Hospital Accreditation Q&A – Flashcards

a) The right to non-discrimination based on race, color, national origin, age, disability, sex, or gender identity. b) The right to receive information in a manner he or she understands. c) The right to participate in decisions about his or her care. d) The right to give or withhold informed consent. e) The right to have family members, including registered domestic partners or surrogate decision-maker, participate in their care as appropriate. f) The right to have complaints reviewed by the hospital.

A list of patient's rights and responsibilities can be found on the UW Medicine public website (http://www.uwmedicine.org/patient-resources/rights-responsibilities) and in brochures available in the Resource Center. A copy of the patient rights and responsibilities are included in the "Information About Your Healthcare" brochure which is given to patients at the time of registration.

Speak to your manager and ask his or her advice on how to address the issue. In addition, any member of the medical or hospital staff involved in the care of the patient may request an ethics consultation from the Clinical Ethics Consultation Service (CECS); patients and family members can also ask for a consultation. (Reference APOP 80.49 Ethics Consultation.

a) Protecting (and not sharing) computer passwords and logging off immediately after each use. b) Not discussing patients or patient medical records in hallways, elevators, over the telephone (releasing information over the telephone about a patient's condition must be limited to the legal next of kin, legal guardian or a person designated by the patient to receive information), and other public places. c) Following appropriate mechanisms for the release of information. d) Maintaining confidential access to all patient information including information related to employees, family, and friends of Harborview.

Staff are encouraged to resolve complaints at this point of service. If the incident cannot be resolved by the staff member who receives the complaint, the issue is referred to the department manager and/or Patient Relations. Patient Relations can be reached at 744-5000, [email protected] or in the Resource Center. (Reference APOP 5.14 Patient Complaints and Grievances).

a. To focus on serving the patients and their families. b. To provide the highest quality care c. To become the employer of choice. d. To practice fiscal responsibility.

Data on our quality improvement goals can be found on our Access to Excellence dashboards. The A to E dashboards can be accessed through the HMC intranet; look for "Access to Excellence" listed under "Most Popular" on the right side of the HMC Intranet main page.

Key organizational initiatives include: a) Focus on Patient/Family: Rounding, Discharge phone calls. b) Quality care: Hand washing compliance; C. difficile containment; reducing patient falls; improved handoff communications. c) Fiscal responsibility; process improvement initiatives. d) Employer of choice; Staff rounding, reducing turnover rate. Every area/clinic unit is involved in improvement initiatives. Can you name others that your area/unit tracks? Unit Practice Councils work, Magnet status, unit handoff work, hand hygiene monitoring, cleaning audits.

You can bring any improvement suggestion to your manager. You can submit patient safety concerns through PSN as well. You can also submit suggestions to the Bright Ideas site on the HMC intranet under the right hand "Most Popular" column.

Definition: TJC defines a sentinel event as a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in any of the following: death, permanent harm or severe temporary harm. An Adverse event is the list of 29 serious reportable events adopted by National Quality Forum and DOH. See Adverse Sentinel Events 80.8 and Non-Punitive Event Occurrence Reporting 115.3)

Staff, residents and faculty should complete and submit a Patient Safety Net (PSN) report on-line regarding an adverse sentinel event. All staff should also notify their manager and risk management promptly. An Intensive Review (IR) and/or Root Cause Analysis (RCA) is conducted after an adverse sentinel event. Action Items are developed and tracked to create a safer environment for our patients. For additional information, see (Adverse/Sentinel/Serious Events #80.8 and Non-Punitive Event Occurrence Reporting 115.3).

Birth date, patient name This should be compared to the patient's name band, requistion/order/documentation

Anytime you do something to/or with a patient. Including admitting, transferring, discharging, providing any treatments/procedures, including administering medications, blood components, drawing lag specimens, etc.

Documents with PHI must be stored so that only those authorized to use the information for their job-related duties are allowed and able to access it. Documents with PHI must be disposed of in designated recycling containers; never in the general waste or garbage.

HMC primary mission is to provide healthcare for the most vulnerable residents of King County; to provide and teach exemplary patient care; to provide care for a broad spectrum of patients from throughout the region; and to develop and maintain leading-edge centers of emphasis. As the only Level I Adult and Pediatric Trauma Center in Washington, HMC provides specialized comprehensive emergency services to patients throughout the region, and serves as the disaster preparedness and disaster control hospital for Seattle and King County.

The following groups of patients are Harborview's priority populations: Persons who are non-English speaking poor Persons who are uninsured or underinsured Persons who experience domestic violence Persons who experience sexual assault Persons incarcerated in King County's Jails Persons with mentally ill patients, particularly those treated involuntarily Persons with substance abuse Persons with sexually transmitted diseases Persons who require specialized emergency care Persons who require trauma care Persons who require burn care

Being aware of the environment, asking questions and offering help. Communication between caregivers. Verifying patient identification. Hand hygiene to promote infection control. Patient Safety Net reporting for adverse events or near misses. Medication Reconciliation. Encourage active patient involvement in their care.

Chris Cottingham is our Patient Safety Officer. Please visit the Patient Safety page on the HMC intranet at: https://hmc.uwmedicine.org/BU/patientsafety/Pages/default.aspx Liz Kindred is our Safety and Laser Safety Officer.

Darcy Jaffe is the Chief Nursing Officer

The Administrative Policies & Procedures Manual (APOP) is available on the HMC intranet at http://hmc.uwmedicine.org/PolicyProcedure/Pages/PolicyHome.aspx

Place work order or call Clinical Engineering at 744-3496 to report broken equipment. The Clinical Engineering Service Requestor is available through their intranet page at: https://hmc.uwmedicine.org/BU/ClinicalEngineering/Pages/default.aspx Tag the equipment as "Out of Service" using form UH0666 from the Forms repository at https://uwnetid.medical.washington.edu/Document/forms/forms_images/UH0666.pdf

All HMC employees are considered essential staff. During a disaster, staff should refer to the following resources: Familarize yourself with The Emergency Reference Guide (flipchart). Departmental and the hospital disaster plans. Follow the instructions of your Emergency Warden in an Emergency or Disaster.

I would RACE: R- Rescue persons in immediate danger, if the area is safe to enter. A- Activate the alarm. C- Contain the fire by closing doors and windows. E- Evacuate the area if directed or Extinguish if safe to do so.

Code Red = Fire Code Blue = Cardiac or Respiratory Failure Code Orange = Hazardous Material Spill or Release Code Gray = Uncontrolled Behavior Code Silver = Active Shooter Code Amber = Infant and/or Child Abduction Code Zebra = Heightened State of Alert External Triage = External Disaster Internal Triage = Internal Disaster Internal Triage + Bravo = Bomb Threat Internal Triage + Cyber = Cyber Disaster Internal Triage + Echo = Evacuation

Per HMC policy, a full e-cylinder contains greater than 1500 psi of oxygen. An empty e-cylinder contains less than 1500 psi of oxygen.

Safety Data Sheets or SDSs are available on-line at MyChem. https:/cspc.admin.washington.edu/mychem/uwnetid/home/greeting.aspx

Inpatient units: Evacuate laterally to the adjacent building (EH, WH, MB), beyond the double fire doors. Outpatient clinics: Some clinics within the hospital can evacuate laterally to the adjacent building (EH, WH, MB) beyond the double fire doors. West Clinics, Pat Stel, NJB and Offsite clinics evacuate vertically down the stairs.

File an on-line incident report in PSN Report incident to my supervisor Take immediate steps to prevent further injury, harm or property damage. If necessary, seek care at the Emergency Department or Employee Health Office.

Ongoing competency is identified through participation in the following activities: Hiring/application process. Licensure/registration/certification verification according to position and discipline requirements. The following are examples of credentials documents: skills validation/competency check lists, general and department-specific competencies, education records, certifications, Performance evaluations. Orientation - New Staff Orientation (NSO), department and job-specific. For additional information, see the Competency Assessment and Development Policy #105.13 in the HMC Policy Manual.

New Employee Orientation Workplace Violence Prevention Training Compliance Training Organization Development and Training Web site: https://hmc.uwmedicine.org/bu/HRODandT/Pages/default.aspx ORCA (Electronic Medical Record) education Clinical Education Dept Training

1. Hand hygiene upon entry and exit of patient rooms- for staff, patients and visitors. 2. Respiratory Etiquette- cover your cough, wash your hands; and wear a mask for a persistent cough. 3. Clean, and as appropriate then disinfect or sterilize reusable equipment between patients. 4. Clean the environment; use Sani-Wipes on electronic equipment, otherwise use hospital disinfectants. 5. Immunize patients and staff. 6. Wear gloves, masks, eye protection and gowns as needed (PPE) to protect yourself and patients depending on activity with patient; -Gloves for any contact with mucous membranes or body fluids -Gowns for splatter -Mask with eye protection when working with airway and for myelograms, spinal taps and epidural access. 7. Injection safety: do not re-use or share needles, IV bags, or syringes on multiple patients. 8. Eliminate sharps or dispose of them at the point of use without recapping. 9. Use additional levels of precaution such as Contact, Contact Enteric, Droplet, or Airborne Respirator Precautions for patients with suspected or confirmed transmissible infection control policy.

The Infection Control Manual located online at: https://hmc.uwmedicine.org/BU/InfectionControl/Pages/InfectionControlManual.aspx

-Patients have the right to be free of any restraint not needed to improve their well-being, support healing and/or assure safety of themselves and that of others. -The decision to use restraints is driven not by diagnosis, but by assessment, which concludes that for this patient, at this time, the use of a less restrictive measure has been determined to be ineffective and poses a greater risk than the risk of using a restraint. -Alternative meaures will be used or considered prior to any type of restraint. For more information, please refer to HMC APOP: RESTRAINT MANAGEMENT 5.33A

-Learning assessment includes patient needs, how they learn best (seeing, hearing or doing), and challenges to learning. -Ask patient and/or family what their priorities are and start there. Family may include any support systems (e.g. friends, caregivers, etc.).

-In ORCA -->Results Reviews--> Patient Education Sheet to view all the documentation related to patient education. -Refer to previous documentation for recommendations, topics to be reinforced, or topics still to be covered, referral and follow-up plans.. -Refer to standard teaching protocols for suggested topics. Find out if patient and family know and understand: the diagnosis/disease process, medications, and know when and who to call with questions. You can also see the last 7 Days of information in ORCA --> Plan Summary --> Show Full Flowsheet.

-Harborview staff and providers reach interpreters 24/7/365 by calling 744-9250. -Interpreters are available by telephone, videoconferencing (limited availability) or on site. -Qualified interpreters are employees, agency contractors and telephonic interpreters who have been assessed, trained and certified. -Family members and translation software are not an effective way to meet LEP patients' communication needs.

-HMC patient education materials found on HMC Intranet site. -Interpreter Services can provide support for LEP patients. -Intranet also has brochures, written material translated by Interpreter Services. -Helpful Patient Education Websites from Patient Ed website: https://hmc.uwmedicine.org/PatientEducation/Pages/Home.aspx Ethnomed Healthy Roads Media MedlinePlus Medline Plus Spanish Vaccine Information Sheets (VIS) in CDC (also in Vaccine category) S*P*I*R*A*L - Selected Patient Information and Resources in Asian Languages -The Resource Center, groups, classes, videos.

Teach-back is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands. Teach-back is: -Asking patients to repeat in their own words what they need to know or do, in a non-shaming way. -Not a test of the patient, but of how well you explained a concept. -A chance to check for understanding and , if necessary, re-teach the information. More information is available on the Patient Education website on the HMC Intranet.

In ORCA -->IVIEW & PN --> Detailed Assessment (Band) --> Patient Education Data; or use the Patient Instructions/Education note type. -There is also a paper Patient Education Record that is scanned into ORCA. These notes are found in ORCA Clinical notes, under Outpatient Records, in Patient Instruction/Education folder. Patient and/or family education also is found in discipline specific notes. -Inpatient education documentation is also found in the discharge instructions. -Outpatient education documentation includes time in minutes spent with patient and/or family. -View all documentation of patient and/or family education by going to Results Review --> Patient Education Sheet.

Therapeutic Recreation

The review of medical records is based on hospital-defined indicators: presence, timeliness, legibility (handwritten or printed), accuracy, authentication, and completeness of data and information.

The hospital identifies, in writing, the staff that are authorized to receive verbal orders, in accordance with law and regulations. Only authorized staff receives and record verbal orders.

Information introduced into the medical record through transcription, dictation or hand written identifies the author. Authentication can be verified through electronic signatures or written signatures.

The patient's name, address, date of birth, and the name of any legally authorized representative. The patient's sex; the legal status of any patient receiving behavioral health care and the patient's language and communication needs.

Many types of professionals provide care either directly or indirectly to HMC patients and must document their interventions in the individual patient's medical record. These professionals are either members of the medical staff, UW employees or have a formal professional relationship with the Medical Center. Refer to HIM Policy 100.9

Every medical record entry requires that each entry be dated, timed and signed (authenticated) by the author.

-The time and means of arrival; -Indication that the patient left against medical advice, when applicable; -Conclusions reached at the termination of care, treatment, and services, including the patient's final disposition, condition, and instructiions given for follow-up care, treatment and services; -A copy of any information made available to the practitioner or medical organization providing follow-up care, treatment, or services.

-Reason for the hospitalization -Procedures performed and care, treatment, and services provided. -Patient's condition and disposition at discharge. -Information provided to the patient and family. -Provisions for follow-up care.

Medical staff privileges are available online. To access this information, open MINDSCAPE and click on "Med Staff Privileges." You can search by practitioner or privilege. During business hours, you may also call the Office of the Medical Director at 744-3134. This database does not include resident staff. The Graduate Medical Education Office at (206) 543-0065 can help you identify resident staff privileges.

The requirements are detailed in HMC APOP policy Sedation/Analgesia For Procedures by Non-Anesthesia Care Providers 80.3 RNs may administer and monitor sedation/analgesia for procedures as prescribed by a qualified physician or dentist. RNs assisting procedural sedation must: 1. Attend Sedation education classes and updates; 2. Complete airway competency checklist; 3. Complete precepted clinical orientation; 4. ACLS certification strongly encouraged; 5. Communicate and collaborate with the Physician performing the procedure in order to effectively address concerns related to the patient's well being.

-Identify patients correctly (asking what is your name and DOB) -Improve staff communication (get test results to right person on time) -Use medicines safely (label all substances not in their original containers) -Use alarms safely (respond to critical alarms in a timely manner, tailor alarm limits to the patient's vital signs). -Prevent Infection (wash hands with soap and water and use alcohol gel) -Identify patient safety risks (Find out which patients are most likely to commit suicide). -Prevent mistakes in surgery (Make sure the correct surgery is done on the correct patient and the correct place on the patient's body).

Fear of speaking up

Check Back, Call Out, and SBAR

Internal Code Triage is when the hospital disaster plan is activated due to a problem within our campus, and example would be a large flood or loss of power. An External Code Triage is activated when we are activating the hospital disaster plan to, for example, prepare for a large patient influx from a train crash.

Norm Maleng Building 111/112

HMC Board of Trustees