QUALITY AND PATIENT SAFETY

1. QUALITY AND PATIENT SAFETY The Joint Commission helps ensure quality healthcare through the National Patient Safety Goals (NPSG�s). The National Patient Safety Goals (NPSGs)�are designed to stimulate health care organizations' improvement activities for�several of the most�challenging patient safety issues. The goals are reviewed and published each year and�are a critical component of The Joint Commission's overall efforts to improve health care.

2. QUALITY AND PATIENT SAFETY Healthcare facilities undergo review by Joint Commission every 3 years to ensure that healthcare facilities comply with the standards and regulations set forth from the Joint Commission and the NPSG�s.(Nation Patient Safety Goals) Accreditation is granted for 3 years upon successful completion

3. STUDENT RESPONSIBILITIES All students will be expected to familiarize themselves with all hospital policies and procedures, equipment and unit specific care and safety practices. Students will be expected to conduct themselves in a professional manner; their attire as well as their appearance will conform to accepted standards of UMMMC.

4. National Patient Safety Goals Identify ,understand and comply with National Patient Safety Goals to promote patient safety. It is the objective of this training module to familiarize you with these goals and to better prepare you for providing the highest quality of care possible.

5. National Patient Safety Goals The purpose of the NPSG�s is to promote patient safety. Providing our patients with a safe high quality experience is core to the mission of the hospital. Why are the NPSG�s important? They help to provide safe patient care Inherent to a culture of safety Patient safety is central to the Joint Commission review These goals address the identified problematic areas across health care that affect patient quality and safety outcomes. They are reviewed and may change each year. .

6. National Patient Safety Goals 2012 National Patient Safety Goals . The Joint Commission has approved one new National Patient Safety Goal for 2012 that focuses on catheter-associated urinary tract infection (CAUTI) for the hospital and critical access hospital accreditation programs. For more information visit the Prepublication Standards section at the site listed below. There are no new NPSGs effective January 1, 2012 for the other accreditation programs. http://www.jcrinc.com/National-Patient-Safety-Goals

7. National Patient Safety Goals Other NPSG�s Read back verbal order Do not use Abbreviations Critical result Hand off communications Look alike/sound alike drugs Fall prevention Patient family involvement Early recognition/response http://www.jointcommission.org/standards_information/npsgs.aspx

8. GOALS Assuring patient safety is everyone�s responsibility! During the on-site survey, the JCAHO surveyor will be observing staff and physicians to determine compliance with these goals.

9. GOALS NPSG.01.03.01. Eliminate transfusion errors related to patient misidentification Before initiating a blood or blood component transfusion: Match the blood or blood component to the order Use a two-person verification process, one individual conducting the identification verification is the qualified transfusionist who will administer the blood or blood component to the patient When using a two-person verification process, the second individual conducting the identification verification is qualified to participate in the process, as determined by UMMMC

10. GOALS NPSG.02.03.01 Report critical results of tests and diagnostic procedure on a timely basis. Critical results of tests and diagnostic procedures may indicate a life-threatening situation. Objective is to provide the responsible caregiver the results within an established time frame so that prompt treatment can be provide. Results should go to MD/LIP; if not available then RN can take result Write down & reads back result Person giving result confirms it was read back Contact ordering MD/LIP ASAP; document in patient's chart If nurse takes results, document in nursing notes date/time received result, and if/when given to MD/LIP (Policy # 204)

11. NPSG.03.04.01) Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Medication containers include syringes, medicine cups, and basins. Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have resulted from medications and other solutions removed from their original containers and placed into unlabeled containers. Labeling occurs anytime med or solution transferred from original package to another container. No more than one med or solution is prepared, verified & labeled at one time. Name, strength, amount, expiration date and time if not used with in 24 hrs.Labeling not required if preparing clinician also immediately administering. (Policy # 2203) GOALS

12. GOALS NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Anticoagulation medications due to complex dosing, insufficient monitoring, and inconsistent patent compliance are more likely to cause harm. Goal is to have a positive impact of patients on this class of medications and result in better outcomes. Patient education and involvement are vital components of this NPSG. Is a baseline INR available Is a programmable infusion pump being used for heparin or other IV anticoagulant medication Written education provided to staff, patient and families Importance of follwo0up monitoring Compliance Drug food interaction Potential adverse drug reactions and interactions Approved protocol being used for the administration of an anticoagulant (Policy #2074)

13. GOALS NPSG.07.01.01 Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World According to the Centers for Disease Control (CDC), each year millions of people acquire an infection while receiving care, treatment, and services in a health care organization. Health care-associated infections (HAIs) are a patient safety issue that affects all health care organizations. Hand hygiene is one of the most important ways to prevent HAI�s. An organization should assess its compliance with the CDC and /or WHO guidelines through a comprehensive program that provides a hand hygiene policy, fosters a culture of hand hygiene, and monitors compliance and provides feedback. Hand hygiene practices ( foam in, foam out) decontaminate hands before direct patient contact Foam used when gloves are removed and reapplied Hands visibly soiled-wash with antimicrobial soap or soap & water (Policy# 5009)

14. GOALS NPSG.07.03.01 Implement evidence-based practices to prevent care-associated infections due to multidrug resistant organisms in acute care hospitals. Hand hygiene, contact precautions, as well as cleaning and disinfecting patient care equipment and the patient�s environment are essential for preventing the spread of health care-associated infections. Do you know how long you wait in-between disinfecting a bed, stethoscope, IV pole, etc. Do you know what precautions to take for MRSA, VRE, HEP, TB Are you washing your hands, removing gloves between patients Do you provide your patients and their families with education on how they can help the spread of infection (policy # 5003,5001)

15. GOALS NPSG.07.04.01 Implement evidence �based practices to prevent central line-associated bloodstream infections. Short and long term central venous catheters and peripherally inserted central catheter (PICC) lines. Prior to insertion of a central venous catheter, educated patients and as needed their families about central line-associated bloodstream infection prevention. Use catheter checklist and a standardized protocol for central venous catheter insertion Perform hand hygiene prior to catheter insertion or manipulation For adult patients, do not insert catheters into the femoral vein unless other sites are unavailable Use a standardized supply cart or kit that contains all necessary components for the insertion of central venous catheters Use standardized protocol for sterile barrier precautions during central venous catheter insertion Use chlorhexidine-based antiseptic for skin preparation during central venous catheter insertion in patients over 2 months of age, unless contraindicated Use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports IV administration tubing is replaced on a routine basis every 72 hours. Special considerations: Parenteral nutrition every 24 hours, Blood every 4 hours and specific medications as designated by pharmacy. (Policy #5032)

16. GOALS NPSG.07.05.01 Implement evidence-based practices for preventing surgical sites infections. Education staff involved in surgical procedures and surgical site infections and the importance of prevention. Educate patients, and their families as needed who are undergoing a surgical procedure about surgical site infection prevention. Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to evidence-based best practices. When hair removal is necessary, use clippers or depilatories. DO NOT SHAVE NPSG.08.01.01 A process exists for comparing the patients current medication with those ordered for the patient while under the care of the hospital. At the time the patient enters the hospital or is admitted, a complete list of the medications the patients taking at home (including dose, route, and frequency) is taken and documented. 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 entry to the hospital. Any discrepancies are reconciled and documented while the patient is under the care of the hospital. 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.

17. GOALS NPSG.08.02.01 A complete reconciled list of medications is communicated to the next provider of service and documented. The transferring hospital provides information on how to obtain clarification on list if needed. NPSG.08.03.01 Complete list of patient�s medication is provided to patient when they leave the hospital. NPSG.08.04.01 In areas where medications are used minimally or prescribed for a short duration a modified reconciliation process is performed.

18. GOALS NPSG.15.01.01 Identify patients at risk for suicide for patients being treated for emotional or behavioral disorders. Identifying patients at risk for suicide is an important step in protecting at-risk individuals. Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide Address the patient�s immediate safety needs and most appropriate setting for treatment When a patient at risk at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.

19. Universal protocols Know you have the right person and the right procedure, right side Any missing information or discrepancies in patient identification, procedure, sit or side should be resolved before the procedure takes place. (policy #2014) UP.01.01.01Conduct a pre procedure verification process. A pre procedure verification process is gathering and confirming information. It�s purpose is to make sure all relevant documents and related information and equipment are available prior to the start of the procedure. Follow each area�s standardized list of what should be needed for a procedure. UP.01.02.01 mark the procedure site Any site with laterality Before the procedure is performed By the person performing the procedure No X must have initials Know alternative if marking is not technically or anatomically possible or patient refuses.

20. Universal protocols UP.01.03.01 A time-out is performed before any invasive procedures Correct Patient Identified Correct Consent at hand Correct Procedure Correct Site and Side and properly Positioned Allergies Verified Any safety precautions based on patient history or medication use Properly labeled relevant diagnostic and radiology studies at hand Relevant Implants, devices/ equipment at hand Blood products available if required Need to administer prophylactic antibiotics or fluids for irrigation purposes

21. Emergency Management Emergency Preparedness What is an emergency? Per The Joint Commission, �An emergency is an unexpected or sudden event that significantly disrupts the organization�s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization�s services�

22. Emergency Preparedness Welcome to the lesson on emergency preparedness. This lesson covers: Disaster events Emergency response plans Types of Disaster Events Healthcare organizations must be prepared to respond to disasters such as: Natural disasters Technological disasters Major transportation accidents Terrorism Nuclear, biological, and chemical events To prepare, each facility must: Identify events that could occur Determine the probability that each event will occur Develop strategies for dealing with each event Emergency Management

23. Emergency Response Plans Facilities document how they will deal with disaster in an Emergency Response Plan. A written plan alone is not enough for an effective response. Staff must be: Educated on the procedures in the plan Trained and drilled to respond to disaster according to the plan Must make sure YOU are ready to respond to disaster: Know the disaster events that pose a risk for your facility Participate in all emergency response training and drills Know your specific role in an emergency event Emergency Management

25. Emergency Management Where can I get more information? Red Emergency Guide books Located on every unit Contain information for responding to specific type of disasters Have listing of helpful phone numbers and other resources you might need during a disaster

26. Emergency Management Wear ID Badge at all Times! Question those without ID badge Protect patient & your own valuables Lock doors and your car - Keep personal items out of sight & secure Personnel Escorts available Report incidents & suspicious activities Bomb Threat - Record all pertinent information & details Security is everyone�s responsibility

27. DETECTING AND REPORTING ABUSE Detecting and Reporting Abuse All health care organizations accept the responsibility to intervene in situations which threaten the general welfare of patients/residents. All cases of suspected abuse and neglect involving children, geriatric patients, and physically and mentally challenged patients/residents are required by law to be reported. Abuse is defined as physical, emotional or sexual injury and financial exploitation.Neglect is defined as failure by another individual to provide a person with the necessities of life including, but not limited to, food, shelter, clothing, and the provision of medical care. PHYSICAL ABUSE is the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, choking, pulling hair, and burning. In addition, inappropriate use of drugs and physical restraints, force-feeding, reckless driving, and physical punishment of any kind also are examples of physical abuse.

28. LATEX ALLERY The term �latex� refers to natural rubber latex, the product manufactured from a milky fluid derived from the rubber tree, Hevea brasiliensis Several types of synthetic rubber are also referred to as "latex," but these do not cause allergic reactions Latex allergy is a reaction to certain proteins in latex rubber. What products contain natural rubber latex? Disposable gloves ,Airway & IV tubing ,Syringes, Stethoscopes, Catheters, Dressings & Bandages 40,000 consumer products contain latex: (I.e. condoms, athletic shoe soles, rubber toys, nipples and pacifiers, etc.) Persons at increased risk for latex allergies are: Healthcare workers, Occupational exposure, persons with frequent catherizations, persons with multiple surgeries, or persons with allergy to foods such as banana, avocado, chestnut, kiwi, potato, tomato. Avoidance of Latex is the only means to assure prevention of a latex allergy; and it is the only protection from allergic symptoms in a person who has already developed a latex allergy. For more information read UMMMC policy # 1074

29. DETECTING AND REPORTING ABUSE Detecting and Reporting Abuse All health care organizations accept the responsibility to intervene in situations which threaten the general welfare of patients/residents. All cases of suspected abuse and neglect involving children, geriatric patients, and physically and mentally challenged patients/residents are required by law to be reported. Abuse is defined as physical, emotional or sexual injury and financial exploitation.Neglect is defined as failure by another individual to provide a person with the necessities of life including, but not limited to, food, shelter, clothing, and the provision of medical care. PHYSICAL ABUSE is the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, choking, pulling hair, and burning. In addition, inappropriate use of drugs and physical restraints, force-feeding, reckless driving, and physical punishment of any kind also are examples of physical abuse.

30. DETECTING AND REPORTING ABUSE SEXUAL ABUSE is non-consensual sexual contact of any kind and includes any unwanted touching, forced sexual activity, be it oral, anal or vaginal, forcing the victim to perform sexual acts, painful or degrading acts during intercourse (e.g.. urinating on victim), and exploitation through photography or prostitution. NEGLECT is defined as the refusal or failure to provide life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials as obligated. Neglect may also include failure of a person who has fiduciary responsibilities to provide care (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care. FINANCIAL ABUSE is the mismanagement of money or stealing property belonging to the victim. Financial abuse may include denying access to funds, to making a person solely responsible for all finances. Examples include, but are not limited to, cashing a physical or mentally challenged person�s or elderly person's checks without authorization or permission; forging a person's signature; misusing or stealing a person's money or possessions; coercing or deceiving a person into signing any document (e.g., contracts or will); and the improper use of conservatorship, guardianship, or power of attorney For more information read UMMMC policy # 1074

31. Planetree Partnership - UMass has become an affiliate of Planetree Planetree is a non-profit organization that provides education and information in a collaborative community of healthcare organizations, facilitating efforts to create patient centered care in healing environments. Today, Planetree is an internationally recognized leader in patient-centered care. In healthcare settings throughout the United States, Canada, and Europe, Planetree is demonstrating that patient-centered care is not only an empowering philosophy, but a viable, vital, and cost-effective model.

32. Our affiliate sites operate in diverse healthcare settings, with each site adapting the Planetree model as required by its unique needs. These facilities range from small rural hospitals with 25 beds to large urban medical centers with over 2,000 beds. The Planetree model is implemented in acute and critical care departments, emergency departments, long term care facilities, outpatient services, as well as ambulatory care and community health centers.

33. As a Planetree Affiliate, UMass Memorial would: Commit to create a more compassionate patient centered environment that promotes healing of the whole person, as well as greater staff satisfaction Offer 8 hours of instruction focused on patient centered elements that UMass Memorial�s workforce will participate in during implementation Participate with Planetree staff in an annual on-site evaluation of UMass Memorial�s progress Provide patient satisfaction scores At contract initiation & annually to measure impact on patient experience Annual representation at the Planetree conference Incorporate Planetree patient care principles into policies and procedures