Otsego Memorial Hospital Association Corporate OverviewTo provide exceptional healthcare that meets the needs of our patients and the communities we serve.
Our service area includes: Gaylord, Elmira, Wolverine, Vanderbilt, Johannesburg, Atlanta, Lewiston, Indian River, Frederic and Waters
Munson Healthcare Otsego Memorial Hospital will be preferred and trusted as the center for patient-focused care that is comprehensive, coordinated and accessible. Through committed teamwork, we will build a sustainable and secure future of improving health for the communities of northern Michigan.
• Established 1951
• Accredited
• Otsego Memorial Hospital • McReynolds Hall • OMH Foundation • OMH Medical Group
• OMH Medical Group–Gaylord • OMH Medical Group–Elmira • OMH Medical Group–Indian River • OMH Medical Group–Lewiston • OMH Cancer & Infusion Center • OMH Orthopedic Surgery • OMH Walk-In Clinic
• OMH Auxiliary
Beds: 46 Acute Care (Hospital) 34 Long Term/Skilled (McReynolds)
250,000+ Annual Patient Visits
Appreciating diversity and treating all with compassion, dignity and courtesy • Show the person you are interacting with that they are
your priority
• Convey empathy – put 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 value
Unwavering commitment to honesty and trust • Do the right thing for the right reason
• Protect confidentiality and privacy
• Advocate for our patients, employees and organization
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
Accepting Responsibility for our actions See It • Be engaged to contribute positively • Acknowledge opportunities by learning from our experiences
Own It • Understand how individual actions contribute to desired outcomes
Solve It • Follow through on commitments and responsibilities
• Recognizing opportunities and creating solutions that bring value to our patients, staff and the communities we serve.
Customer Service
• Patient satisfaction is directly related to how we treat our customers
• You will be receiving addition education regarding our customer service
• The following are the behaviors we ask our employees to exhibit
Customer Service
Greet Value as a customer Ask how you can help Listen words, tone and body language Help meet their needs Invite them to contact us
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 measurement
FLACC Scale Non Verbal
Rights
Patients have a right to: • Privacy • Treatment records are confidential • Review their medical records • Be free from discrimination • Discuss continuing care needed after
hospitalization
Rights
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
Rights
Patients have a right to: • Be informed of outcomes of care including
unanticipated outcomes • Raise concerns through a formal grievance • Access Protective Services
Rights
Patients have a right to: • Comfort measures/peace and dignity at
end of life • Patients who have a Do Not Resuscitate status will
have a purple armband placed around their wrist • McReynold's Hall patients have a purple dot placed on
their identification bracelet
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 firearms/weapons
Advance Directives
Advance Directives are: A legal document that gives the
appointed advocate permission to make medical decisions when the patient is deemed incompetent by 2 physicians
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 located
Infection Control
Washing or sanitizing 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
WASH IN WASH OUT
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 substances
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 clothing
• Don’t 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-
CONTACT-AIRBORNE-DROPLET
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 Department
• Complete the “Exposure Form” • Report to ED for evaluation • If exposure to eyes, flush for 15 minutes at eye
wash station with COLD water
PERSONAL PROTECTIVE EQUIPMENT (PPE)
Personal Protective Equipment (PPE)
Order for Removing PPE
Age Specific Care
• Be aware that all ages have different physical, psychological, and social needs
• Tailor education to the patient’s age and needs • If staff and volunteers are aware
then it is a safer environment • Involve family in the care
Abuse
• Child • Abuse, Neglect
• Observed or suspected – we are required by law to report it!
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 Goals
• 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 practice
• 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
• 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 result
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
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…
SBAR S=Situation B=Background A=Assessment R=Recommendation
Any Questions?
S=Admitted an 82 year old with pneumonia, possible aspiration.
B=History of stroke, has been having increased cough x 3 weeks per family, fever began today..
A=RR is 24 and unlabored, temp is 101 degrees F, swallowing evaluation ordered for a.m., alert and oriented x2. First antibiotic completed at 0300.
R=Keep 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.
Verify Labels
• 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 time. • 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.
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 Process
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 Infections
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)
WASH IN WASH OUT
• Hand Hygiene • Infection prevention and control • Flag charts and communicate information to staff
regarding patients known to be infected with MDRO • 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/client’s current medications upon the patient/resident/client’s admission/entry to the organization and with the involvement of the patient/resident/client.
• A complete list of the patient/resident/client’s 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.
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
Identify Safety Risks
population
Goal 15A: The organization identifies patients at risk for suicide
Suicide Risk Assessment
Hospital Information Page Forms
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 patient’s nurse in assessing condition and provides support in communicating findings to patient’s 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 blame
Reporting a Medical/Safety Occurrence
Report the occurrence to the charge nurse and complete VOICE Report
Examples: • Medication error • Patient fall • Needle stick • Treatment error
Reporting an Employee Incidence
If something happens to an employee, Report in VOICE System
Variance Report
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 patient
• By reporting near misses we can help avoid errors from occurring
“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.
C.U.S.P. Comprehensive Unit Safety Program
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
at 731-7703 Employees also have the choice of reporting safety
or quality concerns to the Joint Commission at (630) 792-5636 or
complaint@jointcommission.org
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
Professional Work Environment
• Professional Work Environment • Everyone has the right to be treated with
dignity and respect
• 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
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 classification;
Professional Work Environment
offensive touching, pinching, brushing the body, or impeding or blocking movement.
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.
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 • Or dial 55555 and the Operator will page
OMH Codes
Code Red = Fire – OMH Code Red Policy – Doors are numbered and lettered for Fire
Department 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
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
Security Alert-Bomb Threat • 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 evacuation
OMH Codes
Security Alert • 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
OMH Codes
Amber Alert • Missing child/Possible Abduction • Page Amber Alert, 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
by an individual with a weapon OR
• If you observe a hostage situation on Hospital property
Initiating Lock DownPlan
• Seek cover and discretely warn others (close by) of the situation
• Dial “55555”- Report the location, number of suspects/hostages, type of weapons
• Operator will dial 911 • Operator will page “Security Alert- Lock Down”+
location 3 times
Workplace Violence
• Healthcare and social service workers face an increased risk of work-related assaults
• If threat is imminent, call Security Alert!
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 penalties.
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-Full Activation • Code Triage Standby • Code Triage ED
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
Weather Alert • Emergency Department has weather alert radio • ED also notified by MI State Police Dispatch • ED Shift Coordinator will announce warnings
overhead • 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
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
HIPAA
• The HIPAA Privacy Rule protects a patient’s fundamental right to privacy and confidentiality
• ANY information obtained about another person’s medical condition is treated as confidential and is not to be discussed or revealed to unauthorized persons
HIPAA
• Protected Health Information is anything that connects a patient to his or her health information: Date of Birth, SS#, diagnosis, address, etc.
HIPAA
HIPAA’s 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 consists of a diverse group of members including:
• Providers • Licensed professionals • Frontline staff • Community members • Any staff member can make a referral to the
Ethics Committee
Appropriate Ethics Referrals
• A staff member’s belief system is in conflict with a patient’s treatment plan.
• A family/patient is in conflict with the proposed treatment.
• Resource allocation
• Offering support for clinical or medical issues with ethical implications.
Medical Record Documentation
The purpose of medical record documentation includes: •To record complete and accurate clinical information
•To communicate with other members of the healthcare team
•To comply with legal, regulatory and accreditation requirements
•To ensure adequate reimbursement
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 folder.
Environment of Care
We have 6 plans in place to assure the safety of our patients and our staff: Plan 1: Biomedical Equipment Management Plan 2: Life safety Management Plan 3: Hazardous Material and Waste Management Plan 4: Utility systems Management Plan 5: Security Management Plan 6: Safety Management
Chemical Hazards “Right To Know”
Employees have the right to know how to keep themselves safe on the job
• SDS- safety data sheets available online (Web link MSDS on line in 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)
• 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
Ergonomics and Back Safety
• Our goal is to use this science of ergonomics to reduce work-related Musculoskeletal disorders (MSD’s)
• Everyone, not only those involved in direct patient care, needs to have training in proper body mechanics and lifting
Safe Lifting
• Use your strong leg muscles • Keep objects close • Tighten abdominal muscles • Bend knees and squat • Use proper lift equipment • Ask for help when needed • Keep head and shoulders up (keeps spine curves
in alignment)
Comfort and Care at the End of Life
• Managing symptoms is the goal • Even if patients are not responsive, always
explain care/treatment • Respect personal choices and values
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 • Hospital required to call all imminent
deaths to Transplantation Society of Michigan
Cultural Competence
• Treat every patient as an individual • Communicate respect • Language issues-seek translation if needed • Be aware of non-verbal communication
Questions
• Any questions about this information can be directed to the HR Department, instructor or your department director.
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Infection Control
Infection Control
Infection Control
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Infection Control
Sharps Safety
Infection Control
AIRBORNE Precautions
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Age Specific Care
How National Patient Safety Goals affect your practice
Goal 1: Improve the Accuracy of Patient/resident/client Identification.
Implementation Expectations 1A Use at least two patient identifiers whenever:
1B: Implement the Universal Protocol for Invasive Procedures
Goal 2: Improve Effectiveness of Communication
Standardize a list of abbreviations, acronyms, and symbols that are not to be used throughout the organization
The Official OMH “Do Not Use” List Includes:
2E: Hand Off Communication
Goal 4 : Eliminate Wrong-site, Wrong Patient, Wrong Procedure Surgery.
Goal 4B Implement a Process to Mark the Surgical Site and Involve the Patient in the Marking Process
Goal 7 Reduce the Risk of Health Care Associated Infections
Goal 7C MDRO
Goal 8 Accurately and Completely Reconcile Medications Across the Continuum of Care.
Reduce the Risk of Patient/resident/client Harm Resulting From Falls
Identify Safety Risks
Suicide Risk Assessment
Rapid Response Team
Rapid Response Team
Reporting a Concern
Infant Abandonment
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Organ and Tissue Donation