CATHOLIC MEDICAL CENTER

MISSION, VISION and VALUES

The Mission: The heart of Catholic Medical Center is to provide health, healing, and hope in a manner that offers innovative high quality services, compassion, and respect for the human dignity of every individual who seeks or needs our care as part of Christ’s healing ministry through the Catholic Church

2020 Vision: Our wealth of resources are clinically aligned and integrated into patient-centered, information-rich systems of care that enhance satisfaction, quality, and safety.

Pillars of Excellence: CMC adopted five core pillars of excellence - People, Service, Quality, Finance and Growth. The use of these pillars has successfully defined and strengthened the culture of the organization. Each value can be briefly described as:

  • People: Operate as a healthcare system of choice for employees and medical staff community.
  • Service: Exceed expectations and lead as a recommended healthcare provider.
  • Quality: Provide the right care and experience for every patient and visitor, every time.
  • Finance: Allocate resources to achieve the mission and accomplish goals.
  • Growth: Evolve services to meet the community’s wellness and healthcare needs.

CMC’s Patient Rights & Responsibilities

It shall be the policy of all Catholic Medical Center employees to assure the well-being of the patient consistent with legal requirements and the Ethical and Religious Directives for Catholic Health Care Services (“ERDs”). In defining the rights and responsibilities of patients, CMC acknowledges that “neither the health care professional nor the patient acts independently of the other; both participate in the healing process” (ERDs, Part Three, Introduction).

All patients shall have the following rights as prescribed by the New Hampshire Patients’ Bill of Rights (see RSA 151:21):

Student Nurse Standards of Behavior

  1. Wear name badge and uniform at all times.
  2. Identify self as student at all times.
  3. Practice at their level of knowledge and experience.
  4. Practice within their defined scope of practice, and only skills/procedures previously taught.
  5. Complies with all hospital and nursing staff policies including dress code (HR 303 Appearance and Grooming) and parking.
  6. Complies with Confidentiality and Privacy Policy (HIPAA).
  7. Documents on patient’s permanent record only after collaborating with nursing faculty, direct care nurse or preceptor then securing co-signature. Documentation must include student name and title.
  8. Documentation in the electronic record is required for any/all interventions performed by student.
  9. Participates in direct patient care under the supervision of the clinical faculty or preceptor.
  10. Inform staff nurse of hours scheduled on unit, including when leaving the unit for break, lunch or alternate learning experience.
  11. Must be knowledgeable about medications prior to their administration.
  12. Prepares to complete patient assignment by reviewing pertinent theoretical knowledge prior to participating in direct nursing care.
  13. Report to nursing faculty/preceptor if she/he becomes ill or injured while on duty. Student may be sent to Emergency Department for treatment, the cost of which will be borne by the school or student. Incident/injury report, if applicable, to be initiated within 24 hours of injury.
  14. Participate in Code Blue situation at the discretion of the RN in charge of the code and/or faculty or preceptor.
  15. Complete Nursing Student Experience Evaluation Form at the end of each rotation

CUSTOMER SERVICE EXPECTATIONS

The future of CMC is highly dependent on our ability to deliver the best experience possible to our patients and their families. SERVICE with a SMILE is a program, a philosophy and a culture at CMC:

You are what people see when they arrive.

You are the eyes they look into

when they are frightened and lonely.

Yours is the intelligence and caring that

people hope they will find here.

If you are noisy, so is the hospital.

If you are rude so is the hospital

And if you are wonderful, so is the hospital.

We have a stake in your attitudes

And the attitudes of everyone who works here.

We are judged by your performance.

We are the care that YOU give, the attention YOU pay,

The courtesies that you extend.

CORPORATE COMPLIANCE

/ CORPORATE COMPLIANCE / The integrity of our organization begins with YOU!

We at CMC operate in accordance with all applicable laws, regulations and standards. The Corporate Compliance Program puts into writing standards that have always existed at CMC, and requires formal acknowledgement by every individual, at all levels of the organization. Policies can be found in the Standards of Business Conduct and on the intranet at.

Your responsibility is to:

Conduct yourself with honesty and integrity and in accordance with the highest ethical standards

Perform your duties in accordance with the principles set forth in CMC’s

Standards of Business Conductpolicies and program

Follow the laws and regulations under which CMC operates

Report or disclose any questionable situations promptly

The Program includes:

A Corporate Compliance Officer available to assist you at 663-6651 or email

Jessica Lamb Arvanitis at:

A Corporate Integrity Committee authorized by the Board of Trustees to develop and oversee the Corporate Integrity Program.

A “Compliance Help Line” –663-6749 –you can call confidentially and anonymously if you believe you have encountered an incident that violates law or CMCCode of Conduct.

An Ethics Committee which is a patient care committee existing as a resource to our healthcare professions, their patients and families.

Built-in-checks, such as regular monitoring of patient billing or coding, to ensure that CMC personnel in all areas of CMC understand and are meeting the program’s expectations.

Remember:

-Students are obligated to treat all information written and/or verbal about

patients as privileged and confidential.

-Students may not access their own or a family’s medical record without

following the same procedure as any other patient.

-Do not discuss patient information with anyone not directly involved in the

patient’s care. Take precautions to prevent others from overhearing conversation about patients.

-Do not identify a patient by name or room number; do not confirm a

patient’s presence to unauthorized persons.

-A student must NEVER release medical information to any telephone request or fax request. Refer all requests for medical information to your responsible nurse.

-Do not share passwords.

-Release of confidential information without a patient’s authorization will be cause for immediate termination of all clinical rotations.

INCIDENT/OCCURENCE REPORTING

What is an incident/occurrence?

/ An unusual incident/occurrence is an actual or a potential incident or event which is inconsistent with the normal or expected operation of the Hospital. The potential for injury is sufficient to be considered an unusual incident/occurrence; however an actual injury need not occur. (incident/occurrence will be referenced as incident going forward)
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All unusual incidents must be documented on the appropriate form within 24 hours, preferably before the end of the shift the incident occurred on. All forms should be forwarded to the Risk Management Department within 24 – 48 hours.

-Incidents are reported via the online “2BSafe” link found on the CMC intranet home page

Who should complete an Incident Report?

Unusual incidents will be immediately reported by the person or persons most directly involved, or by those who observed or discovered the unusual event.

The person, who was involved in the incident, observed the incident or first discovered the incident should complete the Incident Report.

Students should notify their Clinical Instructor and the Unit Director/Resource Nurse of the need to fill out an Incident Report. Together you can complete the report.

Reports are then sent electronically to Department/Unit Manager, Risk Management and other areas responsible for follow-up, depending on the type of incident.

What happensshould incidents be reported?

The Unit/ Department Director or Designee will receive and review all Unusual Incidents generated by his/her staff.

Under NH State Law, RSA 151:13 A, the investigation of any serious or potentially serious events involving patients will be done at the direction of the Quality Management Committee of the Board of Directors. The events will be reviewed and, if necessary, analyzed through our Performance Improvement Process and Quality/Peer Review Process so as to initiate improvements, policy development or revisions, staff education, and the like.

Medical Equipment Failure

In the event of a medical equipment failure, call Clinical Engineering or the device’s designated service provider. Refer to department’s equipment contingency plan. Check inspection equipment stickers for current dates before use.

Emergency Preparedness

EMERGENCY CODES

Our in-house emergency number is Ext.2111. It connects you immediately with the switchboard operator. It is to be used in all emergency situations. Always specify location, type of emergency (see card with ID badge) and repeat the information twice.

Students do not respond to emergencies unless directed by the Unit Director/Resource Nurse.

Code Red (Fire)
The switchboard operator will overhead page “ Attention: Code Red (and location)” / All students are expected to be familiar with the Medical Center’s Fire Alarm activation and response guidelines (RACE).
Rescue: move patients from the immediate area
Alarm: Activate pull station, Dial emergency number 2111 on site or off site 911.
Contain: Close doors
Extinguish/Evacuate:
Extinguish if manageable (evacuate as directed)
Code Blue (Cardiorespiratory arrest or unresponsive person other than an infant/child)
The switchboard operator will overhead page “ Attention: Code Blue (and location)”
Code Amber-Infant(Missing Infant from MOM’s Place)
Code Amber-Child(Missing Infant or child from other than MOM’s Place)
Code Amber–Adult (Missing Adult Without Decision Making capacity)
If you discover an infant, child or incapacitated adult is missing, dial ext. 2111. This will connect with the switchboard / For missing children, state clearly and distinctly, “CODE Amberspecify location,” and repeat twice.
For missing adult, state, “CODE Amber – ADULT (specify location), and repeat twice.
Code Grey(Behavioral Emergency)
Dial ext. 2111, advise Communications (operator) of patient location and explain the situation in detail.
State clearly and distinctly, "Code GREY, LOCATION, FLOOR and DEPARTMENT." (REPEAT).
All available male personnel and Security will respond to the location during normal business hours. After hours, ALL available Nonviolent Crisis Intervention (CPI) trained personnel will be announced overhead and be requested to respond to the location requested.
2.Security personnel will determine when enough staff has arrived.
The switchboard operator will overhead page “ Attention: Code Grey (and location)” / Security after consultation with clinical staff, they will take charge of the situation. If the situation is not contained, the security will call Nashua Police Department.
Code Blackbomb threat Dial 2111 and inform the operator of the Code Black, then the operator will connect you to Manchester Police Department. Give the police/operator all the information you collected on the checklist. Identify yourself give your name, address and phone number. / BOMB Check List If you receive a telephone bomb threat...
•Remain calm.
•Try to prolong the conversation and get as much information as possible.
•Note what you hear. Are there background noises, such as music, voices, or cars? (Refer to left panel checklist insert.)
•Do not hang up.
•How does the caller's voice sound? Any accent? What sex? What age? Any unusual words or phrases?
•Does the caller seem to know about the medical center? How is the bomb location described? Does the caller use a person's name? Does the caller give his/her name
Code White(Mass causality/disaster)
The switchboard operator will overhead page “ Attention: Code White” / The decision to activate the Disaster Plan will be made by the Emergency Department Physician, Director, Clinical Leader, EMS Manager, AdministratorOnCall, CEO, or other designee. Activation of the Disaster Plan dictates that all elective procedures within the facility are suspended until the termination of disaster operations. All available staff within the facility are expected to report to their department for assignment. Departments, unless specified within this plan, are not to activate their call lists unless requested by CatholicMedicalCenter's CommandCenter.
Code Orange(hazardous materials/decontamination) Call Ext 2111
Code Green (Area to be evacuated) / During a fire emergency or some other type of internal disaster in the hospital, a quick evacuation of patients may be required with the movement of patients to a safe area. The safe area may be on the same floor (horizontal), lower floors (vertical), or total evacuation.
In the event of an evacuation of a floor or area, Communications (operator) shall overhead page “CodeGREEN - (AREA TO BE EVACUATED)" three times. The overhead page will be repeated in one minute.
Code Silver(hostagesituation/weapon)
Code Stroke (Initiate calling a CODE STROKE to elicit a stroke team response.
Code Yellow / Communication/power failure: each unit has a designated land-line (usually single line phone) for use during this type of failure

For more information: T:\ED Shared Folder\Disaster Management\Codes\CodeAmber.htm

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BACK SAFETY

Your back supports you in everything you do~ support your back by using good posture, exercise and body mechanics for strength, flexibility and balance!

Be sure to apply proper lifting techniques – whether working alone, as a team, or with the aid of a mechanical helper. Look for simple solutions to make your work easier on you and your back.

Use mechanical lifts whenever possible

During any patient transferring task, if any caregiver is required to lift more than 35 lbs. of a patient’s weight, then the patient should be considered to be fully dependent and assistive device should be used for the transfer.Equipment used to lift, transfer, reposition, and move patients. Examples: Encore, Tempo, and Tenor Lifts.

Lift properly

Getting Ready to Lift:

Assess the situation, Can you safely lift alone?

Lift the load yourself only if it’s safe to do so

Make sure your footing is firm and your path is clear

Get close to what you are lifting

Test the weight

HAZ – COM

The Occupational Safety and Health Safety and Health Administration require employers to communicate information about hazardous chemicals in the workplace to each employee. This hospital has developed the following plan in order to comply with OSHA requirements 29CFR 1910.1200 and to fulfill its commitment to providing safe and healthful workplace for employees. Information concerning the hazards of chemicals used in the workplace will be communicated to employees by means of:

  • Container labeling
  • Safety Data Sheets (SDS)
  • Employee Training
  • Written hazard communication plan

/ Spills/Releases-Each department is responsible to be prepared, trained and equipped to clean up (incidental releases) and appropriately respond to releases to hazardous substances used. IF the release constitutes an EMERGENCYor is otherwise beyond the capabilities of the department requiring an trained (external)Spill Team a “Code Orange” is to be activated

SDS Sheets– Master manual located in the Emergency Department. Sheets can also be found on the intranet under “Safety”.Department Directors are responsible for obtaining an SDS for each identified hazardous chemical prior to purchase. Department Directors are responsible for providing the most current SDS to the Safety Department to be included in the Master SDS Manual. It is preferred that SDS be obtained in a .pdf format and submitted electronically to the Safety Department.

It is at the department director’s discretion whether or not the department will maintain copies of all SDS sheets in ADDITION to the master manuals. If the department chooses to do this, a department policy must be established to outline process and responsibility to assure that the sheets are the most current available and that employees are aware of the availability of the sheets.

Catholic Medical Center will rely on the information provided on the SDS, supplied by the manufacturer/distributor, for all training and emergency response procedures.

For new chemicals, an SDS can be obtained from the manufacturer. A sample request (form) letter may be obtained from the Safety Manager to assist with this as requests should be made in writing.

HAZARDOUS WASTE DISPOSAL
The hazardous Waste disposal plan is located on the Environment of Care Website on the CMC intranet.

Infection Prevention Practices

Hand washing. Catholic Medical Center has adopted the Center for Disease Control hand hygiene guidelines. Hand washing is the single most important method of reducing the spread of infection. These guidelines can be found in the Infection Control Policy – Hand washing, located in the Infection Control Manual on the Infection Prevention Department’s intranet site. An outline of this policy is below:

  • DO NOT wear artificial fingernails or extenders when providing patient care or handling/processing sterile supplies.
  • Keep natural nail tips less than ¼-inch long.
  • Wear gloves when contact with blood or other potentially infectious materials, mucous membranes or non-intact skin could occur.
  • Remove gloves after caring for each patient. Do not wear the same pair of gloves for the care of more than one patient and do not wash gloves between uses with different patients. Change them.
  • Change gloves during patient care if moving from a contaminated body site to a clean body site or when moving from one contaminated body site to another.
  • The use of gloves does not eliminate the need for hand hygiene. Gloves reduce hand contamination by 70 - 80%, prevent cross contamination and protect patients and health care personnel from infections. Gloves MUST be changed before and after each patient. Hands must be washed after removing gloves.

Sharps Safety. Sharps must always be handled and disposed of safely so as not to be a potential hazard to yourself, patients or others.

  • Do not bend, recap by hand, shear or break contaminated needles or other sharps.
  • Where medically necessary, needles should be recapped using a mechanical device or a one-handed method.
  • Do not remove used needles from disposable syringes by hand.
  • Do not point a used sharp toward any part of your body.
  • Immediately after use, engage sharp safety mechanism, dispose of contaminated sharps in an appropriate puncture-resistant, leak proof container.
  • Report any sharps containers that are not easily accessible to Infection Control.

Prevent contact with sharps as this is your best defense. Be sure to always: