Ralph H. Johnson VA Medical Center Orientation

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Ralph H. Johnson VA Medical Center Orientation

• AY 2007-2008

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WELCOME TO THE CHARLESTON VAMC
Dr. Hutchison Chief of Staff
John Barilich Director
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CHARLESTON VAMC MISSION

• MISSION STATEMENT
• The mission of the Ralph H. Johnson Department
  of Veteran Affairs Medical Center is to improve
  the health of the veteran population by providing
  primary, specialty and extended care and related
  social support services through an integrated
  healthcare delivery system.

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CHARLESTON VAMCVISION

• VISION STATEMENT
• We will be the recognized leader.
• in providing innovative methods for treating
  patients and supporting their total health care
  needs.
• in recognizing and developing employees who
  enthusiastically and significantly contribute to
  the medical center and community.
• in conducting meaningful research which provides
  breakthroughs in treatment and prevention of
  disease.
• in continually improving everything we do in
  order to meet the needs of those we serve.

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CHARLESTON VAMCVALUES

• VALUES STATEMENT
• We value and expect
• TRUST
• A high degree of confidence in the honesty,
  integrity, reliability and sincere good intent of
  those with whom we work, the services that we
  provide, and the system that we are a part of.
  Trust is the basis for the caregiver-patient
  relationship and is fundamental to all that we do
  in healthcare.

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CHARLESTON VAMCVALUES

• We value and expect
• RESPECT
• Honoring and holding in high regard the dignity
  and work of our patients and their families, our
  co-workers, and the system we are a part of. It
  means communicating and relating to each other
  with understanding, and a sensitivity and concern
  for each persons individuality and importance.

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CHARLESTON VAMCVALUES

• We value and expect
• COMMITMENT
• Dedication and a promise to work hard to do all
  that we can to provide service to our coworkers
  and our patients that is in accordance with the
  highest principles and ethics governing the
  conduct of the healthcare professions and public
  service. It is being bound emotionally and
  intellectually to our mission and vision a
  pledge to assume personal responsibility for our
  individual and collective actions and a
  willingness to do and give whatever it takes to
  make our vision a reality. It means meeting our
  goals through unity of purpose and teamwork.

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CHARLESTON VAMCVALUES

• We value and expect
• COMPASSION
• Empathy and caring in all that we say and do. It
  means taking the time and responsibility to
  consider workers, our patients and their
  families, and all others with whom we are involved

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CHARLESTON VAMCVALUES

• We value and expect
• EXCELLENCE
• Exceptionally good and of the highest quality.
  It means being the most competent and the finest
  in everything we do, an effort encompassing all
  aspects of work and personal relationships. It
  means having pride in our accomplishments and a
  sense of worth from doing a job the very best
  that we can. It means continually improving what
  we do. It means demonstrating a willingness to
  be innovative and creative in the workplace for
  problem solving, management and patient care.

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FACILITY SAFETY SECURITY

• All hospitals strive to provide a safe
  environment for patients, visitors and staff and
  to safeguard property from damage. The Office of
  Public Safety tries to prevent problems from
  occurring and is responsible for the parking and
  visitor areas, lost and found articles, illegal
  drugs, solicitation, etc. Officers wear clearly
  defined uniforms for quick identification.

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FACILITY SAFETY SECURITY

• How can YOU help?
• Report all incidents (thefts, accidents,
  suspicious persons) immediately by stopping by
  the security office, 1st floor, B197, or by
  dialing ext. 7251 or 0 for operator.
• Report malfunctioning patient care equipment to
  Biomedical Engineering for repair or replacement.
• Report problems with non-patient equipment (A/C,
  heating plumbing, etc.) to Engineering Service.
• Report other safety hazards to the Safety
  Officer.
• Security Issues
• All PERSONNEL are required to wear ID badges at
  all times. The badge is returned upon
  termination. Some areas require additional
  security due to special activities, such as, the
  facility computer and communication systems.
  Access to these sensitive areas is limited. In
  order to protect property from theft or damage,
  hazards, such as burned out lights, broken locks,
  missing signs, etc., should be reported. Keys
  should not be left unattended and computer access
  codes should not be shared.

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FACILITY SAFETY SECURITY

• SERVICES PROVIDED
• Maintain close relations with local police
  department.
• Patrol indoors and outdoors 24 hours a day.
• Increase patrols after dark, including door
  checks.
• Personal escorts to and from vehicles for
  employees.
• Store valuables, property and lost and found
  articles.
• Register employee vehicles and control parking.
• Investigate injuries, incidents or thefts.
• Help manage emergencies per emergency plans.
• Control identification process.

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Drug-Free Workplace

• Random drug tests can be performed at any time on
  patient care or support staff
• Drug usage by a VA employee could result in
  property damage or destruction, injury, or death
• The VA has a goal of being a drug-free workplace,
  and the plan includes policies for employee
  education

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FIRE SAFETY

• Prevent these three components from coming
  together and you prevent a fire.
• OXYGEN HEAT FUEL

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FIRE SAFETY

• Remember the RACE procedure when safely and
  quickly responding to a fire
• Rescue anyone in immediate danger (patients,
  staff and visitors).
• Alarm by engaging a fire alarm or calling 7911
• Contain by closing doors or covering the fire.
• Evacuate Assist in patient evacuation.

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FIRE SAFETY

• Evacuation..Use the unit concept when
  evacuating a hospital. Each evacuation step is a
  unit.
• Horizontal Relocation Moving patients and staff
  during a fire emergency through a fire door to a
  safer area on the same floor. Know where the
  nearest fire compartment is in your work area.
  Look for fire/smoke wall signs above doorways.
• Vertical Relocation Moving patients down an
  enclosed fire escape stairwell. This method is
  used when horizontal relocation is not possible.
• NOTE Never turn off the main O2 valve on a
  ward. The Charge Nurse/Supervisor in charge is
  responsible to do this in the event of fire.

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EQUIPMENT SAFETY

• If patient care equipment malfunctions contact
  Biomedical Engineering for repair or replacement.
• If theres a problem with non-patient care
  electrical equipment, HVAC, plumbing or doors,
  contact Engineering Services (24 hours a day),
  ext. 7269.
• If you find a hazard and dont know what to do,
  contact Safety and Security or Risk Manager (QM)
  for help, ext. 6331 MED1

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Protect Confidentiality

• Patient records are confidential and accessed on
  a need to know basis by members of the Health
  care team.
• Responsible for safekeeping records and
  information pertaining to the patients care and
  treatment
• Avoid discussion of individual patient care
  issues in public areas

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COMPUTER SECURITY

• Safeguarding patient or employee information in
  the hospitals automated information system (AIS)
  is the duty of everyone.
• Responsibilities The Privacy Act of 1974
  mandates that sensitive patient or employee
  information will be accessed on a need to know
  basis.
• The facility Information Security Officer is
  responsible for oversight of the AIS security
  program and training employees who access
  sensitive patient information.
• All VA employees, contractors and others using
  AIS resources are responsible for completing
  initial and annual Cyber Security training and
  following AIS policies and procedures.

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COMPUTER SECURITY

• Securities DOs and DONTs
• Safeguard assigned access/verify codes.
• Never leave disks containing sensitive
  information unsecured.
• Use privacy screens to prevent disclosure of
  patient data from passers-by.
• Safeguard computer printouts.
• Shred sensitive documents after they are no
  longer needed.
• Take care of equipment by never eating or
  drinking at the computer.
• Protect disks from magnetic hazards.
• Make certain the anti-virus software in always
  present and running on the equipment.
• Thumb drives are strictly prohibited from use and
  on most computers they are inoperable

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COMPUTER SECURITY

• REMEMBER!!!! Just because you can access patient
  information does not mean that you have the
  privilege to do so. It is never appropriate to
  look at patient or employee information that you
  do not have a legitimate need to view.
• REPORT ALL SECURITY VIOLATIONS. First, tell
  your responsible provider. Then, report to the
  Information Security Officer, ext. 7036.

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Cyber Security Privacy Training

• Training for CYBER PRIVACY must be completed on
  the following website.
• www.ees-learning.net
• Please remember all usernames and passwords!
• This will take approximately 90 min
• You will have to print a certificate with your
  name on it for each course and turn in a copy to
  education service or your service coordinator

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EMERGENCY PREPAREDNESS

• What is a Disaster? Disasters are emergencies
  that result in large-scale severe injuries and
  may bring in an unexpected number of patients,
  putting strain on a hospitals staff, facility
  and other resources. The problems that a
  disaster creates require hospitals to do tasks
  that are not part of the normal routine and can
  cause major disruption in the environment of
  care.
• What is an Emergency? An emergency is a natural
  or man-made event that happens suddenly and can
  disrupt a healthcare facilitys ability to
  provide care to patients. Emergencies are either

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EMERGENCY PREPAREDNESS

• Internal are those that occur within the building
  or on the grounds, and directly and immediately
  affect the hospital, staff and its operations,
  such as
• natural disasters
• large scale power outage
• riots/terrorism/hostage situations
• fires/bomb threats
• transportation accidents
• hazardous materials release
• public health disaster

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EMERGENCY PREPAREDNESS

• External are those that happen outside the
  building but affect the facility when many
  casualties are brought to be treated, such as
• fire, smoke or fumes
• loss of environmental support services
• loss of medical gases
• explosion
• acts of terrorism
• hazardous material release
• mass casualties

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EMERGENCY PREPAREDNESSPLANS/DRILLS

• All people in the hospital have a role in the
  Emergency Preparedness Plan. The Emergency
  Preparedness Committee is responsible for proper
  organization and implementation of training,
  drills and procedures involving disaster
  planning, but each service has its own policies
  and procedures, as well as a set of duties to
  perform.
• Drills are held to
• Prepare all personnel by educating all
  participants
• Provide an opportunity to practice assigned
  duties in a real emergency
• Allow for continuous improvement
• Evaluate effectiveness and outcomes to a changing
  environment or emergency type.

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EMERGENCY PREPAREDNESS

• What is your responsibility?
• Know the plan (See CPM 138-16)
• Know your duties
• Know your priorities
• Know where to report
• Know to whom you report
• Know location of supplies
• Take part in training and drills
• Ask questions

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EMERGENCY PREPAREDNESS

• What to do in a typical emergency procedure?
• Activate the Fan Out (normal duty hours) or the
  Call Back (off hours) system.
• Notify key personnel of the emergency.
• Listen for announcements/updates over the
  intercom system and media
• Employees report to assigned stations and await
  special assignments.
• Every department has a copy of its emergency plan
  and respond accordingly

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EMERGENCY PREPAREDNESSPLAN EXAMPLE

• Medical Center Director
• establishes a command post
• Surgical/Nursing Service/Primary Care Services
• setup triage areas of casualties.
• Engineering Service
• provides hand held 2-way radios, emergency
  electrical power, repairs, and maintains
  operational level of fuel, tools and spare parts.
• Materials Management
• provides supplies/equipment.
• Patient Care Staff
• prepares for alternate patient care sites and
  duties.
• Police and Security Service
• provides traffic control.

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EMERGENCY PREPAREDNESS

• When the emergency or disaster is over
• Personnel will be notified via the Fan Out/Call
  Back systems and via overhead pages.

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Violence in the Workplace Prevention
Appropriate Response

• Julian Libet, Ph.D.
• Chairman, VBPC
• Associate Manager, Mental Health Service

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Violence What Do We Mean?

• Physical violence against patients, staff,
  students, visitors, or VA property
• Credible threats of harm against patients, staff,
  students, visitors, or VA property
• Repeated disruptive or larcenous behavior that
  undermines safe and quality patient care
• The RHJ VA Medical Center has a 0 tolerance for
  this kind of behavior

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Violence What To Do - 1?

• Report the Incident of Disruptive Behavior to
  prevent its recurrence
• If an emergency
• Call x7911
• If not an emergency
• Call the VA Police Service x7251 or x7354
• Tell us
• What, where, when it happened
• Names SSNs of involved parties
• Whether anyone was injured or traumatized
• Document the incident in CPRS using the PN
  Template
• Disruptive Behavior Incident

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Violence What To Do - 2?

• Position yourself for an avenue of escape
• Remain quiet, centered, unruffled!, but show
  concern about for the patient
• If possible, describe the disruptive behavior to
  the patient request that it cease
• If possible, inform the patient of the potential
  consequences of the disruptive behavior
• If necessary, excuse yourself, call the VA Police
  either discontinue the visit or request the
  Police to stand by

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Violence What Not To Do?

• Do Not
• Invade the patients personal space
• Become louder, faster, co-escalate, challenge,
  make demands, or use You messages
• Take it personally
• Acting out is a response to the provocation, your
  own sensitive buttons, your feelings of anger,
  outrage, or an inclination to twist the Golden
  Rule

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Violence What We Will Do- 1

• The VA Police will issue a warning to the patient
  either verbally, face-to-face, or via certified
  letter refer to the Violent Behavior Prevention
  Committee (VBPC) if indicated
• The VBPC will
• Conduct a thorough violent behavior threat
  assessment
• Direct fact-finding from meeting with providers
• Delineation of operative static and dynamic risk
  factors

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Violence What We Will Do- 2

• The VBPC may
• Place a Category 1 National Behavioral Flag in
  CPRS indicating
• Status of the patient (including notification of
  the VA Police for scheduled visits)
• Triggers or sensitive buttons for the patient
• Recommended actions / precautions on patient
  visits
• Currently we have about 75 patients flagged at
  the Charleston VAMC (25 generated locally)

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Violence What We Will Do- 3

• The VBPC may
• Draft and co-present an individualized
  Behavioral Health Care Agreement with clear
  expectations (and consequences) with due
  process rights incorporated
• All BHCAs will be placed in CPRS under an
  identical PN Title
• Recommend (as a last resort) to the Medical
  Center Director the total barring of the patient
  from the Medical Center for not less than 1 year
• Currently we have 10 patients barred from the
  Charleston VA Medical Center allied CBOCs

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Violence What To Do for Prevention

• Listen to the patient. Be attentive to the
  patients needs and satisfaction early relieve
  (at least empathize with) patients frustrations
• Set clear boundaries and mutual roles
  responsibilities early
• Make your expectations match the attention span,
  ability, motivation level of the patient and ?
  for understanding
• Sometimes insufficiently managed clinical issues
  such as
• Narcotics Abuse
• Non-adherence to the Treatment Plan
• Access Issues
• lead to escalation set limits or Heath Care
  Agreements (contracts) early

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Questions / Concerns Down the Road

• Contact
• Julian Libet, Ph.D.
• Chairman, VBPC
• x7133 or Pager 220-6994
• Roger Summerlin
• Chief of VA Police
• x7251, x7373, 7354

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Infection Control Program

• The Infection Control Program is a Center wide
  discipline that develops effective measures to
  prevent, identify and control infections acquired
  in the Medical Center or brought into the Medical
  Center from the community.

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Infection Control Policies/Procedures

• Blood Borne Pathogens Exposure Control Plan
• Isolation Precautions
• Tuberculosis Control Guideline
• Hand Hygiene, just to name a few
• All these policies/guidelines follow the
  Occupational Safety and Health Administration
  (OSHA) and Center for Disease Control and
  Prevention(CDC) mandates that were implemented to
  help protect and prevent health care workers and
  patients from acquiring infections.

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Who do you call when you have questions about
Infection Control?

• Infection Control Practitioner
• Marietta Hill, RN,BSN,CIC
• Ext. 7469

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What is the single most important means to
prevent the spread of infection?

• Good Hand Hygiene Practices

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When should I wash my hands?

• Before and after patient contact
• After contact with any infectious or potentially
  infectious material
• After removing gloves or before
• putting on a new pair
• After using the restroom
• Before and after eating

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Hand Hygiene

• Options
• Regular soap and Water
• Antimicrobial hand soap and water
• Alcohol hand gels
• Lotions

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Blood Borne Pathogens

• HIV
• Hepatitis B
• Hepatitis C
• These are the top three of most concern for
  healthcare workers
• Every direct healthcare worker should be
  vaccinated against Hepatitis B!

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If You have possible HIV exposure

• Wash exposed site with water and soap (If eye,
  flush with water only)
• In this order of preference contact
• Employee Health
• Emergency Department
• Infection Control Physician on call
• Tests for HIV will most likely occur immediately
  and 3, 6, and 12 months after exposure.

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Source of exposure

• You dont know if the source of the exposure is
  HIV positive.
• Testing can ONLY be conducted with the patients
  consent.
• You may possibly receive antiviral prophylaxis,
  depending on the nature of the exposure.

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Your patient receives a positive test result

• Report your patient to infection control. They
  will handle the report to DHEC.
• If any information is needed from you for the
  DHEC report, Infection control will contact you.

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What are Standard Precautions?

• Taking precautions with everyone and treating
  each person as potentially infected. Using
  barriers i.e., gowns, gloves, mask, face shield
  or goggles to reduce the spread of infection.
• These things are called
• PPE (Personal Protection Equipment)

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Standard Precautions

• Treat every person as potentially infectious
• Use thorough hand-washing (best defense) to
  prevent the spread of infection
• Wear gloves other protective equipment
• Never recap needles! Use Safety devices
• Report any exposures immediately to your
  immediate supervisor

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Isolation Precautions

• Lets talk about Precautions taken in addition to
  standard Precautions called
• Transmission-based Precautions
• CONTACT
• DROPLET
• AIRBORNE

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Contact Isolation

• Used for patients that are infected with
  antibiotic resistant organisms such as
  (Methicillin Resistant Staph, Aureus (MRSA),
  Vancomycin Resistant Enterococi (VRE), or C.
  difficile that can be transmitted by direct
  contact, or by indirect contact with the surface
  of patient care items in the environment. Used in
  addition to standard precautions.

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Isolation

• Contact Precautions
• Private room, if possible
• Cohorting might be necessary
• Gloves Gowns
• Wash hands
• Limit the use of non-critical patient care
  equipment to single patient
• Clean/Disinfect common equipment used between
  patients

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Droplet Isolation

• Used for patients with known or suspected agents
  transmitted by large droplet method (gt5microns).
  Indications Influenza, meningitis, Meningococcal
  pneumonia, and resistant Streptococcus pneumonia
  disease. Used in addition to Standard
  Precautions.

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Isolation

• Droplet Precautions
• Private room
• Wear surgical mask within 3 feet of patient or
  when entering room
• Patient transport
• Limit movement of patients to essential purposes
• Place surgical MASK on patient if transport is
  necessary
• Always notify all staff involved in a a transfer
  of the precautions

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Airborne Isolation

• Used for patients with suspected or diagnosed
  conditions that are transmitted by the airborne
  route such as pulmonary tuberculosis or
  meningococcal meningitis.

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Symptoms of TB

• Cough
• Weakness
• Fatigue
• Unexplained weight loss
• Hemoptysis
• Night sweats
• Mention ppd
• (Everyone does have a current PPD, right?)

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Biohazard Waste

• Red Bag Blood

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Where Does All The Garbage Go?

•  
• Sharps Needles, lancets, surgical staples,
  rods, pins, intravenous catheters, protected
  sharps, syringes with attached needles, scalpels,
  scissors, guide wires, etc 
• Sharps Container Must be emptied when ¾ full.
  They become a danger when overfilled.

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Isolation Room Waste

• Isolation status does not affect Red Bag Waste
  Guidelines Regular trash from an isolation room
  is still regular trash.
• Trash Can
• Liquid Human Waste from reusable containers like
  urine, feces, sputum, blood etc.
• Toilet
• (Use splash precautions)

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Questions to check out be familiar with

• What kinds of precautions do you practice on your
  units?
• How is biohazardous waste handled?
• Where is Personal Protective Equipment (PPE)
  kept? Do you have everything you need?
• How is equipment cleaned
• (I.e., wheelchairs, laryngoscope blades, etc)?

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Questions to look up be familiar with

• How do you give and receive feedback from the
  infection control practitioner?
• How do you know if items are clean or dirty?
• What actions have you taken to reduce risks for
  and/or prevent nosocomial (hospital acquired)
  infections?

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Patient Safety Goal number seven (7) is very
important for infection control

• 7. Reduce the risk of health care acquired
  infections
• (Nosocomial Infections-Hospital Acquired
  Infections)
• Number one wayGood Hand Hygiene
  PracticesWASH,WASH, and WASH AGAIN!

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Infection Control Resources

• Infection Control Practitioner
• Marietta Hill,RN,BSN,CIC
• ext. 7469, Pager 383
• Medical Center Epidemiologist
• Preston Church, MD
• ext. 7714, Pager 14342

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HAZARDOUS MATERIALS

• Substance that may cause physical or health
  related problems
• Labels are the safe way to identify hazardous
  materials
• Signs and symbols warning you about hazardous
  substances

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HAZARDOUS MATERIALS

• Health hazards
• Labeled as carcinogen, toxic, highly toxic,
  corrosive or irritant
• Examples include
• mercury in thermometers
• lead in paints
• formaldehyde used in bio-labs
• xylene solvents.

• Physical hazards
• Labeled as corrosive, organic peroxide or
  oxidizer
• Examples include
• isopropyl alcohol
• flammable acetone
• combustible oxygen.

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HAZARDOUS MATERIALS

• Affects
• Acute or Chronic
• Minor
• Rashes/Coughs
• Serious
• Poisoning
• Birth Defects
• Life Threatening
• Anaphylaxis

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HAZARDOUS MATERIALSExamples

• Substances
• Markers/Correcting Fluids
• Paints and Adhesives
• Mercury
• Cleaners/Solvents
• Waste Products
• Flammable/Compressed Gases
• Radioactive Materials
• Chemotherapy Agents

• Location
• Offices
• Engineering
• Food Service
• Housekeeping
• Central Supply
• Lab/Pathology
• OR
• Pharmacy
• Nuclear Medicine

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HAZARDOUS MATERIALS

• Exposure what to do?
• Each area of the hospital is required to have
  Material Safety Data Sheets (MSDS) for each
  hazardous material it uses, provided by the
  company that ships the material.
• If exposed, follow the steps on the MSDS
• Use personal protective equipment
• Dont eat, drink or smoke in any hazardous
  materials work area
• Wash your hands after working with these
  substances, even if wearing gloves.

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Latex Allergies

• Reaction to proteins which coat natural rubber
  latex
• Increased risk to those who have frequent
  exposure to latex materials
• Examples
• medical gloves
• cuffed enema/enterolysis catheters
• wound drains
• anesthesia masks
• electrode pads
• crutch pads
• bandages
• wheelchair tires
• drug vial stoppers

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Latex AllergiesReactions

• Symptoms can be minor, severe or life threatening
• Examples
• hives or rash on the skin exposed to the latex
• itchy, watery or swollen eyes
• runny nose and sneezing
• asthma symptoms and respiratory distress
• swelling of areas exposed to the latex

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Latex AllergiesReactions

• What to do?...... If you are sensitive to latex
• avoid natural latex products, this facility can
  provide you with non-latex gloves. Please
  request
• Clearly identify yourself to other staff as being
  latex sensitive
• Be prepared for extreme reactions by carrying
  injectable epinephrine.

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PATIENT SAFETY OVERVIEW

• The goal of the Patient Safety Improvement
  Program is to create a Culture of Safety and
  awareness of patient safety issues for all VA
  Employees, Patients and their Families .
• We cant solve problems by using the same kind
  of thinking we used to create them
• ALBERT EINSTEIN

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2007 PATIENT SAFETY GOALS
NEW

• Goal 1- Improve the accuracy of patient
  identification.
• Goal 2- Improve the effectiveness of
  communication among caregivers.
• Goal 3- Improve the safety of using medications
• Goal 7- Reduce the risk of health
  care-associated infections
• Goal 8- Accurately and completely reconcile
  medications across the continuum of care.
• Goal 9- Reduce the risk of patient harm
  resulting from falls.
• Goal 13- Encourage patients active involvement
  in their own care as a patient safety
  strategy.
• Goal 15- The organization identifies safety risks
  inherent in its patient population.
• See Hand Out for 2007Goals

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2007 PATIENT SAFETY GOALS
OVERVIEW

• Goal 1-Improve the accuracy of patient
  identification.
• Goal 2- Improve the effectiveness of
  communication
  among caregivers.
• Goal 8-Accurately and completely reconcile
  medications across the continuum of care.

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2007 PATIENT SAFETY GOALS

• Goal 1
• Improve the accuracy of patient identification

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PATIENT IDENTIFICATION

• Must use 2 patient identifiers (full name full
  Social Security number) whenever you
• Give meds (BCMA scanning counts) or blood
• Draw blood
• Obtain other specimens
• Provide treatments/ procedures
• Example. When you draw blood, you ask the
  patient to state his name SS no.
• (If pt. cannot speak/ is confused, check arm
  band). Then you compare those 2 pieces of info
  with those on the lab order.
• Remember both steps.ask/ check then compare.

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PATIENT ID ( Procedures)

• TIME OUT MARKING THE SITE
• Time out is conducted prior to starting all
  procedures (including bedside and clinic
  procedures) to make sure you have the correct
  patient, correct site and correct side is marked
• Surgical sites-all surgical sites must be marked
  (Limited exceptions )
• Bedside procedures-sites must be marked unless
  you are never leaving the bedside prior to the
  procedure

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PATIENT ID ( Procedures)
Example of a Template to Document these ELEMENTS
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2007 PATIENT SAFETY GOALS

• Goal 2
• Improve the effectiveness of communication among
  caregivers.

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Standardize the way we hand off communication
to the next caregiver.
STANDARIZED COMMUNICATION

• All patient care hand-offs are guided by the
  acronym, P-A-S-S and will include the following
  minimal information, as appropriate
• P Patient (Name and identifiers, such as age,
  sex, location)
• A Assessment (i.e. diagnosis, pertinent vital
  signs, mental status, DNR status, recent
  procedure, current clinical status)
• S - Safety (i.e. isolation, fall/ elopement risk,
  restraints, critical lab values)
• S - Special needs (i.e. equipment, oxygen, needed
  follow-up or action items for next episode of
  care).
• When you hand-off.remember to P-A-S-S!
• (e.g. nursing shift changes, report to
  covering MDs, lunch breaks)

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2007 PATIENT SAFETY GOALS

• Goal 8
• Accurately and completely reconcile medications
  across the continuum of care.

85
MEDication RECONciliation

• Must get a complete, accurate list of the
  patients current (e.g. HOME) medications
  including any OTC/ herbals meds.
• WHEN ?
• upon admission to the hospital
• in the outpatient clinics, Urgent Care, and in
  most cases before an O/P procedure, if
  medications are going to be given or changed.
• Documenting the accurate list is the MD/
  providers responsibility.

86
MEDication RECONciliation
EXAMPLE

• Active Op Meds W/Sig
•    Medicine/Supplies                              
        Qty   Last Filled
• --------------------------------------------------
  ------------------------
• 1) CLOTRIMAZOLE 1 TOP CREAM APPLY THIN
  FILM           15    AUG 01, 2005
•    TOPICALLY TWICE A DAY FOR FUNGAL INFECTION
• 2) LORAZEPAM 1MG TAB TAKE ONE-HALF TABLET BY
  MOUTH     60    JUN 24, 2006
•    EVERY MORNING AND TAKE ONE-HALF TABLET
• 3) BENZTROPINE MESYLATE 1MG TAB TAKE ONE TABLET
  BY     60    JUL 01, 2006
•    MOUTH TWICE A DAY FOR AKATHISIA
• 4) QUETIAPINE FUMARATE 200MG TAB TAKE THREE
  AND        105   JUN 24, 2006
•    ONE-HALF TABLETS BY MOUTH AT BEDTIME MAY CAUSE
  
• 5) RISPERIDONE 4MG TAB TAKE ONE-HALF TABLET BY
  MOUTH   15    JUN 14, 2006
•    AT BEDTIME FOR MOOD
• 6) SERTRALINE HCL 100MG TAB TAKE ONE TABLET BY
  MOUTH   30    JUL 01, 2006
•    EVERY DAY TAKE AT THE SAME TIME EACH DAY.FOR
• The following corrections are made to the above
  active medication list
•         Meds/OTCs patient is taking that are not
  on the above list
•       

87
MEDication RECONciliation
STEP 2

• The pharmacist will compare the current list of
  meds with
• Meds ordered on admission
• Meds ordered on transfer to another unit
• Meds ordered at discharge
• to make sure there are no duplications,
  interactions, omissions, incorrect doses ordered.

88
MEDication RECONciliation
Additional Info

• When the patient transfers to another setting, or
  is discharged, the accurate list of medications
  is communicated to the next provider of care.
• The patient is also given a list of the
  medications.
• At hospital discharge, this is done via the
  Discharge Instructions

89
PATIENT SAFETY REPORTING

• Report any and all Adverse Events/Close
  Calls/Near Misses/Sentinel Events or other
  Patient Safety Concerns using one of the
  following the following
• Patient Safety Hotline _at_ 6331
• Patient Safety Manager _at_ 7220
• Risk Manager _at_ 7717

90
PATIENT SAFETY REPORTING

• We Value Your Concerns and Need Your Help to
  Improve Safety

91
Blood Transfusions

• MD Consent required
• Screens
• Crossmatch
• Blood By Products (FFP, Plasma, Platelets, Cryo)
• COS may authorize in situations where patient or
  surrogate can not sign
• MD Order required (CPRS Clinician Menu)
• Premedication if desired
• Number of Units
• Crossmatch
• Screening
• Transfusion

92
Blood Transfusions

• Emergent Situations
• Requires COS Approval
• MD requestor initiates statement to release
  uncrossmatched blood
• O negative or 0 positive until crossmatch is
  available
• Blood Procedures (Lab Nursing)
• T-Drive
• Hemolytic Transfusion Reaction CPM T-Drive (LAB)
• Infusion stopped
• Notify Blood Bank
• Return Blood, Tubing
• 2 Large Red tubes
• 2 Large Lavender
• MD Completes Report on Transfusion Reaction
  Investigation

93
Pharmacy Formulary

• Sharon Castle, Pharm D. BCPS
• Chief, Pharmacy Service
• Please review the computerized patient record
  system (CPRS) training
• Training is available at www.charleston.va.gov or
  educations service has a CD available for
  checkout

94
On AdmissionOrder Meds Patient Is Currently
Taking
Date last filled
95
Medication Order Dialogs Transmit to Pharmacy
Service
Text Orders remain in Notes
96
The ExceptionC-II Outpatient Rxs

• Written Rx on Prescription Form 10-2577d
• a CPRS Order Entry
• Rx cannot be dispensed until written Rx
  received in Pharmacy Service.

97
Inpatient OrdersFirst Dose Now Check Box
Expected First Dose
Give Additional Dose Now Check Box
98
Medication Quick Orders Menus
Standard defaulted information.
99
Quick OrdersConvenient, but review before
signing.

• Does the order state everything correctly?
• -Dose/Frequency/Indication
• Change if not correct/complete.
• -Discontinues the old order at the same time it
  enters a new order.

100
Indication for all Medication Orders
101
CPRS Consults Tab Non-Formulary Drug Request Menu
102
Routed to Responsible Service
103
Routed to Responsible Service
104
Medication Reconciliation onHospital Discharge
105
VISTA Imaging

• VISTA Imaging is an extension of the VA
  Computerized Patient Record System (CPRS) that
  allows the user to view medical images through
  CPRS.
• All Providers, Nurses, Residents and Students
  have access to VISTA Imaging from the CPRS tool
  bar.

106
Introduction to Nursing Service Mary Fraggos,
RN, MS, CNAA, CNOR

• Inpatient units include Medical, Surgical, Mental
  Health, Nursing Home Care Unit, Medical and
  Surgical Intensive Care Units and Urgent Care.
• 117 authorized beds operating 96 beds and a 28
  bed nursing home care unit
• Annual services consist of 4300 inpatient stays

107
Some People to Know

• Charleston VAMC
• Director and Associate Directors

108
John Barilich Director
Mary Fraggos, RN, MS, CNAA Associate Director for
Nursing and Patient Care Services
Johnetta McKinley Associate Director
Dr. Florence Hutchison Chief of Staff
109
Charleston VAMC

• Service Chiefs

110
SERVICE CHIEFS
Sheila CrewActing Chief of HR Service
Michael Cortright Chief Information Technology
Jan Basile Chief of Primary Care
111
SERVICE CHIEFS
Dr. Warters Chief of Anesthesia
Dr. Merrill Chief of Medicine
Avtar Singh Chief of Lab Service
112
SERVICE CHIEFS
Dr. Derya TaggeChief of Surgical Service
Dr. Freedland Chief of Radiology
Dr. Tyor Chief of Neurology
113
SERVICE CHIEFS
Carolyn MartelChief of Volunteer Service
Dr. Bernard Williams Chief of Dental
Charles Smoak Business Manager
114
SERVICE CHIEFS
Rita Young, PhD Associate Chief of Staff for
Research
Karleen McNealChief of Geriatric Service
Hugh MyrickChief of Mental Health
115
SERVICE CHIEFS
Suzanne Anderson Chief of Canteen Service
Milllie SeeseChief of Prosthetic Service
Nancy GannonChief of Nutrition and Food Service
116
SERVICE CHIEFS
Tracy McFall, M.D. Chief of Phys /
Rehabilitation
Dr. Preston Church Medical Center Epidemiologist
Chief of Infection Control Service
Dr. Joseph John Associate Chief of Staff for
Education
117
SERVICE CHIEFS
Kenneth Turner Chief of Facilities Management
Roger SummerlinChief of Police
Lorenzo Moses Chaplain
118
Customer Service

• VHA has both external and internal "customers."
• The primary customers in VHA are considered the
  veterans who use our services and by extension,
  their families.
• Charleston CBOCs
• Goose Creek (GCPCC)
• Beaufort (BPCC)
• Savannah (SPCC)
• Myrtle Beach (MBPCC)

119
Customer ServicePatients Rights/Responsibilities

• Staff Courtesy. We will treat you with courtesy
  and dignity.
• Timeliness. We will provide you with timely
  access to health care.
• One Provider. One health care team will be in
  charge of your care.
• Decisions. We will involve you in decisions
  about your care.
• Physical Comfort. We will strive to meet your
  physical comfort needs.

120
Customer Service Patients Rights/Responsibilitie
s

• Emotional Needs. We will provide support to meet
  your emotional needs.
• Coordination of Care. We will take
  responsibility for coordinating your care.
• Patient Education. We will try to provide
  information and education about your health care
  that you will understand.
• Family Involvement. We will provide the
  opportunity to involve your family in your care
  when appropriate.
• Transition. We will provide smooth transition
  between your inpatient and outpatient care.

121
Ethics and Patient Abuse

• Ethics Review Committee provides
• An avenue for patient care concerns
• Ethical guidance and review of issues that may
  arise in the course of caring for the patient
• The patient, family, representative, or
  medical/health care staff can request a referral
• Referrals can be directed to any member of the
  committee or to the chairman
• Julian Libet, Ph.D. (extension 7133)

122
Patient Abuse/Neglect/Exploitation

• If any abuse, neglect, or exploitation of a
  patient is suspected, the attending physician
  must be notified immediately.
• Please refer to CPM 11-06, Adult/Child Victims
  of Alleged Abuse, for criteria for identifying
  abuse and for reporting procedures.

123
Unique Health Risks

• WWII\Korea
• Cold Injury
• Nuclear Weapons Exposure
• Chemical Warfare Agents
• Cold War
• Nuclear Testing
• Vietnam
• Agent Orange Exposure
• Hepatitis C

124
Unique Health Risks

• Gulf Wars
• Exposure to Smoke
• Leishmaniasis
• Parasitic Protozoan Skin Disease
• Immunizations
• Chemical or Biological Agents
• Depleted Uranium (DU)

125
Unique Health Risks

• Operation Iraqi Freedom/Operation Enduring
  Freedom (OIF/OEF)
• Combined penetrating, blunt trauma
• Burn or Blast Injury
• Traumatic Brain/Spinal Cord Injury
• Mental Health Issues
• Vision Loss
• Traumatic Amputation
• Chemical or Biological Agents
• Depleted Uranium (DU)

126
EEO

• Equal opportunity in employment to all qualified
  persons
• Based upon merit and fitness
• Regardless of race, color, religion, sex
  (including sexual harassment), age, national
  origin, physical or mental disability, reprisal
  for participation in past EEO complaint activity,
  sexual orientation and status as a parent in
  federally conducted and training programs.
• No benefit will be denied based on discriminatory
  practices.

127
Medical Error Disclosure

• Disclosure and reporting are separate
  requirements
• Adverse events reporting
• Outlined in CPM 00QM-03.
• MED 1 (6331)
• Adverse event should be disclosed to the patient
  unless the patient is unable to participate in
  the disclosure process
• Death
• Incapacitation
• Disclosure made to the patients representative
  or designee

128
Medical Error Disclosure

• Information communicated should come from those
  involved in the adverse event
• Include factual information within the medical
  record
• Information protected
• Privacy Act, Health Insurance Portability and
  Accountability Act (HIPPA), 38 U.S.C. Section
  7332
• Treatment for substance abuse
• Sickle cell anemia
• HIV)
• Section 5705 No Disclosure
• Information obtained from RCA or peer reviews
• Questions call
• Chief, Health Information Management Service
• Medical Centers Privacy Officer
• Daphne Simons, Privacy Officer 7833

129
The Five Rs of Apology

• Recognition
• Keep tabs on how you recognize situations
• Regret
• Id like you to know how very sorry I am
• Responsibility
• I am responsible for your care and this
  regrettable outcome.
• Remedy
• Two components, educational and financial
• Remain Engaged

130
Educational Remedy

• Three Major Questions Patients Want Answered
• What is being done to correct the problem that I
  now have?
• How will this affect my health in the short and
  long term?
• Am I going to be responsible for the cost of this
  error or complication?

131
Ethics Gifts

• Gifts are restricted by value
• Value of no more than 20 per occurrence
• Not to exceed 50 in aggregate value over a given
  12 month consecutive period of time from any one
  source.

132
Compliance and Business Integrity (CBI)

• Veterans Health Administration mandates business
  operations and health information practices
  comply with applicable standards and ethics
  regulations
• Achieve the highest levels integrity and are
  spontaneously audited (IG)
• Requires programs exist at all levels of the
  organization

133
Dress Code

• Appropriate Dress
• Clean
• Tidy
• Professional
• Inappropriate
• Sheer or see-through
• Dresses or skirts over 3 above the knee
• Clothing with offensive language or slogans
• Jeans, jogging\sweat suits, warm-ups or underwear
  worn as outerwear

134
Dress Code

• Employee ID Badges
• Visible
• Worn midway between the waist and shoulder at
  all times while on duty.
• Free of pins or other piercing items that
  obstruct view or may cause damage

135
My HealtheVet

• The gateway to veteran health benefits and
  services.
• Provides access to
• Trusted health information
• Links to Federal and VA Benefits and resources
• Personal Health Journal
• Online VA prescription refill
• WWW.myhealth.va.gov

136
VA Library

• Located in Room CC212
• Resources below located
• Charleston VA Web Page
• Select the Library and Clinical References
• Micromedix
• E-Facts online
• PubMed
• Lippincott Healthcare Reference
• Ebsco Comprehensive Hospital Library
• New England Journal of Medicine

137
Education Service Contact Info
Phone [phone] FAX (843)
789-6112 Joseph F John, Jr., M.D. ACOS/E Brenda
Flannigan-Tyson, RN MSN ANE/E Janice Skipper, RN
MSN Clinical Educator Barbara Knepshield, RN PhD
Clinical Educator Bryan Williams, Affiliation
Coordinator William Kuhn, Education Program
Assistant
138
CONGRATULATIONS!!!

• Youve finished Orientation

139
RHJ VA MEDICAL CENTERTRAINEE HOSPITAL
ORIENTATION

• Please Print and Sign this page only.
• Statement
• I acknowledge that I have read the RHJ Hospital
  Orientation and completely understand the
  content. ______________________________
• SIGNATURE OF EMPLOYEE DATE

140
THANK YOU for completing AY 08-09 Orientation

• Please complete your test (located in the
  checklist), VA Privacy (HIPPA) and Cyber training
  and print certificates of training. These items
  along with your required forms can be turned into
  your service coordinator or VAMC Education
  Service.
• If you need processing forms or training web
  addresses you may access at www_at_charleston.va.gov
  You will need to come in hand with the above
  items along with photo copies of your BLS if
  applicable ACLS and 2 forms of Picture ID. If
  you have any questions please contact the VAMC
  Education Service at 789-7238.