Transcript Otsego Memorial Hospital Association Corporate Overview

Your Champion for
Better Health
Mission Statement
To provide exceptional healthcare that
meets the needs of our patients and
the communities we serve.
Our service area includes:
Gaylord, Elmira, Wolverine, Vanderbilt,
Johannesburg, Atlanta, Lewiston, Indian River,
Cheboygan, Frederic and Waters.
Vision Statement
To be the center of northern
Michigan’s patient focused alliance
dedicated to healthcare excellence.
Values
Respect:
Appreciating diversity and treating all with compassion,
dignity and courtesy
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Show the person you are interacting with that they are your priority
Convey empathy—put yourself in others’ shoes
Listen to and honor the personal, cultural and spiritual needs of
patients and families
Recognize that every job is important and has value
Values
Integrity:
Unwavering commitment to honesty and trust
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Do the right thing for the right reason
Protect confidentiality and privacy
Discuss differences constructively, directly and tactfully
Advocate for our patients, employees and organization
Values
Excellence:
Teamwork and communication dedicated to understanding
and exceeding expectations of quality, safety and
customer service
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Take initiative to promote a culture of accomplishment, enthusiasm
and expertise; take pride in your work
Promote an exceptional healing environment based on individual
needs
Be open to giving and receiving feedback to accomplish mutual goals
Achieve the best results in all we do
Values
Accountability:
Accepting responsibility for our actions
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See it
• Be engaged to contribute positively
• Acknowledge opportunities by learning from our experiences
Own it
• Understand how individual actions contribute to desired
outcomes
Solve it
• Follow through on commitments and responsibilities
Customer Service
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Patient satisfaction is directly related to
how we treat our customers
You will be receiving addition education
regarding our customer service
The following are the behaviors we ask our
employees to exhibit
Customer Service
Greet
 Value as a customer
 Ask how you can help
 Listen words, tone and body language
 Help meet their needs
 Invite them to contact us
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Rights as a Patient
Patients have a right to:
• Considerate and respectful care
• Understandable information
– Patients will have a green dot on their ID
bracelet if they have difficulty understanding
basic communication
– Please see their chart for more information
regarding their communication challenge
Rights as a Patient
Patients have a right to:
• Be free from seclusion and physical/chemical
restraint (refer to policy)
• Consent or refuse treatment
• Appropriate pain assessment/symptom
management (see scale)
Pain Assessment
When assessing pain, a number value should be assigned by
the patient to make for consistent measurement
FLACC Scale Non Verbal
Rights
Patients have a right to:
• Privacy
• Treatment records are confidential
• Review their medical records
• Be free from discrimination
• Discuss continuing care needed after
hospitalization
Rights
Patients have a right to:
• Know the hospital rules
• Consult the Ethics committee
• Know the physician who has primary
responsibility
• A second opinion
• Advanced Directive
Rights
Patients have a right to:
• Be informed of outcomes of care including
unanticipated outcomes
• Raise concerns through a formal grievance
• Access Protective Services
Rights
Patients have a right to:
• Comfort measures/peace and dignity at
end of life
• Patients who have a Do Not Resuscitate status will
have a purple armband placed around their wrist
• McReynold's Hall patients have a purple dot placed on
their identification bracelet
• Spiritual and pastoral care
• Appropriate screening and stabilization
before transfer to another facility
Patient Responsibilities
Patients need to:
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Provide Accurate Information
Keep Appointments
Understand consequences of refusing treatment
Follow hospital rules
Be considerate of others
Be responsible for financial obligation
Notify staff of communication issues
Ask questions if they do not understand
No Alcohol, recreational drugs, or firearms/weapons
Advance Directives
Advance Directives are:
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A legal document that gives the
appointed advocate permission to make
medical decisions when the patient is
deemed incompetent by 2 physicians
OMH Process for Advanced Directives
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Pt. are given information about advanced
directives, if not familiar, at admission
Copies of advance directives are scanned
into the medical record
Upon admission, the advance directive
should be available to the area where the
patient will be located
Infection Control
Washing your hands frequently and
properly is the single most important
action you can take to prevent the
spread of infection.
Infection Control
Hand Sanitizer is effective for hand
hygiene but you should wash with soap
and water if hands are soiled or if
caring for someone with C. diff
Infection Control
Keystone Initiative
Wash your hands upon entering
a patient-care area and upon leaving
WASH IN WASH OUT
Infection Control
Standard Precautions
“All the patients, all the time”
Infection Control
Standard Precautions
• Specific behaviors that healthcare
workers (HCW) follow to protect both
themselves and patients from
infection
• Practice 100% of the time
Infection Control
• Apply to blood, all body fluids, excretions
and secretions except sweat, plus nonintact skin and mucous membranes
• Protect against bloodborne pathogens such
as HIV, hepatitis B and hepatitis C
• Protect against pathogens from moist body
substances
Infection Control
•Wear gloves when touching blood, body fluids,
excretions, and contaminated surfaces
• Wash your hands after contact with body substance
even if gloves are worn
• Wash your hands and change gloves between
patients and between touching clean and dirty sites
on the same patient
• Wear a mask, eye protection and a gown if splashes
or spatters are possible
(Latex free products are available)
Infection Control
Practice Respiratory Etiquette all year
•Use mouthpieces, resuscitation or other ventilation
devices as an alternative to “mouth to mouth”
resuscitation methods
• Be sure reusable equipment is cleaned and
disinfected before used on another patient
Infection Control
Handle all patient care equipment to prevent
exposure to other patients, visitors, and healthcare
workers
• Keep used patient equipment including soiled linens
away from your skin, mucous membranes and
clothing
• Don’t let used equipment or linens contaminate
surfaces or clean items
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Sharps Safety
Never bend, recap, or break
used needles unless the
procedure requires it
Place used sharps in a
designated disposable container
immediately after use
Infection Control
Transmission Based Precautions
• Additional precautions that healthcare workers
practice when a patient is suspected of having an
illness that spreads very easily and is based on
how the infection is spread-
CONTACT-AIRBORNE-DROPLET
AIRBORNE Precautions
Requires patients to be in a negative
pressure room and staff need to wear a
PAPR (Powered Air Purifying Respirator)
 Good ventilation is important for
preventing the spread of TB
 Active TB patients need to wear a mask if
they go outside of the room
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Exposure to
Blood or Fluids
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Wash vigorously the area immediately with soap
and water
Report the exposure to the supervisor of your
Department
Complete the “Exposure Form”
Report to ED for evaluation
If exposure to eyes, flush for 15 minutes at eye
wash station with COLD water
PERSONAL PROTECTIVE EQUIPMENT (PPE)
ORDER FOR DRESSING IN PPE
ORDER FOR REMOVING PPE
Age Specific Care
Be aware that all ages have different physical,
psychological, and social needs
• Tailor education to the patient’s age and needs
• If staff and volunteers are aware
then it is a safer environment
• Involve family in the care
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Abuse
Types of abuse:
• Elders
• Physical Abuse, Neglect, Exploitation
• Child
• Abuse, Neglect
• Observed or suspected
– we are required by law to report it!
Patient Safety:
A National Issue
In an effort to prevent medical errors for all
patients in the healthcare setting, the Joint
Commission issues annual National Patient
Safety Goals
• National Patient Safety Goals are developed as
medical errors that occur across the nation are
analyzed and the root causes identified
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How National Patient Safety
Goals affect your practice
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Your understanding
and compliance with
the National Patient
Safety Goals and
hospital policy is vital
to our patients safety
and your success at
OMH
Goal 1: Improve the Accuracy of
Patient/resident/client Identification.
To prevent medical errors, a patient must be
identified by comparing two types of identifiers
• According to OMH policy, the two patient
identifiers include the patients name and date of
birth found in the medical record documents and
on the identification bracelet
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Implementation Expectations 1A
Use at least two patient identifiers whenever:
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Collecting lab samples
Administering
medications or blood
products
Providing any treatment
or procedure
Label sample collection
containers in the
presence of the patient.
1B: Implement the Universal Protocol for
Invasive Procedures
The “time out” final
verification process to
confirm the correct
patient, procedure, site,
and availability of
documents and
equipment must occur in
the location where the
procedure is to be done
and should involve the
entire team
Goal 2: Improve Effectiveness of
Communication
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For verbal or telephone orders or for telephonic
reporting of critical test results, verify the
complete order or test result by having the
person receiving the order or test result write
down then “read back” the complete order or
test result
Standardize a list of abbreviations, acronyms, and
symbols that are not to be used
throughout the organization
The “Do Not Use” abbreviation list applies to all
orders and other medication-related
documentation when handwritten, entered as
free text into a computer, or on pre-printed forms
The Official OMH
“Do Not Use” List Includes:
Do Not Use:
Write this Instead:
Trailing Zero (1.0)
1mg
Lack of leading zero
0.5mg
U, u, IU, or iu
Units or international units
q.d., QD, Q.D., Q.O.D.
Daily or every other day
MS, MS04, MgS04
Morphine or Magnesium
Sulfate
2E: Hand Off Communication
Implement a
standardized
approach to
“hand off”
communications,
including an
opportunity to ask
and respond to
questions
Implementation Expectations
“In health care there are numerous types of hand
offs, including but not limited to:
• Nursing shift changes
• Physicians transferring complete responsibility for
a patient
• Physicians transferring on call responsibility…
SBAR
S=Situation
B=Background
A=Assessment
R=Recommendation
Any Questions?
Example
S=Admitted an 82 year old with pneumonia,
possible aspiration.
B=History of stroke, has been having increased
cough x 3 weeks per family, fever began
today..
A=RR is 24 and unlabored, temp is 101 degrees F,
swallowing evaluation ordered for a.m., alert
and oriented x2. First antibiotic completed at
0300.
R=Keep HOB elevated at least 30 degrees,
remain NPO until swallowing sturdy complete
and recommendations added to care plan.
Next antibiotic is due at 0900. Additional
assessment and care plan includes patient is
a high risk for falls, bed alarm on and
frequent rounds to assist with toileting
needs.
Verify Labels
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Label all medications, medication containers,
(e.g., syringes, medicine cups, basins), or other
solutions on and off the sterile field in
perioperative and other procedural settings
Implementation Expectations:
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All labels are verified both verbally and visually by two
qualified individuals.
No more than one medication is labeled at one time.
Unlabeled medications or solutions are discarded.
All original containers remain available for reference in
the perioperative area until the conclusion of the
procedure.
At shift change/break, all medications and solutions both
on and off the sterile field are reviewed by entering and
exiting personnel.
Anticoagulation Therapy
Reduce patient harm associated with
anticoagulation therapy
Goal 4 : Eliminate Wrong-site, Wrong Patient,
Wrong Procedure Surgery.
Create and use a
preoperative
verification process
such as a checklist to
confirm that
appropriate
documents are
available
Goal 4B Implement a Process to Mark the Surgical
Site and Involve the Patient in the Marking Process
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Marking is required in all
cases involving right/left
distinction, multiple
structures or levels of the
spine.
Procedures done through
a midline incision
intended for a right/left
distinction are subject to
site marking.
“YES”
Goal 7 Reduce the Risk of Health Care
Associated Infections
Compliance with the CDC hand hygiene
guidelines will reduce the transmission of
infectious agents by staff to
patients/clients/residents, thereby
decreasing the incidence of healthcare
associated infections (HAI)
WASH IN WASH OUT
Goal 7C MDRO
Prevent healthcare–associated infections due to multidrugresistant organisms
• Hand Hygiene
• Infection prevention and control
• Flag charts and communicate information to staff
regarding patients known toe be infected with MDRO
• Educate staff and patients on prevention
• Careful use of antimicrobials
• Clean, disinfect, and sterilize appropriately
• De-colonize persons with specific MDRO
Goal 8 Accurately and Completely Reconcile
Medications Across the Continuum of Care.
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Implement a process for
obtaining and
documenting a complete
list of the
patient/resident/client’s
current medications upon
the
patient/resident/client’s
admission/entry to the
organization and with the
involvement of the
patient/resident/client.
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A complete list of the
patient/resident/client’s
medication is
communicated to the
next provider of service
when a
patient/resident/client is
referred or transferred to
another setting, service,
practitioner, or level of
care within or outside the
organization.
Reduce the Risk of Patient/resident/client Harm
Resulting From Falls
Implement a fall
reduction program
and evaluate the
effectiveness of
the program
Use the Fall Risk
Assessment
Identify Safety Risks
The organization
identifies
safety risks
inherent in
its patient
population
Goal 15A:
The organization
identifies patients
at risk for suicide
Suicide Risk Assessment
“Suicide Risk Assessment”
is found :
Hospital Information Page
Forms
Nursing
Rapid Response Team
Improve recognition and responses to changes in
a patients condition:
Rapid Response Team
To implement early intervention and prevent
deaths in patients, outside of the ICU, who are
progressively failing
Rapid Response Team
Team consists of critical care nurses, respiratory
therapists and primary care nurse.
• The rapid assessment team may be called at any
time by anyone in the hospital to assist in the
care of a patient who appears acutely ill or who
shows signs of decline.
• Team assists patient’s nurse in assessing
condition and provides support in
communicating findings to patient’s physician.
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OMH Patient Safety Plan
Purpose:
To reduce risk to
patients through an
environment that
encourages:
Recognition and
acknowledgement of risks
to patient safety and
healthcare errors
• Actions to reduce risks
• Internal reporting
• Focus on
systems/processes,
minimizing individual
blame
• Learning from errors
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Reporting a Medical/Safety Occurrence
Report the occurrence
to the charge nurse
and complete an
Occurrence Form
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Examples:
Medication error
Patient fall
Needle stick
Treatment error
Reporting an Employee Incidence
If something
happens to an
employee,
they use an
Employee Incident
Form
Variance Report
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This form is used to report near misses,
safety concerns, and quality concerns
It can be submitted anonymously
Variance Report
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What is a near miss?
Any unintended provision of care which
could have constituted a medical
occurrence but was intercepted before it
actually reached the patient
By reporting near misses we can help avoid
errors from occurring
C.U.S.P.
Comprehensive Unit Safety Program
“Tapping The Wisdom of The Frontline”
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Create and maintain a culture of safety and
quality throughout the campus.
98,000 patients are harmed each year
because of medical errors caused by
healthcare defects.
Corporate Compliance
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The purpose of a Corporate Compliance Plan is to
prevent, detect and/or respond to violations of
statutes and regulations dealing with such things
as fraud and abuse
Corporate Compliance
Suspected corporate compliance violations are to be
reported via the Corporate Compliance Hotline
at x 17720 or by completing a Compliance
Violation Report
You Are Valuable to OMH
and Our Patients
Your knowledge and
compliance is vital to
our patients safety:
– Hospital policies and
procedures
– National Patient
Safety Goals
– Reporting occurrences
and concerns
Reporting a Concern
Please contact the Patient Safety and
Corporate Compliance Officer,
Bonnie Byram
at 731-7703
Employees also have the choice of reporting
safety or quality concerns to the
Joint Commission at (630) 792-5636 or
[email protected]
Performance Improvement
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Otsego Memorial Hospital is committed to
providing quality care to the patients we
serve. The Performance Improvement Plan
outlines the systematic approach the
organization takes towards continuous
quality improvement.
Plan
Do
Check
Act
Professional Work Environment
• Professional Work Environment
• Everyone has the right to be treated with
dignity and respect
• Prohibited Conduct
• Sexual Harassment
• Hostile Work Environment
• Report to CEO or HR Director
Professional Work Environment
Prohibited Conduct
• Crude or offensive language, sounds,
innuendoes or jokes, whether
communicated verbally, by electronic
mail or otherwise relating to race, color,
religion, national origin, sex, age, height,
weight, marital status, disability or other
protected classification;
Professional Work Environment
Prohibited Conduct
• The display of sexually suggestive or
otherwise offensive objects, pictures,
letters, gestures, or graffiti relating to
race, color, religion, national origin, sex,
age, height, weight, marital status,
disability or other protected
classification;
Professional Work Environment
Prohibited Conduct
• Unwanted sexual advances, including
offensive touching, pinching, brushing
the body, or impeding or blocking
movement.
Environmental Safety Awareness
Any time an emergency alarm or “Code” is paged,
plan to remain with the patients until instructed
otherwise by hospital staff.
Should evacuation become necessary, you will be
instructed in specific actions to ensure personal
safety of the patient and yourself.
OMH Codes
To announce an emergency an overhead
paging system is in place:
• Dial 477
• Speak Slowly, Loudly & Clearly
• Room numbers posted in each room
OMH Codes
Code Red = Fire
– OMH Code Red Policy
– Doors are numbered and lettered for Fire
Department
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H – hospital
M – McReynolds
P - PMB
OMH Codes
Code Red
• Return to your work area, if safe
• Do not use elevators
• Feel doors, do not open if hot
• Close all doors & windows
• Clear corridors and exits
• Assign staff to answer phones
OMH Codes
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Code Red Response
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Fire Extinguisher use
– R = Remove persons
– P = Pull the pin
from area
– A = Activate fire alarm
– C = Contain fire and
smoke
– E = Extinguish fire or
evacuate
– A = Aim toward the
base of the fire
– S = Squeeze the
handle
– S = Sweep the base of
the fire
OMH Codes
Code Blue
– Cardiac Arrest
– Near Arrest
• Activation
• Code Blue Buttons
• Page Overhead 477
• Signs near patient beds
• Response
– BLS - ALS (on arrival of cart)
– ICU Nurse
– Respiratory Therapist
– ED Nurse
– Physicians
OMH Codes
Code Yellow
• Bomb or Bomb Threat
• If receiving the call….
• Page Code Yellow & Location
• Check area for packages, report anything
suspicious, but do not touch!
• Incident Commander will determine the need
for evacuation
OMH Codes
Code Grey
• Security Situation/Potential for violence
• Page overhead 3 times with location
• Code Grey “Assist”
• Code Grey “911”
• All available personnel go to area
• Show of force
• When to call for help …. Signs of agitation
OMH Codes
Code Pink
• Missing Person/Possible Abduction
• Page Code Pink, Gender, Age, Department
• Observe exits and parking lots
• Search your department
• Observe and be able to describe all persons
• Do not attempt to detain persons
OMH Codes
Code Silver
If you are confronted
by an individual with a
weapon OR
• If you observe a
hostage situation on
Hospital property
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Initiating Code Silver Plan
Seek cover and discretely warn others (close by)
of the situation
• Dial “O”- Report the location, number of
suspects/hostages, type of weapons
• Operator will dial 911
• Operator will page “Code Silver”+ location 3 times
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Workplace Violence
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Healthcare and social service workers face
an increased risk of work-related assaults
If threat is imminent, call Code Grey Assist
or Code Grey 911
Workplace Violence
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OMH has “Zero Tolerance” towards all
expressions of violence.
Individuals who commit such acts may be
removed from the premises and may be
subject to criminal penalties.
OMH Codes
Code Triage
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Shift Coordinator in area or department impacted
will declare “Code Triage”
Any event that impacts or has high potential to
impact normal operations of the facility
Code Triage Internal
Code Triage Standby
Code Triage External
OMH Codes
Code Triage Responsibilities
• Return to department
• Phones for disaster business only
• Management will implement HICS
• Hospital Wide Disaster Plan
• Department-Specific Plan
OMH Codes
Severe Weather
• Emergency Department has weather alert radio
• ED also notified by MI State Police Dispatch
• ED Shift Coordinator will announce warnings
overhead
• Return to your department
• Non-clinical employees go to basement
• Prepare for evacuation if ordered
Hospital Incident Command System (HICS)
• Chain of command for decision and
communication
• Semi-defined roles
• All staff respond to only one individual (upward)
• All supervisors manage 5-7 people
(in command structure)
• HICS implemented in all codes
– Your manager may have additional responsibilities
Infant Abandonment
Michigan law states that a parent or adult
can surrender a newborn up to 72 hours
old
We must accept the newborn
• Call Birthing Center
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Do not press for information
HIPAA
The HIPAA Privacy Rule protects a patient’s
fundamental right to privacy and confidentiality
• ANY information obtained about another
person’s medical condition is treated as
confidential and is not to be discussed or revealed
to unauthorized persons
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HIPAA
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Protected Health Information is anything
that connects a patient to his or her health
information: Date of Birth, SS#, diagnosis,
address, etc.
HIPAA
HIPAA’s focus is on the rights of the patient and the
confidentiality of their information.
Patients have the right to:
• Request an amendment of their medical record
• Request to inspect and copy their record
• Restrict what information is shared
• Receive confidential communication
• Complain about a disclosure of their information
Ethics Committee
OMH has an Ethics Committee that is consists
of a diverse group of members including:
• Providers
• Licensed professionals
• Frontline staff
• Community members
• Anyone staff member can make a referral
to the Ethics Committee
Appropriate Ethics Referrals
A staff member’s
belief system is in
conflict with a
patient’s treatment
plan.
• A family/patient is in
conflict with the
proposed treatment.
• Resource allocation
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Revising/updating
policies/practices with
ethical implications.
• Offering support for
clinical or medical
issues with ethical
implications.
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Medical Record Documentation
The purpose of medical record documentation includes:
•To record complete and accurate clinical information
•To communicate with other members of the healthcare team
•To comply with legal, regulatory and accreditation requirements
•To ensure adequate reimbursement
Documentation that has missing information (time,date), misspelled
words, unapproved abbreviations and policy variances (R.A.W.) could be
interpreted as an indication of substandard care
Impaired Health Professional
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If someone comes to work and seems
unable to do their job due to impairment
because of alcohol, drug use or mental
illness-we must report it immediately to
the Administrator-on-call.
The call schedule is in the Hospital
Information folder.
Environment of Care
We have 7 plans in place to assure the safety of our
patients and our staff:
Plan 1: Biomedical Equipment Management
Plan 2: Emergency Preparedness Management
Plan 3: Life safety Management
Plan 4: Hazardous Material and Waste Management
Plan 5: Utility systems Management
Plan 6: Security Management
Plan 7: Safety Management
Chemical Hazards
“Right To Know”
Employees have the right to know how to keep themselves safe on the job
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MSDS-material safety data sheets available online (Web
link in the Hospital Information)
Use of eyewash station-flush for 15 minutes with COLD
water
Know where eye wash stations are located. Eye wash
stations are checked daily
MRI Safety
(Magnetic Resonance Imaging)
MRI Safety
(Magnetic Resonance Imaging)
• All employees need orientation in magnet safety
• Large metal objects of any kind shall not be permitted in
the scan room until they are checked for ferromagnetism.
Magnetic items should be kept out of the room at all
times
• All items will be tested with a hand held magnet and
found not to be attracted to the magnet before being
permitted in the Magnet/Scan Room
• Do not enter room for Code Blue-patient will be brought
out to the hallway!
• Hearing protection required for patients
Ergonomics and Back Safety
Our goal is to use this science of ergonomics to
reduce work-related Musculoskeletal disorders
(MSD’s)
• Everyone, not only those involved in direct
patient care, needs to have training in proper
body mechanics and lifting
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Safe Lifting
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Use your strong leg muscles
Keep objects close
Tighten abdominal muscles
Bend knees and squat
Use proper lift equipment
Ask for help when needed
Keep head and shoulders up (keeps spine curves
in alignment)
Comfort and Care at the End of Life
Managing symptoms is the goal
• Even if patients are not responsive, always
explain care/treatment
• Respect personal choices and values
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Organ and Tissue Donation
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Gift of Life-we do participate!
Organ procurement done in OR
Tissues procurement can be done at
hospital or funeral home
Hospital required to call all imminent
deaths to Transplantation Society of
Michigan
Cultural Competence
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Treat every patient as an individual
Communicate respect
Language issues-seek translation if needed
Be aware of non-verbal communication
Questions
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Any questions about this information can
be directed to the HR Department,
instructor or your department director.
The End
Welcome