Waived Testing WT.03.01.01, EP 1, 2, 3, 4 CMS CoP§482.27
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Abuse/ Neglect RI.01.06.03 EP 1-3 CMS CoP §482.13 When child abuse or elder/dependent adult abuse is suspected: -Any suspected case of abuse is reported to law enforcement or Adult Protective Services or Child Protective Services as appropriate. Community Hospital’s “Elder And Dependent Adult Suspected Abuse/Neglect Flow Chart” and “Suspected Child Abuse/Neglect Flow Chart” include all procedures and needed phone numbers for making a mandated report. (Refer to intranet under policies) -Community Hospital’s social workers are available to consult on these cases and can assist staff in completing mandated reports. Social workers can be contacted by calling 622-2722. -Community Hospital Education Department also has a Net Learning module available on identification and reporting regulations. GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Advance Directives RI.01.05.01 CoP § 482.13, 482.22, 482.24 Code of California § ?? Advance Directives: Community Hospital supports the patient’s right to participate in health care decision-making. Patients are encouraged to communicate their preferences and values to those who provide their care through education and use of AHCD. We will assure that every surgical or inpatient 18 years and older is: 1) asked, at the time of his or her admission, if he/she has an Advance Health Care Directive (AHCD). • If, at the time of admission, the patient is unable to receive information or articulate whether s/he has executed an advance directive, then staff will give advance directive information to the individual’s family or representative. • Once the patient is no longer incapacitated or unable to receive such information, the staff will provide information to the patient. 2) provided written information describing: • his/her individual rights under California Statutes and court decisions to accept or refuse medical or surgical treatment and to formulate advance health care directives; • hospital policies regarding: patients’ rights to make health care decisions and to formulate advance health care directives and how such decisions and directives will be implemented in the hospital. Refer to policy: Advanced Health Care Directive Policy & Procedure GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Anticoagulant Therapy NPSG .03.05.01, EP 1-9 CoP §482.21, 482.23, 482.25 Physicians and Ancillary Healthcare Providers (AHP) are provided with continuing education about anticoagulant therapy through newsletters, computer-based competency testing (employed providers), committee meetings, and/or contact from the Pharmacy and the Pharmacy and Therapeutics Committee. Additionally...There are established policies and protocols approved by through the Pharmacy and Therapeutics Committee for management of patients receiving heparin (unfractionated), low molecular weight heparin, argatroban, and warfarin. Compliance with these policies is continually reviewed by the Pharmacy. Refer to policy: Anticoagulant Ordering and Monitoring GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Codes & Hospital Incident Command System (HICS) EC.03.01.01, EP 1-3 CoP §482.41 Hospital Codes -Dr. Firestone (Fire) -Dr. Strong (Security Incident) -Code A - (Infant Abduction) -Code B - (Bomb Threat) -Parking Lot Alert - (Medical emergency in parking lot) -Trauma Code – (Incoming trauma patient to Emergency Department) -Code Blue – (Medical Emergency) -Code Blue Pediatric – (Pediatric Medical Emergency) -Code Cath – Activates team to get patient to Cardiac Cath Lab within 90 minutes after arriving in the ED -Code Stroke – Activates team to respond to a patient having a stroke -Code Purple – Notifies staff that patient wait time or the number of patients in the Emergency Department has exceeded an established threshold Hospital Incident Command System (HICS) -HICS is a system for managing people and resources during an emergency. HICS allows CHOMP to activate all or part of the Emergency Operations Plan depending on the type and severity of the incident. -When the CHOMP Emergency Operations Plan is implemented, the following overhead announcement will be made – “The Hospital Incident Command System has been activated. Please refer to the CHOMP intranet for further information.” -This announcement doesn’t necessarily mean that your department has been requested to initiate their departmental Emergency Operations Plan. Further instructions will be announced as the CHOMP Incident Commander initiates the Hospital Incident Command System R.A.C.E. organization-wide fire procedure: R- Remove all persons who are in immediate danger, if safe to do so. A- Announce the fire by calling “1111” at the hospital or 9-911 for all off-site locations; pull a fire alarm pull box; and inform staff members in the area. C- Close all doors and windows and check smoke- and stairwell-barrier doors for proper closure. E- Evacuate patients, visitors, and staff, and turn off oxygen in fire area, if directed to do so by the administrative supervisor or the Fire Department. At offsite locations, follow the evacuation procedure for each location. GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Code of Conduct LD.03.01.01, EP 4 CoP §482.21 Code of Ethical Conduct Handbook includes a public affirmation by the employees, managers, administrators, and Board of Trustees of Community Hospital that we all will act honestly, fairly, and in keeping with the highest ethical standards. This Code of Ethical Conduct provides staff a blueprint for ethical and lawful behavior. The handbook describes hospital staff's responsibility for upholding the Code of Ethical Conduct, including holding hospital staff responsible for maintaining our high ethical standards. Community Hospital also requires that members of the medical staff, through their bylaws, act honestly, fairly, and in keeping with the highest ethical standards. Resources: Community Hospital management Community Hospital compliance officer: (831) 625-4582 Community Hospital compliance hotline: (800) 810-0176 GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Compliance Compliance policies are found on the intranet and members of the medical staff, through their bylaws. Use the Compliance Hot Line or the forms on the intranet to report instances of possible fraud or wrong doing and remain anonymous. Community Hospital complies with the requirements of the Federal Government’s Deficit Reduction Act of 2005 by providing the following information to all its employees about the Federal False Claims Act (FCA), the California False Claims Act (FCA), collectively “the Acts”, and administrative remedies for false claims or statements. Refer to policy: The False Claims Act: Preventing Fraud, Waste and Abuse GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Confidentiality According to Federal law, including HIPAA, all hospital records, medical records and professional counselor records of a patient, or a former patient, including both inpatient and outpatient are confidential records. The hospital will provide for the security of the medical and billing record and establish internal policies to provide for their proper use and disclosure. Refer to policy: Confidentiality of patient and hospital business information GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Disruptive or Unprofessional Behavior LD.02.04.01, EP 1 LD.03.01.01, EP 5 CoP §482.13 Collaboration, communication, and collegiality are essential for the provision of safe, effective, and competent patient care. It is the policy of the medical staff that all members practicing in the hospital must treat others with respect, courtesy, and dignity and conduct themselves in a professional and cooperative manner. In dealing with all incidents of inappropriate conduct, the protection of patients and their families, employees, physicians, and others in the hospital, and the orderly operation of the medical staff and hospital are paramount concerns. Complying with the law and providing an environment free from sexual harassment and discrimination are also critical. A medical staff member who is observed or reported to manifest actions or activities that may represent disruptive or unprofessional behavior shall be evaluated by the Medical Staff pursuant to the procedures described in the Medical Staff Policy: Disruptive or Unprofessional Behavior. If a medical staff member is observed to exhibit actions that may represent disruptive or unprofessional behavior, then such actions shall be recorded by the observer on a hospital staff concern report form. Refer to policy: Disruptive or Unprofessional Behavior GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Diversity HR.01.04.01 EP 5 EXCEEDING EXPECTATIONS is an employee-developed program for making Community Hospital the best possible place to work. It is built around a series of ten standards designed to promote teamwork and communication, and raise expectations and accountability, at all levels and within all departments of the hospital. NEW EMPLOYEE ORIENTATION covers personnel policies and many of the hospital’s opportunities for professional growth. At the hospital-wide orientation for new employees, the vision statement, mission statement and guiding principles are reviewed and resources are given for finding information. EMPLOYMENT APPLICATION states it is the hospital’s policy to comply with all applicable Federal and State laws prohibiting discrimination in employment based on race, religion, color, national origin, ancestry, sex, physical or mental disability, marital status, pregnancy, age, sexual orientation, or veteran status. GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide DO NOT USE: Abbreviations, acronyms, symbols and dose designations NPSG.02.02.01 CoP §482.24 The Joint Commission Information Management standard requires the hospital to have a list of DO NOT USE Abbreviations, acronyms, symbols and dose Designations. The current DO NOT USE list is:
DO NOT USE USE U or u units IU International units QD, Q.D., qd, q.d daily QOD, Q.O.D. every other day trailing 0 (2.0mg) never use a zero after a decimal point (2 mg) No leading 0 (.5mg) always use a zero before a decimal point (0.5mg) MS morphine sulfate MSO4 morphine sulfate MgSO4 magnesium sulfate Refer to policy: Pharmacy & Therapeutics Committee “Use of Abbreviations in all Patient-Specific Documentation” GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide The Dying Patient RI.01.05.01, EP 1, 5 CoP §482.13, 482.22, 482.24 HSC § 442-442.7 AB 2747, sponsored by Compassion and Choices, provides that when a health care provider makes a diagnosis that a patient has a terminal illness the health care provider shall provide the patient with the opportunity to receive information and counseling regarding specified end-of-life options and provide for the referral or transfer of a patient if the patient’s physician does not wish to comply with the patient’s choice of end-of-life care options. Refer to policy: Care of the Dying Patient GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide EMTALA Section 1867(a) of the Social Security Act EMTALA (Emergency Medical Treatment and Active Labor Act) requires that hospitals, including Community Hospital, which receive any Medicare benefits to provide an appropriate medical screening exam to any patient who presents to the emergency department, Family Birth Center, or anywhere on Community Hospital main campus property requesting an examination or treatment for a medical condition complaining of any medical condition or in labor regardless of the ability to pay or source of insurance. The regulation [42 CFR 489.24(a)] adds that the person who does the examination must be specifically determined to be a “qualified medical person” by the hospital bylaws. EMTALA is applicable to any individual who comes to the emergency department.
Dedicated Emergency Departments: CMS has determined that a dedicated emergency department includes other departments of hospitals, if any area of the hospital offers such medical services to treat individuals including:
Labor and delivery units and psychiatric units IF at least one-third of the ambulatory individuals who present to the area;
Urgent care centers (however CMS guidance on the applicability of EMTALA to urgent care centers isn’t wholly consistent, and there is some confusion in this area.)
Where EMTALA Does Not Apply: EMTALA does not apply to the following:
1. An outpatient during the course of his/her encounter (even if the outpatient develops an EMC while receiving outpatient services and is taken to the dedicated emergency department for further examination and treatment);
2. An inpatient (including inpatients who are “boarded” in the dedicated emergency department waiting for an available bed);
3. An individual who presents to any off-campus department of Community Hospital that is not a dedicated emergency department;
4. An individual who presents to a rural health clinic, SNF, or home health agency owned or operated by Community Hospital, whether located on or off campus.
Emergency Medical Condition (EMC): An EMC means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe
pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part; or
2. With respect to a pregnant woman who is having contractions: a. When there is inadequate time to effect a safe transfer to another hospital before delivery;
or b. The transfer may pose a threat to the health or safety of the woman or the unborn child.
Fundamentally, Community Hospital is obligated to provide MSEs and necessary stabilizing treatments to individuals who are EMTALA patients, i.e. they have EMCs, within the capabilities of the staff (including on-call physicians) and facilities available.
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide If Community Hospital does not have the capability to provide necessary stabilizing treatment it must make an appropriate transfer of the patient to another hospital. Also, if the hospital has exhausted its capability or is operating beyond its capacity, a transfer must be made. If a patient with an unstabilized EMC is transferred for medical reasons, the transferring physician must certify that the medical benefits reasonably expected from treatment at the receiving facility outweigh the increased risks to the patient from the transfer. Stabilized: Stabilized means, with respect to an emergency medical condition, that no material deterioration of the condition is likely within reasonable medical probability to result from or occur during the transfer of the individual from Community Hospital or, in the case of a woman in labor, that the woman delivered the child and the placenta. An individual will be deemed stabilized if the treating physician has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved. To Stabilize: To stabilize means to either provide such medical treatment of the emergency medical condition or, in the case of a woman in labor, as both are described above such that the Stabilized condition definition described above is met. GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Emergency Management EM. 02.02.01, EP 1-14, 17 IM.01.01.03, EP 1-6 CoP §482.41 HSC § 1279.6 The expectation here is that the medical staff participates in the development of the Emergency Operations Plan. (Dr. Singh fulfills this role at CHOMP.) The Emergency Operations Plan can be found on the hospital found in CHOMP Emergency Management manual plan to place on intranet Fall 2010. Issues related to response procedures to follow when emergencies occur may include but are not limited to the following:
Maintaining or expanding services Conserving resources Curtailing services Supplementing resources from outside the local community Closing the hospital to new patients Staged evacuation Total evacuation mention disaster privilege policy
The hospital is expected to plan for continuity of its information management processes. To maintain optimal function and add the newest enhancements to SXA, an occasional downtime may be required. When this is necessary, notice will be given as far in advance as possible. These planned downtimes will generally be scheduled during the night shift. Occasionally, technical difficulties arise and the downtime extends into the day shift. Additionally, a system “crash” – though extremely rare – could occur at any time, resulting in unexpected downtime. To improve communication during an extended or unexpected downtime, CHOMP will institute the Hospital Incident Command System (HICS). If the Incident Commander determines that HICS activation is necessary, an overhead announcement will inform staff and physicians to go to the Incident Alert link on the CHOMP intranet for further information. Refer to policy & SXA materials: Emergency Management & Downtime procedures and a “Downtime Physician Reference” guide is available in the “SXA Downtime Management” manual, available on all nursing units & SXA Policies and Procedures quick reference guide, available on the intranet. GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Disaster Privileges EM.02.01.01, EP 1 - 8 CoP §482.41 To provide for the coordination of hospital and community resources during an emergency response, Community Hospital has adopted the Hospital Incident Command System (HICS). This scalable command structure is based on an “all hazards” approach. Its primary purpose is to provide administrative coordination and support for all hospital resources dedicated to the response effort and to establish effective communication and coordination with external response agencies to facilitate the maintenance of hospital operations. Activation of the response phase of the hospital’s Emergency Management Plan occurs when the administrative supervisor on duty receives information judged to be within the criteria for implementation of any part of the Emergency Management Plan. If the emergency requires the implementation of only a “stand-alone” response, that response will be implemented according to current procedures. If the emergency requires additional response, the administrative supervisor may implement the hospital incident command system (HICS). Once the HICS has been implemented, the Incident Commander (IC) will assume responsibility for any further direction to implement elements of the plan. When the hospital disaster plan has been implemented and the immediate needs of the patients cannot be met, the organization may implement a modified credentialing and privileging process for eligible volunteer practitioners. Eligible volunteer practitioners are those qualified Licensed Independent Practitioner (LIP) not currently privileged by the Medical Staff providing patient care services in a disaster must be granted temporary disaster privileges. The practitioner will be identified by a numbered hospital “Disaster Physician” identification badge. A label with the practitioner’s name and specialty will be applied to the badge by the Medical Staff Office or their designee. The practitioner shall be assigned to a Medical Staff member, in the same specialty if possible, with whom to collaborate in the care of patients. This practitioner shall provide oversight on the professional practice of volunteer practitioners and will report any concerns regarding the care rendered as soon as possible to the Chief of Staff or his/her designee. Refer to policy: Disaster Privileges for Licensed Independent Practitioners GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Ethics and Patient Rights RI.01.01.01 RI.01.03.01 CoP §482.13
To help improve patient outcomes by respecting each patient's rights and conducting business relationships with patients in an ethical manner the organization respects the fundamental rights of patients to considerate care that safeguards their personal dignity and respects their cultural, psychosocial, and spiritual values. Understanding and respecting these values that often influence patients' perception of care and illness guide the staff in meeting the patients' care needs and preferences.
Patient Bill of Rights and Responsibilities are developed by hospital leadership. Information about patient’s rights and responsibilities are provided to patients on admission, displayed at entry locations at the main campus and off campus locations, and brochures in public areas. Refer to policy: Patient Bill of Rights and Responsibilities GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Fall Reduction NPSG.09.02.01, EP 4 CoP §482.21, 482.26, 482.27 The aim of our Fall Reduction Program is to evaluate the patients risk for falls and take action to reduce the risk of falling as well as the risk of injury, should a fall occur. The program is coordinated thru the Risk Management department with a designated Falls Project Champion and an interdisciplinary group that is responsible for over-seeing the strategic plan for falls program planning, implementation and evaluation. In addition, the group ensures accurate fall data reporting, staff and patient/family education occurs in an on-going basis. Refer to policy: Fall Prevention GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide HIPAA While practicing at Community Hospital of the Monterey Peninsula, all members of the Medical Staff of Community Hospital are part of an “Organized Health Care Arrangement” with the hospital under the Federal Health Insurance Portability and Accountability Act (HIPAA) regulation. This allows members of the Medical Staff and Community Hospital to comply jointly with HIPAA by adopting joint privacy practices for Community Hospital. Health Information Privacy Practices, HIPAA, as implemented by the HIPAA Privacy Regulation (42 CFR Parts 160 and 164), requires Community Hospital to implement policies and procedures to protect the privacy and security of “protected health information,” and to afford individuals certain rights with regard to their health information. “Protected health information” includes any health-related information that identifies or could be used to identify an individual, including patient medical and billing records. HIPAA applies both to Community Hospital and to its Medical Staff members. Refer to policy: Organized Health Care Arrangement: Medical Staff Policy GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Impaired or Dysfunctional Licensed Independent Practitioner The medical staff is committed to maintaining patient safety and high quality care; promoting a healthful, secure, and safe working environment for medical staff members and hospital staff; and fostering public trust in the services we provide, which can be compromised if a member of the medical staff is suffering from impairment. Practitioner impairment or the appearance of impairment, if not managed, can lead to patient safety issues, reduce the quality of care provided to patients, and erode public trust in our services. Therefore, the medical staff has adopted this zero tolerance policy for the impairment or appearance of impairment of a member while providing care for patients. In addition, the medical staff acknowledges its role in education and prevention of impairment, assisting physicians in rehabilitation of impairment, and in aiding physicians in retaining or regaining optimal professional functioning consistent with the ongoing protection of our patients. In that regard, the medical staff has established the Medical Staff Health and Well-Being Committee (reference: Medical Staff Health and Well Being Policy). The Medical Staff Health and Well-Being Committee (MSHWBC) advises the Medical Executive Committee (MEC) on educational materials that address practitioner impairment issues and that emphasize prevention, diagnosis, and treatment of physical, psychiatric, and emotional illnesses that may lead to impairment. To the extent possible, and consistent with our commitment to providing quality care, the medical staff will handle impairment matters in a confidential fashion. It is a basic professional responsibility and obligation of each medical staff member and the hospital staff to address and/or report potential or actual practitioner impairment issues to the appropriate body of the medical staff or the Medical Board of California. DEFINITIONS: Appearance of Impairment: The smell or ingestion of alcohol or other drugs/medications, or other physical characteristics of substance abuse/misuse or aberrant behavior which would suggest an actual or potential impairment while caring for a patient or exercising clinical privileges. Health Concern: Substance abuse, or a physical, mental or emotional condition that is known to have the potential to impair an individual’s ability to practice safely and competently. Immediate Threat: An incident in which there is ongoing exposure to a risk or hazard unless immediate action is taken to resolve the risk or hazard (for example, a physician with behavior and physical findings suggestive of inebriation who presents to the hospital to care for a patient). Impairment: Substance abuse, or a physical, mental or emotional condition that adversely affects a member’s ability to practice safely and competently. Zero Tolerance Policy: A standard of the medical staff that no level of ingestion, inhalation or administration of substances with the potential to impair functioning is acceptable. In addition, no level of impairment due to physical, mental or emotional conditions is acceptable except those which can be reasonably accommodated with minimal risk of harm to the health or safety of our patients. Mechanism for Reporting and Reviewing Possible Impairment with Immediate Threat to Patient Safety and further information on this topic can be found in the Medical Staff Polices entitled, “Practitioner Impairment” Refer to policy: Practitioner Impairment GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Infection Control/Influenza Vaccination and Prevention NPSG.07.01.01 EP1 CoP §482.28; 482.42 HSC § 1255.8 Practices to prevent the spread of influenza:
Comply with hand washing/hand gel guidelines use soap & water o No hand gel for C diff patients
Influenza vaccination for all health care workers Cover your cough – Respiratory Etiquette Hand hygiene If you are sick, stay home until afebrile for at least 24 hours For fever 100 FP or greater+, cough or sore throat are not to see patients
NPSG. 07.05.01, EP. 5 CoP §482.51 Practices to prevent surgical site infections:
Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to evidence-based standards and guidelines for best practices
When hair removal is necessary, use clippers or depilatories Shaving is an inappropriate hair removal method NPSG. 07.03.01, EP. 6 Temperature maintenance Blood sugar control Hand Hygiene
Practices to prevent multi-drug resistant organisms (MDROs): Education Judicious use of antimicrobial agents Surveillance Infection control precautions Cleaning and disinfection of surfaces Hand Hygiene
NPSG. 07.04.01, EP 5 CoP §482.42
Practices to prevent central-line blood stream infections: Where mask, hair cover, sterile gloves, sterile gown to insert catheter Hand hygiene prior to insertion or manipulation Use a standardized supply cart of kit Use of sterile maximum barrier for insertion Avoidance of femoral vein for access Use of chlorohexidine antiseptic-allow to dry Use a catheter checklist and document use Evaluate routinely and remove nonessential catheters Disinfect hubs & injection ports before accessing
GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Infection Control Precautions for Influenza A H1N1 IC.01.05.01, EP 7 IC.02.01.01 EP 7 CMS CoP§482.42 CMS CoP§482.27, 482.42, 482.51 Enhanced respiratory precautions to include the use of N95 respirators are recommended for the following aerosol-generating procedures (See SHEA Interim Guidance):
Bronchoscopy Open suctioning of airway secretions Resuscitation involving emergency intubation or CPR Endotracheal intubation
The use of N-95 respirators or face shields for respiratory protection during routine patient care activities is recommended. This includes collection of nasopharyngeal specimens from patients with suspected or confirmed novel H1N1, closed suctioning of airway secretions and administration of nebulized medications. GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Information Management Systems Interruption/Downtime IM.01.01.03 EP 3 EM.01.01.01 EP 6 The hospital is expected to plan for continuity of its information management processes. To maintain optimal function and add the newest enhancements to SXA, an occasional downtime may be required. When this is necessary, notice will be given as far in advance as possible. These planned downtimes will generally be scheduled during the night shift. Occasionally, technical difficulties arise and the downtime extends into the day shift. Additionally, a system “crash” – though extremely rare – could occur at any time, resulting in unexpected downtime. To improve communication during an extended or unexpected downtime, CHOMP will institute the Hospital Incident Command System (HICS). If the Incident Commander determines that HICS activation is necessary, an overhead announcement will inform staff and physicians to go to the Incident Alert link on the CHOMP intranet for further information. Refer to: Downtime procedures and a “Downtime Physician Reference” guide is available in the “SXA Downtime Management” manual, available on all nursing units & SXA Policies and Procedures quick reference guide, available on the intranet. GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Language Interpretation Services RI.01.01.03 EP 1 CoP §482.13 Occasionally it is necessary to obtain an interpreter for non-English speaking patients, hospital visitors, or foreign dignitaries. For this reason the hospital maintains a listing of language skills of employees. This list is maintained in the language manual (in Nursing Administration) and the Personnel Manual and is updated annually. The list includes those employees who can translate medical information in addition to conversational translation. The listing also includes those employees who are skilled in communicating with the deaf. In addition, the language manual in Nursing Administration contains communication, dietary, and discharge planning aids. The process for accessing the language line or for access for hearing impaired patients is described in the hospital policy entitled, “Foreign Language Interpretation” found in the Personnel Manual. Refer to policy: Foreign Language Interpretation GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Latex Allergies To provide a hospital environment that reduces exposure to latex to patients and staff who may be sensitized to latex. Products will be selected and practices will be implemented that reduce the risk of allergic reactions. CHOMP will strive to provide a latex-safe environment for our patients and staff. On-going education will be made available to staff and physicians about latex allergy. The organization will participate in on-going monitoring of non-latex products availability, and whenever possible, purchase non-latex products. If non-latex products available, CHOMP will purchase products with the lowest latex content. Refer to policy: Latex Allergy GO BACK TO BEGINNING
From ISMP List of Confused Drug Names and Community Hospital's medication incidents: GENERAL SAFETY STRATEGIES Use of indication whenever possible to differentiate products Separate products in the pharmacy storage areas, if possible Limited verbal orders and read-back techniques used Affix look-alike/sound-alike alert stickers in stock storage areas in the
pharmacy Use of computerized orders sets Store similar look/name products in separate "cubies" in Pyxis
MedStations Brand and generic names listed in all Pyxis, WORx and
SXA screens Encourage and incentivize reporting of errors or circumstances that may lead to errors
Use TALL MAN lettering when possible to change appearance of medication names in all computerized systems
Configuring WORx order master to prevent two similar names from appearing consecutively
amphotericin: lipid-based and conventional Shelf stickers; restrict liposomal to one product (AMBISOME).
ampicillin and ampicillin-sulbactam TALL-Man lettering is possible in Alaris
Bicillin CR and Bicillin LA Removed from Pyxis floor stock; dispensed per patient order
Combivent and Combivir TALL-MAN lettering combivENT and combivIR in SXA, WORx and Pyxis
Cytomel and Cytotec TALL-MAN lettering cytoMEL and cytoTEC in SXA and WORx; brand-generic cross reference in SXA, WORx, Pyxis.
daunorubicin and doxorubicin: lipid-based and conventional TALL-MAN lettering DOXOrubicin and DAUNOrubicin; adult dose check alerts in WORx; brand/generic cross reference in WORx, SXA, Pyxis.
Depakote and Depakote ER Shelf stickers in pharmacy
dobutamine and dopamine TALL-MAN lettering DOBUTamine and DOPamine in SXA & WORx; brand-generic cross reference in SXA, WORx, Pyxis.
glipizide and glyburide TALL-MAN lettering glipiZIDE and glyBURIDE in SXA and WORx; brand-generic cross reference in SXA, WORx, Pyxis.
hydroxyzine and hydralazine TALL-MAN lettering hydrOXYzine and hydrALAzine in SXA browser.
Humulin and Humalog TALL-MAN lettering humULIN and humALOG in SXA browser.
morphine liquids: concentrated and other strengths Generic listing and specific concentrations listed (2mg/mL and 20mg/mL); Roxanol high-conc. warning in Pyxis. High conc. Morphine is standard stock only on Terrace West.
tpa and TNK TALL-MAN lettering TPA and TNKase
tramadol and trazodone
Removed generic tramadol from stock (products too similar); assured correct ordering number for brand was on the new "blue storage bin"; shelf stickers; TALL-MAN lettering for traMAdol and traZOdone in SXA.
vaccines: influenza and pneumococcal and H1N1 "Flu vaccine" cross-referenced in SXA browser; stored in the nursing unit refrigerators in different colored containers. H1N1 dispensed per patient (not Pyxis stock).
valproic acid and divalproex Shelf stickers in pharmacy
vinblastine, vincristine and vinorelbine
TALL-MAN lettering for vinBLAStine, vinCRIStine, vinORELbine; brand/generic cross-reference in WORx, SXA and Pyxis; adult dose check alert in WORx; vinblastine, vincristine and vinorelbine dispensed in 50mL bags.
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide High Risk medications must be procured, stored, dispensed, administered and monitored with special care and used with caution to reduce the likelihood of an adverse drug event and patient harm from occurring. While all medications must be processed with great care, a specific list of High Risk medications is developed by the organization using internal information sources (i.e. high volume, extremely high risk , and medication error and adverse drug reaction reports) and external reference information (i.e. The Joint Commission (TJC) standards, Food & Drug Administration (FDA) Boxed warnings and Institute on Safe Medication Practice (ISMP) High-Alert list). Refer to policy: High Risk Medications (Including "Box Warnings"): Pharmacy and Therapeutics Policy GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Material Safety Data Sheets EC.02.02.01, EP 3, 4 CMS CoP §482.26; 482.41, 482. 53 A material safety data sheet (MSDS) is a form containing data regarding the properties of a particular substance. An important component of product stewardship and workplace safety, it is intended to provide workers and emergency personnel with procedures for handling or working with that substance in a safe manner, and includes information such as physical data (melting point, boiling point, flash points, etc.), toxicity, health effects, first aid, reactivity, storage, disposal, protective equipment, and spill handling procedures. Relevant MSDS can be found in departmental EOC hardcopy manuals located in every department and on a Healthcare MSDS CHOMP intranet link. GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide National Patient Safety Goals, Comprehensive Accreditation Manual for Hospitals CMS CoP§482.26, 482.51 National Patient Safety Goals were introduced by The Joint Commission and are intended to promote specific improvements in patient safety. They highlight problematic areas in health care and describe evidence-and-expert-based consensus as solutions to these problems. Under Joint Commission scoring guidelines, we are required to comply with chapter standards and elements of performance. The goals are listed below. Goal 1 – Improve the accuracy of patient identification. To ensure the accuracy of patient (or resident) identification in general for all services and, in particular, to ensure accurate identification of the patient (or resident) before taking blood samples or administering medications or blood products and to eliminate transfusion errors related to patient misidentification. It is Community Hospital’s policy to use at least two patient or resident identifiers when providing care, treatment or services. Prior to any specimen collection, medication administration, transfusion, or treatment (of any kind), there is active involvement with the patient (and family members, as needed) in this identification procedure. The identity of the patient or resident is confirmed by using at least two identifiers in all care settings or services including (but not limited to) when specimens or blood samples are collected, medications are administered, or blood products administered. Refer to policy: Patient Identification when Providing Care, Treatment or Services Goal 2 – Improve the effectiveness of communication among caregivers. Situation-Background-Assessment-Recommendation (SBAR) technique is the primary model for communication regarding patient information for both the medical staff and clinical staff. SBAR promotes safe, efficient, effective, equitable, timely and patient-centered lines of communication. SBAR ensures that clinical staff will be clear, concise, and ready to answer questions. SBAR should be considered for use by all staff whether initiating or receiving communication. The goal is to improve and standardize processes for communication of essential patient information, create an environment in which individuals can speak up and express concerns, and share common “critical language” to alert team members to unsafe situations.
Refer to policy: SBAR (Situation-Background-Assessment-Recommendation) Technique Goal 3 – Improve the safety of using medications. Critical elements in this goal include:
Labeling medications/solutions Implementing a plan to reduce the likelihood of patient harm associated with the use of
anticoagulant therapy Refer to policy: LABELING OF MEDICATIONS OR SOLUTIONS
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Goal 7 – Reduce the risk of health care-associated infections. Critical elements in this goal include:
Implementation of a hand hygiene program Implementation of evidence-based practices to prevent health care-associated infections due to
multidrug-resistant organisms Implementation of evidence-based practices to prevent central line-associated bloodstream infections. Implementation of evidence-based practices for preventing surgical site infections
Goal 8 – Accurately and completely reconcile medications across the continuum of care. Critical elements in this goal include:
The medication reconciliation process What must the physician do? 1. Sign the medication reconciliation list 2. See that the patient being discharged or transferred to another facility has an updated and accurate medication list
Refer to policy: Medication Reconciliation Process Goal 15 – The hospital identifies safety risks inherent in its patient population. Community Hospital has a process of safety measures and bed placement decisions for the patient assessed as at risk for self-harm while in the hospital. Behaviors include: suicide attempt, drug overdose, self-harm statement, or self-injurious behavior. Refer to policy: Care of the At-Risk Patient for Suicide/Self-Harm (Suicide Attempt, Threat of Self-Harm, or Drug Overdose Patient) Outside of Garden Pavilion Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery The Universal Protocol applies to all surgical and nonsurgical invasive procedures. The Universal Protocol is based on the following principles:
Wrong-person, wrong-site, and wrong –procedure surgery can and must be prevented. A robust approach using multiple, complementary strategies is necessary to achieve the goal of always
conducting the correct procedure on the correct person, at the correct site. Active involvement and use of effective methods to improve communication among all members of the
procedure team are important for success. To the extent possible, the patient and, as needed, the family is involved in the process. Consistent implementation of a standardized protocol is most effective in achieving safety.
Refer to policy: Universal Protocol for Surgical and Procedural Site Verification/Site Marking/Time Out GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Organ Donation TS. 01.01.01, EP 1 – 12 CoP §482.45 Community Hospital’s policy establishes guidelines for identifying potential organ and tissue donors at Community Hospital, obtaining authorization for the donation, and notification of the procurement organization. Referrals will be made to the California Transplant Donor Network for all expirations unless such referrals would violate a patient’s written directive. Refer to policy: Policy for Identification and Referral of Potential Organ and Tissue Donors GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Orientation HR.01.04.01EPs, 1, 2, 4, 5, 6, 7 CMS CoP§482.42 As part of the initial appointment process is a physician orientation program. Community Hospital believes that the orientation of new physicians is essential to document competency and to facilitate the adjustment of a new physicians to: the hospital mission, vision, governance, policies, and procedures; performance expectations including guiding principles, people values, philosophy of patient care, and patient rights; plant, technology, and safety management programs and the physician’s safety responsibilities; emergency procedures; infection control program and the physician's role in the prevention of infection; and the hospital quality assessment and improvement activities and the physician's role in these activities. Refer to: Physician Orientation Checklist GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Pain Management MS.03.01.03, EP 2 RI.01.01.01, EP 8 - CMS CoP§482.13 PC.01.02.07, EP 1 HR.01.04.01 EP 4 Pain is assessed and treated promptly, effectively, and for as long as the pain is present. Pain management is a collaborative effort between the patient/family/significant other and the health care team. Joint participation in the development of the pain management plan is encouraged. Pain is considered the fifth vital sign and pain intensity ratings are documented with routine vital signs as defined in the Assessment Policy. Pain assessment is completed on all patients based upon the clinical presentation, services sought and in accordance with the care, treatment and services provided. A presentation on pain management by a physician is planned for late 2010. Arrangements are pending. Refer to policy: Pain Management GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Patient Identification Patients admitted to Community Hospital are provided with a method of identification. The identifying information includes: A. Patient Name. B. Admission Account Number. C. Medical Record Number. D. Admitting Physician. E. Patient Birth Date. II. The standard form of identification is a plastic bracelet placed, when possible, on the right wrist of the patient. III. The identifying information on the bracelet is verified with the patient prior to placement the patient's extremity. IV. Patient room number will not be used as a method of identification. Refer to policy: Patient Identification Policy GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Patients Right to be Informed RI.01.02.01 EP 22 CoP§482.13 Patients and, when appropriate, their families have a right to be informed about outcomes of care including unanticipated outcomes. The patient's attending practitioner or designee has the responsibility to clearly explain the outcomes of any treatment or procedure to the patient and/or family whenever those outcomes differ from the anticipated outcome secondary to a significant medical error. Refer to policy: Disclosure of Medical Errors GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Performance Improvement PI.03.01.01, EPs 1 – 4 CoP§482.21 and 22 Hospital leaders have ultimate responsibility for performance improvement. Performance improvement activities are directed toward improving the safety and quality of patient care with the end result being better patient outcomes. Quality data is collected, analyzed and reported. Hospital leaders prioritize identified improvement opportunities. The committee overseeing performance improvement at Community Hospital is the Interdisciplinary Quality Committee. GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Rapid Response Protocols PC.02.01.19 To reduce the incidence of cardiac arrests and unplanned transfers to critical care through the identification, assessment, and early intervention of the patient at risk for clinical decline. To provide a standardized response to a medical emergency in which an intensive care unit moves to the bedside. The Rapid Response Team is of paramount importance in the fostering of improved communications, increasing the opportunity for professional and educational growth, and the enhancement of collegial relationships between Medical-Surgical nursing staff, Respiratory Care Practitioners, Pharmacy, and the Critical Care nursing staff. Refer to policy: Rapid Response to Changes in Patient Condition GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Restraints PC.03.05.05, PC.03.05.07, EP 1 CMS CoP§482.13(f) It is the philosophy of Community Hospital to provide an environment where care is provided fostering the patient's safety, dignity, well-being, and preservation of rights, with minimal use of restraints. This will be achieved by the following: -We will strive to create a physical, social, and cultural environment that fosters using restraints only for clinically appropriate and adequately justified situations. -We will actively seek ways to prevent, reduce, or eliminate restraint use through alternative strategies using the least restrictive measures, including family assistance. -When appropriate, we will strive to prevent emergencies that have the potential to lead to the use of restraints. Non-physical interventions will be the preferred interventions for the management of patient behavior. -We will limit the use of restraints for behavioral health purposes to those emergencies in which there is an imminent risk of an individual physically harming self or others, including staff. We will facilitate the discontinuation of such restraint or seclusion as soon as possible. We do not permit the use of such restraint or seclusion for any other purpose, such as coercion, discipline, convenience, or retaliation by staff. -We will not base the use of restraints on an individual's restraint or seclusion history, or solely on a history of dangerous behavior. -The type of physical intervention selected will take into consideration information learned from the individual's initial assessment. -We will raise awareness among staff about how the use of restraints or seclusion may be experienced by the individual. -We will preserve the individual's safety and dignity whenever restraints or seclusion are used. -The organization collects data on the use of restraints in order to monitor and improve performance and processes that involve risk or may result in sentinel events. Order requirements: 1. All restraints must be ordered by a LIP. 2. For restraints utilized for acute medical or surgical purposes, the following order requirements will occur: a. A written order, based on an examination of the patient by a LIP, must be entered into the patient's medical record within 24 hours of the initiation of restraints. A face-to-face evaluation by a LIP is required. b. Continued use of restraints beyond 24 hours requires a new order. Such renewal is issued no less often than once each calendar day and is based upon a face-to-face evaluation of the patient by a LIP. c. In an emergency, an RN may initiate restraint and will obtain the restraint order within one hour of application. 3. For restraints utilized for behavioral health purposes, the following order requirements will be observed: a. A LIP must see an adult patient within four hours after initiation of behavioral restraints. The LIP must see a patient age 17 or under within two hours after the initiation of behavioral restraints. The LIP must review the plan of care and document in the MD progress notes times of evaluation and findings. b. Within one hour of initiating behavioral restraints in an emergency situation with no LIP available, an RN will: (1) Review the physical and psychological status of the patient. (2) Determine whether restraints should be continued. (3) Identify ways to help the individual regain control in order for restraints to be discontinued. (4) Report findings to the responsible LIP and receive an order for the use of behavioral restraint. c. Each written order for a physical restraint is limited to four hours for adults, two hours for children and adolescents ages nine to seventeen, or one hour for children under age nine. A new order is required for restraints to be continued past these time limits.
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide d. If restraints need to be continued, a LIP must conduct an in-person re-evaluation at least every eight hours for adults, or four hours for children and adolescents ages seventeen and younger. e. For the inpatient psychiatric unit (Garden Pavilion), patients placed in restraints must be on an involuntary status, with the exception of minors who are signed in by the responsible party. Refer to policy: Patient Restraint & Application of Restraints or Use of Seclusion and March 24, 2010 Meeting Minutes: Restraint Review with the Department of Medicine/Surgery. Reporting of Death in Restraints/Seclusion PC.03.05.19, EP 1 CMS CoP§482.13 HSC § 1279.1 To comply with the mandated reporting requirements of Health and Safety Code §1279.1 and to support the improvement of patient safety and quality improvement initiatives any adverse event that causes death or serious disability of patients, personnel or visitors will be reported to the local office of Department of Public Health (DPH) within five days after the event has been detected. Events that have ongoing urgent or emergent threat to the welfare, health or safety of patients, personnel or visitors will be reported within 24 hours. Refer to policy: Adverse Event Reporting to the California Department of Public Health GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Reporting of Concerns Regarding Safety and Quality of Care APR.09.03.01 HSC The standard includes the requirement to educate medical staff of the following:
Concerns about safety and quality may be reported to The Joint Commission The hospital will take no disciplinary or punitive actions because a safety or quality-of-care
concern is reported No disciplinary or punitive action will be taken against a physician who reports a concern to The
Joint Commission
Sentinel Event 1. In support of our mission to improve the quality of health care provided to our community, all
occurrences identified which meet the definition of a sentinel event shall be subject to an immediate in-depth root cause analysis as described in the Sentinel Event Policy.
2. Adverse events will be reported to Department of Health Services through the administrative supervisor according to the agencies guidelines.
3. The RCA and action plans will be completed within 45 calendar days of the event or awareness of the event.
4. In addition to specific actions which are taken by the organization in response to a sentinel event occurrence, the organization shall also maintain ongoing programs to reduce the occurrence of sentinel events. Such programs shall include the following: a. Incorporating information from other organizations regarding sentinel events and implementing
practices to reduce such events in our organization. b. Collection of data to monitor the performance of processes that involve risk or may be related to
sentinel events. c. Initiation of an intensified assessment whenever undesirable trends or patterns in performance are
identified. d. Proactive process redesigns using the failure mode, effects and analysis model.
5. Confidentiality of sentinel events includes: a. Submissions of Risk Identification Reports (RIR) to the Vice President responsible for Risk
Management are protected from discovery under the attorney/client relationship. The reports shall be entered into the risk management database for aggregation and trending, and the results of such information will be reported to the Safety and Risk Management Committee on a regular basis.
b. All investigations of events identified as possible sentinel events are conducted either as part of the organizational risk management program or as part of the medical staff peer review and quality assurance process. The records and proceedings of all investigations related to Risk Identification Reports are protected either under the attorney/client relationship or under California Evidence Code 1157.
c. Members of any investigatory team will be sensitive to protecting the confidentiality and privacy of all involved individuals and the confidentiality of all documents related to the review.
Refer to policy: Sentinel Event Policy GO BACK TO BEGINNING
2010 Physician & other Licensed Independent Practitioners (LIPs) Regulatory Education Reference Guide Waived Testing WT.03.01.01, EP 1, 2, 3, 4 CMS CoP§482.27 Test results that are used to assess a patient condition or make a clinical decision about a patient are governed by the federal regulations known as the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88). Waived testing by credentialed physicians shall be under the direction, authority and responsibility of the Director of Laboratory Services. Critical elements in this goal include:
Staff and licensed independent practitioners performing waived tests are competent. Staff and licensed independent practitioners who perform waived testing have received orientation in
accordance with the hospital’s specific services. The orientation for waived testing is documented. Staff and licensed independent practitioners receive training for each test they perform and this training
is documented. Staff and licensed independent practitioners who perform waived testing that requires the use of an
instrument have been trained on its use and maintenance and this training is documented. GO BACK TO BEGINNING
