Mandatory Quest What you need to know……

Pillar of Quality Part 2

Now it is time to move on to the Quality Pillar. The Pillar of Quality Now it is time to move on to the Quality Pillar. Stay tuned while we discuss very important safety information you will need to know as an employee here at Tulare Local Health Care District. The Quality Pillar has two parts, in this first part you will learn about safety and what to do in the event of an emergency.

QUALITY Pillar of Quality: Setting & meeting high standards. Continually exceed all customer’s expectations. Achieve the best possible outcome from our service.

Quality Goals: Pillar of Quality To improve processes Improve patient outcomes Patient Satisfaction Staff Satisfaction

Pillar of Quality We measure our goal achievement through Performance Improvement data collection and analysis Set priorities High volume High-risk Problem-prone processes Patient safety issues New services or programs Regulatory requirements Systematically monitor and analyze the data

Share Data with: Medical Staff Board of Directors Pillar of Quality

PDSA Model Pillar of Quality TRMC utilizes the PDSA model for performance improvement. (P) Plan - gather reliable data, plan the test (D) Do – Run the test on a small scale (S) Study – Analyze the results (A) Act – Develop and implement interventions to promote change

General Employee Safety Responsibilities Pillar of Quality General Employee Safety Responsibilities Every employee is expected to work in a safe manner by not taking chances with their own safety or the safety of others. The following minimum safety rules shall be followed:   Report immediately to your supervisor: any unsafe condition, any unsafe act, defective or damaged equipment, foreign material on floor (remove if possible), life safety of fire safety condition General Employee Responsibility - HR Standard

Pillar of Quality Facility Safety - All employees are responsible for using safe work practices. - For following all policies and procedures. - For assisting in maintaining a safe work environment.

Facility Safety Officer Pillar of Quality Facility Safety Officer Lionel Machado RCP, RRT is our Safety Officer

Work Orders Pillar of Quality When a piece of equipment or a part of the building is in need of repair you must submit a Work Order to the Maintenance Department, Biomed has “out of Order tags available for patient care equipment (example attached).

Environment of Care (EOC) Committee 22-1009 Pillar of Quality EOC COMMITTEE The purpose is as follows: Reduce and control environmental hazards and risks  Prevent and reduce accidents and injuries/illnesses  Maintain safe conditions and minimizes unnecessary   environmental stresses for patients, visitors and staff Maintain an environment of care, which is sensitive to patient needs for comfort and social interaction Environment of Care (EOC) Committee 22-1009

Ergonomic Awareness 13-9026, 13-3014 and 22-1001 Pillar of Quality ERGONOMIC AWARNESS To provide education to employees, identify and correct any potential safety hazards, decrease the work time lost, as well as the incidence of on‑the‑job injuries, particularly to the back. Ergonomic Awareness 13-9026, 13-3014 and 22-1001

OXYGEN SHUTDOWN Pillar of Quality Before shut down is to occur, all affected areas should be informed by the Maintenance Department to assure that no patient will be endangered by this action. Day Shift Procedure   The following persons must be notified in case of a partial or whole system shut down of the oxygen or vacuum system. a. Nursing Supervisor b. Respiratory Therapy Clinical Director or designee c. Director of Maintenance or designee Evening/Night/Weekend Shift Procedure The following persons must be notified in case of a partial or whole system shut down of the oxygen or vacuum system. a. Nursing supervisor b. On-Call Maintenance person c. Respiratory Therapy Oxygen or Vacuum Shutdown Notification 14-3017

Maintenance and ED have SDS binders Pillar of Quality Safety Data Sheets Please look on the Intranet Site for the SDS link available as a resource to all employees. MSDS changed to SDS (Safety Data Sheets). The new format was completely phased in June 1, 2016. Maintenance and ED have SDS binders

Pillar of Quality Radiation Safety - Check with a nurse or person in charge before entering a room with posted radiation caution sign. - Must report an exposure to the Radiation Safety Officer. - Radiation tells you special precautions are in effect. Radiation sign tells you special precautions are in effect. Radiation Safety - 13-7017

Pillar of Quality Electrical Safety Recognize electrical hazards. All electrical equipment must be checked by the Maintenance Department. (includes patient’s equipment from home). Report all damaged electrical equipment . Make sure you know how to use electricity safely.

Security Pillar of Quality Security is provided by a private contract security service 24 hours a day, seven days a week, 365 days a year including holidays. Officers are uniformed, unarmed and qualified by training. Security Management Plan – 22-1002

Security Management Public Safety Pillar of Quality Provides protection to staff, patients and visitors to facilities. Enforce Parking regulations. Oversees Workplace Violence Training. Offer employee and visitor escort services. Handle Lost and Found Items. Investigates security and safety issues. Respond to Emergency Codes.

Security Management Pillar of Quality Minimize Violence in the Workplace Learn and use security procedures. Take advantage of training offered. Violence in the Workplace. Take threatening or violent behavior seriously. Take quick action and stay calm when dealing with angry or violent people. Have an action plan in place before a violent incident occurs and practice it. Learn what causes anger and the warning signs of violent behavior. Obtain and know policies and procedures dealing with Violence in the Workplace.

No Smoking Pillar of Quality Smoking is prohibited on any premises in which Tulare Local Health Care District operates and in all vehicles. Smoking includes the use of e-Cigarettes and all types of smokeless tobacco.

Pillar of Quality Emergency Codes

Hospital Emergency Response Codes Pillar of Quality Hospital Emergency Response Codes Code RED Fire Emergency Code BLUE Cardiac/Respiratory Arrest Code WHITE Infant/Pediatric Cardiac/Respiratory Arrest Code PINK Infant Abduction Code PURPLE Child/Adult Abduction Code YELLOW Bomb Threat Code GRAY Combative Person Code SILVER Person with a Weapon and/or Hostage Situation Code BLACK Active Shooter Code ORANGE Hazardous Material Spill/Release Code TRIAGE Internal Disaster/External Disaster You can also find CODEs on the back of your name tag

All fires are to be reported. HICS Pillar of Quality Fire Disaster Plan The fire alarm pull station activates the fire system in the Hospital and at the Fire Department. Occupants of the Medical Center will be alerted to a “Code Red” by chimes, strobe lights, and Code Red location announcements. Staff should listen for the “Code Red” zone announcement over the paging system to obtain information on the location. All fires are to be reported. Code Red – Fire (Disaster) 21-2001

Code RED Actions Pillar of Quality Rescue Alarm Confine / Contain Learn to RACE in a Fire Situation Rescue Get everyone away from immediate danger. Alarm Pull fire alarm station and call “dial 77” with notification. Confine / Contain Close doors and windows to help keep fire and smoke from spreading. Extinguish / Evacuate Use fire extinguisher to extinguish fire and/or evacuate if fire is out of control.

Fire Disaster Plan Pillar of Quality Assure a standard response to a Code Red Engineering, Nursing Supervisor, Security, RT, Radiation Officer (if alarm in area), and staff from various departments will respond to each Code Red alarm. Administration, or Nursing Supervisor will assume charge. All personnel must know where extinguisher, alarms, and exits are located in their work area.

The Fire Extinguisher Pillar of Quality Pull Aim Squeeze Sweep Pull the pin. Aim Aim the nozzle at the base of the fire. Squeeze Squeeze the operating handle to release the extinguishing agent. Sweep Sweep from side to side at the base of the fire until the fire goes out.

All Staff are Responsible for: Pillar of Quality All Staff are Responsible for:   Ensuring doors leading to exit corridors are not propped open. Knowing the location of the fire alarm pull boxes and fire extinguishers in the department. Keeping stored items at a clearance of at least 18 inches from the fire sprinklers. Attending to microwave ovens, when in use. Storing flammable or combustible liquids in approved cabinets. Following the smoking policy. Not using personal space heaters. Reporting all fires and smoke, immediately. Reviewing the fire plan and the evacuation routes. Reporting concerns, incidents or recommendations for improving the fire safety programs.

Code Red is in a Different Zone Pillar of Quality Code Red is in a Different Zone   Upon being notified of a “Code Red,” remain alert for any follow-up announcements. Remain clam. Ensure the patients are safe. Reassure all patients and visitors in your area.   Staff, not in their department, should return if the alarm zone is in, adjacent, above or below their department or unit (without passing through fire doors). Staff shall remain in their departments until the “All Clear” has been announced. Ensure that all doors and windows are closed. Evaluate the situation. If the fire is in the horizontal adjacent area, or an area that is planning to relocate to your area, focus on where transferred patients would be placed. Avoid using the telephone for routine calls during a “Code Red” procedure. Post someone (when available) at the elevator to ensure it is not being used, except for the Fire Department, Engineering, and/or Security staff. Assist with the removal of all persons from danger and help control or extinguish the fire. Remove all obstructions, such as the crash carts, from the corridors, in case evacuation becomes necessary.

5 Important Tips to Remember Pillar of Quality 5 Important Tips to Remember   In the event of a fire, clear the hallways to make room for evacuating patients safely. Feel the door of a suspect room before going in. If the door is hot, do not enter. If not hot, proceed cautiously. Know where the fire extinguisher and pull boxes are located on your unit/area (or one you may be visiting). Do not turn off oxygen. Only Maintenance, Respiratory Therapy or the Nursing Supervisor can do so, under direction. Always treat a drill as an actual event.

Code Blue/White Cardiopulmonary Resuscitation (Disaster) 21-2002 Pillar of Quality Code Blue/White Code Blue/White Cardiopulmonary Resuscitation (Disaster) 21-2002

Code Pink- Infant Abduction (Disaster) 21-2003 Pillar of Quality Code Pink Code Pink- Infant Abduction (Disaster) 21-2003

Code Purple – Child/Adult Abduction (Disaster) 21-2004 Pillar of Quality Code Purple Code Purple – Child/Adult Abduction (Disaster) 21-2004

Code Pink - Code Purple Pillar of Quality Infant Abduction – Dial 77 / Child/Adult Abduction – Dial 77 Stop all non-critical work. Guard all exists and report suspicious activity. Clinical areas should respond as follows: Med/Surg to the central elevators and stairs. ICU to elevators & stairs to the front lobby. OB or PEDS secure department doors and thoroughly search the department. ED / MI secure department doors. Other staff members go to nearest exits to observe Report all suspicious persons to Security.

Code Yellow – Bomb Threat (Disaster) 21-2005 Pillar of Quality Code Yellow Code Yellow – Bomb Threat (Disaster) 21-2005

If you receive a bomb threat what should you do? Pillar of Quality CODE YELLOW BOMB THREAT – Dial 77 If you receive a bomb threat what should you do? Do not hang up. Remain calm. Be familiar with check list questions. 1. In Emergency Preparedness 2. In Procedures Flip Chart Notify Operator.

Code Gray – Combative Person 21-2006 Pillar of Quality Code Gray Code Gray – Combative Person 21-2006

A combative situation. Dial – 77 Pillar of Quality Code Gray A combative situation. Dial – 77 Recognize early warning signs! Verbal Abuse Verbal threats of harm. Intimidation by words. Physical Battery Create a barrier Call for assistance

Code Silver – Person with a Weapon and/or Hostage Situation 21-2007 Pillar of Quality Code Silver Code Silver – Person with a Weapon and/or Hostage Situation 21-2007

Persons with weapon and/or hostage – Dial 77 Pillar of Quality Code Silver Persons with weapon and/or hostage – Dial 77 Warn others and do not go into specified area. Staff should close all patient and unit exit doors. Take cover behind locked doors if possible. Do not leave area until ALL CLEAR is announced.

Code Black – Active Shooter 21-1000 Pillar of Quality Code Black Code Black – Active Shooter 21-1000

Code Black Pillar of Quality Active Shooter– Dial 77 Evacuate - if save. Hide Out – lock doors, block entry to your hiding place. Take Action - Attempt to incapacitate the shooter as a last resort, only when your life is in danger. When Law Enforcement arrives, follow instructions, raise hands and spread fingers, avoid quick movements.

Pillar of Quality Code Black

Code Orange – Hazardous Material Spill/Release (Disaster) 21-2008 Pillar of Quality Code Orange Code Orange – Hazardous Material Spill/Release (Disaster) 21-2008

Code Orange Pillar of Quality Implement – EIEIO Hazardous Material Spill / Release – Dial 77 Implement – EIEIO E – Evacuate personnel. I – Identify chemical. E – Eliminate spread I – Inform operator. O – Organize clean-up (MSDS) 1. Minor spill: follow department procedures in MSDS binder. 2. Major Spill: call 77, Nursing supervisor & Director of engineering will assess if a CODE ORANGE should be initiated..

Code Triage External Disaster Pillar of Quality Code Triage External Disaster Any event where there are mass casualties that will require support from several departments. Incident Commander will direct situation. Medical command will be provided by the EMC physician. Each department will follow departmental plan. Continue with required duties and await further direction from your supervisor. Employees should accept transfer of station as assigned. Off duty personnel will be contacted if needed. “off-duty” Call Disaster Hotline 559-684-4525 (on name tag). Code Triage External (Disaster) 21-2010

Code Triage Internal Disaster Pillar of Quality Code Triage Internal Disaster 1. Code is activated throughout the facility and/or surrounding area. 2. Severity of incident will determine who responds and what steps to be taken. 3. Departments not affected should do inventory of supplies, departmental status and relay to Command Center. Code Triage Internal (Disaster) 21-2009

HICS Organizational Chart Pillar of Quality HICS Organizational Chart HICS (Hospital Incident Command System) Defines the chain of command and job action sheets during a disaster (Code Triage) event.

Pillar of Quality Evacuation Policy Evacuation Policy 21-2011

Evacuation Procedure & Responsibilities Pillar of Quality Evacuation Procedure & Responsibilities Evacuation initiated by the Incident Commander Evacuation may be: Partial (horizontal or vertical) or Full Evacuate most hazardous areas first (closest to danger or farthest from exit) Nurse managers will determine patient status for evacuation Employees will report to labor pool (in the dinning room) if instructed Review your department Emergency Preparedness Flip chart. Know your role!

Pillar of Quality Return to the Tracker Module to complete Post-Test 2