The JC

BIG eBook

Quick-reference guide for staff and

licensed independent practitioners

Guam Memorial

Hospital Authority

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JC BIG eBook Guam Memorial Hospital Authority’s

Survey Readiness Guide For

Staff and Licensed Independent Practitioners HOME

December 2017 SECTION ONE: For All Staff

Mission, Vision, and Values Why Do We Do A Joint Commission Survey? Focus on Patient Safety (NPSGs/Universal Protocol) How Joint Commission Conducts a Survey What is Expected of You? Leadership Strategic Initiatives

Performance and Quality Improvement Reducing Risk and Improving Patient Safety Patient Rights & Organization Ethics Continuum of Care Infection Control Human Resources Management of the Environment of Care Disaster/Emergency Codes

SECTION TWO: Additional Info for Clinical Staff

Survey Process Related to Visits to the Patient Care Areas Advanced Directives Recording or Filming Patient Assessment Assessment and Management of Pain Nutritional Screening/Assessment Hand-off Communication-SBAR Patient Food Refrigerators

Screening for Rehab Services (Functional Screens) Restraint Information for Staff Procedural Sedation Medication Management Continuum of Care Patient Education Management of Information Medical Staff

SECTION THREE: Physician Reminders

SECTION FOUR: Guide to Accreditation/Regulatory Acronyms

SECTION FIVE: Sample Tracer Questions

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This Survey Readiness Guide has been developed and updated to provide education regarding accreditation standards, and information about how Guam Memorial Hospital Authority utilizes these standards to improve processes and continually provide exceptional care, treatment, and services to our patients and their families. Though a successful Joint Commission survey depends on a number of elements, a major key to success is the ability of our staff and licensed independent practitioners to interact with the survey team and demonstrate the exemplary care they provide. Our goal is that the information contained in this document will not only prove useful in preparing for this survey interaction, but also serve as a reference guide during our ongoing journey to excellence. Please remember that every Guam Memorial Hospital Authority staff member and licensed independent practitioner play an important role in the organization, and has an impact on the care provided to our patients. The December 2017 version of the JC Big Book: Guam Memorial Hospital Authority’s Survey Readiness Guide was updated with the assistance of the various department managers throughout the hospital.

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SECTION ONE: FOR ALL STAFF

MISSION, VISION, AND VALUES FOR THE GUAM MEMORIAL HOSPITAL AUTHORITY

The Guam Memorial Hospital Authority (GMHA) is an autonomous Government of Guam agency that was created in 1964 to administer and operate the Guam Memorial Hospital. Mission Statement: To provide quality patient care in a safe environment. Vision Statement: To achieve a culture and environment of safety and quality patient care meeting national standards and addressing the needs of the community in a fiscally responsible, autonomous hospital. Values:

Accountability Cost Efficiency Excellence in Service Safety; plus Quality

WHAT IS THE JOINT COMMISSION AND WHY DO WE HAVE THEM CONDUCT

SURVEYS?

Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. An independent, not-for-profit organization, The Joint Commission is the nation’s oldest and largest standard-setting and accrediting body in health care. The Joint Commission is governed by a Board of Commissioners that includes physicians, administrators, nurses, employers, a labor representative, health plan leaders, quality experts, ethicist, a consumer advocate and educators. Hospitals that take part in a the Joint Commission survey process do so voluntarily as a measure of achieving excellence in patient safety and quality of care. Additionally, Joint Commission is the “seal of approval” that consumers recognize and the standards help healthcare providers strive for high quality care that helps us serve our patients and families. The Joint Commission identifies 20 functions with which hospitals must comply:

1. Environment of Care 2. Emergency Management 3. Human Resources 4. Infection Prevention and Control 5. Information Management 6. Leadership 7. Life Safety 8. Medication Management 9. Medical Staff 10. National Patient Safety Goals 11. Nursing 12. Provision of Care, Treatment, and Services 13. Performance Improvement 14. Record of Care, Treatment, and Services 15. Rights and Responsibilities of the Individual 16. Transplant Safety 17. Waived Testing 18. Accreditation Participation Requirements 19. Sentinel Event Policy

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Goal 1—Improve the accuracy of patient identification.

20. Patient Safety The Joint Commission’s accreditation process seeks to help organizations identify and resolve problems and to inspire them to improve the safety and quality of care and services provided. The process focuses on systems critical to the safety and quality of care, treatment, and services. During an on-site accreditation survey, The Joint Commission evaluates an organization’s performance of functions and processes aimed at continuously improving patient outcomes. This assessment is accomplished through evaluating compliance with applicable standards in the accreditation manual (see list above), based on the following:

Tracing the care delivered to patients Verbal and written information provided to The Joint Commission On-site observations and interviews by The Joint Commission surveyors Documents provided by the organization.

The on-site accreditation survey process is data-driven, patient-centered and focused on evaluating actual care processes. The objectives of the survey are not only to evaluate the organization, but to provide education and “good practice” guidance that will help staff continually improve the organization’s performance. The on-site survey focuses on continuous operational improvement in support of safe, high quality care, treatment, and services. JOINT COMMISSION FOCUS ON PATIENT SAFETY

Joint Commission has identified patient safety risk points, called the National Patient Safety Goals (NPSGs), and expects hospitals to focus their improvement efforts on the NPSGs to ensure patient safety. Your National Patient Safety Goals (NPSGs) and Universal Protocol Responsibilities:

Know each goal and associated requirements that are applicable to your work area. Be able to explain how your work area is meeting Joint Commission’s requirements. All

clinical areas should report: o Using quality hand hygiene. o Using two patient identifiers for all procedures. o Using the write down/read back policy for critical test results.

Incorporate the requirements (when applicable) into your everyday work practices. Ask your manager if you have specific questions about the NPSGs or Universal Protocol.

Performance Expectation: Use 2 patient identifiers when:

1. Administering medications, blood or blood products 2. Collecting blood samples or other specimens for clinical testing 3. Providing other treatments or procedures

**Note: NEVER use the patient’s room number or physical location as an identifier! Label containers used for blood and other specimens in the presence of the patient (e.g., at the bedside).

National Patient Safety Goals

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Goal 2—Improve the effectiveness of communication among caregivers

Prior to banding the patient, confirm patient by verbally asking for his or her name and date of birth. Inpatients: compare name and medical record number (only in the event that the medical record number is not available, should the patient’s account number be used in the identification process). Outpatients: verbally ask for the patient’s name and date of birth Before initiating a blood or blood component transfusion: Match the blood or blood component to the order. Match the patient to the blood or blood component. Use a two-person verification process—one individual conducting the identification verification is the person who will administer the blood or blood component to the patient and the second individual is qualified to participate in the verification process. Refer to GMHA Administrative Manual, Policy No. A-PS100, Patient Identification for Clinical Care and Treatment. Performance Expectation: Report critical results of tests and diagnostic procedures on a timely basis. GMHA has defined critical test results and results for Laboratory, Radiology, Special Services, and Respiratory. These critical tests and results can be found in GMHA Administrative Manual Policy No. A-PS400, Critical Tests and Critical Results. The nurse, practitioner or physician receiving the result or value and patient identifiers shall:

Write the result or value and document in the medical record, Read the result back to the diagnostic department exactly as

documented, and Receive confirmation from the diagnostic department.

The hospital evaluates the timeliness of reporting the critical results and diagnostic procedures through its performance improvement processes. Refer to GMHA Administrative Manual, Policy No. A-PS400, Critical Tests and Critical Results.

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Goal 3—Improve the safety of using medications.

Performance Expectation: Label all medications on and off the sterile field. This includes medication containers (e.g., syringes, medicine cups, basins), and/or other solutions in peri-operative and other procedural settings, to include bedside procedures if they are not immediately administered. This applies even if there is only one medication being used. Labels must include the following information:

medication name strength amount/quantity (if not apparent from the container) diluents and volume (if not apparent from the container) expiration date when not used within 24 hours expiration time when expiration occurs in less than 24 hours

Verify all medication or solution labels both VERBALLY and VISUALLY. Verification is done by TWO individuals qualified to participate in the procedure whenever the person preparing the medication or solution is NOT the person who will be administering it. Label each medication or solution as soon as it is prepared, unless it is immediately administered. Note: An immediately administered medication is one that is prepared or obtained, taken directly to a patient, and administered to the patient without any break in the process. Immediately discard any medication or solution found unlabeled. Remove all labeled containers on the sterile field and discard their contents at the conclusion of the procedure. All medications and solutions both on and off the sterile field and their labels are reviewed by entering and exiting staff responsible for the management of medications. Performance Expectation: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. Note: This requirement applies only to anticoagulant therapy and/or long-term anticoagulation prophylaxis (for example, atrial fibrillation) where the clinical expectation is that the patient’s laboratory values for coagulation will remain outside normal values. This requirement does NOT apply to routine situations in which short-term prophylactic anticoagulation is used for venous thrombo-embolism prevention (for example, related to procedures or hospitalization) and the clinical expectation is that the patient’s laboratory values for coagulation will remain within, or close to, normal values.

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Use only oral unit-dose products, prefilled syringes, or premixed infusion bags when available. Pediatric patients should only use those preparations designed specifically for children. Use hospital-approved protocols for the initiation and maintenance of anticoagulant therapy. Before starting a patient on warfarin, assess the patient’s baseline coagulation status; for all patients receiving warfarin therapy, use a current International Normalized Ratio (INR) to adjust this therapy. The baseline status and current INR must be documented in the medical record. Implement and communicate dietary food alerts and use authoritative resources to manage potential food and drug interactions for patients receiving warfarin. When heparin is administered intravenously and continuously, use programmable pumps in order to provide consistent and accurate dosing. Ensure that baseline and ongoing laboratory tests that are required for heparin and low molecular weight heparin therapies are done. Provide education regarding anticoagulation therapy to staff, patients, and families. Patient/family education includes the following:

The importance of follow-up monitoring Compliance Drug-food interactions The potential for adverse drug reactions and interactions

The hospital evaluates anticoagulation safety practices through its performance improvement processes. Performance Expectation: Maintain and communicate accurate patient medication information.

At the time the patient enters the hospital as an outpatient or is admitted, a completed list of the current medications the patient is taking at home (including dose, route, frequency, and purpose) is created and documented. Current medications include those taken at scheduled times and those taken on an as-needed basis. The patient and, as needed, the family are involved in creating this list. The medications ordered for the patient while under the care of the hospital are compared to those on the list created at the time of outpatient entry or admission to the hospital. Any discrepancies (that is, omissions, duplications, contraindications unclear information, and changes) are identified and resolved. When the patient’s care is transferred within the hospital (for example, from the ICU to the floor), the current provider(s) informs the receiving provider(s) about the up-to-date reconciled medication list and documents the communication.

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Goal 6 – Reduce the harm associated with clinical alarm systems

Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter (e.g., name, dose, route, frequency, purpose).

Explain the purpose of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter. Instruct the patient to:

o Give a list of his or her medications to her primary care provider.

o Update the information on the list when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added.

o Carry the medication list at all times in the event of emergency situations.

Refer to GMHA Administrative Manual, Policy No. A-PS600, Medication Reconciliation-Emergency Department & Inpatient Admission; and Policy No. A-PS610, Outpatient Medication Reconciliation. Performance Expectation: Improve the safety of clinical alarm systems. Identify the most important alarm signals to manage based on the following:

Input from the medical staff and clinical departments Risk to patients if the alarm signal is not attended to or if it malfunctions Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and

alarm fatigue Potential for patient harm based on internal incident history Published best practices and guidelines

Establish policies and procedures for managing the alarms identified and at a minimum address the following:

Clinically appropriate settings for alarm signals When alarm signals can be disabled When alarm parameters can be changed Who in the organization has the authority to set alarm parameters Who in the organization has the authority to change alarm parameters Who in the organization has the authority to set alarm parameters to “off” Monitoring and responding to alarm signals Checking individual alarm signals for accurate settings, proper operation, and detectability

Educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible. GMHA Administrative Manual, Policy No. A-PS900, Clinical Alarms Management

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Goal 7—Reduce the risk of healthcare-associated infections

Performance Expectation: Comply with the Centers of Disease Control and Prevention (CDC) hand hygiene guidelines. Remember to wash your hands before and after each patient contact. Refer to GMHA Infection Control Manual, Policy No. 6201-120, Hand Hygiene Policy.

HAND HYGIENE MOMENTS Participate in hand hygiene before and after every patient contact, including before direct

contact with a patient’s intact skin. Perform hand hygiene before donning sterile gloves when inserting a central intravascular

catheter. Perform hand hygiene before donning gloves to insert invasive devices; a central

intravascular catheter, indwelling urinary catheter, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure/

Perform hand hygiene before contact with body fluids or excretions, mucous membranes, nonintact skin. And wound dressings.

Perform hand hygiene if moving from a contaminated body site to a clean body site during patient care.

Perform hand hygiene after removing gloves. Perform hand hygiene before eating and after using the restroom. Perform hand hygiene after contact with mucous membranes, non-intact skin, body fluids, or

secretions and wound dressing even if gloves were used. SURGICAL HAND ANTISEPSIS Perform surgical hand antisepsis per hospital policy. POCKET-SIZED ALCOHOL BASED HAND RUBS FROM THE OUTSIDE

When bringing pocket-sized alcohol-based hand rubs from the outside, ensure that the product is alcohol-based in gel form. The alcohol content must be between 62 to 95% alcohol. The product must not be expired.

NAILS, NAIL POLISH, ARTIFICIAL NAILS

Do NOT use nail polish that is non-transparent which blocks view of the presence of dirt/soiling under the nails.

Remove any nail polish that is not intact (e.g. has cracks, even if transparent).\do NOT wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g. those in intensive care or operating room).

Keep nail tips to less than ¼ inch long.

Performance Expectation: Implement evidence-based practices to prevent health care-associated infections due to multidrug resistant organisms in acute care hospitals. Refer to GMHA Infection Control Manual, Policy No. 6201-440, Management of Patients with Epidemiologically Significant Organisms [Multi-Drug Resistant Organisms (MDROs), Methicillin-Resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococcus (VRE)] and Policy No. 6201-490, Management of Patients with Clostridium Difficile-Associated Diarrhea.

Implement Standard Precautions for the care of all patients.

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Immediately implement appropriate Transmission-Based Precautions for patients with epidemiologically significant organisms.

Perform hand hygiene before and after patient contact and after removal of Personal Protective Equipment.

Ensure prudent antibiotic prescribing. Appropriately use Personal Protective Equipment for patients with epidemiologically

significant organisms: perform hand hygiene and wear gloves and an isolation gown prior to every room entry for patients on Contact and/or Special Contact Precautions. Remove and dispose PPE immediately after use and before leaving the patient’s room.

Ensure appropriate patient placement, preferably in a single room that has its own restroom. Whenever possible, dedicate medical equipment/devices for use on a patient on

Transmission-Based Precautions. Performance Expectation: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. Refer to GMHA Infection Control Manual, Policy No. 6201-270, Guidelines for Prevention of Intravascular Device-Related Infections.

Perform hand hygiene before and after manipulating and/or inserting any part of the intravascular device/system.

Use maximum barrier protection when inserting a central line (mask, sterile gloves, sterile gown, head cap)

Use chlorhexidine skin antisepsis appropriately and according to manufacturer’s instructions for use.

Select an optimal catheter site with the least risk for infection. Review line necessity daily and remove promptly any lines that are no longer necessary. Secure central lines appropriately and maintain the lines based on policy.

Performance Expectation: Implement best practices for preventing surgical site infections. Refer to GMHA Infection Control Manual, Policy No. 6201-80, Post-Discharge Follow-Up Surgical Site Infections

Select appropriate antibiotics for the surgery type. Ensure timely administration of preoperative antibiotic

prophylaxis and timely discontinuation of antibiotic prophylaxis postoperatively.

Appropriately remove hair only if indicated by use of clippers. Do NOT use a razor for preoperative hair removal.

Maintain postoperative glucose control especially in patients that have undergone major cardiac surgery.

Maintain postoperative normothermia especially in colorectal surgery patients. Performance Expectations: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). Refer to GMHA Infection Control Policy Manual, Policy No. 6201-290, Guidelines for Prevention of Catheter-Associated Urinary Tract Infections.

Perform hand hygiene before and after inserting and/or manipulation of the urinary catheter system.

Avoid unnecessary urinary catheteterization. Review catheter necessity daily and remove promptly unnecessary urinary catheters.

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Universal Protocol

Insert urinary catheters using aseptic/sterile technique and sterile equipment: sterile gloves, sterile drape, sterile sponge, sterile antiseptic solution for cleaning of the urethral meatus, single-use packet of sterile lubricant jelly for insertion.

Use as small a catheter as possible that is consistent with proper drainage to minimize urethral trauma.

Maintain catheters based on recommended guidelines: perform daily care; maintain a sterile, continuous closed drainage system; maintain unobstructed urine flow; empty collection bags regularly using a separate collection container for each patient, and avoid allowing the drainage spigot to touch the collecting container; keep the urinary catheter properly secured to prevent movement and urethral traction while securing the catheter for unobstructed urine flow and drainage; maintain sterility of the urine collection system; maintain meatal care with routine hygiene; ensure aseptic technique when obtaining urine specimens/samples.

Performance Expectation: Identify and assess patients at risk for suicide. Patients presenting to the ER or those who are for inpatient admission, should be evaluated to ensure they are not at risk for suicide and are not in need of a psychiatric evaluation to further determine risk. A multidisciplinary risk assessment is also conducted to identify specific environmental features that may increase the risk for suicide so that actions may be taken to maximize the patient’s safety. The Suicide Precautions policy is implemented if a patient whose assessment determines that she/he is “at-risk”. Provide information such as a crisis hotline telephone number to individuals at risk for suicide and their family members. Refer to GMHA Nursing Services Manual Policy No. 6301-II, A-8, Suicide Precautions. Performance Expectation: Conduct a pre-procedure verification process that involves the patient, when possible, to verify the correct procedure, for the correct patient, at the correct site. Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, these items include the following:

Relevant documentation (e.g., history and physical, signed procedure consent form, nursing assessment, and pre-anesthesia assessment).

Labeled diagnostic and radiology test results (e.g., radiology images and scans, or pathology and biopsy reports) that are properly displayed.

Any required blood products, implants, devices, and/or special equipment for the procedure. **Match the items that are to be available in the procedure to the patient!

Mark the procedure site.

Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety.

Mark the procedure site before the procedure is performed and, if possible, with the patient involved.

Goal 15— The hospital identifies safety risks inherent in its patient population.

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The procedure site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed. In limited circumstances, the licensed independent practitioner may delegate site marking to an individual who is permitted by the organization to participate in the procedure and has the following qualifications: (1) An individual in a medical residency program who is being supervised by the LIP performing the procedure, is familiar with the patient, and who will be present during the procedure; (2) An advanced practice registered nurse (APRN) or physician assistant (PA) who is familiar with the patient, and who will be present during the procedure.

The method of marking the site and the type of mark is unambiguous and is used throughout the hospital.

Use an alternative process for patients who refuse site marking or when it is technically or anatomically impossible to mark the site.

Perform a time-out immediately before starting the invasive procedure or making the incision.

The time-out has the following characteristics: It is standardized. It is initiated by a designated member of the team. It involves the immediate members of the procedure team, including the individual

performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning.

When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated.

During the time-out, the team members agree, at minimum, on the following: Correct patient identity (Remember to use two patient identifiers!) The correct site The procedure to be done

Document the completion of the time-out. Refer to GMHA Administrative Manual, Policy No. A-PS200, Universal Protocol Corrective Site.

Remember, The Universal Protocol also applies for invasive and other procedures performed outside the operating room and procedural areas, such as at the bedside and in the physician’s office!

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HOW DOES JOINT COMMISSION CONDUCT A SURVEY?

The cornerstone of The Joint Commission survey, the Tracer Methodology¸ is an evaluation method in which Joint Commission surveyors select actual patients, and use their medical records as roadmaps to move through the organization and follow the experience of the patient through the entire health care process. As surveyors follow the course of the patient’s treatment, they assess the organization’s compliance with Joint Commission standards, observe and talk to staff in areas that the patient received care, and evaluate the organization’s systems for delivering safe, quality health care and services. What are the primary objectives of tracer activities?

- To follow the course of care and services provided to the patient - To assess relationships and hand-off communication between disciplines - To evaluate performance of relevant processes (e.g., pain management, restraints, surgery,

etc.) - To assess and evaluate compliance with Joint Commission standards

- Which patients are likely to be “traced”?

Patients with frequently seen diagnoses (the key populations for which we provide care) - Patients who have received multiple and complex services (often those patients close to

discharge) - Patients who cross programs (e.g., hospital and practice) - Patients who encounter these processes: Infection Control, Medication Management,

Surgery, Dialysis, Sedation, Outpatient Care, Interventional Radiology

How many patients will be “traced,” and how long will the tracers take? - The number of tracers completed can vary, but anticipate at minimum two (2) patient tracers

per surveyor per day - Tracers can take 90 minutes or more per patient - Tracers begin in the setting where the patient is located, and move to other areas the patient

has encountered or is scheduled to encounter

What will the surveyor do during a tracer? Review the medical record with Staff

Observe direct patient care

Observe the medication process

Observe the care planning process

Observe the equipment use

Review competencies, evaluations, and continuing education for staff and licensed independent practitioners with whom the surveyor has interacted

Interview the patient and/or family

Review additional medical records, as needed, from other settings

Observe staff and licensed independent practitioner interactions

Observe the environment of care and environmental safety

Discuss National Patient Safety Goals

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HOW TO WORK WITH SURVEYORS

Ask questions if you do not understand. NEVER argue with the surveyors. Be professional and use appropriate language and behaviors. If you do not know an answer, say so, and tell the surveyor where or to whom you would go for the answer. Remember you may use any resources available to you, such as policies, department resources, or your manager. Whenever possible, answer in your own words and keep your answers short and to the point. KISS = Keep It Short and Simple. If you are present when someone else is being interviewed, feel free to add any relevant information without being intrusive. Respond to questions with confidence—you know the answers better than anyone. Speak freely about all of the great things we do---and there are many!

- Patient safety and performance improvement are always very important things to know about.

- Relax-surveyors are physicians, nurses, medical technologists, engineers, and others who have worked in hospitals. They have “been there”!

- Always be honest. Falsification or misrepresentation is absolutely not tolerated and can cause the organization to lose its accreditation.

- Just as in sports, success is dependent on teamwork. Excellent patient care is no different. Your communication and interaction with other members of the health care team is critical to providing excellent care for the patient!

DO be familiar with the information in this booklet. DO wear your hospital identification badge above your waist. DO let your confidence, knowledge, and pride in Guam Memorial Hospital show. DO provide examples from your experience when answering questions. Your examples need

to show the surveyor that you understand that your everyday duties are based on our policies, procedures, and/or mission.

DO make sure doorways are not blocked open or shut. DO make sure that hallways and/or passages are not blocked or used for storage. These are

serious safety violations. (Anything left idle for 30 minutes is considered having been stored.) DO remove surgical masks and shoe covers when leaving surgical areas.

KEEP YOUR ANSWERS FOCUSED AND SPECIFIC TO THEIR QUESTION

BE TRUTHFUL

KEEP THE CONVERSATION PROFESSIONAL

SUPPORT YOUR CO-WORKERS

OTHER TIPS ON PROFESSIONAL INTERACTION WITH SURVEYORS

FINAL REMINDERS FROM PREVIOUS SURVEY FINDINGS

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DO make sure you do not discuss patients in hallways or elevators or in other public areas. DO make sure that employees and visitors do not smoke in any GMHA building or

immediately outside the doors. GMHA is tobacco-free inside and outside. DO know what interim life safety measures are in place at GMHA and be able to explain what

role we play if a Fire Watch is in effect. DO make sure that fire extinguishers, medical gas shut-off valves, and electrical system panels

and annunciators are not blocked AND that you know where these are located in your area. DO make sure that medications are secured (i.e., medication rooms and carts are locked and

that the key is kept with a nurse and not in a drawer). DO make sure that any opened multi-dose vials are labeled with the 28-day expiration date. DO make sure that the daily shift checks have been completed (e.g., narcotic and stock

medication counts, crash carts and defibrillators, medication and patient food refrigerator temperature logs, as well as sterile room temperature and humidity logs).

LEADERSHIP

Leadership for GMHA provides an organizational framework for establishing services that respond to community and patient needs.

The governing board of the hospital sets the organizational tone that supports quality patient care.

The board does this by creating our mission, vision, and bylaws. The board ultimately appoints the medical staff of the hospital. The board expects us to take part in process improvement efforts, particularly as they pertain

to patient safety. GMHA key leaders include:

BOARD OF TRUSTEES Eloy S. Lizama Chairman of the Board Lillian Q. Perez-Posadas Vice Chairperson Melissa Waibel Secretary Vacant Treasurer

Ricardo M. Terlaje, MD Trustee Sharon J. Davis Trustee Jeanine Cruz Ex-officio Member

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HOSPITAL LEADERS PeterJohn D. Camacho, MPH Hospital Administration/CEO Vincent A. Duenas, MD Associate Administrator of Medical Services/ Chairperson, Ethics Committee Kozue Shimabukuro, MD Assistant Administrator of Medical Services/ Assistant Administrator of Professional Support Benita Manglona, CPA, CGMA Chief Financial Officer Gordon Mizusawa, REH Chief Environmental Services/ Chairperson, Environment of Care (EOC) William Kando, MSM Hospital Chief Planner/Vice Chairperson, EOC / Emergency Management Director Veronica Cruz, BSN, RN Performance Improvement Coordinator, Acting Danielle Manglona, MSN, MBA, RNC, CPPS, CPHRM Compliance Officer/Chairperson, Patient Safety Committee, Acting

Zennia, Pecina, MSN, RN, CCHP Assistant Administrator of Nursing Services Rhodora Cruz, MSN, RN, CEN Deputy Assistant of Nursing Services, Acting Jeffrey Ventura Hospital Safety and Security Administrator Yvonne Damian, BSN, RN, ICC Infection Control Practitioner Maria L. Perez, MBA Guest Relations Coordinator Aurora Cabanero Risk Management Program Officer/ HIPAA Compliance Officer Vincent Quichocho Hospital Information Technology Administrator/ HIPAA Security Officer Michael Klemme, RHIT Medical Health Records Administrator/ HIPAA Privacy Officer

STRATEGIC INITIATIVES

Strategic planning at GMHA is a thoughtful and deliberate process that involves key stakeholders across the organization. Particular attention has been paid to building a broad consensus and to taking a data-driven approach for short- and long-term planning. The GMHA leadership determined the following strategic goals to be most important in fulfilling the mission and vision of the hospital:

Achieve Financial Stability Leadership Team Development Establish and Sustain Safety and Quality Culture Training and Education Assessment and Implementation Capital Improvement Planning and Implementation

Specific objectives and strategies were established to achieve results within this framework, and performance is reported in a variety of ways, including data dashboards. PERFORMANCE AND QUALITY IMPROVEMENT

Performance and Quality Improvement involves using improvement science, methods or techniques and continuous monitoring in order to achieve the following:

Performance Improvement (PI) Reduction of system or process

inefficiencies, defects/errors Example – implementation of a system such

as Computerized Physician Order Entry (CPOE) to eliminate potential/actual errors from illegible handwriting

Quality Improvement (QI) Achievement of the best patient outcomes

(end results) possible Example – decreasing the incidence of

pressure ulcers through preventative measures such as identifying risk factors via assessment instruments (such as a risk scoring tool)

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The ultimate goal of Performance and Quality Improvement is to support GMHA with realizing its Mission, Vision, Core Values and strategic priorities. Expectations:

Be prepared at any time to provide an example of how services or care has improved. Know what your department is monitoring, what your compliance rate is, and what improvement opportunities your department or the organization has done.

Each area uses PI tools, such as graphs, to display quality and performance improvement data. Other examples of PI tools: flowcharts, check sheets, data collection/audit sheets, line graphs, Run charts, Pareto charts, control charts and matrices.

How are YOU involved in Performance Improvement efforts?

Suggesting improvements when needed. Participating in hospital-wide surveys and questionnaires. Reporting unusual events through the event reporting process (see Reducing Risk and

Improving Patient Safety). Maintaining standards and best practices related to outcomes and, care and organizational

processes. Such process include: Quality core measures, National Patient Safety Goals (NPSGs), patient/family satisfaction, pain management and other quality and safety measures.

Participating in efforts to improve quality and safety. Performance/Quality and Oversight Structure At GMHA, oversight begins with the governing board. The Board of Trustees is ultimately responsible for performance and quality improvement throughout the organization. The Board directs the Medical Executive Committee and the Executive Management Council to oversee performance and quality initiatives. Improvement activities and projects are then conducted via a variety of forums, which include the Performance Improvement Committee, performance improvement meetings at the division and department levels, related committees, and task forces. Performance/Quality Improvement priorities For 2017 and moving forward, the identified performance improvement priorities include:

Improve Patient Safety and Quality o NPSG compliance monitoring o Trend, Analyze, Act, Feedback on Patient Safety Events (adverse events, medical

errors) o Reduce patient harm from falls and hospital-acquired pressure ulcer incidences

Improve Satisfaction o Monitor/Improve Patient Satisfaction (includes perception of safety, quality of care) o Collect data on Staff Satisfaction (opinions, needs, morale, etc.)

Monitor External Regulatory Compliance Indicators o Operative or other procedures that place patients at risk of disability or death o All significant discrepancies between preoperative and postoperative diagnoses,

including pathologic diagnoses o Adverse events related to using moderate or deep sedation or anesthesia o Use of blood and blood components o All reported and confirmed transfusion reactions o The results of resuscitations o Behavior Management (restraints use) o Significant medication errors o Significant adverse drug reactions o Patient perception of the safety and quality of care, treatment, or services o Centers of Medicare/Medicaid Services (CMS)/The Joint Commission (TJC) Core

Measures/ORYX data (e.g. Emergency Department Throughput, Influenza

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Immunization, Sepsis Early Management Bundle, Perinatal Care/Elective Delivery, Stroke Care, Venous Thromboembolism Care)

o Data (with review and analysis) on Incidents where the radiation dose index (computed tomography dose index [CTDIvol], dose length product [DLP], or size-specific dose estimate [SSDE] from diagnostic CT examinations exceeded expected dose ranges identified in imaging protocols; with comparisons to external benchmarks

o Data on patient thermal injuries that occur during magnetic resonance imaging (MRI) exams

o Data on incidents where ferromagnetic items unintentionally entered the MRI scanner room

o Data on injuries resulting from the presence of ferromagnetic items in the MRI scanner room

What is the process used for quality improvement activities? FOCUS-PDSA Know what measures are monitored and analyzed in your area. Your department may be involved in monitoring and evaluating measures such as, patient satisfaction, employee satisfaction, compliance with the national patient safety goals (NPSGs), use of restraints, medication errors, patient falls, or other high-volume, high-risk, problem-prone issues. Your department, division, and the Performance Improvement Committee (PIC) coordinate the collection and reporting of performance and quality indicator data for ongoing monitoring. This data is part of the hospital-wide performance improvement indicators related to quality (improved health outcomes), efficiency, patient safety (reduction of errors, prevention of harm and adverse events)

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and/or compliance (regulatory requirements). It is reviewed routinely to identify trends and compare performance to established targets. The Centers for Medicare and Medicaid Services (CMS) Quality Indicators (CART data) and The Joint Commission ORYX Core Measures, patient satisfaction and other department-specific performance and quality indicator reports use internal data to compare performance with hospital expectations. Some use externally sourced data for comparisons. Opportunities for improvement are identified through performance measurement and use of comparative data. CMS Reporting and Abstraction Tool (CART) and Joint Commission Core Measures The Joint Commission Core Measures, now called Hospital Quality Measures,” are publicly reported as part of the National Voluntary Hospital Reporting Initiative. These Hospital Quality Measures include data regarding the following:

Immunization (IMM) Severe Sepsis and Septic Shock (SEP) Venous Thromboembolism (VTE) Perinatal Care (PC) Emergency Department (ED)

The GMHA participates in the Hospital Quality Initiative and provides data to the Quality Improvement Organization using the CMS’ Abstraction and Reporting Tool (CART). Participation in this initiative is a requirement of both CMS and The Joint Commission. It is important to be familiar with the quality measures related to your service/department in order to continuously improve performance. Please ask your manager if you have any questions about the CART Data or the Joint Commission Core Measures. What education has been provided regarding Performance Improvement?

Orientation Staff Meetings In-services (written, classroom, and departmental)

Please be prepared to discuss how you are involved in improving patient care and services at GMHA by filling in the blanks for the following statements: How have you participated in Performance Improvement / Quality Improvement? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What performance/ quality indicators or measures does your department monitor? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List two examples of how your department has improved patient care (hint: one example may be related to the national patient safety goals (NPSGs): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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REDUCING RISK AND IMPROVING PATIENT SAFETY

GMHA promotes a culture of safety that is blame-free and encourages any employee or patient to report concerns about safety or quality of care so that “Lessons Learned” can be a benefit for all. Medical Adverse Events and Near Misses Events and “near misses” should be reported through the Risk Management Office. Patient Safety Forms (also known as the “blue forms”) are available on all departments and are to be given to the Risk Manager within 24 hours. The Risk Manager is also available 24 hours a day via pager or you may call the Patient Safety and Medication Concern HOTLINE at 648-6763. It is important to report all medical errors/events and near misses to:

Learn from them. Prevent future adverse events. Proactive improve systems.

Any employee who has concerns about the safety or quality of care provided in the organization has several options for action:

1. Address the issue with your Supervisor. 2. Report the concern using the Patient Safety Form (aka “blue form”). 3. Page the Risk Manager via the Communications Center. 4. Call Patient Safety and Medication Concern HOTLINE. 5. If concerns are NOT addressed through internal processes, Joint Commission may be

contacted: Division of Accreditation Operations Office of Quality Monitoring The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 Fax: 1.630.792.5636 Email: complaint@jointcommission.org GMHA supports a non-punitive environment for employees to report errors, accidents, and mistakes. How are Unanticipated Outcomes disclosed to patients? The attending physician is responsible for coordinating the discussion with the patient and/or family when the outcome of the treatment plan or procedure significantly differs from what was anticipated by the healthcare team. This practice is based on three principles:

All patients should be informed of outcomes that differ significantly from what was anticipated to be the result of a treatment or procedure.

Accurate information should be relayed to the patient in a timely manner. Administrative and medical staff leaders are available to assist you.

Refer to GMHA Administrative Manual, Policy A-PS810, Disclosure of Unanticipated Outcomes Sentinel Events Joint Commission defines a sentinel event as “a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following: Death, Permanent Harm, Severe Temporary Harm.”

An event is also considered sentinel if it is one of the following: Suicide of any patient receiving care, treatment and services in a staffed around-the-clock

care setting or within 72 hours of discharge, including from the hospital’s emergency room Unanticipated death of a full-term infant

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Abduction of any patient receiving care, treatment, and services Discharge of an infant to the wrong family Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of

any patient receiving care, treatment, and services while on site at the hospital Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of

a staff member, licensed independent practitioner, visitor, or vendor while on site at the hospital

Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups)

Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure.

Unintended retention of a foreign object in a patient after surgery or other invasive procedures

Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter) Prolonged fluoroscopy with cumulative dose >1,500 rads to a single field or any delivery of

radiotherapy to the wrong body region or >25% above the planned radiotherapy dose Any elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock

setting (including the ER), leading to death, permanent harm, or severe temporary harm to the patient.

Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care

Any intrapartum (related to the birth process) maternal death Severe maternal morbidity (not primarily related to the natural course of the patient’s illness

or underlying condition) when it reaches a patient and results in permanent harm or severe temporary harm

Based on this definition, if you believe a sentinel event has occurred, please report it through the appropriate chain of command and enter it into the reporting system by completing the Patient Safety Form (also known as the “blue form”) and submitting it to the Risk Management Program Officer within 24 hours of the event’s occurrence. Sentinel Event Team The Patient Safety Officer and Risk Management Program Officer use predetermined criteria and a standard process for determining if an unusual event should be classified as a sentinel event. A Sentinel Event Team is created and tasked to understand why and how an event occurred and to put steps in place to prevent it from happening again. This is done through a comprehensive systematic analysis and is the process of identifying the causal and contributory factors, root causes, and corrective actions to eliminate or control system hazards or vulnerabilities directly related to these factors. If the Joint Commission surveyor asks you about a Sentinel Event, or if we have had a Sentinel Event, how should you respond? Sentinel events should not be discussed with surveyors. Tell the surveyors that they need to speak with the Patient Safety Officer for information. Refer to GMHA Risk Management Manual Policy No. A-PS800, Patient Safety Program, and GMHA Administrative Manual Policy No. A-PS700, Root Cause Analysis for Sentinel Events. Proactive Risk Reduction Strategies Some examples of the methods used to proactively reduce risk are listed below:

Joint Commission National Patient Safety Goals Joint Commission Sentinel Event Alerts Healthcare Failure Mode Effects Analysis (HFMEA)

Healthcare Failure Mode and Effects Analysis (HFMEA)

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HFMEA is a systematic method used for identifying and preventing process problems before they occur and is one of the ways our organization proactively reduces risk, as required by the Joint Commission. This method has been adapted to health care from a commonly used tool in the automotive and aerospace industries. GMHA completed the following HFMEAs:

Critical Tests and Critical Results Reporting (2008) Crash Cart Restocking Process (2008) Medication Stock in the Emergency Room (2009) Magnetic Resonance Imaging Patient Procedures (2010) Patient Safety Reporting System (2011) Telemetry Unit Bedside Monitoring System (2015) Clinical Alarms Management (2015-2016)

WAIVED TESTING Test(s) being conducted

Blood Glucose (Accuchek) Pregnancy Testing

Areas that Conduct Waived Testing:

Emergency Room Urgent Care Operating Room Labor and Delivery Intensive Care Unit/Critical Care Unit Nursery/NICU

Quality Control Vials

1. Put new expiration dates on the QC bottles upon opening. 2. Conduct QC testing as required. 3. Complete at least one set of controls annually to maintain certification/competency

for the testing. The test procedure is located in the Laboratory User Manual within the departments designated for waived testing. PATIENT RIGHTS AND ORGANIZATION ETHICS

Where can you find a list of Patient Rights and Responsibilities?

Patient Registration, Outpatient areas, and the Emergency Room All Inpatient Units GMHA Website GMHA Administrative Manual, Policy No. A-RI200, Patient Rights and Responsibilities;

and Policy No. A-RI210, Patient Rights for Children/Adolescents Confidentiality The HIPAA Privacy Rule must be followed to ensure patient privacy. All medical records must be kept private. Conversations about a patient’s care must protect the patient’s privacy. Patient information in any form must be protected. It should not be shared without proper approval of the patient. Refer to GMHA HIPAA Policies and Procedure Manual, Policy No. 6420-1, Confidential Information Ways to maintain confidentiality include:

Be aware of where you are and who is around when talking about patients.

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Keep medical records secure at all times. Never leave a computer without signing off. Never share your documentation password with anyone. Access patient information only for patient care or job-related purposes. Do not talk about patients and their care in public areas where others can overhear, such as

in: o Halls o Elevators o Lobbies o Cafeteria

Keep charts closed and in the correct location when not in use. Do not leave voicemail messages with detailed patient information. Send patient information by secure e-mail only (encrypted). Do not place diagnosis-specific information about a patient on room signs of white boards

where visitors could see it. Place material with patient information in a secured area when shredding is pending. Do not include a patient’s name in the subject line of an email. Never place patient information in a regular trashcan.

How does the hospital respect a patient’s privacy?

Follow correct release of information procedures. Close doors or curtains during patient care. Interview patients in a private setting or offer a more private setting where possible. Speak as softly as you can when getting information from patients.

Who are the HIPAA Leaders of GMHA?

HIPAA Security Officer: Vincent Quichocho……………………………………..…….647-2207 HIPAA Privacy Officer: Michael Klemme…………………….…………………………..647-2162 HIPAA Compliance Officer: Aurora Cabanero………………………..……………….648-6763

Non-English-Speaking/Hearing-Impaired Patients Interpreters may be needed to communicate during treatment, office visits, or hospital stays. A list of hospital approved interpreters is provided to each department. In addition, the hospital contracts with Cyracom which provides telephonic language interpretation services. TDY/TDD services are available through the hospital’s Communications Center. If you need assistance you may call the Guest Relations department at 647-2503, EEO Office at 647-2218, or the Communications Center at 647-2330. Is there a formal mechanism through which patients and families may voice a complaint or concern? We encourage patients to share concerns with a member of their healthcare team, physician or department/unit manager. If you receive such information, we encourage you to follow up with the appropriate individuals or departments to attempt to resolve the issue to their satisfaction. If staff members/managers need assistance with resolving a patient complaint, call: Guest Relations department…………………………647-2503 (for quality of care complaints) Safety Office…………………………………………………647-2407 (for safety concerns) Patient Safety Chairperson, acting………………..648-6769 (for patient safety concerns) If a patient feels his/her concern has not been resolved internally within the organization , he/she may file a written grievance. Although most concerns can be resolved through this process, if at any time a patient feels their concerns are not being addressed, they may contact the Joint Commission or the Centers for Medicare and Medicaid:

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Division of Accreditation Operations Division of Survey and Certification Office of Quality Monitoring Centers for Medicare and Medicaid The Joint Commission Department of Health & Human Services One Renaissance Boulevard 90 7th Street, Suite 5-300 (5W) Oakbrook Terrace, IL 60181 San Francisco, CA 94103-6707 Fax: 1.630.792.5636 Telephone: 1.415.744.3696 Email: complaint@jointcommission.org If you learn that a patient is or may become a victim of abuse:

Report all information to the patient’s nurse or your supervisor. During evenings and weekends, contact the Nursing Supervisor.

1. All patients seen in the Emergency Room or who are admitted will be assessed by a nurse for

possible factors that may suggest abuse, neglect, or violence. If one or more of the high-risk factors are found, the nurse contacts the patient’s doctor and Social Services.

2. Nurses must follow the policy guidelines for documentation in the medical record, Social Services consult and reporting requirements to Law Enforcement and/or Adult Protective Services/Child Protective Services.

Refer to GMHA Administrative Manual, Policy No. 6431-10, Referral to Adult Protective Services; and Policy No. 6431-7, Child Protective Services. Employee Conduct Standards The GMHA Code of Ethical Conduct and Personnel Rules and Regulations outline the hospitals commitment to ethical business and clinical behavior. They can be found in:

GMHA Website GMHA Administrative Manual, Policy No. A-LD300, Code of Ethical Conduct; and Policy No.

A-LD500 Disruptive and Inappropriate Behavior; and Policy No. 6170-3, Disruptive Practitioners.

Human Resources Office The expectation for employees is discussed during the General Orientation. Bioethical Issues When treatment opinions for the patient’s medical plan of care differ: 1. Try to resolve these concerns through talks with the:

Patient Family Physicians Other healthcare team members

2. A consult to the Ethics Committee can be asked for by the: Patient Family Healthcare team member To request a consult, call the Communications Center at 647-2330.

Refer to GMHA Administrative Manual, Policy No. A-RI100, Ethics Committee Guidelines. CONTINUUM OF CARE

Key Concepts:

1. The importance of the continuum of care is to provide appropriate patient services to meet patients’ ongoing health needs from prevention to illness, convalescence and recovery in the appropriate care setting.

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2. Access to care is driven by a patient’s assessed needs and the hospital’s ability to provide care that meets those needs. Each department has an identified scope of service that addressed the focus for that area. All staff members need to be knowledgeable of their department’s scope.

3. Communication between caregivers and across care sites is critical to facilitating the continuum of care.

INFECTION CONTROL

HAND HYGIENE:

PERFORM HAND HYGIENE AS INDICATED, SUCH AS DURING THE FOLLOWING:

When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or body fluids, wash hands with either non-antimicrobial or antimicrobial soap and water.

Hand hygiene must take place before and after patient contact, including before direct contact with a patient's intact skin (taking a pulse or blood pressure, etc.).

Perform Hand Hygiene before donning gloves to insert invasive devices; a central intravascular catheter, indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure.

Perform hand hygiene before and after any procedure on a patient. Perform hand hygiene after glove removal and contact with body fluids or excretions, mucous

membranes, non-intact skin, or excretions, and wound dressings. Perform hand hygiene if moving from a contaminated-body site to a clean-body site during

patient care. Perform hand hygiene after contact with inanimate objects (including medical equipment)

and surfaces in the immediate vicinity of the patient. Perform hand hygiene after removing gloves. Perform hand hygiene before eating and after using the restroom.

NOTE: Hands should be washed with soap and water if contact with spores, (e.g., C. Difficile, Bacillus anthracis) is anticipated. Antiseptic agents such as alcohols, chlorhexidine, iodophors, etc., have a poor activity against spores.

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A surveyor may watch you wash your hands and time you to make sure that you have soap on your hands for at least 15 seconds. ALCOHOL-BASED HAND RUB:

If hands are not visibly soiled, use an alcohol-based hand rub for decontaminating hands.

A waterless alcohol hand rub is available throughout the hospital. It is the preferred method of hand hygiene when hands are not visibly soiled. When C. difficile precautions are in place, care providers must wash their hands with soap and water instead of using alcohol hand rub.

Approprriate Handwashing Procedure

1. Wet your hands with clean, running water (warm not hot water) and apply an appropriate amount of

soap/product (as recommended by manufacturer) to hands.

2. Rub your hands together to cause a lather and

scrub them well; be sure to scrub all surfaces of

the hands including the backs of your hands,

between your fingers, and under your nails.

3. Continue rubbing your hands for 15 to 20 seconds.

o Need a timer? Hum the "Happy Birthday"

song from beginning to end twice (2x).

4. Rinse your hands well under running water while avoiding touch contamination with surfaces of the sink.

5. Dry your hands thoroughly using a clean disposable

paper towel.

6. Turn off the faucet using a clean, dry disposable

paper towel for faucets that require hand control.

Appropriate Procedure for Use of an Alcohol Hand Rub

l. Apply product to the palm of one hand and rub hands together.

Follow the manufacturer's recommendations regarding the volume of product

to use (ensure the amount applied is sufficient enough to cover all surfaces of

the hands).

2. Rub product on all surfaces of the hands and fingers until hands are dry.

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SURGICAL HAND ANTISEPSIS: Surgical hand antisepsis is required preparation prior to surgical procedures. See the Operating Room Manual policy on Surgical Hand Antisepsis. HAND HYGIENE AGENTS BROUGHT IN FROM THE OUTSIDE: Healthcare Workers may bring in pocket-sized hand rubs for use while providing patient care as long as the following are met:

Product must be alcohol-based The alcohol content must be between 62 to 95% alcohol Product must not be expired The product must be gel-like agent (not foam-like).

NAILS, NAIL POLISH, ARTIFICIAL NAILS:

Do NOT use nail polish that is non-transparent which blocks view of the presence of dirt/soiling under the nails.

Remove any nail polish that is not in tact (has cracks, even if transparent). Do NOT wear artificial fingernails or extenders when having direct contact with patients at

high risk (e.g., those in intensive care or operating room). Keep natural nail tips to less than ¼ inch long.

STANDARD PRECAUTIONS:

STANDARD PRECAUTIONS: Standard Precautions represent the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These evidence-based practices are designed to both protect healthcare personnel and prevent the spread of infections among patients. Standard Precautions include:

1. Hand hygiene, 2. Use of Personal Protective Equipment (e.g., gloves, gowns, facemasks), depending on the

anticipated exposure, 3. Respiratory hygiene and cough etiquette, 4. Safe injection practices, and 5. Safe handling of potentially contaminated equipment or surfaces in the patient

environment.

Summarized Recommendations for Application of Standard Precautions for the Care of All Patients

Component Recommendations

Hand hygiene After touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts

Personal protective equipment (PPE)

Gloves For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin

Mask, eye protection, face shield During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions

Gown During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions and excretions is anticipated

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Soiled patient-care equipment Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visible contaminated; perform hand hygiene

Environmental control Follow procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas

Textiles and laundry Handle in a manner that prevents transfer of microorganisms to others and to the environment. Appropriately place used linen in the designated yellow linen bin.

Needles and other sharps Do not recap, bend, break or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; place used sharps in puncture-resistant container

Patient resuscitation Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions

Patient Placement Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminated the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection

Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter, i.e., triage and reception areas in emergency departments and physician offices)

Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, greater than three (3) feet if possible. For a patient with a cough, place a surgical mask on the patient prior to transport within the facility for medically necessary procedures.

PERSONAL PROTECTIVE EQUIPMENT

Personal Protective Equipment (PPE) PPE such as exam gloves, gowns, face shields, and masks should be available in all areas where there is a risk of exposure to blood or other body fluids. Be able to locate PPE in your area. These equipment include gloves, gowns, masks, and face shields. They are intended for the protection of the user but, must also be used in a way to minimize touch contamination of the patient and the environment. Gloves: Gloves should be donned whenever there is a possibility of contact with the patient’s blood or body fluids, mucous membranes or non-intact skin; when manipulating or handling potentially contaminated patient care equipment and/or environmental surfaces. This protects both the patient and the health care workers. Gloves must be available in all sizes and non-allergenic materials. It is often necessary to change gloves while caring for a patient to prevent cross-contamination from one patient site to another. Whenever gloves are changed, hand hygiene should be practiced before donning a clean pair of gloves. The integrity of the glove may be compromised even if not visible to the eye. Gloves should never take the place of hand washing. Gloves should not be worn outside the patient room and should be removed and disposed of before removing other PPE. Perform hand washing or hand antisepsis as soon as possible after glove and PPE removal. Gloves are not to be washed or decontaminated for reuse (exception: utility gloves)

Caution: Gloves do not provide protection from needle sticks or other puncture wounds caused by sharp objects. Use extreme caution when handling needles, scalpels, etc.

Isolation Gowns: Gowns should be worn to protect the health care workers clothing from being contaminated with a patient’s blood or body fluids and/or other transmittable infectious agents.

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Protective apparel is worn to reduce the risk of exposure to a patient’s blood or body fluids and is mandated by OSHA, as are all of the PPEs. Gowns are always worn in conjunction with gloves and other PPEs as indicated by the extent of contact with infectious agents or blood/body fluids. Gowns should be removed in the patient’s room. The outer side of the gown should be rolled inward to prevent contaminating the health care worker’s uniform. It should be discarded into a designated container. Masks: Masks should be worn to protect the mouth, nose and part of the facial skin. Masks are an important part of PPEs as they can prevent the transmission of infectious agents from the health care worker to the patient when performing a sterile procedure and the mask also protects the health care worker from the patient’s large droplets, which are produced from coughing should the patient have a respiratory infection. Masks used to protect mucosal surfaces against large droplets, splashes and sprays should not be confused with particulate respirators (e.g. N95), which are used to protect against small droplets containing infectious agents, which are transmitted via the airborne route. Goggles and Face Shields: Goggles and face shields should be used during procedures that are likely to generate droplets, spray, or splash of body substances to prevent exposure to mucous membranes of the nose and eyes. Various types of goggles and face shields must be available to fit the differing facial shapes and contours of all health care workers. Removal of gloves should be done before removing the face shield, goggles or mask. Particulate Respirators: Respiratory protection through the use of a NIOSH approved N95 dust/mist respirator is an OSHA requirement for all health care worker to protect them against M.Tuberculosis. N-95 respirators are used in caring for patients with SARS, Varicella zoster (chicken pox), small pox and measles. Respirators should be used when caring for all patients in AII Isolation. The respirator should be removed directly outside the patient’s room and may be reworn by the HCW if the integrity of the mask is intact, i.e., not wet or torn. Refer to GMHA Infection Control Manual, Policy No. 6201-130, Personal Protective Equipment

SAFE INJECTION PRACTICES SAFE INJECTION PRACTICES:

Use aseptic technique in handling parenteral medications and sterile injection equipment.

Needles, cannulae and syringes are sterile, SINGLE-use items, they should not be reused (even if it is for the same patient) for another patient nor to access a medication or solution that might be used for a subsequent patient. --Always use a new sterile syringe and needle to draw up medication.

It is NOT acceptable to use the same syringe to give an IM or IV injection to more than one patient even if the needle is changed between patients and even if draw-backs are not practiced before injecting. A small amount of blood can flow into the needle and syringe even when only positive pressure is applied outward. The syringe and needle are both considered contaminated and must be discarded appropriately.

Use fluid infusion and administration sets (i.e. intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set.

Use single-dose vials for parenteral medications whenever possible. Do not administer medications from single-dose vials or ampules to multiple patients or

combine leftover contents for later use.

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If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. The port of the multidose vial must be scrubbed with 70% alcohol prep prior to every accession.

Assign multi-dose vials to a single patient whenever possible. Handling, preparation, and storage of medications and all supplies used for injections

and infusions – e.g. syringes, needles, intravenous (IV) tubing—in a manner that prevents microbial contamination.

Do not keep multidose vials in the immediate patient treatment area or store in accordance with the manufacturers recommendations; discard if sterility is compromised or questionable.

Medications should be drawn up in a designated “clean” medication preparation area. In general, any item that could have come in contact with blood or body fluids should be kept separate.

Do not use bags or bottles of intravenous solutions as a common source of supply for multiple patients.

Medications should be discarded upon expiration or any time there are concerns regarding the sterility of the medication.

Multidose vials that have been opened must be labeled with date, time, and initials. Manufacturers instructions should be referenced for recommendations on time frame for disposal of an opened multidose vial. If no recommendation is stated, the general rule is that multidose vials must be discarded by 28 days of initial opening, if expiration of the medication is met, or if contamination is questionable, whichever of these comes first.

A needle should never be left inserted into a medication vial septum for multiple uses. This provides a direct route for microorganisms to enter the vial and contaminate the fluid.

Absolute adherence to proper infection control practices must be maintained during the preparation and administration of injected medications.

TRANSMISSION BASED PRECAUTIONS TRANSMISSION BASED PRECAUTIONS used at GMHA include the following:

Contact Precautions Special Contact Precautions Droplet Precautions Airborne Infection Isolation Precautions

CONTACT PRECAUTIONS:

These precautions are to be used to reduce the risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient’s environment.

Examples of these organisms are multiple drug-resistant organisms (MDROs) such as MRSA and VRE. Contact Precautions should be applied empirically if the patient being admitted has a history of Multi-Drug Resistant Organism (MDRO) until such time as a surveillance culture can be obtained and reported as negative or other criteria have been met as determined by the Infection Control Preventionist and/or designee.

Patients should be in a single room or cohorted with another patient who has the same Multi-Drug Resistant Organism.

Healthcare personnel must do hand hygiene and wear a gown and gloves prior to room entry for a patient on Contact Precautions. Masks should be worn if patient care involves the possibility of splatter to the Healthcare Worker’s mucous membranes or for any aerosolizing procedures. Contact precautions should be used whenever a patient presents with excessive wound drainage, or other body discharges that can increase the risk of Multi-Drug Resistant

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Organism transmission. See IC Policy on Management of Patients with Multi-Drug Resistant Organisms.

All Personal Protective Equipment (PPE) should be removed and discarded appropriately in the patient’s room before exiting. Gloves, mask and gowns should not be worn outside the patient’s room once care of the patient has been initiated.

Nursing staff are responsible for ensuring that PPE are readily accessible. Hand hygiene should always be done before leaving the room, either with soap and water or

alcohol-based hand rub. Healthcare Workers should always explain the necessity of Personal Protective Equipment

and Expanded Precautions to the patient and patient’s family. It is the responsibility of the patient’s nurse to ensure that Patient Family Education on Contact Precautions is provided. A hard copy of the signed Patient Family Education form must be placed in the patient’s medical record.

Visitors are restricted. A watcher/support person is allowed as long as they comply with the same precautions. The nurse has the authority to restrict a watcher/support person from room entry.

Affix the Contact Isolation Sign to the door. Contact Precautions for patients with Clostridium difficile are managed by use of Special

Contact Precautions which can be discontinued when the patient’s diarrhea is resolved. Consultation can be made with infection control to determine the discontinuation of Contact Precautions for all other conditions/diseases.

DROPLET PRECAUTIONS:

Droplet precautions are used to reduce transmission of infectious agents from close respiratory or mucous membrane contact, i.e., less than six (6) feet.

N. Meningitidis, B. Pertussis, Influenza and SARS are a few of the infectious agents that are transmitted via large droplets. Droplets do not remain suspended in the air, and are not transmitted by the airborne route.

Masks are required for direct patient contact (when within 6 feet of the patient). However, because these droplets are so large, they do not remain suspended in the air and, therefore, N95 masks are not required. A regular mask (surgical or procedural mask) is appropriate. Masks should not be worn outside the patient’s room once care of the patient has been initiated. Masks should be disposed of in the patient’s room.

Nursing staff are responsible for ensuring that PPE are readily accessible. Hand hygiene should always be performed before leaving the patient’s room. Patients on Droplet Precautions should be placed in a private room unless otherwise directed

by Infection Control. They are to be restricted to their room except for medically necessary procedures, in which case, a regular mask (surgical or procedural mask) is to be placed appropriately on the patient prior to transport.

It is the responsibility of the patient’s nurse to ensure that Patient Family Education on Droplet Precautions is provided. A hard copy of the signed Patient Family Education form must be placed in the patient’s medical record.

Visitors are restricted. A watcher/support person is allowed as long as they comply with the same precautions. The nurse has the authority to restrict a watcher/support person from room entry.

Affix the Droplet Precautions Sign to the door. AIRBORNE INFECTION ISOLATION (AII):

Formerly known as Airborne Precautions (Respiratory Isolation), these precautions are intended to reduce the risk of airborne transmission of important and virulent infectious agents.

Diseases in this category of precautions include Rubeola Virus (measles), Varicella Zoster (Chickenpox), and M.Tuberculosis.

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Required patient placement: This category requires a single patient room equipped with negative air flow, increased air exchanges per hour (minimum of 12 air exchanges per hour) and air exhausted directly to the outsid. The room must be equipped with special air handlers and ventilation capacity that meet AIA/FGI standards, as stated above. See Infection Control Policy, Airborne Infection Isolation Rooms and Instruction for Use.

All hospital staff entering the room must wear a NIOSH approved N-95 mask that they have been fit-tested for on hire and annually thereafter. See Safety and Security Manual (Listed on the Related Policies section of this policy).

Visitors are restricted. A watcher/support person is allowed as long as they comply with the same precautions. The nurse has the authority to restrict a watcher/support person from room entry.

Watcher/support persons entering the room must wear a regular mask (surgical/procedural mask) prior to room entry.

Use of the particulate respirator (e.g. N95) must be based on manufacturer’s recommendations for use.

Healthcare Workers who do not have a known immunity to measles, chicken pox and small pox should not care for patients with these diagnoses. Healthcare Workers immune* to chickenpox or measles may enter the room for patients with these diagnosis without wearing a mask.

o *The varicella vaccination is NOT 100% effective in conferring immunity to chickenpox. Health care workers who have not had the disease but have been vaccinated shall refrain from entering the room of a patient with chickenpox or disseminated zoster when there are other immune caregivers available.

Patients should be confined to their room except for medically necessary purposes, in which case, a regular mask (surgical or procedural) is worn by the patient at all times outside the negative pressure environment.

Affix Airborne Infection Isolation Sign on the patient’s door. SPECIAL CONTACT PRECAUTIONS: Special Contact Precautions have been incorporated for use at GMH for those patients who have symptomatic Clostridium Difficile Associated Diarrhea (CDAD) even in the absence of laboratory confirmation. Patients on this type of precaution must be placed in a private room or cohorted. Hand hygiene shall be done using soap and water (alcohol hand rubs are not effective against spore-forming bacteria). Full barrier precautions (gown and gloves) shall be worn when staff is in contact with patient with CDAD and for contact with their body fluids and environment. PPE should be donned prior to entry. PPE must be removed before exiting the room and hand washing must be practiced. Dedicated patient care equipment shall be used. If items must be shared, cleaning and disinfecting must be done between patient-use by use of a hypochlorite –based disinfectatnt unless contraindicated per manufacturer’s instructions. Disposable dietary trays shall be ordered for use on these patients when possible. Patient transfers must be limited as much as possible. Environmental cleaning and disinfecting must be done using an Environmental Protection Agency (EPA) registered hypochlorite based disinfectant in accordance with label instructions Refer to GMHA Infection Control Manual Policy No. 6201-240, Expanded Precautions (Contact Precautions, Droplet Precautions, and Airborne Infection Isolation). Refer to GMHA Infection Control Manual Policy No. 6201-490, Management of Patients with Clostridium Difficile Associated Diarrhea.

CLEANING, DISINFECTING, AND STERILIZATION CLEANING, DISINFECTING, AND STERILIZATION: Cleaning, disinfection, and/or sterilization, as appropriate, of environmental surfaces, medical devices/equipment in healthcare are fundamental in reducing their potential contribution to the incidence of healthcare-associated infections. CLEANING:

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All objects to be disinfected or sterilized should first be thoroughly cleaned to remove all organic matter (blood and tissue) and other residue.

Large-surface cleaning methods that produce mists or aerosols or disperse dust in patient-care areas is prohibited.

Always use safety precautions and protective equipment as outlined in the Safety Data Sheet (SDS).

DETERMINING THE LEVEL OF DISINFECTION OR NEED FOR STERILIZATION: Determining the level of disinfection or need for sterilization of items in patient care must take into account the intended use of the item, whether the item is reusable (or single-use) and the manufacturer’s instructions. The four categories for decision making can be found in the table below.

Table on Device Classification for Determination of Processing Type Device Classification Device Examples Type of Process Environmental Surfaces:

1. Medical Equipment Surfaces

2. Housekeeping Surfaces

Knobs or handles on hemodialysis machines, x-ray machines, instrument carts, medication carts Floors, walls, tabletops

Cleaning followed by low-level disinfection cleaning

Non Critical Medical Devices Devices that touches intact skin

Stethoscopes, bedpans Cleaning followed by low-level disinfection (exposure time ≤10 minutes)

Semi-Critical Medical Devices Touches mucous membranes or broken (non-intact) skin

Flexible endoscopes, laryngoscopes, endotracheal tubes, respiratory therapy and anesthesia equipment, diaphragm fitting rings

High-level disinfection (exposure time ≥20 minutes)

Oral/rectal thermometers, hydrotherapy tanks

Intermediate-level disinfection (exposure time ≤10 minutes)

Critical Medical Devices Enters sterile tissue or vascular system

Implants, scalpels, needles, other surgical instruments, and endoscopic accessories

Sterilization (cycle time per manufacturer); Liquid sterilants (exposure time in hours per manufacturer)

LOW TO INTERMEDIATE LEVEL DISINFECTION:

Cleaning must come before disinfecting processes are initiated. Disinfecting of equipment must be based on their Device Classification and Processing Type.

Manufacturer’s instructions for recommended disinfection guidelines must be referenced and followed. Apply appropriate concentrations of disinfectant with the appropriate time frames based on manufacturer’s recommendations.

Do not perform disinfectant fogging in patient care areas. In the absence of manufacturer’s instructions, follow certain procedures:

o Clean non-critical medical equipment surfaces with a hospital-approved detergent/disinfectant. This may be followed with an application of an EPA-registered hospital disinfectant with or without tuberculocidal claim (depending on the nature of the surface and degree of contamination), in accordance with disinfectant label instructions.

o Do NOT use alcohol to disinfect large environmental surfaces. o Use barrier protective coverings as appropriate for non-critical equipment surfaces

that are:

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touched frequently with gloved hands during the delivery of patient care; likely become contaminated with blood or body substances; or difficult to clean (e.g. computer keyboards).

Always use safety precautions and protective equipment as outlined in the Material Safety Data Sheet (MSDS).

HIGH LEVEL DISINFECTION AND STERILIZATION:

Indications for Sterilization and High-Level Disinfection o Critical medical devices or patient-care equipment that enter normally sterile tissue

or the vascular system or through which blood flows should be subjected to a sterilization procedure before each use.

o Laparoscopes, arthroscopes, and other scopes that enter normally sterile tissue should be subjected to a sterilization procedure before each use; if this is not feasible, they should receive at least high-level disinfection. Please see Related Policies section of this policy.

o Equipment that touches mucous membranes, e.g., endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment, should receive high-level disinfection.

Methods of Sterilization: o Whenever sterilization is indicated, a steam sterilizer should be used unless the

object to be sterilized will be damaged by heat, pressure, or moisture or is otherwise inappropriate for steam sterilization. In this case, another acceptable method of sterilization should be used. Manufacturer’s recommendations must be followed.

o Flash sterilization [270°F (132°C) for 3 minutes in a gravity displacement steam sterilizer] is not recommended for implantable items and must be used minimally with evaluation of means to minimize us of this form of sterilization (e.g. instrument purchase and surgeon preference cards

Biological Monitoring of Sterilizers: o All sterilizers should be monitored at least once a week with commercial preparations

of spores intended specifically for that type of sterilizer (i.e., Bacillus stearothermophilus for steam sterilizers and Bacillus subtilis for ethylene oxide and dry heat sterilizers).

o Every load that contains implantable objects should be monitored. These implantable objects should not be used until the spore test is found to be negative at 48 hours.

o If spores are not killed in routine spore tests, the sterilizer should immediately be checked for proper use and function and the spore test repeated. Objects, other than implantable objects, do not need to be recalled because of a single positive spore test unless the sterilizer or the sterilization procedure is defective.

o If spore tests remain positive, use of the sterilizer should be discontinued until it is serviced.

Use of Sterile Items : An item should not be used if its sterility is questionable, e.g., its package is punctured, torn, or wet.

Responsible Personnel: o Each department should have a unit-specific listing of all environmental surfaces,

medical equipment, and medical devices that are applicable to their department. This listing should include the following information:

appropriate agent for cleaning, disinfecting or sterilization The frequency for cleaning The accountable personnel Documentation/log requirements

o Although such lists may not be all-inclusive, it is the responsibility of the department manager to ensure that the cleaning/disinfecting/sterilization needs are addressed based on federal agency guidelines and manufacturer’s instructions.

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Refer to GMHA Infection Control Manual, Policy No. 6201-180, Guidelines for Cleaning, Disinfecting, and Sterilization.

RED BIOHAZARDOUS WASTE What trash goes into red bag with biohazard sign?

Blood bank bags and tubing Liquid or semi-liquid blood or other body fluids Items that release bloods or fluids if compressed Items that are caked with dried blood or other fluids that could flake off when handled Sharp Containers that have been secured to prevent spillage Laboratory wastes Pathological wastes

YELLOW TRACE CHEMOTHERAPY WASTE

What trash goes into yellow bag with Trace Chemotherapy Waste Sign?

• “RCRA empty” vials, syringes, IV bags, and tubing. • Gowns, gloves, wipes and other paraphernalia associated with routine handling, preparation,

and administration of chemotherapy; and, • Wipes and other materials used during routine cleaning and decontamination of a Biological,

Safety Cabinet or Glove Box (Unless alcohols, phenols or other hazardous materials are used). How is Trace Chemotherapy Waste Disposed?

• Proper PPE is used in transport of yellow trace chemotherapy waste. • Housekeeper will collect yellow waste and transport in a cart, with cover, to • Gowns, gloves, wipes and other paraphernalia associated with routine handling, preparation,

and administration of chemotherapy; and, • Wipes and other materials used during routine cleaning and decontamination of a Biological,

Safety Cabinet or Glove Box (Unless alcohols, phenols or other hazardous materials are used).

EXPOSURE CONTROL PLAN The Exposure Control Plan Hospital policy that protects employees from exposure to blood and body fluids at work. It is based on the OSHA Occupational Exposure to Blood Borne Pathogens Standard. Refer to GMHA Infection Control Manual, Policy No. 6201-190, Sharps Injury Protection Plan and Policy No. 6201-380 Exposure Control Plan Infection Control Questions and Concerns:

Call the Infection Preventionist at 647-2555 Refer to the GMHA Infection Control Manual available on the GMHA Website at

http://www.gmha.org.

TUBERCULOSIS EXPOSURE CONTROL PLAN The Tuberculosis (TB) Prevention and Exposure Control Program The hospital’s program includes:

Early/prompt detection and evaluation of suspected or Active TB. Prompt initiation of airborne precautions of suspected infectious TB cases Recommended medical management of patients with suspected or confirmed TB disease Functional environmental controls Implementation of the respiratory protection program, and TB testing every six months for staff that work in patient care areas

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Ongoing HCW training and education regarding TB Proper implementation of the TB Exposure Control plan Recognize and correct lapses in infection control

Refer to GMHA Infection Control Manual, Policy No. 6201-420, Tuberculosis Exposure Control Plan.

EMPLOYEE TUBERCULOSIS SCREENING EMPLOYEE TUBERCULOSIS (TB) SCREENING: Employee Health Services shall perform baseline and/or periodic screening of all hospital employees according to their TB risk category.

LOW RISK = Baseline screening upon hire; further screening not required unless exposure occurs or otherwise indicated.

MEDIUM RISK = Baseline screening upon hire then annually. HIGH RISK = Baseline screening upon hire then every six months.

SCREENING FOR EMPLOYEES WITH UNPROTECTED EXPOSURE TO TUBERCULOSIS (TB)

Employees who have had unprotected exposure to a patient with a bacteriologically positive case of Mycobacterium Tuberculosis will be screened and medically followed.

The department manager on duty for the departments identified will be responsible for obtaining a listing of all staff that are identified as exposed and provide the listing to the Employee Health Services Department.

Employee Health will ensure that baseline TB screening is done for prioritized contacts based on their TB status and a post-exposure screening will be done in 8-10 weeks.

HEALTHCARE WORKER IMMUNIZATIONS

IMMUNIZATIONS = All employees (initial and existing) will be assessed for vaccination history and immune status for the required vaccine-preventable diseases.

1. Hepatitis B Vaccine is given, free of charge, to all employees especially those who may be exposed to blood or body fluids. Vaccine is given in three doses: the initial dose, a second dose in one month from the first dose, and third dose in six (6) months from the first dose.

2. Influenza Vaccine is offered to all hospital employees annually, as soon as it becomes available. The best way to protect against influenza is to receive an influenza vaccination every year.

3. Tdap/Tetanus-diphtheria-acellular pertussis 4. MMR/Measles, mumps, rubella vaccine

Refer to Employee Health Services Policy # 6202-130, Employee Health Service Immunizations.

SHARPS INJURY OR BLOOD/BODY FLUID EXPOSURE WHAT TO DO IN CASE OF NEEDLESTICK INJURY OR BLOOD/BODY FLUID EXPOSURE?

1. Wash the affected area immediately 2. Notify your immediate Supervisor regarding the incident 3. Proceed to the Emergency Room to be evaluated by the Physician. Initial blood tests will

be drawn for HBV, HCV, and HIV. 4. The Physician will also determine if HIV prophylaxis is needed 5. Report to Employee Health Office located at the 4th floor annex for further instructions 6. Employee Health will check if the injured employee is up-to-date with Tetanus

(Td/Tdap) vaccine and Hepatitis B vaccine

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7. Employee will be given a schedule on follow-up laboratory testing: 6 weeks, 3 months and 6 months post-exposure.

Refer to Employee Health Services Policy # 6202-110, Blood/Body Fluid Post-exposure testing and Prophylaxis. Where you can find directions about what to do if you are stuck with a needle or have blood or other materials splashed into your eyes/mouth at work?

Notify your supervisor for assistance. Contact the Employee Health Office at 648-6765/4. After hours, contact the Emergency Room

at 3-2491, 3-2489, or 3-2281. Refer to: Employee Health Services, Policy No. 6202-110, Blood/Body Fluid Post-exposure testing and Prophylaxis. HUMAN RESOURCES

Orientation and Competency All new Guam Memorial Hospital staff members should participate in orientation experiences that include:

An orientation covering topics such as mission, vision, values, compliance, safety and customer service.

Orientation to their business/clinical units Orientation to their departments Orientation to individual positions.

o Review of position-specific competencies o Ongoing learning activities to perform job responsibilities

Documentation of orientation and competency assessments should be maintained in the employee’s department file.

The Performance Review discussion is a time to review position competencies and discuss development plans and goals for the coming year.

General orientation information is given to law enforcement officers and custodial agents. This provides them with basic safety and security information to them while assigned to patients. This information can be obtained from Security.

Diversity We have developed guidelines to help caregivers provide appropriate care to patients of the different age groups and the populations we serve. We also have comprehensive foreign language Interpretive Service and Services for the Hearing-Impaired that ensure that we can communicate with all of our patients and their families. These help us meet the physical, cognitive and psychosocial needs of our diverse patient population. Managing Staff Requests A staff member may request to be excused from participating in an aspect of a patient’s care or treatment in situations where the care or treatment presents a perceived conflict with the staff member’s ethics or religious beliefs consistent with our policy. The manager will work to make reasonable accommodations for that staff member unless patient care will be negatively affected. It is expected that all staff will provide treatment and care to all patients without regard to disability, race, creed, color, gender, national origin, lifestyle or ability to pay. Refer to Nursing Services Manual, Policy No. 6301-I D-5, Nursing Staff’s Rights.

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How to find policies and procedures The GMHA Web site contains hospital-wide policies, including:

The Administrative Manual The Safety and Security Manual The Emergency Preparedness Manual The Hazardous Material and Waste Management Manual The Infection Control Manual

To access these policies log onto http://www.gmha.org. Select departmental policies under the employee portal. Policies that are sensitive in nature, such as security policies, emergency preparedness policies, and some hazardous material and waste management policies can only be obtained by logging into the hospital’s intranet. Hard copies of these manuals are also available in each unit/department. MANAGEMENT OF THE ENVIRONMENT OF CARE

How does the hospital manage the Environment of Care? Oversight of management of the Environment of Care is managed by the:

Environment of Care Committee Guam Memorial Hospital Leadership

Every Guam Memorial Hospital employee has responsibility for the Environment of Care. To provide guidance for management of the Environment of Care, the Guam Memorial Hospital Leadership has created eight management plans that are updated annually. The management plans are:

Safety Security Hazardous Materials and Waste Fire Safety Medical Equipment Utilities Emergency Management Life Safety

GMHA is required to conduct an Annual Hazard and Vulnerability Assessment (HVA) to:

Calculate the Probability, Severity and Risks associated with GMHA’s eight (8) areas of the Environment of Care;

Enable GMHA to determine the greatest threats that it faces; and Focus GMHA’s mitigation, preparedness, response and recovery efforts through capital

improvement and capital equipment projects, training, exercises, etc. What are the top ranked naturally occurring hazards identified as a result of the Regional HVA conducted in 2016?

Inundation from Rising Sea Levels (89%) Drought (72%) Earthquake (72%) Volcano Eruption (72%) Tropical Cyclone (67%) Invasive Species (67%) Landslide (61%) Fire, External Environment (61%)

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What are the top ranked human hazards identified as a result of the Regional HVA conducted in 2016?

Terrorism, Cyber Attack (78%) Terrorism, Explosives Attack (67%) VIP Situation/Incident (50%)

What is your responsibility as an employee for the Environment of Care?

To maintain a safe working environment for patients, visitors and staff To identify, correct and/or report any safety hazards To follow all policies and procedures

How do you report unsafe environmental conditions?

Notify your supervisor Call Facilities Maintenance Department at 3-2224/2192 for repairs Call Safety at 3-2117/2407 for other environmental issues

These items must remain ACCESSIBLE and UNOBSTRUCTED:

Medical Gas Shut-off Valves Electrical System Panels and Annunciators Fire Extinguishers Means of egress

Hospital Non Smoking Policy: The Guam Memorial Hospital is tobacco-free inside and outside. For more information on the Tobacco-Free Environment: Safety Office at 3-2117/2407 Refer to GMHA Safety and Security Manual, Policy No. 216, Smoke Free Environment. Employee Identification badges All employees (physicians, staff, students, and volunteers) are required to wear their ID badges above the waist, with the photo outwardly displayed. High-risk Security “Sensitive” Areas in Guam Memorial Hospital: ● Obstetrical Unit ● Emergency Department ● Labor and Delivery ● Operating Room ● Nursery ● Medical Records ● Pharmacy ● Management of Information Services ● Pediatrics ● Security/Control Center ● Intensive Care Unit ● Patient Affairs (Cashier Window) Refer to GMHA Safety and Security Manual, Policy No. 102, Physical Security Management Plan. SECURITY, INFANT ABDUCTION, ‘Code Pink’ Procedure

Alert Communications Center. Call 3-2222 and state “Code Pink”, the location of the occurrence, any description of the infant/child and suspected abductor, if available. The Communications Center will announce “Code Pink” three times (X3).

Hospital lockdown: All units will follow the lockdown assignment and lock doors, hospital-wide.

Department Surveillance Responsibilities 1. Look for suspicious persons, activities or articles.

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2. Go to assigned observation point and establish a checkpoint for anyone entering/exiting through doors. At no point should anyone be allowed out to the balcony areas during code pink.

3. Question in detail, if possible, anyone carrying an infant or a large bag or package that could conceal and infant, or anyone hurrying out of the building.

4. If you cannot detain suspicious person, note description and details. Report to Security immediately by calling 3-2222.

5. Remain at designated observation point until relief or you hear Dr. Clearwater announced overhead.

Refer to GMHA Safety and Security Manual, Policy No. 403, Infant/Pediatric Security Plan. Safety Data Sheets (SDSs) The Hazardous Communication Standard (Right to Know Law) entitles all employees to be made aware of any hazardous materials they may come in contact with in the workplace. SDSs provide information on hazardous materials/chemicals, including details on physical dangers, safety procedures, and emergency response techniques.

Each unit/work area should have the SDS available for items in that area. To access SDS electronically, go to http://www.gmha.org and select GMHA Online SDS Search

under the Employee Portal. The master file of SDSs is kept in Materials Management and the Safety Office and is available

at all times. The Emergency Department also has a copy as well. Contact Materials Management at 3-2165 to get SDS if the internet or computers are down or the Emergency Room at 3-2491/2489 after regular business hours.

Refer to GMHA Hazardous Materials and Waste Management Manual, Policy No. HZ105, Safety Data Sheet (SDS). Symbols of Warning

Biohazard Materials & substance, transferring Human Infection. Radiation Radiation producing devices or materials Poison Substance or chemical can cause serious injury or death if swallowed or inhaled

Corrosive Chemicals can burn/damage the skin, eyes, or mucous membranes

Carcinogen Substance that can increase risk of cancer Fire hazard Warning to not expose the material to sparks, flames, or heat sources Explosive Dangerous and may release a tremendous amount of energy Compressed gas Gases bottled under great pressure and indicates (carefully handling)

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Oxidizer Substance to burn more easily

HAZMAT SPILL RESPONSE GUIDELINES Small Spills Less than 10 mL in size

Obtain spill kit and follow manufacturer's instructions. Don appropriate personal protective equipment Clean up spill Dispose of accordingly Complete GOSHA 900 Form, Hazardous Material/Waste Spill Emergency Report, Patient

Safety Form(blue form) Small Spills 10 to 49 mL in size

Immediately islolate, contain, and barricade the area. Report the spill to Supervisor, Safety Office, and Safety Administrator

If substance known: Follow clean up procedures for the specific substance Ensure adequate ventilation and if necessary, notify FM to adjust the ventilation and/or

exhaust systems Don appropriate personal protective equipment Clean up spill Dispose of accordingly Complete GOSHA 900 Form, Hazardous Material/Waste Spill Emergency Report, Patient

Safety Form (blue form) If substance unknown:

Notify the Hospital Administrator/CEO and the Safety Administrator who will then notify GFD, EPA, and GOSHA.

Refer to GMHA Hazardous Materials and Waste Management Manual, Policy No. HZ110, Procedures for Hazardous Materials and Waste Spills or Exposures (Hazardous Spills LESS THAN 50mL in Size). CODE YELLOW (Hazardous Spills Greater Than 50 mL in size)

Contact the Safety Administrator (who will investigate and determine whether to activate the Spill Response Team Members)

Isolate, contain, and barricade the area. If activated, a Security and/or Safety Officer will report to control traffic; the Spill Response

Team will report and clean up the spill. The Chief of Environmental Services will obtain additional spill kits as needed. Dispose of accordingly Complete GOSHA 900 Form, Hazardous Material/Waste Spill Emergency Report, Patient

Safety Form(blue form) Refer to GMHA Hazardous Materials and Waste Management Manual, Policy No. HZ111, Code Yellow (Hazardous Spills GREATER THAN 50mL in Size). DR. BURNSITE– Fire:

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What to do: R – Rescue person(s) who is in immediate danger

A – Alert staff in the area with hospital code word “Dr. Burnsite;” have someone call the Communications Center (3-2222); and have someone pull the Fire Alarm Pull Station

C – Confine fire by closing all doors E – Extinguish or Evacuate How to use a fire extinguisher: P – Pull the pin between the handles of the extinguisher A – Aim the nozzle at the base of the fire S – Squeeze the handles together to discharge S – Sweep from side-to-side at the base of the fire to extinguish

Immediate Area Evacuation

Each section of the hospital shall have a map of the evacuation routes conspicuously posted close to nearest exits and in corridors. The maps show the locations of:

o Exits o Fire extinguishers o Oxygen shut-off valves o Fire alarm pull stations in the immediate area o Adjacent smoke compartment(s)

Isolate in Place:

To isolate patients, staff, and visitors from fire and smoke while emergency personnel respond to the situation. During a fire:

Portable oxygen is provided for the patient away from the fire. The Hospital Nursing Supervisor on-duty in coordination with the Charge Nurse is

responsible for shutting off oxygen to the area. Fire Extinguishers All fire extinguishers are checked through the Safety Office. If a surveyor wants to see the records, direct him or her to the Safety Office located on the second floor of the Z-wing or call 3-2117/2407. Refer to GMHA Safety and Security Manual, Policy No. 217, Fire Prevention and Protection Plan. Storage of oxygen cylinders All cylinders must be stored in appropriate holders. Oxygen tanks must be segregated into full and empty areas and NOT be stored together. “In Use” cylinders are considered empty and must be stored appropriately. To avoid confusion, different gases must NOT be stored together. The maximum number of full cylinders that can be stored per fire compartment is 12 small/”E” cylinders. How do you know patient care equipment has had preventive maintenance (PM) performed?

Patient care equipment has a unique inventory number with date of next PM. Equipment used for patient care should NOT be past its PM date.

If a problem occurs with patient care equipment, remove it from the patient, tag the equipment as “out of service,” contact Bio-med at 3-2192 or 3-2224, and obtain back-up equipment.*

o The department manager manages non-patient care equipment

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o Questions concerning medical equipment can be answered by calling Bio-medical Shop at 3-2122 or Facilities Maintenance Department at 3-2192 or 3-2224.

*Refer to your department-specific Medical Equipment Failure Response Plan and/or GMHA Equipment Management Manual Policy No. EM6480-004, Medical Equipment Failure Interventions. UTILITIES: Emergency Power Emergency power outlets are identified by having a red outlet and cover or a red cover and ivory outlet. In the event of an island power failure, the emergency generators will energize and provide emergency power throughout the hospital within 10 to 15 seconds. If you do not have emergency power in your area within 10 to 15 seconds, immediately call Communications Center at 3-2222 or the Power Plant at 3-2225. During a disaster/emergency situation:

Stay calm and alert; Report to your supervisor for instructions; Listen for instructions via the GMHA Public Address System or through the Media; and Be prepared, as you may be asked to join a labor pool to assist busy areas within GMHA’s

Hospital Incident Command System (HICS). Incident Command Post (ICP) The GMHA Incident Command Post (ICP) is an area where key hospital leaders will manage the response to a disaster/emergency situation:

Primary ICP: GMHA Boardroom, 1st Floor. Telephone Numbers: 647-2109/2204/2208/2210/2314/2391 Alternate ICP: GMHA Medical Library, 4th Floor.

Emergency Response Preparation Be an active participant through the following activities:

Participate in Training and Exercises; Know where policies and procedures are located (e.g., Emergency Preparedness Manual,

Safety and Security Manual, etc.); Know your roles and responsibilities for the various hazards; Communicate with your Supervisor if you have questions/concerns regarding your roles and

responsibilities during disaster/emergency situations; and Contact the Planning Department (3-2221/2316) if you have emergency preparedness

questions; 3-2215/2217 for Safety issues; and 3-2218/2319 for Security issues. Additional emergency response-related materials are located in the Emergency Preparedness Manual located in each department and on the GMHA Web site: http://www.gmha.org. EMERGENCY CODES

Code Description Call Ext. Dr. Burnsite Fire 3-2222 Dr. Redwood Mass Casualty 3-2222 Dr. Clearwater All Clear 3-2222 RRT Rapid Response Team 3-2222 Code 72 Cardiac/Respiratory Arrest 3-7200 Code 60 Security Disturbance 3-2222 Code 99 Bomb Threat 3-2222 Code Yellow Hazardous Spill/Leak 3-2222 Code Pink Infant/Child Abduction 3-2222 Code Red SNU Emergency 647-2222 Code Black Active Shooter 3-2222

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(1) In the event of an emergency first notify the Communications Center by calling call the above numbers. (2) In the event that there is no answer at the above numbers call Security at 3-2319. (3) In the event that there is no answer at either of the numbers above send a runner to the Communications Center. NOTES:

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SECTION TWO: ADDITIONAL INFORMATION FOR CLINICAL/PATIENT CARE STAFF

SURVEY PROCESS RELATED TO VISITS TO THE PATIENT CARE UNITS

Joint Commission surveyors will start with a patient’s chart and follow the patient through his/her care. Additionally, when surveyors evaluate the plan of patient care, they will observe some actual patient-care activities and meet with the interdisciplinary patient-caregivers. The intent of this approach is to validate patient care.

Be certain an individual has proper identification prior to looking at confidential patient information.

Be sure to ask the patient’s permission prior to a patient-care observation or interviews. ADVANCE DIRECTIVES

What are the hospital staff responsibilities regarding Advance Directives? An Advance Directive allows patients to express their wishes regarding health care. Examples include a living will or a Durable Power of Attorney for healthcare or refusal of blood components. When a patient is being registered for admission, the Patient Service Representatives will ask the patient if he/she had an Advance Directive or if he/she would like to execute one. This information is documented on the patient’s chart. When the Advance Directive becomes available, whether newly executed or a copy brought from home, it is placed in the patient’s chart. If a patient presents a DNR form or verbal request, PLEASE CONTACT THE PATIENT’S PHYSICIAN TO WRITE THE DNR ORDER. The physician must physically write the DNR order after completing required documentation. Telephone orders for DNR are not acceptable. How does a patient execute an Advance Directive? You may contact the Guest Relations Office at 3-2503 or Patient Registration at 3-2238 (1st Floor) or 3-2431 (2nd Floor). If the resource(s) above is not available, a nurse may assist the patient in completing the Advance Directives. Copies of the forms are available through the Guest Relations Office and Patient Registration Office. Withdrawal or Withholding of Life-Sustaining Treatment This is addressed in the Do Not Resuscitate Orders Policy as well as in both the Advance Directives and Informed Consent policies. Who do you notify of a patient’s death?

Page the Hospital Nursing Supervisor via the Communications Center. Refer to GMHA Administrative Manual, Policy No. A-RI400, Patient Self-Determination (Advance Directives) and Policy No. A-RI500, “Do Not Resuscitate” (DNR) Orders. RECORDING OR FILMING

In order to ensure the patient’s privacy and confidentiality, what documentation is required before patient can be filmed or recorded? When recording or filming is to be used only for internal organizational purposes such as performance improvement or education, or if the recording or filming is to be used for external purposes that include the possibility of being heard or seen by the public, the patient must sign a specific, separate consent that includes the circumstances of the use of the recording or film. Consent forms are available from the Guest Relations Office at 3-2503. Media organizations must always be accompanied by the Public Information Officer, Acting or a representative.

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Refer to GMHAA Health Insurance Portability and Accountability Act Manual, Policy No. 6420-1, Confidential Information. PATIENT ASSESSMENT

Patient assessment is essential to determine what kind of care is required for patients as well as to determine patient responses to care delivered. Initial assessments must be completed within 24 hours following admission. Adequate documentation of the initial assessment requires that all sections of the applicable Patient Data Bases are completed and follow-through on positive screens is documented, including physician orders requested, when appropriate. Refer to GMHA Nursing Services Manual Policy No. 6301-I E-1, Electronic Based Documentation Guidelines. ASSESSMENT AND MANAGEMENT OF PAIN

Joint Commission surveyors will check to see how well we are implementing these standards. The standards require us to assess all patients for the presence of pain at the time of admission (or at the time of the outpatient visit). For patients with pain, we assess and document the patient’s description of pain, location and duration, intensity and quality of pain, aggravating/alleviating factors as well as how patient’s day-to-day life caused pain, as well as how patients have been treating their pain. Reassessment for pain is completed after each intervention for pain.

Intensity of pain should be rated by the patient using an intensity scale of 0-10, with 10 representing the worst pain manageable for the patient. For patients who cannot communicate verbally, the Wong-Baker “faces tool” is the appropriate tool. The Critical-Care Pain Observation Tool is used primarily in the intensive care setting for intubated patients. The Pediatrics Population may also use the FLACC (Face, Legs, Activity, Cry, and Consolability) and NIPS (neonatal/infant pain scale) tools.

If no pain is found on admission, the patient is asked throughout his/her stay at periodic intervals (every four hours as the “fifth vital sign”) if pain has appeared.

Pain must be assessed and documented after each intervention and within the time period designated.

Our approach to pain management/interventions will also be surveyed, so it is important to document ongoing assessments for pain as well as relief measures, such as medication and other interventions designed to alleviate pain in the iMedPain Assessment Flowsheet. How we manage pain is a significant determinant of patients’ satisfaction with the care they receive. Documentation of reassessments following interventions (to determine the effectiveness of pain management) is also important. A target for reassessment after intervention is within 30 to 60 minutes. Refer to GMHA Nursing Services Manual Policy No. 6301-II C-12, Pain Management. NUTRITIONAL SCREENING/ASSESSMENT

All patients are screened for nutrition risk within 24 hours upon admission. As part of the initial nursing assessment, nursing will complete a nutrition screening using the diagnostic criteria as established. Affirmation of a special diet order, nutrition related diagnosis, or nutrition related condition triggers an identified nutrition risk level for referral to the dietitian. The dietitians provide comprehensive nutrition assessment and nutrition care planning for all patients determined to be at high risk. All assessments and reassessments are documented in the patient’s medical record. A patient’s nutrition risk level is reassessed when:

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There is a change in the patient’s nutritional status. The patient remains in the hospital longer than the expected length of stay or longer than

seven days. Upon physician ordered dietitian consult.

Nutrition Screening and Risk Level Assignment

The Nurse completes the Nutritional Screening Section on the General Assessment document. Affirmation of a special diet order, nutrition related diagnosis, or nutrition related condition

triggers an identified nutrition risk level. Clinical nutrition staff reviews the information and determine if patient is at low/no risk, moderate, or high nutrition risk on admission.

Screening criteria that may indicate high nutrition risk and dietitian intervention are found in the Nutritional Screening Section of the General Assessment and include:

o Unplanned weight loss or greater than 10 percent in past 3 months o Body Mass Index <18.5 o Difficulty swallowing o Nausea, vomiting, diarrhea > 5 days o Albumin <2.5 o Nutrition Consult o Renal Failure/Dialysis (Acute /New) o Sepsis o Severe Trauma o Tube feeding and TPN o Anorexia o Diabetes Mellitus o Dysphagia o Difficulty swallowing

Patients at low/no nutrition risk are monitored for diet tolerance and adequacy by clinical nutrition staff.

Nutrition Assessment

Completed by the dietitian for high nutrition risk patients Reassessment

Reassessment occurs at least every seven days, or more often, as warranted by the patient’s condition or upon physician-ordered Dietitian Consult.

Refer to GMHA Dietetic Services Manual Policy No. 5.04, Nutrition Screening; and Policy No. 5.05¸ Nutritional Assessment. Food-Drug Interaction Information

Clinical nutrition staff provide instruction on food-drug interactions. Food-Drug interaction information is available through the Dietary Department and the

Nutrition Care Manual online. The Nutrition Care Manual online has the following food-drug interaction client handouts

available: o Anti-inflammatory o Anticoagulant o Bisphosphonate o CYP450 o MAOIs (Monomine Oxidate Inhibitors) o Potassium-Sparing Diuretic o Non-Potassium-Sparing Diuretic o Vitamin K

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Refer to GMHA Pharmacy Department Manual Policy No. 1203, Drug-Food Interaction. HAND-OFF COMMUNICATION: SBAR

S- Situation What is going on with the patient? Briefly state the problem and when it started. B- Background What is the clinical background or context? Diagnosis and co-morbidities. Other relevant clinical background information, for example, medications, procedures. A- Assessment What is the problem? Physical. Cognitive. Emotional. Functional. Support/Care System. What is your assessment of the situation? R- Request/Recommendation What do I recommend/request to be done? When do I use SBAR?

Time-sensitive and/or critical situations When making treatment planning decisions Telephone calls to physicians Change of shift hand-offs (endorsements) Patient transfer hand-offs When you need clarity on something

Ticket to Ride/Return Ticket to Ride/Return is an SBAR communication tool for safely and accurately relaying the patient’s safety needs from one caregiver to another during the transportation of a patient within the hospital. 1. The nurse will complete a

patient Ticket to Ride form – including patient information, destination and status.

2. The Ticket to Ride is then given to the transporter to be delivered with the patient at their destination so that the next caregiver is aware of the patient’s needs.

3. Prior to the patient’s return, the caregiver will complete the Ticket to Return form and give it to the transporter to be delivered with the patient to the nurse from his/her origin.

Refer to GMHA Administration Manual, Policy No. A-PS300, SBAR Communication/Patient Hand-off Communication. PATIENT FOOD REFRIGERATORS

There is a difference between refrigerators used to store medications and refrigerators used to store patient food. (For those areas that store lab reagents in refrigerators, additional information is available in your department.)

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Patient food refrigerators should:

Only contain food. Contrast material or other procedural products taken orally must not

be stored in patient food refrigerators. Contain a thermometer inside so staff can check that the appropriate

temperature is maintained. Be labeled as “FOOD ONLY” and have the following information:

Directions about how to handle patient food: label all patient food with patient name, room number, and date the food was placed in the refrigerator. Discard the food after three days or when the patient has been discharged.

Directions about what to do if the refrigerator temperature is out of range. SCREENING FOR REHAB SERVICES (FUNCTIONAL SCREENS)

Screening all inpatients for functional status and need for Rehab Services (PT/OT/Speech) is an area of focus. The patient Data Base clearly indicates initial assessment of functional status and triggers the possible need for Rehab Services (PT/OT/Speech). Meeting this standard consistently requires that we document our assessments and follow through on positive screens by requesting a physician order when appropriate. Consistent assessment of pain, nutritional status and functional status of patients as well as complete documentation of the care we provide are essential in demonstrating how we meet these Joint Commission standards. Refer to GMHA Rehabilitative Services Manual, Policy No. 101, Inpatient Referral/Order for Occupational Therapy, Speech Therapy, and Physical Therapy. RESTRAINT INFORMATION FOR STAFF

The safe and appropriate use of physical restraints continues to be a strong focus during Joint Commission surveys. Since January 1995, there have been about 187 deaths/injuries to patients in restraints reported to the Joint Commission. Regulatory agencies (Joint Commission and CMS) mandate that restraints be used as interventions when medically necessary or in emergency situations to prevent patients from harming themselves or others. Restraints should be a last resort used only when less restrictive interventions have been proven ineffective in maintaining patient/staff safety. At the Guam Memorial Hospital, our goal is to minimize the use of restraints and ensure appropriate and safe use when they are necessary. Alternatives to restraints are always used first. Some alternatives we use include:

Family presence Patient sitter Frequent toileting Low bed Diversion activities ( for example, television, music, games, books) Modification of the environment to reduce excessive sensory stimuli

Surveyors will ask staff why patients are restrained. Remember that confusion and disorientation alone are not adequate reasons to put patients in restraints. Neither is intubation. Be sure to explain how patient’s behaviors such as pulling at tubes and drains present a significant threat to patient recovery.

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Surveyors will ask staff about requirements for monitoring patient safety/care while in restraints, as well as duration of physician orders. Surveyors will look for confirmation in the medical record that we are following our policy, including notification of the family. Surveyors will also ask staff about training they have received in the application and management of restraints and alternative methods for handling behaviors, symptoms and situations. It is important to remember your required competencies related to the care of patients in restraints. There are two types of restraint use for management of:

Non-violent behavior (e.g., tube pulling) – used for patients primarily in Med-Surg or ICU settings

Violent or self-destructive behavior OR significant change in patient condition The hospital’s policies for restraints explain the definitions, requirements for physician orders and the level of monitoring and care required for each type of restraint. Staff should speak clearly about the types of restraint situations they encounter. Refer to GMHA Nursing Services Manual, Policy No. 6301-II C-16, Restraints for Non-Behavioral Reasons, and Policy No. 6301-II C-30, Restraint Use for Behavior Health Purposes. PROCEDURAL SEDATION

Only physician staff that are specifically credentialed may administer procedural sedation – refer to the Medical Staff Directory of Privileges available on http://www.gmha.org under the Physician Portal to confirm. A written procedural competency assessment examination must be successfully completed prior to being granted privileges to perform and oversee procedural activities within the hospital. In addition to this, the physician must maintain current BLS and age-specific advanced resuscitation certifications (i.e., ACLS, PALS, and/or NRP). The Joint Commission defines the sedation on a continuum of four levels:

1. Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. While cognitive and coordination functions may be impaired, normal cardiovascular and ventilatory functions are maintained.

2. Moderate sedation/analgesia (previously known as “procedural sedation”) is a drug-induced decrease in level of consciousness during which patients respond purposefully to verbal commands with or without tactile stimulation. A patent airway and spontaneous ventilation are adequate without intervention and cardiovascular status is usually maintained.

3. Deep sedation produces a drug-induced decrease in level of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be impaired or inadequate.

4. Anesthesia is defined as a loss of consciousness during which patients cannot be aroused, even with painful simulation. Patients usually require assistance maintaining a patent airway and cardiovascular function may be impaired.

When patients receive sedation for procedures, there is a risk that they may slip into a deeper level of sedation than planned. This risk requires that practitioners who perform these procedures be skilled in rescue of patients from a deeper level of sedation. The skill level required to rescue patients from a deeper than planned level of sedation provides a basis for physician credentialing criteria. Physicians (and staff) managing the care of these patients must have adequate knowledge and skill in emergency care such as airway management, oxygen delivery and equipment, basic and advanced cardiac life support and the function and use of appropriate monitoring equipment.

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Our procedural sedation policy applies to patients when either moderate or deep sedation is planned. The purpose of this policy is to provide guidelines for the care and monitoring of all non-intubated patients while undergoing invasive diagnostic and therapeutic procedures. The Procedural Sedation Forms includes all required elements to meet the Joint Commission standards. Complete documentation of patient assessment, reassessment immediately prior to sedation, the plan of care and care provided is essential in demonstrating how we meet the sedation standards. At the Guam Memorial Hospital, we have a process for monitoring sedation outcomes that looks at each procedure performed using moderate and/or deep sedation. Tracking of complications related to the use of sedation. Tracking of complications related to the use of sedation allows us to continuously assess and improve our performance in this important aspect of patient care. Refer to GMHA Administrative Manual, Policy No. A-PS900 Procedural Sedation. MEDICATION MANAGEMENT

I. Pharmacy & Therapeutics Committee-Approved Policies:

A. Self-Administration of Medications (SAM) This policy outlines which medications and medication orders meet the requirements to be stored at the bedside for patients to “self-administer.” A specific and complete physician’s order must be written for each medication that is to

be self-administered. The order must state, “Self-Medication.” The physician shall determine the competency of the patient who would self-administer

the medication. The nursing staff shall supervise and provide training and information regarding how the medication is to be administered and monitored.

Medication administration must be documented on the patient’s medication administration record (MAR).

All teaching, interventions and patient responses to interventions regarding the self-administered medication must be documented in the nurses’ notes.

Refer to GMHA Pharmacy Department Manual, Policy No. 717, Inpatient Self-Administration of Medication.

B. Handling of Patients’ Home Medications

The use of a patient’s home medications is discouraged, but this policy outlines circumstances in which this practice may be acceptable (e.g., medications not included in the GMHA Formulary of Drugs). A patient’s own medication may be administered only: If the medication is not on the formulary or not regularly available. When there is a specific physician order that identifies the medication name, directions

for use, route of administration, dose, strength, schedule and length of therapy (Note: Orders such as “administer medications as per home” or “continue home meds” are not acceptable and must be clarified.).

If the medication is in the original prescription container, is not expired, is not a sample medication, is not a controlled substance and is the only medication stored in the container.

Following appropriate identification by a pharmacist prior to patient use. The prescriber and patient must be informed and the patients’ home medications must

be sent home (with an adult family member or caregiver) if they do not meet the requirements of this policy.

IMPORTANT: Use of a patient’s home medication does not automatically mean that a medication may be self-administered. Only medications orders specifically for “Self Administration” by the physician can be self-administered.

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Refer to GMHA Pharmacy Department Manual, Policy No. 716, Patient’s Own Medication.

C. Medication Range Order Policy

These guidelines outline the requirements for acceptable “range orders.” Surveyors will be looking at records and asking nursing and pharmacy staff to identify range orders and ensure these orders are used in a safe and effective manner. Certain medications (such as pain medications and other PRN medications) are often prescribed with dosage ranges or frequency ranges for nurses to follow.

Range orders should: Always list the specific reason for the medication use. Determine the dose/route to administer if not written in the physician’s order:

o For MILD pain, nausea, agitation or other symptoms, the nurse will administer the LOWEST dose of the medication ordered for the symptom.

o For MODERATE pain, nausea, agitation or other symptom, the nurse will administer the MIDDLE dose (if applicable) of the medication ordered for the symptom.

o For SEVERE pain, nausea, agitation or other symptom, the nurse will administer the HIGHEST dose of the medication ordered for the symptom.

o EXCEPTION: When a patient’s baseline data indicates that pain is usually controlled with a higher dose of medication the middle to highest dose within the range may be used.

For orders written as IM or IV, IV is the preferred route of administration. To determine the frequency of PRN medication:

o The initial frequency shall be at the longest time interval. o The nurse may adjust subsequent frequency to a shorter time interval, within the

parameters of the orders, if he/she has assessed that the medication effects are not lasting the entire duration as originally administered.

o If an initial dose is suboptimal, the nurse may complete the prescribed dose at any time provided that the supplementary dose does not exceed the cumulative maximum dose and that subsequent doses will be timed to begin after the last dose.

To determine which medication to give when the physician has ordered both oral and parenteral medication:

o PRN medications will be given parenterally until the patient takes fluids by mouth without complications.

o If the patient takes POs without complications, the nurse will give PO PRN medications unless the medication is only dispensed in parenteral form.

o EXCEPTION: Nurse’s assessment of the patient such as number of days post-op, level of functioning GI tract, or the patient’s preference may influence the route of administration.

o The Range Order policy has more information on how to determine which medication to choose when more than one is ordered for a particular symptom.

Refer to GMHA Nursing Services Manual, Policy No. 6301-II C-33, Range Orders.

D. Medication Administration

The six rights to medication administration are: o Right Medication o Right Dose o Right Patient o Right Time o Right Route o Right Documentation

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Additional requirements for verification of the five rights as required by the new Joint Commission Medication Management Standards:

a. Verification that the medication selected for administration is the correct one based on the medication order and the product label.

b. Verification that the medication is stable, based on visual examination for particulates or discoloration and that the medication has not expired.

c. Verification that there is no contraindication for administering the medication. d. Advising the patient (or family member, as appropriate) about potential clinically

significant adverse reactions or other important information about a new medication.

e. Discussing any unresolved, significant concerns about the medication with the patient’s physician, prescriber (if different from patient’s physician) and/or relevant staff involved in the patient’s care, treatment or services.

Requirements for monitoring the effects of a medication as required by the new Joint Commission Medication Management standards. Note: Staff must be able to verbalize how medications are monitored.

a. The healthcare team member (physician, nurse, respiratory therapist, etc.) will evaluate the patient’s response to a medication by monitoring the appropriate clinical parameters for the medication that has been given (as applicable).

b. The healthcare team member will monitor for both intended and unintended/adverse affects of the medication.

c. The healthcare team member will document any adverse reactions and interventions needed as a result of medication administration in the patient’s medical record.

d. Monitoring the effects of the medication given will also include: i. Gathering the patient’s own perceptions about side effects and, when

appropriate, perceived efficacy ii. Referring to information from the patient’s medical record, relevant

laboratory results, clinical response and medication profile e. Monitoring the effects of a medication as well as with subsequent doses of the

medication.

Refer to GMHA Pharmacy Department Manual Policy No. 1205, Adverse Drug Event (ADE) and Adverse Drug Reaction (ADR).

Administration of high-risk medications is covered in GMHA Pharmacy Department Manual Policy No. 703, High Risk/High Alert Medication. High-risk medication classifications include:

Adrenergic agonists Adrenergic antagonists Antiarrhythmics Antithrombotic agents Cardioplegic solutions Chemotherapeutic/antineoplastic agents Dextrose, hypertonic, 20% or greater Dialysis solutions, peritoneal and oral Electrolytes, concentrated Epidural medications Hypoglycemics, oral Inotropic medications Investigational medications Liposomal forms of drugs Look-alike/sound-alike medications Moderate sedation agents , IV Moderate sedation agents, oral for children

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Narcotic/opiates Narrow therapeutic range medications Neuromuscular blocking agents Non-FDA approved medications Psychotherapeutic medications Radiocontrast agents, IV Total parenteral nutrition solutions

The physician must always write the order for high-risk/high-alert medications. Verbal and telephone orders may only be accepted when the delay of the medication may cause harm to the patient. All high-risk/high-alert medications will be labeled as such by the pharmacy prior to dispensing. A double check by two licensed nurses must be done prior to administration of any high-risk/high-alert medications. The IV infusion pump setting must also be checked by two licensed nurses as well. And administration sets must be labeled with the drug name at both the distal end and at the pump channel.

E. Patient-Specific Information Required for Medication Management This policy outlines the minimum amount of information that must be available, either electronically or written, to all healthcare personnel to allow for safe and effective medication management.

1. Age 2. Sex 3. Diagnosis and comorbidities 4. Allergies 5. Sensitivities 6. Current medications (including any over the counter medications and herbal products) 7. Height and weight (when necessary)

Required for all patients receiving weight-based medications Required for all pediatric patients (12 years of age or younger)

8. Pregnancy and lactation information (when necessary) 9. Laboratory results (when necessary)

Refer to GMHA Pharmacy Department Manual Policy No. 707, Patient’s Profile.

F. Medication Orders

This policy outlines institutional requirements for written and transcribed medications orders and steps taken to reduce the potential for error/misinterpretation when orders are written or verbally communicated.

The required elements of a complete medication order are:

1. Medication name, dosage strength, dosage form, quantity or duration (as appropriate) 2. Note: Medication orders are to be written in metric notation ONLY. 3. Route and frequency of administration 4. The reason the drug is ordered/indications for usage (as appropriate) 5. Date and time the order was written 6. Patient name and medical record number 7. Prescriber’s signature

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It is a GMHA expectation that all physician orders are written legibly. Other important requirements/definitions incorporated into this policy include:

“PRN” or as needed orders must include an indication for use and be specific for dose and dosage frequency.

“Hold” orders without specific clinical parameters will be interpreted the same as an order to discontinue the specified medication. To reinstate dispensing and administration of a medication that has been ordered on a hold status, the physician will write “resume” and the name, dose, strength, frequency, and route of the medication.

NOTE: Blanket orders to resume or reinstate previous orders for medications are not permissible. Example: “Resume pre-op medications,” is not acceptable. Medication orders must be rewritten in their entirety.

“Titrating orders” or orders where the dose is either progressively increased or decreased in response to the patient’s status must define physiologic parameters and/or clinical lab values for dosage adjustments.

“Standing orders” are prewritten medication orders and specific instructions from the licensed independent practitioner to administer a medication to a person in clearly defined circumstances. Standing orders must be approved by the medical and nursing staff for use in the hospital. Standing orders may contain orders for the dispensing, administration, and monitoring of patient effects of medication.

“Taper orders” or orders in which the dose is decreased by a particular amount with each dosing interval. These orders must address the tapering steps, the amount of dose decrease for each step, and the tapering interval or frequency.

“Compounded drug and drug mixture orders” It is required for the physician to include the formula in the order or refer to a standardized, approved formula that is on file in the pharmacy.

“Renewal of orders” Nursing staff are to inform the physician of the expiration of any orders by placing a sticker and specifying the name of the drug on the patient’s chart. If the physician wants to continue the drug therapy, he/she can simply sign on it to renew. Or the order can just be rewritten by the physician.

“Transfer orders” All existing order for patients are cancelled when the patient is transferred to another level of care or the operating room. Physicians must rewrite the orders upon transferring patient or after the operation/procedure.

“Orders for off-island transfer” All the medication orders for either scheduled drugs or regular drugs should be written on GMHA prescription pad.

“Herbal product orders” Herbal products are not included on the GMHA drug formulary. Physicians may allow their patients to continue taking their own herbal product while they are an inpatient in the hospital. A complete order including the indication for use shall be entered onto the physician’s order form.

“Orders for investigation medications” Physicians intending to engage in medication investigation should refer to GMHA Pharmacy Department Manual Policy No. 504, Investigation Drugs.

“Orders for medication related devices” (e.g., nebulizers, catheters). All medication related devices must be specifically ordered by the physician. (e.g., ___ mg of Alupent via hand held nebulizer.)

“Orders for medications at discharge” Because GMHA does not dispense out-patient prescriptions, physicians should write out the discharged prescriptions on GMHA prescription pad and give it to the patient upon discharge. Prescriptions will then be filled by a pharmacy in the community.

All pediatric medication orders (patients 12 years of age or younger) will be dosed based according to the patient’s weight, where applicable.

A Broselow ruler will be utilized for medication dosing during pediatric cardiopulmonary arrest/medically emergent situations.

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Refer to GMHA Pharmacy Department Manual Policy No. 701, Medication Orders.

Strategies for Reducing Medication Errors The generic name of a medication is preferred when writing or communicating a

medication order. The prescribing physician will be contacted for incomplete, illegible and unclear

medication orders. Verbal orders and telephone medication orders are minimized. Verbal orders may be

taken by a pharmacist, nurse, respiratory technician, and physical therapist (within their scope of practice). A read-back must be conducted by the person receiving the verbal or telephone order. o Note: Verbal or telephone orders will not be accepted for chemotherapies.

Medication error reports are reviewed individually and in aggregate to identify trends and determine if corrective measures are needed. A formalized list of abbreviations and dose expressions considered “dangerous or confusing” has been developed and are located in the patient’s chart for reference. These include the following: - U Write “units” - IU Write “International Unit” - MgSO4 Write out Magnesium Sulfate - MSO4 Write out Morphine Sulfate - MS Write out Magnesium Sulfate or Morphine Sulfate - QOD Write out “every other day” - QD Write out “every day” or “daily” - .X Include a zero before decimal points (e.g., “0.X”) - X.0 Do not use a trailing zero (e.g., “X”)

Refer to GMHA Medical Records Department Manual Policy No. 6433-75, Unacceptable Abbreviations.

Preprinted order forms and electronic order sets must be reviewed, dated and signed by the prescriber before becoming effective.

Electronic order sets and preprinted order forms follow established hospital guidelines for review, approval and implementation.

Refer to GMHA Administrative Manual Policy No. 6433-74, Health Information Management Committee.

Be familiar with the hospital’s Look-Alike/Sound-Alike Medications List:

Potential Problematic Drug Names: Brand Name (UPPERCASE) and Generic Name (lowercase)

Potential Errors and Consequences

Safety Strategies

1

PLATINOL (cisplatin) Used to treat cancer. PARAPLATIN (carboplatin): Used to treat cancer.

Similarity in names can lead to confusion between these two medications. Doses appropriate for carboplatin usually exceeded the maximum safe dose of cisplatin. Severe toxicity and death have been associated with accidental cisplatin overdose.

Tallman lettering used in all databases for both drugs items stored in non-adjacent bins in all storage area.

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Potential Problematic Drug Names: Brand Name (UPPERCASE) and Generic Name (lowercase)

Potential Errors and Consequences

Safety Strategies

2 ADRENALIN (epinephrine): Used as a bronchodilator and injection used in the emergency treatment of allergic reactions. EPHEDRINE: Used as a bronchodilator.

These medication names look similar and are available in similar packaging (1-ml amber ampules and vials).

Tallman lettering used in all databases for both drugs, items stored in non-adjacent bins in all storage area.

4 DOPAMINE Used for adjunct in the treatment of shock DOBUTAMINE (dobutrex) Used for short term management of patients with cardiac decompensation. DOXAPRAM (dopram) Used as a stimulant for respiratory depression secondary to anesthesia drug-induced CNS depression.

Similar commercial IV bags in sizes, letterings causing the mix-ups of dobutamine and dopamine. The brand name is look alike sounds alike to Dopamine.

Tallman lettering used in all data bases for the drugs, items stored in non-adjacent bins in all storage area. Educate staff to pay more attention on the strength that is specified on the bag. Dopamine is 400mg or 800mg, Dobutamine is 250mg or 500mg. Educate staff to use generic name. Segregate storage from Dopamine.

5 Lipid-based amphotericin products versus conventional forms of amphotericin: Lipid-based AMBISOME (amphotericin B liposomal): Used to treat fungal and protozoal infections. Conventional: AMPHOCIN, FUNGIZONE INTRAVENOUS (amphotericin B desoxycholate): Used to treat fungal and protozoal infection.

Lipid-based formulation dosing guidelines differ significantly from conventional dosing. If conventional amphotericin B is given at a dose appropriate for a lipid-based product, a severe adverse event is likely. Confusion between these products has resulted in respiratory arrest and other dangerous, sometimes fatal outcomes due to potency differences between these drugs.

Educate staff responsible for administering or monitoring amphotericin on: 1. The difference between conventional and lipid-based formulations and dosing. 2. Name similarity resulting in confusion between the liposomal and the conventional formulation. 3. The products are not interchangeable. 4. Referring to the lipid-based products by their brand names and generic names, verbally and in clinical documentation. 5. Verifying that the correct drug is being administered if anyone notices a change in the

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Potential Problematic Drug Names: Brand Name (UPPERCASE) and Generic Name (lowercase)

Potential Errors and Consequences

Safety Strategies

solution’s appearance from previous infusions. 6. Differences in appearances, because lipid-based products may be cloudy, and conventional formulation is clear. 7. Consider limiting lipid-based amphotericin B products to one specific brand. 8. Do not store lipid-based products in patient care areas and automated dispensing cabinets.

6 TAXOL (paclitaxel): Used to treat cancer. TAXOTERE (docetaxel): Used to treat cancer.

Confusion between these two drugs can result in serious adverse outcomes.

Educate staff involved in administering or monitoring the effects of these medications on the differences in dosing recommendations.

7 Prilosec (omeprazole) Used to treat GERD. Prozac (fluoxetine) Used to treat depression.

Similar names, forms and strengths have contributed to medications errors.

Educate staff involved in administering or monitoring the effects of these medications on the differences in diagnosis the med is prescribed.

8 CATAPRES (clonidine): Used to treat hypertension. KLONOPIN (clonazepam): Used to treat seizures.

The generic name of clonidine can be confused as the brand or generic name for clonazepam.

Tallman lettering used in all databases for both drugs, items stored in non-adjacent bins in all storage area.

9 Insulin products: Used to control blood sugar. LANTUS (insulin glargine) LENTE (insulin zinc suspension) NOVOLOG (human insulin aspart) NOVOLIN (human insulin products) HUMULIN (human insulin products) NOVOLIN (human insulin products)

Similar names, strengths and concentration ratios of some products (e.g., 70/30) have contributed to medication errors. Errors have also occurred between the 100 Units/mL and 500 Units/mL insulin concentrations.

Limit the use of insulin analog 70/30 mixtures to just a single product. Limit the variety of insulin products stored in patient care units. Remove patient-specific insulin vials from stock when no longer needed. Consider auxiliary labels for newer products to differentiate them from the established products.

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Potential Problematic Drug Names: Brand Name (UPPERCASE) and Generic Name (lowercase)

Potential Errors and Consequences

Safety Strategies

NOVOLIN 70/30 (70% isophane insulin (NPH) and 30% insulin injection [regular])

Apply bold labels on atypical insulin concentrations.

10 VELBAN (vinblastine): Used to treat cancer. ONCOVIN (vincristine): Used to treat cancer.

Fatal errors have occurred, often owing to name similarity, when patients were erroneously given vincristine intravenously, but at the higher vinblastine dose. Vincristine dose is usually capped at around 1.4 mg/m5 weekly. Vinblastine dose varies, but typical adult weekly dose range is 5.5 to 7.4 mg/m5.

Educate staff involved in administering or monitoring the effects of these medications on the differences in dosing. Refer to the medication using brand names or brand and generic names verbally and in clinical documentation.

11 ZYRTEC (cetirizine): Used to relieve or prevent the symptoms of hay fever and other types of allergies. ZANTAC (ranitidine) Used to treat GERD. XANAX (alprazolam) Used to treat anxiety.

The brand names of these medications are similar in out look and sounding, resulting in frequent mix-ups.

Educate staff involved in administering or monitoring the effects of these medications on the differences in dosing. And try to use generic names instead of brand names.

12 APRESOLINE (hydralazine): Used to treat high blood pressure. ATARAX or VISTARIL (hydroxyzine): Used to treat allergies.

Because the first four letters of their names are identical, they are frequently stored next to one another on pharmacy shelves and automated dispensing cabinets and listed adjacently on computer screens. Their similar dosage strengths (10, 25, 50, and 100 mg) and tablet dosage forms also contribute to confusion. Confusion between the antihistamine (hydroxyzine) and the antihypertensive agent (hydralazine) could lead to serious drug events.

Change appearance of look-alike product names on computer screen, pharmacy and nursing unit shelf labels and bins (including automated dispensing cabinets), pharmacy product labels, and medication administration records. Differentiate drug names by using boldface, color, and/or Atall man@ letters, to help emphasize the letter characters in each name that are unique to that name (e.g., hydrOXYzine, hydrALAzine). Choose generic manufacturers whose products exhibit clear labeling with tall man characters.

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Medication errors associated with ordering medications with look- alike or sound-alike names are minimized by:

What prescribers need to do:

Maintain awareness of look-alike sound-alike drug names as published by various safety agencies.

Clearly specify the dosage form, drug strength, and complete directions on prescription orders. These variables may help staff differentiate products.

With name pairs known to be problematic, reduce the potential for confusion by writing prescription orders using both the brand and generic name.

Include the purpose of the medication on prescription orders. In most cases drugs that sound or look similar are used for different purposes.

Encourage inpatients to question nurses about medications that are unfamiliar or look or sound different than expected.

Give verbal or telephone orders only when truly necessary, and never for chemotherapeutics. Include the drug’s intended purpose to ensure clarity.

Encourage staff to read back all orders, spell the product name, and state its indication.

What all of us at GMHA need to do: Maintain awareness of look-alike sound-alike drug names as published by various

safety agencies. Regularly read information provided to you. Whenever possible, determine the purpose of the medication before dispensing or

drug administration. Most products with look-alike or sound-alike names are used for different purposes.

Accept verbal or telephone orders only when truly necessary, and never for chemotherapy. Encourage all staff to read back orders, spell the product name, and state its indication.

Consider the possibility of name confusion when adding a new product to the formulary. Review information previously published by safety agencies.

Use preprinted orders as appropriate. If possible, print out current medications daily from the pharmacy computer systems and have physicians review for accuracy.

When possible, list brand and generic names on medication administration records. Such redundancy could help someone identify an error.

Change the appearance of look-alike product names on computer screens, pharmacy and nursing unit shelf labels and bins, pharmacy product labels, and medication administration records by highlighting, through bold face, color and/or tall man tellers, the parts of the names that are different (e.g., hydrOXYzine, hydrALAzine).

Install and utilize computer alerts, where possible, to remind providers about potential problems during prescription order processing.

Configure computer selection screens to prevent the two confused drugs from appearing consecutively.

Affix “name alert” stickers to areas where look-alike or sound-alike products are stored.

Store products with look or sound-alike names in different locations in pharmacies, patient care units, and in other settings where applicable.

When applicable, use a shelf sticker to help locate the product that has been moved. Continue to employ independent double checks in the dispensing process (one

person interprets and enters the prescription order into the computer and another reviews the printed label against the original prescription order and the product prior to dispensing).

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Encourage reporting of errors and potentially hazardous conditions with look-alike and sound-alike product names and use information to establish priorities for error reduction. Also maintain awareness of problematic product names and error prevention recommendations provided by ISMP (www.ISMP.org), FDA (www.FDA.gov), and USP (www.USP.org).

Refer to GMHA Pharmacy Department Policy No 704, Look-alike/Sound-alike Drugs and Policy No. 1201, Medication Errors.

G. Disposition of Controlled Substances

This policy established guidelines for nurses on the disposition of controlled substances which ensure that the utilization and administration of all controlled substances are in compliance with federal and state regulations.

Refer to GMHA Nursing Services Manual Policy No. 6301-II C-5, Disposition of Controlled Substances.

H. Adverse Drug Event (ADE) and Adverse Drug Reaction (ADR)

An ADR is any noxious response to a medication that occurs at doses usually used for prophylaxis, diagnosis or treatment. A reportable ADR is a confirmed or suspected ADR that causes discontinuation of a drug, a change in drug therapy (including corrective therapy, such as with an antidote) or results in hospital admission or prolongation of a hospital stay.

Upon discovery of an ADR the healthcare professional responsible for the patient will complete a Patient Safety Form and an ADE Report/Adverse Drug Event Form. As clinically indicated, the health care professional discovering the ADE will also contact the responsible physician in a timely manner.

This policy defines adverse drug reactions (ADRs) and the process for reporting these adverse events (ADEs) at the hospital.

Refer to GMHA Pharmacy Department Manual Policy No. 1205, Adverse Drug Event (ADE) and Adverse Drug Reaction (ADR); and Policy No. 1201, Medication Errors.

II. Latex Safe Medication Preparation

IV Bags—Bbraun Excel IV bags and Baxter Viaflex IV bags are latex-free. Medications may be added through the injection ports.

IV Sets – Bbraun and Care Fusion IV sets are latex-free.

Medication Vials – For patients with a known latex allergy, rubber stoppers must be removed from medication vials prior to removal of solution by using a pair of hemostats. Rubber stoppers should never be punctured unless the medication vial has been determined to be latex-free.

Code (Orange) Box – All prefilled syringes are latex-free and may be used. Since all vials contained in the box are NOT latex-free, vial stoppers should be removed with a pair of hemostats for patients with a known latex allergy.

III. Crash Cart Security

How do we ensure the security of crash carts within the Guam Memorial Hospital?

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Emergency equipment in patient care areas is checked daily by staff each shift (or on each business day in non-24 hour areas).

What should I look for when checking the crash cart each shift? The integrity of the lock on the cart; the expiration date on the top of the cart ; the presence, expiration, and lock of the orange medication box should be checked each shift. The charge and delivery capability of the defibrillator should also be checked each shift. What should be done with a crash cart at the end of a code? Central Supply and Receiving (CSR) should be contacted to exchange the cart for a new one. The Pharmacy department should be contacted to exchange the orange medication box. Refer to GMHA Administrative Manual Policy No 6100-44, Emergency Equipment (Crash Cart) Maintenance, Preparation, and Exchange Process.

IV. What is a Vaccine Information Statement?

A vaccine Information Statement (VIS) is an information sheet produced by the Centers for Disease Control and Prevention (CDC), informing vaccine recipients – or their parents or legal representatives – of the benefits and risks of a vaccine. The law requires them to be given out whenever certain vaccinations are given. Who must give out a VIS? The nurse administering the vaccine will provide the VIS to the patient/parent(s)/legal representative. When must a VIS be given out? The VIS should be given to the patient prior to administration of the vaccine. How do I get a VIS sheet? The VIS sheets for Pneumococcal and Influenza (seasonal and H1N1) vaccines are available on the GMHA Website under the “Patient Education” option of the “Patient Portal” tab. The VIS sheet for the Hepatitis B vaccine is available from the Nursery.

V. Medication Storage, Security and Disposal

A. Sample Medications Sample medications are prohibited in all inpatients and outpatients of the hospital and in the emergency Department. Refer to GMHA Pharmacy Department Manual Policy No. 505, Sample Drugs.

B. Multi-Dose Vials 1. Multi-dose vials must be given a 28-day expiration date from the date of opening.

This date must be documented on the vial itself. The vial must be discarded when its 28-Day expiration date has been reached.

2. Multi-dose vial must be discarded if visible or suspected contamination of the vial has occurred.

3. All vials used during emergency procedures should be discarded. 4. Preservative-free drugs and single-dose vials should be discarded after one use

(including sterile water and sodium chloride). 5. All injections for intra-arterial use must be prepared using a new vial.

Refer to GMHA Pharmacy Department Manual Policy No. 814, Handling of Multi-dose Vial of Injectable Drugs

C. The 5 Ws of Controlled Substances

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WHO can waste controlled substances?

1. An RN, LPN, MD or Pharmacist 2. With a licensed professional (RN, LPN, MD or Pharmacist) as a witness (procedural/ambulatory areas may use other authorized personnel)

WHAT substances should be wasted? 1. All controlled substances should be wasted including:

a. Medication doses with damaged packaging (i.e., the drug is exposed and the tamper-tell seal is broken)

b. Only a partial dose is left in a container (i.e., if half of a morphine syringe is used for a patient, the other half must be wasted)

c. The dose has been opened and is refused by the patient, contaminated, or dropped on the floor.

2. The only items that once removed may be returned to the Narcotic Stock are: a. Vials with the flip-top intact b. Carpuject syringes with tamper-evident packaging in tact. c. Unbroken ampoules.

WHEN do nurses need to take care of discrepancies for controlled substances? 1. The Charge Nurse is responsible before the end of each shift to check for open

discrepancies in their unit/area (procedural/ambulatory areas must check at shift change, where applicable, or at the end of the business day).

2. Nurses who work the designated shift in which a discrepancy occurs should remain in the area until all discrepancies are resolved/addressed and a Controlled Drug Discrepancy Form is completed.

WHERE can the controlled substances be disposed? 1. All controlled substances that are to be disposed of should be flushed down a sink

drain or commode (liquid, tablet or injectable). 2. Fentanyl patches should be folded in-half with adhesive sides sticking together,

shredded with scissors, and disposed of safely in a sharps container. 3. Garbage cans, sharps containers (with the exception of Fentanyl patches), and needle

boxes are inappropriate for controlled substance isposal of any kind.

WHY is proper controlled substance disposal important? 1. Proper handling of controlled substance is included in local and federal law;

therefore, improper handling can carry serious consequences. 2. Proper disposal protects patients and healthcare professionals from unnecessary

exposure to controlled substances.

Refer to GMHA Administrative Manual Policy No. 6301-II C-5, Disposition of Controlled Substances.

D. Medication Refrigeration Monitoring

Patient care units staffed 24 hours/day Twice-a-Day monitoring is required. Actions taken in response to a thermometer alarm must be documented. This is to be

documented on the back side of the temperature monitoring log in the space provided.

Patient care units NOT staffed 24 hours/day

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Thermometers MUST BE CHECKED TWICE DAILY. This is required to ensure appropriate temperature range has been maintained and to determine if any temperature deviations occurred during non-staffed hours.

Daily checks must be recorded. Actions taken in response to a thermometer alarm/deviation must be documented.

Contact the Pharmacy Department (3-2254) for questions/concerns regarding medication stability.

Contact Facilities Maintenance Department (3-2192/2224) to report refrigerator malfunction and for questions on thermometer use and maintenance.

Refer to GMHA Administrative Manual Policy No. 6170-9, Storage of Medications in Patient Care Areas.

VI. Compounding Medications

A. IV Compounding Compounding of sterile IV medications (addition of injectable medication to an IV

bag) may occur outside of the Pharmacy in EMERGENCY SITUATIONS only. Patient care staff that work in areas where compounding is likely to occur (e.g., critical

care areas, OR areas) must complete the IV Admixture Competency Testing. CONTINUUM OF CARE

Key Concepts

The importance of the continuum of care is to provide appropriate patient services to meet patient’s ongoing health needs from prevention to illness, convalescence and recovery in the appropriate care setting.

Access to care is driven by a patient’s assessed needs and the site’s ability to provide care that meets those needs.

Communication between caregivers and across care sites is critical to facilitating the continuum of care.

What assessment procedures do you use to determine the individual’s acceptance for entry to a given service or setting? Site of care and patient placement are determined following an assessment of the patient’s needs and severity of disease, condition, impairment or disability, as well as the scope of service available in a particular site. Assessment is ongoing to ensure the patient continues to move to the appropriate level of care (e.g., ambulatory, inpatient, critical care, rehabilitation, discharge). Patients requiring a short episode (less than 24 hours) of assessment and intervention are placed in short stay beds (e.g., outpatient observation). What essential information do you need to determine appropriateness of the individual’s entry to the setting/service, especially in special care units? Patient assessment data (physical and physiological), diagnosis planned procedures and special care needs are all considered when determining an individual’s entry to a setting or service. A patient care area’s scope of care or service and its admission and discharge criteria are also considered. Know specific information for your patient care unit or critical service. Refer to your scope of care or service and admission/discharge criteria. How are patients and families provided with information about proposed care during the entry process? On or before admission, patients receive a variety of information about GMHA services or at a preoperative visit prior to their admission. Patients and families with unscheduled admissions may

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receive specific information about their care during the admission process. Know population-specific education provided to your patients prior to admission. How do you provide continuity over time among the entry, assessment, diagnosis, planning, treatment and transfer or discharge phases of services? Communication is key to providing continuity of care. Information communicated along the continuum includes: patient demographics, diagnosis, plan of care, patient assessment data, special care needs, discharge needs and, as applicable, financial information. Individuals responsible for communication include: patients and/or families/significant others, physicians and their office staff, utilization review specialists, social workers, registered nurses and other healthcare professionals, patient access services staff, medical information management staff and patient financial services staff. Methods of communication include: written documentation, computerized transfers of information, faxes, telephone reports and face-to-face interactions. Know how to protect patient confidentiality. How do you provide for coordination among the Health Professional(s) and service(s) or setting(s) involved in patient care? The facilitation of care along the continuum is an interdisciplinary process. Communication with the interdisciplinary team occurs through patient care rounds, phone calls, patient-care conferences, shift reports and documentation in the patient care record, including Kardex where applicable. Participating in daily rounds facilitates interdisciplinary care planning. Documentation of interactions with the interdisciplinary is key for all disciplines. All disciplines must be knowledgeable of the medical record and where to find each discipline’s documentation. As a member of the clinical services team, the utilization review specialists are a resource that work closely with the physicians and various other health professionals to assist with planning and coordinating care across the continuum. Describe the process(es) for referral, transfer or discharge of a patient to another level of care, health professional or setting. Referrals, transfers and discharges are initiated by the physician based on the patient’s changing condition. Patients should be informed in a timely manner of the need for discharge or transfer to another organization or level of care. This includes giving the patient and/or family information about the conditions that may result in transfers to another organization or level of care, alternative to transfer (if any), the clinical basis for discharge and the anticipated need for continued care after discharge. There is a risk for a breakdown in the continuum when the patient’s care needs change or he or she moves to a different level of care. Discussing plans with the patient, giving report, writing transfer notes or discharge summaries, initiating new orders, completing and sending continuity of care forms and electronic discharge instructions are important steps to minimize this risk. Resources for facilitating these processes outside of the hospital include the Social Worker assigned to the patient’s unit and other collaborative entities, and Charge Nurse (inter-hospital transfers). Know any population-specific processes. Describe the staff’s role in the discharge planning for this patient care setting. Interdisciplinary team members collaborate with the patient and family in the planning and implementation of patient discharges. The physician initiates the medical discharge and participates in discharge planning by ensuring that all necessary orders, medical instructions and prescriptions are completed. Medical follow-up appointments are addressed, community resources are identified and discharge information is shared with the patient. The social worker and nursing collaborate with the healthcare team to identify patient needs, coordinate the discharge planning through the nursing process from admission to discharge. Other disciplines participate in discharge planning depending on specific patient needs. These disciplines may include pharmacists, physical, occupational, speech and respiratory therapists, dieticians, utilization review specialists, and pastoral care. Know your specific role in the discharge planning process.

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How do you provide for the exchange of appropriate patient care and clinical information when patients are admitted, referred, transferred or discharged? When patients are admitted or transferred from another facility, physicians and their staff provides information to the Hospital Nursing Supervisor on-duty to ensure the appropriate placement of patients. When patients are referred or transferred to another care site or care provider, patient care and clinical information are shared verbally and in writing. When patients are discharged from the hospital, they receive verbal and written discharge instructions. When patients require post-discharge services from community agencies or facilities, a transfer note is completed and report is called to the appropriate staff. What if the patient doesn’t have insurance coverage or his or her payer is denying coverage for the visit? The patient’s care is driven by his or her assessed clinical care needs. As indicated, the hospital appeals payer decisions and provides financial counselors to discuss payment options with the patient. GMHA does not deny treatment or turn patients away based on financial status. In the outpatient setting, what do you do if the scheduled appointment is not completed? If the patient leaves without notice, the time and date it was discovered are documented and the attending physician or designee is contacted to assess whether a follow-up visit, referral or other action is necessary. If a patient misses an appointment, it is called a “no-show.” All no-shows are documented. Each physician’s office is responsible for appropriate follow-up. If a patient decides to leave prior to seeing the physician or having the scheduled test, another appointment should be offered. Know your specific area’s procedures. PATIENT EDUCATION

Where would you find interdisciplinary care planning for patient education? Notes may be found in the interdisciplinary form in iMed, on progress notes, consult forms and reports from rounds or care planning conferences. Where in the patient’s record would you look for documentation of education provided and feedback about how the patient or family understood the patient education, or how learning is progressing? Any of the following:

Progress note Referral or consultation notes Discipline specific notes, like respiratory notes, etc. Discharge instructions Patient-family education form in iMed

What kinds of resources are available for patient education for patients with special needs? Any of the following:

Interpretation services or translated material for foreign language speakers Videotapes for those not able to read or needing more visual learning tools Referrals to other disciplines or community agencies for complex or ongoing needs

These are key areas to focus education for patients and families, based on the patient’s specific situation.

Safe and effective use of medications Nutrition interventions, oral health, diet changes Safe and effective use of medical equipment Pain management Isolation requirements Rehabilitation techniques to help patients become more functionally independent Available resources, and when necessary, how to obtain further care and treatment

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Information about a patient’s responsibilities in his/her care Self-care activities and discharge instructions

MANAGEMENT OF INFORMATION

Abbreviations The GMHA has adopted the Stedman’s Medical Abbreviations, Acronyms, and Symbols book for its list of approved abbreviations. A hard copy of this book is available at the Medical Records Department. This reference is also available online via http://www.stedmansonline.com. Refer to GMHA Medical Records Department Manual, Policy No. 6433-75, Use of Abbreviations, Acronyms, Symbols, and Dose Designations. Legibility and Signature Please be careful when hand-writing entries in the record. For effective communication, it is important that entries be legible. When signing entries, be sure to include your credentials (e.g., RN, PT). Remember: it is important that you document your patient care for safe management of the patient, communication to other caregivers, and for optimal reimbursement for the organization. MEDICAL STAFF

History and Physical Examination (H&P)

The patient must receive a medical history and physical examination no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but PRIOR to surgery or a procedure requiring anesthesia services.

For a medical history and physical examination that was completed within 30 days prior to registration or inpatient admission, an update documenting any changes in the patient’s condition is completed within 24 hours after registration or inpatient admission, but PRIOR to surgery or a procedure requiring anesthesia services.

Physician Privileges Physician clinical privileges are individually granted and are based upon that physician’s

clinical training, experience and competency. Physicians may perform only those privileges that have been granted. A physician may perform any procedure necessary in an emergency situation. Physician privileges may be viewed via online on the GMHA Website (http://www.gmha.org)

under the Physician Portal tab. Impaired Practitioners It is your responsibility to notify the Hospital Administrator, Chairperson of the Credentials Committee, or the President of the Medical Staff either verbally or in writing if you witness or suspect evidence of impairment (such as chemical dependence or abuse) or any other medical, psychiatric or other behavioral issued that renders a member of the medical staff unable to practice medicine competently and safely. The term Licensed Independent Practitioner is meant to include:

All attending medical staff All house-physician staff Nurse practitioners Physician assistants

The (adhoc) Impaired Practitioners Subcommittee has the following functions:

Accepts referrals/self-referrals of practitioners who may be impaired because of chemical dependency or abuse, psychiatric illness or other medical problems.

Evaluate and follow up on any report of impairment. Refers impaired practitioners to appropriate resources for outside evaluation and, when

appropriate, treatment. Provides support and counsel for providers with the previously mentioned issues.

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Provides recommendations regarding the committee’s findings with medical staff leadership (department chairs, division directors).

Oversees monitoring efforts in coordination with departmental mentors or other appropriate resources.

If you suspect a practitioner suffers from an impairment that renders him/her unable to practice medicine with skill and safety to patients, place an anonymous, confidential report by calling the Risk Management Office (3-2259) or you may call any member of the (adhoc) Impaired Practitioners Subcommittee via the Medical Staff Office (3-2023). Refer to GMHA Medical Staff Bylaws available through the Medical Staff Office or online at http://www.gmha.org. Also refer to GMHA Administrative Manual, Policy No. 6170-4, Impaired Practitioner Guidelines.

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SECTION THREE: REMINDERS FOR PHYSICIANS

Mark the site and pause for timeout prior to a procedure or surgery.

Verbal orders should be used as little as possible. Authenticate verbal and telephone orders within 48 hours.

An H&P may be completed up to 30 days prior to a patient’s admission, but it must be updated

upon patient admission within 24 hours or PRIOR to surgery or a procedure requiring anesthesia services.. Notation must be made on or attached to the H&P to indicate review and any updates.

Written informed consent is required for the administration of blood and blood products, any

surgery, and procedures. The informed consent process includes the following: A discussion about the patient’s proposed care, treatment, and services; potential benefits,

risks, and side effect of the patient’s proposed care, treatment, and services, the likelihood of the patient achieving his or her goals; and potential problems that might occur during recuperation.

A discussion about reasonable alternatives to the patient’s proposed care, treatment, and services; risks, benefits, and side effects related to the alternatives, and the risks related to not receiving the proposed care, treatment, and services.

Check patient ID before all procedures using the approved two patient identifiers (name and

medical record number for in-patients; name and birth date for out-patients).

Only use approved abbreviations in both handwritten and free text computer documentation.

Documentation should be done when care is given, never prior to the delivery of care.

When signing entries, be sure to include your credentials (e.g., M.D., D.O.) and include the date and time.

If you need to correct an error, use the appropriate error correction technique (strike through

the error with one line, write “error” and then the correction, date, and initial with credentials). White-out is prohibited.

Restraints can never be ordered as a PRN or “as needed”.

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SECTION FOUR: GUIDE TO ACCREDITATION/REGULATORY ACRONYMS

ADA Americans with Disabilities Act ADC Average Daily Census ADE Adverse Drug Event ADR Adverse Drug Reaction AHJ Authority Having Jurisdiction AIA American Institute of Architects AMP Accreditation Manager Plus (Electronic Accreditation Manual) APR Accreditation Participation Requirement BBI Basic Building Information BMP Building Maintenance Program CAMH Comprehensive Accreditation Manual for Hospitals CAP College of American Pathologists (Lab Cooperative Agreement) CCM Common Communication Method CDC Centers for Disease Control & Prevention CLIA ’88 Clinical Laboratory Improvement Amendments of 1988 CMS Centers for Medicare & Medicaid Services CON Conditional Outcome CoP Conditions of Participation COW Computer on Wheels CPG Clinical Practice Guidelines CPOE Computerized Physician Order Entry CSG Clinical Service Group CSR Continuous Service Readiness e-App Electronic Application for Accreditation EC Environment of Care EP Element(s) of Performance ESC Evidence of Standards Compliance ESO Early Survey Option FDA Food and Drug Administration FMEA Failure Mode and Effects Analysis H&P History & Physical HAI Healthcare-Associated Infection HCO Healthcare Organization HIPAA Health Insurance Portability and Accountability Act of 1996 HR Management of Human Resources HVA Hazard Vulnerability Analysis IC Infection Control ICRA Infection Control Risk Assessment IHI Institute for Healthcare Improvement ILSM Interim Life Safety Measures IM Management of Information IOM Institute of Medicine ISMP Institute for Safe Medical Practice JCR Joint Commission Resources LD Leadership LIP Licensed Independent Practitioner LOS Length of Stay LSC Life Safety Code® MDS Minimum Data Set MEC Medical Executive Committee MedPAR Medicare Provider Analysis and Review MM Medication Management MOS Measure(s) of Success

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MS Medical Staff NPSG National Patient Safety Goal NQF National Quality Forum NR Nursing OASIS Outcome and Assessment Information Set ORYX a Joint Commission performance measurement initiative (does not stand for anything) PC Provision of Care PDA Preliminary Denial of Accreditation PFA Priority Focus Area PFI Plan for Improvement PI Improving Organization Performance POCA Plan of Corrective Action PPR Periodic Performance Review RCA Root Cause Analysis RFI Recommendation for Improvement RI Ethics, Rights and Responsibilities SAG Survey Activity Guide SE Sentinel Event SIG Standards Interpretation Group SOC Statement of Conditions SOW Scope of Work (frequently used by CMS) SV/NP Shared Visions/New Pathways USP United States Pharmacopeia TJC The Joint Commission

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SECTION FIVE: Sample Tracer Questions

Questions for ALL Staff

Describe a quality improvement initiative you’ve implemented on your unit during the last

year? How has it improved patient care? What data do you have that demonstrates improvement?

Tell me how you report an adverse event. What is a sentinel event? What resources are available for patients and families with complaints? What do you do if the patient is unable to be asked about the Health Care Proxy (HCP) due to

his/her condition? How do you communicate with a non-English speaking patient or a patient who is deaf or

hard of hearing? What resources are available to you? What do you do on weekends and off shift?

What resources are available to you for ethical issues? How are you competent to do your job? Show me your SDS (Safety Data Sheets). (Surveyors may select a chemical and request that

staff show them the Safety Data Sheet and point out the actions that should be taken for an exposure)

What is your role in a disaster that results in an influx of patients to your organization? What would you do if you saw smoke coming out of a room? Show me the fire extinguishers and fire alarms in this area. What processes are in place to promote evidence-based practice at GMH? How is information disseminated at GMH? Give an example of an action that was taken proactively to prevent a problem and improve

safety? How are problems related to unsafe or unprofessional conduct managed? What does GMH do to meet the needs of such a diverse patient population? Give examples of interdisciplinary performance improvement activities How is staffing determined on a shift by shift basis and by whom? Who are your expert resources? How do you access them? How do staffs get results about staff satisfaction data and patient satisfaction data? In what

ways are the findings discussed and analyzed? Describe the results for your unit/department?

Questions for Clinical Staff

How do you know if one of your patients has MRSA, VRE, Cdifficile or an MDRO? (NPSG) What precautions do you use for patients with MRSA or VRE? (NPSG) What precautions do you use with patients who have C-diff? (NPSG) If a patient on precautions is leaving the unit to go to x-ray, how does the transporter know

the patient is on precautions? How does radiology know? (NPSG) What training have you received regarding infection control and what does it include? (NPSG)

(Surveyors may request your file to review whether you attended any mandatory hospital training)

Describe the steps that are taken to prevent infection when inserting a central line. (NPSG) Describes steps that are taken to prevent surgical site infections. (NPSG) Describe a few ways you prevent urinary tract infections. What do you do if a patient is suspected of having TB? How do you know that equipment has been cleaned between patients? What is your role in reducing clinical alarm fatigue? (NPSG) What do you consider your high risk clinical alarms in your unit? (NPSG) How are these

managed?

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When do you take verbal orders and telephone orders? Tell me what you do when you take a verbal or telephone order.

Can you tell me any of the unapproved abbreviations that should not be written in the medical record or on MAR's? What do you do if you find one that has been written or entered into the medical record?

(Inpatient units) How are you sure you are performing a treatment or giving a medication to the correct patient? (NPSG)

When is it necessary to label medications and solutions in procedural areas? If the person who labels the medication is not the one administering it, what do you do to

ensure the right medication is being administered at the right time? (NPSG) When is a doctor’s order required? When can oxygen be administered without an order? Where do caregivers document their initial assessment? What is the timeframe for

conducting the initial assessment? Let’s review a few initial assessments to see if they met this timeframe.

Describe to me a patient’s behavior that would warrant restraint for behavioral reasons vs. non-behavioral reasons.

Describe your training regarding use of restraints? When were you trained and what did your training include?

Give me an example of least restrictive measures you would try before applying restraints onto this selected patient. Where are these documented within the patient’s medical record? Let us review the documented evidence that these measures were evaluated for effectiveness prior to the application of restraints?

How often are non-behavioral restraint orders written? When the patient’s behavior requiring restraint resolves and you assess that restraints can

be discontinued what do you do? If the behavior recurs and patient needs to be restrained again, do you need a new doctor’s

order? Can you do a “trial” to see how the patient does out of restraints? Are mitts considered a restraint? When are side rails considered a restraint and when are they not considered a restraint? Where do you document your assessment and interventions re: patient in restraint? Where do you document the updated care plan for the patient on restraints? Let’s review the

care plan now to see if it has been updated and individualize to this patient. When do you initially assess patients for pain? How do you assess for pain? What pain scale do you use? How frequently do you reassess for pain? (Surveyor will request a copy of the hospital’s

policy on pain assessment and verify if the frequency as described by the staff member is in accordance with the policy.)

Where do you document the patient’s response to pain interventions? Describe your falls prevention program. Can you give me examples of interventions? (Surveyor may select a patient who has been

determined to be at high risk for falls and go in to view the patient to see what interventions have been implemented, may request a copy of the hospital’s policy on fall prevention and verify if the interventions are in accordance with the hospital’s policy, may interview the patient to see what he or she has been educated on regarding fall prevention)

What is the fall rate on your unit? When the patient is transferred off the unit to a test or procedure, how do staff receiving the

patient know the patient is on fall precautions? What initiatives have you implemented on your unit to reduce the number of falls and falls

with injury? Describe your program to prevent pressure ulcers Can you give me examples of interventions to prevent pressure ulcers? Describe what you do if the patient has a pressure ulcer?

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What initiatives have you implemented on your unit to reduce the number and severity of pressure ulcers? How do you know that your initiatives are successful? What data are you using to evaluate your success?

How are you competent to care for a patient on anticoagulant therapy? Describe the steps you take to reduce the harm related to anticoagulation therapy What does the patient and family education need to include? Describe your process for reconciling medications across the continuum. What is the reconciliation process at discharge? What is the reconciliation process when the patient is discharged to another health care

facility? (Outpatient practices) What is your process for establishing an accurate medication list for

outpatients? (Procedural areas) What is your reconciliation process for outpatients who come in for a

procedure? How do you verify the identity of a patient who is receiving a transfusion? What is you procedure for monitoring VS before and after transfusion of blood products. What are the signs of a transfusion reaction? What would you do if you suspected one was

occurring? What is a critical result? What is your process when the laboratory reports a critical result by phone? What is done at GMH to protect patients who may be at risk for suicide? How do you know a surgical or invasive procedure is being done on the correct patient? Which procedures require universal protocol to be followed? Can you give me an example of procedures on a general unit that require universal protocol? What do you do if the patient’s condition begins to worsen and you need additional

assistance? How do you know when to call the Rapid Response Team? How do you communicate with other members of the health care team? What information do you receive about a patient when they are transferred to your unit from

another unit? (Therapists and social work). If a different therapist or social worker is seeing a patient, what

is your process for handoffs? What do you do if you have questions? How do you communicate pertinent patient information to staff in procedural and testing

areas? How do you encourage patient’s active involvement in their care? What do you consider when you are teaching the patient and family? Where do you document the patient’s understanding of your teaching? How do you store insulin in order to prevent administering the wrong one? (Surveyors may

want to directly observe insulin storage within the unit.) What does your pharmacy do to prevent errors with sound-alike/look-alike drugs (SALAD)?

Can you give me examples of these drugs? Does a patient who receives a new medication receive special monitoring during the first

dose? When there is a range order for pain medication,, how do you know which dose to use? If a physician shows up on your unit to do a procedure, how do you know he or she is

credentialed? Describe your procedure for obtaining specimens? (NPSG) What POCT do you perform on your unit? How are you competent to perform POCTs? How do you prevent spread of infections while performing POCTs? How do you know the glucometer is working properly? How long are glucometer controls good for? (Surveyors will actually look at the labels to

review) What do you do if you if a piece of medical equipment malfunctions or fails? How do you know a medical device is safe to use?

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What is the process if there is a recall or hazard alert on a piece of equipment? What is your policy regarding checking the defibrillator on the general units? (Surveyors will

look at logs to verify if practice is in accordance with policy) How do you ensure that medications are secure in all locations? How do you know none of the medications on the code cart are expired? What do you do if there is a chemo spill on this unit? Where are the oxygen shut off valves? Under what circumstances would you turn off the

oxygen supply? How long can patient food remain in the refrigerator before you must throw it away?

(Surveyors will look inside refrigerators and look at the labels). What do you do if you find out that the temperature in the refrigerator has been out of range?

(Surveyors will look at logs) Give an example of how you involved a patient and family in the plan of care. Please describe your own process to manage patient flow in the hospital. Who is responsible for the patient flow function? Which staff are involved in conferring on patient flow? How do you train and educate staff on patient flow? What oversight structure (such as a team or committee) do you have in place? How is this

monitored and reported back to leadership? What data collection processes do you have in place to track and monitor patient flow? If a modification needs to be made to your patient flow process, how is that done? Who

documents it? What processes do you have in place to manage and respond to boarding? Do your processes

include a time limit on boarding? Describe how GMHA support continuing education/professional development (internal and

external)? Additional Questions for Medical Staff

How are you monitoring the quality of history and physical exams? What is your understanding of the Ongoing Professional Practice Evaluation and Focused

Professional Practice Evaluation? What quality indicators are being monitored by your department? How are these used to evaluate quality patient care and competency?

What are the patient flow challenges in the emergency room and what role do you play? What are the infection control rates? What do you do with this information? What information does the medical staff departments collect about the quality of its service

and how is that information used? What role do you plan in patient and family education? What is your role in promoting patient safety? How does the medical staff handle reports of disruptive behavior? What is your role in a disaster? How are issues from the medical staff members addressed by the medical executive

committee? How do you handle unclear hand-off communication from another provider? How has the medical staff been involved in the performance improvement of the hospital?

What projects or initiatives is the medical staff involved in? Describe ways in which the medical staff leadership has improved the hospital? How does the medical staff get results about patient satisfaction data? In what ways are the

findings discussed and analyzed? Describe the results for your department? Give an example of how you involved a patient and family in the plan of care. The medical staff may be asked to discuss treatment in a specific case, but should not assume

that this means the surveyor has found an issue of concern. More often, the surveyor is trying to understand the institution’s approach patient care.