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2012 ISMP International Medication Safety Self Assessment® for Oncology Instructions

Completing the Assessment

It is important for each hospital or ambulatory site in a multihospital or ambulatory system to complete the self assessment individually.

  1. Establish an interdisciplinary team consisting of, or similar to, the following:
    • Senior administration representative
    • Chief medical officer
    • Nurse executive
    • Director of pharmacy
    • Chief information officer
    • Clinical information technology specialist
    • Medication safety officer/manager
    • Risk management and quality improvement professionals
    • At least two staff nurses working in oncology care areas
    • At least two staff oncology pharmacists (one clinical and one distribution)
    • At least one active oncology staff physician.

    It is helpful to appoint a team leader to coordinate the process. Other practitioners and staff (e.g., biomedical personnel, certified nurse practitioners, receptionists) may need to join the core team for evaluation of certain sections of the self assessment.

    Your team should be provided with sufficient time to complete the self assessment and be charged with the responsibility to evaluate, accurately and honestly, the current status of medication practices as they relate to oncology in your facility. Because medication use is a complex, interdisciplinary process, the value and accuracy of the self assessment is significantly reduced if it is completed by a single individual or discipline involved in oncology medication use. Based on participant feedback from prior self assessments, we anticipate that it will take three team meetings of approximately 1 to 2 hours each to complete this self assessment.

  2. Read and review the self assessment in its entirety, including the instructions, Key Definitions, and Frequently Asked Questions (FAQs) before beginning the assessment process.

    The team leader should provide copies of the self assessment tool, FAQs and Key Definitions to all team members for review before the first meeting. In the electronic version, FAQ information and Key Definitions can be accessed by hovering over the FAQ icon or the defined item (shown in small capital letters).

  3. Verify your demographic information.

    Before the first team meeting, the team leader should review and verify the responses in the demographics section with the administration of the hospital/ambulatory organization/practice setting as discussed in the FAQs.

  4. Convene the team.

    During the assessment meetings, ensure that each team member can view either a hardcopy or electronic version of the self assessment during the meeting. There are a couple of options for completing the assessment:

    • Option 1: Print hardcopies of the self assessment to share with team members, manually complete the demographic information, and fill in your choice (A through E, or Not Applicable [N/A]) for each self assessment item. Once completed, of the assessment, submit your information online at: http://mssa.ismp-canada.org/oncology.
    • Option 2: Use the online self assessment form to view at team meetings, complete the demographic information, and enter your choice (A through E, or Not Applicable [N/A]) for each self assessment item, saving your username/password-protected document at the end of each meeting. (Please see Step 8 for information regarding accessing the online self assessment form and obtaining a username and password.)
  5. Discuss each core characteristic and evaluate the organization's/practice setting's current success with implementing the self assessment items within that core.

    As necessary, investigate and verify the level of implementation with other healthcare practitioners and staff outside your core assessment team. When a consensus on the level of implementation for each self assessment item has been reached, select the appropriate column (A through D, or Not Applicable [N/A]), using the following scoring key and guidelines:

    Scoring Key

    1. A There has been no activity to implement this item.
    2. B This item has been formally discussed and considered, but it has not been implemented.
    3. C This item has been partially implemented in the organization for some or all areas, patients, drugs, and/or staff.
    4. D This item is fully implemented in the organization for some or all areas, patients, drugs, and/or staff.
    5. E This item is fully implemented throughout the organization for all patients, drugs, and/or staff.
    6. N/A (Not applicable) will be available as an option for specific questions.

    Organizations may want to consider assigning an individual to record any discussion generated around each self assessment item and the rationale behind the selected choice. This information, meant for internal use only, can assist the team when reviewing scores for individual items or reassessing your organization at a later date and will provide insight into why the choice selected for each self assessment item was chosen.

    Scoring Guidelines

    For all self assessment items: Self assessment items refer to chemotherapy/biotherapy medications prescribed, dispensed, and administered to all inpatients and outpatients for both the treatment of oncology and non-oncology disease processes (e.g., methotrexate for rheumatoid arthritis or psoriasis).

    For all self assessment items: Choice of E (full implementation) is appropriate only if all components are present in all areas of the organization, for all patients, all medications, and followed by all staff. If only one or some of the components of the item have been fully implemented in only some or all areas of the organization, your self assessment choice should be D.

    For self assessment items with an option of "Not Applicable" (N/A): Select "Not Applicable" (N/A) only if the item does not correspond to any services you provide in your organization/practice setting. N/A responses are scored the same as answering B (This item has been formally discussed and considered, but it has not been implemented).

  6. Repeat the process outlined in Step 5 for all self assessment items.
  7. If you have questions:

    Refer to the FAQs and Key Definitions — these are directly linked in the online form and identified in the PDF version via an FAQ icon or use of small capitals font for the Key Definitions.

    For additional questions, contact ISMP at oncselfassessment@ismp.org or call 001 215 947 7797 from 9 am - 5 pm (Eastern Daylight-Saving Time). If you are experiencing technical difficulties with the online assessment portal, contact ISMP Canada at: mssa@ismp-canada.org.

  8. To submit your final completed assessment or to use Option 2 to complete the assessment, go to http://mssa.ismp-canada.org/oncology, and click on the link to register.

    See the next section, Instructions for Entering and Submitting Information to ISMP/ ISMP Canada, for further information about obtaining a username and password, entering your information, and submitting your completed assessment.

  9. Once you have entered and submitted your information online, you will be prompted to print a report which will summarize your results. This is explained in detail in the next section.

Instructions for Entering and Submitting Information to ISMP/ISMP Canada

  1. To access the oncology self assessment webpage.

    From any computer with Internet capability, go to: http://mssa.ismp-canada.org/oncology to access the 2012 ISMP International Medication Safety Self Assessment® for Oncology webpage. This webpage will provide all the links you need to print and view the assessment, register, complete the self assessment, submit your information, and view your results.

  2. To register.

    Once the assessment webpage has been accessed, you will see two blue boxes at the top of the page; one for "New User Registration" and the other for "Existing User Login". To register, click on the “New User Registration” box to open the registration page. You will be prompted to select a username and password. You then have the option to provide an email address to be used only if necessary for password recovery. You have a further option to provide your full contact information so that information can be retrieved by ISMP in the event that you lose your login details. If you have not provided your email address or full contact information, ensure you record your username and password, and keep them in a safe place. Your username/password is required to:

    • Enter your information into the online self assessment form
    • Save your entered information and return to the online form at a later time to complete the assessment
    • Submit your completed self assessment to ISMP
    • View and print a report of your self assessment with scoring once it has been submitted
  3. To enter assessment information.
    • Entering data: Once you are logged in, you can start entering data and saving your responses. You can maneuver through the tool by using the dark blue tabs at the top of the screen that relate to each section (Demographics, I, II, III, etc.). You can also move from section to section by using the "Next Section" or "Previous Section" tabs that appear at the bottom right of the screen.
    • Saving data: You can click on the "Save" button at the bottom left of the screen any time after data has been entered. You can always go back and edit your responses and click the save button again to update your information. To exit the online form, click on the "Logout" button found at the top right of the page. In order to return to your saved information, you will need to go to the homepage and click the "Existing User Login" box, and then enter your username/password.
    • Check MSSA for Errors: You can click on this button (located near the "Save" button at the bottom left) at any time to see which items in the demographics section have not been answered or which other sections are incomplete. If all the items in the section have been answered, a green check mark will appear next to the section tab at the top of the screen.
  4. To submit your completed assessment.

    Once all the items have been answered and saved, a message box will pop up telling you, "The MSSA is now complete. Do you want to submit the results to ISMP Canada?" You can click OK to submit your self assessment responses or Cancel to go back to the tool.

    • If you select OK: Your responses will be submitted — you will NOT be able to make any changes to your information if you select OK.
    • If you select Cancel: Your responses will be saved, but you can still go back and make changes. You can even log out and log back in to make changes.
    • If you saved your changes and did not submit your results, the Check MSSA for Errors button will say Submit MSSA results unless you make changes. If you do not make any changes, click on that button to submit your responses. If you make changes and save them, the pop up box will come up again telling you the assessment is complete and will ask if you want to submit your results.
  5. To generate your report.

    Once you have submitted your completed self assessment, a message box will appear stating that the MSSA has been finalized. At this point you can view your responses but you will not be able to make any changes.

    You will be prompted to print a report of your submitted self assessment with your answers and numerical scores for each of the self assessment items, subtotals for each of the core characteristics and key elements, and a total score for the entire self assessment. Note that the scored report will be approximately 20 pages in length.

    If you have not supplied your email or full contact information to obtain a lost or forgotten username/password, ensure that this report and your username/password are maintained in a safe location so you can compare your organization's/practice setting's findings with aggregate data from similar sites when it is available, or to use your results to compare against future results of your organization.

    At any time after submitting your information, you can enter your username/password to view and/or print your self assessment report. However, you will not be able to make any changes to the information you originally submitted.

Explanation of Scores

The assessment items have been scored as follows:

  1. A There has been no activity to implement this item. (Score = 0)
  2. B This item has been formally discussed and considered, but it has not been implemented. (Score = 1)
  3. C This item has been partially implemented in the organization for some or all areas, patients, drugs, and/or staff. (Score = 2)
  4. D This item is fully implemented in the organization for some or all areas, patients, drugs, and/or staff. (Score = 3)
  5. E This item is fully implemented throughout the organization for all patients, drugs, and/or staff. (Score = 4)
  6. N/A (Not applicable) (Score = 1)

Access to Comparative Reports

The Institute for Safe Medication Practices (ISMP) and ISMP Canada are pleased to provide you with access to comparative data from the 2012 ISMP International Medication Safety Self Assessment® for Oncology. This comparative information is available to sites that participated in the self assessment and submitted their information. More than 350 facilities in 13 countries submitted data for the project.

Using our web-based program, you will be able to compare your organization to other demographically similar organizations that have participated in the assessment. Comparisons can be made to the global aggregate and to the aggregate of organizations in your own country if at least 3 sites in your country have participated. We encourage you to share these results with the team you assembled to complete the self assessment or a similar committee.

We appreciate your involvement in this project and hope you will find this comparative information helpful as you prioritize medication safety work related to oncology practice in your organization.

To access the program, go to https://mssa.ismp‐canada.org/oncology and login with the username and password that was used to enter data. Once you are logged in, you will see the basic menu which includes Introduction, Instructions, FAQs, Key Definitions, Printable Version, Compare Own Data, and Assessments with the date submitted. The information below describes the use of the tabs you will need to access and compare your data.

Instructions:

Assessments:

The date listed is the date you submitted your assessment. When you click on the date listed, a menu will appear with 3 choices:

  1. View Assessment:
    By clicking here, you can view your entire completed self assessment with the information you submitted. You cannot change this information. At the bottom of the screen you will see the actual date that the assessment was completed.
  2. Print Results:
    This allows you to print your completed assessment with the information you submitted.
  3. Graph Results:
    This tab provides access to the comparative assessment results. The tabs that run across the top of the graph allows you to view the Key Elements (default), Core Characteristics, and each of the Key Elements I through X. When viewing I through X, the screen displays the scores for each individual item within these elements.

    The yellow bars (user) indicate your results; the blue bars (average) indicate the full international results; the red line indicates one standard deviation from the mean.

    As you scroll over the bars in any of the graphs, the full description of the item is displayed at the bottom of the graph for the Key Elements, Core Characteristics, or the individual assessment items within tab I through X, and the actual percentage score appears in a white bubble on the bar.

    Filters (located below the graph):
    Applying filters allows you to compare your organization to other organizations with similar characteristics/demographics on an international scale. By applying the country filter, you can compare your organization to other organizations with similar characteristics/demographics within your country – this comparison is limited to your country only. If the country filter is selected, the blue bar displays the aggregate data for your country. The number of organizations that have responded to that characteristic or demographic is displayed at the top of each graph (i.e., n = x).

    There are some limitations to the filters. The data will only be displayed if more than 3 organizations (internationally or within your country) selected that response. Otherwise, you will see the following message: “There is not enough data to render the graph. Please change your filter selection.” This was done to keep individual organizations from being identified.

    You can select and/or deselect filters and adjust the graph by clicking on “Apply Filter.” Anytime you change a filter selection, you need to click the Apply Filter button to update the information. Note that multiple filters can be applied at once.

    You can apply filters to the Key Elements, Core Characteristics, and the individual items within those elements by clicking on the respective tab at the top of the graph.

For more information or questions about the comparative results, contact ISMP at oncselfassessment@ismp.org.

Security and Protection of Self Assessment Information Submitted to ISMP/ISMP Canada

All information submitted to ISMP and ISMP Canada is maintained in a secure database maintained solely by ISMP Canada. The application does not allow viewing of data or demographic information associated with individual assessment information. All information is contextually de-identified, and the demographics and submitted results will be used only for aggregate data reports. Usernames/passwords required for submitting information to ISMP are self-selected by the organization/practice setting participating in the self assessment. Access to any contact information voluntarily provided by the organization (i.e., email address for lost or misplaced password only) is restricted to a small number of ISMP Canada personnel and confidentiality is assured.

In addition to the usual high standard of confidentiality associated with any information submitted to ISMP and ISMP Canada, we would also like to remind participants that ISMP is a federally certified patient safety organization (PSO) in the United States. If self assessment information is collected within the hospital's patient safety evaluation system and submitted to ISMP as patient safety work product, the information is granted protection from discovery in connection with a federal, state, or local civil, administrative, or disciplinary proceeding. No contract with ISMP is required for this legal protection. Further guidelines regarding submitting information to ISMP as a PSO can be found at: www.ismp.org/docs/PSOguidelines.pdf.