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Raritan Bay Medical Center Resource Guide Raritan Bay Medical Center Resource Guide

Raritan Bay Medical Center Resource Guide - PowerPoint Presentation

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Raritan Bay Medical Center Resource Guide - PPT Presentation

Raritan Bay Medical Center Resource Guide Dear T eam M embers I am exc it ed t o sha r e w it h you our new R a rit a n B a y M ed i ca l C en t e r R e s ou r c e G u i ID: 770186

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Raritan Bay Medical Center Resource Guide

Dear Team Members: I am exc it ed t o sha r e w it h you our new R a rit a n B a y M ed i ca l C en t e r R e s ou r c e G u i de. It i nc l ude s a comp l e t e lis t i n g of t op i cs t hat are v it a ll y i mpo rt an t t o t he da il y ope r a ti o n of t h e M ed i ca l Ce n te r . Pl ea s e rev i ew t h i s i n f o r ma ti on and b ecom e f am ili a r wit h t he t op i cs and de s c ri p ti on s . Please carr y t he book l e t w it h you as a handy r e f e r enc e t oo l. If you have any que sti on s , please d is cu s s t he m i mmed i a t e l y w it h your s upe r v is o r Best regards , Thomas Shanahan Chief Hospital Executive

Mission: Transform health care and be recognized as the leader of positive change. Vision: Innovation is in our DNA, compelling us to create a world where: the highest quality care is human-centered, accessible and affordable; we deliver outcomes that matter most; and excellence is the standard. Beliefs: Creative …  I will do my part to make things better. Courageous …  I will do the right thing. Compassionate …  I am the human experience. Collaborative …  I embrace teamwork .

T H E J O IN T C O MM ISSIO N ( TJC) Thi s o r g a ni z a ti on i s an ind e p e nd e n t, n ot- f o r - p r o fi t o r g a ni z a ti on th a t acc r e dit s a n d ce rtifi es m o r e th an 20 , 00 0 h ea lth c a r e o r g a ni z a ti o n s a n d p r og r a m s i n th e Uni t ed S t a t e s . J o i n t C o mmissi on acc r e di t a ti on is r e c og ni z ed n a ti o n w id e as a s y mb ol of qu a lit y th a t r e fl ec t s a c o mmitm e n t t o m e etin g th e ir p e r f o rm a n ce st a nd a r ds . Th e M e di c al C e n t er r ece i v es acc r e di t a ti on f o llo w in g p e riodi c un a nn o un ced su r v e y s. Al l h ea lt h c a r e p r o v id e r s p a rti c ip a t e i n th e T J C su r v e y p r oce s s i f a s k ed qu e s ti o ns, r e m e mb er t o : B e h o n e s t a n d a n s w er w it h c o n fid e n ce. I f y ou d o n ot kno w th e a n s w er d o n ot g u e ss, e x pl a i n w h e r e or ho w y ou w o ul d fin d th e a n s w er (e . g. r e f er t o th e p o li cy a n d p r oce du r e m a nu a l , m a n a g e r s or o th er h o spi t al r e s o u r ce). Thin k c a r e full y b e f o r e a n s w e rin g , a s k th e su r v e y or t o r e p e a t a n y qu e s ti on th a t y ou d o n ot und e r st a nd. R e sp o n d t o th e qu e s ti on o f f e rin g th e n ee d ed i n f o rm a ti o n , d o n ot e x p a n d unl e s s a s k ed t o .

A ABUSE , V I C T I M O F Abus e (Domesti c Violence, Sexual, Child, Elder Abuse) I f a bus e i s susp ec t e d , imm e di a t e l y c o n t ac t: Y o u r sup e r v is or P a ti e n t ’ s P h y si c i an Soc i al W o r k Se r v i ces D e p a rtm e n t Nu r sin g Admini s t r a ti on R e f er t o p o li cy o nlin e : ABU SE - A cce s s t o P r o t ec ti v e Se r v i ces A D V AN C E DIR E C TI VE A l e g al d oc um e n t th a t put s i n w ritin g an indi v id u a l ’ s w ish es f or th e m e di c al t r e a tm e n t h e / sh e w o uld w a n t i n th e e v e n t h e / sh e i s un a bl e t o m a k e h ea lth c a r e d ec isi o n s du e t o a s e riou s illn e ss, in j u r y or l o s s of m e n t al c a p ac i t y . P a ti e n t s a r e a s k ed a t th e tim e of a dmissi on i f th e y h a v e an Ad v a n ce Di r ec ti v e. Ad v a n ce Di r ec ti v es a r e pl aced on th e p a ti e n t ’ s m e di c al r e c o r d. Ra ri t an B a y M e di c al C e n t er p r o v id es e du c a ti on a n d a ssi st a n ce f or th e c o mpl e ti on of an Ad v a n ce Di r ec ti v e v i a th e Soc i al W o r k D e p a rtm e n t .

POPU L A T I O N AND A G E S P ECIFIC COMP E T ENCYCare is designated and provided based up on a g e a n d p o pul a ti on sp ec ifi c n ee ds . Cri t e ria, de v e l o p ed t o id e n ti fy th e s e sp ec i al p o pul a ti o ns, a r e : Ne w b o rns P e di a tric s Ad o l e s ce n ce t o y o un g a dult Adult G e ri a tri c Se r v i ce , P r ac ti ce A r ea or S p ec i a lt y C a r e Se r v i ces C o mp e t e n ce i n a g e sp ec ifi c i n t e r v e n ti o n s i s an e x p ec t a ti on of e mpl o y ees w it h p a ti e n t or f a mily c o n t ac t . A g e sp ec ifi c t r a inin g i s p r o v id ed on ne w e mpl o y ee o rie n t a ti o n , i n d e p a rtm e n t sp ec ific o rie n t a ti on a n d o n g o in g. C o mp e t e n cy a ss e ssm e n t of st a f f i n di r ect p a ti e n t c a r e a r eas h a v e p o pul a ti on a n d a g e sp ec ifi c c ri t e ri a m ea su r ed a t l ea s t a nnu a l l y . A ME RICANS WI T H DI S AB ILI T I E S A C T ( A D A) A D A i s a F e d e r al a n ti - dis c rimi n a ti on l a w w hi ch p r o hibit s e mpl o y e r s f r om dis c rimin a tin g a g a i n s t qu a lifi ed indi v idu al s w it h dis a bil i ti es i n job a ppli ca ti on p r oce du r e s , hirin g , a d v a n ce m e n t, c o mp e ns a ti o n , job t r a inin g , a n d o th er t e rm s a n d pri v il e g es of e mpl o y m e n t . A D A a ls o r e qui r es th a t p a ti e n t s w h o a r e “ h a ndi c a p p e d , ” “ dis a bl e d , ” or h a v e “ sp ec i al n ee ds ” a r e n ot dis c rimin at ed a g a in s t .

B BIOETHICS COMMITTEE Th e Bi o e thi cs C o mmi t t ee dis c uss es the options and choices that people have when facing a di f fi c ult m e di c al d ec isi on a n d h e l p s r e s o l v e a n y dis ag r ee m e n t . A n y o n e , in c ludi n g e mpl o y ee s, m a y a s k f or h e lp. A r e qu e s t i s m a d e i n w ritin g t o Ra ri t an B a y M e di c al C e n t er chief hospital executive, Thomas Shanahan a nd mu s t in c lud e th e sp ec ifi c issu e t o b e a dd r e ss e d. P h y si c i a n s w ri t e th e i r r e qu e s t i n th e m e di c al r e c o r d st a tin g th e sp ec ifi c issu e t o b e a dd r e ss ed in li eu of c o n t ac tin g th e chief hospital executive . B L OO DB O RNE P A T H O G EN PL AN Ra ri t an B a y M e di c al C e n t er h as an E x p o su r e C o n t r ol P l an b a s ed up on OS H A ’ s Bl ood b o rn e P a th o g en S t a nd a r d . Th e g oal of th e pl an i s t o minimi z e th e ris k of i n f ec ti on f r om occ up a ti o n a ll y t r a nsmi t t ed bl ood b o rn e dis ea s e , su ch as HI V , H e p a titi s B a n d H e p a titi s C. C C A S E M AN A GEME N T / S O CI AL W O R K C ase M a n a g eme n t Th e c a s e m a n a g e m e n t d e p a rtm e n t i s st a f f ed b y li ce ns ed p r o f e ssi o n al nu r s es a n d p h y si c i an a d v is o r s w h o a r e r e sp o nsibl e f or th e o n g o in g a ss e ssm e n t a n d e v a lu a ti on of each p a ti e n t ’ s le v el of c a r e i n o r d er t o d e li v er qu a lit y , c o s t- e f f ec ti v e h ea lth c a r e a n d th e e f fi c i e n t us e of h o spi t al r e s o u r ce s .

Social Work Services T h e so c ial w o r k dep artment is staffed by licensed professional social worker s ded i ca t e d t o me e t i n g th e c o n t i nu i n g he al t h c a r e need s of th e c o mmun i t i e s w e s e r v e . Up on r e f er r al or r eque s t, so c ial w o r k e r s a r e a v aila b le t o assi s t p a t i e n t s a n d the ir f a m ili e s in d e v e lo p i n g a s a f e d is ch a r g e p la n . D epend i n g on he al t h c a r e need s up on d is ch a r g e, so c ial w o r k e r s will t a k e th e p a t i e n t s’ p r e f e r ence s a n d th ose of th e f a m ily i nt o a c c o u n t a n d wi t h i n s u r a nc e a n d p h y si c ian a pp r o v al, t o assi s t wi t h o b t ai n i n g a v aila b le r e so u r ce s a t t i m e of d is ch a r g e. T h e g oal is t o assi s t th e p a t i e n t a n d f a m ily in m aki n g a s m oo t h t r a n si t io n . T h e t y pe s of s e r v i ce s p r ov i de d m a y i nc l ud e r e f er r als t o : Ho m e c a r e a g enc i es D u r a b le med i c al equ i pme n t c o mp a n i e s IV the r a p y c o mp a n i e s R eh a b ili t a t ion f a c ili t i e s Sk ill e d nu r si n g f a c ili t i e s or o the r lo n g t er m c a r e / s he l t e r e d c a r e f a c ili t i e s. Dial y sis F a c ili t i e s Pub lic Assi s t a nc e p r og r a m s ( M ed i c ai d, SS I , SS D , G ene r al A ssi s t an ce, P AA D , e t c.) C o mmun i t y a g enc i e s s uc h as M e als on Whee ls Amer i c an C a nce r S o c i e t y , l e g al s e r v i ce s , s upp o r t g r o u p s , s e lf -he lp g r o u p s , e t c . Hos p i c e p r og r a ms Adu lt d a y c a r e p r og r a m s Ho me l e ss s he l t e r s P r o t ect i v e s e r v i c e a g enc i e s ( Di v isi o n of Y o ut h & F a m ily Se r v i ce s , Adu lt P r o t ect i v e Se r v i ce s, W o me n A w a r e, e t c. ) A l c o h ol a nd / or s u b st a nc e a bu se c o un s e li n g P r ov i d e a d j u s tme n t t o ill ne ss c o un s e li n g P r ov i d e i n f o rm a t ion c o ncern i n g Ad v a nc e Di r ect i v e s

COBRA / EMTALA LAW Thi s l a w m a nd a t es th a t Raritan Bay Medical Center provide an app r o pri a t e m e di c al s c r eening examination for any individual who presents to the Emergency Department and requests medical examination or treatment to determine if an emergency medical condition exists. If an emergency medical condition exists, the individual shall be admitted or provided with stabilizing treatment prior to discharge, unless the individual refuses admission or treatment. Medical screening and examination shall not be delayed to verify an individual’s insurance, ability to pay or to inquire about an individual’s catchment area for psychiatric screening. C O MMU N IC A TI ON W IT H P A TIE N T S P a ti e n t s w it h sp ec i al n ee d s a r e p r o v id ed w ith: S i gn l a n g u a g e i n t e rp r e t e r s a n d D e a f T a l k Vid eo S i g n - L a n gu a g e de v i ce T T Y d e v i ce t e l e ph o n es F o r e i gn L a n g u a g e I n t e rp r e t e r s T e l e ph o n e : Language Line Services Audi o t a p es f or v isu a ll y imp a i r ed Y e llo w c o mmuni c a ti on b ook w it h pi c tu r es Audi o e nh a n ced t e l e ph o n es Cl o s ed c a p ti on TV

CONFIDENTIALITY A C o n fid e n ti a lit y A g reemen t is signed by every RBMC employee and volunteer. I n o r d er t o w o r k at RBMC we agree to:Discuss patient information only if necessary and only in a private setting, and never in public places such as hallways, elevators or cafeteria.Only those persons responsible for the patient’s care may access the medical record.Information whether clinical or business related, must not be shared with any other party unless there is an established “need to know.”Computer access codes (usernames and passwords) are issued to limit access, to assign responsibility and maintain confidentiality.Do not let others use your computer access code.Log off the computer when leaving work area.CORPORATE COMPLIANCE PROGRAMCode of Conduct“Doing the Right Thing Right”The following st a nd a r d s h a v e b een p r e p a r ed t o h e l p a l l e mpl o y ees a n d a g e n t s of Ra ri t an B a y M e di c al C e n t er m a k e th e ri g h t c h o i ces w h en f aced w it h d ec isi o n - m a k i ng: T r e a t o th e r s w it h c o ur t e s y a n d r e sp ec t . C o mpl y w it h l aw s . B e acc u r a t e a n d h o n e s t . D o n ot e n g a g e i n s c h e m es or dish o n e s t p r ac ti ce s .

CORPORATE COMPLIANCE PROGRAM Code of Conduct (cont’d) M a i n t a i n c o n fid en ti a lity.Follow legal and ethical standards.Do n ot p e r s o n a ll y p r o fi t or assist others in profiting at the expense of the organization.Conduct transactions free from gifts, favors or improper inducements.Do not participate in inappropriate activities that may influence decision-making.Make prudent and effective use of RBMC resources.Properly and accurately report finances, travel and entertainment expenses.Treat others with courtesy and respectReport suspected fraud, waste or abuse to the compliance officer or compliance hotlineTo get answers to compliance related issues, identify or report potential ethical and legal concerns or possible violations call:Corporate Compliance Hotline (Complyline)Confidential, Non-retaliatory- Toll Free:1-877-888-8030

Crash/Emergency Carts D e fibrill a t o r s a r e t ested e v ery working day. Locks and oxygen cylinders are c h ec k ed d a il y w h en the d epartment is open.Crash cart contents are reviewed:Whenever a lock is brokenAfter a codeOnce a month, the pharmacy checks medications.Crash cart locks are replaced by bringing the old lock to the pharmacy and exchanged for a new lock.CULTURAL DIVERSITYCultural Diversity staff training is included in initial orientation and ongoing in educational, community and patient experience activities. Patients cultural needs are included in the patient assessment process and plan of care. Patient’s communications needs and language preferences are identified.

E EME R GE N C Y C O MMU N IC A TI ON S YSTEMEmergency Telephone Numbers Dial 555 5 – Em e r g e n cy O perator – Perth Amboy Division Dial 4444 – Emergency Operator – Old Bridge DivisionEverbridge Emergency Notification System is used for employee emergency notifications. The system relies on updated personal contact information in PeopleSoft HRA computer down time system is utilized in the event of a computer services failure.The emergency telephone system is utilized in the event of loss of telephone services.Cellular telephones may be used during an emergency.EMERGENCY PREPAREDNESSThe Emergency Power Plan includes the use of backup generators that flow power to the red cover outlets as well as to emergency lights.EXCLUSION FROM PATIENT CARE - EMPLOYEE REQUESTEmployees may request not to participate in certain patient care activities based on their sincerely held personal or religious beliefs or professional convictions. The Medical C enter w ill consid e r m aki n g reaso nabl e acco mmodation s for that e m p lo y ee , if feas ible . In no inst an ce, ho we ve r , w ill pat ien t care or qu ali ty he al t h care be co m pr o m i s ed . A sk your D epa r t m en t D irect o r for the po li cy and proce du re for m ore inf o r m a t ion

F Fire Safety In event of a fire: R.A.C.E. Rescue – Anyone from immediate danger of the fire Alarm – Pull the nearest fire alarm and call 5555 – PAD 4444 – OBD from a safe area Contain – Fire by closing all doors in the fire area Extinguish / Evacuate – Extinguish small fires, if not, evacuate the area and close the door Use P.A.S.S. to use a fire extinguisher Pull – Pull the pin Aim – Aim extinguisher at the base of the fire Squeeze – Squeeze the handle of the fire extinguisher Sweep – Sweep from side to side at the base of the fire

F F ME A F ai lu re M ode and E f fect Analysis is a team based performance improvement tool used to an al yze a process and id en t i f y potential risks or failures so that action can be taken before a negative outcome occurs. Recent FMEA’s include: suicide identification program, fire prevention in the operating room, Code White, infant abduction, and potential for violence in the hospital, and preventing ventilator assisted pneumonia.HHAND HYGIENEWashing hands and changing gloves between patients are the two most important actions to ensure compliance with Standard Precautions and to decrease transmission of infections within the hospital. If hands are not visibly soiled, use of the waterless alcohol-based cleanser is recommended by the Centers for Disease Control and Prevention (CDC). Staff with patient contact and care providers: nails are to be no longer than 1/4 inch. No artificial nails, gels, tips, wraps or extensions may be used by any direct patient care provider. Nail polish must be clear, light colored, not chipped and no nail art.

I INCIDENT COMMAND SYS T EM ( ICS) Ra r itan Bay Medical Center (RBMC) utilizes the ICS Emergency Management System to manage disaster response. ICS is made up of positions on an o r ganizational cha r t. Each position has a specific mission to address an emergency situation. Each position has an individual checklist designed to direct the assigned individual in disaster recovery tasks. ICS utilizes forms that enhance the overall system and promote accountability. The ICS plan is flexible. Only those positions or functions which are needed should be activated. The ICS plan allows for the addition of needed positions, as well as the deactivating of positions at any time. This equates to promoting efficiency and cost effectiveness. The ICS system utilized by the hospital is compatible with the National Incident Management System (NIMS). This allows for the integration of all agencies responding to a disaster.INFECTION PREVENTIONThe Infection Prevention department monitors infection control practices for patients, personnel and visitors. Infection Control policies and procedures and the Occupational Safety and Health Administration (OSHA) Exposure Control Plans can be found on theIntranet under policies and procedures.

INTERDISCIPLINA R Y PLAN O F CARE E ach discip li n e that comp le t es an assessment on a patient makes an entry into the Plan of C are id enti fy in g the pro ble m and desir ed outcome. Disciplines come together on a regular basis to discuss patients’ care.ISOLATION PRECAUTIONSStandard PrecautionsStandard Precautions are to be utilized for the care of all patients, regardless of their diagnosis or presumed infection status. This is designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection.Personal Protective Equipment (PPE)Should be used whenever healthcare workers are in direct contact with any body substance. PPE’s include:GlovesGogglesMasksImpervious gownsFace shieldsTransmission Based PrecautionsExtra precautions taken (Isolations) are based on the way a specific organism and/or disease is spread.

Isolation Precautions A i r bo r ne Pr eca u t i o ns : ( Blue Sign)In addition to Standard Precaution need to be used for dise a ses that are trans mitte d by small particles circulating in the air andin the air vent systems. Specific diseases are listed on the back of each Isolation sign.Precautions include: Private NegativePressure room, N95 Respirator Mask with employee Fit Testing.Droplet Precautions: (Green Sign)In addition to Standard Precaution needs to be used for diseases that are transmitted by large droplets. Close contact with droplets within 3 feet of the patient is necessary for transmission to occur.Precautions include: Cohorting or private room, mask required when working within 3 feet of patient.Contact Precautions: (Red Sign)In addition to Standard Precautions needs to be used for diseases and/or organisms transmitted by person to person skin contact and/or by sharing of equipment.Precautions include: Cohorting or private room, gloves must be w orn, go w ns w orn as ne eded . P ati en t care eq uip m en t shou l d not be shar e d w ith oth e r pat ien t s un le ss cle ane d and disi n f e c t e d bet w e e n pat ie n t s .

Isolation Precautions Continued Enhanced Contact Precautions- (Brown Sign) In addition to standard precautions, enhanced contact precautions need to be used for Clostridium Difficile and Norovirus patients. Spores can live on surfaces for up to 6 months. MUST wash hands with soap and water and use bleach wipes (orange top with a contact time of 4 minutes) to disinfect surfaces and equipment . L L A TE X A LLE R Y R B MC has a “Latex Allergy Precautions” policy, which st a t es t hat t he hospi t al environment minimizes the use of latex allergy products for patients and staff. All patients are screened and if identified at risk, are provided with an environment as latex free as possible.Employees are educated on the proper use of gloves and on ways to minimize latex exposure for themselves. Employees are evaluated for allergic reaction through the Employee Health Department. Patients with an identified latex allergy receive a teal green color safety band.

LI N E N C lean lin e n m ust re main covered at all times. All linen carts must be clean and free of dust. Clean li ne n shou l d never be plac e d in close contact with soiled linen. Linen is never to be placed on chairs, ledges or window sills. Soiled linen should be handled as little as possible and placed in bags that prevent leakage.MMAGNETSince 2004, Raritan Bay Medical Center, Perth Amboy and Old Bridge division has been nationally recognized as a Magnet organization for Nursing Excellence. This means that RBMC has been recognized for providing quality patient care, nursing excellence, and advances in professional nursing practice. The Magnet recognition program provides our patients and families with the ultimate standard to measure the quality of care that they can expect to receive at Raritan Bay Medical Center. Why choose a Magnet hospital? While this award means a great deal to Raritan Bay Medical Center, it means even more to our patients. It establishes Raritan Bay Medical Center as a true hea l t h care le ade r w ith except iona l resul t s and a proven track record of excee di n g stan da rd care and achi e v in g bet t e r pat i e n t outc ome s.

MAGNET ( C ont ’ d) Of Ame r ica ’ s 7,500 hospitals and 2.9 million register ed nurses, Raritan Bay Medical Center and its nursing staff are ranked at the top of the list. One mo r e example of how the nation ’ s best health care is available right here in your community.MEDICAL EQUIPMENTAll patient care equipment is initially evaluated by Bio-Medical Engineering to be included in the equipment management plan. This plan includes the testing and labeling of medical devices. Labels include identification and next inspection due date. All equipment must be checked for inspection date prior to use. Broken or outdated equipment should not be used. For equipment repair, place a work request with Bio-Medical Engineering, or after hours, “page” the operator.In case of an emergency, “page” Bio-Medical Engineering through the operator.

ORGAN/ T ISSUE DON A T ION In acco r dance with New Jersey’s Unifo rm Anatomical Gift Act, as amended in 2001 and in 2008, and Federal Medicare Regulations, Hospital Conditions of Pa r ticipation for O r gan Donation as of June 1998, all acute care hospitals are required to develop policies and procedures to ensure the routine referral of all deaths and impending deaths (brain death) to their regional organ procurement organization (OPO) for the determination of medical suitability for organ and or tissue donation. The NJ Sharing Network (is the federally designated, state certified organ procurement organization for Raritan Bay Medical Center.Raritan Bay Medical Center has 3 policies that address organ donation:Organ and Tissue Donation: This policy assures that all potential organ and/or tissue donors are identified, and patients or their surrogates are provided the opportunity of donation in compliance with the law. This policy provides a mechanism for Raritan Bay Medical Center to document each referral in accordance with federal and state regulations and gu idelin e s pro mulga t e d by the C ent e r for M ed i c aid - M ed i c a re S ervices ( CMS ), the N ew Jersey D epar tm en t H eal t h and S eni o r S ervices and the Joint C o mm iss io n . D ecl ar a t i o n of D eath U pon the B asis O f N eu r olog i ca l Cr ite r ia ( Br ain D eath ) : This pol i cy is based on “ D eclar a t io n of D eath up o n the B asis of N eur ologi c a l C riter ia ” ad op t e d by N J B oard of M ed i c a l E xa m i ne rs A ug u st 3, 199 2 , a m e nde d O ctober 19 99 , revised and read o p t e d M ay 20 07 . It def ine s the criter i a and proce du r e w her eb y bra i n de a th up o n the basis of ne u r ologi c a l criter i a can be det e r m ined .

O r g a n Do n a ti o n a f t e r C ardiac Death: (Cont’d)Organ Donation after Cardiac D eath : A ll pat ien t s or the ir surrogates have the right to elect the event of termination of life support in compliance with the law. While the vast majority of organ donors have been persons declared dead by neurological criteria (brain death), this institution believes it is ethically appropriate to allow patients who die after withdrawal of life support, to proceed with organ donation, even though such donation will necessitate declaration of death based on traditional cardio-pulmonary criteria and not brain death. It is an important distinction that patients being considered for donation after cardiac death have had the decision for withdrawal of life sustaining treatment made prior to any discussion of organ donation. This policy defines the criteria and procedure for organ donation after cardiac death.PPAST OR A L CAR E Th e P a st o r al C a r e P r og r am o f f e r s spiritu al c a r e a n d e m o ti o n al supp o r t t o p a ti e n t s of a ll d e n o min a ti o n s f r om i n f a n t/p e di a tri c a g e g r o u p th r o u gh g e ri a tri c a g e g r o up . Nu r sin g st a f f , p a ti e n t a n d f a mil y r e qu e s ts, h e l p t o id e n ti fy indi v idua l s r e quirin g spiritu al supp o rt . Th e p r og r am o f f e r s c o m f o r t t o th e si c k, h e l p s f a milie s c o p e w it h l o s s a n d illn e ss , a n d e n a bl es th e c l e r gy t o ea sil y v isit h o spi t a li z ed c o n g r e g a n ts . Eu c h a ri s ti c Mini st e r s a n d c l e r gy a r e av a i la b l e f or th e p a ti e n t s up on r e qu e s t f r om th e p a ti e n t a nd / or f a mil y . A t a p a ti e n t ’ s a nd / or f a mil y ’ s r e qu e s t, a C a th o li c Ch a pl a i n is av a il ab l e , or a c o mmuni t y c l e r gy m e mb er c an b e c o n t ac t e d . Em e r g e n cy o n - c a l l c l e r gy of v a rious d e n o min a ti o n s a r e av a il ab l e 2 4 h o u r s a d a y . C o mmuni t y c l e r gy a r e o n - c a l l. Eu c h a ri s ti c Mini st e r s a r e av a il ab l e se v en d a y s a w eek a t b o t h l o c a ti o ns . Th e s e s e r v i ces c an b e acce ss ed b y c o n t ac tin g th e V o lu n t eer Se r v i ces or the communications d e p a rtm e n t .

Patient Education P a ti e n t e du c a ti on i s provided by p r o fessional staff from any discipline, and documented on the Multi - Dis c i p l i n a r y P a tient Education form. The educational resources available for patients and families include:Interactive individual/significant other and family teachingCommunity Health Screening and Educational ProgramsWritten materialsVideos/DVDsChannel 8 (closed circuit TV)Patient education guides (Spanish information is indicated when available)Electronic Systems: Micromedex and Lexicomp Multi-languageMedical LibraryDischarge InstructionsIntegrative Therapies ModalitiesPATIENT RIGHTSEvery patient deserves to be treated with consideration and respect. Raritan Bay Medical Center has compiled a list of Patient Rights. This list of Rights is given to every patient upon admission and is posted in a l l p a ti e n t a r eas. P r i v ac y : K n ock on th e p a ti e n t ’ s d oor b e f o r e e n t e rin g. R e sp ect p a ti e n t ’ s pri v acy w h en h e / sh e i s usin g th e ph o n e a n d during f a mil y v isits .

Pr i v a c y ( C o n t ’ d) H o n or patient’s privacy rights as outlined in our Note of P ri v acy P r ac ti ce s . Assure patients are adequately draped whenever transporting.Patient SafetyRaritan Bay Medical Center has a comprehensive patient safety program designed to minimize the risk of preventable medical errors. RBMC follows the guidelines of multiple national and local patient safety organizations including Leapfrog, The Joint Commission and the Institute of Health Improvement.If you notice a patient safety risk that requires immediate attention, you should alert the staff caring for the patient or notify your supervisor right away.RBMC has a culture of patient safety that encourages our staff to report patient safety issues without fear of retribution or penalty.National Patient Safety Goals:A si g nifi c a n t p a r t of th e p r og r am i s a t t e n ti on t o N a ti o n al P a ti e n t S a f et y g oa l s as o utlin ed b y The J o i n t C o mmissi o n . Th e g oa l s a n d ho w Ra ri t an B a y M e di c a l C e n t er i s m e etin g th em f o llo w : Identify Patients Correctly o Al l st a f f a t R BM C mu s t id e n ti fy th e p a ti e n t b y th e i r n a m e a n d d a t e of birt h ( D O B ) , “ 2 id e n tifi e r s” pri or t o r e nd e rin g a n y t y p e of p a ti e n t c a r e. Thi s p r oce s s i s d o n e b y a skin g the p a ti e n t th e i r n a m e a n d D OB a n d a ls o m a t c hin g th e i n f o rm a ti on on th e i r r e c o r d , m e di c a ti on a dmini s t r a ti on r e c o r d , c o ns e n t or r e quisiti on t o th e p a ti e n t ’ s id e n tifi c a ti on b r ace let .

N a ti on a l P a ti e n t S a f e ty Goals:A significant p a r t of th e p r og r am i s attention to National Patient Safety goals as outlined by The Joint Commission. The goals and how Raritan Bay Medical Center is meeting them follow:Identify Patients Correctlyo All staff at RBMC must identify the patient by their name and date of birth (DOB), “2 identifiers” prior to rendering any type of patient care. This process is done by asking the patient their name and DOB and also matching the information on their record, medication administration record, consent or requisition to the patient’s identification bracelet.The patient room number or physical location is not used as an identifierSpecimens are labeled in the presence of the patient at the point of obtaining the specimen.

N a ti on a l P a ti e n t S a f e ty Goals: (Cont’d)Improve the e f f ec ti v e n e s s of communication among caregiversThe critical test results order form is used by the RN when a “critical value,” is reported. The reporting of critical tests results is monitored for timeliness and documented on the critical test results order form.All orders and test result information that is communicated between healthcare providers is “read back” to be sure the order or test result is accurate and complete.Standardized lists of do not use abbreviations, acronyms, symbols are used throughout RBMC. Unacceptable abbreviations are posted on nursing units, in physician lounges and on physician order forms.SBAR, S=Situation, B=Background, A=Assessment, R=Recommenda ti on i s a st a nd a r di z ed c o mmuni c a ti on meth od for escalation us ed a t R BM C t o b e su r e th a t h ea lth c a r e p r o v id e r s give and receive patient information in a systemized, consistent format.RBMC uses color coded safety patient arm bands to alert all healthcare providers: Red - AllergiesPurple dot on White – Elopement Purple – DNRMagenta - Hospice. Y e llo w - R is k f or F a lls Li g h t G r een - Impla n t a b l e De v i ce P in k - Lim b Al e rt Blu e – M R S A

Use Medicines Safely o R BM C h as st a nd a r d dru g concentrations and limitations programmed into ou r i n fusi on pum p s as s a feguards.RMBC has posted on all nursing units and in the pharmacy a list of drugs that sound and look alike. Stickers are placed on drugs that look or sound alike by pharmacy for patients that are on two or more drugs that have similar spelling names or maybe sound alike. The MAR has TALL man lettering alerting the nurse to this potentially dangerous drug.RBMC has a policy for high risk medication infusions for Heparin, Insulin, concentrated electrolytes, neuromuscular blockers, narcotics, chemotherapy, Dopamine and Dobutamine. We apply color code labels for medications and tubing for Heparin, Insulin, Chemotherapy and Neuromuscular IV infusions to assist in identifying them as high risk, th i s a l so a ll o w s t he nu r se t o t r a c e t he i n fus i o n f r om t he me d i c a t i o n bag t o the patient’s IV insertion site.All solutions, syringes and containers are labeled on and off the sterile field in the perioperativeand other procedural settings at RBMC. No pre-labeling of syringes or containers.An t i c o a g u l a t i o n s a f e t y has s t anda r d i z e d p r a ct i ce s . The p r oce ss o f me d i c a t i o n r e c o ncili a t i o n i s d o ne o n e v e r y i np a t i e n t ad mi s s i o n a nd w h e n p a t i e n t s a r e t r an s f e r r e d f r om t he Su r g i c a l Sui t e s t o an i np a t i e n t b e d o r t o and f r om ICU t o an ot h e r nu r sing c a r e uni t . The m e di c a t i o n r e c o n c i li a t i o n f o rm i s a p e r m an e n t part o f t he p a t i e n t ’ s r e c o r d and i s u t ili z e d f r om ad mi s s i o n u n t i l d i s cha r g e . A t d i s c h a rg e t he p a t i e n t i s g i v e n a c op y . A l s o , a c om p l e t e li s t o f t he p a t i e n t ’ s me d i c a t i o n i s c omm un i c at e d t o t he n e x t c a r e p r o v i de r w h e n e v e r t he p a t i e n t i s r e f e r r e d o r t r an s f e r r e d t o an ot h e r f aci l i t y o u t s i de o f t he o r g an i z a t i o n

Prevent Infection A l l p a t i e n t s ad mi t t ed or transferred into the Intensive Car e uni t s h a v e nas a l s w ab cultures done to detect MRSA infection and patients are kept on contact isolation until the results of the swab are known. If a patient is positive for MRSA they remain isolated until two negative culture swabs are obtained.Hospital wide surveillance is maintained for multidrug resistant organisms and reported to leadership and their respective units.Education is provided to the staff in orientation and yearly regarding the prevention of hospitalacquired infections.Education is provided to patients and families regarding the prevention of central line associated infections, surgical site i n f ect i o ns and m u l t i drug r e s i s t a n t o r g an i sms . Su r g i c a l Ca r e I m p r o v eme n t P r o j ec t (SCI P ) goal is to reduce risk of surgical site and urinary tract infections.In compliance with CDC guidelines for hand-hygiene, RBMC has alcohol based hand gels in patient c are areas throughout the medical center. CDC guidelines also reco mm e nd t he use o f s o ap and w a t e r t o w ash hand s ; t his sh o u l d be d o ne b y al l s t a f f f or a t le a s t 20 se c o nd s. Ob s e r v a t i o n and t r aining a r e d o ne b y t he I n f ect i o n C o n t r o l Nu r se and un i t i n f ect i o n c o n t r o l r e p r e s e n t a t i v e s .

Use Alarms Safely RBMC e s t abl i sh e d alarm s ys t em safety as a hospital priority and created a task force t o p e r f o rm an a sses sm e n t o f clinical alarms with the goal to minimize unnecessary alarm signals that may contribute to alarm noise and alarm fatigue, and to ensure alarms are heard and responded to on time.Identify Patient Safety RisksRBMC has had a fall reduction plan in place for many years. All patients are assessed by an RN for their risk of fall. Once a patient is assessed as being at risk they are placed on “Fall Precautions.” Fall precautions consist of placing a yellow arm band on the patient placing them close to the nurses’ station when ever possible and using a doorway sign so that all healthcare providers are alert to the patient’s potential risk for injury from falls.All patients treated at RBMC are assessed for suicide risk. Patients are routinely screened for harmful behaviors, postpartum depression and language barriers. Interventions are put into place for those patients who have been screened as high risk for suicide such as close1:1 observation.The Rapid Response Team enabl e s hea l t h care sta f f m e mbe rs at RBM C to direc t l y req ue st ad di t iona l assista n ce from speci all y trai n e d in di v idual s w hen the patient’s condition appears to be deteriorating.

W e a ls o h a v e a Str oke response team for p a tients exhibiting stroke sympto ms, Semi Team for patient’s exhibiting symptoms of a heart attack.When these medical alerts are announced overhead and b y b ee p e r , R BM C sp ec i ally trained teams of physicians, nurses and respiratory therapists respond immediately.Prevent Mistakes in SurgeryTime out is done prior to any invasive procedure to ensure team the agreement on correct patient, correct procedure, correct side, level site, correct patient positioning safety precautions based on history or medication use, special equipment/implants, required antibiotics or irrigations, and if applicable, correct radiographs.PATIENT EXPERIENCEPatient experience is a primary focus and is measured and monitored through on going patient experience surveys, rounding and other modes of communication. By using the Care Model. Raritan Bay Medical Center employees are able to reduce patient anxiety, increase patient compliance, improve clinical outcomes and ultimately enhance the patient experience.Keep the C.A.R.E. acronym in mind for great customer service:Communication (clearly communicate the process and set expectations)Accountability (take responsibility for fixing the problem or getting an answer)Responsiveness (don’t make the customer wait for your communication or a solution)Empathy (acknowledge the impact that the situation has on the customer)Solution (at the end of the day, make sure to solve the issue or answer the question) 

In efforts to create a Human Connection, RBMC adheres to the following guidelines: M a k e e y e c o n t ac t, smile and i n troduce yourselfDoes someone need help? Prov id e a ssi st a n ce or fin d s o meone who canKeep patients and families informedAnswer requests promptlyBe sensitive to the needs for privacyListen with concern and try to helpCooperate/TeamworkQuiet please: use beepers whenever possible versus overhead paging; be mindful of conversations in corridors near patients rooms and noise with equipment.Answer the phone promptly, smile and introduce yourself and your departmentConform to a professional image and wear ID badge at all times, keep a neat work environment.Universal ExpectationsEveryone answers call lightsEveryone pitches in and picks up clutterEveryone smiles and offers assistance to visitors, guests and patients

Patient Experience Monitoring Ra ri t an B a y M e di c al Center pa rti c ipates in patient experience survey processes known as HCAHPS and Real Time Feedback through a partnership with NRC Health . Th e C e n t e r s f or M e dicare and Medicaid Services developed a standardized survey (HCAHPS,) which stands for Hospital Consumer Assessment of Healthcare Providers and Systems to be used by all hospitals in the U.S. to measure the patient’s perceptions of their hospital experience. The HCAHPS survey allows public sharing of comparable data across acute care hospitals. Real Time Feedback enables a quick survey process for patients within 48 hours of point of service. This feedback enable us to target our improvement initiatives toward those areas of greatest concern and have the potential to enhance our HCAHPS performance as well as the satisfaction of our customers. PERFORMANCE IMPROVEMENT PROCESS: PDCAThe methodology used at RBMC for Performance Improvement is Plan-Do-Check-Act (PDCA).Plan: Plan change b y s tud y in g a p r oce ss, d ec idin g w h a t c o ul d imp r o v e it, a n d id e n ti fy in g d a t a to h e lp . D o : Carry out the plan on a small scale or by simulation.Check: Observe the results of the change; modify the change if necessary.Act: Implement the change or abandon the plan and repe at cycle.

POL S T ( P r a c t iti o ne r Or de r s for Life-Sustaining T r e a t m e n t ) PO L S T is a set of medical orders that help give seriously ill or frail elderly patients more control over end-of-life care. POLST specifies the types of medical treatment that a patient wishes to receive toward the end of life.The medical center also recognizes the right of competent adults to discuss their health care choices and treatment options with health care practitioners and to complete a POLST and to have the POLST executed in accordance to State law.POPULATION SPECIFIC CONSIDERATIONSSpecial needs of patients and families are addressed at RBMC and are included in assessment, planning, communication, patient care needs and education. Sp ec ifi c c o nsid e r a ti o n s in c lud e bu t n ot limi t ed t o : A D A ( Am e ri c a n s w it h Dis a biliti es A c t ) A g e S p ec ifi c ConsiderationCommunication (Deaf Talk/Interpreters)Cultural DiversityPastoral CareVictims of AbuseBariatric CareOncology CareStroke

Q. Quality Ra ri t an B a y M e di c al Center h as a plan that establishes objectives, develops plans, an d m a n a g es p r oce ss es t o assess, improve, evaluate and maintain the quality of all aspects of the hospital.Quality oversight, through performance improvement activities, is the primary responsibility of the Clinical Practices and Quality Management Committee (CPC). CPC reports directly to the Medical Staff Executive Committee. This Clinical Practices and Quality Management Committee are composed of leaders from the medical staff, nursing, clinical, and quality assessment and improvement areas. It oversees, coordinates and integrates the hospital-wide performance assessment and improvement program.RBMC participates in the surgical care improvement project, a voluntary national quality improvement program aimed at re du c in g su r g i c al c o mpli c a ti o n s b y imp r o v in g su r g i c al c a r e. Q u a lit y p a ti e n t c a r e o u tcomes are key goals for RBMC.QUALITY: CLINICAL OUTCOMES AND REPORTING PROCESSThe hospital systematically collects data needed to (a) design and ass ess new processes, (b) assess the dimensions of performance relevant to func ti o n s , p r oce ss e s, a n d o u t c o m e s, (c) id e n ti fy a r eas f or p o ssibl e imp r o v e m e n t of e x i s tin g p r oce ss e s, a n d ( d ) d e t e rmin e w h e th er c h a n g es imp r o v ed the p r oce ss es a n d h a v e b een su st a in e d. Thi s d a t a i s r e v ie w ed a t r eg ul ar i n t e r v a l s a n d c o n t a in s b e n c hm a r k s w hi ch a r e d e ri v ed f r om the li t e r a tu r e , c o mpa r a ti v e d a t a b a s es or hi st o ri c al r e v ie w of R BM C p r ac ti ce s . R BM C C o r e M ea su r es d a t a i s r e p o r t ed qu a r t e rl y t o th e publi c .

R RESTRAINTS R estrai n t s are used only w hen abso l u tely necessary. When alternatives to restraints are unsuccessful and the ne e d for restra in t s is determined, a physiciansorder is required.RBMC utilizes physician order stickers that contain specific elements for the application of restraints based on patient’s behavior. Patients and family members are updated based on the consent of the patients, regarding the reason for and progress in the removal of restraints.Through frequent assessment and reassessment the determination is made for safe removal of the restraints evidenced by the absence of the reason for restraint. Patients are monitored at minimum every two hours and more frequently when restraints are necessary to prevent self and/or staff harm. Monitoring and assessment outcomes are documented on the restraint flow sheet daily and as needed. Notes contain the reas on s for the restra in t epis ode and the outco m e s.

S SA F E T Y D A T A S H EE T S (SDS)Each department has an SDS on file for each hazardous material used in the department. T he Nu r sing o f fice, Secu r ity and the Emergency departments have master files of all SDS and additional information on hazardous materials used in the Medical Center.Information about the handling of hazardous material spills, exposures or poisonings can be obtained by calling the Safety Data Sheets Hotline- 800-451-8346SAFETY/SECURITYID badges must be worn at all times.Staff personal valuables must be kept under lock and key.In the event of a security issue, call Security immediately atExtension 5107 or PAD Operator – 5555OBD Operator - 4444

Safety and Security R E PO R T IN G A D VE R SE EVEN TS Ad v erse event - An event that is a n e g a ti v e c o ns e qu e n ce of care that results in unintended injury or illness which may or may not have been preventable.Near miss - Means an incident that could have resulted in an adverse event , but the adverse event was prevented.Serious preventable adverse event- means an adverse event that is a preventable event and results in death or loss of body part, or disability or loss of bodily function lasting more than 7 days or still present at the time of discharge from a health care facility.Incident - Any non-routine or unexpected event that occurs within the medical center or on medical center property whether there is injury to the person involved or not.TO REPORT SAFETY CONCERNS:Complete a Onelink report as soon as possible, any immediate or serious safety concerns should be immediately reported to your manager and risk management. SENT IN E L EVEN T A s e n tin el e v e n t i s an un e x p ec t ed occ ur r e n ce i n v o l v in g d e a t h or s e riou s p h y sical or psycho- logical injury, or the risk thereof. As this is a very serious undesirable outcome, RBMC has a specific sentinel event policy for identification and respons e to a sentinel event.

S T AFF E D U C A T I O N Emplo y ees r ece i ve education on an ongoing b a si s d e ri v ed f r om a departmental specific needs assessment, annual and other required programs.CompetencyCompetency is assessed initially upon interview and hire according to the performance expectations and job description. Competency is validated throughout the orientation and introductory period and is assessed on an ongoing basis. Staff must demonstrate competency through ongoing, periodic evaluation including a yearly performance appraisal. Competency assessment includes population, age specific and cultural aspects.MID: Annual Mandatory In-serviceThis “online” computer program allows employees to complete their annual mandatory training via RBMC Intra net . E n v i r onme n t o f C a r e/ S a f e t y an d In f ec ti o n C o n t r ol Pr o g r ams R e v ie w of d e p a rtm e n t specific programs.Review of hospital-wide policies on Safety, Life Safety, Fire/Security, OSHA Hazard Communication Standards, Blood Borne Pathogens, Standard Transmission Precautions, Tuberculosis, Disaster Drills, Ha zm a t a n d OS H A Ch e mi c al S p i l l s a n d Em e r g e n cy M a n a g e m e n t . P r og r a m s a r e p r o v id ed up on hi r e a n d a nnu a l l y th e r e a f t e r . R e p o rtin g in c id e n ts / a c c i d e n t s a n d a d v e r s e e v e n ts . C o rp o r a t e C o mplian c e.

I n f o r m a ti o n M a n a g eme n t TrainingProvided (departm e n t sp ec ifi c) b y m a n a g er or through in-services:DataComputerRecordsWritten reports/recordsConfidentiality and patient rights are included*Note: Confidentiality & password agreements must be obtained and administrative approval for any system access. Passwords are never sharedOrientationEveryone receives orientation including volunteers and students.One day hospital wide program.Departmental/unit specific orientation.“Verbal/Just-in-Time Training/Orientation” is provided to those staff that are temporarily assigned and/or floated.Team building/diversity/patient and customer satisfaction.TTRANSFERS ACUTE CAREA patient is transferred to another acute care facility only if:The patient or family h as m a d e th e r e qu e s t Th e c ur r e n t f ac ilit y i s un a bl e t o p r o v id e th e n ece ss a r y c a reIn accordance with COBRA/EMTALA, a patient to be transferred receives advance explanation of the reason for a transfer and possible alternatives.

T UBE R CU L OSI S ( T B ) PL AN Airb o rn e Precautions are required for any pati e n t w it h susp ec t ed tub e r c ulosis. The patient must be placed in a negative pressure room and all personnel entering the room must wear an N95 respirator mask. Employees who may have to wear an N95 respirator in the course of their work must be fit tested annually. Every employee regardless of job description must have an annual TST or fill out at TB screening form. All of these systems are in place to provide protection for RBMC staff.UUTILITIES MANAGEMENTThe Engineering Department is responsible for maintaining and repairing the following:Utility Systems – electrical, plumbing, heating, ventilation, air-conditioning, medical gases, vacuum (Suction), O2, shut off valves, and elevators.Equipment – beds, stretcher s, w h ee l c h a i r s, r e fri g e r a t o r s, i ce m ac hi n e s, wa t er c oo l e r s . G e n e r al – d oo r s, w a lls, ceilings, locks, handrails, windows, shelves, brackets.Emergency power availability varies depending on location. A red cover plate identifies emergency power outlets. Emergency power is available throughout the Medical Center in the event of a power failure. R e qu e s t s f or s e r v i ce sh o ul d b e pl aced on th e R BM C I n t r a ne t P o r t al p a g e. R e qu e s t s f or e m e r g e n cy s e r v i ce c an b e pl aced a t e x t e nsi on 525 2 durin g n o rm al h o u r s ( M - F , 7:00 am - 3:30pm ) a n d th r o u gh th e t e l e ph o n e o p e r a t or a f t er n o rm al h o u r s .

Waste Management Ra ri t an B a y M e di c al C e n t er has a comprehensive and integrated waste m a n a g e m e n t p r og r am w hich is managed by the department of Environmental Services in partnership with Stericycle. The main waste streams include the following categories:Hazardous WastePharmaceutical WasteRegulated Medical WasteRecyclingSolid WasteEach of these is monitored and involves overlapping regulatory requirements. The important thing to know is that it is everyone’s responsibility to dispose of waste appropriately and safely. All staff receive an annual refresher on regulatory waste streams. Remember that hazardous waste and regulated medical waste are costly waste streams. You should understand your impact, know where to put your waste and make the right choice!Contact Environmental Se r v i ces a t x 500 4 f or furth er ti p s on s eg r e g a ti on a n d o u r su st a in a bi l it y initi a ti v e s .