Otsego Memorial Hospital Association Corporate Overview

1
Your Champion for Better Health
2
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

3
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)

4
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

5
(No Transcript)
6
Mission Statement

• To 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,
  Cheboygan, Frederic and Waters.

7
Vision Statement

• To be the center of northern Michigans patient
  focused alliance dedicated to healthcare
  excellence.

8
Values

• 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
  value

9
Values

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

10
Values

• 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

11
Values

• Accountability
• 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

12
Otsego Memorial Hospital Affiliates

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

13
Otsego Memorial Hospital Partners

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

14
Customer Service

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

15
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

16
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

17
Value People

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

18
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

19
Listen to People

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

20
Help People

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

21
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

22
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

23
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)

24
Pain Assessment
When assessing pain, a number value should be
assigned by the patient to make for consistent
measurement
25
FLACC Scale Non Verbal
26
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

27
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

28
Rights

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

29
Rights

• 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
  wrist
• 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

30
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

31
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
  physicians

32
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

33
Infection Control

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

34
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

35
Infection Control(Keystone Initiative)

• Wash your hands upon entering
• a patient-care area and upon leaving
• WASH IN WASH OUT

36
Infection Control

•         Standard Precautions
• All the patients, all the time

37
Infection Control

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

38
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

39
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)

40
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

41
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
• Dont let used equipment or linens contaminate
  surfaces or clean items

42
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

43
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

44
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

45
Exposure toBlood 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

46
(No Transcript)
47
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

48
Abuse

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

49
Overview of Evidence-basedPractice 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

50
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
51
Evidence-based PracticeRegulations

• 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.

52
Evidence-based PracticeReimbursement

• 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!

53
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

54
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

55
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

56
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.

57
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

58
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

59
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

60
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
61
2E Hand Off Communication

• Implement a standardized approach to hand
  off communications, including an opportunity to
  ask and respond to questions

62
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

63
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

64
Hand-offs Must Allow Time for Questions and
Answers

• 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
  recommendation
• SBAR

65
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?

66
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

67
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

68
3D

• 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

69
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.

70
Goal 3
Reduce patient harm associated with
anticoagulation therapy
71
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

72
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

73
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

74
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
  MDRO
• Educate staff and patients on prevention
• Careful use of antimicrobials
• Clean, disinfect, and sterilize appropriately
• De-colonize persons with specific MDRO

75
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.

76
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

77
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

78
Goal 15A
The organization identifies safety risks inherent
in its patient population
Goal 15A The organization identifies patients
at risk for suicide
79
Suicide Risk Assessment
Suicide Risk Assessment is found Hospital
Information Page Forms Nursing
80
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
81
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.

82
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
• Learning from errors

83
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

84
Reporting an Employee Incidence

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

85
Variance Report

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

86
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

87
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.

88
Sentinel Event or HFMEA ?
HFMEA is Healthcare Failure Mode Effects
Analysis A systematic approach to identify and
prevent product and process problems before they
occur.
89

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.

90
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

91
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

92
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

93
Reporting a Concern

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

94
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

95
(No Transcript)
96
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

97
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

98
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
  classification

99
Professional Work Environment

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

100
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.

101
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

102
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

103
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.

104
(No Transcript)
105
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

106
OMH Codes

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

107
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

108
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

109
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

110
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
  evacuation

111
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

112
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

113
OMH Codes

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

114
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
  times

115
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

116
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.

117
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

118
OMH Codes

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

119
OMH Codes

• Severe Weather
• 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

120
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

121
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
122
Chemical HazardsRight 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

123
MRI Safety(Magnetic Resonance Imaging)
124
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

125
(No Transcript)
126
Ergonomics

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

127
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
  vibration

128
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
129
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

130
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

131
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
  donors
• Persons with HIV or Hep B can be organ donors
• Bev Cherwinski, Support Group

132
Cultural Competence

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

133
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

134
HIPAA

• 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

135
HIPAA

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

136
HIPAA

• 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

137
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

138
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
  treatment.
• Resource allocation

• Revising/updating policies/practices with ethical
  implications.
• Offering support for clinical or medical issues
  with ethical implications.

139
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
• 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
  care

140
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.

141
Questions

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

142
The End
Welcome