YECDCS Know Your Center

KNOW YOUR CENTER

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TABLE OF CONTENTS

I. Governance and Leadership (GLD)
II. Patient’s Rights and responsibilities (PRR)
III. Access to Care and Continuity of care
IV. Care of Patients (COP) and Assessment of Patients (AOP)
V. Patient and Family Education
VI. Medication Management and Use (MMU)
VII. Anesthesia and Surgical care
VIII. Quality Improvement and Patient Safety (QIPS)
IX. International Patient Safety Goals (IPSG)
X. Facility Management and Safety (FMS)
XI. Staff Qualification and Education (SQE)
XII. Management of Communication and Information (MCI)
XIII. Prevention and Control of Infection (PCI)

PURPOSE

This booklet has been prepared to serve as Reference guide for activities at Yateem
Eye Center and Day Care Surgery (YECDCS), which every employee needs to know.
For more specific information, please refer to the following sources;

 Your supervisor
 HR Policies
 Your Departmental Policy & Procedure Manual.
 Quality Improvement and Patient Safety Manual.
 Safety Management Internal & External Disaster Plan Manual.
 Infection Control Manual

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I. GOVERNANCE AND LEADERSHIP

Our Mission
To achieve our vision, we at YECDCSDCS are dedicated to:

1. Maintaining an unparalleled healthcare reputation, that positions the well-
established Yateem brand as the number one provider of eye care in
region.

2. Providing exemplary, compassionate and high quality comprehensive care
for each of our patients and their family.

3. Acquiring the latest state of art eye technologies and surgical platforms
conforming to the highest safety and quality standards.

4. Ensuring excellence through constant innovation, education, outreach
programs and continuous performance improvement.

5. Exhibiting effective stewardship and leadership in the management of all
available resources.

Our Vision
We aspire to be the most trusted and leading, region-wide source of the highest
quality contemporary eye care.

Core Values
1. Patient first: Our Patients are the reason why we are here and they are at the

center of everything we do. We always put our patients first.
2. Excellence: We are dedicated to be the best that we can be. We strive to

exceed our patients and stakeholders expectations every time.
3. Quality: We aim to maintain the highest quality standards. We achieve this by

continually measuring and improving our outcomes.
4. Trust: Honest and open communication with patients and stakeholders.
5. Compassion: We demonstrate our commitment to world-class care by

providing a supportive environment for our patients, patients’ families and fellow
caregivers.
6. Integrity: We provide service with honesty and honor; while complying with
laws, regulations, policies and procedures.
7. Teamwork: We collaborate and share knowledge to benefit patients and fellow
caregivers for the advancement of our mission.
8. Accountability: We accept responsibility for performance and act as stewards
of our financial, intellectual, and human resources.
9. Diversity: We understand and embrace the diverse beliefs, needs, and
expectation of our patients, community and employees.
10. Respect: We honor the uniqueness of each individual and treat him/her

equally.

GOVERNING BODY
 The governing for Yateem Eye Center and Day Care Surgery is the Executive

Committee chaired by the executive president Mr. Nasser Yateem.

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 We also have Medical Board chaired by Dr. Yogesh Kapoor, our Medial Director.
 Other committees such as Quality Improvement, Infection Control, Safety and

others are in place to oversee and monitor related functions and departments.

STRATEGIC PLAN IS GUIDED BY:
 The hospital’s Mission and Vision
 Assessment of the Community’s needs through interaction with community

leaders and patients’ satisfaction surveys.
 Collaboration among the hospital’s leadership, medical staff, general staff and

community representatives.

WE ALLOCATED RESOURCES THROUGH:
 Budgets, which are based on department and unit plans for services, volume,

equipment and capital needs.
 Staffing guidelines and plans written in their scope of care by each department

and unit.
 The strategic planning process.
 The performance improvement process.

WE COMMUNICATE:
 Quarterly

 Governing Body: The Executive Committee.
 Monthly

 Medical Board
 Other Standing Committees
 Weekly
 Departmental meetings
 Ongoing
 Staff meetings, Memos, Official emails, policy and procedure up-dates,

quality data communication.
 Caregivers communicate by reading the medical record and

acknowledging the information of each provider, and by attending and
participating in the interdisciplinary team patient care meetings and rounds.

WE COORDINATE SERVICES THROUGH:
 Standardized practices, policies, and procedures, so that care is the same
throughout the hospital.
 The same level of patient care services is provided throughout the
organization for patients with the same health problems.
 Qualified and competent staff.
 Multi-disciplinary approach to care.

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OUR ETHICS FRAMEWORK
 Human Resources & Ethics Committee addresses health care concerns
that may involve religious, ethical or personal beliefs.
 Any individual, including staff, physicians, patients and family members
may request that the HR & ethics committee consider an ethical issue. The
committee meets when needed.
 We don’t conduct any clinical research.
 “DO NOT RESUSCITATE” (DNR) orders are not acceptable.
 Direct sponsorship, grants and gifts from vendors for any staff member are
not permitted.

II. PATIENT RIGHTS AND RESPONSIBILITIES

Patient Rights:
At YECDCS, all valued patients have the right to:
 Be treated to the highest professional standards by appropriately licensed,

qualified and experienced practitioners in a properly licensed and approved
facility.
 Be involved in any decision making about your treatment and care.
 Have communications in your native language or through the services of an
interpreter.
 Refuse or accept treatment based on personal decision.
 Have access to your medical records and expect those records to be up-to-date
and accurate.
 Receive information on admission regarding the health care facilities regulations
and relevant policies.
 Reasonable safety in relation to the healthcare facility environment and
practices.
 Seek a second opinion if you so choose.
 Privacy, both of person and information.
 Be informed regarding any uncovered costs and expenses prior to making
decisions.
 Receive information on how to make a complaint to the healthcare facility if
unhappy about the lack of access to your rights, medical examination or
treatment, behavior of the staff or healthcare facility safety standards.

Patient Responsibilities
At YECDCS, it is our valued patients’ responsibility…
 To bring their insurance card with them when they attend a healthcare facility.
 To follow any specific rules and regulations of the health care facility.
 Follow the treatment plan as outlined by the health care professional.
 Ask any questions if they are not clear about any aspect of their health care

provided.

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 To consider the rights and responsibilities of other patients and health care
professionals.

 Not to use abusive language or display unsocial behavior to other patients,
visitors or staff.

 To show consideration for the needs of others at all times.
 To give accurate information about personal details, medical history, medication

you are receiving and history of allergies or sensitivity to medicines.
 Face the outcomes of your own actions if you decide not to follow any advice,

instructions and/or treatment plan and recommendations.
 To safeguard your belongings whilst receiving any health care treatment.
 To keep appointments and inform staff if you are unable to attend so that the

time can be used by other patients.
 To inform staff if you have any special needs for effective discharge from a

hospital or clinic. You should try to make preparations for discharge to the best
of your ability as soon as you are medically fit.
 To be accountable for payment of any deductible or medical services excluded
from the insurance scheme provided by the practitioner/facility.

Patient Feedback
We at YECDCSDCS advise our patient to always provide their feedback:
 If a patient/visitor is unhappy with any medical examination or treatment you

have received, the behavior of the professional staff or the safety standards at
Yateem Eye Center and Day Care Surgery, he has the right to make a complaint
to our management or the Health Authority – Abu Dhabi (HAAD).
Abu Dhabi, Airport Road
Abu Dhabi, United Arab Emirates
P.O. Box 5674
Tel: +971 2 449 3333
Fax:+971 2 444 9822
Toll Free no. 800555
 If patient or a visitor wish to make a complaint or a positive comment to us, he
can fill the feedback form at the reception desk or email it to
[email protected] and we will contact him within 24 hours.

CONFIDENTIALITY / PRIVACY
 Confidentiality of patient information is the responsibility of all staff
members.
 Patient information is confidential. Do not discuss a patient’s condition in a
public place, (e.g. elevators, staircases, or the cafeteria).
 Patient charts, forms and computer screen information must be protected
at all times.
 Patient information is utilized on a “Need to Know” basis.
 Knock on doors before entering a patient’s room. Introduce yourself and
ask permission to see the patient.

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 Patient’s privacy (Physical and Informational) must be considered at all
times. Ensure auditory and visual privacy whenever possible.

 Any document that contains patient information must be shredded prior to
disposal in the waste bin.

PATIENT COMPLAINTS
 You are expected to bring patient and family complaints and/or concerns
to your manager’s attention if you cannot immediately resolve them.
 Patient complaints must be taken seriously and should be handled and
corrected where they originate.
 If the complainant is not satisfied, please refer them to the patient affairs
or customer service department.
 Patient and families are given access to complain, to suggest or to
appreciate through contacting our front desk or patient relation officer any
of the patient and completing the feedback/complaint form whenever
needed.

PATIENT PERCEPTION OF CARE
Patient satisfaction is measured through patient surveys on an ongoing basis.
EMPLOYEE OPINION
Employee opinion is measured through random sampling surveys of employees on
an ongoing basis (at least on annual basis).

LANGUAGE INTERPRETATION SERVICES
 A limited Arabic/English proficient individual is a person who does not
speak Arabic or English as his/her primary language and who has limited
ability to read, write or understand Arabic and English at a level that permits
him/her to interact effectively with healthcare providers. This is one the
most important barriers we identified in our Hospital in addition to cultural
barriers.
 We do not encourage asking family members to interpret and minors
should never interpret.
 We have bilingual staff to decrease the barriers for patients and to make
our hospital customer friendly for all patients such as PRO, receptionist
and others.
 Information such as Feedback/Complaint forms, satisfaction surveys,
Patient Rights & Responsibilities, Consent Forms and Educational
materials are available in English and Arabic.

III. ACCESS TO CARE AND CONTINUITY OF CARE
 All patients are screened at the point of first contact.
 Patients with urgent, emergent or immediate need s are given priority for
assessment and treatment.
 Triage is conducted by a competent and trained staff using evidence-based
triage process.

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 All patients are seen under the care of a specific specialist or consultant
who will be identified as the most responsible physician.

 All patients are screened for any discharge planning needs upon admission
criteria.

 All patients have the right to participate in their discharge options.
 All patients receive a written discharge notice prior discharge.

IV. CARE AND ASSESSMENTS OF PATIENT
 All patients must have completed individualize assessment, completed
within the time frame set by their discipline.
 Assessments trigger referrals to their disciplines, as they are
multidisciplinary.
 Admitted patients must have a history and physical completed within 24
hours.
 Assessment are the basis of all treatment provided by the multidisciplinary
treatment team.
 An integral part of the staff’s role in the treatment of the patient involves
communication with the patient and his/her family.
 Please explain to the patient what is being done for them. Patients must
be involved in their care decisions and should be kept informed.
 Care is multidisciplinary and collaborative. Physicians, nurses and
pharmacist must coordinate and integrate the care of patients.
 Plan of care should be documented clearly by physicians and nurses.
 All patients are screened for abuse. Abuse can be mental, physical neglect
or exploitation.
 Report abuse, suspected abuse and/or neglect to the most responsible
physician and patient affairs officer. It is preferable that the most
responsible physician makes the decision whether to notify police
department through patient affairs officer after conducting a thorough
evaluation except when there is a strong evidence of abuse or if the delay
in taking actions is deemed inappropriate.
 All patients are screened for pain. If a patient has pain, a complete
assessment occurs. Reassessment of pain must be done timely if pain
treatment is administered.

V. PATIENT AND FAMILY EDUCATION
 Education is multidisciplinary.
 Documentation of education should be made on the form titled “Patient and
Family Education Form”.
 Education needs are assessed initially and ongoing basis.
 Language needs of each patient are identified and documented.
 Any barriers to learning or impairments including hearing and vision loss
must be identified and documented.
 Cultural or religious concerns are addressed.
 Patient, their family and or significant others are involved.

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 Patients should agree with the educational methods used to ensure
collaborative practice.

 Patient should be educated on medical equipment used in the processes
of care during admission to the hospital.

VI. MEDICATION MANAGEMENT
Medication administration policies must be followed:

 Our medication management system is evaluated annually through a risk
assessment process.

 Orders must be complete (date and time, route, frequency and duration).
 PRN orders must contain the indication and minimum duration between

doses (example: Paracetamol 1000mg PO for pain every 6 hours as
needed)
 Multidose vials are dated and good only for 30 days or as specified by the
manufacturer unless there is discoloration and unusual particles are
observed.
 Multidose oral liquids are dated and good for 90 days or as specified by
the manufacturer or pharmacy department.
 Code carts are checked and signed off twice per day, and after a code.
Code carts are secured with numbered lock at all times.
 All adverse drug reactions are reported by completing an adverse drug
reaction form.
 Medication errors are reported using Occurrence of Variance Report form
(OVR).
 High alert medications (examples: Insulin, Heparin, IV contrast) are
separated and labeled clearly with high alert medication red label.
 Double check the high alert medication and the required dilution with
another nurse when administered of high alert medication.
 Accurately and completely reconcile medications across the continuum of
care. Obtain and document on the medications reconciliation form and a
complete list of the patient’s current medications. This process includes a
comparison of the medications the organization provides to those on the
list.
 Medication reconciliation is also done during transfer and on discharge.

VII. ANESTHESIA AND SURGICAL CARE
 Time-out process is conducted prior to any invasive procedure inside and
outside Operating Theatre.
 YECDCSDCS has a list of procedures considered invasive. Special
consent, site marking and time out process is mandatory for all procedures
mentioned in the list unless otherwise indicated by the policy.
 Moderate sedation must be conducted only by the competent staff with
specific privileges.

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 We are monitoring any use of reversal agents for moderate sedation such
as Naloxone and Flumazenil.

 We are monitoring an unplanned return to Operating Theatre within 48
hours.

VIII. QUALITY AND PATIENT SAFETY
A performance improvement team is an interdisciplinary group of hospital employees
who are asked to work together to improve a service, problem or process.

OUR QUALITY IMPROVEMENT PLAN (QIP)
 The continuous improvement of the process in providing health care
services to meet the needs of patients.
 A way to identify activities that affect patient satisfaction and patient care
outcomes.
 Carried out through inter-disciplinary staff participation.
 Our P.I. methodology is: PLAN, DO, CHECK and ACT (PDCA).
 The steps for PDCA cycle are:
 Plan – to improve performance in a systematic coordinated manner
 Do – to do the improvement according to priorities
 Check – analyze the data and the process
 Act – take action to sustain and improve identified processes
 Root Cause Analysis RCA: is a Q.I tool is to identify underlying problems
that increase the likelihood of errors. Our Q.I team use it to analyze serious
adverse events (i.e. sentinel events).

OUR KEY PERFORMANCES INDICATORS (KPIs)
 HR KPIs:

 Staff turnover
 Absenteeism rates
 Patient Centered KPIs:
 Patient Satisfaction Rate.
 Average Waiting Time in clinic.
 Average Waiting Time for Elective Surgery/Procedure.
 Quality and Patient Safety KPIs:
 Rate of Adverse Events/ Medication Errors
 Monthly number of patient falls.
 Complaint rate.
 Infection Control:
 Percent Compliance of Hand Hygiene.


OUR CLINICAL FOCUS AREAS FOR 2017:
 Cataract Treatment.
 Retinal Diseases and Treatment

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 Lasik And Refractive Surgeries
 Glaucoma Management.
 Special Clinics for Special Conditions.

RISK MANAGEMENT HIGHLIGHTS
 An Occurrence of Variance Report (OVR) is the form used to report any
happening which is not consistent with the routine operation of the hospital
or the routine performance of a job.
 An incident may be an accident or situation, which results in bodily injury
to a patient, visitor or staff member.
 Incident involving employee’s safety are reported using the same form, and
are given to the manager or supervisor on the shift.
 Staff may require to fill forms for adverse events / medication errors or other
forms based on the nature of variance and its implications.

NEAR MISS
 A near miss is a variance which but for luck or skillful intervention would in
all probability have become a variance.
 That is all undesired circumstances or events which could have led to loss,
ill health or injury.
Examples:
o A faulty piece of equipment is identified before it causes injury.
o A medication error is prevented before it causes harm or an
adverse reaction.
o We conduct root cause analysis for near miss incidents.

SENTINEL EVENT
 Death or major permanent loss of function unrelated to the natural course
of the patient’s illness or underlying condition
Examples:
o Suicide of any individual receiving care, treatment or services in
a staffed around-the-clock care setting or within 72 hours of
discharge.
o Unanticipated death of a full-term infant.
o Abduction of any individual receiving care, treatment or services.
o Discharge of an infant to the wrong family.
o Rape
o Hemolytic transfusion reaction involving administration of blood
and other blood products having major blood group
incompatibilities.
o Surgery in the wrong individual or wrong body part.
 When sentinel event occurs, a root cause analysis is conducted by a
sentinel event team. An initial report is submitted to the hospital

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management and SEHA within 24 hours and full report and action plan
within 45 days.

ROOT CAUSE ANALYSIS
Root Cause Analysis is a thorough review of all systems and employees involved to
understand the root cause of the occurrence. The process helps to uncover the
factors that led to the event. This process focuses on:

 Systems rather individuals, looks at policies, work processes etc. that need
to be improve to avoid similar problems in the future.

 Looks for underlying causes such as: Pinpointing what went wrong (human
or mechanical system) broader issue (workflow, education, competency)
which might have contributed to the event.

FAILURE MODE EFFECTS ANALSYS (FMEA)
Our hospitals risk management program conducts proactive activities to reduce risks
to patients, staff and visitors.

 We use the “FAILURE MODES” process to identify where there may be
undesirable variations, and what serious effect each identified failure mode
may have on the patient.

 Those identified as having the most critical effects have an action plan
performed to review/investigation as to why the failure mode leading to that
effect may occur. The ultimate goal is to prevent the “undesirable variation”

 Annually, one (1) high-risk process is monitored to determine the degree
of variation.

IX. INTERNATIONAL PATIENT SAFETY GOALS
The following are the current International Patient Safety Goals.
GOAL 1: Improve the accuracy of patient identification.

i. Patients are identified using two patient identifiers, not including the use of
the patient’s room number or location.

ii. Patients are identified before administering medications, blood or blood
products.

iii. Patients are identified before taking blood and other specimens for clinical
testing.

iv. Patients are identified before providing treatments and procedures.

GOAL 2: Improve the effectiveness of communication among caregivers:
i. The complete verbal and telephone order or test result is written down by
the receiver of the order or test result.
ii. The complete verbal and telephone order or test result is read back by the
receiver of the order or test result.
iii. The order or test result is confirmed by the individual who gave the order
or test result.

iv. Standardize a list of approved abbreviations and “do not use “abbreviations
are available.

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v. Avoid the following “do not use” abbreviations:
 ‘u’ or ‘U’ for units, read as zero, or 4(4U for 40;4u for 44)
 Zero after a decimal point -1.0mg read as 10mg instead of 1mg
 No zero before a decimal point -.5mg read as 5mg instead of 0.5mg.
 “IU” for international unit(s), mistaken for IV (intravenous), correction use
“unit(s)
 ‘QOD’ or “qod” meaning every other day, misinterpreted as ‘q.d” (daily)
 “MSO4” (Morphine Sulphate), “MgSO4” and MS (Magnesium Sulphate)
confused for one another.
 “QD” or ‘q.d’ meaning every day, mistaken as qid

GOAL 3: Improve the Safety of using high alert medications:
i. The identification, location, labeling, and storage of high alert medications
are done according to best practice guidelines and pharmacy department
manual.
ii. Concentrated electrolytes are not present in patient care units unless
clinically necessary and actions are taken to prevent inadvertent
administration in those areas where permitted by policy.
iii. Concentrated electrolytes, that are stored in patient care units are clearly
labelled and stored in a manner that restricts access.

GOAL 4: Ensure correct -site, correct- procedure and correct-patient surgery
i. YECDCS uses an instantly recognizable mark (an arrow according to
YECDCS policy) for surgical -site identifications and involves the patient
in the marking process.
ii. YECDCS uses a checklist or other process to verify preoperatively the
correct site, correct procedure, and correct patient and that all
documents and equipment needed are on hand, correct, and functional.

iii. The full surgical team conducts and documents a time-out procedure
just before starting a surgical procedure

GOAL5: Reduction of health care -associated infections
i. YECDCS has adopted WHO hand -hygiene guidelines.
ii. YECDCS implements an effective and comprehensive hand-hygiene
program registered with the WHO.
iii. YECDCS has an established, comprehensive infection prevention and
control program to reduce the risk of HAI.

GOAL 6: Reduce the risk of patient harm resulting from falls
i. YECDCS implements a process for the initial assessment of patients
for fall risk and reassessment of patients when indicated by a change
in condition or medications, among others.
ii. Measures are implemented to reduce fall risk for those assessed to be
at risk.

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iii. Measures are monitored for results, both successful fall injury reduction
and any unintended related consequences.

GOAL 7: Accurately and completely reconcile medications across then
continuum of care

GOAL 8: Encourage patient’s active involvement in their own care as patient
safety strategy.

GOAL 9: Improve recognition and response to changes in a patient’s condition.

GOAL 10: Reduce the risk of hospital fires.

X. FACILITY MANAGEMENT AND SAFETY
NO SMOKING POLICY
Smoking is not allowed in the building or near center entrances.
The “No Smoking Policy “provides for disciplinary actions against those who violate
the policy.

WEAR YOUR ID BADGE AT ALL TIMES WHILE IN THE FACILITY!!!

ENVIRONMENT OF CARE PLANS
 Environmental and Health Safety Plan: provides a fire safe
workplace environment free from hazards and discuses staff activities
to reduce the risk of injury. It also establishes and maintains a
program to protect staff, patients and staff from harm.
 Fire Safety and Evacuation Plan: Provides a fire safe hospital
environment and ensure effective response to internal and external
emergency events.
 Waste Management Plan: controls the handling of hazardous
materials, clean-up and the removal of hazardous waste from the
hospital.
 Biomedical Equipment Plan: maintains medical equipment to
promote safe and effective use.

Know your Department Safety procedures:
 All equipment in the corridor should be on the same side.
 No trash, storage, carts or other equipments are allowed in
stairwells, doorways, or in front of emergency exits.
 Place trash in waste containers. Do not overfill.
 Discard infectious waste only in Red bag containers. Follow the
infection control policies and procedures.

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 BLOOD SPILL; First cover the spill. Block off the area, notify the
housekeeping staff to bring the blood spill kit and to clean the area.

 CHEMICAL SPILL; Laboratory department have special chemical
spill kits.

 Know the location of the MSDS sheets for your work unit. Keep
the MSDS accessible to all shifts.

 OXYGEN SHUT OFF: An assigned nurse in each unit is required
to know the location of patients requiring 02 in the unit and is
responsible for shutting off the oxygen in case of emergency.

 During an electrical outage use only the emergency electrical
outlet for essential patient care equipment.

 YECDCS has safety committee, safety and security issues are
referred to this committee

FIRE ALARMS:
 You will hear continuous alarm if the fire is in your area and intermittent alarm if

the fire is away from your area.
 Fire alarm boxes and evacuation maps are located next to exits in each unit.

Please orient yourself to their locations. To activate the fire alarm, push the
button to break the glass.

In case of FIRE follow the R.A.C.E Procedure:
R RESCUE =Yourself and other in immediate danger
A ALARM =Activate the nearest ALARM; use nearest phone and &dial 999.Tell
operator the location of the fire
C CONFINE=Close all doors and windows, and clear corridor.
E Extinguish/Evacuate =Horizontally to the opposite side of the same floor.
Vertically down floors TO STREET level.

We have three fire assembly areas outside the hospital building.
Fire Extinguisher at YECDCS
Red: Dry powder for all kinds of fire (ABC)
Black: CO2 for flammable liquids and gases (BC)

The operation of fire extinguisher: PASS
P: Pull the pin from the extinguisher handle
A: Aim at the base of the fire
S: Squeeze the handle to discharge the agent
S: Sweep from side to side

EMERGENCY MANAGEMENT
 Our EMERGENCY CODES are announced by the telephone
operator and provided to staff in their badges.
 In case an EMERGENCY code sounds: Refer to your action card or
report to your supervisor who will obtain information from the

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command center and give further instructions, DO NOT leave the
work area without your supervisor’s permission.

Code Orange: External disaster
Code Green: Internal disaster
Code Blue: Cardiac arrest arrest
Code Pink: Cardiac arrest pediatrics
Code Brown: Hazardous\chemical spill
Code black: Bomb threat
Code Yellow: Missing person
Code White: Violent person
Code Amber: Child /infant abduction
Code Silver: Weapon threat
Code Gold: Utility Failure
Code Grey: Severe Weather
Code Red: Fire
Code Violet: Unexpected Electronic Health Information (System shut
down)

 During major disaster, off duty employees should report to their assigned work
or disaster assembly location and establish contact with their respective
supervisor or department head and await further instructions.

BIO-MEDICAL EQUIPMENT
 Immediately report to Bio-Medical engineering all equipment malfunctions
and /or problems through Asset plus on line program, or contact biomedical
engineer by phone for emergency category. In addition, complete an OVR.
 Identify /tag all equipment taken out of service clearly.
 Keep “clean” equipment separate from “dirty” equipment.
 Keep broken equipment away from usable equipment.

UTILITIES SYSTEMS
 Immediately report to biomedical engineering departments any system
malfunctions.
 Don’t attempt any “emergency repairs”.

XI. STAFF QUALIFICATION AND EDUCATION

COMPETENCE:
Employees competence is assured through:
 Department orientation by senior nurse in charge
 Competency training for nurses is done by the senior nurse in charge.
 Performance indicators for individual staff members (example: Annual physician

profile)

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 Continuous Medical/Nursing/Pharmacy education requirement.
 Education and training when new procedures or equipment are introduced.

Training is given by training manager or senior staff nurse in charge.
 Annual evaluation of the employees by the management ,HR and staff nurse in

charge.

 The ability of an employee is measured regarding
 Critical thinking
 Interpersonal skills
 Knowledge
 Psycho motor skills

 The competence is validated by:
 Demonstration of skills
 Verbalized knowledge
 Direct observation
 Pre-and post-tests
 Staff assignments are based on patient care needs and staff
competencies.

MEDICAL STAFF PRIVILAGES
 Physician privileges to perform procedures are available in the medical and
nursing director offices, patient units, operating room, at all times. All
inquiries of questions a physician’s privileges to perform should be referred
to one of these locations.

XII. MANAGEMENT OF COMMUNICATION AND INFORMATION (MCI)
 Do not leave a patient’s medical record unattended in public places.
Medical records need to be secured at all times
 All hospital applications containing, electronic protected health information
is password protected.
 “Sign -off “each time you have completed your work.
 Access to patient records is recorded in audit trail and monitored
periodically.
 Automatic “sign- out” is done if someone walks away without signing out.
 Do not use Dangerous Abbreviations (Do not use abbreviations)
 There are contingency plans in place in the event of system failure (back
up)
 In case of system failure, we activate code violet and use manual order
forms.

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XII. PREVENTION AND CONTROL OF INFECTIONS

YECDCS Uses STANDARED PRECAUTIONS; we treat all blood and body fluids as
if they are infectious.

CONTACT PRECAUTIONS
Are used for example for patients colonized or infected with an antibiotic resistant
organism (MRSA, VRE, ESBL). Gloves and Gowns are needed.

DROPLET PRECAUTIONS
Are used for patients with certain airborne diseases. Regular surgical masks are
sufficient for protection.

AIRBORNE PRECAUTIONS
Are followed for patients (for example) diagnosed with tuberculosis, measles or
varicella infections. N-95 mask is needed and patient must be placed in one of the
negative pressure rooms available at YECDCS. The pressure difference is
maintained below 2.5pascal (<-2.5) and we monitor the pressure difference daily.

HAND HYGIENE
The most effective way to decrease the risk of Hospital Acquired Infections.
Hands are washed before and after patient care; after use of gloves; and after using
the bathroom. Waterless hand sanitizer can be used to sanitize hands when hands
are not visibly soiled.
When dealing with any spore forming organism related infection (like C. difficile),
washing hands with soap and water is the recommended procedure.
Personnel protective equipment (ie. gloves, masks, face shields, eye protection) are
used when coming in contact with blood or body fluids.
Single used items must never be re -used or sterilized again according to our policy.

NEEDLE STICK INJURIES
Needle stick injuries are wounds caused by needles, that are accidently puncture the skin.

Never recap any sharps/ needless!!
 Used sharps to be disposed in the puncture proof sharp container
 If you sustain a needle stick /sharp injury, clean the area, report it to your
supervisor immediately and submit the incident report. Post exposure
prophylaxis after sharp injury according to YECDCS policy

BIOMEDICAL WASTE MANAGEMENT
Health care facilities, health care staff, and all concerned staff handling medical waste.

RESPONSIBILITY:
 It is the responsibility of health care facility’s management to ensure proper
implementation of this policy

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 It is the responsibility of all staff working in a health care facility to abide by
this policy and the waste management policies and procedures of health care
facility they work in

COLOR CODES OF BIO MEDICAL WASTE MANAGEMENT
Black-general wastes
-medical wastes
Red -infectious wastes

EMPLOYEE HEALTH SERVICES (EHS)
 Remember to report to HR for the annual mandatory assessments.
 The scope of EHS program:

i. Initial screening and immunization /prophylaxis: Hepatitis Measles,
mumps, rubella, varicella, TB

ii. Annual reassessment for TB and other health problems. Patient
with latent TB infection are offered INH prophylaxis for 9 months

iii. Monitoring and trending of sharp injuries and body fluid exposure
and taking actions to decrease it.

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