Caring For Our Patients

Annual Safety Training 2012/2013 Part 3

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Primary purpose of risk management is to ensure quality care at Affinity Medical Center

The definition of an unusual occurrence is defined as any occurrence or event involving a patient, employee, medical staff member, or visitor which is not consistent with the normal operating procedures of Affinity Medical Center or routine care, regardless of whether or not there was an apparent injury or other damage

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T Examples of Unusual Occurrences

-Falls

-Patients leaving Against Medical Advice (AMA)

-Unexpected Deaths

-Medication Errors

-Spills

-Negative Outcomes from Treatments or Procedures

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All hospital employees have the responsibility to report unusual occurrences

Utilize the appropriate form and forward to Risk Management within 24 hours

If the occurrence involves a visitor or employee it is strongly recommended that they be evaluated by the Emergency Department

GO

ALS

2012 National Patient Safety Goals

1. Improve the Accuracy of Patient Identification

2. Improve the Effectiveness of Communication Among Caregivers

3. Improve the Safety of Using Medications

4. Reduce the Risk of Health Care Associated Infections

5. The Organization Identifies Safety Risks Inherent in its Patient Population

6. Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery

FALL

RED

UC

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Affinity is committed to the safety of its patients

Falls can account for a significant portion of injuries in hospitalized persons

Fall prevention and education is priority

All Leadership and Supervisors are responsible for supporting the fall reduction program

ALE

RTS

Patients at risk for falls will have a yellow leaf placed on the frame of their door

Yellow arm bands will denote the patient is at risk for fall.

Yellow nonskid slippers will be placed on the patient

Inpati

ent

Unit

s

A fall risk assessment will be completed on admission

Low risk patients will be assessed every 24 hours

Pts will be assessed with any change in environment, mental status, or mobility

High risk patients will be reassessed every shift

Outp

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ent

Are

as

Patients will also be assessed for fall risk and yellow arm band be placed on patient if at high risk for fall.

Pati

ent

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hts

Affinity recognizes and respects the rights of each individual

Pt rights are provided to each person receiving services at Affinity

Pt rights are posted throughout the hospital

Pati

ent

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The right to participate in the development and implementation of his or her care

Or his or her representative (as allowed under State Law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. The right must not be constructed a s a mechanism to demand the provision of treatment or services deemed medically unnecessary to inappropriate.

Pati

ent

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hts

The right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with theses directives

The right to have a family member or representative of his or her own choice and his or her own physician promptly notified of his or her hospital admission.

The right to personal privacy

The right to receive care in a safe setting

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ent

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The right to be free from all forms of abuse or harassment

He right to confidentiality of his or her own medical records

The right to access information contained in his or her own clinical record within a reasonable time frame. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek these requests as quickly as its record keeping system permits

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The right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff

The right to be fully informed of and to consent or refuse to participate in any unusual, experimental or research project without compromising his/her access to services

The right to know the professional status of any person providing his/her care or services

Pati

ent

Rig

hts

The right to know the reasons for his/her transfer wither within or outside of the hospital

The relationship of the hospital to other persons or organizations participating in the provision of his/her care

The right to access the cost, itemized when possible of services rendered within a reasonable period of time

Pati

ent

Rig

hts

The right to be informed of the source of the hospital’s reimbursement for his/her services, and of any limitations which may be placed upon his/her care

Informed of the right to have pain treated as effectively as possible

Pati

ent

Gri

evance

Pro

cess

Process for patients and families to file a complaint: EVERYONE is an ADVOCATE for the Patient

Employee is to immediately try to solve the complaint

Notify department supervisor of the complaint

Utilize the chain of command to solve the problem

Pts can also call the Ohio Department of Health Complaint Line at 1-800-342-0553

Advance

Dir

ect

ives

Under Ohio Law the hospital must explain to every patient their right to state their wishes regarding medical care and provide information on Advance Directives

This can be canceled at any time or be changed

Advance Directives are Living Wills or Durable Power of Attorney

Livin

g W

ill

Allows patient to put his/her medical care in writing

Living Will tells how a patient wants the use of life-support methods to lengthen or extend their life when in a coma or beyond medical help

Health care providers must follow what the patient states in the Living Will or in the Doctor’s order to resuscitate or do not resuscitate order

Dura

ble

Pow

er

of

Att

orn

ey

Allows a patient to choose someone to carry out their healthcare wishes

An adult friend or relative acts for the patient when they can not act for themselves

Pati

ent

Confidenti

alit

y

Affinity is committed to maintaining confidentiality

Confidential information will not be discussed outside of patient care areas such as in public areas, elevators, rest rooms, or the cafeteria or outside of the hospital

Employees have access to confidential information only to perform their job if the patient is under their direct care

Do not release or discuss patient information with others unless it is necessary to care for the patient, is required by law, or the patient has consented to such disclosure

Pati

ent

Rest

rain

ts

Affinity strives to be a restraint free facility

Sitters are utilized in place of restraints

Restraints will only be utilized to protect a patient from injury to him/herself or to others to prevent imminent and serious disruption of the therapeutic environment

Alternatives should be attempted prior to initiation

All patients have the right to considerate, respectful care, at all times with recognition of their personal safety

Restraint use will be discontinued at the earliest time possible if initiated

Pati

ent

Rest

rain

ts

Affinity strives to be a restraint free facility

Sitters are utilized in place of restraints

Restraints will only be utilized to protect a patient from injury to him/herself or to others to prevent imminent and serious disruption of the therapeutic environment

Alternatives should be attempted prior to initiation

All patients have the right to considerate, respectful care, at all times with recognition of their personal safety

Restraint use will be discontinued at the earliest time possible if initiated

Abuse

and N

egle

ct Types of Abuse and Neglect

Domestic Violence

Child Abuse/Neglect

Adult/Elder Abuse Neglect

Emotional Abuse

Report

ing

Healthcare Workers Responsibility is to report suspected abuse and or neglect

Provide appropriate inquiries

Provides sensitive, non-judgemental support

Address patient safety

Document in medical record finding of abuse

Report

ing

Professionals required by law to report abuse:

Physicians, Nursing Personnel, Hospital or Medical Personnel, Social Work Personnel, School Teacher, School Administrator, Guidance Counselor, Child/Daycare Personnel, Law enforcement Personnel

These people can not be prosecuted or held personally liable, even if the subsequent investigation determines that the reported abuse did not occur

Abuse

Report

ing a

nd L

ogs

Case management maintains a log for ICU, CVSICU, Rehab, Med-Surg, and Med-Tele on suspected abuse cases

Senior Mental Health and Emergency Department maintains their log on suspected abuse cases

Case Management will then report the suspected abuse and or neglect to the appropriate authorities

Age S

peci

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Age S

peci

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We deal with people of different stages

It is important to be prepared to deal with them when you encounter them in a work setting

Provide a comfortable safe environment

Consider patients, visitors, volunteers, physicians, and fellow employees as customers and recognize what stage of development they are in and respond appropriately

Late

x S

ensi

tivit

y Watch for this in patients and employees we

are a LATEX reduced facility and a LATEX free cart is located in Central Sterile

Three types of reactions to latex

Itchy, dry, irritated areas on the skin, usually on the hands

Allergic-contact dermatitis which begins with a rash and may progress to oozing blisters (similar to poison ivy)

Latex allergy is an immediate reaction that ranges from redness, hives or itching, to runny nose, itching eyes, scratchy throat, breathing difficulty, and possible collapse

Qualit

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anagem

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Chief Quality Office Pam Shanklin RN prepares the Quality Assessment and Performance Improvement Plan for Affinity Medical Center

Approved by the Board of Trustees and drives each department’s efforts in monitoring and maintaining quality care

Quality and Patient Satisfaction Data is also shared with government and other external regulatory bodies

This information is available to the public as a guide for customers when choosing their hospital

Qualit

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Idea Cycle is a process that is utilized here at Affinity

I-A problem is Identified

D-The cause is Determined

E-Possible solutions are Explored

A-Solutions are Activated

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All employees are encouraged to communicate opportunities for improvement by utilizing the “Quality Improvement Opportunity/Problem Referral Form”

The form is available in the Quality Department or from your Director

All forms will be reviewed by QIC and utilizing a prioritizing method, may be assigned a team to research the opportunity or resolve the problem

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MISSION

Affinity Medical Center is committed to partnering with our community, patients, physicians, and employees to provide high quality, personalized, compassionate health care; contributing to a healthier community by promoting healthful living; and providing educational opportunities for healthcare professionals

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VISION

Affinity Medical Center will be the premier healthcare resource in western Stark County and surrounding areas

We will achieve this by:

Recruiting and retaining qualified, compassionate caring staff

Ensuring access to communities we serve

Advancing clinical capabilities with state-of-the –art technology and best practice standards of care while preserving the friendly community atmosphere

Behavio

rs

Collaborating with other healthcare providers, payers, and customers to better serve our patients’ needs

Exercising prudent stewardship of our assets and resources

Behaviors

Accountability

Compassion

Excellence

Integrity

Teamwork

Cust

om

er

Serv

ice Always strive to provide outstanding

customer service

Goal to exceed our customer expectations

Provide them with utmost kindness, care, compassion, courtesy, empathy, and respect

Greet customers with in a warm manner with a friendly, open smile and direct eye contact

Golden Rule “Treat others as you would want to be treated”

Patients, Families, Physicians, Co-workers, are all customers

Cust

om

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Serv

ice

Display professionalism with all encounters

Be kind in every situation

Greet everyone with a friendly hello

Maintain eye contact when speaking with others

Use please and thank you as appropriate

Listen without interrupting

Cust

om

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Serv

ice AIDET

Provide prompt service

Inform customers about delays

Thank customers for waiting and apologize for delays

Answer call lights as soon as possible

Let individuals know you are happy to help them

Before leaving the room ask “Is there anything else I can do for you?”

Tele

phone C

ourt

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Communication creates a lasting impression

Be professional and caring when answering the phone

Identify the hospital, department, and your name as you answer the call

Be ready to answer questions about specific services

Tele

phone C

ourt

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If you can’t help the caller, offer to connect them to someone who can

Continue to be friendly and polite throughout the conversation

Thank the person for their inquiry as you end the call

Take a moment to think: Was this call unusual in any way? Should I mention it to my supervisor? Do we need to keep track of this kind of call?

Code o

f C

onduct

“Doing the Right Thing”

We strive to provide service excellence

“Community Cares Service Excellence Standards of Performance Handbook” provides clear and specific behavioral expectations

Hourl

y R

oundin

g

Use opening words to decrease anxiety

Perform scheduled tasks

Address the 4 “P’s”: Pain, Potty, Possessions, Positions

Assess additional comfort needs

Conduct an environmental assessment

Close conversation

Tell each patient when you will be back

Document round on chart

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