mandatory annual safety education anti- harrassment

Mandatory Annual Safety Education

ANTI-HARRASSMENT

Anti-Harassment Policy Statement

Culpeper Regional Hospital maintains that harassment of applicants and employees based on race, color, sex, religion, national origin, age, genetic

information, marital status, military membership or veteran status or disability, including sexual harassment (all as defined by applicable law) is

prohibited and will not be tolerated. The Hospital will not tolerate unlawful harassment of any employee, patient, vendor, contractor or medical staff

member by anyone else including hospital managers, co-workers, patients, visitors, vendors, contractors, or medical staff members. All forms of

unwelcome and potentially unlawful conduct should be reported immediately to the Vice President Human Resources or the Vice President

of their area. Unlawful harassment by managers or employees will be grounds for prompt, appropriate disciplinary action up to and including

termination.

Sexual HarassmentSexual Harassment is defined as unwelcome sexual

advances, requests for sexual favors and other verbal or physical conduct of a sexual nature when submission is made a term or condition of

employment; employment decisions are based upon submission to or rejection of the conduct; or the

conduct unreasonably interferes with an employee’s work performance or creates an intimidating, hostile

or offensive work environment.

Sexual Harassment• Both men and women can be victims of sexual harassment

• Quid Pro Quo – Latin for “something for something” -describes a situation in which a supervisor conditions an employment decision in exchange for sexual favors.

• For example, it is quid pro quo sexual harassment for a boss to offer a raise in exchange for sex.

• Formal, courteous, respectful, pleasant and non-coercive contacts between individuals that are acceptable to both are not considered sexual harassment.

Hostile Work Environment

•Conduct that is pervasive enough to change the terms and conditions of employment. Hostile work

environment harassment is a work environment that a reasonable person would find offensive.

•For example: Unwelcome sexual attention, sexually oriented conversation, displaying of graphic pictures or

jokes, which are clearly considered offensive.

Types of Sexual Harassment

• Gender Harassment• Same Sex Harassment

• Sexual Orientation Harassment• Transgender Harassment

Other Types of Harassment

Racial Harassment• Ethnic slurs or jokes, offensive or

derogatory comments, or other verbal or physical conduct based on an employee’s race/color constitutes

harassment if that conduct creates an intimidating, hostile or offensive work

environment.

Age Harassment• The federal Age Discrimination in Employment Act protects employees from age discrimination and harassment.• Age harassment can include age-based jokes or comments, offensive cartoons, drawing, symbols, or gestures, and other verbal and physical conduct based on an individual's age.

Disability Harassment• The Americans with Disabilities Act prohibits discrimination

based on a person’s disability.

• Under this law, when a disabled worker is constantly subjected to pervasive and severe harassment due to their disability that creates a hostile work environment.

•Disabilities include mental impairments as well as physical.

•Offensive remarks regarding a person’s disability would be considered harassment.

.

Religious Harassment• Occurs when employees are required or coerced to

abandon, alter or adopt a religious practice as a condition of employment or when an employee is subjected to

unwelcome statements or conduct that is based on religion that is so severe that the employee finds the work

environment to be hostile or abusive.

• Antagonizing, ridiculing, mocking or making derogatory comments about a person’s beliefs is considered religious

harassment.

National Origin• Discrimination or harassment due to a

person’s place of birth, ancestry, culture or linguistic characteristics common to a specific ethnic group.

• Harassing conduct might include slurs or jokes about a particular ethnic group, comments or questions about a person's cultural habits, or physical acts of particular significance to a certain ethnic group.

More Types of Harassment

• Harassment based on someone’s filing a worker’s compensation claim

•Harassment based on someone taking leave under the Family Medical Leave Act

• Harassment based on a person’s political affiliation

Continued•Harassment based on an employee’s status as a

whistleblower

• Harassment based on union membership or non membership

• Harassment based on complaints about safety violations

• Harassment that is a result of retaliation

Employee Responsibilities

Harassment can have a devastating effect on victims and can undermine the morale of an entire organization.• All employees must assume an active role

in the prevention of any type of harassment.• Treat everyone with respect.• Set a good example.

Continued

• Examine your own behaviors, gestures and comments.

• Pay attention to the response of others to avoid unintentional offense.

• Be aware and conscious of engaging in potential harassment behaviors.

Continued• Discourage behaviors that negatively affect

your work, department or organization.• Do not encourage harassers by smiling or

laughing.• Speak up - Let the harasser know you find

the behavior offensive.• Report harassment to the appropriate

person.

REMEMBER

• It is important to prevent harassment in all areas of our organization. Not only does it conflict with our Core Values, it is illegal under federal and state law.

Anti-HarassmentCulpeper Regional Hospital’s Anti-Harassment policy prohibits any type of

harassment in the work place. All forms of unwelcome and potentially unlawful conduct should be reported immediately to your director, the Vice

President of Human Resources or call the Hotline at

(877) 888-4806. All complaints of harassment are taken seriously and will require a workplace investigation by Human Resources.

The Anti-Harassment policy #602.0 can be found online in Policy Manager..

In Closing

Culpeper Regional Hospital is committed to maintaining a workplace free of harassment. No employee will be retaliated against for making a good faith complaint or assisting with the investigation of a complaint.

BACK SAFETY


Your Spine

• Consists of:– 24 vertebrae– Shock-absorbing

discs

• 3 natural curves– Cervical, thoracic,

and lumbar– Distribute weight

evenly– Maintain these

curves for good posture and body mechanics

6 B’s for Better Back Safety

• Be Prepared– Test the load before lifting or moving it by

trying to move it with your foot– Clear the path of transfer of any debris– Ask for help if you are not sure you can

perform something safely on your own• Bend Knees

– Bent knees protect the back by maintaining a neutral spine

– Lift with your legs and not your back


• Be Neutral– Keep spine in a neutral position to protect

the spinal curves– Tighten the stomach muscles

• Base of Support Should be Wide– Separate knees and feet about shoulder

width apart– Ease of balance

• Be Close– Keep the patient/object close to your body,

no further away than elbows reach– Raise the bed surface to you to keep spine

neutral


• Be Mobile– Move your feet, do not twist your

spine– Transfer your weight from one foot

to the other when moving a patient up in bed

Seated Activities

• Be Prepared– Desktop should be clutter-free– Tasks requiring 75% or more of your time should be

at elbows reach– Tasks requiring less than 25% of your time should

be at shoulders reach– Know when and how to take micro-breaks,

stretching, etc.

• Be Close– Computer monitor should be at fingertips reach

directly in front of you– Shoulders relaxed, elbows at sides and bent to 90

degrees to reach the keyboard tray– Feet flat on the floor or propped up on a footrest

Seated Activities

• Be Neutral– Use your back support– Shoulders over your hips and your

head over your shoulders– Keep wrists neutral

• Be Mobile– Pivot in the chair, no spinal twisting– Push around on the wheels of the

chair rather than overreach

Sitting/Standing Postures

Standing Activities

• Be Prepared– Tasks requiring 75% or more of your

time need to be at elbows reach– Tasks requiring 25% or less of your

time need to be at shoulders reach

• Bend Knees– Do not stand with your knees locked

backwards or straight– Rest one foot up on a stool, a

footrest, or a cabinet– Bent knees assist with the neutral

spine position

Standing Activities

• Be Neutral– Keep spine in a neutral position– Tighten stomach muscles to assist

with keeping spinal curves stable

• Be Mobile– Move your feet, do not twist your

body– Stretch periodically, forward,

backward, and side to side

• Base of Support Should be Wide– Better balance– Able to get closer to the task

• Be Close– Less stress on your back

Lifting

• Common cause of back injury

• Two general rules – Keep the load close – Bend at the knees

Lifting Safely

• Analyze the load

• Place one foot out in front of you

• Feet flat on the floor

• Knees slightly bent

• When lifting:– Move both feet

closer to the load

– Bend at the hips

• Maintain neutral spine

• Move smoothly

Golfer’s Lift

• The golfer’s lift is a way to lift a light-weight object from the floor while still maintaining good body mechanics.

• You can hold on to a solid object for balance if needed.

Reaching Overhead

When performing a task involving reaching, always:– Get close to the object using a

stool or ladder– Bring the object close to you

when lifting– Take frequent breaks if reaching

overhead for extended periods of time

- Always maintain the 3 curves of your back

Mechanical Lift Systems

Maxi Sky Maxi Sky

Tempo

Maxi Sky Lift

A Maxi Sky 600 is located in each patient room on the Med/Surg, Step Down and ICU units. This unit will accommodate up to a 600 lb person for transfers. There is a Maxi Sky 1000 located on Step Down that will accommodate up to 1000 lb. There are several size slings for these lifts, all stored on the individual floors. Slings are marked with the size and the type patient lift in which they are to be used.

Tempo Lift

The Tempo Lift is located in the Storage Room on Step Down. It is a portable patient lift that can be used throughout the hospital. The Tempo Lift has several size slings that are stored with the unit. Each is marked with the size and the type of lift for which it is to be used. The Tempo Lift is designed to lift a person weighing up to 440lb.

Maxi Sky and Tempo Lifts

These units will: 1. Lift a patient from the

floor 2. Lift a patient from

bed to chair/chair to bed 3. Lift a patient to

scoot them up in bed 4. Lift a patient to

change the bed linens

Patient Transfers

• Proper body mechanics

• Ask the patient to help

• Get an assistant

• Mechanical lift

Other Patient Lift/Transfer Equipment

Hover Jack

Hover Matt

Pushing vs. Pulling

• Push, don’t pull!!• Remain close to the load • Don’t lean forward• Use both arms and tighten stomach muscles• Keep elbows close to your body to

help maintain a better spine position

Protect your Back!

• Repetitive motion can cause an injury over time.

• Being aware of your body mechanics during everyday activity can help prevent injury in the future!

Pressure Ulcer Prevention

Wound Care Education

What is a Pressure Ulcer?

Areas of damaged skin and tissue that develop when sustained pressure decreases circulation to vulnerable parts of your body, especially the skin over bony areas (buttocks, hips and heels). Without adequate blood flow, the affected tissue dies.

Pressure Ulcer Facts from JCAHO

An estimated 2.5 million patients are treated for pressure ulcers in acute care facilities in the United States each year.

An estimated 60,000 patients die each year from complications due to hospital-acquired pressure ulcers.

The estimated cost of managing a pressure ulcer is as high as $70,000, and the total cost for treatment of pressure ulcers in the United States is estimated at $11 billion per year.

How does this impact CRH?

If a pressure ulcer develops or worsens in a Hospital, the hospital can be held responsible for all costs related to the pressure ulcers. Insurance may also deny payment for the entire inpatient stay.

Therefore, it is each person’s responsibility to thoroughly assess and document all reddened and broken areas of a patient’s skin upon admission and at regular intervals while in our care.

How does this impact CRH?

It is everyone’s responsibility to recognize signs of breakdown and know how to implement an immediate course of action.

Hospital Acquired Pressure Ulcers lead to decreased patient satisfaction, increased patient health complications, and increased legal actions.

How does this affect you?

Emergency Room – mattresses are typically very thin; skin breakdown can begin to occur in a matter of a few hours; a thorough skin assessment should be done with brief notations of where current breakdown is located, especially if the patient is there for more than an hour and is at a higher risk for breakdown


ICU/StepDown/MedSurg – Patients may be admitted with existing wounds. Immobility and multiple other factors can lead to skin breakdown if not closely monitored.

FBC – Skin breakdown can begin to occur within a few hours. If the patient has existing medical problems that increase the risk of breakdown, even a new mother can end up with a pressure ulcer. Surgical patients are at times admitted to this unit as overflow. Due to decreased mobility, these patients are at a higher risk of developing a pressure ulcer.


O.R. – Surgical patients who are under anesthesia for extended periods often have an increased risk of developing pressure ulcers.

Diagnostic testing – Stretchers and tables are typically very thin. 30 minutes to an hour on these surfaces can be enough to cause a Stage I pressure ulcer in an at risk patient.


Dietary/Housekeeping – These departments may enter the patient’s room several times a day for various reasons. If you notice the patient is in the same position they were in the last time you saw them, mention this to their nurse; they may need nursing to assist them in turning to a different position.

Pressure Ulcer Prevention

Leading cause of most pressure ulcers:– Friction– Shear– Moisture– Pressure

**Even though a patient may be on an air mattress or placed on a total care bed with rotation settings, the patient must still be repositioned at least every 2 hours.**

Pressure Ulcers

Risk Factors:– Age– Immobility– Incontinence– Inadequate nutrition– Sensory deficiency– Multiple co-morbidities– Circulatory abnormalities– Dehydration– Altered level of consciousness/mentation– Prior history of pressure ulcers– Chronic Disease states (Diabetes, CAD…)

Patient Positioning

Prevention of pressure ulcers is an important aspect of care in any patient at any age.

It is Culpeper Regional Hospital’s policy to reposition patients at least every 2 hours.

Patient Positioning

Reasons for repositioning a patient:– Prevent a pressure ulcer– Provide comfort for the patient

Areas of Pressure

Main pressure points found on the body– Sacrum– Hips– Shoulders– Heels – Elbows– Ankles– Back– Back of the head

Causes of Pressure

Hospital equipment that may cause pressure ulcers:– Bedpans– I.V. tubing– Wires (ECG and/or BP)– Siderails– Foley tubing– S.C.D tubing– Casts, cervical collars– N.G. tube– Syringes and caps

Preventing Pressure Ulcers by Frequent Rotation Reposition the patient every 2 hours at

minimum. A consistent rotation schedule for all patients

can help all staff know which position the patient should be in, and can offer assistance to ensure rotations are completed.

Individualizing the rotation schedule may be necessary for some patients (ie. A patient that is unable to lie on one side due to pain from a hip fx).

Nutrition and Wound Management The Standard nutrition recommendation

for wound healing is a balanced diet with adequate calories, proper hydration, and rich in protein.

Basic energy recommendations are 25-35 Cal/Kg, depending on the severity of illness and BMI.– Goal: Provide adequate energy to

maintain or regain lost weight.

Nutrition and Wound Management A Nutrition Consult would be

appropriate if the patient:– Is not eating most of his/her meals– Has other medical issues that affect eating

and/or nutrition– Is diabetic and/or currently has a wound

Remember that prevention is the best treatment for pressure ulcers.

Striving for Competency Across Cultures

Improving care and communications

Ethnic Diversity

Ethnic diversity includes a variety of religions, races and cultures

More than one in four Americans are now either Asian, Hispanic, or African-American descent

Certain areas of the country contain more individuals of various cultures than others

Hispanics constitute 16.7% of the nation’s population, making them the largest ethnic or race minority currently in the U.S.

Diversity TodayU.S. census estimated Hispanic population in the country as of July, 2011 = 52 million

Hispanic population in the U.S. during the 1990 census (22.4 million) was less than half the current total

More than one of every two people added to the nation’s population between July 2008 and July 2009 was Hispanic

Ethnic / Race Diversity Data

Virginia is one of 16 states with at least a half million Hispanics residing*

For the first time, Asian immigration (36% of all new immigrants) to the U.S. in 2010, surpassed Hispanics (31% of all new immigrants)*

African Americans (multi race) total 13.6% of the U.S.* population or 42 million people

*Courtesy of U.S. Census Bureau 2010 Statistics

2010 U.S Census Bureau DataPeople Quick Facts: Culpeper Virginia USA

White persons, percent (a) 78.9% 71.3% 78.1%

Black persons, percent (a) 16.3% 19.8% 13.1%

Asian persons, percent (a) 1.5% 5.8% 5.0%

Native Hawaiian & Other Pacific Islander (a) 0.1% 0.1% 0.2%

Persons reporting two or more races, percent 2.5% 2.5% 2.3%

Persons of Hispanic /Latino Origin, percent (b) 8.9% 8.2% 16.7%

White persons not Hispanic, percent 71.8% 64.5% 63.4%

(a)Includes persons reporting only 1 race

(b) Hispanics of any race, so also included in applicable race categories

US Census Bureau Projected Populations for 2050

Projected Hispanic population is 132.8 or 30% of total U.S. population

Projected African American population is 65.7 million or 15% of total U.S. population

Projected Asian American population is 37.6 million or 9.3% of total U.S. population

Defining Culture

Culture…

Involves a total way of living

Includes values, beliefs, language, thought process, behavioral norms and communication styles

Guides decisions and actions of a population through time

ValuesIndividual’s foundation

Each culture promotes different ones

Americans value money, freedom, independence, privacy, health, fitness and appearance

Understanding values is the key to understanding behaviors*

* Our behaviors reflect our values

Cultural Competency

Competency suggests adopting a set of behaviors, practices, attitudes and practices that allow effective care cross culturally

Developing cultural competency within an organization begins with awareness, grows with knowledge, and thrives with continued learning and teaching

Achieving Cultural Competence

First you must recognize your own personal culture and biases and become sensitive to the culture of others

Next you must improve your knowledge and understanding of other cultures

Finally you must apply what you have learned in a caring and competent way

How Culturally Aware Are You?

Do you know what you don’t know?

Recognize Your AwarenessSome cultures believe:

Conversing with your hands in your pockets is impolite

Introductory social conversation is inappropriate

Patients should not ask questions of health professionals because to do so challenges the professional’s authority

Illnesses originate magically and can be treated only with voodoo medicine

Self-care is not important

Refusing pain relief is a means of atonement

Cultural & Language Barriers Affect the Clinical Experience

Clinical experience is impacted by:

Religious customs and beliefs

Cultural beliefs, behavior patterns, and communication

View of mental health and acceptable practices concerning recognition/treatment

Cultural & Language Barriers Affect the Clinical Experience

Religious customs and beliefs impact:

Beliefs about blood, autopsy and amputation

Privacy and confidentiality expectations

Cause and treatment of disease

Dealing with death

Cultural & Language Barriers Affect the Clinical Experience (cont.)

Beliefs, behavior patterns & communication impact:

Expectations concerning diagnosis, treatment and symptom relief

Gender and family roles in decision making

Beliefs about body, health and diet

Reaction to pain

Cultural & Language Barriers Affect the Clinical Experience (cont.)

Mental health practices impact:

Recognizing depression

Seeking treatment

Use of Counseling

Use of Psychiatry

Improving Care and Communications Among the

Populations We Serve

Means for Improving CareBecome aware of your own values towards health since they impact the way you assess a situationRecognize own preferences & cultural biasesSeek to understand patients and their situations within the context of their group & resourcesProvide care that promotes respect for the other person’s values, preferences and needsAvoid stereotyping based on culture / religionIncrease own knowledge of customs, communication patterns and differences in health beliefs

Communication Challenges

“Researchers in the Center for Health Policy Research in the UC Irvine School of Medicine have found that language barriers between patients and healthcare providers result in longer hospital stays, more medical errors and lower patient satisfaction”

Science Daily (Nov. 14, 2007)

Communication Challenges

Language barriers make it difficult for patients to explain their symptoms and concernsLanguage barriers can increase the risk of complications Delays in seeking treatment can be due to language barriers

Today, there are over 60 million Americans who speak a primary language other than English, and that will rapidly grow in coming years. That's a big population that health care providers committed to providing quality care must not ignore!

Measures for Improving Communications

Speak slowly, not loudly

Address person by formal name unless told otherwise

Don’t force a person to make eye contact

Face the person and use pictures to help communicate

Use a trained interpreter whenever possible

Measures for Improving Communications (cont.)

Be careful interpreting facial expressions and the presence or absence of emotions such as crying

Use hand and arm gestures with caution since they mean different things in different cultures

Keep what you want to say simple

Measures for Improving Communications (cont.)

Rephrase and summarize often

Ask open ended questions and don’t interrupt

Use available resources, such as language barrier help manuals, scripts, and CyraCom translation phone services to get your message across

CRH Communication Resources

CyraCom phone – enables you to access interpreters 24 hours a day for interpreting over 170 languages

Scripts’ – print on demand education handouts available in Spanish as well as English

Language Barrier Help Manuals – books with pictures and English to Spanish translation of frequently used health care words

CyraCom Phone UseTo place a call using ClearLink (patented dual hand set phone):

Locate an analog phone outlet ( all patient rooms at CRH have an analog phone jack)Connect dual hand set phone to the analog phone outlet*Follow the 1-2-3 instructions displayed on the CyraCom phone to place your call* See slide “Other Features” for what to do if analog outlet is unavailable

CyraCom Conference CallTo conference a call:

Press ‘1’ when prompted if you would like to add an additional person to the call

Follow the prompts to enter the added person’s phone number

When the interpreter greets you, say you are adding an additional person and supply the name of the person you are calling along with purpose of the call

CyraCom Conference Call (cont.)

To conference a call when an interpretation session is already in progress:

Press ‘8’ to be prompted to enter the phone number of the person you want added to the call

Follow prompts

Cyracom Phone AccessoriesBlue splitter is available for use when analog line is not available

24 hour assistance service # 1-800-481-3289 is available for help at any time

Directions attached to CyraLink phones provide the service number along with ‘step by step’ instructions for placing/conferencing calls when using the splitter

If planning a conference call, have available the accessory equipment you will need

Using CyraCom EffectivelyKnow where the ClearLink phones are kept in your work area (ClearLink Phones available on each nursing unit and in patient care designated areas)

Use the language ID chart attached to the phone if you need help with identifying a patient’s language

Obtain interpreter’s ID number for patient record documentation purposes

Provide interpreter with brief explanation for the call

Using CyraCom Effectively CRH currently spends $1900.00/month average for

phone based language translation servicesYou can help contain costs for this valuable service by consistently doing the following:

Organize questions in advance:• Identify what you need to say before calling• Group questions and be specific

Be clear, brief, and simple with communications

Ask the interpreter to please ask the patient if he has questions before ending the call

About scripts’Scripts’ is an online accessed program offered by Pritchett & HullCovers essential information about:

Wellness and preventionDisease managementLifestyle changes

Allows print on demand education handouts for English and Spanish speaking patients

About Scripts’ (cont.)

Materials provided offer basic information that is up to date and easy to read

Topics that have basic information on disease process, management and complications include: diabetes, congestive heart failure and hypertension

Accessing Scripts’

Log onto www.p-h.com

In left lower corner of scripts’ page, click on link titled ‘scripts print on demand’

Scripts’ page then will request you sign in

Click on sign in link and enter: ‘CRH’ for user name

‘nurse’ for the password

http://www.p-h.com/

Accessing Scripts (cont.)Choose ‘e folder’ link to find CRH specific education materials routinely used by our patient ed teamLocate the topic you want and click on it Choose the language you want your handouts in and click on the ‘handouts' tab Check what handouts you want printed and the order you want printed -then click print

Language Barrier Help ManualsSeveral departments offer these manuals

Manuals offer pictures and language instruction for health care providers

Manual types and design vary among departments

Ask your manager where to find your department specific manual

In-house Interpreters

Restricted to identified employees – (current list kept in nursing office)

Assist only to the level of their ability

Family and friends DO NOT qualify as acceptable medical interpreters

CyraCom service should be used when a qualified in house interpreter is not available

In-house Interpreters

Volunteer interpreters must be:

Fluent in the language they are asked to interpret

Knowledgeable in the terminology and subject matter being asked to translate

Accepted by the patient as a recipient and translator of confidential information

Cultural Competence

As a patient centered organization, it is vital that every employee become culturally competent. For more resources and information to help you become culturally competent in the healthcare setting - visit: http://www.ggalanti.com/

Happy Learning!

http://www.ggalanti.com/

EMERGENCY MANAGEMENT


Emergency Management

• The Four Phases of Emergency Mgmt.– Mitigation activities refer to the actions

an organization undertakes in attempting to lessen the severity and impact of a potential emergency.

– Preparedness activities are those actions that an organization undertakes to build capacity and identify resources that may be used if an emergency occurs.

– Response activities refer to those actions taken by both management and staff when confronted by an emergency.

– Recovery strategies are the short and long term actions directed at restoring essential services and resuming normal operations.


• National Incident Management System (NIMS)– A consistent nationwide approach for Federal,

State, tribal and local governments to work effectively and efficiently together to prepare for, prevent, respond to and recover from domestic incidents, regardless of cause, size or complexity.

– Establishes standardized incident processes, protocols & procedures to help agencies/organizations to work together during any type of incident’.

– Applicable across jurisdictions & functions and provides a flexible framework that facilitates all levels working together. It requires that all domestic incidents use a common management system.

– CRH uses Hospital Incident Command System or HICS.


• Emergency Operations Plan (EOP)– The EOP was created and is revised to ensure

predictable behavior by the majority of staff during an emergency situation.

– It provides specific guidelines for staff to follow in an emergency and is located in your Environment of Care Manual.

– It establishes a team of individuals who can assess damage and make informed decisions about how to handle the immediate situation while arranging for experts to deal with long-term consequences of the incident. This group of individuals makes up the structure of the Hospital Incident Command System or HICS.

– Emergency Management is the responsibility of all hospital staff. If you are on shift during an emergency management exercise, you are expected to participate as if it were a real event. However, care of patients in-house remains top priority.

Critical Function Areas

• CRH uses the HICS response system. The critical function areas of response include:– Communication– Resources & Assets– Safety & Security– Staff– Utilities– Clinical Activities

Hospital Command Center (HCC)• The activities of the Hospital Command

Center (HCC) are directed by the Incident Commander (IC).

• The IC has overall responsibility for all activities within the HCC.

• The IC may appoint other Command Staff personnel to assist as the situation and resources warrant. These personnel may include: Public Information Officer (PIO), Safety Officer, Liaison Officer and/or Medical Technical Specialist.

• The HCC at CRH is located in the Administration area, but may start out in the Nursing Office.

When the EOP has been activated, ONLY the PIO or their designee may communicate with the media.

Command Staff Identification

All personnel assigned

to an incident command

role should wearidentification thatcorrectly

communicatestheir role.

Job Action Sheets

• Job Action Sheets (JAS) have been designed for each command position and can provide “just in time” training for hospital staff. They are located in the Hospital Incident Command Cart.

• Some of the information provided on a Job Action Sheet includes a radio identification title, purpose of the position, to whom they report, and critical action considerations.

• These tasks are intended to “prompt” the incident management team members to take needed actions related to their roles and responsibilities.

HICS Communications ToolIf you hear an Alert of any level paged

overhead, one person from each department should log on to

the HICSCommunications Tool in Outlook Web App. This

is a communication tool between the Hospital Command

Center and hospital departments.

Log-In Instructions for HICS Communication Tool

1. Go to Hospital web site at www.culmem.com2. Click on “Outlook Web App”3. Use departmental or CRH generic login, i.e. CRHICS4. All Passwords are set to MAYDAY (case-sensitive)

http://www.culmem.com/


• Alert Levels– Alert Level 1 –

Informational/Preplan– Alert Level 2 – Response Needed– Alert Level 3 – More Resources

Needed– Alert Level 4 – MAYDAY


• Example of ALERT Levels in action:– Alert Level 1 – the emergency department has

been notified that there has been a bus accident on Rt. 29. This would be in incident in our community that may impact normal operations of the hospital so we would Alert staff by an Alert Level 1.

– Alert Level 2 – the first patients begin arriving in the emergency department all at once and we need an Operations Section Chief and perhaps some other positions in the Command System be filled to manage the current situation.

– Alert Level 3 – the media and concerned family members begin to arrive at the hospital. We need to assign a Public Information Officer (PIO) and may need support from the local police department for crowd control

– Alert Level 4 – some of the passengers on the bus are covered with diesel fuel and require decontamination. We would need to set up our decon area and activate our decon team.

OSHA – Exposure Control Plan

• The exposure control plan is the employer's written program that outlines the protective measures an employer will take to eliminate or minimize employee exposure to blood and OPIM (Other potentially infectious materials).

• The three primary methods/mechanisms that reduce exposure include:– Personal Protective Equipment(PPE) (such as gloves,

gowns and masks)– Work Practices (The term, “Work Practice Controls” means

controls that reduce the likelihood of exposure by altering the manner in which a task is performed {e.g., prohibiting recapping of needles by a two-handed technique})

– Engineering Controls (The term, "Engineering Controls," refers to [controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace].)

Standard Precautions• Standard Precautions is OSHA's required method of control

to protect employees from exposure to all human blood and OPIM(Other Potentially Infectious Materials means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. The term, “Standard Precautions," refers to a concept of bloodborne disease control which requires that all human blood and certain human body fluids are treated as if known to be infectious for

HIV, HBV, and other bloodborne pathogens. • Employees are responsible to: -Know what tasks they perform that have potential for occupational

exposure to blood borne pathogens or tuberculosis prior to beginning work.

-Plan and conduct all work activities according to hospital policies and procedures.

OSHA Respiratory Protection Standard

1910.134(a)(1)• In the control of those occupational diseases

caused by breathing air contaminated with harmful dusts, fogs, fumes, mists, gases, smokes, sprays, or vapors, the primary objective shall be to prevent atmospheric contamination. This shall be accomplished as far as feasible by accepted engineering control measures (for example, enclosure or confinement of the operation, general and local ventilation, and substitution of less toxic materials). When effective engineering controls are not feasible, or while they are being instituted, appropriate respirators shall be used pursuant to this section.

OSHA Respiratory Protection Standard 1910.134(a)(2)

• A respirator (N95 Mask) shall be provided to each employee when such equipment is necessary to protect the health of such employee. The employer shall provide the respirators which are applicable and suitable for the purpose intended. The employer shall be responsible for the establishment and maintenance of a respiratory protection program, which shall include the requirements outlined in paragraph (c) of this section. The program shall cover each employee required by this section to use a respirator.

• Only wear the style of respirator that you have been fit tested for!!

CRH Masks – Type is N95

• 3M 1870 Universal

• 3M 1860: Small/Regular • PAPR (Powered Air Purifying

Respirator) Type is N100

Workers’ CompensationIMPORTANT POINTS: • REPORT any accident, injury, illness or exposure must

be immediately to your supervisor. • COMPLETE incident report using the on-line

• “Quality Care Control Reporting System, • “Live Reporting System.”

• Fill out an incident report as soon as possible. Make sure you are completing all the information on all of the screens. This gives Employee Wellness a complete picture of the incident. Please make sure your description of the incident is thorough: what happened, how it happened, where it happened, what was hurt.

List witnesses and who was notified by name.• Follow up with Employee Wellness as soon as or with

in one business day or your reported injury. • CRH’s Workers Compensation insurance company will

decide whether the incident is accepted or denied.• VA law states that YOU are responsible for the first 7

days out of work – it’s on your time.

Workers’ CompensationEmployee Wellness

DutiesReview of the accident and resulting

injuryOffer CRH Workers’ Compensation

Panel of Physicians If you choose to go to the ED and need

a follow up visit you MUST choose a physician from the approved panel

Employee Wellness does not approve or deny services. We act as an agent to notify and facilitate care with the CRH contracted WC carrier.

Workers’ CompensationEmployee Responsibilities

• Employee Responsibilities: Always report to supervisor** Determine if immediate medical attention is required – You may

choose to be evaluated in the ED (Note: NO ONE can make you seek medical attention or file a workers’ compensation claim) Ask yourself this question: “If this happened at home would you seek follow up treatment?”** It is your choice.

Complete incident report (immediately or by the end of your shift) Call Employee Wellness at time of injury or within 24 hours** Complete Urine Drug screen – IF seen by a physician post incident Provide Employee Wellness with regular updates after each

physician visit** Contact your WC representative for approvals of services as needed

and regular updates on your progress Request and return a completed “Return to Work” form when you

are ready to come back to work, either full duty or transitional duty**

Contact Employee Wellness if you have any questions or concerns** Follow the directions, treatments and limitations set by your

physician**

**The above guidelines apply to all injuries, illnesses or exposures, whether on the job or off the job

Employee Wellness• ReadySet is the ON-LINE Employee Health

Portal used to complete annual wellness tasks. It is accessed at https://culpeperhospital.readysetsecure.com

• This software will be used by all employees, and contract staff.

• “Tasks” are assigned in the “My Health Portal”. These must be completed prior your annual appointment or to receive a PPD or Immunization. Contact us if you need assistance using the ReadySet system.

• Annual wellness evaluations are done annually during YOUR HIRE month – you must complete both fit testing (if applicable) and your TB screen or skin test by the last day in your hire month.

• Auxiliary/Chaplains are due annually in May

Employee Wellness

Routine Office hours are Monday-Friday 8:00 am – 4:30 pm. • Annual Wellness visits are routinely scheduled

on the 1st , 2nd and 3rd Tuesdays and the 2nd Monday of each month.

• Annual Wellness visits are done by appointment only. Please call the office to schedule an appointment.

• You may contact us at 540-829-5743.

Safe Working Practices• CRH strives to provide a

workplace free from hazards. Those hazards can also pertain to employees returning to work. It is expected that the employee follow up with Employee Wellness prior to any return to work after an injury or illness.

• Employee Wellness clearance is needed for the use of: removable splints, casts, walking boots, crutches, walkers, canes or any assistive devices, etc…while at work.

Safe Patient Handling (SPH)

• Safe patient movement and handling benefits patients. The potential for patient (falls or skin tears) and staff (strains/sprains) injury as a consequence of manual handling is reduced by using assistive equipment and devices. Equipment and devices provide a more secure process for lifting, transferring or repositioning patients. Patients are afforded a safe means to progress through their care, have less anxiety, are more comfortable, and maintain their dignity and privacy. Assistive patient handling equipment can be selected to match a patients ability to assist in his or her own movement, thereby promoting patient autonomy and rehabilitation.

SPH cont…..• Safe patient movement and handling benefits healthcare

workers. Patient handling tasks are recognized as the PRIMARY cause for musculoskeletal disorders among healthcare workers.

• CRH patient handling equipment:o Tempo Lift: floor model can handle patients up to

440#’s; o MaxiSky: overhead lift system, can handle patients up to

600#’s; o Slip Sheets: new draw sheet with slippery texture that

allows less friction when repositioning patiento HoverMat: blow up mattress with NO weight limit for

lateral transferso HoverJack: blow up mattress’ (3) that can lift a patient

off the floor to bed height.o The National Institute for Safety recommends a 35 lb.

maximum weigh limit for use in handling tasks. o Injury Prevention & Other Benefits of Safe Lifting:

o Caregiver injury preventiono Improved clinical outcomes for patientso Greater patient protection, safety & comforto Workers’ Compensation and related cost savings

Construction

• Employees are NOT to enter any construction area, at any time. This is for your safety.

• Please know that construction dirt, dust, smoke, or noxious fumes may be released into the air during construction, and can enter the ventilation system and lower the entire facilities air quality. Some safety items you may encounter while construction is being done: – Hepa filters – clean the air, – Sticky mats – at entrances and exits to construction areas (clean the

shoes of workers so they do not track debris around the hospital), – Closed off areas – allow construction to continue with minimum amount

of disturbance to patients and staff.

• If you have any concerns regarding construction safety or health related issues – you may contact:Facilities Department x4336, Infection Control x4385, Employee Wellness x4102.

Misconceptions about the flu…

Q: Can a flu shot give you the flu?A: No, a flu shot cannot cause flu illness. The influenza viruses

contained in a flu shot are inactivated (killed), which means they cannot cause infection. Flu vaccine manufacturers kill the viruses used in the vaccine during the process of making vaccine, and batches of flu vaccine are tested to make sure they are safe.

Q: Why do some people not feel well after getting the seasonal flu shot?

A: The most common side effect of seasonal flu shots in adults has been soreness at the spot where the shot was given, which usually lasts less than two days. The soreness is often caused by a person’s immune system making protective antibodies to the killed viruses in the vaccine. These antibodies are what allow the body to fight against flu. The needle stick may also cause some soreness at the injection site. According to the Advisory Committee on Immunization Practices (ACIP), rare symptoms include fever, muscle pain, and feelings of discomfort or weakness. If these problems occur, they are very uncommon and usually begin soon after the shot and last 1-2 days.

Q: What about people who get a seasonal flu vaccine and still get sick with flu-like symptoms?

A: There are several reasons why someone might get flu-like symptoms even after they have been vaccinated against seasonal flu.

1. People may be exposed to one of the influenza viruses in the vaccine shortly before getting vaccinated or during the two-week period that it takes the body to gain protection after getting vaccinated. This exposure may result in a person becoming ill with flu before protection from the vaccine takes effect.

2. People may become ill from non-flu viruses that circulate during the flu season, which can also cause flu-like symptoms (such as rhinovirus). Flu vaccine will not protect people from respiratory illness that is not caused by flu viruses.

3. A person may be exposed to an influenza virus that is very different from the viruses included in the vaccine. The ability of a flu vaccine to protect a person depends largely on the similarity or "match" between the viruses or virus in the vaccine and those in circulation. There are many different influenza viruses.

Unfortunately, some people can remain unprotected from flu despite getting the vaccine. This ismore likely to occur among people that have weakened immune systems or the elderly. However, even among these people, a flu vaccine can still help prevent complications.

Seasonal influenza vaccine provides the best protection available from seasonal flu—even when the vaccine does not exactly match circulating seasonal flu strains, and even when the person getting the vaccine has a weakened immune system. Vaccination can lessen illness severity and is particularly important for people at high risk for serious flu-related complications and close contacts of high-risk people. Children younger than 6 months old are the pediatric group at highest risk of influenza complications, but they are too young to get a flu vaccine. The best way to protect young children is to make sure members of their household and their caregivers are vaccinated.

Q: Is it too late to get vaccinated ?A: No. Vaccination can still be beneficial as long as influenza viruses

are circulating. CDC recommends that providers begin to offer influenza vaccination as soon as vaccine becomes available in the fall, but if you have not been vaccinated by Thanksgiving (or the end of November), it can still be protective to get vaccinated in December or later. Influenza is unpredictable and seasons can vary. Seasonal influenza disease usually peaks in January or February most years, but disease can occur as late as May.

Q: Is the "stomach flu" really the flu?A: No. Many people use the term "stomach flu" to describe illnesses

with nausea, vomiting or diarrhea. These symptoms can be caused by many different viruses, bacteria or even parasites. While vomiting, diarrhea, and being nauseous or "sick to your stomach" can sometimes be related to the flu – more commonly in children than adults – these problems are rarely the main symptoms of influenza. The flu is a respiratory disease and not a stomach or intestinal disease.

Q: What are the symptoms of the flu?A: The flu can cause mild to severe illness, and at times can lead to death. The flu is different from a cold. The flu usually comes on suddenly and you can spread the virus one day prior to symptoms starting. Flu symptoms include:• A 100oF or higher fever or feeling feverish (not everyone with the flu

has a fever) • A cough and/or sore throat • A runny or stuffy nose • Headaches and/or body aches • Chills and Fatigue • Nausea, vomiting, and/or diarrhea (most common in children)

Employee Drug-Free Workplace Education

• Working Partners for an Alcohol- and Drug-Free Workplace

• Provided by the Office of the Assistant Secretary for Policy U.S. Department of Labor

Overview of Drug-Free Workplace

• Accomplishes two major things:• Sends a clear message that alcohol and

drug use in the workplace is prohibited• Encourages employees who have problems

with alcohol and other drugs to voluntarily seek help

The Drug-Free Workplace exists to:

• Protect the health and safety of all employees, customers and the public

• Safeguard employer assets from theft and destruction

• Protect trade secrets• Maintain product quality and company integrity

and reputation• Comply with the Drug-Free Workplace Act of

1988 or any other applicable laws

Impact of Substance Abuse in the Workplace

• Employee Health – People who abuse alcohol or other drugs tend to neglect nutrition, sleep and other basic health needs. Substance abuse depresses the immune system. Its impact on the workplace includes higher use of health benefits; increased use of sick time and higher absenteeism and tardiness.

• Productivity – Employees who are substance abusers can be physically and mentally impaired while on the job. Substance abuse interferes with job satisfaction and the motivation to do a good job. It’s impact on the workplace includes reduced output; increased errors; lower quality of work and reduced customer satisfaction.

• Decision Making – Individuals who abuse alcohol and/or other drugs often make poor decisions and have a distorted perception of their ability. Here, substance abuse’s impact on the workplace includes reduced innovation; reduced creativity; less competitiveness; and poor decisions, both daily and strategic.

Impact of Substance Abuse in the Workplace

• Safety – Common effects of substance abuse include impaired vision, hearing and muscle coordination and low levels of attention, alertness and mental acuity. Its impact on the workplace includes increased accidents; and more workers’ compensation claims.

• Employee Morale – The presence of an employee with drug and/or alcohol problems creates a strain on relationships between coworkers. Organizations that appear to condone substance abuse create the impression that they don’t care. Impact on the workplace includes higher turnover; lower quality; and reduced team effort.

• Security – Employees with drug and/or alcohol problems often have financial difficulties, and employees who use illegal drugs may be engaging in illegal activities in the workplace. In this area, substance abuse’s impact on the workplace can include theft and law enforcement involvement.

• Finally, substance abuse impacts Organizational Image and Community Relations – Accidents, lawsuits and other incidents stemming from employee substance abuse problems may receive media attention and hurt an organization’s reputation in the community. The impact on the workplace includes reduced trust and confidence; and reduced ability to attract high-quality employees.

Signs and Symptoms of Substance Abuse

Emotional effects of substance abuse: Aggression Burnout Anxiety Depression Paranoia Denial

Behavioral effects of substance abuse:• Slow reaction time • Impaired coordination • Slowed or slurred speech • Irritability • Excessive talking • Inability to sit still • Limited attention span • Poor motivation or lack of energy

Physical effects of substance abuse:• Weight loss • Sweating • Chills • Smell of alcohol

Specific Drugs of Abuse

• Alcohol• Marijuana• Inhalants• Cocaine• Stimulants

• Depressants

• Hallucinogens

• Narcotics

• Designer Drugs

All drugs, including alcohol, chemically alter the mind and body. As a result, use of drugs and/or alcohol can impair motor skills, hinder judgment, distort perception, decrease reaction time and interfere with other skills necessary to do a job safely and efficiently.

Assistance is available

• Difficulty performing on the job can sometimes be caused by unrecognized personal problems - including addiction to alcohol and other drugs

• Help is available • Although a supervisor may suspect that an employee’s

performance is poor because of personal problems, it is up to the employee to decide whether or not that is the case

• It is an employee’s responsibility to decide whether or not to seek help

• Addiction is treatable and reversible• An employee’s decision to seek help is a private one and will

not be made public

CRH Substance Abuse Policy

• Located online in Policy Manager– Policy# 627.0– EAP and Employee Wellness are here to

help you– Confidentiality is assured

– If you have any questions, please contact HR, Employee Wellness or your direct supervisor.

FIRE SAFETY MANAGEMENT


The Fire Triangle

• The three “sides” of the fire triangle are a fuel source, an air (oxygen source), and heat (ignition source).

• For any fire to occur, all three components of the fire triangle must interact. For example, if a patient is having facial surgery and receiving supplementary oxygen (oxygen source) at the same time that an active electrode (ignition source) is being used, and if the active electrode tip accidentally touches the patient’s drape (fuel source), they could ignite in the oxygen-enriched environment and a fire could occur.

Fire Safety

RACE TO SAFETYR = rescue A = alarm/Announce C = contain E =

extinguish

Rescue anyone in immediate danger. Sound the fire alarm through the

nearest pull station and announcing the fire location overhead. Announce

overhead by dialing 777 from any hospital phone and repeating Code Red

+ Location three times. If there is more than one staff member in the

area of origin, designate one staff member to pull the alarm while the

other announces the fire overhead. All corridors should be cleared

and doors should be closed to contain fire.

If you are away from the fire’s point of origin and hear the fire alarms

sound, you should remain in your current location until the Code Red is

canceled. Do not breach fire doors while the fire alarm is activated.

Fire Extinguishers• PASS

– Pull the pins between the handles of the extinguisher

– Aim the nozzle at the base of the fire– Squeeze the handles together– Sweep from side to side

“Fire First Responders” at CRH include staff members from Facilities Management, Security and Housekeeping. Members from these departments are trained to respond to the site of the fire with an extinguisher.

Fire Drills• CRH is required to complete a fire drill at least once per shift

per quarter.• During fire drill we evaluate that staff know when and how to

sound the fire alarms, when and how to transmit to off-site fire responders, how to contain smoke and fire, how to transfer patients to areas of refuge (as necessary); how to use the fire extinguisher, and how to prepare for building evacuation.

• After any activation of the fire alarm, each department should fill out a “departmental fire drill critique” and send to Facilities Management. This allows us to get feedback from all areas of the hospital even if they aren’t directly observed by the fire drill team. This document is attached to the Code Red plan in your Emergency Preparedness & Response Guide in Policy Manager. Evacuation

• In a fire situation, you may be called on to help evacuate patients, patient information, and medical equipment. In most cases, this will involve moving to another compartment in our facility, but in extreme cases we may need to evacuate the entire building to another location.

• If an evacuation order has been given, use the pillow system for tagging the rooms already evacuated to avoid unnecessary backtracking.

HAZARDOUS MATERIALS

AND WASTE


• Cultures and stocks• Pathological waste• Human blood and blood products• Sharps, including needles, scalpels, blades, lab slides• Isolation waste• Blood or drainage-soaked dressing• Disposable items that could release blood or other potentially infectious

materials if compressed• Laboratory waste• IV tubing with visible blood

Regulated Medical Waste

Regular Waste• Sponges• Disposable gloves• Slightly soiled dressings• Paper• Cardboard• Glass products

Our Laundry Department does have the capability to launder blood soaked linens. Do not put in red bag containersDo not dispose of regular trash in red bag containers. Red bag trash cost 10x more to dispose of than regular trash.

• Global Harmonization requires that labels follow strict guidelines and include the following elements:

• Product Identifier - This is how the chemical is identified, which could be chemical name, code or batch number. This is determined by the manufacturer, importer, or distributor.

• Signal Word - The signal word will either be “Danger” or “Warning” to reflect the hazard class of the chemical. Danger will reflect more severe hazards; warning will reflect the less severe hazards.

• Hazard Statements - These statements describe the nature of the hazard.

• Precautionary Statements - This is a phrase that will describe recommended measures to minimize or prevent adverse effects resulting from chemical exposure.

• Pictograms - There are eight pictograms that identify chemical hazards. They are pictured on next slide

Label Elements

All Safety Data Sheets (SDS) will consist of these 16 sections:

• Section 1, Identification (Product)• Section 2, Hazard(s) Identification• Section 3, Composition/Information on Ingredients• Section 4, First-Aid Measures• Section 5, Fire-Fighting Measures• Section 6, Accidental Release Measures• Section 7, Handling and Storage • Section 8, Exposure Controls/Personal Protection• Section 9, Physical and Chemical Properties• Section 10, Stability and Reactivity• Section 11, Toxicological Information• Section 12, Ecological Information* • Section 13, Disposal Considerations* • Section 14, Transport Information* • Section 15, Regulatory Information* • Section 16, Other Information... includes the date of preparation or last revision. * Denotes optional information

Safety Data Sheet (SDS)

– When PPE is necessary for job tasks– What PPE is necessary for job tasks– Where PPE is located– How to properly don, doff, adjust, and wear PPE– Limitations of PPE– Care, maintenance, useful life and disposal of PPE– Chemicals should be stored with like hazards and

no higher than eye level.

If you have any questions about required PPE in your department, ask your director or supervisor

What should you know specific to your department?

– Don’t clean up a spill of any hazardous material unless you have the training and equipment to do so.

– Alert others in the area of the hazmat spill. Alert the Facilities Management Department, x8840, Employee Wellness, x4102 and Safety Officer, x4164.

– If possible, keep the area ventilated.– If possible, try to contain the spill with absorbent

materials until the spill responders arrive.– If possible, get a copy of the Safety Data Sheet

(SDS) to assist the responders.– Turn off all ignition and heat sources if possible.

Hazmat Spills

• Two Ways to Get a Copy of an SDS– 3E Company Fax-On-Demand 800-451-

8346• Use this method if you have had an exposure or

spill. 3E Company has Safety Specialist/Toxicologist on staff who can help you with initial first aid information and clean-up procedures.

– 3E Company On-line• Go to www.3eonline.com Log In is CRH and the

Password is MSDS. After you are signed in, you can search for the product by name, hit enter, and you will have a chance to view/print a copy of the SDS.

SDS

http://www.3eonline.com/

Culpeper Regional Hospital

Infection Prevention & Control

Tina Myers, RN, BAShirley Ann Bayne, RN, BSN, MSHA

What is the role of Infection Prevention & Control (IP&C)?

• Assess, analyze, and eliminate the risks of hospital acquired infections (HAIs)

• Conduct surveillance activities• Monitor trends in anti-microbial resistance• Educate clinical staff about strategies to

prevent infection• Participate in performance improvement and

patient safety activities• Ensure that evidence based infection

prevention practices are used• Identify and manage infectious outbreaks• Monitor the effectiveness of the IPC program• Communicate with staff & leadership

Infection Prevention & Control Works to Break the Chain of

InfectionPathogenic Organism

Reservoir

Portal of Exit

Mode of Transmission

Portal of Entry

Susceptible Host

HANDWASHING: The single MOST important

measure in preventing infections!

Our expected hand hygiene compliance is

100%Proper hand hygiene means that you wash

your hands or use hand sanitizer every time you

enter and exit a patient’s room and after every patient encounter.

CLEAN HANDS SAVE LIVES

Standard Precautions• Previously called Universal

Precautions• Assumes blood and body fluid of

ANY patient could be infectious.• Recommends personal protective

equipment (PPE) and other infection control practices to prevent transmission of infections.

• PPE use should be determined based on the type of clinical interaction occurring between the HCW and patient.

Personal Protective Equipment (PPE)

• Gowns• Gloves• Goggles/Face Shields• Masks• PPE Storage Cart or Caddy• YOU are responsible for using the

correct size of PPE• YOU are responsible for wearing

PPE at the appropriate times

When to use PPE…..Wear GLOVES when there is a likelihood of touching: • Blood• Body fluids, secretions, excretions (such as emptying

a foley bag or drawing blood)• Mucus membranes• Any non-intact skin or wounds

Wear a GOWN during:• Procedures• Patient care activities when anticipating contact of clothing

or exposed skin with:– blood/body fluids – secretions– excretions

When to use PPE…..

Mask , goggles and/or a face shield – Use during patient care activities • that generate splashes or sprays

of – blood – body fluids– secretions– excretions

• when patients are coughing

Order to Don PPE

• Gown• Mask• Goggles• Gloves

Order to Remove PPE

• Gloves• Wash Hands• Goggles• Gown• Mask• Wash Hands

TYPES OF ISOLATION

• Contact• Droplet• Airborne

CONTACT ISOLATION

Used for infectious organisms that can be spread by direct OR indirect contact.

PPE Required• Must wear gloves and

gown, except when in the “safe zone”.

• Organisms can “hitch” a ride on clothes, hands, medical equipment and transfer to the next patient.

Safe Zone for Contact Isolation

The safe zone is the area located in the vestibule of a patient care room in which isolation PPE is not required for contact isolation as long as a staff member remains in this area and does not touch any part of the walls, curtain, or other objects in the room. Staff members are still expected to perform hand hygiene.

DROPLET ISOLATION

• Can be spread by large particle droplets.

• Requires close contact, usually within 3-6 feet of patient for transmission.

PPE Required

• Surgical mask • Gloves, if handling secretions

AIRBORNE ISOLATION

• Pathogens that can be transmitted via the airborne route.

• Remains in environment for extended period of time.

PPE Required• N95 respirator or PAPR prior to

entering room.

• Patient must be in negative pressure room with door closed.

Why should we be concerned?

Patient safety: • Prevent the transmission of organisms within

the hospital • The Joint Commissions 2010 National Patient

Safety Goal 07.03.01: Implement evidence-based practices to prevent Healthcare Associated Infections (HAIs)

• Due to multi-drug resistant organisms (MDROs) in acute care hospitals.

MDROs: • Difficult to treat• Treatment can encourage colonization of

other MDROs• Increase length of stay• Implicated in many Healthcare Associated

Infections National Patient Safety Goal to identify those with MDRO and to prevent HAI

Monitoring Negative Pressure

Air flow indicator devices are available on all negative pressure rooms for continuous monitoring.

Report any malfunctions to Facilities Management.

Periodic checks are required to maintain the desired negative pressure and the optimal operation of monitoring devices.

Facilities Management is responsible for monitoring and will be logged weekly.

System in place to monitor positive/negative pressure rooms. Ping Pong balls should be:

• Positive Pressure – outside room;

• Negative Pressure – inside room

Transporting a Contact Isolation Patient

Assisting staff should perform hand hygiene and wear gown and gloves.

Via bed: • Wipe handrails and head/foot boards

of bed. • Patient should have clean top sheet

placed over bed. • Patient should wash his/her hands

upon entry/exit to the room. Via wheelchair: • Clean gown should be placed on

patient.• Place clean top sheet over patient.

Transporting a Droplet Isolation Patient

• Patient wears surgical mask if leaving room for diagnostic tests.

• Mask should NOT be removed until patient returns to his/her room.

• If mask must be removed from patient, then HCW MUST wear surgical mask.

Transporting an Airborne Isolation Patient

• Visitors wear surgical mask.• Patient wears surgical mask if leaving his/her room for diagnostic tests and must not remove it.

• HCW should NOT wear a mask when transporting the patient.

Multi Drug Resistant Organisms(MDRO’s)These highly resistant organisms require special attention and Contact Isolation in

healthcare facilities.

MRSA: Methicillin (oxacillin) Resistant Staphylococcus aureusVISA: Vancomycin Intermediate Staphylococcus aureusVRSA: Vancomycin Resistant Staphylococcus aureusVRE: Vancomycin Resistant EnterococcusC-diff: Clostridium difficile – MUST wash hands w/ soap & water for 15 seconds.CKP: Carbapenem-resistant klebsiella pneumoniae

Transmission of MDROs can occur through direct or indirect contact

• Direct: contact with contaminated body fluid

• Indirect: contact with contaminated surfaces (linen, siderails, bedside tables etc…)

• Controlling transmission of MDRO’s involves all departments and medical staff – thorough cleaning of all surfaces in patient rooms and multi-use items (stethoscopes, BP cuffs)

• Proper hand hygiene must be performed by all!

CDC guidelines to reduce MDRO and HAI

Surveillance Measurement of Interventions Infection Control

Hand Hygiene Consistent use of Standard precautions for

all patients Contact isolation for all those

colonized/infected with MDRO-additional as indicated

Proper use of PPE by all staff Environmental and Patient Care Equipment

Cleaning

Environmental and Patient Equipment Cleaning

• Before patient care use

• After patient care use• All high touch areas such as side

rail, call bell, telephone, overbed table, equipment handles, datascope, pulse oximeter, accucheck, and baby scales

Infection vs. Colonization• Infected means the organism is

present and patients show specific signs or symptoms of bacterial invasion of a specific organ, such as the lung in pneumonia.

• Colonized means the organism is present and patients show no signs or symptoms, but still could spread the MDRO from person to person.

• While the greatest concern is for patients infected with an MDRO, other patients may simply be colonized with these bacteria but are still capable of spreading it to others.

Hospital Acquired Infections/Conditions

(HAIs/HACs)• Healthcare-associated infections are estimated to occur in 5% of all hospitalizations in the United States.

• Healthcare-associated infections result in longer length of stay, mortality and healthcare costs.

• In 2002, an estimated 1.7 million healthcare-associated infections occurred in the United States, resulting in 99,000 deaths.

• In March 2009, the CDC released a report estimating overall annual direct medical costs of healthcare-associated infections that ranged from $28-45 billion.

Monitoring HAIs

CRH monitors the following HAIs: • Central Line Bloodstream Infection

{CLABSI}, • Ventilator Acquired Pneumonia {VAP},• Catheter Associated Urinary Tract

Infections {CAUTI}, • Clostridium difficile • Surgical Site Infections {SSIs}• MRSA infections

REMEMBER EVERYONE is a member of the Infection Prevention & Control Team! WASH YOUR HANDS AND PROTECT YOUR PATIENTS!Infection Prevention = Patient Safety

QUALITY & PATIENT SAFETY


Our patients’ expectations:

Heal me (Evidence-Based Quality of Care)

Don’t hurt me (Patient

Safety)

Be kind to me (Patient experience/satisfaction)

See It – Be on the lookout for unsafe situations and recognize Red Flags that warn of potential problems

Say It – Communicate what you see to your team members – make sure you tell the people who can make the needed changes

Fix It – Take action – don’t stop until the issue is resolved

Patient SafetyYour Responsibility

http://www.securities-administrators.ca/uploadedImages/General/images/Red%20Flag.jpg?n=1636

If you have a concern about something that poses an immediate threat to a patient’s safety you should:

“STOP THE LINE” by taking immediate action to prevent patient harm

If you are aware of any unusual incident that has harmed a patient or that could harm a patient:

1. Notify a supervisor, manager or administrator on call

2. Complete an incident report in the rL Solution system

3. Phone the Patient Safety Officer at 829-8825

Patient Safety

When you need to be sure to get a response when immediate action is needed (to “Stop the Line”, you can use an assertive statement. Use this model:

Get Attention – Call the person by nameExpress Concern – Use an “I” statement – I’m concerned, I’m uncomfortableState the Problem – Be brief, clear and objectivePropose a Solution – Use a “we” or “let’s” statement – “We should stop and double check this,” “Let’s get some help”

Assertive Statements

The following are important members of your team as an employee at Culpeper Regional Hospital and a healthcare provider…

People in your department People in departments who you work with most days People in departments who you don’t work with often Members of the Medical Staff Administrators Board of Trustee Members Members of the Auxiliary (Pink Ladies) Students And the most important member of the team…

Who is your team?

And the most important member of the team…

Who is your team?

…Our patients and their families

How do we include our patients as members of the team?

Communicate with Them Listen to what they have to say Ask them what they need Ask them if they understand Let them know what to expect Tell them what you are doing while you are in

their room Include them in the discussion about their

plan of care Listen as much as you talk!

Patients as Team Members

Errors can happen because…

Communication failure Lack of effective training Memory lapse Inattention Poorly designed equipment Exhaustion, fatigue Ignorance Distractions Complacency Failure to follow policy

Poor communication or failure to communicate

with members of the healthcare team (including

our patients and their families) is the number one cause of medical

errors that harm patients

To improve patient safety, CMS (Centers for Medicare & Medicaid Services) along with most insurance companies will not pay the hospital for “never events” when they occur in the hospital. Some of the Never Events are:

Air embolismsBlood incompatibility for transfusions Catheter-related urinary track infections (CAUTI)Patient fall with an injuryObject left in following surgery Pressure ulcer (Stage 3 or 4) Central Line Associated Bloodstream Infection

(CLABSI)

Deep Vein Thrombosis (DVT)

Never Events

You can find information about the quality of care delivered by the hospital on these websites:

www.culpeperhospital.com www.jointcommission.org www.hospitalcompare.hhs.gov

www.hospitalsafetyscore.org

On these websites you will find information in regards to patient satisfaction, patient safety, and quality of care for certain diseases.

Quality Reporting

http://www.culpeperhospital.com/

http://www.jointcommission.org/

http://www.hospitalcompare.hhs.gov/

http://www.hospitalsafetyscore.org/

Excellent websites to learn more about healthcare quality and patient safety

www.ihi.org (Institute for Healthcare Improvement

www.ahrq.gov (Agency for Healthcare Research and Quality

www.npsf.org (National Patient Safety Foundation

www.qualityforum.org (National Quality Forum) www.jointcommission.org (The Joint

Commission)

Quality & Safety Resources

http://www.ihi.org/

http://www.ahrq.gov/

http://www.npsf.org/

http://www.qualityforum.org/

http://www.jointcommission.org/

Suicide Prevention

Quick Facts

• Suicide is the 10th leading cause of death in the US

• Nearly 4% of the adult population report thinking about committing suicide in the past year

• Nearly 16% of high school students report thinking about suicide in the past year

• Females are more likely to think about suicide

• Males are more likely to act on thoughts of suicide www.cdc.gov/

violenceprevention

http://www.google.com/url?sa=i&rct=j&q=depression&source=images&cd=&cad=rja&docid=KRSdhnX8U0qTJM&tbnid=IAazNDSL5RpDoM:&ved=0CAUQjRw&url=http://www.npr.org/blogs/health/2012/11/06/164392091/depression-and-health-spending-go-together&ei=wBkwUdigKpDw0QH_rYE4&bvm=bv.43148975,d.dmQ&psig=AFQjCNGrrJDZE7XD0u16yC9VPb21ZKNaRQ&ust=1362193163217810

Who does suicide affect?• Suicide affects everyone!

But some groups are at higher risk than others:• Men are about 4 times more likely than women to

die from suicide• However, 3 times more women than men report

attempting suicide • Suicide rates are high among middle aged and

older adults, as well as teens

www.cdc.gov/violenceprevention

http://www.google.com/url?sa=i&rct=j&q=depression&source=images&cd=&cad=rja&docid=4JWoZrJ80kUpyM&tbnid=IbwGCE_92ByxVM:&ved=0CAUQjRw&url=http://www.npr.org/blogs/health/2010/01/catching_depression_in_teens_m.html&ei=0BowUZXQIMqB0AH94IHoBQ&bvm=bv.43148975,d.dmQ&psig=AFQjCNGrrJDZE7XD0u16yC9VPb21ZKNaRQ&ust=1362193163217810

Risk Factors

Several factors can put a person at risk for attempting or committing suicide. But, having these risk factors does not always mean that suicide will occur.

Risk factors for suicide include: • Previous suicide attempt(s)• History of depression or other mental illness• Alcohol or drug abuse• Family history of suicide or violence• Physical illness• Feeling alone or hopeless• Major life change like job loss or relationship loss

www.cdc.gov/violenceprevention

Warning SignsThese are some of the warning signs to look for:

• Talking about wanting to die or to kill themselves.• Looking for a way to kill themselves, such as searching

online or buying a gun• Talking about feeling hopeless or having no reason to

live.• Talking about feeling trapped or in unbearable pain.• Talking about being a burden to others.• Increasing the use of alcohol or drugs.• Acting anxious or agitated.• Sleeping too little or too much.• Withdrawing or isolating themselves.• Showing rage or talking about revenge.• Displaying extreme mood swings

www.suicidepreventionlifeline.org

The risk of suicide is greater if a behavior is new or has increased and if it seems related to a painful event, loss, or change. If you or someone you know exhibits any of these signs, seek help as soon as possible

Warning Signs

Where to get help:• National Suicide Hotline at 1-800-273-TALK (8255).• If they are a hospital patient, ask the doctor to call

the Community Service Board (CSB)• If they are not a hospital patient, get them to the

Emergency Department• If the risk seems immediate, call 911

tel:18002738255

What to do if you’re concerned about a hospitalized patient

• Ask the doctor to consult CSB• If you’re not involved in the patient’s care,

you may choose to speak with the nurse caring for the patient

• If CSB has already seen the patient and you’re still concerned, they can be called to send another case worker to talk to the patientWhen you’re concerned about someone’s

risk for hurting themselves, always take the time to find someone who can help.

Protective FactorsThere are some things that help people who are thinking of suicide choose not to act on their thoughts:

• Treatment for mental and substance use disorders • Restricted access to highly lethal means of suicide

• Strong connections to family and community support• Support through ongoing medical and mental health

care relationships• Help with skills in problem solving, conflict resolution

and handling problems in a non-violent way• Support from a religious leader or faith community

www.suicidepreventionlifeline.org

RADIATION SAFETY &AWARENESS


Radiation Awareness:

Radiation awareness and safety is everyone's business.

A common misconception some people have is that you can only be exposed to sources of ionizing radiation in the Medical Imaging department.

Actually, you may be exposed to sources of ionizing radiation throughout the hospital.

Radiation Awareness:

Radiation is the transmission of energy in the form of electromagnetic waves or fast moving particles. There are two forms:

Ionizing Radiation: Radiant energy that causes an ionization of an atom , removal or addition of an electron. *Sun, nuclear weapons, radon gas, x-rays, gamma rays, alpha and beta particles.

Non-Ionizing Radiation: Radiant energy that only causes an excitation of an atom. *Microwaves, cell phones.

Common Areas Where Employees May Be Exposed

To Radiation: Medical Imaging Department Operating Room Emergency Department Cafeteria/Coffee Shop Hospital Lobby and Waiting Rooms Halls and Elevators

Sources of Ionizing Radiation:

X-ray exams which are being performed portably in the ED, OR, or in Inpatient rooms.

C-Arm fluoroscopy procedures performed in the Operating Room.

Any patient who has had a nuclear medicine procedure, in which they received an administration of radioactive pharmaceutical. These individuals are still radioactive long after they leave the medical imaging department.

Radiation Safety Key Concept:

ALARA is an acronym for the radiation safety philosophy in which one tries to reduce their radiation exposures by keeping them “As Low As Reasonably Achievable”.

You can achieve this goal by employing the techniques outlined in the Golden Rule of radiation protection.

Radiation Safety Key Concept:

The “Golden Rule” of radiation protection is Time, Distance and Shielding.

Time: Do not linger around an area of potential radiation exposure any longer than you need to in order to accomplish the task at hand.

Distance: Maintain the greatest distance you can between you and the source of radiation at all times. At least 6ft from a patient having a x-ray.

Shielding: Use appropriate shielding techniques to reduce the amount radiation you receive.

Radiation Safety Measures:

Shielding Techniques: Staff wear personal

protective equipment; such as, lead aprons, lead lined gloves, and even lead eyewear to protect themselves.


Shielding Techniques: Structural shielding built

into the exam room helps to reduce staff exposures.

Mobile barrier shields can be utilized in areas that do not have fixed shielding to reduce staff exposures.

Lead curtains fixed to exam tables help shield.


Signs or placards are displayed in areas where radioactive materials are used and stored or where x-ray procedures are performed. They alert and warn individuals of a possible radiation exposure.

While in medical imaging, you can do your part to reduce un-necessary radiation exposures by knocking before entering an exam room.

Radiation Protection Program:

Culpeper Regional Hospital is required by state and federal regulations to administer and maintain a radiation safety program.

The Radiation Safety Officer(RSO) is typically responsible for managing this program in order to make sure all aspects of the program are being observed.

Dr. David Weber is our RSO here at CRH. You can contact him by calling the nuclear medicine department at ext. 4151 or by calling the medical imaging department at ext(s). 4144/4145 after normal business hours.


As part of the radiation protection program, the RSO checks to make sure that the occupational radiation dose for individual employees does not exceed 10% of the maximal allowable adult dose limit/year as defined by the NRC and the State of Virginia.

Medical Imaging and OR staff wear Film Badges and/or TLD devices to record and measure their individual occupational radiation exposures.


In addition to the RSO, our medical health physicist from Krueger-Gilbert Health Physics, Inc., assists in evaluating and maintaining our radiation safety program.

The medical physicist comes to CRH at least once every year to survey our imaging equipment, check our film badge reports and evaluate our records. He does this to ensure that everything is functioning properly and safely within specified limits.

MRI SAFETY


MRI Safety Major Objectives for MRI Safety

Magnet Safety Considerations

MRI Site Access Restriction

MRI Safety Education


The Magnet is ALWAYS ON – and maintains the potential for serious injury or deathWhen the magnet needs an emergency shutdown – it will be quenched. The cost to restore the system after a quench is over $50,000All devices about to enter Zone 3 – must be positively identified and/or tested to at least partially assess for ferromagnetic concern / MR safety.Patients with cardiac pacemakers can NEVER enter Zones 3 or 4 and can NEVER have an MRI.All external devices must be positively labeled as “MR Safe” prior to being permitted to enter into Zone 4


No “codes”/resuscitative efforts should be run

in Zone 4– Patient should be stabilized and removed

from the magnet room as soon as possible and moved to Zone 2 – where emergency personnel will be safe to perform the necessary measures

MRI Accidents

An off-duty police officer who was a patient - misunderstood the instructions given by the Technologist and brought his handgun into the magnet room. The handgun became a projectile – struck the magnet bore and despite two safety mechanisms being engaged – the handgun discharged – narrowly missing the officer.

MRI Accidents

A firefighter in Germany responding to a hospital fire, ran through an MRI room with an oxygen tank strapped to his back. He became sucked into the magnet bore, fracturing his skull. As he tried to free himself – the magnetic field took the oxygen tank further into the magnet – folding him in half and collapsing both lungs. The magnet was quenched and he was freed from the magnet and survived his injuries.

MRI Accidents

A 6 year old boy who had just recovered from the successful removal of an astrocytoma (brain tumor) was having a pre-discharge MRI. The child was being sedated for the scan – and during the procedure the Anesthesiologist notice the wall oxygen was reading empty. He tells this to the two Technologist who leave the control room and the entrance to the magnet room - to exchange the tank for the wall oxygen. The Anesthesiologist becomes inpatient and begins to yell for oxygen. A Nurse passing by hears the Physician call for an order and brings an oxygen tank to the door of the magnet room- where she is met by the Anesthesiologist. He brings the tank into the room and as he approaches the bore – the tank flies out of his hands – strikes the child in the head and becomes lodged in the bore against the child's head. The child dies several hours later from these head injuries.

MRI SITE ACCESS RESTRICTION

Four MRI Related Safety Zones

Zone 1: Public Access

Zone 2: Unscreened MRI patients and

family

Zone 3: Restricted Access / Badge Access

to MRI Control Room

Zone 4: The Magnet Room Itself

Site Access Restrictions for Zone 3

Inside the MRI control room

The area around the MRI scanner wherein free access by unrestricted non-MRI personnel and/or equipment can result in serious injury or death

Non-MRI Personnel are ***NEVER*** to be permitted unrestricted / unaccompanied access to Zone 3


Inside the magnet room -wherein free access by unrestricted non-MRI personnel and/or equipment can result in serious injury or death

Non-MRI Personnel are ***NEVER*** to be permitted unrestricted / unaccompanied access to Zone 4


Before anyone (staff, patient, visitor) can enter the magnet room, a screening form must be completed and reviewed by an MRI TechnologistBefore entering the magnet room, (staff, patient, visitor) must remove from their person any watches, pagers, wallets, pens, pencils, hair/money clips, jewelry, keys, coins and any other items that could become a projectile in the presence of the magnetic field.

MRI Safety Education

All Hospital Staff and anyone with the potential need to be in the MRI Scan Room area need to be trained in MRI safety

MRI Personnel receive extensive training in MRI safety issues

This training includes:

– The hazards of the magnet environment

– Patient heating issues

– Contrast agent safety

Any questions about MRI safety issues should be directed to the MRI Technologists.

http://images.google.com/imgres?imgurl=http://www.canamglobal.com/mri/images/Warning-English.jpg&imgrefurl=http://www.canamglobal.com/mri/acessor2.html&h=250&w=166&sz=11&hl=en&start=15&tbnid=FBgxXv9aZDu_JM:&tbnh=111&tbnw=74&prev=

SAFETY & SECURITY

MANAGEMENT


Safety Management

Every hospital has inherent safety risks associated with providing care to patients and performing daily activities. Some common safety risks of which all employees should be aware are:

Needlesticks Back injuries Exposure to radiation or other hazardous materials Combative patients Workplace violence Slip, trip and fall hazards Fires Noise Bloodborne pathogens Property Damage

Safety Management

There are a number of ways our organization identifies, minimizes and eliminates safety risks. Some of these actions include the following:

Safety policies and procedures Incident reporting systems Proactive risk assessments and EOC tours Data collection Engineering controls

Safety Management

You are the eyes and ears of the hospitals efforts to keep everyone safe! Should you witness a safety incident, or if you are aware of conditions or practices that create safety risks, you should always report them to your department director or the Hospital Safety Officer, Mark Utz. You will NEVER be penalized for reporting a safety concern.

Safety Management

Sometimes a risk or hazard can be fixed immediately – for example, if a chair is blocking an exit or there is a wet spot on the floor. When possible, fix safety problems to prevent immediate risks to patients, staff and visitors. However, incidents should still be reported because they may be symptoms of a bigger problem. For example, the chair blocking an exit can easily be moved, but it may indicate furniture overcrowding or an inappropriate room layout.

Safety Management

To further identify and address safety hazards in the environment, CRH conducts regular environmental tours or EOC Tours. These help us determine the presence of unsafe conditions and whether our current processes for managing safety risks are being practiced correctly and efficiently. EOC tours are completed in patient care areas twice a year.

Safety Management

Data that is obtained during EOC tours is analyzed and reported to the EOC Committee. Any problematic findings are acted upon, and appropriate feedback regarding problem correction is provided to those affected.

Security ManagementHOSPITAL SECURITY OFFICERS ARE ON SITE 24/7 AND CAN BE

REACHED ON THE SECURITY MAIN CELLPHONE – (540) 212-8743

• Objectives Security Management– To prevent security-related incidents– To respond to and properly manage

security incidents that do occur.– To provide general services that support

the achievement of CRH’s mission.– To create an environment in which staff,

visitors, and individuals served perceive that they are interacting in a safe and secure setting.

– Report suspicious activity relative to visitors, other staff, or patients.

– Report any security issues that make you feel uncomfortable.

– Use only assigned parking areas. Refer to light blue shaded areas on Parking Map

– Appropriately wear/display CRH employee identification badge.

– Properly store and secure facility and personal property.

– Never loan or duplicate CRH-issued keys.– Comply with all CRH Policies and Procedures.– Work in cooperation with CRH Security Officers to

ensure the safety of your work area.

Expectations of all CRH staff:

• CRH staff members are identified by CRH color picture badges that are worn above the waist. The badge must be in plain view. This ID serves to verify personnel identity, as well as to indicate staff status.

• Your ID badge is electronically equipped to activate various security access control devices in the facility.

• Patients in our facility are identified by wristband. Staff members and patients can recognize visitors by a lack of arm band or staff ID badge.

Identifying Staff, Patients and Visitors

– Patrolling the facility on foot.– Monitoring access to the building.– Locking and unlocking doors.– Issuing the proper identification badges to visitors,

outpatients, students, contractors, vendors and employees.

– Securing valuables/property.– Monitoring/Reviewing security camera footage.– Ensuring the safety & welfare of staff from physical

abuse by patients, visitors or colleagues.– Responding to all security incidents and

emergencies.

Responsibilities of the Security Department

– The National Institute for Occupational Safety & Health defines workplace violence as – “any physical assault, threatening behavior, or verbal abuse occurring in the workplace.”

Workplace Violence

– Non-treatment issues contributing to Healthcare Violence

• Proliferation of guns and other weapons.• Gang activity.• Abusive domestic and personal relationships.• The influence of chemical abuse.• The opportunity for property crimes.

– Treatment issues contributing to Healthcare Violence

• Frustration with inadequate resources.• Unrealistic expectations (often in relation to

behavioral health)• Overcrowded care delivery environments.• Unreasonably long wait times for care.• Lack of perceived care giver respect• Lack of communication.

Issues Contributing to Workplace Violence

– Spontaneous events: these are unpredictable and represent 15% of all workplace violence events.

– Situational events: these are preceded by warning signs. These type of events represent 85% of all workplace violence events. The Security Department offers Crisis Prevention Intervention (CPI) class to train staff on how to recognize and de-escalate potentially violent situation. This class is educational and fun with many hands-on activities. Sign up today - Mox Library.

Types of Workplace Violence (WV)

– Pacing with a display of being tense and angry– Flushed face, twitching face or lips, and shallow

breathing – Darting or jerking eye movements, rapid looking

around – Making threats– Demanding unnecessary services or attention– Making unwarranted claims of entitlement

– Challenging authority, invading personal space– Making statements about losing control (veiled

threats)– Acting chronically disgruntled– Escalating loudness, often with profanity– Using overly aggressive actions and language,

possibly due to intoxication or drug abuse

Warning Signs of WV

Stand at an angle to the disturbed person, which is less threatening than directly facing him/her

Do not invade personal space; stay at least 4’ from the individual

Do not maintain a rigid stance or cause the individual to feel cornered.

Do not touch the individual unless it is necessary to manage extreme behavior

Move and speak clearly, calmly, and confidently

Break eye contact with the individual to reduce the suggestion of aggression or control

Show that your are listening to the individual and respect his/her feelings

Indicate that you want to help resolve the situation and do not make any promises you can’t enforce

Clarify communication and ask for specific responses.Don’t get caught up in challenges. Comment only on the

person’s behaviorTake all threats seriously

WV De-Escalation Techniques

– Make an effort to remember conversations you may have overheard before or during the incident

– Obtain identity information from persons who may otherwise leave the area before security can interview them

– Memorize the physical description of perpetrators or others who may have fled the scene

– Be alert for unusual behavior that may occur before security responders arrive or while they are occupied managing the scene

– Reassure and support care recipients and other staff

– Maintain an appropriate level of confidentiality regarding details of the incident

– Write down everything while it’s still fresh in your mind

Staff involvement in Security Incidents

Compliance, Risk & Regulatory

Patricia Sautel Slater, CPHRM, CHC CSHA

Compliance, Risk & Regulatory Officer

http://www.culpeperhospital.com/index.html

Health Care Oversight

Culpeper Regional Hospital


Compliance issues include Patient safety & quality issues Adhering to licensing and accreditation requirements

(Department of Health, The Joint Commission) Meeting all Medicare Conditions of Participation Correcting survey deficiencies Fraud & Abuse laws (Stark, Anti-Kickback, False

Claims) Privacy & Security (HIPAA, HITECH) OSHA and Worker’s Compensation Employment Matters (ADA, FMLA, etc.)

Improper or fraudulent billing is the No. 1 compliance issue

WHAT IS COMPLIANCE?Doing the Right Thing


Office of Inspector General RISK AREAS FOR HOSPITALS

1. Submissions of accurate claims and information.

2. Self-referral and anti-kickback statutes.

3. Payments to reduce or limit services.

4. The Emergency Medical Treatment and Labor Act (“EMTALA”).

5. Substandard care.

6. Relationships with federal health care program beneficiaries.

7. HIPAA privacy and security rules.

8. Billing Medicare or Medicaid substantially in excess of usual charges.


Anti-Kickback Statute

Physician Self Referral

(“Stark”) Law

False Claims Act

Civil Monetary Penalties

Law

FRAUD AND ABUSE LAWS


254

Health Insurance Portability & Accountability Act (HIPAA)

Federal law to protect patient privacy, confidentiality & access to patient health information

Access to patient information must be legitimate & authorized

CRH enforces compliance with training, policies & procedures.

Privacy Officer for CRH is Patricia Sautel SlaterAuditing of access is done through monthly auditsViolations are subject to penalties & fines. Reporting

to the Department of Health for licensed staff.


Civil Penalties

• Civil Monetary Penalties

• Treble Damages• Discretionary

Exclusion• Corporate Integrity

Agreements

Criminal Penalties

• Fines • Prison Time• Mandatory Exclusion

CONSEQUENCES OF NON-COMPLIANCE


EFFECTIVE COMPLIANCE PROGRAMESSENTIAL ELEMENTS

1. Implementing written policies, procedures, and standards of conduct.

2. Designating a compliance officer and compliance committee.

3. Conducting effective training and education.

4. Developing effective lines of communication.

5. Enforcing standards through well publicized disciplinary guidelines.

6. Conducting internal monitoring and auditing.

7. Responding promptly to detected offenses and developing corrective action.


Code of Conduc

t

Compliance

Officer

Compliance

Committee

Reporting

Enforcement

Education &

Training

Monitoring &

Auditing

Investigation &

Response

Program Effectiveness

A SOLID INFRASTRUCTURE

Policies & Procedures


Compliance Program Participation

Conflicts of Interest Disciplinary Action Document Retention Fair Treatment of Hospital

Employees Intellectual Property Impermissible Patient

Referrals Kickbacks Occupational Safety

Patient Care Patient Confidentiality Patient Transfers Relationships with Patients Submission of Accurate

Healthcare Claims Tax Exempt Status Truth, Accuracy and

Completeness in Business Unfair Competition

CODE OF CONDUCT GUIDING PRINCIPLES


A SOLID INFRASTRUCTURE

Board of Trustees

Oversight Committee

Management

Compliance Officer

Physicians

Staff


BOARD OF TRUSTEES

“ The Culpeper Regional Hospital Compliance Program remains a top

priority for the Board of Trustees. Our goals of quality care and patient safety will

be significantly enhanced by a strong compliance program. The Board will continue to support the efforts of our

compliance team.”

Thomas Reynolds, MD, Board Chair


Subcommittee of the Board of TrusteesMechanism for direct Board involvementReviews the work of the Compliance

Committee and advises full Board on effectiveness

Ensures the Board is aware of significant compliance issues

COMPLIANCE OVERSIGHT COMMITTEE


Patricia Sautel Slater, CPHRM, CHC, CSHA

Patricia Sautel Slater, CPHRM, CHC, CSHA

In her role as Compliance Officer, Ms. Slater is responsible for ongoing development and execution of the Compliance Program.The Compliance Officer is supported in her duties by the Compliance Committee and she reports to the CEO and the Board.

COMPLIANCE OFFICER


COMPLIANCE OFFICER

Duties and Responsibilities: Oversees, monitors and modifies the

Compliance Program Reports to CEO and Board (Culpeper Class) Investigates suspected compliance violations Provides compliance training and education Etc.

Authority to review documents and information necessary to carry out duties.


COMPLIANCE COMMITTEE

Assists Compliance Officer with development, implementation & operation of Compliance Program

Meets regularlyDuties and Responsibilities

Assists in identifying legal duties and risks. Assists in development and revision of policies . Develops annual audit plan. Monitors internal controls. Develops strategies for detecting compliance violations. Assists with reviews, audits, investigations, etc.


Reporting: Each employee is required, as a condition of employment, to report any practice that the employee believes does or may violate the law, the Code of Conduct or any Compliance Program policies or procedures.

Non-Retaliation: Persons reporting compliance issues in good faith will not be subject to retaliation or reprisal.

REPORTING OBLIGATIONS


REPORTING OPTIONS

Compliance Officer: 829-5703 (internal x5703)

Compliance Hotline: 1-877-888-4806

Email: [email protected]

In person or in writing to Director, Supervisor or Compliance Officer


REPORTING PROCESS

Reports are kept confidential to the greatest extent possible.

Persons filing reports are provided with feedback regarding investigation, substantiation/non-substantiation, and follow-up action taken.

If reported anonymously, must call back to request feedback.


Risk Management has responsibilities for overseeing the Incident Reporting System (RL Solutions).

Incident reports should be completed at the time of detection of the incident (no later than 24 hours).

Some examples of unexpected events include but are not limited to: medication events, adverse drug events, patient/visitor falls, equipment failure, property damage, injury related, diagnosis related, and treatment related events.

An incident report is not used to retaliate against an employee or used for disciplinary purposes.

An incident report is a confidential document that is not part of the patient’s medical record.

The appropriate director will research the reported incident and follow-up accordingly.

RL Solutions Reporting System


ENFORCEMENT

Any Hospital employee, medical staff member, contractor or volunteer who violates the Code of Conduct, Compliance Program policies or procedure or any relevant law will be subject to disciplinary action.

All individuals who fail to comply will receive consistent and appropriate discipline, regardless of position.

The Hospital will impose disciplinary action equally to all executives, managers, supervisors, and employees.


270

Abuse, Neglect & Domestic Violence

Virginia law requires reporting abuse & neglect Adult Abuse – 60 years or older or an adult who is

mentally incapacitated Child Abuse – 12 years and younger

• Mandated reporting if diagnosed with sexually transmitted disease

• Minor who has had sexual relations with adult (rape) reportable to police

Protection from immunity


Americans with Disability Act (ADA)

Service Animals

Under the Americans with Disabilities Act (ADA), organizations that provide services to the public, such as

hospitals, must allow service animals (i.e. dogs that are trained to do work or perform tasks for an individual with a disability) to accompany people with disabilities in all areas of the facility where the public is normally allowed to go. Individuals with service animals cannot be isolated or treated less favorably than other patients.

You must accept an individual’s assurance that the dog is a service animal. The law prohibits asking

questions about the individual’s disability or for documentation regarding the service animal’s training. Staff may ask two questions: (1) is the dog a service animal required because of a disability, and (2) what work or task has the dog been trained to perform. Staff cannot ask about the person’s disability, require medical documentation, require a special identification card or training documentation for the dog, or ask that the dog demonstrate its ability to perform the work or task.

We cannot request that the service animal be removed from the premises unless: (1) the dog is out of control

and the handler does not take effective action to control it or (2) the dog is not housebroken. When there is a legitimate reason to ask that a service animal be removed, staff must offer the person with the disability the opportunity to stay and receive services without the animal’s presence. Prior to refusing access or services please contact the Nursing Supervisor or Administrator on Call.

Honoring disabled individuals’ rights is of upmost importance to Culpeper Regional Hospital. Should you have

any questions regarding the ADA requirements or your responsibilities, please contact Patricia Slater at 540-829-5703.


272

Regulatory

The hospital is accredited by The Joint Commission which is known as having the “gold standard” in quality of care and patient & staff safety.

Survey’s occur every 18 – 39 months after a previous full survey. These survey’s are unannounced.

Ongoing readiness is essential in patient and staff safety. Everyone has a role in regulatory readiness!

Patients and staff are informed on how to get answers to questions about the safety and quality of care they receive through the “Speak Up” brochure (see next slide). This is posted in each patient treatment room and area. In addition all new

employees and medical staff receive this information.


Speak Up

Everyone has a role in making health care safe. That includes doctors, health care executives, nurses and many health care technicians. Health care organizations all across the country are working to make health care safe. As a patient, you can make your care safer by being an active, involved and informed member of your health care team.

Speak up if you have questions or concerns, and if you don't understand, ask again. It's your body and you have a right to know.

Pay attention to the care you are receiving. Make sure you're getting the right treatments and medications by the right health care professionals. Don't assume anything.

Educate yourself about your diagnosis, the medical tests you are undergoing, and your treatment plan. Ask a trusted family member or friend to be your advocate. Know what medications you take and why you take them. Medication errors are the most common health

care errors. Use a hospital, clinic, surgery center, or other type of health care organization that has undergone a rigorous

on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by Joint Commission.

Participate in all decisions about your treatment. You are the center of the health care team.If you have questions about the safety or quality of the care you receive, please speak with your doctor or your nurse about your concerns. You may also ask to speak with the charge nurse or nursing supervisor.

If you feel that your concerns are not addressed, please contact Hospital Administration (540) 829-4300. If these concerns cannot be resolved, you may contact: The Joint Commission Office of Monitoring at (800) 994-6610 or email [email protected]

mailto:[email protected]


Risk Management Program Goals and Objectives

Risk Management has responsibilities for:Minimizing losses to the organization overall by proactively

identifying, analyzing, preventing, and controlling potential clinical, business, and operational risks.

Facilitating compliance with regulatory, legal, and accrediting agency requirements (e.g., Joint Commission and Centers for Medicare and Medicaid Services).

Protecting human and intangible resources (e.g., reputation).


mandatory annual safety education anti- harrassment

Documents