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ANNUAL MANDATORY UPDATE TRAINING * Complete AMUT and Win a Prize In an effort to attain 100% completion goal, the staff education department is holding a drawing. – PowerPoint PPT presentation

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Complete AMUT and Win a Prize
  • In an effort to attain 100 completion goal,
  • the staff education department is holding a
  • Each employee who successfully completes AMUT and
    find the total of
  • bouncing AMUT Dogs will be entered into a
    drawing. The winner of the drawing will receive a
  • prize and bragging rights in the leadership
  • bulletin!
  • Entry forms are located at the bottom of the AMUT
    Completion form. Send your name and of bouncing
    to attn Kelli
  • Houston (Staff Education- PC). Entries must be
    received by December
  • 31st. The winner will be announced on Monday,
    January 3, 2011.

Age Appropriate Care
  • Age-related competency means having the
    knowledge and skills required for a
  • specific developmental group of patients.
  • What are the developmental groups, their
    behaviors, and the best approaches
  • for care?
  • Infant (Birth through 12 months)
  • Clings to parents and cries when they leave
  • Handle infant gently and speak in a soft,
    friendly tone of voice
  • Toddler (1 to 2 years)
  • Experiences separation anxiety
  • Give the child simple, direct, and honest
    explanations just before treatment or surgery
  • Pre-school (3 to 5 years)
  • Experiences separation anxiety may panic or
    throw tantrums, especially when parents leave
  • Use simple, neutral words to describe procedures
    to the child
  • School Age (6 to 12 years)
  • Alternatively converts to adult standards and
    rebels against them
  • Explain logically why a procedure is necessary
  • Adolescence (12 to 18 years)

AMUT Check-Up Quiz
  • 1. Which developmental age group fluctuates in
    their willingness to participate in
  • care because of their need for independence and
  • A. School age children
  • B. Adolescents
  • C. Middle Adult
  • D. Older adult/Geriatric
  • Correct answer B. Adolescents
  • 2. The Joint Commission requires that staff
    members have the knowledge and
  • skills necessary to meet age-specific needs.
  • True
  • False
  • Correct answer True
  • 3. To maintain competencies in age-specific care,
    you must be updated on new
  • technologies, procedures or therapies for your

Americans with Disabilities Act (ADA)
  • The Americans with Disabilities Act (ADA) was
    enacted on July 26th, 1990 by
  • the United States Congress. This federal law
    prohibits discrimination and
  • ensures equal opportunity for persons with
    disabilities in
  • 1) Public accommodations
  • 2) Employment
  • 3) Transportation
  • 4) State and local government services and
  • 5) Telecommunications (e.g. Telephone Device for
    the Deaf)
  • Under the ADA Act, disability is defined with
    respect to an individual as a
  • physical or mental impairment that substantially
    limits one or more of the
  • major life activities of such individual a
    record of such an impairment or
  • being regarded as having such an impairment.
    Major life activities includes
  • functions such as activities of daily living,
    walking, seeing, hearing, breathing
  • and working to name a few.
  • In health care the ADA definition of a disability
    is expanded to include
  • individuals temporary limitations which include

AMUT Check-Up Quiz
  • Which of the following would be considered an
    inappropriate action when serving a physically
    disabled member who uses a wheelchair?
  • A. Calling the department next door to use
    their wheelchair weight scale as your department
    does not have one.
  • B. Assume you will need the lift team to help
    transfer the member to a gurney.
  • C. Crouch to make yourself shorter when speaking
    to the member.
  • D. Waiting for the member to respond after
    asking if they need assistance
  • moving about in their chair.
  • Correct answer B

Ergonomics/Body Mechanics
  • Ergonomic tips for sitting at a computer

AMUT Check-Up Quiz
  • 1. The potential for back injury can be reduced
    by understanding your back anatomy, maintaining
    correct posture and using correct body mechanic
    during activities
  • True
  • False
  • Correct Answer True
  • When working in a sitting position which of the
  • applies
  • Sit close to your work
  • Maintain one static position for as long as
  • Arrange your work to the side so you can twist
    back and neck
  • Maintenance of the spines three natural curve is
    not necessary in sitting
  • Correct Answer A
  • Which of the following would be considered
    inappropriate action when carrying a load
  • Using your feet to change direction
  • Carrying a load over your head
  • Setting the load down and resting for a few
  • Keeping your back straight or slightly arched

1. Keep head upright
ears, shoulders and hips in a
relaxed posture 2. Shoulders relaxed elbows
by sides of Body 3. Adjust backrest to
support curve in lower back. 4. Sit in
relaxed posture with buttocks against
back of chair and close to your work 5.
Thighs parallel to floor or hips slightly
above knees
6. 1-4 between front edge of seat and
back of knees 7. Feet flat on floor or floor
rest 8. Top of monitor at or slightly below
eye level (lower for bifocals) 9. Monitor
distance at arms length 10. Monitor,
keyboard and mouse inline keyboard
flat on surface mouse beside
keyboard. Adjust desk or keyboard
tray so forearms are parallel to
  • Lifting Safely
  • Keep your back straight or slightly arched use
    abdominal muscles
  • Walk Slowly and surely
  • Use your feet to change directions. Never twist
    your back
  • Avoid leaning over
  • Avoid lifting a load over your head
  • If you become tired, set the load down and rest
  • Ask for help especially if you believe the load
    is too heavy or use a cart

  • Compliance Expectations
  • Achieving compliance takes everyones commitment.
    Here are some compliance
  • expectations for all workforce members
  • Use the Principles of Responsibility, our formal
    code of conduct, as a tool for making decisions
    about compliance and ethics issues.
  • Identify potential fraud, waste, and abuse and
    take appropriate action.
  • Protect the confidentiality and security of
    patient information.
  • Report potential instances of noncompliance as
    part of your job.
  • The Principles of Responsibility
  • You should understand The Principles of
    Responsibility (or POR), Kaiser
  • Permanentes code of conduct, applies to everyone
    and is meant to help each of us
  • accomplish the organizations mission in an
    ethical work environment.
  • A few of the topics included in the Principles of
    Responsibility are
  • Non-Retaliation - Kaiser Permanente has a clear
    non-retaliation policy. We do not tolerate
    retaliation against individuals who refuse to
    participate in or report illegal and unethical
    acts to KP or government agencies. Anyone who
    retaliates against these individuals is subject
    to disciplinary action, up to and including
  • Conflict of Interest - Conflicts of interest have
    the potential to damage the reputation of both
    you and the organization. A conflict may arise
    when your personal or financial interests
    influenceor appear to influenceyour judgment or
    interfere with your work responsibilities.
  • Fraud Awareness and Prevention
  • In the simplest terms, fraud occurs when someone
    lies to gain benefit or advantage.
  • An example of fraud is when someone uses another
    persons medical identification
  • card to receive treatment. Preventing fraud
    protects our members health, our
  • resources, and our reputation.
  • There are many fraud risk areas throughout the
  • If you work with members, you may find
    medical-identity theft or members enrolling
    ineligible dependents.
  • If you work with vendors you may see conflicts of
    interest or kickbacks.
  • If you work with drugs you may see drug theft or
    forged prescriptions.
  • If you work with claims you may discover
    suspicious or false claims by members or
  • If you work with other employees you may see
    fraud, waste and abuse such as cash theft,
    timekeeping fraud, misuse of assets or personal
    business on work time.
  • As part of your job, you are required to report
    all instances of non-compliance.
  • To maintain competencies in age-specific care,
    you must be updated on new
  • technologies, procedures or therapies for your
  • Privacy and Security

  • Here are some frequently asked questions and
    answers to clarify
  • some of the more common misconceptions
  • Can I look up my coworkers address in the system
    to send him/her a get-well card?
  • NO. You must not look up this information for
    personal reasons. When it comes to the privacy
    and security of protected information, accessing
    demographics is no different than accessing
    clinical information. You should contact the
    employees manager for instructions.
  • Can I look up my 5-year old daughters lab
  • NO. As the parent of a 5-year old you do have a
    right to this information however you must
    obtain it the same way a non-Kaiser Permanente
    workforce member would obtain it.
  • I work in an open area with three other
    employees. When I leave my workstation, I dont
    lock it up (Ctrl-Alt-Del buttons). Is that okay?
  • NO. Although your coworkers are employees, this
    does not automatically give them access to the
    information on your computer. Use the minimum
    necessary principle. You must only use, access or
    disclose the minimum amount necessary to get the
    job done. Always lock up your workstation
    whenever you step away.
  • The consequences for inappropriately accessing
    medical records can be severe.
  • Employees have been terminated for this very
    reason. In addition, individuals can
  • be fined up to 25,000, per a new state law (SB
  • Reporting Compliance Concerns
  • At KP, we foster a culture of compliance. In the
    POR, under Where to Get
  • Help you will find several methods for reporting
    potential compliance
  • concerns
  • We encourage you to go to your supervisor first,
    however we realize sometimes this may not be
    possible so there are other internal resources
    available to you.
  • Avoid Conflicts of Interest, Do the Right Thing
  • What is a Conflict of Interest?
  • A conflict of interest arises when personal or
    financial interests influence your professional
    judgment, business decision-making, or interfere
    with your Kaiser Permanente responsibilities. In
    addition, a potential conflict of interest exists
    when it might appear to others that personal or
    financial interests could influence professional
    judgment or decision-making.
  • For instance, Jane is a senior registered nurse
    who assists physicians in the Emergency
    Department (ED). As a senior nurse, Jane is
    well-respected, and other employees, including
    physicians, rely upon her expertise and advice to
    keep the ED running smoothly. Recently, Jane
    befriended John, a contractor who sells emergency
    room equipment to hospitals and has previously
    sold products to Kaiser Permanente. John has
    offered Jane a gift, a high-quality digital
    camera in a case with the vendor's name and logo
    on it. The value of the camera is more than 25,
    and Jane knows John would like to sell his
    products at her facility.
  • The above scenario demonstrates a conflict of
    interest for Jane because her personal
    relationship with John may cloud her loyalties to
    Kaiser Permanente, and interfere with her job
    responsibilities. The right thing for Jane to do
    is to decline the gift and inform her manager in
    writing of the relationship and the potential
    contracting issue.
  • Other Conflicts of Interest Examples
  • Here are some conflicts of interest examples.
    They occur when an employee has
  • A financial interest with organizations doing
    business with Kaiser Permanente.
  • Accepted gifts or benefits for work related
  • Influenced business decisions with organizations
    in which they or their family hold a direct
    financial interest.
  • Supervised a member of his or her family as a job
  • Served as an officer or member of a board of
    directors of another organization that could pose
    a conflict as an employee of Kaiser Permanente.

  • When, How to Report Conflicts of Interest
  • Whenever you become aware of a potential conflict
    of interest, you are required to disclose it in
    writing to your manager, supervisor, medical
    center compliance officer, Human Resources
    representative, chief, or department
    administrator. If you become aware of a conflict
    of interest that is currently taking place in
    your work environment, you may also call the
    anonymous Kaiser Permanente Compliance Hotline,
    888-774-9100 (toll free). KP has a
    non-retaliation policy that protects employees
    who report conflicts or potential conflicts of
    interest in good faith.
  • Learn More about Conflicts of Interest
  • Refer to our Principles of Responsibility, Kaiser
    Permanente's code of conduct
  • Contact your Compliance Officer
  • Visit the Southern California Compliance Web site
  • Send an e-mail to SCAL-Compliance-and-Privacy-Offi

AMUT Check-Up Quiz
  • 1. The KP Code of Conduct is my guide for telling
    me how to work honestly and ethically at Kaiser
    Permanente, and I understand it is my obligation
    to report something that is a violation of the
    Code of Conduct, to my supervisor, manager, my
    Compliance Officer, or call the Compliance
  • True
  • False
  • Correct answer True
  • According to the KP Code of Conduct, the
    principle that tells me that I cannot take cash
    or gift cards from vendors is
  • The Principle for Respecting Confidentiality,
    Privacy and Security
  • The Principle for Safeguarding and Proper Use of
  • Assets
  • The Principle for Protecting the Environment
  • The Principle for Conflict of Interest
  • Correct answer D

Customer Service
SERVICE EXCELLENCE We interviewed some of our
members about the service they had received in
area medical offices and what we can do to
provide the best possible care experience. They
provided us with valuable insights into how they
define the qualities and characteristics they
hope to see in our reception team, our medical
assistants and our nurses.Tina Han, Panorama
City, SCPMG Service Leader
  • KP Members have listed the following qualities
    and behaviors when describing
  • excellent service What are the developmental
    groups, their behaviors, and the
  • best approaches for care?
  • Show Courtesy By
  • Treating members politely and with respect.
  • Being friendly and greeting each member warmly.
  • Engaging the member in conversation to reinforce
    your personalized, focused attention on them.
    Conversations with co-workers should end
    immediately when a member approaches you.
  • Smiling and making eye contact.
  • Using a pleasant tone of voice.
  • Taking your time with each member and not rushing
    them through the check-in process.
  • Show Helpfulness By
  • Offering to help before being asked. Proactively
    offering instructions about where to wait, what
    to do with forms, giving directions to other KP
    departments and location (pharmacy, lab, parking,
    nearest exit, etc.).
  • Walking members to their destination whenever
    possible. If you cant leave your work area,
    provide members with a campus map and show them
    where they need to go. Maps are available online
    at http//voices-pc.
  • Always asking, Is there anything else I can do
    for you today?
  • Following up on requests made by the member.

AMUT Check-Up Quiz
  • 1. Our members expect a smile, eye contact,
    attentiveness, and a pleasant tone of voice to
    demonstrate courteous behavior.
  • True
  • False
  • Answer True
  • 2. Proactive offering of help is a key element of
    patient satisfaction
  • True
  • False
  • Answer True
  • 3. Listening attentively demonstrates caring and
  • True
  • False
  • Answer True
  • 4. Kaiser Permanentes Service Quality Credo
    says, Our cause is health. Our passion is
    service. Were here to make lives better.

Our Service CredoOur cause is health. Our
passion is service. Were here to make lives
Service and SCPMG Leadership Dept. website
Service Advisor http//
Culturally Responsive Care
  • The United States, already one of the most
    diverse societies in the world, is becoming
    increasingly multicultural and multilingual.
    Immigrant, refugee, limited-English
  • and non-English proficient (LEP/NEP) populations
    are continuing to grow. According to the 2000
    U.S. Census, 47 million residents were
    non-English speaking and this
  • population is expected to reach 40 by the year
    2030. For health care organizations, providing
    linguistic and culturally appropriate health care
    services that ensures
  • quality of care to diverse populations has
    becoming increasingly imperative and complex.
  • At Kaiser Permanente, we believe it is our
    responsibility to protect a patients right to
    receive the information necessary to make
    informed health care decisions. To
  • continue providing quality of care to our
    patients, especially those that are
    limited-English and non-English speaking,
    effective communication is key to the delivery
  • of culturally competent health care.
  • Qualified Interpreter Services available
  • Qualified Bilingual Staff (QBS) Level 1 (L1)
    interpreter - can be used to provide language
    assistance to patients/members at a basic
    conversational level excluding medical
  • Qualified Bilingual Staff (QBS) Level 2 (L2)
    interpreter - can be used to provide language
    assistance to patients/members in encounters
    including those that are clinical interactions
    with the use of medical terminology.
  • Telephone Language Line Interpreter for all
    languages can be accessed 24 hours, 7 days a
  • Only qualified, tested, and trained bilingual
    staff for Spanish, Tagalog, and Armenian can be
    used to provide interpretation
  • services to members. Bilingual staff speaking a
    language outside of the three Panorama City
    Approved languages cannot provide
  • interpretation to patients. For language services
    where Qualified Bilingual Staff (QBS) is not
    available, the Language Line Service

Culturally Responsive Care
  • How to Use the Language Line Telephone
    Interpreting Services (non-English language only)
  • 1. Establish a conference call between you, the
    member/parent and the language interpreter
  • Language Line Services 1-800-523-1786
  • Client I. D 136520 (Panorama City outlying
  • 295204 (Antelope Valley only)
  • 2. When you reach the Language Line
    Representative, you will be asked for a client
  • code (Client I.D.) You must also give her/him
    your full name, your department and the language
  • that the member/parent speaks. If you are not
    sure what language the member/parent speaks, use
  • the Language Identification Card to assist you in
    identifying the language. For Language Line
  • Identification cards, please contact Dionne
    Hunte, x3439.
  • 3. Within minutes you will be connected to an
    interpreter. Stay on the line with the
    member/parent until you are sure that the
    interpreter and the member/parent have connected.
  • 4. When using two hand held phones
  • Give one to the patient
  • Provider/Staff uses the other
  • Begin dialogue between yourself, patient, and

AMUT Check-Up Quiz
  • For Clinical interactions where medical
    terminology is used, what type of Qualified
    Bilingual Staff member may be used for
  • A. Language Line
  • B. QBS Level 1
  • C. QBS Level 2
  • D. Family Member/Friend
  • Correct answer C. QBS Level 2
  • 2. The language line can only assist in the
    following languages Spanish, Tagalog, and
  • True
  • False
  • Correct answer False
  • Under no circumstance, should a member/patient
    ever be asked to bring their own interpreter to
  • an Administrative or Clinical Point of Contact.

Emergency Management
  • Earthquakes
  • Crush injuries or death occur from falling debris
    and breaking glass or when people fall from
    shaking. Fires may be caused by gas leaks. Most
    common injuries
  • Burns
  • Crush or orthopedic injuries
  • Lacerations
  • Lung damage from inhaled debris
  • When many people are hurt by the same event, this
    is called a Mass Casualty Incident... When mass
    casualty incidents involve more patients than the
    Emergency Room can treat under relatively normal
    conditions, the emergency management plan may be
  • Plane crashes and bombings are other examples of
    mass casualty incidents. Plane crashes cause
    crush injuries. Bombings cause crush injuries and
    concussions. Both plane crashes and bombings
    result in burns. Plane crash burns can be
    particularly severe. Respiratory damage is a
    common injury in both plane crashes and bombings.
  • Multiple motor vehicle accidents and train
    derailments may also be multiple casualty
    incidents, and may likewise cause the activation
    the emergency management plan. Vehicle and train
    accidents often cause the following injuries
  • Head trauma
  • Crush injuries
  • Hemorrhage
  • Amputation
  • Burns from fuels fires
  • When a disaster strikes, the Medical Centers
    Emergency Operation Plan (EOP) may be activated.
    Typically, a message is sent out on the overhead
    paging system to indicate what type of disaster
    has occurred. The paging code for disaster is
    Code Orange Disaster
  • Review the information in the EOP that applies to
    you and your department prior to a disaster.
    Knowing what to do will help you respond calmly
    and effectively. Depending on the scope of the
    situation, expect to
  • When a disaster strikes, the Medical Center may
    become a center of activity
  • The community may look to the organization for
    leadership and safety
  • The injured may be brought for treatment
  • The facility itself may also be directly affected
    by the disaster
  • If a disaster strikes, Medical Center employees
    are expected to follow the Medical Centers
    Emergency Operation Plan (EOP) and know what is
    expected. Here are some of the roles that you
    may need to perform during and emergency
  • Provide care to the injured
  • Minimize confusion by being calm and
  • Provide support and services to other staff
    involved in disaster response
  • The Medical Center has developed an Emergency
    Operation Plan (EOP) for
  • dealing with disasters and emergencies. The EOP
    outlines what you and your
  • Department are expected to do if a particular
    situation arises. Disaster drills
  • are also conducted at least two times each year.
    Knowing what to do will help
  • you stay calm in a disaster.
  • Be prepared
  • Locate where the Emergency Operation Plan (EOP)
    in DMS

Emergency Management
  • If there is a loss of electricity
  • Locate flashlights or light sticks in your
  • Note whether the emergency generator goes on
  • Locate emergency outlets. These have red cover
  • Verify that all patient equipment is plugged into
    emergency outlets and that it is operating
  • Call or send a runner to the Command Center or
    Maintenance for additional equipment
  • If there is a loss of water
  • Obtain safe bottled drinking water supplies
  • Use waterless hand cleaner
  • During some internal disasters, it is necessary
    to evacuate a specific area or building. If the
    Command Center or outside emergency response
    groups (such as fire or police department)
    determines that your unit must be evacuated,
  • Rescue anyone in immediate danger first
  • Evacuate ambulatory patients before those who are
    non -ambulatory
  • Dont use the elevators
  • A responsible person should be designated to make
    a final work-through to be sure that everyone has
    been evacuated.
  • When a disaster is over, staff members will need
    to talk. If the situation is prolonged or
    traumatic, shift debriefings help provide comfort
    and rumor control.
  • Review the information in the EOP that applies to
    you and your
  • department prior to a disaster. Knowing what to
    do will help you
  • respond calmly and effectively. Depending on the
    scope of the
  • situation, expect to
  • Maintain normal working patterns, but stand by.
    DO NOT plan to leave the facility unless you are
    released by your manager
  • If directed, stop nonessential functions and
    prepare for reassignment
  • When a disaster strikes, the Medical Centers
  • Operation Plan (EOP) may be activated
  • Typically, a message is sent out on the overhead
    paging system to indicate what type of disaster
    has occurred. The paging code for disaster is
    code Orange.
  • Review the information in the EOP that applies to
    you and your department prior to a disaster.
    Knowing what to do will help you respond calmly
    and effectively. Depending on the scope of the
    situation, expect to
  • Maintain normal working patterns, but stand by.
    DO NOT plan to leave the facility unless you are
    released by your manager
  • If directed, stop nonessential functions and
    prepare for reassignment
  • In certain types of disasters, internal utility
    system interruption may occur. Downed power lines
    can cut electrical power to lighting and
    equipment. Broken pipes cause loss of running
    water and toilet flushing. Phone lines can
    overload or be damaged. This will require you to
    use other methods of communication. If oxygen
    lines break, alternate oxygen sources will be
    needed for oxygen-dependent patients.

Fire Life Safety
  • Smoke can confuse you, making escape more
    difficult. Smoke is lighter than air and rises,
    so stay low where you can breathe the best air
    even if it means crawling. Patients who are able
    to walk should be moved in a group. Provide
    blankets or towels for protection as they move to
  • Since beds can block halls, they should not be
    used to move patients unless nothing else can be
    used. Use techniques taught in the fire
    certification class to get patients to safety.
  • Although you must get people away from the fire,
    you must also move to an area that can support
    any necessary medical equipment. Think ahead of
    time where that will be or bring the medical
    equipment with you. Take patient records with you
    so that you can account for everyone later and to
    facilitate the necessary on-going treatment.
  • If you need to open a door on the way to your
    exit but you are not sure is there is fire
    burning behind it, first feel the door with the
    back of your hand first. If hot, do not open it,
    since a burst of flames could come at you. If you
    must open the door, stand behind it to protect
    yourself, and open slowly. Always remove the
    patient first in the event of any type of fire if
    it is safe to do so.
  • An ABC extinguisher can be used for all types of
    fires. Never use a type A or water extinguisher
    to fight electrical fires. Check what kind of
    extinguishers you have in your work area.
  • Never block fire doors from closing by the
    placing of either equipment or doorstops. A piece
    of improperly stored equipment could slow down or
    even prevent exit in a fire. Fires occur when you
    least expect, so keep passages and exits clear at
    all times.
  • Remember P.A.S.S. when operating a fire
  • P Pull the pin on top of the extinguisher.
  • A Aim at the base of the fire.
  • S Squeeze the extinguisher trigger.
  • S Sweep over the fire.
  • Dont try to put out a fire that is too big for
    you. Your time will be better spent alerting
    others. The fire extinguisher will only last for
    a few seconds, so remember to aim carefully. A
    sweeping motion will ensure that the base of the
    fire is saturated.
  • In a fire, thing P.C.A.E. Familiar yourself with
    the written fire plan for your department. For
    any questions contact Security or Environmental
    Health Safety.
  • Life Safety
  • Fire can only occur when Fuel, Heat and Oxygen
    combined in a fire
  • triangle. By keeping these elements from coming
    together, you can
  • prevent fires.
  • In a fire, think P.C.A.E
  • P Patients are to be removed from immediate
  • C Contain the fire by closing doors
  • A Activate the alarm system by pulling the fire
    alarm box and by dialing
  • extension 2222
  • E- Extinguish the fire with a fire extinguisher
    only if safe to do so
  • Fire safety calls for a team effort. A fire plan,
    fire drills, and working with the
  • local fire department are parts of that effort.
    The most important part of the
  • team, however, is you. Hospital fires can be
    dangerous because moving
  • patients is not easy. The key will be to gain
  • Even if the fire does not look big, after
    removing the patient from immediate
  • danger, contain the fire by closing the door and
    pull the alarm and dialing
  • extension 2222. Smoke can make it hard to see,
    breathe and think. Smoke

PC Facility Codes
  • Emergency/Urgent--Dial 2222
  • Internal External Disaster
  • Fire
  • Infant Security Alarm Activation
  • Persons requiring assistance in any area of the
    hospital/medical center
  • (hallways, elevators, cafeteria, lobbies, parking
  • Any injury or illness to a person in the
  • Medical Center who is conscious but NOT in a Code
    Blue situation.

AMUT Check-Up Quiz
  • Which Emergency Code indicates Hemorrhage
  • Code Purple
  • Code Red
  • Code P
  • Code H
  • None of these above
  • Correct answer A
  • 2. Which of the following is the most appropriate
    way to initiate a code from the hospital?
  • Dial 3333 and provide code
  • Dial 911, provide code and location
  • Dial 2222, provide code type and exact location
  • Dial 911 only
  • All of these above
  • Correct answer C
  • 3. Which Emergency Code indicates baby in
    distress during C Section
  • Code Blue
  • Code Apgar

Hazardous Communications
  • Many chemicals dont pose a risk, but others can
    be harmful if handled improperly.
  • To reduce the risk of chemical illness and
    injuries caused by chemicals, the Hazard
  • Communication Standard has been developed by the
    Occupational Safety and
  • Health Administration (OSHA). You have THE RIGHT
    TO KNOW about the
  • hazards you are exposed to at work and a
    responsibility to use safe practices at all
  • times. Chemicals come in solid, liquid and gas
    form. When handled improperly,
  • some chemicals can cause illness ranging from
    skin rashes to more serious health
  • hazards. Other chemicals can cause physical
    hazards like fires or explosions.
  • The purpose of the Hazard Communication Standard
    is to provide information. You
  • receive this information from labels and from
    Material Safety Data Sheets (MSDS).
  • Always read the label before and every time you
    use any chemical. The label and
  • MSDS inform you about safe handling practices of
    the chemicals you work with.
  • The Medical Center is required to have a written
    Hazardous Communication
  • Program. It should contain information on
  • OSHA Standards
  • Safe procedures
  • List of hazardous chemicals
  • If a container has lost its label, and the liquid
    is clear and has no odor. If its
  • unlabeled, assume its unsafe. Also, many
    hazardous chemicals have no smell,
  • so never sniff anything on purpose.
  • Flammable is a physical hazard because it tells
    you that the chemical can be
  • ignited easily. Toxic is a health hazard, meaning
    it could cause sickness or
  • even death. Explosive could cause physical harm
    from a rapid and violent
  • expansion of gases. A sensitizer is a health
    hazard because it causes a large
  • portion of exposed people to develop an allergic
    reaction after repeated
  • exposure.
  • An irritant is a health hazard because it causes
    a reversible
  • inflammatory reaction at the site of contact. A
    carcinogen is a health hazard.
  • Carcinogenic chemicals are those considered to
    cause or promote cancer.
  • Compressed gas represents a physical hazard
    because if tanks are handled
  • improperly, they could be propelled with enough
    force to blast through a wall.
  • Corrosives are a health hazard because they erode
    things they touch and can
  • cause damage at the site of contact. Corrosives
    are commonly found in
  • cleaners and solutions, and in many pharmacy or
    laboratory products.

Hazardous Communications
  • NFPA label
  • Red Fire Hazard (Flammable chemicals such as
    gasoline, oxygen, etc.)
  • Blue Health Hazards (Carcinogens and similar
    dangers to health.)
  • Yellow Reactivity Hazard (Radioactive dyes and
    other substances.)
  • White Other Hazards (Poisons, corrosive
    materials, explosives, etc.)
  • Reactivity tells you that the substance reacts
    violently with water or can
  • explode at higher temperatures.
  • Use the following information to help you become
    familiar with the MSDS
  • (Material Safety Date Sheet). This standard form
    with 8 sections has been
  • developed by the Department of Labor
  • Section I The Basics
  • Section I contains the basics. It tells the name
    of the product or chemical, who made
  • it, and what phone number to call for technical
    information or emergencies.
  • Section II Hazardous Ingredients/Identity
  • Section VI Health Hazard Data
  • Chemicals can enter your body through breathing,
    skin contact, or
  • swallowing. Section VI tells you how you could
    get exposed, what
  • effects to expect if you are exposed, and what to
    do about it.
  • Remember, its important to know what to do in an
    emergency before
  • you get into the emergency.
  • Section VII Precautions for Safe Handling and
  • Section VII gives you vital information on
    handling and use. Here you will find out
  • exactly how to handle a spill, the method of
    waste disposal, and any special
  • precautions you need to take.
  • Section VIII Control Measures
  • Section VIII details how to prevent exposure
    through the use of protective clothing.
  • These include face shields, respirators,
    gowns/suits, gloves and boots.
  • Remember, Safety First
  • Most accidents occur when youre in a hurry. Even
    if its inconvenient, your safety
  • is important. Read the MSDS. Protective clothing
    can be uncomfortable and hard to

Electrical Safety
  • Never try to fix an item yourself. Always allow
    the experts in the
  • Biomedical Engineering to service electrical
  • Either the ABC or CO2 extinguishers can be used
    on electrical
  • fires.
  • There are three steps to take when you find an
    electrical hazard.
  • 1.) Turn off the device and unplug it, if
  • 2.) Call Biomedical Engineering to report the
  • 3.) Remove the item from the patient area, if
    possible If the
  • item is small, then take it to Biomedical
  • Otherwise, label it and write the details to
    the problem on the
  • service request.
  • Medical Center employees need to think and act
    when they see electrical
  • hazards. Everyone needs to keep the workplace
    safe from electrical hazards.
  • Report all accidents and equipment problems
  • Hospital Grade Plugs and Cords must be used where
    there are patients. These
  • plugs have three prongs and a green dot. Both the
    plug and the cord are heavy duty.
  • The three prong plug grounds the electrical
    current through the third prong. The
  • heavy duty cord and plug are not as easily
    damaged as ordinary plugs. The hospital
  • grade cords and plugs provide additional
    protection from short circuits and
  • electrical current leakage. Hospital grade
    outlets provide stronger prong tension
  • which secures the plug more firmly in the socket.
  • CHEATER) PLUGS. The hospital maintains
    documentation that its electrical
  • Equipment is safe. But you should also check for
    hazards every time you use
  • electrical equipment.
  • Biomedical Engineering inspects the Medical
    Centers medical equipment. Be
  • sure to check that the item has been inspected by
    looking for the inspection sticker
  • or tag. As long as the equipment is not outside
    the inspection period, it is fine to
  • use. A visual inspection for loose parts and
    cracks in the plastic should be made
  • each time you use an outlet. Likewise, outlets
    should be tested each time you use a

LMP Workplace Safety
  • Kaiser Permanente and the Coalition of Kaiser
    Permanente Unions believe that
  • an injury free workplace is the goal and
    responsibility of every physician,
  • manager and employee, and an essential ingredient
    of high-quality, affordable
  • patient care. Working in Partnership, we are
    establishing the health care
  • industry standard by setting the goal of
    eliminating all causes of work-related
  • injuries and illnesses, so as to create a
    workplace free of injuries.
  • Our goal is to eliminate workplace injuries
    throughout Kaiser
  • Permanente.
  • Foster a Culture of Safety by engaging all staff
  • Reduce workplace injuries
  • Involve employee safety in Operations
  • Discuss Safety issues at department staff
  • What Role can you play in Workplace Safety
  • Be accountable for your personal safety
  • Help keep your co-workers safe
  • Work Safely at all times
  • Report all safety hazards and incidents
  • The Benefits of Safety Observations
  • Prevents injuries
  • Involves Everyone in identifying both Safe and
  • Sets forth the expectation that we all work
  • Increases ownership of safety which is felt among
    all employees, managers, and physicians
  • Reveals System Failure

LMP Workplace Safety
  • Incident Investigations
  • The purpose is to establish and maintain an
    effective workplace safety
  • incident investigation process in a way that
    ensures methodical
  • examination, determination of facts and key
    contributing factors, and
  • appropriate measures to prevent recurrence of
  • The Incident Investigation process contains
  • Employee is injured and immediately notifies
    their Supervisor/Manager
  • Manager Reports the Incident within 24 hours
  • An investigation team is formed
  • Determine the facts
  • Determine the key factors
  • 6. Determine systems to be strengthened
  • 7. Recommend an Action Plan to prevent
  • 8. Document findings within 7 days
  • 9. Communicate findings
  • 10. Follow-up and close action plan
  • If your Injured at Work, What should you do?

AMUT Check-Up Quiz
  • Kaiser Permanente and the Coalition of Kaiser
    Permanente Unions believe that an injury free
    workplace is the goal and responsibility of every
    physician, manager and employee, and an essential
    ingredient of high-quality, affordable patient
  • True
  • False
  • Correct answer True
  • 2. Our goal at Kaiser Permanente is to eliminate
    workplace injuries. What and how can you
  • A. Discuss Safety Issues at dept staff
  • B. Be accountable for your personal safety
  • C. Report all Safety Hazards and incidents
  • D. Think Safety Begins With Me!
  • E. All the Above
  • Correct answer E
  • 3. The ultimate purpose of the incident
    investigation is to find the root cause and
    recommend an action plan to prevent recurrence.
  • True
  • False
  • Correct answer True

2010 Joint Commission National Patient Safety
  • Patient Safety Goal 1 Improve the accuracy of
    patient identification
  • Use at least two patient identifiers when
    providing care, treatment or services.

  • Prior to the start of any invasive procedure,
    conduct a final verification process (such as a
    time out) to confirm the correct patient,
    procedure, site, using active not passive
    communication techniques.
  • Label containers used for blood and other
    specimens in the presence of the patient.
  • Patient Safety Goal 2 Improve the
    effectiveness of communication among caregivers.
  • For verbal or telephone orders or for telephonic
    reporting of critical test results, verify the
    complete order or test result by having the
    person receiving the information record and read
    back the complete order or test result.
  • Measure, assess, and if appropriate, take action
    to improve the timeliness of reporting, and the
    timeliness of receipt by the responsible licensed
    caregiver, of critical tests and critical results
    and values.
  • Standardize a list of abbreviations, acronyms,
    symbols, and dose designations that are not to be
    used throughout the organization.
  • Implement a standardized approach to hand-off
    communications, including an opportunity to ask
    and respond to questions.
  • REMEMBER When reading back a number, sound out
    each number such as one, five (15) not fifteen,
    or five, zero (50) not fifty when reading back
  • Patient Safety Goal 3 Improve the Safety of
    using medications.
  • Label all medications, medication containers (for
    example, syringes, medicine cups, basins), or
    other solutions on and off the sterile field.
  • Reduce the likelihood of patient harm associated
    with the use of anticoagulation therapy.
  • Identify and, at a minimum, annually review a
    list of look-alike/sound-alike drugs used by the
    organization, and take action to prevent errors
    involving the interchange of these drugs.

2010 Joint Commission National Patient Safety
  • Patient Safety Goal 8 Accurately and completely
    reconcile medications across the continuum of
  • There is a process for comparing the patients
    current medications with those ordered for the
    patient while under the care of the organization.

  • A complete list of the patients medications is
    communicated to the next provider of service when
    a patient is admitted, referred or transferred to
    another setting, service, practitioner or level
    of care within or outside the organization. The
    complete list of continued medications is also
    provided to the patient on discharge from the
  • Patient Safety Goal 9 Reduce the risk of
    patient harm resulting from falls.
  • Implement a fall reduction program including an
    evaluation of the effectiveness of the program.
  • Patient Safety Goal 15 The organization
    identifies safety risks inherent in its
  • The organization identifies patients at risk for
    suicide. applicable to psychiatric hospitals and
    patients being treated for emotional or
    behavioral disorders in general hospitals
  • The organization identifies risks associated with
    long-term oxygen therapy such as home fires.
  • Universal Protocol (UP1)
  • The organization fulfills the expectations set
    forth in the Universal Protocol for Preventing
    Wrong Site, Wrong Procedure, Wrong Person Surgery
    and associated implementation guidelines.
  • Conduct a preoperative verification process, as
    described in the Universal Protocol.
  • Mark the operative site as described in the
    Universal Protocol.
  • Conduct a time out immediately before starting
    the procedure as described in the Universal

AMUT Check-Up Quiz
  • 1. How do we know that we have the correct
  • Correct answer Check their ID band and ask the
    patient to state his or her
  • name.
  • 2. What two identifiers are used when
    administering medications or taking/giving blood?
  • Correct answer The patients Name and MRN on the
    order form and ID band
  • 3. What is the process for taking verbal or
    telephone orders and critical test results that
    requires verification?
  • Correct answer Write the order out in its
    entirety read it back and wait for
  • confirmation from the
    person giving the order/critical test
  • result.
  • 4. When does labeling of medication need to
  • Correct answer Anytime you do not have
    continuous contact with the medication.
  • 5. What are two easy and most effective ways to
    prevent the spread of infection?
  • Correct answer By washing your hands and if you
    take care of patients, by removing artificial

Kaiser Permanente Patient Safety Themes
Safe Culture, Safe Care, Safe Staff, Safe Support
Systems Safe Place, Safe Patients
Security Threat
  • At Kaiser Permanente, we want to ensure a safe
    environment for all employees,
  • physicians, members, students, volunteers
    contractors and visitors in which
  • to ensure the best care possible. Kaiser
    Permanente will not tolerate Acts
  • and/or threats of violence.
  • Acts and/or threats of violence include physical
    assaults and actions or
  • statements which, either directly or indirectly,
    by words, gestures, symbols,
  • intimidation, or coercion give reasonable cause
    to believe that the
  • personal safety of the affected individual or
    others may be at risk. Intimidation
  • includes behavior, which has the purpose or
    effect of inspiring fear in a
  • reasonable person. All physicians and employees
    are obligated to report any
  • incident where they believe they have been the
    subject of threatened violence
  • arising out of their relationship with Kaiser or
    if they observe or otherwise
  • learn of such conduct by any person employed by
    Kaiser, using Kaiser
  • services or on Kaiser premises.
  • Reports can be made to any of the following
  • Department Manager/Supervisor
  • Human Resources

AMUT Check-Up Quiz
  • Which of the following are examples of skills and
    techniques for de-
  • escalation?
  • A. Stay professional and in control
  • B. Remain non-threatening
  • C. Provide choices and consequences
  • D. All of the above
  • E. None of these above
  • Correct answer D
  • 2. All Physicians and employees are obligated to
    report any incident of
  • threatened violence
  • True
  • False
  • Correct answer True

Radiation Safety
  • Radiation Protection Concepts
  • The ALARA acronym is As Low As Reasonably
    Achievable. This program is in place to reduce
    the risk of the possible harmful effects of
    radiation. Every effort is made to keep the
    exposure levels well below federal and state
  • Time If you decrease the amount of time you
    spend near the source of radiation, you will
    decrease the amount of radiation exposure you
  • Distance The farther away you are from a
    radiation source, the less exposure you will
  • Shielding If you use shielding (gloves, aprons,
    lead barriers) correctly you will decrease your
  • Dosimeters If you are required to wear a
    radiation monitoring device (badge) do not take
    them home, leave them in your car, put them in
    the wash, share them, or leave them near the
    source of radiation. Turn them in for monitoring
    in a timely fashion.
  • Recognition
  • Radiation sources are marked by the International
    Radiation Hazard Symbol a
  • magenta trefoil on a bright yellow background.
  • Did you know..?
  • There are sites to help you calculate your annual
    dose. One example is
  • http//
  • Barium used in medical imaging is not
  • In X-ray the machines generate the source of
    radiation. In Nuclear Medicine,
  • the radioactive isotopes are the source of
    radiation, not the
  • Ionizing Radiation
  • Defined Energy and/or energetic particles that
    are emitted from
  • radioactive atoms and/or x-ray machines that can
    ionize tissue.
  • This ionizing radiation, if absorbed, may cause
    damage to tissue.
  • Radiation to humans is measured in dose units
    traditionally called rem. The new
  • Standard International (SI) term is sievert
  • Sources of Ionizing Radiation
  • Natural Sources of Ionizing Radiation
  • Approximately 80 of human exposure to radiation
    comes from natural
  • sources radon gas, the human body, outer space,
    rocks and soil. An
  • average American is naturally exposed to 300
    mrem/year or 3 mSv/year .
  • Man-Made Sources of Ionizing Radiation
  • About 20 of human exposure to radiation comes
    from man-made
  • sources. Approximately 15 of this man-made
    radiation comes from
  • medical imaging.

Radiation Safety
AMUT Check-Up Quiz
  • Tips To Avoid Contamination from Radioactive
  • Wear gloves
  • Avoid contact with objects or areas that may be
  • Dont eat, drink, or smoke in areas where
    radioactive materials are in use
  • Dont apply cosmetics or groom your hair while in
    the area
  • Wash your hands when leaving the area
  • Read and follow all signs and instructions
  • Dont handle radioactive materials unless you are
    trained to do so
  • 1. The average American is exposed to how much
    ionizing radiation from natural sources?
  • 100 mrem/year
  • 200 mrem/year
  • 300 mrem/year
  • 2. Non-radiation hospital workers have an
    ionizing radiation exposure limit of ?
  • 100 mrem/year
  • 200 mrem/year
  • 300 mrem/year

Quality Improvement
  • Quality is a central priority for Kaiser
    Permanente. As a quality health care
    organization, we strive to ensure that our
    members will remain healthy and safe and that our
    processional staff and employees will continue to
    support our goal of quality improvement to better
    patient outcomes. Improving quality improves our
    organization performance.
  • All employees are involved in quality
    improvement. Improvement measure are linked to
    the organizations strategic goals, hospital or
    department goals. As an employee you participate
    in the work processes of this Medical Center and
    lead or participate in improvement processes.
  • In health care, quality is the delivery of
    outstanding patient care that includes
  • Patient safety
  • Identifying process which can be improved
  • Clinical outcomes
  • Patient satisfaction
  • Quality means doing the right thing the first
    time. Examples of high quality of care
  • Patient focused/centered
  • Correct level of care
  • Correct diagnostic procedures
  • Correct medications
  • Correct site surgery
  • Relieving pain by assessment.. right medication,
    right dose, right time and right route

AMUT Check-Up Quiz
  • How do know we are performing well or need to
  • improve?
  • Correct answer Performance data.
  • 2. Where do performance goals and measures
    come from?
  • Correct answer National Patient Safety Goals,
    National performance benchmarks, Regional
    Comparative data and Unit-Based Goal setting
  • 3. What 3 questions should you ask before
    starting performance improvement project.
  • Correct answer
  • What you trying to accomplish?
  • What change can we make that will lead to
  • How will we know the change was an improvement

Infection Control
  • Standard Precautions are routine precautions
    designed for the care of all patients
  • regardless of their diagnosis or presumed
    infection status.
  • The precautions are designed to reduce the risk
    of transmission of organisms from
  • both recognized and unrecognized sources of
  • Based on the anticipated contact with the
    patients blood and body substances, non-
  • intact skin such as rashes and mucous membranes
    (eyes, nose, mouth) personal
  • protective equipment (PPE) is worn. Each
    department has a supply of the PPE
  • required for both Standard and Transmission Based
    Precautions. Ask your
  • Department Administrator if you do not know where
    these are kept.
  • Gloves for any anticipated contact with blood,
    body fluids, non-intact skin or rashes.
  • Hand Hygiene after removal of gloves.
  • Gloves must be worn when your hands have any open
    areas, cuts, or abrasions
  • If the glove is torn or punctured, remove the
    glove, wash hands immediately, and put on a new
    glove as promptly as patient safety permits.
  • Gloves must be changed after completing
    procedures in different body areas, after contact
    with each patient or when contaminated.
  • Mask and Eye Protection for any anticipated
    splash or spray of blood or body fluids to
    prevent exposure of mucous membranes of the
    mouth, nose and eyes.
  • Reusable eyewear or face shields should be
    cleaned with appropriate disinfectant per
    manufacturers recommendation.

Infection Control
AMUT Check-Up Quiz
These are used in addition to Standard
Precautions Airborne Precautions includes
diseases such as Tuberculosis, SARS, Chickenpox,
and Measles. The N95 respirator is used for
Tuberculosis, SARS and other significant but rare
diseases such as many of the Bioterrorism agents.
A Blue Airborne sign that lists the necessary
PPE is used for this precaution. Droplet
Precautions includes diseases transmitted via
large particles which require close contact
usually 3ft or less. These diseases include
Pertussis, Mumps, Meningococcal disease and
Plague. A surgical mask is worn when within 3
feet from the patient to prevent exposures. An
Orange Droplet sign that lists the necessary PPE
is used for this precaution. Contact Precautions
reduces transmission by direct or indirect
contact. Direct contact transmission involves
skin to skin contact and indirect transmission is
to contact via a contaminated item in the
patients environment. Gowns and gloves are worn
every time upon entering the room of a patient on
Contact Precautions. MRSA, VRE, Scabies, Lice,
RSV are included in this category. A Green
Contact sign has been developed that includes all
the necessary PPE is used for this precaution.
Precautions for Creutzfeldt-Jacob Disease
(CJD) In addition to Standard Precautions, follow
the CJD policy on DMS for Infect Control and
care of the patient with suspected or confirmed
CJD. What do I need to know about Multi-drug
resistant organisms (MDRO) like methacillin
resistant staphylococcus aureus MRSA? One of the
germs that commonly live on the skin and in the
nose is called staphylococcus or staph
bacteria. Usually this germ causes no harm.
However sometimes it enters the body through a
break in the skin or contact with mucous
membranes like the nose, mouth and eyes and
causes infection. When staph cannot be killed
by common antibiotics this means that the
bacteria has developed resistance to those
antibiotics and is called MRSA. MRSA is spread by
contact with body secretions, skin to skin
contact and contact with the environment if
contaminated with MRSA. Anyone can get MRSA as
it is found in the community and in healthcare
facilities. There are two ways that you can have
MRSA bacteria. You can have active infection
with clinical symptoms or you can be colonized
(also known as carrier) with out any
symptoms. To prevent problems of spread of MRSA
the most important thing to remember is to wash
your hands with soap and water for 15 seconds or
used alcohol foam for hand hygiene. Cleaning of
equipment and not sharing equipment between
patients, use of transmission based precautions
that include PPE is also needed to stop the
spread of MRSA and other resistant organisms.
  • 1. What is the single most important way of
    stopping the spread of
  • MRSA that a person can do?
  • A. Wash hands or use alcohol foam
  • B. Eat more vegetables
  • C. Exercise frequently
  • Correct answer-A
  • 2. What other ways is there to protect the
    patients and staff from the
  • spread of infection besides Standard
  • A. Take a bath
  • B. Use transmission based precautions
  • C. Eat more vegetables
  • Correct answer B

Airborne Transmissible Diseases
California has adopted this protective standard
to control occupational exposure to Aerosol
Transmissible diseases (ATD) this standard
applies to hospitals, clinics, laboratories,
home health care, emergency services, homeless
shelters, drug treatment programs, police
departments and prisons. What information does
the ATD Plan provide? The ATD Plan explains to
the employer and healthcare worker
responsibilities in pre