GENERAL �ANNUAL MANDATORY EXAM

Directions:

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• Review each slide of the presentation.

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• On the final slide click on the Post-Test link

�����University Hospital at Downstate��

WE Care Values Standards of Behavior

Equity

W

E

C

A

R

E

Fair, Just, Impartial, Unbiased

Ownership, Directness, Clarity, Empathy

Teamwork, Cooperative, Build Relationships

Friendly, Smiling, Inviting, Pleasant

Revere, Honor, Adore, Admire, Esteem, Empower, Engage

Quality and Safety Outcomes, Distinction,

Top Decile Performance

Welcoming to all

Collaboration

Accountability

Respect

Excellence

UHD’s 7 Strategic Drivers are the Stepping Stones on our WE CARE Journey Toward ZERO Harm

Goal 6: Improve Community Health

Goal 4: Achieve Top Performance

Goal 2: Regional Provider of Choice

Goal 7: Attain Economic Stability

Goal 5: Touch More Lives

Goal 3: Excellence in clinical outcomes

Goal 1: Top Place to Work

Operational Efficiency

Growth

Community

Financial Health

Service Excellence

Quality & Patient Safety

Workforce Engagement

Highly Reliable Organization

07

05

03

01

06

04

02

7 Strategic

Drivers

Strategic Plan

What is a High Reliability Organization (HRO)?

High Reliability Organizations (HRO) are organizations that perform well for a long period of time without having any serious accidents or bad outcomes.

1. Examples of organizations that benefit from applying high reliability techniques are Airlines, Nuclear Power Plants, The Military, and Health Care Systems.
2. The concept of high reliability is attractive for health care, due to the complexity of what we do each day and the possible risk of permanent injury or death to our patients. 
3. Once achieved, HROs have very few or no serious bad outcomes.
4. When mistakes happen there are systems in place to prevent them from impacting the patient. In short, HROs avoid bad outcomes for long periods of time. 

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© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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WE Care Journey�

Self-check using STAR:

• Stop: Pause 1-2 seconds to focus attention on task at hand.
• Think: Think about what is to be done. Visualize action(s).
• Act: Concentrate and perform the task.
• Review: Check for the desired result(s)

3-way Repeat Back & Read Back:

Sender sends; Receiver repeats or writes down and reads

back; Sender confirms by saying “That’s correct”

Phonetic & Numeric Clarifications:

Avoid mistakes with sound alike words or numbers

(e.g. ‘C’ as in ‘Charlie’ or ‘15…that’s one-five’)

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Clarifying Questions: ask 1-2

questions to solidify understanding

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Dec

2022

WE Care Journey�

Design Sessions Leadership &

HRO Relationship Skills

Current State

Validation

Assess UHD capability

to perform and improve

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Leadership Development Academy

Leading Self, People & Change

MESSAGE ON MISSION

• Start Every Meeting with a

WE CARE Story

• Support those who
• SPEAK UP
• Put safety first in decision making

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ANTICIPATE TO AVOID EVENTS

• Daily Safety Huddles
• Unit/Department Huddles
• Daily Visual Management Systems Boards
• Brief / Execute / Debrief

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REINFORCE AND BUILD ACCOUNTABILITY

• Fair & Just Culture
• Performance Management Decision Guide
• High Reliability Rounding w/ 4Cs (create, can do, concern & commitment)
• 5:1 Feedback and Collaborative Coaching

Universal Reliability and Relationship Skills

• Self-check using STAR
• 200% Accountability
• Cross Check:
• 3-way Repeat Back & Read Back

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Prioritized Recommendations

Shared with UHD

HRO Principles at Work at UHD

• Daily Safety Huddles (Hospital-wide and Department)

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• Leadership Rounds

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• Ticket to Ride and Two Patient Identifiers

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• Time Out (Just prior to surgical procedure)

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• Diligent observance of all practices listed in The Joint Commission’s National Patient Safety Goals

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© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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Thank You!

© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

Welcome to

University Hospital at Downstate

Advancing Health Equity

University Hospital at Downstate

There are persistent and widespread inequities in health outcomes in the United States based on race, sex, language, socioeconomic class, and other factors. Such inequities have historical roots.

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(New Engl J Med. 2020;382(6):301-3.)

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In 1999 To Err is Human : was released, creating momentum to accelerate progress in patient safety.

Our Journey to ZERO HARM

          EXPLAINED 

There is no such thing as high-quality, safe care that is inequitable 

(N Engl J Med. 2020;382(6):301-3.)

Numerous lessons and strategies that have evolved over the last 20 years in the realm of patient safety can now be applied to inform strategic efforts to improve equity in health care.​

Understanding Diversity, Equity & Inclusion

© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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Understanding Diversity, Equity & Inclusion

© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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Achieving Zero Inequity: �Lessons Learned: Patient Safety is the Focus 

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Measurement of inequities must become the norm, with segmentation of data by race, ethnicity, 

gender, and other characteristics.“

(catalyst.nejm.org by Thomas Lee on May 27, 2021)

Recent events (including the Covid-19 pandemic and social justice protests) have prompted a long-needed focus on improving inequities in health care. ​�​

At risk populations are more likely to experience worse health outcomes compared to their non-minority counterparts due to…..

• lower preventive care utilization 
• limited access to chronic disease  management 
• poor health literacy 
• higher rates of hospital readmissions  
• multiple comorbidities 
• limited health insurance choices

Medicare Claims and Encounter Data: Services January 1 to August 15, 2020, Received by September 11, 2020

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At risk populations include racial and ethnic minorities, sexual and gender minorities, people with disabilities, and individuals living in rural areas.

Initiatives

WORKFORCE FOCUS

• Create Diversity Council to develop and adopt a common Health Equity Impact Statement for the hospital.
• Develop and Implement a DEI cultural competency orientation and ongoing training program for the Downstate Workforce.
• Create a DEI Dashboard with data definitions; work on data collection/stratification and analysis of findings.
• Hire and place leaders with diverse cultural, racial, gender and ethnic backgrounds that mirror the UHD community.
• SLT and Department Heads model the behaviors and promote the agreed upon Health Equity initiatives.
• Diversify our contracts for goods and services with vendors that are owned, managed and operated by minorities.

PATIENT FOCUS

• Develop and use linguistically and culturally appropriate health education materials for patients.
• Implement an effective communication program to include listening methods for current, former, potential, new patients.
• Increase consumer-based advocacy partnerships.

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Key Performance Indicators

• Employee Engagement Scores.

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• Adding New PG Health Equity Questions on Patient Survey addressing feelings of discrimination.

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• Segmentation of data by SDOH like race, gender, weight, age, socio-economic status, zip code.

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• Collect demographic data upon admission.

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• OBH & UDH Health Equity Index

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UHD DEI Strategic Objective 2.2 �Adopt the guiding principles of health equity and patient centricity

Global Reach

Our Workforce, Students, Patients and Community are multicultural

Downstate Team

Employees and Students

5000+

We are from

Countries

40+

Across

Continents

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               Service Excellence:

Patient Interaction

Focus on Communication with Doctors & Nurses HCAHPS

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Service Standards – Treat Everyone with Respect

(Reinforce Behaviors)

How to create positive 1^st impressions

• Knock before entering a patient’s room
• Protect confidentiality and privacy
• Use engaging body language
• Make eye contact
• Sit at the bedside
• Listen to what the patient has to say without interrupting
• Introduce yourself and explain your purpose to the patient and family members every time you enter a patient’s room.
• Ask the patient and family members if there is anything else you can do before leaving the room.
• Ensure that conversations with patients and family members are private and cannot be overheard by others.
• Speak positively about other patients, staff and the organization.

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NEVER

10 things Never to Say to a Patient or Family Member

1. Never make a promise
2. Do not offer a guarantee.
3. Do not overstate qualifications or what is possible. 
4. Never offer personal opinions
5. Do not let patients and visitors hear staff gossiping or griping. 
6. Avoid topics in the news that are related to a patient’s care. 
7. Never tell a patient that care is substandard. 
8. Do not tell a patient you are providing certain care because “That is what your insurance will pay for.” 
9. Do not use insurance as a scapegoat for avoiding a better answer. 
10. Do not speak too freely or defensively after an adverse event

Communication is KEY​

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CREATING A WELCOMING ENVIRONMENT FOR ALL PEOPLE

© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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Address patients using their preferred names and pronouns. Using the wrong name or pronoun can cause embarrassment and confusion.

Ask about gender identity on registration forms. In addition to gender identity, include listed sex at birth, preferred name, and pronouns. 6

Enter the information into the electronic health record (EHR) so that all staff have access to this information. This information will help staff to use proper pronouns, from the front desk staff to the provider’s office.

Avoid using gender terms or pronouns with new patients until this information is known, whether in-person or over the phone. For example: Instead of “How may I help you, sir?” ask “How may I help you?” Instead of “He is here for his appointment,” say “The patient is here in the waiting room,”

Ask patients how they would like to be addressed. It is acceptable to privately and politely ask, “What name and pronouns would you like me to use?” note it in the chart and use this name in all interactions.

Apologize for mistakes. If a slip occurs, it is fine to say something like, “I apologize for using the wrong pronoun/name. I did not mean to disrespect you.” Never refer to a person as ‘it’

�Example of Acceptable Pronouns

For further information visit the CDC page at: https://tinyurl.com/mptfxkxs

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(CDC.GOV)

Five Elements to Telephone Etiquette�

1. Greeting
• Pleasant welcome statement and thank you for calling…. sets a positive tone.
• Use friendly words and phrases.

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• Identify Campus or Hospital Location
• University Hospital at Downstate

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• Identify Department
• Clinic or Assigned Work Areas

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• Identify Yourself
• personalizes the conversation and gives a contact name and resource for future reference.

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• Offer Help  

      “How may I help you?” Remember to offer Options…. Avoid NO, put things in the positive

"Good (morning, afternoon, or evening), thank you for calling 

University Hospital at Downstate (Department name). 

(Your Name) speaking, 

"How may I help you?"

Winning Words……..� Good Vs. WOW�

Instead of …..

1. AVOID saying…. “I don’t know”
2. “Do you want/need”
3. You’re Welcome
4. We/You can’t
5. No problem
6. Recognizing a guest from a past stay
7. Ignoring patients and family
8. Making excuses for service failures 
9. Treat the guest the way you would like to be treated. 

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Make it WOW by……

1. Stating - Let me see what I can find out… ask someone
2. Saying “What would you like”?
3. Responding with "My pleasure"
4. Offering an alternative: "May I suggest…"
5. Responding with "Happy to help"  
6. Remembering their preferences
7. Greeting a guest with a smile/Engaging them in conversation
8. Apologizing. Offer heartfelt empathy and share potential solutions
9. Treat the guest the way they want to be treated 

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Complaint & Grievance Management �

Receive Concern

Is the pt still in house?

Is staff present to assist in resolving?

Did the patient request file as a formal complaint?

Was the pt satisfied with the resolution?

NO

NO

NO

NO

YES

YES

YES

YES

Define as a Grievance

Read/Review Carefully /Assign to PR

Enter into Log

Respond

Begin Investigation

Is input from another dept. needed?

Investigation completed w/in 7 days?

Risk Review/Send letter to the patient explaining actions taken to resolve

Define incident as a COMPLAINT

Log into RESPOND

Use information for trending/analysis/PI

Report out to EPIC

Complete Documentation FILE

Complainant satisfied with resolution?

Invite complainant in for a “Family Meeting”

Send reminder to department head (s) & Risk/COPC

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***********

Send extension request to

complainant

NO

YES

NO

Escalate investigation to senior level within the Dept.

Investigation completed <30days?

NO

YES

YES

Complainant satisfied with resolution?

YES

Offer continued support

Complete Documentation FILE

Concern Sources

Complaint & Grievance Management

DEFINITIONS

• Complaints are requests or concerns that are resolved at the time of the complaint by staff present at the time of the complaint or who can quickly be present to resolve the complaint. Verbal complaints made after discharge about matters that could have been quickly resolved if they had been made while the patient was admitted are also complaints.

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• Grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations.

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• When a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements.

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• Billing issues are not usually considered grievances for the purposes of these requirements. However, a Medicare beneficiary billing complaint is considered a grievance.

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• Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding the patient’s care or with an allegation of abuse or neglect.

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• Whenever the patient or the patient's representative requests that his or her complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance.

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• Information obtained from patient satisfaction surveys usually does not meet the definition of a grievance. However, if an identified patient writes or attaches a written complaint on the survey, then the complaint meets the definition of a grievance.

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RESPONSIBILITIES

The Governing Body of Downstate has delegated its responsibility for the grievance process to the Concerns over Patient Care Committee (COPC). This committee is facilitated by the Chief Experience Officer and chaired by the Chief Medical Officer or designee.

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Complaints

Every staff member who receives a patient’s concern is responsible to try to resolve the concern and forward actions taken to the Patient and Guest Relations (718-270-1111) for logging and follow through to resolution. If staff is unable to resolve the issue, they should escalate the matter to the next level of supervision for immediate resolution.

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Grievances

If the complaint cannot be quickly resolved, staff must escalate such issues to their immediate supervisor and department head who would apprise the Patient and Guest Relations Department of the patient’s concerns (718-270-1111).

During off hours and on weekends, the AOD/Nursing Supervisor is responsible for ensuring that patient complaints and grievances are appropriately handled and referred to the Patient and Guest Relations Department.

Staff member should advise the complainant that the Patient and Guest Relations Department will contact the complainant the next work day.

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Telephone Interpretation:

All Treatment areas are equipped with Cordless or Double Handset phones (pic above). 

Video Interpretation: Staff may access video/interactive language interpretation including American Sign Language (ASL) by using the iPad-equipped mobile carts.

Turn on iPad, select language (audio/video call) then follow prompts

It’s really that simple.

Call Patient Relations (ext. 1111) to request Propio Video (iPad) Mobile Device.

On nights and weekends contact the Nursing Supervisor

Double Handset

&�Cordless Phones

Culturally Linguistically Appropriate Services (CLAS)​�Limited English Proficiency (LEP)​

• Telephones​
• Video iPADs​
• Mobile Devices​
• Interpretation​
• Translation​

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Corporate Compliance�Presented by the Office of Compliance & Audit Services (OCAS)

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Downstate’s Compliance Program provides a framework of policies, procedures and assessment activities designed to help prevent and detect violations of laws and regulations.

SUNY Downstate’s Corporate Compliance Program is mandated by the State of New York’s Office of Medicaid Inspector General.

Visit for more information:

www.downstate.edu -> Our Administration -> Compliance & Audit

Visit the OCAS website for brochures & resources

Elements for an Effective Program:

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• Policies & Procedures
• Compliance Officer –
• Shoshana Milstein (718) 270-4033

& Committee Oversight

• Training & Education
• Open Communication
• Disciplinary Policies
• Auditing/Monitoring
• Investigation/Response and Remediation
• Non-Intimidation/Non-retaliation Policy

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Deficit Reduction Act (DRA)�Detecting & Preventing Fraud, Waste and Abuse: The DRA requires education on the Federal and State laws regarding fraud and abuse, whistleblower protections under these laws and Downstate’s Compliance policies in preventing and detecting fraud, waste and abuse.�

• Federal False Claims Act
• New York False Claims Act
• New York State Finance Law

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A false claim is a violation of State and Federal Law. Civil, administrative and criminal penalties may be levied based assessment of the following factors:

• Knowingly presenting a false claim for payment
• Knowingly making, using or causing a false statement to get a false claim paid;
• Conspiring to defraud; or
• Knowingly making, using or causing a false statement to conceal, avoid or decrease an obligation to pay.

Violations may include up to $10,000 per false claim (adjusted for inflation) and exclusion from Federal health care programs.

Private persons are eligible to file qui tam/whistleblower lawsuits (without threat of employer retaliation) on behalf of the Federal government.*

If successful, 15-30% of recoveries may be awarded.

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*Downstate Medical Center is a component of the State University of New York, and thus is a State agency. The United States Supreme Court has held that private persons may NOT be eligible to file qui tam / whistleblower lawsuits against State agencies and may NOT be entitled to a share of the proceeds of any FCA recoveries.

These laws establish liability for any person who engages in unlawful acts with respect to Federal, State or local government.

Other applicable laws:

Federal Program Fraud Civil Remedies Act

New York Social Services Law

New York Penal Law

New York Labor Law

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EXAMPLES OF FALSE CLAIMS:

• A physician billing Medicare / Medicaid for medical services not medically necessary/not provided;
• Billing Medicare / Medicaid for skilled professional services performed by non-licensed / non-professionals.
• The acceptance of gifts or kickbacks in exchange for referrals or use of specific pharmaceutical drugs or devices.

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Click here for Downstate’s DRA Brochure

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Click here for Downstate’s DRA Policy

Report Violations

Downstate’s confidential Compliance Line is a 24/7 hotline service available as an internal reporting mechanism for reporting illegal or unethical conduct.

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If you become aware of a situation that may jeopardize Downstate’s ethical integrity, it is up to you to report it!

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Call: Compliance Line

(877)-349-SUNY; or

Click on “Compliance Line” link on Downstate’s webpage @ www.downstate.edu

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HIPAA Refresher Training

Presented by:

Office of Compliance & Audit Services

Under HIPAA regulations, health information or Protected Health Information (PHI), includes 19 identifiers that must be kept private.

PHI identifiers include:

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Patient name

Birthdate

Address/Email

Dates of service

Social Security number

Medical Record number

Insurance information

Payment information, including credit card numbers

Full face photos

Common Sense Safeguards for Protecting PHI

• Don’t leave PHI around or discuss patient specific information in public places.
• Do not assume a visitor at patient’s bedside is privy to treatment discussions- including naming meds- always ask patient first.
• Never share passwords and log out of workstation upon leaving your desk- all electronic activity is logged and audited!
• Never dispose PHI in trash cans! Use shredders or assigned locked bins.
• Be mindful of sharing information on social media- don’t post pictures with patients, workplace identifiers, associates in background and never include patient info!
• Never use personal accounts or unapproved cloud services for sending or sharing PHI.
• Insert “Confidential” in email subject line in Outlook when sending PHI external to Downstate to automatically encrypt the message.
• Smartphones, laptops, USB drives, portable devices must be encrypted if using for PHI.
• Always double check printed material provided to patients to ensure the correct name is stated on the paperwork.

Click here for more information on safeguarding PHI.

HIPAA Website

• Policies – if you work with patients, or with patient information, you must familiarize yourself with Downstate policies on the appropriate use and safeguarding of this data.
• Contact Information – ask before you act. Once violated, privacy can never be restored – contact the Privacy Office with any questions.
• Reporting Possible Violation – report suspected violations and breaches of confidential information ASAP. The sooner Downstate is aware, the better our chances of reducing risk of harm.

Visit for more information:

www.downstate.edu -> Our Administration -> HIPAA

REGULATORY AND  ACCREDITATION AGENCIES

• Regulatory and accrediting agencies establish standards and guidelines that hospitals must follow to ensure patient safety

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• Regulatory agencies are governmental organizations that implement and enforce compliance with the standards at both federal and state levels. UHD is required to comply with all standards established by:

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• Accrediting agencies are not-for-profit organizations that improve healthcare through evaluations of specific standards. The Joint Commission (TJC) surveys and accredits UHD every three years

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• TJC also assesses and surveys UHD on behalf of CMS and NYSDOH
•  Non-compliance with regulatory and accreditation requirements could result in cancellation of  reimbursements if found and not corrected

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������REGULATORY AND  ACCREDITATION AGENCIES

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Tracer Methodology

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• Regulatory and accreditation agencies use

       the tracer methodology for their survey process

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• Tracer methodology put patients at the

       center of the survey process

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• Tracer methodology uses information from

       the hospital to follow the experience of 

       care, treatment, or services for a number of

       patients through the hospital’s entire health

       care delivery process; from admission to

       discharge and to follow-up care 

© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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NY STATE PATIENT BILL OF RIGHTS

New York State Hospital Patients' Bill of Rights 

As a patient in a hospital in New York State, you have the right, consistent with law, to: 

1. Understand and use these rights. If for any reason you do not understand or you need help, the hospital MUST provide assistance, including an interpreter. 

2. Receive treatment without discrimination as to race, color, religion, sex, gender identity, national origin, disability, sexual orientation, age or source of payment. 

3. Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints. 

4. Receive emergency care if you need it. 

5. Be informed of the name and position of the doctor who will be in charge of your care in the hospital. 

6.Know the names, positions and functions of any hospital staff involved in your care and refuse their treatment, examination or observation. 

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7. Identify a caregiver who will be included in your discharge planning and sharing of post-discharge care information or instruction. ​

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8. Receive complete information about your diagnosis, treatment and prognosis. ​

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9. Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment. 

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10. Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet "Deciding About Health Care - A Guide for Patients and Families." ​

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"Patients' Bill of Rights" is also available in Portable Document Format (PDF). This document is also available in the following languages: Spanish (PDF), Russian (PDF), Chinese (PDF), Creole (PDF), Korean (PDF)

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NY STATE PATIENT BILL OF RIGHTS

11. Refuse treatment and be told what effect this may have on your health. 

12. Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation. 

13. Privacy while in the hospital and confidentiality of all information and records regarding your care. 

14. Participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge. 

15. Review your medical record without charge and, obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay. 

16. Receive an itemized bill and explanation of all charges. 

17. View a list of the hospital's standard charges for items and services and the health plans the hospital participates with. 

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18. Challenge an unexpected bill through the Independent Dispute Resolution process.

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19. Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response. If you are not satisfied with the hospital's response, you can complain to the New York State Health Department. The hospital must provide you with the State Health Department telephone number. ​

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20. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors.

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21. Make known your wishes in regard to anatomical gifts. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues, upon their death, by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as a health care proxy, will, donor card, or other signed paper). The health care proxy is available from the hospital. ​

Public Health Law(PHL)2803 (1)(g)Patient's Rights, 10NYCRR, 405.7,405.7(a)(1),405.7(c) ​

Publication Number 1500, Version 2/2019 ​

https://health.ny.gov/publications/1500/  ​

PATIENT SAFETY OVERVIEW

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Patient safety is the prevention of errors and adverse effects to patients.

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Patient safety systems are designed by providers and hospital staff to prevent harm to patients. 

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Here are some of our major initiatives:

• Joint Commission National Patient Safety Goals
• Falls Prevention Program
• Failure Modes and Effects Analysis (FMEA)
• Leapfrog Hospital Survey
• Culture of Safety Survey

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We encourage staff to report safety concerns, even if they never reached the patient. “Great catches” and “near misses” help identify areas with risk for harm.

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NATIONAL PATIENT SAFETY GOALS

In 2002, The Joint Commission established the National Patient Safety Goals (NPSG) to highlight significant problems in health care safety.

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Processes, policies, and practices have been developed to create safety mechanisms for each goal.

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The following slides provide an overview of the NPSG and roles of direct care providers to prevent patient harm.

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Team members should be familiar with their roles to meet NPSG requirements.

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NPSG – Patient Identification

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NPSG – Communication and Clinical Alarms

NPSG – Infection Prevention

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multi-drug resistant organisms

central-line associated bloodstream infections

post-surgical infections

catheter-associated infections

NPSG – Labeling Medications

Medications drawn from a sterile vial 

(in patient care areas) must be used or discarded within �1 HOUR

NPSG – Medication Reconciliation

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NPSG – Universal Protocol

Conduct a team TIME- OUT immediately prior to EACH procedure (and EVERY change in team members)

NPSG – Suicide Prevention

NPSG – Suicide Risk Assessment

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NPSG – Suicide Risk Assessment (Continued)

Minimize Risk and �Promote Protective Factors

AIM to SAVE

ADVANCE DIRECTIVES

INCIDENTS/OCCURRENCES/NEAR MISSES

HOW DO WE INVESTIGATE A SENTINEL  EVENT?

HOW DO WE INVESTIGATE A SENTINEL EVENT?

CHAIN OF INFECTION 

INFECTION CONTROL

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HAND HYGIENE  �SOAP AND WATER

7/7/2022

HAND HYGIENE  ALCOHOL-BASED HAND RUB​

HAND HYGIENE FINGER NAILS

BIOVIGIL®  HAND HYGIENE 

• An electronic hand hygiene monitoring device.
• Must be worn in inpatient areas
• Staff members provide feedback to each other 
• Color-coded alerts as reminders (see above)

HEALTHCARE ASSOCIATED INFECTIONS (HAI)

A Healthcare Associated Infection (nosocomial infection) occurs when a patient goes to a health-care setting and gets a new infection during their encounter.​

The hospital is not reimbursed for treatment of these HAIs:​  

- Surgical site infection 

​- CLABSI​ 

- CAUTI ​

Common HAIs

PREVENTING HOSPITAL ACQUIRED INFECTIONS�

STANDARD 

PRECAUTIONS ​

TRANSMISSION

BASED PRECAUTIONS

PUTTING ON AND REMOVING PPE

Isolation precaution signs outside the patient's’ room provide PPE guidance. Please observe, read and follow

COVID –19 – Stay Safe 

PPE are required for Health Care Providers (HCPs) caring for patients with confirmed or possible SARS-COV-2 infection

• N95 respirator
•  N95 should be  worn for confirmed or possible  COVID-19
• Patient on Airborne Precautions or Enhanced Precautions
•  All aerosolizing procedures. Note patients requiring aerosolizing procedure such as intubation, HFNC, bronchoscopy must be placed in a negative pressure room. 
• Don N-95, gown, gloves and eye protection before entering room.
• Upon exiting- doff gloves and gown and perform hand hygiene.   
• Note: N-95 can be worn for up to a shift (8-12 hours) if it’s not contaminated, torn, or wet.   
• The same N-95 respirator can be used between patients if it is covered by a regular face mask.   
• Clean and disinfect eye protection and equipment upon removal or exiting patient room.   
• The N-95 respirator should be folded and stored in brown paper bag as soon as it is removed (avoid contamination).  Always cleans hands with soap and water or use the alcohol sanitizer before removing eye protection or mask. 
• Isolation gown wear when appropriate, do wear gloves, protect eyes with goggles or face shields as needed 

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TB PREVENTION

7/7/2022

Infection Control Cont... ENVIRONMENT

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What Is An Emergency?

A natural, technological, or human-caused event that:

• Disrupts the environment of care
• Examples: damage to our building�due to flooding, storms, or fire
• Disrupts care and treatment
• Examples: loss of utilities, such as power, water, or telephones
• Results in sudden, significantly changed or increased demands for our services
• Examples: terrorist attack, building collapse, or plane crash in our community

Some severe emergencies are called “disasters”

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EMERGENCY MANAGEMENT ​

Hospital Incident Command System  (HICS)

• Hospital Incident Command System (HICS), methodology used to improve hospital in emergency management, planning, response and recovery.
• Hospital Command Center (HCC), located in the green Room or Executive Board Room depending on size of activation
•  Incident Commander (IC) - Person responsible for managing hospital response:
• gathers information about the incident, 
• decides how the hospital should respond, and what actions we should take 
• groups incident activities into four major sections: Operations, Logistics, Planning, and Finance/ Administration 
• NOTE: Only Supervisors can call the Command Center at extension 1515

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HICS LEVELS​

• Level 1, or Alert - the hospital is alerted about something that has not affected us yet​
• Level 2, or Minor Impact - actual situation having a minor impact on the hospital (only one or two departments affected; most of the hospital continues business as usual)​
• Level 3, or Moderate Impact - actual situation, moderate impact on the hospital (about half the hospital is affected, and the remainder continues business as usual)  ​
• Level 4, or Major Impact - actual situation having a major impact on the hospital (most or all hospital activities are focused on addressing the problem)​

Emergency Plans 

• All-Hazards Emergency Operations Plan (EOP) -�any type of emergency, regardless of cause, impact, or areas affected
• Department Emergency Operations Plans, called DEOPs (pronounced “dee-ops”) - department’s role in a crisis

SUBPLANS:  

• Critical Event Annexes - high priority emergencies e.g., evacuation, multiple casualty

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Accessing Hospital Emergency Management plans:

1. Click on the icon on your desktop ​

2. From Intranet; ​

• http://www1.downstate.edu/regulatory/emergencyprep.html​

MOST EMERGENCIES – Public Address System:

"Attention Attention, Code HICS Level [1, 2, 3, or 4] has been activated"

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OTHER EMERGENCIES – via telephone, pager, computer, your supervisor.

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END OF EMERGENCY - "Attention Attention, Code “All Clear”,  Code HICS has been secured"

​

​

Emergency Notifications

Send Word Now is the hospital’s mass notification system used as a method of communicating with staff. ​

         How do I join the "Send Word Now" System?​

• To join the new Send World Now system, please follow the following instructions:​
• Go to http://downstate.sendwordnow.com​
• Click “Register Now”. (If you have already registered and wish to change your information, click “Login”.)​
• Read the Registration Agreement and Click “I Agree” and click “I have read and understand the privacy policy.” Then click “Submit”

Emergency Communication

If we lose normal telephone service, we may communicate using alternate means, including:

• Portable radios
• Emergency backup telephone system 
• Cellular phones and text messaging
• Facsimile telephone outlets (fax machines)
• Computer messages and e-mail
• Pagers
• Overhead public address announcements
• Runners and written messages
• GETS cards- only for Key staff -GETS is a program of the Department of Homeland Security, Office of Emergency Communications that prioritizes calls over wireline networks. Users receive an access card (GETS card), which has both the universal GETS access number and a Personal Identification Number (PIN).

​

​

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To:

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Fellow employees

​

​

​

Patients and families

​

​

​

Media and the 

general public

Information You May Provide:

​

• Pass on FACTS
• Do NOT spread rumors or unverified information
• Refer them to their supervisors

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• Ensure their safety and well-being
• Be truthful and reassuring
• Refer them to your supervisor

​

​

• Refer them to the Public Information Officer (PIO) or the Press Office

What Do I Say When People Ask Me for Information?�

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What Should I Do In An Emergency?

• Avoid using the telephone, which gets overloaded quickly
• Make an appropriate notification (e.g., pull the fire alarm for a fire, notify your supervisor and/or security)
• Refer to your Department Emergency Operations�Plan (DEOP) for instructions
• Return to your department if you are away
• Report to your supervisor for instructions
• Job assignments may be modified during an emergency.

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What if I’m Off-Duty During an Emergency?

• CALL - your Departmental Supervisor for instruction

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• COME TO WORK - if requested

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• REPORT FOR SCHEDULED SHIFT -
• If not requested, or unable to make contact

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• IF UNABLE TO COME TO WORK as scheduled, contact your supervisor for instructions

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• DO NOT respond to the scene of an emergency in the community unless you are part of the planned, organized response (e.g., if you are a volunteer firefighter or EMT)

When Might We Evacuate?

3 types of evacuation: Emergent, Urgent, and Planned

1. Emergent Evacuation -  immediate evacuation without delay is essential 
• Delay is potentially life threatening e.g., fire 
• The person in charge of that space (e.g., charge nurse; department head) is authorized to order an emergent evacuation
• Evacuation is limited to the extent necessary to safely remove all occupants from immediate harm
2. Urgent Evacuation
• When difficulty in maintaining an acceptable environment of care is occurring that cannot be readily corrected 
• Evacuation will commence within four hours
• Example: loss of utilities that cannot be corrected
1. 2.     Planned Evacuation
• Circumstances may require relocation of patient care or ancillary service activities with at least 48 hours of advance notice
• Example: major hurricane approaching the Island
• Ample time exists to inform patients and staff, plan activities, and mobilize resources

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How Do I Get Ready?

• Review available materials to help you prepare�your home and family for emergencies
• Web sites with useful information:

http://ready.gov/

 http://www.redcross.org/home/

http://www.nyc.gov/readyny

�Arrange for your family, dependents, pets, and home to be cared for in case you are called to duty (or are unable to go home) during an emergency

• Remember, our hospital can only help our patients if you, our staff, are here!  

FIRE SAFETY

• If you see a fire:  Shout “Code RED”  
• Pull a fire alarm pull station
• Call ext. 2626 for the University Police – State "Code RED" and give your location

ALARM

Do not use elevators

Close all doors and windows

Keep telephone lines clear (answer only)

Wait for “all clear” signal

Nursing personnel must know location of unit’s oxygen shut off valve

The charge nurse is responsible for turning off the oxygen shut off valve in case of a fire emergency

 NOTIFICATIONS

Strobes flash -Alarm sounds 

FIRE NOTIFICATION : 

There will be 3 temporal sounds, “warp” “warp” “warp”

Followed by PLAIN Language CODE Announcement: 

  "FIRE, FIRE  Hospital Building, 

   4^th Floor, Nurse Station 42.” -REPEATED THREE TIMES -

CARBON MONIXIDE NOTIFICATION: 

 "Carbon Monoxide detected, Carbon Monoxide detected, Hospital Building, 4th Floor, Nurse Station 42.” -

REPEATED THREE TIMES

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R-ESCUE/R-EMOVE

• Rescue/Remove anyone in immediate danger
• If possible, remove patients or employees from immediate danger of fire or smoke

C-ONTAIN

• Contain fire by closing all doors and windows to confine the fire, smoke, heat or gases 
• Move combustible materials away from the fire area

Don’t allow smoke and fire to spread​

E-EVACUATION/E-EXTINGUISH

EVACUATE: 

Horizontal evacuation to the adjacent compartment (i.e., east/west across the double corridors doors)

Vertical evacuation at the direction of the Fire Department

• Employees, clients and visitors are moved downward and out of the building
• Elevators are not to be used for evacuation

EXTINGUISH:

• Small Fire - you may attempt to put it out with the appropriate extinguisher.
• Use an extinguisher only after you have initiated an alarm and rescued anyone in danger.
• DO NOT attempt to extinguish the fire if it will endanger yourself or anyone else.

FIRE EXTINGUISHERS - TYPES

PASS​

1. Pull​
2. Aim​
3. Squeeze​
4. Sweep​

HOW TO USE A FIRE EXTINGUISHER

Hazardous Materials & �Wastes Management

• The Right-To-Know Law or Hazard Communication Standard require employers to provide training upon initial assignment and when new chemical hazard is introduced.
• Upon an employee’s request, the employer shall provide a safety data sheet (SDS) specific to the chemical
• SDS must be readily accessible to employees during all shifts 
• Obtain SDS (from manufacturer, distributor or online) for all hazardous chemicals present or produced.  

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HAZARD COMMUNICATIONS

YOU HAVE

A 

RIGHT-TO- KNOW!

Please follow all instructions carefully.  If any difficulties are encountered while trying to gain access to this information, please call the Environmental Health & Safety Office at x5212 or x1216.

1. Go to www.downstate.edu - 

On the left side of the computer screen, there is a list of services offered 

2. Click on  “Administration”

3. Scroll Down to “Intranet”  

4. Click on “Safety Data Sheets”

5. A search page comes-up with the following information:

   Common Name:         _________________________________

   Manufacture Name:   _________________________________  

   Full Text:                    _________________________________

6. Type in name of chemical or the manufacturers’ name, whichever is    

         applicable/available. Then click on the ‘Search option’ 

7. If no results came up when using the name of the chemical or the  manufacturer's  name, a full-text search with name of the chemical can also  be done to find the available information.

How to Gain Access to Downstate Medical Center​ SAFETY DATA SHEETS (SDS) On-Line �

HOW ARE HAZARDS COMMUNICATED –�LABEL ELEMENTS

• Signal word - Indicate the relative level of severity of hazard and alerts the reader to a potential hazard on the label

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• Danger - used for more severe hazards
• Warning - used for less severe

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• Hazard statement - Describes the nature of the hazard(s) of a chemical, including, where appropriate, the degree of hazard

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• Toxic if inhaled
• Causes severe burns and eye damage
• Extremely flammable liquid

Pictograms

CHEMICAL ROUTES OF ENTRY�

Chemicals can only cause health effects when they come into contact with your body.  

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Routes of Entry

• Skin contact (absorption through the skin or damage on contact to skin or eyes)
• Inhalation
• Ingestion
• Injection

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APPROPRIATE PPE SHOULD BE WORN DEPENDING ON THE ROUTE OF ENTRY

EMPLOYEE RIGHTS

EMPLOYEES RESPONSIBILITIES

HAZARDOUS MATERIALS & �WASTES MANAGEMENT

Hazardous waste categories:

• Regulated medical waste or infectious waste
• Chemical waste
• Radioactive waste

CHEMICAL WASTE DISPOSAL

CHEMICAL WASTE  

any liquid, solid or gaseous substances which are flammable, have toxic properties, can cause air and water pollution, or produce adverse physiological reaction

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• Disposal of chemical wastes is handled by the Office of Environmental Health & Safety @ Ext. 5212.

  ​

• The waste must be in appropriate CONTAINERS with labels of the waste’s identity or composition.​

REGULATED MEDICAL WASTE

SHARPS

• Clinical sharps that include but are not limited to:
• Medical needles -  Scalpel blades
• Glass slides -  Blood vials

PATHOLOGICAL MATERIAL

• Human blood and blood products, 
• including plasma and blood-soaked materials.
• Human pathological materials:
• Body tissues - Organs - Fluids
• Animal pathological materials
• Any item that has a biohazard symbol on it 

HANDLING REGULATED MEDICAL WASTE

Regulated medical wastes:

•  Placed in red bags, specially designed and marked containers and removed from site for decontamination or destruction
• Should never be mixed with regular garbage

OTHER

• Infectious agents
• Vaccines
• And the items contaminated by these materials

RADIOACTIVE WASTE DISPOSAL

• Radioactive materials are solid, liquid, or gaseous substances that emit ionizing radiation
• When they lose their radioactive properties, they can be disposed of as chemical waste
• Procurement of radioactive materials and disposal of radioactive waste are coordinated by the Office of Radiation Physics @ ext.1423

ELECTRICAL SAFETY

• Provides emergency power if an electrical failure occurs.
• The red outlets are used for life support equipment such as ventilators, cardiac monitors etc.
• Always disconnect plugs from the wall by grasping the safety plug and not the power cord.

EMERGENCY GENERATOR OUTLET SYSTEM

• Check to ensure equipment maintenance sticker is current prior to use.​
• Extension cord use is prohibited.​
• Power strips with a circuit breaker are permitted.​
• Inspect all equipment and cords for damaged wiring, plugs, cords, EKG leads, etc.
• Use caution when operating electrically powered equipment around sources of water (sinks & wet floors)
• If equipment does not operate properly, turn it off, unplug it, affix a defective tag, notify supervisor and send equipment for repair 
• Any equipment or Biomedical device (purchased, rented and loaned) must be inspected by the Scientific Measurement, Instrumentation & Calibration Department (SMIC) prior to use.
• Send all malfunctioning medical equipment to SMIC Department or call ext. x1664.

FIRST EMPLOYEE(S) TO IDENTIFY AN ACTIVE SHOOTER SITUATION

• Call the University Police and report active shooter situation (include the location of the incident and a description of the person (s) with the weapon, and type of weapon if known.
• Patients, visitors and staff should be evacuated from the area to a secured location away from the shooter (s) if safe to do so.
• Limit access by securing doors.

Active Shooter Response

Active Shooter – Notification

�If an Active Shooter enters an area where you are located, YOU SHOULD:�

• Remain calm  - Have 1 person call University Police ext: 2626, state “we have an active shooter in the Hospital”.(Give location).
• Warn other staff, visitors and patients to take immediate shelter 
• Go to a room that can be locked or barricaded  -  Lock and barricade doors or windows 

​

• Follow the guidelines: Run, Hide, Fight​
• Try to remain calm
• Try not to do anything that will provoke the active shooter
• If there is no possibility of escaping or hiding, only as a last resort when your life is in imminent danger, you could make a personal choice to attempt to negotiate with or overpower the shooter ​
• If the active shooter(s) leaves the area, barricade the room or go to a safer location.​

If Your location is distant from the active shooter; or you are not able to leave the area safely:

• Turn off lights  - Turn off radios or other devices that emit sound (i.e., cell phones)
• Keep yourself out of sight and take adequate cover/protection (i.e., concrete walls, thick desks, cabinets)
• Close all patient rooms on units, and barricade patient doors as much as possible 

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University Police Response

UNIVERSITY POLICE TAKE DOMESTIC VIOLENCE SERIOUSLY

Violence in the Workplace

​

​

Employees will be held accountable for engaging in the following behavior: 

• Using state resources to commit an act of domestic violence; 
• Committing an act of domestic violence from or at the workplace or from any other location while on official state business; or 
• Using their job-related authority and/or state resources in order to negatively affect victims and/or assist perpetrators in locating a victim and/or in perpetrating an act of domestic violence.

​

If you have a question or concern about domestic violence, please

contact one of our trained staff who will provide confidential assistance.

​

University Police

445 Lenox Road

718 270 2626

​

Employee Assistance Program

718 270 1489

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Labor Relations

320 Lenox Road

718 270 3019

​

Shuttle service is available by calling x 4051 or x2626.

Questions About Domestic Violence?

NYC Domestic Violence Hotline

(800-621-4673. TDD 866-604-5350)or call 311 and ask for the hotline

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PRINCIPLES OF PROPER BODY MECHANICS

Protect Your Back Protect Your patients 

  Body mechanics is the  utilization of correct muscles to complete a task safely and  efficiently, without undue strain on  any muscle or joint.

Maintain a stable center of gravity

• Keep your center of gravity low
• Keep your back straight
• Bend at the knees and hips

Maintain a Wide Base of Support

       This will provide you with  maximum stability while lifting

• Keep your feet apart
• Place one foot slightly ahead of the other
• Flex your knees to absorb jolts
• Turn with your feet

Maintain the Line of Gravity

       The line should pass vertically  through the base of support

• Keep your back straight
• Keep the object being lifted close to your body

Maintain Proper Body Alignment.

• Tuck in your buttocks - Pull your abdomen in and up
• Keep your back flat - Keep your head up
• Keep your chin in
• Keep your weight forward and supported on the outside of your feet

Lifting

• Use the stronger leg muscles for lifting
• Bend at the knees and hips; keep your back straight
• Lift straight upward, in one smooth motion

Reaching

• Stand directly in front of and close to the object
• Avoid twisting or stretching
• Use a stool or ladder for high objects
• Maintain a good balance and a firm base of support
• Before moving the object, be sure that it is not too large or too heavy

Pivoting

• Place one foot slightly ahead of the other
• Turn both feet at the same time, pivoting on the heel of one foot and the toe  of the other
• Maintain a good center of gravity 
• while holding or carrying the object

Avoid Stooping

• Squat (bending at the hips and knees)
• Avoid stooping (bending at the waist)
• Use your leg muscles to return to an 
• upright position

RADIATION SAFETY

• ALARA - The goal of Radiation Safety is to keep the dose As Low As Reasonably Achievable

​

• The primary purpose of radiation safety is to keep radiation doses within acceptable limits

​

• The federal, state, and city governments set occupational dose limits for workers

​

There are 2 main sources of ionizing radiation within the healthcare setting:

1. Equipment – machines designed to emit x-ray radiation for imaging. CT, portables, c-arms
2. Radioactive materials –  injected or ingested materials used in Nuclear Medicine and PET Scan (positron Emission Tomography)

​

There are 3 basic precautions in radiation protection:

1. Time – spend the least amount of time in the room during exposure
2. Distance – stand as far away from the radiation source as possible (rule of thumb is 6 feet or more from the source of radiation)
3. Shielding – always wear lead shielding when in a room during exposure

This Photo by Unknown Author is licensed under CC BY-SA

This Photo by Unknown Author is licensed under CC BY-NC-ND

RADIATION SAFETY

• Most hospital workers receive little to no occupational radiation exposure

DOSIMETER BADGES

• Issued by radiation safety to employees who may receive a level of radiation when working in radiation areas. 
• Used to monitor the amount of exposure
• Badge should be stored at the end of each shift
• Do not wear your badge outside of the hospital
• Exchange your badge each month so exposure levels can be monitored
• In general, pregnant health care providers  should not care for patients receiving therapeutic radiation treatments such as I-131 thyroid ablation and radioactive seed implants

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This Photo by Unknown Author is licensed under CC BY

RADIATION SAFETY

STROKE – DEFINITION & TYPES

A stroke occurs when something blocks blood supply to part of the brain (ISCHEMIC STROKE) or when there is bleeding in the brain (HEMORRHAGIC STROKE).

​

Patients experience a stroke will present with acute focal (depending on area of injury) neurological deficits.

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© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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STROKE – SIGNS & SYMPTOMS (BE FAST)

BE FAST POSITIVE:

If the patient reports any 'BE FAST' symptoms started in the last 24 hours.

GET HELP:

- Ask the nurse or provider to assess the patient.

- Dial 2323 to call a "CODE STROKE"

© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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Organ Donation – Organ Procurement Org. (OPO)

© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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LiveOnNY is the federally designated Organ Procurement Organization (OPO) for UHD. 

​

CMS (Centers for Medicare and Medicaid Services) & The Joint Commission require that every death & every imminent death in every hospital in the United States be reported to the OPO for that hospital.

​

LiveOnNY is the OPO for UHD (and every hospital in the metro NY area). 

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LiveOnNY is HIPAA privileged - any & all patient information can be provided to LiveOnNY.

Organ Donation – LiveOn New York

WHEN TO REPORT & WHO REPORTS?

© SUNY Downstate Health Sciences University 2021 – Privileged & Confidential

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EVERY DEATH in the hospital must be reported to LiveOnNY WITHIN 1 HOUR of patient’s death - regardless of:

• their medical diagnosis; 
• cause of death; 
• age; 
• religion; 
• ethnic; 
• or cultural background; 
• and regardless of whether or not they signed up to be a donor   

WHO REPORTS?: As per UHD policy -  the nurse caring for the patient in the unit where the patient dies, must report the death to LiveOnNY.

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• LiveOnNY must also be called WITHIN 1 HOUR of mechanically vented patients meeting any of these conditions: 
• Absence of two or more brain stem reflexes 
• Glasgow Coma Scale < 5 
• Anticipated family discussion about withdrawal of life-sustaining therapies    

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NOTE:  You should not mention donation to patients’ family members.

LiveOnNY will speak with families about donation if and when it is appropriate to do so. 

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Mechanically Vented Patients

THANK YOU

You have now completed the General Annual Mandatory.

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Please click HERE to proceed to the

AME Post Test.

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