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Martin Health System Module 1 1
Martin Health System
Module 1
1
Directions Reference Material Learning Goals
Go through each slide and read/listen to the information (this module will be marked as ‘Completed Unsuccessfully’ until you have viewed all of the slides) Access and review documents as indicated by searching online or using the links provided in the ‘2017 AME Guide’
Learning Goals are outlined so you are able to identify what is expected of you upon completion of the training.
Learning Guide
2
Throughout the Module there will be notes like this
that will list additional materials to access. Refer to
your ‘2017 AME Guide’
(provided at the beginning of this training and as a
downloadable attachment)
Module 1: Martin Health System
Lesson 1.1: Mission, Vision, Values
Lesson 1.2: Code Of Conduct
Lesson 1.3: Patient Experience
• Topic 1.3.1: Customer Service And Patient-Focused Care
• Topic 1.3.2: HCAHPS
• Topic 1.3.3: Diversity
Lesson 1.4: Performance Excellence And Lean
Lesson 1.5: Medical Errors In Healthcare
Module Outline
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Mission, Vision, and Values
Module 1: Martin Health System Overview
Lesson 1.1
• Identify the purpose of our Mission, Vision, Values.
Lesson Learning Goals
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Our Mission, Vision, and Values drive everything. They outline a way of life at work that will help you and MHS be successful. Let the mission, vision, and values become part of your actions each and every day.
Mission, Vision, and Values
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Our Mission is our reason for being. It is why we do what we do.
Mission
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Our Vision is what we setout to achieve.
Vision
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Our 5 Values
Our Values are how we behave.
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By incorporating ICARE into every interaction (with patients, families, physicians, volunteers, and each
other) we will achieve our mission and vision.
Behaviors Matter
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They are connected.
We cannot achieve one without the other.
Summary
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Code of Conduct
Module 1: Martin Health System Overview
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Lesson 1.2
• Identify the purpose of our Code of Conduct
• Locate and read our Code of Conduct on MartinLink
• Label the correct answers to questions in the quiz about our Code of Conduct
Lesson Learning Goals
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The purpose of The Code of Conduct is to make sure that MHS meets the highest standards of excellence both legally and ethically. It is everyone’s responsibility to make sure that the principles outlined in The Code of Conduct are upheld.
The Purpose of the Code of Conduct
• Please review The Code of Conduct. It can be accessed on MartinLink at any time.
• The MHS Code of Conduct reflects the ICARE values • After you complete this module your next task will be to view the
MHS Code of Conduct before you complete a quiz that will include: – Questions about Module 1 and The Code of Conduct – A Code of Conduct Attestation where you confirm these statements:
I know where to find a copy of the MHS Code of Conduct I understand and will act in a way that complies with the requirements of the
MHS Code of Conduct at all times. I understand that I have the responsibility to report any associates, vendors, or
contractors who are in violation of the MHS Code of Conduct.
– A Conflict of Interest Attestation where you confirm these statements: I understand that it is my responsibility to discuss concerns about conflicts of
interest with my immediate supervisor and/or Vice President-Chief Resource Officer or designee
I understand that concerns about conflicts of interest are conflicts between myself and the interests of MHS and can include actual or potential: transactions, activities, or relationships.
Review the Code of Conduct
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For additional information: On MartinLink- → MHS Code of Conduct → MHS Handbook On Hospital Portal- → Administrative Policy:
Vendor Gifts → Administrative Policy:
Patient Gifts
Patient Experience
Module 1: Martin Health System Overview
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Lesson 1.3
• Understand the core aspects of the Patient Experience
• Identify the key tools of the Martin Health Way
• Recall our Service Promise
• Label HCAHPS measures
• Identify areas of potential cultural difference
Lesson Learning Goals
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What do we mean by the Patient Experience
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• A Patient’s Experience is their perception of all interactions with Associates, Physicians and Volunteers as they progress through their continuum of care.
• Creating a positive patient experience is the responsibility of EVERYONE because every touch point makes a difference.
• In every interaction, our goal is to create peace of mind for the Patient and family members.
• Every person wearing a Martin Health System name badge that a patient sees in their room or walking in the hallway adds to their perception ( + or - ) of the experience.
• You make a difference irrespective of your job role.
Patient Experience
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Module 1:
Martin Health System Overview
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The Martin Health Way
Lesson 1.3 Patient Experience
Topic 1.3.1
Service Promise
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Our Service Promise is the way that we bring our mission, vision and values to life every day.
Service Promise
Created by us and our patients for us and our patients
Human Business Human
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• To create peace of mind, we make a human connection at the beginning of every interaction. This includes in person, on the phone and even in email. A simple good morning or good afternoon will work.
• Then we conduct our business with expertise and efficiency.
• Wrap up any interaction with another human connection such as a fond farewell.
HUMAN BUSINESS HUMAN
Graffiti is defined as anything that distracts or detracts from the intended ideal patient and family experience.
We work constantly to eliminate the things our patients see, feel and hear that do not create peace of mind.
Graffiti
Operational Priorities
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We want to use all four of these in harmony to provide peace of mind. When there are conflicting priorities, use this order to make decisions.
In our patient driven Operational Priorities, our patients want us to provide care in this order:
• Safety & Quality
• Compassion
• Expertise
• Efficiency
On the Spot Recognition
When you see someone creating peace of mind for patients or for our team, recognize them with a Caring on the Spot card. Simply fill out the card and hand it to the person you want to recognize!
While we try our very best every day to create peace of mind for our patients and their families, there will be times when we unfortunately will not deliver on our service promise and mission.
Service Recovery
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It is everyone's responsibility to identify and resolve these situations.
The HEART Model
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• Everyone is empowered to perform Service Recovery.
• Utilizing the HEART Model will
ensure a positive outcome, not only for the patient, but also for the person performing Service Recovery.
• If you cannot resolve a problem, then get help immediately by talking to your leader.
• Discuss solutions and agree on best action to solve the problem
• Follow up to make sure the customer is satisfied with the resolution. It is essential that we always follow through with what we have promised.
If you cannot resolve a problem
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Tracking in iReport (RL Solutions)
• Our patient gift policy requires us to track directly through iReport all commercial gift cards given during service recovery.
• Track Service Recovery into iReport even if a gift card was not given out to patient or family member
• You can access iReport from Epic or from MartinLink
Service Recovery
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The Martin Health Way tips:
• Create peace of mind in every interaction.
• Greet people in a warm and friendly manner, in the halls and elsewhere; gain eye contact and smile.
• Give people sincere care and concern, which establishes trust and loyalty.
• Ask how you can help.
• Listen with empathy.
• Walk with visitors to help them find their destination or further assistance.
Ways to Provide Excellent Service
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Module 1:
Martin Health System Overview
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HCAHPS
Lesson 1.3 Patient Experience
Topic 1.3.2
• HCAHPS stands for Hospital Consumer Assessment of Healthcare Providers and Systems
• HCAHPS is a national, standardized publicly reported survey of patients’ perspectives of hospital care. It can be administered to patients’ from 48 hours to 6 weeks after discharge.
• HCAHPS measures key aspects of the patient experience via a survey sent out to our patients by a third party vendor (Press Ganey).
• The survey is nationally standardized and conducted by an outside agency. The results are publicly reported, available for all to see.
What is HCAHPS?
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• What our scores mean for Our mission – These HCAHPS measurements are a great way to see how
we are reaching our mission ‘to provide exceptional healthcare, hope, and compassion to every person, every time’.
• What our scores mean for Our facilities – The survey provides us with feedback, helping us to
continuously improve – We can see how we are performing in relation to other
providers. – High scores show positive patient experience of care.
Positive patient experience can lead to fewer re-admissions, which is good for the patients!
What is HCAHPS
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The HCAHPS survey asks patients how well and how often we responded to their needs:
Ultimately, it is asking how we made them feel!
What the HCAHPS Survey Asks
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Never Sometimes Usually Always
What the HCAHPS Survey Measures
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• Communication with Nurses – Exhibit a positive, caring and courteous attitude while asking what is most
important during their hospital stay.
• Responsiveness of staff – Respond to requests and questions completely and in a timely manner. – An example would be the call bell and how long it takes to respond
• Communication about Medicines – Ask patients, “Do you have any questions about the new medicines you are
taking?” – When administering all medication, make sure to share these essential five
components: 1. Medication’s name 2. Medication’s purpose 3. Medication’s dosage 4. Medication’s potential side effects 5. Medication’s duration
Examples
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• Communication with Doctors – Getting eye level with the patient by sitting on a chair,
communicating things in a way the patient can understand and listening carefully to the patient’s needs.
• Discharge Information – Review discharge materials to ensure they will facilitate a
seamless, successful transition to the next level of care.
• Overall rating of hospital – Be positive and respectful. If you are following the mission to
provide exceptional healthcare, hope, and compassion to every person, every time then you should be ensuring that people rate our hospital highly. Keep in mind our Service Promise and our ICARE values at every step of the way.
Examples
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Module 1:
Martin Health System Overview
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Diversity
Lesson 1.3 Patient Experience
Topic 1.3.3
Our Patients, their families and visitors along with our colleagues come from a diverse range of cultures. Diversity is about acceptance, understanding and respect in a safe, positive and nurturing environment. Diversity includes the various scopes of race, ethnicity, gender, sexual orientation, socio-economic status, age, physical abilities, religious beliefs, political beliefs, generations or other principles. We aim to be inclusive in all our interactions. Your awareness , understanding and respect for cultural differences will help you provide exceptional health care, hope and compassion, every person, every time.
What is Diversity
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• Here are some areas of potential cultural differences. Considering these areas can help you make sure that you are meeting needs respectfully.
• People have – Different accents – Different languages – Different rules relating to eye contact – Different personal space boundaries – Different roles of who make the decisions in the family – Different on devoting time to come for follow-up care – Different health focuses – Different healthcare resources – Different beliefs
• Awareness of cultural backgrounds helps us to provide respectful, competent, and
appropriate care to every person, every time.
• Cultural sensitivity helps limit judgment of others
• If you are unfamiliar with someone’s culture, ask them to help you understand what would be helpful to know when providing care to them and their family.
Potential Cultural Differences
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• Every associate has the right to have an ethical concern heard.
• The role of the Ethics Committee is to provide a mechanism for analysis of ethical issues arising out of specific patient issues or business practices by MHS and/or its affiliates. If you have questions or an ethical concern, refer to the ‘Ethics Committee’ policy and ‘Ethics Consult Pathway’ on Hospital Portal.
Ethics Committee
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For additional information: On Hospital Portal- → Policy: Ethics Committee → Ethics Consult Pathway
• The law requires equal employment. This means respecting the differences of others. Any discrimination is unacceptable and goes against MHS values.
Equal Employment Practices Prohibit Discrimination
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Employment Practices Employment practices that impact groups of people differently are considered unlawful. The U.S. Equal Employment Opportunity Commission lists the following as types of discriminations:
• Age • Disability • Equal pay/compensation • Genetic information • Harassment • National origin • Pregnancy • Race/color • Religion • Retaliation • Sex • Sexual harassment
• LGBT means Lesbian, Gay, Bi sexual and transgender
• Hospital policy prohibits discrimination against LGBT patients, employees and job applicants based on their LGBT status.
• The federal Equal Employment Opportunity Commission has also ruled that discrimination against LGBT individuals violates Title VII of the 1964 Civil Rights Act.
• In addition, gay and lesbian employees who are legally married may cover their legal spouse under those Hospital benefit programs that provide spousal benefits.
LGBT Policy
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• Section 1557 of the ACA prohibits covered entities from discrimination on the basis of:
– Race/Color/National origin
– Sex
– Age
– Disability
• Individuals shall not be excluded from participation in, be denied benefits of, or be subjected to discrimination under any health program which received federal monies
• Protects individuals in the U.S., whether lawfully or not, who experience discrimination under any Section 1557’s prohibited bases
Patient Care- Nondiscrimination
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Nondiscrimination: Race/Color/National origin
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Example:
- A physician at a hospital’s emergency department denied a mother with LEP a Spanish interpreter when she requested language assistance. Instead, the physician used the mother’s 13-year-old son as the interpreter, while he was being treated for a dog bite. The hospital also failed to translate or orally explain the discharge instructions in Spanish.
Cannot:
- Segregate, delay, or deny services or benefits based on an individual’s race, color, or national origin
- Delay or deny effective language assistance services to individuals with limited English proficiency (LEP)
Must:
- Take reasonable steps to provide meaningful access to each individual with LEP.
- Reasonable steps may include language assistance services, oral or written translation services.
Nondiscrimination: Gender
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Example:
- A pharmacist would not provide a flu vaccine to a woman and questioned her about her non-gender-conforming clothing and hairstyle.
- Staff at a hospital’s emergency department ridiculed a male patient who arrived after sustaining injuries in a domestic incident. Staff did not evaluate the patient under a domestic violence protocol because he was male.
Cannot:
- Deny or limit gender-specific health services based solely on the fact that gender identity or gender recorded for an individual does not align with the gender of the individuals who usually receive those types of gender-specific services)
Must:
- Provide equal access to health care, health insurance coverage, and other health programs without discrimination cased on gender, including pregnancy, gender identity, or gender stereotypes
- Treat individuals consistent with their gender identity
Nondiscrimination: Age
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Example:
- A physician’s practice may not deny a 62-year-old man health services because it only accepts patients under age 60.
Cannot:
- Exclude, deny, or limit benefits and services based on an individual’s age
Must:
- Base actions on age when it is a factor necessary to the normal operation
- Provide different treatment based on age when the treatment is justified by scientific or medical evidence or based on specialty
Nondiscrimination: Disability
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Example:
- A hospital denied a visually impaired woman her request for a consent form in an alternative format that was accessible to her. The woman informed the hospital that she could access the information on the form if it was provided in large print or an accessible electronic format that she could read with her screen reader, but the hospital provided her with neither.
Cannot:
- Exclude or deny benefits or services because of a disability
Must: - Make reasonable changes to policies, procedures, and practices where necessary to provide equal access for individuals with disabilities
- Make all health programs and activities provided electronically accessible to individuals with disabilities
- Ensure newly constructed facilities are physically accessible by individuals with disabilities
- Provide effective communication with individuals with disabilities, including patients and their companions
- Provide auxiliary aids and services to individuals with disabilities free of charge and in a timely manner
Obesity Sensitivity There are some negative stereotypes of an obese
person.
Such as:- – Lazy
– Less competent
– Sloppy
– Less conscientious
– “Think slower”
– Poor self discipline
– Emotionally unstable
What can we do as Health Care Providers?
• It is our role not to act on these stereo types and show understanding and compassion.
• Consider that patients may have had previousnegative experiences with
health professionals
• Recognize that being overweight is a product of many factors
• Recognize that many patients have tried to lose weight repeatedly
• Emphasize behavioral changes rather than weight
• Acknowledge the difficulty of lifestyle change
• Realize small weight losses can result in big health gains
• Create a Supportive Environment
Create a Supportive Environment
• Treat patient with dignity and respect: Direct eye contact, Good listening skill, Empathy
• Utilize wider beds and furniture: Know weight limits & comfort
• Avoiding labeling that indicates obesity to others
• Know how to use bariatric equipment
• Have proper size BP cuffs & gowns
• Scales that are handicap & wheelchair accessible & appropriate maximum weight
Privacy for the Bariatric Patient
• Scales should be kept in a place where patients can be weighed privately
• Don’t make loud requests for extra large items
• Don’t say: “I need a “Big Boy” bed” – Instead, say: “I would like to request a Bariatric
Wheelchair/Bariatric Bed”
• Don’t say: All available lifting help to room 123 – Instead, say: “All available help for transfer report to
Nurses’ station”
From Administrative Policy, Non-Discrimination:
If you believe that MHS has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex you can file a grievance with the Section 1557 Coordinator (Chief Compliance Officer, Maggie Hopkins) at P.O. Box 9010, Stuart, FL 34995, 772-223-1983 or 772-419-3957, FAX 772-223-5987, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD)
Reporting Discrimination
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For additional information: On Hospital Portal → Administrative Policy:
Non-Discrimination Policy
Disability Rights FL: To report that a staff member of a health care facility has not made reasonable accommodations to meet your specific needs or has discriminated against you because of disability, please call toll free 1-800-342-0823.
• Concerns related to discrimination can be reported through your chain of command, to Human Resources, and/or Corporate Compliance. – If you do not feel comfortable reporting
this way, you can report the concern to: Chief Compliance Officer at ext. 13957 Compliance Hotline at 877-785-0002
• Please refer to the Code of Conduct for additional information on discrimination concerns and reporting.
Reporting Discrimination
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For additional information: On MartinLink → MHS Code of Conduct Contact Information → Chief Compliance Officer
at ext. 13957 → Compliance Hotline at
877-785-0002
Performance Excellence and Lean
Module 1: Martin Health System Overview
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Lesson 1.4
• List the 3 key elements of Lean management
• Identify the reasons why MHS is utilizing Lean management
• Identify examples of Lean management practice
• Identify what role all associates can have in building a culture of continuous improvement
Lesson Learning Goals
• Lean is defined as: – The pursuit of delivering perfect value to the customer
through the elimination of waste in the process
• Key elements of Lean management & culture: 1. Focus always on what the patient identifies as valuable
from our healthcare service.
2. Improve the process (time it takes and quality of work) through rigorous problem solving anchored in scientific method
3. Develop associate’s capability and desire to continuously improve how we deliver care!
What is Lean?
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• Evidence shows the top providers of Healthcare in the USA are those organizations who have developed a Lean culture.
• We believe using Lean as the anchor to our management system
will support our mission to consistently provide exceptional healthcare, hope, and compassion to every person, every time
• Put simply, lean methodology will help us to make things better for
the communities we serve!
• The Performance Excellence team functions as our internal Lean consultants. Their role is to teach and coach leaders and associates on Lean principles and practice helping build the Lean culture at MHS.
Why is Martin Health System utilizing Lean Management?
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Term Definition
Gemba The place where the work happens
Kaizen Continuous improvement; change for the better
Value Stream Sequence of activities that an organization goes through to deliver a product/service. The value stream goes from when a customer requests the product/service to when it is delivered.
VSA (Value Stream Analysis)
Leadership Activity to understand the Value Stream and set the Vision and Targets to Improve
Performance Excellence “Buzz words”
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Term Definition
A3 thinking Consistently thinking about problem solving using scientific methods
A3 document
• Single sheet of 11x17” paper • Standard way to present A3 thinking regarding a problem • Tool to teach A3 thinking • Reinforce concise communication
RIE (Rapid Improvement Event)
• Problem solving event utilizing A3 thinking • Delivers results in 1 week • Team consisting of: people doing work, fresh eyes, leadership • Coached & facilitated by Performance Excellence team
Performance Excellence “Buzz words”
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Example: Huddle Boards and Huddle Time • Have an idea for an improvement to a process
in your work area? Use a huddle board! • Goal of Huddles: to keep moving problems and
improvement ideas through the PDSA (Plan-Do-Study-Act) cycle so that MHS is able to make improvements to our processes. – Each huddle time will address/discuss problems
or improvement ideas that you and your colleagues have placed on the huddle board.
• Throughout the work week – The ideas are tested on a small scale to see what
impact they have – What happens is discussed at the next huddle – An idea is moved across the huddle board based
on where it is at in the PDSA cycle
How do all associates become involved in Lean activities?
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Do
Study Act
Plan
The mission starts with you.
– You have a role to play in Lean management regardless of your position at MHS.
– To help build a culture of continuous improvement:
Be open to learning lean through experiences guided by the PE team
Become comfortable pointing out problems
Respect every individual’s ideas
Building a Culture of Continuous Improvement through Lean
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• We all have a responsibility to do 2 things every day. In other words you could say you have 2 jobs— – Do work by following the standard process for doing your work
– Improve work by using huddle boards and participating in Rapid Improvement Events.
‘Do’ and ‘Improve’
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Your two jobs at MHS
Do Work Improve
Work
Medical Errors in Healthcare
Module 1: Martin Health System Overview
Lesson 1.5
• Select the actions to be taken to avoid preventable medical errors
Lesson Learning Goals
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What is Just Culture?
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• A culture that recognizes errors as system failures rather than individual failures and, at the same time, does not shrink from holding individuals accountable for their actions.
• Rarely are medical errors the result of the carelessness or misconduct of a single individual.
• 85/15% Rule- 85% of the time errors are a result of system errors
• Martin Health System supports a Just Culture.
• The top 3 causes of death in the US are – Cancer – Heart disease
– Preventable medical errors
• Preventable medical errors cause 1,000 deaths per day. This could be compared to two 747 planes crashing per day.
• Medical errors are a huge concern and even the best person can make mistakes, but it is important to always try to prevent medical errors.
*July 2014: Tejal Gandhi, MD, president of the National Patient Safety Foundation and associate professor of medicine, Harvard Medical School, Senate hearing, Washington DC
Preventable Medical Errors
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• Some actions that you can take to prevent medical errors are to: – Check Identifiers (name and date of birth) – Slow down and do not multi-task when you are doing
something important (Do not rush so much that you are not paying attention)
– Think about what you are doing to verify that it is correct
– Regularly verify that the system or process is working correctly
– Verify e-mails, phone numbers, and fax numbers – Follow protocol and policies (If you think there is a
better way, then tell your leader about your idea. Do NOT just start doing something differently.)
Preventing Medical Errors
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For additional information: → National Quality Forum
website
Clinical References
CINAHL/Ebscohost database allows review of:
• Nursing and Allied Health literature • Journals • Biomedicine, health science,
complementary medicine, consumer health literature and more
• Health care books • Dissertations • Conference proceedings • Standards of practice • Audiovisuals • Book chapters • Full-text journals • Legal cases • Clinical trials
Nursing Reference Center is a point-of-care resource database that provides:
• CEUs
• Quick Lessons
• Evidence-based care sheets
• Drug references
• Practice Guidelines
• Patient education handouts and more….
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Both databases can be accessed on MartinLink under the Clinical Education webpage.
You have now reached the end of this module! • You can now review any content in this module by using the back button
or the Table of Contents on the left side of the screen. • This module will be marked as ‘Completed Unsuccessfully’ until you have viewed
each slide. You will not be able to proceed to the quiz until it is marked ‘Completed Successfully’.
Once you finish reviewing this module, you can return to iLearn to take the Module 1 Quiz. • Click the ‘X’ at the top right corner of the screen to exit the module and
confirm that you have reviewed all content and reference material. Then click ‘Exit and Finish’.
• Please make sure to review the Code of Conduct as it will be referenced in Module 1 Quiz. You can then start the quiz by clicking ‘launch’ in the list of activities.
Module 1! Complete
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