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Presentation on theme: "1 PATTIE A. CLAY REGIONAL MEDICAL CENTER PRESENTS."— Presentation transcript:






6 5 LEADERSHIP w Q.1What Changes Can We Expect at Our Next JCAHO Triennal Survey?

7 6 LEADERSHIP w First, all employees could be involved in the survey since the JCAHO surveyors may choose to come back during off shifts to talk with additional staff members. Typically, this will happen when surveyors are getting mixed responses from staff or variations are identified.

8 7 LEADERSHIP w Second, our survey schedule will be changed to allow even more time to interact with staff members and inquire further on issues that may show weaknesses. w These survey activities have changed:

9 8 LEADERSHIP w Patient Care Setting Visits have been increased to 90 minutes each & a minimum of 2 open charts will be reviewed per unit. w

10 9 LEADERSHIP w Information Management Interview has been combined with Medical Records Interview. More open chart reviews in patient care areas and less opportunities to select specific closed charts for review.

11 10 LEADERSHIP Patient Care Interview will concentrate on issues picked up during the survey and will also include: w Anesthesia, Operative and Other Invasive Procedures w Patient and Family Education w Continuum of Care w Medication Use and Nutrition Care w Ethics and Patient Rights

12 11 LEADERSHIP Special Interview/Issue Resolution or Patient Unit Visit w includes time to allow surveyors to resolve any issues or spent visiting more areas that were not on the agenda. Surveyors may also use this time to review additional open charts.

13 12 LEADERSHIP w Performance Measurement and Improvement Interview combines the PI Overview, PI Team Presentation and PI Steering Committee Interview. Only 1 team will present (we select the team) and it will be limited to 15 minutes. The majority of time will be spent discussing ORYX data results and improvements being made as the result of this data

14 13 LEADERSHIP w Building Tour and Environment of Care Interview have both been increased by 30 minutes each. w Tour 3 hours, w Document Review 2 ½ hours.

15 14 LEADERSHIP w Q.2 Why are we having an inservice now when our survey isn’t until January 2002?

16 15 LEADERSHIP w TWO REASONS: w Mainly, the JCAHO is now sending updates nearly every quarter instead of annually. This requires us to be more timely with making changes and communicating these changes with all staff.

17 16 LEADERSHIP w Second, JCAHO is now conducting a higher number of RANDOM UNANNOUNCED SURVEYS!

18 17 LEADERSHIP w Q.3 What are the odds of Pattie A. Clay Regional Medical Center being selected for a random survey?

19 18 LEADERSHIP w A.3 We have more than 992,000 chances that we will have a Random Unannounced Survey than winning the Kentucky Lottery!! Here is how it works:


21 20 LEADERSHIP w GUARANTEED TOPICS INCLUDE: w PI: Aggregation/Analysis of Performance Data w TX: Medication Use w TX: Restraint Use w MS: Credentialing w EC: Plans Design & Review the Statement of Condition w HR: Competencies and Evaluations


23 22 LEADERSHIP w Q.4 What is the Future Vision for JCAHO for 5 or more Years Down the Road? w A.4 JCAHO is currently working on the following plans for the future: w INTEGRATION OF SELF-ASSESSMENT ACTIVITIES w DIVISION OF ON-SITE EVALUATION BROKEN DOWN INTO TWO (2) SEGMENTS IN AN 18-MONTH INTERVAL



26 25 LEADERSHIP w Q.5If we are having a survey, what don’t you do when approached by a JCAHO Surveyor?

27 26 LEADERSHIP w A.5 Don’t attempt to hide, ignore, avoid or run from them, unless of course you are involved in a patient care activity which would prohibit you from immediately responding !

28 27 LEADERSHIP w In other words, go about your work and be certain to greet the surveyor (good morning/afternoon). Based on past experience, the employees that “dodge” the surveyors are exactly the employees that they want to talk to. So, don’t be afraid and remain calm and friendly! RELAX..TAKE A DEEP BREATH!!

29 28 LEADERSHIP w To date, no hospitals have ever reported any employee injuries during a JCAHO survey! Just remember they too are human beings and it is not as painful as you may think to tell them what you know. Just in case you do panic, it will still be okay if you don’t know the answer, then tell them so.

30 29 LEADERSHIP w Q.6What is a mission statement? w A.6Any of the following answers are good: It is the purpose of an organization it stands for what we believe in/it tells us where we want to be in the future/it explains who we are and what we do.

31 30 LEADERSHIP w Q.7What does your hospital mission statement mean to you? w A.7Any of the following answers are good but you probably have a much better answer yourself!!! BE PREPARED TO ANSWER IN YOUR OWN WORDS!

32 31 LEADERSHIP w We serve a culturally diverse population..which means we treat patients from all walks of life, therefore, we must respect their differences and meet their special needs. (Examples: 1) migrant workers who are non-English speaking, 2) elderly patients who have difficulty hearing, seeing, and may be frightened, alone, confused etc. 3) young first time mothers who may need more education and emotional support, etc.

33 32 LEADERSHIP w Our mission statement tells me how we define quality.which is providing friendly service to our customers by doing the right thing, the right way, the first time. I help deliver that quality by. (give a simple example of what you do that is good! Brag on yourself!!


35 34 LEADERSHIP MISSION STATEMENT w We work hard to be clinically effective and economically efficient..which means we can’t be everything to everybody.what we do, we must do well and affordable.

36 35 LEADERSHIP w Our mission statement tells me our vision of “serving the healthcare needs of people in our region as we have become a regional healthcare facility.

37 36 LEADERSHIP w Our mission statement tells me that we value patients rights involve our patients and families in decision making regarding their care and respect their ability to make choices including end of life decisions.. We must inform them of the risks, benefits, alternatives & respect their decisions

38 37 LEADERSHIP w Q.8 What is your definition of quality? w A.8 We define quality as providing friendly service to our customers by doing the right thing, the right way the first time.

39 38 LEADERSHIP w Q.9Who are your customers? w A.9 Everybody! Patients, Families, Visitors, Physicians, Co-workers within my department and other departments

40 39 LEADERSHIP w Q.10What is a “hospital wide patient plan of care” mean to you? w A.10It is a detailed document that describes the services offered in each department— (scope of services), description of department, location, hours of operation, staffing plans, etc.

41 40 w This plan is a policy # ADM- 010-040 throughout the hospital, and is used by management to plan for improvements and/or changes in the services we provide. It is useful in making good patient care decisions which is helpful in strategically planning for our future. Be sure you know what is included under your department section of this plan.

42 41 LEADERSHIP w Q.11How do you make certain the same level of care is provided to your patients throughout the hospital?

43 42 LEADERSHIP w A.11Our staff and Management develop collaborative policies and procedures which allows various departments to work together to maintain consistency in processes done in different locations of the hospital. Ongoing communication and interaction with other departments is key to our success.

44 43 LEADERSHIP w (You need to be prepared for giving an example of how something done is your department that is also done by others is performed with consistency could be as simple as our hospitalwide handwashing techniques to minimize the spread of infections, transporting DNR information with all patients as they visit different departments/units, etc.) w


46 45 EOC LIFE SAFETY w Q.1Who is responsible for safety at your hospital? w A.1All employees!! Safety is an important part of every employee’s job at Pattie A. Clay Regional Medical Center.

47 46 EOC LIFE SAFETY w Q.2What does “Environment of Care” mean? w A.2“EOC” is another word for managing our safety program.

48 47 EOC LIFE SAFETY w Q.3What is included in your safety program at our hospital? w A.3Our safety program consists of seven(7) areas which is monitored/measured at all times including :

49 48 EOC LIFE SAFETY w 1)General Safety: Visitor/Patient Incidents Employee Accidents Common Space/Grounds Safety

50 49 EOC LIFE SAFETY w 2) Life Safety::Fire w 3)Security: Theft, violence, etc. Workplace Violence w 4)Emergency Preparedness: w Disaster w Tornado w Bomb Threat, etc. w 5)Hazardous Materials and Waste: w Right To Know w MSDS w Chemicals, Radioactives, Gas Explosives, and Wastes w Mercury

51 50 EOC LIFE SAFETY w 6) Medical Equipment: Patient Care w 7)Utilities Management: Electric Phones Water Sewage, etc.

52 51 EOC LIFE SAFETY w Q.4What is the goal of the Safety Program at Pattie A. Clay? w A.4The goal of the program is to promote a safe environment for patients of all ages, visitors, employees and all other people coming in contact with our organization.

53 52 LIFE SAFETY FIRE w Q.5What should you do if you see smoke coming from a patient room, a fire in a wastebasket, or any other signs of a fire? w A.5Follow the R-A-C-E protocol:

54 53 LIFE SAFETY FIRE w R = Rescue all persons from the immediate area of the fire. w A = Activate the alarm and dial 3373 to report the fire. w C = Contain the smoke or fire by closing all doors. w E = Extinguish/Evacuate by using the proper fire extinguisher.

55 54 LIFE SAFETY FIRE w Q.6Where are the fire alarm pull boxes and fire extinguishers located in the department? w A.6(Department-specific answer required.) Know the locations of fire extinguishers and fire alarm pull boxes in your area. (You should be able to point to them 20 feet from an exit.)

56 55 LIFE SAFETY: FIRE w Q.7How do you use a fire extinguisher? w A.7P-A-S-S:

57 56 LIFE SAFETY FIRE w P = Pull the pin located between the two handles. w A = Aim the base of the fire. w S = Squeeze the handles together. w S = Sweep from side to side at the base of the fire. Watch for re- flash and use extinguisher again if needed.

58 57 LIFE SAFETY FIRE w Q.8 Which extinguisher can be used for extinguishing fires involving burning cloth, paper, or wood? w A.8 The fire extinguisher Type ABC, containing dry chemicals; or Type A, containing water.

59 58 LIFE SAFETY FIRE w Q.9 Which extinguisher can be used for electrical equipment motors, switches, and flammable liquids? w A.9 The fire extinguisher Type ABC or Type BC containing dry chemicals.

60 59 LIFE SAFETY FIRE w Q.10Which fire extinguisher should not be used on electrical equipment, motors, and flammable liquids? w A.10Fire extinguisher Type A that contains water.

61 60 LIFE SAFETY FIRE w Q.11Where is the nearest fire exit? w A.11(Department-specific answer required.) Know the fire exit route for your department. If you are a person who works in all areas of the hospital, know where all of the fire exits are located.

62 61 LIFE SAFETY FIRE w Q.12How would you respond if told, “A fire has broken out?” w A.12Literally, respond as if there were a real fire. Initiate R-A-C-E Protocol.

63 62 LIFE SAFETY FIRE w Q.13How often do you have fire drills? w A.13Fire drills are held quarterly, one drill per shift. During construction, we will be required to have one additional drill per shift.

64 63 LIFE SAFETY FIRE w Q.14 What is the hospital code for a Fire? w A.14 Dr. Red

65 64 LIFE SAFETY FIRE w Q.15What does “Interim Life Safety Measures” mean to you? w A.15During construction, additional life safety drills must be conducted


67 66 EMERGENCY PREPAREDNESS w Q.16Where do you find information regarding employee responsibilities during a disaster? w A.16In the Emergency Red Manual which is located in each department.

68 67 EMERGENCY PREPAREDNESS w Q.17What does Pattie A. Clay Regional Medical Center consider a “disaster?” w A.17Any situation which would overwhelm our capacity to safely manage the influx of patients based on existing staffing levels and available resources.

69 68 EMERGENCY PREPAREDNESS w Q.18How do we test our emergency preparedness program? w A.18The Safety Committee stages two (2) mock disaster drills per year.

70 69 EMERGENCY PREPAREDNESS w Q.19Where is your department’s Emergency Red Manual located? w A.19 Know where your department’s Emergency Red Manual is located.

71 70 EMERGENCY PREPAREDNESS w Q.20Can you describe your role in the emergency preparedness plans? w A.20Discuss this with your department director and know the answer to this question!

72 71 EMERGENCY PREPAREDNESS w Q.21Who is trained to evacuate patients? w A.21Everyone is taught the principles of evacuation because all personnel might be asked to help.

73 72 EMERGENCY PREPAREDNESS w Q.22What is your responsibility during an external disaster? w A.22Specific departmental roles are defined in the Code Blue Policy outlined in Emergency Red Manual.

74 73 EMERGENCY PREPAREDNESS Q.23What information should one attempt to obtain from someone calling in a bomb threat? A.23Exact Language used by the caller. w Location of the bomb. w When explosion is to occur. w Type of speech of caller. w Background noise noted. w Gender of the caller.

75 74 EMERGENCY PREPAREDNESS w Q.24Who should be contacted upon receiving a bomb threat? w A.24Administrator Vice President of Patient Care Services Security Safety Officer Department Heads

76 75 EMERGENCY PREPAREDNESS w Q.25What do you do if someone, whether a patient, visitor, or employee becomes extremely agitated or violent? w A.25Remain calm, allow them to verbalize, keep distance, keep exit open.

77 76 EMERGENCY PREPAREDNESS w Q.26What is the hospital code for a Disaster? w A.26Code Blue.

78 77 EMERGENCY PREPAREDNESS w Q.27What is the hospital code for a Tornado? w A.27Code Black.

79 78 EMERGENCY PREPAREDNESS w Q.28What is the hospital code for a Cardiac Arrest? w A.28Code 99.


81 80 MEDICAL EQUIPMENT w Q.29Can you show me where test sticker is located? w A.29Test sticker is located on side of equipment or near the PAC No.

82 81 MEDICAL EQUIPMENT w Q.30When new equipment is bought or loaned to your unit you should? w A.30Call the work order line for a visual and electrical inspection before use.

83 82 MEDICAL EQUIPMENT w Q.31How do you report an equipment malfunction? w A.31Put an out of order tag on it and take it out of service! Call in a work order or send directly to Plant Operations/Biomed for service.

84 83 MEDICAL EQUIPMENT w Q.32Whose responsibility is it to be certain the equipment you are using is functioning properly ? w A.32It is your responsibility prior to using equipment that it is working properly. It is your responsibility to also adequately maintain equipment in addition to removing equipment from service and reporting it promptly !

85 84 MEDICAL EQUIPMENT w Q.33Where are the oxygen valves located in your patient care unit? w A.33(Answer will be unit specific.) Review all areas of department for location.

86 85 MEDICAL EQUIPMENT w Q.34Who is authorized to shut off the oxygen valves in the event of a fire or another emergency? w A.34Charge nurse on specific unit.

87 86 MEDICAL EQUIPMENT w Q.35What is your specific role in Code Pink? w A.35(This answer is department specific. Ask you supervisor for very detailed information.)


89 88 UTILITIES MANAGEMENT w Q.36What happens in the event of a utility failure (i.e. electric, water, gas, medical gas, or telephone)?

90 89 UTILITIES MANAGEMENT w We have backup electrical generators that kick in within 10 seconds of a power failure. In this situation, only the equipment plugged into red, emergency outlets will work. w In the event of a water outage, water will be distributed by Central Stores. All employees will make an effort to conserve as much water as possible.

91 90 UTILITIES MANAGEMENT w In the event there is a natural gas outage, the Maintenance Department will shut off all incoming gas valves. w In the event there is a medical gas outage, call the Maintenance Department.

92 91 UTILITIES MANAGEMENT w In the event of a telephone outage, use security radios, pay phones, runners, plant operations radios. w We have a “What If” list in our department that we can refer to in any of these situations!


94 93 HAZARDOUS MATERIALS w Q.37Where can the details about every chemical used be found? w A.37In the Material Safety Data Sheet (MSDS) Manual. Each chemical used in the department is in the department’s manual. The Master MSDS Manual is located in the Security Office, Emergency Room and Administration.

95 94 HAZARDOUS MATERIALS w Q.38Other than the Material Safety Data Sheet (MSDS), where can the hazardous material name and hazard warning for that material be found? w A.38On the container label.

96 95 HAZARDOUS MATERIALS w Q.39Do you use hazardous materials in your area? w A.39(Department-specific answer required.) However, all departments should have an MSDS Manual.

97 96 HAZARDOUS MATERIALS w Q.40Can you name at least two hazardous materials that can be found in your department? w A.40Ask your department director to review what hazardous materials are found in your department.

98 97 HAZARDOUS MATERIALS w Q.41What first aid measures are necessary when working with the hazardous chemicals found in your department? w A.41Check the MSDS for each specific chemical in the MSDS Manual located in your department.

99 98 HAZARDOUS MATERIALS w Q.42How is your waste disposed of in your department? w A.42Medical waste is disposed of in covered containers labeled with a “Biohazardous Waste” warning label. The container is then removed from the department by Housekeeping and taken to a central area for disposal from the hospital by a contracted company.

100 99 HAZARDOUS MATERIALS w Q.43What should you do if you have a hazardous spill in your area? w A.43Evacuate all personnel and seal off the area as best as possible. Pull material safety data sheet if aware of chemical. Contact Plant Operations Director, Eddie Beach, at beeper 222- 3291.


102 101 SAFETY MANAGEMENT w Q.44What committee is responsible for the management of the hospital’s safety management program? w A.44The Safety Committee; Bo Young; Materials Management Assistant Director is the Chairman of this Committee.

103 102 SAFETY MANAGEMENT w Q.45Who is the Safety Officer at Pattie A. Clay Regional Medical Center w A.45Eddie Beach, Director of Plant Operations.

104 103 SAFETY MANAGEMENT w Q.46How are the safety activities reported to Administration and the Board? w A.46The minutes of the Safety Committee are submitted to the CEO/Board of Directors monthly.

105 104 SAFETY MANAGEMENT w Q.47Who is responsible for maintaining safe practices in the hospital? w A.47Everyone is responsible for safe practice! Potential safety hazards should be reported to your immediate supervisor!!

106 105 SAFETY MANAGEMENT w Q.48What type of safety/environment of care training have you had during the last twelve months? w A.48On a yearly basis, all employees attend mandatory retraining on Fire Safety, General Safety, Infection Control, Electrical Safety, Body Mechanics, Hazardous Waste, and Incident/Accident Reporting. In addition, patient care employees attend CPR training EVERY TWO YEARS

107 106 SAFETY MANAGEMENT w Q.49Describe your hospital-wide smoking policy. w A.49Patients are not allowed to smoke in our hospital without a physicians order to do so. The criteria followed by our medical staff is patients that are terminally ill and the benefits of smoking outweigh the consequences.

108 107 SAFETY MANAGEMENT w However, if the patient is unable to be escorted outside, then arrangements are made through the House Supervisor to accommodate them in a patient room with negative airflow. w All employees are required to smoke in the designated employee smoke area only which is located by the employee parking lot.

109 108 SAFETY MANAGEMENT w Q.50What type of incidents should you report? w A.50Any patient, visitor, employee, or physician incident or unusual happening. Fill out an Incident Report obtained from your supervisor.

110 109 SAFETY MANAGEMENT w Q.51How do you report an employee incident? w A.51Fill out an Incident Report immediately. w Notify your supervisor immediately.


112 111 SECURITY MANAGEMENT w Q.52What would you do if you are suddenly involved in a potentially dangerous situation? w A.52Protect yourself and call for help as soon as possible. Remain calm.

113 112 SECURITY MANAGEMENT w Q.53How soon after witnessing a security incident should an Incident Report be completed? w A.53As soon as the incident occurs.

114 113 SECURITY MANAGEMENT w Q.54What procedure do you follow when a theft has occurred in an area? w A.54Whether hospital or personal property, make sure the item has not been misplaced. Alert your supervisor. Fill out a Security Incident Report. (The supervisor will contact Security.)


116 115 HR w STAFF COMPETENCY w Q.1How do you maintain your competency/skills in order to perform your job? w A.1Educational Preparation, competency checklists/skills lists, on the job training, certifications, licenses, etc.

117 116 HR w Q.2How were you oriented to your job? w A.2Talk about all orientation activities including: hospital, departmental, unit, and job- specific orientation.

118 117 HR General Regional Medical Center orientation includes : w 1) Mission Effectiveness/ Continuous Quality Improvement w 2) Proper lift and bending techniques and other body mechanics w 3) Guest Relations and Patient Rights/Advance Directives

119 118 HR w 4) Infection Control issues such as HIV/AIDS, TB, handwashing, infectious waste disposal w 5) Environment of Care issues such as: life safety, utilities, medical equipment, general and safety, security issues.

120 119 HR w 6) Hospital History and Structure w 7) Human Resources Policies and Benefits

121 120 HR Department Specific Orientation: w Job Description w Policies w General Tour w Orientation Checklists w Job Specific Orientation: w Skill lists w Evaluation Conferences w Inservices/Continuing Education Opportunities

122 121 HR w Q.3Did you receive training during department orientation on equipment used in your area? w A.3Medical equipment used in assigned areas were reviewed in department orientation. New equipment is in-serviced before used and additional review of equipment is periodically held.

123 122 HR w If I am ever unfamiliar with a piece of equipment I can go to a co-worker with training on the equipment, the operators manual, our Biomedical staff or my manager.

124 123 HR w Q.4What age of patients do you care for? Have you received age- specific instructions and care for all of these ages? w A.4If the ages of the patients you serve are from birth - death, you will need to give examples of age-specific competencies you have completed.

125 124 HR w Q.5How is your competency measured? w A.5It is measured by performance evaluations, license where applicable, general orientation for new employees, competency based orientation as appropriate and continuing education.

126 125 HR w Q.6Do you have access to educational materials related to your profession? w A.6Materials are available on the unit (textbooks, journals, etc.), through Staff Development, the Internet, and other educational inservices and programs.

127 126 HR w Q.7How are provisions made concerning assignments that conflict with your personal beliefs? (for example, abortion, sterilizations, blood transfusions, etc). w A.7I would voice my concerns to my manager who would in turn, make arrangements for the patient to be cared for by other staff member as soon as possible.

128 127 HR w A7 (CONT) w I would not abandon my patient until appropriate arrangements have been made. My patient of course, would continue to receive the proper care from me until I am relieved of those relieved of those responsibilities. See policy # ADM-010-022.

129 128 HR w Q.8Who has the responsibility of orienting borrowed equipment? w A.8My manager or designee who borrows equipment has the responsibility to provide their employees the orientation necessary to operate the borrow equipment safely.

130 129 HR w A8 (CONT) Under no circumstances, do we allow equipment to be delivered to our department without making arrangements with Plant Operations to perform a safety check on it before it is put in use. I know a particular piece of equipment is borrowed when I see a yellow loaner sticker readily available on the piece of equipment. I have the obligation not to operate a piece of equipment that is unfamiliar to me and until I have received adequate training by my manager or other individual giving the inservice.

131 130 HR w Q. 9 HOW DO YOU ADDRESS YOUR LEARNING NEEDS??? w A.9 w 1. Attendance to continuing education council (multi-disciplinary) to determine what the needs of myself and coworkers are for the upcoming year.

132 131 HR w 2. Attendance to inservice programs, study packets etc. that provide me with input on areas to improve upon. w 3. Access to television satellite television with various programming w 4. Request to attend special programs presented @ outside agencies. w 5. Self learning packets

133 132 HR w Q.10What are some examples of training offered as a result of a learning needs assessment? w A.10 –.Computer Skills Classes on Windows and Lotus Notes Lab computer –.JCAHO standards updates and issues which are ongoing to our staff

134 133 HR w Q.11How is staffing decided and adjusted? w A.11Typically, for inpatient units, it is based on patient acuity level. In non-patient care areas, it depends on volume of work. (Your supervisor can give you more details)



137 136 PI w Q.1How do you have input on what should be improved in your area? A.1Staff meetings, interviews, and questionnaires are used to provide input on our performance improvement initiatives. Department Directors also respond to concerns addressed in the patient satisfaction survey process and discuss these issues in department meetings.

138 137 PI INPUT ON IMPROVEMENTS w Each department has their own initiatives, based upon their core process and data identifying opportunities to improve. In addition, any employee may suggest quality opportunities which are chartered in the Quality Improvement Steering Committee.

139 138 PI w Q.2How does the Hospital establish priorities for defining which processes need to be improved? w A.2The Quality Improvement Steering Committee establishes priorities based on input from staff, patients, doctors and administrators.

140 139 PI (ESTABLISHING PRIORITY) w The Quality Steering Committee requires that teams to be chartered must involve 2 or more departments so that they are multi- disciplinary! Many good suggestions are submitted each year, and even they are not approved, they certainly can still be projects to work on among the departments involved!!

141 140 PI (ESTABLISHING PRIORITY) w Priorities are then determined based on criteria including but not limited to: high risk, high volume, high cost, problem prone, strategically important to the organization, in-line with the mission and values, multidisciplinary nature of the opportunity and the impact on customer service.

142 141 PI w Q.3What are some of the teams and their priorities for 1999-2000: w A.3 Team 1: Missing In Action: Med/Surg/ICU/OB/Lab/Radiology/Hea lth Info/Computer Operations/UR; focus on improving availability of reports in the inpatient’s current medical record (ex: labs, xray reports, H&P’s).

143 142 PI w Team 2: Double Trouble: Quality Review/Computer Operations/Health Info/OB/ER; Focus is to better utilize the available space on present computer systems by entering necessary data needed for state requirements and performance improvement into already existing computer programs within the hospital and making available for review to the departments involved (should prevent duplication of data collection).

144 143 PI w Team 3: Three’s Company: Computer Operations/Health Info/Human Resources/ Staff Development; Focus is similar to previous team as to better utilize available space on present computer systems within the hospital and that would provide clinical managers and department heads easier access to necessary information regarding employee competencies, attendance records, staff education, and CEU’s.

145 144 PI w Q.4 What were some of the accomplishments in the past year? w A.4CONTINUOUS QUALITY IMPROVEMENT (CQI) TEAMS w Our CQI teams have made changes, big and small, over the past year. This year we elected to have only three hospital wide multidisciplinary teams.

146 145 PI EACH OF THE THREE TEAMS w Strived to reduce inefficiency, cut costs, and simplify work processes. These teams have a greater understanding and respect of each persons role in achieving our goals and fulfilling our mission.

147 146 PI w MISSING IN ACTION: Improved the process of certain reports being available on the inpatient’s medical record. This allows for more efficient healthcare planning by the patient’s physician, nursing, and other disciplines involved in the individual’s healthcare needs. This also reduces the LOS by having all available information present to determine discharge planning.

148 147 PI DOUBLE TROUBLE: w Improved the process of data collection with present computer operations within the hospital. This helped reduce duplication of data collection by different departments including OB and quality review.

149 148 PI w THREE’S COMPANY: w This team has not completed it’s goal yet, but is diligently focused on the opportunity to improve the communication Electronically (computer) between clinical managers, department heads, personnel and staff development.

150 149 PI w Q.5What is everyone’s responsibility in data collection? w A.5Everyone is accountable for information being accurate. It is our responsibility to call attention to apparent incorrect data for collection.

151 150 PI w Q.6What quality initiatives are in place in your department? w A.6Check with your department director for specific quality efforts, measurements and also guest relations improvements.

152 151 PI w Q.7What is your responsibility in performance improvement? w A.7To ensure excellent personal performance; to share ideas about improvement in and streamlining of processes; to provide excellent customer service and to listen to internal and external customers

153 152 RESPONSIBILITY IN PI w To participate in basic performance improvement education; to participate in data collections as requested; and to participate on performance improvement teams when requested.

154 153 PI w Q.8 If our hospital should need to scale down its efforts for any of various reasons, what criteria would the Quality Steering Committee use to prioritize the minimal efforts to be continued? w A.8As outlined in the Quality Improvement Plan (Policy # QUR-001- 003), the following 3 criterion is used to select the efforts to be maintained:

155 154 PI w 1.Processes that affect 50% or more of our patient population w 2.Processes that place patients at-risk if not performed well w 3.Processes that have been or are likely to be problem-prone.

156 155 PI w Q.9Are performance improvement activities carried out in a collaborative fashion among departments and various disciplines? w A.9 Yes! (Be prepared to give examples of how your department has worked with one or more other departments to improve processes).

157 156 PI w Department managers plan and carry out improvement processes with other departments—be prepared to give 1-2 examples of quality teams from last year and their accomplishments as well as 1- 2 examples of quality teams that have just gotten underway this year!


159 158 PI w Q.10How is data systematically collected? w A.10Collecting data helps us to assess outcomes or determine the performance of a function or process (i.e.; specific work tasks). When data collection is systematic, the data can be used to:

160 159 PI w 1)Establish a baseline when a new process is implemented w 2) Identify the performance or stability of existing processes w 3) Measure the dimensions of performance relevant to functions, processes and outcomes w 4) Identify areas for possible improvement w 5) Determine whether changes improved the process


162 161 PI w Q.11. Can you tell me something that your department has improved from this time last year? In other words, why would I want to be a patient or customer of in your department today rather than this time last year? w A.11You and your co-workers need to tell the surveyors about any departmental improvements, quality initiatives and/or guest relations activities that have improved your department in the last year.

163 162 PI w Be sure you know of any CQI teams that have involved your department last year as well as the new teams just underway for this coming year. Also, if our patient satisfaction survey has information pertaining to your department, you need to know what patients have viewed positively and areas that patients have shown less satisfaction and what you are doing as a department to improve satisfaction in the future!!

164 163 PI w Q.12What model is used by CQI teams to improve performance at Pattie A. Clay Regional Medical Center? w A.12Focus - PDCA

165 164 PI w F(Find an opportunity) w O(Organize a team) w C(Clarify current knowledge of process) w U(Uncover root problems) w S(Start the improvement cycle):

166 165 PI w PDCA w P(lan): Identify the problem, develop a problem statement, collect data to support solutions, use QI tools to narrow the problem and decide on a solution. w D(o): Implement a plan, test using a trial run, identify costs, people and materials, educate staff.

167 166 PI (PDCA) w C(heck): Monitor the plan’s progress, obtain feedback, compare data with original, use QI tools to monitor, determine the success or failure of the plan/action. w A(ct): Incorporate the improvement into policy, inform and educate all parties, distribute new information to all key players, look for new improvements.

168 167 PI w Q.13 What education have you had in Performance Improvement? w A.13 Management and/or employee basic performance improvement in orientation; CQI training for supervisors and managers; team leader and facilitator classes for selected groups of employees; advanced training for CQI delegates and Steering Committee Quality Improvement. For staff, education is provided through “Just in Time Training” when you participate on a hospital CQI team.

169 168 PI w Q.14How is Customer Satisfaction Monitored? w A.14Through the development of quality improvement measures; patient satisfaction surveys, one-on-one customer feedback, and interviews. Results and actions are discussed in Guest Relations Committee, Quality Steering Committee, Management Staff and Department Meetings.

170 169 PI w Q.15How is the same level of care consistently assured? w A.15Through the Patient Bill of Rights, use of Clinical Care guidelines and medical protocols (standing orders), policies and procedures, Quality Improvement activities.

171 170 PI w Q.15How is the same level of care consistently assured? w A.15Through the Patient Bill of Rights, use of Clinical Care guidelines and medical protocols (standing orders), policies and procedures, Quality Improvement activities.

172 171 PI w Q.16 What is the Performance Improvement Plan for Pattie A. Clay? w A.16It is our plan for organization-wide participation in continuously improving our work processes to meet and hopefully exceed customer needs and expectations. See policy # QUR-001-003 for specific details.

173 172 PI w Q.17What are your key processes (important aspects of care or service)? w A.17Discuss with your Department Director the specific work processes for your area.

174 173 PI w Q.18What does “ORYX” mean? w A.18JCAHO requires all hospitals to have a standardized system for measuring performance and outcomes. This system must be approved by JCAHO. Our hospital has selected two vendors to assist us in being able to compare ourselves to other hospitals (known as “benchmarking”).

175 174 PI w Our Quality Steering Committee has chosen the 7 following aspects of care outlined below to measure and assess for improvements, due to their high volume in our facility. Collectively, this represents 25% of our patient population.

176 175 PI w There is going to be a move from Oryx to Core Measures which will be selected by clinical performance, patient perception of care, health status and administrative or financial measures. An example of a core measure that our hospital will be involved in is Heart Failure.

177 176 w Vendor: National Registry of Myocardial Infarction (NRMI): w Aspects of Care to Measure/Assess: 1. Aspirin usage within 24 hours 2. Door to drug time for acute myocardial infarction 3. No initial reperfusion strategy

178 177 PI w Vendor: Indiana Hospital and Health Association (IHHA): w Aspects of Care to Measure/Assess : 1. Readmissions within 30 days of respiratory service discharge 2. Primary cesarean sections 3. Repeat c-section 4. Total c-section

179 178 PI w Q.19What training have you had on CQI? w A.19All employees receive CQI training as part of mandatory inservice as well as new employee orientation. Also, if I serve on a CQI team, then I would receive training in my team meetings from our team CQI delegates.

180 179 PI w Delegates are co-workers that have received additional training to help educate team members on using FOCUS- PDCA and the best tools to assist us in measuring and improving our team’s efforts.

181 180 PI w Q.20What are “Sentinel Events” and how should you respond? w A.20A “Sentinel Event” is defined by policy (# ADM-010-026) when the following events occur: The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition or the event is one of the following:

182 181 PI (SENTINAL EVENT) – suicide of a patient – rape of a patient – hemolytic transfusion reaction involving the administration of blood or blood products having major blood group incompatibilities –surgery on the wrong patient or wrong body part

183 182 PI w When the event occurs, as applicable, first treat the patient as directed by the physician. Second, notify the Department Director or House Administrator. They, in turn, will notify the Vice President of Patient Care Services, who will coordinate an investigation with appropriate staff.

184 183 PI w When the event occurs, as applicable, first treat the patient as directed by the physician. w Second, notify the Department Director or House Administrator. They, in turn, will notify the Vice President of Patient Care Services, who will coordinate an investigation with appropriate staff.

185 184 PI w Q.21 What are clinical pathways and how do they effect the outcome of the patient? w A.21 Clinical pathways are simply a documentation tool that is pre- printed, pre-approved, outlining the course/plan of treatment for a given diagnosis (ADM-010-025).

186 185 PI w The use of clinical pathways can: Reduce or eliminate system breakdown Improve continuity of care Improve liability management and outcomes Improve quality, reduce lengths of stay, and reduce cost

187 186 PI w Clinical pathways are tools that offer approaches to patient care that assist in improvingresource utilization and promote quality patient outcomes through reducing variation among healthcare practitioners.

188 187 PI w Clinical paths are not: w A substitution or replacement of any physician’s professional judgment In the care and treatment of a patient. w Standards of care.

189 188 PI w Q.22How are clinical issues identified? w A.22 Clinical issues are identified by: w Improved methods of diagnosis and treatment of a significant related group of patients (ex: COPD, CHF, chest pain) w Treatment of high cost diagnosis (ex: respiratory failure)

190 189 PI w Treatment of high cost diagnosis (ex: respiratory failure) w Variation in outcome of healthcare services (LOS variances, OB 2 day vaginal delivery stay) w Requirements of regulatory, accrediting third party payers, and oversight organizations (HCFA, JCAHO, BCBS, etc).

191 190 PI w Q.23 What are some examples of clinical pathways at our facility that have been successful? w A.23 Vaginal Delivery Pathway, Newborn Pathway, Newborn Jaundice Pathway, Chest Pain, Post Partum Tubal Pathway.

192 191 PI w Q.24 What are some clinical pathways that we are working on and planning to implement within the coming year? w A.24 Fractured hip pathway, SDS pathway, COPD pathway, Csection pathway, CHF pathway, Extension of chest pain pathway that will continue on telemetry or ICU.


194 193 MANAGEMENT OF INFO w Q.1What is your role in managing information? w A.1 Protect Our Hospital Computer System by following proper procedures for protecting records and information from tampering/damage, unauthorized access or use and theft.

195 194 ROLE IN INFO MANAGEMENT w Make entries in a patient’s record only if you are authorized to do so. w Never leave open files on your computer screen or reports from a printer unattended. w Keep patient information confidential.

196 195 ROLE IN INFO MANAGEMENT w For example: Get written permission from the patient before you share information with any unauthorized person or agency. Do not talk about patients in public areas such as the elevator or cafeteria. Never leave patient files open or unattended where unauthorized people could see them.

197 196 ROLE IN INFO MANAGEMENT w Keep documentation up to date and accurate. All entries should be signed, dated and checked for accuracy. w Anytime you see how a process can be improved, tell your supervisor!

198 197 ROLE IN INFO MANAGEMENT w Q.2Where would you find quick access to the poison control information number in patient care areas? w A.2The Poison Control Information Number is located in the automated phonebook located through your phone system. The poison control number is also posted in patient care areas.

199 198 MANAGEMENT OF INFORMATION w Q.3 What information do you need to do your job? w A.3 In general, information needs to be timely and accurate. For all departments, information is needed during staff meetings, mandatory inservices/orientation and ongoing educational opportunities.

200 199 MANAGEMENT OF INFO For specific departments, basic examples include: w Housekeeping: timely and accurate patient discharge time w Radiology: medical indication for a patient having a procedure w Laboratory: precautions for sticking a patient

201 200 MANGEMENT OF INFO w CRC: information of if the patient has an advanced directive w Nursing: results of labs or exams w Nutritional Services: patient medical history for specific nutritional needs w Patient Accounting: specific information on the patients insurance plan

202 201 MANAGEMENT OF INFO w Q.4What would you do if you were not getting the needed information to do your job? w A.4Staff and managers need to communicate effectively.

203 202 MANAGEMENT OF INFO w Staff has the responsibility to let his/her supervisor know if there is a problem. w Management has the responsibility to determine if the system can be improved to provide staff with more timely and accurate information.

204 203 MANAGEMENT OF INFO w Q.5From what sources do you get information? w A.5 Memos sent to your department or via pay stub Bulletin boards and communication books/logs Staff meetings Other employees Newsletters, etc. Lotus Notes /Email Web Site and Internet.

205 204 MANAGEMENT OF INFO w Q.6 What is knowledge-based information? w A.6Information that is used in problem solving can be found in clinical, scientific and management literature. w On the patient floors are many reference books, text books, drug books, journals, etc.

206 205 MANGEMENT OF INFO w In the Staff Development office there are additional textbooks, reference materials and journals. w In the medical staff library there are journals, textbooks, reference materials and other resources.

207 206 IM w In the computer lab and various departments in the hospital, employees have access through their supervisor to access the internet world wide web with unlimited medical information.

208 207

209 208 MANAGEMENT OF INFO w Q.7 One of your co-workers has forgotten her computer password and asks to use your password so she can get her work complete. What do you do?

210 209 IM w A.7Inform your coworker that you cannot share your password as you have agreed not to share your password with anyone else by signing a form stating you will keep your password confidential. You suggest she see her supervisor to get her password. If the supervisor is unavailable you assist your coworker with her work or find someone who can help her until the password is received.

211 210 MANAGEMENT OF INFO w Q.8 You learn, as a result of your work, that a close friend is on the surgery schedule. Another friend asks you what you know about this patient. How do you handle the situation? w A.8 You do not discuss this patient with your friend.

212 211 IM any  Our policy states any Information that is contained in the patient’s chart, accessible by computer, or available through any other written or computerized source shall be considered confidential, and shall not be accessed, reviewed or discussed unless such information is necessary for completion of specific job duties. @

213 212 MANAGEMENT OF INFO w Q.9 What is the vision of our hospital as it relates to Management of Information? w A.9 Our hospital has a Management of Information Plan that outlines how we are obtaining information through networking in addition to the future plans for our hospital. See policy # ADM-010-037 for more information.

214 213 MANAGEMENT OF INFO w Q.10Is comparative data available to assess performance? w A.10Yes, from Information Management or the department responsible for data.

215 214 MANAGEMENT OF INFO w Q.11Has your department or staff been provided with proper equipment and training to use the equipment? w A.11Classes are offered in house on a regular basis Information Management can offer suggestions for training and equipment needs.

216 215 MANAGEMENT OF INFO w Q.12Are department and hospital policies and procedures readily available? w A.12There should be a paper copy in every department. w Current Policies are available electronically in Lotus Notes. All supervisors have access to this database.

217 216 MANAGEMENT OF INFO w Q.13How are you informed of policy and procedure changes? w A.13Through staff meetings, inservices and posting new policies. w Lotus Notes policy database will have the latest policies. These can be viewed, searched and printed.

218 217 MANAGEMENT OF INFO w Q.14When are you given initial instruction and continue instruction on how to access necessary data and instructed on the confidentiality statement? w A.14Initial instruction is given during employment orientation program and yearly during inservice/continuing education.

219 218 MANAGEMENT OF INFO w Q.15If you have access to confidential information via computer system, is it okay to leave it on this screen while you attend to another task away from this system? w A.15The proper procedure is to sign off any screen that shows confidential information. This way an unauthorized person cannot access this information while the PC is unattended.

220 219 MANAGEMENT OF INFO w Q.16Information on hazardous material is located where? w A.16In the Medical Safety Data Sheet book located at each work station.


222 221 PT RIGHTS/ ETHICS w Q.1What rights and responsibilities do our patients have? (ADM-010-002) w A.1RIGHTS FOR TREATMENT: w Patients have the right to be treated without discrimination. They cannot be denied appropriate and necessary services because of their race, religion, national origin, gender or ability to pay.

223 222 PT RIGHTS/ ETHICS w Patients also have a right to care that is considerate and respectful of their personal values and beliefs. w Patients have a right to appropriate assessment and management of pain.

224 223 PT RIGHTS/ETHICS w ACCESS TO INFORMATION: Patients have the right to review their medical record. They also have the right to have their questions about their condition answered.

225 224 PT RIGHTS/ETHICS w INFORMED CONSENT: w Patients have the right to know: w Treatment options including alternative options and the option to refuse treatment w Risks, benefits and alternatives of each option including the expected length of recovery

226 225 PT RIGHTS/ETHICS w Possible side effects of treatments and medications w Costs including what the patient’s insurance may and may not cover

227 226 PT RIGHTS/ETHICS w INVOLVEMENT IN CARE DECISIONS: Patients have the right to be involved in making decisions which includes informed consent, withholding resuscitative services, care at the end of life and other options outlined in various documents known as “advance directives”. Patients also have the right to file a complaint and receive help in resolving any conflicts. w

228 227 PT RIGHTS/ ETHICS w CONFIDENTIALITY: Information about a patient (medical records, test results, etc.) must be kept private. Anyone not directly involved in the patient’s care, including family members, must have the patient’s permission to get information.!

229 228 PT RIGHTS/ ETHICS CONFIDENTIALITY: w Staff must not needlessly talk about a patient’s personal or medical details! Be cautious of where and how you discuss patient information! Remember you signed a confidentiality statement upon employment that must be taken seriously

230 229 PT RIGHTS/ORGANIZATION ETHICS w PRIVACY: All care (examinations, tests, etc.) should be given in ways that respect the patient’s dignity. Some examples of how you do this should include:

231 230 PT RIGHTS/ETHICS w Knocking before entering the patient’s room w Keeping curtains drawn during examinations w Discussing sensitive issues in a private area w Asking the patient’s permission to speak about his or her condition in front of visitors and/or family members.

232 231 PT RIGHTS/ETHICS w ACCESS TO PROTECTIVE SERVICES: Know our facility policy ADM- 010-032 addressing issues of suspected abuse and neglect. All healthcare workers are responsible for notifying our Social Workers (Kara Hill and Earlene Davis Ext.3129 and 3166 ) when suspicion of abuse or neglect exists!

233 232 PT RIGHTS/ETHICS w PATIENT RESPONSIBILITIES: These include giving accurate information, following instructions, asking questions when something isn’t clear, showing respect and consideration for other patients, hospital staff and visitors, and following hospital rules such as visiting hours and no smoking within the building).

234 233 PT RIGHTS/ETHICS w Q.2How is the patient informed about his/her rights? w A.2The patient receives patient information through our admitting department ext. 3122 which lists/explains patient’s services, rights, and responsibilities.

235 234 PT RIGHTS/ETHICS w *During their hospitalization, if patients have any questions regarding their rights, please notify the supervisor, who can access the information for the patient. The patient rights and responsibility statements are also available in Spanish.

236 235 PT RIGHTS/ ETHICS w How do you ensure the patient’s right to confidentiality? w A.3 Do not share computer password. w Do not discuss patients in open areas (i.e., elevators, cafeteria, hallways). w Use caution when giving information over the phone. w Share patient information only with appropriate staff.

237 236 PT RIGHTS/ ETHICS w Tear up papers that contain patient information and place in recycling bins to be confidentially shredded. w Do not use patient’s name when voice paging MD’s. w Employees, volunteers, students and affiliated care givers sign an agreement of confidentiality at time of employment. w Only authorized individuals are permitted to access records (Paper or via computer)

238 237 PT RIGHTS/ETHICS w Job descriptions/evaluations address confidentiality. w Boards or sign-in sheets with patient’s address or diagnosis should never be visible to the public. w Also, reclose doors/curtains to maintain as much privacy as possible with the patient.

239 238 PT RIGHTS/ETHICS w We provide pen/paper to our patients if they seem embarrassed or uncomfortable. We move to a more private area when possible. We assure patient gowns fit properly. We close bathroom doors when occupied, etc.

240 239 PT RIGHTS/ETHICS w Q.4What is your role in obtaining informed consent? (NUR-002-036) and (NUR-002-037) w A.4The staff’s role is to verify with the patient (by the patient’s signature on the consent form) that the patient has all the information needed regarding the risks, benefits, and alternatives of the procedure to make an informed choice.

241 240 PT RIGHTS/ETHICS w Risks, benefits, and alternatives of the procedure MUST BE ADDRESSED BY THE PATIENT’S PHYSICIAN.

242 241 PT RIGHTS/ETHICS w If the patient has questions, the nursing staff may choose to delay the consent process until the physician has satisfactorily answered all the patients’ questions and then proceed with the consent process.

243 242 PT RIGHTS/ETHICS w Q.5What is an Advance Directive? (ADM-010-016) w A.5A way for a patient to decide in advance how he or she wants to handle life-threatening situations. Examples of AD’s are Living Will, Health Care Surrogate, Durable Power of Attorney.

244 243 PT RIGHTS/ETHICS w Q.6What is a Living Will? w A.6An Advance Directive that allows a person to specify his/her health care decisions in the event of a life-threatening condition or terminal illness.

245 244 PT RIGHTS/ETHICS w Q.7What is a Durable Power of Attorney? w A.7An Advance Directive that allows a person to appoint someone as their health care surrogate to make all health care decisions for them if they are unable to communicate or make decisions for themselves.

246 245 PT RIGHTS/ETHICS w Q.8How are patients informed of their rights regarding Advance Directives? w A.8Upon admission, registration personnel in the Admission office give patients a pamphlet on Advance Directives and ask patients if they have an Advance Directives. If they do not have an AD and want more information or assistance in formulating an Advance Directive, they are referred to Social Services, ext. 3129 or 3166.

247 246 PT RIGHTS/ETHICS w Q.9What structures are in place to address end of life decisions, resuscitative measures or withholding life-sustaining treatments? (ADM- 010-030) w A.9The staff act as patient advocates and advise the attending physicians of patient/family concerns surrounding these issues. patient support, as is the hospital Ethics Committee.

248 247 PT RIGHTS/ETHICS w There is a hospital/medical staff policy on DNR and end of life decisions. Chaplain Service is available for family.

249 248 PT RIGHTS/ETHICS w Q.10How is organ and tissue donation handled? (ADM-010-024) and (ADM-010-034) w A.10 Organ and tissue donation is discussed with the patient/family in appropriate cases. Refer to the Organ Donation policy. The Kentucky Organ Donation Association personnel is available to the staff and family as needed. If the donation is granted, consent is obtained on the Organ/Tissue Donation form.

250 249 PT RIGHTS/ETHICS w Q.11 How do you demonstrate family participation in care decisions when appropriate? w A.11 Participation is documented in the plan/care map or standard of care and in the nursing focus notes. Family involvement is part of being a patient advocate while maintaining the focus on the patient.

251 250 PT RIGHTS/ETHICS w Q.12How do we evaluate the need for restrictions such as telephones, mail, visitors, etc.? (ADM-010-043) w A.12Policies and procedures are in place to govern restrictions which are patient specific. When restriction of telephone calls or visitors is deemed appropriate, patients/families/friends are educated regarding this decision per policy on patient rights. Patient/family/friend education related to practice is performed on admission.

252 251 PT RIGHTS/ETHICS w Q.13How does the organization ensure patients’ care is not negatively affected if a staff member asks not to participate in an aspect of care due to personal, ethical, cultural, or religious values? (ADM-010- 022) w A.13There is a policy which defines conditions by which employees can refuse to participate in the care of a patient because of cultural, ethical or religious conflicts.

253 252 PT RIGHTS/ETHICS w The policy addresses the right that employees have to request a reassignment of work duties when conflict arises. The manager and employee evaluate this request on an annual basis. The Human Resources Department can assist with questions if needed.

254 253 PT RIGHTS/ETHICS w Q.14How do we help assure the hospital conducts its business and patient care practices in an honest, decent and proper manner? w A.14The hospital has a Code of Ethical Behavior (See Policy # ADM- 010-017) which addresses marketing, managed care, billing and admitting practices.

255 254 PT RIGHTS/ETHICS w Hospital staff have been involved in developing this policy that makes certain these issues are all handled in an ethical manner.

256 255 PT RIGHTS/ETHICS w Billing practices are monitored to ensure that patients are billed only for the services that were provided, patients are given an itemized statement and patient accounting staff are available to answer patient questions and resolve conflicts. The hospital mission statement and annual business plan care used as guides to provide a consistent, ethical framework for it’s business and patient care operations.

257 256 PT RIGHTS/ETHICS. Q.15 Do we treat patients based on their ability to pay for services? A.15No. We treat all patients based on their need for services

258 257 PT RIGHTS/ETHICS w Q.16 Who can look in a medical record? w A.16Health care professionals with a need to know and who are involved in the patient’s care.

259 258 PT RIGHTS/ ETHICS w Q.17 What has been done to accommodate patients and visitors with disabilities? (HRM-070-035) w A.17The hospital emergency room entrance is designed for disability entrance, disability restrooms, elevators with Braille letters, and general information in large print. Other needed materials can be enlarged on a copier or provided verbally..

260 259 PT RIGHTS/ETHICS w Outpatient registration area has a TDD machine to communicate with the hearing impaired. The current list of interpreters who can be called for deaf patients if the need arises is available through Jo Helen Cloys or the House Supervisors office. All televisions are equipped with closed captioning. (ADM-010-015).

261 260 PT RIGHTS/ETHICS w Q.18 What has been done to accommodate culturally diverse patients and visitors? w A.18For non-English speaking patients/visitors, arrangements are made through the House Supervisor for a translator to be available. For patients with limited education, staff communicate various ways to make certain the patient understands to the best of their ability.

262 261 PT RIGHTS/ETHICS w For patients with certain religious or cultural beliefs that prevent them from seeking certain treatments, procedures, etc. we as healthcare workers respect their rights to refuse treatment. For elderly patients we communicate in various ways to make certain they see and hear what we’re saying..

263 262 PT RIGHTS/ETHICS w Q.19If you have an ethical question on any aspect of patient care delivery, what resources are available to discuss the situation? (ADM-010-027) w A.19 There is a hospital Ethics Committee. Contact the Vice President of Patient Care Services; Jill Cornelison ext. 3119, Shelia Powell, Director of ICU/CCU, ext. 3550 or the House Supervisor.

264 263 PT RIGHTS/ETHICS w Q.20 How are you as a staff member made aware of the ethical issues surrounding patient care and the hospital’s policies governing these issues? w A.20A multidisciplinary ethics committee exists and staff are made aware through hospital policies and procedures, mandatory inservice, orientation, supervisors, patient guest handbook (given at the time of admission), and communications through the hospital ethics committee. (Review our hospital policy # ADM-010-027).

265 264 PT RIGHTS/ETHICS w Q.21 What is your department’s role in the development and implementation of the mechanisms designed to address patient rights? w A.21All departments are responsible for making sure that patient’s rights have been respected and departmental input is needed in developing, implementing and abiding by policies.

266 265 PT RIGHTS/ETHICS w Departments represented on the Ethics Committee include: ICU/CCU, Nursing Administration, Social Services, Community Chaplain, Administration, Hospital Board, Hospital Attorney and a Professional Ethicist from EKU faculty

267 266 PT RIGHTS/ETHICS w Q.22How is the patient complaint managed? (ADM-010-010) w A.22The employee should clarify the nature of the complaint before contacting their supervisor, department director, house supervisor or administrator on call. That individual should promptly investigate and analyze the situation and notify the appropriate department director/manager for assistance. All in-house complaints must receive a verbal response within 24 hours.

268 267 PT RIGHTS/ETHICS w Outpatient and emergency department complaints must be responded to within five days. A patient comment/complaint form must be completed by the individual responding to the patient complaint and returned to Jo Helen Cloys, Patient and Public Relations Director, ext. 3446.

269 268 PT RIGHTS/ETHICS w Q.23How are patients pastoral (spiritual) needs met? (ADM-010-021) w A.23Our staff recognizes that patients have spiritual needs and assess their desire for such services. We have an organized chaplaincy program with minister call coverage for pastoral visits or counseling. The spiritual leader will document on the Pastoral Care Notes and this is placed on the patient record. Chaplains may discuss spiritual care with the patient’s nurse.

270 269 PT RIGHTS/ETHICS w To protect the patients right to confidentiality, each patient is asked on admission if their name can be given out to our Chaplains on call.

271 270 PT RIGHTS/ETHICS w Q.24How do we inform other departments that a patient being transported to their area has a valid advance directive or DNR orders? w A.24We always send the patient’s chart with the patient. The code status sheet is located at the front of every chart and directly behind the code status sheet a living will is kept if one exists.

272 271 PT RIGHTS/ETHICS w Q.25 What rights do patients have regarding pain management? (NUR-002-007) w A.25The patient has the right to make decisions to manage pain effectively and to have an assessment of pain. Patients have a right to information about pain and pain relief measures.

273 272 PT RIGHTS/ETHICS w Q.26How is a patients pain assessed and managed? w A.26The patient is asked about pain level, location, description on admission using a scale 0-5. Policy and Procedures are in place defining alternatives to help with pain management.


275 274 IC (INFECTION CONTOL) Q:1 Why is there an Infection Control Department? A:1 To reduce the risk of infection between patients, visitors and our employees

276 275 IC w Q: 2 What single action is recognized by the CDC (centers for Disease Control and Prevention) as the most effective means of preventing the spread of infection within a facility w A:2HANDWASHING!!!!!

277 276 IC w Q:3Who is responsible for Infection Control? w A:3ALL of us at PAC are responsible for preventing infections. Kim Jarvis IC coordinator, Lisa Gamble Employee health Dr. Barnwell Chairperson IC committee assist with this effort

278 277 IC  Q.4What does the term “Standard Precautions” mean?  A.4 Pattie A. Clay has adopted the 1996 CDC Isolation Precautions. Under these guidelines, standard precautions are used. Standard precautions mean that blood, non-intact skin, and all body fluids with the exception of sweat are treated as potentially infectious, so we must use personal protective equipment to protect ourselves from being exposed to these body fluids.

279 278 IC  Q.5What would you do for an occupational exposure to bloodborne pathogens (needle stick, splash or spray to eyes, non-intact skin)?

280 279 IC  A.5Go through the needlestick protocol. Report exposure to your supervisor, then contact either the Employee Health Nurse (Lisa Gamble), the Infection Control Coordinator (Kim Jarvis) or the House Supervisor to complete an exposure packet which is available from any of the above individuals. The details of the exposure will be reviewed with you and the risk of transmission of a bloodborne pathogen will be determined. At this point you will be instructed further regarding any action needed. Lisa Gamble will follow up with you regarding the results of testing.

281 280 IC  Q 6 What isolation system do we use at Pattie A. Clay and what do the signs mean?  A.6Pattie A. Clay Regional Medical Center uses the CDC Isolation Precautions which mandate standard precautions are to be used at all times with all patients. In addition to Standard Precautions there are three categories of transmission based precautions:

282 281 IC (6) THREE CATEGORIES :  Airborne - for TB, chickenpox or other airborne disease.  Droplet - for meningitis, pertussis, influenza or certain other diseases.  Contact -used for patients with VRE, MRSA or other drug resistant organisms.

283 282 IC (6) Signs instruct visitors and other persons to report to the nursing station for information regarding precautions to be taken before entering the patient’s room. Standard precautions are always used in addition to transmission based precautions.

284 283 IC  Q.7What is personal protective equipment? Name an example and when you should use it.  A.7Personal protective equipment protects us from contact with blood or body fluids. Gloves, masks, goggles or face shields and gowns are personal protective equipment

285 284 IC QQ8 If a patient has an infection which requires isolation, where would you find information regarding the type of isolation required? AA.8The Blue Exposure Control Manual located in each department, or Isolation policies may be accessed via Lotus Notes.

286 285 IC  Q.9 What are items that go in Red bags or Red containers?  A.9Items that are full of blood or have the potential to break or splash blood go into the red bagged waste containers. Needles and sharp items which may puncture bags go into the sharps disposal boxes. This is called Biohazardous waste.

287 286 IC  Q.10Who monitors refrigerator temperatures in our facility and what action should be taken to correct an out of range reading?  A.10In the main facility temperatures are checked daily and logged by our Security personnel. Any variance is reported to Plant Operations. Our off campus facilities assign clinical staff to monitor refrigerator temperatures and report any variances to Plant Operations.

288 287 IC  What immunizations are available to our employees?  A.11All of our employees are offered the Hepatitis B vaccine. MMR (measles, mumps, and rubella) and varicella (chickenpox) are offered to employees who are not immune to these diseases. All employees are offered the flu vaccine yearly.

289 288 IC  Q. 12 What precautions are taken for patients with known or suspected TB?  A.12The patient is placed in a private room with negative air pressure, outside ventilation and an isolation sign is placed on the door. Only rooms 429 and 431 on 4 West and bed 2 in ICU are appropriate. The employee flips the switch located outside the room to turn on the second fan which makes the room have negative air pressure.

290 289 IC  An employee who has been fit tested for an approved mask is assigned to care for the patient. Patients should not leave the room unless required for testing or treatment and then they must wear a mask the entire time they are out of the room. Only employees fit tested with an approved mask may enter the room.

291 290 IC  Q 13 Do you recap needles?  A.13Generally needles are never recapped, but if there should be a situation where recapping is necessary then you must use a one handed scoop method or a mechanical device designed for needle recapping.

292 291 IC  How do you dispose of sharps?  A.14Needle/sharps boxes are where all contaminated sharp items are disposed of.


294 293 CARE OF THE PATIENT  Q.1. Can restraints be initiated by an R.N.?  A.1. Yes, if the physician is not available, with the approval of the House Supervisor based on appropriate assessment of the patient and sound clinical judgment. The physician must be contacted for a written or verbal order as soon as possible but within 12 hours of the restraint application.

295 294 CARE OF THE PATIENT  Q.2. What must the physician order include for the use of restraints?  A.2. a) The condition present that warrants the use of restraints. b) Type of restraint c) Time of the order d) Date e) Physician's signature

296 295 CARE OF THE PATIENT  Q.3. How long is a Med/Surg restraint order good for?  A.3. No longer than 24 hours.

297 296 CARE OF THE PATIENT  Q.4. If a patient is restrained for sudden aggressive behavior, how soon must the patient be assessed face-to-face by the physician and how long is the restraint good for?  A.4. If a patient exhibits sudden aggressive behavior and poses an imminent danger to himself or others and restraints are applied, a physician must see and evaluate the need for restraint within ONE hour after the intervention.

298 297 CARE OF THE PATIENT A.4 (CONT) Each written order for a physical restraint for aggressive behavior is limited to four (4) hours for adults, two (2) hours for children and adolescents age 9-17 and one (1) hour for children under the age of 9.

299 298 CARE OF THE PATIENT When the time span for the original order is close to expiring, a nurse is to telephone the physician, report the results of his/her most recent assessment and request that the original order be renewed for another period of time.....not to exceed the time limits set by the original order. The physician does not have to perform another face- to-face assessment until the 24hr. maximum is reached.

300 299 CARE OF THE PATIENT  Q5. What is a chemical restraint?  A.5. A medication that is used to control behavior or to restrict the patient's freedom of movement and is NOT a STANDARD OF TREATMENT for the patient's medical or psychiatric condition.

301 300 CARE OF THE PATIENT w The most difficult issue is determining if the drug is being used as a chemical restraint. w Is giving a hospitalized ICU patient Xanax prn considered chemical restraint if they have never had a history of anxiety? w No- the doctor is anticipating that they might experience anxiety in the ICU setting.

302 301 CARE OF THE PATIENT w What about a hypnotic agent to a teenager (no history of insomnia) the night before scheduled surgery ? w No- again, it is expected that the patient might have trouble sleeping being away from home and worried about the procedure.

303 302 CARE OF THE PATIENT KEY QUESTIONS to ask yourself regarding drug orders : w 1. If the drug is given will it alter the mood, mental status or behavior? IF the answer is yes -> CHEMICAL RESTRAINT

304 303 CARE OF THE PATIENT w 2. Does the patient have a history of a condition or a new condition which is usually managed by this type of drug? IF the answer is yes -> this is not chemical restraint IF the answer is no -> this could be construed as a chemical restraint


306 305 CARE OF THE PATIENT  Q.7. Who is responsible for monitoring resuscitation (Code 99) outcomes and how often is this performed?  A.7. The house supervisor conducts a review of all Code 99"s after the code has ended. Completed sheets are forwarded to Utilization Review with reports presented quarterly at the Nursing Management meeting and to any affected area.

307 306 CARE OF THE PATIENT  Q.8. How can you be certain that a crash cart on a different unit is stocked the same as the crash cart on your unit?  A.8. All crash carts are restocked by the pharmacy using the same criteria for each and every crash cart

308 307 CARE OF THE PATIENT  Q.9. How often does the pharmacy check the contents of all crash carts?  A.9. The pharmacy checks the content of all crash carts on a monthly basis for completeness and expiration dates.

309 308 CARE OF THE PATIENT  Q.10. How often such staff involved in patient care attend the Code 99 Review inservice?  A.10. Every two (2) years.


311 310 CONSCIOUS SEDATION Q.6What is conscious sedation? A.6A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patient airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

312 311 CONSCIOUS SEDATION w Q.7 What is the difference between “conscious sedation” and other types of sedation? w A.7 Minimal sedation is defined as a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.(such as medication given for pain or pre-operative medication).

313 312 CONSCIOUS SEDATION w Deep sedation/analgesia is defined as a drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.(these patients will have an anesthestist in attendance)

314 313 CONSCIOUS SEDATION w Q.8What equipment is to be readily available in monitoring the patient for conscious sedation? w A.8The following equipment and supplies must be available for the administration of intravenous conscious sedation:

315 314 CONSCIOUS SEDATION w Continuous monitoring non- invasive blood pressure and pulse oximetry; and cardiac monitoring (only if known cardiac patient) during and immediately following in the recovery period of the procedure.

316 315 CONSCIOUS SEDATION w *Continuous intravenous infusion of an appropriate solution functional suction apparatus with appropriate suction catheters.

317 316 CONSCIOUS SEDATION w Telephone or some other system so as to be able to activate the emergency medical system if required.

318 317 CONSCIOUS SEDATION w An emergency crash cart which includes respiratory emergency equipment. w Reversal agents/medications. w Sedation and analgesia medications as ordered by M.D.

319 318 CONSCIOUS SEDATION w Q.9 Who is responsible for assessing and/or reassessing the patient immediately prior to administering anesthesia when a nurse anesthetist is not involved in the procedure? w A.9The independent licensed practitioner.

320 319 CONSCIOUS SEDATION w Q.10How do you know if a physician or other licensed independent practitioner has privileges to do a certain procedure in your area? w A.10On every floor there is a delineation of privilege book

321 320 TX3

322 321 TX 3  Q1How do you ensure emergency meds are consistently available, controlled & secure?  A1.Every shift, during normal hours the department is open, the staff verifies that the red numbered lock is intact and that the lock number matches that recorded on the orange sticker affixed to the cart. This shows that the cart is complete.

323 322 TX3  Q2. What would you do if you found that the emergency box or crash cart was unlocked ?  A2. During pharmacy hours (8a-8p M- F, 8a-6p SS) call pharmacy. After pharmacy hours, call house supervisor to obtain emergency replacement cart from night cabinet. Red Box is to be returned to Pharmacy via dumbwaiter when they reopen (8am).

324 323 TX3  Q3.How are medications distributed, stored, secured ?  A3.INPATIENT AREAS: Pharmacy uses unit dose distribution system. Deliver a 24hr supply of meds and IV products every day. Medications are locked in carts. DEA scheduled meds (Controlled substances) are kept double locked in carts or cabinets.

325 324 TX3  OUTPATIENT AREAS: Drugs routinely used are kept as floor stock. Once used, the charges are sent to Pharmacy for replacement and billing. Meds are kept locked, controlled substances are kept double locked. Doses are signed out on control sheets as used.

326 325 TX3  Q4.Describe how the medication orders are processed for your hospital.  A4.Practitioners write orders in patient chart. Nurse verifies order and order is copied onto med administration record (medix). Copy or order goes to pharmacy via dumbwaiter. Pharmacy sends up enough doses until time of cart exchange, when a new 24hr supply is delivered. Pharmacy and nursing reconcile drugs being delivered at cart exchange against nursing medix. Use chart to clarify discrepancies.

327 326 TX3  Q5.How are pharmacy services provided when pharmacy is closed? Who has keys to pharmacy?  A5.Per KY law, only pharmacists may have keys to pharmacy. After pharmacy closes, night cabinet is available to nursing supervisors for new orders/admits

328 327 TX3  Q6. How are drug storage areas checked?  A6.Pharmacy staff checks all areas monthly for expiration dates. –

329 328 TX3  Q7.How do you monitor the effects of medications on patients?  A7.Depends on the drug. If analgesic, go back and ask patient to rate their pain, using pain scale. If anti-hypertensive, take blood pressure. If antibiotic, check WBC, temp, confirm C&S for bug and drug. Etc. Overall there is a Multidisciplinary approach

330 329 TX (7) Multidisciplinary  Pharmacy screens for drug-drug interactions, drug-food interactions.  Lab reports sub therapeutic or toxic levels/labs.  Everyone evaluates patient for suspected adverse reactions.  Nursing documents SE, effects.  Physician, UR monitor outcomes.

331 330 TX3  Q8.Describe how you are addressing the patient’s right to pain management.  A8. First of all, the patient is informed of the right to pain management in the admission brochure. Upon admission, the nursing assessment is used to assess pain. A standard pain scale (0 pain free-5 worst ever pain) is used to document the pain..

332 331 TX3 Pain Management (cont)  Medications are ordered by the physician and administered according to the instructions. Appropriate selection and dose of drugs are monitored by pharmacists. When doses are administered, the nurse re-checks the patient and documents pain after the analgesic dose (or non- pharmacologic) intervention

333 332 TX3 (8 CONT)  Care plans include the pain scale. The physician is informed if the pain regimen prescribed is not effective at managing the patients pain. In addition, PCA pumps are now available at PAC. This allows the patient to assist in their pain management. Patients are educated about their pain meds by the nurse when given the med and before being discharged home on a pain med.

334 333 TX3  Q9. Are there any therapeutic interchanges/drug substitutions in place at PAC?  A9.Yes. Pharmacy & Therapeutics committee has approved several automatic substitutions.

335 334 TX3 (9)  H2 blocker (po)= Zantac 150 bid(for any oral H2 ; Axid, Pepcid, Tagamet)  H2 blocker (iv)= Pepcid 20mg iv q 12h ( for any inj H2)  Proton pump inhibitor= Prevacid 15mg qd (for Prilosec 20mg)  Antacid= Maalox Plus(for Mylanta)  Maalox Plus XS (for Mylanta II)  Multivitamins= Theragran M qd

336 335 TX3  Q10.How are those substitutions documented?  A10.Pharmacy sends up sticker noting interchange to be placed in chart (with order)Nursing unit staff is to note drug patient actually receiving on med administration record.

337 336 TX3  Q11.How long is a multiple dose drug good for?  A11.MULTIPLE DOSE VIAL FOR INJECTION 30 days from date opened, as long as not visibly contaminated. Staff is to write date and initials on vial when opened.

338 337 TX3  BULK OR MULTI ‑ USE CONTAINER LIQUID, ETC Up to manufacturer’s expiration date as long as no visible signs of contamination and proper dispensing/administration techniques are used

339 338 TX3  Q12.Where do you get the red numbered locks for crash carts?  A12.Pharmacy controls locks. They sign them out in Pharmacy. Issue with new sticker for cart/box (with new lock number).

340 339 TX3  Q13.How are samples used at PAC?  A13.Pharmacy does not keep samples for inpatients. If a doctor supplies samples for a patient, they are delivered to pharmacy and pharmacy will distribute via normal cartfill procedure. Profile reflects samples used: no charge.

341 340 TX3 (13 CONT)  INSTANT CARE & MIDWIFE: samples are logged into stock upon receipt. Log reflects lot & exp. dates. Samples are labeled and dispensed by practitioner to their patients and labeled with instructions. Documentation that samples given is noted in chart.

342 341 TX3  Q14.How are herbal products used at PAC?  A14.Pharmacy & Therapeutics committee approved a policy that states the PAC pharmacy will not stock/dispense herbal products for inpatients. Nursing assessments do include a question for the patient about use of herbal, food supplements or OTC products at home.

343 342 TX3  Q15.What has been done at PAC to minimize risk of medication errors?  A5.Re-implemented cartfill exchange reconciliation. Developed an IV potassium protocol - removed undiluted Kcl vials from floorstock and crash carts.  Standardized iv drip Concentrations  Use of routine orders (annually review & revise)

344 343 TX3 (15 CONT)  Converted from heparin to saline lock (flushes)  Reduced drugs available in night cabinet  Focus articles in Pharmacy newsletters on steps to reduce med errors.  Held CE program, “How to avoid the Headlines: Medication Error Prevention.”

345 344 TX3 (15 CONT)  Review of P&P for safety related to med distribution, administration, dispensing  Performance improvement looking at prescribing (completeness of orders)  Evaluating house wide computerized charting software  Analyze and trend medication errors

346 345 TX3  Q16.Is there an automatic stop policy at PAC? How does it work?  A16. Yes. It requires the practitioner to re-evaluate the use of certain types of drugs every 5 days and either re-order (to continue therapy) or discontinue. Antiinfective agents, inj corticosteroids, controlled substances. Pharmacy sends notice to unit secretaries about drugs which are reaching the 5 day limit and they write note in chart asking Dr to renew or d/c the drug.

347 346 TX3  Q17.What MUE (medication use evaluations) have been done this year?  A17.Allergy reporting, CHF, B blocker+ ASA in post MI patients, Epogen, Pain management


349 348 NUTRITION  Q.: How are nutritional needs assessed and monitored?  A: Patients are screened and if needed assessed. The assessment includes a plan of care, documented in the chart in the multi-dis. plan of care. This plan of care is undated and redefined dependent on each individual patient and their individual needs. Therapies are monitored by nutrition services, nursing, pharmacy and other disciplines. These may include: intake, weight change, lab values, wound healing

350 349 NUTRITION  Q: How is nutrition services triggered to see patients?  A: Each inpatient has a screening tool completed by nursing staff to identify problems on admission. The tool has 4 copies, one for the chart, one for nutrition, one for social services, and one for PT. This alters these disciplines to review the charts. Nutrition can also be consulted via physician, nursing, pharmacy, other disc. or via discharge planning group.

351 350 NUTRITION  Q: What happens to patients needing trays between meals of in off hours?  A: Nursing may call down for trays anytime during operating hours. The trays are filled and placed on the dumb-waiter.  During off hours there are a variety of food stuffs available on the floors, juices, soups, Jell-O, frozen dinners, milk, crackers, nabs, fruit.

352 351 NUTRITION  Q: What are you doing to comply with HACCP guidelines for enteral support?  A: We use a closed system, with RTH ( ready to hang) formula when ever possible. This allows the formula to be hung for a 24 hour period.

353 352 NUTRITION  There are several formulas not available in the RTH, these are poured into containers, with enough for only 8 hours at a time, the containers are then rinsed before new formula is added.

354 353 NUTRITION  We do not manipulate our formulas with dye, but have color pelled systems which allow the formula to be colored without manipulation.  Formula is dated and timed by nursing. We also have an enteral feeding form which alerts nutrition to assess patients on enteral support.

355 354 NUTRITION  Q: Are dietitians available on weekends?  A: Yes, our dietitians rotate weekends

356 355 NUTRITION  Q: How are you sure patients get the correct diet?  A: Nursing services verify the trays/ diet orders with food service staff prior to trays being passed. This is repeated for each meal.



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