Organization Frederick Memorial Hospital. Solution Title PI & EOC: Collaborative Rounding for Success. Program/Project Description, including Goals:

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1 Organization Frederick Memorial Hospital Solution Title PI & EOC: Collaborative Rounding for Success Program/Project Description, including Goals: Continual readiness for survey activity is a key driver of many initiatives within a health system. At FMH, our goal is not to be in survey preparation mode, but to work in an environment that is continuously meeting all accreditation and regulatory standards as a means of providing high quality, patient-centered care in an environment that promotes safety and well-being. A coordinated, systematic approach to patient safety and environment of care rounding is the cornerstone of this effort. Learning Objectives 1. Describe challenges associated with implementing and maintaining an effective patient and environmental safety initiative. 2. Articulate the link between Patient Safety and Environmental Safety. 3. Identify tools and resources to help improve identification of issues, opportunities and barriers to patient and environmental safety, implementation of rapid cycle improvement and staff education and awareness. 4. Presenters will describe their journey to develop and implement best practices for patient and environmental safety. Process: In 2012, the EOC Committee evaluated our current process. Numerous opportunities were identified requiring improvement. In early 2013, a part-time position for the Safety Coordinator was created. The EOC team reviewed current practices and compared them to best practices in other organizations. Solution: While numerous areas were identified, FMH took action and can demonstrate significant progress in several areas. There is now heightened attention to environmental safety issues, patient safety issues, staff performance during patient tracers, and increased staff education. FMH has a dedicated Accreditation and Regulatory Compliance department, developed as a part of the Performance Improvement Department, which reports to the Vice President of Medical Affairs. Feedback from customers has been very positive. Measurable Outcomes: We achieved a systematic approach to rounding for potential patient and environmental safety issues and taking real-time actions to avoid harm and risk to patients and staff. Staff members are more aware of safety issues and report problems through new processes.

2 Sustainability: The Environment of Care multi-disciplinary committee continues to meet on a routine basis to review variations in standards and implement plans to adjust and correct these deviations. The committee reviews best practice and assures that the actions are taken to meet requirements. Report cards have been developed for each area which illustrates their compliance over time. These report cards are reviewed with leadership and action plans developed to address noncompliance. The results are publicized at the department/unit level by leaders and throughout the organization by the Environment of Care committee. Continuous staff education is conducted to assure awareness of safety issues and hazards. Role of Collaboration and Leadership: Key players involved include: VPMA, Quality/Performance Improvement, Patient Safety Officer, Safety Coordinator, Environment of Care Committee, Plant Operations, Security & Public Safety, BioMed, and Environmental Health Services. Nursing and ancillary leadership support was critical in the success of this initiative. Healthcare providers across the spectrum had to be aware of and understand the impact for patients and the caregivers. Innovation: This solution is innovative because it utilizes a collaborative team rounding approach across the continuum not only including the hospital itself, but off sites and outpatient centers. The team also has dedicated follow-up and uses visual aids (pictures of noncompliance) to increase awareness and education to assure the safety of our patients. Related Tools and Resources See Attached. Contact Person Sharon Powell, MS, RN, CPHQ Title Patient Safety Officer & Director, Performance Improvement, Accreditation & Regulatory Compliance, Infection Prevention & Control, Medical Staff Office, & Interpreter Services spowell@fmh.org Phone The Solutions selected to receive the Minogue Award for Patient Safety Innovation will reflect the following Award criteria: Be innovative Demonstrate measurable change Exhibit strong collaboration Exhibit strong leadership Advance the culture of patient safety Constitute a best practice with the ability to spread

3 Environment of Care Rounding Survey Date: Unit: Manager: EOC Group ID: Recorder: A) Infection Control IC / EC A.01 Storage and work areas are clean and orderly A.02 Air vents are clean A.03 Food and drinks are not present in care areas A.04 Refrigerator temp logs are completed A.05 Nutrition refrigerator is clean, items are labeled and in date A.06 Clean linen is covered and stored properly A.07 Ceiling tiles are in place and without stains B) General Safety EC B.01 No slip, trip, or fall hazards are present B.02 Daily crash cart log is completed B.03 Oxygen tanks are properly stored and secure C) Security EC C.01 ID badges are worn by all staff and external vendors C.02 Special security measures are in place (Family Ctr, Peds, BHU, etc) C.03 Medications are secure and properly stored C.04 Restricted areas are secure (electrical, chutes, storage areas, etc) 1

4 D) Hazardous Materials EC D.01 EHS closet is organized and has no food or personal items present D.02 Chemicals are properly stored and labeled D.03 Waste is properly segregated and stored appropriately D.04 The necessary PPE is available and being used appropriately D.05 Eye wash stations are accessible and clearly labeled D.06 Housekeeping carts are attended D.07 MSDS information is available and current E) Fire Safety EC / EC / LS E.01 Smoke/fire doors close and latch properly E.02 Exit signs are illuminated E.03 Sprinkler heads are unobstructed (18" clearance) E.04 Pull stations, fire extinguishers, and fire exits are unobstructed E.05 Corridors and patient rooms are unobstructed E.06 Items in the corridors are on wheels, to one side, and in use E.07 Exit stairwells are free of storage E.08 Flammable liquids (including hand sanitizer) are stored properly Above the ceiling penetration check complete by: 2

5 F) Utilities EC F.01 Emergency "red" outlets are used appropriately F.02 Medical gas valves are labeled F.03 Access to electrical panels is unobstructed F.04 Negative pressure rooms function properly F.05 Nurse call system and emergency lights function properly G) Medical Equipment EC / EC G.01 Preventative maintenance stickers are on all equipment G.02 Preventative maintenance is current on all equipment G.03 Medical equipment alarms are functioning properly G.04 Equipment is clean H) Emergency Preparedness EM H.01 A copy of the current Emergency Operations Plan exists 3

6 Environment of Care Questionnaire Date: Unit: Manager: EOC Group ID: Recorder: A) Infection Control A.01 A.02 A.03 Q: Do you know how the airflow isolation works? A: Key switch is turned on, reading must go to or a greater negative, Plant Ops is notified if alarm activates. Q: What is the proper procedure to follow after a needle stick or exposure to blood / body fluid? A: Wash area immediately, report incident to charge RN, complete the Employee Accident/Exposure Report Form, and go to Employee Health (contact hospital supervisor if E.H. is closed). Q: Give an example of a high touch item that requires frequent disinfecting. A: High touch items are those items that are routinely touched by patients, staff, and visitors on the unit and in patient rooms. B) General Safety B.01 Q: How do you respond when a patient is locked in the bathroom and the call light is pulled? A: Retrieve keys kept at nursing alcove hanging under light. B.02 Q: Who are the Safety Officers at FMHS? Who is responsible for identifying unsafe conditions? A: Safety Officers - Bob Hajjar and Phil Giuliano. Identifying unsafe conditions is everyone's responsibility. B.03 Q: Does FMHS have an interdisciplinary committee that examines and works to improve the environment of care? A: Yes, the Environment of Care Committee meets monthly. 4

7 C) Security C.01 Q: In the event of a security incident (threat to staff member), what emergency procedures should be followed? A: Call 3344 to report Green or Purple codes (areas with panic buttons should immediately activate alarms). D) Hazardous Materials D.01 Q: What is an MSDS? A: A Material Safety Data Sheet details information on a product's safe use, handling, chemical properties, and exposure instructions. D.02 Q: Demonstrate how to find MSDS information. A: Staff should use computer icon to access. E) Fire Safety E.01 Q: What do you do when you discover a fire or smoke condition? How do you alert others? A: Follow RACE response (Rescue, Alarm, Confine, Extinguish). Activate pull station alarm and call E.02 Q: What's the procedure for shutting off oxygen during a fire? A: Contact Respiratory Therapy and floor supervisor. Shutoff valve location varies per unit (usually around the CCC or nurse s station). 5

8 F) Utilities F.01 Q: What is the significance of red electrical outlets? A: They are connected to both normal and emergency electrical power. G) Medical Equipment G.01 G.02 G.03 Q: How often should you check equipment? A: Every time you use it. Q: What do you do if a piece of equipment isn't functioning properly? A: Remove from service, tag with appropriate label, and contact Biomed or appropriate department. Q: Demonstrate how to assess if a piece of equipment has been tested or when it's due for preventative maintenance. A: Staff should point out sticker on a piece of equipment. H) Emergency Preparedness H.01 H.02 Q: What do you do if you hear a Code Pink? A: Observe all door and fire exits, patients, and visitors for unusual behavior. Q: What should you do if a patient evacuation is necessary? A: Listen to the "person in charge" and always evacuate horizontally first past smoke/fire doors to the nearest safe area if possible. 6