lws_jcaho handbook_4x5_6-24-11 (2)_1.pdf

8/14/2019 LWS_JCAHO handbook_4x5_6-24-11 (2)_1.pdf

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Table of Contents

Introduction

Patient Safety Program National Patient Safety Goals

Pain Management

Patient Rights

Ethics/OPI

Assessment of the Patient

Care of the Patient

Plan of Care

Sedation/Analgesia Restraints

Crash Carts

Medications Administration

Adverse Drug Reactions

Education of the Patient and Family

Continuum of Care

Performance Improvement

Lovelace Westside Mission/Vision Lovelace Westside Basics

Lovelace Westside Improvements

Management of Environment of Care

Emergency Codes

MSDS Sheets

Medical Equipment Safety

Management of Human Resources

Surveillance, Prevention and Control of Infection Management of Information

Tracer Activity

Medical Staff Information

Common Survey Questions

Documentation Rules for Medical Staff

THE JOINT COMMISSION HANDBOOK


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STANDARDS OF CONDUCT

Employees communicate the real spirit of a health care facility. We ar

expected to be responsible for our attitudes and actions at all times,

consistent with the standard and behaviors contained in The LovelaceWestside Handbook, individual job descriptions, department guideline

and performance evaluations.

Manuals

You should be familiar with the following Manuals and their location.

Department Procedure Manual (on units or in department)

Administrative Policy and Procedure Manual (In AdministrativeOffice)

MSDS (Material Safety Data Sheets) in the Plant Operations office

and on Fastlane

Infection Control- Infection Control office and on Fastlane

Emergency Preparedness In Lovelace Policy Manager on Fastlane

under Emergency Management

Perry and Potter Nursing Intervention Guidelines on 2N and 2W, ICU

and L&D.

Points to Remember and verbalize

Surveyors will evaluate how we fulfill our Mission Statement. Everythin

we do to convey our commitment to quality and safety shows surveyors

(and everyone else) our highest priorities. If you meet a surveyor, be

welcoming, smile and demonstrate how very good we are.


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THE PATIENT SAFETY PROGRAM:

The scope of the Patient Safety Program encompasses the patient

population, visitors, volunteers and staff (including medical staff). The

program addresses maintenance and improvement of patient safetyissues in every department throughout the facility in an effort to reduc

clinical errors or events.

Patient Safety Manager: Tinley Vermoesen

Focus of the Patient Safety Program is on processes and systems.

Goal of the patient Safety Program is to improve patient safety andreduce risk to patients through an environment that encourages:

Recognition and acknowledgement of risks to patient safety and

medical/healthcare errors;

The initiation of actions to reduce these risks;

Minimization of individual blame or retribution for involvement in a

medical/healthcare error in order to encourage reporting;

Organizational learning about medical/healthcare errors as a

prevention measure;

Internal reporting of what has been found and the actions taken;

Support of the sharing of that knowledge to effect behavioral

changes in itself and other healthcare organizations.

Employees who have concerns about the safety and/or quality ofcare provided may report these concerns to the Joint Commission.

As a matter of courtesy and professionalism, employees should

make every effort to discuss all issues and concerns with hospital

management, or Tinley Vermoesen at 72456 before reporting them to

THE JOINT COMMISSION HANDBOO3


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the Joint Commission. No disciplinary action will be taken against

any employee who reports safety or quality concerns to the Joint

Commission. Contact numbers are on the Joint Commission websi

SENTINEL EVENTS

TJC defines a sentinel event as: A sentinel event is an unexpected

occurrence involving death or serious physical or psychological injury

or the risk thereof. Serious injury specifically includes loss of limb o

function. The phrase or the risk thereof includes any process variatio

for which a reoccurrence would carry a significant chance of a serious

adverse outcome.

2011 National Patient Safety Goals

Goal 1: Improve the accuracy of patient

identification

Use at least two (2) patient identifiers when providing care,

treatment, or services. We use the patients name and date of birth Make sure the correct patient gets the correct blood when they get

blood transfusion

Goal 2: Get important test results to the right staff person on tim

For verbal or telephone orders or for telephonic reporting of critica

test results, verify the complete order or test result by having

the person receiving the information record and read-back thecomplete order or test results, and sign RBO in the medical record.

Standardize a list of abbreviations, acronyms, symbols, and dose

designations that are not to be used throughout the organization.


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DO NOT USE THESE ABBREVIATIONS!!

U (unit) Mistaken for 0 (zero),

the number 4 (four)

or cc

Write unit

IU Mistaken for IV

(intravenous) or the

number 10 (ten)

Write International Uni

Q.D., QD, q.d., qd, (daily)

Q.O.D., QOD, q.o.d., qod

(every other day)

Mistaken for each other,

or period after the Q

mistaken for I and O

mistaken for an I

Write daily

Write every other day

Trailing zero

(X.0 mg)

Lack of leaning zero (.x

mg)

Decimal point is missed Write X mg

Write 0.X mg

MS

MSO4 and MgSO4

Can mean morphine

sulfate or magnesiumsulfate and confused for

one another

Write morphine sulfate

Write magnesiumsulfate

Measure, assess, and if appropriate, take action to improve the

timeliness of reporting and the timeliness of receipt by the responsible

licensed caregiver, of critical test results and values.

Implement a standardized approach to hand off communications,

including an opportunity to ask and respond to questions. (SBAR Hand-of



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Goal 3: Improve the safety of using medications

Before a procedure, label medicines that are not labeled. Label all

medications, medication containers (i.e. syringes, medicine cups,

basins), or other solutions on and off the sterile field.

Reduce the likelihood of patient harm associated with the use of

anticoagulation therapy.

Goal 7: Reduce the risk of healthcare associatedinfections

Comply with current World Health Organization (WHO) hand hygiene

Centers for Disease Control (CDC) hand hygiene guidelines.

Use the proven guidelines to prevent infections that are difficult to trea

(MDROS)

Use proven guidelines to prevent infections of the blood from central

and PICC lines.

Use proven guidelines to prevent infection after surgeries.

Goal 8: Accurately and completely reconcile medications across thcontinuum of care

There is a process for comparing the patients current medications wit

those ordered for the patient while under the care of the organization.

A complete list of the patients medications is communicated to the

next provider of service when the patient is referred or transferred to

another setting, service, practitioner or level of care within or outside

the organization. The complete list is also provided to the patient on discharge from the

organization.

Some patients may get medicine in small amounts or for a short time.

Make sure that it is OK for those patients to take those medicines with

their current medicines.


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Goal 15: The organization identifies safety risks inherent in its

patient population.

The organization identifies patients at risk for suicide.

The organization selects a suitable method that enables health care staff

members to directly request additional assistance from a specially traine

individual(s) when the patients condition appears to be worsening.

UNIVERSAL PROTOCOL

Wrong site, wrong person, wrong procedure surgery can be prevented. Th

universal protocol is intended to achieve that goal. The universal protocois composed of 3 important components,

1. Conduct a pre-operative verification process. (Correct documentation,

correct labs, correct images, etc.)

2. Mark the operative site. (Mark with the patients involvement using

yes, and person doing the procedure should mark the site.)

3. Conduct a time-out immediately before starting the procedure.

4. Also, before we give bloodor insert a PICCline we must call for atime outto ensure that all appropriate procedures are followed, and

consents are signed.

PAIN MANAGEMENT

Is failure to rapidly respond to a patients request for

alleviation of pain considered a violation of the patients

rights?YES!

REMEMBER: All nurses must document when a pain medication or

intervention is given and the patients response to the medication or

intervention.



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LWSH policy Patient Safety: Pain Management (#337) related to pain state

Provide information about pain and pain relief measures to patients.

Provide a staff that is committed to pain prevention and management.

Provide staff that will respond quickly to reports of pain.

Provide staff that will believe a patients complaints of pain.

Provide state of the art pain relief measure

The hospital uses many scales to determine pain: Wong Baker FACES

(smile-frown) scale, the Numeric or Verbal Scale; NIPS and N-Pass scales

are used for newborns: FLACC for infants and children (2months to 7years); and Non Communicative and Pain/Discomfort Behavior scale.

When a patient does not understand spoken English, an interpreter must

utilized to ensure that the patient does not suffer needlessly.

Pain should be assessed at the following points: On admission or first contact with the organization as part of the overa

evaluation

When care is transferred from one setting or provider to another(change of shift) ( SBAR hand off report)

Assess for pain one (1) hour after any intervention to ensure reductionor alleviation pain for PO meds and 30 minutes for IV or IM painmedications.

Assess every shift patients that say they have no pain.

Immediately before discharge


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PATIENT RIGHTS

Patients are exposed to information regarding their rights on admission

and Patient Rights are posted in registration areas and available in writing

upon request.

Examples of Patient Rights:

Right to know who is caring for them:

WEAR YOUR BADGE!

AND WASH YOUR HANDS!

RIGHT TO PRIVACY:

Knock on door before entering and introduce yourself.

Close doors and curtains when doing patient care.

RIGHT TO CONFIDENTIALITY:

Do not talk about patients/families in public areas.

Be certain that computer screens with patient information are not inpublic view or left unattended.

RIGHT TO VOICE A COMPLAINT:

Patients may tell any staff member of dissatisfaction with care or

services; all attempts to solve the complaint are made.

RIGHT TO BE TOLD OF DIAGNOSIS, TREATMENT OPTIONS, RISKSBENEFITS:

The patient receives complete information in order to accept or refuse car

If the patient is mentally and physically able to make those decisions,

no one else can make those decisions for him. (This includes signing

consent forms.)



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RIGHT TO BE FREE FROM ABUSE OR HARASSMENT:

Adult Protective Services (elderly person over age 65, or mentally or

physically disabled person over age 18) is notified when a patient is a

potential/actual victim of abuse.

Hotline for Adult Protective Services: 841-4500

RIGHT TO APPROPRIATE ASSESSMENT AND MANAGEMENT OF

PAIN:

Staff is committed to pain prevention and management & responds

quickly.

RIGHT TO A SECURE ENVIRONMENT

What security issues do you have in your area and

how are they addressed

Right to have respect for a patients choices, cultures,

and beliefs.

RIGHT TO MAKE ADVANCE DIRECTIVES:Advance Directives are documents patients use to communicate their

decisions regarding the medical care they wish to receive in the event the

are unable to make those decisions.

The patient has the right to appoint someone to make care decisions if

he becomes mentally or physically unable to do it for himself.

The patient may choose to withhold or withdraw life-sustaining

treatment in case of terminal illness or,

Each patient is asked if they have an advance directive. If not, they are

given the opportunity to complete one.

Chaplain Services is available for those patients who wish to ask

questions or who wish to complete an advance directive.


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If the patient has an advance directive but has not brought it to the

hospital with them, they are asked to provide a copy, and if unable to d

so, to complete a new one.

EMTALA - Emergency Medical Treatment and Labor Act is a statute

which governs when and how a patient must be (1) examined and offered

treatment or (2) transferred from one hospital to another when he is in an

unstable medical condition.

Every patient who presents to the emergency department must be given

a medical screening exam to determine if they are suffering from anemergent medical condition prior to being asked about ability to pay fo

service or transfer.

INFORMED CONSENT

Authorization and consent for treatment of patients:

Allows each patient to fully participate in decisions about treatment.

An Informed Consent shall be signed by the

Patient as evidence that the patient has been provided with informatio

by his/her physician concerning the care, treatment, and services that

the patient receives. Discussion by the physician of potential problems

that might occur during recuperation, the likelihood of achieving goals

and the risk, benefits and side effects related to alternatives, including

the possible results of not receiving care, treatment and services.

What procedures require Informed Consent?

Surgical procedures and Invasive procedures

Blood and blood products transfusions

PICC line placement

Consent to treat (on admission)



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Review the Lists and your practices for consents!

If a care decision is made that the patient, family, or staff member feels

uncomfortable with or disagrees with, Chaplain Services may be contacte

to help resolve the issue.

ETHICS

(For an Ethics Consultation contact the Case Manager,

Director of Quality or the CNO/ COO).

END OF LIFE CARE

Treat all patients with respect and dignity regardless of prognosis oroutcome.

Involve patients, families, and surrogate decision makers in

multidisciplinary planning.

Manage the patients pain effectively.

Address issues of autopsy and organ/tissue donation with sensitivity.

Respect the patients values, religion and philosophy.

Involve the patient, and where appropriate, the family, in every aspect

of care.

Respond to the psychological, social, emotional,

spiritual, and cultural concerns of the patient and family.

ORGAN/TISSUE DONOR

The New Mexico Donor Services works with families, physicians and sta

to facilitate patient wishes regarding organ/tissue donation. Nursing shal

promptly contact (within 15 minutes NMDS by telephone in all cases of

impendingand actual deaths for determination by NMDS or donation of

organs and/or tissues.


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ASSESSMENT OF THE PATIENT

Initial Assessment:

Physical assessment is completed within 2 hours of admission.

Assessment of pain is an essential part of the initial assessment. The

complete data base assessment should be completed by 24 hours.

H&P completed and on the chart within 24 hours of admission.

An LPN may collect specific data points for the assessment, but the RN

is responsible for completing and signing the assessment.

The patient will be screened for physical, psychological, social

(including violence, abuse or neglect) spiritual, nutritional, functionaland discharge planning needs.

Medication reconciliation and readiness to learn / patient education

forms are part of this assessment.

Re-assessment:

Nursing reassessments are performed every shift or whenever a chang

in the patients status indicates a need for reassessment.

Re-assessment is made whenever a treatment or intervention that

has the potential to change the patients status is implemented, i.e.

intervention for pain.

CARE OF THE PATIENT

The Basics:

Introduce yourself and explain your role in the

patients care for the day.

Call the patient by his/her preferred name.

Sit with the patient for at least 5 minutes per shift to plan/review care

and the goals to meet that day.

Use touch: handshake, a touch on the arm



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Select a behavior unique to your personality and approach that

differentiates you from your colleagues

Update white boards in each patients room with name of patient care

nurse, current date, and CNA for the shift.

PLAN OF CARE

Care planning is interdisciplinary, goal directed & individualized, and include

Patient/family input

Physician order sets/physician orders orders must be dated, timed an

signed within 72hours.

Patient discharge summary

Interdisciplinary patient education record

Progress notes must be completed daily.

Interdisciplinary team meetings (IPOC)

Medication reconciliation record, updated at

discharge, copy given to patient

SEDATION/ANALGESIA

Sedation/analgesia is produced by administering

pharmacological agents for therapeutic and/or diagnostic procedures.

RESTRAINTS:

Restraint is used as a last resortafter alternative

measures have failed.

The assessment of the RN or physician to protect the patient or others

from injury identifies the need for restraint.

Alternatives to restraints for acute med/surge care may include:

Review of systems - assess the patient to rule out factors such as pain, full

bladder, inadequate O2 saturation, incontinence, hunger, constipation or fev


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Providing companionship and supervision through a family, friend or

volunteer to stay with the patient, determining when the patient needs

one-on-one attention, increased nursing rounds, or the use of sitters.

Reassessing medication or treatments and modifying or eliminating

when possible. Recommend initiation of oral medications or feedings if

possible, removal of catheters and drains as soon as possible, monitorin

of drugs and side effects and discuss alternatives with physician.

Modifying the environment such as increasing or decreasing the

amount of light in the room, positioning a bedside commode for easy

access, arranging for the patient to be near the nursing station, placinga mattress on the floor so the patient can move about freely without

falling, placing the bed in lowest position with wheels locked and

keeping the call button accessible.

Bed alarm.

Offering diversionary and physical activities such as TV, radio or music

exercise, ambulation, or providing sensory stimulating object, repetitiv

activities (rolling bandage, folding towels) Comfort measures such as repositioning the patient on pillows, adjusti

the temperature, offering snacks, applying or removing blankets.

Reality orientation such as involving the patient in conversation,

explaining procedures to reduce fear and convey a sense of calm, usin

relaxation techniques or attempting to verbally redirect behavior.

A physician order is required to apply restraints.

An order for restraint is limited to:

- 24 hours for medical-surgical care.

- 4 hours for behavioral management (abrupt, unexpected aggressive/

threatening behavior).



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For behavioral management:

Restraints cannot be re-ordered and continued for more than 12 hours

without a face-to-face evaluation by the physician for patients 18 years

of age or older.

The patient is monitored by the nurse

Every 2 hours for medical surgical care.

Every 15 minutes for behavioral management.

With a behavioral restraint, the MD must do a face-to-face assessment

within 1 hour of initiation of restraint even if the patient has been

released before the hour has ended.

Standing or PRN orders for restraints are NEVER permitted

CRASH CARTS:

What system is in place for assuring the integrity of the crash cart?

Daily standardized crash cart checks by nursing..

Crash cart locks for drug tray drawers are obtained through andcontrolled by Pharmacy.

Crash cart locks are broken only in emergency situations (NOT access

for routine supplies).

Pharmacy, Materials Management and Nursing check the crash cart fo

outdates routinely. Replacements for any drugs or supplies are made fo

anything soon to expire. Outdates for supplies and drugs are posted on

the outside of each crash cart.

Crash cart integrity is checked every day and the lock number is verifie

The defibrillator is tested daily at the manufacturers recommendations

Daily checks for the presence and volume of the oxygen tank.


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Laryngoscope and blades are checked and batteries changed, if needed

anytime an outdate for supplies or medications occurs, and if the car

is opened for use. Extra bulbs and batteries are available in the cart.

Verify that the Pharmacy has inspected the cart and replaced any drug

soon to expire.

Anytime a new lock is placed on the cart, the new number is recorded

on the log sheet.

Complete check of crash cart if found unlocked.

Patient Nourishment Refrigerators: The temperature of the refrigerator and the freezer is

monitored and recorded each day.

No open containers are returned to the refrigerator.

Milk, formulas, etc. are checked for expiration dates.

The Nursing staff keeps the refrigerator clean.

MEDICATION ADMINISTRATION:

How do you store and use medications in your department?

Food is stored in a separate refrigerator from all refrigerated floor stoc

and patient medications.

Multi-dose vials with preservatives may be used. Multi-dose vials

are only good for 28 days from the time they are opened as long as

recommended storage conditions have been followed or unless there iconcern for contamination at which point the vial is discarded.

Vials without preservatives are for single doses only.

Disinfectants and items for external use are properly labeled and kept

separate from internal medications.



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General medication areas are neat and uncluttered.

The temperatures of the medication refrigerators are monitored and

recorded each day.

What actions are taken when a refrigerator temperature is out of

range?

Try to determine the cause for temperature variation and make the

appropriate adjustment to correct it (i.e. door left ajar or refrigerator

requires defrosting).

Temperature is rechecked in 30 minutes and documented.

If unable to determine reason, notify Pharmacy to relocate medication

and notify plant operations.

Medications and food are relocated and discarded as appropriate.

ADVERSE DRUG REACTIONS:

What is an adverse drug reaction (ADR)?

An ADR is any undesired, unintended, excessive or exaggerated effect of

drug due to either the drug itself or patient idiosyncrasy (excluding gross

overdose and therapeutic failures). These reactions may be expected or

unexpected.

How do you report an ADR?

Notify your patients physician

Notify your pharmacist.

Complete an incident report by Remote Data Entry (RDE) thru Fastlan

All ADRs will be reviewed by pharmacy and Risk Management.


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Discharge Planning:

Initial Discharge Planning begins on admission.

Assessments to identify potential Discharge Planning needs are ongoin

Informal discussion may occur daily between clinical disciplines and

formally during bi-weekly Interdisciplinary Plan of Care (IPOC) meeting

EDUCATION OF THE PATIENT AND FAMILY

Education Assessment

Begins on admission.

An interdisciplinary approach is used to providepatient/family education.

The RN assesses and documents the patients ability to learn. This

information is included on each shift assessment.

How are our patients religious or cultural needs met?

Chaplain Services

Patient/family care conferences Individualized care plan

Dietary preferences

Non-English patient educational material

Language interpreters

Ongoing re-assessment for readiness to learn will be performed prior toeach educational opportunity.

All clinical disciplines that teach the patient must know the above

assessment findings in order to incorporate them into their teaching.

The patient record is an interdisciplinary tool developed to facilitate

documentation and communication/coordination among caregivers.



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CONTINUUM OF CARE

Communication

The hospital communicates appropriate information to any organizatio

or provider to which the patient is transferred or discharged.

The information shared includes the following, as appropriate to care,

treatment and services provided:

- The reasons for transfer or discharge.

- The patients physical and psychosocial status.

- A summary of care, treatment, and services provided and progress

toward goals.

- Community resources or referrals provided to the patient.

SBAR communication is utilized for providing information between

departments within the facility and between nursing shifts. (AKA

Handoff Communication)

REACT Team:

Was implemented for early response to changes in patients conditionby specially trained individuals. The expectation is that this may reduce

cardiopulmonary arrests and mortality. The bedside nurse will notify the

house supervisor (379-4319). He/she will respond along with RT and the

bedside nurse.

CODE BLUE :

Is paged overhead for patients who are assessed to be in a resuscitation

state. Overhead paging is completed by dialing 7-5049 and announcing;

Code Blue, Lovelace Westside Hospital, unit and room number (repeat 3

times).


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PERFORMANCE IMPROVEMENT

Performance Improvement means designing processes to improve patien

outcomes and hospital performance.

Q. How is this done?A. Any staff member or physician may identify an area

for improvement.

1. The first step is to identify the problem.

2. Develop an action utilizing Plan, Do, Check, Act (PDCA) methodolog

3. Initiate the PDCA.

4. Re-evaluation the situation.

5. Make adjustments, as necessary.6. Monitor results in order to maintain the gain.

7. List 2 things your organization is working on towards performance

improvement;

a)________________________________

b)________________________________

LOVELACE WESTSIDE HOSPITALMISSION STATEMENT

Lovelace Health Services is a premier provider of healthcare services,

delivered with compassion for patients and their families; respect

for employees, physicians and other health professionals; with

accountability for our fiscal and ethical performance; and with

responsibility to the communities we serve.

VISION

Lovelace Health Services will be the healthcare provider of choice for

our patients, employees, physicians and other health professionals by

consistently performing at a superior level, while maintaining sound

ethical standards and returning a fair value to our financial partners.



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THE LOVELACE WESTSIDE BASICS:

1. This is our hospital. I will demonstrate pride of ownership every day.

2. I will communicate positively, manage conflict, listen and respond to

needs.3. Every person deserves respect.

4. I choose to be a positive representative of Lovelace Westside Hospital.

5. Exceptional customer satisfaction is my responsibility.

a. See a problem.

b. Own the problem.

c. Fix the problem.

d. Everyone has $25.00 to fix a problem.6. Celebrate! I will recognize and acknowledge our success.

7. Teamwork gets the job done. I will support and respect my co-worker

8. Safety is my responsibility.

9. I am responsible for uncompromising levels of cleanliness of our facili

10. I will always protect confidential information.

11. Customer service and basic etiquette is my responsibility. I will smile

greet and escort customers to their destination within the hospital.12. I will show pride in my appearance as a reflection of my

professionalism and commitment to our high standards.

13. Quality improvement starts with me. I will continually push for highe

standards.

LOVELACE WESTSIDE IMPROVEMENTS

What have we done to improve? Can you give an example?Patient Satisfaction and Patient Safety

Hourly rounding

Rounding with purpose

Changing PCT shift start time


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TCAB initiatives

Reopened 2N

All private rooms Fall team

Skin and Wound team

New staffing grid

New beds with alarms

Noise reduction processes

All employees are empowered to answer call lights Infection Control Interviews

Hand Hygiene Surveillance

Quality Grand Rounds

Continuing education regarding Core Measures, HCAHPS and Patient

Satisfaction

Redesigned patient admission information packet



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MANAGEMENT OF ENVIRONMENT OF CARE

Safety Officer Paul Bugie

Emergency Codes:

PAGE SITUATION KEY INFORMATION

Code Red FireDial 7-5049

All services located inadjoining builidings are

instructed to dial 911for fire.

RACE

Rescue - remove allpersons from dangersAlert - Dial 911 give yourname, your location and

the location of the code,pull the nearest fireboxConfine - close all doorsExtinguish

PASS

Pull- pull the pinAim at the base of the firSqueeze- the handleSweep- side to sideKnow the location ofthe nearest fire pull andfire extinguisher and theevacuation routes

Code Blue Cardiac/Resp ArrestOverhead page using7-5049

Code Blue Teamresponse

All services located inadjoining builidings areinstructed to dial 911 foremergencies.


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Code Pink Infant abductionOverhead page using7-5049

Search all hospital areasand man all exits

Code Grey Security alertOverhead page using7-5049 or call 206-7328

Contact on site security

Code Orange Hazardous SpillCall 206-4558

Spill Team will respondto evaluate

Code Triage Disaster Activate plan

Code TriageStandby

Inbound disaster Assess needs

Code Yellow Disaster Emergency department

is designated commandfor influx.

Material Safety Data Sheets (MSDS)

You have the right to know about chemicals used in your working

environment.

MSDS provides the information you need to know when working with

ALLchemicals. Procedures to use, safety precautions, and emergency response

techniques are found on each MSDS.

For your personal safety and that of fellow employees, MSDS

information is located on Fastlane-Clinical-Hazsoft and begin your

search. Copies of all MSDS sheets are located in Plant Operations.



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MEDICAL EQUIPMENT SAFETY

Safe Medical Device Act

In the event of actual or suspected equipment malfunction resulting in

patient injury or death; Take the equipment out of service.

Report to Maintenance at 727-2670. If there is a patient injury involved

notify Patient Safety and Risk Management 727-2456.

Complete an incident report thru Remote Data Entry on Fastlane.

Electrical Safety: All hospital electrical equipment should be inspected by Maintenance

and tagged with a Safety Checked /Date sticker.

Red outlets and red switches provide power in the event of an electrica

failure.

Oxygen Shut-off:

In the event that it becomes necessary to shut off the oxygen valve topatient care areas, the House Supervisor performs this task.

Patient Evacuation: There are 4 types of evacuation.

Defend in Place- Stay and listen for updates. Low risk

Horizontal Evacuation-moves patient from one area to another on the

same floor

Vertical Evacuation -moves patients from one floor to another.

Total Evacuation- moves patients out of hospital to staging areas.


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MANAGEMENT OF HUMAN RESOURCES AND EMPLOYEE HEALTH

Competencies at the Lovelace Westside reflect the priority focus as well

as key performance indicators of the hospitals. The hospital provides an

adequate number and mix of staff consistent with the hospitals staffingplan and with job descriptions and responsibilities.

Competency is determined at the following stages:

1. Selection process Includes multiple interviews,

reference and background checks, job description

requirements and pre-employment drug screening.

2. Upon Hire Includes hospital orientation, department orientation,

competency validation, and development plan.

3. Ongoing Includes annual performance evaluations, skills labs, regula

staff meetings, internal and external training and education, case

studies, and annual educational needs assessment.

4. The hospital uses data on clinical/service screening indicators and

human resource screening indicators to assess and continuouslyimprove staffing effectiveness.

Lovelace Westside Hospital

Staffing Effectiveness Indicators for 2011:

Staffing effectiveness is determined through a hospital grid system that

incorporates number of patients and their acuity. Employee and patient

satisfaction scores are used as partial measurements of the appropriatestaffing levels.



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SURVEILLANCE, PREVENTION AND CONTROL OF INFECTIONS

JJ Juckette IP 727-2457

Hand washing is the single most important way to

STOPthe spread of infections!

At the Lovelace Westside Hospital, ALL clinical

managers provide continuous hand washing

surveillance!

Lovelace Westside follows the hand hygiene guidelines recommended by

the Center for Disease Control (CDC) and the World Health Organization(WHO).

National Patient Safety Goal #7

Set goals for improving hand cleaning. Use the goals to improve hand

cleaning.

- Every department participates in hand washing surveillance.

- Hand hygiene with alcohol-based gels or foams.

- For C.diff infections use soap only- Between every patient contact

- Before donning and after removing gloves

- Up to a maximum of 7-8 applications of hand gel/foam- then soap.

Use proven guidelines to prevent infections that are difficult to treat

- We monitor all patients for MDROs and inform patients via IP visit or

my mail if the patient was positive in the Emergency Dept. and then

discharged home. Use proven guidelines to prevent infection of the blood from central line

- LWSH participated in the NMDOH/NMMRA CLABSI collaborative.

- We established a Vascular Access RN that is a VA-BC

- Standardized checklist for catheter insertion.


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Use proven guidelines to prevent infection after surgery.

- Only clippers used for hair removal

- Antibiotics are given and monitored as a Core Measure

Patient/Staff Safety Measures:

Standard Precautions apply toALLpatients,ALLthe time in regard

to handling blood, body fluids, secretions and excretions (excluding

sweat), non-intact skin, mucous membranes and/or potentially

infectious material

Transmission based (isolation) precautions apply to those cases wherea more restrictive level of isolation is necessary based on known or

suspected diagnosis, clinical evidence or patient signs and symptoms.

Categories for this isolation include:

Contact (GREEN sign) for MRSA, VRE, Clostridium Difficile (C-Diff),

Group A Strep,and ESBL.

Droplet (PINK signs) for Influenza, Meningitis (bacterial)and

Airborne (BLUE signs) are for airborne conditions such as TBand

Legionellae

Barrier precautions include the use of certain personal protective

equipment (PPE) until certain infections are ruled out. These PPE includ

Fluid resistant gowns Latex/powder free gloves

Masks (fluid resistant with or without face shields)

Goggles

Biohazard labeled zip lock specimen bags



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Appropriate waste disposal of infectious waste includes:

Infectious waste is described as any bodily fluid collection containers

(i.e. Foley and collection bags) or any items saturated with body fluids

or blood. (i.e. saturated dressings)

Placing all infectious waste in a red biohazard bins.

Placing red biohazard bins or bags in the Soiled Utility Room for

collection by Housekeeping Services.

Disposal of sharps includes:

Availability of sharps containers in all patient rooms and

work areas. Closest to use site

Closing, locking and exchanging these containers before they are fu

Ensuring all safety-engineered devices are activated.

Taking the sharps container to the soiled utility room for pick up when

full.

Lovelace Westside Hospital Safety Committee is responsible for final

decision regarding safety-engineered devices.

Keep your work area/unit clean, free of dust and debris.

Maintaining control of non-approved break areas includes

restricting bad habits such as:

Eating

Drinking

Application of cosmetics

Application of lip balm or contact lenses in the direct

patient care and work areas

NO employee food or drink at the nurses station, hallways or any other

patient care area!


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MANAGEMENT AND PRIVACY OF MEDICAL INFORMATION

A written organizational and medical staff policy restricts the removal of

medical records from the organizations jurisdiction and safekeeping only

to those situations governed by a court order, subpoena, or statue.

STUDENTS MAY NOT COPY PATIENT MEDICAL

RECORDS-EVER!

Confidentiality Patient health information should not be left accessible

in areas where individuals without a need to know can

view it. Discard all patient health information in document destruction bins.

Do not discuss patient health information outside of nursing stations oin hallways, cafeteria, etc. where it can be overheard by others.

Do not leave patient charts unattended.

Retrieve confidential patient information immediately from fax machine

TRACER ACTIVITYWhat do I need to consider for the tracer activity when the

surveyors come to my unit?

Have appropriate assessments (including pain assessments) andreassessments been done? Is the H & P timely?

Is there evidence of informed consent to treatment?

Is there evidence of patient rights issues (e.g. Do Not Resuscitate (DNRorders, Advance Directives?

Are all entries in the medical record dated and signed according to polic Are all orders timed, dated, and signed within 72 hours?

Is discharge planning documented?

Does the primary care nurse have accessibility to patient lab results?

Do you know what the process is for reporting critical lab results?



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MEDICAL STAFF INFORMATION

Chief of Staff Daman Sacoman MD

Director of Anesthesiology Anita Delgado, MD

Director of Surgery Lillibeth Sanchez, MDDirector of Medicine Julie Harrigan, MD

Director of Pulmonology Abderrahmane Temmar, MD

Director of Emerg Dept. Sanjay Kholwadwala, MD

Director of Bariatrics Adam Smith, DO

Director of OB Douglas Krell, MD

Common Survey Questions regarding the Medical Staff:

Q: How can you identify if a Physician is currently

credentialed on the Medical Staff?

A:The House Supervisor is supplied with the list of current

credentialed physicians.

Q: How do you know if a physician is privileged to perform a procedure?A: All physicians are credentialed and re-credentialed through the Medic

Executive committee and Governing Board. All competencies and random

peer assessments are reviewed at that time.

Q: How do you respond if you suspect that a physician is impaired?

A: Report any suspected concern to your supervisor. The details of

your concern should be submitted on an incident report. The NursingSupervisor will be informed and Administration will be contacted to

address the immediate situation. The Medical Staff has a defined process

to address impairment issues.


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Documentation Rules for medical staff:

History and Physical Examinations

Any credentialed M.D., D.O. on the Medical Staff can complete a

history and physical examination. A history and physical examinatiomay also be performed by an appropriately licensed and credentialed

allied health professional PA, CNP that has been granted such

privileges under the supervision of a member of the Medical Staff.

Documentation of the supervision is noted by the countersignature o

the physician. (Within 24 hrs)

The history and physical examination is to be completed within 24 hours

the admission.

All entries into the medical record must be authenticated, dated and time

Legibility

All documentation written in the hard copy of the chart should be

legible with a signature, date / time and written in ink! Anyone that

makes an entry into the hard chart must sign the signature page in the

front of the medical record.

Thank you Ladies and Gentlemen.

IF YOU CAN REMEMBER ANY OF THIS, YOU CAN

PASS THE JOINT COMMISSION SURVEY!



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Lovelace Westside Hospital

10501 Golf Course Rd. NW | Albuquerque N.M. 87114

lws_jcaho handbook_4x5_6-24-11 (2)_1.pdf

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