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At our best when it matters most. 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, Frederic and Waters Otsego Memorial Hospital will be preferred and trusted as the center for patientfocused care that is comprehensive, coordinated and accessible. Through committed teamwork, we will build a sustainable and secure future of improving health for the communities of northern Michigan. • Established 1951 • Private, Non-Profit Corporation • Governed by 10 Member Board of Directors • Accredited • • • • Otsego Memorial Hospital OMH Foundation McReynolds Hall OMH Medical Group • • • • • • • OMH MedCare Walk-In Clinic OMH Medical Group–Gaylord OMH N’Orthopedics OMH Medical Group–Lewiston OMH Medical Group–Indian River OMH Medical Group–Urology OMH Medical Group–Boyne Valley • OMH Auxiliary • Munson Healthcare • Munson Home Care/ Home Services Workforce: 800 Employees Physicians: 100+ Affiliated including 70 employed providers Beds: 46 Acute Care (Hospital) 34 Long Term/Skilled (McReynolds) 225,000+ Annual Patient Visits Appreciating diversity and treating all with compassion, dignity and courtesy • Show the person you are interacting with that they are your priority • Convey empathy – put yourself in others’ shoes • Listen to and honor the personal, cultural and spiritual needs of patients and families • Recognize that every job is important and has value Unwavering commitment to honesty and trust • Do the right thing for the right reason • Protect confidentiality and privacy • Discuss differences constructively, directly and tactfully • Advocate for our patients, employees and organization Teamwork and communication dedicated to understanding and exceeding expectations of quality, safety and customer service • Take initiative to promote a culture of accomplishment, enthusiasm and expertise; take pride in your work • Promote an exceptional healing environment based on individual needs • Be open to giving and receiving feedback to accomplish mutual goals • Achieve the best results in all we do Accepting Responsibility for our actions See It • • Be engaged to contribute positively Acknowledge opportunities by learning from our experiences Own It • Understand how individual actions contribute to desired outcomes Solve It • Follow through on commitments and responsibilities • Recognizing opportunities and creating solutions that bring value to our patients, staff and the communities we serve. Customer Service • • • Patient satisfaction is directly related to how we treat our customers You will be receiving addition education regarding our customer service The following are the behaviors we ask our employees to exhibit Customer Service Greet Value as a customer Ask how you can help Listen words, tone and body language Help meet their needs Invite them to contact us Rights as a Patient Patients have a right to: • Considerate and respectful care • Understandable information – Patients will have a green dot on their ID bracelet if they have difficulty understanding basic communication – Please see their chart for more information regarding their communication challenge Rights as a Patient Patients have a right to: • Be free from seclusion and physical/chemical restraint (refer to policy) • Consent or refuse treatment • Appropriate pain assessment/symptom management (see scale) Pain Assessment When assessing pain, a number value should be assigned by the patient to make for consistent measurement FLACC Scale Non Verbal Rights Patients have a right to: • Privacy • Treatment records are confidential • Review their medical records • Be free from discrimination • Discuss continuing care needed after hospitalization Rights Patients have a right to: • Know the hospital rules • Consult the Ethics committee • Know the physician who has primary responsibility • A second opinion • Advanced Directive Rights Patients have a right to: • Be informed of outcomes of care including unanticipated outcomes • Raise concerns through a formal grievance • Access Protective Services Rights Patients have a right to: • Comfort measures/peace and dignity at end of life • Patients who have a Do Not Resuscitate status will have a purple armband placed around their wrist • McReynold's Hall patients have a purple dot placed on their identification bracelet • Spiritual and pastoral care • Appropriate screening and stabilization before transfer to another facility Patient Responsibilities Patients need to: • • • • • • • • • Provide Accurate Information Keep Appointments Understand consequences of refusing treatment Follow hospital rules Be considerate of others Be responsible for financial obligation Notify staff of communication issues Ask questions if they do not understand No Alcohol, recreational drugs, or firearms/weapons Advance Directives Advance Directives are: A legal document that gives the appointed advocate permission to make medical decisions when the patient is deemed incompetent by 2 physicians OMH Process for Advanced Directives • • • Pt. are given information about advanced directives, if not familiar, at admission Copies of advance directives are scanned into the medical record Upon admission, the advance directive should be available to the area where the patient will be located Infection Control Washing or sanitizing your hands frequently and properly is the single most important action you can take to prevent the spread of infection. Infection Control Hand Sanitizer is effective for hand hygiene but you should wash with soap and water if hands are soiled or if caring for someone with C. diff Infection Control Keystone Initiative Wash your hands upon entering a patient-care area and upon leaving WASH IN WASH OUT Infection Control Standard Precautions “All the patients, all the time” Infection Control Standard Precautions • Specific behaviors that healthcare workers (HCW) follow to protect both themselves and patients from infection • Practice 100% of the time Infection Control • Apply to blood, all body fluids, excretions and secretions except sweat, plus nonintact skin and mucous membranes • Protect against bloodborne pathogens such as HIV, hepatitis B and hepatitis C • Protect against pathogens from moist body substances Infection Control •Wear gloves when touching blood, body fluids, excretions, and contaminated surfaces • Wash your hands after contact with body substance even if gloves are worn • Wash your hands and change gloves between patients and between touching clean and dirty sites on the same patient • Wear a mask, eye protection and a gown if splashes or spatters are possible (Latex free products are available) Infection Control Practice Respiratory Etiquette all year •Use mouthpieces, resuscitation or other ventilation devices as an alternative to “mouth to mouth” resuscitation methods • Be sure reusable equipment is cleaned and disinfected before used on another patient Infection Control • Handle all patient care equipment to prevent exposure to other patients, visitors, and healthcare workers • Keep used patient equipment including soiled linens away from your skin, mucous membranes and clothing • Don’t let used equipment or linens contaminate surfaces or clean items Sharps Safety Never bend, recap, or break used needles unless the procedure requires it Place used sharps in a designated disposable container immediately after use Infection Control Transmission Based Precautions • Additional precautions that healthcare workers practice when a patient is suspected of having an illness that spreads very easily and is based on how the infection is spread- CONTACT-AIRBORNE-DROPLET AIRBORNE Precautions Requires patients to be in a negative pressure room and staff need to wear a PAPR (Powered Air Purifying Respirator) Good ventilation is important for preventing the spread of TB Active TB patients need to wear a mask if they go outside of the room Exposure to Blood or Fluids • • • • • Wash vigorously the area immediately with soap and water Report the exposure to the supervisor of your Department Complete the “Exposure Form” Report to ED for evaluation If exposure to eyes, flush for 15 minutes at eye wash station with COLD water PERSONAL PROTECTIVE EQUIPMENT (PPE) ORDER FOR DRESSING IN PPE ORDER FOR REMOVING PPE Age Specific Care • Be aware that all ages have different physical, psychological, and social needs • Tailor education to the patient’s age and needs • If staff and volunteers are aware then it is a safer environment • Involve family in the care Abuse Types of abuse: • Elders • Physical Abuse, Neglect, Exploitation • Child • Abuse, Neglect • Observed or suspected – we are required by law to report it! Patient Safety: A National Issue • In an effort to prevent medical errors for all patients in the healthcare setting, the Joint Commission issues annual National Patient Safety Goals • National Patient Safety Goals are developed as medical errors that occur across the nation are analyzed and the root causes identified How National Patient Safety Goals affect your practice • Your understanding and compliance with the National Patient Safety Goals and hospital policy is vital to our patients safety and your success at OMH Goal 1: Improve the Accuracy of Patient/resident/client Identification. • To prevent medical errors, a patient must be identified by comparing two types of identifiers • According to OMH policy, the two patient identifiers include the patients name and date of birth found in the medical record documents and on the identification bracelet Implementation Expectations 1A Use at least two patient identifiers whenever: • • • • Collecting lab samples Administering medications or blood products Providing any treatment or procedure Label sample collection containers in the presence of the patient. 1B: Implement the Universal Protocol for Invasive Procedures The “time out” final verification process to confirm the correct patient, procedure, site, and availability of documents and equipment must occur in the location where the procedure is to be done and should involve the entire team Goal 2: Improve Effectiveness of Communication For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result write down then “read back” the complete order or test result Standardize a list of abbreviations, acronyms, and symbols that are not to be used throughout the organization The “Do Not Use” abbreviation list applies to all orders and other medication-related documentation when handwritten, entered as free text into a computer, or on pre-printed forms The Official OMH “Do Not Use” List Includes: Do Not Use: Write this Instead: Trailing Zero (1.0) 1mg Lack of leading zero 0.5mg U, u, IU, or iu Units or international units Daily or every other day q.d., QD, Q.D., Q.O.D. MS, MS04, MgS04 Morphine or Magnesium Sulfate 2E: Hand Off Communication Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions Implementation Expectations “In health care there are numerous types of hand offs, including but not limited to: • Nursing shift changes • Physicians transferring complete responsibility for a patient • Physicians transferring on call responsibility… SBAR S=Situation B=Background A=Assessment R=Recommendation Any Questions? 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. Verify Labels • Label all medications, medication containers, (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings Implementation Expectations: • • • • • All labels are verified both verbally and visually by two qualified individuals. No more than one medication is labeled at one time. Unlabeled medications or solutions are discarded. All original containers remain available for reference in the perioperative area until the conclusion of the procedure. At shift change/break, all medications and solutions both on and off the sterile field are reviewed by entering and exiting personnel. Anticoagulation Therapy Reduce patient harm associated with anticoagulation therapy Goal 4 : Eliminate Wrong-site, Wrong Patient, Wrong Procedure Surgery. Create and use a preoperative verification process such as a checklist to confirm that appropriate documents are available Goal 4B Implement a Process to Mark the Surgical Site and Involve the Patient in the Marking Process Marking is required in all cases involving right/left distinction, multiple structures or levels of the spine. Procedures done through a midline incision intended for a right/left distinction are subject to site marking. “YES” Goal 7 Reduce the Risk of Health Care Associated Infections Compliance with the CDC hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients/clients/residents, thereby decreasing the incidence of healthcare associated infections (HAI) WASH IN WASH OUT Goal 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 to be infected with MDRO • Educate staff and patients on prevention • Careful use of antimicrobials • Clean, disinfect, and sterilize appropriately • De-colonize persons with specific MDRO Goal 8 Accurately and Completely Reconcile Medications Across the Continuum of Care. • Implement a process for obtaining and documenting a complete list of the patient/resident/client’s current medications upon the patient/resident/client’s admission/entry to the organization and with the involvement of the patient/resident/client. • A complete list of the patient/resident/client’s medication is communicated to the next provider of service when a patient/resident/client is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization. Reduce the Risk of Patient/resident/client Harm Resulting From Falls Implement a fall reduction program and evaluate the effectiveness of the program Use the Fall Risk Assessment Identify Safety Risks The organization identifies safety risks inherent in its patient population Goal 15A: The organization identifies patients at risk for suicide Suicide Risk Assessment “Suicide Risk Assessment” is found : Hospital Information Page Forms Nursing Rapid 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 Rapid Response Team • Team consists of critical care nurses, respiratory therapists and primary care nurse. • The rapid assessment team may be called at any time by anyone in the hospital to assist in the care of a patient who appears acutely ill or who shows signs of decline. • Team assists patient’s nurse in assessing condition and provides support in communicating findings to patient’s physician. OMH Patient Safety Plan Purpose: To reduce risk to patients through an environment that encourages: • Recognition and acknowledgement of risks to patient safety and healthcare errors • Actions to reduce risks • Internal reporting • Focus on systems/processes, minimizing individual blame • Learning from errors Reporting a Medical/Safety Occurrence Report the occurrence to the charge nurse and complete an Occurrence Form • • • • Examples: Medication error Patient fall Needle stick Treatment error Reporting an Employee Incidence If something happens to an employee, they use an Employee Incident Form Variance Report • • This form is used to report near misses, safety concerns, and quality concerns It can be submitted anonymously Variance Report • • • What is a near miss? Any unintended provision of care which could have constituted a medical occurrence but was intercepted before it actually reached the patient By reporting near misses we can help avoid errors from occurring C.U.S.P. Comprehensive Unit Safety Program “Tapping The Wisdom of The Frontline” • • Create and maintain a culture of safety and quality throughout the campus. 98,000 patients are harmed each year because of medical errors caused by healthcare defects. Corporate Compliance • The purpose of a Corporate Compliance Plan is to prevent, detect and/or respond to violations of statutes and regulations dealing with such things as fraud and abuse Corporate Compliance Suspected corporate compliance violations are to be reported via the Corporate Compliance Hotline at x 17720 or by completing a Compliance Violation Report You Are Valuable to OMH and Our Patients Your knowledge and compliance is vital to our patients safety: – Hospital policies and procedures – National Patient Safety Goals – Reporting occurrences and concerns Reporting a Concern Please contact the Patient Safety and Corporate Compliance Officer, Kelly Martin 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] Performance Improvement Otsego Memorial Hospital is committed to providing quality care to the patients we serve. The Performance Improvement Plan outlines the systematic approach the organization takes towards continuous quality improvement. Plan Do Check Act Professional Work Environment • Professional Work Environment • Everyone has the right to be treated with dignity and respect • Prohibited Conduct • Sexual Harassment • Hostile Work Environment • Report to CEO or HR Director Professional Work Environment Prohibited Conduct • Crude or offensive language, sounds, innuendoes or jokes, whether communicated verbally, by electronic mail or otherwise relating to race, color, religion, national origin, sex, age, height, weight, marital status, disability or other protected classification; Professional Work Environment 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; Professional Work Environment Prohibited Conduct • Unwanted sexual advances, including offensive touching, pinching, brushing the body, or impeding or blocking movement. Environmental Safety Awareness Any time an emergency alarm or “Code” is paged, plan to remain with the patients until instructed otherwise by hospital staff. Should evacuation become necessary, you will be instructed in specific actions to ensure personal safety of the patient and yourself. OMH Codes To announce an emergency an overhead paging system is in place: • Dial 477 • Speak Slowly, Loudly & Clearly • Room numbers posted in each room OMH Codes Code Red = Fire – OMH Code Red Policy – Doors are numbered and lettered for Fire Department H – hospital M – McReynolds P - PMB OMH Codes Code Red • Return to your work area, if safe • Do not use elevators • Feel doors, do not open if hot • Close all doors & windows • Clear corridors and exits • Assign staff to answer phones OMH Codes Code Red Response Fire Extinguisher use – R = Remove persons – P = Pull the pin from area – A = Activate fire alarm – C = Contain fire and smoke – E = Extinguish fire or evacuate – A = Aim toward the base of the fire – S = Squeeze the handle – S = Sweep the base of the fire OMH Codes Code Blue – Cardiac Arrest – Near Arrest • Activation • Code Blue Buttons • Page Overhead 477 • Signs near patient beds • Response – BLS - ALS (on arrival of – – – – cart) ICU Nurse Respiratory Therapist ED Nurse Physicians OMH Codes Code Yellow • Bomb or Bomb Threat • If receiving the call…. • Page Code Yellow & Location • Check area for packages, report anything suspicious, but do not touch! • Incident Commander will determine the need for evacuation OMH Codes Code Grey • Security Situation/Potential for violence • Page overhead 3 times with location • Code Grey “Assist” • Code Grey “911” • All available personnel go to area • Show of force • When to call for help …. Signs of agitation OMH Codes Code Pink • Missing Person/Possible Abduction • Page Code Pink, Gender, Age, • • • • Department Observe exits and parking lots Search your department Observe and be able to describe all persons Do not attempt to detain persons OMH Codes Code Silver • If you are confronted by an individual with a weapon OR • If you observe a hostage situation on Hospital property Initiating Code Silver Plan • Seek cover and discretely warn others (close by) of the situation • Dial “12345”- Report the location, number of suspects/hostages, type of weapons • Operator will dial 911 • Operator will page “Code Silver”+ location 3 times Workplace Violence • • Healthcare and social service workers face an increased risk of work-related assaults If threat is imminent, call Code Grey Assist or Code Grey 911 Workplace Violence • • OMH has “Zero Tolerance” towards all expressions of violence. Individuals who commit such acts may be removed from the premises and may be subject to criminal penalties. OMH Codes Code Triage • • • • • Shift Coordinator in area or department impacted will declare “Code Triage” Any event that impacts or has high potential to impact normal operations of the facility Code Triage Internal Code Triage Standby Code Triage External OMH Codes Code Triage Responsibilities • Return to department • Phones for disaster business only • Management will implement HICS • Hospital Wide Disaster Plan • Department-Specific Plan OMH Codes Severe Weather • Emergency Department has weather alert • • • • • radio ED also notified by MI State Police Dispatch ED Shift Coordinator will announce warnings overhead Return to your department Non-clinical employees go to basement Prepare for evacuation if ordered Hospital Incident Command System (HICS) • Chain of command for decision and communication • Semi-defined roles • All staff respond to only one individual (upward) • All supervisors manage 5-7 people (in command structure) • HICS implemented in all codes – Your manager may have additional responsibilities Infant Abandonment Michigan law states that a parent or adult can surrender a newborn up to 72 hours old • We must accept the newborn • Call Birthing Center • Do not press for information HIPAA The HIPAA Privacy Rule protects a patient’s fundamental right to privacy and confidentiality • ANY information obtained about another person’s medical condition is treated as confidential and is not to be discussed or revealed to unauthorized persons • HIPAA • Protected Health Information is anything that connects a patient to his or her health information: Date of Birth, SS#, diagnosis, address, etc. HIPAA HIPAA’s focus is on the rights of the patient and the confidentiality of their information. Patients have the right to: • Request an amendment of their medical record • Request to inspect and copy their record • Restrict what information is shared • Receive confidential communication • Complain about a disclosure of their information Ethics Committee OMH has an Ethics Committee that consists of a diverse group of members including: • Providers • Licensed professionals • Frontline staff • Community members • Any staff member can make a referral to the Ethics Committee Appropriate Ethics Referrals A staff member’s belief system is in conflict with a patient’s treatment plan. • A family/patient is in conflict with the proposed treatment. • Resource allocation • • Revising/updating policies/practices with ethical implications. • Offering support for clinical or medical issues with ethical implications. Medical Record Documentation The purpose of medical record documentation includes: •To record complete and accurate clinical information •To communicate with other members of the healthcare team •To comply with legal, regulatory and accreditation requirements •To ensure adequate reimbursement 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 Impaired Health Professional • • If someone comes to work and seems unable to do their job due to impairment because of alcohol, drug use or mental illness-we must report it immediately to the Administrator-on-call. The call schedule is in the Hospital Information folder. Environment of Care We have 7 plans in place to assure the safety of our patients and our staff: Plan 1: Biomedical Equipment Management Plan 2: Life safety Management Plan 3: Hazardous Material and Waste Management Plan 4: Utility systems Management Plan 5: Security Management Plan 6: Safety Management Chemical Hazards “Right To Know” Employees have the right to know how to keep themselves safe on the job • 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 MRI Safety (Magnetic Resonance Imaging) • All employees need orientation in magnet safety • Large metal objects of any kind shall not be permitted in the scan room until they are checked for ferromagnetism. Magnetic items should be kept out of the room at all times • All items will be tested with a hand held magnet and found not to be attracted to the magnet before being permitted in the Magnet/Scan Room • Do not enter room for Code Blue-patient will be brought out to the hallway! • Hearing protection required for patients Ergonomics and Back Safety • Our goal is to use this science of ergonomics to reduce work-related Musculoskeletal disorders (MSD’s) • Everyone, not only those involved in direct patient care, needs to have training in proper body mechanics and lifting Safe Lifting • • • • • • • Use your strong leg muscles Keep objects close Tighten abdominal muscles Bend knees and squat Use proper lift equipment Ask for help when needed Keep head and shoulders up (keeps spine curves in alignment) Comfort and Care at the End of Life • Managing symptoms is the goal • Even if patients are not responsive, always explain care/treatment • Respect personal choices and values Organ and Tissue Donation • • • • Gift of Life-we do participate! Organ procurement done in OR Tissues procurement can be done at hospital or funeral home Hospital required to call all imminent deaths to Transplantation Society of Michigan Cultural Competence • • • • Treat every patient as an individual Communicate respect Language issues-seek translation if needed Be aware of non-verbal communication Questions • Any questions about this information can be directed to the HR Department, instructor or your department director. The End Welcome