2010-2011 Safety Fair

1. 2010-2011 Safety Fair House Staff Edition

2. Overview • What is Safety Fair? • All hospitals must provide annual reviews of safety and quality information for all employees. At GCH, this is called “Safety Fair.” • Many of these topics are conditions for our hospital’s accreditation through HFAP (Healthcare Facilities Accreditation Program) • This presentation has been customized from the GCH Safety Fair material to provide information most relevant to house staff.

3. Safety and Survey Handbook • Check your mailbox in the House Staff Lounge for your copy of the Safety and Survey Handbook. • Keep the handbook with you – you can refer to it if asked questions by an inspector. • Follow along in the handbook as you view this presentation. Handbook page numbers are referenced throughout. Page 2 in your handbook

4. Safety and Survey Handbook • Look for these symbols: • “«” Means this section if critical for HFAP accreditation • “t” Means this section is critical for Fire Marshal visits • Dashed boxes (like this) are to be filled out with information specific to your training program or Medical Education. These are typical questions asked of employees during a survey or inspection and will be detailed in this presentation.

5. To meet your Safety Fair requirement Option 1: View this presentation online Complete the online quiz by November 22, 2010 Option 2: Attend a Safety Fair session at one of the posted dates and times

6. Hospital Leadership • Chief Executive Officer (CEO) – Gary Ley • V.P. Operations (CAO) – Art Greenlee • V.P. Chief Finance Officer (CFO) – Tim Jodway • V.P. Medical Admin. (CMO) – Gary Moorman, D.O. • V.P. Chief Nursing Officer (CNO) –Debra Williams • V.P. Human Resources, Steve Solomon • V.P. Medical Education, Kirsten Waarala, D.O. • Reporting to the Vice Presidents • Directors and Department Heads • Coordinators, Managers and Supervisors • If asked, you report to Dr. Waarala and to your residency program director Page 4 in your Handbook

7. Part I:Accreditation Standards

8. Accreditation Standards Accreditation standards include patient care processes, facilities, policies, etc. - anything and everything related to running a hospital. Many of these standards are also requirements of the Federal Government through the Centers for Medicare and Medicaid Services (CMS). Failure to meet CMS standards – also known as conditions of participation – is a serious matter in that a hospital could lose its ability to care for Medicare patients.

9. Accreditation Standards Key issues for all physicians and house staff involve the medical record. The following are must-haves for HFAP and CMS. Delinquent Medical Records All medical records must be complete within 30 days of discharge. This is required by HFAP and by the Centers for Medicare and Medicaid (CMS). H&P’s Must be documented within 24 hours of admission Must be complete, including osteopathic structural exam (OSE)

10. Accreditation Standards, continued Key issues for all physicians and house staff, continued • Orders, Progress Notes, and Consultations • Must include date and TIME! • Must be signed – including telephone orders • Include printed name and pager number • Legible! • Informed Consent • Must include all required elements: • Date and TIME • Signature of patient, person obtaining consent, and witness • Restraint Orders • Required for all patients • Must be completed according to policy (more on this later in this presentation)

11. Employee Code of Conduct All employees of GCH, including house staff, must adhere to the Code of Conduct. This includes: Laws and Regulations: GCH will operate in accordance with all laws and regulations. Business and Ethical Practices: GCH is committed to ethical business conduct and integrity. Confidentiality: In keeping with various laws, regulations and professional ethical guidelines, GCH employees must maintain the confidentiality of medical records and other patient information Continued next slide Page 7 in your handbook

12. Employee Code of Conduct All employees of GCH, including house staff, must adhere to the Code of Conduct. This includes: Conflict of Interest: GCH employees are expected to act in a manner that is in the best interest of the hospital and the patients it serves. Quality of Care A central concern of GCH in meeting patient needs is serving the whole person in his or her spiritual, intellectual, emotional and physical dimensions. Page 7 in your handbook

13. Employee Standards The Employee Standards include: Commitment to Patient Commitment to Appearance Commitment to Attitude Commitment to Communication Commitment to Co-Workers Pages 9-14 in your Handbook

14. Commitment to Patient The manner in which we will provide service to our patients: Compassionate Informed Respectful Safe Timely Pages 9-14 in your Handbook

15. Commitment to Appearance We will represent GCH in a professional manner to our customers: Personal Facility & Environment Good Neighbor Pages 9-14 in your Handbook

16. Commitment to Attitude The manner in which we show our attitude while providing service to our patients, customers and co-workers: Positive Respectful Professional Friendly Pages 9-14 in your Handbook

17. Commitment to Communication The manner in which we will communicate with our patients, customers and co-workers: Respectful Promptness Professionalism Pages 9-14 in your Handbook

18. Commitment to Co-Workers The manner in which we will relate to our co-workers: Respect Friendliness Mentoring Pages 9-14 in your Handbook

19. Patient Rights and Responsibilities CMS and HFAP require that patient have certain rights which are re • A list of patient rights and responsibilities may be found in your handbook. They are also posted throughout the hospital and given to patients. • Read and familiarize yourself with them. Be sure to respect them in your work. • Know how patient rights are protected • Special Policies • The Uniform Standard of Care Pages 15-18 in your Handbook

20. Patient Satisfaction • GCH measures patient satisfaction for all inpatient and outpatient encounters internally using a paper survey sent to patients by the NRC Picker company • We are also measured by the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. This is a national, standardized, publicly reported survey of patients' perspectives of hospital care. • HCAHPS (pronounced “H-caps”), is a standardized survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. • HCAPS satisfaction data for GCH and other hospitals are publicly reported at www.hospitalcompare.hhs.gov.

21. Patient Satisfaction House staff should be aware of the HCAHPS satisfaction measurements relevant to physicians. As you are often on the front line of patient care, your interactions with patients are reflected in these questions. Patients answer on a scale from “Never” to “Always” – we need you to help earn “Always!” During this hospital stay, how often did doctors Treat you with courtesy and respect? Listen carefully to you? Explain things in a way you could understand? Did you have confidence and trust in the doctors treating you? Did your family or someone else close to you have enough opportunity to talk to your doctor?

22. Responding to Complaints • First steps • Listen carefully • Apologize (I’m sorry this happened to you) • Take action to resolve the issue • Follow-up with the complainant about what you did • If you cannot help, then in order… • Ask other staff for assistance • Contact the Patient Representative • Contact Medical Education or Administration • What is a grievance? • A written complaint (letter, email, fax) • An unresolved complaint • A complaint involving a healthcare provider • Special steps are needed for grievances – notify a supervisor or Medical Education Pages 18-19 in your Handbook

23. Interacting with Surveyors and Inspectors • Be friendly, helpful, and honest. • Answer the question asked, then stop! Don’t volunteer additional information, thoughts or concerns. • Focus on the positive – describe what we do, not what we don’t. • Refer to your handbook if you need to. • Ask for the question to be re-stated or said differently if you don’t understand it. 25 in your Handbook

24. Part II:Patient & Environmental Safety

25. What is Patient Safety? • The prevention of harm to patients using a system that… • Prevents errors • Learns from errors that do occur • Is built on a culture of safety that involves health care professionals, organizations, and patients Page 26 in your Handbook

26. GCH Patient Safety Initiatives • Examples of patient safety initiatives for Medical Education include the following. Enter in your handbook on page 26 • Rapid Response Team • Code Blue Peer Review Forms • Feedback on use of standard orders • unauthorized abbreviations, etc. Page 26 in your Handbook

27. Your Role in “Playing it Safe” • Report immediate dangers to Medical Education or to Security • Report non-urgent concerns to • Medical Education • Your attending physician • The Safety Officer, Greg Harrison (x4234)

28. Oxygen Safety • Oxygen tanks should be stored: • 5 feet away from combustibles in a sprinkler protected room • 20 feet away from combustibles in a non-sprinkler protected room • Oxygen tanks cannot be stored in corridors • Tanks must be stored in an approved holder. If you see a loose tank, notify a manager in that area to secure the tank. Pages 27-28 in your Handbook

29. Hazard Communication Every employee has the right to know the dangers of the chemicals used where they work. Every employee also has responsibility to ask for further information and to follow hazardous chemical precautions. MSDS stands for Material Safety Data Sheets Provide chemical hazard information These references are available in the ED for all chemicals used in hospital in case of exposure Pages 28-29 in your Handbook

30. Spills If you find it – make sure it is cleaned up! • Clean up simple spills (see the table in your handbook on page 15) • Report contaminated or large chemical spills by calling the operator and asking for Security or the Housekeeping Supervisor • Be aware of proper disposal for different medical wastes (handbook page 30) Pages 29-30 in your Handbook

31. Electrical Safety Basics • Make sure that all equipment has a grounded plug • Don’t overload outlets • All electronics, including small appliances, are to be tagged by Biomedical Equipment. This includes items in call rooms and offices. Call x4297 for assistance. Page 32 in your Handbook

32. Medical Devices • A medical device is anything that is used in the care of the patient that is not a drug • In case of malfunction of a medical device: • If nobody is injured contact Biomed Department (x4297) for repairs • If a patient or employee may have been injured • Assure the safety of the patient/employee • Secure the device – do not change settings • Contact Biomed (x2829) and Risk Management (x3403) • EXAMPLE: malfunctioning defibrillator; vent that didn’t alarm  Contact Biomed Page 32-35 in your Handbook

33. Baxter Infusion Pumps • Keep It GREEN, Plug it in! • Keep the pump plugged in at all times when not transporting • Ensure GREEN PLUG icon is illuminated next to the on/off button. This is important as battery failure will take the pump out of service for up to a day. • Prior to transport, always check the Battery Charge Level icon • See instructions in your handbook, page 35 Page 35 in your Handbook

34. Codes and Disaster Protocol The following codes may be called overhead: • CodeBLUE: cardiac and/or respiratory arrest • Code RED: fire • Code PINK: infant abduction • Code BLACK: severe weather/tornado warning • Code TRIAGE: disaster (internal or external) • Code ALPHA: administrative team alert Pages 40-42 in your Handbook

35. In the event of a code RED: DO keep all doors shut DO remain in your area DO listen for overhead pages with further instructions DO move patients and visitors to behind fire doors DO treat all Code Reds as “the real thing” DO NOT go through closed fire doors DO NOT use elevators DO NOT assume a Code Red is a drill CodeRED: Fire Alarm Signal Pages 35-37 in your Handbook

36. Fire Response: R.A.C.E. A fire marshal or inspector may ask you how you would respond to a fire. Remember the acronym R.A.C.E.  What does R.A.C.E. stand for? • Rescue - Persons in immediate danger • Alarm - Activate the fire alarm system and call 3333 • Contain - Contain the fire by closing doors. Never open a door to check on a fire • Extinguish - Attempt to extinguish the fire but only if it is safe to do so Pages 35-37 in your Handbook

37. Fire Response: P.A.S.S. A fire marshal or inspector may ask you how to use a fire extinguisher. Remember the acronym P.A.S.S.  What does P.A.S.S. stand for? • Pull – the pin to activate the trigger • Aim – the nozzle at the base of the fire • Squeeze – the trigger firmly • Sweep – the nozzle from side to side Pages 35-37 in your Handbook

38. Code PINK - Infant Abduction Code PINK is the signal for a potential infant abduction. All staff are expected to assist in monitoring stairs and exits. • Stop all non-critical work. • Guard all interior stairwell doors, elevator areas and exit doors. • Do not allow anyone (including employees) to exit the building that is carrying a child or package/bag that could contain an infant. • Wait for all-clear message. Page 40 in your Handbook

39. CodeBLACK: Severe Weather Code BLACK is the signal for severe weather. Employee actions include: Remain on assigned duties Move patients and visitors to internal corridors if possible If patients cannot be moved out of room, move them away from windows, close windows, draw curtains and blinds. Help to reassure patients and visitors Page 40 in your Handbook

40. Code TRIAGE – Disaster • Code TRIAGE is the signal for an internal or external disaster. • The guidelines on the next slide indicate the appropriate actions by specialty or assignment. This applies to those individuals on duty or at home on pager call. Note this on page 42 of your handbook. • In most cases, house staff should report to the labor pool in the auditorium to sign in. If you are not immediately needed, you may leave the pool and resume your usual duties. Pages 40-41 in your Handbook

41. Code TRIAGE – DisasterHouse Staff Actions

42. Employee Response in Disasters • Each one of us must consider our commitment to the safety and welfare of our patients, and co-workers when planning how we will respond to the disaster needs of the hospital • Planning should include discussing your hospital commitment with your family and preparing your family to respond effectively to disaster events Page 39 in your Handbook

43. Weapons of Mass Destruction • “WMDs” include: • Chemical • Biological • Radiation • Nuclear weapon • Explosives Pages 42-44 in your Handbook

44. WMD: Scenarios & Factors • WMD incidents could result in two primary scenarios: • A large number of burn or blast trauma casualties • An increasing number of infectious illness, chemical poisoning or radiation disease victims • WMD incident may include complicating factors for the delivery of hospital care • Region-wide evacuation or quarantine • Contaminated victims: biological, chemical or radiation Pages 42-44 in your Handbook

45. WMD: Hospital Preparation • GCH has prepared for contaminated victims through… • Stockpiling of personal protective equipment, antibiotics and other medications • Planning for regional isolation of hospital areas in the event of contamination • Participation in region-wide disaster drills • Mutual aid agreements with community agencies • ED: decontamination tent and use of high level personal protective equipment Pages 42-44 in your Handbook

46. Violent or Threatening Behavior • First, keep yourself safe • Contact Security for help (x3333) • Do what you can to avoid problems— • Wear your badge • Maintain locked entrances – no propped open doors • Report suspicious individuals or circumstances • Lock up valuables, purses, etc. Pages 37-38 in your Handbook

47. Part I11: Preventing Illnesses and Injuries on the Job

48. Reporting Work Injury or Illness When a work injury or exposure occurs… Report the incident to Med Ed immediately or within 24 hours Complete an Employee Incident form. (Available on line or in the Emergency Department) Register and receive initial treatment in the Emergency Department Follow-up care and determination of temporary restrictions, if any, will be made by Dr. Sczecienski’s office at the our Westland Facility Contact Human Resources with questions about Workman’s Compensation

49. Hand Washing • The single most important procedure for preventing infections for • Patients • Co-workers • Yourself • Options include soap and water or waterless hand scrubs. • Wash your hands before and after examining patients – they expect this and will notice if you don’t! Page 45 in your Handbook

50. Blood Borne Pathogens (BBP) BBP’s are infectious agents, such as hepatitis B, hepatitis C, and HIV, that can be transmitted by blood & other body fluids. All personnel who have direct patient contact – e.g. all house staff – will be tested for immunity against HBV. Vaccination is available through Employee Health. Pages 46-47 in your Handbook