Your Champion for Better Health

Otsego Memorial Hospital Otsego Memorial Hospital AssociationAssociation

OMH is owned by the OMH Association, comprised of members of the community who pay annual dues.

• Established 1951• Non-profit Corporation• Governed by 10-Member Board of Directors• Accredited by Joint Commission, CMS

Otsego Memorial Hospital HighlightsOtsego Memorial Hospital Highlights

Workforce: 650+ EmployeesProviders: 90+ Affiliated including 58

employed26 are Mid-Level Practitioners

Beds: 46 Acute Care (Hospital)

34 Long Term/Skilled (McReynolds)

Businesses within OMH AssociationBusinesses within OMH Association

Otsego Memorial HospitalMcReynolds Hall

MedCare Walk-In Clinic OMH Medical Group OMH N’Orthopedics

OMH Medical Group LewistonOMH Medical Group Indian River

OMH Foundation

Mission StatementMission 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 StatementVision Statement

To be the center of northern Michigan’s patient focused alliance dedicated to healthcare excellence.

ValuesValues

Respect: Appreciating diversity and treating all with compassion,

dignity and courtesy• 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

ValuesValues

Integrity: Unwavering commitment to honesty and trust• 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

ValuesValues

Excellence: Teamwork and communication dedicated to understanding

and exceeding expectations of quality, safety and customer service

• 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

ValuesValues

Accountability:Accepting responsibility for our actions• 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

Otsego Memorial Hospital Otsego Memorial Hospital AffiliatesAffiliates

OMH AuxiliaryA self-governed group of 150 volunteers who raise

funds to support the mission of OMH

Otsego Memorial Hospital Otsego Memorial Hospital PartnersPartners

Munson HealthcarePartner for services such as IT, phones and supplies

Munson Home Care/Home ServicesOMH is a small equity ownership, which we

must disclose when offering home care services

Customer ServiceCustomer Service

We want customers to think of us as the very best option for their healthcare

Customer ServiceCustomer Service

• Part of our Strategic Plan• Why it is important ?

• Customers share their experience• The following are the behaviors we ask our

employees to exhibit

Greet PeopleGreet People

Make eye contact (be aware of cultural diversity)

Tune the world out and them inIf appropriate, thank them for coming in or

contacting you

Value PeopleValue People

Think things like:“You’re the customer-I’m here to serve you!”‘You deserve to be treated with dignity and respect!”“There’s something about you I value!”

Ask How You Can HelpAsk How You Can Help

Ask “How may I help you?”Find out why they came in or contacted

youAsk open-ended questions to further

understand their needs.Open-ended question require more than a “yes” or “no” answer

Listen to PeopleListen to People

Listen to wordsListen to tone of voiceListen to body language

Help PeopleHelp People

Help PeopleSatisfy their wants or needsSolve their problemsGive them extra value

Invite PeopleInvite People

Invite people to have further contactThank them for choosing our organizationAsk them to contact you again if they need

further helpLeave them with a good feeling about their

encounter with you

Rights as a PatientRights 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 PatientRights 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 AssessmentPain Assessment

When assessing pain, a number value should be assigned by the patient to make for consistent measurement

FLACC Scale FLACC Scale Non VerbalNon Verbal

RightsRights

Patients have a right to: • Privacy• Treatment records are confidential• Review their medical records• Be free from discrimination• Discuss continuing care needed after

hospitalization

RightsRights

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

RightsRights

Patients have a right to:• Be informed of outcomes of care including

unanticipated outcomes• Raise concerns through a formal grievance• Access Protective Services

RightsRights

Patients have a right to:• Comfort measures/peace and dignity at

end of life• Patients who have a Do Not Rescusitate 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 ResponsibilitiesPatient Responsibilities

Patients need to:• 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

What are Advance Directives? 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 DirectivesOMH Process for Advanced Directives

• 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 ControlInfection Control

Washing your hands frequently and properly is the single most important action you can take to prevent the spread of infection.

Infection ControlInfection 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 ControlInfection Control(Keystone Initiative)(Keystone Initiative)

Wash your hands upon entering a patient-care area and upon leaving

WASH IN WASH OUTWASH IN WASH OUT

Infection ControlInfection Control

Standard Precautions“All the patients, all the time”

Infection ControlInfection Control

Standard Precautions• Specific behaviors that healthcare

workers (HCW) follow to protect both themselves and patients from infection

• Practice 100% of the time

Infection ControlInfection Control

• Apply to blood, all body fluids, excretions and secretions except sweat, plus non-intact skin and mucous membranes

• Protect against bloodborne pathogens such as HIV, hepatitis B and hepatitis C

• Protect against pathogens from moist body substances

Infection ControlInfection 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 ControlInfection 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 ControlInfection 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

Sharps SafetySharps 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 ControlInfection 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-

CONTACTCONTACT--AIRBORNEAIRBORNE--DROPLETDROPLET

AIRBORNE PrecautionsAIRBORNE 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

Exposure toExposure toBlood or FluidsBlood or Fluids

• 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 CareAge 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

AbuseAbuse

Types of abuse:• Elders

• Physical Abuse, Neglect, Exploitation• Child

• Abuse, Neglect• Observed or suspected

– we are required by law to report it!

Overview of Evidence-basedOverview of Evidence-basedPractice: Practice: What Is It?What Is It?“The conscientiousexplicit, and judicioususe of current bestevidence in decisionmaking”

(Sackett, et al, 1997)www2.uta.edu/ssw/trainasfa/glossary.htm

Evidence-based Practice: Evidence-based Practice: Example- Example- ClinicalClinical

ConditionCentral Line-AssociatedBloodstream Infections area serious complication inhospitals across the nationand may cause increasedlength of stay, increasedcost and risk of mortality.

Research SummaryTo reduce the incidence ofblood stream infections:• Use appropriate hand

hygiene• Chlorhexidine for skin

preparation• Full barrier precautions

during insertion • The subclavian vein as the

preferred site. Quality and Safety Research Group, Johns Hopkins University, Revised 1.14.05

Evidence-based Practice:Evidence-based Practice:RegulationsRegulations • Centers for Medicare

and Medicaid Services• Michigan Department of

Consumers Industry Services• Joint Commission Agencies that survey healthcare organizations expectcompliance with all rules andregulations proven to provide safe,quality care.

Evidence-based Practice:Evidence-based Practice:ReimbursementReimbursement

Healthcare reimbursement is

in a transitional phase and

“Pay for Performance” or

“Value Based Purchasing”

requires hospitals to submit

data which reveals how well

they comply with evidence-

based standards of care.

It pays to provide quality care!

Patient Safety: Patient Safety: A National IssueA 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

How National Patient Safety How National Patient Safety Goals affect your practiceGoals affect your practice

• 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 Goal 1: Improve the Accuracy of Patient/resident/client Identification.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

Implementation Expectations 1A Implementation Expectations 1A Use at least two patient identifiers whenever:Use at least two patient identifiers whenever:

• 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 1B: Implement the Universal Protocol for Invasive ProceduresInvasive 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 Goal 2: Improve Effectiveness of CommunicationCommunication

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

2B Standardize a list of abbreviations, acronyms, 2B Standardize a list of abbreviations, acronyms, and symbols that are not to be used throughout the and symbols that are not to be used throughout the

organizationorganization

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 The Official OMH ““Do Not UseDo Not Use”” List Includes: 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 Communication2E: Hand Off Communication

Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions

Implementation ExpectationsImplementation 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…

Implementation ExpectationsImplementation Expectations

• Temporary responsibility for staff leaving the unit for a short time

• Anesthesiologist report to post anesthesia recovery room nurse

• Nursing and physician hand off from the emergency department to inpatient units, different hospitals, nursing homes and home health care

• Critical lab and radiology results sent to physician offices

Hand-off’s Must Allow Time for Hand-off’s Must Allow Time for Questions and AnswersQuestions and Answers

The Joint Commission wants to know how physicians and staff who work at OMH communicate a “hand off” of patient care

Institute for Healthcare Improvement recommendation:

SBAR

SBARSBAR

S=SituationB=BackgroundA=AssessmentR=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.

3B Standardize and Limit the Number of Drug 3B Standardize and Limit the Number of Drug Concentrations Available in the OrganizationConcentrations Available in the Organization

• OMH Pharmacy stocks limited concentrations and performs quality control monitoring of the crash carts for standardization of drug concentrations according to PALS and ACLS

3C 3C Identify and, at a minimum, annually review a list of look-Identify and, at a minimum, annually review a list of look-

alike/sound alike drugs used in the organization and take action alike/sound alike drugs used in the organization and take action to prevent errors involving the interchange of these drugs.to prevent errors involving the interchange of these drugs.

• OMH has an on-line formulary which contains the list of look alike/sound alike medications and the Pharmacy & Therapeutics Committee provides oversight to the annual review

3D3D

• 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:Implementation Expectations:

• 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.

Goal 3Goal 3

Reduce patient harm associated with anticoagulation therapy

Goal 4 : Goal 4 : Eliminate Wrong-site, Wrong Patient, Eliminate Wrong-site, Wrong Patient, Wrong Procedure Surgery.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 Goal 4B Implement a Process to Mark the Surgical Site and Involve the Patient in the Marking ProcessSite and Involve the Patient in the Marking Process

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 Goal 7 Reduce the Risk of Health Care Associated InfectionsAssociated 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 OUTWASH IN WASH OUT

Goal 7C MDROGoal 7C MDRO

Prevent healthcare–associated infections due to multidrug-resistant 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 Accurately and Completely Reconcile Medications Across the Continuum of Care.Medications Across the Continuum of Care.

• 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.

• 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.

Goal 9 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

Goal 13Goal 13

• Define and communicate the means for patients and families to report concerns about safety and encourage them to do so

• Encourage patients' active involvement in their own care as a patient safety strategy

Goal 15AGoal 15A

The organization identifiessafety risks inherent in its patient population

Goal 15A:The organization identifies patients at risk for suicide

Suicide Risk AssessmentSuicide Risk Assessment

“Suicide Risk Assessment”is found :

Hospital Information PageForms

Nursing

Goal 16Goal 16

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.

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

Reporting a Medical/Safety OccurrenceReporting a Medical/Safety Occurrence

Report the occurrence to the charge nurse and complete an Occurrence Form

Examples:• Medication error• Patient fall• Needle stick• Treatment error

Reporting an Employee IncidenceReporting an Employee Incidence

If something happens to an employee, they use an Employee Incident Form

Variance ReportVariance Report

• This form is used to report near misses, safety concerns, and quality concerns

• It can be submitted anonymously

Variance ReportVariance Report

• 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

Sentinel EventSentinel Event

A Sentinel Event is :

•An unexpected “event” that is serious and “sends a warning” that requires immediate attention.

•We must complete a root cause analysis (RCA) after a sentinel event or near miss that could have resulted in a sentinel event.

Sentinel Event or HFMEA ?Sentinel Event or HFMEA ?

HFMEA is :

Healthcare Failure Mode Effects Analysis

A systematic approach to identify and prevent product and process problems before they occur.

“Tapping The Wisdom of The Frontline”

•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.

C.U.S.P.C.U.S.P. Comprehensive Unit Safety ProgramComprehensive Unit Safety Program

Corporate ComplianceCorporate Compliance

• 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 ComplianceCorporate 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 You Are Valuable to OMH and Our Patientsand 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 ConcernReporting a Concern

Please contact the Patient Safety and Corporate Compliance Officer,

Bonnie Byram at 731-7703

Performance ImprovementPerformance Improvement

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.

PlanPlan DoDo CheckCheck ActAct

Professional Work EnvironmentProfessional 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 EnvironmentProfessional 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 EnvironmentProfessional 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 EnvironmentProfessional Work Environment

Prohibited Conduct• Unwanted sexual advances, including

offensive touching, pinching, brushing the body, or impeding or blocking movement.

Code of ConductCode of Conduct

The Hospital’s Board of Directors has established a Code of Conduct Policy that applies to all who work in the Hospital. A procedure has been established for reporting violations of this policy. Please refer to the full text of the policy available online to report a violation.

Code of ConductCode of Conduct

Acceptable ConductThe policy defines Acceptable Conduct as

conduct that is professional and cooperative and that positively affects the ability, or could affect the ability, of Hospital employees or physicians to perform their jobs

Code of ConductCode of Conduct

Disruptive ConductThe policy defines Disruptive Conduct as

conduct that is demeaning, abusive, intimidating, threatening or insulting and that adversely affects, or could affect, the ability of Hospital employees or physician to perform their jobs

Environmental Safety AwarenessEnvironmental 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 CodesOMH 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 CodesOMH Codes

Code Red = FireCode Red = Fire– OMH Code Red Policy– Doors are numbered and lettered for Fire

Department H – hospital M – McReynolds P - PMB

OMH CodesOMH Codes

Code RedCode 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 CodesOMH Codes

Code RedCode Red Response– R = Remove persons

from area– A = Activate fire alarm– C = Contain fire and

smoke– E = Extinguish fire or

evacuate

Fire Extinguisher use– P = Pull the pin– A = Aim toward the

base of the fire– S = Squeeze the

handle– S = Sweep the base of

the fire

OMH CodesOMH Codes

Code BlueCode 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 CodesOMH Codes

Code YellowCode 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 CodesOMH Codes

Code GreyCode 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 CodesOMH Codes

Code PinkCode 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 CodesOMH Codes

Code SilverCode Silver• If you are confronted

by an individual with a weapon OR

• If you observe a hostage situation on Hospital property

Initiating Code Initiating Code SilverSilver Plan 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

Workplace ViolenceWorkplace Violence

• Healthcare and social service workers face an increased risk of work-related assaults

• If threat is imminent, call Code GreyCode Grey Assist or Code GreyCode Grey 911

Workplace ViolenceWorkplace Violence

• 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 CodesOMH Codes

Code TriageCode Triage• 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 CodesOMH Codes

Code TriageCode Triage Responsibilities• Return to department• Phones for disaster business only• Management will implement HICS• Hospital Wide Disaster Plan• Department-Specific Plan

OMH CodesOMH Codes

Severe WeatherSevere 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)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

Environment of Care

We have 7 plans in place to assure the safety of our patients and our staff:Plan 1: Biomedical Equipment ManagementPlan 2: Emergency Preparedness ManagementPlan 3: Life safety ManagementPlan 4: Hazardous Material and Waste ManagementPlan 5: Utility systems ManagementPlan 6: Security ManagementPlan 7: Safety Management

Chemical HazardsChemical Hazards“Right To Know”“Right To Know”

Employees have the right to know how to keep themselves safe on the job

• 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 SafetyMRI Safety((Magnetic Resonance Imaging)Magnetic Resonance Imaging)

MRI SafetyMRI Safety((Magnetic Resonance Imaging)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

ErgonomicsErgonomics

• 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

Musculoskeletal DisordersMusculoskeletal Disorders

• MSD’s include disorders of the muscles, nerves, tendons, ligaments, joints, cartilage, blood vessels or spinal discs

• Be aware that risk factors related to MSD’s include movements that result in repetition, force, awkward postures, contact stress, and vibration

Comfort and Care at the End of Life

“The Purpose of End of Life Care is to create an environment to support a death, which is satisfactory to the patient and the family and is respectful of and responsive to individual preferences, culture, needs, and values while ensuring that patient/family guide all clinical decisions.

Focus on comfort, dignity and quality of life.”

Virginia Page,MSN,RN,NP Henry Ford Hospital

Please see our policy Code# MCR.h.05

Comfort and Care at the End of Life

• Managing symptoms is the goal• Fear of addiction can be a barrier to

effective pain management• Even if patients are not responsive, always

explain care/treatment

Organ and Tissue DonationOrgan and Tissue Donation

• Gift of Life-we do participate! • Organ procurement done in OR • Tissues procurement can be done at

hospital or funeral home

Gift of LifeGift of Life

• Hospital required to call all imminent deaths to Transplantation Society of Michigan

• Persons over 75 years of age can be organ/tissue donors

• Persons with HIV or Hep B can be organ donors• Bev Cherwinski, Support Group

Cultural CompetenceCultural Competence

• Treat every patient as an individual• Communicate respect• Language issues-seek translation if needed• Be aware of non-verbal communication

Infant AbandonmentInfant 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• Do not press for information

HIPAAHIPAA

• 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

HIPAAHIPAA

• 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 CommitteeEthics 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 ReferralsAppropriate 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

• Revising/updating policies/practices with ethical implications.

• Offering support for clinical or medical issues with ethical implications.

Medical Record DocumentationMedical 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 ProfessionalImpaired Health Professional

• 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.

QuestionsQuestions

• Any questions about this information can be directed to the HR Department, instructor or your department director.

The EndThe EndWelcome