Employee Comprehensive Education

Dr. Ihab Nada,DOE.MSKMC

Table of Contents• Section 1: Employee Code of Conduct• Section 2: Fire Safety (Code Red)• Section 3: Utilities Management• Section 4: Hazardous Materials• Section 5: Radiation Safety• Section 6: MRI Safety• Section 7: Public Safety• Section 8: Disaster/Emergency Preparedness• Section 9: International Patient Safety Goals

Table of Contents (cont.)• Section 10: Patient/Visitor Incident Reporting • Section 11: Employee Work-Related Accident, Injury, or Illness

Reporting• Section 12: Patient Care Equipment• Section 13: Infection Control• Section 14: BloodbornePathogens• Section 15: Tuberculosis• Section 16: Age-Specific Care• Section 17: Confidentiality and Personal Information

Table of Contents (cont.)

• Section 18: Receiving Gifts• Section 19: Policies, Procedures, Guidelines and Directives• Section 20: Employee Training Next Steps

Section 1:Employee Code of

Conduct

Our Commitment

• MSKMC is committed to helping all our employees, physicians, volunteers, and contractors act in a way that preserves the trust and respect of those whom we serve and with whom we deal.

• Our goal is to do the right thing

Code of Conduct

• Is a guide to MSKMC staff in making decisions and choosing actions

No Patient or Employee Abuse, Neglect, or Harassment is allowed at MSKMC

• MSKMC protects patients from abuse, neglect and harassment of all forms whether from staff, other patients or visitors. In the event that an individual alleges abuse, neglect or harassment by other patient, Medical center employee or member of the medical staff the hospital will ensure a prompt and complete investigation of all serious complaints

• The Medical Center has a ZERO tolerance for violence, also committed to maintaining a Drug and Alcohol Free work place

Fraud, Waste and Abuse - Definitions

• Fraud – e.g.: spouse medical insurance• Waste – e.g.: spilling , improper size , paper

abuse ……….etc• Abuse – Improper behaviors or practices that

are inconsistent with policies/laws and create unnecessary costs.

Fraud, Waste and Abuse - Examples

• Pharmacy and Prescriptions:– Billing for brand when generic was dispensed

– Billing Multiple Payers for the Same Prescription• Identity Theft

Integrity

We live our mission, keep our promises, follow applicable laws.

Respect

We treat everyone with dignity, kindness, and significance.

Compassion

We listen attentively, help solve problems, apologize when necessary.

Excellence

• We commit to high standards, take accountability, and strive to grow.

Stewardship

We live within our means so that we can be better tomorrow.

Community

We practice cultural competency by honoring patients’ and each other’s cultural orientation.

Service to the Community“Service to the community is at the core …and

an important part of our mission. We have a covenant to care for the underserved

Section 2: Fire Safety (Code Red)

The Medical Center uses the phrase CODE RED for all fire emergencies

• We have an acronym all employees should remember. This acronym helps you remember what you need to do in the event of a code red

R.A.C.E.

R.A.C.E.

Rstands for Rescue• Remove anyone from harms way who is not

capable of self rescue• Do not put yourself in danger while rescuing

R.A.C.E.A stands for Alarm• Sound the Alarm by activating a pull station and• Always call the emergency line #___________ from a safe

distance to notify responders of the precise location of smoke/fire.

• When contacting the emergency number, employees must be prepared to give the following information: Type of Code emergency (Code Red); Location of emergency (building, floor, room number); caller’s name and call back number.

R.A.C.E.

C stands for Contain• Contain the fire by closing all doors, windows

and other openings. • By closing doors you trap smoke and heat

allowing time for evacuation• By trapping heat you activate the sprinkler

system quickly

R.A.C.E.

E stands for Extinguish / Evacuate• Use portable fire extinguishers to put out

small fires, if trained and can be done safely.• Execute your specific department evacuation

plan including taking direction from the Floor Marshal, Fire Department and /or Safety Officer. evacuation of the whole area either horizontally or vertically.

Know the Following Department Specific Fire Safety Information

• Fire alarm pull stations, extinguishers, and emergency exit locations

• Identification of your Floor Marshal• Location of your department’s evacuation plan• Doors that need to be shut• Location of oxygen shut-off (if applicable)• Location of designated meeting spot• Recognition of the all-clear notification

Prevention Strategies• Smoking is NOT permitted inside the hospital or

outside on hospital property-Refer to the hospital No Smoking Policy

• Keep and store flammable or combustible materials away from heat sources.

• Keep all exits, stairwells and corridors free of obstructions.

• Doors are not to be propped open or blocked from closing freely.

Operating Fire ExtinguishersPull the pin.Aim low, at the base of the fire.Squeeze the handle.Sweep from side to side.

• Use your judgment. Never jeopardize personal safety!

• Initially stand 6-8 feet away from the fire and aim at the burning material

• Position yourself so you can exit the area easily.• Fire extinguishers should only be deployed by those

trained in their use. • You are not required to use an extinguisher• Only use a fire extinguisher if the fire is small

Section 3: Utilities Management

Utility Examples

• Steam• Plumbing System• Heating, Ventilation, and Air Conditioning• Medical Gas System• Natural Gas System• Electrical• Elevators

What should you do in the event of failure or problems with these

utilities?

Utility Failure

• Call Maintenance • Be careful around leaking steam; .• If you suspect a natural gas leak, do not turn on lights, electrical

appliances, or other sources of ignition; open all windows.• Be aware of electrical hazards:• Do not use frayed/broken power cords.• The use of extension cords is prohibited.• All equipment should have hospital grade, grounded 3-prong

plugs.

Section 4: Hazardous Materials

Chemicals and Hazardous Materials in Your Department

• All departments must maintain an accurate inventory of hazardous materials in use.

• You must be familiar with thecontents and location of the Inventory.• Each hazardous material must have aMaterial Safety Data Sheet (MSDS).

What Information is on the MSDS?

The MSDS includes information about:• Chemical components• Safe use & Protective equipment• Storage &Disposal• Routes of exposure• Symptoms of acute and chronic exposures• Emergency response guidelines (spills or

exposures)

Master Files of All MSDS

• Electronic database• For 24-hour MSDS access

All Containers Must Be Appropriately Labeled

• Original containers from suppliers must be pre-labeled with– Product name– Hazardous ingredients– Hazard warnings– Name of the manufacturer

• All secondary containers should be labeled with contents.• All labels should be printed in English; additional language

translations may be added if necessary.

Hazardous Material Spills – Chemical, Biological, or Radiological

• Small, incidental spills can be cleaned up by users, if trained and personal protective equipment & spill kit available.

• For large or acutely hazardous spills: CODE ORANGE– Address any medical emergencies first– Evacuate spill area– Call #____________ - Identify location, material &quantity

spilled, name & contact information– Remain in safe location to provide incident specifics to

response team

Section 5:Radiation Safety

Identifying Radiation AreasThis symbol may be found on:

• Hallway doors• Work areas within restricted areas• Waste cans• Packages• Fume hoods, sinks, and refrigerators

What Should You Do If You See A Radiation Symbol?

• Do NOT enter the area unless:– You have received specialized

education. OR– There is a trained radiation

worker present to supervise your work.

Will I Be Exposed to Radiation inX-Ray Rooms?

• There is no residual radiation present immediately after the machine is turned off.

• The operator or technician is ALWAYS present when radiation is being produced.

• Door interlocks cut off radiation immediately when the door to an X-Ray room opens during radiation use.

5 Basic Methods to Keep Radiation Exposure to a Minimum

• Time• Distance• Shielding• Contamination Control• Training

Time

• Spend as little time as possible near a radiation source.

Distance

• Work as far away from the radiation source as possible.

Shielding

• Inside a radiation use area, lead containers, Plexiglass shields, and lead aprons are used to minimize the exposure to radiation.

Section 6: MRI SAFETY

When can you safely enterthe MRI Scan Rooms?

• Before you go into the scan rooms you MUST be screened by the MRI Technical staff.

• This screening will identify whether you have anything in your body that can harm you in the presence of the magnetic field.

• DO NOT ENTER THE SCAN ROOM UNTIL THE TECHNOLOGIST SAYS YOUCAN!

All MRI Sites Have Restricted Access because the MRI Magnets are Always On!

Other Objects that Should NOT Enter the Magnetic Field

• Metallic objects can become projectiles and can cause severe injury or death. The following list identifies some of the many objects that may NOT be brought into the MRI scan rooms:– Pens, scalpels, screwdrivers, hammers, or other common

metal tools– Stretchers, wheelchairs, IV poles, oxygen tanks, code carts,

monitoring devices– Cleaning or custodial supplies such as mops, buckets, ladders– Credit cards and ATM cards, pagers, cell phones, and watches

• Any person entering the room should be reminded to check and empty their pockets.

Section 7:Security

Name

What Can You Do to Help Maintain a Secure Environment?

• Wear your ID badge at all times and in a visible manner.

• Secure your work area—even if away for 5 minutes.– Sign out of the computer– Lock you door/desk

• Report all missing items promptly.• Report all unusual activity

Other Measures to Maintain aSecure Environment

• Call Security to report someone “out of place.”e.g. me in bank

• Do not share access cards or combinations, and do not hide keys.

.• Protect patient valuables

Section 8: Disaster andEmergency Preparedness

What Is Emergency Management?

• Emergency Management refers to the Medical Center’s program which develops plans to prepare, mitigate, respond and recover from emergency events that might occur either within the Medical Center – or in the local community, city, or region.

How Are Emergencies Announced?

Through the over head announcement system• ____“CODE RED”• ____“CODE ORANGE”• ____“CODE PURPLE”• ____“CODE TRIAGE”.

CODE TRIAGE

• CODE TRIAGE is the code phrase used to announce the activation of our Emergency Operations Plan in response to an emergency event or disaster.

• CODE TRIAGE notifications are communicated by pager to key positions on the Incident Command Team, may be blast e-mailed to all employees, or heard over the overhead paging system.

• Onlythe Administrator on Call (AOC) can activate the Code Triage alarm.

There Are Two Types of Code Triage

1 External “Influx”Emergencies

2 Internal “Non-influx”Emergencies

External “Influx” Emergencies

• Multi-casualty incidents which take place in the surrounding city and region, and which may require the mobilization of resources to treat potentially large numbers of people.

• Examples include: plane crash, train crash, hurricane, earthquake, civil unrest, or other large-scale disaster.

Internal “Non-Influx” Emergencies

• Failures or accidents within the Medical Center that may require alteration in our normal operations or services.

• Examples include: using power-fail phones during a Telecomm failure, plugging critical equipment into red outlets during a power failure or evacuating areas due to a fire.– All Ventilators attached to patients and equipment during

surgery should be plugged into the Red Outlets at all times

Key Resources During a Disaster• Your manager• Color coded “Flipcharts” are in all departments which outline

emergency response actions• Your department’s own specific “Plan of Action”:

– This may include a fan-out call list for your department.• The hospital organizes its response utilizing the Hospital Incident

Command System (HICS).• The Incident Command group is responsible for directing and

coordinating care to patients and managing hospital operations during a disaster.

Plan of Action

• Be sure to know where your department’s “Flipchart” and disaster plan is kept.

Other Important Reminders

• Always try to remain calm during a disaster

• Follow the directives of the Floor Marshal or your manager/supervisor

Check With Your Manager

• Be sure to check with your manager to determine if you are needed to provide assistance prior to leaving work.

• From home or work you can obtain recorded updates on Code Triage events and other emergencies by calling the Command Center Event Update Line.

Emergency Call Numbers

• Add Numbers here

Section 9:International Patient Safety Goals

Joint Commission International: International Patient Safety Goals

• MSKMC is a hospital that is/will be accredited by Joint Commission International (JCI). MSKMC uses JCI Standards to guide us on how we administer care and continuously improve performance.

• The International Patient Safety Goals are those goals Joint Commission International considers of highest priority to patient safety and quality care in a healthcare organization. The International Patient Safety Goals are specific measures that can be used for comparison across healthcare settings and offer all who participate the opportunity to learn evidence- based “best practice”.

International Patient Safety Goals• IPSG.1 Identify Patients Correctly• IPSG.2 Improve Effective Communication• IPSG.3 Improve the Safety of High-Alert Medications• IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-

Patient Surgery• IPSG.5 Reduce the Risk of Health Care–Associated

Infections• IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls

Reliable Identification• Reliable identification of patients can be achieved by:• Using two fail-safe patient identifiers before

procedures, blood draws, transfusions, and/or administering medications. Some examples:• Use name and date of birth, or name

and medical record numberAsk the patient to state his / her

identifying information whenever possible

Label specimens in the presence of the patient

Name

Communicate More Effectively

• “Write it down and read it back” for verbal orders and critical test results.

• Perform “Time-Out” before Surgery or Procedure• Do not use prohibited abbreviations!• Provide pertinent information at hand off and

leave opportunity for clarification/ questions.

Improve the Safety of High-Alert Medications

• High-alert medications are those medications involved in a high percentage of errors and/or sentinel events, medications that carry a higher risk for adverse outcomes, as well as look-alike/sound-alike medications.

• Lists of high-alert medications are available from organizations such as the World Health Organization or the Institute for Safe Medication Practices.

Label all medications, medication containers and other solutions on and off the sterile field

Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

• Wrong-site, wrong-procedure, wrong-patient surgery is an alarmingly common occurrence in health care organizations.

• These errors are the result of ineffective or inadequate communication between members of the surgical team, lack of patient involvement in site marking, and lack of procedures for verifying the operative site.

• In addition, inadequate patient assessment, inadequate medical record review, , problems related to illegible handwriting, and the use of abbreviations are frequent contributing factors.

Reduce the Risk of Health Care–Associated Infections

• Infections common to all health care settings include catheter-associated urinary tract infections, blood stream infections, and pneumonia (often associated with mechanical ventilation).

• Central to the elimination of these and other infections is proper hand hygiene.

Reduce Hospital Acquired Infections due to multidrug – resistant organisms

• MSKMC conducts periodic risk assessments for multi-drug resistant organisms. This is done by the infection control department

• Data is shared with key leaders• MSKMC has a lab based alert system that

identifies new patients with multidrug resistant organisms.

Reduce Central Line Associated Bloodstream Infections

• Use the MSKMCcentral line insertion checklist when inserting central lines

• Use the standardized kit for central line insertion

• MSKMC educates staff about protocol for maintaining central lines

Reduce Surgical Site Infections

• MSKMC educates staff and physicians about the prevention of surgical site infections

• MSKMC conducts surveillance of surgical site infections and measures infection rates and reports this to key leaders

• MSKMC has a surgical site infection prevention bundle that includes proper antibiotic administration, control of blood sugar and temperature and hair removal

Reduce the Risk of Patient Harm Resulting from Falls

• Patients are assessed for their risk to fall on admission in the Emergency Department

• IF a patient is at risk to fall, the “fall prevention bundle” of interventions is implemented by the care team

• Any patient fall should be immediately reported in the MSKMC patient safety reporting system

Triggers: Rapid Response Team

• MSKMC has a ”Triggers” program to enable staff to directly request additional assistance from specially trained individuals when the patients condition appears to be worsening.

• There are specific criteria that nurses and physicians can use to activate a “trigger”

• Patients and families can activate a similar response by speaking with their nurse

Medication Reconciliation

• MSKMC has a process for

– Comparing the patients home medication list with those ordered in the hospital

– For communicating the medication list to the next level of care when patients are transferred

– For providing a complete list of medications to the patient or family when the patient is discharged from the hospital

Section 10: Patient/Visitor Incident Reporting

What Is a Reportable Incident?

• An occurrence which is not consistent with the routine care of the patient, or the routine operation of the Medical Center.

Examples of Events to Be Reported

• Slips, falls, or burns• Medical errors• Equipment malfunction• Misidentified patients• Wrong side surgery

Who Is Responsible forIncident Reporting?

• Any employee or practitioner of the facility who is involved in, witnesses, or discovers the incident.

Why Is It Important toReport an Incident?

• To provide information, and provide opportunities, for quality improvement

• To track and trend events• To identify system breakdowns• To identify the need for continuing education• To alert the hospital to possible liability• To comply with the law

How Are Incidents Reported?

• The MSKMC computer based Patient Safety Reporting System is the mechanism for reporting incidents.

• If you are unable to use this system, please contact your manager for instructions on how to report incidents or unexpected occurrences in the Patient Safety Reporting System.

• Temporarily , written or verbal notification to department director

Section 11: Employee Work-Related Accident, Injury, or Illness Reporting

What Should I Do If I Am Injured At Work?

• Immediately:• Notify your manager • Complete the “Report of Employee Work

Related Injury, Accident, Illness Form”.

What Should I Do If I Am Exposed to Blood or Body Fluids at Work?

• Immediately -– Wash wound with soap and water or rinse eyes

with eye wash or tap water.– Report injury to manager.– Go immediately for evaluation and medical

assessment .

Section 12:Patient Care Equipment

How do I know this piece of equipment is okay to use?

• Where applicable, the equipment is affixed with a green Preventive Maintenance (PM) sticker, which indicates that the equipment:– Has been inspected by Clinical Engineering– Is enrolled in the Preventive Maintenance Program– Indicates how long the inspection is good for (Has

an expiration date, same as on food products)

Section 13:Infection Control

What Is Infection Control at MSKMC?

• A program designed to prevent and control infections

• Whose mission is to reduce the risk of transmission of infection to patients, employees, and visitors

• Every employee is responsible for compliance with infection control procedures:

Infection Control Resources

• Infection Control Practitioners on page• Online infection control manual (Insert Link)

What Is the Single Most Effective Measure to

Prevent the Spread of Infection??

Hand Hygiene• You should clean your hands:

– After using the bathroom– After blowing your nose– After covering a sneeze– Before eating and drinking– Before handling food

• In addition if you have patient contact:– Before and after patient contact– After contact with patient’s environment– After handling items contaminated with blood or body fluids– Before donning gloves– After removing gloves

What Else Is Important In Hand Hygiene?

The Nail Is an Area of Special Concern in Hand Hygiene

Research has shown:• The area under the nail contains

the highest microbial count on the hand.

• Both long natural nails and artificial nails may serve as reservoirs for bacteria.

• Persons with artificial nails are more likely to harbor pathogens on their hands than those without artificial nails.

How Do You Know Whether Patients are on Special Isolation/Precautions?

Infection Control Signage• Signage is the best way to

identify if a patient is on special isolation/precautions.

• Signs identify appropriate precautions to take when entering a patient room.

• If you don’t know or understand the sign found outside a patient’s room, ask the nurse before entering.

Other Measures to Help Reducethe Spread of Infection

• Immunizations– Be sure your immunizations are

up to date.

Section 14:BloodbornePathogens

What Are BloodbornePathogen Exposures?

• Blood borne pathogens are transmitted through infected blood or body fluid.

• Exposures can occur when the following happen:– Injury with contaminated

needles/sharps– Splashes to eyes/nose/mouth

with contaminated blood or body fluid

Some Duties Which May Cause Exposure

• Handling needles or sharps contaminated with blood or body fluids

• Handling laundry or other items contaminated with blood or body fluids

• Performing phlebotomy or other invasive procedures

• Cleaning up a blood or a body fluid spill

• Handling biohazard waste

Reducing Exposure to Bloodborne Pathogens

• Follow Standard Precautions– Remember, the best way to reduce the risk of

exposure is to handle ALL patients’ blood and body fluid as potentially infectious.

Engineering Controls

• Needle and sharp safety devices

• Needle and sharp collection containers

• Biohazard waste disposal containers

Personal Protective Equipment• Is available in all patient care areas• Is used to protect you from contact with blood and

body fluids– Gloves, to be used when touching blood, body

fluids, mucous membranes, or non-intact skin of patients; when touching surfaces or equipment soiled with blood or body fluids; when performing phlebotomy

– Gowns or aprons, when splashes to skin or clothing are likely

– Masks and goggles or face shields, when splashes to the mouth, nose, or eyes are likely

– Surgical caps/hoods, shoe covers/boots for situations where gross contamination is likely

What to Do If Exposed

• Wash the affected area; flush the skin, eyes, nose, or mouth.

• Report exposure immediately to Employee Occupational Health Services (EOHS) or the Emergency Department during off-shifts.

• Antiviral therapy may be needed and should be started as soon as possible after an exposure.

Section 15:Tuberculosis

The MSKMC Occupational TB Program Includes

• Education• TB skin test screening• Respiratory protection program

How Is TB Spread?

• Tuberculosis (TB) is a communicable disease.

• TB causes an infection of the lungs.

• TB is transmitted through the air when a person with active TB disease coughs, sneezes, laughs, and sometimes, speaks.

Measures to Reducethe Exposure to TB

• Early detection and treatment of patients with TB

• Engineering controls• Personal protective equipment• Occupational screening for TB

Engineering Controls• Isolation of

patients with active TB disease

• Negative pressure room with posted signs on patient’s door

Personal Protective Equipment

• N95 respirators are required when caring for a patient with pulmonary TB.

Occupational TB Screening Routine and Post-exposure Screening

• TB test screening of employees takes place by EOHS– Annually– After a TB exposure

Section 16:Age-Specific Care

Neonate or Infant

• Explain the medical condition and any procedures to the parents

.• Ensure that medical equipment is

appropriate for the infant’s size..

Toddler, Pre-School, and School-Aged

• Engage the child in conversation about the hospitalization and procedures using age appropriate terminology.

• Recognize that some fears may come from the concrete thinking of a child when confronted with unfamiliar sights and words.

• Allow younger children the opportunity to play

• Involve the child in the age appropriate treatment

Adolescence

• Adolescence is a transitional stage of physical and mental development, beginning with the onset of puberty. – Allow for increased independence during this

transition

– When appropriate, give the patient a choice about having a parent present.

Young and Middle Adulthood

• Accept the adult’s chosen lifestyle, and assist with necessary adjustments related to health

.• Involve the patient in all planning.

Late Adulthood• The health care worker must respect the older patient's

wisdom• To better provide age-specific care to the older adult, the

health care worker should:– Provide mobility aids/assistive devices, such as walkers

and canes, if needed

– Assist the patient if visual or auditory impairments are present.

– Not speak loudly, unless you are certain that the patient is hard of hearing.

Section 17:Confidentiality and Personal

Information

What Information IsConfidential or Personal ?

• Patient health information: names, phone numbers, insurance, and clinical information

• Personal information: names and address, combined with complete social security number, driver’s license or other state-issued numbers, complete credit card or bank account numbers

• Employee information and personnel records• Research information• Information about business affairs

How Is Confidential and Personal Information Transmitted?

• Spoken: conversations, both formal and informal, over the phone or in person

• Written: memos, reports, and medical and personnel records

• Electronic: computers, emails, PDAs and faxed documents

How Can You Keep Electronic Information Confidential?

DO:• Log off your PC when you leave the area.• Lock diskettes with confidential and personal information.• Password protect laptops, PDA’s, phones, etc.

.• Choose passwords with a mix of alphanumeric characters.

– Change your password regularly.• Keep papers and reports secured.• Shred documents when no longer needed.

What Is the Protocol for Faxing Confidential and Personal Patient Information?

• First, verify the identity of the requesting party and confirm that the fax number is correct.

• Fax under the following conditions only:– When necessary for emergency care of the patient– Following the transfer of a patient to another

facility or physician, when the information cannot be sent with the patient

– When required for continued stay approvals from third-party payers

Section 18:Receiving Gifts

Gifts

• Gift giving is a common practice for everyone. Gifts are often exchanged in business to promote good will or to say thank you to a care provider.

• Gifts can cause problems when they compromise or even appear to compromise, our ability to make objective decisions on behalf of our patients or the Medical Center.

How Do I Know If What I Am Doing Is A Problem?

Ask yourself:• Is it against the law?• Does it violate a hospital policy?• Does it make you feel uneasy, nervous, or

frightened?

Section 19: Policies, Procedures, Guidelines and

Directives

Know how to access Policies, Procedures, Guidelines and Directives (PPGDs)

• PPGDs are located at theMSKMC Website under Organization Policies, Procedures, Guidelines or Directives. Some departmental PPGDs are also located on this site but could also be in paper copy within your dept.

How do I keep updated regarding changes to PPGDs?

• Relevant PPGDs will be reviewed at Departmental/ Division Meetings and/ore-mailed and documented that they have been shared with all staff

• VPs, Directors and Managers should let you know about PPGD changes that impact your work

• As PPGDs are updated there is a website link on the General Portal that will have the monthly updates