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2012-2013 Safety Fair


2012-2013 Safety Fair Annual Training and Review for Quality, Safety and Compliance House Staff Edition ... – PowerPoint PPT presentation

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Title: 2012-2013 Safety Fair

2012-2013 Safety Fair
  • Annual Training and Review for
  • Quality, Safety and Compliance
  • House Staff Edition

  • What is Safety Fair?
  • All hospitals must provide annual reviews of
    safety and quality information for all employees.
    At GCH, this is called Safety Fair.
  • Many of these topics are conditions for our
    hospitals accreditation through HFAP (Healthcare
    Facilities Accreditation Program)
  • This presentation has been customized from the
    GCH Safety Fair material to provide information
    most relevant to house staff. UPDATED PROCESSES

Safety and Survey Handbook
  • This program will refer to the green Handbook
    distributed last year. Copies will be placed in
    new house staff mailboxes if you need a copy
    contact Med Ed staff.
  • Keep the handbook with you you can refer to it
    if asked questions by an inspector.
  • Follow along in the handbook as you view this
    presentation. Handbook page numbers are
    referenced throughout.

Page 2 in your handbook
Safety and Survey Handbook
  • Look for these symbols
  • Means this section if critical for HFAP
  • t Means this section is critical for Fire
    Marshal visits
  • Dashed boxes (like this) are to be filled out
    with information specific to your training
    program or Medical Education. These are typical
    questions asked of employees during a survey or
    inspection and will be detailed in this

To meet your Safety Fair requirement
  • View this presentation online
  • Complete the online quiz by Friday December 7,
    2012 link at the end of the presentation
  • Note All Safety Fair Training will be done
    online this year.
  • There will be no live sessions.

Hospital Leadership
  • Chief Executive Officer (CEO) Gary Ley
  • V.P. Chief Operating Officer (COO) John Knox
  • V.P. Chief Finance Officer (CFO) Tim Jodway
  • V.P. Chief Nursing Officer (CNO) Bette Fitz, RN
  • V.P. Human Resources, Steve Solomon
  • V.P. Medical Services, Kirsten Waarala, DO
  • Medical Director, Rex Ruettinger, DO
  • Reporting to the Vice Presidents
  • Directors and Department Heads
  • Coordinators, Managers and Supervisors
  • If asked, you report to Dr. Waarala and to your
    residency program director

Note that Page 4 in your Handbook is not up to
Garden City Hospital Mission
  • Medical Education is part of why we are here!
  • Garden City Hospital is committed to
    providing healthcare that improves the well being
    of the whole person and the health status of the
    community at large through the provision of
    comprehensive healthcare services, osteopathic
    medical education and healthcare related

Page 6 in your handbook
GCH Values
  • Integrity.
  • We will be honest and trustworthy in everything
    we do.
  • Compassion.
  • We will respect all people with a sense of caring
    and understanding.
  • Commitment.
  • We pledge to work toward the greater good of the
  • Communication.
  • We will share information in a timely and
    accurate manner.
  • Quality.
  • We do everything with excellence.

Ref pg 6-7
GCH Values
  • Quality should be a given. Our priorities in
    caring for the patient and their family should be
    to provide quality care as well as
  • Safety
  • Comfort
  • Compassion
  • Consider how you incorporate these values into
    the care you deliver

Part IAccreditation Standards

Accreditation Standards
  • Accreditation standards include patient care
    processes, facilities,
  • policies, etc. - anything and everything related
    to running a
  • hospital.
  • Many of these standards are also requirements of
    the Federal
  • Government through the Centers for Medicare and
  • Services (CMS). Failure to meet CMS standards
    also known as
  • conditions of participation is a serious matter
    in that a hospital
  • could lose its ability to care for Medicare

Accreditation Standards
  • Key issues for all physicians and house staff
    involve the medical
  • record. The following are must-haves for HFAP
    and CMS.
  • Delinquent Medical Records
  • All medical records must be complete within 30
    days of discharge. This is required by HFAP
    and by the Centers for Medicare and Medicaid
  • (CMS).
  • Discharge summaries must be completed within 7
    days of discharge
  • HPs
  • Must be documented within 24 hours of admission
  • Must be complete, including osteopathic
    structural exam (OSE)

Accreditation Standards, continued
  • Key issues for all physicians and house staff,
  • Orders, Progress Notes, and Consultations
  • Must include date and TIME!
  • Must be signed including telephone orders
  • Include printed name and pager number
  • Legible!
  • Restraint Orders
  • Required for all patients
  • Must be completed according to policy (more on
    this later in this presentation)

Accreditation Standards, continued
  • Key issues for all physicians and house staff,
  • Informed Consent
  • Informed consent is a process, not a form. It is
    the discussion with the patient or their
    representative about a procedure in language they
    can understand, including
  • whats involved
  • risks and benefits
  • alternatives
  • answering questions.
  • This discussion is documented on the informed
    consent form.
  • Must include all required elements
  • Date and TIME
  • Signature of patient, person obtaining consent,
    and witness

Employee Code of Conduct
  • All employees of GCH, including house staff, must
    adhere to the
  • Code of Conduct. This includes
  • Laws and Regulations
  • GCH will operate in accordance with all laws and
  • Business and Ethical Practices
  • GCH is committed to ethical business conduct and
  • Confidentiality
  • In keeping with various laws, regulations and
    professional ethical guidelines, GCH employees
    must maintain the confidentiality of medical
    records and other patient information
  • Continued next slide

Page 7 in your handbook
Employee Code of Conduct
  • All employees of GCH, including house staff, must
    adhere to the
  • Code of Conduct. This includes
  • Conflict of Interest
  • GCH employees are expected to act in a manner
    that is in the best interest of the hospital and
    the patients it serves.
  • Quality of Care
  • A central concern of GCH in meeting patient needs
    is serving the whole person in his or her
    spiritual, intellectual, emotional and physical

Page 7 in your handbook
Employee Standards
  • The Employee Standards include
  • Commitment to Patient
  • Commitment to Appearance
  • Commitment to Attitude
  • Commitment to Communication
  • Commitment to Co-Workers

Pages 9-14 in your Handbook
Commitment to Patient
  • The manner in which we will provide service to
    our patients
  • Compassionate
  • Informed
  • Respectful
  • Safe
  • Timely

Pages 9-14 in your Handbook
Commitment to Appearance
  • We will represent GCH in a professional manner to
    our customers
  • Personal
  • Facility Environment
  • Good Neighbor

Pages 9-14 in your Handbook
Commitment to Attitude
  • The manner in which we show our attitude while
    providing service to our patients, customers and
  • Positive
  • Respectful
  • Professional
  • Friendly

Pages 9-14 in your Handbook
Commitment to Communication
  • The manner in which we will communicate with our
    patients, customers and co-workers
  • Respectful
  • Promptness
  • Professionalism

Pages 9-14 in your Handbook
Commitment to Co-Workers
  • The manner in which we will relate to our
  • Respect
  • Friendliness
  • Mentoring

Pages 9-14 in your Handbook
Patient Rights and Responsibilities
  • CMS and HFAP require that patient have certain
  • The list of patient rights and responsibilities
    has been updated this year from 19 to 23 items.
    Copies are available on the gchmeded.org website
    and are posted throughout the hospital.
  • Read and familiarize yourself with them. Be sure
    to respect them in your work.
  • Know how patient rights are protected
  • Special Policies
  • The Uniform Standard of Care

Pages 15-18 in your Handbook
Patient Satisfaction
  • GCH measures patient satisfaction for all
    inpatient and outpatient encounters internally
    using a paper survey sent to patients by the NRC
    Picker company
  • We are also measured by the HCAHPS (Hospital
    Consumer Assessment of Healthcare Providers and
    Systems) survey. This is a national,
    standardized, publicly reported survey of
    patients' perspectives of hospital care.
  • HCAHPS (pronounced H-caps), is a standardized
    survey instrument and data collection methodology
    for measuring patients perceptions of their
    hospital experience.
  • HCAPS satisfaction data for GCH and other
    hospitals are publicly reported at

Patient Satisfaction
  • House staff should be aware of the HCAHPS
  • measurements relevant to physicians. As you are
    often on the front
  • line of patient care, your interactions with
    patients are reflected in
  • these questions. Patients answer on a scale from
    Never to
  • Always we need you to help earn Always!
  • During this hospital stay, how often did doctors
  • Treat you with courtesy and respect?
  • Listen carefully to you?
  • Explain things in a way you could understand?
  • Did you have confidence and trust in the doctors
    treating you?
  • Did your family or someone else close to you have
    enough opportunity to talk to your doctor?

Responding to Complaints
  • First steps
  • Listen carefully
  • Apologize (Im sorry this happened to you)
  • Take action to resolve the issue
  • Follow-up with the complainant about what you did
  • If you cannot help, then in order
  • Ask other staff for assistance
  • Contact the Patient Representative
  • Contact Medical Education or Administration
  • What is a grievance?
  • A written complaint (letter, email, fax)
  • An unresolved complaint
  • A complaint involving a healthcare provider
  • Special steps are needed for grievances notify
    a supervisor or Medical Education

Pages 18-19 in your Handbook
Interacting with Surveyors and Inspectors
  • Be friendly, helpful, and honest.
  • Answer the question asked, then stop! Dont
    volunteer additional information, thoughts or
  • Focus on the positive describe what we do, not
    what we dont.
  • Refer to your handbook if you need to. You dont
    need to memorize this!
  • Ask for the question to be re-stated or said
    differently if you dont understand it.

25 in your Handbook
Part IIPatient Environmental Safety

What is Patient Safety?
  • The Institute of Medicine has defined patient
    safety as the prevention of harm to patients
    using a system that
  • Prevents errors,
  • Learns from errors that do occur, and
  • Is built on a culture of safety that involves
    health care professionals, organizations,
    and patients

Page 26 in your Handbook
GCH Patient Safety Initiatives
  • Examples of patient safety initiatives for
    Medical Education include the following. Enter
    in your handbook on page 26
  • Rapid Response Team
  • Code Blue Peer Review Forms
  • Feedback on use of standard orders
  • unauthorized abbreviations, etc.
  • GCH has a Hospital Safety Council and a Patient
    Safety Council. Policies that promote safety are
    available online on the hospitals shared drive.

Page 26 in your Handbook
Your Role in Playing it Safe
  • Report immediate dangers to Medical Education or
    to Security
  • Report non-urgent concerns to
  • Medical Education
  • Your attending physician
  • The Safety Officer, Greg Harrison (x4234)

Oxygen Safety
  • Oxygen tanks should be stored
  • 5 feet away from combustibles in a sprinkler
    protected room
  • 20 feet away from combustibles in a
    non-sprinkler protected room
  • Oxygen tanks cannot be stored in corridors
  • Tanks must be stored in an approved holder. If
    you see a loose tank, notify a manager in that
    area to secure the tank.

Pages 27-28 in your Handbook
Hazard Communication
  • Every employee has the right to know the dangers
    of the chemicals used where they work. Every
    employee also has responsibility to ask for
    further information and to follow hazardous
    chemical precautions.
  • MSDS stands for Material Safety Data Sheets
  • Provide chemical hazard information
  • These references are available in the ED for all
    chemicals used in hospital in case of exposure

Pages 28-29 in your Handbook
  • If you find it make sure it is cleaned up!
  • Clean up simple spills (see the table in your
    handbook on page 15)
  • Report contaminated or large chemical spills by
    calling the operator and asking for Security or
    the Housekeeping Supervisor
  • Be aware of proper disposal for different medical
    wastes (handbook page 30)

Pages 29-30 in your Handbook
Hazardous Materials
  • Disposal rules
  • Medical waste red biohazard bins with lids,
    located in soiled utility rooms
  • Chemotherapy IV bags and tubing labeled chemo
    waste bucket
  • Chemical waste per manuafacturers instructions
  • Sharps in sharps container

Pages 31 in your Handbook
Electrical Safety Basics
  • Make sure that all equipment has a grounded plug
  • Dont overload outlets
  • All electronics, including small appliances, are
    to be tagged by Biomedical Equipment. This
    includes items in call rooms and offices. Call
    x4297 for assistance.

Page 32 in your Handbook
Medical Devices
  • A medical device is anything that is used in the
    care of the patient that is not a drug
  • In case of malfunction of a medical device
  • If nobody is injured contact Biomed Department
    (x4297) for repairs
  • If a patient or employee may have been injured
  • Assure the safety of the patient/employee
  • Secure the device do not change settings
  • Contact Biomed (x2829) and Risk Management
  • EXAMPLE malfunctioning defibrillator vent that
    didnt alarm ? Contact Biomed

Page 32-35 in your Handbook
Codes and Disaster Protocol
  • The following codes may be called overhead
  • Code BLUE cardiac and/or respiratory arrest
  • Code RED fire
  • Code PINK infant abduction
  • Code PURPLE child (gt1 year) abduction
  • Code BLACK severe weather/tornado warning
  • Code TRIAGE disaster (internal or external)
  • Code ALPHA administrative team alert

Pages 40-42 in your Handbook- Note Code Purple
Code RED Fire Alarm Signal
  • In the event of a code RED
  • DO keep all doors shut
  • DO remain in your area
  • DO listen for overhead pages with further
  • DO move patients and visitors to behind fire
  • DO treat all Code Reds as the real thing
  • DO NOT go through closed fire doors
  • DO NOT use elevators
  • DO NOT assume a Code Red is a drill

Pages 35-37 in your Handbook
Fire Response R.A.C.E.
  • A fire marshal or inspector may ask you how you
  • respond to a fire. Remember the acronym R.A.C.E.
  • ? What does R.A.C.E. stand for?
  • Rescue - Persons in immediate danger
  • Alarm - Activate the fire alarm system and call
  • Contain - Contain the fire by closing doors.
    Never open a door to check on a fire
  • Extinguish - Attempt to extinguish the fire but
    only if it is safe to do so

Pages 35-37 in your Handbook
Fire Response P.A.S.S.
  • A fire marshal or inspector may ask you how to
    use a fire
  • extinguisher. Remember the acronym P.A.S.S.
  • ? What does P.A.S.S. stand for?
  • Pull the pin to activate the trigger
  • Aim the nozzle at the base of the fire
  • Squeeze the trigger firmly
  • Sweep the nozzle from side to side

Pages 35-37 in your Handbook
Code PINK - Infant Abduction
  • Code PINK is the signal for a potential infant
    abduction. All staff are expected to assist in
    monitoring stairs and exits.
  • Stop all non-critical work.
  • Guard all interior stairwell doors, elevator
    areas and exit doors.
  • Do not allow anyone (including employees) to exit
    the building that is carrying a child or
    package/bag that could contain an infant. If they
    exit, follow them to get description of vehicle.
  • Wait for all-clear message.

Page 40 in your Handbook
Code PURPLE- Infant Abduction
  • Code PURPLE is the signal for a potential child
    (gt1 year) abduction. All staff are expected to
    assist in monitoring stairs and exits.
  • Stop all non-critical work.
  • Guard all interior stairwell doors, elevator
    areas and exit doors.
  • Do not allow anyone (including employees) to exit
    the building that has a child matching the
    description to exit. If they exit, follow them
    to get description of vehicle.
  • Wait for all-clear message.

New for 2012
Code BLACK Severe Weather
  • Code BLACK is the signal for severe weather.
  • Employee actions include
  • Remain on assigned duties
  • Move patients and visitors to internal corridors
    if possible
  • If patients cannot be moved out of room, move
    them away from windows, close windows, draw
    curtains and blinds.
  • Help to reassure patients and visitors

Page 40 in your Handbook
Code TRIAGE Disaster
  • Code TRIAGE is the signal for an internal or
    external disaster.
  • The guidelines on the next slide indicate the
    appropriate actions by specialty or assignment.
    This applies to those individuals on duty or at
    home on pager call. Note this on page 42 of your
  • In most cases, house staff should report to the
    labor pool in the auditorium to sign in. If you
    are not immediately needed, you may leave the
    pool and resume your usual duties.

Pages 40-41 in your Handbook
Code TRIAGE DisasterHouse Staff Actions
Emergency Medicine Stay in the ED
Surgery General, Neuro, Ortho, Urology If in OR, finish case tell OR desk your status If urgent need, scrub out, report to designated area If not in OR sign in at manpower pool
Internal Medicine Check in at manpower pool Go to ICU, 2C to evaluate patients for transfer off unit in case beds are needed Assist with transfer/discharge of patients to free up beds (coordinate with House Officer)
House Officers Check in at manpower pool Continue with admissions/floor call Assist with transfers/discharges with IM team
Everyone else, including medical students Check in at manpower pool Continue with usual duties, assist HO as needed
Code ALPHA Administrative Alert
  • Code ALPHA is the signal for the administrative
    team to assemble in order to deal with an
  • House staff should stay tuned for a follow-up
    code or other instructions if code ALPHA is

Page 40 in your Handbook
Employee Response in Disasters
  • Each one of us must consider our commitment to
    the safety and welfare of our patients, and
    co-workers when planning how we will respond to
    the disaster needs of the hospital
  • Planning should include discussing your hospital
    commitment with your family and preparing your
    family to respond effectively to disaster events

Page 39 in your Handbook
Weapons of Mass Destruction
  • WMDs include
  • Chemical
  • Biological
  • Radiation
  • Nuclear weapon
  • Explosives

Pages 42-44 in your Handbook
WMD Scenarios Factors
  • WMD incidents could result in two primary
  • A large number of burn or blast trauma casualties
  • An increasing number of infectious illness,
    chemical poisoning or radiation disease victims
  • WMD incident may include complicating factors for
    the delivery of hospital care
  • Region-wide evacuation or quarantine
  • Contaminated victims biological, chemical or

Pages 42-44 in your Handbook
WMD Hospital Preparation
  • GCH has prepared for contaminated victims
  • Stockpiling of personal protective equipment,
    antibiotics and other medications
  • Planning for regional isolation of hospital areas
    in the event of contamination
  • Participation in region-wide disaster drills
  • Mutual aid agreements with community agencies
  • ED decontamination tent and use of high level
    personal protective equipment

Pages 42-44 in your Handbook
Violent or Threatening Behavior
  • First, keep yourself safe
  • Contact Security for help (x3333)
  • Do what you can to avoid problems
  • Wear your badge
  • Maintain locked entrances no propped open doors
  • Report suspicious individuals or circumstances
  • Lock up valuables, purses, etc.

Pages 37-38 in your Handbook
  • A decision to evacuate the Hospital can only be
    made by the following individuals or
  • Incident Commander
  • Chief Medical Officer
  • Highest ranking Administrator on duty
  • Fire Department having jurisdiction
  • House staff and med students will be expected to
    assist in any way with moving patients and staff
    to safety.
  • Refer to employee responsibilities on page 39 in
    Safety Survey Handbook regarding a family plan.

Ref pg 43
  • Everbridge is a web-based communication system
    that allows
  • designated users access to specified employees
    and physicians.
  • Users are able to send urgent and emergency
    notification with receipt that call was received.
  • Only designated employees may send messages.
  • All Hospital members in the system may receive
  • Confirming receipt of an Everbridge message is
    important because the Everbridge system will
    notify the sender that the message was received.
    The system will continue to attempt contact until
    it receives confirmation.
  • Staff members are required to submit, in writing,
    any personal contact changes to Med Ed - home or
    cell phone numbers, e-mail address.

Ref pg 44
Hospital Emergency Numbers During Internal Telcom
  • When service to the Hospital phone system is
    interrupted, the operator will announce overhead
    The phone system is temporarily out of service.
    Please use alternate phone.
  • Plug RED emergency phone into the jack marked
  • All employees must be aware of red phone and
    emergency jack locations.
  • Hospital emergency numbers can be found in phone
    directory located on the Intranet or spiral bound
    GCH Directory.

Part I11 Preventing Illnesses and Injuries
on the Job

Reporting Work Injury or Illness
  • When a work injury or exposure occurs
  • Report the incident to Med Ed immediately or
    within 24 hours
  • Complete an Employee Incident form. (Available on
    line or in the Emergency Department)
  • Register and receive initial treatment in the
    Emergency Department
  • Follow-up care and determination of temporary
    restrictions, if any, will be made by Dr.
    Sczecienskis office at the our Westland Facility
  • Contact Human Resources with questions about
    Workmans Compensation

Hand Washing
  • The single most important procedure for
    preventing infections for
  • Patients
  • Co-workers
  • Yourself
  • Options include soap and water or waterless hand
  • Wash your hands before and after examining
    patients they expect this and will notice if
    you dont!

Page 45 in your Handbook
Blood Borne Pathogens (BBP)
  • BBPs are infectious agents, such as hepatitis B,
    hepatitis C, and HIV, that can be transmitted by
    blood other body fluids.
  • All personnel who have direct patient contact
    e.g. all house staff will be tested for
    immunity against HBV. Vaccination is available
    through Employee Health.

Pages 46-47 in your Handbook
Blood Borne Pathogens (BBP)
  • To protect yourself against BBP
  • Minimize/control splashing of fluids
  • Use appropriate Personal Protective Equipment
  • Practice good sharps safety
  • Cover cuts and scrapes
  • Dont eat or drink where body fluid contamination
    may be present
  • Use proper equipment to clean up broken glass
  • Never reach into trash - handle trash bags from
    the edges
  • Follow appropriate procedures to wipe blood and
    body fluid spills
  • Clean up after procedures, dressing changes, etc.

Pages 46-47 in your Handbook
  • Take precautions if a patient has symptoms which
    could represent TB (persistent cough, blood in
    sputum, unexplained weight loss, night sweats,
    upper lobe infiltrate)
  • Provide a mask to suspected patients who are
    awaiting a room
  • Admit to a negative pressure room with
    respiratory isolation
  • Complete appropriate workup
  • Use appropriate respirator masks when entering
    the patients room

Page 48 in your Handbook
Masks for Respiratory Precautions
  • Employees that have direct patient contact must
    be FIT tested annually.
  • FIT tested employees must wear an N95 respirator
    mask when entering the room of
    a confirmed or
    suspected TB patient. These are available
    Pyxis but you must know your size.
  • Employees that cannot wear an N95 mask (e.g. poor
    fit, beard/moustache) must wear a Hepahood when
    entering room. Contact Respiratory Therapy to
    sign out blower keep the hood for your personal
    use in future.

Page 48 in your Handbook
  • Seasonal and H1N1 Influenza vaccinations (flu
    shots) have been administered by Employee Health.
    If you missed getting yours, watch for updates
    on community based immunization clinics.
  • The flu can cause life-threatening illness in
    some individuals, especially the young, old and
  • Even if you have never had the vaccine or felt
    you were ill with flu, you may still be a carrier
  • Patients
  • Family
  • Co-workers
  • Save lives, get vaccinated!

Page 49 in your Handbook
Isolation Precautions See Page 49-50
Type of Isolation Restrictions/Protective Equipment. Infectious Agents / Clinical Scenario
Contact Isolation Must wear gown and gloves upon entry into room Lice, scabies Drainage not contained
Special Precautions Must wear gown and gloves upon entry into room Acinetobacter
Enteric Precautions Must wear gown and gloves. Private room recommended. Wash hands/equipment (stethoscope) with soap and water. Clostridium difficile NOTE C. diff is not killed by hand scrubs!
Droplet Isolation Must wear surgical mask on entry into room. Wear N-95 mask for respiratory tract procedures. Influenza and most communicable childhood diseases
Airborne Isolation Must wear surgical mask on entry into room. Wear N-95 mask for respiratory tract procedures. Private room recommended. Varicella chicken pox, disseminated shingles
N-95 Isolation Must wear N-95 mask or Hepa-hood. Negative pressure room required. Suspected or confirmed tuberculosis
Sharps Safety
  • NEVER re-cap a needle.
  • Count sharps before and after procedures.
  • Properly dispose of sharps.
  • Change sharps containers that are 2/3 or more
    full. (Contact Environmental Services)
  • Use safety devices when available.

Pages 46-47 in your Handbook
Sharps Safety
  • The patients bed or linens
  • Bedside stand or over-bed table
  • Food tray
  • Floor
  • IV pump

Pages 46-47 in your Handbook
Needlesticks and Exposures
  • In the event of a needlestick/sharps injury
  • and/or blood or body fluid exposure
  • Wash the area with soap and water.
  • Go immediately to the Emergency
    Department for evaluation.
  • Complete the Employee Incident Report form.
  • If needlestick/sharps injury Complete the Med
    Ed needlestick questionnaire as well.
  • Follow medical orders for follow-up care.
  • DO NOT initiate orders for HIV/HBV/HCV testing on
    the patient this will be done through the

Pages 46-47 in your Handbook
Lifting Dos and Don'ts
  • Dont
  • Lift with your back
  • Use an unstable base
  • Use an overextended reach
  • Lift overhead
  • Twist while reaching for or lifting a load
  • Do
  • Lift with your legs
  • Hold the load close to your body
  • Look straight ahead
  • Use lift devices to prevent injury
  • Use carts and dollies to move loads

Pages 51-52 in your Handbook
Part IV Quality

Quality Management Essentials
  • Quality is defined as
  • Providing the right care or service to the right
    person in the right way to meet and exceed the
    customers expectations.
  • Requirements of HFAP and JCAHO CMS.
  • Quality Management QM efforts involve every
  • Goals of QM are to improve
  • Work processes
  • Outcomes
  • Clinical care
  • Efficiency
  • Customer satisfaction
  • Hospital market share

Page 52 in your Handbook
Quality Management MethodPDSA
  • Plan identify an improvement opportunity, gather
    data, analyze current process.
  • Do develop and implement a new or redesigned
  • Study Examine data to identify whether or not
    the change (s) led to the expected improvement.
  • Act make it permanent or if process needs
    continued work, begin the PDSA cycle again.
  • Complete boxes on pages 53 and 54 in the Safety
    Survey Handbook.

Ref pg 52-56
Reporting Quality Concerns
  • If you suspect an issue involving quality of
    care, report it immediately to your attending
    physician, the patients nurse or nursing
    supervisor, or notify Medical Education
  • Quality Control Reports (QCR) This is the form
    used for reporting a quality concern.
    If you are called to evaluate a
    patient regarding a fall, medication error, etc.
    complete your portion of the QCR but DO NOT
    document in the chart that a QCR was completed.

Page 55 in your Handbook
Your role in selected quality initiatives
  • For Heart Failure, Acute MI, and Pneumonia
  • These will be available in CPOE in January 2013!
  • The use of standard order sets has been shown to
    reduce errors and omissions and improve quality.
  • Our performance on these initiatives is publicly
    reported and may influence reimbursement.
  • It is vital that house staff cooperate in these

Heart Failure Initiative
  • GCH is seeking to improve its performance on CHF
    quality measures. House staff need to remember
  • Use the standard order set on admission.
  • Ensure that ejection fraction is documented on
    the chart
  • Use key documentation terms systolic or
    diastolic CHF and acute or acute on chronic
  • Prescribe an ACE-inhibitor or ARB - if
    contraindicated, document this in the progress
    notes and/or discharge summary and state reason
    (e.g. ACEI/ARB not prescribed due to renal
  • Complete the Medication Reconciliation Form to
    indicate medications to continue or stop, plus
    add any new medications and/or dosages

Patient Identification Safety
  • Correctly checking patient ID can prevent death
    or injury, increased costs and improper billing.
  • ID of the patient is required prior to providing
    any treatment, procedure, medication or
  • Failure to appropriately ID a patient is a major
    safety offense and subject to disciplinary action.

Surgery Time Out
  • A protocol designed to avoid operating on the
    wrong site or wrong patient
  • Prior to the start of the case, the team verifies
  • Patient identity is correct
  • Procedure planned is correct
  • Site for operation is correct and marked
  • Documentation is in order

Conditions Present on Admission
  • Payers may not pay for conditions acquired in the
  • It is critical that conditions that are present
    on admission (POA) be documented on the HP or
    admitting progress note.
  • Key conditions include
  • Decubitus ulcers document stage
  • Infections, e.g. UTI, pneumonia
  • EMR NOTE PROBLEM LISTS will be included in the
    January 2013 go-live. Designate the onset of
    conditions as present on admission by selecting a
    date or entering free text.

Medication Reconciliation
  • Medication errors are more likely to occur at
    transfer points in the healthcare system, e.g.
  • Home to inpatient
  • Transfer between inpatient units
  • Discharge to home or ECF
  • Medication Reconciliation is a process which
    seeks to reduce errors at those points.
  • EMR NOTE The following slides have been updated
    to include the NEW PROCESS as of January 2013

Medication Reconciliation
  • On admission
  • A record of home medications will be made and
    will serve as the source of truth. Home meds
    collection will be completed in NetAccess by the
    patients RN at the time of admission. This step
    may also be completed by house staff.
  • The intern or resident completing the admission
    will complete Medication Reconciliation in
    NetAccess. When completing the HP, state see
    med reconciliation in EMR for home meds
  • When completing admitting orders, review each
    medication and decide whether to continue,
    discontinue or adjust it. Home meds may be
    selected for continuation orders.
  • Reconciliation will be completed in NetAccess at

Medication Reconciliation
  • At discharge complete these steps in NetAccess
  • Review home and in-hospital medications determine
    which should be continued after discharge.
  • Add any additional medications.
  • Provide prescriptions to the patient.
  • Review medication instructions with the patient
    and/or family at discharge.
  • Ensure that ALL medications are noted, even over
    the counter e.g. aspirin for acute MI patient

Part V Privacy and Compliance

Definitions HIPAA and PHI
  • Patient procedures and any medical records that
    are generated are protected under HIPAA (Health
    Insurance Portability and Accountability Act -
  • Protected Health Information or electronic
    protected health information (PHI or e-PHI) is
    anything that would be considered an individual
    identifier for a patient, such as name, address,
    MRN, gender, date of encounter, date of birth,

Pages 57-59 in your Handbook
Assuring Confidentiality
  • GCH employees should review patient charts or
    electronic medical information only if they are
    providing direct care to the patient
  • Patient Information should be discussed only with
    persons directly involved in that patients care.
  • Avoid discussing PHI in public areas (e.g.
    corridors, the cafeteria line, etc.)
  • All documents with PHI (including documents
    copied from patient records, patient lists,
    copies of dictations, etc.) must be kept secure.
    When discarding, these MUST be disposed of in the
    locked recycling bins.
  • Do not discuss patient information via social
    media (e.g. Facebook)

Pages 57-59 in your Handbook
Assuring Confidentiality
  • Do not look up records for
  • Yourself
  • Your family, friends or neighbors even with
    their permission
  • Go through Health Information Management to
    request records or results
  • Electronic records are monitored for unauthorized
  • It is acceptable to access charts for purposes of
    education, lecture preparation, scientific
    papers, etc. De-identify patient information
    used in lectures and case presentations.
  • Remember that all research projects involving
    medical records needs to be approved first by the
  • These guidelines apply to out-rotations as well

Pages 57-59 in your Handbook
Information Requiring Extra Care
  • Sensitive Health Information such as mental
    health, chemical dependency, sexually transmitted
    diseases and HIV should never be sent via fax
  • Any requests for records containing this kind of
    information should be discussed with your
    Supervisor or Compliance Officer prior to being
  • Unless it is for a physician consultation, the
    patient must first sign a HIPAA authorization to
    release the information

Pages 57-59 in your Handbook
Prevent Unauthorized Data Access
  • You are responsible for access under your
  • LOG OUT when you are done!
  • You are responsible for unauthorized
    access that occurs under your
  • Change Passwords Frequently
  • Passwords should be constructed so they cannot be
    easily guessed, at least 8 characters in length,
    and can include UPPER and lower case letters and
    incorporate punctuation marks to make them more
  • Remember that you will have a new physician
    number and password for electronic signature in
    NetAccess. Do not use other physicians
    credentials and do not allow anyone else to use

Violations and Reports
  • Violations
  • HIPAA complaints are reported to the Office of
    Civil Rights
  • The penalty parameters for violating HIPAA ranges
    from 50,000 fine up to 250,000 fine including
    imprisonment for up to 10 years, depending upon
    the nature of the violation
  • Reporting
  • Call the Compliance Officer at Ext. 4428, or
  • Call the Compliance Hotline at 734-458-4298 to
    make a confidential report

Pages 57-59 in your Handbook
Other Compliance Matters
  • Only document and bill for services/procedures
    that you actually performed
  • Use the correct patients name and identifying
    numbers when accessing Pyxis or running EKGs or
    other tests
  • Never accept any gifts or kickbacks from vendors
    or suppliers
  • Never offer gifts or kickbacks to vendors or
  • Contact Medical Education for information on
    applications for educational grants

Pages 59-61 in your Handbook
Safety Alert/Fall Risk Program
  • Patients with potential for falling have
  • A yellow Fall Risk ID wristband
  • YELLOW Safety Alert Signs
  • If a patient at risk for falls is attempting to
    get out of bed
  • Stay with patient
  • Call for assistance
  • Say, Please STAY in bed patients with
    confusion or dementia respond better to this than
    to Dont get out of bed.

Pages 61-63 in your Handbook
Proper Patient Identification
  • Two identifiers are needed before any patient
    care interaction
  • Patient name
  • Date of birth
  • Medical record number
  • Wrist bands are color coded for safety

RED Allergy Alert
YELLOW Fall Risk
PURPLE DNR (Do Not Resuscitate)
ORANGE Mastectomy
WHITE Patient ID
CLEAR THIN Pediatric
TYPENEX Blood Bank
Pages 63-64 in your Handbook
Foreign Language Interpreters
  • The hospital must provide an interpreter to
    anyone with limited English proficiency
  • We have hospital staff who can interpret.
  • The Interpreter List is updated and distributed
  • You can volunteer if you speak another language
    notify Med Ed.
  • If you cannot find a hospital interpreter, please
    use Language Line
  • Language Line 1-800-643-2255 Emergency number
    1-800-523-1786 and the GCH client I.D. is 208015
  • Do not use family members to interpret
  • It could jeopardize patient safety
  • Take your time and use Language Line

Page 65 in your Handbook
Pain Management Basics
  • Principles of Pain Management
  • Pain is what the patient says it is
  • Patients have the right to pain management
  • Control of pain is a key element of care
  • Patients are assessed for pain throughout their
  • Use the objective 10 point pain scale to assess
  • All house staff are expected to respond promptly
    to assess and manage pain. Concerns regarding
    type or amount of pain medication or the
    potential abuse of pain medications should be
    discussed with the attending physician.

Pages 65-66 in your Handbook
Ethical Issues
  • Employees can refer ethical concerns to
  • Their direct manager (Med Ed)
  • The Ethics Advisory Committee (EAC)
  • The Ethics Advisory Committee
  • is confidential
  • Accepts referrals from anyone that has a concern
    about an issue
  • Is advisory
  • Process
  • Complete the form Ethics Advisory Committee
    Request for Consultation
  • Forward to the office of the Medical Director or
    Outcomes Management Director
  • Potential Cases might include
  • Termination of life support systems
  • Providing treatment to a minor child in the face
    of parental objections
  • Ceasing of futile interventions in the face of
    family objections

Pages 66-67 in your Handbook
  • Remove restraints at the earliest possible time
  • Know the difference between behavioral and
    medical restraints and use the proper order form
  • Explain the reason for restraints to the family
    they may be able to stay with the patient as an
    alternative to restraints
  • Restraints include
  • Full side rails
  • Physical hold or escort
  • Mitts, soft wrist or ankle
  • Vest
  • Lock and Key

Pages 68-71 in your Handbook
Restraint Orders Use the Proper Form!
  • Behavior Restraints
  • Violent/self destructive behavior example
    patient hitting/ kicking staff
  • Requires physician order and assessment
  • Order lasts for 4 hours for adult, 2 hours for
  • 15 minute monitoring
  • Hourly assessments
  • Removed at the earliest possible time
  • OR
  • Medical Restraints
  • Patient is disrupting treatment example
    pulling out IV
  • Requires physician order and assessment
  • Order lasts for 24 hours
  • Hourly monitoring
  • Assessment every 2 hours
  • Removed at the earliest possible time
  • (More detail in your handbook)

Pages 68-71 in your Handbook
Stroke Response
  • The Stroke Team includes the Rapid Response Team
    as well as the Neurology and Diagnostic Radiology
  • For any suspected strokes in inpatients, it is
    required that the team be activated by calling
  • A code stroke page will go out as 4444
    followed by the room number
  • Use the Stroke order sets these will be
    available in CPOE in January
  • All OGME1 house staff plus residents in
    Neurology, Internal Medicine, Emergency Medicine
    and Neurosurgery are required to complete the NIH
    Stroke Scale training program annually.

TRIP Project
  • TRIP stands for Technology and Records
    Integration Project. TRIP is our journey to
    meeting Meaningful Use requirements, and includes
  • CPOE
  • Allergy and drug interaction checking
  • Electronic medication reconciliation
  • Clinical documentation (nursing)
  • Quality data reporting

Post-Test and Attestation
  • Thank you for completing the Safety Fair
    training. You now need to proceed to the
    post-test and attestation by clicking on the link
    below. If you have any questions, please contact
    Medical Education.
  • http//www.surveymonkey.com/s/7Y69GLR
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