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Otsego Memorial Hospital Association Corporate Overview


Title: Otsego Memorial Hospital Association Corporate Overview Author: OMH Last modified by: Ragan, Nancy Created Date: 12/17/2001 12:37:20 PM Document presentation ... – PowerPoint PPT presentation

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Title: Otsego Memorial Hospital Association Corporate Overview

Your Champion for Better Health
Otsego Memorial Hospital Association
  • OMH is owned by the OMH Association, comprised of
    members of the community who pay annual dues.
  • Established 1951
  • Non-profit Corporation
  • Governed by 10-Member Board of Directors
  • Accredited by Joint Commission, CMS

Otsego Memorial Hospital Highlights
  • Workforce 650 Employees
  • Providers 90 Affiliated including
    58 employed
  • 26 are Mid-Level Practitioners
  • Beds 46 Acute Care (Hospital)
  • 34 Long Term/Skilled (McReynolds)

Businesses within OMH Association
  • Otsego Memorial Hospital
  • McReynolds Hall
  • MedCare Walk-In Clinic
  • OMH Medical Group
  • OMH NOrthopedics
  • OMH Medical Group Lewiston
  • OMH Medical Group Indian River
  • OMH Foundation

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Mission Statement
  • To provide exceptional healthcare that meets the
    needs of our patients and the communities we
  • Our service area includes
  • Gaylord, Elmira, Wolverine, Vanderbilt,
    Johannesburg, Atlanta, Lewiston, Indian River,
    Cheboygan, Frederic and Waters.

Vision Statement
  • To be the center of northern Michigans patient
    focused alliance dedicated to healthcare

  • Respect
  • Appreciating diversity and treating all with
    compassion, dignity and courtesy
  • Show the person you are interacting with that
    they are your priority
  • Convey empathyput yourself in others shoes
  • Listen to and honor the personal, cultural and
    spiritual needs of patients and families
  • Recognize that every job is important and has

  • Integrity
  • Unwavering commitment to honesty and trust
  • Do the right thing for the right reason
  • Protect confidentiality and privacy
  • Discuss differences constructively, directly and
  • Advocate for our patients, employees and

  • Excellence
  • Teamwork and communication dedicated to
    understanding and exceeding expectations of
    quality, safety and customer service
  • Take initiative to promote a culture of
    accomplishment, enthusiasm and expertise take
    pride in your work
  • Promote an exceptional healing environment based
    on individual needs
  • Be open to giving and receiving feedback to
    accomplish mutual goals
  • Achieve the best results in all we do

  • Accountability
  • Accepting responsibility for our actions
  • See it
  • Be engaged to contribute positively
  • Acknowledge opportunities by learning from our
  • Own it
  • Understand how individual actions contribute to
    desired outcomes
  • Solve it
  • Follow through on commitments and responsibilities

Otsego Memorial Hospital Affiliates
  • OMH Auxiliary
  • A self-governed group of 150 volunteers who raise
    funds to support the mission of OMH

Otsego Memorial Hospital Partners
  • Munson Healthcare
  • Partner for services such as IT, phones and
  • Munson Home Care/Home Services
  • OMH is a small equity ownership, which we
  • must disclose when offering home care services

Customer Service
  • We want customers to think of us as the very best
    option for their healthcare

Customer Service
  • Part of our Strategic Plan
  • Why it is important ?
  • Customers share their experience
  • The following are the behaviors we ask our
    employees to exhibit

Greet People
  • Make eye contact (be aware of cultural diversity)
  • Tune the world out and them in
  • If appropriate, thank them for coming in or
    contacting you

Value People
  • Think things like
  • Youre the customer-Im here to serve you!
  • You deserve to be treated with dignity and
  • Theres something about you I value!

Ask How You Can Help
  • Ask How may I help you?
  • Find out why they came in or contacted you
  • Ask open-ended questions to further understand
    their needs.
  • Open-ended question require more than a yes
    or no answer

Listen to People
  • Listen to words
  • Listen to tone of voice
  • Listen to body language

Help People
  • Help People
  • Satisfy their wants or needs
  • Solve their problems
  • Give them extra value

Invite People
  • Invite people to have further contact
  • Thank them for choosing our organization
  • Ask them to contact you again if they need
    further help
  • Leave them with a good feeling about their
    encounter with you

Rights as a Patient
  • Patients have a right to
  • Considerate and respectful care
  • Understandable information
  • Patients will have a green dot on their ID
    bracelet if they have difficulty understanding
    basic communication
  • Please see their chart for more information
    regarding their communication challenge

Rights as a Patient
  • Patients have a right to
  • Be free from seclusion and physical/chemical
    restraint (refer to policy)
  • Consent or refuse treatment
  • Appropriate pain assessment/symptom management
    (see scale)

Pain Assessment
When assessing pain, a number value should be
assigned by the patient to make for consistent
FLACC Scale Non Verbal
  • Patients have a right to
  • Privacy
  • Treatment records are confidential
  • Review their medical records
  • Be free from discrimination
  • Discuss continuing care needed after

  • Patients have a right to
  • Know the hospital rules
  • Consult the Ethics committee
  • Know the physician who has primary responsibility
  • A second opinion
  • Advanced Directive

  • Patients have a right to
  • Be informed of outcomes of care including
    unanticipated outcomes
  • Raise concerns through a formal grievance
  • Access Protective Services

  • Patients have a right to
  • Comfort measures/peace and dignity at end of life
  • Patients who have a Do Not Rescusitate status
    will have a purple armband placed around their
  • McReynold's Hall patients have a purple dot
    placed on their identification bracelet
  • Spiritual and pastoral care
  • Appropriate screening and stabilization before
    transfer to another facility

Patient Responsibilities
  • Patients need to
  • Provide Accurate Information
  • Keep Appointments
  • Understand consequences of refusing treatment
  • Follow hospital rules
  • Be considerate of others
  • Be responsible for financial obligation
  • Notify staff of communication issues
  • Ask questions if they do not understand
  • No Alcohol, recreational drugs, or

Advance Directives
  • What are Advance Directives?
  • A legal document that gives the appointed
    advocate permission to make medical decisions
    when the patient is deemed incompetent by 2

OMH Process for Advanced Directives
  • Pt. are given information about advanced
    directives, if not familiar, at admission
  • Copies of advance directives are scanned into the
    medical record
  • Upon admission, the advance directive should be
    available to the area where the patient will be

Infection Control
  •   Washing your hands frequently and properly is
    the single most important action you can take to
    prevent the spread of infection.

Infection Control
  •   Hand Sanitizer is effective for hand hygiene
    but you should wash with soap and water if hands
    are soiled or if caring for someone with C. diff

Infection Control (Keystone Initiative)
  • Wash your hands upon entering
  • a patient-care area and upon leaving

Infection Control
  •         Standard Precautions
  • All the patients, all the time

Infection Control
  • Standard Precautions
  • Specific behaviors that healthcare workers (HCW)
    follow to protect both themselves and patients
    from infection
  • Practice 100 of the time

Infection Control
  • Apply to blood, all body fluids, excretions and
    secretions except sweat, plus non-intact skin and
    mucous membranes
  • Protect against bloodborne pathogens such as
    HIV, hepatitis B and hepatitis C
  • Protect against pathogens from moist body

Infection Control
  • Wear gloves when touching blood, body fluids,
    excretions, and contaminated surfaces
  • Wash your hands after contact with body
    substance even if gloves are worn
  • Wash your hands and change gloves between
    patients and between touching clean and dirty
    sites on the same patient
  • Wear a mask, eye protection and a gown if
    splashes or spatters are possible
  • (Latex free products are available)

Infection Control
  • Practice Respiratory Etiquette all year
  • Use mouthpieces, resuscitation or other
    ventilation devices as an alternative to mouth
    to mouth resuscitation methods
  • Be sure reusable equipment is cleaned and
    disinfected before used on another patient

Infection Control
  • Handle all patient care equipment to prevent
    exposure to other patients, visitors, and
    healthcare workers
  • Keep used patient equipment including soiled
    linens away from your skin, mucous membranes and
  • Dont let used equipment or linens contaminate
    surfaces or clean items

Sharps Safety
  • Never bend, recap, or break used needles unless
    the procedure requires it
  • Place used sharps in a designated disposable
    container immediately after use

Infection Control
  • Transmission Based Precautions
  • Additional precautions that healthcare workers
    practice when a patient is suspected of having an
    illness that spreads very easily and is based on
    how the infection is spread-

AIRBORNE Precautions
  • Requires patients to be in a negative pressure
    room and staff need to wear a PAPR (Powered Air
    Purifying Respirator)
  • Good ventilation is important for preventing the
    spread of TB
  • Active TB patients need to wear a mask if they go
    outside of the room

Exposure to Blood or Fluids
  • Wash vigorously the area immediately with soap
    and water
  • Report the exposure to the supervisor of your
  • Complete the Exposure Form
  • Report to ED for evaluation
  • If exposure to eyes, flush for 15 minutes at eye
    wash station with COLD water

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Age Specific Care
  • Be aware that all ages have different physical,
    psychological, and social needs
  • Tailor education to the patients age and needs
  • If staff and volunteers are aware
  • then it is a safer environment
  • Involve family in the care

  • Types of abuse
  • Elders
  • Physical Abuse, Neglect, Exploitation
  • Child
  • Abuse, Neglect
  • Observed or suspected
  • we are required by law to report it!

Overview of Evidence-based Practice What Is It?
  • The conscientious
  • explicit, and judicious
  • use of current best
  • evidence in decision
  • making
  • (Sackett, et al, 1997)
  • www2.uta.edu/ssw/trainasfa/glossary.htm

Evidence-based Practice Example- Clinical
  • Condition
  • Central Line-Associated
  • Bloodstream Infections are
  • a serious complication in
  • hospitals across the nation
  • and may cause increased
  • length of stay, increased
  • cost and risk of mortality.
  • Research Summary
  • To reduce the incidence of
  • blood stream infections
  • Use appropriate hand hygiene
  • Chlorhexidine for skin
  • preparation
  • Full barrier precautions during insertion
  • The subclavian vein as the preferred site.

Quality and Safety Research Group, Johns Hopkins
University, Revised 1.14.05
Evidence-based Practice Regulations
  • Centers for Medicare
  • and Medicaid Services
  • Michigan Department of
  • Consumers Industry Services
  • Joint Commission
  • Agencies that survey
  • healthcare organizations expect
  • compliance with all rules and
  • regulations proven to provide safe,
  • quality care.

Evidence-based Practice Reimbursement
  • Healthcare reimbursement is
  • in a transitional phase and
  • Pay for Performance or
  • Value Based Purchasing
  • requires hospitals to submit
  • data which reveals how well
  • they comply with evidence-
  • based standards of care.
  • It pays to provide quality care!

Patient Safety A National Issue
  • In an effort to prevent medical errors for all
    patients in the healthcare setting, the Joint
    Commission issues annual National Patient Safety
  • National Patient Safety Goals are developed as
    medical errors that occur across the nation are
    analyzed and the root causes identified

How National Patient Safety Goals affect your
  • Your understanding and compliance with the
    National Patient Safety Goals and hospital policy
    is vital to our patients safety and your success
    at OMH

Goal 1 Improve the Accuracy of
Patient/resident/client Identification.
  • To prevent medical errors, a patient must be
    identified by comparing two types of identifiers
  • According to OMH policy, the two patient
    identifiers include the patients name and date of
    birth found in the medical record documents and
    on the identification bracelet

Implementation Expectations 1A Use at least two
patient identifiers whenever
  • Collecting lab samples
  • Administering medications or blood products
  • Providing any treatment or procedure
  • Label sample collection containers in the
    presence of the patient.

1B Implement the Universal Protocol for
Invasive Procedures
  • The time out final verification process to
    confirm the correct patient, procedure, site, and
    availability of documents and equipment must
    occur in the location where the procedure is to
    be done and should involve the entire team

Goal 2 Improve Effectiveness of Communication
  • 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 order or test result write
    down then read back the complete order or test

2B Standardize a list of abbreviations,
acronyms, and symbols that are not to be used
throughout the organization
  • The Do Not Use abbreviation list applies to
    all orders and other medication-related
    documentation when handwritten, entered as free
    text into a computer, or on pre-printed forms

The Official OMH Do Not Use List Includes
Do Not Use Write this Instead
Trailing Zero (1.0) 1mg
Lack of leading zero 0.5mg
U, u, IU, or iu Units or international units
q.d., QD, Q.D., Q.O.D. Daily or every other day
MS, MS04, MgS04 Morphine or Magnesium Sulfate
2E Hand Off Communication
  • Implement a standardized approach to hand
    off communications, including an opportunity to
    ask and respond to questions

Implementation Expectations
  • In health care there are numerous types of hand
    offs, including but not limited to
  • Nursing shift changes
  • Physicians transferring complete responsibility
    for a patient
  • Physicians transferring on call responsibility

Implementation Expectations
  • Temporary responsibility for staff leaving the
    unit for a short time
  • Anesthesiologist report to post anesthesia
    recovery room nurse
  • Nursing and physician hand off from the emergency
    department to inpatient units, different
    hospitals, nursing homes and home health care
  • Critical lab and radiology results sent to
    physician offices

Hand-offs Must Allow Time for Questions and
  • The Joint Commission wants to know how
    physicians and staff who work at OMH communicate
    a hand off of patient care
  • Institute for Healthcare Improvement
  • SBAR

  • Example
  • SAdmitted an 82 year old with pneumonia,
    possible aspiration.
  • BHistory of stroke, has been having increased
    cough x 3 weeks per family, fever began today..
  • ARR is 24 and unlabored, temp is 101 degrees F,
    swallowing evaluation ordered for a.m., alert and
    oriented x2. First antibiotic completed at 0300.
  • RKeep HOB elevated at least 30 degrees, remain
    NPO until swallowing sturdy complete and
    recommendations added to care plan. Next
    antibiotic is due at 0900. Additional assessment
    and care plan includes patient is a high risk for
    falls, bed alarm on and frequent rounds to assist
    with toileting needs.
  • SSituation
  • BBackground
  • AAssessment
  • RRecommendation
  • Any Questions?

3B Standardize and Limit the Number of Drug
Concentrations Available in the Organization
  • OMH Pharmacy stocks limited concentrations and
    performs quality control monitoring of the crash
    carts for standardization of drug concentrations
    according to PALS and ACLS

3C Identify and, at a minimum, annually review
a list of look-alike/sound alike drugs used in
the organization and take action to prevent
errors involving the interchange of these drugs.
  • OMH has an on-line formulary which contains
    the list of look alike/sound alike medications
    and the Pharmacy Therapeutics Committee
    provides oversight to the annual review

  • Label all medications, medication containers,
    (e.g., syringes, medicine cups, basins), or other
    solutions on and off the sterile field in
    perioperative and other procedural settings

Implementation Expectations
  • All labels are verified both verbally and
    visually by two qualified individuals.
  • No more than one medication is labeled at one
  • Unlabeled medications or solutions are discarded.
  • All original containers remain available for
    reference in the perioperative area until the
    conclusion of the procedure.
  • At shift change/break, all medications and
    solutions both on and off the sterile field are
    reviewed by entering and exiting personnel.

Goal 3
Reduce patient harm associated with
anticoagulation therapy
Goal 4 Eliminate Wrong-site, Wrong Patient,
Wrong Procedure Surgery.
  • Create and use a preoperative verification
    process such as a checklist to confirm that
    appropriate documents are available

Goal 4B Implement a Process to Mark the Surgical
Site and Involve the Patient in the Marking
  • Marking is required in all cases involving
    right/left distinction, multiple structures or
    levels of the spine.
  • Procedures done through a midline incision
    intended for a right/left distinction are subject
    to site marking.
  • YES

Goal 7 Reduce the Risk of Health Care Associated
  • Compliance with the CDC hand hygiene guidelines
    will reduce the transmission of infectious agents
    by staff to patients/clients/residents, thereby
    decreasing the incidence of healthcare associated
    infections (HAI)

Goal 7C MDRO
  • Prevent healthcareassociated infections due to
    multidrug-resistant organisms
  • Hand Hygiene
  • Infection prevention and control
  • Flag charts and communicate information to staff
    regarding patients known toe be infected with
  • Educate staff and patients on prevention
  • Careful use of antimicrobials
  • Clean, disinfect, and sterilize appropriately
  • De-colonize persons with specific MDRO

Goal 8 Accurately and Completely Reconcile
Medications Across the Continuum of Care.
  • Implement a process for obtaining and documenting
    a complete list of the patient/resident/clients
    current medications upon the patient/resident/clie
    nts admission/entry to the organization and with
    the involvement of the patient/resident/client.
  • A complete list of the patient/resident/clients
    medication is communicated to the next provider
    of service when a patient/resident/client is
    referred or transferred to another setting,
    service, practitioner, or level of care within or
    outside the organization.

Goal 9 Reduce the Risk of Patient/resident/client
Harm Resulting From Falls
  • Implement a fall reduction program and evaluate
    the effectiveness of the program
  • Use the Fall Risk Assessment

Goal 13
  • Define and communicate the means for patients and
    families to report concerns about safety and
    encourage them to do so
  • Encourage patients' active involvement in their
    own care as a patient safety strategy

Goal 15A
The organization identifies safety risks inherent
in its patient population
Goal 15A The organization identifies patients
at risk for suicide
Suicide Risk Assessment
Suicide Risk Assessment is found Hospital
Information Page Forms Nursing
Goal 16
Improve recognition and responses to changes in a
patients condition Rapid Response Team To
implement early intervention and prevent deaths
in patients, outside of the ICU, who are
progressively failing
Rapid Response Team
  • Team consists of critical care nurses,
    respiratory therapists and primary care nurse.
  • The rapid assessment team may be called at any
    time by anyone in the hospital to assist in the
    care of a patient who appears acutely ill or who
    shows signs of decline.
  • Team assists patients nurse in assessing
    condition and provides support in communicating
    findings to patients physician.

OMH Patient Safety Plan
  • Purpose
  • To reduce risk to patients through an
    environment that encourages
  • Recognition and acknowledgement of risks to
    patient safety and healthcare errors
  • Actions to reduce risks
  • Internal reporting
  • Focus on systems/processes, minimizing individual
  • Learning from errors

Reporting a Medical/Safety Occurrence
  • Report the occurrence to the charge nurse and
    complete an Occurrence Form
  • Examples
  • Medication error
  • Patient fall
  • Needle stick
  • Treatment error

Reporting an Employee Incidence
  • If something happens to an employee,
    they use an Employee Incident Form

Variance Report
  • This form is used to report near misses, safety
    concerns, and quality concerns
  • It can be submitted anonymously

Variance Report
  • What is a near miss?
  • Any unintended provision of care which could have
    constituted a medical occurrence but was
    intercepted before it actually reached the
  • By reporting near misses we can help avoid errors
    from occurring

Sentinel Event
  • A Sentinel Event is
  • An unexpected event that is serious and sends
    a warning that requires immediate attention.
  • We must complete a root cause analysis (RCA)
    after a sentinel event or near miss that could
    have resulted in a sentinel event.

Sentinel Event or HFMEA ?
HFMEA is Healthcare Failure Mode Effects
Analysis A systematic approach to identify and
prevent product and process problems before they

C.U.S.P. Comprehensive Unit Safety Program
  • Tapping The Wisdom of The Frontline
  • Create and maintain a culture of safety and
    quality throughout the campus.
  • 98,000 patients are harmed each year because of
    medical errors caused by healthcare defects.

Corporate Compliance
  • The purpose of a Corporate Compliance Plan is to
    prevent, detect and/or respond to violations of
    statutes and regulations dealing with such things
    as fraud and abuse

Corporate Compliance
  • Suspected corporate compliance violations are to
    be reported via the Corporate Compliance Hotline
    at x 17720 or by completing a Compliance
    Violation Report

You Are Valuable to OMH and Our Patients
  • Your knowledge and compliance is vital to our
    patients safety
  • Hospital policies and procedures
  • National Patient Safety Goals
  • Reporting occurrences and concerns

Reporting a Concern
  • Please contact the Patient Safety and Corporate
    Compliance Officer,
  • Bonnie Byram
  • at 731-7703

Performance Improvement
  • Otsego Memorial Hospital is committed to
    providing quality care to the patients we serve.
    The Performance Improvement Plan outlines the
    systematic approach the organization takes
    towards continuous quality improvement.
  • Plan Do Check Act

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Professional Work Environment
  • Professional Work Environment
  • Everyone has the right to be treated with dignity
    and respect
  • Prohibited Conduct
  • Sexual Harassment
  • Hostile Work Environment
  • Report to CEO or HR Director

Professional Work Environment
  • Prohibited Conduct
  • Crude or offensive language, sounds, innuendoes
    or jokes, whether communicated verbally, by
    electronic mail or otherwise relating to race,
    color, religion, national origin, sex, age,
    height, weight, marital status, disability or
    other protected classification

Professional Work Environment
  • Prohibited Conduct
  • The display of sexually suggestive or otherwise
    offensive objects, pictures, letters, gestures,
    or graffiti relating to race, color, religion,
    national origin, sex, age, height, weight,
    marital status, disability or other protected

Professional Work Environment
  • Prohibited Conduct
  • Unwanted sexual advances, including offensive
    touching, pinching, brushing the body, or
    impeding or blocking movement.

Code of Conduct
  • The Hospitals Board of Directors has established
    a Code of Conduct Policy that applies to all who
    work in the Hospital. A procedure has been
    established for reporting violations of this
    policy. Please refer to the full text of the
    policy available online to report a violation.

Code of Conduct
  • Acceptable Conduct
  • The policy defines Acceptable Conduct as conduct
    that is professional and cooperative and that
    positively affects the ability, or could affect
    the ability, of Hospital employees or physicians
    to perform their jobs

Code of Conduct
  • Disruptive Conduct
  • The policy defines Disruptive Conduct as conduct
    that is demeaning, abusive, intimidating,
    threatening or insulting and that adversely
    affects, or could affect, the ability of Hospital
    employees or physician to perform their jobs

Environmental Safety Awareness
  • Any time an emergency alarm or Code is
    paged, plan to remain with the patients until
    instructed otherwise by hospital staff.
  • Should evacuation become necessary, you will
    be instructed in specific actions to ensure
    personal safety of the patient and yourself.

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OMH Codes
  • To announce an emergency an overhead paging
    system is in place
  • Dial 477
  • Speak Slowly, Loudly Clearly
  • Room numbers posted in each room

OMH Codes
  • Code Red Fire
  • OMH Code Red Policy
  • Doors are numbered and lettered for Fire
  • H hospital
  • M McReynolds
  • P - PMB

OMH Codes
  • Code Red
  • Return to your work area, if safe
  • Do not use elevators
  • Feel doors, do not open if hot
  • Close all doors windows
  • Clear corridors and exits
  • Assign staff to answer phones

OMH Codes
  • Code Red Response
  • R Remove persons from area
  • A Activate fire alarm
  • C Contain fire and smoke
  • E Extinguish fire or evacuate
  • Fire Extinguisher use
  • P Pull the pin
  • A Aim toward the base of the fire
  • S Squeeze the handle
  • S Sweep the base of the fire

OMH Codes
  • Code Blue
  • Cardiac Arrest
  • Near Arrest
  • Activation
  • Code Blue Buttons
  • Page Overhead 477
  • Signs near patient beds
  • Response
  • BLS - ALS (on arrival of cart)
  • ICU Nurse
  • Respiratory Therapist
  • ED Nurse
  • Physicians

OMH Codes
  • Code Yellow
  • Bomb or Bomb Threat
  • If receiving the call.
  • Page Code Yellow Location
  • Check area for packages, report anything
    suspicious, but do not touch!
  • Incident Commander will determine the need for

OMH Codes
  • Code Grey
  • Security Situation/Potential for violence
  • Page overhead 3 times with location
  • Code Grey Assist
  • Code Grey 911
  • All available personnel go to area
  • Show of force
  • When to call for help . Signs of agitation

OMH Codes
  • Code Pink
  • Missing Person/Possible Abduction
  • Page Code Pink, Gender, Age, Department
  • Observe exits and parking lots
  • Search your department
  • Observe and be able to describe all persons
  • Do not attempt to detain persons

OMH Codes
  • Code Silver
  • If you are confronted by an individual with a
    weapon OR
  • If you observe a hostage situation on Hospital

Initiating Code Silver Plan
  • Seek cover and discretely warn others (close by)
    of the situation
  • Dial O- Report the location, number of
    suspects/hostages, type of weapons
  • Operator will dial 911
  • Operator will page Code Silver location 3

Workplace Violence
  • Healthcare and social service workers face an
    increased risk of work-related assaults
  • If threat is imminent, call Code Grey Assist or
    Code Grey 911

Workplace Violence
  • OMH has Zero Tolerance towards all expressions
    of violence.
  • Individuals who commit such acts may be removed
    from the premises and may be subject to criminal

OMH Codes
  • Code Triage
  • Shift Coordinator in area or department impacted
    will declare Code Triage
  • Any event that impacts or has high potential to
    impact normal operations of the facility
  • Code Triage Internal
  • Code Triage Standby
  • Code Triage External

OMH Codes
  • Code Triage Responsibilities
  • Return to department
  • Phones for disaster business only
  • Management will implement HICS
  • Hospital Wide Disaster Plan
  • Department-Specific Plan

OMH Codes
  • Severe Weather
  • Emergency Department has weather alert radio
  • ED also notified by MI State Police Dispatch
  • ED Shift Coordinator will announce warnings
  • Return to your department
  • Non-clinical employees go to basement
  • Prepare for evacuation if ordered

Hospital Incident Command System (HICS)
  • Chain of command for decision and communication
  • Semi-defined roles
  • All staff respond to only one individual (upward)
  • All supervisors manage 5-7 people
  • (in command structure)
  • HICS implemented in all codes
  • Your manager may have additional responsibilities

Environment of Care
We have 7 plans in place to assure the safety of
our patients and our staff Plan 1 Biomedical
Equipment Management Plan 2 Emergency
Preparedness Management Plan 3 Life safety
Management Plan 4 Hazardous Material and Waste
Management Plan 5 Utility systems
Management Plan 6 Security Management Plan 7
Safety Management
Chemical Hazards Right To Know
  • Employees have the right to know how to keep
    themselves safe on the job
  • MSDS-material safety data sheets available online
    (Web link in the Hospital Information)
  • Use of eyewash station-flush for 15 minutes with
    COLD water
  • Know where eye wash stations are located. Eye
    wash stations are checked daily

MRI Safety (Magnetic Resonance Imaging)
MRI Safety (Magnetic Resonance Imaging)
  • All employees need orientation in magnet safety
  • Large metal objects of any kind shall not be
    permitted in the scan room until they are checked
    for ferromagnetism. Magnetic items should be
    kept out of the room at all times
  • All items will be tested with a hand held magnet
    and found not to be attracted to the magnet
    before being permitted in the Magnet/Scan Room
  • Do not enter room for Code Blue-patient will be
    brought out to the hallway!
  • Hearing protection required for patients

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  • Our goal is to use this science of ergonomics to
    reduce work-related Musculoskeletal disorders
  • Everyone, not only those involved in direct
    patient care, needs to have training in proper
    body mechanics

Musculoskeletal Disorders
  • MSDs include disorders of the muscles, nerves,
    tendons, ligaments, joints, cartilage, blood
    vessels or spinal discs
  • Be aware that risk factors related to MSDs
    include movements that result in repetition,
    force, awkward postures, contact stress, and

Comfort and Care at the End of Life
The Purpose of End of Life Care is to create an
environment to support a death, which is
satisfactory to the patient and the family and is
respectful of and responsive to individual
preferences, culture, needs, and values while
ensuring that patient/family guide all clinical
decisions. Focus on comfort, dignity and quality
of life. Virginia Page,MSN,RN,NP Henry Ford
Hospital Please see our policy Code MCR.h.05
Comfort and Care at the End of Life
  • Managing symptoms is the goal
  • Fear of addiction can be a barrier to effective
    pain management
  • Even if patients are not responsive, always
    explain care/treatment

Organ and Tissue Donation
  • Gift of Life-we do participate!
  • Organ procurement done in OR
  • Tissues procurement can be done at hospital or
    funeral home

Gift of Life
  • Hospital required to call all imminent deaths to
    Transplantation Society of Michigan
  • Persons over 75 years of age can be organ/tissue
  • Persons with HIV or Hep B can be organ donors
  • Bev Cherwinski, Support Group

Cultural Competence
  • Treat every patient as an individual
  • Communicate respect
  • Language issues-seek translation if needed
  • Be aware of non-verbal communication

Infant Abandonment
  • Michigan law states that a parent or adult can
    surrender a newborn up to 72 hours old
  • We must accept the newborn
  • Call Birthing Center
  • Do not press for information

  • The HIPAA Privacy Rule protects a patients
    fundamental right to privacy and confidentiality
  • ANY information obtained about another persons
    medical condition is treated as confidential and
    is not to be discussed or revealed to
    unauthorized persons

  • Protected Health Information is anything that
    connects a patient to his or her health
    information Date of Birth, SS, diagnosis,
    address, etc.

  • HIPAAs focus is on the rights of the patient and
    the confidentiality of their information.
  • Patients have the right to
  • Request an amendment of their medical record
  • Request to inspect and copy their record
  • Restrict what information is shared
  • Receive confidential communication
  • Complain about a disclosure of their information

Ethics Committee
  • OMH has an Ethics Committee that is consists of a
    diverse group of members including
  • Providers
  • Licensed professionals
  • Frontline staff
  • Community members
  • Anyone staff member can make a referral to the
    Ethics Committee

Appropriate Ethics Referrals
  • A staff members belief system is in conflict
    with a patients treatment plan.
  • A family/patient is in conflict with the proposed
  • Resource allocation
  • Revising/updating policies/practices with ethical
  • Offering support for clinical or medical issues
    with ethical implications.

Medical Record Documentation
  • The purpose of medical record documentation
  • To record complete and accurate clinical
  • To communicate with other members of the
    healthcare team
  • To comply with legal, regulatory and
    accreditation requirements
  • To ensure adequate reimbursement
  • Documentation that has missing information
    (time,date), misspelled words, unapproved
    abbreviations and policy variances (R.A.W.) could
    be interpreted as an indication of substandard

Impaired Health Professional
  • If someone comes to work and seems unable to do
    their job due to impairment because of alcohol,
    drug use or mental illness-we must report it
    immediately to the Administrator-on-call.
  • The call schedule is in the Hospital Information

  • Any questions about this information can be
    directed to the HR Department, instructor or your
    department director.

The End
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