1. Quality Services Risk Management Patient Satisfaction Ethics Committee Spiritual Care Quality Services
Annual Update Section 4

2. “Doing the Right Thing at the Right Time to the Right Patient.”
Quality is #1
At SBMC, Quality is defined as meeting or exceeding patient and/or customer needs and expectations through improved outcomes, within the available resources of the medical center. Quality Services is concerned with preventing problems by creating attitudes and controls that make prevention possible.
Quality management is a systematic way of:
“Doing the Right Thing at the Right Time to the Right Patient.”
The Quality Department uses Quality Improvement Coordinators to monitor the quality of care at SBMC.
Risk Management
Risk Management identifies, investigates, analyzes, and evaluates all risks (exposure to the potential for injury, damage or loss) and participates in the selection of the most advantageous method to correct, reduce or eliminate identified risks.
ADVERSE EVENT REPORTING
An ADVERSE EVENT is reported on an Event Report on-line. The form is located on-line “ERS” (Event Reporting System) and is located in the tunnel.

3. Quality it #1 cont.
Event Reports are not intended to be punitive, but to identify and fix high-risk situations.
An “event” is defined as any occurrence not consistent with normal/usual operation of the Medical Center. Injury does not have to occur. The potential for injury and/or property damage is sufficient for an occurrence to be reported on an Event Report.
Any employee observing or discovering the unusual incident is responsible for initiating the Event Report, documenting only the facts. The Supervisor will review the report before submitting to Risk Management.
A Serious Adverse Event must be reported immediately to the Department Supervisor or Nursing Supervisor (during off shifts). Risk Management will immediately be involved.
IVOS Event Reports are confidential and must be sent to the Risk Manager in Quality Services within 48 hours of the event. An Event Report is NOT used to report Employee injuries. (Use the Employee Injury Form.)
DO NOT document an Event Report was completed in the patient’s medical record, it is for hospital records only.

4. Patient Privacy
HIPAA (Health Insurance Portability & Accountability Act) regulations include controls for the use and disclosure of Protected Health Information.
HITECH ACT expands HIPAA and makes individuals subject to penalties, fines, license revocation, and jail terms.
Employees are responsible for:
1. Reading the Privacy and Data Security Employee handbook.
2. Abiding by all Dignity Health Privacy and Data Security policies and Procedures
3. Complying with Federal & State Privacy and Data Security regulations.
4. Reporting all known or suspected privacy or data security incidents / potential breaches.
5. Understanding the consequences for non-compliance with regulations or dignity health policies.
Remember fines for a HIPAA breach are directed toward the hospital AND the individual who makes breaches privacy.

5. Patient Privacy cont. Examples of a HIPAA breach: (these are not all)
Telling friends or relatives about patients in the hospital
Discussing private health info in lobby, cafeteria, elevator, or over the phone in a public area
Not logging off computer
Looking at your own health information
Allowing members of media to interview a pt in substance abuse facility
Including private health info in sent over internet
Releasing info about minors without parental consent

6. Patient Complaints Complaint: A Grievance:
A complaint expressed by the patient or their representative concerning care and can be resolved promptly by staff present.
Complaint about billing, not involving care issues.
A Grievance:
Requires written response from Risk Services addressing care concerns.
A complaint put in writing
A complaint that is not handled promptly by staff present and referred to Risk Management for further investigation.
Use the CHAIN OF COMMAND if necessary for resolution of the complaint - your immediate Supervisor, Manager, Nursing Supervisor or Patient Representative. Document in the complaint in medical record and submit a report in IVOS on- line, note do not document that the IVOS was completed in the medical record.

7. Ethics Committee
When an ethical dilemma is identified, access to the Ethics Committee is available 24 hours/7 days via the Nursing Supervisor or the patient's attending physician.
Please refer to Ethics Committee Rules-Policy ADM – Access the policy on line.
Consult your manager first for any ethical issues.

8. Spiritual Needs
The spiritual needs of our patients are met by our Spiritual Care Dept. Access is available 24 hours/7 days by dialing "0" and requesting a Chaplain or Spiritual Care Representative.

9. Reporting of Safety & Quality Concerns
All employees, patients and visitors are given information on how to file a complaint with the TJC (Joint Commission),CDPH (California Dept. of Public Health) and CMS (Centers for Medicare & Medicaid Services) through the Quality Improvement Organization (QIO). Employees are advised to discuss concerns with their department leadership before contacting a regulatory body or the DIGNITY HEALTH Compliance Hot Line –

10. SBMC Patient Representatives
Patients and staff receive daily visits from the Sisters (Nuns) who provide support and ensure that problems or complaints are resolved in a timely manner.
Kimberlee Prokopij is the Patient Satisfaction Representative
Daily rounding on floors is done by Directors and Managers to assess patient satisfaction and resolve any care issues in a timely manner.

11. BE EVER DILIGENT THAT WE ARE ALWAYS SAFELY CARING FOR PATIENTS
Survey Readiness
With the continued appearance of regulatory agencies within our hospital it will benefit all if we practice as if CMS/TJC is here all the time.
Reminders:
No meds out on counters even in med room
No meds on WOWs EVER!!!-behind keyboard, in baggies etc.
No sharing of multi-dose vials
Be attentive to warmers, expiration dates, labels, dressings, etc
Monitor KCL at all times, IVs IVPBs, carts,
BE EVER DILIGENT THAT WE ARE ALWAYS SAFELY CARING FOR PATIENTS