1. Mandatory Quest What you need to know……

2. Pillar of Quality
Part 2

3. 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.

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

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

6. 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

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

8. 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

9. 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

10. 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.

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

12. 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).

13. 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

14. 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 , and

15. 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

16. 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

17. 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

18. 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.

19. 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 –

20. 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.

21. 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.

22. 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.

23. Pillar of Quality
Emergency Codes

24. 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

25. 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)

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

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

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

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

35. 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.

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

37. 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.

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

39. 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

40. 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

41. 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.

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

43. 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.

44. Pillar of Quality
Code Black

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

46. 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..

47. 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 (on name tag).
Code Triage External (Disaster)

48. 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)

49. 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.

51. Pillar of Quality
Evacuation Policy
Evacuation Policy

52. 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!

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