Revision of Hospital Emergency Codes Stonewall Jackson Memorial Hospital Chuck Chabanik – Director of Facilities & Safety Officer Jennifer Barnes, RN – Chief Quality Officer

BACKGROUND - How this project began… 70% Data collection during rounds Questioning staff about emergency codes Nurse & New Hires Sometimes a group effort Results – not where we Would like them to be

BACKGROUND - How this project began… Heat of the Moment Calling the correct code All the additional information needed

BACKGROUND - How this project began… Missing Child “CODE AMBER…UM CODE ADAM… MALE… INFANT… OB”

BACKGROUND - How this project began… I need to call CODE SILVER ?

BACKGROUND - How this project began… We had a meeting… Then Chuck went to a meeting…

The Region 6/7 Meeting Proposed to standardize Emergency Codes across Region Many Healthcare workers are employed in more than 1 facility Many people who work in healthcare are also first responders Need to be as transparent as possible Increased situational awareness

The Region 6/7 Meeting GOAL 1 – Every organization in Region 6/7 to adopt the same codes GOAL 2 – Be an example to the State for consistent overhead emergency codes Chuck Chabanik volunteered to work with Maxine Cantis – Environmental Safety @ Mon General to propose consistent codes to be used within our facilities

NOT A NEW CONCEPT 2012 – Joint Commission recommended moving to standardization in their publication, Emergency Management in Health Care: An All Hazards Approach. Plain Language and Standardization supported by: US Department of Health & Human Services US Department of Homeland Security The National Incident Management System The Institute of Medicine

CURRENT EMERGENCY CODES AT SJMH OUR CURRENT STATE CURRENT EMERGENCY CODES AT SJMH Code YELLOW General Disaster Code RED Fire Code GRAY Security Needed Code ORANGE Haz Mat Spill (Internal) Code SILVER Active Shooter (Internal) Code BROWN Bomb Threat Code AMBER/ADAM Missing Child (Gender) Code AMBER/ADAM SENIOR Missing Adult (Gender) Code PINK Missing Infant Code SEVERE WEATHER Severe Weather

OUR FUTURE STATE FUTURE EMERGENCY CODES AT SJMH Activate Emergency Operations General Disaster Code RED Fire Code GRAY Security Needed Code ORANGE Haz Mat Spill (Internal) Code AMBER Missing Child Code WALKER / ELOPEMENT Missing Adult Code PINK Missing Infant Code BLACK Bomb Threat ACTIVE SHOOTER Active Shooter Code Weather Severe Weather Items listed in RED are codes that will be changed at SJMH

OPPORTUNITY FOR IMPROVEMENT Review of our ALL Emergency Operations & Codes Develop Subject Matter Experts Review Department Level Response Plans Standardized Template Reviewed in conjunction with Subject Matter Experts

HOW ARE WE GETTING THERE DMAIC - Our performance improvement model Using evidenced-based tactics for creating change Right people at the table Roles & Responsibilities Due Dates Set a ‘GO-LIVE’ DATE November 15, 2017

First Meeting – July 17, 2017 OUR TASK FORCE VOLUN-TOLDS VOLUNTEERS Safety Officer Education Infection Control / Quality Environmental Services House Supervisor / Nursing Surgery Department Human Resources (Military Police) Supply Chain (retail background) Marketing Administrative Assistant Chief Nursing Officer AD HOC Members: Asst. CEO and IT First Meeting – July 17, 2017

OUR PLAN Using Florida Hospital Association “Overhead Emergency Codes – 2014 Hospital Guidelines” as a model Theirs is 34 pages - ours is 6 Includes Project Background Evidenced-based support of change Action Phase – (How we got started) Implementation Strategy

OUR PLAN Developed an Action Plan Divided into 3 PHASES Implementation (Planning & Education) Go Live Post Go Live Assigned Responsible Parties Set Due Dates

METRICS FOR COMPLETION & SUCCESS OUR PLAN Established metrics to measure success at each stage METRICS FOR COMPLETION & SUCCESS PLANNING EDUCATION GO-LIVE POST -ACTIVATION Completion of action items Departmental Education for each code Completion of Go-Live Items Code knowledge during rounding Completion of Dept. response to existing codes Success of conducted drills Completion of Dept. response to NEW codes

CLOSING Emergency Management is essential Involvement of Senior Leadership Hospitals must be prepared for the unknown This size of a project cannot be accomplished by one individual Find your subject matter experts Data drives change You cannot manage what you cannot measure

QUESTIONS Chuck Chabanik – Director of Facilities/Safety Officer (304) 269-8131 cchabanik@stonewallhospital.net Jennifer Barnes, RN – Chief Quality Officer (304) 269-8533 jbarnes@stonewallhospital.net