SERVICE EXCELLENCE …another name for Customer Service

1. SERVICE EXCELLENCE…another name for Customer Service Service Excellence is not just a good attitude, it’s a great one… Service Excellence is a way of working, a way of interacting and a way of thinking about our jobs as we work together with others to create positive patient experiences.

2. WHY SERVICE EXCELLENCE MATTERS • Service Excellence is about the patient’s impression and perception, we get one chance to make a first impression. • It is about making a difference in the patient experience. • It is about quality patient care. • To ensure a positive experience, remember…. • Every person has a role – direct care givers and support departments – both are equally important. • We need to provide a consistent product – with every patient, every time! • We are here for the patient, they come first!

3. TO PROVIDE GREAT SERVICE EXCELLENCE…. • Let the patient know that we are a team • Put yourself in the role of the patient • Treat the patient as you would want caregivers to treat you or your family member • Ask yourself have you done as much as you could to make this patient’s experience a positive one • REMEMBER to adhere to the essential components of our RUMC Service Excellence Program…

4. RUMC Standards-WE CARE Employee Recognition The Chronicle Expressions of Appreciation HCAHPS AIDET Visitor Courtesy Essential Components of our Service Excellence Program

5. Telephone Etiquette White Boards Hourly Rounding Service Recovery Quiet Campaign More Essential Components SERVICE

6. RUMC STANDARDS Welcoming Energized Compassion Advocacy Respect Excellence

7. WELCOMING We are the ambassadors of our hospital • We do A-I-D-E-T • Acknowledge our patients • Introduce ourselves and our skills • Describe the Duration of the test • Explainthe procedure and how we do things for their safety • Thank you for choosing our hospital.

8. ENERGIZED We are proud to use our energy performing purposeful work. • We follow through, follow-up. • We show confidence in our ability to provide care. • We keep up with continuing education. • We contribute new ideas, input, new initiatives to improve care.

9. COMPASSIONATE We care for our patients as if they are our own family. • We listen carefully to our clients, their families and each other and to respond quickly and appropriately to needs expressed. • We spontaneously offer assistance. • We are empathetic by putting ourselves in each patient’s situation and taking action.

10. ADVOCACY We support our patients, our community and each other. • We help our patients and their families resolve problems and concerns. • We are the voices of our patients when needed. We take our voices as employees a step further when we can. • We educate patients about their rights, how to consider appropriate choices and achieve positive outcomes.

11. RESPECT We treat others as we want to be treated. • We provide privacy for our patients and their families. • We follow HIPAA rules of confidentiality. • We treat all with dignity. • We give patients our full attention, keeping side conversations to a minimum during patient care activities.

12. EXCELLENCE We make every encounter, every day, excellent through consistent service. • We show confidence in our abilities. • We assess and know the customers needs versus expectations. • We are thorough and comprehensive including having sensitivity to cultural and spiritual needs. • We adhere to all hospital policies including dress code.

13. Survey created by CMS to consistently measure patient’s perspectives of care Mandatory participation for all U.S. hospitals Questions focus on frequency of specific behaviors and actions Survey results are publicly reported along with other clinical measures (core measures) Part of our CMS reimbursement will be based on these measures What is HCAHPS? (Hospital Consumer Assessment of Healthcare Providers & Systems)

14. Dress Code • Your appearance and manner are reflective of our values to our patients, visitors, and the communities we serve and to each other. • Your appearance is an expression of our collective commitment to treat everyone with RESPECT and to continually strive to achieve EXCELLENCE in the quality of the service we provide. • Body piercing or tattoos should not be apparent and should be covered where possible. • Beards and mustaches must be neat and well trimmed. Hair must be properly groomed. • Head-ties/ Doo rags/Skull caps/ Hats are not appropriate. • Fingernails must be neatand comply with infectioncontrol standards. Heavy perfumes, colognes, or other strong odors are not acceptable. • ID badges will be worn at all times so that the information is easily visible to patients and visitors.

15. Annual Physicals • All employees are responsible to have their annual physical during the month of their birthday. Even if their birth month falls less than a year from their start date. • Staff are responsible for ensuring that they visit Personnel Health Services, complete their annual health assessment form and have their PPD placed and read before the end of their birth month. • Failure to comply may lead to removal from duty.

16. DISCRIMINATION AND HARASSMENT • Any behavior, including verbal or physical conduct that constitutes, in any form, discrimination against or harassment of any member or guest of the Medical Center isprohibited. Retaliation in any form against a person because he or she complained about an act of discrimination or harassment is prohibited. • Discrimination is: any behavior (however manifested, and whether anonymous or overt) that limits, segregates or classifies an individual or group in such a way that might deprive them of the opportunity fully to function and participate as a member of the Medical Center. Discrimination includes any behavior that might reasonably beconsidered unlawful discrimination under applicable NYS and/or federal law. • Harassment is: any behavior (however manifested, and whether anonymous or overt) that is intended to cause or could reasonably be expected to cause an individual or group to feel intimidated, demeaned, or abused, or fear or have concern for their personal safety. Harassment includes any behavior that might reasonably be considered unlawful harassment under applicable NYS and/or federal law.

17. IT IS CRUCIAL TO REMEMBER • If you feel you are being discriminated against or harassed, you should take action which may include any/all of the following: • Speak with the individual and let him or her know that the behavior is unwelcome and unacceptable. • Talk with your supervisor/manager. • Contact Human Resources, or call the Corporate Compliance Hotline (800-826-6762).

18. Diversity At RUMC, diversity means that we believe everyone is unique and has different talents and abilities. All of us contribute in various ways to provide our customers, the organization, and the community with excellent service. When we value diversity we can fulfill our highest potential as a team and as individuals. To meet the needs of each person we interact with, we must be trained to understand the complex dimensions of diversity. These include, but are not limited to: Age, Physical or mental abilities, Race, Culture, Ethnicity, Sexual orientation, Gender, Learning abilities.

19. Diversity By examining our own attitudes, values, and behavior (as well as those of others), we begin to achieve real understanding. Teamwork is essential in a diverse work force. Qualified and diverse team members learn to respect each other’s differences. Job satisfaction will be greatly increased if each employee is valued and treated with respect. Every employee will become empowered to build strength for our team. When each member of a team has high morale, the productivity of the organization and the quality of service will be enhanced. This leads to increased customer satisfaction andimproved community relations. It is up to each of us to learn about others and address individual needs so we can work together to serve our customers. We are stronger through diversity.

20. Diversity Inclusion means creating an organizational environment and culture where every employee feels valued and is able to function at his or her best. The key to inclusion is harnessing the talents, strengths and personal motivation of each individual in our diverse workforce and aligning each person’s talents, abilities and skills with the organization’s goals, mission and values. IT IS CRUCIAL TO REMEMBER:  Our workforce is diverse; we must respect differences and make them work for us.  Interpersonal relations and organizational effectiveness are improved through encouraging new ideas and perspectives.

21. Diversity Stereotypical views of others limit our ability to understand those different from us. Every human being is unique; we need to create an environment where all employees feel they can contribute to their fullest potential.

22. Replaces all other incident reports • Allows for immediate reporting of an event • Mandates investigation into each event • Encompasses actual events and near misses.

23. One Consolidated Form • Replaces • Employee Incident Report • Safe Medication Event Form • Workplace Violence Form • Memo to Quality Assurance Form • Safety Report

24. Timely Reporting & Follow up • Two part form allows for immediate notification to various departments such as Risk, Employee Health, Quality, Pharmacy. This will allow for appropriate and timely reporting to external authorities if necessary. External authorities include: NYPORTS; DOH; OMH; OSHA; and Insurance Carriers. Failure to report within a timely manner can lead to citations and fines. • Investigation to event can then be carried out as appropriate and will “catch up” with initial notification.

25. Actual Events & Near Misses • Actual events are those that happen – a fall, a medication error, a back sprain, a theft. • A near miss – is a potential event that is caught because of an internal mechanism of checks and balances or by chance – for example wrong medication is delivered to the unit but not received by the patient.

26. Event Reporting Guidelines • The hospital investigates all Events: including occurrences, incidents, sentinel events, or near misses, to understand the causes that underlie the event and to make changes to the hospital’s systems and processes in order to prevent the probability of recurrence of the event. • It is the policy of the Medical Center to ensure that proper actions are taken, adequate documentation, and notification to the appropriate persons or regulatory bodies is made when an event happens.

27. Event Reporting Guidelines • This event may involve a patient, visitor, volunteer, employee or property or may be an actual or potential interruption of services necessary to the continued safe operation of the hospital. • Many of these events are reported for tracking purposes only. Reporting is not meant to imply negligence, wrong doing, or place blame. • Every effort must be made to report and investigate as quickly as possible. Any lag deters from the investigation and provides a window for recurrence.

28. Types of Events to Be Reported • An unexpected event or situation related to a patient, visitor, or staff irrespective of outcome * fall, med error, test on wrong patient • An unexpected occurrence which leads to serious harm or death or has the potential for same * rape, amputation, wrong surgery • Work related employee illness or injury or potential for same • An unexpected event not necessarily associated with a person * Code Red • Act of commission or omission that could have resulted in harm • Workplace violence

29. Event Reporting Guidelines Actions • Stabilize the situation. Perform immediate actions to decrease harm and protect. • Assess the person and render appropriate care. Documentation • All patient events that reach the patient should be fully documented in the patients medical record by the staff identifying the event, the clinical staff assessing the patient, and staff carrying out the interventions-if necessary. The entry must be objective, stating the facts only.

30. Event Reporting Guidelines Documentation (continued) • An event report should be initiated as soon as possible after the event by the person with the best knowledge of the event, typically this is the individual who first discovers the situation. • Do not reference the event report in the medical record or during conversation with the patient and/or family. Disclosure • Disclosure of events should occur ideally by the attending physician and after consultation with the Quality/Risk Management Leadership.

31. Event Reporting Guidelines Investigation • The manager is responsible for taking the lead in investigating the who, what, when, where, and why of the events. • This investigation along with any corrective action is reviewed with the Senior Leader for the area.

32. Event Reporting Form Guidelines The event report should be initiated by the person who has direct knowledge of the situation • Place patient label in the identification box if a patient event. If visitor, staff, or other person document demographic information. • Identify if the event is an incident, sentinel event, or near miss only if the determination can be made at the time. If it is believed that a sentinel event has occurred- immediate notification to the Quality/Risk management or the ADN must occur. • In the event of work place violence, security and/ or the ADN must be notified.

33. Event Reporting Form Guidelines • Document the date, time (military) and location of the event. Be as specific as possible. • Document the nature of the event If a category does not exist, use the other selection in the first column. • Identify a potential cause of the event if possible. • For blood borne pathogen exposures, identify the device utilized. Specifically indicate the brand, model number and any other identifying information. Every effort should be made to retain the device in a safe manner.

34. Event Reporting Form Guidelines • Describe the event. • Include the who, what, where, and how • Identify equipment by brand, model, and serial number. Every effort should be made to secure any equipment that is believed to have contributed to the event. This may be essential to the investigation. • Identify any witnesses • Indicate any initial treatment rendered • Identify the specific outcomes and disposition of the involved party

35. Event Reporting Form Guidelines • Indicate to whom notifications were made. Include name, badge number, report number, when possible. • Signatures- The person initiating the form The physician evaluating the individual The supervisor on duty Distribution: • Send one copy of page 1 immediately to Quality/Risk Management Villa Building • Send the second copy of page 1 to: • Personal Health if an employee event • Pharmacy if a medication event • Forward all remaining forms to your immediate supervisor for further investigation

36. FAMILY HEALTH CARE DECISIONS ACT (FHCDA) New York State Family Health Care Decisions Act June 1, 2010

37. FHCDA OVERVIEW • Applies to patients in hospitals and nursing homes in New York State • Empowers families and close friends to make treatment decisions for patients without capacity • Overcomes legal barriers by permitting those closest to patient to make decisions based on patient’s known wishes and/or in the patient’s best interest • Does not apply to patients who have a Health Care Proxy

38. FHCDA HIGHLIGHTS • Provides a list of surrogates in order of priority who have authority to make decisions when patients no longer have capacity • Does away with clear and convincing evidence for end-of-life decisions • Makes it possible to provide care and to withhold or withdraw life-sustaining treatment from patients without capacity or with no surrogate • Permits artificial nutrition and hydration to be withdrawn whether or not patient has discussed wishes

39. FHCDAModifications to Hospital Policies • New and revised policies • Eight (8) new forms • FHCDA Hospital Form 1-7 • Withhold/Withdraw/Refusal of Treatment Consent Form • Eliminates DNR Form 2-7

40. INFECTION CONTROL

41. Infectious Agent INFECTION PREVENTION & CONTROL Susceptible Host Reservoir Portal Of Exit Portal Of Entry It’s all about breaking the Chain of Infection Mode of Transmission

42. Handwashing is the single most effective way of stopping the spread of infections! How do we break the chain of infection?

43. When Do You Wash Your Hands? • Before eating or handling food • After using the restroom • Before and after each patient contact • Before handling clean equipment • Before and after performing procedures • After removing a used pair of gloves

44. Use Soap and Water When your hands are visibly soiled with blood and/or body fluids- WASH FOR AT LEAST 15 SECONDS! If patient is confirmed or suspected of having C.difficle Use Waterless Hand Gel When your hands are not visibly soiled In between washing with Soap and Water Let the gel thoroughly dry before touching any equipment, including phones that may be powered by electricity. How Do You Wash Your Hands?

45. Hand Hygiene • Keep natural nails less than ¼ inch long • Artificial nails, extenders, tip, wraps, permanent French, etc. MUST NOT be worn by all personnel assigned to an acute in-patient unit and/or staff performing patient related procedures, or preparing equipment or supplies for patient use.

46. How do we break the chain of infection? Standard and Transmission Based Precautions • CDC Guidelines • Established to control the spread of communicable diseases and protect against unknown organisms. Always notify Infection Control Ext# 3134 when placing someone on Isolation

47. Standard Precautions • Practices that apply to all patients in any setting • Hand Hygiene • Use of Personal Protective Equipment (PPE) • gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure • Safe Injection Practices • All Blood & Body Fluids Treated as Infectious: (Blood, Body Fluids (Except Sweat), Non-intact Skin, Mucous Membranes

48. STANDARD PRECAUTIONS: INFECTION CONTROL MEASURES THAT ARE IN PLACE ON ALL PATIENTS ALL THE TIME

49. Caught in the act! Personal Protective Equipment (PPE) (shoe and head covers, gloves, gowns, etc.) must be disposed of in a proper receptacle before exiting the work area. This is especially important for employees working with patients at high risk for cross-contamination (OR, L&D, NICU). No employees are exempt. Thank you for every effort you undertake to make RUMC a more patient-centered environment.

50. Transmission Based Precautions • Extra Precautions • Used in addition to Standard Precautions • Used with highly transmissible or contagious pathogens