2009 - 2010 Safety Fair House Staff Edition. Overview What is Safety Fair? All hospitals are required to provide annual reviews of safety and quality

2009 - 2010 Safety Fair

House Staff Edition

Overview

What is Safety Fair? All hospitals are required to provide annual reviews of

safety and quality information for all employees. At GCH, this is called “Safety Fair.”

This presentation has been customized from the GCH Safety Fair material to provide information most relevant to house staff

What’s new this year? GCH is preparing for its annual AOA-HFAP* accreditation

survey. This is a three-day site visit anticipated to occur in early 2010.

Information relevant to our accreditation standards and to quality and safety has been compiled in a Safety and Survey Handbook. Copies have been distributed to your mailbox in the House Staff Lounge. House staff who are out-of-state may request a Handbook by mail.(*Healthcare Facilities Accreditation Program)

Safety and Survey Handbook

Check your mailbox in the House Staff Lounge for your copy of the Safety and Survey Handbook.

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.

2 in your Handbook

Safety and Survey Handbook

Look for these symbols: “” Means this section if

critical for HFAP accreditation “” 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 presentation.

To meet your Safety Fair requirement

Option 1: View this presentation online Complete the online quiz by November 15, 2009

Option 2: Attend a Safety Fair session – dates and times are

posted and have been sent by email.

Part I:Healthcare Facilities

Accreditation Program (HFAP)

Anticipated Survey: Jan-March 2010

4 in your Handbook

HFAP inspection: Keys for House Staff

The HFAP inspection will evaluate patient care, facilities, policies, etc.

anything and everything related to running a hospital. Key issues for all

physicians and house staff are listed below.

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). Now is the time to get your charts in order and maintain compliance.

H&P’s Must be documented within 24 hours of admission Must be complete, including osteopathic structural exam (OSE)

Orders and Progress Notes Must include date and TIME! Must be signed – including telephone orders Include printed name and pager number Legible!

4 in your Handbook

HFAP inspection: Keys for House Staff

Key issues for all physicians and house staff, continued Informed Consent

Must include all required elements: Date and TIME Signature of patient, person obtaining consent,

and witness Restraint Orders

Required for all patients Must be completed according to policy (more on

this later in this presentation)

4 in your Handbook

Interacting with Surveyors and Inspectors

Be friendly, helpful, and honest.

Answer the question asked, then stop! Don’t volunteer additional information, thoughts or concerns.

Focus on the positive – describe what we do, not what we don’t.

Refer to your handbook if you need to.

Ask for the question to be re-stated or said differently if you don’t understand it.

5-6 in your Handbook

Patient Rights and Responsibilities

These apply to every patient. A list of patient rights and responsibilities may be

found in your handbook. They are also posted throughout the hospital and given to patients.

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


Patient Satisfaction

GCH measures patient satisfaction for all inpatient and

outpatient encounters. All employees need to know:

How do we measure patient satisfaction? Our satisfaction survey is conducted by the

NRC Picker company. Patients receive a survey in the mail.

How do we make improvements in patient satisfaction? We call our satisfaction effort C2E or

Commitment to Excellence Specific tools used include AIDET (described on

next slides)


AIDET

AA AcknowledgeAcknowledge

II IntroduceIntroduceDD DurationDuration

EE ExplanationExplanationTT Thank YouThank You

AIDET is a proven tool to facilitate respectful and effective communication during a patient encounter.

Use of AIDET has been shown to improve patient satisfaction. House staff are to utilize this approach when interacting with patients.

A = Acknowledge

AA AcknowledgeAcknowledgeThe The

MinimuMinimumm

Knock Greet person by name – “Hello Mr. Smith” Ask permission to enter roomMake eye contact

The The Next Next LevelLevel

Greet with a smile Acknowledge others in roomAcknowledge privacy

I = Introduce

II IntroduceIntroduceThe The

MinimuMinimumm

Give your name Indicate your role“I’m Dr. Jones – I’m a resident working with Dr. Doe”


Describe why you are here Describe your skill sets – make people Acknowledge other in the team“I am here because Dr. Doe has asked me to insert a central line. I’ve got lots of experience doing this and it should not be uncomfortable for you.”

D = Duration

DD DurationDurationThe The

MinimuMinimumm

Give an accurate time expectation (or your best estimate) for when things will happen or how long they will take“The procedure will probably take about 15-20 minutes. I’ll need a few minutes to get everything ready then I’ll be back.”


Over-deliver on times - give an expectation that can be met Think of the patient/family perception of how long something will take Apologize for delays

E = Explain

EE ExplainExplainThe The

MinimuMinimumm

Provide an explanation for your questions, physical exam, tests, procedures, new medications, etc. Let the patient ask questions

“We need this special IV to give you the medication you need.”


Discuss with family on patient’s request Defer to attending if there are questions you can’t answer“I’m not sure but I’ll discuss that with Dr. Doe and we’ll answer that question when we see you on rounds later today.”

T = Thank

TT ThankThankThe The

MinimuMinimumm

Say “thank you” when you have finished the encounter – for their time, cooperation, etc.

“Thanks for your patience. Let us know if you need anything else.”


Thank the patient for using Garden City Hospital Thank the family for their assistance/support


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 www.hospitalcompare.hhs.gov.



House staff should be aware of the HCAHPS satisfactionmeasurements relevant to physicians. As you are often on

the frontline of patient care, your interactions with patients are

reflected inthese 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?


Part II:Patient & Environmental

Safety

11 in your Handbook

What is Patient Safety?

The prevention of harm to patients using a system that… Prevents errors Learns from errors that

do occur Is built on a culture of

safety that involves health care professionals, organizations, and patients


GCH Patient Safety Initiatives

Hospital wide initiatives Patient Safety Rounds – Talking to employees Environmental Rounds – Visual inspection Purchase of New Beds – To reduce fall rates Medication Administration:

New Medication Reconciliation Form Bedside Bar Coding for Medication Administration

New Surgical Center Pressure Ulcer Team Falls Team Moving towards Electronic Medical Record


GCH Patient Safety Initiatives

Examples of Medical Education initiatives - enter in your handbook on page 12

Rapid Response Team Code Blue Peer Review Forms Feedback on use of standard orders unauthorized abbreviations, etc.


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)


What is Environmental Safety?

Oxygen safety Spill safety Hazardous chemicals safety Electrical safety Medical device safety Emergency Preparedness Sharps safety Infection Control

12 in your Handbook

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.


Hazardous Materials/Spill Safety

The basic elements— Hazardous chemicals are present in

virtually all areas 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


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

Spills

If you find it – make sure it is cleaned up! Clean up simple spills (see the table in

your handbook on page 15) Communicate spill hazards Report contaminated or large chemical

spills by calling the operator and asking for Security or the Housekeeping Supervisor

Learn about proper disposal for different medical wastes (handbook page 17)

15,17 in your Handbook

Electrical Safety Basics

Make sure that all equipment has a grounded plug

Don’t overload outlets

Don’t use damaged equipment

16,18 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/employeeSecure the device – do not change

settingsContact Biomed (x2829) and Risk

Management (x3403) EXAMPLE: malfunctioning defibrillator; vent

that didn’t alarm Contact Biomed


Baxter Infusion Pumps

Keep It GREEN, Plug it in! Keep the pump plugged in at all times when

not transporting Ensure GREEN PLUG icon is illuminated next to

the on/off button Prior to transport, always check the Battery

Charge Level icon See instructions in your handbook, page 20

20 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 BLACK: severe weather/tornado

warning Code TRIAGE: disaster (internal or

external) (has replaced Code Yellow)

Code ALPHA: administrative team alert

Code RED: Fire Alarm Signal

Code RED page and/or alarm can occur in response to: A phone report of smoke or fire An alarm “pull” An automatic smoke detector signal

21 in your Handbook

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

instructions DO move patients and visitors to behind fire

doors 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

21 in your Handbook

Fire Response: R.A.C.E.

A fire marshal or inspector may ask you how you would

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 3333 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

21 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

21 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.


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.

Wait for all-clear message.

26 in your Handbook

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

26 in your Handbook

Code TRIAGE – Disaster

Code TRIAGE is the signal for an internal or external disaster. (Note: This was previously called Code Yellow.)

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 28 of your handbook.

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.


Code TRIAGE – DisasterHouse Staff Actions

HOUSE STAFFDEPT/ASSIGNMENT

ACTION IN THE EVENT OF CODE TRIAGE

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 areaIf 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

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


Weapons of Mass Destruction

“WMDs” include: Chemical Biological Radiation Nuclear weapon Explosives

28 in your Handbook

WMD: Scenarios & Factors

WMD incidents could result in two primary scenarios: 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

radiation


WMD: Hospital Preparation

GCH has prepared for contaminated victims through… 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

29 in your Handbook

Part IV: Preventing Illnesses and Injuries on the Job

30 in your Handbook

Hand Washing

The single most important procedure for preventing infections for Patients Co-workers Yourself

Review proper techniques Page 30 of your handbook

Wash your hands before and after examining patients – they expect this and will notice if you don’t!


Influenza

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 ill

Even if you have never had the vaccine or felt you were ill with flu, you may still be a carrier infecting— Patients Family Co-workers

Save lives, get vaccinated!

31 in your Handbook

Blood Borne Pathogens (BBP)

BBP’s 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.

31 in your Handbook

Blood Borne Pathogens (BBP)

To protect yourself against BBP: Follow STANDARD PRECAUTIONS Minimize/control splashing of fluids Use appropriate Personal Protective Equipment Practice good sharps safety Cover cuts and scrapes Don’t 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.

31 in your Handbook

Sharps Safety

NEVER re-cap a needle. Count sharps before

and after procedures. Properly dispose of

sharps. Change sharps

containers that are 3/4 or more full. (Contact Environmental Services)

Use safety devices when available.


Sharps Safety

DO NOT PUT SHARPS ON The patients’ bed or linens Bedside stand or over-bed table Food tray Floor IV pump


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 NEW 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 protocol.


Tuberculosis

In 2007 over 12,700 new tuberculosis (TB) cases were reported in the U.S.

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 patient’s room

32 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 through Pyxis but you must know your size.

32 in your Handbook

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.

Lifting Do’s and Don'ts

Don’t 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


Part V: Quality

35 in your Handbook

Quality Management Essentials

Goals of QM are to improve… Work processes Outcomes Clinical care Efficiency Customer satisfaction Hospital market share

35 in your Handbook

Selected Quality Initiatives

Current organization-wide quality/patient safety initiatives… Heart Failure Surgical Infection Prevention Acute MI Pneumonia Patient Safety ICU Keystone Surgery Keystone

37 in your Handbook

A Question of Quality

Quality affects reimbursement because… If a patient develops an infection or a

pressure ulcer or falls while in the hospital – the insurance provider will not pay for continued care related to those problems

If you suspect an issue involving quality of care… Report it immediately to you supervisor

37 in your Handbook

Your role in selected quality initiatives

For Heart Failure, Acute MI, and Pneumonia:

USE THE STANDARD ORDER SETS!

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 efforts.

Heart Failure Initiative

GCH is seeking to improve its performance on Heart Failure quality measures. House staff need to remember to: Use the standard order set Prescribe and ACE-inhibitor or ARB; if

contraindicated, document this and state reason (e.g. “ACEI/ARB not prescribed due to renal insufficiency”)

Complete the discharge instructions properly. MUST REWRITE names and doses of all

medicationsDO NOT write “resume home meds”

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 hospital.

It is critical that conditions that are present on admission (“POA”) be documented on the H&P or admitting progress note.

Key conditions include: Decubitus ulcers – document stage Infections, e.g. UTI, pneumonia

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 relatively new process which seeks to reduce errors at those points.


On admission: A record of home medications will be made

and will serve as the “source of truth” A physician (house staff or attending) will

review the meds and sign the form When completing the H&P, state “see med

reconciliation form” for home meds When writing admitting orders, decisions will

still be made regarding continuation of home meds

The form will be used again at discharge to document instructions for prior meds as well as any new prescriptions


On transfers and after surgery: An order form listing most recent inpatient

medications will be printed A physician (house staff or attending) will

review the meds and circle “continue”, “discontinue” or change

This will eliminate the need to rewrite all medications and doses by hand

It is not permitted to write “resume prior meds” after surgery

Part VII: Privacy and Compliance

40 in your Handbook

Definitions: HIPAA and PHI

Patient procedures and any medical records that are generated are protected under HIPAA (Health Insurance Portability and Accountability Act - 1996)

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, etc.


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 patient’s care. Avoid discussions in public areas (e.g. corridors, the cafeteria, etc.

All documents with PHI (including documents copied from patient records, patient lists, copies of dictations, etc.) MUST be disposed of in the locked recycling bins. These documents cannot be


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

access 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 IRB.

These guidelines apply to out-rotations as well


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 sent

Unless it is for a physician consultation, the patient must first sign a HIPAA authorization to release the information


Prevent Unauthorized Data Access

You are responsible for access under your password! Do not share passwords with others! LOG OUT when you are done! You are responsible for unauthorized

access that occurs under your password! Change Passwords Frequently

Passwords should be constructed so they cannot be easily guessed

At least 8 characters in length Can include UPPER and lower case

letters and incorporate punctuation marks to make them more secure


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 –

Lisa Sielski at Ext. 4428 Or Call the Compliance Hotline at 734-458-

4298 to make a confidential report


Other Compliance Matters

Only document and bill for services/procedures that “you actually performed”

Use the correct patient’s name and identifying numbers when accessing Pyxis or running EKG’s or other tests

Never accept any gifts or kickbacks from vendors or suppliers

Never offer gifts or kickbacks to vendors or suppliers

Contact Medical Education for information on applications for educational grants


Responding to Complaints

First steps Listen carefully Apologize (I’m 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

Special steps are needed for grievances (handbook page 43)


Safety Alert/Fall Risk Program

Patients with potential for falling have… A yellow Fall Risk ID wristband YELLOW Safety Alert Signs

All staff should… All staff train themselves to listen for bed alarm Respond to bed alarms Stay with patient while calling for additional

assistance All staff should, upon seeing a safety alert sign or

yellow wristband anywhere in the hospital… Make sure patient not trying to get out of bed Smile (when observing patients) Greet patient (show them you care)


Safety Alert, contd.

If a patient 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 “Don’t get out of bed”.

Communication of Fall Risk is essential between caregivers, shifts, and departments Magnetic “Safety Alert” card is placed on the

doorframe outside of the patient room At shift change report When patients are transported to other

departments


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

YELLOWYELLOW Fall RiskPURPLE DNR (Do Not

Resuscitate)

ORANGEORANGE MastectomyWHITE Patient ID

CLEAR CLEAR THINTHIN

Pediatric

TYPENEX Blood Bank


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

quarterly. 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

48 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 stay Use the objective 10 point pain scale to assess pain Pain management is a collaborative effort of…

Physicians Nurses Pharmacists Others

Pain control includes… Medications Noninvasive measures including: distraction technique,

cutaneous stimulation, relaxation techniques and position changes


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


Restraints

Restraints are used only when alternative measures have been tried and are ineffective

The best alternative measure is family Patients are more comfortable and relaxed with

family Restraints include

Full Side rails Mitts Soft Wrist Soft Ankle Vest Physical Hold Physical Escort Lock and Key


Restraint Orders Must Indicate…

Behavior Restraints

Violent/self destructive behavior

Requires physician order and assessment

Order good for 4 hours for adult, 2 hours for child

15 minute monitoring Hourly assessments Removed at the

earliest possible time

OR…

Medical Restraints Patient is disrupting

treatment Requires physician order

and assessment Order good for 24 hours

Hourly monitoring Assessment every 2

hours Removed at the earliest

possible time

(More detail in your handbook)

52 in your Handbook

Hospital Leadership

Chief Executive Officer (CEO) – Gary Ley V.P. Operations (CAO) – Art Greenlee V.P. Chief Finance Officer (CFO) – Dan Babb V.P. Medical Admin. (CMO) – Gary Moorman,

D.O. V.P. Chief Nursing Officer (CNO) –Debra Williams V.P. Human Resources, Steve Solomon V.P. Medical Education, Kirsten Waarala, D.O.

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

64 in your Handbook

Part VIII: 2008 – 2009In Review


Quality Care Awards

5th consecutive year awarded Governor’s Quality Award (4 different awards)

Selected to Participate in National Quality Improvement Collaborative


Corporate Awards

Ranked #31 in the nation and highest in Southeast Michigan, as a “Best Places to Work” by Modern Healthcare

Recognized by the American Heart Association with National Gold Achievement Award, designating Garden City Hospital as a “fit friendly” company

101 Best and Brightest companies 6 years running


What’s New

Hospital Wound Care Expansion (new treatment

rooms) Sports Medicine Practice at WestlandMed Ed Approved for fellowships in

Gastroenterology and Nephrology (to begin in 2010)

Application in process for Sports Medicine Fellowship


Patient and Visitor Satisfaction

Introduced The Patient and Family Advisory Council

New Patient Information EnvelopeNew patient mattresses installed in

every inpatient roomPatient pay processes upgraded:

Enhanced assistance for Medicaid-eligible patients

Introduced self-pay discounts Enabled point-of service payment


In Our Community

MHA Food DriveHalloween Party GrowsSantaland ParadeHeart WalkFor Med EdCommunity service opportunities

include educational presentations, participation in health fairs, etc.


In Our Facility

Nursing floor renovations continue: Underway

2 Center & 2 North

Complete3 East3 Center3 West2 WestCentral monitoring

relocated to lower level


New Technology

Improvements in radiology workflow with AMICAS

iDoc - Health Information Archival & Retrieval System

Emergency Department Invests in the highly advanced CAREpoint EMS Workstation

Implemented Emergisoft’s CCHIT Certified ® Emergency Department HER

In Med Ed: Expanding online evaluations and other

functions of New Innovations Online duty hours reports


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. Sczecienski’s office at the our Westland Facility

Contact Human Resources with questions about Workman’s Compensation


Part IX: Standards of Behavior

See the complete set of standards

in your Handbook


Employee Commitments

Five Commitments Commitment to Patient Commitment to Appearance Commitment to Attitude Commitment to Communication Commitment to Co-Workers


Commitment to Patient

The manner in which we will provide service to our patients: Compassionate Informed Respectful Safe Timely


Commitment to Appearance

We will represent GCH in a professional manner to our customers: Personal Facility & Environment Good Neighbor


Commitment to Attitude

The manner in which we show our attitude while providing service to our patients, customers and co-workers: Positive Respectful Professional Friendly


Commitment to Communication

The manner in which we will communicate with our patients, customers and co-workers: Respectful Promptness Professionalism


Commitment to Co-Workers

The manner in which we will relate to our co-workers: Respect Friendliness Mentoring


Part VIII: Post-Test andAttestation

Post-Test and Attestation

Complete the online post-test by clicking the link below. There is also a link on the Med Ed website.

http://www.surveymonkey.com/s.aspx?sm=Str2Ewh33yLdrT3UwmGPPg_3d_3d

Thank you!

Documents

2009 - 2010 Safety Fair House Staff Edition. Overview What is Safety Fair? All hospitals are required to provide annual reviews of safety and quality