St. Luke s Rehabilitation Volunteer/Student Orientation Safety and Security Infection Control Customer service Professional boundaries Conscience conflicts Diversity Process Improvement
St. Luke s Rehabilitation Institute Vision Our vision is to be nationally recognized as the regional rehabilitation center of choice based upon reputation, quality outcomes and innovative care. Mission Our mission is to be a resource for health and wellness, in order to optimize the potential for a full and productive life. We serve individuals and their families requiring expertise in medical rehabilitation. St. Luke s Rehabilitation Institute seeks to provide value to those served by treating the whole person with regard to physical, intellectual, emotional, cultural and spiritual needs in order to restore to their fullest potential the capacity for living. Excellence of care will take place in an atmosphere of compassion, reverence and integrity.
Accreditations St. Luke s Rehabilitation is accredited by the Joint Commission and Commission on Accreditation of Rehabilitation Facilities (CARF). Joint Commission surveys are every 3 years CARF surveys are every 3 years The Washington State Department of Health surveys the facility annually.
Safety & Security St. Luke s has a safety goal to provide an environment safe from recognizable hazards and to make every reasonable attempt to protect the life, health, and safety of each patient, employee, and visitor.
Emergency Codes For all codes at St. Luke s dial 855. (For employees at offsite locations dial 911 or the hospital emergency number on the back of your employee badge). Code Name Code Red Code Blue Code Orange Code Gray Code Silver Amber Alert External Triage Internal Triage Rapid Response Team Code Name Clear Emergency Situation Fire Heart or respiration stopping Hazardous material spill or release Combative person Person with weapon/hostage situation Infant or child abduction External disaster Internal emergency Summon rapid response team To clear a code
Safety Rules Report any unsafe condition or act you observe to your supervisor. Immediately remove any foreign material on floors to prevent injury to others. If you can t remove it, report it to the proper person. Report defective or damaged equipment immediately. Report all injuries, however slight, and near misses to your manager or supervisor and get immediate first aid as needed. Dispose of needles, other sharps and broken glass properly in the rigid plastic sharps containers. Keep fire doors, corridors, exits, fire alarm pull stations, and fire extinguishers free from obstructions. Always use proper body mechanics when lifting and follow safe patient handling guidelines. Know your limits and if in doubt, get assistance! Respond in a calm manner when dealing with a person who may be expressing signs of anger. Leave the area, if necessary. No smoking in the buildings or within 25 feet of the buildings.
What are GHS and SDS? Global Harmonizing System and Safety Data Sheets Harmonized criteria for classifying substances and mixtures according to their health, environmental and physical hazards. Harmonized hazard communication system including requirements for labeling and safety data sheets (SDS).
Safety Data Sheets Safety Data Sheets (SDS) are reports on the various materials with which you may come into contact in your environment. These sheets include sections on such subjects as: Identification the physical composition of the material Reactivity the stability of the material; what conditions to avoid Health hazards Environmental impact Exposure control eye, skin, and respiratory protection Work practices handling and storage; clean-up and disposal methods Emergency & First Aid procedures
Label Pictograms
Safety Data Sheets SDS sheets available electronically MSDS OnLine Click the MSDS icon on managed computers Safe as a favorite http://hq.msdsonline.com/inhssl If you have any questions about any of the materials you work with, SDS are located on www.myinhs.org under Human Resources/Safety
Workplace Violence INHS is committed to maintaining a work environment free from violence, threats of violence, harassment, intimidation, coercion and other disruptive behaviors. Therefore, we have a zero tolerance policy regarding workplace violence. INHS will not tolerate violence or threatened violence against any of our employees, or against other persons on our premises, by anyone. Employees are encouraged to bring disputes and differences with others to the attention of their supervisors, Security or Human Resources before a situation escalates into potential violence. INHS prohibits the possession or use of any and all weapons on company property or while attending work related off site functions. In the event an employee feels he/she has an extenuating circumstance regarding his/her personal safety, that employee is encouraged to meet with Human Resources.
Fire: What is your responsibility? Know the location of the fire extinguishers in your department and the general location of the fire alarm pull stations Know your building s fire plan and at least two exits from your department. During a fire situation, clear all hallways and exit routes immediately. In case of a fire, follow the acronym RACE: Rescue any endangered person (s) Remove all persons in immediate danger. Activate the alarm Immediately call the emergency number (855 for St. Luke s; 911 for other locations) AND pull the nearest fire alarm. Contain the fire Close all doors and windows to the area to best contain the fire Extinguish the fire and/or Evacuate the building
Evacuation If evacuation is ordered by the Fire Department or Incident Commander: First evacuate horizontally to the next compartment (s). Next, evacuate vertically down to a lower level. Only a total evacuation would require you to leave the building. When an evacuation is necessary, leave the lights on.
Infection Control
What Is Infection Control? Infection Control refers to the process of preventing illnesses which can be acquired at a healthcare facility. These can include urinary tract infections, post-operative infections, respiratory infections, bloodborne illnesses, hepatitis B/C, and HIV/AIDS. Purpose of infection control: Provide a safe environment for personnel, patients and visitors. Prevent the spread of communicable diseases. Reduce the incidence of exposure to infectious organisms. Establish policy and procedure guidelines according to standards. For patients: infections can lengthen their hospital stay; increase health-care costs; cause inconvenience, pain, and even death. For employees: exposure to many germs can lead to illness and missed work days. There is the possibility of spreading the illness to family, friends, and co-workers.
How Are Infections Spread? The spread of infection requires all 6 of these links in the infection chain: 1. A microorganism which can cause disease. 2. A person, a patient or a healthcare worker, who carries the microorganism. 3. A way out of the carrier, a method of leaving the body, such as sneezing or coughing 4. A method of traveling, such as through the air, through direct physical contact, or through contaminated hands, linens, towels, or instruments 5. A way into another person, a means of introducing the microorganism to a person, such as breathing, swallowing, or skin puncture. 6. A susceptible person, someone who does not have resistance and becomes infected. Infection Control procedures are aimed at breaking the infection chain by removing one of these links.
Hand Hygiene The single most important behavior to prevent the spread of infection is hand washing or hand decontamination. Using hand gels: Hand gels can be used in place of hand washing when your hands are not visibly soiled or contaminated. Apply to the palm of your hand. Rub hands together, covering all surfaces of hands and fingernails until your hands are dry (usually 15-20 seconds). Hand gels should not be used when caring for patients with C-Difficile. NOTE: If you have direct patient contact, your fingernails must be short. Artificial nails are not allowed. 5 Moments for Hand Hygiene Wash/gel before patient contact Wash/gel before aseptic tasks Wash/gel after body fluid exposure risk Wash/gel after patient contact Wash/gel after contact with patient s surroundings
Bloodborne Pathogens There are three common bloodborne pathogens Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus (HIV). These pathogens can be spread when infected fluids enter the body through: Needlestick injuries Cuts, scrapes, and other breaks in the skin Splashes into the mouth, nose, and eyes Oral, vaginal, and/or anal sex Infected drug needles At this time, there is a vaccine available for Hepatitis B.
Multi-drug resistant organisms (MDROs) Methicillin Resistant Staphylococcus Aureus (MRSA) and Oxacillin- Resistant Staphylococcus Aureus (ORSA) Vancomycin Resistant Enterococcus (VRE) Clostridium Difficile (C-diff.) Extended-spectrum Beta Lactamase (ESBL) organisms Follow Contact Precautions when a patient has any one of the MDROs listed to the left Remember: MDRO s can survive on environmental surfaces for weeks or months.
Personal Protective Equipment Personal Protective Equipment includes gloves, masks, and gowns that provide a barrier to prevent the spread of infection. PPE is found in clean storage areas. Emergency PPE is found on the units. Eye wash kits are located throughout the facility. Gloves are located by patient sinks and at the entrance to patient rooms. If you need additional supplies, please follow up with your department contact. Standard Precautions safeguard you and the patient against infection. These precautions must be used for ALL patients even if a patient is on an additional precaution. Wash/gel hands upon entering and leaving the patient s room and after contact with any body fluids. Cough into arm or, if using a tissue, dispose of it directly into a trash container and wash/gel hands. Wear gloves and gown when coming into contact with body fluids. This is MANDATORY. Use a mask and goggles/face shield if working with open wounds or for invasive procedures. Use sharps safely and dispose of them into a sharps container. Clean and disinfect multi-use patient care equipment between patients.
Isolation Precautions Signage Precaution signs for patient rooms: Follow instructions on sign when entering an isolation room. Front Staff Instructions Posted on Patient s Door Back Patient, family, and visitor information sheets
Accidental Exposure If you are accidentally exposed to blood or other bodily fluids: Wash the area with soap and water. Contact your Supervisor or Manager on duty immediately. Fill out the Work Related Injury/Illness Report as soon as possible. Report to an Emergency Room, Urgent Care, or your private physician depending on the type of exposure. The source person also needs to be tested, if known. Post-exposure Prophylaxis (PRP) may be done if there is a high risk blood exposure. Confidential follow-up will be done, if needed.
Infection Control Points Follow these guidelines to aid in reducing the spread of infection: Treat all blood and body fluids as infected (Standard Precautions) All trash and linen are considered contaminated; handle as little as possible. Never use hands or feet to compact trash. Clean equipment between patient use. Clean any contaminated equipment or surfaces. Food trays are considered dirty after being returned to food carts. Use antiseptic wipes on phones and computer keyboards daily. Contain any spills and call Housekeeping, so they can clean using correct cleaning solution per MSDS sheet. Use dedicated equipment for patient in isolation (manual B/P cuff, stethoscope, thermometer) & leave it in the room If you use Integrity, you will have to use the ideal kill-time of 10 minutes! (use the disinfectant spray to clean the B/P cuff Velcro)
Customer Service St. Luke s is committed to providing an excellent experience valued by all employees, patients and visitors. Always use manners such as please and thank you Always knock prior to entering a patient s room and ask for permission to enter. Always thank patient/family members prior to leaving a patient s room or treatment area. Always ask a patient/family member if there Is anything else that I can do? I have time. Always act with honesty, integrity, loyalty. Not engage in gossip. Always manage up. Do not blame someone else for a problem. Do not discuss staffing, other personnel or sensitive personal issue in front of patients, families or peers. Recognize coworkers for their hard work and efforts.
Professional Relationships As employees of St. Luke s, it is important to be aware of the trust and attraction issues that may arise during patient care. Staff will not enter into personal relationships with patients or their family members during the course of the patient s treatment. Staff members who have had a prior relationship with a patient prior to treatment, will notify his/her supervisor and attempt to exclude themselves from the treatment. Staff members will not enter into a personal or sexual relationship with a previous patient from discharge to 2 years. (The Department of Health may have specific timelines based on the licensed professional, please refer to applicable WAC and/or RCW.)
Conscience Conflict If an employee perceives that participation in the care of a given patient is in conflict with personal values, ethics or religious beliefs, he or she should immediately contact their Manager or Nursing Supervisor on duty. An assignment will be made for another employee to care for the patient, as soon as practical, while the issue is being resolved, in order to ensure that no patient's care will be compromised. An evaluation of the employee's request, and a decision regarding the request will be made within 48 hours. This decision will be made in conjunction with HR and the employee s Director.
Diversity and Inclusion
Benefits of Diversity in the Workplace Inclusion helps to build teams and enhances communication skills that brings in new attitudes and processes that profit the whole team With so many different and diverse minds coming together, many more solutions will arise as every individual brings in their way of thinking, operating and solving problems and decision making Attracting and retaining talent adds a competitive edge to any organization. Feeling included and appreciated increases loyalty and feeling of belonging. Diversity in our employee populations assists us in meeting our diverse patient and customer base Prevention of risk for discriminatory practices in the workplace
What You Can Do Recognize each person as an individual. Be aware of and try to correct your biases Stop people when you hear them joke about or put down others Reach out and invite people to join you Get to know people from other cultures and share stories Try to understand people where they are coming from. Most of them have reasons for what they do Deal with conflicts right away instead of carrying grudges.
Patient Demographics St. Luke s Rehabilitation staff serve patients with diverse race, ethnicity, age, gender and religious background. As care providers it is important for us to recognize the needs of the patient served. For more information: There is a Culture and Clinical Care resource handbook at each of the St. Luke s locations and Inpatient team offices.
Process Improvement & Outcomes
PDSA St. Luke s uses the process improvement model known as PDSA. These letters stand for PLAN, DO, STUDY, and ACT. These four steps are used by quality improvement teams to systematically improve processes. Step 1: PLAN In this step, the improvement team (a group of employees and a team leader) decides a process improvement project is needed and clearly defines what is going to be improved. The improvement could involve a patient care process or a non-patient care process. The team: 1. Reviews any information available regarding the current level of performance 2. Sets a measurable goal for improvement 3. Decides what will be done to improve 4. Tests its improvement idea to see if it works
PDSA Step 2: DO In this step, the team implements its improvement plan and collects data to measure the effectiveness of the improvement it has implemented. Step 3: STUDY In this step, the team reviews the data. It checks to see whether or not the goal was achieved. Step 4: ACT If the goal has been achieved, the team monitors the data for several months to ensure the improvement gains are maintained. If the goal has not been achieved, the team makes changes to its improvement plan and implements revised plans until the goal is met.
Outcome Systems & Measures St. Luke s collects, summarizes (aggregates), and analyzes patient outcomes. Outcome data is important because it tells the organization how well patients are functioning during treatment and after discharge. Data is collected to evaluate the effectiveness of treatment, efficiency of treatment (resource use), access to services, and overall customer satisfaction. Some examples of the outcomes collected for Inpatient Rehabilitation are: Press Ganey Inpatient Satisfaction Survey: a survey mailed to the patient s home 2 weeks after discharge Functional Independence Measures (FIM): the patient s level of functioning assessed by nurses and therapists, using the FIM scoring tool Med Tel Outcomes: the patient s level of functioning assessed using the FIM tool. This survey is completed via telephone 90 days after discharge.
More Outcome Systems & Measures Some examples of the outcomes St. Luke s collects and analyzes for Outpatient Rehabilitation, the Pain Program, and Occupational Rehabilitation Program are: Admission and discharge physical capacities Average number of days from referral to initial evaluation Patient s employment status: Is there a return to work plan? Focus on Therapeutic Outcomes (FOTO): functional status and patient satisfaction
Uses of Outcome Data Each quarter, St. Luke s receives performance reports from contracted companies to provide outcomes data. These companies include: Press Ganey, UDSmr (FIM), Med Tel Outcomes, and FOTO. The reports show how St. Luke s is performing in comparison to other rehab facilities. This helps St. Luke s know how it ranks, and if there are areas for improvement. These reports are presented to the St. Luke s Quality Council Committee, and improvement action plans are developed and implemented as needed. The Outpatient, Chronic Pain, and Occupational Rehab Programs compare their data with their performance in previous quarters, so they can identify opportunities for improvement.
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