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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Principles of Responsibility
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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Principles of Responsibility
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]