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2009 - 2010 Safety Fair. House Staff Edition. Overview. What is Safety Fair? All hospitals are required to provide annual reviews of safety and quality information for all employees. At GCH, this is called “Safety Fair.”

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2009 2010 safety fair

2009 - 2010 Safety Fair

House Staff Edition

  • What is Safety Fair?
    • All hospitals are required to provide annual reviews of safety and quality information for all employees. At GCH, this is called “Safety Fair.”
    • This presentation has been customized from the GCH Safety Fair material to provide information most relevant to house staff
  • What’s new this year?
    • GCH is preparing for its annual AOA-HFAP* accreditation survey. This is a three-day site visit anticipated to occur in early 2010.
    • Information relevant to our accreditation standards and to quality and safety has been compiled in a Safety and Survey Handbook. Copies have been distributed to your mailbox in the House Staff Lounge. House staff who are out-of-state may request a Handbook by mail.

(*Healthcare Facilities Accreditation Program)

safety and survey handbook
Safety and Survey Handbook
  • Check your mailbox in the House Staff Lounge for your copy of the Safety and Survey Handbook.
  • Keep the handbook with you – you can refer to it if asked questions by an inspector.
  • Follow along in the handbook as you view this presentation. Handbook page numbers are referenced throughout.

2 in your Handbook

safety and survey handbook1
Safety and Survey Handbook
  • Look for these symbols:
    • “«” Means this section if critical for HFAP accreditation
    • “t” Means this section is critical for Fire Marshal visits
  • Dashed boxes (like this) are to be filled out with information specific to your training program or Medical Education. These are typical questions asked of employees during a survey or inspection and will be detailed in this presentation.
to meet your safety fair requirement
To meet your Safety Fair requirement

Option 1:

View this presentation online

Complete the online quiz by November 15, 2009

Option 2:

Attend a Safety Fair session – dates and times are posted and have been sent by email.

part i healthcare facilities accreditation program hfap

Part I:Healthcare FacilitiesAccreditation Program (HFAP)

Anticipated Survey:

Jan-March 2010

4 in your Handbook

hfap inspection keys for house staff
HFAP inspection: Keys for House Staff

The HFAP inspection will evaluate patient care, facilities, policies, etc.

anything and everything related to running a hospital. Key issues for all

physicians and house staff are listed below.

  • Delinquent Medical Records
    • All medical records must be complete within 30 days of discharge. This is required by HFAP and by the Centers for Medicare and Medicaid (CMS). Now is the time to get your charts in order and maintain compliance.
  • H&P’s
    • Must be documented within 24 hours of admission
    • Must be complete, including osteopathic structural exam (OSE)
  • Orders and Progress Notes
    • Must include date and TIME!
    • Must be signed – including telephone orders
    • Include printed name and pager number
    • Legible!

4 in your Handbook

hfap inspection keys for house staff1
HFAP inspection: Keys for House Staff

Key issues for all physicians and house staff,


  • Informed Consent
    • Must include all required elements:
      • Date and TIME
      • Signature of patient, person obtaining consent, and witness
  • Restraint Orders
    • Required for all patients
    • Must be completed according to policy (more on this later in this presentation)

4 in your Handbook

interacting with surveyors and inspectors
Interacting with Surveyors and Inspectors
  • Be friendly, helpful, and honest.
  • Answer the question asked, then stop! Don’t volunteer additional information, thoughts or concerns.
  • Focus on the positive – describe what we do, not what we don’t.
  • Refer to your handbook if you need to.
  • Ask for the question to be re-stated or said differently if you don’t understand it.

5-6 in your Handbook

patient rights and responsibilities
Patient Rights and Responsibilities
  • These apply to every patient.
  • A list of patient rights and responsibilities may be found in your handbook. They are also posted throughout the hospital and given to patients.
  • Read and familiarize yourself with them. Be sure to respect them in your work.
  • Know how patient rights are protected
    • Special Policies
    • The Uniform Standard of Care

6-9 in your Handbook

patient satisfaction
Patient Satisfaction

GCH measures patient satisfaction for all inpatient and

outpatient encounters. All employees need to know:

  • How do we measure patient satisfaction?
    • Our satisfaction survey is conducted by the NRC Picker company. Patients receive a survey in the mail.
  • How do we make improvements in patient satisfaction?
    • We call our satisfaction effort C2E or Commitment to Excellence
    • Specific tools used include AIDET (described on next slides)

10-11 in your Handbook

  • AIDET is a proven tool to facilitate respectful and effective communication during a patient encounter.
  • Use of AIDET has been shown to improve patient satisfaction. House staff are to utilize this approach when interacting with patients.
patient satisfaction1
Patient Satisfaction
  • GCH measures patient satisfaction for all inpatient and outpatient encounters internally using a paper survey sent to patients by the NRC Picker company
  • We are also measured by the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. This is a national, standardized, publicly reported survey of patients' perspectives of hospital care.
  • HCAHPS (pronounced “H-caps”), is a standardized survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience.
  • HCAPS satisfaction data for GCH and other hospitals are publicly reported at www.hospitalcompare.hhs.gov.

10-11 in your Handbook

patient satisfaction2
Patient Satisfaction

House staff should be aware of the HCAHPS satisfaction

measurements relevant to physicians. As you are often on the front

line of patient care, your interactions with patients are reflected in

these questions. Patients answer on a scale from “Never” to

“Always” – we need you to help earn “Always!”

During this hospital stay, how often did doctors

Treat you with courtesy and respect?

Listen carefully to you?

Explain things in a way you could understand?

Did you have confidence and trust in the doctors treating you?

Did your family or someone else close to you have enough opportunity to talk to your doctor?

10-11 in your Handbook

what is patient safety
What is Patient Safety?
  • The prevention of harm to patients using a system that…
    • Prevents errors
    • Learns from errors that do occur
    • Is built on a culture of safety that involves health care professionals, organizations, and patients

11-12 in your Handbook

gch patient safety initiatives
GCH Patient Safety Initiatives
  • Hospital wide initiatives
    • Patient Safety Rounds – Talking to employees
    • Environmental Rounds – Visual inspection
    • Purchase of New Beds – To reduce fall rates
    • Medication Administration:
      • New Medication Reconciliation Form
      • Bedside Bar Coding for Medication Administration
    • New Surgical Center
    • Pressure Ulcer Team
    • Falls Team
    • Moving towards Electronic Medical Record

11-12 in your Handbook

gch patient safety initiatives1
GCH Patient Safety Initiatives
  • Examples of Medical Education initiatives -

enter in your handbook on page 12

    • Rapid Response Team
    • Code Blue Peer Review Forms
    • Feedback on use of standard orders
    • unauthorized abbreviations, etc.

11-12 in your Handbook

your role in playing it safe
Your Role in “Playing it Safe”
  • Report immediate dangers to Medical Education or to Security
  • Report non-urgent concerns to
    • Medical Education
    • Your attending physician
    • The Safety Officer, Greg Harrison (x4234)

11-12 in your Handbook

what is environmental safety
What is Environmental Safety?
  • Oxygen safety
  • Spill safety
  • Hazardous chemicals safety
  • Electrical safety
  • Medical device safety
  • Emergency Preparedness
  • Sharps safety
  • Infection Control

12 in your Handbook

oxygen safety
Oxygen Safety
  • Oxygen tanks should be stored:
    • 5 feet away from combustibles in a sprinkler protected room
    • 20 feet away from combustibles in a non-sprinkler protected room
  • Oxygen tanks cannot be stored in corridors
  • Tanks must be stored in an approved holder. If you see a loose tank, notify a manager in that area to secure the tank.

12-13 in your Handbook

hazardous materials spill safety
Hazardous Materials/Spill Safety
  • The basic elements—
    • Hazardous chemicals are present in virtually all areas
    • Every employee has the right to know the dangers of the chemicals used where they work
    • Every employee also has responsibility to ask for further information and to follow hazardous chemical precautions

14-15 in your Handbook

hazard communication
Hazard Communication

Every employee has the right to know the dangers of the chemicals used where they work. Every employee also has responsibility to ask for further information and to follow hazardous chemical precautions.

MSDS stands for Material Safety Data Sheets

Provide chemical hazard information

These references are available in the ED for all chemicals used in hospital in case of exposure


If you find it – make sure it is cleaned up!

  • Clean up simple spills (see the table in your handbook on page 15)
  • Communicate spill hazards
  • Report contaminated or large chemical spills by calling the operator and asking for Security or the Housekeeping Supervisor
  • Learn about proper disposal for different medical wastes (handbook page 17)

15,17 in your Handbook

electrical safety basics
Electrical Safety Basics
  • Make sure that all equipment has a grounded plug
  • Don’t overload outlets
  • Don’t use damaged equipment

16,18 in your Handbook

medical devices
Medical Devices
  • A medical device is anything that is used in the care of the patient that is not a drug
  • In case of malfunction of a medical device:
    • If nobody is injured contact Biomed Department (x4297) for repairs
    • If a patient or employee may have been injured
      • Assure the safety of the patient/employee
      • Secure the device – do not change settings
      • Contact Biomed (x2829) and Risk Management (x3403)
    • EXAMPLE: malfunctioning defibrillator; vent that didn’t alarm  Contact Biomed

18-20 in your Handbook

baxter infusion pumps
Baxter Infusion Pumps
  • Keep It GREEN, Plug it in!
    • Keep the pump plugged in at all times when not transporting
    • Ensure GREEN PLUG icon is illuminated next to the on/off button
  • Prior to transport, always check the Battery Charge Level icon
    • See instructions in your handbook, page 20

20 in your Handbook

codes and disaster protocol
Codes and Disaster Protocol

The following codes may be called overhead:

  • CodeBLUE: cardiac and/or respiratory arrest
  • Code RED: fire
  • Code PINK: infant abduction
  • Code BLACK: severe weather/tornado warning
  • Code TRIAGE: disaster (internal or external)

(has replaced Code Yellow)

  • Code ALPHA: administrative team alert
code red fire alarm signal
Code RED: Fire Alarm Signal
  • Code RED page and/or alarm can occur in response to:
    • A phone report of smoke or fire
    • An alarm “pull”
    • An automatic smoke detector signal

21 in your Handbook

code red fire alarm signal1
In the event of a code RED:

DO keep all doors shut

DO remain in your area

DO listen for overhead pages with further instructions

DO move patients and visitors to behind fire doors

DO treat all Code Reds as “the real thing”

DO NOT go through closed fire doors

DO NOT use elevators

DO NOT assume a Code Red is a drill

CodeRED: Fire Alarm Signal

21 in your Handbook

fire response r a c e
Fire Response: R.A.C.E.

A fire marshal or inspector may ask you how you would

respond to a fire. Remember the acronym R.A.C.E.

 What does R.A.C.E. stand for?

  • Rescue - Persons in immediate danger
  • Alarm - Activate the fire alarm system and call 3333
  • Contain - Contain the fire by closing doors. Never open a door to check on a fire
  • Extinguish - Attempt to extinguish the fire but only if it is safe to do so

21 in your Handbook

fire response p a s s
Fire Response: P.A.S.S.

A fire marshal or inspector may ask you how to use a fire

extinguisher. Remember the acronym P.A.S.S.

 What does P.A.S.S. stand for?

  • Pull – the pin to activate the trigger
  • Aim – the nozzle at the base of the fire
  • Squeeze – the trigger firmly
  • Sweep – the nozzle from side to side

21 in your Handbook

violent or threatening behavior
Violent or Threatening Behavior
  • First, keep yourself safe
  • Contact Security for help (x3333)
  • Do what you can to avoid problems—
    • Wear your badge
    • Maintain locked entrances – no propped open doors
    • Report suspicious individuals or circumstances
    • Lock up valuables, purses, etc.

23-24 in your Handbook

code pink infant abduction
Code PINK - Infant Abduction

Code PINK is the signal for a potential infant abduction. All staff are expected to assist in monitoring stairs and exits.

  • Stop all non-critical work.
  • Guard all interior stairwell doors, elevator areas and exit doors.
  • Do not allow anyone (including employees) to exit the building that is carrying a child or package/bag that could contain an infant.
  • Wait for all-clear message.

26 in your Handbook

code black severe weather
CodeBLACK: Severe Weather

Code BLACK is the signal for severe weather.

Employee actions include:

Remain on assigned duties

Move patients and visitors to internal corridors if possible

If patients cannot be moved out of room, move them away from windows, close windows, draw curtains and blinds.

Help to reassure patients and visitors

26 in your Handbook

code triage disaster
Code TRIAGE – Disaster
  • Code TRIAGE is the signal for an internal or external disaster. (Note: This was previously called Code Yellow.)
  • The guidelines on the next slide indicate the appropriate actions by specialty or assignment. This applies to those individuals on duty or at home on pager call. Note this on page 28 of your handbook.
  • In most cases, house staff should report to the labor pool in the auditorium to sign in. If you are not immediately needed, you may leave the pool and resume your usual duties.

26-28 in your Handbook

employee response in disasters
Employee Response in Disasters
  • Each one of us must consider our commitment to the safety and welfare of our patients, and co-workers when planning how we will respond to the disaster needs of the hospital
  • Planning should include discussing your hospital commitment with your family and preparing your family to respond effectively to disaster events

24-25 in your Handbook

weapons of mass destruction
Weapons of Mass Destruction
  • “WMDs” include:
    • Chemical
    • Biological
    • Radiation
    • Nuclear weapon
    • Explosives

28 in your Handbook

wmd scenarios factors
WMD: Scenarios & Factors
  • WMD incidents could result in two primary scenarios:
    • A large number of burn or blast trauma casualties
    • An increasing number of infectious illness, chemical poisoning or radiation disease victims
  • WMD incident may include complicating factors for the delivery of hospital care
    • Region-wide evacuation or quarantine
    • Contaminated victims: biological, chemical or radiation

28-30 in your Handbook

wmd hospital preparation
WMD: Hospital Preparation
  • GCH has prepared for contaminated victims through…
    • Stockpiling of personal protective equipment, antibiotics and other medications
    • Planning for regional isolation of hospital areas in the event of contamination
    • Participation in region-wide disaster drills
    • Mutual aid agreements with community agencies
    • ED: decontamination tent and use of high level personal protective equipment

29 in your Handbook

hand washing
Hand Washing
  • The single most important procedure for preventing infections for
    • Patients
    • Co-workers
    • Yourself
  • Review proper techniques
    • Page 30 of your handbook
  • Wash your hands before and after examining patients – they expect this and will notice if you don’t!

30-31 in your Handbook

  • Seasonal and H1N1 Influenza vaccinations (flu shots) have been administered by Employee Health. If you missed getting yours, watch for updates on community based immunization clinics.
  • The flu can cause life-threatening illness in some individuals, especially the young, old and ill
  • Even if you have never had the vaccine or felt you were ill with flu, you may still be a carrier infecting—
    • Patients
    • Family
    • Co-workers
  • Save lives, get vaccinated!

31 in your Handbook

blood borne pathogens bbp
Blood Borne Pathogens (BBP)

BBP’s are infectious agents, such as hepatitis B, hepatitis C, and HIV, that can be transmitted by blood & other body fluids.

All personnel who have direct patient contact – e.g. all house staff – will be tested for immunity against HBV. Vaccination is available through Employee Health.

31 in your Handbook

blood borne pathogens bbp1
Blood Borne Pathogens (BBP)

To protect yourself against BBP:


Minimize/control splashing of fluids

Use appropriate Personal Protective Equipment

Practice good sharps safety

Cover cuts and scrapes

Don’t eat or drink where body fluid contamination may be present

Use proper equipment to clean up broken glass

Never reach into trash - handle trash bags from the edges

Follow appropriate procedures to wipe blood and body fluid spills

Clean up after procedures, dressing changes, etc.

31 in your Handbook

sharps safety
Sharps Safety

NEVER re-cap a needle.

Count sharps before and after procedures.

Properly dispose of sharps.

Change sharps containers that are 3/4 or more full. (Contact Environmental Services)

Use safety devices when available.

32-33 in your Handbook

sharps safety1
Sharps Safety


The patients’ bed or linens

Bedside stand or over-bed table

Food tray


IV pump

32-33 in your Handbook

needlesticks and exposures
Needlesticks and Exposures

In the event of a needlestick/sharps injury

and/or blood or body fluid exposure:

Wash the area with soap and water.

Go immediately to the Emergency Department for evaluation.

Complete the NEW Employee Incident Report form.

If needlestick/sharps injury: Complete the Med Ed needlestick questionnaire as well.

Follow medical orders for follow-up care.

DO NOT initiate orders for HIV/HBV/HCV testing on the patient – this will be done through the protocol.

32-33 in your Handbook


In 2007 over 12,700 new tuberculosis (TB) cases were reported in the U.S.

Take precautions if a patient has symptoms which could represent TB (persistent cough, blood in sputum, unexplained weight loss, night sweats, upper lobe infiltrate)

Provide a mask to suspected patients who are awaiting a room

Admit to a negative pressure room with respiratory isolation

Complete appropriate workup

Use appropriate respirator masks when entering the patient’s room

32 in your Handbook

masks for respiratory precautions
Masks for Respiratory Precautions

Employees that have direct patient contact must be FIT tested annually.

FIT tested employees must wear an N95 respirator mask when entering the room of a confirmed or suspected TB patient. These are available through Pyxis but you must know your size.

  • Employees that cannot wear an N95 mask (e.g. poor fit, beard/moustache) must wear a Hepahood ® when entering room. Contact Respiratory Therapy to sign out blower; keep the hood for your personal use in future.

32 in your Handbook

lifting do s and don ts

Lift with your back

Use an unstable base

Use an overextended reach

Lift overhead

Twist while reaching for or lifting a load


Lift with your legs

Hold the load close to your body

Look straight ahead

Use lift devices to prevent injury

Use carts and dollies to move loads

Lifting Do’s and Don'ts

34-35 in your Handbook

part v quality

Part V: Quality

35 in your Handbook

quality management essentials
Quality Management Essentials
  • Goals of QM are to improve…
    • Work processes
    • Outcomes
    • Clinical care
    • Efficiency
    • Customer satisfaction
    • Hospital market share

35 in your Handbook

selected quality initiatives
Selected Quality Initiatives
  • Current organization-wide quality/patient safety initiatives…
    • Heart Failure
    • Surgical Infection Prevention
    • Acute MI
    • Pneumonia
    • Patient Safety
    • ICU Keystone
    • Surgery Keystone

37 in your Handbook

a question of quality
A Question of Quality
  • Quality affects reimbursement because…
    • If a patient develops an infection or a pressure ulcer or falls while in the hospital – the insurance provider will not pay for continued care related to those problems
  • If you suspect an issue involving quality of care…
    • Report it immediately to you supervisor

37 in your Handbook

your role in selected quality initiatives
Your role in selected quality initiatives

For Heart Failure, Acute MI, and Pneumonia:


The use of standard order sets has been shown to reduce errors and omissions and improve quality.

Our performance on these initiatives is publicly reported and may influence reimbursement.

It is vital that house staff cooperate in these efforts.

heart failure initiative
Heart Failure Initiative

GCH is seeking to improve its performance on Heart Failure quality measures. House staff need to remember to:

Use the standard order set

Prescribe and ACE-inhibitor or ARB; if contraindicated, document this and state reason (e.g. “ACEI/ARB not prescribed due to renal insufficiency”)

Complete the discharge instructions properly.

MUST REWRITE names and doses of all medications

DO NOT write “resume home meds”

surgery time out
Surgery “Time Out”
  • A protocol designed to avoid operating on the wrong site or wrong patient
  • Prior to the start of the case, the team verifies
    • Patient identity is correct
    • Procedure planned is correct
    • Site for operation is correct and marked
    • Documentation is in order
conditions present on admission
Conditions Present on Admission
  • Payers may not pay for conditions acquired in the hospital.
  • It is critical that conditions that are present on admission (“POA”) be documented on the H&P or admitting progress note.
  • Key conditions include:
    • Decubitus ulcers – document stage
    • Infections, e.g. UTI, pneumonia
medication reconciliation
Medication Reconciliation
  • Medication errors are more likely to occur at transfer points in the healthcare system, e.g.
    • Home to inpatient
    • Transfer between inpatient units
    • Discharge to home or ECF
  • Medication Reconciliation is a relatively new process which seeks to reduce errors at those points.
medication reconciliation1
Medication Reconciliation
  • On admission:
    • A record of home medications will be made and will serve as the “source of truth”
    • A physician (house staff or attending) will review the meds and sign the form
    • When completing the H&P, state “see med reconciliation form” for home meds
    • When writing admitting orders, decisions will still be made regarding continuation of home meds
    • The form will be used again at discharge to document instructions for prior meds as well as any new prescriptions
medication reconciliation2
Medication Reconciliation
  • On transfers and after surgery:
    • An order form listing most recent inpatient medications will be printed
    • A physician (house staff or attending) will review the meds and circle “continue”, “discontinue” or change
    • This will eliminate the need to rewrite all medications and doses by hand
    • It is not permitted to write “resume prior meds” after surgery
definitions hipaa and phi
Definitions: HIPAA and PHI
  • Patient procedures and any medical records that are generated are protected under HIPAA (Health Insurance Portability and Accountability Act - 1996)
  • Protected Health Information or electronic protected health information (PHI or e-PHI) is anything that would be considered an individual identifier for a patient, such as name, address, MRN, gender, date of encounter, date of birth, etc.

40-41 in your Handbook

assuring confidentiality
Assuring Confidentiality
  • GCH employees should review patient charts or electronic medical informationonly if they are providing direct care to the patient
  • Patient Information should be discussed only with persons directly involved in that patient’s care. Avoid discussions in public areas (e.g. corridors, the cafeteria, etc.
  • All documents with PHI (including documents copied from patient records, patient lists, copies of dictations, etc.) MUST be disposed of in the locked recycling bins. These documents cannot be

40-41 in your Handbook

assuring confidentiality1
Assuring Confidentiality

Do not look up records for:


Your family, friends or neighbors – even with their permission

Go through Health Information Management to request records or results

Electronic records are monitored for unauthorized access

It is acceptable to access charts for purposes of education, lecture preparation, scientific papers, etc. De-identify patient information used in lectures and case presentations.

Remember that all research projects involving medical records needs to be approved first by the IRB.

These guidelines apply to out-rotations as well

40-41 in your Handbook

information requiring extra care
Information Requiring Extra Care
  • Sensitive Health Information such as mental health, chemical dependency, sexually transmitted diseases and HIV should never be sent via fax
  • Any requests for records containing this kind of information should be discussed with your Supervisor or Compliance Officer prior to being sent
  • Unless it is for a physician consultation, the patient must first sign a HIPAA authorization to release the information

40-41 in your Handbook

prevent unauthorized data access
Prevent Unauthorized Data Access
  • You are responsible for access under your password!
    • Do not share passwords with others!
    • LOG OUT when you are done!
    • You are responsible for unauthorized access that occurs under your password!
  • Change Passwords Frequently
    • Passwords should be constructed so they cannot be easily guessed
    • At least 8 characters in length
    • Can include UPPER and lower case letters and incorporate punctuation marks to make them more secure

40-41 in your Handbook

violations and reports
Violations and Reports
  • Violations
    • HIPAA complaints are reported to the Office of Civil Rights
    • The penalty parameters for violating HIPAA ranges from $50,000 fine up to $250,000 fine including imprisonment for up to 10 years, depending upon the nature of the violation
  • Reporting
    • Call the Compliance Officer – Lisa Sielski at Ext. 4428
    • Or Call the Compliance Hotline at 734-458-4298 to make a confidential report

40-41 in your Handbook

other compliance matters
Other Compliance Matters
  • Only document and bill for services/procedures that “you actually performed”
  • Use the correct patient’s name and identifying numbers when accessing Pyxis or running EKG’s or other tests
  • Never accept any gifts or kickbacks from vendors or suppliers
  • Never offer gifts or kickbacks to vendors or suppliers
  • Contact Medical Education for information on applications for educational grants

40-41 in your Handbook

responding to complaints
Responding to Complaints
  • First steps
    • Listen carefully
    • Apologize (I’m sorry this happened to you)
    • Take action to resolve the issue
    • Follow-up with the complainant about what you did
  • If you cannot help, then in order…
    • Ask other staff for assistance
    • Contact the Patient Representative
    • Contact Medical Education or Administration
  • What is a grievance?
    • A written complaint (letter, email, fax)
    • An unresolved complaint
  • Special steps are needed for grievances (handbook page 43)

42-43 in your Handbook

safety alert fall risk program
Safety Alert/Fall Risk Program
  • Patients with potential for falling have…
    • A yellow Fall Risk ID wristband
    • YELLOW Safety Alert Signs
  • All staff should…
    • All staff train themselves to listen for bed alarm
    • Respond to bed alarms
    • Stay with patient while calling for additional assistance
  • All staff should, upon seeing a safety alert sign or yellow wristband anywhere in the hospital…
    • Make sure patient not trying to get out of bed
    • Smile (when observing patients)
    • Greet patient (show them you care)

43-45 in your Handbook

safety alert contd
Safety Alert, contd.
  • If a patient is attempting to get out of bed…
    • Stay with patient
    • Call for assistance
    • Say, “Please STAY in bed” – patients with confusion or dementia respond better to this than to “Don’t get out of bed”.
  • Communication of Fall Risk is essential between caregivers, shifts, and departments
    • Magnetic “Safety Alert” card is placed on the doorframe outside of the patient room
    • At shift change report
    • When patients are transported to other departments

43-45 in your Handbook

proper patient identification
Proper Patient Identification
  • Two identifiers are needed before any patient care interaction—
    • Patient name
    • Date of birth
    • Medical record number
  • Wrist bands are color coded for safety…

46-47 in your Handbook

foreign language interpreters
Foreign Language Interpreters
  • The hospital must provide an interpreter to anyone with limited English proficiency
    • We have hospital staff who can interpret.
    • The Interpreter List is updated and distributed quarterly.
    • You can volunteer if you speak another language – notify Med Ed.
  • If you cannot find a hospital interpreter, please use Language Line
    • Language Line: 1-800-643-2255 Emergency number: 1-800-523-1786 and the GCH client I.D. is 208015
  • Do not use family members to interpret
    • It could jeopardize patient safety
    • Take your time and use Language Line

48 in your Handbook

pain management basics
Pain Management Basics
  • Principles of Pain Management
    • Pain is what the patient says it is
    • Patients have the right to pain management
    • Control of pain is a key element of care
  • Patients are assessed for pain throughout their stay
  • Use the objective 10 point pain scale to assess pain
  • Pain management is a collaborative effort of…
    • Physicians
    • Nurses
    • Pharmacists
    • Others
  • Pain control includes…
    • Medications
    • Noninvasive measures including: distraction technique, cutaneous stimulation, relaxation techniques and position changes

48-49 in your Handbook

ethical issues
Ethical Issues
  • Employees can refer ethical concerns to
    • Their direct manager (Med Ed)
    • The Ethics Advisory Committee (EAC)
  • The Ethics Advisory Committee
    • is confidential
    • Accepts referrals from anyone that has a concern about an issue
    • Is advisory
  • Process
    • Complete the form “Ethics Advisory Committee Request for Consultation”
    • Forward to the office of the Medical Director or Outcomes Management Director
  • Potential Cases might include
    • Termination of life support systems
    • Providing treatment to a minor child in the face of parental objections
    • Ceasing of futile interventions in the face of family objections

49-50 in your Handbook

  • Restraints are used only when alternative measures have been tried and are ineffective
  • The best alternative measure is family
    • Patients are more comfortable and relaxed with family
  • Restraints include
    • Full Side rails
    • Mitts
    • Soft Wrist
    • Soft Ankle
    • Vest
    • Physical Hold
    • Physical Escort
    • Lock and Key

50-53 in your Handbook

restraint orders must indicate
Behavior Restraints

Violent/self destructive behavior

Requires physician order and assessment

Order good for 4 hours for adult, 2 hours for child

15 minute monitoring

Hourly assessments

Removed at the earliest possible time


Medical Restraints

Patient is disrupting treatment

Requires physician order and assessment

Order good for 24 hours

Hourly monitoring

Assessment every 2 hours

Removed at the earliest possible time

(More detail in your handbook)

Restraint Orders Must Indicate…

52 in your Handbook

hospital leadership
Hospital Leadership
  • Chief Executive Officer (CEO) – Gary Ley
    • V.P. Operations (CAO) – Art Greenlee
    • V.P. Chief Finance Officer (CFO) – Dan Babb
    • V.P. Medical Admin. (CMO) – Gary Moorman, D.O.
    • V.P. Chief Nursing Officer (CNO) –Debra Williams
    • V.P. Human Resources, Steve Solomon
    • V.P. Medical Education, Kirsten Waarala, D.O.
  • Reporting to the Vice Presidents
    • Directors and Department Heads
    • Coordinators, Managers and Supervisors
  • If asked, you report to Dr. Waarala and to your residency program director

64 in your Handbook

part viii 2008 2009 in review

Part VIII: 2008 – 2009In Review

64-66 in your Handbook

quality care awards
Quality Care Awards
  • 5th consecutive year awarded Governor’s Quality Award (4 different awards)
  • Selected to Participate in National Quality Improvement Collaborative

64-66 in your Handbook

corporate awards
Corporate Awards
  • Ranked #31 in the nation and highest in Southeast Michigan, as a “Best Places to Work” by Modern Healthcare
  • Recognized by the American Heart Association with National Gold Achievement Award, designating Garden City Hospital as a “fit friendly” company
  • 101 Best and Brightest companies 6 years running

64-66 in your Handbook

what s new
What’s New


  • Wound Care Expansion (new treatment rooms)
  • Sports Medicine Practice at Westland

Med Ed

  • Approved for fellowships in Gastroenterology and Nephrology (to begin in 2010)
  • Application in process for Sports Medicine Fellowship

64-66 in your Handbook

patient and visitor satisfaction
Patient and Visitor Satisfaction
  • Introduced The Patient and Family Advisory Council
  • New Patient Information Envelope
  • New patient mattresses installed in every inpatient room
  • Patient pay processes upgraded:
    • Enhanced assistance for Medicaid-eligible patients
    • Introduced self-pay discounts
    • Enabled point-of service payment

64-66 in your Handbook

in our community
In Our Community
  • MHA Food Drive
  • Halloween Party Grows
  • Santaland Parade
  • Heart Walk

For Med Ed

  • Community service opportunities include educational presentations, participation in health fairs, etc.

64-66 in your Handbook

in our facility
In Our Facility
  • Nursing floor renovations continue:
    • Underway
      • 2 Center & 2 North
    • Complete
      • 3 East
      • 3 Center
      • 3 West
      • 2 West
      • Central monitoring relocated to lower level

64-66 in your Handbook

new technology
New Technology
  • Improvements in radiology workflow with AMICAS
  • iDoc - Health Information Archival & Retrieval System
  • Emergency Department Invests in the highly advanced CAREpoint EMS Workstation
  • Implemented Emergisoft’s CCHIT Certified ® Emergency Department HER

In Med Ed:

  • Expanding online evaluations and other functions of New Innovations
  • Online duty hours reports

64-66 in your Handbook

reporting work injury or illness
Reporting Work Injury or Illness
  • When a work injury or exposure occurs…
    • Report the incident to Med Ed immediately or within 24 hours
    • Complete an Employee Incident form. (Available on line or in the Emergency Department)
    • Register and receive initial treatment in the Emergency Department
    • Follow-up care and determination of temporary restrictions, if any, will be made by Dr. Sczecienski’s office at the our Westland Facility
  • Contact Human Resources with questions about Workman’s Compensation

67-68 in your Handbook

part ix standards of behavior

Part IX: Standards of Behavior

See the complete set of standards in your Handbook

68-74 in your Handbook

employee commitments
Employee Commitments
  • Five Commitments
    • Commitment to Patient
    • Commitment to Appearance
    • Commitment to Attitude
    • Commitment to Communication
    • Commitment to Co-Workers

68-74 in your Handbook

commitment to patient
Commitment to Patient
  • The manner in which we will provide service to our patients:
    • Compassionate
    • Informed
    • Respectful
    • Safe
    • Timely

68-74 in your Handbook

commitment to appearance
Commitment to Appearance
  • We will represent GCH in a professional manner to our customers:
    • Personal
    • Facility & Environment
    • Good Neighbor

68-74 in your Handbook

commitment to attitude
Commitment to Attitude
  • The manner in which we show our attitude while providing service to our patients, customers and co-workers:
    • Positive
    • Respectful
    • Professional
    • Friendly

68-74 in your Handbook

commitment to communication
Commitment to Communication
  • The manner in which we will communicate with our patients, customers and co-workers:
    • Respectful
    • Promptness
    • Professionalism

68-74 in your Handbook

commitment to co workers
Commitment to Co-Workers
  • The manner in which we will relate to our co-workers:
    • Respect
    • Friendliness
    • Mentoring

68-74 in your Handbook

post test and attestation
Post-Test and Attestation
  • Complete the online post-test by clicking the link below. There is also a link on the Med Ed website.