The Joint Commission Handbook

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Table of Contents
Introduction Patient Safety Program National Patient Safety Goals Pain Management Patient Rights Ethics/OPI Assessment of the Patient Care of the Patient Plan of Care Sedation/Analgesia Restraints Crash Carts Medications Administration Adverse Drug Reactions Education of the Patient and Family Continuum of Care Performance Improvement Lovelace Westside Mission/Vision Lovelace Westside Basics Lovelace Westside Improvements Management of Environment of Care Emergency Codes MSDS Sheets Medical Equipment Safety Management of Human Resources Surveillance, Prevention and Control of Infection Management of Information Tracer Activity Medical Staff Information Common Survey Questions Documentation Rules for Medical Staff 1 3 4 7 9 12 13 13 14 14 14 16 17 18 19 20 21 21 22 22 24 24 25 26 27 28 31 31 32 32 32

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INQUIRING MINDS WANT TO KNOW

INtRODUctION This booklet provides assistance in answering a variety of questions for surveyors from outside our organization. A survey provides us an opportunity to demonstrate processes and procedures that produce quality patient care. THE FActS We are accredited by multiple organizations that conduct site visits. These include The Joint Commission (TJC), and CMS (Centers for Medicare and Medicaid Services) Surveyors may request to talk to any employee and tour any area providing patient care or support services. The Joint Commission (TJC) is an independent, not-for-prot, national organization that develops standards for health care facilities. For TJC, accreditation surveys occur every three (3) years, and are unannounced. We anticipate our re-survey will occur some time in early to mid 2012. MISSION Our focus is always the patient. Our mission is to provide safe, excellent care and service. To meet our mission, we set specic targets for - Clinical excellence - Patient and staff satisfaction - Financial strength

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StANDARDS Of CONDUct Employees communicate the real spirit of a health care facility. We are expected to be responsible for our attitudes and actions at all times, consistent with the standard and behaviors contained in The Lovelace Westside Handbook, individual job descriptions, department guidelines, and performance evaluations. Manuals You should be familiar with the following Manuals and their location. Department Procedure Manual (on units or in department) Administrative Policy and Procedure Manual (In Administrative Ofce) MSDS (Material Safety Data Sheets) in the Plant Operations ofce and on Fastlane Infection Control- Infection Control ofce and on Fastlane Emergency Preparedness In Lovelace Policy Manager on Fastlane under Emergency Management Perry and Potter Nursing Intervention Guidelines on 2N and 2W, ICU and L&D. Points to Remember and verbalize Surveyors will evaluate how we fulll our Mission Statement. Everything we do to convey our commitment to quality and safety shows surveyors (and everyone else) our highest priorities. If you meet a surveyor, be welcoming, smile and demonstrate how very good we are.

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THE PAtIENt SAfEtY PROGRAM: The scope of the Patient Safety Program encompasses the patient population, visitors, volunteers and staff (including medical staff). The program addresses maintenance and improvement of patient safety issues in every department throughout the facility in an effort to reduce clinical errors or events. Patient Safety Manager: Tinley Vermoesen Focus of the Patient Safety Program is on processes and systems. Goal of the patient Safety Program is to improve patient safety and reduce risk to patients through an environment that encourages: Recognition and acknowledgement of risks to patient safety and medical/healthcare errors; The initiation of actions to reduce these risks; Minimization of individual blame or retribution for involvement in a medical/healthcare error in order to encourage reporting; Organizational learning about medical/healthcare errors as a prevention measure; Internal reporting of what has been found and the actions taken; Support of the sharing of that knowledge to effect behavioral changes in itself and other healthcare organizations. Employees who have concerns about the safety and/or quality of care provided may report these concerns to the Joint Commission. As a matter of courtesy and professionalism, employees should make every effort to discuss all issues and concerns with hospital management, or Tinley Vermoesen at 72456 before reporting them to

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the Joint Commission. No disciplinary action will be taken against any employee who reports safety or quality concerns to the Joint Commission. Contact numbers are on the Joint Commission website. SENtINEL EVENtS TJC denes a sentinel event as: A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specically includes loss of limb or function. The phrase or the risk thereof includes any process variation for which a reoccurrence would carry a signicant chance of a serious adverse outcome. 2011 National Patient Safety Goals Goal 1: Improve the accuracy of patient identication Use at least two (2) patient identiers when providing care, treatment, or services. We use the patients name and date of birth. Make sure the correct patient gets the correct blood when they get a blood transfusion Goal 2: Get important test results to the right staff person on time. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and read-back the complete order or test results, and sign RBO in the medical record. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

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DO NOT USE THESE ABBREVIATIONS!!

U (unit) Mistaken for 0 (zero), the number 4 (four) or cc Mistaken for IV (intravenous) or the number 10 (ten) Mistaken for each other, or period after the Q mistaken for I and O mistaken for an I Decimal point is missed Write unit

IU

Write International Unit

Q.D., QD, q.d., qd, (daily) Q.O.D., QOD, q.o.d., qod (every other day) Trailing zero (X.0 mg) Lack of leaning zero (.x mg) MS MSO4 and MgSO4

Write daily Write every other day

Write X mg Write 0.X mg

Can mean morphine sulfate or magnesium sulfate and confused for one another

Write morphine sulfate Write magnesium sulfate

Measure, assess, and if appropriate, take action to improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions. (SBAR Hand-off)

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Goal 3: Improve the safety of using medications Before a procedure, label medicines that are not labeled. Label all medications, medication containers (i.e. syringes, medicine cups, basins), or other solutions on and off the sterile eld. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. Goal 7: Reduce the risk of healthcare associatedinfections Comply with current World Health Organization (WHO) hand hygiene or Centers for Disease Control (CDC) hand hygiene guidelines. Use the proven guidelines to prevent infections that are difcult to treat. (MDROS) Use proven guidelines to prevent infections of the blood from central and PICC lines. Use proven guidelines to prevent infection after surgeries. Goal 8: Accurately and completely reconcile medications across the continuum of care There is a process for comparing the patients current medications with those ordered for the patient while under the care of the organization. A complete list of the patients medications is communicated to the next provider of service when the patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list is also provided to the patient on discharge from the organization. Some patients may get medicine in small amounts or for a short time. Make sure that it is OK for those patients to take those medicines with their current medicines.

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Goal 15: The organization identies safety risks inherent in its patient population. The organization identies patients at risk for suicide. The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patients condition appears to be worsening. UNIVERSAL PROtOcOL Wrong site, wrong person, wrong procedure surgery can be prevented. The universal protocol is intended to achieve that goal. The universal protocol is composed of 3 important components, 1. Conduct a pre-operative verication process. (Correct documentation, correct labs, correct images, etc.) 2. Mark the operative site. (Mark with the patients involvement using yes, and person doing the procedure should mark the site.) 3. Conduct a time-out immediately before starting the procedure. 4. Also, before we give blood or insert a PICC line we must call for a time out to ensure that all appropriate procedures are followed, and consents are signed. PAIN MANAGEMENt Is failure to rapidly respond to a patients request for alleviation of pain considered a violation of the patients rights? YES! REMEMBER: All nurses must document when a pain medication or intervention is given and the patients response to the medication or intervention.

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LWSH policy Patient Safety: Pain Management (#337) related to pain states: Provide information about pain and pain relief measures to patients. Provide a staff that is committed to pain prevention and management. Provide staff that will respond quickly to reports of pain. Provide staff that will believe a patients complaints of pain. Provide state of the art pain relief measure The hospital uses many scales to determine pain: Wong Baker FACES (smile-frown) scale, the Numeric or Verbal Scale; NIPS and N-Pass scales are used for newborns: FLACC for infants and children (2months to 7 years); and Non Communicative and Pain/Discomfort Behavior scale. When a patient does not understand spoken English, an interpreter must be utilized to ensure that the patient does not suffer needlessly.

Pain should be assessed at the following points: On admission or rst contact with the organization as part of the overall evaluation When care is transferred from one setting or provider to another (change of shift) ( SBAR hand off report) Assess for pain one (1) hour after any intervention to ensure reduction or alleviation pain for PO meds and 30 minutes for IV or IM pain medications. Assess every shift patients that say they have no pain. Immediately before discharge

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PAtIENt RIGHtS Patients are exposed to information regarding their rights on admission and Patient Rights are posted in registration areas and available in writing upon request. Examples of Patient Rights: Right to know who is caring for them: WEAR YOUR BADGE! AND WASH YOUR HANDS! RIGHt tO pRIVAcY: Knock on door before entering and introduce yourself. Close doors and curtains when doing patient care. RIGHt tO CONfIDENtIALItY: Do not talk about patients/families in public areas. Be certain that computer screens with patient information are not in public view or left unattended. RIGHt tO VOIcE A cOMpLAINt: Patients may tell any staff member of dissatisfaction with care or services; all attempts to solve the complaint are made. RIGHt tO BE tOLD Of DIAGNOSIS, tREAtMENt OptIONS, RISKS, BENEfItS: The patient receives complete information in order to accept or refuse care. If the patient is mentally and physically able to make those decisions, no one else can make those decisions for him. (This includes signing consent forms.)

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RIGHt tO BE fREE fROM ABUSE OR HARASSMENt: Adult Protective Services (elderly person over age 65, or mentally or physically disabled person over age 18) is notied when a patient is a potential/actual victim of abuse. Hotline for Adult Protective Services: 841-4500 RIGHt tO AppROpRIAtE ASSESSMENt AND MANAGEMENt Of pAIN: Staff is committed to pain prevention and management & responds quickly. RIGHt tO A SEcURE ENVIRONMENt What security issues do you have in your area and how are they addressed Right to have respect for a patients choices, cultures, and beliefs. RIGHt tO MAKE ADVANcE DIREctIVES: Advance Directives are documents patients use to communicate their decisions regarding the medical care they wish to receive in the event they are unable to make those decisions. The patient has the right to appoint someone to make care decisions if he becomes mentally or physically unable to do it for himself. The patient may choose to withhold or withdraw life-sustaining treatment in case of terminal illness or, Each patient is asked if they have an advance directive. If not, they are given the opportunity to complete one. Chaplain Services is available for those patients who wish to ask questions or who wish to complete an advance directive.

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If the patient has an advance directive but has not brought it to the hospital with them, they are asked to provide a copy, and if unable to do so, to complete a new one. EMTALA - Emergency Medical Treatment and Labor Act is a statute which governs when and how a patient must be (1) examined and offered treatment or (2) transferred from one hospital to another when he is in an unstable medical condition. Every patient who presents to the emergency department must be given a medical screening exam to determine if they are suffering from an emergent medical condition prior to being asked about ability to pay for service or transfer. INFORMED CONSENT Authorization and consent for treatment of patients: Allows each patient to fully participate in decisions about treatment. An Informed Consent shall be signed by the Patient as evidence that the patient has been provided with information by his/her physician concerning the care, treatment, and services that the patient receives. Discussion by the physician of potential problems that might occur during recuperation, the likelihood of achieving goals and the risk, benets and side effects related to alternatives, including the possible results of not receiving care, treatment and services. What procedures require Informed Consent? Surgical procedures and Invasive procedures Blood and blood products transfusions PICC line placement Consent to treat (on admission)

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Review the Lists and your practices for consents! If a care decision is made that the patient, family, or staff member feels uncomfortable with or disagrees with, Chaplain Services may be contacted to help resolve the issue. ETHICS (For an Ethics Consultation contact the Case Manager, Director of Quality or the CNO/ COO). END OF LIFE CARE Treat all patients with respect and dignity regardless of prognosis or outcome. Involve patients, families, and surrogate decision makers in multidisciplinary planning. Manage the patients pain effectively. Address issues of autopsy and organ/tissue donation with sensitivity. Respect the patients values, religion and philosophy. Involve the patient, and where appropriate, the family, in every aspect of care. Respond to the psychological, social, emotional, spiritual, and cultural concerns of the patient and family. ORGAN/TISSUE DONOR The New Mexico Donor Services works with families, physicians and staff to facilitate patient wishes regarding organ/tissue donation. Nursing shall promptly contact (within 15 minutes NMDS by telephone in all cases of impending and actual deaths for determination by NMDS or donation of organs and/or tissues.

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ASSESSMENT OF THE PATIENT Initial Assessment: Physical assessment is completed within 2 hours of admission. Assessment of pain is an essential part of the initial assessment. The complete data base assessment should be completed by 24 hours. H&P completed and on the chart within 24 hours of admission. An LPN may collect specic data points for the assessment, but the RN is responsible for completing and signing the assessment. The patient will be screened for physical, psychological, social (including violence, abuse or neglect) spiritual, nutritional, functional and discharge planning needs. Medication reconciliation and readiness to learn / patient education forms are part of this assessment. Re-assessment: Nursing reassessments are performed every shift or whenever a change in the patients status indicates a need for reassessment. Re-assessment is made whenever a treatment or intervention that has the potential to change the patients status is implemented, i.e. intervention for pain. CARE OF THE PATIENT The Basics: Introduce yourself and explain your role in the patients care for the day. Call the patient by his/her preferred name. Sit with the patient for at least 5 minutes per shift to plan/review care and the goals to meet that day. Use touch: handshake, a touch on the arm

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Select a behavior unique to your personality and approach that differentiates you from your colleagues Update white boards in each patients room with name of patient care nurse, current date, and CNA for the shift. PLAN Of CARE Care planning is interdisciplinary, goal directed & individualized, and includes: Patient/family input Physician order sets/physician orders orders must be dated, timed and signed within 72 hours. Patient discharge summary Interdisciplinary patient education record Progress notes must be completed daily. Interdisciplinary team meetings (IPOC) Medication reconciliation record, updated at discharge, copy given to patient SEDAtION/ANALGESIA Sedation/analgesia is produced by administering pharmacological agents for therapeutic and/or diagnostic procedures. REStRAINtS: Restraint is used as a last resort after alternative measures have failed. The assessment of the RN or physician to protect the patient or others from injury identies the need for restraint. Alternatives to restraints for acute med/surge care may include: Review of systems - assess the patient to rule out factors such as pain, full bladder, inadequate O2 saturation, incontinence, hunger, constipation or fever.

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Providing companionship and supervision through a family, friend or volunteer to stay with the patient, determining when the patient needs one-on-one attention, increased nursing rounds, or the use of sitters. Reassessing medication or treatments and modifying or eliminating when possible. Recommend initiation of oral medications or feedings if possible, removal of catheters and drains as soon as possible, monitoring of drugs and side effects and discuss alternatives with physician. Modifying the environment such as increasing or decreasing the amount of light in the room, positioning a bedside commode for easy access, arranging for the patient to be near the nursing station, placing a mattress on the oor so the patient can move about freely without falling, placing the bed in lowest position with wheels locked and keeping the call button accessible. Bed alarm. Offering diversionary and physical activities such as TV, radio or music, exercise, ambulation, or providing sensory stimulating object, repetitive activities (rolling bandage, folding towels) Comfort measures such as repositioning the patient on pillows, adjusting the temperature, offering snacks, applying or removing blankets. Reality orientation such as involving the patient in conversation, explaining procedures to reduce fear and convey a sense of calm, using relaxation techniques or attempting to verbally redirect behavior. A physician order is required to apply restraints. An order for restraint is limited to: - 24 hours for medical-surgical care. - 4 hours for behavioral management (abrupt, unexpected aggressive/ threatening behavior).

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For behavioral management: Restraints cannot be re-ordered and continued for more than 12 hours without a face-to-face evaluation by the physician for patients 18 years of age or older. The patient is monitored by the nurse Every 2 hours for medical surgical care. Every 15 minutes for behavioral management. With a behavioral restraint, the MD must do a face-to-face assessment within 1 hour of initiation of restraint even if the patient has been released before the hour has ended. Standing or PRN orders for restraints are NEVER permitted CRASH CARtS: What system is in place for assuring the integrity of the crash cart? Daily standardized crash cart checks by nursing.. Crash cart locks for drug tray drawers are obtained through and controlled by Pharmacy. Crash cart locks are broken only in emergency situations (NOT access for routine supplies). Pharmacy, Materials Management and Nursing check the crash cart for outdates routinely. Replacements for any drugs or supplies are made for anything soon to expire. Outdates for supplies and drugs are posted on the outside of each crash cart. Crash cart integrity is checked every day and the lock number is veried. The debrillator is tested daily at the manufacturers recommendations. Daily checks for the presence and volume of the oxygen tank.

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Laryngoscope and blades are checked and batteries changed, if needed, anytime an outdate for supplies or medications occurs, and if the cart is opened for use. Extra bulbs and batteries are available in the cart. Verify that the Pharmacy has inspected the cart and replaced any drugs soon to expire. Anytime a new lock is placed on the cart, the new number is recorded on the log sheet. Complete check of crash cart if found unlocked. Patient Nourishment Refrigerators: The temperature of the refrigerator and the freezer is monitored and recorded each day. No open containers are returned to the refrigerator. Milk, formulas, etc. are checked for expiration dates. The Nursing staff keeps the refrigerator clean. MEDICATION ADMINISTRATION: How do you store and use medications in your department? Food is stored in a separate refrigerator from all refrigerated oor stock and patient medications. Multi-dose vials with preservatives may be used. Multi-dose vials are only good for 28 days from the time they are opened as long as recommended storage conditions have been followed or unless there is concern for contamination at which point the vial is discarded. Vials without preservatives are for single doses only. Disinfectants and items for external use are properly labeled and kept separate from internal medications.

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General medication areas are neat and uncluttered. The temperatures of the medication refrigerators are monitored and recorded each day. What actions are taken when a refrigerator temperature is out of range? Try to determine the cause for temperature variation and make the appropriate adjustment to correct it (i.e. door left ajar or refrigerator requires defrosting). Temperature is rechecked in 30 minutes and documented. If unable to determine reason, notify Pharmacy to relocate medications and notify plant operations. Medications and food are relocated and discarded as appropriate. ADVERSE DRUG REActIONS: What is an adverse drug reaction (ADR)? An ADR is any undesired, unintended, excessive or exaggerated effect of a drug due to either the drug itself or patient idiosyncrasy (excluding gross overdose and therapeutic failures). These reactions may be expected or unexpected. How do you report an ADR? Notify your patients physician Notify your pharmacist. Complete an incident report by Remote Data Entry (RDE) thru Fastlane. All ADRs will be reviewed by pharmacy and Risk Management.

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Discharge Planning: Initial Discharge Planning begins on admission. Assessments to identify potential Discharge Planning needs are ongoing. Informal discussion may occur daily between clinical disciplines and formally during bi-weekly Interdisciplinary Plan of Care (IPOC) meetings. EDUcAtION Of tHE PAtIENt AND FAMILY Education Assessment Begins on admission. An interdisciplinary approach is used to provide patient/family education. The RN assesses and documents the patients ability to learn. This information is included on each shift assessment. How are our patients religious or cultural needs met? Chaplain Services Patient/family care conferences Individualized care plan Dietary preferences Non-English patient educational material Language interpreters Ongoing re-assessment for readiness to learn will be performed prior to each educational opportunity. All clinical disciplines that teach the patient must know the above assessment ndings in order to incorporate them into their teaching. The patient record is an interdisciplinary tool developed to facilitate documentation and communication/coordination among caregivers.

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CONTINUUM OF CARE Communication The hospital communicates appropriate information to any organization or provider to which the patient is transferred or discharged. The information shared includes the following, as appropriate to care, treatment and services provided: - The reasons for transfer or discharge. - The patients physical and psychosocial status. - A summary of care, treatment, and services provided and progress toward goals. - Community resources or referrals provided to the patient. SBAR communication is utilized for providing information between departments within the facility and between nursing shifts. (AKA Handoff Communication) REACT Team: Was implemented for early response to changes in patients condition by specially trained individuals. The expectation is that this may reduce cardiopulmonary arrests and mortality. The bedside nurse will notify the house supervisor (379-4319). He/she will respond along with RT and the bedside nurse. CODE BLUE : Is paged overhead for patients who are assessed to be in a resuscitation state. Overhead paging is completed by dialing 7-5049 and announcing; Code Blue, Lovelace Westside Hospital, unit and room number (repeat 3 times).

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PERFORMANCE IMPROVEMENT Performance Improvement means designing processes to improve patient outcomes and hospital performance. Q. How is this done? A. Any staff member or physician may identify an area for improvement. 1. The rst step is to identify the problem. 2. Develop an action utilizing Plan, Do, Check, Act (PDCA) methodology. 3. Initiate the PDCA. 4. Re-evaluation the situation. 5. Make adjustments, as necessary. 6. Monitor results in order to maintain the gain. 7. List 2 things your organization is working on towards performance improvement; a)________________________________ b)________________________________ LOVELACE WESTSIDE HOSPITAL MISSION STATEMENT Lovelace Health Services is a premier provider of healthcare services, delivered with compassion for patients and their families; respect for employees, physicians and other health professionals; with accountability for our scal and ethical performance; and with responsibility to the communities we serve. VISION Lovelace Health Services will be the healthcare provider of choice for our patients, employees, physicians and other health professionals by consistently performing at a superior level, while maintaining sound ethical standards and returning a fair value to our nancial partners.

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THE LOVELAcE WEStSIDE BASIcS: 1. This is our hospital. I will demonstrate pride of ownership every day. 2. I will communicate positively, manage conict, listen and respond to needs. 3. Every person deserves respect. 4. I choose to be a positive representative of Lovelace Westside Hospital. 5. Exceptional customer satisfaction is my responsibility. a. See a problem. b. Own the problem. c. Fix the problem. d. Everyone has $25.00 to x a problem. 6. Celebrate! I will recognize and acknowledge our success. 7. Teamwork gets the job done. I will support and respect my co-workers. 8. Safety is my responsibility. 9. I am responsible for uncompromising levels of cleanliness of our facility. 10. I will always protect condential information. 11. Customer service and basic etiquette is my responsibility. I will smile, greet and escort customers to their destination within the hospital. 12. I will show pride in my appearance as a reection of my professionalism and commitment to our high standards. 13. Quality improvement starts with me. I will continually push for higher standards. LOVELAcE WEStSIDE IMpROVEMENtS What have we done to improve? Can you give an example? Patient Satisfaction and Patient Safety Hourly rounding Rounding with purpose Changing PCT shift start time

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TCAB initiatives Reopened 2N All private rooms Fall team Skin and Wound team New stafng grid New beds with alarms Noise reduction processes All employees are empowered to answer call lights Infection Control Interviews Hand Hygiene Surveillance Quality Grand Rounds Continuing education regarding Core Measures, HCAHPS and Patient Satisfaction Redesigned patient admission information packet

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MANAGEMENT OF ENVIRONMENT OF CARE Safety Ofcer Paul Bugie Emergency Codes:

PAGE SItUAtION KEY INfORMAtION

Code Red

Fire Dial 7-5049 All services located in adjoining builidings are instructed to dial 911 for re.

RACE Rescue - remove all persons from dangers Alert - Dial 911 give your name, your location and the location of the code, pull the nearest rebox Conne - close all doors Extinguish PASS Pull- pull the pin Aim at the base of the re Squeeze- the handle Sweep- side to side Know the location of the nearest re pull and re extinguisher and the evacuation routes

Code Blue

Cardiac/Resp Arrest Overhead page using 7-5049

Code Blue Team response All services located in adjoining builidings are instructed to dial 911 for emergencies.

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Code Pink

Infant abduction Overhead page using 7-5049 Security alert Overhead page using 7-5049 or call 206-7328 Hazardous Spill Call 206-4558 Disaster

Search all hospital areas and man all exits Contact on site security

Code Grey

Code Orange

Spill Team will respond to evaluate Activate plan

Code Triage

Code Triage Standby

Inbound disaster

Assess needs

Code Yellow

Disaster

Emergency department is designated command for inux.

Material Safety Data Sheets (MSDS) You have the right to know about chemicals used in your working environment. MSDS provides the information you need to know when working with ALL chemicals. Procedures to use, safety precautions, and emergency response techniques are found on each MSDS. For your personal safety and that of fellow employees, MSDS information is located on Fastlane-Clinical-Hazsoft and begin your search. Copies of all MSDS sheets are located in Plant Operations.

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MEDIcAL EQUIpMENt SAfEtY Safe Medical Device Act In the event of actual or suspected equipment malfunction resulting in patient injury or death; Take the equipment out of service. Report to Maintenance at 727-2670. If there is a patient injury involved, notify Patient Safety and Risk Management 727-2456. Complete an incident report thru Remote Data Entry on Fastlane. Electrical Safety: All hospital electrical equipment should be inspected by Maintenance and tagged with a Safety Checked /Date sticker. Red outlets and red switches provide power in the event of an electrical failure. Oxygen Shut-off: In the event that it becomes necessary to shut off the oxygen valve to patient care areas, the House Supervisor performs this task. Patient Evacuation: There are 4 types of evacuation. Defend in Place- Stay and listen for updates. Low risk Horizontal Evacuation-moves patient from one area to another on the same oor Vertical Evacuation -moves patients from one oor to another. Total Evacuation- moves patients out of hospital to staging areas.

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MANAGEMENT OF HUMAN RESOURCES AND EMPLOYEE HEALTH Competencies at the Lovelace Westside reect the priority focus as well as key performance indicators of the hospitals. The hospital provides an adequate number and mix of staff consistent with the hospitals stafng plan and with job descriptions and responsibilities. Competency is determined at the following stages: 1. Selection process Includes multiple interviews, reference and background checks, job description requirements and pre-employment drug screening. 2. Upon Hire Includes hospital orientation, department orientation, competency validation, and development plan. 3. Ongoing Includes annual performance evaluations, skills labs, regular staff meetings, internal and external training and education, case studies, and annual educational needs assessment. 4. The hospital uses data on clinical/service screening indicators and human resource screening indicators to assess and continuously improve stafng effectiveness. Lovelace Westside Hospital Stafng Effectiveness Indicators for 2011: Stafng effectiveness is determined through a hospital grid system that incorporates number of patients and their acuity. Employee and patient satisfaction scores are used as partial measurements of the appropriate stafng levels.

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SURVEILLANCE, PREVENTION AND CONTROL Of INFECTIONS JJ Juckette IP 727-2457 Hand washing is the single most important way to STOP the spread of infections! At the Lovelace Westside Hospital, ALL clinical managers provide continuous hand washing surveillance! Lovelace Westside follows the hand hygiene guidelines recommended by the Center for Disease Control (CDC) and the World Health Organization (WHO). National Patient Safety Goal #7 Set goals for improving hand cleaning. Use the goals to improve hand cleaning. - Every department participates in hand washing surveillance. - Hand hygiene with alcohol-based gels or foams. - For C.diff infections use soap only - Between every patient contact - Before donning and after removing gloves - Up to a maximum of 7-8 applications of hand gel/foam- then soap. Use proven guidelines to prevent infections that are difcult to treat - We monitor all patients for MDROs and inform patients via IP visit or my mail if the patient was positive in the Emergency Dept. and then discharged home. Use proven guidelines to prevent infection of the blood from central lines - LWSH participated in the NMDOH/NMMRA CLABSI collaborative. - We established a Vascular Access RN that is a VA-BC - Standardized checklist for catheter insertion.

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Use proven guidelines to prevent infection after surgery. - Only clippers used for hair removal - Antibiotics are given and monitored as a Core Measure Patient/Staff Safety Measures: Standard Precautions apply to ALL patients, ALL the time in regard to handling blood, body uids, secretions and excretions (excluding sweat), non-intact skin, mucous membranes and/or potentially infectious material Transmission based (isolation) precautions apply to those cases where a more restrictive level of isolation is necessary based on known or suspected diagnosis, clinical evidence or patient signs and symptoms. Categories for this isolation include: Contact (GREEN sign) for MRSA, VRE, Clostridium Difcile (C-Diff), Group A Strep, and ESBL. Droplet (PINK signs) for Inuenza, Meningitis (bacterial) and Airborne (BLUE signs) are for airborne conditions such as TB and Legionellae Barrier precautions include the use of certain personal protective equipment (PPE) until certain infections are ruled out. These PPE include: Fluid resistant gowns Latex/powder free gloves Masks (uid resistant with or without face shields) Goggles Biohazard labeled zip lock specimen bags

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Appropriate waste disposal of infectious waste includes: Infectious waste is described as any bodily uid collection containers (i.e. Foley and collection bags) or any items saturated with body uids or blood. (i.e. saturated dressings) Placing all infectious waste in a red biohazard bins. Placing red biohazard bins or bags in the Soiled Utility Room for collection by Housekeeping Services. Disposal of sharps includes: Availability of sharps containers in all patient rooms and work areas. Closest to use site Closing, locking and exchanging these containers before they are full. Ensuring all safety-engineered devices are activated. Taking the sharps container to the soiled utility room for pick up when full. Lovelace Westside Hospital Safety Committee is responsible for nal decision regarding safety-engineered devices. Keep your work area/unit clean, free of dust and debris. Maintaining control of non-approved break areas includes restricting bad habits such as: Eating Drinking Application of cosmetics Application of lip balm or contact lenses in the direct patient care and work areas NO employee food or drink at the nurses station, hallways or any other patient care area!

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MANAGEMENT AND PRIVACY OF MEDICAL INFORMATION A written organizational and medical staff policy restricts the removal of medical records from the organizations jurisdiction and safekeeping only to those situations governed by a court order, subpoena, or statue. STUDENTS MAY NOT COPY PATIENT MEDICAL RECORDS-EVER! Condentiality Patient health information should not be left accessible in areas where individuals without a need to know can view it. Discard all patient health information in document destruction bins. Do not discuss patient health information outside of nursing stations or in hallways, cafeteria, etc. where it can be overheard by others. Do not leave patient charts unattended. Retrieve condential patient information immediately from fax machines. TRACER ACTIVITY What do I need to consider for the tracer activity when the surveyors come to my unit? Have appropriate assessments (including pain assessments) and reassessments been done? Is the H & P timely? Is there evidence of informed consent to treatment? Is there evidence of patient rights issues (e.g. Do Not Resuscitate (DNR) orders, Advance Directives? Are all entries in the medical record dated and signed according to policy? Are all orders timed, dated, and signed within 72 hours? Is discharge planning documented? Does the primary care nurse have accessibility to patient lab results? Do you know what the process is for reporting critical lab results?

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MEDIcAL StAff INFORMATION Chief of Staff Director of Anesthesiology Director of Surgery Director of Medicine Director of Pulmonology Director of Emerg Dept. Director of Bariatrics Director of OB

Daman Sacoman MD Anita Delgado, MD Lillibeth Sanchez, MD Julie Harrigan, MD Abderrahmane Temmar, MD Sanjay Kholwadwala, MD Adam Smith, DO Douglas Krell, MD

Common Survey Questions regarding the Medical Staff: Q: How can you identify if a Physician is currently credentialed on the Medical Staff? A: The House Supervisor is supplied with the list of current credentialed physicians. Q: How do you know if a physician is privileged to perform a procedure? A: All physicians are credentialed and re-credentialed through the Medical Executive committee and Governing Board. All competencies and random peer assessments are reviewed at that time. Q: How do you respond if you suspect that a physician is impaired? A: Report any suspected concern to your supervisor. The details of your concern should be submitted on an incident report. The Nursing Supervisor will be informed and Administration will be contacted to address the immediate situation. The Medical Staff has a dened process to address impairment issues.

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Documentation Rules for medical staff: History and Physical Examinations Any credentialed M.D., D.O. on the Medical Staff can complete a history and physical examination. A history and physical examination may also be performed by an appropriately licensed and credentialed allied health professional PA, CNP that has been granted such privileges under the supervision of a member of the Medical Staff. Documentation of the supervision is noted by the countersignature of the physician. (Within 24 hrs) The history and physical examination is to be completed within 24 hours of the admission. All entries into the medical record must be authenticated, dated and timed. Legibility All documentation written in the hard copy of the chart should be legible with a signature, date / time and written in ink! Anyone that makes an entry into the hard chart must sign the signature page in the front of the medical record.

Thank you Ladies and Gentlemen. If YOU cAN REMEMBER ANY Of THIS, YOU cAN pASS THE JOINT COMMISSION SURVEY!

Lovelace Westside Hospital 10501 Golf Course Rd. NW | Albuquerque N.M. 87114 505.727.2000 | lovelace.com