2012 core review students

7/29/2019 2012 Core Review Students

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CORE REGULATORY

REVIEW

2012


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Kaiser Permanente

South San Francisco

We exist to provide high quality,

affordable, health care services and to

improve the health of our members and thecommunities that we serve.

We strive to be The Best Place to Work


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Achieve World Class Hospital

STATUS

Every Kaiser Permanente patient will

experience the highest quality care

and service at every encounter and

every department and every hospital,

every time."


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WORLD CLASS

South San Francisco

World Class Hospital Goals!

Highly skilled & Motivated Workforce

The Quality Leader

Exceptional Care Experience

Care Without Delay Hospitals


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Principles of Responsibility

Code of Conduct Guides us in our daily work to improve

members health. Do the right thing. Patient & member focus, Quality, Service, Affordable,

Best Place to Work.

* Respect Members, Patients, Customers &Each Other keeping data confidential


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Fair and honest business practicesfollow anti

fraud laws. Protect our assets

Protect our reputation - Market & communicate

about KP accurately and strategically.

Treat everyone with dignity and respect

Value workforce diversity

Respect & value patient diversity


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Foster a harassment free environment

Focus on workplace safety

Non-retaliation

Avoid conflicts of interestmembers, patient,

customers, university and training programs,

community based programs Meet government expectations


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Health Insurance Portability and Accountability Act

HIPPArequires all KP workforces members

regardless of job title or hours worked, to understand the

risks and safeguard the privacy and security of

individually identifiable information of our members

patients.

Personal Health Information can be: oral, written,

electronic

HIPPA violations can result in huge fines to the

organization and termination of the individual.


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Facility Safety

FACILITY SAFETY

WEB BASED ON KP LEARN

Topics include: Hazard communicationeye wash (15 minutes),

PPE, Spills, Lockout-tagout.

Written plan- hazardous chemical inventory, MSDS

sheets, Labels


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Facility Safety

Follow Occupational Safety and Health

Administration Guidelines (Federal)

National Fire Association Label 0-4

Blue Health

Red Fire

White Specific Hazard

Yellow - Reactivity


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Facility Safety

Asbestos Risks

FIRE SAFETY

Code Red ( Call 5000) Know exits, fire alarms, fire extinguishers

RACERescue, Alarm, Contain, Extinguish orEvacuate

PASS Pull, Aim, Squeeze, Sweep


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Facility Safety

Prevention of Bloodborne diseases-

Microorganisms present in blood and other body

fluids which causes diseases such as Hep B & C,HIV/AIDS

Universal Standard Precautions;

Consider every person, all blood, and most body

fluids to be potential carriers of disease.


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Facility Safety

Prevention of TB-contagious airbornedisease

Disaster & Emergency Prepardness

Electrical Safety

Violence in workplace

Ergonomics

Latex


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Facility Safety

Radiation

MRI Safetystaff and members must

be screened

Medication patches/patients in MRI

Ergonomics

ADA Compliance


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Members Rights & Responsibilities

KAISER PERMANENTE respects the rights of members and recognizes thateach member/patient is an individual with unique health care needs.

Reasonable access to care

Respect and dignity Medical Treatment Options

Confidentially and privacyInformed consent

Participate in care decisions

Rights for Minors

Ethics Process Visitors

Pastoral Care


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Patient Rights Continued

Advance Directives - Physicians Orders for Life SustainingTreatment (POLST)

Abuse ReportingChild-Elderly/Adult-Spousal-Domestic Violence

Member Service Call Center

1-8000-788-0616 California Dept of Managed Health Care

1-800-400-0815


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Staff Rights

Industrial reporting

Equal Employment Opportunity

Sexual Harassment Laws Zero tolerance for violence in the work place

Right to refuse in certain aspects of care


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Quality Performance and Improvement

Management of the delivery of care

and support services with the focus on

providing optimal outcomes in: Quality

Safety

Satisfaction Cost Efficiency

What is best for the patient!


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CORE MEASURES

Standarized sets of valid, reliable, and

evidenced based measures

(Scientific Based) to improve safetyand quality of care.

Acute MI

CHF Community acquired pneumonia

Surgical Care Improvement Project


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National Patient Safety Goals

NPSG.01.01.01 Patient Identification

Two patient identifiers Eliminate transfusion errors

NPSG.02.03.01 CommunicationCritical resultslab, radiology, POC testing

NPSG.03.04.01Medication SafetyLabeling medications on and off sterile field

Anticoagulation

Medication reconciliation


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Goals Continued

NPSG.07.01.01 Infection PreventionComply with WHO Hand Hygiene Guidelines

Prevention of health care associated infections (MRSA, VRSA)

Prevention of surgical site infections

Prevention of central line infections

Prevention of in dwelling catheter associated infections urinary tractinfections (CAUTI)

NPSG.15.01.01 Suicide Prevention Screen patients at risk for suicide

UP.01.01.01 Universal Protocol (right person, site, procedure) Pre-procedure verification

Site Marking

Time out


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RISK Management

Organized effort to identify, analyze, report and reducerisk to everyone, as well as organizational assets in theinterest of improving health.

Identify and report risks and or any potential risks eRRF ( Just Culture) Significant/Sentinel events to be

completed for a finding.

Reportable conditions: AMA, Fall, Equipment,

Medication errors.


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INFECTION CONTROL

Hand hygienehand washingdegermer

Blood borne pathogens

TB

Aerosol Transmissible Diseases

Flu

Multi drug resistance organisms

Catheter related infections


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Contact Precautions


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Contact Plus Precautions


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Airborne Precautions


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Droplet Precautions


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WHO Hand Hygiene


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Health Connect

Electronic Medical Record

Code White: Health Connect isdown

If there is no documentation, it isconsidered not done.

Nursing if you did not chart it you did

not do it


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POPULATION SPECIFIC CARE,

CULTURALLY COMPETENT CARE, DISPARITIES,

HOMELESS

Why important?

Improves relationships, satisfaction (both

provider and patient), compliance with care.

Cultures look at health care in different ways

reflective of their beliefs, religion and culture.

SSF is very diverse - patient population and

staff


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Health DisparitiesWhat does it mean?

Health disparities are differences

between health and health care,

resulting in out-comes that are worsefor one population more than another.

Causes can include:

Cultural beliefs socioeconomic occupational hazards Gender Age Sexual orientation

Physical ability Language barriers


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Homeless Population in

San Mateo County

Information from 2009 homeless

census;

31% disabled 9% families with children

14% veterans

2011 Census information not yetavailable


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CLAS Standards

Federal and State Requirements. Providers of health care are to provide culturally

competent care and language access to their members. Interpreters & qualified bi-lingual staff

Sign Language

Translation of documents

AT&T language line.


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Emergency Medical treatment and

Active Labor Act

Applies to ED only! Prohibits patient dumping!

Emergency medical condition: Woman in labor

Whatever the patient states it is! (abd pain, cold,

flu, chest pain).

Have to have a medical screening exam by aprovider.


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EMTALA

Prior to MSE, we can not ask the patient anyquestions regarding ability to pay.

A physician examines the patient, orders anynecessary lab or radiologic tests, treats and eitherdischarges the patient with follow upinstructions, admits the patient or transfers thepatient out based on services needed, which are

not provided by SSF. Example head trauma!


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TEAM ALERT

The Team Alert will provide the initial response to

medical events, falls or injuries outside of the inpatient,

HAS, or PACU. Team Alert maybe used for visitors

within the inpatient areas. Team Alerts may also be usedwhen a patient on our premises; parking areas, facility

driveway, and sidewalks is reported to need assistance

Team Alert was developed to notify the most appropriate

staff to respond to the needs of the patient.


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TEAM ALERT

The operator is called by dialing 5555, the

operator answering the call will ask:

Is the person talking? If yes, the operator will activate the TEAM

ALERT

The Charge Nurse and the ED TECH will

respond bringing the transport gurney. The

operator will also notify Security.


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Rapid Response Team (RRT)

RRT is to provide support and collaboration among staffto enhance clinical outcomes.

Clinical resource for patient assessment and clinical

intervention. Early intervention and stabilization to prevent

deterioration and improve outcomes.

Call 5900


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CODE BLUE

5555

The purpose of the Code Blue is to provide a systematicresponse to members, visitors experiencing an unexpected

medical event or cardiopulmonary arrest at 1200 El Camino

Real only


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INFANT ABANDONMENT/

SAFE SURRENDER

Safe Surrender Site is a location within the hospital

(Emergency Department) where an infant can be

voluntarily surrendered by a parent or other person

with lawful custody. The individual will be immune fromcriminal liability for child abandonment Kaiser Foundation

Hospital (KFH) South San Francisco accepts physical

custody of children, defined as: (an infant 72 hours or

younger) For specific information refer to Policy and Procedure:

Infant abandonment/Safe Surrender PC.09.01


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STROKE

A stroke occurs when the blood flow to the brainis reduced or blocked, resulting in neurologicdeficit and tissue damage. Remember: A stroke

can injure the brain like a heart attack can injurethe heart.

Stroke is third leading cause of death in US

About 7,000,000 Americans have strokes each

year. Someone has a stroke every 45 seconds

Someone dies from a stroke every 3-4 minutes


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STROKE

F.A.S.T. Signs and symptoms are usually sudden

onset

F (Face) Ask person to smile, If one side of the face does

not move the same as the other it is a problem

A (Arm) Ask person to hold both arms straight out and

keep raised, unable to do so is a problem

S (Speech) listen to speech, speech unclear, slurred, uses

wrong words, unable to speak are problems

T (Time) If symptoms are present get help


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FALL-Unplanned descent to the floor

A major health concern that threatens the function of

older adults is the risk of falls which can result in injury

and disability. Even falls that do not result in serious

injury may affect an older persons function and qualityof life. Both the incidence of falling and the severity of

fall-related complications rise steadily after about age

65. Falls are the leading cause of injury and injury-

related death among older adults.

Please help patients who appear to be needing assistance.


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PAIN

Definition: Pain is what the experiencing personsays it is, existing whenever he or she says it does. (The

Joint Commission). In other words, pain is subjective

believe the patient. Patient self-report is considered the

most reliable method to assess pain.


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Pain Management

1.) Using an appropriate pain scale

2.) Identifying the patients acceptable level ofpain

3.) Reporting of pain

4.) Meeting the related education needs


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Agitated patient/restraints

Overview - Restraint use is considered alast resort after alternative measureshave been considered or were shown to

be ineffective. Introduction: KPsphilosophy is that the

individual rights of a persons privacy, personal dignity,and protection from harm must be preserved. Measuresshould be taken throughout a patients time in the

hospital to prevent the use of restraints, decrease the useof restraints and/or to eliminate restraints. The use ofrestraints shall only be used after a comprehensiveassessment.


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TEMPORARY RELEASE

Visualization and observation is expected at

intervals indicated by the individual patients

condition and type of restraint and preferably at

least every hour.

As part of the plan of care, a temporary release

may occur for the purpose of caring for a

patients physical, psychosocial, diagnostic andtreatment needs, (e.g., for toileting, feeding,

range of motion).


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SKIN, WOUND ULCER

PREVENTION

Patients will maintain their skin integritythroughout the course of their hospitalization.

Pressure ulcers are preventable. Hospitalacquired pressure ulcers are classified by the

National Quality Forum as a never event.These are errors in care that indicate a problemin the safety and credibility of a health care

facility.


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END OF LIFE CARE

The dying patient has unique needs for

respectful, responsive care. All staff should be

sensitive to the needs of the patient and family.

Some patients with life threatening illnesses wish

to pursue care until the end. Patients may wish

to forgo treatment options or may not have

curative options available.


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Organ/Tissue Donation

Anatomical organ donation is an important part

of the end of life care. Our goal is to honor the

wishes of patients and their families or

authorized surrogates in regard to the donation of

anatomical gifts (donation of all or part of a

human body to take effect upon or after death).


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Donation Continued

STATISTICS: More than 80,000 men, women and children are

currently waiting for life saving transplants.

46,532 cornea transplants were performed in 2001. In 2001 there were 6,081 deceased organ donors and

6,510 living donors.

Every 13 minutes another name is added to the transplantlist.

ONE DONOR CAN: Save or enhance the lives of more than 50 people.

Kidneys can free two people from dialysis,

Corneas can give sight to two people.

ADDITIONAL MODULES


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ADDITIONAL MODULES

for 2012 INCLUDE:

Medication Management:

Multi-dose

Single dose Labeling of medications on and off sterile field

Medication Error Reduction Program

Blood administration

MERP

High Alert Meds

Tubing misconnections

Do not use abbreviations


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South San Francisco

1200 El Camino Real SSF

Hospital Clinics ( Allergy, Medicine, Surgical

Services Neurology, Radiology (CT, MRI)

395 Hickey Daly CityPediatrics, OB/Gyn, Medicine, Eye

901 El Camino San Bruno Medicine

801 Traeger San Bruno PT, DERM, OCC

Med, Physical Medicine


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South San Francisco

800 Oyster Point Blvd SSF Radiation Oncology

San Bruno Sneath Home Care

Medical Records

Simulation Lab


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Key Reminders

Policies and Procedures are locatedon SSF Intranet Site

Code Red, Code Blue, Securityinformation located on the back of yourname badge

Do not share pass words

Patient information on a need to knowbasis HIPPA


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CONCLUSION

Thank you for your time & attention.

Please remember it is about providing

compassionate, confidential, quality care to the: MEMBERS OF KAISER PERMANENTE

Presented by: JoEllen Elliott, RN, CPN, BSN

650-742-2106

Email [email protected]

2012 core review students

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