1. Department of Patient RelationsMeasuring to Achieve Patient Safety Safety Observer’s Orientation

2. Measuring to Achieve Patient Safety Today’s Agenda Introductions Orientation Presentation Question & Answer Session Schedules

3. Measuring to Achieve Patient Safety Safety & U.S. Healthcare 98,000 deaths occur in the US each year due to errors in medical care 50% of these occurrences are preventable Healthcare industry is determined to improve and is imposing strict regulations towards patient safety

4. Measuring to Achieve Patient Safety JCAHO Joint Commission on Accreditation of Healthcare Organizations Independent, not for profit organization Objectively evaluates and accredits nearly 20,000 healthcare organizations and programs across the U.S.

5. Measuring to Achieve Patient Safety Mission of JCAHO “ To continuously improve the safety and quality of care provided to the public through the provisions of healthcare accreditation and related services that support performance improvement in healthcare organizations”.

6. Measuring to Achieve Patient Safety UCLA & JCAHO JCAHO conducted its audit of UCLA in April- May 2004 UCLA received a perfect score from JCAHO One of the main objectives of project MAPS is to help the hospital get prepared for the JCAHO audit in the spring

7. Measuring to Achieve Patient Safety UCLA Healthcare Safety Initiatives UCLA continually assesses its present systems and implements changes to improve these systems in order to reduce patient risks One such initiative is MAPS Project MAPS originated from a request of UCLA’s JCAHO Core Group team, and the Hospital and Nursing teams.

8. Measuring to Achieve Patient Safety MAPS Objective “To facilitate improvement of patient safety processes by observing clinical processes at UCLA Medical Center and Outpatient Clinics, and providing highly reliable feedback to the leadership and management of UCLA Healthcare”.

9. Measuring to Achieve Patient Safety MAPS Overview MAPS is an observational study The project will collect data in various clinical settings in over 70 locations in the hospital Observations will also be conducted in some clinical areas in the Med Plaza

10. Measuring to Achieve Patient Safety Patient Safety Observation Tools Based on JCAHO’s 2004 National Safety Goals Three audit tools: Medication Administration Blood Specimen Hand Washing

11. Measuring to Achieve Patient Safety Medication Administration Triggers Nurse entering medication room or approaching Pyxis machine Nurse carrying medication into patient’s room Looking for Medication Order Request taken to the bedside? Patient identified using at least two patient identifiers (name, medical record number)?

12. Measuring to Achieve Patient Safety Blood Specimen Triggers Phlebotomist with lab tray entering a room Nurse entering patient’s room with lab tubes Looking for Requisition and MRN taken to the bedside? Unlabeled tubes taken to the bedside? Patient labels taken to the bedside? Two patient identifiers

13. Measuring to Achieve Patient Safety Hand Washing Trigger Any caregiver entering/leaving patient rooms Any caregiver –patient contact Looking for Did caregiver wash his hands with soap and water for 15 seconds? OR Did he/she use alcohol based hand cleanser between patient contact?

14. Measuring to Achieve Patient Safety A Regular Day Come to Medical Center at scheduled time and sign in Put on volunteer jacket and ID badge Checked schedule for assigned observation area Call up the charge nurse to give advance notification Proceed to assign observation area. Introduce yourself to charge nurse and explain your purpose in the area

15. Measuring to Achieve Patient Safety A Regular Day … Proceed to make observations with accuracy Communicate all findings (compliances and non compliances) to charge nurses and floor managers Enter the data in the computer File observations Sign out

16. Measuring to Achieve Patient Safety Do’s Always wear your jacket and ID Badge Introduce yourself to both nurses and patient’s Adhere to confidentiality standards Conduct yourself in a professional manner

17. Measuring to Achieve Patient Safety Don’ts Do not enter a restricted area Do not discuss with the patient his or her diagnosis or medical condition, even if he or she initiates such a conversation. Do not purchase or give any food or drink to the patient Try not to block traffic in patient areas since these are very busy locations

18. Measuring to Achieve Patient Safety Working As a Team MAPS is a UCLA Healthcare Initiative. We are working together with the medical staff to improve patient safety Doctors and nurses are generally very busy, and under high stress levels. Do not take negative reactions personally. Keep a positive attitude and reiterate that we’re a team Make use of the Frequently Asked Question Sheet whenever necessary.

19. Measuring to Achieve Patient Safety Volunteer Requirements In exchange for your volunteer experience on the floors, we request that you: Complete training/shadowing sessions Conduct 4 hours of observations per week Complete at least one early morning shift per quarter Obtain and report accurate data

20. Measuring to Achieve Patient Safety THANK YOU!