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Presentation on theme: "MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 PATIENT RELATIONS VOLUNTEER SERVICES Sabina Sanchez MEADOWLANDSHOSPITAL.ORG."— Presentation transcript:


2 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 Patient Satisfaction and Customer Service Definition of customer service: Wikipedia states that “Customer Service is the provision of service to customers before, during and after a purchase. Customer Service is a series of activities designed to enhance the level of customer satisfaction-that is, the feeling that a product or service has met the customer’s expectation. A customer service experience can change the entire perception a customer has of the organization” MEADOWLANDSHOSPITAL.ORG

3 How can our team provide excellent customer service? -Give everyone a “warm welcome”! Greet patients/visitors with a smile. Maintain eye contact. Make customer service a priority! -Respond in a timely manner. You may not have the answer to a request-but you have the power to contact the appropriate department/person who has the answer! Give the patient/visitor a time frame. Follow up to ensure request was fulfilled! -Way finding Accompany patients or visitors to their destination or ask someone else to assist. -Take ownership! Resolve the problem or issue or involve a colleague who can. MEADOWLANDSHOSPITAL.ORG

4 - Show you care! Demonstrate sincerity, enthusiasm and warmth in delivering care and in communicating with patients, visitors and fellow team members! -Take pride in your appearance! Dress in compliance with MHMC Dress Code Policy. Wear the appropriate uniform. ID badges are always worn at eye level. Remember you are the face of our facility! -Be positive! Leave your personal issues and concerns at home! Be wary of your body language and tone of voice. We never look good by making other people look bad! If you encounter a situation with a patient, visitor or team member that you feel you need assistance with-contact supervisor/manager/director for guidance. MEADOWLANDSHOSPITAL.ORG

5 What is a service failure? - A service failure is any patient’s perception of interruption of service or the lack thereof. -Service failure could be perceived differently by each patient. -Research has shown that patients (customers) who have had a service failure resolved quickly and properly are more loyal than are patients who have never had a service failure. -Hospitals with high patient satisfaction are also the facilities with high patient concerns/complaints-it is how they resolve the concerns that make them great! MEADOWLANDSHOSPITAL.ORG

6 The Three “A”s of Service Failure -Acknowledge-Recognizing that the patient/visitor/team member has experienced a “service failure” and actively listening to the concern/complaint. -Apologize- Voicing your sincere regret for the concern even if you were not responsible or aware of the failure relays to the patient that you care. A simple “I am sorry for your inconvenience” goes a long way. -Amend-Making amends for the service failure could be as easy as picking up the phone to contact the appropriate person or department to resolve the problem. All employees have the power to make amends for a service failure! The patient or visitor may request to speak to a Clinical Director, Nursing Supervisor, Patient Advocate or member of Administration. MEADOWLANDSHOSPITAL.ORG

7 Effective patient complaint resolution is a GUARANTEE for high patient satisfaction.

8 HCAHPS-Hospital Consumer Assessment of Healthcare Providers and Systems The HCAHPS Survey is the first national, standardized, publicly reported survey of patient’s perceptions of hospital care. It is a 32 question survey instrument and data collection methodology for measuring patient’s perceptions of their hospital experience. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally and nationally. Adult patients who are admitted on Med/Surg, Telemetry, ICU and Maternity can complete an HCAHPS survey. MHMC surveys 100% of discharged patients in these areas. MHMC utilizes Press Ganey for survey distribution and data collecting. HCAHPS scores are based on consecutive quarters of patient surveys and are publicly reported on A portion of CMS reimbursement to hospitals is based on HCAHPS data

9 ADVANCE DIRECTIVES What is an Advance Directive for Health Care? -It is a written document which gives direction regarding your health care in case you are no longer able to make your wishes known. An Advance Directive may be a living will, a durable power of attorney for health care or a combination of both. It is an effective means of maintaining control over your care, if you become incompetent to make decisions. The document also states specific directions regarding life-prolonging treatments and the conditions under which you would or would not want such treatments to be carried out. -All admitted MHMC patients over the age of 18 are asked if they have or would like an Advance Directive-regardless of why they are in the hospital. -Patient Advocate or Nursing Supervisor can assist in completing Advance Directive. MEADOWLANDSHOSPITAL.ORG

10 Sabina Sanchez Patient Advocate, Volunteer and Community Services Coordinator 201-392-3397 Monday through Friday 9-5 Thank you and good luck!

11 Workplace Etiquette & Professional Conduct Marat Rysmendiev, Director Marketing, Communications, PR & Protocol MEADOWLANDSHOSPITAL.ORG

12 Workplace etiquette and professionalism is about conducting yourself respectfully and courteously. You are the ambassador of the business. When you start a new job, you need to make a good impression on your employer and co-workers. Below are some etiquette concepts that should be remembered and followed at a workplace. MEADOWLANDSHOSPITAL.ORG

13 - The Art of Appreciation and Being Polite and Friendly - Attitude is Everything - On Your feet! - Write It Right Emails And Not Using Spellcheek (Oops!) - Please Listen Carefully... - Call Back MEADOWLANDSHOSPITAL.ORG

14 - Play the Game by the Rules - Say My Name! - Reciprocate with Others - An Unprofitable Mix - Rescue Rangers Beware! - Don't Sneeze on It and Personal Hygiene MEADOWLANDSHOSPITAL.ORG

15 - FU Manners - Cell Phone Etiquette - Check Your Attire! - Hay is for Horses - Watch the Clock - An Invitation That Gets a Yes MEADOWLANDSHOSPITAL.ORG

16 - Are You A Brain-Picker? - Don't Be a Mailing List Abuser - Be Authentic! - "The Interrupter" Are You One? - Show Up or Call - Brutally Honest or Just Brutal MEADOWLANDSHOSPITAL.ORG

17 - Don't Turn Your Back - The Power of the Written Word! - Say No to the Lambada at Work - Watch What You Say and Where You Say it! - Multi-Culturalism IQ - Common Courtesy and Common Sense MEADOWLANDSHOSPITAL.ORG


19 TEAMSTEPPS-J MALAVE, RN COMMUNICATION Effective communication skills are vital for patient safety Enables team members to effectively relay information The mode which most strategies and tools are executed

20 COMMUNICATION IS … ◦ The process by which information is exchanged between individuals, departments, or organizations ◦ The lifeline of the Core Team ◦ Effective when it permeates every aspect of an organization

21 STANDARDS OF EFFECTIVE COMMUNICATION COMPLETE Communicate all relevant CLEAR Convey information that is plainly understood Brief Communicate the information a concise manner Timely Offer and request information in an appropriate timeframe Verify authenticity Validate or acknowledge information

22 SBAR PROVIDES……… A framework for team members to effectively communicate information to one another Communicate the following information: Situation: What is going on with the patient? Backround: What is the clinical backround or context? Assessment: What do I think the problem is? Recommendation: What would I recommend?

23 HANDOFF IS…………. The transfer of information during transfers in care across the continuum Includes an opportunity to ask questions, clarify, and confirm

24 Handoff Consists of…… Handoff Consists of…… Transfer of responsibility and accountability Clarity of information Verbal communication of information Acknowledgment by receiver Opportunity to review “I PASS THE BATON”


26 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 Infection Prevention and Control Infection Prevention and Control Program Goal: To reduce the risk and prevent infections Hospital Acquired Infections / year in the US : Estimated 2 million infections Accounts for nearly 100,000 deaths. Estimated costs $10 billion Can prevent 30% infections by following standard and transmission based precautions. MEADOWLANDSHOSPITAL.ORG

27 Standard Precautions Consider all blood and body fluids as infectious. Follow for all patients regardless of diagnosis Hand hygiene before and after donning gloves. Gloves, Gowns, Masks, and Eye when splashing of body fluids are expected Dispose sharps in proper receptacles. Lab samples transported in appropriate containers in biohazard bags. MEADOWLANDSHOSPITAL.ORG

28 Donning and Doffing Personal Protect Equipment Must to in correct order Donning (bottom up): 1 st Gown 2 nd Mask 3 rd Goggles 4 th Gloves Doffing (alphabetical): 1 st Gloves 2 nd Goggles 3 rd Gown 4 th Mask Donning and Doffing Personal Protect Equipment Must to in correct order Donning (bottom up): 1 st Gown 2 nd Mask 3 rd Goggles 4 th Gloves Doffing (alphabetical): 1 st Gloves 2 nd Goggles 3 rd Gown 4 th Mask

29 Standard Precautions (continued): Do not wear Personal Protective Equipment (PPE)in hallway. Blood Spills - remove with blood spill kit Soiled Linen- wear gloves / avoid contact with your clothing. Single patient use means only for 1 patient Single use vials are for one patient one time use, They do not have a preservative Discard immediately after use Bacteria can survive for days on equipment and surfaces.

30 Transmission Based Precautions Based on mode of disease transmission 2007 CDC guidelines for isolation precautions: Determines type and duration of isolation Located on our intranet in Infection Control Policies Compliance is monitored with isolation precautions and hand washing. Noncompliance reports to employee’s manager Education will be done For repeated events disciplinary actions per HR policy. MEADOWLANDSHOSPITAL.ORG

31 Contact Precautions For known or suspected infections Infections transmitted by patient contact or their environment. Direct Contact person to person transmission Indirect Contact transmission with contaminated objects. Wear gloves and gowns when entering the room Discard PPE before exiting the room. Examples: C- difficile, and MRSA infections.

32 MEADOWLANDSHOSPITAL.ORG Droplet Precautions Prevents transmission of microorganisms in mucus membranes by coughing, sneezing, talking, and suctioning. Droplets can travel 3-6 feet of the patient Examples: meningitis, influenza, pertussis, mumps and pneumonia. Wear mask prior to entering the room Remove mask without touching front of mask Patient wears mask when leaving the room

33 Airborne Precautions Diseases with very small microorganisms can travel long distances on air currents and be inhaled Requires a negative pressure room with doors closed Ball in the wall device alert for functioning of negative pressure Examples: Tuberculosis, Varicella (chicken Pox), Measles, and Disseminated Herpes Zoster (Shingles). Requires N 95 particulate respirator mask and annual fit test Patients wear a surgical mask when leaving the room.

34 Pulmonary Tuberculosis Location of negative pressure rooms: 374, 375, ICU 11, 12, ED, PP, and 445 Peds. R/O TB 3 consecutive days of sputum for AFB culture and smear is required. Samples must be dated and timed for 3 consecutive days. Sputum for induction can be used AFB smears are sent out to Quest and usually released the following evening. The culture report takes about 55 days. Employees involved with patient contact need annual skin test or symptom inventory form annually

35 Pulmonary Tuberculosis If the patient has a positive AFB smear, the Hudson County Chest Clinic is to be notified immediately on Monday through Friday. Call infection control nurse or nursing supervisor to make aware. Patient cannot be discharged until 3 negative AFB smears at least 8 hrs apart. DOH must visit patient in the hospital and do a home assessment to evaluate people in contact that will need testing for TB. TB /Chest clinic deliver meds daily to the patients house to observe them taking meds.

36 Hand Washing Most effective deterrent to the spread of infection Instruct patients, family, and visitors about hand hygiene and to remind their healthcare providers to wash their hands if they do not see them do so Let the patient see you wash your hands We follow CDC guidelines with 20 second hand wash Fingernails for direct care givers- No artificial nail products. Nails to be well manicured, and length < ¼” above the finger tip.

37 When to wash your hands Before and after glove application Before and after touching a patient After touching patient environment Before and after a clean / aseptic procedure After body fluid exposure When you enter and exit the room.

38 Soap and Water For visibly soiled hands and C- difficile precautions Wet hands, apply soap, and wash all surfaces of your hands for 20 seconds; dry with towel, then rinse (sing (Happy Birthday) twice). Use paper towel to turn off water. Alcohol Based Gel (Purell) Routine decontamination of hands When no hand washing facilities are available Directions- Apply alcohol based gel to the palm of one hand and rub hands together covering all surfaces until it is dry

39 C- difficile Precautions(Deadly Diarrhea): Use contact precautions Pink sign to cover alcohol based gel dispenser, stating not to use this product, advising to use soap and water Alcohol based gel has no effect on c-difficile Call EVS for terminal cleaning with Yanex Machine for air and surface disinfection Spores live for months on surfaces waiting for someone new to infect

40 Prevention of Multidrug Drug Resistant Organisms (MDRO). MDROs are increasing world wide Increases the risk of morbidity, mortality; and cost. Problem is that antibiotics are used incorrectly, leading to antibiotic resistance Not able to develop new antibiotics to treat these infections Careful use of antibiotics and following isolation precautions is crucial to prevent the transmission MDRO Alerts posted on EMR cover page.

41 Urinary Catheter Orders USE Order set under Procedure section on each department order menu [ ] External condom catheter [ ] Straight Cath Drop down menu for this selection [ ] for urine sample [ ] other: _____________________ [ ] RN to Insert Indwelling Foley Catheter (selection includes a drop down field for foley indication): [ ] Strict Intake and Output measurements in the Intensive Care Unit Only [ ] Urinary retention including obstruction and neurogenic bladder [ ] Short perioperative use in selected surgeries (less than 24 hours) and for urologic studies or surgery on contiguous structures. [ ] Assist healing of perinea and sacral wounds: stage (3 or 4) in incontinent patients [ ] Required immobilization for trauma or surgery [ ] Hospice/comfort care or palliative care, if requested by patient [ ] Chronic indwelling urinary catheter on admission [ ] Other reason: ________I_________ ******INCOTINENCE ALONE IS NOT AN ACCEPTABLE INDICATOR****** [ ] Urologist to Insert Indwelling Catheter (Name of urologist): _____________________________________ (Exclude from nursing protocol for the nurse to remove the Foley when no longer indicated) __________________________________________________________________________________ RN TO EVALUATE THE INDICATION DAILY IF THE FOLEY IS NO LONGER INDICATED, DISCONTINUE IT USE ORDER SET TO KNOW THE INDICATION (located under procedure section in dept. order menu) BLADDER SCAN PRIOR TO INCERTION OR REINCERTION DISCUSS IN REPORT THE INDICATION FOR THE FOLEY IF TRANSFERRING FROM ICU AND STRICT I&O IS THE ONLY INDICATION THEN DC THE FOLEY

42 Latex Allergy Skin reactions to latex can start as an irritant dermatitis Can develop into severe life threatening allergic reaction. Read labels on products Examples of products that may have latex: Ace bandages, airways, bite blocks, BP cuffs, breathing bags, electrode pads, and stethoscope tubing etc. Non-medical products containing latex: Adhesive tape, air mattress, balloons, chewing gum, condoms, telephone cords, and pacifiers.

43 Employee Blood/Body Fluid Post Exposure Resource Guide If an exposure occurs, immediately wash the area, notify your supervisor and go report to the ED. Labs to be done: EMPLOYEE: Rapid HIV Total Cholesterol Hep B surface Ab CBC with differential Triglycerides Hep C Ab Syphilis Screen UA CMP Hep B Ag UCG (females) SOURCE PATIENT: Rapid HIV (If source is positive, complete on misc slip HIV resistance test to Truvada and Insentress; genotype and phenotype viral load. Hep B Ag, Hep C AB, and Syphilis Screen Must follow up with employee health nurse for all injuries / incidents The employee health nurse will follow up with any pending results not completed at the time of your ED evaluation.

44 MRSA Screening and Chlorhexidine Gluconate (CHG) Bathing Reduces bacteria on the skin to prevent infections (SSIs and CLABSIs). CHG bathing is done: Once daily on all ICU patients Adults on Med-surg units with central lines. Inpatient and outpatient pre op procedures: S pinal fusion cases; and podiatry and orthopedic cases requiring implants. Nasal Swab for MRSA (screening) is done preoperatively on inpatient and outpatient surgical procedures listed above. Mupericin nasal treatment is needed for positive MRSA tests for at least 5 days before surgery. This is to reduce nasal colonization of MRSA, to reduce risk of transmitting this bacteria from the nose to the surgical site. If results are known less than 5 days pre op, it must be continued to complete 5 days of treatment.

45 Cleansing of Equipment: Always use dedicated equipment for isolation rooms when possible. All equipment (including stethoscopes) going from patient to patient should be cleaned and decontaminated after each patient use. Always follow manufactures recommended disinfection chemicals/agents and wear gloves. PDI Sani-Cloth Germicidal wipes. Contact time – is the amount of time the surface is wet when wiping equipment. The amount of contact time is printed on the label. Bacteria and viruses are being killed during the drying time. Super Sani Cloth Germicidal Disposable Wipe (Purple top) Disinfects in 2 minutes contact time (wet time). Ideal for daily use fast-paced environments that require the shortest contact time. High touch surfaces such as bed rails, countertops and carts Effective against 27 microorganisms Sani Cloth Bleach Germicidal Disposable Wipe (Orange top) for Glucometer, norovirus, MDROs and CDI Disinfects in 4 minutes contact time (wet time). Sani Cloth AF3 (Grey Color) is ALCOHOL FREE Use for computers Contact time 3 Minutes

46 ISO DOCUMENT CONTROL, RETIEVAL & VERIFICATION & Organization Structure Felicia Karsos CEO

47 International Organization for Standardization

48 ISO Standards ◦ ISO = International Organization for Standardization ◦ ISO standards – are generic standards (can be applied to all types of industries) ◦ The ISO 9001 standard is used for quality management of the entire hospital.

49 Quality Management Quality management means what the hospital does to ensure that its products or services satisfy the customer's quality requirements and comply with any regulations applicable to those products or services.

50 Quality management (cont.) Quality management also means what the hospital does to: enhance customer satisfaction, and achieve continual improvement of its performance.

51 DNV, ISO, NIAHO Det Norske Veritas (DNV) (hospital’s accreditation body) uses ISO 9001 standards and NIAHO standards during their annual survey visit for accreditation. ISO 9001 gives the requirements for what the organization must do to manage processes affecting quality of its products and services (delivering healthcare).

52 DNV, ISO, NIAHO NIAHO = National Integrated Accreditation for Healthcare Organizations NIAHO standards – are more specific, only for healthcare. NIAHO standards - based upon the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation and State Operations Manual Regulations.

53 What are processes? The processes that the hospital uses to carry out the standards are the hospital’s policies and procedures. The current versions of all policies are found on the homepage of the intranet.  5 main manuals and separate department folders.

54 Document Control The intranet contains the most up-to- date version of all policies and procedures. All policies printed from the intranet are verified as the most current version. Once a policy is printed, it is considered an “uncontrolled document” and is no longer considered the most current version.

55 EXAMPLE – Process Medication Management Policy & Procedure for Medication Management is located on the intranet Patient Care Manual (ISO) Collect data on the compliance with the P&P (ISO) Collect and analyze data on medication errors and develop corrective action plan (ISO) P&P addresses administration of pain medication as well as effectiveness of pain management. (NIAHO) Medications administered within 2 hours of time schedule for routine medications and 60 minutes for critical medications. (NIAHO) Organization identifies critical medications. (NIAHO) The P&P is reviewed at least every 3 year or more frequently as required (NIAHO & ISO)

56 In Summary ISO Standards are the backbone. Can be applied to many industries. NIAHO standards – for healthcare. DNV uses both standards as a way to check that the hospital is following hospital policy and the standards/regulations in everyday functions.

57 Organizational Structure Governing Board Quality Mgt Oversight Comm.Patient Safety & Quality Comm. Felicia Karsos, CEOM. Bellifemine, CMO -Ancillary depts-Medical Staff Office/GME -MarketingE Garrity, VP, HR -General Counsel-HR -CFO-Food & Nutrition -Revenue Cycle -Environmental Services -Finance D. Ortiz, CNO Stanley Galichenko, VP -Nursing units -Security -Infection Control, Emp Health -Facilities -Pharmacy, Respiratory Dr. Alan Rimmer -EMS -Lab -Emergency Department -Registration

58 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 Vision, Mission,Values & Evidence Based Management Felicia Karsos Chief Executive Officer MEADOWLANDSHOSPITAL.ORG

59 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 MEADOWLANDSHOSPITAL.ORG VISION To be the destination of choice when your loved one needs care in the Hudson/ Meadowlands region.

60 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 MEADOWLANDSHOSPITAL.ORG MISSION Our mission is to provide exceptional patient outcomes through our commitment to safety. We do this with service excellence and sophisticated information technology to bring evidence-based medicine and evidence- based best practices to our patients.

61 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 MEADOWLANDSHOSPITAL.ORG CORE VALUES Medicine with compassion Evidence based practices Accountability Dignity for our patients Open and transparent communication Welcoming to our community

62 Drama drains our energy Drama reduces innovation Drama depletes our passion for our work Drama contributes to disease MEADOWLANDSHOSPITAL.ORG

63 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 Everything in life is perception. There is no reality. The only thing we want to hear is: “Who Said what” or “Did what” Everything else is your opinion. EVIDENCE We use EVIDENCE …… EMOTION not EMOTION MEADOWLANDSHOSPITAL.ORG

64 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 MEADOWLANDSHOSPITAL.ORG Everything in life is perception. There is no reality. The only language we want is: “Who said what” and “Who did what” Everything else is your opinion. MHMC uses EVIDENCE …… It’s safer for our patients

65 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 MEADOWLANDSHOSPITAL.ORG MHMC wants engaged employees MHMC wants evidence, not emotion CONNECT instead of BLAME CREATE instead of COMPLAIN COACH instead of CRITICIZE of


67 Workplace Etiquette & Professional Conduct Patient Safety Dona Ortiz Acting Chief Nursing Officer MEADOWLANDSHOSPITAL.ORG

68 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 Patient Safety Actions undertaken by individuals and organizations to protect healthcare recipients from being harmed by the effects of healthcare services. MEADOWLANDSHOSPITAL.ORG

69 Patient Safety Increase Focus on the Human Factors: Memory lapse, Failure to communicate, Poorly designed Equipment, Exhaustion, Ignorance, Noisy working conditions, other personal and environmental factors. GOALS Design safer process- Barriers or safeguards can prevent untoward events. Reduce Harm Caused By Mistakes- People must be able to quickly recognize the adverse event and take action. MEADOWLANDSHOSPITAL.ORG

70 Implementing a Patient Safety Program Consider safety improvement recommendations made by external groups (DNV, CDC, IOM, HRET) Share safety improvement ideas. Focus attention on high-risk processes Incident reports and other information are used to identify risk-prone patient care processes MEADOWLANDSHOSPITAL.ORG

71 Implementing a Patient Safety Program Redesign our processes so that simple mistakes don’t end up harming patients Eliminate opportunities for errors – Failure Modes and Effects Analysis (FMEA) Build better safeguards to catch and correct errors before they reach the patient Establish a Culture of Safety MEADOWLANDSHOSPITAL.ORG

72 Safe Patient Handling “Safe Patient Handling Act” N.J.S.A. 26:2H-14.8 et. seq., requires hospitals to minimize unassisted patient handling by utilizing assistive patient handling technology. Safe patient handling program Assessment of patient’s need for assisted patient handling Evaluation of assistive devices available within the facility Education and Training of Personnel Review of work related injuries MEADOWLANDSHOSPITAL.ORG

73 Risk Management Incident: any unusual occurrence or mishap Incident reports: Tool used to track and trend incidents Health Care Incident Report: Patient/visitor incident Employee Incident Reports: For EMPLOYEES ONLY Examples of Incidents: Accidents, Lost/Damaged Property, Equipment (Damage/Malfunction), Exposure to Infectious/Hazardous Material, Medication Error MEADOWLANDSHOSPITAL.ORG

74 Abuse/Neglect Abuse: physical, sexual, or psychological attack or assault on the elderly or vulnerable adult/child. Vulnerable: Any adult/child who, due to physical or mental incapacitation, is at risk for abuse/neglect Neglect: Any omission of care which results in harm to the health or welfare or risk of harm to the elderly or vulnerable adult/child. Exploitation: Financial or material gain as a result of acts of trickery, threat or in any way taking advantage of an elderly or vulnerable adult. MEADOWLANDSHOSPITAL.ORG


76 Compliance Program The Compliance Program provides an overview of key legal and regulatory requirements System that lays the foundation of ethical behavior composed of: ◦ Individuals ◦ Polices and procedures ◦ processes

77 Compliance Program  MHMC is committed to providing high quality care in compliance with all applicable laws, rules, regulations and standards  Employee: act with the highest level of integrity  Management: support/carry out objectives  Compliance Officer: ensures that compliance program is being properly operated and implemented  Governing Board: provides vision, guidance, and support

78 Combating Fraud and Abuse Medicare Fraud: making false statements or representations to material facts to obtain some benefit or payment for which no entitlement exists Medicare Abuse: occurs when doctors or suppliers do not follow good medical practices that lead to ◦ unnecessary costs to Medicare ◦ improper payment ◦ services that are not medically necessary

79 HIPAA (Health Insurance Portability and Accountability Act) Patient confidentiality – ALWAYS protect/secure paper & electronic health information – Only accessible through need-to-know basis – Can only be released upon written consent from patient PHI (Protected Health Information) – Demographic information – Medical data/results/records – Account handling/Billing Management – The Privacy Rule protects all individually identifiable health information

80 EMTALA (Emergency Medical Treatment & Labor Act) Ensures public access to emergency services regardless of ability to pay Requires hospitals to provide an examination and needed stabilizing treatment without consideration of insurance coverage/ability to pay

81 Whistleblowing Federal Whistleblower rule allows anyone who knows about a person or entity submitting false claims to bring a lawsuit on behalf of the government. NJ Law-Conscientious Employee Protection Act (CEPA) You are protected by law from retaliation relating to any report made in good faith.

82 Chain of Command  Duty to report suspected wrongdoing or misconduct  Compliance Office is located on the 2 nd floor of MHMC with the Administration suite  Compliance Office phone #: 201-392-3262  Anonymous Compliance Hotline: 201-392- 3191


84 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 Rules of Conduct MHMC provides a safe environment for employees, patients and visitors The following are examples of behaviors that will not be permitted: Theft Falsification of information Destruction of property Insubordination Disclosing confidential information Being under the influence of alcohol or illegal drugs while at work Smoking on Hospital property Violence in the Workplace Please see the HR Rules of Conduct Policy for additional information and details. MEADOWLANDSHOSPITAL.ORG

85 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 ANTI - HARASSMENT POLICY MHMC is dedicated to providing a workplace that is free of all forms of employment discrimination, including sexual and other unlawful harassment. Any conduct that creates an intimidating, hostile or offensive work environment is not tolerated. Some examples of sexual harassment are unwelcome behaviors such as: Sexual advances, propositions, off color jokes, touching, physical assault, sexually explicit conversations,suggestive pictures, etc. Some examples of other forms of harassment are: Verbal or physical conduct relating to an individual’s race, religion, creed, color, national origin, citizenship, disability, age, military status, marital status, sexual orientation, ancestry, or veteran status. Please see the HR Anti Harassment Policy for additional information and details. MEADOWLANDSHOSPITAL.ORG

86 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 DRESS CODE All employees are expected to dress appropriately and professionally. Employees whose position requires that they wear a uniform must wear the correct uniform and footwear. Employees working in other areas of the hospital must dress in a professional business manner. Examples of items of clothing such as flip flops, shorts, jeans, tee shirts, leggings, hats, etc. are not appropriate or permitted. Please see the HR Dress Code Policy for additional information and details. MEADOWLANDSHOSPITAL.ORG

87 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 ATTENDANCE POLICY It is vital that all employees are at work on their scheduled times and dates. It is every employee’s responsibility to adhere to their schedules. It is also every employee’s responsibility to find out what their own department’s policy is when calling in an absence,or lateness., how much time prior to the beginning of their shift is required and who to contact. Excessive ( three or more occurrences in a three month period) absences or lateness may lead to disciplinary action up to and including termination of employment. No call no shows, excessive missed clock ins/outs, or forgotten clock ins/outs and patterned absences will be reviewed and may lead to disciplinary action up to and including termination of employment. Please see the HR Attendance Policy for additional information and details. MEADOWLANDSHOSPITAL.ORG

88 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 HR SERVICES HR Online – Information System for Employees View and Print Paystubs, W2 forms, change demographic information, etc. MystaffingPro – Applicant Tracking View and apply for open positions via hospital website/careers section Benetrac – Online Benefits System Enroll, or waive benefit coverage and view and manage your personal benefit plans Kronos – Timekeeping system Manage your time at work online and submit time off requests MEADOWLANDSHOSPITAL.ORG

89 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 Glenn Berchtold, Director EMS & Emergency Management & Safety Officer MEADOWLANDSHOSPITAL.ORG

90 90 EMPLOYEE SAFETY RESPONSIBILITIES:  Safety at Meadowlands Hospital is every employee’s responsibility.  Every employee is expected to follow hospital safety policies. Policies can be found on the Intranet under Main Manuals  Employees are expected to make recommendations for safety improvements.  Familiarize yourself with policies related to CODES & DRILLS

91 91 REPORTING SAFETY PROBLEMS: A life threatening situation requires immediate action. Report any safety issue or incidents/occupational injuries to your Supervisor or, if after hours, the Nursing Supervisor on duty. all the Safety Officer at ext. 3219 Always call the Safety Officer at ext. 3219 Dial 8 for any emergency

92 92 Prevention of Injury Bending and Lifting ◦ Avoid lifting when possible, use patient safe handling equipment ◦ Bend your knees to let your legs do the work,keep abdominal muscles tightened ◦ Store heavy objects at waist level ◦ Ask for help when necessary. Pushing and Pulling ◦ Push rather than pull, avoid leaning over the object and move with the object ◦ Use whole body to push and not just your arms, and get help when you need it.

93 You work on a SMOKE FREE CAMPUS!

94 94 Emergency Preparedness HOSPITAL WIDE DRILLS The purpose of disaster planning and drills is to prepare all personnel and members of the medical staff to cope with real incidents when they occur. We conduct 2 drills per year Drills help us to assess our effectiveness in the case of a disaster. The command post (EOC) is located in the 2 Center Conference Room Check with your Supervisor for your assigned duties during a drill.

95 Emergency Codes 95 Code Triage - External Mass Casualties/Internal Emergency Code Red – Fire Code Blue – Adult Medical Emergency/Cardiac Arrest Code White – Pediatric Medical Emergency Code Amber - Infant/Child Abduction Code Yellow- Bomb/Bomb Threat Code Gray –Patient Elopement Code Silver –Threat of Violence (Active Shooter) Code Orange – Hazmat Situation/Decon-Needed Code 9 – Utility Failure Code Clear – The Situation/Emergency is now cleared Emergency - Dial 8

96 96 Code Response for Terroristic Actions Bioterrorism IED’s (explosives) Bomb Threats Protective Measures ◦ Report anything suspicious to Supervisor and/or Security immediately. ◦ Utilize Standard Precautions and Hand Washing ◦ Avoid direct contact with suspicious items ◦ Contain the affected area by closing doors and shutting down ventilation system. ◦ Possible evacuation plan implementation ◦ Safety Officer or Security will contact proper local authorities.

97 97 Emergency Preparedness Meadowlands Hospital provides ◦ Trained staff for decontamination ◦ Personal protective equipment and detection equipment ◦ Decon tent & trailer for showers-back of the hospital Emergency Backup Communications Systems ◦ Portable radios ◦ State Police radio system ◦ Cell phones ◦ EMS dispatch center-4 th fl

98 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 Gary Patterson Director of Environmental Services MEADOWLANDSHOSPITAL.ORG

99 Hazardous Materials/Waste Management (Right-to-Know) This section covers health risks, routes of entry with exposure, and procedures for clean-up related to hazardous materials. Hazard Communications ◦ OSHA Requirements  Written plan by employer, labeling by manufacturer  Labeling by employee, training and education Types of Hazards ◦ Flammables, Corrosives, Toxins, Reactive

100 Hazardous Materials/Waste Management RECOGNIZE HAZARDOUS SUBSTANCES BY THEIR : ◦ Signs (to an area) ◦ Color Coding (usually red or yellow) ◦ Container Labels (always read the label BEFORE using a hazardous substance) ROUTES OF ENTRY : ◦ Inhalation (lungs) ◦ Absorption (skin) ◦ Ingestion (digestive system) ◦ Injection (puncture or open wound) HEALTH HAZARD : ◦ Acute = immediate effect ◦ Chronic = long term effect

101 HAZARDOUS MATERIALS/WASTE MANAGEMENT - SPILLS WHAT DO I DO IF THERE IS A HAZARDOUS MATERIAL SPILL? Should an incident occur that involves the spill of a hazardous substance, your first concern will be for the protection of yourself, your co-workers in the area, patients or visitors. “Isolation and evacuation of the immediate area by all persons who are in danger should be your first priority” After evacuation, refer to your Material Safety Data Sheets/MSDS to determine the hazards present, and PPE/personal protective equipment. Report spill by calling the hospital emergency line. Dial 8 and explain to the operator that you are reporting a possible CODE ORANGE Additionally, a hospital or employee incident report will be completed and forwarded to Risk Management or Employee/Occupational Health respectively. For large hazardous materials spills you should contact the Operator at *8 and report a CODE ORANGE. Specify the hazardous material that was spilled and the exact location.

102 Role of Safety Data Sheets in the Harmonized System - SDS Safety Data Sheets (SDS) Safety Data Sheets are an essential component of the GHS and are intended to provide comprehensive information about a substance or mixture for use in the workplace chemical management. Minimum Information for an SDS 1. Identification of the substance or mixture and of the supplier a) GHS Product Identifier b) Other means of Identification c) Recommended use of the chemical and restrictions on use d) Supplier’s details (including name, address, phone number etc.) e) Emergency phone number 2. Hazard identification 8. Exposure controls/personal protection 3. Composition/information on ingredients 9. Physical and chemical properties 4. First aid measures 10. Stability and reactivity 5. Fire-fighting measures 11. Toxicological information 6. Accidental release measures 12. Ecological information 7. Handling and storage 13. Disposal information 14. Transport information What is the Globally Harmonized System (GHS)? GHS stands for the Globally Harmonized System of Classification and Labelling of Chemicals. GHS defines and classifies the hazards of chemical products, and communicates health and safety information on labels and safety data sheets). The goal is that the same set of rules for classifying hazards, and the same format and content for labels and safety data sheets (SDS) will be adopted and used around the world. An international team of hazard communication experts developed GHS. SDS FORMS ARE AVAILABLE ON THE HOSPITAL INTRANET. MAIN SECURITY DESK, and ED

103 Why is global harmonization necessary? Currently many different countries have different systems for classification and labelling of chemical products. In addition, several different systems can exist even within the same country. This situation has been expensive for governments to regulate and enforce, costly for companies who have to comply with many different systems, and confusing for workers who need to understand the hazards of a chemical in order to work safely. GHS promises to deliver several distinct benefits. Among them are: Promoting regulatory efficiency. Facilitating trade. Easing compliance. Reducing costs. Providing improved, consistent hazard information. Encouraging the safe transport, handling and use of chemicals. Promoting better emergency response to chemical incidents. Reducing the need for animal testing.

104 What is a pictogram? Pictograms are graphic images that immediately show the user of a hazardous product what type of hazard is present. With a quick glance, you can see, for example, that the product is flammable, or if it might be a health hazard. Most pictograms have a distinctive red "square set on one of its points" border. Inside this border is a symbol that represents the potential hazard (e.g., fire, health hazard, corrosive, etc.). Together, the symbol and the border are referred to as a pictogram. Pictograms are assigned to specific hazard classes or categories. The graphic below shows hazard pictograms. The bold type is the name given to the pictogram; the words in the brackets describe the hazard.


106 Personal Protective Equipment EYES Safety Glasses Face Shield Splash Goggles SKIN Gloves Boots Protective Apron Full Suit Respiratory Dust Respirator Vapor Respirator Mask or Hood

107 MEADOWLANDS HOSPITAL MEDICAL CENTER 55 Meadowlands Parkway, Secaucus, NJ 07094 Michael Acquaviva Facilities Supervisor MEADOWLANDSHOSPITAL.ORG

108 108 Utility Systems Utilities ◦ Electric ◦ Water ◦ HVAC (Heating/Ventilation/Air Conditioning) User Failure Plan ◦ Notify Plant Operations/Emergency Operator if failure occurs ◦ In the case of a power failure, use emergency electrical outlets (in red)

109 109 Electrical Safety Emergency Power ◦ Automatic within 10 seconds. ◦ Daisy chains are prohibited on Hospital property. ◦ Power will only be provided by the RED outlets. Essential lighting in main corridors and patient care areas will remain lit. ◦ Always use Emergency outlets RED for critical patient care equipment (you cannot predict an outage).

110 110 Medical Equipment Safety Considerations ◦ All medical equipment must be inspected prior to use & with a current sticker ◦ Never use equipment without proper inservicing ◦ Use three prong/grounded equipment only & avoid use of extension cords ◦ When unplugging grasp the body of the plug to prevent damage to the prongs ◦ All electrical equipment brought by employees, vendors or physicians must be checked for electrical safety by the Biomedical Engineering Department before use. ◦ Do not touch patients while touching medical or electrical devices. Employee Responsibilities ◦ Ensure all equipment is checked and tagged prior to use ◦ Remove malfunctioning equipment from service ◦ Complete incident report for and report problem to Supervisor

111 Facilities Dept-Landport Landport is a work order management system that was implemented to provide a more efficient way to send and monitor maintenance requests. ALL maintenance requests are to be submitted through Landport and will be addressed within 2 days. 1. Go to the company intranet page: Select Landport work order log-in icon. The main login page should appear 2. Type in your user ID and password: User ID: mead-staff Password: mead2013 3. Press the "Login" button to access your personal account. 4. Click the link "Create Request" and follow the directions to describe and submit your maintenance request. It's easy to use. You may track maintenance request progress at any time by simply logging in. If you have any questions or need help, I can be reached at or extension 3162.

112 112 WHAT TO DO IF EQUIPMENT MALFUNCTIONS: Immediately remove the equipment from service. Fill out a healthcare incident report and report to the Nursing Manager/Supervisor or Biomed department immediately. Tag the equipment so that anyone can identify that the equipment cannot be used. Essential equipment that is needed, and not functional for patient care during off hours, can be handled by having the operator contact the Biomedical Engineering Technician on-call, who is available 24 hours a day by dialing 0.

113 113 Medical Equipment EMPLOYEE OR PATIENT HARM BY A MEDICAL DEVICE: ◦ A device that has been identified as causing patient harm, or in some way brings into play the “Safe Medical Devices Act of 1990: must be handled in the following manner:  Immediately respond to the individual’s clinical needs.  Remove the equipment from service, saving all attachments, and tag the equipment with a service tag or label.  Notify your supervisor immediately. If an incident occurs after normal working hours, notify the Nursing Supervisor or Administrator-On-Call who will contact the appropriate individuals.

114 CROTHALL HEALTHCARE Biomedical Engineering Department 114 Manager on Site:- Venugopal Kalathur Current Office Room:- 406 Phone Extension:- 3149 Standard Hours at Hospital :- Week Days :- 8.30 AM to 5.00 PM Time is Flexible based on the need. After Office Hours On Call for Emergency Needs. For Emergency needs contact Hospital Switch Board. They will reach him on his mobile. Response Time :- 2.00 Hours.

115 Stanley Galichenko Director of Security

116 116 Security Management Security Management The Overall Goals of the Security Management Plan are to: ◦ Safeguard hospital and personal property from damage or theft. ◦ Maintain an environment conducive to the health and safety of patients, visitors, and employees. ◦ Identify and correct security and safety hazards. ◦ Maintain order throughout Meadowlands Hospital and to prevent disruptions to the hospital’s operations by persons or groups behaving in an improper manner. IDENTIFICATION ◦ All employees and volunteers are required to wear identification badges issued by the Security Department. ◦ Wear your identification badge where patients and visitors can see it and identify all our employees by name. We also expect all of our employees to introduce themselves when interfacing or communicating with patients or visitors.

117 Employee Responsibilities Wear your identification badge at all times Maintain patient confidentiality Secure patient valuables, & your personal valuables Report all security incidents to Ext. 3269 Dial “8” for all emergencies!!!

118 118 MHMC Practices to Promote Safety  Limit access to facility (direct all visitors and vendors to Security desk when accessing the building)  We conduct 1 fire drill/month. Be prepared and know your responsibilities.  Have your code card attached to ID at all times so you know your responsibility.  See something; say something (such as unattended bags/packages or suspicious objects/persons) report to ext 3269.

119 119 Life Safety Fire / Evacuation Plan Fire Alarm System ◦ Use the pull station to activate the fire alarm during smoke or a fire condition. ◦ Dial “8” to notify Customer Services to announce the Code for a fire ( CODE RED ) ◦ Close the doors & Clear the corridors Compartmentation ◦ Fire & smoke doors close automatically. ◦ Close all patient room doors Employee Responsibility ◦ Complete required education & Attend drills ◦ Know locations for pull station; fire extinguishers; & fire and smoke doors. Contact your manager for these locations.

120 120 At the Scene of the Fire (RACE) In the event of a fire emergency or a drill, Meadowlands Hospital used the R.A.C.E. procedure, which stands for: ◦ R escue/move patients to a safe area ◦ A larm: pull Alarm AND notify Operator by dialing “8” to provide location of fire ◦ C onfine by closing all doors ◦ E xtinguish (extinguish small fires)

121 121 At the Scene of the Fire (RACE) In the event of a fire emergency or a drill, Meadowlands Hospital used the R.A.C.E. procedure, which stands for: Evacuation ◦ Horizontal/Initial Evacuation: From one fire compartment to another compartment (through the fire doors). ◦ Vertical Evacuation: Going from one floor to the floor below and is only done when a horizontal evacuation is not possible. Know the location of your department's oxygen shut-off valve These are clearly labeled in each patient care area.

122 122 EMPLOYEE RESPONSIBILITIES FOR FIRE DRILS OR EMERGENCIES Patients, visitors, & others will be looking to you for guidance and direction. Make sure all doors, windows and fire doors are closed in your area. Listen for instructions over PA system or directly from your supervisor. Do not use the elevators. Restrict travel of visitors and staff (moving through doors allows smoke through). Remove all guests or visitors from the corridors immediately and return patients to their rooms. Keep all corridors clear for emergency personnel. Evacuate patients horizontally from the area in their beds and disconnect all mechanical devises.

123 123 FIRE Extinguishers TYPES OF FIRES ◦ Class A – ordinary combustibles (ash) ◦ Class B – flammable liquids (boiling liquids) ◦ Class C – electrical fires (current) FIRE EXTINGUISHERS ◦ ABC ◦ Type K (Portable Extinguisher for Cooking Hoods) FIRE EXTINGUISHER OPERATION (PASS) ◦ P Pull the Pin ◦ A Aim the extinguisher at the base of the flames ◦ S Squeeze the trigger while holding the extinguisher upright ◦ S Sweep the extinguisher from side to side



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