ABLEH Employee Reference Guide

Anne Bates Leach Eye Hospital How do you protect a patient’s privacy? PATIENT COMPLAINTS / GRIEVANCES
• Patients are covered during transport
Constant-State-of-Readiness • Curtain drapes are pulled during care or How are patient complaints addressed?
Survey Preparation Reference Guide Complaints are addressed immediately at the
treatments unit level, utilizing Service Recovery principles
Created by: Ruben R. de la Vega Jr., RN • Before entering, knock on the patient’s door before the situation escalates to a “grievance”.
Quality Management • Speak quietly in private location when relaying ABLEH has a Patient Advocacy Program that
provides an opportunity for patients to identify
Revised 05/16/2017 patient care information issues, provide resolution, and service recovery.
• In areas where privacy is difficult due to the Patients/Family members may call the Patient
What is Anne Bates Leach Eye Hospital’s Mission and Visitor Services (305-243-HELP) directly to
Statement? physical design (e.g. ED or Registration), signage is discuss complaints.
To transform lives through excellence in eye care, posted informing patients that they can request a
ophthalmic education and vision research. private area for discussion RESTRAINTS

What does this Mission Statement mean to ADVANCE DIRECTIVES What is ABLEH’s philosophy regarding use of
you? Restraints?
To be recognized as the leading Eye During admission process, patients (18-years-of-age • Only use when clinically appropriate and
Institute/Hospital in the world through or older) are asked if they have an Advance
continuous development of quality, state-of-the- Directive. justified (patient harm to self; patient harm
art patient care, education, and research. to others; alternatives have been ineffective)
Advance Directives may include the following: • Use least restrictive type of restrain first
PATIENT’S RIGHTS 1. Living Will • Physician order must be obtained; “PRN”
2. Healthcare Surrogate Designation orders are NOT acceptable
How is Patient Rights information given to 3. Refusal of Treatment • Monitor at a minimum of every 2-hours for
patients? 4. Durable Power of Attorney for Healthcare “non-behavioral” restraint use
Patient Access staff provides the information 5. Organ Donation
upon admission. Patient Rights and PATIENT SCREENING
Responsibilities signage are in Patient Access, ETHICAL CONCERNS
Emergency Department Waiting Room and in What are the essential Patient Screens when
public Lobby areas. How are patient care conflicts or ethical issues rendering care?
resolved? 1. Pain
How do you ensure a patient’s right to Through utilization of the “Chain-of-Command” 2. Nutritional
confidentiality? (Supervisor, Department Head, and/or 3. Functional
Information related to a patient’s care is only Administrator) or through consultation with 4. Discharge Planning
shared to those participating in the care of the Physicians or Patient Representative. 5. Abuse / Neglect
patient. 6. Fall Risk
7. Suicide

What is the policy regarding reporting of ABUSE NATIONAL PATIENT SAFETY GOALS • At ABLEH, alarms on medical equipment are
and/or NEGLECT? audible and responded to promptly.
It is the legal responsibility of all personnel to Goal 1: Identify patients correctly
alert the proper authorities (1-800-96-ABUSE) in • At ABLEH, we use “Patient’s Name” & “Date-of- Goal 7: Prevent infections
the event of a minor/elderly/disabled patient • At ABLEH, we wash our hands when soiled
identified as a victim of alleged or suspected Birth” when performing the following:
abuse/neglect, including sexual abuse. - prior to rendering treatment or procedure after providing patient care. If not soiled, use
- administering medications or blood products an alcohol-based hand sanitizer.
How is PAIN screened/assessed? - collecting blood samples and other specimens • Direct patient care providers are expected to
Numerical Pain Scale of 0-10, with 10 being the maintain fingernails short (1/4” in length);
worst level of pain, is used to assess for clinical testing --- labels are placed in the artificial nails are prohibited.
pain/discomfort. presence of the patient • Health care providers are offered annual
influenza vaccination; free of charge.
Wong-Baker Faces (picture) scale is used to Goal 2: Improve staff communication • Isolate patients with Multi-Drug Resistant
assess for patient body language for signs of • Professionals verify through “READ BACK” all Organism (MRSA)
pain.
telephone or verbal orders and telephonic Goal 15: Identify patient safety risks
FLACC (Face-Leg-Activity-Cry-Consolability) Scale reporting of critical test results. • At ABLEH, patient risk screening includes:
is used to assess pain in children under the age of • A list of hospital-approved and “Do Not
3-years old or cognitively impaired adults. Use”/“Unacceptable” abbreviations, acronyms, - identification of factors and features that
and symbols can be found on-line Manual. At may increase or decrease risk for suicide;
NIPS (Neonatal Infant Pain Scale) is used to ABLEH, “Do Not Use” list applies to all orders and
assess pain in neonates up to 2-months of age. all medication-related documentation when hand- - immediate safety needs and most
written or entered as free text into a computer. appropriate setting for treatment; and
PATIENT SAFETY PROGRAM • Identify – Situation – Background – Assessment -
Recommendation (I-S-B-A-R) is used as a “Hand- - provision of crisis prevention information
What is your role in “Patient Safety”? Off” communication regarding a patient’s care, to individuals as deemed appropriate.
At ABLEH, “Patient Safety” is everyone’s treatment, condition, and/or any recent changes
responsibility: or anticipated changes. • Once patients are identified as suicide risk,
• Seek out and report errors, near misses, and Crisis Intervention and Security are
Goal 3: Use medicines safely contacted.
barriers to safety practices. • “Sound-Alike/Look-Alike” posters are available to
• Maintain competency skills, and keep abreast Universal Protocol: Prevent mistakes in
prevent errors involving interchange of the drugs. surgery
of new policies and procedures. • Medications, medication containers (syringes, At ABLEH, we:
• Conduct pre-operative verification process
Who is ABLEH’s Patient Safety Officer? medicine cups, basins) and solutions “on-and-off”
Joanne Martin, CNO/COO sterile fields are labeled with the drug name, (verify correct person, correct procedure,
strength, amount, expiration date and time if not correct site/side, relevant documentation,
used immediately. relevant images, & any required
• Care and precautions are considered for patients implants/special equipment)
who take blood thinner medication(s). • Mark the operative site by the procedural
physician
Goal 6: Use alarms safely • Conduct “time-out” immediately before
starting the procedure (final verification) by
the entire procedural team using “active”
(verbal) communication confirming: the
correct person, agreement on the procedure
to be done, correct site/side, correct patient

positioning; and availability of correct implants MEDICATION SAFETY & MANAGEMENT • If the multi-dose vial is thought to be
or special equipment or special requirements. contaminated or not appropriate for use, it
• Document the “time-out” in the patient’s What security is required relative to medications? is discarded immediately.
chart. All medications (including eye drops) and
prescription pads are secured in locked rooms, To avoid confusion, it is safe medication practice
What Patient Safety Program Initiatives have cabinets, drawers, or medication carts. Only to:
been implemented at ABLEH? authorized personnel are allowed access to • spell-out the drug name
• Rapid Response Team is available that enables medication storage areas. • place a zero for dosage less than 1
• avoid trailing zero for dosage greater than 1
health care workers, patients and visitors to What is an Adverse Drug Reaction (ADR)? • spell-out the frequency for administration.
request assistance from specially trained Any unexpected, unintended, undesired, or
individuals when a patient’s condition appears excessive response to a medication that requires ABLEH published a list of abbreviations that
to be worsening. discontinuing the medication, changing therapy, must be spelled-out to avoid
• Fall Reduction Program is available that modifying the dosage, necessitating admission, misunderstandings. “Do Not
includes: increasing length-of-stay, and/or resulting in Use”/”Unacceptable” abbreviations, acronyms,
- interventions to reduce patient fall risk; temporary or permanent harm, disability or death. and symbols can be found in the Administrative
- staff education and training on the Fall Manual.
How do you report an ADR?
Reduction Program; Submit an occurrence report via on-line Quantros. Inappropriate Appropriate
- patient/family education on the Fall Spell “Units” instead
What is ABLEH’s policy regarding patients using U Spell “International
Reduction Program; and their own home medications? Units” instead
- evaluation of the effectiveness of the Fall • Patients may not self-administer home IU Use “mcg” for
micrograms
Reduction Program medications. µ (Greek mu symbol) Use leading zero (0.5 mg)
• Patients and families are informed on how to • Physician may order patient’s home
Doses <1 unit (e.g. Do not use trailing zero
report concerns related to care, treatment, medication(s) to be administered by Nursing. .5mg)
services, and safety and quality issues. • Nursing/Pharmacy/Physician checks the integrity Doses > 1 unit Write “daily”
• Nursing personnel conduct post procedure (e.g. 15.0)
phone calls to solicit patient/family feedback. of the medication prior to administration. Q.D.

Medication Reconciliation What is ABLEH’s policy on the use of multi-dose Q.O.D. Write “every other day”
• At ABLEH, “current” list of the patient’s medication vials (for injections)? MS or MSO4
• Multi-dose vials are labeled, used and stored Write “Morphine Sulfate”
medications is obtained upon admission/entry. MgSO4
All new medications ordered are compared according to the manufacturer’s SC or sc Write “Magnesium
with those on the list and any discrepancies are recommendations. Sulfate”
resolved. • Upon opening, the medication vial is labeled with Write “Subcut” or
• A “complete” list of the patient’s medication is the date and the initials of the nurse/tech to “Subcutaneously”
communicated to the next provider of service ensure the medication is properly disposed of
when a patient is referred or transferred to within 28-days of opening.
another setting, service, practitioner, or level
of care within or outside ABLEH.
• A “complete” list of the patient’s medication is
provided to the patient on discharge from
ABLEH.

INFECTION CONTROL C – Check (Monitor the Plan’s progress; Meet with CODES EMERGENCY NUMBERS
staff to discuss changes; Compare new data with
What does ABLEH do to reduce Hospital- original data using PI tools (e.g. graphs) BLACK - Bomb Threat 7-3333
Acquired Infections?
• Hand-wash or use hand sanitizer before-and- A – Act (Incorporate the Plan and/or solution into BLUE - Cardiac/Respiratory Arrest 7-3333
Department policy or standards; Inform and educate
after patient care all involved; Distribute new standards to key BROWN - Severe Weather 7-3333
• Use Personal Protective Equipment (PPE) (e.g. individuals; Look for new problems to solve or ways
to improve) GRAY - Violence/Security Alert 7-3333
gloves, mask, gown)
• Conduct Infection Control surveillance rounds Name at least two performance improvement GREEN - Mass Casualty/Disaster 7-3333
• Monitor the use of antibiotics activities currently monitored in your area?
• Investigate healthcare associated infection(s) (Examples: Hand-Hygiene, Press Ganey Patient ORANGE - Hazmat/Bioterrorism 7-3333
• Clean medical equipment after use with Satisfaction, Chart Audits, Patient Flow (Emergency
Department, Outpatient Clinic, and Surgical Services) PINK - Missing/Abducted Child 7-3333
germicide wipe. Check manufacturer contact
“dwell” time. Check your Department’s Communication Board. RED - Fire Emergency 7-3333
Consult with your Department Head/Manager)
What items can go in red bags? WHITE - Hostage 7-3333
• Items saturated with blood and/or other What is a “Sentinel Event”?
A “Sentinel Event” is an unexpected occurrence YELLOW - Lock down 7-3333
potentially infectious materials involving death or serious physical or psychological
• Any item removed from a body cavity injury, or the risk thereof. FIRE / LIFE SAFETY
• Laboratory waste
What happens if ABLEH have a “Sentinel Event”? What is ABLEH’s Smoking Policy?
PERFROMANCE IMPROVEMENT A performance improvement team would meet to Smoking is NOT permitted within the building.
conduct a “root cause analysis” and develop
What Performance Improvement (PI) Model corrective strategies to reduce/eliminate recurrence What should you do in the event of a FIRE?
does ABLEH follow? of the event. R - Rescue; move people to safety
A - Alarm; sound alarm, dial 73333; indicate
P – Plan (Identify the problem; Collect data to ENVIRONMENT OF CARE SAFETY the location and advise Code RED (know
determine problem, cause, and solution; Use PI the location of the pull alarm in your area;
tools to narrow the problem; Decide on a Who is ABLEH’s Environment-of-Care (EOC) Safety usually next to the EXIT door)
solution to implement) Officer? C - Confine; close doors/windows
Billy Williams, Director of Facilities and EVS E - Extinguish fire with fire extinguisher;
D – Do (Implement the Plan; Test the solution; evacuate
Identify costs, people, materials; Educate staff on EMERGENCY CODES & NUMBERS
changes in process) How do you use a Fire Extinguisher? (Know the
location where the fire extinguisher is
stored/located in your area)

P - Pull the pin
A - Aim at the base of fire
S - Squeeze handle
S - Sweep from side-to-side

Where are the medical gas shut-off valves SDS contains information prepared by the EQUIPMENT MANAGEMENT
located in your area(s), and who has the manufacturer or importer of a chemical product that
authority to shut them off in the event of a describes the hazards of the material, provides How do you ensure that the medical
FIRE? information on how it can be safely handled, stored equipment is safe to use on a patient?
(Locate the medical gas shut-off valves in your and used, and recommends first aid and/or The Biomedical Engineering personnel perform
area(s). emergency procedures. Preventative Maintenance (PM) checks of
5th & 6th Floor Charge Nurse, Safety Officer and medical equipment. Equipment without a PM
Fire Marshall can turn them off. The Hazard Communication Standard (“Right-to- sticker, or past the PM “due date” must be
Know” Law) entitles all employees to be made aware taken out of service, placed a “red” tag, remove
Where is your Department-specific FIRE of any hazardous materials they may come in out of patient care area, and immediately
Management Plan Policy located? contact with in the workplace, how to protect contact Bio-Medical Engineering at (305) 243-
(Locate your Department-specific FIRE themselves, training and personal protective 5999 (UM IT Service Desk – Option #1) or
Management Plan Policy and/or consult with equipment. http://facilities.med.miami.edu
your Manager.)
What do you do if you encounter an unknown Are all pieces of electrical and bio-medical
What is the purpose of smoke compartments? substance? equipment (including loan items) inspected
To contain fire or smoke and to 1. Seal-off the area; and tested prior to their use in your area?
compartmentalize in order to provide safe areas. 2. Alert co-workers at once; Yes, by Biomedical Engineering personnel.
3. Alert Security x76130; and
DISASTER / EMERGENCY PREPAREDNESS 4. Call UM Environmental Health and Safety Office at What do you do when your patient brings
personal electric devices?
Where can you find ABLEH’s DISASTER (305) 243-3400. Check for UL sticker; check the electrical cord
Management Plan? integrity; and consult with Physical Plant and
On-line In the Environment-of-Care Safety SECURITY Biomedical Engineering personnel.
Manual
What is ABLEH’s policy for employee identification? HUMAN RESOURCES
What is your Department’s role in the event of a All personnel must wear identification badges (on
DISASTER? the shirt/blouse lapel) with their picture visible while How are you deemed competent to perform
(Locate your Department-specific DISASTER on the hospital premises. your duties?
Management Plan Policy and/or consult with By virtue of:
your Manager.) What would you do if someone in your • educational training;
department/unit does not have an ID badge? • maintenance of up-to-date certification(s)
HAZARDOUS MATERIEL Question his/her business in your area; Contact
Security if you are not satisfied with the response or and licensure;
What should you have for the chemicals you if he/she refuses to leave when requested. • annual performance evaluation is conducted;
work with? • skills competency is monitored on a continual
SDS – Safety Data Sheets available on-line via What should you do if you witness workplace
MyUM portal. violence, acts of vandalism, or disruptive behavior? basis, and
Dial 73333 (Code Grey), and advise of the location • required mandatory educations are assigned
and situation.
annually.

Have you received training on TEAM dynamics?
Yes, during initial orientation and annually.
Examples:
• AIDET/Rapid Response Team – Team Building

Session
• Costumer Service

Have you received training on CULTURAL
DIVERSITY?
Yes, as part of initial orientation and annual CBL

Describe/demonstrate your role and
responsibilities relative to Safety.
It is important that everyday precautions for
minimizing risks, including those related to
Patient Safety and Environmental Safety are
properly implemented; for example, hand-
hygiene, Falls Prevention, reporting of incidents.
Additionally, appropriate emergency procedures
are instituted should an incident or failure occur
in the environment.

PATIENT & FAMILY ENGAGEMENT

How does ABLEH promote patient and family
engagement?
• We ensure patients and family members

understand what is happening during the
patient’s hospitalization or clinic visit stay.
• We foster patient and family participation with
care and discharge preparations.
• We use patient navigators and peers to provide
support.
• We have patients and community members
represented at Hospital committees (Patient
Safety and Board of Governors).
• We encourage patient/family to activate rapid
response.
• We promote use of on-line personal health
record.