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Your Champion for Better Health

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Page 1: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Your Champion for Better Health

Page 2: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Mission StatementMission 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.

Page 3: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Vision StatementVision Statement

To be the center of northern Michigan’s patient focused alliance dedicated to healthcare excellence.

Page 4: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

ValuesValues

Respect: Appreciating diversity and treating all with compassion,

dignity and courtesy• Show the person you are interacting with that they are your priority• Convey empathy—put yourself in others’ shoes• Listen to and honor the personal, cultural and spiritual needs of

patients and families• Recognize that every job is important and has value

Page 5: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

ValuesValues

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

Page 6: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

ValuesValues

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

Page 7: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

ValuesValues

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

Page 8: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Customer ServiceCustomer Service

• Patient satisfaction is directly related to how we treat our customers

• You will be receiving addition education regarding our customer service

• The following are the behaviors we ask our employees to exhibit

Page 9: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Customer ServiceCustomer Service

GreetValue as a customerAsk how you can helpListen words, tone and body languageHelp meet their needs Invite them to contact us

Page 10: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Rights as a PatientRights 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

Page 11: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Rights as a PatientRights 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)

Page 12: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Pain AssessmentPain Assessment

When assessing pain, a number value should be assigned by the patient to make for consistent measurement

Page 13: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

FLACC Scale FLACC Scale Non VerbalNon Verbal

Page 14: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

RightsRights

Patients have a right to: • Privacy• Treatment records are confidential• Review their medical records• Be free from discrimination• Discuss continuing care needed after

hospitalization

Page 15: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

RightsRights

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

Page 16: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

RightsRights

Patients have a right to:• Be informed of outcomes of care including

unanticipated outcomes• Raise concerns through a formal grievance• Access Protective Services

Page 17: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

RightsRights

Patients have a right to:• Comfort measures/peace and dignity at

end of life• Patients who have a Do Not Resuscitate status will

have a purple armband placed around their wrist • McReynold's Hall patients have a purple dot placed on

their identification bracelet • Spiritual and pastoral care• Appropriate screening and stabilization

before transfer to another facility

Page 18: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Patient ResponsibilitiesPatient 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

Page 19: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Advance DirectivesAdvance Directives

Advance Directives are: A legal document that gives the

appointed advocate permission to make medical decisions when the patient is deemed incompetent by 2 physicians

Page 20: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH Process for Advanced DirectivesOMH 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

Page 21: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection Control

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

Page 22: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection 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

Page 23: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection Control

Keystone InitiativeWash your hands upon entering a patient-care area and upon leaving

WASH IN WASH OUTWASH IN WASH OUT

Page 24: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection Control

Standard Precautions“All the patients, all the time”

Page 25: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection Control

Standard Precautions• Specific behaviors that healthcare

workers (HCW) follow to protect both themselves and patients from infection

• Practice 100% of the time

Page 26: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection 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

Page 27: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection 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)

Page 28: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection 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

Page 29: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection Control

• Handle all patient care equipment to prevent exposure to other patients, visitors, and healthcare workers

• Keep used patient equipment including soiled linens away from your skin, mucous membranes and clothing

• Don’t let used equipment or linens contaminate surfaces or clean items

Page 30: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Sharps SafetySharps Safety

Never bend, recap, or break used needles unless the procedure requires it

Place used sharps in a designated disposable container immediately after use

Page 31: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Infection ControlInfection 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-

CONTACTCONTACT--AIRBORNEAIRBORNE--DROPLETDROPLET

Page 32: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

AIRBORNE PrecautionsAIRBORNE 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

Page 33: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Exposure toExposure toBlood or FluidsBlood 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

Page 34: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ORDER FOR DRESSING IN PPE ORDER FOR REMOVING PPE

Page 35: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Age Specific CareAge Specific Care

• Be aware that all ages have different physical, psychological, and social needs

• Tailor education to the patient’s age and needs• If staff and volunteers are aware

then it is a safer environment• Involve family in the care

Page 36: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

AbuseAbuse

Types of abuse:• Elders

• Physical Abuse, Neglect, Exploitation• Child

• Abuse, Neglect• Observed or suspected

– we are required by law to report it!

Page 37: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Patient Safety: Patient Safety: A National IssueA 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

Page 38: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

How National Patient Safety How National Patient Safety Goals affect your practiceGoals 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

Page 39: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Goal 1: Improve the Accuracy of Goal 1: Improve the Accuracy of Patient/resident/client Identification.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

Page 40: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Implementation Expectations 1A Implementation Expectations 1A Use at least two patient identifiers whenever: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.

Page 41: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

1B: Implement the Universal Protocol for 1B: Implement the Universal Protocol for Invasive ProceduresInvasive 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

Page 42: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Goal 2: Improve Effectiveness of Goal 2: Improve Effectiveness of CommunicationCommunication

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

Page 43: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Standardize a list of abbreviations, acronyms, and Standardize a list of abbreviations, acronyms, and symbols that are not to be used symbols that are not to be used

throughout the organizationthroughout 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

Page 44: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

The Official OMH The Official OMH ““Do Not UseDo Not Use”” List Includes: 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

Page 45: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

2E: Hand Off Communication2E: Hand Off Communication

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

Page 46: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Implementation ExpectationsImplementation 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…

Page 47: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

SBARSBARS=SituationB=BackgroundA=AssessmentR=Recommendation

Any Questions?

Example

S=Admitted an 82 year old with pneumonia, possible aspiration.

B=History of stroke, has been having increased cough x 3 weeks per family, fever began today..

A=RR is 24 and unlabored, temp is 101 degrees F, swallowing evaluation ordered for a.m., alert and oriented x2. First antibiotic completed at 0300.

R=Keep HOB elevated at least 30 degrees, remain NPO until swallowing sturdy complete and recommendations added to care plan. Next antibiotic is due at 0900. Additional assessment and care plan includes patient is a high risk for falls, bed alarm on and frequent rounds to assist with toileting needs.

Page 48: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Verify LabelsVerify Labels

• Label all medications, medication containers, (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings

Page 49: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Implementation Expectations: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.

Page 50: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Anticoagulation TherapyAnticoagulation Therapy

Reduce patient harm associated with anticoagulation therapy

Page 51: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Goal 4 : Goal 4 : Eliminate Wrong-site, Wrong Patient, Eliminate Wrong-site, Wrong Patient, Wrong Procedure Surgery.Wrong Procedure Surgery.

Create and use a preoperative verification process such as a checklist to confirm that appropriate documents are available

Page 52: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Goal 4B Implement a Process to Mark the Surgical Goal 4B Implement a Process to Mark the Surgical Site and Involve the Patient in the Marking ProcessSite 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”

Page 53: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Goal 7 Reduce the Risk of Health Care Goal 7 Reduce the Risk of Health Care Associated InfectionsAssociated 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 OUTWASH IN WASH OUT

Page 54: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Goal 7C MDROGoal 7C MDRO

Prevent healthcare–associated 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

Page 55: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Goal 8 Accurately and Completely Reconcile Accurately and Completely Reconcile Medications Across the Continuum of Care.Medications Across the Continuum of Care.

• Implement a process for obtaining and documenting a complete list of the patient/resident/client’s current medications upon the patient/resident/client’s admission/entry to the organization and with the involvement of the patient/resident/client.

• A complete list of the patient/resident/client’s medication is communicated to the next provider of service when a patient/resident/client is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.

Page 56: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Reduce the Risk of Patient/resident/client Harm Reduce the Risk of Patient/resident/client Harm Resulting From FallsResulting From Falls

Implement a fall reduction program and evaluate the effectiveness of the program

Use the Fall Risk Assessment

Page 57: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Identify Safety RisksIdentify Safety Risks

The organization identifiessafety risks inherent in its patient population

Goal 15A:The organization identifies patients at risk for suicide

Page 58: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Suicide Risk AssessmentSuicide Risk Assessment

“Suicide Risk Assessment”is found :

Hospital Information PageForms

Nursing

Page 59: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Rapid Response TeamRapid Response Team

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

Page 60: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Rapid Response TeamRapid Response Team

• Team consists of critical care nurses, respiratory therapists and primary care nurse.

• The rapid assessment team may be called at any time by anyone in the hospital to assist in the care of a patient who appears acutely ill or who shows signs of decline.

• Team assists patient’s nurse in assessing condition and provides support in communicating findings to patient’s physician.

Page 61: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH Patient Safety PlanOMH 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

Page 62: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Reporting a Medical/Safety OccurrenceReporting 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

Page 63: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Reporting an Employee IncidenceReporting an Employee Incidence

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

Page 64: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Variance ReportVariance Report

• This form is used to report near misses, safety concerns, and quality concerns

• It can be submitted anonymously

Page 65: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Variance ReportVariance 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

Page 66: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

“Tapping The Wisdom of The Frontline”

•Create and maintain a culture of safety and quality throughout the campus.•98,000 patients are harmed each year because of medical errors caused by healthcare defects.

C.U.S.P.C.U.S.P. Comprehensive Unit Safety ProgramComprehensive Unit Safety Program

Page 67: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Corporate ComplianceCorporate 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

Page 68: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Corporate ComplianceCorporate Compliance

Suspected corporate compliance violations are to be reported via the Corporate Compliance Hotline at x 17720 or by completing a Compliance Violation Report

Page 69: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

You Are Valuable to OMH You Are Valuable to OMH and Our Patientsand Our Patients

Your knowledge and compliance is vital to our patients safety: – Hospital policies and

procedures – National Patient

Safety Goals– Reporting occurrences

and concerns

Page 70: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Reporting a ConcernReporting a Concern

Please contact the Patient Safety and Corporate Compliance Officer,

Bonnie Byram at 731-7703

Employees also have the choice of reporting safety or quality concerns to the

Joint Commission at (630) 792-5636 or [email protected]

Page 71: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Performance ImprovementPerformance 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.

PlanPlan DoDo CheckCheck ActAct

Page 72: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve
Page 73: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Professional Work EnvironmentProfessional 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

Page 74: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Professional Work EnvironmentProfessional 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;

Page 75: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Professional Work EnvironmentProfessional 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;

Page 76: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Professional Work EnvironmentProfessional Work Environment

Prohibited Conduct• Unwanted sexual advances, including

offensive touching, pinching, brushing the body, or impeding or blocking movement.

Page 77: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Environmental Safety AwarenessEnvironmental 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.

Page 78: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve
Page 79: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

To announce an emergency an overhead paging system is in place:

• Dial 477• Speak Slowly, Loudly & Clearly• Room numbers posted in each room

Page 80: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

Code Red = FireCode Red = Fire– OMH Code Red Policy– Doors are numbered and lettered for Fire

Department H – hospital M – McReynolds P - PMB

Page 81: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

Code RedCode 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

Page 82: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

Code RedCode 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

Page 83: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

Code BlueCode 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

Page 84: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

Code YellowCode 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

Page 85: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

Code GreyCode 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

Page 86: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

Code PinkCode 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

Page 87: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

Code SilverCode Silver• If you are confronted

by an individual with a weapon OR

• If you observe a hostage situation on Hospital property

Page 88: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Initiating Code Initiating Code SilverSilver Plan 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

Page 89: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Workplace ViolenceWorkplace Violence

• Healthcare and social service workers face an increased risk of work-related assaults

• If threat is imminent, call Code GreyCode Grey Assist or Code GreyCode Grey 911

Page 90: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Workplace ViolenceWorkplace 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.

Page 91: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

Code TriageCode 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

Page 92: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

OMH CodesOMH Codes

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

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OMH CodesOMH Codes

Severe WeatherSevere 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

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Hospital Incident Command System (HICS)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

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Infant AbandonmentInfant 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

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HIPAAHIPAA

• The HIPAA Privacy Rule protects a patient’s fundamental right to privacy and confidentiality

• ANY information obtained about another person’s medical condition is treated as confidential and is not to be discussed or revealed to unauthorized persons

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HIPAAHIPAA

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

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HIPAAHIPAA

HIPAA’s focus is on the rights of the patient and the confidentiality of their information.

Patients have the right to:• Request an amendment of their medical record• Request to inspect and copy their record• Restrict what information is shared• Receive confidential communication• Complain about a disclosure of their information

Page 99: Your Champion for Better Health. Mission Statement To provide exceptional healthcare that meets the needs of our patients and the communities we serve

Ethics CommitteeEthics 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

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Appropriate Ethics ReferralsAppropriate Ethics Referrals

• A staff member’s belief system is in conflict with a patient’s treatment plan.

• A family/patient is in conflict with the proposed treatment.

• Resource allocation

• Revising/updating policies/practices with ethical implications.

• Offering support for clinical or medical issues with ethical implications.

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Medical Record DocumentationMedical 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

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Impaired Health ProfessionalImpaired 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.

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Environment of CareEnvironment of Care

We have 7 plans in place to assure the safety of our patients and our staff:Plan 1: Biomedical Equipment ManagementPlan 2: Emergency Preparedness ManagementPlan 3: Life safety ManagementPlan 4: Hazardous Material and Waste ManagementPlan 5: Utility systems ManagementPlan 6: Security ManagementPlan 7: Safety Management

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Chemical HazardsChemical Hazards“Right To Know”“Right 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

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MRI SafetyMRI Safety((Magnetic Resonance Imaging)Magnetic Resonance Imaging)

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MRI SafetyMRI Safety((Magnetic Resonance Imaging)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

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Ergonomics and Back SafetyErgonomics and Back Safety

• Our goal is to use this science of ergonomics to reduce work-related Musculoskeletal disorders (MSD’s)

• Everyone, not only those involved in direct patient care, needs to have training in proper body mechanics and lifting

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Safe LiftingSafe Lifting

• Use your strong leg muscles• Keep objects close• Tighten abdominal muscles• Bend knees and squat• Use proper lift equipment• Ask for help when needed• Keep head and shoulders up (keeps spine curves

in alignment)

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Comfort and Care at the End of LifeComfort and Care at the End of Life

• Managing symptoms is the goal• Even if patients are not responsive, always

explain care/treatment• Respect personal choices and values

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Organ and Tissue DonationOrgan and Tissue Donation

• Gift of Life-we do participate! • Organ procurement done in OR • Tissues procurement can be done at hospital

or funeral home• Hospital required to call all imminent deaths

to Transplantation Society of Michigan•

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Cultural CompetenceCultural Competence

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

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QuestionsQuestions

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

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The EndThe EndWelcome