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Otsego Memorial Hospital Association Corporate Overview

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Otsego Memorial Hospital Association Corporate Overview Powered By Docstoc
					Your Champion for
     Better Health
        Otsego Memorial Hospital
               Association
OMH is owned by the OMH Association, comprised
of members of the community who pay annual dues.

    •   Established 1951
    •   Non-profit Corporation
    •   Governed by 10-Member Board of Directors
    •   Accredited by Joint Commission, CMS
Otsego Memorial Hospital Highlights
Workforce: 650+ Employees
Providers: 90+ Affiliated including 58
           employed
           26 are Mid-Level Practitioners
Beds:      46 Acute Care (Hospital)
           34 Long Term/Skilled (McReynolds)
Businesses within OMH Association
      Otsego Memorial Hospital
          McReynolds Hall
       MedCare Walk-In Clinic
        OMH Medical Group
         OMH N’Orthopedics
     OMH Medical Group Lewiston
    OMH Medical Group Indian River
          OMH Foundation
                                                               ORGANIZATIONAL CHART
                                                                       Board of Directors
                                                                          10 Members

                                                                                                                            Medical Staff

                                                             Thomas R. Lemon
                                                             Chief Executive Officer




  Robert Courtois        Barbara Miller                                                                                                              Ralph Pardo
   V.P. Finance          V.P. Physician                                                                  Diane Fisher
                                                Melissa            Anita Percy                         V.P. Patient Care                V.P. Professional and Ancillary Services
                            Services             Boyer             Performance
                                               Director of   Improvement/Accreditation
                                               Operations
     Kevin
     Wahr
                      OMH Medical Group                                                   Gayle Smith           Laura Sincock
     Chief
                       OMH Rural Health                                                  Birthing Center       Emergency Dept.               Chris Hope             Ethel Crandell
    Revenue                                      Jeanne         Bonnie Byram
     Officer                                     Hough         Risk Mgt/Pt Safety                                                           Rehabilitation          Materials Mgt.
                                                  Care         Comp. Compliance                                                               Services
                           Oncology &
                         Infusion Center       Management                                  Sandra                   Cathy Schalau
   Karen Yale                                                                             Oltersdorf                   Infection
 Patient Financial                                                                         Surgical                  Prevention/                                   Brian Techel
                      OMH Specialty Center                                                                                                    Sharon
     Services                                                                              Services                Employee Health                                   Facilities/
                                                                Terra Deming                                                                  Pudvan
                                                  Nancy                                                                                                           EOC Chairperson
                                                               Human Resources                                                               Laboratory
                                                  Ragan
    Amy Bilyea             MedCare                 Staff
                                                                                         Nancy Burke                 Kay Hanna-
     Controller          Walk-In Clinic          Develop.                                                                               Andrew Lanway              Cindy Griffith
                                                                                             ICU                       DeLuca
                       Rural Health Clinic                                                                                                 Radiology               Food Service/
                                                                                          Med Surg                    Pharmacy
                                                               Christie Perdue                                                          Cardiopulmonary           Nutrition Services
                                                               OMH Foundation
 Lisa Mackowiak        OMH Montmorency                           Marketing
  Payroll/Benefits       Medical Clinic                          Volunteers               Mary Steele
   Acct. Payable       Rural Health Clinic                                               McReynolds Hall                                                            Cindy Corby
                                                                                                                                                                    Environmental
                                                                                                                                                                      Services

                      OMH N’Orthopedics



                      Medical Staff Services


     Tim Hella
Chief Information     Nancy Kussrow
Officer/Information   Health Information
    Technology          Management
       Mission 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.
        Vision Statement

    To be the center of northern
Michigan’s patient focused alliance
dedicated to healthcare excellence.
                              Values
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
                               Values
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
                             Values
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
                            Values
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
    Otsego Memorial Hospital
           Affiliates

                OMH Auxiliary
A self-governed group of 150 volunteers who raise
        funds to support the mission of OMH
 Otsego Memorial Hospital
         Partners

            Munson Healthcare
Partner for services such as IT, phones and supplies
 Munson Home Care/Home Services
  OMH is a small equity ownership, which we
 must disclose when offering home care services
            Customer Service
   We want customers to think of us as the
    very best option for their healthcare
            Customer Service
•   Part of our Strategic Plan
•   Why it is important ?
     • Customers share their experience
•   The following are the behaviors we ask our
    employees to exhibit
             Greet People
 Make eye contact (be aware of cultural
  diversity)
 Tune the world out and them in
 If appropriate, thank them for coming in or
  contacting you
             Value People
Think things like:
 “You’re the customer-I’m here to serve
  you!”
 ‘You deserve to be treated with dignity and
  respect!”
 “There’s something about you I value!”
       Ask How You Can Help
 Ask “How may I help you?”
 Find out why they came in or contacted
  you
 Ask open-ended questions to further
  understand their needs.
     Open-ended question require more
     than a “yes” or “no” answer
           Listen to People
 Listen to words
 Listen to tone of voice
 Listen to body language
              Help People
 Help People
 Satisfy their wants or needs
 Solve their problems
 Give them extra value
             Invite People
 Invite people to have further contact
 Thank them for choosing our organization
 Ask them to contact you again if they need
  further help
 Leave them with a good feeling about their
  encounter with you
          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 Rescusitate 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

What are Advance Directives?
 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 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 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
             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!
Overview of Evidence-based
Practice: What Is It?
“The conscientious
explicit, and judicious
use of current best
evidence in decision
making”

(Sackett, et al, 1997)
www2.uta.edu/ssw/trainasfa/glossary.htm
            Evidence-based Practice:
                Example- Clinical
          Condition                               Research Summary
Central Line-Associated                      To reduce the incidence of
Bloodstream Infections are                   blood stream infections:
                                             • Use appropriate hand
a serious complication in
                                                hygiene
hospitals across the nation                  • Chlorhexidine for skin
and may cause increased                         preparation
length of stay, increased                    • Full barrier precautions
cost and risk of mortality.                     during insertion
                                             • The subclavian vein as the
                                                preferred site.
  Quality and Safety Research Group, Johns Hopkins University, Revised 1.14.05
Evidence-based Practice:
Regulations
•  Centers for Medicare
   and Medicaid Services
• Michigan Department of
   Consumers Industry Services
• Joint Commission
Agencies that survey
healthcare organizations expect
compliance with all rules and
regulations proven to provide safe,
quality care.
Evidence-based Practice:
    Reimbursement
           Healthcare reimbursement is
           in a transitional phase and
           “Pay for Performance” or
           “Value Based Purchasing”
           requires hospitals to submit
           data which reveals how well
           they comply with evidence-
           based standards of care.

            It pays to provide quality care!
              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
 2B 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

q.d., QD, Q.D., Q.O.D.   Daily or every other day

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…
    Implementation Expectations
•   Temporary responsibility for staff leaving the unit for a
    short time
•   Anesthesiologist report to post anesthesia recovery room
    nurse
•   Nursing and physician hand off from the emergency
    department to inpatient units, different hospitals, nursing
    homes and home health care
•   Critical lab and radiology results sent to physician offices
Hand-off’s Must Allow Time for
   Questions and Answers
               The Joint Commission wants
                 to know how physicians
                 and staff who work at
                 OMH communicate a
                 “hand off” of patient care

               Institute for Healthcare
                  Improvement
                  recommendation:
                            SBAR
            SBAR
                                        Example

                    S=Admitted an 82 year old with pneumonia,
S=Situation            possible aspiration.
                    B=History of stroke, has been having increased
B=Background           cough x 3 weeks per family, fever began
                       today..
A=Assessment
                    A=RR is 24 and unlabored, temp is 101 degrees F,
R=Recommendation       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.
   Any Questions?      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.
    3B Standardize and Limit the Number of Drug
     Concentrations Available in the Organization

•   OMH Pharmacy stocks limited concentrations
    and performs quality control monitoring of the
    crash carts for standardization of drug
    concentrations according to PALS and ACLS
                                3C
    Identify and, at a minimum, annually review a list of look-
alike/sound alike drugs used in the organization and take action
   to prevent errors involving the interchange of these drugs.
•     OMH has an on-line formulary which contains
    the list of look alike/sound alike medications and
    the Pharmacy & Therapeutics Committee
    provides oversight to the annual review
                       3D
•   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.
                  Goal 3

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
                                  “YES”
    a midline incision
    intended for a right/left
    distinction are subject to
    site marking.
 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 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
     Goal 8 Accurately and Completely Reconcile
      Medications Across the Continuum of Care.

•   Implement a process for     •   A complete list of the
    obtaining and                   patient/resident/client’s
    documenting a complete          medication is
    list of the                     communicated to the
    patient/resident/client’s       next provider of service
    current medications upon        when a
    the                             patient/resident/client is
    patient/resident/client’s       referred or transferred to
    admission/entry to the          another setting, service,
    organization and with the       practitioner, or level of
    involvement of the              care within or outside the
    patient/resident/client.        organization.
Goal 9 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
                 Goal 13
• Define and communicate the means for
  patients and families to report concerns
  about safety and encourage them to do so

• Encourage patients' active involvement in
  their own care as a patient safety strategy
             Goal 15A
The organization
identifies         Goal 15A:
                   The organization
safety risks       identifies patients
inherent in        at risk for suicide
 its patient
population
    Suicide Risk Assessment

“Suicide Risk Assessment”
is found :
      Hospital Information Page
           Forms
                Nursing
                   Goal 16
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:                • Recognition and
                          acknowledgement of risks
 To reduce risk to        to patient safety and
                          healthcare errors
  patients through an   • Actions to reduce risks
  environment that      • Internal reporting
  encourages:           • 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
             Sentinel Event
A Sentinel Event is :
• An unexpected “event” that is serious and
  “sends a warning” that requires immediate
  attention.
• We must complete a root cause analysis
  (RCA) after a sentinel event or near miss that
  could have resulted in a sentinel event.
   Sentinel Event or HFMEA ?

HFMEA is :
Healthcare Failure Mode Effects Analysis
A systematic approach to identify and
prevent product and process problems
before they occur.
                       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,
           Bonnie Byram
            at 731-7703
      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.
            Code of Conduct
The Hospital’s Board of Directors has
  established a Code of Conduct Policy that
  applies to all who work in the Hospital. A
  procedure has been established for
  reporting violations of this policy. Please
  refer to the full text of the policy available
  online to report a violation.
            Code of Conduct
Acceptable Conduct
The policy defines Acceptable Conduct as
  conduct that is professional and
  cooperative and that positively affects the
  ability, or could affect the ability, of
  Hospital employees or physicians to
  perform their jobs
            Code of Conduct
Disruptive Conduct
The policy defines Disruptive Conduct as
  conduct that is demeaning, abusive,
  intimidating, threatening or insulting and
  that adversely affects, or could affect, the
  ability of Hospital employees or physician
  to perform their jobs
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 = Aim toward the
    – A = Activate fire alarm         base of the fire
    – C = Contain fire and          – S = Squeeze the
      smoke                           handle
    – E = Extinguish fire or        – S = Sweep the base of
      evacuate                        the fire
                  OMH Codes
Code Blue
                       • Activation
  – Cardiac Arrest
                          • Code Blue Buttons
  – Near Arrest           • 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 “O”- 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
           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: Emergency Preparedness Management
Plan 3: Life safety Management
Plan 4: Hazardous Material and Waste Management
Plan 5: Utility systems Management
Plan 6: Security Management
Plan 7: 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)
                     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
• 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
     Musculoskeletal Disorders
• MSD’s include disorders of the muscles, nerves,
  tendons, ligaments, joints, cartilage, blood vessels
  or spinal discs
• Be aware that risk factors related to MSD’s
  include movements that result in repetition,
  force, awkward postures, contact stress, and
  vibration
Comfort and Care at the End of Life

“The Purpose of End of Life Care is to create an
environment to support a death, which is satisfactory
to the patient and the family and is respectful of and
responsive to individual preferences, culture, needs,
and values while ensuring that patient/family guide
all clinical decisions.
Focus on comfort, dignity and quality of life.”
Virginia Page,MSN,RN,NP Henry Ford Hospital
        Please see our policy Code# MCR.h.05
Comfort and Care at the End of Life

• Managing symptoms is the goal
• Fear of addiction can be a barrier to
  effective pain management
• Even if patients are not responsive, always
  explain care/treatment
      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
                 Gift of Life
• Hospital required to call all imminent deaths to
  Transplantation Society of Michigan
• Persons over 75 years of age can be organ/tissue
  donors
• Persons with HIV or Hep B can be organ donors
• Bev Cherwinski, Support Group
          Cultural Competence
•   Treat every patient as an individual
•   Communicate respect
•   Language issues-seek translation if needed
•   Be aware of non-verbal communication
           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 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
      Appropriate Ethics Referrals
• A staff member’s         • Revising/updating
  belief system is in        policies/practices with
  conflict with a            ethical implications.
  patient’s treatment      • Offering support for
  plan.                      clinical or medical
• A family/patient is in     issues with ethical
  conflict with the          implications.
  proposed treatment.
• Resource allocation
 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.
                 Questions
•   Any questions about this information can
    be directed to the HR Department,
    instructor or your department director.
     The End
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