Orientation Education Mission Statement Cartersville Medical Center is
- Slides: 103
Orientation Education Mission Statement Cartersville Medical Center is committed to treating all of our patients with compassion, kindness, and dignity. We will collaborate with our stakeholders to continuously improve patient care, evaluate and establish services beneficial to our community, and position our hospital as the preferred health care provider and a desirable business partner.
960 Joe Frank Harris Parkway Cartersville, GA 30120 (770) 382 -1530 Hospital opened September 1, 1985 112 Total Beds 14 Intensive Care 88 Med/Surg 10 OB/Maternity beds 31 Beds in the Emergency Department 8 Operating Rooms 7, 157 Admissions 919 Births An Overview of Cartersville Medical Center Personnel 750 Employees 300 Physicians Volume (FY 2015) 57, 501 ER Visits 37, 328 Outpatient Visits 9, 198 Surgeries
Cartersville Medical Center Executive Management Team Jan Tidwell, Associate Administrator Ed Moyer, Chief Nursing Officer Robbie Tatum, VP of Human Resources Keith Sandlin, Chief Executive Officer Benny Mc. Donald, Chief Financial Officer Lori Rakes, Chief Operating Officer Phoebe Stieber, VP of Quality Resources
Customer Service and HCAHPS Objectives • Increase awareness of HCAHPS and its impact on facility • Discuss how patient loyalty impacts satisfaction • Apply HCAHPS initiatives in your work setting to help “move the bar” on current results
What is HCAHPS? • Hospital Consumer Assessment of Healthcare Providers and Systems • The nation’s first standardized, publicly reported survey of patients’ perspectives of hospital care. Cliff Notes: It’s what our patients think about us after they leave our hospital.
Why is HCAHPS Important? The HCAHPS survey asks patients who have stayed at our hospital (inpatients) 27 questions, including 18 items about key aspects of their hospital experience. These are broken down into the following domains: Communication with nurses and doctors The responsiveness of hospital staff Cleanliness and quietness of hospital environment Pain management Communication about medicine Discharge information Overall rating of the hospital And recommendation of the hospital
Caring Behaviors It’s all about the things we do Our collective acts of all hospital staff have important consequences for patients, and directly affect their perceptions of the quality of care they received.
AIDET • A – Acknowledge Say hello to patients, visitors and co-workers • I – Introduce Provide your name and info about your skills/training • D – Duration Describe how long an event will take • E – Explain Provide important details about the procedure/situation • T – Thanks Thank patients for choosing CMC
Diversity Learning Objectives • Describe the impact of the multi-language workplace on our facility • Identify your responsibility to respect different cultures in our organization and patient base • Identify your responsibility in ensuring that we do not exclude others just because English is not their first language • Describe how to apply a commonsense approach for addressing situations in which language might tend to exclude others • Identify other ways in which our behaviors might exclude others and strategies for demonstrating respectful, inclusive behaviors
Core Concepts and Definitions Respect Showing appreciation and regard for the rights, values, and beliefs of others Culture A system of shared beliefs, values, customs, and behaviors Diversity The similarities and differences among all groups that make up HCA
Core Concepts and Definitions Cultural Diversity The differences and unique characteristics of the various groups that make up our business environment Workforce Diversity The differences that are created by HCA’s own structure and culture Cultural Competence Having the knowledge and ability to recognize and respond appropriately to our similarities and differences and use that knowledge and understanding to make better decisions
Ethics and Compliance Cartersville and HCA have a comprehensive, values based Ethics and Compliance Program, which is a vital part of the way we conduct ourselves. Because the Program rests on our Mission and Values, it has easily become incorporated into our daily activities and supports our tradition of caring – for our patients, our communities, and our colleagues. We strive to deliver healthcare compassionately and to act with absolute integrity in the way we do our work and the way we live our lives. All work must be done in an ethical and legal manner. It is your responsibility and your obligation to follow the code of conduct and maintain the highest standards of ethics and compliance.
Ethics and Compliance If you have questions or encounter any situation which you believe violates the provisions of the code of conduct or the corporate integrity agreement, you should immediately consult your supervisor, another member of the management team, the VP of HR (Robbie Tatum ext 1141), the Ethics and Compliance Officer (Jan Tidwell ext 1070), or the HCA Ethics Line (1 -800 -455 -1996). Each employee and volunteer is required to attend two hours of initial code of conduct training and a one hour annual refresher training session. Leaders and individuals in key jobs have additional annual education requirements.
Georgia False Claims Laws There is a federal False Claims Act, and there also Georgia laws that address fraud and abuse in the Georgia Medicaid program. Any person or entity that knowingly submits a false or fraudulent claim for payment of funds is liable for significant penalties and fines. The False Claims Act has a “qui tam” or “whistleblower” provision. This allows a private person with knowledge of a false claim to bring a civil action on behalf of the US Government. If the claim is successful, the whistleblower may be awarded a percentage of the funds recovered. For additional information please see the Georgia False Claims Statutes Policy.
Infection Prevention Our goal is to identify and reduce risks of healthcare associated infections in patients, visitors, and healthcare workers Hand hygiene is the single most effective way to prevent the spread of infection. Hand hygiene with an alcohol based products is preferred as long as hands are not visibly soiled. Rub hands together for 15 -20 seconds, covering all surfaces of the hands. Hand hygiene with soap and water is required if hands are visibly soiled. Wet hands with water, add soap, and rub vigorously for 15 -20 seconds, covering all surfaces of the hand. Rinse under running water, and turn the faucet off with a paper towel
• Hand Hygiene Indications for hand hygiene with an alcohol-based hand rub (unless hands are visibly soiled): GEL IN – GEL OUT! • • • Before having direct contact with patients, including between patient contacts. Before donning sterile gloves when inserting a central intravascular catheter. Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. After contact with a patient’s intact skin (e. g. when taking a pulse or blood pressure, and lifting a patient). After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings. If moving from a contaminated body site to a clean body site during patient care. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves and/or other personal protective equipment. After handling trash and/or infectious waste.
Hand Hygiene Indications for hand hygiene with plain soap and water, or antimicrobial soap and water: ◦ If hands are visibly dirty, contaminated with proteinaceous material or visibly soiled with blood or other body fluids. ◦ Before eating. ◦ After using a restroom. ◦ After covering the nose and mouth when coughing and sneezing. ◦ If exposure to Bacillus anthracis (anthrax) spores is suspected or proven. This is because alcohol hand rubs have poor activity against spores and the action of washing and rinsing hands is needed to physically remove spores from the hands.
Hand Hygiene Compliance • Infection Prevention champions monitor hand hygiene in our facility. The use of gloves does not eliminate the need for good hand hygiene. • Patients have the right to ask if you performed hand hygiene before you take care of them. • Our goal for hand hygiene is 100%
Prevention of Surgical Site Infections All healthcare workers must perform hand hygiene before and after contact with the patient Appropriate patient skin preparation Clipping of hair instead of shaving Timely administration of antibiotics Surgical team wears masks, cap, gown, and gloves during surgery Surgical hand scrubs before procedure
Prevention of Bloodstream Infections Insert central lines only when necessary using sterile technique, follow “central line insertion bundle” which includes special skin prep, inserter wearing gown, mask, sterile gloves, patient fully draped, choose safest site for insertion. Central line maintenance: ◦ Perform hand hygiene prior to touching line or giving medication through the line ◦ “Scrub the hub” using purposeful friction for 15 -20 seconds. ◦ Sterile dressing changes and tubing changes per hospital policy. Remove line when no longer necessary.
Prevention of Multi-Drug Resistant Organisms Hand hygiene before and after patient contact Gown and glove when caring for patients under contact and special contact precautions. Gowns and gloves required for entry into rooms of patients on these precautions. Patients are placed in private rooms whenever possible. Certain patients are screened for MRSA upon admission. Meticulous cleaning of hospital equipment. Patients are educated regarding disease transmission.
Examples of Multi-Drug Resistant Organisms (MDROs) Methicillin Resistant Staph aureus (MRSA) ◦ Staph aureus are commonly found in nose and on skin of healthy people. ◦ MRSA can be present without causing disease. This is called colonization. If MRSA is causing disease (e. g. fever, pneumonia), it is called infection. ◦ MRSA is spread by contact; therefore, “Contact” precautions are used. ◦ Hand hygiene is the best prevention for spread of MRSA. Clostridium difficile ◦ Causes severe diarrhea ◦ Spread by contact; requires “Special Contact” precautions “Special” refers to additional requirements for environmental services for cleaning the room ◦ Hand hygiene is the best prevention for spread. Vancomycin Resistant Enterococci (VRE) ◦ VRE can be present without causing disease. This is called colonization. If VRE is causing disease, it is called infection. ◦ VRE is spread by contact; therefore, “Contact” precautions are used.
Prevention of Urinary Tract Infections Related to Foley Catheters Hand hygiene prior to inserting a Foley catheter. Catheters are inserted only when medically necessary following established indications. ◦ Inserted with sterile technique ◦ Skin prep with antiseptic prior to insertion Maintenance ◦ Involves daily perineal care, catheter securement, Foley bag below level of bladder, no kinks in tubing, aseptic collection of specimen Prompt removal of Foley when no longer medically indicated.
Prevention of Ventilator Associated Events, Including Pneumonia • • Hand hygiene prior to care Mouth care every two hours Head of bed at 30 degrees unless contraindicated Daily evaluation of readiness to remove from ventilator • Peptic ulcer disease prophylaxis • Deep venous thrombosis prophylaxis
Personal Protective Equipment Personal protective equipment (PPE) is provided at no cost. PPE includes, but is not limited to: gloves, gowns, masks, N 95 respirators, and goggles. Appropriate PPE is available in each department. At a minimum, gloves must be worn when it can be reasonably anticipated that there may be hand contact with blood, body fluids, mucous membranes (e. g. eyes, nose, mouth), non-intact skin, or contacted with contaminated items or surfaces. Replace gloves if torn or punctured or if their ability to function as a barrier is compromised. Disposable gloves are single patient use only. Other PPE must also be worn as appropriate.
Personal Protective Equipment Wear appropriate face and eye protection when splashes, sprays, splatters, or droplets of blood or body fluids may pose a hazard to the eye, nose, or mouth. Any garment contaminated with blood or body fluids must be removed immediately or as soon as feasible. PPE must be removed prior to leaving the patient’s room. Hand hygiene must be performed after glove (and other PPE) removal. PPE may be disposed of in the regular trash unless contaminated with blood. If contaminated, they must be disposed of in red biohazard bags.
Standard Precautions means that we assume every patient is potentially infected or colonized with an organism (germ) that could be transmitted in the healthcare setting and requires the application of standard infection prevention practices during the delivery of healthcare. Standard Precautions applies to blood, all body fluids, secretions, and excretions, mucous membranes, nonintact skin. By using standard precautions, you will substantially reduce your risk of acquiring an infection from a patient.
Isolation Precautions Used for patients known or suspected to be infected or colonized with highly transmissible or epidemiologically important microorganisms (germs) for which additional precautions are needed to prevent transmission. Used in ADDITION to Standard Precautions 5 categories (patients may need more than 1 category): ◦ ◦ ◦ Contact Special Contact Droplet Airborne Protective
Contact Precautions and Special Contact Precautions • Transmission occurs by direct contact or by contact with a contaminated environment. • Patient placed in private room. • Requires gown and gloves for entering room. • Patients should wear an isolation gown and perform hand hygiene prior to leaving the room.
Droplet Precautions Transmission occurs when droplets are generated from the infected patient primarily through coughing, sneezing, talking, and during certain procedures like bronchoscopy. Droplets are propelled a short distance and are infectious if they enter the eyes, nose, or mouth. Can also occur if you touch a surface recently contaminated with droplets and then touch your eyes, nose, mouth. ◦ Short distance = usually 3 feet or less Patient placed in private room. Requires standard procedure mask to enter. Patients must wear a standard procedure mask if they need to leave the room.
Airborne Precautions Transmission occurs by dissemination of airborne droplet nuclei (5 micron or smaller) that remain suspended in the air for long periods of time. Can be dispersed by air currents over long distances and be inhaled by others. Patient in private room with special ventilation (negative air flow). N 95 required to enter room. ◦ Requires fit test in advance Patient to wear a standard procedure mask if they must leave the room for medical purposes. Persons not immune to Rubella (German Measles) or Mumps should not enter if other immune caregivers are available. Pregnant women who are not immune should not care for patients with Rubella.
Protective Precautions • Used for patients who are immuno-compromised (e. g. leukemia, lymphoma, severe burns, organ transplants, low white blood cell count). • Patient placed in private room. • If ill, should not enter room. • Patient should wear a standard procedure mask if they need to leave the room.
For all MRDOs Use disposable equipment (e. g. BP cuffs, stethoscopes, tourniquets) as much as possible. Any equipment taken into the room must be disinfected prior to removing it from the room Receiving departments must be notified that patient is on precautions. Procedures should be scheduled when there are fewer patients in the area. When leaving the room, patients should wear a clean gown and perform hand hygiene prior to leaving the room.
Tuberculosis (TB) TB is spread from person to person through air droplets from someone who has TB. Symptoms of TB include: cough greater than 3 weeks, unexplained fever, weight loss, night sweats, coughing up blood. TB infection: a positive PPD skin test, no illness. Germ is in body, but not causing disease. Cannot spread to others, but there is a risk if untreated that can progress to TB disease: signs and symptoms of disease. May be contagious.
Tuberculosis (TB) Upon hire, associates are required to have a PPD skin unless they have ever had a positive skin test. Cartersville Medical Center is a “low risk” facility for TB. This means that an annual PPD test is not required. Our risk is re-evaluated yearly and can change. Associates with active TB are not allowed to work until they are cleared as no longer being infectious and are healthy enough to perform their work duties.
Tuberculosis (TB) Patients suspected of having active TB are placed on “Airborne” precautions in a private room with negative air flow. The door must remain closed at all times except when entering and exiting the room. Anyone entering the room is required to wear an N 95 respirator. A “fit check” must be done each time the mask is put on. If mask doesn’t fit, contact Occupational Medicine for a repeat fit test.
Influx of Infectious Patients • The hospital is prepared should there be an influx of infectious patients. • We would activate our emergency preparedness plan. • This plan addresses staffing, supplies, and other issues that might occur as a result of increased patient load.
Bloodborne Pathogens Bloodborne pathogens are germs that are present in blood that can cause disease. Includes, but it not limited to: HIV, Hepatitis B, and Hepatitis C The hospital has a written plan that explains what bloodborne pathogens are, how to minimize risk of exposure, and what steps to take should an exposure occur. A copy is available to all associates.
Bloodborne Pathogens The following body fluids are considered to be potentially infectious for bloodborne pathogens: ◦ Blood or any other body fluid containing visible blood ◦ Other potentially infectious materials Semen, vaginal secretions, cerebrospinal fluid, synovial fluid, peritoneal fluid, pericardial fluid, amniotic fluid, pleural fluid, saliva in dental procedures, all body fluids where it is difficult or impossible to differentiate between body fluids, any unfixed tissue or organ (other than intact skin) from a human (living or dead), cell or tissue cultures, organ cultures, and culture medium or other solutions which may contain bloodborne pathogens, HIVcontaining cell or tissue cultures, organ cultures, and HIV or HBV containing culture medium or other solutions, and blood, organs, or other tissues from experimental animals infected with HIV or HBV
Bloodborne Pathogens Occupational modes of transmission of bloodborne pathogens: ◦ Percutaneous exposure (needlesticks or other sharp object injuries) to infected blood or other potentially infectious materials ◦ Mucous membrane (eyes, nose, mouth) exposure to infected blood or other potentially infectious materials. ◦ Open lesion exposure to infected blood or other potentially infectious materials ◦ Intact skin exposure to infected blood or other potentially infectious materials if it involves an extensive area or is prolonged.
What is HIV? Human Immunodeficiency Virus (HIV) is the virus that causes the disease Acquired Immune Deficiency Syndrome (AIDS). HIV damages the immune system and makes a person more likely to get serious infections and other diseases. To become infected with HIV, the virus must get into your body and enter your bloodstream. Many people who have HIV do not have symptoms for years. Persons who are HIV positive or have AIDS can spread the disease to others. Currently, there is no vaccine to prevent HIV infection.
What is Hepatitis B? • Hepatitis is a disease of the liver. • Hepatitis B virus (HBV) is just one of many things that can cause liver disease. • Symptoms include jaundice, fatigue, fever, nausea, and abdominal pain. • A vaccine is available that is very effective in preventing Hepatitis B infection.
What is Hepatitis C? • Hepatitis is a disease of the liver. • Hepatitis C virus (HCV) is just one of many things that can cause liver disease. • Many people with Hepatitis C do not have any symptoms. If there are symptoms, they are very similar to those of Hepatitis B infection. • Currently, there is no vaccine to prevent Hepatitis C virus infection.
How to Reduce the Risk of Exposure to Bloodborne Pathogens Use Universal Precautions when caring for ALL patients. This means that we assume every patient that we are caring for has a bloodborne illness and take the same reasonable precautions to prevent exposure to infectious materials. Use engineering controls (controls that remove the risk from the workplace). These include sharp safety devices, sharps disposal containers, and biohazard waste cans, for example. Observe good work practice controls such as never recapping needles, performing hand hygiene, no eating or drinking or applying cosmetics or lip balm where there is a potential for exposure. Use appropriate personal protective equipment. ◦ Know the job tasks in your department that may involve exposure to blood or other potentially infectious materials.
Post Exposure to Blood or Other Potentially Infectious Materials If your skin is exposed to blood or other potentially infectious materials, wash the area with soap and water as soon as possible (even if the exposure was a needlestick). If mucous membranes are exposed, flush with large volumes of water. If the injury is serious, go immediately to the Emergency Department. Otherwise, notify your immediate supervisor of the exposure. You will be provided information on appropriate follow up procedures.
Risk of Acquiring a Bloodborne Pathogen from an Exposure Risk varies based on pathogen involved, type of exposure, amount of blood/body fluid involved in the exposure, the amount of virus present in the patient’s blood at the time of exposure. The following factors are associated with an increased risk of getting HIV from an exposure from an infected patient: ◦ ◦ Deep injury Visible blood on device that caused the injury Device was in the infected patient’s vein or artery The patient is end-stage AIDS
Risk of Acquiring a Bloodborne Pathogen from an Exposure If patient is HIV+: ◦ The average risk of infection is 0. 3%. If patient is HBV+: ◦ If you have completed the series of Hepatitis B vaccine and developed immunity, you are at virtually no risk for infection. ◦ If you are unvaccinated, the risk if 6 -30%. If patient is HCV+ ◦ The average risk of infection after a needlestick is about 3%.
Post-Exposure Treatment HIV: ◦ Treatment involves starting anti-HIV medications as soon as possible after the exposure. HBV: ◦ Treatment involves starting the Hepatitis B vaccine or receiving “HBIG”. HCV: ◦ There is no vaccine and no recommended treatment after exposure. ◦ Following infection prevention practices and preventing exposure is imperative.
Preventing Sharp Object Injuries • • • • Receive appropriate training on using the sharps safety devices available to you. Keep the exposed sharp in view. Keep you hands behind the sharp/needle at all times. Be aware of people around you. Stop if you feel rushed or distracted. Focus on your task. Avoid hand-passing or sharps (e. g. use a tray) and use verbal alerts when moving sharps. Watch for sharps in linen, beds, on the floor, or in waste containers. Don’t recap used needles. Do not use a needle with a needleless IV system. Activate safety mechanism immediately after use. Never remove the safety feature. Never force an item into a sharps container. Do not overfill a sharps container; they are to be replaced when they are ¾ full. Do not reach by hand into containers where sharps are placed. If you identify a sharp item without a safety device, discuss this with your supervisor, Employee Health, or Infection Prevention.
Latex Allergies • Latex allergies pose a serious problem for nurses, other health care workers, and for 1% to 6% of the general population. Anaphylactic reactions to latex can be fatal. • Health care workers’ exposure to latex has increased dramatically since universal precautions against blood borne pathogens were mandated in 1987. Latex can trigger three types of reactions: irritant contact dermatitis, allergic contact dermatitis, and immediate hypersensitivity. • Many medical devices contain latex that might trigger serious systemic reactions by cutaneous (skin) exposure, (i. e. ECG electrodes, masks, bandages, catheters, gloves, and tape. ) There are some diagnostic tests to determine if a person has an allergy to latex. If a patient tells you they are allergic to latex, notify Materials Management and they will provide a cart with latex-free products. Need more information? Contact the Nursing House Supervisor at ext. 6910. For associates with latex allergies, contact Employee Health Services ext. 2129.
Employee Health Body Mechanics • Use mechanical help when possible • Ask for help if needed • Remember to push, not pull • Bend your knees • Avoid twisting
Potential Hazard Increased potential for employee injury exists with awkward postures with include: • Twisting while lifting • Bending over to lift • Lateral of side bending • Back hyperextension or flexion Forces on the spine increase When lifting, lowering or handling objects with the back bent or twisted. This occurs because the muscles must handle your body weight in addition to the weight of the object being lifted. This is unsafe lifting back posture.
CMC is a Drug Free Workplace • CMC drug screens for the following: • Pre-Placement drug screen • Reasonable Suspicion drug screen • Any time you have an injury at work you will have to complete a post accident urine drug screen as soon as possible prior to the end of your shift.
12 Principles of Ergonomics • • • Keep everything in easy reach Work at proper heights Reduce excessive forces Work in good postures Reduce excessive repetition Minimize fatigue Minimize direct pressure Provide adjustability and change of position Provide clearance and access Maintain a comfortable environment Enhance clarity and understanding Improve work organization
Ergonomics: The “Do Not’s” • Upper Extremity • Shoulder • Reaching over 90 degrees (vertical flexion) • External rotation of greater than 45 degrees • Elbow • Avoid static hold time of flexion • Lower Extremity • Sitting position • The hip, knee, and ankle should be placed at 90 degrees • Body positions to avoid • Deep knee bends • Constant standing in hip and knee extension • Walking with feet externally rotated
Performance Improvement Continual Quality Improvement • What is PI? • PI is a work philosophy that encourages every employee to find new and better ways of doing things. All accredited healthcare organizations are required to have an improvement program. Cartersville is accredited by The Joint Commission.
Performance Improvement Continual Quality Improvement Key Points to Remember Customers come first. Every employee is important. Communication is essential. Tasks (processes) are streamlined whenever possible. Ongoing improvement is crucial. Improvement should be maintained. We want to improve everything we do! We owe this to our ultimate customer - the patient.
2016 National Patient Safety Goals for Hospitals • The purpose of the National Patient Safety Goals is to improve patient safety. • The Goals focus on problems in health care safety and how to solve them.
2016 National Patient Safety Goals for Hospitals • Identify patients correctly • Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. • Make sure that the correct patient gets the correct blood when they get a blood transfusion.
2016 National Patient Safety Goals for Hospitals • Improve staff Communication • Get important test results to the right staff person on time. • Use medicines safely • Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. • Take extra care with patients who take medicines to thin their blood. • Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
2016 National Patient Safety Goals for Hospitals • Use alarms safely • Make improvements to ensure that alarms on medical equipment are heard and responded to on time. • Prevent infection • Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. • Use proven guidelines to prevent infections that are difficult to treat. • Use proven guidelines to prevent infection of the blood from central lines. • Use proven guidelines to prevent infection after surgery. • Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
2016 National Patient Safety Goals for Hospitals • Identify patient safety risks • Find out which patients are most likely to try to commit suicide. • Prevent mistakes in surgery • Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. • Mark the correct place on the patient’s body where the surgery is to be done. • Pause before the surgery to make sure that a mistake is not being made.
Patient Rights • We believe that most patients want to understand participate in their care. Therefore, it is important that each patient understand his or her rights and responsibilities while at Cartersville. It is also necessary as healthcare workers that we understand patient rights and responsibilities to ensure that quality care is provided. • How are patients informed of their rights? • Upon admission, each patient is given a handbook, which includes a list of patient rights and responsibilities. This patient bill of rights tells a patient and his or her family what they can expect of caregivers and what caregivers expect of them.
Patient Rights • What is your role in patient rights? • Everyone is involved in protecting the rights of patients, not just those involved in direct patient care. For example, the right to confidentiality means not telling your friends and/or relatives when someone you know has been a patient. Also, you provide privacy for patients by making sure you always knock before entering a patient’s room or any room where a patient might be having a procedure. • Patients have a right to a secure environment, which means you should know how to respond during a disaster or fire in the building. Patients are informed of their right to establish advance directives. • Patients also have a right to file a grievance. You can assist with the investigation and response by contacting Risk Management (Clair Williams) at ext. 1004 or Administration at ext. 8161 should you have a question.
Patient Rights • Where can you find a list of patient rights? • In facility Policy HW 362 Rights and Responsibilities of Patients, the Patient Handbook, posted beside the elevator in the front lobby and at outpatient services, and on Cartersville’s Intranet site. • Access the Ethics and Compliance Officer at 770 -607 -1070 • Access the grievance process. Express complaints or concerns regarding care or services, including discharge. • Facility contact: 770 -606 -2206 • Corporate Ethics Line: 1 -800 -455 -1996
Reportable Events • State (Georgia) Reportable Events: • The following type events should be reported to the State of Georgia Office of Regulatory Services: • Any unanticipated patient death not related to the natural course of the patient’s illness or underlying condition; • Any surgery on the wrong patient or the wrong body part of the patient; • Any rape of a patient which occurs in the hospital. • Cartersville Medical Center’s employees and the medical staff should report to the appropriate department leader and Risk Management at 1004 or Regulatory Compliance at 3038 in the event that any of the above situations occur to a patient at Cartersville. A multidisciplinary group will review the situation, complete the State forms, and provide them to the Office of Regulatory Services within 24 hours of knowledge that the event meets one of the State definitions.
Occurrence Reporting • 3 Types • Patient: All patients • Non Patient: Visitors, Contractors, Students, Physicians • Employee: CMC Employees • • Completed in the Meditech Module Completed ASAP prior to the end of your shift Risk Assessment: Prevent/Limit harm to the patient Never print report! Never write statements that point fingers Be factual, brief, and objective Tell the end of the story if known
What should I report? • • Patient, visitor, and employee falls or injury Sentinel Events Medication events and near misses, ADRs* Equipment and supply related events Lost/damage to personal belongings Adverse surgical/procedural outcomes Behavioral issues • Against Medical Advice, Left Without Being Treated, Refusal of treatment, Elopement • Other events that may result in injury or potential unfavorable outcome such as disruptive behavior • Complaints regarding patient care or treatment
Recognizing Abuse & Neglect Signs of Abuse • History inconsistent with nature and extent of injury • Delay in seeking medical treatment • Frequent Emergency Room visits • Accident prone • Discrepancy in patient’s and family’s story • Bruises in various stages of healing • History of previous trauma in patient or sibling Signs of Neglect • Failure to thrive • Poor hygiene • Dehydration • Malnutrition • Poor social skills
Reporting Abuse • • Nursing Interventions: • Routinely screen during each patient encounter. • Screen one-on-one in a private environment. • Assess patient’s immediate safety. • Listen with a non-judgmental attitude. • Document in the medical record the following: abuse history (subjective and objective), results of safety assessment, authorities notified, family notified, treatment given, and any safety instructions provided. The person suspecting the abuse should notify Social Services during weekday hours and the House Supervisor at night and on weekends to inform them of the situation. These resource persons will assist with the notification of the authorities.
Reporting Abuse • Reporting Responsibilities: • Notify the MD. • Notify DFACS or Adult Protective Services (APS) of the possibility and the appropriate authorities. • GA has general mandatory reporting laws. MUST report to law enforcement the following: injuries resulting from general violence and injuries inflicted by gun, firearm, knife, or other sharp object. • Resources: Department of Family and Children Services (DFACS): (770) 720 -3610 Police Department: 911 Battered Woman/Domestic Violence Hotline: 1 -800 -334 -2836 Prevent Child Abuse GA: 1 -800 -532 -3208 Adult Protective Services: 1 -888 -774 -0152
Environment of Care • Safety and Security • Fire Safety • Hazardous Materials and Waste • Medical Equipment • Utilities • Other Physical Environment Requirements • Floors and Walking Surfaces • MSDS
Safety and Security • EC. 02. 01, EC. 02. 01. 03 • The hospital identifies and manages safety and security risks • Electrical Safety • Incident/Accident and Near Miss Reporting • Infection Control Precautions • Storage (medical gas, supplies ETC. )
Your Role: • Wearing Proper ID • Knowing the Location of Emergency Plans and your role in them • How to Respond to and Document Incidents/Accidents • Access Control • How to obtain an MSDS
Floors & Walking Surfaces • • Dry, Level, Clear of Obstructions / Debris Well Lit Appropriate Mat Placement Condition of Carpet Walk to Center or Right Watch Intersections Keep hallways clear of clutter
Material Safety Data Sheets (MSDS)/Safety Data Sheet (SDS) • The MSDS/SDS is used by chemical manufacturers and vendors to convey hazard information to users. • They should be obtained when a chemical is purchased. • A chemical inventory list, and MSDS/SDS, for each chemical are required to be maintained
Hazardous Materials Management • OSHA Hazard Communication Standard Right-to. Know (R 2 K) • Material Safety Data Sheets (MSDS’s)/Safety Data Sheets (SDS) • Training and Labeling Requirements • Storage, Handling and Disposal of Hazardous Materials • Jan Tidwell 770 -607 -1070 • John Coley 770 -387 -8168
Medical Equipment • Avoid use of extension cords • If you don’t know how to safely use equipment, don’t. • Make sure all electrical equipment has been inspected by the biomed department before use. • Make sure all Medical Equipment has a current inspection sticker
Hazardous Materials and Waste • Radiation Safety • International radiation symbol will be used near sources of radiation • Radiation used in x-rays is known to cause harm at large doses. • If you work in an area where x-rays are being performed, you should wear all required PPE • The use of radioactive material is overseen by the Radiation Safety Officer and the Radiation/Laser Committee • Frank Homiller – 678 -721 -5580
Hazardous Materials and Waste • Biohazard Waste - Standard Precautions • Use gloves, masks, shoe coverings, eye protection, fluid resistant gowns when appropriate. • Sharps must be discarded in sharps containers. • Seal and discard sharps containers when ¾ full
Hazardous Materials and Waste • Biohazard waste that cannot be disposed of in the Municipal Waste System must be discarded in leak proof, break resistant containers • Red Bags – What can and cannot go in them • Needle boxes – What can and cannot go in them
Utility Systems • Code White • Utility system failure • Power • Water • Communication systems • HVAC System
Security • Security of the hospital requires a cooperative effort and is a responsibility of each employee. • Wear ID badges at work • Secure valuables and belongings • Be alert. Report any suspicious activity • Assure secured areas stay that way
Cartersville Medical Center Communication • Telephone use: • Dial “ 0” for the PBX operator • Dial “ 9” for outside line • Dial “ 66” for emergency phone • Departments located outside the main hospital building must call 911 for emergencies.
Fire Safety Code Red • Using a fire extinguisher: • P-A-S-S • Pull the retaining pin • Aim the fire extinguisher at the base of the fire • Squeeze the handle to release contents • Sweep the nozzle from side to side
Fire Safety RACE Fire Response Plan Remove Anyone in immediate danger Alarm Pull closest alarm; Dial “ 66” Confine Close doors and windows Turn off air moving equipment Extinguish Use closest proper extinguisher
Security Code Gray Alerts Security to the department where the code is being called
Security Code Silver A–D–D A – Avoid the shooter, gather as many people as you can and run from the area and leave the hospital. D – Deny. If you can’t leave, find a hiding place and lock the doors and or barricade yourself in. D – Defend. If you can’t leave or find a hiding place, you will have to defend yourself with whatever weapons you can find regardless if what you find is designed to be a weapon, make what you find into a weapon and use it as a weapon and fight.
Code Blue • Cardiopulmonary Arrest (adult or child) – Code Blue • Dial “ 66” and tell the PBX operator to page “Code Blue” to your location • Code Blue response team: Charge and primary nurse from the floor where the code was called, charge nurse from ICU, ER, respiratory therapy, and the ED MD. • Other personnel will be called if needed
Code Neonate • Cardiopulmonary Arrest (neonate) – Code Neonate • Dial “ 66” and tell the PBX operator to page “Code Neonate” to your location • Code Neonate response team: Charge nurse from OB, ER and 2 C, respiratory therapy, and the ER MD. • Other personnel will be called if needed
Code Pink • • • Infant/Child Abduction All hospital staff on alert Dial “ 66” to report Secure all exits and entrances Advise leaving staff, visitors, and contractors • Do not physically stop anyone
Code Triage • External Disaster – Code Triage • Code Triage Standby: employees will be notified and called to hospital as needed • Code Triage Activate: employees will immediately activate disaster plan
Code Weather • Sighting of Tornado: Code Weather • Notification by civil defense radio, 911, or weather channel. • Administration will notify and ask PBX to page “Code Weather” • Move visitors into internal hallways or patient rooms. • Reassure and calm patients • Updates will be communicated by Administration via PBX
Code Runner • Patient Elopement -“flight risk” patient is missing • “Flight Risk” is defined as any patient who is assessed to be confused, disoriented, or demented and mobile • Dial “ 66” and tell the PBX operator to call Code Runner
Code Orange • Chemical or large biohazard spill or event. • Dial “ 66” and ask the PBX operator to call Code Orange • Secure the area
Code Medic • Visitor or employee injury or severe illness • Dial “ 66” and ask PBX operator to page Code Medic. • ED RN and security will respond
Information Security Cartersville Medical Center relies heavily on computers to meet its operational, financial, and informational requirements. The computer systems, related data files, and the derived information are important assets of the company. Cartersville has established a system of internal controls to safeguard these valuable assets by processing information in a secure environment. As a Cartersville employee, you are expected to share the responsibility for the security, integrity, and confidentiality of this information. • Policy Enforcement Any employee who has knowledge of a violation of the IT & S Security policy must immediately report the violation to his/her supervisor. Anyone who violates the policy is subject to: • Suspension • Termination • Civil and/or criminal prosecution • Other Disciplinary action Secure your workstation at all times!
Information Security • CMC standards and policies include information about: • Individual accountability for the use of any computing and network resources • The authentication process to allow access to, and use of, systems and networks • Audit trails of sensitive security events • A means to ensure the integrity of systems, networks, and processes • The design and implementation of security controls with adequately met identified risks • The controls necessary to interface Carterville computer systems/networks with foreign computer systems/networks • Please refer to policies IS. SEC. 001 – 005 for additional information.
HIPAA & HIM-Health Information Management “Medical Records” Lakeba Wallace, HIM Manager, ext 1106
HIPAA Privacy Policies can be located on Cartersville’s Intranet 1. Notice of Privacy Practices 2. Patient’s Right To Opt Out of Facility Directory 3. Right to Request Confidential Communications 4. Patient’s Right To Access 5. Patient’s Right To Amend
Practicing Privacy 1. 2. 3. 4. Treat all information as if it were about you or your family Access only those systems you are officially authorized to access Use only your own User ID & Password to access system(s) Access only the information you need to do your job
Practicing Privacy 5. 6. 7. 8. Only share sensitive & confidential information with others that have a “need to know” Refrain from discussing patient info in public places Create “hard to guess” passwords & never share them Log-off when finished
Thank you! HR/Orientation/Oreintationeducation/July 2016