2017 Joint Commission SmartBook

"Remember: It's not about the next
Joint Commission survey, it is about

the next patient care experience.”

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LRMC Joint Commission

STAFF SMARTBOOK

“It’s not about the next Joint Commission survey,
it’s about the next patient care experience.”

COL JAMES A. LATERZA
Commander, LRMC

MISSION
LRMC (PRIDE) The strategic medical platform delivering Professional,
Reliable and Innovative care by a team Devoted to Excellence

VISION
A team of professionals inspiring patient trust and respect; the leader
in the global medicine environment.

IMPORTANCE OF STAFF PREPARATION
The Joint Commission (TJC) survey process requires commitment
from all LRMC and Army Health Clinics staff, to include military, ci-
vilian, and Local National members, from every department, unit,
and clinical area. Continuous Survey Readiness is our commitment
to the quality and safety of our patients. TJC certifies our achieve-
ment of this goal and assists us with improving our hospital.
But, it’s not just about “passing the TJC test”. It’s about the safe,
quality care we provide for our patients every day. While Readiness
is our main strategic objective, preventing medical mistakes (“Zero
preventable Harm”) is at the core of this. We continuously strive to
improve the care we deliver to our patients, as we embrace the ten-
ets of a High Reliability Organization.
Thank you for your continuous cooperation and collaboration. We
wish you a successful TJC survey!

-QMD Staff

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LRMC POLICIES AND MEMOS

POLICIES & MEMORANDAS Numbers

Medical By Laws LRMC PAM 40-2
MEDCOM 15-043
Chaperone LRMC PAM 40-9
Infection Prevention and Control LRMC 40-59
MEDCOM 16-102
Falls prevention LRMC 40-2
LRMC 40-56
NPSG - Alarms Fatigue LRMC 600-2
LRMC 420-2
Two identifiers LRMC 40-60
LRMC 40-84
Medical orders (VO/TO) LRMC 40-110
Smoking Policy LRMC 40-8
Fire & Safety LRMC 40-86
Sign Consents LRMC 40-92
Moderate Sedation LRMC 40-15
Patient Rights LRMC 40-29
Restraint LRMC 40-69
Staff Right LRMC 40-61
Ethic Committee LRMC 40-19
Patient Records LRMC 40-83
Critical Values
Language Line LRMC 190-5
Time Out LRMC 40-51
Patient Safety
Identify and Report Domestic Abuse

Security
Medication Reconciliation

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JOINT COMMISSION MEDSHARE

https://medsharevm.ermc.amedd.army.mil/sites/LRMC/
DCCS/qmd/default.aspx

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LRMC STRATEGIC PRIORITIES

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TJC GENERAL INFORMATION
Since its founding in 1951, TJC has been
acknowledged as the leader in developing the
highest standards for quality and safety in the
delivery of health care, and evaluating organi-
zation performance based on these standards.
Operational Definitions
Standard: Performance expectations, structures, or processes
that provide the foundation for safe, high quality care, treatment,
and services.
Element of Performance: Specific performance expectations,
structures, or processes that must be in place in order to provide
safe, high quality care, treatment, and services.
SAFER Matrix: New TJC Scoring system (JAN 2017)
•Real time evaluation of deficiencies on SAFER matrix, to
assess likelihood of harm and scope (i.e. how widespread).
•Single observation could reveal widespread problem.
•No more Direct/Indirect Impact findings.

https://www.jointcommission.org/safer_matrix_new_scoring_methodology/

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TRANSPLANT SERVICES

TRANSPLANTS SERVICES
Q. Does LRMC do organs transplant? Y/N
A. No, we do not perform organ transplants. However, we do have

tissues that are implanted.
B. However, if the appropriate medical situation results in a poten-

tial for organ-donation in our hospital, a local team (i.e. German)
will come in to harvest those organs.

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WET PREP/KOH PREP TESTING
Only some providers are allowed to perform the Wet PREP/KOH
testing. Certification (CAP and CLIP) MUST be in place.
MODERATE AND HIGH COMPLEXITY TESTING
Moderate and High Complexity Testing are performed by the lab.

All records are maintained for a period of at least 2 years, and are
kept at the site performing the testing.

Quality Control records must include results of internal (when appli-
cable) and external controls, and individual patient results must be
able to be traced to associated Quality Control and Instrument Rec-
ords.

Instrument Records include any required functional check, tempera-
ture recordings, maintenance, etc., for instruments used in perform-
ing patient tests. Patient test results must be documented in the pa-
tient’s clinical records.

Q. What clinical areas in LRMC perform Point Of Care Testing?

A.

 ICU

 ED

 NICU

 8D

 L&D

 APU

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HOW TO USE THIS SMARTBOOK

This Smart Book is a tool for preparation for the Joint Commis-
sion Survey which can serve as a reference for basic organization
policies and procedures. Each section contains relevant infor-
mation that every staff in the organization should know.

THE IMPORTANCE OF STAFF PREPARATION

The Joint Commission (TJC) survey process affects all LRMC staff.
This includes everyone from doctors and nurses, to housekeep-
ers, logistical support, and facility maintenance. We are ALL re-
sponsible for the continuous survey readiness (CSR), and the
commitment to daily quality, safe care environment.

Any member of this organization (to include housekeeping, facil-
ity maintenance, etc.) may be stopped in the hallway and ques-
tioned by a surveyor. YOU COULD BE THAT PERSON.

Our challenge is for ALL staff at ALL levels to be fully prepared to
comfortably state the answer (or at least know where to find the
answer) to any question that may be asked by the JC surveyors at
any time. We must continue to perform our daily activities in a
way that depicts our commitment to excellence in quality
healthcare. Remember: it’s not about the Joint Commission sur-
vey, it’s about the safe, quality healthcare that we deliver every
day.

UNIT LEVEL PERFOMANCE IMPROVEMENT (PI) PROJECT

It is the responsibility of all staff to learn about their section’s PI
project. Ask about the current and immediate past PI projects,
and why that PI project was chosen. Finally, have a discussion
with your unit leadership on how that project supports the ten-
ets of a high reliability organization (HRO).

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TJC PREPARATION/INFORMATION

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WAIVED TESTING
POINT OF CARE TESTING (POCT)
Point Of Care Testing refers to performing a lab test at the point of
care or where the patient receives care. The complexity of the testing
is classified as waived testing.
WAIVED TESTS (WT)
Waived tests use methods that are simple and accurate as to render
the likelihood of erroneous results negligible, pose no reasonable risk
or harm to the patient if performed incorrectly, and have been cleared
by FDA for home use.
Waived test may be performed by personnel who have been
TRAINED and demonstrate COMPETENCY.
POCT examples are the following:
 Finger stick Glucose
 Urine Dipstick
 Rapid Strep testing
 Urine Pregnancy test
QUALITY CHECK FOR POCT
Quality Control is necessary to verify that equipment, reagents, and
test methods used are working properly.
Appropriate/required Quality Control is defined in each test proce-
dure and must be performed as stated in the procedure.
*If Quality Control does not meet established criteria, patient
testing cannot be performed
PROVIDER PERFORMED MICROSCOPY (PPM)
PPM requires examination to be personally performed by a physician,

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RECORD OF CARE
What is the requirement for the Informed Consent?

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TJC PREP/SURVEY ETIQUETTE

Make a good first impression. Act and dress professionally. This in-
cludes wearing a clean lab coat, scrubs, shoes or boots.

Don’t panic! Take a deep breath.

Smile and greet the surveyor.

Be able to articulate the “Scope of Service” for your unit, PI projects,
success stories, and lessons learned. Be proud of your area!

All staff members must wear their LRMC/AHCs identification badges
while on duty IAW LRMC Memo 190-6, Staff Identification Badge
Policy.

Do not argue with the surveyor. Listen carefully to the question and
answer honestly. If you do not understand the surveyor's question,
ask for clarification or to restate the question. When in doubt, con-
tact your supervisor or refer to a policy. If you do not know, say you
don’t know. Do NOT make up an answer (they will know it.)

If the surveyor asks to speak to a patient or family member, remem-
ber to obtain permission from the patient/family member before
you bring the surveyor into the patient's room.

Just answer the question asked--Never volunteer additional or unre-
lated information. Refrain from embellishing information.

Reply with “Yes or No Ma’am or Sir.”

Show enthusiasm for your job! Avoid becoming defensive. Survey-
ors are asked to perform this service for us. Aggressive behavior
may trigger defensive responses from all involved.

Speak in a positive manner. When appropriate, use phrases like,
“Always or Never” and avoid phrases like “Sometimes,” “We try,”
“Occasionally,” or “I think, feel, or assume.” These phrases imply
that you are not consistent. Base your answers on data, information,
and knowledge.

• Remember: if you are asked a question that you don’t know, a safe
answer would be “I would ask my supervisor”. (Don’t make up an-
swers. The surveyors will know…)

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Keep your worksite clean and orderly. Signs and papers should not
be taped or thumb tacked to walls, windows, or other surfaces.
Data on bulletin boards should be up to date and should be dis-
played in a professional manner.
Display information on Advanced Medical Directives, Patient Rights,
and applicable patient education on an appropriate bulletin board.
Be sure you binders are current for safety, infection control, MSDS
(now changed to SDS) material, and emergency planning.

TJC PREPARATION/HELPFUL TIPS AND HINTS
Elements of the visit usually include:

 Discussion with the unit manager

 Tour of the unit

 Conversation with patient and family who have consented to
participate

 A “TRACER” patient may be followed through the MTF, (e.g.
“I’m a patient with acute chest pain. Walk me through your sys-
tem.”)

 Patients’ medical records from clinic or inpatient visits may be
reviewed. The surveyors will identify the medical records of their
choice.
It is a survey with surveyors, not an inspection by inspectors. A goal
of the surveyors is to educate us on alternative or better ways to do
things. Take advantage of suggestions or information they are will-
ing to share.
Remember: Patient privacy will always be scrutinized in both the
ambulatory care and inpatient settings.

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PERFORMANCE IMPROVEMENT (PI)
What staff members need to know about their area?
 Who is your ward / section / area PI Representative?
 Where is my ward / section / area PI Binder located?
 What PI Project(s) is your ward / section / area working on?
 How do these project(s): enhance patient outcomes, decrease

patient safety events, impact organizational effectiveness?
 What are my roles / responsibilities in these projects?
 During the past year, what PI project are you most proud of

(why)?
 How does my project support high reliability tenets (HRO)?

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PERFORMANCE IMPROVEMENT (PI)
When looking at your processes, consider:
 Efficacy: Are we getting the desired result?
 Appropriateness: Is this relevant to the patient?
 Availability: Available when the patient needs it?
 Timeliness: Provided at the best

time?
 Effectiveness: Was it provided correctly
 Continuity: Was the care coordinated?
 Safety: Was the risk reduced?
 Efficiency: Outcomes v. cost of resources
 Respect and Caring: Were we sensitive and collaborative with

the patients?

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Informed consents must be obtained prior to the administration of
blood or blood products. If the patient is too unstable to obtain an
informed consent, two providers can sign and document in the Pro-
gress Notes.

Ensure that you child-proof exposed electrical outlets where neces-
sary.

Use of Log books/Sign-in books should be minimal and should not
contain the patient’s SSN/patient information i.e. diagnosis.

Medications should be stored appropriately, expiration dates should
be monitored regularly, and medication should be replaced before
expiration.

Patient interviews will likely be conducted to assess education on
their illness or hospitalization. Examples are as follows: “Are you
getting the information you need about your illness? Do you know
what you are getting in your IV? What is the Heparin for? How long
will you be here? When you go home, what medication(s) will you
need? Will you be back to the clinic after discharge? How do you feel
the staff has explained things to you? Was the staff able to spend
time with you to alleviate your anxieties? If you could change any-
thing about your hospitalization, what would it be?”

Be able to describe improvements in patient care, to include im-
provements in patient safety that resulted from the performance im-
provement initiatives undertaken in your work area.

Emphasize that we are always looking for ways to improve the deliv-
ery of patient care by improving existing programs and processes.

You should be able to describe procedures related to your job. But, in
some cases, a surveyor may ask you to explain or demonstrate a gen-
eral procedure, for example, “What you would do in case of a fire?”

Know where the SOPs, Regulations and LRMC policies are located in
your department/unit and on the MEDSHARE website.

 Know how information gets to you from your leadership?

 Know how you get information to your most junior soldier/
airman/employee.

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Think about how your work relates to the overall mission and
vision, as well as how it helps meet the organization’s overall
goals.

 Review the mission and vision statements.

 Fire, disaster and other safety procedures.

 Understand policies and procedures. These include:

 By-laws, policies and regulations

 Performance Improvement Plan

Participate in the Joint Commission Continuous Readiness activi-
ties (i.e. tracer tours, TJC University, TJC Highly Focused Training
(HeFTy)). Participate in unit/departmental mock surveys. These
self-assessments can improve policies and procedures and help
ease anxiety by giving you a chance to practice.

Know the Joint Commission standards that pertain to your job,
area, and department. Be sure to take part in all training sessions,
read materials your supervisor provides, and ask questions if you
are not sure how a standard affects your work.

If you do not know the specific answer to a question, describe
how you would find out the information and where you would go
for the answer. This might include a policy, a supervisor, or an-
other department.

Practice explaining what you do.

Again, relax. Remember to:

 Answer with confidence

 Be friendly and smile

 Be aware of your body language (facial expressions, gestures,
attitudes, etc.).

Emphasize TeamSTEPPS & teamwork. Let the surveyors know
that you work with others , both inside and outside your service/
work area, to get the job done.

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PERFORMANCE IMPROVEMENT (PI)
POC: Richard Rhodes, Performance Improvement Program Manager,
590-8704
Reference: LRMC MEMO 40-66, Performance Improvement Plan
PI MEDSHARE Site: Found under DCQS, QMD, PI
The goal of PI: is a continuous process that uses data to measure im-
portant processes and services that focus on outcomes of care, treat-
ment, and services.

PI is:
 data driven
 a continuous process
 measuring important processes and services
 focusing on outcomes of care, treatment, and services

PI is not:

 changing a process or service unless data supported
 reworking a memo / policy / regulation
 buying new equipment unless data supported
 an “officer-driven” program

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HIPAA

POC: Eric Emmer-Ross, Royce Staley
Goal: To ensure that individuals’ health information is properly
protected while allowing the flow of health information needed
to provide and promote high quality health care, as well as to
mitigate and resolve breaches that do occur.
What is HIPAA?
Public Law 104-191 Health Insurance Portability and Accounta-
bility Act of 1996; Section 1177 of Subtitle F—Administrative
Simplification addresses wrongful disclosure of individually
identifiable health information.
What does HIPAA cover?
The protected health information of all recipients of health care.
What is the difference between HIPAA and PHI?
HIPAA is public law that addresses health care access, portabil-
ity and renewability of insurance coverage.
PHI is protected health information, which is addressed within
HIPAA.
What is the training requirement for HIPAA?
All staff members are required to complete core HIPAA training
on initial entry to the organization, as well as annual HIPAA re-
fresher training. Where required, remedial training is also con-
ducted.

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Your chain of Command should be the first line to resolve issues
or concerns at the lowest level. However, as a staff member, you
have a right to contact The Joint Commission about concerns of safe-
ty or quality of care being provided by LRMC, without fear of re-
course for your actions.

Quick scenarios for TJC prep

Q1. The surveyors just arrived at your unit, department or clin-
ic; now what do you do?
A1. The staff member should shake hands, introduce yourself, ask to
see a form of ID such as a visitor's badge, and ask the purpose for
the visit. Ask for another staff member to get the OIC and NCOIC, if
not already with the surveyors. This is YOUR work center; be in con-
trol, but courteous, and professional. BE PROUD OF YOUR AREA!

Q2. What information do you give the surveyors after introduc-
tions are completed?
A2a. For Inpatient Areas- Unit's mission, bed capacity, staff
(providers, nurses, medics and clerks), average daily census, average
length of stay, types of patients you care for (high volume-low risk
and low volume-high risk), age range of your patients (pediatric,
adult and elderly), types of procedures performed on the ward (Top
5 Current Procedural Terminology), [CPT] codes with Patient Ad-
ministration [PAD]). Percent of patients coming from OIR/OEF, AF-
RICOM (combat related).

A2b. For Outpatient Areas- Unit's mission, outpatient visits per day
(average) and per year, staff (providers, nurses, medics/technicians
and clerks), types of patients you care for (high volume-low risk and
low volume-high risk), age range of your patients (pediatric, adults
and elderly), top five procedures performed in the clinic (research
your CPT codes with PAD

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Q3. Where do you take the surveyors if they want to interview
your staff?
A3. Surveyors should be escorted to a private location such as your
conference room, staff lounge or room large enough for a group.
Consider privacy of the information being discussed since surveyors
will most likely review charts (electronic and/or paper) and inter-
view staff members as to the coordination of the care, treatment and
procedures related to specific patients. This is the surveyor's first
impression of your environment and how management is running
operations!

Items to have readily accessible for the surveyors:
-CAF for all assigned/attached staff member to include volunteers
-HAZMAT binder
-Patient Safety binder
-PI binder
-Infection Control binder
-EC binder
-Equipment binder or log where you track your medical equipment
-Work order log complete with dates and status of work order re-
quests.

ITEMS TO CHECK BEFORE YOUR TJC VISIT:

 Is the meeting room clean and clutter free?
 Are all posters (e.g., NPSGs and PI) current on all bulletin

boards?
 Are cardboard boxes removed off the floor within 30 minutes of

arrival to the unit?
 Are microwaves, refrigerators and other wares clean and clutter

free?
 Is your supply room clean, clutter free and all (100%) supplies

within expiration dates?
 Is your equipment room clean, clutter free and all (100%)

equipment with an updated DD2163?

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Patient Advocacy:
POCs: Elaine Williams; Judith Srey
The goal of the Patient advocacy is:
To ensure that we meet our patients’ expectations at every en-
counter.

What is a Patient Advocate?
Patient advocates support and promote patients' rights as they
navigate the health care system.
Serves as a liaison between patients and Landstuhl Regional Med-
ical Center (LRMC), the hospital staff and the community for is-
sues pertaining to patient’s rights and care. The office acts on be-
half of the patient and the Hospital Commander to resolve prob-
lems, expedite services or implement necessary corrective meas-
ure measures within established facility policies, and where ap-
propriate through committee participation. Assists patients in
understanding their rights as well as their responsibilities
Who and when patients can be refer to the patient advocacy? All
patients and family members are free to contact the patient advo-
cate via email at:
[email protected]
or 590-8326/6589

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How do I contact the Ethics Committee and/or request a meeting?

Notify the attending physician of patient for whom a consult is re-
quested. The physician will contact the DCCS to request an Ethics
Committee Review. The decision will then be made as to whether
or not to convene an Ethics Committee meeting .

When should you refer a patient or staff request to the Ethics Com-
mittee?

If such issues arise which may include, but are not limited to: treat-
ment refusal, withholding or withdrawal of life support systems,
rationing limited medical resources, and/or issues involving clini-
cal care, research, and educational priorities.

Who are the members of the Ethics Committee?

 Medical Corps Officer or Civilian Medical Physician
 Nurse Corps Officer or Civilian Registered Nurse
 Medical Service Corps of Officer
 Chaplain Corps Officer/Representative
 Judge Advocate General Corps Officer/Representative
 Senior Member of the Hospital Corps
 Behavioral Healthcare Representative- (Formerly SWS)
 Patient Advocate Representative
 If available, a Medical Ethicist
 Local subject matter expert on AdHoc basis

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ITEMS TO CHECK BEFORE TJC VISIT (continued) ...

 In every room, are items stored below 18" from the sprinkler
head?

 Do all under sink areas contain only "in use" cleaning supplies?
 Are all medications and sharps (needles, blades, etc.) secured

and under lock?
 Are all eye wash stations inspected weekly and free of obstruc-

tion? Is this documented? (for 12 months!)
 Are all doors leading to eyewash stations properly labeled?
 Are all fire extinguishers inspected monthly and inspections

documented? ( for 12 months!)
 Are all curtains clean (labeled with 6 months from last wash)?
 Are all sharps containers less than 3/4 full, mounted on wall,

keys removed and no items stored directly on top?
 Are all medication/food refrigerator temperatures logged daily

and cleanings conducted weekly?
 Are all hand sanitizers stocked with gel that is within expira-

tion dates (open the Purell dispenser and look)?
 Are all corridors and egress doors free of obstruction (carts,

beds, boxes, or nutrition carts)? NOT propped open?
 Are all staff members wearing their hospital badge? (expired?)
 Are all CAFs available and up-to-date (Key topics; EC, IC and

Unit Orientation)?
 Are patients screened for falls and pain? If so, how do you doc-

ument screening and further assessment if patient is at risk for
falls or has pain?
 Are Look Alike/Sound Alike Medications and/or High Risk
medications stored in the unit? If so, how are they segregated,
stored, and labeled? Where is the list located? Who approved
this list and how often is the list revised? How do items make it
into the list?
 Where are your primary and secondary means of egress
during a Code Red (fire)? Rally point?
 Remember: rehearse of at least discuss code plans with all
people who work on the unit (to include housekeeping).

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THINGS TO CHECK BEFORE YOUR TJC VISIT (continued…)

 Who is authorized to shut off any of the medical gases such as O2
in the unit? (Must match SOPs!) Who is authorized to turn back
on?

 Where do you keep your medical record delinquency/end of day
report?

 Are consent forms signed, dated, timed (witness, patient and
provider)?

 Are basic hands washing instructions in all bathrooms?
 Are combinations to locks exchanged (anesthesia and medica-

tion carts and pharmacy)?
 Are functional, nutritional, suicide risks and pain assessments

documented?
 Is the treatment plan agreed upon with the patient and is it doc-

umented?
 Are chaperone signs placed where they are required?
 Can the staff articulate what to do during any of the emergency

codes ?

 Know how each of the Priority Focus Areas affects your area and
your processes:

 Care of Patients, Rights and Ethics
 Credentialed and Privileged Providers
 Patient Safety
 Infection Prevention and Control
 Performance Improvement
 Medication Management Staffing
 Orientation and Training of Staff Equipment Use
 Communication within the Organization
 Information Management
 Organizational Structure
 Physical Environment

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INDIVIDUAL RIGHTS & RESPONSIBILITIES (RI)

POC: LTC Doug Weeks

Reference: LRMC Memo 40-110. LRMC Memo 40-92

Goal: To ensure that Landstuhl Regional Medical Center maintains
the highest standard of ethical patient care, to include respect for
the rights and dignity of its beneficiary population, and provision of
considerate, respectful patient-centered care.

What is RI and what does it cover?

To affirm the patient’s right to make decisions regarding medical
care, including the decision to discontinue life-sustaining treatment
to the extent permitted by law and military regulations, and to en-
sure the hospital staff assists patients in exercising their rights.

To inform and aid patients, families and designated surrogates in
understanding and upholding their responsibilities with respect to
care, care givers, and others impacted by them in the hospital and
clinic setting.

What are the functions of the Ethics Committee?

To improve care, treatment, service, outcomes and general business
practices by recognizing and respecting the rights of patients and
staff, in accordance with ethical principles. Said principles will en-
sure that all services are provided in a manner that respects and
fosters dignity, autonomy, positive self-regard, civil rights and pa-
tient involvement.

To provide guidance in establishing hospital policy and procedures
and for addressing medical ethics issues raised by an MTF staff
member, patients, family member or other interested party.

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RESTRAINTS
Q. What clinical areas in LRMC use restraints?
A.
 In-patient Psychiatric unit (9C)
 Emergency Room
 ICU
Q. When we can seclude a patient?
A. LRMC does not seclude patients.
Q. How is the medical staff involved in the need for equipment in
each section?
A. All team members/staff have input including the medical staff.
Equipment is requested through the department/section chief or
NCOIC.
Q. How do you processes provide continuity of care among the as-
sessment and diagnosis, planning and treatment phase of the pa-
tient’s services?

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Q4. What do you do if the surveyors are interested in ob-
serving a procedure?
A4: Review the list of procedures that are scheduled in your unit,
request authorization from the patient/caregiver, ensure room is
ready, patient privacy is maximized, and that any documentation
related to the procedure such as the informed consent and "time
out" are completed accurately and expeditiously. Ensure that "time
out" is conducted with staff placing full attention to the task and
stopping all other distractions. Ensure staff is following infection
control procedures, wearing correct PPE and that patient's pain is
managed appropriately. Ensure documentation includes follow-up,
pain control, contact information if complications arise. Document
patient discharge planning education.
Other key information:
Again, minimize use of words like "normally", "usually",
"sometimes" as they reflect variations in the procedures/policy!
Articulate how you manage restraints, pain management, medica-
tion reconciliation, falls, handoffs, medication management, patient
identifiers and critical tests and results!
Don't pre-label any syringes. Label only after medication is in the
syringe if not injecting immediately after drawing without breaks
or pauses in the process!
Anesthesia and medication carts (Pyxis) - Inventory list, security
and safety!
Articulate how you protect your patients from harm and ensuring
the use of National Patient Safety Goals (NPSGs)!

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LRMC JC FMTs/SMEs

Functional Telephone

TJC Chapters

Management Team DSN 590-

Leadership (LD) COL Laterza 8105
Medical Staff (MS) Col Martinez 8385
Nursing (NR) COL Hall 8110
Behavior Health (CTS) Dr. Brown 5249
Environment of Care (EC) LTC Aquino 8279

Life Safety - Fire Safety / Utilities (LS) Mr. Keeling 4268

Human Resources (HR) Mr. Reisler 6827

Infection Prevention and Control (IC) Ms. M. Jane Pool 8508

Information Management (IM) LTC Peters 8699
Emergency Management (EM) Mr. Beltra 7349
Medication Management (MM) LTC Walthall 5513

National Patient Safety Goal (NPSG) Ms. Bonin 4851

Performance Improvement (PI) Mr. Rhodes 8704
Provision of Care (PC) LTC O’Connell 5536
Waived Testing (WT) MAJ Grave 4324
Record of Care, Treatment & Services
(RC) Mr. Staley 4248
Rights and Responsibilities (RI)
Transplant Services (TS) LTC Weeks 4293
Ms. Mozdy 5143

EOC Pillars and QMD / JC Coordinator 6497
5815
Medical Maintenance (EOC) Mr. Gasaway 6566
8015
HAZMAT (EOC) MAJ Dais
Safety (EOC) Mr. Raith
Security (EOC) Mr. Hawthorne

Deputy, Quality Management Division COL Smith 6620

Joint Commission Readiness LTC Rosa 4158

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Child Abuse /Neglect Indicators:

 Unexplained bruises, welts, burns
 Unkempt, malnourished appearance
 Scarring/discoloration in genital area
 Bruises on non-bony parts of body
 Loss of appetite
 Disturbed sleep
 Childhood immunizations not current
 Extensive dental cavities
 Excessive absences from school

Spouse Abuse (Domestic Violence) indicators:

 Injuries minimized by the victim
 Inadequate explanation of injuries
 Serious bleeding injuries to face, head & internal organs
 Frequent presentations for physical injury
 Continuous somatic symptoms
 Person threatened or injured with a weapon
 Any injury during pregnancy
 Person reports being sexually assaulted

Elder Abuse (Care Provider) Abuse Indicators:

 Neglect, isolation, emotional abuse,
 Physical injury, misuse of monies or over medicating a person

over 65 year of age
 Old and new bruises, indicating frequent repeated injuries
 Fractures/signs of fracture with unreasonable explanation
 Untreated injuries/medical conditions
 Bedsores

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BEHAVIORAL HEALTH
Identification of Individuals at Risk for Suicide.
Q. What is the process for assessing patients at risk for suicide at
LRMC?
A. LRMC has developed two questions that must be administered
and answered at each patient visit in the Outpatient Primary Care
clinics. Behavioral Health has a more expansive checklist for pa-
tients. It is very important to note that if for any reason a staff mem-
ber suspects a patient may be at risk for suicide. The Behavioral
Health section must be contacted immediately to coordinate care.
PATIENT ABUSE
Q. As an employee, what should you do if you suspect a patient is a
potential victim of abuse?
A. All suspected cases of abuse are reported to Social Work services.
Q. How were you trained in cases of abuse?
A. Each employee is trained about abuse during initial unit orienta-
tion. This information is also shared in Identifying and Reporting
Suspected Abuse and LRMC Memorandum _40-83, Sexual Assault.
Q How do you identify a victim of abuse?
A. Staff members need to know if a patient has been abused as well
as the extent and circumstances, in order to give the patient appro-
priate care. Objective criteria for identifying and assessing possible
victims of abuse are used.

64

HOW COMMUNICATION OCCURS/INFORMATION FLOWS
FROM LEADERSHIP TO THE STAFF

The Hospital Commander passes information to the most junior
staff member through various channels.
 Adjutant Notes
 Commander’s Notes
 Town Halls
 Hospital Newcomer’s Orientation
 “Coffee with the Commander “
 Via chain of command and various committees

The Deputy Commander of Clinical Services (DCCS) communi-
cates with his/her medical staff via:
 Executive Committee of the Medical Staff (ECOMS) meeting
 Professional Medical Staff Meeting (PROSTAFF)

The Deputy Commander of Nursing (DCN) communicates with
his/her nursing staff and nurses via:
 Nursing Executive Staff Meeting (NEC)
 Town Hall

The Deputy Commander for Administration (DCA) communi-
cate with his/her staff via:
 Adjutant Notes

17

ENVIOREMENT OF CARE (EOC)

Environment of Care Plan

Safety Security
Mr. Raith, 590-8616 Mr. Hawthorne, 590-8015

Fire Safety HAZMAT
Mr. Keeling, 486-6352 MAJ Dais, 590-6673

Equipment Management Utility Systems
CW3 Coehlo, 590-6229 Mr. Arseneau, 486-8795

18

INFORMED CONSENTS
The licensed independent provider is responsible to provide
the information to the patient about the procedure, including
the risks (side effects), benefits, and alternatives to treatment.
The nurse or other qualified health care staff can obtain the pa-
tient’s signature on the consent form ONLY AFTER the patient
has been fully informed by the licensed provider.
ALL consents must be signed by the provider, signed/dated,
and TIMED by the patient, and signed by the witness. (This
should occur in that order).
Q. What clinical areas in LRMC performs Moderate Sedation?
A: GI clinic-(colonoscopy/EGD); Cardiac Cath lab (Cardiology);
ICU (Pulmonary-bronchoscopy); ED.
Q. What is the Same Day Surgery discharge planning process?
A. It starts at the time of admission and focuses on meeting the
patient’s health care needs after discharge, to include:
 Physical, Emotional, Spiritual care at home
 Transportation
 Social and other needs

63

SURGICAL PATIENTS

The history and physical must be done within 30 days of the
procedure. Otherwise, the H and P must be redone on the
day of surgery.

Q. What must be documented in the patient record prior to a
surgical procedure?

 A completed Consent (signed, date/TIMED by patient,
signed by provider and witness)

 Doctor’s orders
 “Risks, benefits and alternatives” statement (H&P)
 Pre-OP H&P within 30 days (redo if older)
 Anesthesia Assessment
 Required laboratory and other diagnostic tests
 Site verification (TIME-OUT)

Q. Is there a Pre-anesthesia assessment performed for each
patient before anesthesia induction?

A. Yes, each patient receives a Pre-anesthesia assessment, in
Same Day Surgery unit/APU before going to the OR.

ADVANCED MEDICAL DIRECTIVES (AMD)

An advanced medical directive is a written statement of the pa-
tient’s wishes regarding their health care & medical treatment.
It’s used to guide decisions when and if the patient is unable to
communicate. This information is available in the Patient Ad-
ministration Division (PAD) office.

Q. Who is responsible to educated and ensure the AMD is avail-
able?

 Patient Administration Division (PAD)

 Nurses during the admission assessment

62

(EOC) SECURITY:

POC: Mike Hawthorne & Justin Bartoli/DSN 590-8015
Reference: LRMC Memo 190-5; LRMC Memo 190-6
MEDSHARE Site: https://medsharevm.ermc.amedd.army.mil/sites/

LRMC/DCA/otd/security/default.aspx
The goal of Security:
 To manage the security of patients, staff, and individuals com-

ing to the organization’s buildings; and
 Manage security of the established environment, equipment,

supplies and information as appropriate
What is Security? The protection of staff, patients and visitors
against criminal and terrorist events.

****Overall Staff Responsibility for Physical Security
IDENTIFICATION BADGES

 The LRMC Badge has an expiration date!

 The LRMC Badge identifies you as a LRMC employee to visitors
and patients, and helps identify unauthorized personnel.

 You are required to wear the badge while in the LRMC/Army
Health Clinics.

 Report lost badges immediately to the Security Office.

 Badges will not be worn when off duty, or outside the hospital.

 When you out-process, the badge will be collected by the Tran-
sition Center.

 Vendors/Contractors must be issued a visitor pass.

19

LIFE SAFETY / FIRE SAFETY

20

Q. How does staff assess patient/family understanding of what is
being taught?
A. Patient/family members verbalize or demonstrated understand-
ing, MUST be documented.
CLINICAL CARE OF THE PATIENT
Q. What factors does your work section consider when making pa-
tient care assignments?
A. Staff competency, licensure/certification, and training.
Q. How do you care, treatment and rehabilitation planning process
ensure that care is appropriate to the patient’s specific needs and the
severity of the disease, condition, impairment, or disability?
A. The patient’s individual needs are assessed during the initial visit
and each visit thereafter.
VERBAL ORDERS/TELEPHONE ORDERS (VO/TO)
 VOs (with very few exceptions) are only authorized in Emergen-

cies.
 VO/TOs need to be sign in 24 hours per TJC standards.
NUTRITION CARE
The patient’s concerns about diet, weight or nutrition status MUST
be addressed and documented during the first 24 hours of the ad-
mission.

61

EDUCATION OF THE PATIENT AND FAMILY
Q. Who is involved in patient/family education? How is it docu-
ment?
A. ALL health care personnel al LRMC are involved in patient edu-
cation. Patient education MUST be documented in the patient’s
record (AHLTA/Essentris).
Q. What two aspects should be considered when assessing educa-
tion needs of patients and families?
A. The patient’s ability to learn & learning needs, skills and

knowledge deficits: Culture , Religion, Emotional barriers, De-
sire and motivation , Physical /cognitive limitations, Language.
LANGUAGE LINE: When your patient requires an interpreter
for health care information exchange.
•This is not for translation of written reports.•Your doctor/nurse
cannot use YOU to interpret health care information.•If you are a
nurse, and speak (e.g.) German, you can speak with the patient di-
rectly; you cannot interpret for someone else. Use the language line
for inpatient services!•Document refusals in medical record.

60

21

SAFETY

LRMC Safety Manager:
Harry Raith
DSN: 590-8616
Email: [email protected]

Army Health Clinics Safety Manager:
Joe Petrotta
DSN: 590-6388
BB: 0173 670 1980
Email: [email protected]

LRMC Safety Specialist:
Henriette Moll
DSN: 590-8616
Email: [email protected]

LRMC Safety NCO:
SGT Daniel Woodruff
DSN: 590-4814
Email: [email protected]

Location
Building 3700, 3rd Floor, Room 310

22

CLINICAL CARE OF THE PATIENT
Q. What factors does your work section consider when making pa-
tient care assignments?
A. Staff competency, licensure/certification, and training.
Q. How do you care, treatment and rehabilitation planning process
ensure that care is appropriate to the patient’s specific needs and
the severity of the disease, condition, impairment, or disability?
A. The patient’s individual needs are assessed during the initial vis-
it and each visit thereafter.

59

CORDINATION OF PATIENT CARE
Care is coordinated throughout patient entry, assessment, diagno-
sis planning, treatment, and transfer or discharge with appropriate
resources within the continuum. Coordination of services may in-
volve social work, managed care, preventative medicine services,
physical therapy, vision and hearing, promoting communication to
facilitate family support to other follow-up. Through our referral
system and acknowledgment of results through telephone consults
(T-cons).
Q. How does LRMC provide patients with services that our organi-
zation CANNOT provide?
A. Outpatients are referred in the TRICARE network to obtain nec-
essary services. The provider requests follow-up on all external
referrals. Reports/results from outside referrals return to LRMC
either via mail or hand-carried by patient, and are scanned to the
patient’s medical record in HAIMS. Reports in other languages are
first translated by our certified translation service.

58

23

(EOC ) ENVORIMENTAL HEALTH
POC: MAJ Dais
Reference: LRMC 40-99 HAZMAT and LRMC 40-98 RMW
MEDSHARE Site: https://medsharevm.ermc.amedd.army.mil/

sites/LRMC/DCCS/pc/default.aspx
The goal of Environment health services: Ensure the wellbeing
and readiness of Soldiers and civilians inside our area of opera-
tions.
What is MSDS/SDS? Material Safety Data Sheets/Safety Data
Sheets use the same requirements to identify specific health haz-
ards related, and describe safety measures to use mitigate the
hazards.
NOTE: “MSDS” has been replaced by SDS. Please ensure your
SDS sheets have been updated in your SDS binder.
When to contact the EHS? After attempting to mitigate, notifying

your supervisor, and HAZMAT POC; then contact EHS.

24

PAIN ASSESSMENT AND MANAGEMENT
All patients (adult and pediatric) are to be screened and assessed
for pain. If the patient reports a problem with pain, the health care
provider will, within the scope of practice, conduct a focused initial
assessment of that pain. This assessment should seek to include the
following: location, onset, quality, duration, frequency, and intensity
of the pain, as well as aggravating and alleviating factors, the impact
the pain has on quality of life for functional activities, and significant
medication history.
The LRMC Pain Tool should be used for the assessment and manage-
ment of pain. The pain assessment is made by using appropriate/

57

PROVISION OF CARE

POCs: LTC OConnell, William

LTC Gladu, Michael

MAJ Miller, Justin

Provision of Care encompasses any and all services, procedures,
and processes which are involved with patient care.

All of the clinical LRMC Regulations are on-line in MEDSHARE.
Each section should have pertinent up to date SOPs easily available
for staff. It is advisable to print out pertinent regulations in case the
electronic system is not available.

Provider’s initial assessment should include:

Physiological
Cultural
Spiritual
Social (including potential for abuse)
Psychological
Educational
Nutritional
Functional
Discharge Planning Needs
Pain
Factors that trigger a more intense physical, nutritional, func-
tional, and/or psychological assessment:

Screening criteria
Treatment being sought
Patient’s medical condition (e.g. pain)
Patient’s agreement to treatment
Response to treatment
Requirements by Law or Regulation

56

Eye Wash Station

Quick Tips for Eye Wash inspection
LRMC Memo 40-99

1. Where should eye wash stations be located?
Within 50 feet or 10-second walk from workplace hazard.

2. Never behind a locked door; make sure path unimpeded.
3. Inspect weekly; let water run for 15 seconds or until clear.
4. Documentation: Maintain inspection log at eyewash station.

25