Copyright©2000 Franciscan Health System West
Reprinted here with permission.

OPENING A CLINIC CHECKLIST

1. CLINIC IDENTIFICATION

	Clinic Self-Referral
	Expansion plan
	Identified specialty clinics	_____________________________________	__

2. SITE READINESS

	Leadership commitment
	Number of physicians		__
	Number of eligible patients (include Medicare patients		__
	Financial commitment	____________________	__
	Space and equipment available
	Capability of generating office visit lists on 5 diagnoses
	(Heart, Cancer, Lung, CVA, Dementia)
	Medical records commitment
	Computer, software, modem, printer

3. INITIAL PRESENTATION & PLANNING MEETINGS

Improving Care through the End of life Medical Director

Mimi Pattison, MD

Improving Care through the End of life Director

Georganne Trandum, RN, OCN

	Clinic Medical Director	___________________
	Clinic Administrator	___________________
	Physician Champion	___________________

	Initial Presentation	(___/___/___)
	Subsequent Meetings	(___/___/___)(___/___/___)(___/___/___)

4. SECURE STAFFING

	Clinic Care Coordinator/Sponsor		__________________
	Chaplain/Sponsor		__________________
	Volunteer Coordinator/Sponsor		__________________
	Volunteers (initial base of 4)	(1)	__________________
		(2)	__________________
		(3)	__________________
		(4)	__________________

5. EDUCATION (Physicians, Nurses, PAs, ARNPs )

OUTCOME: 80% of providers will complete 5 hours of education 8 weeks
from clinic startup

	1-hour introduction with "Supportive Care of the Dying" Video
	4 hours education (one 4-hour segment or two 2-hour segments)
	Video: "Pain & Symptom Management & Hospice Referrals"
	Booklets (Hospice Teaching Tool)
	Pain and Symptom Management File
	"Giving Bad News"
	Advance Care Planning-How to complete forms
	Education for Physicians on End of life Care (EPEC) curriculum
	Resources

6. EDUCATION/TRAINING (Clinical Care Coordinator)

	Computer Training	..................
	-Word     -Excel     -PowerPoint     -Access
	Referral Process	..................
	-Criteria     -How to generate lists
	Medical Records	..................
	-Retrieval of charts     -System to identify patients     -Authorization to document end-of-life care in medical records
	Data Collecting	..................
	-Referrals     -ICD9 codes     -Survey Data     -Access database (# of patients, deaths, LOS, support services etc.)    -IHI Methods
	Communication with Physician/Triage Nurses	..................
	-Informal (hallways)     -Formal (monthly written reports)     -Weekly with Physician Champion     -Documentation in Medical Record
	Communication with Patients	..................
	-Initial Contact     -Home Visits     -Office Visits     -Ongoing intermittent calls in assessment of acute or chronic issues     -Monthly Volunteer Contact
	Communication with Team Members	..................
	-Chaplains     -Volunteers     -Other disciplines and health care professionals     -Public
	Resources	..................
	-System-wide     -Community     -Nurses in clinic     -Manual
	Chaplain Training	..................
	-Referral Process     -Home Visitation     -Communication/Documentation
	Volunteer Training	..................
	-Basic Recruitment and Interview     -Expectations/Contract     -Survey Data Training     -Support     -Ongoing Education
	Follow-up and Support from Director	..................
	-Informal Calls, contacts     -Formal, monthly reports     -Task Force Meetings     -Steering Committee Meetings

7.

EDUCATION/TRAINING OF VOLUNTEERS

8.

EDUCATION/TRAINING OF CHAPLAIN

9. FORMS

	Opening a Clinic Checklist
	Sample Note to Physicians/Providers
	Referral Form
	Nursing Assessment
	Patient Information Flow Scheme
	Referral Approval
	Follow-up Introduction to Patients
	Advance Care Planning Information Sheet
	"This May Be the Greatest Gift You Can Give Your Family"
	Advance Care Planning Form
	Volunteer Job Description
	Volunteer Application
	Volunteer Contract
	Welcome Memorandum
	Volunteer Training
	Initial Training Procedure
	Patient Survey
	Diagnosis Abbreviation list
	Ideas for Questions
	Volunteer Call Schedule
	Help With Survey Questions
	Developmental Landmarks and Tasks for the End of Life
	Volunteer Information on Hospice
	When a Patient is Referred to Hospice
	Tips on listening
	Tips on Total listening
	Listening Skills
	Ongoing Education- Perspectives on Dying Questionnaire
	What to do with a Complaint
	Bereavement Calls
	Evaluation
	Volunteer Evaluation
	Improving Care through the End of life Memorandum
	Spiritual Care Counselor/Chaplain Time Journal

[Return to Featured Innovation]
[Return to Resources and Tools]