CORE REGULATORY REVIEW

2012

Kaiser Permanente South San Francisco

We exist to provide high quality, affordable, health care services and to improve the health of our members and the communities that we serve. We strive to be The Best Place to Work

Achieve World Class Hospital

STATUS

Every Kaiser Permanente patient will experience the highest quality care and service at every encounter and every department and every hospital, every time."

WORLD CLASS South San Francisco

World Class Hospital Goals!

Highly skilled & Motivated Workforce The Quality Leader Exceptional Care Experience Care Without Delay Hospitals

Principles of Responsibility
Code of Conduct

Guides us in our daily work to improve members health. Do the right thing.
Patient & member focus, Quality, Service, Affordable, Best Place to Work.

Respect Members, Patients, Customers & Each Other keeping data confidential

Principles of Responsibility

Fair and honest business practices follow anti fraud laws. Protect our assets Protect our reputation - Market & communicate about KP accurately and strategically. Treat everyone with dignity and respect Value workforce diversity Respect & value patient diversity

Principles of Responsibility

Foster a harassment free environment Focus on workplace safety Non-retaliation Avoid conflicts of interest members, patient, customers, university and training programs, community based programs Meet government expectations

Health Insurance Portability and Accountability Act

HIPPA requires all KP workforces members regardless of job title or hours worked, to understand the risks and safeguard the privacy and security of individually identifiable information of our members patients. Personal Health Information can be: oral, written, electronic

HIPPA violations can result in huge fines to the organization and termination of the individual.

Facility Safety

FACILITY SAFETY WEB BASED ON KP LEARN Topics include: Hazard communication eye wash (15 minutes), PPE, Spills, Lockout-tagout. Written plan- hazardous chemical inventory, MSDS sheets, Labels

Facility Safety

Follow Occupational Safety and Health Administration Guidelines (Federal) National Fire Association Label 0-4 Blue Health Red Fire White Specific Hazard Yellow - Reactivity

Facility Safety

Asbestos Risks FIRE SAFETY

Code Red ( Call 5000) Know exits, fire alarms, fire extinguishers RACE Rescue, Alarm, Contain, Extinguish or
Evacuate PASS Pull, Aim, Squeeze, Sweep

Facility Safety

Prevention of Bloodborne diseasesMicroorganisms present in blood and other body fluids which causes diseases such as Hep B & C,
HIV/AIDS

Universal Standard Precautions;

Consider every person, all blood, and most body fluids to be potential carriers of disease.

Facility Safety

Prevention of TB-contagious airborne disease Disaster & Emergency Prepardness Electrical Safety Violence in workplace Ergonomics Latex

Facility Safety

Radiation MRI Safety staff and members must be screened Medication patches/patients in MRI Ergonomics ADA Compliance

Members Rights & Responsibilities

KAISER PERMANENTE respects the rights of members and recognizes that

each member/patient is an individual with unique health care needs.

Reasonable access to care Respect and dignity Medical Treatment Options Confidentially and privacy Informed consent Participate in care decisions Rights for Minors Ethics Process Visitors Pastoral Care

Patient Rights Continued

Advance Directives - Physicians Orders for Life Sustaining

Treatment (POLST)

Abuse Reporting Child-Elderly/Adult-Spousal-

Domestic Violence

Member Service Call Center 1-8000-788-0616 California Dept of Managed Health Care 1-800-400-0815

Staff Rights

Industrial reporting Equal Employment Opportunity Sexual Harassment Laws Zero tolerance for violence in the work place Right to refuse in certain aspects of care

Quality Performance and Improvement

Management of the delivery of care and support services with the focus on providing optimal outcomes in:

Quality Safety Satisfaction Cost Efficiency

What is best for the patient!

CORE MEASURES

Standarized sets of valid, reliable, and evidenced based measures (Scientific Based) to improve safety and quality of care.

Acute MI CHF Community acquired pneumonia Surgical Care Improvement Project

National Patient Safety Goals

NPSG.01.01.01 Patient Identification

Two patient identifiers

Eliminate transfusion errors

NPSG.02.03.01 Communication Critical results lab, radiology, POC testing NPSG.03.04.01 Medication Safety
Labeling medications on and off sterile field

Anticoagulation Medication reconciliation

Goals Continued

NPSG.07.01.01 Infection Prevention

Comply with WHO Hand Hygiene Guidelines Prevention of health care associated infections (MRSA, VRSA) Prevention of surgical site infections Prevention of central line infections Prevention of in dwelling catheter associated infections urinary tract infections (CAUTI) NPSG.15.01.01 Suicide Prevention Screen patients at risk for suicide Pre-procedure verification Site Marking Time out

UP.01.01.01 Universal Protocol (right person, site, procedure)

RISK Management

Organized effort to identify, analyze, report and reduce risk to everyone, as well as organizational assets in the interest of improving health. Identify and report risks and or any potential risks eRRF ( Just Culture) Significant/Sentinel events to be completed for a finding. Reportable conditions: AMA, Fall, Equipment, Medication errors.

INFECTION CONTROL

Hand hygiene hand washing degermer Blood borne pathogens TB Aerosol Transmissible Diseases Flu Multi drug resistance organisms Catheter related infections

Contact Precautions

Contact Plus Precautions

Airborne Precautions

Droplet Precautions

WHO Hand Hygiene

Health Connect Electronic Medical Record

Code White: Health Connect is down

If there is no documentation, it is considered not done. Nursing if you did not chart it you did not do it

POPULATION SPECIFIC CARE, CULTURALLY COMPETENT CARE, DISPARITIES, HOMELESS

Why important?

Improves relationships, satisfaction (both provider and patient), compliance with care. Cultures look at health care in different ways reflective of their beliefs, religion and culture. SSF is very diverse - patient population and staff

Health Disparities What does it mean?

Health disparities are differences between health and health care, resulting in out-comes that are worse for one population more than another. Causes can include:

Cultural beliefs Gender Physical ability

socioeconomic occupational hazards Age Sexual orientation Language barriers

Homeless Population in San Mateo County

Information from 2009 homeless census;

31% disabled 9% families with children 14% veterans 2011 Census information not yet available

CLAS Standards

Federal and State Requirements.

Providers of health care are to provide culturally competent care and language access to their members. Interpreters & qualified bi-lingual staff Sign Language Translation of documents AT&T language line.

Emergency Medical treatment and Active Labor Act

Applies to ED only!
Prohibits patient dumping! Emergency medical condition: Woman in labor Whatever the patient states it is! (abd pain, cold, flu, chest pain). Have to have a medical screening exam by a provider.

EMTALA

Prior to MSE, we can not ask the patient any questions regarding ability to pay. A physician examines the patient, orders any necessary lab or radiologic tests, treats and either discharges the patient with follow up instructions, admits the patient or transfers the patient out based on services needed, which are not provided by SSF. Example head trauma!

TEAM ALERT

The Team Alert will provide the initial response to medical events, falls or injuries outside of the inpatient, HAS, or PACU. Team Alert maybe used for visitors within the inpatient areas. Team Alerts may also be used when a patient on our premises; parking areas, facility driveway, and sidewalks is reported to need assistance Team Alert was developed to notify the most appropriate staff to respond to the needs of the patient.

TEAM ALERT

The operator is called by dialing 5555, the operator answering the call will ask:

Is the person talking?

If yes, the operator will activate the TEAM ALERT The Charge Nurse and the ED TECH will respond bringing the transport gurney. The operator will also notify Security.

Rapid Response Team (RRT)

RRT is to provide support and collaboration among staff to enhance clinical outcomes. Clinical resource for patient assessment and clinical intervention. Early intervention and stabilization to prevent deterioration and improve outcomes.

Call

5900

CODE BLUE
5555

The purpose of the Code Blue is to provide a systematic response to members, visitors experiencing an unexpected medical event or cardiopulmonary arrest at 1200 El Camino Real only

INFANT ABANDONMENT/ SAFE SURRENDER

Safe Surrender Site is a location within the hospital (Emergency Department) where an infant can be voluntarily surrendered by a parent or other person with lawful custody. The individual will be immune from criminal liability for child abandonment Kaiser Foundation Hospital (KFH) South San Francisco accepts physical custody of children, defined as: (an infant 72 hours or
younger) For specific information refer to Policy and Procedure: Infant abandonment/Safe Surrender

PC.09.01

STROKE

A stroke occurs when the blood flow to the brain is reduced or blocked, resulting in neurologic deficit and tissue damage. Remember: A stroke can injure the brain like a heart attack can injure the heart. Stroke is third leading cause of death in US About 7,000,000 Americans have strokes each year. Someone has a stroke every 45 seconds Someone dies from a stroke every 3-4 minutes

STROKE

F.A.S.T. Signs and symptoms are usually sudden onset F (Face) Ask person to smile, If one side of the face does not move the same as the other it is a problem A (Arm) Ask person to hold both arms straight out and keep raised, unable to do so is a problem S (Speech) listen to speech, speech unclear, slurred, uses wrong words, unable to speak are problems T (Time) If symptoms are present get help

FALL-Unplanned descent to the floor

A major health concern that threatens the function of older adults is the risk of falls which can result in injury and disability. Even falls that do not result in serious injury may affect an older persons function and quality of life. Both the incidence of falling and the severity of fall-related complications rise steadily after about age 65. Falls are the leading cause of injury and injuryrelated death among older adults.
Please help patients who appear to be needing assistance.

PAIN

Definition: Pain is what the experiencing person

says it is, existing whenever he or she says it does. (The Joint Commission). In other words, pain is subjective believe the patient. Patient self-report is considered the most reliable method to assess pain.

Pain Management

1.) Using an appropriate pain scale 2.) Identifying the patients acceptable level of pain 3.) Reporting of pain 4.) Meeting the related education needs

Agitated patient/restraints

Overview - Restraint use is considered a last resort after alternative measures have been considered or were shown to be ineffective. Introduction: KPs philosophy is that the
individual rights of a persons privacy, personal dignity, and protection from harm must be preserved. Measures should be taken throughout a patients time in the hospital to prevent the use of restraints, decrease the use of restraints and/or to eliminate restraints. The use of restraints shall only be used after a comprehensive assessment.

TEMPORARY RELEASE

Visualization and observation is expected at intervals indicated by the individual patients condition and type of restraint and preferably at least every hour. As part of the plan of care, a temporary release may occur for the purpose of caring for a patients physical, psychosocial, diagnostic and treatment needs, (e.g., for toileting, feeding, range of motion).

SKIN, WOUND ULCER PREVENTION

Patients will maintain their skin integrity throughout the course of their hospitalization. Pressure ulcers are preventable. Hospital acquired pressure ulcers are classified by the National Quality Forum as a never event. These are errors in care that indicate a problem in the safety and credibility of a health care facility.

END OF LIFE CARE

The dying patient has unique needs for respectful, responsive care. All staff should be sensitive to the needs of the patient and family. Some patients with life threatening illnesses wish to pursue care until the end. Patients may wish to forgo treatment options or may not have curative options available.

Organ/Tissue Donation

Anatomical organ donation is an important part of the end of life care. Our goal is to honor the wishes of patients and their families or authorized surrogates in regard to the donation of anatomical gifts (donation of all or part of a human body to take effect upon or after death).

Donation Continued

STATISTICS: More than 80,000 men, women and children are currently waiting for life saving transplants. 46,532 cornea transplants were performed in 2001. In 2001 there were 6,081 deceased organ donors and 6,510 living donors. Every 13 minutes another name is added to the transplant list. ONE DONOR CAN: Save or enhance the lives of more than 50 people. Kidneys can free two people from dialysis, Corneas can give sight to two people.

ADDITIONAL MODULES for 2012 INCLUDE:

Medication Management:

Multi-dose Single dose Labeling of medications on and off sterile field Medication Error Reduction Program MERP High Alert Meds Tubing misconnections Do not use abbreviations

Blood administration

South San Francisco

1200 El Camino Real SSF Hospital Clinics ( Allergy, Medicine, Surgical Services Neurology, Radiology (CT, MRI) 395 Hickey Daly City Pediatrics, OB/Gyn, Medicine, Eye 901 El Camino San Bruno Medicine 801 Traeger San Bruno PT, DERM, OCC Med, Physical Medicine

South San Francisco

800 Oyster Point Blvd SSF

Radiation Oncology

San Bruno Sneath

Home Care Medical Records Simulation Lab

Key Reminders

Policies and Procedures are located on SSF Intranet Site Code Red, Code Blue, Security information located on the back of your name badge Do not share pass words Patient information on a need to know basis HIPPA

CONCLUSION
Thank you for your time & attention. Please remember it is about providing compassionate, confidential, quality care to the: MEMBERS OF KAISER PERMANENTE Presented by: JoEllen Elliott, RN, CPN, BSN 650-742-2106 Email JoEllen.Elliott@kp.org