annual mandatory education - Memorial Hospital of Rhode Island

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					2011 - 2012

                                    ANNUAL MANDATORY

 Welcome to this year’s                                                             INNOVATION
                                               OUR VISION
 Annual Mandatory
                                                                           The introduction of a new idea
                                                                                     or method.
 Please read this entire packet
 and complete the Annual
 Mandatory Education                                                         To highly regard and show
 Questionaire. If you have any                                                 esteem or concern for.
 questions about the content of
 this document or the exam,                                               While our job descriptions tell
 please contact your supervisor.                                          us “what” to do, our values tell
                                     To excel as a primary health         us “how” to do it. As employees
 Thank you.                          care network and community           of Memorial Hospital of Rhode
 Human Resources                     teaching hospital. This requires     Island, we all share the same
                                     us to:                               values. Those values should
 Memorial Hospital is a not-for-
                                                                          be reflected in our day-to-day
 profit health, teaching, and        •     Continuously improve the
 research center serving the               quality, maximize the value,
 Blackstone Valley region of               and expand access to           CONTENTS
 Rhode Island as well as the               patient services.
 Bristol County region of                                                 Standards of Performance,
 Massachusetts.                      •     Build a learning
                                                                          Performance Improvement
                                           organization by creating an
                                                                          CARES Program
        OUR MISSION                        environment and structures
                                           to foster role development.    Cultural Diversity / Interpreter
 Our Mission is primary care and                                          Services / Patient Rights
 preventative medicine providing     •     Support research efforts
 advanced diagnosis and                    and translate research         MHRI Code of Ethics / Abuse
 treatment with a focus on                 findings into standards that   Recognition / Impaired Clinicians
 teaching and research. An                 measure and improve            Care of Prisoners
 essential resource in achieving           patient care for high volume   Staff Competency and
 our mission is the medical                and/or under served            Responsibilities / Patient Safety
 expertise provided by our                 vulnerable populations         Goals/ Code Blue Response
 competent and caring                      within our community.
 professional staff. We strive to                                         Infection Control / Bio-Terrorism
 achieve the timely and efficient             OUR VALUES                  Body Mechanics & Ergonomics
 delivery of care in a                           INTEGRITY
 compassionate atmosphere.                                                Environment of Care -
                                         A firm adherence to a code of    Emergency Mgmt. Program
                                                    values.               Hazardous Materials & Waste
                                                                          Program / Medical Equipment
                                                EXCELLENCE                Mgmt. Program / Utility
                                                                          Management Program / Safety
                                      The quality of being superior to    Management Program
                                       others or the best of its kind.    Safety Alert Program / Code Blue
                                             COLLABORATION                Response
                                                                          Security Mgmt. Program / Life
                                         To work jointly with others to
                                                                          Safety Program
                                           achieve a common goal.
                                                                          Risk Management – Incident
                                                                          Corporate Compliance Program
  2                                   MHRI ANNUAL MANDATORY EDUCATION
                                        Speak calmly and professionally.
                                                Assist someone who            Commitment to Co-Workers,
       STANDARDS OF                                                           Physicians & Volunteers
       PERFORMANCE                              appears to be lost.
                                        Unacceptable: Curt rude                   Treat one another as a
                                                behavior. Not listening           professional deserving
All employees, professional
                                                to what an individual is          courtesy, honesty and
affiliates, students and volunteers
                                                saying. Ignoring people           respect. Avoid last minute
are expected to adhere to
                                                who appear lost and not           requests. Offer to help
acceptable principles in matters
                                                trying to help them find          whenever possible. Work as
of personal conduct. A high
                                                their destination.                a team. Cooperate with one
degree of personal courtesy and
                                                Speaking in disruptive            another. Give praise when
integrity must be exhibited in all
                                                tones. Not answering              ever possible. Do not
dealings with each other as well
                                                the phone or answering            chastise or embarrass
as patients, vendors and others
                                                without stating the               people in front of others.
with whom Memorial employees
                                                department, your name             Address problems by going
come in contact.
                                                and “How may I help               to the appropriate supervisor.
This involves a respect for the
rights, beliefs and feelings of
others regardless of their position
and requires the use of commonly           CARES PROGRAM
accepted standards of
performance.                            C - Courtesy
                                        A - Attitude
Attitude                                R - Respect
                                        E - Excellence
                                        S - Service

                                        The CARES Program reinforces
                                        the standards of performance that     Elevator Etiquette
                                        help to provide excellent service
                                        to our patients, their families and       Hold the door open for
                                        to each other.                            others. Always smile and
                                                                                  acknowledge fellow
Acceptable:                             The purpose of the CARES                  passengers. Step aside for
Acknowledge an individual’s             recognition award is to encourage         others. Always face
presence          immediately.          and recognize employees for               wheelchairs toward the door.
Smile   and introduce your self.        achievements, behaviors, actions          Exit with care. If a person in
Unacceptable: Ignoring an               and contributions that go “above          a bed or stretcher is being
        individual. Not smiling         and beyond” the expected job              transported, wait for the next
        and failing to introduce        responsibilities. The program             elevator.
        your self.                      hopes to inspire and motivate all
                                        employees to do what they can to      Privacy
                                        strengthen our spirit of service.         Knock before entering
Acceptable: Follow MHRI dress
        code. Wear your                 A CARES Recognition Award                 rooms. Close curtains or
        identification                  Nomination form may be                    doors during exams and
        badge. Keep your work           completed by an employee, a               procedures. Provide a robe
        area in order.                  visitor, a physician or any other         or second gown for
Unacceptable: Not following the         individual who has been positively        ambulating or wheelchair
        dress code. Poor                impacted by a staff member.               bound patients. Make sure
        hygiene. Not wearing            Nomination forms are available in         the patient is properly
        your identification badge       the public relations department as        covered. Keep patient
        or wearing it improperly.       well as the hospital intranet.            information confidential.
        An unclean work area.                                                     Never discuss patients or
Communications                                                                    their care in public areas.
Acceptable: Courteous behavior.                                               Sense of Ownership
        Answer phone calls
        within 3 or 4 rings and                                                   Take pride in this
        identify your                                                             organization as if you own it.
        department,                                                               Adhere to the policies and
        yourself (first name)                                                     procedures. Provide
        and say “How may I                                                        superior service in all areas
        help you?”                                                                of your job responsibilities.
  3                                      MHRI ANNUAL MANDATORY EDUCATION
     Live the values of the                Tool” is supplied in every new
     organization.                         employee orientation packet          Bi-lingual staff is often recruited
                                           and is available in Human            for certain key areas of the
                                           Resources as well as the             Hospital.
                                           hospital intranet.
                                                                                Communication Devices for
                                                                                the Deaf or Hearing Impaired
                                            INTERPRETER SERVICES
                                           Patients and their families have
                                                                                •   A Telecommunication
                                           the right to effective
                                                                                    Device for the Deaf (TDD)
                                           communication regarding their
                                                                                    is available in the
                                                                                    Emergency Department. A
      IMPROVEMENT (PI)                     The Human Resources                      checklist for its use is
                                           Department responds to                   posted near the device.
                                           requests for interpreter needs
In order to ensure that our                from 8:30am - 5:00pm, Monday         •   A portable TDD and
patients are receiving safe quality        through Friday. Call extension           telephones with volume
care, treatment and services, we           2670 for the interpreter request         control are available from
must first measure our                     procedure. Requests for                  the Operator in the
performance. The performance                                                        Communications
                                           interpreters should be made as
data is collected, analyzed and                                                     Department. These phones
                                           far in advance as possible.
then used to make improvements.
                                                                                    can be brought to a
Continued performance
                                           The Nursing Administrative               patient’s room if needed.
measuring ensures that we are
continually striving to do better.         Coordinator in the Clinical
It’s about doing the right thing           Operations Department at             •   A national relay line is used
well, at the right time, for the right     extension 2299 responds to               to handle voice to TDD or
                                           requests for interpreters during         TDD to voice calls. This
                                           all other hours.                         enables two parties to
                                                                                    communicate when only
                                           Patients are not responsible for         one has a TDD. We may
                                           providing their own interpreters.        use the relay line to place a
                                                                                    voice call to a person who
                                                 LANGUAGE LINE                      uses a TDD. The Operator
                                                                                    can access this line.
                                           A language line is available 7
                                           days per week, 24 hours per          •   Communicating by writing
patient.                                                                            messages on a pad of
                                           day. The line provides
                                           interpretation services in 135           paper is also an alternative.
   CULTURAL DIVERSITY                      languages, and can be
                                           accessed by dialing “0” for the      •   When more complex
Cultural Diversity refers to the           Operator. This resource should           communications are
variations and differences                                                          needed, it may be
between cultural groups                                                             necessary to obtain a sign
resulting from differences in life                                                  language interpreter. Sign
styles, languages and values.                                                       language interpreters can
It is necessary to understand                                                       be obtained by contacting
these differences when                                                              Human Resources at
interacting and caring for                                                          extension 2670.
patients and families to provide
culturally sensitive care.                 be used for all needs that                 PATIENT RIGHTS
                                           require services for 30 minutes
The Cultural Tool                          or less.

The “Cultural Tool” has been               Spanish translation cards are
developed to assist employees              available on nursing and other
in understanding belief                    patient care units to assist staff
practices, nutritional                     members in communicating
preferences, communication                 with patients who speak
awareness, patient care and life           Spanish. If you need a copy of
issues for the various cultural            the cards, contact Human             Each patient and/or family
groups we serve. The “Cultural             Resources at extension 2670.         member is informed of his/her
    4                                    MHRI ANNUAL MANDATORY EDUCATION
rights. These rights are posted                                                      of a patient between
and are provided upon                                                                departments
admission in the Patient                                                        •    Close doors or draw curtains
Information Guide.                                                                   for treatments or interviews.

Every patient has the right to:
•   Considerate and respectful care                                                 MHRI’s CODE OF ETHICS
•   Be well-informed about his/her
    illness, possible treatments and
    likely outcomes and be                                                      Each employee is required to
    immediately informed of any                                                 follow the hospital’s Code of
    unexpected outcomes                                                         Ethics - see hospital policy 21 for
•   Satisfactory resolution of                                                  full text.
    conflicts regarding care
•   Refuse treatments
                                                 Maintain Patient               Patient Access to Care /
•   Advance Directives, such as                  Confidentiality                Admission
    Living Will or Durable Power of
    Attorney for Health Care               •   Share patient information        The hospital will admit and care
•   Privacy and confidentiality and            only with those providers        for patients uniformly regardless
    security                                   directly involved in the         of race, color, disability, gender,
•   Review his/her medical record
    and have information explained
                                               patient’s care.                  sexual orientation, creed, age,
•   Expect that the hospital will          •   Honor the patient’s right to     national origin or availability of
    deliver necessary services                 determine which friends or       insurance or ability to pay.
    including treatment or transfer            family members are given
•   Know about relationships the               information about the            Billing Practices and Disputes
    hospital has with other parties            patient’s diagnosis and
    that may influence treatment
                                                                                Patient billings include complete
                                               treatment. Understand that       information concerning services
•   Consent or decline participation           HIPAA regulations allow
    in research studies                                                         rendered with an itemization of
                                               patients to opt out of the
•   Be informed of alternatives when                                            procedures, dates of service
    hospital care is no longer                 patient directory.
                                           •   Make sure discussions about      and telephone number for
                                               the patient occur only within    questions. Patients can receive
•   Be informed about and have
    access to protective services              the confines of the patient      explanations for any charge or
•   Be informed about charges and              care areas.                      ask that charges be
    payment methods                        •   Properly dispose of copies of    investigated to verify accuracy.
•   Be informed of contacts to assist          medical reports or
    in resolving problems or conflicts                                          Access To Protective Services
                                               documents containing
    about their hospital visit or care
    by calling: Public Relations at            financial and/or patient         The hospital supports patients
    729- 2459 or nursing office after          information, including           and assists in determining a
    5:00                                       computer printouts.              patient’s need for special
•   For more information call the          •   Use computer systems only        services such as guardianship
    Department of Health at 222-               to access information            and/or other protective services
    5200 or The Joint Commission at            relevant to your professional
    800-994-6610                                                                while keeping the patient’s best
                                               practice.                        interest in mind.
                                           •   When using the computer
Every patient can expect                       system, your computer            Confidentiality
appropriate medical care,                      activity is subject to audit.
effective management of                    •   Speak to your supervisor or      All staff must ensure the
pain and a safe environment                    the privacy officer regarding    maintenance and protection of
while a patient at Memorial                    suggestions you may have         a patient’s medical information
Hospital of RI without                         about patient confidentiality.   and utilize proper procedures
regard to gender, culture,                 •   Report any breach of             for the release of information to
                                               confidentiality to the privacy   requesting parties.
background or source of
                                               officer at extension 2148.
payment.                                                                        Conflict Resolution and Ethical
                                           To Respect Patient Privacy           Dilemmas in Care. – see
                                                                                hospital policy 19 for full text.
                                           •   Knock and wait before
                                               entering a patient’s room        The hospital has several
                                                                                mechanisms in place to provide
                                           •   Address patients with respect    support to patient, family
                                               (as Mrs. not use first    members and health care
                                               names unless asked to)           providers when faced with ethical
                                                                                questions and/or dilemmas.
                                           •   Provide appropriate attire
                                               and blankets during transport    DO YOU KNOW?
    5                                MHRI ANNUAL MANDATORY EDUCATION
Informed consent of the patient            treatments if he/she has a         Child Abuse: abuse and/or
must be obtained by the                    terminal condition and is no       neglect of a person under 18
physician or advanced practice             longer able to make                years of age.
clinician before performing                decisions.
                                                                              Elderly Abuse: abuse and/or
surgery, blood transfusions or         A person may change or revoke          neglect of a person over 60
any invasive procedures. This          an advance directive at any            years of age.
consent must be documented in          time.
the patient record and entails                                                Health Care Facilities Abuse:
describing the risks, benefits         Advance Directives at MHRI             abuse and/or neglect of an
and alternatives in a manner                                                  adult resident or patient of a
                                       Upon admission, patients are
the patient can understand.            asked about an advance                 state licensed nursing home,
                                       directive. If the patient does not     shelter or hospital by staff
Refusing Treatment
                                       have one, information regarding        members or by other patients.
Patients may refuse treatment.         their right to make this decision is
                                                                              Developmentally Disabled
In the event a patient wants to        provided. If the patient has an
                                                                              Abuse: abuse and/or neglect
leave the hospital against             advance directive, a copy is
                                                                              of a person 18 years of age or
medical advice, the physician          placed in the patient’s chart. The
                                       Rhode Island Advance Directive         older who has a chronic
explains the risks and
                                       forms are available in Public          disability which limits the ability
document that the patient
                                       Relations or on the hospital           to care for his/herself.
understands these risks.
                                       intranet.                              Only With Patient Consent
Resource Guide For Patients
                                       Organ Donation is encouraged.          Reporting
                                       The New England Organ Bank
                                                                              Domestic Violence: physical
                                       works closely with our hospital to
This guide                                                                    violence occurring between
                                       educate clinical staff and provide
identifies                             support to patients and families in
                                                                              spouses, former spouses, adult
financial or                           making choices to donate tissues       relatives, adults living together,
legal                                  or organs.                             adults who have lived together
support and                                                                   in the past, adults who have
protective advocacy services.             ABUSE RECOGNITION                   children, whether married or not
Contact Social Services, Public                                               married, or living together.
Relations or the Administrative
                                                                              Sexual Assault: any assault
Coordinator to obtain a guide.
                                                                              involving sexual contact with an
It is also located on the hospital
                                                                              adult victim.
MHRI’s Notice of Privacy               State law and Hospital policy
Practices (NPP) is given to all        dictate that any staff member             IMPAIRED CLINICIANS
patients to explain their rights       who suspects or witnesses
concerning confidentiality and         abuse of a patient must contact
privacy and summarizes the             his/her supervisor or the
ways in which the hospital uses        Administrative Coordinator at
and discloses their health             extension 2271 immediately.
                                       Reporting Responsibility:
Advance Directives are                 The law protects anyone who
documents that allow a person          reports known or suspected             While there are many
to designate how medical               abuse/neglect. The attending           components to ensuring patient
decisions should be made if            physician or designated                safety, there is one that
he/she is unable to make               individual will contact Risk           requires watchful eyes….YOUR
decisions.                             Management and the                     EYES.
                                       appropriate agency within 24           In the event that you observe
•   Durable Power of Attorney          hours.                                 that the physical, mental or
    for Health Care names
                                                                              emotional health of a patient
    another person to act as the       There is no state law requiring
    person’s (patient) agent to
                                                                              care giver might endanger the
                                       reporting of domestic violence
    make health care decisions if                                             safety and well being of our
                                       or sexual assault (rape).
    the person (patient) is unable                                            patients, you must report this to
                                       However, if you suspect
    to make his/her own.                                                      your Supervisor or the
                                       domestic violence, notify your
                                                                              Administrative Coordinator.
•   Living Will identifies a           supervisor immediately or the
                                                                              Policy #4, Medical Staff
    person’s wishes to provide or      Administrative Coordinator.
                                                                              outlines the confidential process
    withhold life sustaining
                                       Mandatory Abuse Reporting
  6                                    MHRI ANNUAL MANDATORY EDUCATION
for physician review and                 Prisoners will be subject to the      What are some other staff
treatment referral.                      same restrictions at the hospital     responsibilities?
                                         that are in place for the prisoner             Staff responsibilities
What To Look For….                       at the correctional facility.                  can be found in
Physical limitations: may be             Imposition of disciplinary                     individual job
important, based on each                 restrictions follows the                       descriptions and
individual’s role. For example,          correctional facility’s policies               performance appraisal
tremors may not impair a                 and procedures.                                tools as well as
physician from taking care of a                                                         professional
heart attack patient, but would          STAFF COMPETENCY AND                           regulations and
create risks during surgery.                RESPONSIBILITIES                            hospital procedures.
It does not matter what causes                                                 Staff Competency:
the impairment – Alzheimer’s,                                                  Staff members and managers
brain tumor or alcohol/drug                                                    share responsibility for
induced confusion – the focus                                                  providing high quality care and
remains on providing safe                                                      service to our patients and their
patient care.                                                                  families. We need to evaluate
Mental capacity: may be in                                                     performance and maintain and
question - information must be                                                 improve competence.
repeated several times and/or
information recently provided is                                               How is competency assessed?
misinterpreted.                          Staff Responsibilities:               Performance appraisal tools are
Reading ability :may be in               Human Resources Policy # 61           designed to measure core skill
question – numbers transposed            provides staff with a mechanism       competency, performance
as may occur with dyslexia can           for declining to participate in       improvement activities,
pose a risk for drug doses to be         certain aspects of patient care       customer service and
wrong or lab values to be                due to staff member’s bona fide       communication skills and
misinterpreted.                          religious, ethical and/or cultural    general role responsibilities.
Hearing or vision ability :may be        beliefs. Some examples of staff
in question – if corrected with          beliefs that may conflict with        When is competency
hearing aid or glasses there is          patient care might include            assessed?
no problem. If uncorrected,              transfusing blood, assisting with     Managers constantly monitor a
orders or information may be             sterilization surgery or              staff’s competence. Before
interpreted incorrectly, posing a        withdrawing life support.             hire, credentials are verified.
risk to safe patient care.               Is refusing to treat a patient        Upon hire, an orientation
Behavior may be in question – if         because of the patient’s race         checklist is completed. Other
behavior raises questions of             or fear of contracting a              measures or tools are utilized
being under the influence of             disease or virus covered by           such as written tests and/or
alcohol or other drugs,                  this policy?                          checklists. At the completion of
immediately notify your                            No. Patient caregivers      orientation and at regular
Supervisor.                                        may not refuse to           intervals thereafter, a
                                                   provide care due to a       performance appraisal
   CARE OF PRISONERS                               patient’s background or     documents competence and
                                                   because of fear of          identifies goals.
The nurse assigned to care for
                                                   contracting a disease
the patient prisoner each shift
                                                   or virus.                   How is competency improved?
will discuss the expectations of
                                         What is the staff member’s            Staff is actively involved in the
the guard in supporting the
                                         responsibility to provide             competency assessment
medical and nursing care of the
                                         patient care if a bona fide           process along with his/her
patient or responding to an
                                         conflict arises?                      manager in identifying areas for
emergency within the hospital
                                                   A staff member’s            improvement. This may entail
and provide an Orientation
                                                   request not to              specific coaching, more on-the-
Guide to each guard during
                                                   participate in an aspect    job training or attending in-
his/her first shift at the hospital.
                                                   of patient care cannot      service and continuing
The prisoner will be
                                                   negatively affect or        education programs. Outside
accompanied by at least one
                                                   compromise the              class registration may be
armed uniformed guard from
                                                   patient’s care. Thus,       reimbursed with tuition
the correctional facility at all
                                                   staff must continue to      assistance, professional
times. The guard is responsible
                                                   provide care to the         development and/or
for maintaining visual contact
                                                   patient until relieved by
with the prisoner at all times.
                                                   another staff member.
    7                                MHRI ANNUAL MANDATORY EDUCATION
management directed                    •   Provide constant supervision    physical abilities and may also
education.                                 and do not leave tools or       be caregivers for their parents.
                                           instruments unattended
                                                                           •   Acknowledge their
Are special competencies
                                       PRESCHOOLERS (4-6 years)                responsibilities
Every role at MHRI has defined           Preschool children learn          •   Provide thorough
competencies and                       social manners and respond to           explanations but avoid
qualifications. All hospital staff     rewards and punishment. They            medical jargon
is expected to provide care and        have strong and vivid
                                                                           •   Recognize that their health
services that address the              imaginations.
                                                                               behavior is influenced by
communication and safety                                                       personal values and past
needs for each individual’s age        •   Allow child to express              experiences
and/or developmental level.                feelings and make choices
The hospital is committed to               when possible
providing the correct medical          •   Explain therapy and
treatment as well as providing             unfamiliar objects
                                       •   Offer praise for good
services that are responsive to
the age-specific and cultural
needs of our patients and

How can all hospital staff
respond to age-specific needs?                                             GERIATRICS (over 65)
It is important to understand the                                          An older adult develops habits
characteristics of different age                                           over time. They may lose the
groups and adjust your                                                     capacity that is needed to
approach to each.                                                          perform normal activities of
                                       SCHOOL AGE (6 - 12 years)
                                                                           daily life. They want to be
                                          School age children want to
                                                                           valued and respected.
                                       achieve goals and try to test
                                       rules. They ask questions and       •   Address by title (unless
                                       are aware of other’s reactions.         asked not to)
                                       •   Involve child in interactions   •   Foster and support
                                       •   Support privacy and
                                           independence                    •   Speak clearly in a normal
                                                                               pitch. If asked to clarify,
                                       •   Foster friendships with peers       rephrase what was said, do
INFANTS                                                                        not just repeat it
                                       ADOLESCENTS (12-18 years)
(Birth - 1 year)
 Infants feel secure when needs           Adolescents conform to peer
are met. They develop fear of          pressure and want to be spoken      PATIENT SAFETY GOALS
strangers (7-8 months) and             to as adults. They may appear
tend to place objects in their         moody and rebellious.               MHRI’s goal is to provide
mouths.                                                                    quality, age and culturally
                                       •   Allow adolescent to make        sensitive care in a caring and
•   Involve parent in interactions
    and keep parent in infant’s                                            safe environment. We are
    line of vision                     •   Communicate directly with       committed to ensuring safety for
•   Speak softly and in a calm             the adolescent, rather than     our patients, staff and visitors.
    manner                                 just with parents
•   Keep small objects out of                                              National Patient Safety Goals
    reach                              •   Provide full explanation
                                                                           Goal 1: Improve accuracy of
                                                                           patient identification
TODDLERS (1 - 4 years)
Toddlers learn to walk, run and                                            Use at least 2 patient identifiers
talk. They assert their                ADULTS (18-65 years)                (patient’s full name and date of
independence and will. They                                                birth) when providing care,
are curious and like to explore.       Adults are involved with            treatment or services.
•   Kneel or bend down when            personal, social and
                                                                           Use at least 2 patient identifiers
    talking                            occupational issues, while          when administering medications
•   Use simple words and               adjusting to subtle changes in      or blood products and collecting
    explanations                                                           specimens.
  8                                     MHRI ANNUAL MANDATORY EDUCATION
Containers for specimens must             Reduce likelihood of patient harm      Patient Information Guide informs
be labeled in the presence of the         from use of anticoagulation            patients to report concerns.
patient.                                  therapy. (Warfarin order sheet
                                          and Heparin Therapy order form)        Staff encourages patients and
The patient room number can not           For patients receiving this            their families to report concerns.
be used as an identifier.                 therapy, educate the patient and       Goal 8: Identify patients at
Goal 2: Improve the                       their family regarding the             risk for suicide.
effectiveness of                          importance of follow-up
                                          monitoring, compliance, drug –         Assess all patients for suicide
communication among
                                          food interactions and potential        risk.
caregivers.                               adverse drug reactions.
                                                                                 Meet patients’ immediate safety
When taking all telephone orders                                                 needs in an appropriate setting.
                                          Goal 4: Reduce the risk of
or reports of a critical test result,
write the complete order or test          health care –associated                Provide Crisis Hotline information
result down and READ BACK the             infections                             as appropriate to patient and
complete order or test result to          Hand hygiene compliance at all         family.
verify. The caller confirms               times. Refer to Infection Control
accuracy of order and/or result.                                                 Goal 9: Improve recognition
                                          section on page 9.                     and response to changes in
Critical test results must be             Review cases of unanticipated          a patient’s condition.
written down with two patient             death or major permanent loss of
identifiers (patient’s full name and                                             The hospital has a method for
                                          functions associated with a health
date of birth). Room number                                                      staff to request assistance from a
                                          care-associated infection as a
cannot be used.                                                                  specially trained individual who is
                                          sentinel event.
                                                                                 part of the Rapid Response Team
A verbal or telephone order must          Goal 5: Accurately and                 when a patient’s condition seems
be written down on the Physician                                                 to be worsening.
                                          completely reconcile
Order Sheet.
                                          medications across the                     UNIVERSAL PROTOCOL
DO NOT use abbreviations for              continuum of care.
any orders, medications, related
documents or pre-printed forms.           Create or update a list of current
(Do not use QD, QOD, U, IU, MS,           medications on each visit or
MS04, MGS04, AD, AU, AS, OD,              admission with patients.
OU, OS, trailing or leading zero.)        Compare list with any
Measure timeliness of critical test       medications ordered for patient.
reporting and improve, if                 Provide complete list to next
appropriate. The physician must           provider of care (at transfer within
be notified within one hour of the        the hospital and at discharge).        •    To ensure the correct patient,
receipt of critical test results.                                                     correct procedure, correct
                                          Give patient complete list of
Use standardized approach to                                                          site and as applicable,
                                          medications upon discharge and
“HAND OFF” communication                                                              correct implants and/or
                                          explain the importance of bringing
(report to next caregiver) that                                                       equipment.
                                          the medication list to all medical
allows opportunity for questions.         appointments.                          •    Applies to all invasive
Always use complete patient                                                           procedures that expose
identification when transferring          Goal 6: Reduce the risk of                  patients to more than
information to the next caregiver.        patient harm resulting from                 minimal risk, including those
Goal 3: Improve safety of                 falls                                       performed at patient’s
using medications                                                                     bedside.
                                          The Hospital has a fall reduction
                                          program (patients at risk are          •    Site should be marked by
Drug concentrations are
                                          identified with a yellow ID bracelet        performing physician.
standardized and their number is
                                          and yellow star on name board
limited (per hospital policy                                                     •    Entire team participates in
                                          and outside patient room).
Medication Use Policy #20).                                                           final verification of patient,
                                          Staff educates patient and family           procedure, site and implants
The P&T Committee annually
                                          about fall risk and interventions to        (if applicable)
reviews the list of look-
                                          prevent them.
alike/sound- a - like drugs used                                                 •    Documentation of completed
and takes steps to prevent errors.        Goal 7: Encourage patients’                 time out is done on the
Label all medications and                 active involvement in their                 Procedural Safety Checklist.
containers (i.e. sterile bowls) or        own care as patient safety
                                                                                         TEAM STEPPS
other solutions on and off sterile        strategy.
  9                                  MHRI ANNUAL MANDATORY EDUCATION
This team approach to patient          the Rhode Island Cabinet on             SPEECH
safety comes from more than 25         Nursing Practice. All admitted               Is the speech
years in the military, aviation.       patients will still wear a white             slurred? Have the
nuclear power and business             identification bracelet but will also        person repeat a
industries. Because Health Care        be appropriately banded with the
is a dynamic, complex and high         following colored wristbands:
risk environment, this approach is                                             TIME
                                       YELLOW -     Fall Risk                       Time is of the
an idea one to provide the
opportunity for improvement in         PINK   -     Restricted Extremity            essence. Call the
communications and teamwork.           GREEN -      Latex Risk                      stroke team!
                                       RED    -     Allergy
Research shows that even highly
                                         CODE BLUE RESPONSE                    Early recognition is important in
skilled professionals are
                                                                               the prevention of devastating long
vulnerable to error. When team
                                       If you discover a person who            term complications.
of individuals communicate
effectively, back each other up        appears to be unconscious,
and “catch” errors before they         bleeding, short of breath or who
happen, the result is an               has stopped breathing, call a
improvement in the quality of          Code Blue. Dial extension 2222
health care, the prevention of         and tell the operator that there
medical error and patient harm.        is an adult or pediatric code and
Every employee is part of the          give the exact location. Always
Team STEPPS Safety program.            stay with the person until help
By being aware of the actions of       arrives. Competent staff is
other team members, a “safety          expected to initiate CPR
net” is provided to ensure             (cardiopulmonary resuscitation)          INFECTION CONTROL
mistakes and oversights are            per American Heart Association
caught on. Watch each others           guidelines.                             Standard and Contact
back-speak up if you think             Automated External                      Precautions
something is not “right”. I am         Defibrillators (AED) are
                                                                               Standard and contact
                                       stationed on key locations
UNCOMFORTABLE. This is a                                                       precautions must be followed
                                       throughout the hospital. The
SAFETY issue. Using this “CUS”                                                 to minimize and prevent the
                                       AED’s may be used by anyone
approach will alert your team to                                               spread and transmission of
                                       trained in basic life support.
potential situations that could        They are in the main lobby,             infections to patients, visitors
result in compromised patient
                                       Medical Staff Auditorium, the           and other staff members. All
care.                                                                          human blood and body fluids,
                                       corridor outside the
How do we achieve safe quality         Communications area, in 555             contaminated surfaces and
patient care?                          Prospect Street and the                 equipment are considered
                                       ambulatory care building.               infectious and protective
         Safety begins with you
                                                                               equipment must be used such
         and your communication
         and collaboration with        STROKE TEAM RESPONSE                    as those listed below:
         your team members.                                                    • Gloves
                                       MHRI is an accredited stroke            • Gowns
                                       center. Part of the stroke              • Masks
COLORED ALERT                          program includes a dedicated            • Protective eyewear (not
WRISTBANDS                             stroke team to respond to                   personal glasses)
                                       patients with questionable
nurses                                 stroke-like symptoms.
and                                    To remember what to look for
providers                              think of the word FAST:
are often
employed at more than one                                                      Hospital Acquired Infections
facility, there is a need to have      FACE                                    Hospital acquired infections
certain medical conditions                      Does one side droop?           are those infections that occur
conveyed in a transparent and                                                  within the hospital
                                                Ask the person to
universal fashion so that patient
                                                smile.                         environment. These
safety is maintained. Standard
colored wristbands will provide a      ARMS                                    infections, most commonly
quick recognition of medical                    Is one arm weak or             spread or transmitted by
conditions. MHRI has adopted                    numb? Does one arm             hospital staff, are primarily
this initiative recommended by                  drift downward?
  10                                 MHRI ANNUAL MANDATORY EDUCATION
preventable by four basic             Prevention of Central Line-      surgery. Interventions that
steps:                                Associated Blood Stream          are known to help reduce the
1. Hand Hygiene                       Infections                       risk of surgical site infections
All staff                                                              include:
members                               Patients who have central
(this                                 lines that are placed or used            1. Hand Hygiene
includes                              during hospitalization are at               before and after
non-                                  increased risk of infection.                caring for each
clinical                              Strategies to prevent central               patient.
staff) are                            line infections include the
                                                                               2. Removing any
required to wash their hands          following:
                                                                                  hair prior to
with soap and water or alcohol-
                                          1. Use of central line                  surgery with
based gel before and after
EVERY patient contact, before                checklist during                     electrical clippers-
and after glove use, as well as              insertion procedures                 not razors.
after contact with a patient’s               to ensure adherence
                                                                               3. Administering
environment. When providing                  to infection prevention
care to patients in their hospital           practices.
                                                                                  antibiotic within
rooms, the phrase “Foam IN,               2. Strict adherence to                  60 minutes before
Foam Out” might be a useful
                                             hand hygiene prior to                surgery starts.
way to remember to wash your
                                             insertion and at any
hands.                                                                         4. Controlling blood
                                             time the central line
                                                                                  glucose levels
                                             may be manipulated.
Respiratory                                                                       during the
Etiquette                                 3. Avoidance of the use                 immediate post-
                                             of the femoral vein for              operative period.
All staff                                    central venous
should cover                                                                   5. Maintaining
a cough or                                                                        normal body
sneeze with a                             4. Use of an all-inclusive              temperature
tissue or the                                catheter cart or kit.                through out the
elbow/upper arm.                                                                  surgical
                                          5. Use of maximum
                                             sterile barrier
                                             precautions during
3. Personal Protective                       insertion.
                                          6. Use of a
                                             antiseptic for skin
                                             preparation prior to
                                          7. Disinfection of
When indicated, all staff are                catheter hubs, needle
required to use appropriate                  less connectors and
                                                                       Safe Injection Practices
protective equipment when                    injection ports before
caring for patients.                         accessing the             Healthcare providers should
                                             catheter.                 never reuse a needle or
4. Disinfection of Equipment                                           syringe. One needle only for
                                          8. Removal of all
It is a new policy at MHRI that                                        one patient only should be
                                             unnecessary central
all equipment (dinamaps,                                               used. Both needle and
glucometers, stethoscopes, IV                                          syringe must be discarded. It
Poles, etc.) used on patients                                          is also not safe to change the
must be disinfected between                                            needle but reuse the syringe –
                                      Prevention of Surgical Site      this can transmit disease.
each patient use.                     Infections                       Once a needle and syringe
                                      Surgical site infections         are used on a patient, they
                                      develop in about 1 to 3 out of   should be discarded into a
                                      every 100 patients who have      sharps container. Safe
    11                               MHRI ANNUAL MANDATORY EDUCATION
injection practices and sharps        There is no vaccine against        •   Enteric diseases such as
safety go hand-in-hand.               Hepatitis C or HIV.                    diarrhea, salmonella, ecoli,
                                                                             C-diff, etc.
By following safe injection           Exposure to Blood/Body
                                                                         •   Hepatitis
practices to protect patients,        Fluids
                                                                         •   Meningitis
healthcare providers are also         If an exposure occurs, the
protecting themselves. The            employee should:                   Clostridium Difficile
unsafe practice of syringe                 1. Wash area with soap
                                                                         Closridium difficile, sometimes
reuse puts healthcare                          and water. Rinse
                                                                         called C. difficille or C Diff, is a
                                               mucous membranes
providers at risk of needle                                              bacterium that can cause
                                               with water.
stick injury and potential blood                                         symptoms ranging from
                                           2. Report exposure to the
borne pathogen exposure.                       supervisor.
                                                                         diarrhea to life-threatening
                                                                         inflammation of the colon.
Remember: ONE needle,                      3. Fill out incident report
                                                                         Illness from C. difficile most
ONE syringe, only ONE Time                     and bring to Employee
                                                                         commonly affects older adults
                                                                         in hospitals or long term care
                                           4. Go to employee Health
                                                                         facilities. In recent years, C
                    Blood borne                Office Monday through
                                                                         difficile infections have become
                    Diseases                   Friday (8am to 4pm) or
                                                                         more frequent, more severe
                    Certain                    the Emergency
                                                                         and more difficult to treat. Each
                    healthcare                 Department (evenings,
                                                                         year, tens of thousands of
                    workers are                weekends and
                                                                         people in the United Sates get
                    at risk for an             holidays) to be
                                                                         sick from C. difficile, including
                    occupational               evaluated by a
                                                                         some otherwise healthy people
exposure to blood and body                     Healthcare Provider.
                                                                         who are hospitalized.
fluids during the performance of                                         In an effort to reduce infections
their duties. The most common         The Exposure Control Plan is
                                                                         as a result of clostridium
blood borne pathogens in the          part of the Infection Control
                                                                         difficile, MHRI personnel, when
hospital setting include              Program, and has been              providing care to infected
Hepatitis B and C and HIV. The        developed to control hospital-     patients, are required to (1) use
exposure can occur to the eyes,       associated infections and          gloves and gowns, (2) wash
mouth or other mucous                 protect employees from             their hands with soap and water
membranes, non-intact skin or         acquiring infections. A copy       instead of using the alcohol-
parenteral contact by:                of the plan is maintained by       based gel and (3) clean patient
                                      each department in the             rooms with a bleach water
•   A puncture wound or cut
    from a needle or sharp.
                                      Infection Control Manual, and      solution.
•   Blood or body fluid               can be obtained from your
    splashes to the eyes, nose,       supervisor.
    or mouth.
•   Contact with non-intact
    wounds or lesions                 Exposure to Communicable
    especially to chapped,            Diseases
    abraded, or skin afflicted        The Employee Health Office
    with dermatitis.                  provides evaluation and chemo
•   A human bite.                     prophylaxis as appropriate, to
                                      employees exposed to
                                      communicable diseases both         Multi-drug-resistant
All health care workers are           on and off the job.                Organisms
encouraged to receive the                                                Multi-drug-resistant organisms
Hepatitis B vaccination, which is     If an exposure occurs, the         (MDROs), such as methicillin-
free of charge. This vaccine          employee should report to the      resistant staphylococcus aureus
offers protection against             Employee Health Office for         (MRSA), vancomycin-resistant
Hepatitis B and may eliminate         evaluation. Examples of the        entercocci (VRE) and extended
the need for Hepatitis B              types of infections that need to   spectrum beta-lactamase
immune globulin as post-              be evaluated by the Employee       producers (ESBLs) have
exposure prophylaxis. Hepatitis       Health Office are:                 important infection control
B vaccine is offered to newly         • Shingles/ Varicella              implications in all healthcare
hired staff, at the time of                (Chicken Pox)                 settings.
exposure, and is available at         • Influenza (Flu)                  The prevention and control of
any time during employment.           • H1N1 (Swine Flu)                 MDROs is a national priority
  12                               MHRI ANNUAL MANDATORY EDUCATION
that requires all healthcare        posted. Watch for these             terrorism-related outbreak are
facilities and agencies to          announcements so you can            identified.
assume responsibility. At           make plans to receive your flu
                                                                        If a bio-terrorism event is
MHRI, patients who are              vaccine. Staff members who
                                                                        suspected, immediate
suspected or known to be            decline a flu vaccine will be
                                                                        notification of the following key
infected or colonized with an       asked to complete a declination
                                                                        people must be initiated: your
MDRO are placed on                  form.
                                                                        Supervisor (off shifts- call
precautions. In some
                                                                        administrative coordinator),
instances, nares swabs and          Tuberculosis
                                                                        Hospital Administrator (off
rectal swabs may be obtained.       Tuberculosis (TB) is caused by
                                                                        shifts –administrative
All staff members, as well as       bacteria that are spread when
                                                                        coordinator will notify hospital
visitors are expected to observe    an infected person coughs or
                                                                        administrator on call, Program
strict adherence to hand            sneezes.
                                                                        Manager of Infection Control
hygiene and the appropriate
                                                                        (off shift call the Infectious
use of personal protective          Most common symptoms of
                                                                        Disease Fellow ), Infectious
equipment when providing care       tuberculosis are a persistent
                                                                        Disease Physician (infection
to patients with a known or         cough for greater than 3 weeks,
                                                                        control officer). The response
suspected MDRO.                     anorexia, fever, night sweats,
                                                                        to the event will be activated
                                    weight loss and bloody sputum.
                                                                        according to policies delineated
Influenza                           Health care workers are at risk
                                                                        in the Environment of Care
                                    when a patient with TB is not
                                    yet identified and infection
                                    control precautions are not         Standard precautions are to be
                                    implemented.                        utilized for all patients. This
                                    To prevent the spread of TB:        includes proper hand washing
                                                                        techniques, gloves when in
                                    •   Insure patients identified      contact with blood/body fluids,
                                        with confirmed or               and gowns, masks and eye
                                        suspected TB are assigned       protection when splashing of
Influenza (The Flu) is a
                                        to a negative pressure          blood and/or body fluid is
contagious respiratory illness
                                        room that vents the air         anticipated. Depending on the
caused by influenza viruses. It
                                        directly to the outside or to   suspected pathogen, droplet or
can cause mild to severe illness
                                        a private room with a U/V       airborne precautions may be
and at times can lead to death.
                                        light.                          required. Consult with ID
Some people, such as older                                              physician and/or Infection Control
                                    •   Instruct patients to cover
people, young children and                                              Practitioner for guidance.
                                        their nose and mouth when
people with certain health
                                        coughing or sneezing.                BODY MECHANICS
conditions, are at high risk for
                                    •   All staff must wear an N-95
serious flu complications. The                                                    AND
                                        respirator or PAPR when
best way to prevent The Flu is
                                        entering the room.
by getting vaccinated each
                                    •   Insure you have been fit
                                        tested and trained to wear
In 2009-2010, a new and very
                                        the N-95 respirator or
different influenza virus (H1N1)
spread worldwide causing the
                                    •   When transporting patients,
first flu pandemic in more than
                                        insure that the patient
40 years. During the 2011-
                                        wears a surgical mask and
2012 flu season, The Centers
                                        other people are not
for Disease prevention and
                                        allowed on the elevators
Control expects the H1N1 virus
to cause illness again along
                                        with the patient.                       ERGONOMICS
with other influenza viruses.
                                    Staff are tested for TB upon        To prevent back injuries, the
The 2011-2012 flu vaccine will
                                    hire, on an annual basis, and       following body mechanics
protect against H1N1 and two
                                    after potential exposure to TB.     should be considered:
other influenza viruses.
                                                                        •   Always stand with your feet
MHRI makes influenza vaccine        Health care facilities, including       slightly apart (shoulder
available to hospital employees.    hospitals and clinics, may be           width).
When Flu Season begins,             one of the first institutions       •   Bend at your knees and
information announcements           where victims from a bio-               hips, not your waist.
and vaccine dates will be
    13                                MHRI ANNUAL MANDATORY EDUCATION
•   Lift with your legs, not your              o    Change the side        employee who believes that a
    back, keeping patients or                       your mouse and         patient and/or an employee has
    objects close to your body.                     monitor are on         been exposed to an
•   Lower patients or objects                       periodically.          unacceptable risk or injury may
    slowly.                                                                report the incident to the Safe
                                               o    Make sure your
•   Work as a team with co-                                                Patient Handling Committee
                                                    arms are parallel to
    workers when lifting heavy                                             who reports annually to the
                                                    the floor when
    patients or objects.                                                   Safety Committee and
•   Ask for help when you need                                             Performance Improvement
    it.                                        o    Do head turns and      Committee.
•   Use mechanical aids, such                       shoulder rolls
    as a lifting belt, dolly, cart,                 frequently to          EMERGENCY MANAGEMENT
    gait belt, sliding board, or                    prevent injury.              PROGRAM
    Hoyer lift whenever
                                               o    Look away from         This program provides an “all-
                                                    the monitor            hazards” approach to
•   Anticipate lifting and plan
                                                    occasionally to        emergency management that
    your move before you lift.
                                                    avoid eye strain.      permits appropriately flexible
•   Avoid twisting your body -
                                                                           and effective responses. The
    move your feet instead.
                                                                           focus of the program is to plan
•   Test the load before you lift
                                                                           for managing six critical areas
                                                                           of the organization.
•   Lift, carry or push only what
    you can handle safely.                                                 The six critical areas are:
•   When standing for long
    periods of time, balance                                                   1.   Communication
    one foot on a low object.                                                  2.   Resources and assets
•   Support your lower back
    with a cushion or rolled up                                                3.   Safety and security
    towel if you sit a lot.                                                    4.   Staff responsibilities
•   When sitting, adjust your          SAFE PATIENT HANDLING
    chair to allow both feet to        AND MOVEMENT                            5.   Utilities management
                                                                               6.   Patient clinical and
                                       The Hospital seeks to ensure                 support activities
                                       that patients are cared for
                                       safely, while maintaining a safe    Exercises are conducted to
                                       work environment for                assess the Emergency
                                       employees. To accomplish this       Operations Plan’s
                                       both inpatient and outpatient       appropriateness, adequacy and
                                       employees must identify and         effectiveness of logistics,
                                       assess movement techniques          human resources, training,
                                       associated with lifting,            policies, procedure and
                                       transferring, repositioning or      protocols.
                                       movement of a patient in            The hospital’s emergency
    be flat on the floor.              advance of the move to              management plan is activated
•   Don’t slouch.                      determine the safest technique      when an unexpected or sudden
Ergonomics:                            to reduce risk of injury. Safe      event in the community or in the
                                       patient handling techniques         hospital significantly disrupts
•   Change your position               should be practiced at all times.   the organization’s ability to
    frequently. If you sit a lot,      Staff education will include        provide care, disrupts the
    stand up occasionally.             identification, assessment and      environment of care itself or
                                       use of devices and/or handling      results in a sudden, significantly
•   At the computer:
                                       aids.                               changed or increased demand
         o    Keep the screen          Supervisors will ensure that        for the organization’s services.
              directly in front of     mechanical lifting devices and
              you, 18” to 24”          other safe patient equipment
              away at eye level        and/or aids are accessible to
              Consider a               staff. Devices will be regularly
              document holder if       maintained, kept in proper          Emergency Management
              typing frequently.       working order and stored in a       Codes
                                       convenient location. Any
                                                                           Code “Triage Standby”
    14                             MHRI ANNUAL MANDATORY EDUCATION
•   Announcement to be used         Physician on duty. The Senior         •    Common language to
    to alert administration that    Vice President or designee                 promote
    the Department of               working with other members of              communication and
    Emergency Medicine has          the EDCT, notifies (if                     facilitate outside
    become aware of a Mass          warranted) senior management               assistance and cost
    Casualty Incident (MCI)         who will in turn decide whether            effective emergency
    with a potential for an         or not to activate the Incident            planning with the
    increased influx of patients    Command System.                            health care
    to the hospital.                                                           organization.
                                    Internal Disaster – When a
Code “Triage External”              disaster that impacts patient         Specific roles are assigned
                                    care occurs, staff in the             based on the HICS Incident
•   Announcement to be made
                                    immediate area will: initially        Management Team (see
    over the hospital’s public
                                    manage the safety of the              last page of this Annual
    address system to inform
                                    patients and call the hospital        Mandatory Education).
    staff that the Incident
                                    Operator and explain the
    Command System has                                                    Pre-assigned areas in
                                    situation. The Operator will
    been activated due to an                                              effect during a Code Triage
                                    notify senior management who
    emergency outside the                                                 (Memorial Hospital only):
                                    will decide whether or not to
                                    activate the Incident Command         Command Center
Code “Triage Internal +             System.
                                                                      •   Administrative conference
                                    Each associated facility              area – 2nd floor Sayles
•   Announcement made over          maintains an evacuation plan          Bldg.
    the hospital’s public           that is flexible and able to
                                    respond to any disaster               Media Center
    address system that the
    Incident Command System         situation that may place          •   Physicians’ Auditorium –
    has been activated due to       patients in harms way.                ground floor Richardson
    an emergency inside the                                               Bldg.
                                    Hospital Incident Command
    hospital (applies to Notre
                                    System                                Inpatient Discharge Area
    Dame also).
                                    The Hospital Incident             •   Dining Room 3/Cafeteria –
Code “Triage All Clear”
                                    Command System (HICS) will            ground floor Wood Bldg.
•   Announcement to be made         be placed into operation
    over the hospital’s public      whenever an internal or           Disaster Patients’ Discharge
    address system to inform        external “Code Triage” is         Area
    staff that the facility has     initiated. This system allows     •   Coffee Shop – 1st floor
    been returned to normal         the hospital to respond quickly       Sayles Bldg.
    operation (applies to Notre     with structure and a focused
    Dame also)                      direction of activities.          Labor Pool Holding Area and
                                                                      Sign In
Incident Command System             HICS features:
Activation                                                            •   Physical Therapy Gym –
                                        •   Predictable chain of          ground floor Sayles Bldg.
External Disaster – When                    management.
notified of a disaster or MCI                                         Psychological
                                        •   Flexible Incident         Casualties/Families
occurring in the hospital’s
                                            Management Team
emergency service area, the                                               Sayles Conference Room –
                                            that allows a scaleable   •
Department of Emergency                                                   ground floor Sayles Bldg.
                                            response to specific
Medicine Nurse Manager or
                                            emergencies.              See your supervisor/manager
Charge Nurse immediately
forms a unified command called          •   Prioritized response      for specific details on your role
the Emergency Department                    checklist.                and responsibility in preparing
Command Team (EDCT)                                                   for building evacuation. Refer
                                        •   Accountability of         to the Environment Of Care
consisting of Senior Vice
                                            function.                 Manual for further information.
President- Operations, the
Patient Care Director-                  •   Improved
Emergency Department or                     documentation for
Administrative Coordinator (off             improved accountability
shifts) and the Physician-in-               and cost recovery.
Chief of Emergency Medicine or                                        ENVIRONMENT OF CARE
senior Emergency Department
  15                                   MHRI ANNUAL MANDATORY EDUCATION
The Environment Of Care                 Safety Data Sheets (SDS)               The Bio-Medical Engineering
(EOC) Program ensures that              The Safety Data Sheet, SDS             Department is responsible for
the facilities of Memorial              (formerly Material Safety Data         inventorying, inspecting, and
Hospital provide a safe,                Sheet) furnishes hazard and            managing the repair of all
functional, supportive and              toxicological information              medical equipment.
effective environment for               required by the OSHA's Hazard
patients and staff. Each                Communication Standard, and            A Bio-Medical Engineering
department has a copy of the            is provided by the manufacturer        Department inventory sticker is
EOC Manual.                             for all potentially hazardous          attached to all equipment listed
                                        substances.                            in the Medical Equipment
  HAZARDOUS MATERIALS                                                          Inventory.
          AND WASTE                     SDS’s can be found in the              If you notice a piece of
  MANAGEMENT PROGRAM                    bright yellow binder located in        equipment that should be in the
A hazardous material or waste           each department.                       inventory, but does not have an
is any substance that is toxic,                                                inventory sticker, call the
flammable, corrosive, reactive,                                                Clinical Engineering
or capable of causing harm or             LATEX GLOVES AND                     Department at extension 2345.
serious injury, and also includes       OTHER LATEX PRODUCTS
hazardous energy sources such                                                  Medical Equipment
as ionizing or non-ionizing             Although the hospital no longer        Management Program
radiation, lasers, microwave, or        uses latex gloves and is phasing       Requirements
ultrasound.                             out all latex products, it should be   • Present all personal,
Hazardous Materials and                 noted that repeated contact with          Hospital or
Waste Management Program                any latex may cause a latex               patient-
                                        allergy or may worsen a present           owned
                                        latex allergy. Reactions to latex         electrical
• Use all
                                        may include: skin rashes, hives,          equipment
   safety                               asthma, nasal, eye or sinus
   equipment                                                                      or
                                        symptoms and allergic shock
   and                                                                            appliances
                                        (anaphylactic shock). If you or
   protective                                                                     to the Bio-Medical
                                        your family is having these
   clothing required.                                                             Engineering Department for
                                        symptoms, call your health care
• Attend department                     provider (your doctor, nurse or           inspection prior to use.
   hazardous materials                  dentist) immediately.                  • Do not use equipment that
   training.                                                                      is in disrepair.
• Know the location and                                                        • Contact the Bio-Medical
   operation of the nearest                                                       Engineering Department
   eyewash/emergency                                                              immediately to have
   shower station.                                                                medical equipment
• Never use material from an                                                      repaired.
   unmarked container.                                                         • Contact the Purchasing
• Never clean up a                                                                Department if you become
   hazardous material or                                                          aware of a product recall or
   waste spill unless you have                                                    safety alert.
   been trained.                                                               • Notify your supervisor and
• Know the precautions for                                                        complete the appropriate
   and hazards of selecting,              MEDICAL EQUIPMENT                       Incident Report if you
   handling, storing, using,             MANAGEMENT PROGRAM                       experience an incident
   and disposing of hazardous                                                     involving a patient, staff, or
   materials and waste.                                                           visitor resulting from
                                        The Medical Equipment
• Know the emergency                    Inventory consists of all                 malfunction or misuse of
   procedures to be followed            equipment used for the                    medical equipment.
   in case of exposure.                 diagnosis, treatment, monitoring       • Know the medical
                                        and care of patients, including           equipment’s capabilities,
If you are involved in a spill,                                                   limitations, and operating
property damage, or patient,            electrically operated beds, and
                                        all equipment including non-              and safety procedures.
staff, or visitor injury/illness due                                           • Know the proper
to exposure to hazardous                clinical equipment located in
                                        patient care areas or                     emergency procedures
materials or waste, notify your                                                   including clinical
supervisor and complete the             laboratories.
                                                                                  intervention if the medical
appropriate Incident Report.
    16                               MHRI ANNUAL MANDATORY EDUCATION
     equipment fails while in         Utility Management Program           •   Never leave valuables in
     use.                             Requirements                             your car or work area.
•    Report all medical               • Report any utility system          •   Keep your lockers locked.
     equipment problems,                   failure to Maintenance          •   Notify your supervisor of
     failures, and user errors to          immediately.                        any breach of security,
     the Bio-Medical                  • Know your department’s                 such as theft or vandalism,
     Engineering Department.               policy for turning off the          and complete the
                                           oxygen supply.                      appropriate Incident
    SAFETY MANAGEMENT                 • Know the capabilities,                 Report.
         PROGRAM                           limitations, and basic
                                                                           Code Amber
                                           operating and safety
                                                                           The Infant / Child Abduction
Safety Management Program                  procedures of the utility
                                                                           Program was established to
Requirements                               systems you use.
                                                                           facilitate the prompt and safe
• Keep hallways and work              • Know the location and use
                                                                           recovery of an abducted infant.
    areas free of clutter and              of emergency shut off
    obstruction.                           controls.
                                      • Know the proper
                                                                           Code Grey
• Use only approved ladders
                                           emergency procedure to be       There are occasions when an
    for climbing, and step
                                           followed when the utility       individual becomes so
    stools with rubber feet.
• Do not use extension cords               system fails.                   disturbed that they present a
    in patient rooms unless           • Oxygen Cylinders (full,            potential for violence. When
    absolutely necessary and               partially full or empty) must   the immediate staff, including
    then only those prepared               be secured at all times to      Security, are unable to safely
    by Maintenance up to a                 prevent them from falling or    control the situation
    maximum of two hours.                  being knocked over.             employees at the Memorial
• Never pull on a cord to                       .                          campus are directed to
    remove it from the outlet.         SECURITY MANAGEMENT                 request intervention.
• Follow all safety rules.                     PROGRAM                          • Call the Operator at
• Only use equipment you              Security Management                           extension 2222
    have been trained to              Program Requirements                      • Request the Code
    operate.                          • Wear your                                   Grey Team
• Only use equipment if it is            name                              Employees at all other
    in 100% operational                  badge at all                      locations:
    condition.                           times. Do                              • Call 911
• Report all safety risks to             not leave                              • Request the local
    your supervisor                      your badge
                                                                                    authorities to respond
    immediately.                         at work.

                                      •   Ask anyone who appears                    FIRE SAFETY
                                          lost if you can help direct              MANAGEMENT
                                          him or her to the                            PROGRAM
                                          appropriate area.                Fire Safety Management
                                                                           Program Requirements
                                      •   If you see anyone                • Understand what is
                                          attempting to access a               required of you if a fire or
                                          restricted area or who you           fire hazard exists within the
                                          feel is a security threat            facility.
                                          contact security                 • Know the evacuation routes
                                          immediately.                         in your area.

Utility systems include:              Security Emergency
electricity, heating, steam,          Telephone Numbers:
medical gases (oxygen),               Memorial Campus…ext. 2222
communications, potable water,        Notre Dame….ext 3333
wastewater discharge, data            All other facilities: call 911 for
systems, emergency power, air         local authorities.
conditioning, ventilation, natural    • Do not leave doors open or
gas, elevators, fuel, and                  place objects in the
                                           doorway to keep them from       •   Know the location of the
hazardous waste disposal.
                                           closing /locking.                   nearest and next nearest
                                                                               areas of safe refuge.
    17                             MHRI ANNUAL MANDATORY EDUCATION
•   Know the location of the        If you are in the location of the    Administrative Staff or the Fire
    nearest fire alarm pull         fire’s point of origin, follow       Department.
    station and fire                R.A.C.E:
                                                                         The Operator will announce
•   Observe the Tobacco Use         (R) RESCUE – Anyone in
                                                                         “Code Red + Location” to notify
    Policy.                         immediate danger.
                                                                         staff of a fire emergency.
•   If a patient or visitor is
    found smoking on Hospital       (A) ALARM - Pull the nearest
                                                                         The Operator will announce
    property, explain Hospital      fire alarm pull box. Dial the
                                                                         “Code Red All Clear” when
    policy emphasizing our          Operator at extension “2222”
                                                                         there is no longer any fire
    intent to provide a safe and    and report the type of fire and
    healthful environment, and      the exact location.
    if the patient continues to                                          Evacuation
    smoke, contact your             (C) CONTAIN - Close all doors        Anyone in immediate danger
    supervisor or the               and windows, shut off fans and       shall be moved immediately
    Administrative Coordinator      air conditioners.                    during a fire emergency. All
    in the Clinical Operations                                           other patients, visitors, and staff
    Department.                     (E) EXTINGUISH * -Try to             shall evacuate only when
•   Store combustible materials     extinguish the fire only if you      directed to do so by Senior
    in designated storage areas     are not needed to assist             Management or the Fire
    only and not on top of          patients, visitors or staff to the   Department, following your
    microwaves, toasters,           nearest safe area of refuge.         department’s evacuation plan.
    coffee pots, etc.
•   Exercise extreme caution        Nursing personnel not in their       For the Ambulatory Care
    when handling oxygen.           work area when a “Code Red”          Complex: (Includes the Center
•   Report frayed cords, bare       is announced should remain           for Primary Care, Cancer
    wires, damaged electrical       where they are until a “Code         Center, Ambulatory Care
    outlets, etc., to your          Red All Clear” is announced. If,     Building, Goff Mansion, and
    supervisor immediately.         however, the “Code Red” is           ABC Complex)
•   Do not block doorways, fire     located in your work area,           If you are in the location of the
    doors, stairways, fire          return to assist unless directed     fire’s point of origin:
    extinguishers or fire alarms    otherwise. Do not return to          (R) RESCUE - Anyone in
    with furniture, equipment or    your area if your safety will be     immediate danger.
    supplies.                       endangered.
•   Move wheeled devices out                                             (A) ALARM - Pull the nearest
    of corridors during a Code      If you are away from the fire’s      fire alarm pull box. Dial the
    Red or Code Triage              point of origin:                     Operator at extension “2222”
    Internal.                                                            and report the type of fire and
•   Do not prop open fire           1.   Reassure patients/visitors.     the exact location.
    doors.                          2.   Close all doors.
•   Do not leave toasters,          3.   Prepare for evacuation by       (C) CONTAIN - Close all doors
    coffee pots, or microwaves           insuring patients are able to   leading to the fire’s point of
    unattended when in use.              be safely evacuated, and        origin.
•   Know the types of fire               all vital supplies and
    extinguishers available and          equipment are identified to     (E) EXTINGUISH * - Try to
    what types of fire they              assure continuous patient       extinguish the fire only if you
    extinguish.                          care; and evacuate only if      are not needed to assist
                                         necessary or you are told to    patients, visitors or staff to the
If you discover fire, smoke, a           do so.                          nearest safe area of refuge.
burning odor or hear the fire       4.   Stay where you are until
alarm, the steps you take will           “Code Red All Clear” is         (E) EVACUATE – the smoke
differ depending on the building         announced.                      compartment in which the fire
in which the fire emergency is      5.   Do not pass through fire        emergency is located in an
located.                                 doors unless you are            orderly and timely fashion, by
                                         evacuating the area.            checking all exam rooms,
For the Main Hospital:
(Includes MacColl, Sayles,                                               restrooms, and waiting areas
                                    Do not use the elevators or turn     and assisting all patients and
Wood, Hodgson, Richardson,
                                    off water valves unless directed     visitors to the nearest safe area
Endoscopy, Maintenance
                                    to do so by a member of the          of refuge.
Garage and the Boiler Room).
     18                              MHRI ANNUAL MANDATORY EDUCATION
If you are away from the fire’s       patients, visitors or injured staff   Management or the Fire
point of origin:                      to the nearest safe area of           Department, following your
                                      refuge.                               department’s evacuation plan.
1.   Reassure patients/visitors.      * See portable Fire Extinguisher
                                      Safety Rules.
                                                                            For all facilities other than
2.   Close all doors.
                                                                            those located on the
3.   Prepare for evacuation by
                                      Nursing personnel not in their        Memorial Hospital Campus
     insuring patients are able to
                                      work area when a “Code Red”           and Notre Dame:
     be safely evacuated, and
     all vital supplies and           is announced should remain
                                      where they are until a “Code          If you are in the location of the
     equipment are identified to
                                      Red All Clear” is announced. If,      fire’s point of origin:
     assure continuous patient
     care, and evacuate only if       however, the “Code Red” is
                                      located in your work area,            (R) RESCUE - Anyone in
     necessary or you are told to
                                      return to assist unless directed      immediate danger.
     do so.
4.   Stay where you are until         otherwise. Do not return to
                                      your area if your safety will be      (A) ALARM - Pull the nearest
     “Code Red All Clear” is
                                      endangered.                           fire alarm pull box.
5.   Do not pass through fire
                                      If you are away from the fire’s       (E) EVACUATE - In an orderly
     doors unless you are
                                      point of origin:                      fashion, check all exam rooms,
     evacuating the area.
                                                                            restrooms, and waiting areas
                                      1.   Reassure patients/visitors.      and assist all patients, and
Do not use the elevators or turn
                                      2.   Close all doors.                 visitors to the nearest exit and
off water valves unless directed
                                      3.   Prepare for evacuation by        then to the outside of the
to do so by a member of the
                                           insuring patients are able to    building following your
Administrative Staff or the Fire
                                           be safely evacuated, and         department’s evacuation plan.
                                           all vital supplies and
                                           equipment are identified to      If you are away from the fire’s
Notification                               assure continuous patient        point of origin:
The Operator will announce                 care, and evacuate only if
“Code Red + Location” to notify            necessary or you are told to     (E) EVACUATE - When you
staff of a fire emergency.                 do so.                           hear the fire alarm, check all
                                      4.   Stay where you are until         exam rooms, restrooms, and
The Operator will announce                 “Code Red All Clear” is          waiting areas and in an orderly
“Code Red All Clear” when                  announced.                       fashion, assist all patients, and
there is no longer any fire           5.   Do not pass through fire         visitors to the nearest exit and
danger.                                    doors unless you are             then to the outside of the
                                           evacuating the area.             building following your
For the Notre Dame                                                          department’s evacuation plan.
Ambulatory Care Center:               Notification
                                      The Receptionist will announce        •   Do not use the elevators or
If you are in the location of the     “Code Red and Location” to                turn off water valves unless
fire’s point of origin, follow        notify staff of a fire emergency.         directed to do so by the
R.A.C.E.:                             The Receptionist will announce            Fire Department or a
                                      “Code Red All Clear" when                 member of the
(R) RESCUE - Anyone in                there is no longer any fire               Administrative Staff.
immediate danger.                     danger.                               •   Move to the designated
                                                                                area of the parking lot as
(A) ALARM - Pull the nearest          Do not use the elevators or turn          stated in your department’s
fire alarm pull box. Dial the         off water valves unless directed          evacuation plan and count
Reception Desk at extension           to do so by a member of the               staff, patients and visitors.
“3333” and report the type of         Administrative Staff or the Fire      •   Notify the Fire Department
fire and the exact location.          Department.                               immediately upon their
                                                                                arrival of anyone presumed
(C) CONTAIN - Close all doors         Evacuation                                to be still in the building.
and windows, shut off fans and        Anyone in immediate danger            •   From a phone outside the
air conditioners.                     shall be moved immediately                building, call the Operator
                                      during a fire emergency. All              at Memorial Hospital of
(E) EXTINGUISH *- Try to              other patients, visitors, and staff       Rhode Island to notify the
extinguish the fire only if you       shall evacuate only when                  Vice President of
are not needed to assist              directed to do so by Senior
    19                                MHRI ANNUAL MANDATORY EDUCATION
    Environmental and Support          ordinary materials (burning        Squeeze the lever - to
    Services.                          paper, cardboard, plastics and     discharge the extinguishing
•   Do not re-enter the                wood) where a potential            agent.
    building, until the Fire           electrical shock hazard may
                                                                          Sweep from side to side -
    Department has announced           exist. Unlike a water
                                                                          watching the fire, sweep from
    that the building is safe to       extinguisher, the misting nozzle
                                                                          side to side until the flames
    re-enter.                          provides safety form electric
                                                                          appear to be out. If the fire re-
                                       shock and reduces the
                                                                          ignites, repeat the process.
                                       scattering of burning materials.
                                       This is one of the best choices
                                       for protection of hospital              RISK MANAGEMENT
                                       environments, books,                         PROGRAM
                                       documents and clean room                 Incident Reporting
                                       CLASS B FIRES
                                       Class B fires involve flammable
                                       or combustible liquids such as
                                       gasoline, kerosene and
                                       common organic solvents used
Portable Fire Extinguisher             in the laboratory. Use CLASS
Safety Rules                           BC EXTINGUISHERS (Red              A reportable incident is any
• Only attempt to put out a            container with large nozzle) or    unusual occurrence or event
    fire with a portable fire          CLASS ABC                          such as:
    extinguisher if the fire is        EXTINGUISHERS (Red                 •   Work-related injury or
    small and confined to a            container with a small nozzle)         illness
    small area.                                                           •   Any incidents involving
• Use the proper fire                  CLASS C FIRES
                                                                              patient safety, falls,
    extinguisher.                      Class C fires involve                  medication errors or
• NEVER turn your back to              energized electrical                   incorrect surgery
    an extinguished fire.                                                     Medical equipment/device
                                       equipment, such as                 •
• NEVER place your hand on                                                    malfunction/incidents
                                       appliances, switches, panel
    the cone of a CO2                                                         Theft, vandalism and lost
                                       boxes, power tools, hot plates     •
    extinguisher.                                                             patient items
• NEVER use water                      and stirrers. Water can be a
                                       dangerous extinguishing            •   Needle stick or blood/body
    extinguishers on an                                                       fluid exposure
    electrical fire or a               medium for Class C fires
    flammable liquids fire.            because of the risk of             Your role is to:
• NEVER attempt to                     electrical shock. Use a
                                       CLASS BC EXTINGUISHER              •   Immediately inform your
    extinguish a fire if there is a
                                                                              supervisor if you become
    possibility you may                (Red container with a large
                                                                              involved in, or aware of a
    endanger yourself or               nozzle) or a CLASS ABC
                                                                              reportable incident.
    others.                            EXTINGUISHER (Red                  •   If you need medical
                                       container with a small nozzle)         attention, seek treatment
Which Type of Fire Requires
                                       CLASS K FIRES                          from Employee Health, the
Which Type of Extinguisher?
                                                                              Emergency Department, or
CLASS A FIRES                          Class K fires are kitchen fires.       Notre Dame Center for
                                       Use a CLASS K                          Occupational Health,
Class A fires are ordinary             EXTINGUISHER.                          depending on the
materials like burning paper,                                                 seriousness of the
lumber, cardboard, plastics, etc.      Follow the PASS procedure
                                       when using a fire                      injury/illness.
Use CLASS A FIRE                                                          •   Complete and send the
EXTIGUISHERS (Chrome                   extinguisher:
                                                                              appropriate Incident Report
container, water filled) or            Pull the pin - to unlock the           within 24 hours of the
CLASS ABC FIRE                         operating lever and discharge          incident to the Risk
EXTIGUISHERS (Red                      the extinguisher (twist the pin        Management Department.
container with small nozzle) or        as you pull it).
WATER MIST EXTIGUISHERS                                                   See your supervisor for blank
(White and Blue colored) Water         Aim low - keeping your back to     Incident Report forms. The two
mist extinguishers are ideal for       an exit, point the extinguisher    Incident Report forms are:
                                       nozzle at the base of the fire.
  20                                MHRI ANNUAL MANDATORY EDUCATION
1. Employee Incident Report          of the laws that are designed to
                                     deter non-compliance, including
        For staff incidents only.
                                     the Federal Civil False Claims                  QUESTIONS OR
2. Confidential Report of            Act, the Federal Civil Monetary                  COMMENTS
Incident                             Penalties law, the Federal
                                     Program Fraud and Civil                     If you have any questions or
        Specifically for patient,    Remedies Act and the Rhode                  comments about the Annual
        visitor, volunteer, and      Island Medicaid Fraud Act.                 Mandatory Education, please
        environment of care                                                    share them with your supervisor.
        related incidents.           Another important part of MHRI’s
                                     Corporate Compliance Program is the
(Refer to the Hospital Policy,       policy of encouraging employees to
Administration 2 for further         report possible instances of non-
information).                        compliance with legal and ethical
                                     requirements. Any hospital employee
 Sentinel Event is an                may communicate such concern
unexpected occurrence                directly to his/her immediate
involving death or serious           supervisor or to an operations
physical or psychological injury     manager or vice president in charge
                                     of the employee’s department.
to a patient. When there is any      Alternately, employees may report
question of a sentinel event,        these concerns to the corporate
staff must report the event          compliance officer either in writing or
details to the Risk Manager. All     by voice mail at extension 2148.
staff involved in the event join     Reports may be made anonymously if
                                     so desired. Per hospital policies
together to analyze the event
                                     Human Resources 66 and Corporate
and identify the root cause.         Compliance 5, no employee will suffer
Often, we look for root causes       any discipline in retaliation for
when a situation involves            reporting a corporate compliance
potential injury, so we can          concern.
modify our practices to avoid
sentinel events in the future.

CORPORATE COMPLIANCE                       Thanks for your
      PROGRAM                        contributions to a safe and
                                        caring environment!
Memorial Hospital has in place
a Corporate Compliance
Program that is designed to
maintain the hospital’s culture
of ethical integrity and to
promote continuing adherence
to legal requirements related to                                                           HRBEV911
billing, reimbursement and           For more information details
other business functions. An         and to keep up-to-date on
important part of this program is    activities and performance
the Corporate Compliance             improvement initiatives
Code of Conduct, hospital            within the hospital, please
policy Compliance 2, which           read our Survey Readiness
outlines principles and              Update Booklet to prepare
standards for the way in which       and be confident during The
MHRI personnel are expected          Joint Commission (TJC) and
to conduct the hospital’s            other regulatory surveys.
business. These principles and
standards address, among             Visit the MHRI intranet
other things, business ethics        ( for
and business relationships,          policies, information and
conflicts of interest and
                                     other hospital news.
protection of MHRI assets. The
principles and standards also
address legal compliance and
provide information about some

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