
The Quality Assessment Plan is reviewed and updated annually by the Lab Manager, State Lab
Technical
Consultant, and all Laboratory Technicians.
66
67
Medical Records
Medical records are maintained for each patient. Records contain accurate recording of the
following when indicated:
1. Physiological status
2. Mental status
3. Administered fluids, medications, and/or blood
4. Allergic reactions
5. Procedure complications
6. Pathology and laboratory results
7. Medications prescribed and/or administered
8. Any adverse effect of medications on patient
9. Dietary needs when applicable
10. Referrals and information from other agencies/providers/clinics
11. Informed consent to treatment
AppHealth uses an Electronic Medical Record (EMR), so that progressively less paper records
are being produced. The EMR is secured by standard electronic security measures that include strong
passwords, rotating passwords, locking screens requiring passwords to access, and security profiles for
different members of the active staff. The paper-based medical records that remain are stored in locked
cabinets, or in secure spaces such as locked rooms in order to assure the confidentiality of medical
records, and also to protect them from loss, tampering, alteration, and destruction. During offi ce hours
staff secures records. All persons having access to the cabinet or to the secure spaces used for storing
medical records, whether an employee of the center or a contracted service, are governed by written
confidentiality pledges.
Data is entered into the medical record by the end of each clinic day. Active medical records are
stored for a period of seven years, unless otherwise stipulated by state regulation (see Management of
Information for details). Inactive medical records are retired in accordance to state regulation. The
release of any information contained in the medical record may only be performed with the written
consent of the patient.
Verbal orders for medications (orders received via telephone) may be initiated by authorized
health care providers and executed by nurses under their direction. Any time verbal orders for
medications are received; they will be entered into the patient record and countersigned by the healthcare
provider initiating the order within 48 hours of the next day the provider is in the practice. Communication
by email or other electronic means constitutes written orders, and as such, do not have to be signed in
any way.
Rehabilitation Plans: A rehabilitation plan is developed by the appropriate primary care provider based
on accepted professional standards, with the goal of restoring or improving the patient’s best level of
independence and quality of life. The following criteria are assessed in the development of a
rehabilitation plan:
1. Patient’s needs
81717760. Patient’s ability
81717761. Patient’s education
81717762. Patient’s support system
81717763. The treatment necessary to reach defined and reasonable goals
81717764. Patient’s housing environment
81717765. Patient’s vocational environment
81717766. Patient’s social environment
68
A qualified professional implements rehabilitation plans. Planning for eventual discharge from
rehabilitation programs is initiated early in the treatment process. Written discharge criteria determine a
patient’s readiness to end rehabilitation services.
69
PATIENT SPECIFIC INFORMATION (MEDICAL RECORDS)
Goal: The goal of maintaining accurate and timely information for each patient is to promote the effective
and efficient provision of healthcare services.
Customer Health Record: The organization at the first patient contact shall establish a patient health
record. The record, as applicable, shall include the following documentation:
● patient demographic information (including but not limited to the patient's name, gender,
address, phone number, date of birth, height, weight, as well as the name, address, and
phone number of any legally authorized representative
● legal status of patients receiving mental health services
● any findings and assessments
● conclusions and impressions drawn from medical history and physical examination
● the diagnosis or diagnostic impression
● evidence of known advance directives
● evidence of informed consent for procedures and treatments as appropriate
● diagnostic and therapeutic orders
● all diagnostic and therapeutic procedures, tests, and results
● all operative and other invasive procedures
● progress notes made by authorized individuals, including the date, staff person, and care or
service provided
● all reassessments
● all consultant reports
● every medication prescribed
● every dose of medicine administered to the patient, including the strength, dose or rate of
administration, administration devise used, access site or route, known drug allergies,
adverse drug reactions, and patient's response to medication (if known)
● all relevant diagnoses established during the course of care
● referrals or communications made to external or internal care providers and community
agencies
● when appropriate and necessary, treatment summaries and other pertinent documents to
promote continuity of care
● documentation of clinical research interventions, as appropriate, which are distinct from
entries related to regular patient care.
When appropriate, information received from treatment of the patient from other providers of care will be
included in the health record.
PRE & POST OPERATIVE DOCUMENTATION (This section does not generally apply to primary care
practices but may apply to dental and some procedures performed.)
The customer health record shall thoroughly document operative and other procedures as well as the use
of anesthesia. This documentation, if applicable, shall include:
● a preoperative diagnosis (documented prior to the procedure by the responsible licensed
independent practitioner)
● operative reports which document the provider and assistants, findings, technical procedures
used, specimens removed, and postoperative diagnosis
● authentication of the operative report in accordance with the organization's timeliness policy
● postoperative documentation which records the patient's vital signs, level of consciousness,
medications (including intravenous fluids), and any unusual events or postoperative
complications
70
● patient's discharge from post anesthesia care by a responsible licensed independent
practitioner or according to discharge criteria: as well as the documentation of the licensed
independent practitioner responsible for the discharge.
Please note that the organization does not have any approved discharge criteria. However, the
organization reserves the right to develop such criteria in the future ad such criteria will be strictly followed
to determine the patient's readiness for discharge.
SUMMARY LIST (PROBLEM LIST)
A summary list including all significant diagnoses, special procedures, drug allergies, and medication lists
will be produced in the health record as information is gathered and input into EMR. This will be as
complete as possible by the third consecutive visit of a customer to the organization's facility.
URGENT CARE ACTIVITIES
In the event of an urgent or emergent issue, particularly when the patient is being transferred or rushed to
another provider of care, it is the responsibility of the organization to provide information quickly to the
provider of follow-up care within the constraints and limits of confidentiality. Additionally, the medical
record should note:
● the time and means of arrival
● when a patient leaves against medical advice (AMA): as well as
● the conclusions at termination of treatment (including final disposition, condition, and
instructions for follow-up care).
Finally, authorization for the transfer of the health record should be granted by the patient or the legally
authorized representative before information can be released.
TIMELY MANAGEMENT & ACCCESS TO HEALTH RECORD INFORMATION
Access to health record information should be on a timely basis. The timeliness of records is determined
by the type of information and its use.
For example: documentation of assessment, care, and education provided on site should be complete
and in the medical record generally within 24 hours and not later than three business days after the
services are rendered. Outside laboratory and x-ray reports should normally be received from the
vendors within 48 hours and no later than five business days from the date of the service. Finally,
information provided to referral services should normally be received at least 24 hours prior to the delivery
of services and no later than prior to the delivery of services
Periodic assessments of the timeliness of medical record completeness will be a routine component of
the organization's performance improvement activities. Any deviations from the standards of practice wil l
be treated as incidents and will be tracked throughout the year. The results of this tracking will be shared
with the relevant quality committees and the medical staff on at least an annual basis.
VERBAL ORDERS
The use of verbal orders is an acceptable practice in this organization. However, documentation and
authentication of verbal orders shall comply with the timeliness policy of this organization or applicable
law, whichever is the stricter requirement.
71
DATING AND AUTHENTICATION OF HEALTH RECORD ENTRIES
The organization shall maintain and update, as appropriate, a list of all those individuals authorized to
make entries into the customer health record. The organization shall also have a standardized and
approved method (including initial and signatures) for identifying and authenticating entries by authors.
Furthermore, unless approved by the Board of directors, the use of signature stamps is prohibited.
Those individual with signature stamps which are approved for use by the Board of Directors will sign a
statement assuring that the signature stamp will be kept under tight controls and will only be used by
them.
72
AGGREGATE DATA & INFORMATION
Goal: The goal of developing and utilizing aggregate data is to compile information regarding the
processes and outcomes of an organization to make informed decisions to improve the provision of
patient care.
Aggregation of Process and Outcomes Data: The organization will utilize a number of sources to
aggregate and analyze process and outcomes data. These sources include, but are not limited to:
● internal and external financial reports (i.e. monthly and annual)

● internal and external utilization reports
● reports to external funding sources (i.e. UDS, Title 330 Grant, etc.)
● medical record and peer reviews: and
● clinical tracking systems (i.e. Clinical Outcomes Measures)
The scope of the aggregation will deliberately not be limited to allow management to track and trend any
data it feels necessary for the effective management of the organization's processes.
Copies of the most recent of each of the above reports are included at the end of this section.
73
KNOWLEDGE BASED INFORMATION
Goal: The goal of maintaining knowledge based information is to ensure that the organization is
managing itself and performing its processes utilizing the most effective, up to date methods and
technology.
Scope: The scope of knowledge based information to be maintained shall include all staff within the
organization. The scope may also involve informing the community about any changes or recent
breakthroughs in the medical and other health related fields.
Orientation and Training: The organization has established an orientation program which is specific to
the classification of the employee (See Personnel Policies). This program will ensure that the
organization's employees are knowledgeable in the essential aspects of:
● their job responsibilities

● the organization's plan for managing its risks in the environment of care
● procedures for controlling nosocomial infections
● specific administrative rules and processes that the organization requires
● the scope of services provided by the organization, as well as
● other patient care related issues.
The objective of the orientation and training program will be to promote a learning culture within the
organization which will develop the most informed and competent staff possible.
Competence Assessment: On-going competence assessments will further ensure that staff maintain
their knowledge of clinical and operational issues as well as to ensure that their basic competencies (i.e.
those covered during their initial orientation), have been maintained over time. Additionally, on-going
competency assessments will ensure that the staff's knowledge has been updated as new knowledge and
technologies become available.
Assessments of staff competence will be performed on a regular basis. Ideally this assessment would be
performed annually, but the time between assessments should never exceed two years. These
assessments, both individually and as aggregate data, will be used as the foundation for planning the
organization's training and education program.
Continuing Education: Annually the organization approves, as part of its budget, several items relating
to the continuing education of staff. These allocations can come in the form of a continuing education
budget for individual medical providers and other staff.
Library/Holding Area: Where possible, the organization will develop a small holding area or library for
these publications and will make them available to all staff. Additionally, every effort will be made to
make computer based information sources such as "Epocrates" available to all providers.
74
COMPARATIVE DATA & INFORMATION
Goal: The goal of interpreting and utilizing comparative data is to develop baselines of organizational
performance and using internal and external benchmarks, to evaluate and measure the organization's
effectiveness, as well as to identify priorities for performance improvement.
Utilization and Contribution to External Databases: The organization utilizes a number of external
databases to evaluate itself and set priorities for improvement. These data bases may include, but are
not limited to:
● Clinical Outcomes Measures

● BCHDANET Report (Accumulation of UDS performance data)
● BPHC Benchmarks for performance (i.e. Program Expectations)
The organization contributes information to each of the databases identified above on an annual basis.
Security and Confidentiality of Information: When contributing to external agencies and databases
every effort will be made to remove identifier information which could compromise confidentiality and
security.
75
76

Clinic-Protocol-Manual

Uploaded by

Document Informationclick to expand document information

Document Informationclick to expand document information

Copyright:

Available Formats

Clinic-Protocol-Manual

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Clinic-Protocol-Manual

Uploaded by

Copyright:

Available Formats

Clinic Protocols

for Quality and

COMMUNITY HEALTH CENTER

Approval Date: July 6, 2016

Medical Director: Danielle Darter, M.D.

QI Coordinator: Stephanie Bunch

Deputy Health Director/COO: Jennifer Greene, MPH

Health Director/CEO: Beth Lovette, RN, BSN, MPH

A. PURPOSE: To ensure quality of care and operations for the organization.

Rotating Members, minimum composition:

One nurse (MAs, LPNs, or dental assistant)

H. QUALITY IMPROVMENT METHODOLOGY

Adapted from Institute for Healthcare Improvement

Commented [1]: Add Clinic QI to the FQHC block;

EXISTING ELEMENTS OF THE RISK MANAGEMENT PROGRAM:

ACCEPTABLE RATE OF COMPLIANCE:

HOW OFTEN TO AUDIT: Ongoing, with monthly trending.

HOW MANY PATIENTS TO SURVEY: all patients

How Often to Audit: Annually

How Often to Audit: Annually

How Many Charts to Audit: 10 per FTE provider

Acceptable Level of Compliance:

Goal: To reduce dental decay in children

Age of Child <0.3ppm 0.3-0.6ppm >0.6ppm

How Many Charts to Audit: 10 per provider

Acceptable Level of Compliance:

Goal: To adequately assess growth, nutrition, and development in pediatric population.

4. Developmental Delay - Children with delayed development, suggested on the basis of

Acceptable Level of Compliance: 80% of charts audited will be in compliance

Acceptable Level of Compliance:

The following will also be reviewed for compliance rate of 65%:

Goal: To reduce unnecessary death and disability from diabetes.

Established people with diabetes

How Often to Audit: Annually

How Many Charts to Audit: 10 per FTE

Acceptable Level of Compliance:

Chronic Hypertensive Patients:

How Often to Audit: Annually

How Many Charts to Audit: 10 per provider

Acceptable Level of Compliance:

Goal: To reduce unnecessary morbidity and disability from uncontrolled asthma.

How Often to Audit: Annually

How Many Charts to Audit: 10 per provider

Acceptable Level of Compliance:

Classification* Symptoms† Night symptoms Lung function

Step 1: mild Symptoms occurring twice a Symptoms occurring FEV1/FVC is 80% or

Classification of Asthma Control

Symptoms ≤2 days/week >2 days/week Throughout the day

Nighttime awakening ≤1x/month ≥2x/month ≥2x/week

Interference with normal

Progressive loss of lung

Medication side effects can vary in intensity from none to very

How Many Charts to Audit: 10 per provider

Identify Charts: Random screen of patients who are active users.

Acceptable Level of Compliance:

PATIENT NAME DATE

a) Little interest or pleasure in things.

□ Not difficult at all □ Somewhat difficult □ Very difficult □ Extremely difficult