Tulare Local Health Care District Board of Directors Regular Meeting Agenda Wednesday, September 28, 2016 Board Convenes at 4:00 p.m. Evolution Fitness & Wellness Center Conference Room 1425 E. Prosperity Ave. Tulare, CA 93274 I. CALL TO ORDER -Chair of the Board II. CITIZEN REQUESTS/PUBLIC COMMENTS III. APPROVAL OF MINUTES - Regular Board Meeting Minutes of August 24, 2016 and Special Board Meeting Minutes for September 1, 2016. Proposed Action: Approval of Minutes for August 24, 2016 Regular Board Meeting and for September 1, 2016 Special Board Meeting Minutes. IV. OPEN SESSION AGENDA A. Consent Agenda 1. Request to approve the following Tulare Local Health Care District (TLHCD) Medical Executive Committee Policies: 12-1045 12-3099 12-3100 12-3101 12-3102 12-3103 20-8011 20-8012 20-8018 ISO50-1000 Pain Assessment and Management Central Service- Traffic Control Central Service- Environmental Cleaning of Central Service Central Service- Infection Control Central Service- Department Cleaning Central Service Storage of Sterile Supplies Reportable Diseases and Conditions Pregnant Healthcare Worker Work Restrictions and Management of Personnel Illnesses and Exposures to Communicable Diseases Quality Manual System Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member Tulare Regional Medical Center is a Division of Tulare Local Health Care District 2. Request to approve the following Tulare Local Health Care District (TLHCD) Hospital Policies: 10-1002.2 13-12001 13-12002 Corporate Compliance Plan Educational Services Plan AHA Training Center Proposed Action: Approval of Consent Agenda Items B. Board of Director Update/Action Items - Board Chair 1. Board Member Reports D. Medical Staff Report – Ronald Ostrom, D.O., Chief of Medical Staff (or MEC representative) 1. MEC Recommendations to the Board and Report of Actions Proposed Action: Acceptance of MEC Recommendations V. SUSPEND OPEN SESSION - ADJOURN TO CLOSED SESSION VI. CLOSED SESSION A. Medical Executive Committee Report of Hospital Medical Audit or Quality Assurance Activities -Ronald Ostrom, D.O., Chief of Medical Staff (or MEC representative) MEC Reports relating to Peer Review, Credentialing, and Quality Assurance, pursuant to Health and Safety Code section 32155 B. Conference with Legal Counsel Existing Litigation pursuant to subdivision (d)(1) of Government Code section 54956.9: Discussion regarding Aghapy Group, Inc. dba Aghapy Construction v. Tulare Local Healthcare District Tulare County Superior Court Case No.: 264380 C. Conference With Legal Counsel Significant exposure to litigation pursuant to Subdivision (d)(4) of government Code section 54956.9: Discussion regarding two (2) potential actions D. Conference With Legal Counsel Existing Litigation pursuant to Subdivision (d)(1) of Government Code section 54956.9 Discussion regarding Tulare Regional Medical Center Medical Staff v. Tulare Local Healthcare District Tulare County Superior Court Case No.: 264227 E. Conference With Legal Counsel Existing Litigation pursuant to subdivision (d)(1) of Government Code section 54956.9: Discussion regarding Parmod Kumar, M.D., et al. v. Abraham Betre, D.O. et al. Tulare County Superior Court Case No.: VCU265230 F. Conference With Legal Counsel Existing Litigation pursuant to subdivision (d)(1) of Government Code section 54956.9: Discussion regarding Opper v. Tulare Regional Medical Center, et al. Tulare County Superior Court Case No.: 263554 G. Conference With Legal Counsel Existing Litigation pursuant to subdivision (d)(1) of Government Code section 54956.9: Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member 609682513.1 Discussion regarding Carlos Chavez, Kevin Lopez and Christian Lopez v. Ronald Allen Smith, M.D., David Smith, M.D. and Tulare Regional Medical Center Tulare County Superior Court Case No.: 261060 H. Conference With Legal Counsel Existing Litigation pursuant to subdivision (d)(1) of Government Code section 54956.9: Discussion regarding Deanne Martin-Soares and Emily Yenigues v. Tulare Local Health Care District, et, al. Tulare County Superior Court Case No.: 266902 I. VII. Conference With Legal Counsel Existing Litigation pursuant to subdivision (d)(1) of Government Code section 54956.9: Discussion regarding Firstsource Solutions USA, LLC v. Tulare Regional Medical Center Eastern District of California Case No.: 1:15-01136-KJM-EPG ADJOURN CLOSED SESSION/RECONVENE OPEN SESSION -Public report of action taken in closed session, pursuant to Government Code section 54957.1 VIII. ADJOURNMENT Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member 609682513.1 NOTICE TO THE PUBLIC Tulare Regional Medical Center does not discriminate against any person on the basis of gender, religion, race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact: Bruce Greene of Baker & Hostetler LLP at telephone number (310) 442-8834 or by e-mail at bgreene@bakerlaw.com. PUBLIC COMMENT PERIOD FOR REGULAR MEETINGS At this time, members of the public may comment on any item of interest to the public that is within the subject matter jurisdiction of the Board (Gov’t Code, § 54954.3(a)). Provided, however, the Board shall not take action on any item not appearing on the agenda unless the action is otherwise authorized by law. Any person addressing the Board will be limited to a maximum of three (3) minutes so that all interested parties have an opportunity to speak. OPEN SESSION AGENDA ITEMS All writings, materials and information provided to the Board for their consideration relating to any Open Session Agenda item of the meeting are available for public inspection during regular business hours at the Administration Office of the District located at 869 Cherry Street, Tulare, California. CLOSED SESSION AGENDA ITEMS As provided in the Ralph M. Brown Act, Government Code §54950 et seq., the Board may meet in closed session with members of its staff, employees and its attorneys. These sessions are not open to the public and may not be attended by members of the public. The matters the Board will meet on in closed session are identified in the Regular Meeting agenda. Any public reports of action taken in the closed session will be made in accordance with Government Code § 54957.1. COMPLIANCE WITH ADA This agenda shall be made available upon request in alternative formats to persons with a disability, as required by the Americans with Disabilities Act of 1990 (42 U.S.C. § 12132) and the Ralph M. Brown Act (Cal. Gov’t Cod. § 54954.2). Persons requesting a disability related modification or accommodation in order to participate in the meeting, should contact the Executive Office at (559) 685-3462, during regular business hours. Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member 609682513.1 Tulare Local Health Care District Board of Directors Regular Meeting Minutes Wednesday, August 24, 2016 Board Convenes at 4:00 p.m. Evolution Fitness & Wellness Center Conference Room 1425 E. Prosperity Ave. Tulare, CA 93274 PRESENT Sherrie Bell, Chair Richard Torrez, Treasurer Linda Wilbourn, Secretary Laura Gadke, Board Member ABSENT Parmod Kumar, MD, Vice Chair OTHERS PRESENT Benny Benzeevi, M.D., Chair HCCA Claudia Razo, Executive Assistant Community Members Legal Counsel (Baker & Hostetler LLP) I. CALL TO ORDER Chair Sherrie Bell called the meeting to order at 4:00 p.m. II. CITIZEN REQUESTS/PUBLIC COMMENTS The following individuals provided public comments: - Ms. Susana Aguilera-Marrero - Mr. Tim Moore - Ms. Sally Boucher - Dr. Edward Henry, DVM - Mr. Shawn Burgess - Mr. Dou McNearney - Ms. Michelle Moore - Mr. Steven Harold Mr. Tim Ward presented the hospital with a trophy and a certificate for its services in connection with the March of Dimes campaign. III. APPROVAL OF MINUTES Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member Tulare Regional Medical Center is a Division of Tulare Local Health Care District - Regular Board Meeting Minutes of July 27, 2016. Action: Laura Gadke made a motion to approve the minutes for the Regular Board Meeting of July 27, 2016 with the minutes amended to correct two typos. Linda Wilbourn seconded the motion. The motion passed unanimously. IV. OPEN SESSION AGENDA A. Consent Agenda 1. Request to approve the following Tulare Local Health Care District (TLHCD) Medical Executive Committee Policies: 13-5008 13-9028 Hospital Drug Formulary Approved Abbreviations-Symbols and Prohibited Abbreviations, Acronyms and Symbols (Do not use) List 2. Request to approve the following Tulare Local Health Care District (TLHCD) Hospital Policies: 10-1113 22-1009 22-1012 22-1015 22-1016 22-1017 22-1019 22-1020 General HIPAA Overview for Education Purpose (HIPAA) --DELETE Safety (Environment of Care) Committee Eyewash Management Lockout Tagout Plan Hazardous Communication Program Hazardous Waste Management Program Medical Waste Management Plan Incarcerated Patient Policy 3. Request to approve the following Tulare Local Health Care District (TLHCD) Physician Orders: None 4. Request to approve the following Physician/Other Agreements: a. Physician Orders 645 Hypertension Preeclampsia--NEW b. Second Amendment Medsphere Systems Corporation c. Lease Agreement- Renewal Indulgence Salon & Spa Action: Laura Gadke made the motion to approve the Consent Agenda Items. Richard Torrez seconded the motion. The motion passed unanimously. B. Report by Administration - HCCA Management 1. Finance a. Monthly Financial Update – Alan Germany presented the financial summary highlighting the results for the month of July. He also provided an overview of the volume trends of the various operating components within the healthcare District. He noted that the District’s operating margin continues to be solidly positive. Average daily census was 43, deliveries have slightly increased from prior month with a volume of 52 for July. Primary Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member 609598956.3 care visits had a growth of 9.2% from July 2015 to July 2016. The cash position continues to be solid, but is weighed down by Tower construction costs. Action: Laura Gadke made the motion to approve of the July 2016 Financial Statements. Richard Torrez seconded the motion. The motion passed unanimously. 2. Compliance and Quality a. Compliance Presentation Update – Alan Germany C. Board of Director Update/Action Items - Board Chair 1. Board Member Reports The next regularly scheduled board meeting will take place on September 28, 2016 at 4:00 p.m. D. Medical Staff Report 1. MEC Recommendations to the Board and Report of Actions Action: Laura Gadke made the motion to approve the of MEC Recommendations (which were presented in written form). Richard Torrez seconded the motion. The motion passed unanimously. V. SUSPEND OPEN SESSION - ADJOURN TO CLOSED SESSION Chair Sherrie Bell adjourned to closed session at approximately 4:53 p.m. VI. CLOSED SESSION Chair Sherrie Bell opened closed session at approximately 5:20 p.m. A. Medical Executive Committee Report of Hospital Medical Audit or Quality Assurance Activities MEC Reports (which were presented in written form) relating to Peer Review, Credentialing, and Quality Assurance, pursuant to Health and Safety Code section 32155 B. Conference With Legal Counsel Significant exposure to litigation pursuant to Subdivision (d)(2) of Government Code section 54956.9: - One (1) potential action C. Conference With Legal Counsel Existing Litigation pursuant to subdivision (d)(1) of Government Code section 54956.9: Discussion regarding Opper v. Tulare Regional Medical Center, et al. Tulare County Superior Court Case No.: 263554 D. Conference With Legal Counsel Existing Litigation pursuant to subdivision (d)(1) of Government Code section 54956.9: Discussion regarding Ibarra v. Tulare Regional Med Center, David Smith, Douglas Middleton, Family Health Care Network, David Larios, and DOES 1 to 10 United States District Court, Eastern District of California Case No.: 1:16-cv-0039-LJO-BAM E. Conference With Legal Counsel Significant exposure to litigation pursuant to Subdivision (d)(4) of government Code section 54956.9: Discussion regarding two (2) potential actions Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member 609598956.3 F. Conference With Legal Counsel Existing Litigation pursuant to Subdivision (d)(1) of Government Code section 54956.9 Discussion regarding Tulare Regional Medical Center Medical Staff v. Tulare Local Healthcare District Tulare County Superior Court Case No.: 264227 G. Conference With Legal Counsel Existing Litigation pursuant to subdivision (d)(1) of Government Code section 54956.9: Discussion regarding Parmod Kumar, M.D., et al. v. Abraham Betre, D.O. et al. Tulare County Superior Court Case No.: VCU265230 VII. ADJOURN CLOSED SESSION/RECONVENE OPEN SESSION Chair Sherrie Bell adjourned closed session and reconvened to open session at approximately 5:40 p.m. Pursuant to Government Code section 54957.1, the following reportable actions were taken by the Board in Closed Session: Item A – The Board took action to accept the closed session MEC Reports relating to Peer Review, Credentialing and Quality Assurance. The motion was made by Laura Gadke to accept the MEC Reports. Chair Sherrie Bell seconded the motion. The motion passed unanimously. Item B – The Board voted unanimously to approve the rejection of a government claim as untimely. Notice of Rejection of the Claim was signed by Chair Sherrie Bell and will be sent via certified mail to the claimant shortly after the meeting, which will make the action final. The motion was made by Richard Torrez and seconded by Laura Gadke. No further action was taken. VIII. ADJOURNMENT There being no further business, Chair Sherrie Bell adjourned the meeting at approximately 6:00 p.m. Respectfully submitted, ___________________________ Linda Wilbourn, Secretary Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member 609598956.3 NOTICE TO THE PUBLIC Tulare Regional Medical Center does not discriminate against any person on the basis of gender, religion, race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact: Bruce Greene of Baker & Hostetler LLP at telephone number (310) 442-8834 or by e-mail at bgreene@bakerlaw.com. PUBLIC COMMENT PERIOD FOR REGULAR MEETINGS At this time, members of the public may comment on any item of interest to the public that is within the subject matter jurisdiction of the Board (Gov’t Code, § 54954.3(a)). Provided, however, the Board shall not take action on any item not appearing on the agenda unless the action is otherwise authorized by law. Any person addressing the Board will be limited to a maximum of three (3) minutes so that all interested parties have an opportunity to speak. OPEN SESSION AGENDA ITEMS All writings, materials and information provided to the Board for their consideration relating to any Open Session Agenda item of the meeting are available for public inspection during regular business hours at the Administration Office of the District located at 869 Cherry Street, Tulare, California. CLOSED SESSION AGENDA ITEMS As provided in the Ralph M. Brown Act, Government Code §54950 et seq., the Board may meet in closed session with members of its staff, employees and its attorneys. These sessions are not open to the public and may not be attended by members of the public. The matters the Board will meet on in closed session are identified in the Regular Meeting agenda. Any public reports of action taken in the closed session will be made in accordance with Government Code § 54957.1. COMPLIANCE WITH ADA This agenda shall be made available upon request in alternative formats to persons with a disability, as required by the Americans with Disabilities Act of 1990 (42 U.S.C. § 12132) and the Ralph M. Brown Act (Cal. Gov’t Cod. § 54954.2). Persons requesting a disability related modification or accommodation in order to participate in the meeting, should contact the Executive Office at (559) 685-3462, during regular business hours. Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member 609598956.3 Tulare Local Health Care District Board of Directors Special Meeting Minutes Thursday, September 1, 2016 Board Convened at 5:00 p.m. Evolution’s Fitness & Wellness Center Conference Room 1425 E. Prosperity Ave. Tulare, CA 93274 PRESENT Sherrie Bell, Chair Parmod Kumar, MD, Vice Chair Linda Wilbourn, Secretary Richard Torrez, Treasurer ABSENT Laura Gadke, Board Member OTHERS PRESENT Benny Benzeevi, M.D., Chair HCCA Claudia Razo, Executive Assistant Community Members Legal Counsel (Baker & Hostetler LLP) (Closed session only / Telephonically) I. CALL TO ORDER Chair Sherrie Bell called the meeting to order at 5:07 p.m. II. CITIZEN REQUESTS/PUBLIC COMMENTS The following individual provided public comments: - Mr. Kevin Northcraft III. OPEN SESSION AGENDA A. Board of Directors Update / Action Items 1. Loan from Bank of Sierra – Board Chair Approval of loan from Bank of Sierra in the amount of $800,000 and the related resolutions as set forth in Exhibit A and incorporated herein by this reference. Action: Dr. Kumar made a motion to approve the resolutions set forth in the attached Exhibit A and authorize Chair Sherrie Bell to sign such resolutions. Linda Wilbourn seconded the motion. The motion passed unanimously. 2. Percutaneous Coronary Intervention (PCI) program – Alan Germany Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member Tulare Regional Medical Center is a Division of Tulare Local Health Care District Alan Germany, Chief Financial Officer and Chief Operating Officer, presented to the Board the new PCI program to perform cardiac interventions. No action was taken. IV. SUSPEND OPEN SESSION - ADJOURN TO CLOSED SESSION Chair Sherrie Bell adjourned to closed session at approximately 5:19 p.m. V. CLOSED SESSION Chair Sherrie Bell opened closed session at approximately 5:25 p.m. A. Conference With Legal Counsel Significant exposure to litigation pursuant to Subdivision (d)(2) of Government Code section 54956.9: - One (1) potential action VI. ADJOURN CLOSED SESSION/RECONVENE OPEN SESSION Chair Sherrie Bell adjourned closed session and reconvened to open session at approximately 5:35 p.m. Pursuant to Government Code section 54957.1, the following reportable actions were taken by the Board in closed session: Item A – The Board voted unanimously to approve entering into a final settlement agreement with respect to Item A on the closed session agenda. Dr. Kumar made the motion and Richard Torrez seconded the motion. Immediately after the motion was carried, Sherrie Bell signed the settlement agreement, making it fully executed and final. By way of the settlement agreement, in return for a payment to Novia Solutions, Inc., a California corporation, Novia has released the Tulare Regional Medical Center from all claims and liabilities arising out of a dispute between Novia and TRMC over payments for services rendered. The details of the settlement are subject to confidentiality provisions set forth in the settlement agreement, which can be released only by a public records act request. VII. ADJOURNMENT There being no further business, Chair Sherrie Bell adjourned the meeting at approximately 5:40 p.m. Respectfully submitted, ___________________________ Linda Wilbourn, Secretary Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member 609598860.2 NOTICE TO THE PUBLIC Tulare Regional Medical Center does not discriminate against any person on the basis of gender, religion, race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact: Bruce Greene of Baker & Hostetler LLP at telephone number (310) 442-8834 or by e-mail at bgreene@bakerlaw.com. PUBLIC COMMENT PERIOD FOR REGULAR MEETINGS At this time, members of the public may comment on any item of interest to the public that is within the subject matter jurisdiction of the Board (Gov’t Code, § 54954.3(a)). Provided, however, the Board shall not take action on any item not appearing on the agenda unless the action is otherwise authorized by law. Any person addressing the Board will be limited to a maximum of three (3) minutes so that all interested parties have an opportunity to speak. OPEN SESSION AGENDA ITEMS All writings, materials and information provided to the Board for their consideration relating to any Open Session Agenda item of the meeting are available for public inspection during regular business hours at the Administration Office of the District located at 869 Cherry Street, Tulare, California. CLOSED SESSION AGENDA ITEMS As provided in the Ralph M. Brown Act, Government Code §54950 et seq., the Board may meet in closed session with members of its staff, employees and its attorneys. These sessions are not open to the public and may not be attended by members of the public. The matters the Board will meet on in closed session are identified in the Regular Meeting agenda. Any public reports of action taken in the closed session will be made in accordance with Government Code § 54957.1. COMPLIANCE WITH ADA This agenda shall be made available upon request in alternative formats to persons with a disability, as required by the Americans with Disabilities Act of 1990 (42 U.S.C. § 12132) and the Ralph M. Brown Act (Cal. Gov’t Cod. § 54954.2). Persons requesting a disability related modification or accommodation in order to participate in the meeting, should contact the Executive Office at (559) 685-3462, during regular business hours. Board of Directors: Sherrie Bell Chairman and President Parmod Kumar, MD Vice Chairman Richard Torrez Treasurer Linda Wilbourn Board Member Laura Gadke Board Member 609598860.2 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: All Departments FROM: Administration SUBJECT: Pain Assessment and Management I. Introduction: Patients requiring pain management at Tulare Regional Medical Center can expect staff to respect and support the patient’s right to optimal pain assessment and management. Pain is assessed in all patients. The organization will address the appropriateness and effectiveness of pain management. II. Process: A. III. 1. Improved coordination of care and education 2. Multiple reinforcement of pain management objectives 3. Consistent approach to assessment and treatment Policy: A. IV. A multi-disciplinary team approach will be used to provide care. This team will consist of physicians, independent licensed practitioners, nursing staff, Respiratory Care staff, Medical Imaging, Laboratory staff, Pharmacists, Social Services, Physical Therapist and Case Management. Benefits of this approach include: Effective pain assessment and management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the patient experiencing pain enhances healing and promotes both physical and psychological wellness. Patients need to be involved in all aspects of their care including pain management. Assessment: A. It is the responsibility of all clinical staff to assess and periodically reassess the patient for pain and relief from pain including the intensity and quality (i.e., character, frequency, location and duration of pain), and responses to treatment. ___________________________________________________________________ Effective Date: (12) Clinical Services General: APPROVED: Pain Assessment and Management 12-1045 Medical Executive Comm.: 09/14/16 Board Of Directors: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE B. 1. At time of admission to the facility, the patient will be questioned regarding pain during the initial nursing assessment. 2. All other clinical department staff will also question the patient regarding pain during the initial patient assessment performed by that department’s care provider. 3. Questions related to pain may include, but are not limited to: a. Nature of pain b. Duration c. Type d. Intensity e. Any pain relief methods that have proven effective f. Patient’s desires for pain management, i.e., pain control, complete pain relief. Intensity of pain may be assessed by one of the methods below as appropriate to the patient’s ability to respond: 1. Wong-Baker (adjusted to 0-10 scale) 2. NIPS (neonate/Infant scale) 3. Analog (Linear) (0-10 scale) 4. FLACC (0-10 scale) C. Intensity ratings will be categorized as mild 1-3; moderate 4-7; severe 8-10. Any rating of 5 or greater requires an intervention. D. All patients will undergo reassessment of pain every shift with vital signs, after every pain control mechanism employed by patient care providers, and prn. Each department scope of practice may vary; (see Department Specific Scope of Practice). E. Any patient care provider, from any department, that has implemented a pain control mechanism will reassess the patient in approximately 30 minutes for injectable pain medications and 60 minutes for oral pain medications from time of administration to determine amount of pain control or relief achieved and respond Effective Date: Page 2 of 7 #12-1045 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE to the patient’s needs accordingly. V. F. Management of the patient’s pain is an interdisciplinary process and is to be included in the interdisciplinary plan of patient care. Inclusion of this component of the patient’s care process will alert and educate all members of the healthcare team regarding the patient’s pain experience. Pain management issues will be included in topics of discussions during interdisciplinary care planning conferences. G. Pain Management is a patient’s right. If barriers prevent TRMC staff from providing pain management, refer to Chain of Command policy #12-3078. Patient and Family Education Topics: A. Patients will be taught that pain management is part of their treatment. B. The patient and his/her family/significant other (s) will receive education provided by the staff regarding management of the patient’s pain. Education included, but is not limited to: C. VI. 1. Types of pain the patient actually or potentially experience. 2. Pain control mechanisms available and/or that have been employed. 3 Potential limitation of pain management and treatment. 4. Potential and/or actual side effects of pain management and treatment. 5. Determination of the patient’s acceptable level of pain; e.g., the terminally ill patient may wish complete relief from pain, knowing this may render him/her in a semi-somnolent state; or this patient may request relief from pain to the degree where pain may still be experienced, however his/her ability to remain mentally alert and relate to family/significant others remains intact. 6. Discharge planning process with emphasis on symptom management (e.g. pain, nausea or dyspnea). All patient care providers will provide information to the patient and the patient’s family/significant others that optimal management of pain is a primary goal of patient care and is consistent with the organization’s mission and value statement. Documentation: A. Refer to department specific documentation if there are any deviations from below: Effective Date: Page 3 of 7 #12-1045 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE 1. Initial assessment of patient pain will be documented in the Electronic Health Record (EHR) and electronic Medication Administration system as follows: a. Care Plan Management (CPM) b. Pain Assessment Flowsheet. c. Electronic Medication Administration. d. Unit specific nursing care record. 2. Vital Signs will be charted. 3. Electronic documentation of pain medication administered with pain related comment and reassessment. a. The clinician must indicate numeric pain score. b. The clinician must indicate which Pain Scale was used for pain assessment. c. The clinician must reassess pain level. Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines concerning this matter and is effective immediately. Effective Date: Page 4 of 7 #12-1045 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE ATTACHMENT A WONG BAKER PAIN SCALE Wong-Baker FACES Pain Rating Scale Brief word instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose face that best describes own pain and record the appropriate number. Original instructions: Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. • • • • • • Face 0 is very happy because he doesn't hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling. Rating scale is recommended for age 3 years and older. Effective Date: Page 5 of 7 #12-1045 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE ATTACHMENT B (NIPS) NEONATAL/INFANT PAIN SCALE Effective Date: Page 6 of 7 #12-1045 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE ATTACHMENT C ANALOG (LINEAR) PAIN SCALE ATTACHMENT D FLACC Scale Category Scoring 1 2 3 Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jaw Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, Arched, rigid or jerking tense Cry No cry (awake or asleep) Moans or whimpers; occasional complaint Crying steadily, screams or sobs, frequent complaints Reassured by occasional touching, hugging or being talked to, distractible Difficult to console or comfort Consolability Content, relaxed Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which results in a total score between zero and ten. Effective Date: Page 7 of 7 #12-1045 Descriptive Name: Pain Assessment and Management Descriptive Type: Revised Policy Document Number: 12-1045 Attachments: Yes Author: Carol Bradford Typist: Melissa Arend Creation Date: 08/27/09 Revision Date: 12/09/15 Previous Dist. Date: 04/26/12 Committee Review and Approval: P & T Committee Family Medicine Service MEC Board of Directors Approval Date: 04/14/16 08/25/16 09/14/16 Comments: Effective Date: Forward To: Policy Binders – (PBX and Administration) and Post to Intranet Site Disposition: Copy and Distribution - Administration Comments: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: Medical Staff, Clinical Services FROM: Administration SUBJECT: Central Service- Traffic Control I. PURPOSE: II. POLICY: • Traffic control is strictly enforced in Central Service Department: • All doors opening into the main corridor are to remain closed at all times. • Decontamination door is the only door used to enter Central Service.  • Personnel who are not members of Central Service but find it necessary to enter the department (engineers, servicemen, physicians and administrative personnel, etc.) must don shoe covers, head and cover-up clothing before being allowed to enter the department. The flow of traffic in and out of the department will be kept to a minimum. Effective Date: APPROVED: Medical Executive Comm.: 09/14/16 Board Of Directors: (12) Clinical Services Inpatient Care Units: Central Service-Traffic Control #12-3099 Descriptive Name: Central Service-Traffic Control Descriptive Type: New Policy Document Number: 12-3099 Attachments: None Author: Paul Stratman Typist: Maritza Sevillano/Melissa Arend Creation Date: 9/16/15 Revision Date: N/A Prev. Dist. Date: N/A Committee Review and Approval: Infection Prevention Committee Surgery Committee MEC Board of Directors Approval Date: 03/21/16 08/17/16 09/14/16 Comments: Effective Date: Forward To: Policy Binders (PBX and Administration) and Post to Intranet Disposition: Copy and Distribution - Administration Comments: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: Medical Staff, Clinical Services FROM: Administration SUBJECT: Central Service-Environmental Cleaning of Central Service I. PURPOSE: To maintain a standard of environmental cleanliness. II. POLICY: III. PROCEDURE: • All shelves shall be wiped with an approved antibacterial solution weekly. • Wire racks and carts shall be cleaned on a weekly basis with a hospital approved germicide. • Table tops, counters, sinks and cupboard doors require daily cleaning. • Environmental Services shall clean all walls weekly, and floors on a daily basis. • Air conditioning vent surfaces are to be cleaned on a weekly basis by Environmental Services. • Air conditioning filters will be changed by the Engineering Department on a routine basis. • All cleaning procedures shall be documented on the appropriate cleaning checklist by the person performing the cleaning. The checklist shall be dated and initialed. ___________________________________________________________________ Effective Date: (12) Clinical Services Inpatient Care Units: APPROVED: Central Service-Environmental Cleaning of Central Service Medical Executive Comm.: 09/14/16 #12-3100 Board Of Directors: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL IV. RESPONSIBILITY: • • Central Service personnel are responsible for completion and documentation of assigned environmental cleaning. Environmental Services and Engineering Departments are responsible for completion and documentation of their designated environmental cleaning. Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines and is effective immediately. Effective Date: Page 2 of 2 #12-3100 Descriptive Name: Central Service-Environmental Cleaning of Central Service Descriptive Type: New Policy Document Number: 12-3100 Attachments: None Author: Paul Stratman Typist: Maritza Sevillano/Melissa Arend Creation Date: 9/16/15 Revision Date: N/A Prev. Dist. Date: N/A Committee Review and Approval: Infection Prevention Committee Surgery Committee MEC Board of Directors Approval Date: 03/21/16 08/17/16 09/14/16 Comments: Effective Date: Forward To: Policy Binders (PBX and Administration) and Post to Intranet Disposition: Copy and Distribution - Administration Comments: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: Medical Staff, Clinical Services FROM: Administration SUBJECT: Central Service-Infection Control I. PURPOSE: To provide infection control guidelines for Central Service; including standardized policies and procedures for receiving, processing, storing and issuing various kinds of materials which are purchased pre-sterilized, sterilized in the hospital and certain equipment requiring cleaning and processing in an area designated, equipped and staffed for this purpose. II. POLICY: III. RESPONSIBILITIES: • Central Service Manager: • Formulates, in writing, Infection Control policies and procedures for Central Service. • Provides written procedures for the following:  Handling of disposable and non-disposable items  Checking and returning of outdated items to Central Service  Storage and rotation of sterile supplies  Dating of sterile processed supplies  Separation of clean supplies from those to be processed  Handling of contaminated supplies; decontamination Proper methods for sterilization ___________________________________________________________________ Effective Date: (12) Clinical Services Inpatient Care Units: APPROVED: Central Service-Infection Control #12-3101 Medical Executive Comm.: 09/14/16  Board Of Directors: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL  Cleaning and disinfection of equipment which cannot be sterilized • Establishes proper flow patterns for handling supplies and traffic and maintains separate dirty/clean work areas. • Maintains all requirements of cleaning, wrapping, packaging and storing of sterile items processed or stored within the hospital. • Provides and documents continuing education in infection control and safety for Central Service personnel. • Maintains personnel health standards and required dress attire policies. • Reports potential infection hazards to the Infection Control Practitioner. • Is a member (or assigns a representative of the department) of the Infection Control Committee. • Central Service Technician: • Shall be qualified by training and experience, and operates under the supervision of the Central Service Manager. • Shall observe all policies and procedures of the Central Service Department. • Infection Control Practitioner: • Reviews all infection control practices and processes in Central Service. • Orders environmental cultures as indicated. • Assists in the preparation and presentation of educational infection control programs. • Acts as a resource person. • Makes periodic prevalence rounds to determine adherence to guidelines. Effective Date: Page 2 of 9 #12-3101 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL • Infection Control Committee: • Reviews and approves all policies and practices relevant to infection control. • Serves as consultant to all of the above. INFECTION CONTROL PRACTICES: • • • Employee Health: • Employees shall comply with the Employee Health Program. • Personnel shall not work if they have skin, respiratory or gastrointestinal infections. • Eating, drinking or smoking shall not be permitted in Central Service. • Personnel off duty for three (3) or more days because of an illness shall be cleared by a physician before returning to work. • Personnel with a communicable disease shall be referred to the Infection Control Practitioner for follow-up. Personal Hygiene: • Cleanliness and good personal hygiene habits are mandatory. • Frequent and thorough hand-washing is mandatory. • Gloves shall be used when handling and sorting soiled bio-hazardous articles. Dress Code: • Keep nails short; use nail sticks to clean under the nails. • Remove excessive or hanging jewelry and other ornaments before reporting to duty. These items often have bacteria which can be transmitted to clean or sterile materials. Effective Date: Page 3 of 9 #12-3101 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL • • Hair shall be completely covered with disposable head cover while assembling trays and discarded at end of shift. Shoe covers will be worn as required. • Personnel shall wear designated scrub uniforms - one day use only. Scrubs will be changed if exposed to spills. • Personnel shall wear impermeable cover gowns, gloves, goggles/face shields and shoe covers when cleaning soiled bio-hazardous instruments, utensils, etc., and change appropriately when leaving dirty areas. Visitor Control: • • • With the approval of the Central Service Manager or designee, visitors may be allowed to enter the Central Service area with the proper apparel:  Head cover  Cover gown/jump suit  Shoe covers Education: • Programs in infection control measures begin in orientation and continue with on-the-job training and in-service education. Personnel will attend annual update yearly. • Basic training in aseptic techniques, personal hygiene, sterility, storage and safe handling practices shall be a requirement at the time of hire. • Continuing education specific to Central Service is strongly encouraged. Indications for Sterilization/Disinfection: • Patient care equipment that enters normally sterile tissue or the vascular system, or through which blood flows, shall be sterile. • Laparoscopes and other scopes that enter the peritoneal cavity shall be subjected to a sterilization procedure before each use. Effective Date: Page 4 of 9 #12-3101 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL • • • Endoscopes and respiratory therapy equipment that go though mucous membranes shall be subjected to a sterilizing procedure before each use. Method of Processing: • Patient care equipment contaminated with blood shall be sterilized; if this is not feasible, it shall receive high-level disinfection. • Most environmental surfaces contaminated with blood shall be cleaned with a solution of hospital-approved germicide. • Other patient care and environmental objects that are potentially contaminated with virulent microorganisms shall be processed accordingly with the hospital-approved germicide solution. Equipment and Packaging: • The most reliable type of sterilization available for each type material will be used. • Non-sterile items:  • • Sterile reusable equipment and material:  Must be processed in two (2) physically separate areas by separate staffs. If this is not possible, careful hand-washing and uniform change shall be required before the move from "dirty" to "clean" areas.  Written procedures are established for washing, wrapping and arranging packages, and the various types and sizes of materials or containers used.  Equipment and supplies shall be purchased on the basis of their reaction to steam or plasma i.e. Sterrad. Use chemicals only when absolutely necessary. Sterile supplies:  Effective Date: Areas in Central Service are designated for receiving, servicing, cleaning, storing and issuing of non-sterile equipment. Proper storage and handling of sterile supplies shall be maintained to prevent contamination. Page 5 of 9 #12-3101 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL •  Stock shall be rotated to reduce the need for re-sterilization.  Procedures are written and maintained in the department for establishing shelf life of sterile items and/or for checking outdated supplies or package integrity in event-related shelf-life sterility.  Any sterile reusable materials that leave Central Service and are then returned are considered contaminated and shall be cleaned, re-sterilized and/or reprocessed. Disposable items:  • • Traffic and Supply Control: • Good flow patterns shall be established for handling supplies and traffic. • Transportation system shall be used as "one-way" systems for either clean or dirty supplies. Environmental Services: • • • Written procedure for staff handling disposable items shall include inspection of packaging, expiration date or package integrity, stock rotation, inventory control and disposal. All work surfaces, shelves and fixtures shall be cleaned daily with approved germicidal cleaner. Engineering: • Preventive maintenance records are kept on equipment in the Bio Med/Engineering Department. Please refer to equipment lists. • Equipment shall be carefully tested and inspected before it is cleaned and dispensed for patient use by Central Service personnel. Rental equipment must be inspected and approved by the Engineering Department prior to use on any patient. • Manufacturers’ recommendations shall be followed regarding care, use and/or repair of equipment. Decontamination/Cleaning: Effective Date: Page 6 of 9 #12-3101 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL • Objects to be disinfected or sterilized shall be thoroughly cleaned to remove all blood, tissue, food and other debris, before reprocessing. The using department shall return objects to Central Service in plastic bags to confine and contain contamination. CONTROLS OF THE SYSTEM: • Administrative: • Autoclave indicating tape:  • Sterilizer logs, chart chemical/biological tests and spore tests shall be maintained as required. • Expiration dates:  • See event-related shelf-life sterilization. Lot control:  • Indicating type autoclave tape, indicating labels or indicating printed legends shall by affixed to or printed on all hospital assembled packages intended for sterilization. Tape, label or legend shall be examined after sterilization and also before use to make sure that it indicates adequate exposure to the appropriate sterilizing process. Lot control numbers shall be placed on each package for later retrieval if needed. Process Control: • Recording charts and gauges:  • Effective Date: Shall be examined by the sterilizer operator at the beginning and end of each cycle (temperature and pressure). There is a written procedure for this activity. Records shall be maintained per hospital/regulatory requirements. Chemical indicators: Page 7 of 9 #12-3101 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL  • Biological Indicators: • • There is a written biological indicator procedure for steam or plasma. Rotation of Supplies: • • A temperature accurate chemical indicator is used at the center of each package of hospital-assembled material and among materials which are heat-sterilized without packaging. There is a written procedure covering the rotation of supplies, including shelf life of various packaging and event-related shelf life. Autoclaves and Sterilizers: • Autoclaves and sterilizers will be maintained in operating condition at all times. • Instructions for operating autoclaves and sterilizers are posted in the area where the autoclaves and sterilizers are located. • Written procedures are developed, maintained and available to personnel responsible for sterilization of supplies and equipment that include, but are not limited to, the following: Effective Date:  Time, temperature and pressure for sterilizing the various bundles, packs, dressings, instruments, solutions, etc.  Cleaning, packaging, storing and issuing of supplies and equipment  Dating of materials sterilized  Loading of the sterilizer  Daily checking of log sheets recording and indicating thermometers and filing for seven (7) years of recording thermometer charts  Weekly (on steam; biweekly on gas) bacteriological test, the bacterial organism used and filing for seven (7) years of the test results Page 8 of 9 #12-3101 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL  • Length of aeration time for materials gas-sterilized is eight (8) to 30 hours. See manufacturer’s recommendations. Recall: • There is a written system for recall of all sterilized goods. Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines and is effective immediately. Effective Date: Page 9 of 9 #12-3101 Descriptive Name: Central Service-Infection Control Descriptive Type: New Policy Document Number: 12-3101 Attachments: None Author: Paul Stratman Typist: Maritza Sevillano/Melissa Arend Creation Date: 9/16/15 Revision Date: N/A Prev. Dist. Date: N/A Committee Review and Approval: Infection Prevention Committee Surgery Committee MEC Board of Directors Approval Date: 04/18/16 08/17/16 09/14/16 Comments: Effective Date: Forward To: Policy Binders (PBX and Administration) and Post to Intranet Disposition: Copy and Distribution - Administration Comments: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: All Departments FROM: Administration SUBJECT: Central Service Department Cleaning I. POLICY: • Central Service is a housing area for sterile and clean supplies intended for patient usage. Bacteria shall be controlled as much as mechanically and humanly possible by all employees who work in this area. • Establishing a clean work and storage environment is a constant aim that shall be achieved in Central Service in order to maintain an asepsis state. Cleaning procedures shall be considered one of the most important tasks. and each technician or other staff member is responsible for cleaning the area he/she has been assigned to. In addition, those areas that are not used exclusively to store or handle direct patient contact items, but are a part of the department, are to be kept clean and in order. This is the responsibility of all Central Service personnel. • The Environmental Service Department is responsible for cleaning the floors, walls, overhead vent surfaces and hoppers • Central Service is responsible for all other cleaning tasks. • For all cleaning assignments, obtain clean cloths, clean basins, water, hospital-approved soluble detergent and a germicide solution. Be sure to follow mixing instructions for all cleaning solutions and germicide solutions. This applies to all of the following work assignments:  Surface Area Cleaning: ♦ Surface cleaning, shelves, closets, woodwork, tables, etc. Purpose: To provide for cleanliness and orderliness on a continuing basis for supplies and equipment. ___________________________________________________________________ Effective Date: (12) Clinical Services Inpatient Care Units APPROVED: Central Service Department Cleaning 12-3102 Medical Executive Comm.: 09/14/16 Board Of Directors: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL  Closed and Open Shelving - Sterile Area: Once a week or more often as needed, wash shelves with disinfectant solution starting from the top down. allow to air dry  Work Tables and Counters: ♦  Work Areas: ♦  All work areas must be kept neat and clean at all times. Allow 10 minutes before going off duty to make certain the work area is in proper order. : ♦  . The continuous cleaning of these surface areas isare necessary throughout the day. A dampened cloth (germicide solution) is used for continued cleaning. . Closed Sterile Supply Carts:    Cart Wheels: ♦ Shall be checked daily to remove any debris or lint which may adhere to wheels. Use soap and water solution for cleaning. Rinse well.  Central Service's Storage Room: ♦ Effective Date: closed carts used for sterile instruments and supplies movement. All carts used for transport of sterile instruments and supplies shall upon their return to CPD be wiped down with a germicidal solution and allowed to air dry according to the Mfr’s. IFU. . Storage racks and shelves must be cleaned and stock neatly arranged. . Supplies must be 18 inches from the ceiling as sprinkler system (fire) must be kept clear. Do not store case goods on the floor. Page 2 of 3 #12-3102 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL  Satellite Areas: ♦ Cleaning procedures are identical to departmental cleaning and sterile storage areas, as this area is your clean and sterile supply distribution point. ♦ All storage areas used for the purpose of sterile supplies must be kept neat and clean at all times. All areas are on a rotating schedule for terminal cleaning. Should be done Bimonthly. Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines and is effective immediately. Effective Date: Page 3 of 3 #12-3102 Descriptive Name: Central Service Department Cleaning Descriptive Type: New Policy Document Number: 12-3102 Attachments: No Author: Paul Stratman Typist: Maritza Sevillano/Melissa Arend Creation Date: 09/16/15 Revision Date: N/A Prev. Dist. Date: N/A Committee Review and Approval: Infection Prevention Committee Surgery Committee MEC Board of Directors Approval Date: 03/21/16 08/17/16 09/14/16 Comments: Effective Date: Forward To: Policy Binders (PBX and Administration) and Post to Intranet Disposition: Copy and Distribution - Administration Comments: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: All Departments FROM: Administration SUBJECT: Central Service-Storage of Sterile Supplies I. PURPOSE: To outline proper storage of sterile supplies. II. POLICY: • • All sterile supplies shall be stored in a secure location which maintains the integrity of the sterile item. • All storage areas shall be clean, dry, protected from moisture, vermin or insect excreta. • Before storage, all sterile items shall be checked for the following:  Make certain items are completely dry  Integrity of the outer wrap  Coloring of sterile indicator tape, date prepared, initialed  Sterilization  Sterile expiration date (if item is not included in event-related sterility program)  Lot number labels All sterile cloth and paper wrap items are stored in the Central Service sterile area in closed shelf section or in drawers as designated. These items shall be double-wrapped. ___________________________________________________________________ Effective Date: (12) Clinical Services Inpatient Care Units: APPROVED: Central Service Storage of Sterile Supplies Medical Executive Comm.: 09/14/16 12-3103 Board Of Directors: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL • Stock shall be rotated so that items do not outdate. Stock is checked monthly in order to verify that no item in the sterile storage area is outdated. Stock shall be rotated so that older stock is in front and newer stock is placed in back or older stock is on the right and newer stock is on the left. Paper wrappers also may become brittle with age and this compromises sterility. • The closures of sterile items shall be tamper proof and impossible to reseal. If there is a suspicion of incomplete closure, the item shall not be used. • Cases and cartons shall not be placed directly on the floor when stored. They shall be stocked on lower shelves or platforms. • A cloth or paper-wrapped tray or items which are seldom used shall be protected by protective plastic wrap immediately after a thorough cooling period. Heat seal or tape opening. • All storage areas shall be clearly labeled. Any item sterilized by the hospital shall be identified on outside of the wrap with the following information: • Effective Date: • Name of item • Month, day and year • Sterile expiration date (if item is not included in event-related sterility program) • Lot and load number label or stamp • Initials of the Central Service employee who processed and wrapped the item Sterile supplies shall be separated from clean supplies: • A clean non-sterile storage area is designated for this purpose. • Ideally, items shall not be stacked or piled on top of each other in storage. If space determines this must occur, then items shall be of the same size and shape, neatly stacked, with item identification plainly visible. Page 2 of 3 #12-3103 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL • Do not store any item in the sterile or clean area in the original carton. Articles are to be removed from the shipping boxes and placed on small transfer cart which can be wheeled into the area. All sterile supplies are to be stored at least eight (8) to 10 inches above floor level to allow for cleaning and wet mopping and to lessen the possibility of contamination. To allow for air circulation, supplies are to be stored 18 inches from the ceiling, and to reduce the possibility of bacteria invasion and for air circulation purposes, a minimum distance of two to three (2-3) inches from the wall is maintained. • • I. Storage of sterile supplies shall be done under conditions which tend to preserve, not threaten the integrity of the packaging. • Traffic in storage areas shall be kept to minimum. • Rubber bands, paper clips, etc., shall not be placed around "paper or plastic" packages. • Supplies shall be handled as little as possible, to reduce risk of damage. • When stored in drawers, packages shall not be "packed in", due to risk of tearing or sliding when drawer is opened. • No sterile packages of any type shall be placed next to or below any sink. Water contaminates sterile packages automatically and necessitates their reprocessing (or disposal) before use. RESPONSIBILITY: All personnel in Central Service, Materials Management and other areas with sterile supplies are responsible for proper storage of these supplies. Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines and is effective immediately. Effective Date: Page 3 of 3 #12-3103 Descriptive Name: Central Service Storage of Sterile Supplies Descriptive Type: New Policy Document Number: 12-3103 Attachments: No Author: Paul Stratman Typist: Maritza Sevillano/Melissa Arend Creation Date: 09/16/15 Revision Date: N/A Prev. Dist. Date: N/A Committee Review and Approval: Infection Prevention Committee Surgery Committee MEC Board of Directors Approval Date: 03/21/16 08/17/16 09/14/16 Comments: Effective Date: Forward To: Policy Binders (PBX and Administration) and Post to Intranet Disposition: Copy and Distribution - Administration Comments: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: All Departments FROM: Administration SUBJECT: Reportable Diseases and Conditions I. POLICY: A. All reportable diseases and conditions are, by State law, required to be promptly reported as designated by the attached Title 17, California Code of Regulations (CCR) §2500 “Reportable Disease and Conditions Report “ form (See Attachment A). B. Outpatient Procedure: Lab will fax lab report to Tulare County. Tulare County will follow up with Confidential Morbidity Report from physicians. C. Inpatient Procedure - ED and Inpatients: Lab will send identifying lab report to the Infection Prevention and Control department as soon as disease or condition is identified. The Infection Prevention Department will facilitate completion of the CMR into California Reportable Disease Information Exchange website (CalREDIE) https://calredie.cdph.ca.gov/webcmr/pages/login/login.aspx . If CalREDIE is unavailable a paper CMR will be generated and faxed to Tulare County Department of Public Health at 559-685-4835. In the event a case will need to be reported immediately, on the weekend or a holiday, call 559-471-7092. D. In the event the lab report is not available and the disease is identified, a report can be filed by those health care providers who have ready access to the clinical information. The provider will complete a CMR and fax to the health department at 559-685-4835. A copy must be sent to the Infection Prevention and Control department. The copy can be faxed to 3888. Any questions should be referred to the Infection Prevention and Control department at extension 3487. E. The Confidential Morbidity Report may be accessed by clicking on the following links: To report reportable diseases: http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph110a.pdf Effective Date: Approved: Medical Executive Comm.: 09/14/16 Board Of Directors: (20) Clinical Guidelines: Infection Control Reportable Diseases and Conditions 20-8011 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL To report TB: http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph110b.pdf Reports to the DMV http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph110c.pdf II. III. IV. ALL REPORTABLE DISEASES EXCLUDING TUBERCULOSIS AND CONDITIONS REPORTABLE TO DMV • • Use Confidential Morbidity Report (CMR) PM 110 A (see Attachment B) Responsibility of Infection Prevention and Control and TRMC Laboratory • Complete all the applicable fields on the form related to: o Patient demographic data o Date of disease onset o Add any treatment provided for reported STDs o Attach laboratory data supporting the diagnosis of the reportable disease o Add your contact information REPORTING TUBERCULOSIS • Use Confidential Morbidity Report (CMR) PM 110 B (see Attachment C) • • Responsibility of Infection Prevention and Control and Case Management • Complete all the applicable fields on the form related to: o Patient demographic data o Date of disease onset o Date first specimen collected o Date of diagnosis o Complete fields related to tuberculosis treatment if this information is available o Fax the CMR to 559-685-4786 Attention: TB Program o Add your contact information • Note: Refer to Policy 20-8013 Tuberculosis Prevention Plan “TB Inpatient Notification/Discharge Planning” for additional reporting requirements unique to Tuberculosis NON-COMMUNICABLE DISEASES & CONDITIONS • Alzheimer's Disease and Related Conditions • Disorders Characterized by Lapses of Consciousness • Use Confidential Morbidity Report (CMR) PM 110 C (see Attachment D) • Responsibility of Emergency Department Physicians • Complete all the applicable fields on the form related to: o Patient demographic data Effective Date: Page 2 of 8 #20-8011 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL o Add your contact information V. PESTICIDE-RELATED ILLNESS OR INJURY (KNOWN OR SUSPECTED CASES) • Contact Tulare County Department of Public Health - Health Officer at (559)685-5730. In the event a case will need to be reported immediately, on the weekend or a holiday, call (559) 471-7092. • Responsibility of Emergency Department Physicians o Be prepared to share information regarding:  The type of pesticide involved in the exposure  How many people exposed  Duration of exposure  How exposure occurred • Note: The Health Officer will contact the County Agricultural Commissioner who will in turn determine whether the State Office of Environmental Health and Hazard Assessment must be notified. Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines and is effective immediately. Effective Date: Page 3 of 8 #20-8011 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL ATTACHMENT A Effective Date: Page 4 of 8 #20-8011 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL Effective Date: Page 5 of 8 #20-8011 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL ATTACHMENT C (PAGE 1) Effective Date: Page 6 of 8 #20-8011 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL ATTACHMENT C (Page 2) Effective Date: Page 7 of 8 #20-8011 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL Effective Date: Page 8 of 8 #20-8011 Descriptive Name: Reportable Diseases and Conditions Descriptive Type: Revised Policy Document Number: 20-8011 Attachments: Yes Author: Joetta Denney Typist: Melissa Arend Creation Date: 08/25/11 Revision Date: 07/29/16 Prev. Dist. Date: 06/27/13 Committee Review and Approval: Infection Prevention Committee MEC Board of Directors Approval Date: 08/15/16 09/14/16 Comments: Effective Date: Forward To: Policy Binders (PBX and Administration) and Post to Intranet Disposition: Copy and Distribution - Administration Comments: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: All Departments FROM: Administration SUBJECT: Infectious Diseases of Concern to the Pregnant Employee PURPOSE: To provide information to staff who may have concerns regarding pregnancy and infectious diseases possibly encountered while in the workplace and especially for health care workers in the clinical environment. – See latest APIC Text The following precautions are outlined per infectious disease: INFECTIOUS DISEASE In-hospital Source(s) PRECAUTIONS HIV Blood, body fluids, vaginal secretions, semen Standard Precautions No reassignment of pregnant worker is necessary. CYTOMEGALOVIRUS (CMV) Urine, blood, semen, vaginal secretions, semen, the immunosuppressed (transplant), dialysis, Standard Precautions Good hand washing. No reassignment of pregnant worker is necessary. Respiratory secretions, blood, immunocompromised patients Droplet Precautions Feces, blood (rare) Contact Precautions Fifth’s Disease (Parvovirus B19) Erythema infectiosum HEPATITIS A Defer care of immunocompromised patients with chronic anemia when possible. Good hand washing. Gowns if soiling likely. Gloves if touching infective material. No reassignment of pregnant worker necessary. HEPATITIS B Blood, body fluids, vaginal secretions, semen Standard Precautions No reassignment of pregnant worker necessary. Hepatitis B vaccine strongly recommended for employees who have contact with blood or bloodcontaining body fluids. Vaccine safe during pregnancy. INFECTIOUS DISEASE In-hospital Source(s) PRECAUTIONS Effective Date: Approved: Medical Executive Comm.: 09/14/16 Board of Directors: (20) Clinical Guidelines Infection Control: Infectious Diseases of Concern to The Pregnant Employee 20-8012 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL HEPATITIS C Blood, sexual transmission Standard Precautions No reassignment of pregnant worker is necessary. HERPES SIMPLEX (Virus) Vesicular fluid, oropharyngeal and vaginal secretions Standard precautions Add Contact Precautions when lesions present. Reassignment of the pregnant worker is not necessary. HERPES ZOSTER (SHINGLES) Vesicular fluid Airborne & Contact Precautions Administer VZIG within 96 hours of exposure. Restrict assignment of all susceptible health care workers. RUBELLA (GERMAN MEASLES) Respiratory secretions Droplet Precautions for Acute Infection. Contact Precautions for Congenital < 12 mos. in age. Pregnant women who are not immune should not care for these patients. RUBEOLA (THE “HARD” MEASLES) Respiratory secretions, cough Airborne Precautions Vaccine can be done within 6 days of exposure. Pregnant women who are not immune should not care for these patients. SYPHILIS Blood, lesion, fluid, amniotic fluid Standard Precautions Gloves until 24 hours of effective therapy completed for infants with congenital syphilis and all patient with skin and mucous membrane lesions. TOXOPLASMOSIS Rare through blood transfusion, contact with raw meats, No human-to-human spread. TUBERCULOSIS Sputum, skin contact (rare) Airborne Isolation The pregnant employee may not be able to tolerate wearing the respirator, as it is somewhat airflow restrictive. Reassignment may be necessary. May take TB Meds. VARICELLA (CHICKENPOX) Vesicular secretions, Respiratory secretions, Cough Airborne & Contact Isolation The non-immune health care worker, pregnant or not, should not have patient care contact with varicella patients. The immune worker can safely care for varicella patient. Reference: Association for Professionals in Infections Control and Epidemiology. (APIC TEXT) 4th Edition CDC 2007 Guideline for Isolation precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Effective Date: Page 2 of 3 #20-8012 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines concerning this matter and is effective immediately. Effective Date: Page 3 of 3 #20-8012 Descriptive Name: Infectious Diseases of Concern to the Pregnant Employee Descriptive Type: Revised Document Number: 20-8012 Attachments: None Author: Joetta Denney Typist: Melissa Arend Creation Date: 05/27/10 Revision Date: 07/29/16 Prev. Dist. Date: 06/27/13 Committee Review and Approval: Infection Prevention Committee MEC Board of Directors Approval Date: 08/15/16 09/14/16 Comments: Effective Date: Forward To: Policy Binders (PBX and Administration) and Post to Intranet Disposition: Copy and Distribution - Administration Comments: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: All Departments FROM: Administration SUBJECT: Work Restrictions and Management of Personnel Illnesses and Exposures to Communicable Diseases PURPOSE: To Prevent the Transmission of Infection to Patients and Other Personnel A. Employees who report to work ill or have a health condition that may restrict work. Employees who report to work ill or become ill while at work and employees who may have a condition that may limit their ability to work may be sent home at the discretion of their supervisors. If there are questions of infectiousness or work restrictions, the supervisor may refer the employee to the Emergency Department physician for screening of the illness or condition. If the ED physician imposes work restrictions, they must be followed by employee. The Emergency Department physician will screen the patient for the necessity of work restrictions related to the current condition with possible referral to the employees primary medical physician for further follow up and, if necessary, for return to work release. Employee Illness or Condition that may Require Work Restrictions Employee goes to ED Employee is Screened by the ED Physician If Work Related Workers' Compensation Process Initiated Work Restrictions may be necessary Employee may be Referred to their PMD for further treatment, Return to Work Release Required if longer than 3 days ___________________________________________________________________ Effective Date: (20) Clinical Services Guidelines Infection Control: APPROVED: Work Restrictions and Management of Personnel Medical Medical Executive Comm.: 09/14/16 Illnesses and Exposures 20-8018 Board of Directors: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL Management of Personnel Exposed to Various Diseases: Exposure occurs when an employee comes in contact with an infectious or potentially infectious agent in a manner that may lead to acquisition of the disease. 1. Employees who believe they have been exposed to a communicable disease outside of work, shall notify the RN Infection Preventionist or if the RN Infection Preventionist is not available, the House Supervisor, prior to reporting to work. The RN IP or Supervisor will determine if it is safe for the employee to report for work. In the event it is determined the employee has been exposed to an infectious agent and must remain off work, the employee will be referred to their PMD for treatment and for a Return to Work Release. 2. If the exposure occurred at work, an employee will notify their supervisor and report to the Emergency Department for follow through. The Emergency Department practitioner may determine that prophylactic treatment is indicated as per current CDC recommendations, APIC Text 4th edition, , Red Book 2015 30 thEd.). The Infection Prevention & Control Department should be notified at this time. RECOMMENDATIONS FOR PROPHYLAXIS AFTER EXPOSURE TO VARIOUS DISEASES RECOMMENDATIONS DISEASE When prophylactic treatment with drugs, vaccines, or immune globulins is necessary, personnel should be informed of alternative means of prophylaxis, the risk (if known) of infection if treatment is General not accepted, the degree of protection provided by the therapy, and the potential side effects. A positive C&S (if Applicable) should be available to support the diagnosis. Administration of IG to hospital personnel caring for patients with hepatitis A is not indicated routinely, unless an outbreak among Hepatitis A patients between patients and staff is documented. See The Red Book 2015 (30th Ed.) for recommendations for Post exposure Immunoprophylaxis of Hepatitis A . For prophylaxis against hepatitis B after percutaneous (needlestick) or mucous membrane exposure to blood that might be Hepatitis B infective, the recommendations in Clinical Guideline #20-8007 Blood and Body Fluid Exposure Control and Guidelines, should be followed. For prophylaxis against hepatitis C after percutaneous (needlestick) or mucous membrane exposure to blood that might be Hepatitis C infective, the recommendations in Clinical Guideline #20-8007 Blood and Body Fluid Exposure Control and Guidelines, should be followed. Effective Date: Page 2 of 5 #20-8018 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL HIV Measles Meningococcal disease Neisseria Meningitidis Mumps Pertussis Rubella Varicella Viral, Aseptic and nonmeningococcal/ H.influenzae meningitis Prophylaxis treatment must begin as soon as possible post exposure. See Clinical Guideline #20-8007 Blood and Body Fluid Exposure Control and Guidelines. HIV prophylaxis kit available in pharmacy The measles vaccine should be administered to susceptible hospital personnel, who have had contact with a measles patient, within 72 hours. Personnel who are not immune must be excluded from work 5 days after first exposure to 21 days after last exposure per APIC Text 4th edition. Routine prophylaxis is not recommended for healthcare professionals unless they have had intimate exposure such as occurs with unprotected mouth to mouth resuscitation, intubation or suctioning. Prophylactic therapy should be administered immediately after the unprotected exposure. Should Chemoprophylaxis be necessary, Ciprofloxacin 500mg orally as a single dose or Rifampin 600mg orally every 12 hours for 2 days or Ceftriaxone 250 mg IM x 1 injection (recommended for pregnant healthcare professionals). (The Redbook 2015 30th edition. Two doses of MMR vaccine should be administered to personnel who do not have immunity following exposure. Exclusion from work is recommended the 9th day after the first exposure to the 26th day after the last exposure. APIC Text 4th edition Prophylaxis treatment recommended for susceptible personnel is a 14 day course of Erythromycin 500mg PO four times daily, Azithromycin 500mg PO x 1 dose on Day 1 then 250mg PO daily on days 2-5, a 7 day course of clarithromycin 500mg PO twice daily, or a 14 day course of Trimethoprim-Sulfamethaxozole 800mg-160mg PO twice daily. Exposed personnel who do not have immunity should be excluded from duty from the 7th day after the first exposure through the 21st day after the last exposure. APIC Text 4th edition. Susceptible personnel should be excluded from duty from the 10th day after exposure through the 21st day after exposure Do not routinely provide prophylaxis. Reference: APIC Text –4th edition, CDC Guideline for Infection Control in Health Care Personnel, Current CDC recommendations, Red Book 2015 (30th Edition) , Effective Date: Page 3 of 5 #20-8018 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines and is effective immediately. Effective Date: Page 4 of 5 #20-8018 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE Summary of suggested work restrictions for health care personnel exposed to or infected with infectious diseases of importance in health care settings, in the absence of state and local regulations (modified from ACIP recommendations) and the CDC HICPAC Guideline for the Prevention and Control of Norovirus Gastroenteris Outbreaks in Healthcare Settings. Disease/Problem Work Restriction Duration Restrict from patient contact and contact with the patient's environment No restriction Conjunctivitis Cytomegalovirus infections Diarrheal diseases Acute stage (diarrhea with other symptoms) Restricts from patient contact, contact with the patient's environment, or food handling Convalescent stage, Salmonella spp. Restrict from care of high-risk patients Diphtheria Exclude from duty Restrict from care of infants, neonates, and immunocompromised patients and their environments Restrict from patient contact, contact with patient's environment, and food handling Exclude from duty Enteroviral infections Hepatitis A Norovirus Hepatitis B Personnel with acute or chronic hepatitis B surface antigens who do not perform exposure-prone procedures Personnel with acute or chronic hepatitis B e antigen who perform exposure-prone procedures Hepatitis C Herpes Simplex Genital Hands (herpetic whitlow) Orofacial Human immunodeficiency virus Measles Active No restriction*; refer to state regulations; standard precautions should always be observed Do not perform exposure-prone invasive procedures until counsel from an expert review panel has been sought; panel should review and recommend procedures the worker can perform, taking into account specific procedure as well as skill and technique of worker; refer to state regulations No recommendation No restriction Restrict from patient contact and contact with the patient's environment Evaluate for need to restrict from care of high-risk patients Do not perform-prone invasive procedures until counsel from an expert review panel has been sought; panel should review and recommend procedures the worker can perform, taking into account specific procedure as well as skill and technique of the worker; standard precautions should always be observed; refer to state regulations Exclude from duty Disease/Problem Effective Date: Until symptoms resolve Unit symptoms resolve, consult with local and state health authorities regarding need for negative stock cultures Until antimicrobial therapy completed and 2 cultures obtained ≥24 hours apart are negative Until symptoms resolve Until 7 days after onset of jaundice A minimum of 48 hours after resolution of symptoms Until hepatitis B e antigen is negative Until lesions heal Until 7 days after the rash appears Work Restriction Page 5 of 5 Until discharge ceases Duration #20-8018 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL Postexposure (susceptible personnel) Meningococcal infections Mumps Active Exclude from duty Exclude from duty From 5th day after 1st exposure through 21st day after last exposure and/or 4 days after rash appears Until 24 hours after start of effective therapy Exclude from duty Until 9 days after onset of parotitis Postexposure (susceptible personnel) Exclude from duty Pediculosis Pertussis Restrict from patient contact Active Postexposure (asymptomatic personnel) Postexposure (symptomatic personnel) Scabies Staphylococcus aureus infection Active, draining skin lesions Carrier state Streptococcal Infection, group A Tuberculosis Active disease PPD converter Varicella Active Postexposure *susceptible personnel) Zoster Localized, in healthy person Generalized or localized in immunocompromised person Postexposure (Susceptible personnel) Viral respiratory infections, acute febrile Effective Date: Exclude from duty No restriction, prophylaxis recommended Exclude from duty Restrict from patient contact Restrict from contact with patients and patient's environment or food handling No restriction, unless personnel are epidemically linked to transmission of the organism Restrict from patient care, contact with patient's environment, or food handling From 12th day after 1st exposure through 26th day after last exposure or until 9 days after onset of parotitis Until treated and observed to be free of adult and immature lice From beginning of catarrhal stage through 3rd week after onset of paroxysms or until 5 days after start of effective antimicrobial therapy Until 5 days after start of effective antimicrobial therapy Until cleared by medical evaluation Until lesions have resolved Until 24 hours after adequate treatment started Exclude from duty No restriction Until proved noninfectious Exclude from duty Until all lesions dry and crust From 10th day after 1st exposure through 21st day (28th day if VZIG given) after last exposure Exclude from duty Cover lesions; restrict from care of high-risk patients (neonate, immunocompromised people) Restrict from patient contact Restrict from patient contact Consider excluding from the care of high-risk patients ( for complications of influenza) or contact with their environment during community outbreak of RSV and influenza Page 6 of 5 Until all lesion dry and crust Until all lesions dry and crust From 10th day after 1st exposure through 21st day (28th day if VZIG given) after last exposure or, if varicella occurs, until lesions dry and crust Until acute symptoms resolve #20-8018 Descriptive Name: Work Restrictions and Management of Personnel Illnesses and Exposures Descriptive Type: Revised Policy Document Number: 20-8018 Attachments: None Author: Joetta Denney/Stefanie Parreira Typist: Melissa Arend Creation Date: 02/28/13 Revision Date: 05/17/16 Prev. Dist. Date: 05/29/14 Committee Review and Approval: Infection Prevention Comm. MEC Board of Directors Approval Date: 08/15/16 09/14/16 Comments: Effective Date: Forward To: Policy Binders – (PBX and Administration) and Post to Intranet Site Disposition: Copy and Distribution - Administration Comments: Quality Management System ISO 9001:2008 Tulare Regional Medical Center 869 North Cherry Street Tulare, California 93274 Phone: 559.688.0821 Website: www.TulareRegional.org This manual is the property of Tulare Regional Medical Center and is a controlled document. It may not be reproduced, either in part or full, without prior written permission of the organization. Effective Date: 1 (ISO 9001) #50-1000 INTRODUCTION PART TABLE OF CONTENTS PAGE 0 INTRODUCTION 3 1 HOSPITAL PROFILE 3 SCOPE General Application 6 6 7 TERMS and DEFINITIONS 8 4 4.1 4.2 QUALITY MANAGEMENT SYSTEM General QMS Requirements Documentation Requirements 11 12 13 5 5.1 5.2 5.3 5.4 5.5 5.6 MANAGEMENT RESPONSIBILITY Management Commitment Customer Focus Quality Policy Planning Responsibility, Authority and Communication Management Review 15 16 16 16 17 18 25 6 6.1 6.2 6.3 6.4 RESOURCE MANAGEMENT Provision of Resources Human Resources Infrastructure Work Environment 26 26 26 27 28 7 7.1 7.2 7.3 7.4 7.5 7.6 PRODUCT REALIZATION Planning of Product Realization Customer-Related Processes Design and Development Purchasing Production and Service Provision Control of Monitoring and Measuring Equipment 28 28 29 30 30 31 32 8 8.1 8.2 8.3 8.4 8.5 MEASUREMENT, ANALYSIS and IMPROVEMENT General Monitoring and Measurement Control of Nonconforming Product Analysis of Data Improvement 33 33 33 35 35 36 ISO PROCESS MAPS REVISION HISTORY 38 45 1 1.1 1.2 3 Appendix A Appendix B Effective Date: 2 (ISO 9001) #50-1000 Tulare Regional Medical Center (TRMC) developed and implemented a Quality Management System (QMS) to demonstrate its ability to provide consistent services that meet customer and applicable statutory, regulatory and legal requirements, and to address customer satisfaction through the effective application of the system, including continual improvement and the prevention of nonconformity. The QMS complies with the International Organization for Standardization (ISO), ISO 9001 and to statutory, regulatory and legal requirements. HOSPITAL PROFILE Tulare Local Healthcare District, dba Tulare Regional Medical Center, is a rural general acute care hospital licensed for 112 Medical / Surgical, Labor and Delivery and ICU (Intensive Care Unit) patient care beds. The hospital district, located in Tulare County, geographically identified as California’s the Central Valley Region was established in 1946 and comprised both incorporated and unincorporated communities. Agriculture and Dairy are the predominate industries in the District. According to 2010 US Census Data, 79,130 individuals live in the Tulare Local Healthcare District. The ethnic makeup of the District is 60.3% Hispanic, 33.1% Non-Hispanic White, 3.1% Non- Hispanic Black, 1% Native American and 2.1% Asian Pacific Islander. Tulare Regional Medical Center (TRMC) provides clinical and non-clinical, diagnostic, treatment and support services, for newborn, pediatric, adult and geriatric populations in our District. Prevention, early detection and recovery strategies are encouraged through the four Rural Health Clinics operated by TRMC and our Fitness and Wellness Center. The services available at TRMC and its clinics can be found in Exhibit 1. The interrelationship of these service components can be found in the process map in Exhibit 2. The performance improvement model, Plan, Do, Study, Act (PDSA), can be found in Exhibit 3. Effective Date: 3 (ISO 9001) #50-1000 Exhibit 1 Clinical Services: • Obstetrics and Gynecology • General Surgery • Internal and Family Medicine • Intensive Care • Cardiac Catheterization Laboratory • • • • • Pediatric Ambulatory Surgery Emergency Room Gastroenterology Interventional Radiology • • • • • • • Clinical Laboratory Nutritional Services Social Services Home Healthcare Services Speech Therapy Respiratory Care Services Medical Imaging Clinical Support Services: • • • • • • • Physical Therapy Inpatient Pharmacy Biomedical Engineering Case Management Occupational Therapy Sleep Disorder Center Toxicology Laboratory Non-Clinical / Ancillary Support Services: • Housekeeping • Engineering • Health Information Management • Admitting / Business Office • Materials Management • Infection Prevention • Risk Management • Quality Management • Admitting / Registration • Finance Department • Information Systems • Human Resources • Security • Education / Organizational Development • Business Development • Foundation / Marketing • Evolutions Fitness Wellness Center • Hospital Administration Effective Date: 4 (ISO 9001) #50-1000 Exhibit 2 Admit Treat CLINICAL REGISTRATION ER Patient w/o Orders Home - w/ Services Clinical Services - Med / Surg - ICU / PICU - PEDS - OB / Gyn - Neonatal - Ambulatory - ER - Surgical Serv. - Chemotherapy Get Orders Patient w/ Orders Home - w/o Services Death Transfer / Other Facility Ancillary Services - Radiology - Laboratory - PT / OT - Pharmacy - Respiratory - Sleep Lab - Dietician Labor & Delivery Outpatient Contract Staff - Hospitalist - Intensivist - Anesthesia - ER Group - Radiologist - Surgeons - Pathologist SUPPORT Home Care Other Clinics Skilled Nursing General Services EVS * Engineering * Biomed * Food Service * Security * IT * Materials Mgmt. ** Central Processing Discharge Clinical Support Radiology / Imaging PT / OT / ST RT / EEG Laboratory Pharmacy Nutrition Pastoral Social Services Wound Care Financial Services Admitting * Business Office * Finance Case Mgmt. HIM Contract Services - Dialysis - Speech - Pathology Other - see List of Contracted Services Resources HR / Education Risk Management Compliance Quality Infection Prevention Foundation / Marketing Medical Staff Office PBX * Contracted ** Contracted Mgmt. MANAGEMENT BOARD Finance, QI, Compliance, HR MEC SMT DATA Process Map Support Departments Management Effective Date: PI Committee Service Excellence/ Directors Meeting Senior Leadership Patient Flow Resources to support patient flow Resources and decisions to support patient flow 5 (ISO 9001) #50-1000 Exhibit 3 Quality Management System • Improve it (Act) Management Review • Say What you do (Plan) Prevention Corrective Action Improvement Quality Policy, Objectives, Document & Record Control Process Design &Management ISO Measurement Data Analysis Core Processes Service/Product Realization • Prove it (Study) • Do what you say (Do) Auditing of Processes 1 SCOPE 1.1 General TRMC maintains a strong commitment to quality and customer safety. The Quality Management System (QMS) provides the basis for analyzing customer requirements, defining the processes that contribute to the achievement of a service and the provisions for keeping these processes in control. Patient safety is an essential and inseparable component of TRMC policy. The top level document defining the overall quality management system is the Quality Manual.. It is patient focused and aimed at enhancing patient satisfaction and winning their loyalty. It also meets the regulatory and legal requirements of the service. Quality Policy: TRMC’s Quality Policy goal is to promote positive patient outcomes by designing processes well, and systematically monitoring, analyzing and improving performance. The Quality Policy, committed to by Senior Leadership: a) provides a framework for establishing and reviewing quality initiatives b) is communicated and understood within the organization Effective Date: 6 (ISO 9001) #50-1000 c) is reviewed for continuing suitability These goals are supported by our Mission below and our Vision, Values and Guiding Principles as stated in Exhibit 4. Mission Statement: To develop a best-in-class, performance-driven, integrated delivery system focused on wellness and improving the health status of the community. 1.2 Application Exclusions: Clause 7.3, Design and Development: TRMC does not perform design and development activities. TRMC provides the services, surgery and treatments, which are accepted worldwide in medical circles as standards of performance/practice. 2 Normative References The following documents are referenced in this manual and unless otherwise specified, the latest edition of the document applies. 2.1 International Standards/Industry Standards The standardized documents guiding the organization’s approach to quality are: a) ISO 9000 Quality Management Systems – Fundamentals and Vocabulary b) ISO 9001:2008 Quality Management Systems – Requirements c) ISO 9004 Managing for the Sustained Success of an Organization – A Quality Management Approach d) ISO 19011 Guidelines for Quality and/or Environmental Management Systems Auditing e) NIAHO Accreditation Requirements The parent documents guiding the development of the quality manual are: a) b) c) d) e) f) ISO 9001 4.2.3 Document Control Policy ISO 9001 4.2.4 Record Control Policy ISO 9001 8.2.2 Internal Audit Policy ISO 9001 8.3 Nonconforming Policy ISO 9001 8.5.2 Corrective Action Policy ISO 9001 8.5.3 Preventive Action Policy Effective Date: 7 (ISO 9001) #50-1000 2.2 Approval: a) Board of Directors b) Senior Leadership/Management Review (Informational Input, not for approval) 2.3 Distribution: a) Senior Leadership/Management Review b) Board of Directors c) Organization wide 2.4 Management Systems: a) Business Management These are the departments and processes that manage the organization’s resources such as finances, people and the facility. While all departments may not have direct contact with the provision of patient care and service, they are indirectly related because of their impact on product, people, environment and financial stability. They support Tulare Regional Medical Center’s Vision, Values and Guiding Principles as stated in Exhibit 4 and Mission to develop a best-in-class, performance-driven, integrated delivery system focused on wellness and improving the health status of the community.. b) Regulatory / Compliance Compliance management is focused on meeting legal and regulatory requirements such as NFPA and EPS regulations, CMS requirements for accreditation and applicable State and Federal laws. The departments involved in meeting legal and regulatory requirements are directly related to the provision of safe patient care.. c) Quality Management This management process refers to the organization’s performance and its ability to develop systems to monitor, prevent and correct deficiencies and variances from the expected outcomes. Quality Management focuses on the patient/customer and utilizes a process approach to understand and organize all levels of service in order to recognize variation, take action and prevent the variation from repeating. 3 TERMS AND DEFINITIONS Audit A planned, independent and documented assessment to determine whether agreed-upon requirements are being met. Competence The ability of an individual to perform a specific job or task. Effective Date: 8 (ISO 9001) #50-1000 Corrective Action Action taken to eliminate the causes(s) of existing problems, defects or any other desirable situation in order to prevent recurrence. Customer Organization or person that receives a service DNV Stiftelsen Det Norske Veritas. Is a classification society organized as a foundation, with the objective of "Safeguarding life, property, and the environment". The organization's history goes back to Document 1864, when the foundation was established in Norway to inspect and evaluate the technical condition of Norwegian merchant vessels. Today, DNV Healthcare is an accreditor of US hospitals integrating ISO 9001 quality compliance with the Medicare Conditions of Participation. Any written item of a factual or informative nature. Document Control A system to regulate the handling and management (including archiving, storing and destruction) of documents containing information that communicates policies, processes, procedures as well as records and usually pertains to documents that are part of the QMS. Empowerment Giving staff the authority and responsibility to make decisions and take action. Error A deviation from truth, accuracy or correctness; a mistake. Form A paper or electronic document on which information or results are captured. Once completed, a form becomes a record. Incident A single distinct occurrence or event. ISO International Organization for Standardization. A network of standards institutes from 140 countries working in partnership with international organizations, governments, industry, business and consumer representation. The source of more than 13,000 international standards for business, government and society. NIAHO National Integrated Accreditation for Healthcare Organizations. The core of DNV hospital accreditation is the NIAHO® standards platform, created by DNV in 2008 for US hospitals. DNV’s belief is that accreditation is not an inspection but rather a catalyst for quality and patient safety. This innovation allowed DNV accreditation to earn acceptance from the US Centers for Medicare and Medicaid Services (CMS). NIAHO® integrates requirements Effective Date: 9 (ISO 9001) #50-1000 based on the US CMS Conditions of Participation (CoPs) with the internationally recognized ISO 9001 Standard, ISO 14001 and ISO 27001 and international standards of medical care for patients. This approach helps healthcare organizations reach maximum effectiveness and efficiency, with improved clinical performance, financial outcomes and operational processes. Occurrence Something that generally happens; an event, incident. Policy A written statement of overall intentions and directions defined by those in the organization and endorsed by management. Preventive Action Action taken to eliminate potential problems, defects, or any other undesirable situation from happening. Preventive Maintenance Scheduled periodic work on a piece of equipment that is not the result of malfunction or failure and is intended to avert such failure. Procedure A specified way to perform an activity. Written work instructions for each step in a process. Process Series of inter-related steps involved in an activity or examination that uses resources and is managed to transform inputs into outputs. Process Control Operational techniques and activities that are used to fulfill requirements for quality. Quality The totality of characteristics of an entity that bear on its ability to satisfy stated and implied need and expectations. Quality Assurance Planned and systematic activities to provide adequate confidence and evidence that requirements for quality will be met. Quality Management All activities of the management function that determine quality objectives, responsibilities and implementation including quality planning, process control, quality assurance; and quality improvement. Management Representative An individual with delegated responsibility and authority to ensure compliance with the quality management system. Quality Policy Overall intentions and direction of an organization with regard to quality (e.g. quality system essentials) as formally expressed in writing by Senior Leadership. Quality System A quality system is a program developed to support efficient and effective, high quality and appropriate patient services. It is a Effective Date: 10 (ISO 9001) #50-1000 comprehensive and coordinated effort (policies, processes and procedures) designed to meet quality objectives, to direct and control an organization with regard to quality and encompasses quality (management) system and quality assurance. Record A document that furnishes objective evidence of information obtained, activities performed or results achieved. Service The result generated by activities at the interface between the provider and the customer and by provider internal activities to meet the customer needs. Methods and techniques used to generate, analyze, interpret and present data. Statistical Tools Value Degree of worth relative to cost and relative to possible alternatives of a product, service, process, asset, or function. Vendor An organization that provides a product or service to the organization. Verification The confirmation by examination and provision of objective evidence that specified requirements has been fulfilled. 4 QUALITY MANAGEMENT SYSTEM TRMC’s Vision, Values and Guiding Principles are stated in Exhibit 4. Effective Date: 11 (ISO 9001) #50-1000 EXHIBIT 4 4.1 General QMS Requirements TRMC has developed and implemented a documented QMS to meet the requirements of ISO 9001:2008 standards for ensuring that the service conforms to customer satisfaction. The QMS is supported by documents and records for individual departments as required. Effective Date: 12 (ISO 9001) #50-1000 The associated metrics and goals of the QMS shall be evaluated for continued suitability as part of the QMS Review. Senior Leadership reviews the organization's quality management system, at planned intervals, to ensure its continuing suitability, adequacy and effectiveness. This review includes assessing opportunities for improvement and the need for changes to the quality management system, including the quality policy and quality objectives. Records from Senior Leadership reviews are maintained see 4.2.4. Specific authority is given to those responsible for product, process or system quality to: • • • • • • • • Determine the sequence and interaction of the processes needed to maintain the QMS and their application throughout the organization Determine criteria and methods needed to ensure that both the operation and control of the processes are effective Ensure availability of resources and information necessary to support the operation and monitoring of the processes Monitor, measure where applicable and analyze the processes and implement actions necessary to achieve planned results and continual improvement Initiate action to prevent nonconformance Initiate action to identify, record and correct anomalies Initiate, recommend or provide solutions Verify implementation of solutions The sequence and interaction of the process within the QMS is described below: 4.2 Documentation Requirements 4.2.1 General The QMS documentation is comprised of the following: a) b) c) d) documented statements of a quality policy and quality objectives a quality manual documented procedures and records required by this International Standard documents, including records, determined by the organization to be necessary to ensure the effective planning, operation and control of its processes NOTE 1: Where the term “documented procedure” appears within this International Standard, this means that the procedure is established, documented, implemented and maintained. A single document may address the requirements for one or more procedures. A requirement for a documented procedure may be covered by more than one document. Effective Date: 13 (ISO 9001) #50-1000 NOTE 2: The documentation can be in any form or type of medium. 4.2.2 Quality Manual The organization’s established and maintained quality manual (this manual) includes, see Exhibit 5: a) the scope of the quality management system, including details of and justification for any exclusions, see 1.2 b) the documented procedures established for the quality management system or reference to them c) a description of the interaction between the processes of the quality management system EXHIBIT 5 ISO 9001 QMS Document Structure Level 1 Quality Manual Organization Policies Departmental Policies Procedures, Protocols, Forms Specifications, Records, Manuals Level 2 Level 3 Level 4 Level 5 4.2.3 Control of documents Documents are required by the QMS for efficient and effective documentation of product, process and outcome performances. Records are a special type of document and controlled according to the requirements given in 4.2.4. A documented procedure, ISO 9001 4.2.3, is established that defines the controls needed to: a) approve documents for adequacy prior to issue b) review and update as necessary and re-approve documents Effective Date: 14 (ISO 9001) #50-1000 c) ensure that changes and the current revision status of documents are identified d) ensure that relevant versions of applicable documents are available at points of use e) ensure that documents remain legible and readily identifiable f) ensure that documents of external origin determined by the organization to be necessary for the planning and operation of the quality management system are identified and their distribution controlled g) prevent the unintended use of obsolete documents, and to apply suitable identification to them if they are retained for any purpose 4.2.4 Control of Records Records needed to provide evidence of conformity to requirements and of the effective operation of the quality management system are controlled. The organization established a documented policy to define the controls needed for the identification, storage, protection, retrieval, retention and disposition of records, as referenced in ISO 9001 4.2.4, see Appendix A. Records remain legible, readily identifiable and retrievable. 5 MANAGEMENT RESPONSIBILITY Senior Leadership has established a quality policy and quality objectives that identify the process for collecting, identifying, analyzing, interpreting and acting upon opportunities or deficiencies and helps the organization improve its ability to provide quality care, treatment, and services. The hospital collects data from many areas, including internal data obtained from staff, medical staff, patients, records and observations. Data is also available from risk management activities and external accrediting and regulatory agencies. The goal of the quality policy is to promote positive patient outcomes by designing processes well, and systematically monitoring, analyzing and improving performance. The quality policy and effectiveness of the QMS will be evaluated annually during Senior Leadership Meetings, where quality measurements are analyzed against their established objectives and suggestions for improvement of the system are considered. Further quality planning is also conducted during Senior Leadership Meetings to ensure the continuing availability of the resources necessary to meet the expectations of our customers. Effective Date: 15 (ISO 9001) #50-1000 5.1 Management Commitment Senior Leadership has established a quality policy as a framework for establishing and reviewing quality objectives. The quality objectives are controlled according to the Document and Records Control procedure, see ISO 9001 4.2.3. Senior Leadership ensures that the quality policy is communicated and understood by staff and that the policy is implemented throughout the organization. In order to maintain the quality standard committed, Senior Leadership and the leadership team of TRMC will monitor and review its quality performance from time to time through the implementation of an effective Performance Improvement Committee and Quality Management System based in accordance with the ISO standards. Senior Leadership will maintain an environment of continuous improvement and empower its staff to achieve success in both individual performance and teamwork. 5.2 Customer Focus TRMC ensures to provide compassionate, courteous, respectful and dignified care, maintaining confidentiality and sensitivity to every individual through an independent audit process through a third party vendor. Results and actions are handled through the Service Excellence/Directors Meeting. 5.3 Quality Policy TRMC will be recognized as the premier provider of high-quality care, based on the best practices and in collaboration with Medical Staff that exceeds patient expectations. Quality objectives establish measurements to monitor its performance. The scope of measurement will take into consideration, and be consistent with, the care and services provided, the critical functions of the hospital and industry identified areas of concern. Senior Leadership sets the priorities for performance improvement activities and patient health outcomes. The following criteria are used to determine the prioritization of performance measurement and improvement: a) b) c) d) Improve the safety of the health care environment. Improve the safety of the care provided to the recipients. Further the Mission and strategic objectives of TRMC. Meet legal, regulatory, licensure and accreditation requirements. Effective Date: 16 (ISO 9001) #50-1000 e) Improve the effectiveness, timeliness and stability of processes that are high risk, high-volume or problem prone. f) Improve desirable outcomes of care for at-risk patient populations. g) Reprioritize performance improvement activities in response to changes in the internal or external environment. h) Data shall be collected quarterly, unless otherwise specified and shall be organization-wide. i) The availability of evidence-based practices applicable to our scope of services. 5.4 Planning To expand access and availability of healthcare while growing services based on regional need. 5.4.1 Quality Objectives TRMC has established measurements to monitor its performance. The scope of measurement will take into consideration and be consistent with, the care and services provided, the critical functions of the organization and industry identified areas of concern. Senior Leadership set the priorities for performance improvement activities and patient health outcomes. The following are the organization’s quality objectives for financial year 2015-2016: Departmental Quality Objectives 1) Reduce the 30-day re admission rate by 5% 2) Achieve customer satisfaction rate of 85% 3) Before implementation of the new EHR, 100% of staff will be trained and compentent 4) Reduce the Left Without Being Seen (LWBS) rate to the national average 5) Maintain necessary regulatory requirements 5.4.2 Quality Management System Planning The plans of the QMS are in accordance with the requirements of TRMC quality objectives and ISO standards. Effective Date: 17 (ISO 9001) #50-1000 Senior Leadership ensures that the integrity of the QMS is maintained by evaluating performances and changing the QMS as necessary. The approach and deployment to quality planning include as appropriate: Goals for improving quality and customer satisfaction which can focus on: 1) 2) 3) 4) 5) 5.5 Service Excellence Clinical Quality Training Procedure capability Potential Failure Mode and Effects Analysis (FMEA) Responsibility, Authority and Communication 5.5.1 Responsibility and Authority Senior Leadership ensures that responsibilities and authorities are defined and communicated within the organization as follows: a) b) c) d) e) Job Descriptions for staff Annual Performance Evaluations Centralized Annual Update Monthly Directors Meeting Organizational wide notification system Staff are authorized to identify and record any service quality anomaly and is responsible for forwarding the anomaly to the appropriate department director for resolution. Staff are also empowered to resolve issues at time of notice. An organizational chart, Exhibit 6, has been established to show the interrelation of personnel in the organization. Job descriptions define the responsibilities and authorities of each of the positions on the organizational chart. Job descriptions and the organizational chart are reviewed and approved by Senior Leadership for adequacy and are available in Administration. Effective Date: 18 (ISO 9001) #50-1000 Exhibit 6 Organizational Chart HCCA Tulare Regional Medical Center Administration Leadership mm Admin?ssist. UP Market'ng HR Diremnr Effective Date: 19 (ISO 9001) #50?1000 2% was: 33.8. 83 ?3353 El. n3?n?1 Effective Date: Page 3 of 6 #13-12,001 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL month). This assures inclusion in the yearly and monthly calendar and assistance in planning, if needed (i.e., consultation, instructors, room, CE [per Policy # 13-12004 Continuing Education for Clinical Staff], advertising, participant registration, supplies provided, etc.). D. Regularly scheduled education meetings are conducted through the Professional Development Team, reinforcing a collaborative working relationship and assurance of use of sound educational principles. E. Departmental leaders will support and schedule time for staff to attend educational opportunities within the organization to assist the employee in maintaining competence. F. Employees are encouraged to participate in outside professional educational conferences related to their positions. All outside participant attendees should send a copy of the certificate of attendance to the education department for inclusion in the employee’s records. G. TRMC Educational Services plans and provides a General yearly calendar (calendar year). The calendars outline all routine and mandatory classes, as well as continuing education programs. H. Staff input (yearly and per class) for content and program prioritization is considered in planning all educational events. I. Educational Services supports and provides classroom space, as well as other resources as necessary to academic programs and students/instructors, when available. J. All educational programs provided by Educational Services are educationally sound with written curricula (see Educational Program Record). This includes outline, class description, learning objectives, lesson plan, teaching aids, references used, as well as methods of evaluation; which requests input and feedback from participants regarding future learning needs. Appropriate and qualified instructors are chosen. K. All programs and participants are documented in the "Education Tracker." Reports are provided to department leaders upon request. VIII. ROUTINE PROGRAMS OFFERED: A. Organizational Development/Continuing Education/Staff Education: 1. General Orientation M - monthly (first Monday) Effective Date: Page 4 of 6 #13-12,001 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL 2. Centralized Annual Update M - Once a year (fall) 3. Computer Training 4. Clinical Orientation - monthly (following General Orientation) M 5. Nonviolent Crisis Intervention- Twice yearly 6. Advanced Cardiac Life Support - Twice yearly 7. Pediatric Advanced Life Support - Twice yearly 8. Neonatal Resuscitation Program - Twice yearly 9. Vascular Access Device Update - Monthly with Clinical Orientation an yearly with CAU 10. Cardiac Dysrhythmia - Twice yearly 11. Preceptorship - Twice yearly 12. Domestic Violence and Abuse Reporting - Online 13. Infection Prevention and Reduction of HAIs- General Orientation/Annual Update, and online as needed 14. Online Education Modules-various topics as needed 15. Fire extinguisher practice, fire lifts/carries – PRN 16. CNA continuing education Classes - As needed 17. Other classes - As designated per need M-mandatory B. Community Education: 1. Perinatal Series - Monthly 2. BLS HCP CPR Classes – Monthly Effective Date: Page 5 of 6 #13-12,001 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY/GUIDELINE MANUAL IX. 3. Basic Skills Diabetes classes – Monthly 4. Industrial CPR/First Aid – As requested 5. Others identified by need ON LINE INTRANET EDUCATION TRMC Educational Services maintains an intranet website related to educational needs of staff. Various classes are listed with descriptive information, healthcare related websites (including cultural diversity), as well as some educational programs and online modules for learning. Questions concerning any aspects of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines concerning this matter and is effective immediately. Effective Date: Page 6 of 6 #13-12,001 Descriptive Name: Organizational Development and Educational Services Plan Descriptive Type: Revised Document Number: 13-12,001 Attachments: None Author: Carol Bradford Typist: Melissa Arend Creation Date: 11/30/06 Revision Date: 07/19/16 Prev. Dist. Date: 03/29/12 Committee Review and Approval: Board of Directors Approval Date: Comments: Effective Date: Forward To: Policy Binders – (PBX and Administration) and Post to Intranet Site Disposition: Copy and Distribution - Administration Comments: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: All Departments FROM: Administration SUBJECT: American Heart Association Community Training Center POLICY: As a Community Training Center for the American Heart Association, Tulare Regional Medical Center is contracted to provide BLS, PALS, and ACLS classes for the purpose of educating hospital staff, other health professionals in the community, individuals involved in public safety and the general community. Tulare Regional Medical Center agrees to abide by the terms of the contractual agreement and the regulations and guidelines of the American Heart Association. PROCEDURES: A. Classes 1. The Training Center Coordinator is responsible for coordinating the Basic Life Support Classes. The Staff Educator coordinates the Advanced Life Support Courses. Class schedules for the year are published in the Education Calendar and distributed to staff and the community. 2. Basic Life Support (BLS, HCP) classes are routinely offered monthly for a fee of $60.00 for HealthCare Provider. Both Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) are offered twice a year for a fee of $60 for TRMC employees and $220 for outside healthcare professionals. Rerecognition classes for TRMC employees are $40 and $130 dollars for outside professionals. 3. Class fees are refundable only if the student is not accepted as a participant in the class, class is cancelled or the participant notifies the department of withdrawal at least two working days prior to the scheduled date. ___________________________________________________________________ Effective Date: (13) Ancillary Services Educational Services: APPROVED: American Heart Association Community Training Center 13-12,002 Board Of Directors: TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE 4. Hospital staff attending a BLS class make a ten-dollar deposit, which is refunded when the employee attends the class and returns the loaner book. B. Instructor Courses/Renewal 1. Instructor Candidates must complete an instructor course at their own expense. Instructor candidates are encouraged to observe one or more CPR classes taught by an experienced instructor. 3. Within 6 months of instructor course completion, the instructor candidate is required to teach a class under the observation of the training center facility or lead instructor. An instructor candidate monitoring form is completed at that time and forwarded to the training center coordinator for processing. An instructor card for the appropriate discipline is issued to the successful candidate. 4. Each instructor is responsible for purchasing and maintaining the instructor manuals and provider text for the courses they teach. Supplemental materials for the courses will be provided by the training center. 5. Instructors must maintain current Provider status and teach a minimum of four (4) courses per 2 -year cycle. 6. Instructors are expected to attend scheduled updates and renewal courses taught by the training center faculty. Each instructor has access to the Instructor Network on the AHA website. 7. Teaching ability will be monitored and documented during the renewal course or on an individual basis every two years. C. CARDS 1. American Heart Association course cards certify successful completion of the course and are valid for two years. 2. The TC Coordinator or designee is responsible for ordering all course cards. 3. All cards are stored in a locked cabinet for security purposes. 4. Instructors will issue cards on successful completion of the course, or within 30 days of completed paperwork. Effective Date: Page 2 of 5 #13-12,002 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE 5. AHA cards expire on the last day of the month noted for recommended renewal. There is no grace period for expired cards. If a card is expired less than six months, the training center faculty may decide whether the student will be required to attend the initial course or just a renewal session. 6. If an instructor allows his/her card to expire it will be left to the discretion of the training center facility as to whether the instructor must attend a new candidate instructor course. 7. Students requesting a replacement card will be issued a card marked duplicate at the top. Copies of duplicate cards will be stored with the copy of the original card. D. Textbooks/Tool Kits 1. Each student attending an AHA course will have the current appropriate AHA course textbook readily available for use before, during, and after the course. The student can either choose to purchase the book or obtain a loaner. Students who arrive at class without a text will be issued a loaner for use during the class. 2. Instructor Tool Kits are stored in the Education Department and are readily accessible to all Instructors. E. Manikins 1. Manikins are stored in the Educational Services Department. 2. Life Safety manikins will not be loaned or rented to agencies or individuals for the purposes of providing training not solicited or scheduled by the training center. 3. Manikins are to be cleaned following classes as follows: a. Using gloves and protective clothing, remove the face, old tubing, and lungs. b. Discard the lungs and tubing. c. Wash all the mannequin faces, pocket masks and valves with warm soapy water, or disinfectant wipes. d. Soak all of the above in disinfectant (Alrkem A-456-N) for 2 minutes. Make the solution with one capful of disinfectant and four quarts of warm water. e. Rinse and dry the mannequin faces and allow the masks and valves to air dry on paper towels. Effective Date: Page 3 of 5 #13-12,002 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE f. Wash the exterior of the mannequins with soap and water, rinse and dry well or use disinfectant wipes. g. Remove and discard disposable gloves. Put on a new pair of gloves. h. Insert new lungs and tubing. i. Replace mannequin faces and connect to tubing. Discard gloves. j. Place clean mannequins in appropriate storage case and the pocket masks and valves in their respective plastic bags with the “clean” label. F. Record Maintenance 1. Records for each course taught through the training center will be maintained on file for a minimum of four years. These records will include the course roster, attendance sheets, copies of the course completion cards, individual answer/skill performance sheets, class registration forms, participant evaluations and class data summary sheets detailing the number of participants, learning hours and profit/loss. 2. Each student attending a life safety course will be registered in the Education Tracker software program for tracking purposes. 3. Instructor binders will be kept current and include a signed liability form, instructor/provider record form, copy of the current instructor card, instructor monitor forms and a report of classes taught. G. Performance Improvement 1. Each student is asked to complete a subjective evaluation form rating, among other things, the instructor’s preparation, knowledge and presentation of the material. 2. Evaluation results will be summarized and reported. Ratings below the 90% threshold will be reviewed and recommendations for improvement will be discussed with the instructor. H. Internal Disputes 1. If a class instructor is unable to resolve a disputed issue during a CPR class, it is the responsibility of the instructor to notify the training center coordinator. The training center coordinator will approach the appropriate training center faculty for resolution. Effective Date: Page 4 of 5 #13-12,002 TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE 2. The American Heart Association will only become involved in disputes, complaints or problems that are listed in the current Program Administration Manual (PAM) and according to the procedure outlines. Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines and is effective immediately. Effective Date: Page 5 of 5 #13-12,002 Descriptive Name: American Heart Association Community Training Center Descriptive Type: Revised Document Number: 13-12,002 Attachments: None Author: Carol Bradford Typist: Melissa Arend Creation Date: 01/15/09 Revision Date: 07/19/16 Prev. Dist. Date: 03/29/12 Committee Review and Approval: Board of Directors Approval Date: Comments: Effective Date: Forward To: Policy Binders (PBX and Administration) and Post to Intranet Disposition: Copy and Distribution - Administration Comments: