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Summary of hospital orientation
JHHClinicalOrientationTopicsfor
NursingAgencyandFaculty
JHH Department of Nursing
Linda Goodman MS, RN, BC
Version 1.0 May 2012
Overview and Objectives
This online course will provide nursing agency,
faculty and students with an introduction to the
Johns Hopkins Hospital.
Please also refer to the Clinical Topics for Clinical
Staff orientation packet.
After completion of this course, the learner will have
a basic understanding of the JHH orientation
process and policies.
All policies are available online on the JHH Intranet.
Topics to be reviewed
Mission, Vision, Values
Infection Control
Blood Borne Pathogens
Patient Safety
Corporate Compliance
PI/QI Approach
Cultural Diversity
Regulatory
Emergency Management Risks to the Environment
Fire Safety
Service Excellence
Hazardous
Communication
Team Building
M
Mission, Vision, and Values
Mission
The mission of Johns Hopkins Medicine is to
improve the health of the community and the world
by setting the standard of excellence in medical
education, research and clinical care.
Diverse and inclusive, Johns Hopkins Medicine
educates medical students, scientists, health care
professionals and the public; conducts biomedical
research; and provides patient-centered medicine to
prevent diagnose and treat human illness.
Vision
Johns Hopkins Medicine provides a diverse and
inclusive environment that fosters intellectual
discovery, creates and transmits innovative
knowledge, improves human health, and
provides medical leadership to the world.
Values
Excellence & Discovery
Leadership & Integrity
Diversity & Inclusion
Respect & Collegiality
Blood borne Pathogens
Blood borne Pathogens
Blood borne pathogens (BBP) are microorganisms, such as
viruses and bacteria, which are carried in the blood and other
potentially infectious materials (such as semen, vaginal
secretions, pleural fluid, etc.) and can cause human disease.
3 Main Bloodborne Pathogens: Hepatitis B and C and HIV
Transmission Routes
• Perinatally (Mother to Baby)
• Sexually
• Parenterally (Blood to Blood or Blood to Other Body Fluids)
 Needle Stick Exposure
 Splashes to Eyes, Nose or Mouth
BBP Exposure Prevention
Follow Standard Precautions
• Treat all blood and body fluids as
though potentially infectious
Wear Personal Protective
Equipment (PPE) such as
Gowns, Gloves or Masks
Use Safety Devices & Never
Recap Needles
BBP Exposure Prevention
Dispose of Sharps in the Sharps
Container
• Sweep up glass & dispose in sharps
container (Do not use hands)
• Do not overfill sharps container
• Do not dispose of other trash in
sharps container
Dispose of All Materials Saturated
with Blood/Body Fluids in Red,
Biohazard Bags
BBP Post-Exposure Management
Wash the exposed area
• Use soap & water for exposed skin
• For eye/mucous membrane
exposures, flush with water
Immediately report the injury to
5-STIX
Inform supervisor and complete an
Employee Incident Report
5-
Corporate Compliance
Impaired Provider
Workplace Violence
Who Oversees Compliance?
The Department of Corporate Compliance.
This Department was established to educate and
train employees, preserve continued ethical and
legal conduct and protect organizational and
employee reputations.
What is Corporate Compliance?
Compliance means we adhere to the rules and
regulations required by Federal, State & Local
laws.
JHHS is committed to following all applicable laws
and regulations and in particular, those that
address health care fraud, waste, and abuse and
the proper billing of Medicare, Medicaid, and other
government funded health care programs.
JHHS recognizes its employees rights under these
laws and is committed to abiding by them. We rely
heavily on our employees, to help us comply with
all requirements by identifying potential problems,
reporting them and asking questions.
What is the Compliance Program?
A program comprised of various policies and
procedures to detect and prevent fraud, waste,
and abuse, and to protect those who report
suspected instances of fraud, waste, and abuse.
They are:
• JHHS Corporate Compliance Plan
• JHHS Non Retaliation Policy
• JHHS Organizational Ethics Statement
• Conflict of Interest Policy
Why have a Program?
To ensure that we:
•protect our organization, employees, and
customers;
•preserve the level of integrity that JHHS is
known for;
•promote the continued effort to do the right
thing;
•maintain effective internal controls that promote
adherence to legal and ethical standards;
•promote detection, prevention, and resolution of
illegal or unethical conduct.
Special Compliance Issues
Interaction with others
Conflict of interest
Workplace conduct and responsibility
Interaction
with others with
Interactions
Others
Gifts: With the exception of biomedical, pharmaceutical,
and medical device vendors, nominal “gifts” may be
accepted if the item offered is edible or usable in the
workplace. Any other gifts should be discussed with the
Compliance or Legal Department.
Supplier, Vendor of Consultant: JHHS and its staff
may not accept gifts or contributions to influence with
whom we do our daily business.
Physician and Provider Agreements: Contracts and
other formal relationships should always be reviewed by
our Legal Counsel.
Workplace Conduct & Responsibility
Obey applicable laws, rules and policies.
Behave honestly, use good judgment with high
ethical standards.
Strive for mutual respect and trust.
Avoid personal conflicts of interest.
Report actual or suspected concerns/violations to
management by following the chain of command.
Failure to follow the Code may put yourself, patients,
co-workers, institutions and/or the System at risk!
Workplace Violence
JHH is committed to providing a safe and secure
workplace and environment free from physical
violence, threats, and intimidation.
Conduct and behaviors of physical violence,
threats or intimidation by an employee may
result in disciplinary action up to and including
discharge.
JHH does not permit retaliation against anyone
who, in good faith, bring a complaint of
workplace violence or speaks as a witness in the
investigation of a compliant.
Workplace Conduct & Responsibility
Verbal Abuse – statements, expressions which
create fear or intimidation in other employees.
Physical Abuse – touch, gestures, pushing,
striking, stalking or the use of objects; intrusion
into one’s personal space.
Creating a Hostile Work Environment –
intimidating or harassing behaviors or actions
which interfere with the work performance of an
individual or group.
Workplace Violence
If you see physically
violent behavior and or
feel that the threat of
violence is imminent,
call security @ 5-5585
or 911.
If you believe a faculty
or staff member is
potentially dangerous
but the threat of violence
is not imminent, call
Human Resources
@ 5-6783 or FASAP @
5-1220
Impairment in the Workplace
Risk Factors and Background Indicators
• Family history of addiction
• History of frequent job changes
• Jobs with limited supervision
• Prior medical history
• Home/family problems
Impairment: Signs and Symptoms
Job performance changes
• Attendance issues such as absenteeism or tardiness
• Job shrinkage/getting less done
• Inability to meet deadlines
• Illogical or sloppy documentation
• Excessive errors in judgment in patient care decisions
• Increased on the job injuries
• Increased patient complaints
Impairment: Signs and Symptoms (cont)
Personality changes
Behavioral changes
• Irritability
Mental status changes
• Withdrawal
Physical changes
• Mood swings
Social changes
• Increased isolation
• Decreased interest in
outside activities
Help and Resources
If you have concerns about a co-worker /staff
member report this using your chain of command.
REMEMBER to keep this information confidential.
Organizational resources
• FASAP
• Compliance reporting line
You have a legal and ethical obligation to report.
Cultural Diversity
What is diversity?
Diversity includes all
the
characteristics,
experiences,
and differences of
each
individual.
Cultural Competence
Culture – Set of learned and shared beliefs and
values that are applied to social interactions and to
the interpretation of experiences and is shaped by
proximity, education, gender, age etc.
Cultural Competence – The ability of health care
providers to understand and respond effectively to
the cultural and language needs brought by a patient
to the health care encounter.
Working Toward Cultural Competence
Be aware of and examine your own cultural and
family values.
Seek to share your culture and learn about
other cultures.
Focus on the similarities as well as the
differences between your culture and the
cultures of others.
Respect in the Workplace
We’re committed to preventing the disrespectful
little "paper cuts" co-workers unknowingly inflict
upon each other.
Through training we raise awareness and
emphasize the importance of maintaining a
thoughtful and respectful workplace.
Patient and Family Centered Care
At JHH this approach is used in the planning,
delivery, and evaluation of health care that is
grounded in mutually beneficial partnerships
among health care providers, patients, and
families.
This approach shapes policies, programs, facility
design, and staff day-to-day interactions.
Patient and Family Centered Care
Recognizes the vital role that families play in
ensuring the health and well-being of family
members of all ages.
Acknowledges that emotional, social, and
developmental support are integral components of
health care.
Promotes the health and well-being of individuals
and families and restore dignity and control to
them.
Patient and Family Centered Care Goals
• Better health outcomes
• Wiser allocation of resources
•
Greater patient and family satisfaction
• Greater accountability for health
maintenance by patients and families
Emergency Management
Emergency Management
An emergency may be defined as any
occurrence, either within our facility (internal), or
the surrounding community (external) that affects
our ability to successfully complete our mission.
Example of Emergency Management
• Severe Weather
• Mass Transit Accident
• Utility Outage
• Severe Fire
• Supply Shortage
• Large Patient Influx
• Chemical or Radiation Exposure
• Major Infectious Disease Outbreak
Emergency Management Codes
Code Red—fire
Code Gold—bomb threat
Code Yellow Bio—bioterrorism
Code Yellow Chemical—chemical
Code Yellow Radiation—radiation
Code Yellow ED—patient influx of up to 10
patients from a single event
Code Yellow Hospital—patient influx of more
than 10 patients from a single event
Fire Safety
Response to FIRE/SMOKE
1. Remove anyone in immediate danger
2. Close the door
3. PULL THE ALARM (found along your exit
route)
4. Call the emergency number 5-4444 when in a
safe location
How are you to respond to a fire alarm in your area?
Healthcare Occupancy :
• Defend in place. Close doors, clear hallways,
and place all patients and visitors in their rooms.
Review the Unit Specific Life Safety Plan for
your unit.
Business Occupancy:
• Evacuate patients, visitors, and employees to a
connecting building. If not connected to a
different building, evacuate down the stairs and
go 50’ from the building.
Is your area a healthcare or business occupancy?
HSE policy #408 lists out all the hospital buildings
and floors and designates them as either healthcare
or business.
Oxygen Shut-Off
In the event of a fire in a
Healthcare Occupancy, DO NOT
turn off and/or disconnect any
medical gases.
DO NOT activate the emergency
zone shut-off valve for oxygen.
If a patient is in immediate
danger, oxygen is to only be
turned off at the wall outlet.
Employee-Specific Evacuation Plan
Evacuation Plans
 Building
Designed
for employees who have
either temporary or permanent
restrictions that limits the use of
stairs in the event of an evacuation.
 Employees self-identify through the
Department of Safety.
 They will meet with an Occupational
Safety Officer who will develop a
site-specific evacuation plan for that
employee.
Fire Extinguishers
DO NOT attempt to use fire extinguishers –
even for small fires—unless trained annually.
Elevators
Do not use elevators in
buildings that are in alarm.
Use the stairs or exit to a
connecting building.
What should you do in the meantime?
Keep all egresses clear including stairwells.
Do not block fire equipment, such as pull
stations, fire extinguishers, and fire hose
connections.
Do not block open self-closing smoke/fire
doors.
Keep all required flammable liquids in a
flammables cabinet.
Smoke only in designated areas.
Make sure all EXIT lights are lit.
Check stairwell doors to make sure they latch.
Know your egress routes.
Do not block sprinkler heads.
Smoking Policy
REMINDER:
Smoking by staff members,
visitors and patients
is permitted ONLY in designated
areas.
Hazardous Communication
Mgmt of Hazardous Materials/Chemicals
HSE Policy 701 – Hazard Communication –
Employee “Right-to-Know” Law
JHH employees have the right to know about the
hazardous chemicals and materials with which they
are working, and how to dispose of these chemicals
properly.
The primary objective is for you to know how and
where to find specific hazard information.
Hazard Communication
Primary Container Labels must contain the
following information:
• Name of Chemical
• Appropriate Hazard Warnings
• Name and Address of Manufacturer
Secondary Container labels need to contain the full
name of the chemical. It is also recommended that
the container be dated and initialed.
Hazard Communication
Signage 
Management of Hazardous Materials
All excess, used, spent and
unwanted chemicals must
be collected for disposal.
All containers must be
labeled.
• Chemical names
• PI/Location/Phone #
• Date filled
Labeling is the responsibility
of the USER.
Chemical Spill Procedure
Evaluate the spill
• Are the materials innocuous, corrosive,
flammable, toxic, or explosive?
• Identify all material by common or chemical
name.
• Estimate how much is spilled.
• Evaluate the degree of danger to the immediate
area. (Patients, staff, visitors, equipment or
property.
• Questions? Call 5-4444.
Chemical Spill Procedure
Hospital personnel who are appropriately trained may
clean up the spilled material:
• For example: spills of acids or bases can be
cleaned up by using the appropriate
neutralizers/absorbents and proper personal
protective equipment.
Infection Prevention & Control
Hospital Epidemiology & Infection Control (HEIC)
Mission Statement –
To promote patient safety by reducing the risk of
acquiring and transmitting infections
Department Functions –
Prevention and control of HAIs & resistant organisms
through:
Education, Surveillance including Hand Hygiene
Monitoring and Evidence-Based Policies & Procedures
Chain of Infection
Example – Influenza
Pathogenic Microorganism: Influenza virus
Reservoir: Pt infected with the flu
Means of Escape: Cough, sneeze and respiratory
secretions
Mode of Transmission: Droplets, contaminated
hands/surfaces
Means of Entry: Inhalation, touching mucous
membranes
Host Susceptibility: No immunity to Influenza virus
(did not receive annual Influenza vaccine),
decreased immune system, elderly or very young
Break the Chain
Infection prevention and control is everyone’s
responsibility.
It is important for all employees
to protect themselves, patients,
visitors, co-workers and their
families by practicing infection
prevention & control techniques
in compliance with hospital
polices.
Healthcare Associated Infections (HAIs)
Occur when a patient comes to a healthcare
facility and acquires a new infection during
his/her care, for example:
• Surgical Site Infection (SSI)
• Central Line Associated Bloodstream
Infection (CLABSI)
• Ventilator Associated Pneumonia (VAP)
• Catheter Associated Urinary Tract Infection
(CAUTI)
Impact of HAIs
In the US, more than 2 million HAIs develop yearly
• Of these, >99,000 die from HAIs
• ICU patients have a 30% chance of acquiring
a HAI
HAIs cost the United States $28-$33 billion a year
HAI rates are increasingly being used as indicators
of quality and patient safety in healthcare facilities
• Many states require hospitals to report certain
HAIs
Hand Hygiene –The #1 Way to Prevent the Spread of Germs!
Hand Hygiene with Either Waterless Hand Sanitizers (Purell)
or Soap & Water is Required:
• Upon entering & leaving a patient’s room/environment
• Between patients
• Before & after using gloves
• Moving from a contaminated to a clean body site
• Before & after handling an invasive device
• After contact with body fluids, excretions, mucous
membranes, non-intact skin or contaminated items
• Before handling food or oral medications
• As needed after coughing or sneezing
Hand Hygiene
Hand Hygiene with Soap & Water is Required:
• Before eating
• After using the restroom
• Anytime hands are visibly soiled
• After caring for patients with spore producing
organisms
(For example: Clostridium difficile)
• When there is significant build-up of waterless
hand sanitizer
Hand Hygiene Technique
Waterless Hand Sanitizer: Dispense a thumb sized
amount of sanitizer into the palm and briskly rub over all
surfaces of both hands until dry
Soap & Water:
• Wet hands with water then apply soap
• Vigorously rub together all surfaces of both hands for
15 seconds
• Thoroughly rinse hands under a stream of water
• Dry hands with a paper towel and turn off faucet using
paper towel
Hand Hygiene Technique
Use only hospital approved lotion to maintain skin
integrity.
For care providers with direct patient care or who
work with open sterile supplies:
• No artificial nails, No chipping fingernail polish;
Natural nails less than ¼ inch long
Standard Precautions
Treat all blood & body fluids as though potentially
infectious; Apply to all patients to protect yourself from BBP
Perform hand hygiene
before and after patient
care.
If touching blood, body
fluids, secretions, excretions,
and/or contaminated items is
likely, wear gloves.
If sprays/splatters are
possible, add a gown and
fluidshield mask with eye
protection.
Respiratory Etiquette
• Cough or sneeze into your sleeve
• Stay Home if you have Upper Respiratory
Illness (URI) and Fever
• If You Have URI and No Fever, wear a Mask for
patient care
• Practice good hand hygiene
• Stay up to date on influenza
vaccination
Transmission Based Precautions
Apply to patients who are known/suspected to be colonized/infected with multidrug resistant
organisms (MDROs) and other epidemiologically significant organisms STANDARD
PRECAUTIONS STILL APPLY
Contact Precautions
For organisms spread by
contact (MRSA, VRE, or
C. difficile)
Hand hygiene, gloves and gown required
Droplet Precautions
For organisms spread by
droplets (Influenza or
RSV)
Hand hygiene, gloves, fluidshield mask with eye shield and gown required
Airborne Precautions
For organisms spread by
air (Tuberculosis,
Measles or
Shingles/Chickenpox)
Hand hygiene and PAPR or fit-tested N95 required
Why are transmission-based precautions critical?
MDROs are gram negative organisms with
emerging resistance and have few or no treatment
options.
VRE is the most common multi-drug resistant
organism (MDRO) seen in our patients.
Methicillin-resistant Staphylococcus aureus (MRSA)
is seen in many of patients (colonized or infected).
MRSA can cause skin and soft tissue, blood stream
and surgical site infections.
CONTACT PRECAUTIONS
Standard Precautions always apply
C
O
N
T
A
C
T
Before entering room
Ready to Enter
Before leaving room
1. Clean your hands.
1. Remove gloves and
gown.
2. Put on an isolation gown.
3. Put on gloves.
CONTACT PRECAUTIONS
15-810420 (6/08)
(2/08)
2. Clean your hands
on your way out.
C
O
N
T
A
C
T
Clostridium difficile (C. Diff)
Anaerobic, spore-forming rod which can produce
toxins.
Disease can range in severity from diarrhea to
colitis and in some cases, death.
Main risk factor is acquisition of the bacteria then
antibiotic exposure.
• Elderly and hospitalized patients are at increased
risk
Spread by fecal to oral route.
Clostridium difficile
Prevention:
Contact Precautions
Hand Hygiene with Soap & Water
after patient care
Clean Environment and equipment
using Oxivir
Antimicrobial stewardship
DROPLET PRECAUTIONS
D
R
O
P
L
E
T
Standard Precautions always apply
Before entering room
Ready to Enter
Before leaving room
1. Clean your hands
1. Remove gloves, gown
2. Put on an isolation gown.
OR
and fluidshield mask
w/eye shield or mask
w/goggles in room.
3. Put on a fluidshield mask
w/eye shield or mask
w/goggles.
2. Clean your hands on the
way out of the room.
4. Put on gloves.
DROPLET PRECAUTIONS
15-IIII (2/08)
15-810410 (Revised
05/2009)
D
R
O
P
L
E
T
AIRBORNE PRECAUTIONS
Standard Precautions always apply
A
Before entering room
Ready to Enter
1. Remove gloves
and gown,
if worn.
I
R
B
O
Before leaving room
1. Clean your hands.
2. Close the door as you leave
the room.
2. Put on PAPR or fit-tested
N-95 respirator.
Positive Air Purifying
Respirator
(PAPR)
R
OR
After leaving room
A
I
R
B
1. Remove PAPR or N-95.
O
R
OR
N-95 respirator
N
See isolation policy for
immunity exemption.
E
AIRBORNE PRECAUTIONS
15-IIII (2/08)
15-IIII (6/08)
2. Clean your
hands.
N
E
Patient Safety
Reporting Patient Safety and Quality of Care Concerns
For immediate hazards, call the existing
emergency phone numbers.
For urgent patient safety concerns, contact your
supervisor.
Use the departmental chain of command for
assistance.
Report events in Patient Safety Net (PSN).
What is PSN?
PSN is a web based event reporting system
that can be found on any public workstation
under PSN: Report an Event or Service
Concern
No passwords are required.
Any staff member can place events.
Reporting Patient Safety and Quality of Care Concerns
Compliance Hotline 1-877-WE COMPLY
(1-877-932-6675)
• Anonymous reporting
For unresolved concerns, call the Safety
Hotline at 410-955-5000.
Reporting Patient Safety and Quality of Care Concerns
Contact the Law Office at 410-955-7949
immediately if any of these patient events occur:
• Temporary harm and required initial or
prolonged hospitalization
• Permanent harm
• Near-death event (e.g., required ICU care or
other intervention necessary to sustain life)
• Death
Reporting Patient Safety and Quality of Care Concerns
Since JHH is a Joint Commission accredited hospital,
employees can also report quality of care
concerns. Both JHH and TJC policy forbid retaliatory
actions being taken against employees for having
reported quality of care concerns to TJC.
E-Mail:
[email protected]
Fax:
Office of Quality Monitoring
630-792-5636
Mail:
Office of Quality Monitoring
Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Phone:
800-994-6610
Quality PI/QI approach
We All Impact Quality!
Quality Improvement
Risk
Management
Patient
Safety
Departments
Infection
Control
Health,
Safety, &
Environment
Nursing
Operations
Integration
Units
Service
Excellence
Regulatory
Affairs
Armstrong Institute
Six Aims of Quality Health Care
Safe
Timely
Effective
Efficient
Equitable
Patient-centered
Institute of Medicine Report: Crossing the Quality Chasm
(2001)
PDSA Model for Quality Improvement
Act
Plan
Study
Do
A Cycle for Learning and Improvement
The Johns Hopkins Hospital Initiatives
Safety
Service
•
Hospital Acquired Conditions
•
First Point of Contact : Access
•
Hand Hygiene
•
Caring Communication
Clinical Process
Improvement
•
•
Clinical Documentation Improvement
Preventable Readmissions
Business Process
Improvement
•
•
NCB Move-in
Epic and Meaningful Use
QI Department Initiatives
•
Core Measures: Heart failure, AMI, Pneumonia,
SCIP (also Psychiatry, Ambulatory, Pediatric
Asthma and Global Immunization)
•
Pay for Performance/Maryland Hospital Acquired
Conditions
•
Procedure reviews
•
Clinical Communities: Committed to finding
solutions guided by the best scientific evidence:
ICU, Hospitalists, Medication Safety and PACU
•
Patient Centered Care
Regulatory/TJC readiness
What is TJC?
TJC (The Joint Commission) is a regulatory body
that establishes standards for hospitals and other
health care organizations.
TJC periodically (unannounced sometime within 1836 months of previous survey) evaluates
compliance with these standards and will award
accreditation to organizations that satisfactorily
meet the requirements.
What is your role in the Hospital?
• Knowledge of and adherence to policies and
procedures for the
hospital/department/unit/service
• Maintenance of current licensure, certification
and credentialing as required by your job
description
• Keeping current on required ongoing and annual
education/training
What is your role in the Hospital?
Reporting patient safety and/or quality of care issues
• Hospital – Compliance Line, Patient Safety Net
(PSN)
• Regulatory – TJC (no retaliation policy) 1-800-9946610 or email [email protected]
• TJC Contact information can also be found on the
JHH HR website at:
http://www.hopkinsmedicine.org/jhhr/
Priority Areas
• Compliance with National Patient Safety Goals
(NPSGs) as they relate to your role
• Your orientation to the JHH and to your job
• Your job/role/responsibilities
• Your role in a disaster
Priority Areas
• Your role in infection prevention and control
• Your role in patient safety and quality of care
• Your role in upholding patient rights
NPSG: Upholding Patient Rights
Patients receive:
• the Partnership Pledge
• Patient Handbook
Patient Bill of Rights posted throughout the hospital.
The hospital assures the needs of patients with
vision, speech, hearing or cognitive impairment are
met via linguistic services, sign language,
interpreting and large print.
NPSG: Patient ID
• Use name and history number for inpatients;
use name and date of birth for outpatients
• Compare two identifiers on the patient ID
band against the same two identifiers on the
MAR, specimen label or requisition form.
• Never use the room number as a patient
identifier.
NPSG: Patient ID
Label all specimens in the patient’s presence –
ALWAYS.
Before starting a blood transfusion, always
match the blood to an order, match the patient to
the blood, and verify with a second qualified
person.
NPSG: Communication
For critical action values, write it down & read it
back, asking the giver or receiver to confirm.
Get critical test results to the right person in a
timely manner.
?
NPSG: Med Labeling & Anticoagulation Therapy
For procedural and
OR areas, label all
meds, solutions &
containers on & off
the sterile field.
Reduce the likelihood
of patient harm
associated with the
use of anticoagulation
therapy (includes
having a program with
approved protocols,
lab tests, monitoring,
and evaluation).
NPSG: Medication Reconciliation
Prescribers will consider home medications at
admission, transfer & discharge. Make sure the
patient knows which medicines to take at home.
Tell the patient it is important to bring their upto-date list of medications every time they visit a
doctor.
NPSG: Prevent HAI
Implement HEIC policies addressing:
Hand Hygiene - Clean hands frequently & between
patients - remember natural nails only & less than ¼inch long.
Prevention of Multi-Drug Resistant Organism
(MDRO) infections (VRE, MRSA, C-diff)
Prevention CLABSI, SSI, CAUTI
NPSG: Suicide Risk
Identify patients being treated for emotional or
behavioral disorders (Behavioral Health only) &
assess them for suicide risk.
NPSG: Universal Protocol
To help ensure right patient, right procedure, right
site surgery include 3 elements:
•
pre-procedural verification process
•
site marking
•
time-out immediately before procedure.
Risks to the Environment
Risks to the Environment
Medical Equipment Risks
Basic Safety Tips:
Make sure all patient care equipment is
appropriately cleaned and disinfected prior to use.
Utilize equipment only if you have been
appropriately trained. Seek instruction from
experienced user.
Utilize equipment in the manner it was intended for
use. Never alter or use for non-approved functions
(e.g., using an infusion pump to deliver tube
feedings).
Report equipment problems to CES, 5-2100, don’t
work around broken equipment
Medical Equipment Risks
Broken/Malfunctioning Equipment:
If you suspect an equipment problem, remove
from patient use immediately. If patient injury,
leave any disposables, or accessories intact
(e.g. tubing, etc...). This will significantly aide
in the investigation of the system.
Clearly label the equipment as broken and
indicate problem (use pre-printed broken
equipment labels)
Call CES, 5-2100, ext 515 to pick up
equipment involved in PSN events.
Reference the equipment ID number (on CES
yellow barcode tag) and complete the PSN
report.
Unsafe Work Conditions
Report all unsafe work conditions to your
Supervisor.
Report all work-related injuries to your Supervisor.
HSE (Safety office) will follow up on most
incidents.
Examples of Unsafe Work Conditions
- Spills and wet floors—clean them up
- Rain and snow events – wear proper shoes
- Walking down steps—hold on to the handrail
- Trips—make sure cords are off the floor
- Texting while walking
Construction Safety
Recognize and Avoid Hazards:
New construction - ongoing
Renovations - do not enter areas
Vibration, noise, arc flash
Slips, trips and falls
Asbestos removal
Concerns? Contact HSE.
Medical Equipment Failures
JHH also has their own in-house Clinical
Engineering department that maintains the safe,
reliable, and functional operation of medical
devices.
A medical device is ANY device that is used on a
patient.
If medical device fails, call Clinical Engineering
Services at 4-SAFE ext. 3.
Safe Patient Handling Program
The Johns Hopkins Hospital has implemented a
safe patient handling program.
The program implements mechanical patient lifts
and transfer devices to lower the risk of employee
injuries due to moving of patients.
Safe Patient Handing Equipment
The Maxi-Move portable
patient lift.
The Maxi-Sky ceiling
patient lift.
The Pink Slip patient
transfer device.
MRI Safety
An MRI magnet is ALWAYS
on, even if it is not in use.
Metal objects become
projectile and can seriously
compromise safety.
If working in an MRI area
you will receive MRI Safety
Training and screening.
Access to Secure Medication Areas
Your job may require accessing secure medication
storage areas.
Secured medication areas may be accessed by:
• Licensed employees
• Security staff
• Maintenance services
• Pharmacy Technicians
staff
• Environmental services
staff
• Central Stores staff
• OR Technicians
• Anesthesia Technicians
• Others as required by
their job function
Access to Secure Medication Areas
Do
Don’t
Ensure that the storage
area is secure/locked
when leaving
Handle medications
outside of routine job
functions specified in your
job description
Immediately notify the
Charge Nurse or Nurse
Manager if you suspect
that the medications have
been tampered with or
stolen.
Transfer medications from
a secure area to an
unsecured/unsupervised
area
Allow unauthorized
personnel into the
medication storage area
Service Excellence
Service Excellence
Service Excellence: Standards of Behavior
Customer Relations
Self Management
Teamwork
Communication
Ownership/Accountability
Continuous Performance Improvement
Customer Relations
Treat patients and other customers with courtesy,
respect and caring behaviors.
Respond quickly and appropriately to customer
requests.
Anticipate customer needs and initiate action to
meet those needs.
Self Management
Present a positive image of Johns Hopkins through
professional appearance and behavior.
Identify own areas of development and seek
opportunities for personal and professional growth.
Carry out responsibilities in a safe and timely
fashion and request assistance as needed.
Teamwork
Work cooperatively within own unit/ department and
with other units/departments.
Willingly accept additional responsibility; try to make
others’ jobs easier.
Recognize and support the skills and qualities of
others.
Willingly exchange appropriate and professional
information with coworkers.
Communication
Listen to customer needs and respond in a
courteous and tactful manner.
Provide timely feedback to the appropriate
customer in a clear and concise manner.
Use professional judgment in providing information
based on the situation and be sensitive to
individual/organizational concerns.
Consistently ensure that information known about
the customer is kept private and confidential.
Ownership/Accountability
Treat customers’ property and Johns Hopkins’
property with care and respect.
Demonstrate conservation and responsible use
of resources.
Contribute to the safety and security of the
Johns Hopkins environment through personal
actions.
Continuous Performance Improvement
Effectively and efficiently fulfill responsibilities to
achieve the greatest benefit at an acceptable cost.
Continually strive to suggest and implement ways
to improve personal departmental and institutional
performance.
Teamwork
Teamwork
Working in a healthcare setting means working
as part of a healthcare team.
It is only by working collaboratively that we can
meet the needs of all of our customers.
Whether you are working directly with patients
or working behind the scenes, each employee’s
role in the team is important.
Teamwork and communication are also critical
to building a culture of safety.
Definitions
“A team is a group of people who go out of their
way to make each other look good.”
“An energetic group of people who are committed
to achieving common objectives, who work well
together and enjoy doing so, and who produce
high quality results.”
“Teams are collections of people who must rely on
group collaboration if each member is to
experience the optimum of success and goal
achievement.”
Definitions
“Teams are groups of individuals with a clear
purpose and agreed-upon processes and outputs
who display respect for each other, air and
resolve differences and learn from the experience
to grow and take greater calculated risks.”
“Together Everyone Achieves More.”
Being a good team member means:
Being on time/ be prepared
Engaging in open communication, saying what you
think
Listening to understand and speaking to be
understood
Sticking to the agenda
Being optimistic/positive about the team
Being a good team member means:
Critiquing ideas without criticizing team members
Performing promised follow-up
Taking problems seriously
Being courteous, honest, trusting
Practicing innovative thinking and taking risks
Helpful Team Behaviors
Using “we” expressions and thoughts
Supporting each other
Displaying a sense of humor
Setting realistic goals/time frames
Establishing clearly defined roles
Understanding, agreeing with and committing to
department and organizational goals
Helpful Team Behaviors
Maintaining a customer focus
Anticipating needs of others
Accepting and practicing personal responsibility
Pursuing quality
Seeking help and giving help without taking back
responsibility
Being open to suggestions
Committing to continued learning, growth and
improvement
Conclusion and Resources
This course has provided you with an introduction
to the Johns Hopkins Hospital.
If you have any questions, please discuss with
your unit nurse manager or educator.
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