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MAPSMeasuring to Achieve Patient Safety
TRAINING MANUAL
Department of Patient Affairs
at the
Ronald Reagan UCLA Medical Center
MAPS CONTACTS
General MAPS email:[email protected]
Cait Walsh RN, MRN
Accreditation Manager
Petra Fritz, RN
Accreditation Coordinator
Carey McCarthy
Director of Volunteer Services
Lisa Harden
Volunteer Coordinator of Volunteer Services
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IntroductionThe minimum that patients should expect when they enter a hospital is safe and compassionate care. But today, in the complex world of medicine, the best intentions can have unforeseen and sometimes harmful consequences. To gain patient trust and begin a journey toward building safer healthcare systems, organizations should continually improve upon the present systems and implement changes to reduce patient risks.
UCLA is one such retrospective organization that believes in an honest assessment of patient safety and the organizational infrastructure that places the patients at risk. In November 2003, in an effort to improve patient safety as a part of its ongoing patient safety goals, and in light of an upcoming accreditation visit by the Joint Commission (JC), the Department of Patient Affairs at UCLA initiated Project MAPS. Project MAPS is designed to assess clinical practices in the hospital and improve patient safety by using the patient safety audit tools, designed as per JC, to the most superior standards of patient care.
Safety in the U.S. HealthcareAccording to estimates in medical literature, as many as 99,000 deaths occur in the United States each year due to errors in medical care; as many as 50% of such deaths are preventable. This situation should be improved and such occurrences must be prevented. For such prevention to be effective there should be an establishment of accurate methods of gathering and analyzing data from the field. A systems approach that emphasizes process improvement is a preferred method to generate useful information from which to draw the most appropriate meaningful changes. Project MAPS is an initiative by UCLA to improve its already superior patient safety record. Project MAPS is an approach which targets inculcation of a “Culture of Safety” at UCLA
Joint commission (JC) and its MissionAn independent, not for profit organization, the Joint Commission has become a world leader in fairly and objectively evaluating and accrediting nearly 20,000 healthcare organizations and programs across the country—from rural clinics to the largest, most complex healthcare networks. The Joint Commission stimulates the industry to create a stronger, more rewarding healthcare environment for everyone.
As a tool to hold itself to its image, JC constantly field tests the relevancy of its standards and takes initiatives to ensure that it reflects the current best practices and new developments in the healthcare industry. JC also conducts random unannounced surveys with no advanced warning; this can be anytime between 9 to 30 months after the triennial survey and is conducted on 5 percent of the accredited organizations. This survey can change the accreditation status of the organization.
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Considering the stringent measures, UCLA has to follow to be accredited by JC and to live up to the expectations of its patients, Project MAPS will “map” us against the performance guidelines set by JC.
Project MAPS OverviewProject MAPS is an initiative by the Department of Patient Affairs, on request of Hospital and Nursing leadership at the UCLA Medical Center, and as a part of UCLA’s continuous effort to improve patient safety and the quality of care. The MAPS program has quantifiable audit tools that measure performance in clinical processes. Performance measurement represents what is done and how it is done. The goal is to accurately understand the basis for current performance so that better results can be achieved through focused improvement actions.
Objective of MAPS
“To facilitate improvement of patient safety by observing clinical processes at UCLA Medical Center and provide highly reliable feedback to the leadership and management of UCLA healthcare.”
Audit Tools In order to measure performance, MAPS observers (volunteers) make use of four main audit tools. The audit tools are internet- or paper-based observation questionnaires that allow you to document clinical processes as per the guidelines suggested by JC. These audit tools adhere to JC’s patient safety goals for 2007. The four audit tools are described below:
1. Medication Administration - For correct identification of the patient for administering medication, JC guidelines suggest that before administering medication to patients, at least two patient identifiers (i.e. patient name and Medical Record Number (MRN)) should be used. Labeling of syringes will also be measured.
2. Syringe - Syringes must be labeled with a manufacturer tag or pre-labeled as normal saline syringes, which means it is a new syringe. Syringes (labeled or not) must be attended in a patient’s room.
3. Blood Specimen Draws - For correct identification of the patient for drawing blood, JC guidelines suggest that when drawing blood samples or giving blood products, at least two patient identifiers should be used before the procedure is carried out. These patient identifiers can be the patient’s name and Medical Record Number (MRN).
4. Hand Washing – UCLA Health Care uses the (Center for Disease Control) guidelines. It states that caregivers are to wash their hands with soap and water for a minimum of 15 seconds (specification: at least 15 seconds of soap, meaning total time will definitely be more than 15 seconds with the addition of
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water-rinsing time) OR use an alcohol-based cleanser between each patient contact or contact with equipment in patient’s room.
5. Isolation (Personal Protective Equipment) – To properly identify correct use of Personal Protective Equipment (PPE), a caregiver must put gloves and a gown on, tied on both the top and bottom portions, prior to entering rooms in which they will have contact with. All PPE used by the personnel must be disposed of when leaving the patient’s room.
Trigger Events
Events preceding any of the clinical processes listed in the audit tools are known as trigger events. These events serve as cues to begin observations. Each audit tool has different trigger events.
Medication Administration
1. Nurse entering medication room 2. Nurse handling the Pyxis machine (medicine storage distributor) 3. Nurse carrying medications into a patient’s room (syringes, pills) 4. Nurse walking with a MAR/KARDEX/Order Sheet (medication identification form)
Syringe
1. Nurse carrying a syringe from the medication room to the patient’s room2. Unattended syringes in patient rooms (does not matter if it is labeled or not)
Blood Specimen Draws
1. Phlebotomist with lab tray getting off the elevator or entering a patient’s room 2. Nurse is in area where specimen supplies (blood tubes) are stored 3. Nurse entering a patient’s room with blood tubes 4. Caregiver printing outpatient labels
Hand Washing
1. Caregiver/staff leaving patient’s room 2. Any caregiver or staff having contact with patients 3. Any caregiver or staff having contact with patient’s equipment in room
Isolation (Personal Protective Equipment)
1. Caregiver/staff entering a patient’s room that is marked “contact/spore precaution” or “isolation room”
2. Caregiver/staff exiting room that is marked “contact/spore precaution” or “isolation room”
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Data Collection Process – Step-by-Step
On a regular basis, you will be required to follow the subsequent protocol: 1. Come to the Medical Center and sign in at the kiosk computer (or use the sign-in
sheet at the Information Desk in RRMC if the computer is not available). 2. Make sure you are wearing your volunteer jacket and have your ID badge. 3. Check your assigned units and area of observation. 4. Call the charge nurse/floor manager 5 minutes before you go to your designated
area to let them know that you are coming. 5. When you go to your assigned unit, introduce yourself to the charge nurse or
floor manager. 6. Explain your purpose of observation. 7. Proceed with your observations with accuracy. 8. Communicate all of your observations to the charge nurse.
If using all-paper observations, record compliant and non-compliant observations on paper and keep them for yourself.
Whether using online paperless application or all-paper observations, record the noncompliant observations onto the appropriate separate paper observation tools and give them to the charge nurse.
9. If using all-paper observations while on the unit: at the end of your shift, enter in all the observations you have completed into the paperless application using your electronic device. At this point, online paperless app users have already entered their observations into the application.
10.Sign out of the kiosk computer (or the sign-in/out sheet).
Safety Observer Expectations
Confidentiality UCLA Healthcare makes every effort to safeguard the rights of their patients. Safety Observers will not interact with the patients in any form until prompted or asked specific questions by the patient. Any conduct deemed inappropriate may lead to immediate dismissal from the project.
Conduct and Professionalism We expect Safety Observers to maintain a professional demeanor at all times. Be polite and exit the area when finished with the observations. Safety observers are expected to be professionally dressed while visiting the patient’s areas. Wear your volunteer jacket and ID Badge at all times during the volunteering periods in the hospital.
Attendance & Punctuality Attendance and punctuality are extremely important. We will be on a schedule to achieve a number of completed observations in a required time frame. You should be at the appointed place on time (ie MAPS meetings). If you will not be able to volunteer for a certain week, you are responsible for notifying a MAPS Intern of your volunteering status for the week.
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Communication E-mail will be the primary form of communication by MAPS Interns and Supervisors. Announcements will be made by email and emails that require a reply should be done so as soon as possible. It is recommended that any questions or concerns from the volunteer should be addressed to the MAPS Interns by email at [email protected]. The MAPS Team will be delighted to help volunteers on issues such as questions about techniques, processes, or concerns about certain situations and various scenarios witnessed in the Ronald Reagan Medical Center.
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General Admonition
DO NOT’s 1. Do not participate in the medical treatment of the patients. Do not discuss with
the patient his or her diagnosis, medical conditions, or any physical discomfort, even if he or she initiates such a conversation. It is best to inform them that this is beyond your level of training and duties and you can inform the corresponding nurse or doctor for assistance.
2. Do not look up medical information for the patient on the Internet, nor offer advice or treatment.
3. Do not remove any patient information from the patient’s room, and do not handle any equipment in the room.
4. Do not purchase or give any food or drinks to the patient. Also be cautious not to wake up a sleeping patient.
5. Do not question the judgment or the decision a physician or nurse has made for the patient. If you detect something suspicious or unusual, consult the charge nurse or the Patient Affairs office or email your MAPS Intern who will help you afterwards.
Precautions 1. Before entering a patient’s room, identify any special precautions you must take
before entering by asking the nurse and examining the signs posted at the entrance, i.e. “Contact Precaution” signs. Be extremely cautious of signs that could pose a threat to you or the patient.
2. Patient areas are busy locations; try not to block traffic and stand at the least obstructive place to make observations.
Evaluation and Letters of Recommendation
The goal of Project MAPS is to produce quality data for performance improvement. This experience will provide you with multiple opportunities to be directly involved in the Medical Center’s major performance improvement project, and to gain experience with survey methodology, observational skills, and data collection techniques. As a Safety Observer, we understand that you may wish to reflect this experience on your graduate school applications.
The Ronald Reagan Medical Center Volunteer Office and the MAPS Team will be pleased to provide you with a Letter of Reference reflecting your performance. These letters will be provided to Safety Observers who complete the program for at least one year. Letters of Reference may include the following:
1. Work Quality: Your performance as a volunteer.o Dependability o Attitudeo Initiative
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2. Interpersonal Skills o Interaction with other volunteers and interns o Interactions with healthcare and administrative professionals
3. Professionalism 4. Personal Strengths 5. Productivity
o Completed Observations o Number of Safety Observation hours o Number of scheduled units completed
No Observations or Lack of Observations on Scheduled Floors
If, for any reason, you cannot complete one or more of your assigned units for a given week (finals, midterms, family emergency, or illness), you must let one of the interns know ahead of time via email at [email protected]. In addition, you must make up the uncompleted units at another time. This can be done with careful planning. For example, do an extra assigned unit the week before or an extra assigned unit the week after, etc. Either way, all units must be completed by the end of the month. This is your obligation and commitment to our volunteer program. Failing to meet these criteria will result in the following:
1. First time the interns are not notified, an email will be sent to you at the end of the month reminding you of your commitment and obligation to our volunteer program (signed contract). Uncompleted units must be made up.
2. Second time the interns are not notified, you will receive another email at the end of the month reminding you of your commitment and obligation to our volunteer program (signed contract). Uncompleted units must be made up.
3. Third time the interns are not notified, you will be dropped from the program. This will result in a negative volunteer profile & reputation of your volunteer status to both the MAPS Program and the Ronald Reagan Medical Center Volunteer Center & Volunteer Records. Future volunteer programs and letter of recommendations will highly be unlikely.
We hope that you understand that this policy was implemented in order to improve the data that we collect and distribute to hospital staff and administration within the medical center. We want to ensure that every unit gets covered for a given month since our data is so heavily relied upon by a significant variety and number of staff at the Ronald Reagan Medical Center.
This is your commitment to our program and we hope with a well-established and understanding of your contract as well as your duties and obligations to make our UCLA health care a better place, you will be able to make our health care environment safer and thus, contribute to the fact that you are helping to save lives.
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TRAINING FOR M.A.P.S. CHECKLIST
Name of Trainee: ____________________________
This checklist is to serve as a guide for new volunteers and the intern during training. Please make sure that you check off all of the procedures and possible scenarios listed below.
PREPARING FOR OBSERVATIONS □ CVS MAPS office building code□ Where to store your belongings □ Where to access tools [hand washing, medication administration, syringe, blood
specimen draw, isolation (PPE)] and supplies [unit directory, pen, clipboard] □ Access your assigned units (Assignments will be emailed to you at the beginning of each
month.)□ How to sign into the kiosk computer to volunteer
SETTING UP YOUR OBSERVATIONAL TOOLS □ How to open and sign in to the online paperless application? (mps.uclahealth.org)□ Which wifi do I use? MEDGUEST□ Identify the unit you will be conducting observations [For Training, we will be going to a
General Unit, Intensive-Care Unit, and Phlebotomy] □ Call up the charge nurse to notify them that you will be conducting Patient Safety
Observations on their unit. □ Introduce yourself upon arrival to the unit□ Identify a patient’s room number & bed □ How to differentiate amongst different members of the medical staff
MEDICATION ADMINISTRATION □ What are the trigger events?□ What are examples of patient identifiers?□ What if the staff/caregiver does not use two patient identifiers but only one? □ Is it OKAY if the staff/caregiver only asks the patient for name and date of birth and does
not actively identify the patient using two identifiers?□ If the patient takes more than one medication, does the staff/caregiver only need to scan
the patient’s ID band once?
SYRINGE □ What are the trigger events?□ Is it OKAY to have a labeled syringe in a patient’s room while the nurse leaves the room
to grab something from the medication room?
BLOOD SPECIMEN DRAWS □ What if the staff/caregiver checks patient identifiers but does not label tubes at the
bedside? □ Is right outside the room by the door considered “bedside”?□ Can nurses draw blood?
HAND WASHING
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□ What are the trigger events?□ How do I note if the person does not wash hands after patient contact? □ What if caregiver does not rub hands for 15 seconds? □ What if the caregiver does not use soap and rinses hands only in water? □ What if the caregiver does not wash hands in between changing gloves?
ISOLATION (PERSONAL PROTECTIVE EQUIPMENT) □ What are the trigger events?□ What are examples of Personal Protective Equipment (PPE)?□ What if a healthcare staff is already in the Isolation Room but you did not see whether
he/she washed his/her hands?□ What are the criteria for “Gown worn properly”? □ What do the abbreviations [HH, GNTT, GNTB] mean? □ What fields have to be marked “Y” in order for the overall observation to be compliant?
AFTER OBSERVATIONS□ Whether using the MAPS online paperless application or all-paper observations:
o You must write down the noncompliant observations onto separate paper observation tools.
o Give these papers to the charge nurse at the end of your shift. □ If you are using all paper for observations:
o Record compliant and non-compliant observations on paper and keep them for yourself. Enter in all the observations you have completed into the paperless application using your own electronic device.
□ How to sign out of the kiosk computer (or the sign-in/out sheet)
OTHER □ Need to note the date and time you completed each unit
o You will need to enter these dates and times into the google form emailed to volunteers at the end of the month.
□ Where to go and what to do if main MAPS office cannot be accessed□ Where to go and what to do if volunteering early in the morning or at night (before 9AM
or after 5:00PM) □ Where to go and what to do if volunteering on the weekends□ What to do if alternative office is not accessible
SANTA MONICA HOSPITAL□ Interested in volunteering in another hospital setting?□ Transportation shuttles or Big Blue Bus can take you there.
FALL AMBASSADOR PROGRAM□ Interested in another aspect of the MAPS Program?□ Fall Prevention
Be pro-active to get the most out of MAPS. Do not be aggressive, but you should be engaged in your volunteering, not studying notes, texting, etc.VOLUNTEER AGREEMENT (VOLUNTEER COPY)
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This agreement is intended to represent the seriousness with which we treat our
volunteers. Its purpose is to assure you of our deep appreciation of your services and to
indicate our commitment to do the very best we can to make your volunteer experience
with UCLA and MAPS a productive and rewarding one.
THE MAPS LEADERSHIP TEAM AND VOLUNTEER PROGRAM
We, The MAPS Leadership Team, agree to accept the services of _______________________________beginning on __________________and we commit to the following:
1. To provide adequate information, training, and assistance for the volunteer to be
able to meet the responsibilities of the MAPS requirements, mission statement,
and volunteer program.
2. To ensure supervisory support and to provide feedback on the volunteer’s
performance.
3. To be receptive to any questions or comments from the volunteer regarding ways
in which we might better accomplish our respective tasks or assistance.
4. To respect the skills and needs of the volunteer, and to treat the volunteer as an
equal partner of the MAPS project, jointly responsible for the completion of its
goals and the fulfillment of its mission.
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THE VOLUNTEER (VOLUNTEER COPY)
I,________________, agree to serve as a MAPS volunteer and commit to the following:
1. To complete all medical requirements as outlined by the Volunteer Services Office in the Ronald Reagan Medical Center before entering patient areas.
2. To observe the guidelines of the volunteer dress code. This includes: Volunteer jacket, khaki pants only, closed toe shoes, and ID Badge to be displayed at all times.
3. To fulfill the requirements of the Ronald Reagan Medical Center Volunteer Services Office.
4. To complete sufficient training in three areas: General units (i.e. 6 West), Intensive- Care units (i.e. 6ICU), and Phlebotomy. This will be done with a MAPS Intern.
5. To conduct observations of a minimum of 8 units per month, for at least 2 hours per unit. This means a total of 16 hours each month. Summer, Winter Break, and Spring Break are optional in regards to volunteer commitments (MAPS Volunteer Program goes gray, not dark, during this time).
6. To commit to a minimum of three quarters starting the quarter that the volunteer receives training.
7. To complete all of my assigned units by the end of the month. In case of a conflict, I will be responsible for notifying the MAPS Leadership Team at [email protected] and scheduling an alternate make-up time.
8. To notify the MAPS Leadership Team of any difficulties, questions, concerns, or conflicts that may arise during observation hours.
9. To attend quarterly meetings in order to discuss all-MAPS-related updates, announcements, statistics, results, and address questions regarding the observation processes. If a volunteer is not capable of attending a meeting due to significant reasons such as midterms scheduling conflicts, please inform the MAPS Leadership Team at [email protected] of your absence with a legitimate reason. The MAPS Leadership Team will follow up on those who are no-shows without a notification to our meetings.
10.To perform my volunteer duty to the best of my ability in order to provide reliable data that will help improve patient safety performance levels at Ronald Reagan UCLA Medical Center.
11.To conduct myself with the utmost professionalism and to abide by the UCLA Healthcare Confidentiality guidelines.
Volunteer (Print)______________________________________ Date: ____________Volunteer (Signature)__________________________________ Date: ____________MAPS Intern/Supervisor (Print)__________________________ Date: ____________MAPS Intern/Supervisor (Signature)_______________________ Date:____________
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THE VOLUNTEER (MAPS INTERN/SUPERVISOR COPY)
I,________________, agree to serve as a MAPS volunteer and commit to the following:
1. To complete all medical requirements as outlined by the Volunteer Services Office in the Ronald Reagan Medical Center before entering patient areas.
2. To observe the guidelines of the volunteer dress code. This includes: Volunteer jacket, khaki pants only, closed toe shoes, and ID Badge to be displayed at all times.
3. To fulfill the requirements of the Ronald Reagan Medical Center Volunteer Services Office.
4. To complete sufficient training in three areas: General units (i.e. 6 West), Intensive- Care units (i.e. 6ICU), and Phlebotomy. This will be done with a MAPS Intern.
5. To conduct observations of a minimum of 8 units per month, for at least 2 hours per unit. This means a total of 16 hours each month. Summer, Winter Break, and Spring Break are optional in regards to volunteer commitments (MAPS Volunteer Program goes gray, not dark, during this time).
6. To commit a minimum of three quarters starting the quarter that the volunteer receives training.
7. To complete all of my assigned units by the end of the month. In case of a conflict, I will be responsible for notifying the MAPS Leadership Team at [email protected] and scheduling an alternate make-up time.
8. To notify the MAPS Leadership Team of any difficulties, questions, concerns, or conflicts that may arise during observation hours.
9. To attend quarterly meetings in order to discuss all-MAPS-related updates, announcements, statistics, results, and address questions regarding the observation processes. If a volunteer is not capable of attending a meeting due to significant reasons such as midterms scheduling conflicts, please inform the MAPS Leadership Team at [email protected] of your absence with a legitimate reason. The MAPS Leadership Team will follow up on those who are no-shows without a notification to our meetings.
10.To perform my volunteer duty to the best of my ability in order to provide reliable data that will help improve patient safety performance levels at Ronald Reagan UCLA Medical Center.
11.To conduct myself with the utmost professionalism and to abide by the UCLA Healthcare Confidentiality guidelines.
Volunteer (Print)______________________________________ Date: ____________Volunteer (Signature)__________________________________ Date: ____________MAPS Intern/Supervisor (Print)__________________________ Date: ____________MAPS Intern/Supervisor (Signature)_______________________ Date:____________
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SAFETY OBSERVER VOLUNTEER CONTACT SHEET
First and Last Name: _________________________________
Year in School: ______________________________________
Major: ______________________________
Primary Email: ___________________________________
Cell Phone #: _______________________
University ID #: _____________________
CHECK WHEN COMPLETED:
□ Volunteer Referral slip signed □ ID Badge obtained □ Volunteer Jacket & Uniform obtained □ Successfully completed summary & review of MAPS Training Manual □ MAPS Contract Signed & Completed □ Passed MAPS Training Manual Quiz □ Administrative training completed □ General floors training completed □ Intensive-care unit training completed □ Phlebotomy training completed □ Passed MAPS Post-Training Quiz
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