MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
PATIENT RELATIONS
VOLUNTEER
SERVICES
Sabina Sanchez
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Patient Satisfaction and Customer Service
Definition of customer service:
Wikipedia states that “Customer Service is the provision of
service to customers before, during and after a purchase.
Customer Service is a series of activities designed to enhance
the level of customer satisfaction-that is, the feeling that a
product or service has met the customer’s expectation. A
customer service experience can change the entire perception
a customer has of the organization”
MEADOWLANDSHOSPITAL.ORG
How can our team provide excellent
customer service?
-Give everyone a “warm welcome”! Greet patients/visitors
with a smile. Maintain eye contact. Make customer service a
priority!
-Respond in a timely manner. You may not have the answer
to a request-but you have the power to contact the
appropriate department/person who has the answer! Give the
patient/visitor a time frame. Follow up to ensure request
was fulfilled!
-Way finding Accompany patients or visitors to their
destination or ask someone else to assist.
-Take ownership! Resolve the problem or issue or involve a
colleague who can.
MEADOWLANDSHOSPITAL.ORG
-Show you care! Demonstrate sincerity, enthusiasm
and warmth in delivering care and in communicating
with patients, visitors and fellow team members!
-Take pride in your appearance! Dress in compliance
with MHMC Dress Code Policy. Wear the appropriate
uniform. ID badges are always worn at eye level.
Remember you are the face of our facility!
-Be positive! Leave your personal issues and concerns at
home! Be wary of your body language and tone of voice.
We never look good by making other people look bad!
If you encounter a situation with a patient, visitor or team
member that you feel you need assistance with-contact
supervisor/manager/director for guidance.
MEADOWLANDSHOSPITAL.ORG
What is a service failure?
-A service failure is any patient’s perception of
interruption of service or the lack thereof.
-Service failure could be perceived differently by each
patient.
-Research has shown that patients (customers) who have
had a service failure resolved quickly and properly are
more loyal than are patients who have never had a service
failure.
-Hospitals with high patient satisfaction are also the
facilities with high patient concerns/complaints-it is how
they resolve the concerns that make them great!
MEADOWLANDSHOSPITAL.ORG
The Three “A”s of Service Failure
-Acknowledge-Recognizing that the patient/visitor/team member has
experienced a “service failure” and actively listening to the
concern/complaint.
-Apologize- Voicing your sincere regret for the concern even if you
were not responsible or aware of the failure relays to the patient that
you care. A simple “I am sorry for your inconvenience” goes a long
way.
-Amend-Making amends for the service failure could be as easy as
picking up the phone to contact the appropriate person or
department to resolve the problem. All employees have the power to
make amends for a service failure! The patient or visitor may request
to speak to a Clinical Director, Nursing Supervisor, Patient Advocate
or member of Administration.
MEADOWLANDSHOSPITAL.ORG
Effective patient complaint resolution is a
GUARANTEE for high patient satisfaction.
HCAHPS-Hospital Consumer Assessment
of Healthcare Providers and Systems
The HCAHPS Survey is the first national, standardized, publicly
reported survey of patient’s perceptions of hospital care. It is a 32
question survey instrument and data collection methodology for
measuring patient’s perceptions of their hospital experience. Since
2008, HCAHPS has allowed valid comparisons to be made across
hospitals locally, regionally and nationally.
Adult patients who are admitted on Med/Surg, Telemetry, ICU and
Maternity can complete an HCAHPS survey. MHMC surveys 100%
of discharged patients in these areas.
 MHMC utilizes Press Ganey for survey distribution and data
collecting.
 HCAHPS scores are based on consecutive quarters of patient
surveys and are publicly reported on
www.medicare.gov/hospitalcompare
 A portion of CMS reimbursement to hospitals is based on
HCAHPS data


ADVANCE DIRECTIVES
What is an Advance Directive for Health Care?
-It is a written document which gives direction regarding your health care
in case you are no longer able to make your wishes known. An Advance
Directive may be a living will, a durable power of attorney for health care
or a combination of both. It is an effective means of maintaining control
over your care, if you become incompetent to make decisions. The
document also states specific directions regarding life-prolonging
treatments and the conditions under which you would or would not
want such treatments to be carried out.
-All admitted MHMC patients over the age of 18 are asked if they have
or would like an Advance Directive-regardless of why they are in the
hospital.
-Patient Advocate or Nursing Supervisor can assist in completing
Advance Directive.
MEADOWLANDSHOSPITAL.ORG
Sabina Sanchez
Patient Advocate,Volunteer and
Community Services Coordinator
201-392-3397
Monday through Friday 9-5

Thank you and good luck!
Workplace Etiquette & Professional Conduct
Marat Rysmendiev,
Director Marketing,
Communications, PR &
Protocol
MEADOWLANDSHOSPITAL.ORG
Workplace etiquette and professionalism is about conducting yourself
respectfully and courteously. You are the ambassador of the business. When
you start a new job, you need to make a good impression on your employer
and co-workers. Below are some etiquette concepts that should be
remembered and followed at a workplace.
MEADOWLANDSHOSPITAL.ORG
- The Art of Appreciation and Being Polite and Friendly
- Attitude is Everything
- On Your feet!
- Write It Right Emails And Not Using Spellcheek (Oops!)
- Please Listen Carefully...
- Call Back
MEADOWLANDSHOSPITAL.ORG
- Play the Game by the Rules
- Say My Name!
- Reciprocate with Others
- An Unprofitable Mix
- Rescue Rangers Beware!
- Don't Sneeze on It and Personal Hygiene
MEADOWLANDSHOSPITAL.ORG
- FU Manners
- Cell Phone Etiquette
- Check Your Attire!
- Hay is for Horses
- Watch the Clock
- An Invitation That Gets a Yes
MEADOWLANDSHOSPITAL.ORG
- Are You A Brain-Picker?
- Don't Be a Mailing List Abuser
- Be Authentic!
- "The Interrupter" Are You One?
- Show Up or Call
- Brutally Honest or Just Brutal
MEADOWLANDSHOSPITAL.ORG
- Don't Turn Your Back
- The Power of the Written Word!
- Say No to the Lambada at Work
- Watch What You Say and Where You Say it!
- Multi-Culturalism IQ
- Common Courtesy and Common Sense
MEADOWLANDSHOSPITAL.ORG
TEAMSTEPPS
JANINE MALAVE, NURSE MANAGER
MATERNAL CHILD HEALTH
TEAMSTEPPS-J MALAVE, RN
COMMUNICATION
Effective communication skills are vital for
patient safety
 Enables team members to effectively relay
information
 The mode which most strategies and
tools are executed

COMMUNICATION IS …
◦ The process by which information is
exchanged between individuals,
departments, or organizations
◦ The lifeline of the Core Team
◦ Effective when it permeates every aspect of
an organization
STANDARDS OF EFFECTIVE
COMMUNICATION
COMPLETE
Communicate all relevant
CLEAR
Convey information that is plainly
understood
Brief
Communicate the information a concise manner
Timely
Offer and request information in an appropriate
timeframe
Verify authenticity
Validate or acknowledge information
SBAR PROVIDES………






A framework for team members to effectively
communicate information to one another
Communicate the following information:
Situation: What is going on with the patient?
Backround: What is the clinical backround or
context?
Assessment: What do I think the problem is?
Recommendation: What would I recommend?
HANDOFF IS………….

The transfer of information during
transfers in care across the continuum

Includes an opportunity to ask questions,
clarify, and confirm
Handoff Consists of……
Transfer of responsibility and
accountability
 Clarity of information
 Verbal communication of information
 Acknowledgment by receiver
 Opportunity to review


“I PASS THE BATON”
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Nancy Brobeck,
Director
INFECTION
CONTROL
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Infection Prevention and Control
Infection Prevention and Control Program Goal:
To reduce the risk and prevent infections
Hospital Acquired Infections / year in the US :
• Estimated 2 million infections
• Accounts for nearly 100,000 deaths.
• Estimated costs $10 billion
• Can prevent 30% infections by following standard and
transmission based precautions.
MEADOWLANDSHOSPITAL.ORG
Standard Precautions
•
Consider all blood and body fluids as infectious.
•
Follow for all patients regardless of diagnosis
•
Hand hygiene before and after donning gloves.
Gloves, Gowns, Masks, and Eye when splashing
of body fluids are expected
• Dispose sharps in proper receptacles.
•
•
Lab samples transported in appropriate
containers in biohazard bags.
MEADOWLANDSHOSPITAL.ORG
Donning and Doffing Personal Protect
Equipment
Must to in correct order
Donning (bottom up):
1st Gown
2nd Mask
3rd Goggles
4th Gloves
Doffing (alphabetical):
1st Gloves
2nd Goggles
3rd Gown
4th Mask
Standard Precautions (continued):
•
•
•
•
•
•
Do not wear Personal Protective Equipment
(PPE)in hallway.
Blood Spills - remove with blood spill kit
Soiled Linen- wear gloves / avoid contact with
your clothing.
Single patient use means only for 1 patient
Single use vials are for one patient one time use,
They do not have a preservative Discard
immediately after use
Bacteria can survive for days on equipment and
surfaces.
Transmission Based Precautions
•
•
•
•
•
•
Based on mode of disease transmission
2007 CDC guidelines for isolation precautions:
Determines type and duration of isolation
Located on our intranet in Infection Control Policies
Compliance is monitored with isolation
precautions and hand washing.
Noncompliance reports to employee’s manager
Education will be done
For repeated events disciplinary actions per HR
policy.
MEADOWLANDSHOSPITAL.ORG
Contact Precautions
• For known or suspected infections
• Infections transmitted by patient contact or their
environment.
• Direct Contact person to person transmission
• Indirect Contact transmission with contaminated objects.
• Wear gloves and gowns when entering the room
• Discard PPE before exiting the room.
• Examples: C- difficile, and MRSA infections.
Droplet Precautions
•
•
•
•
•
•
Prevents transmission of microorganisms in
mucus membranes by coughing, sneezing,
talking, and suctioning.
Droplets can travel 3-6 feet of the patient
Examples: meningitis, influenza, pertussis,
mumps and pneumonia.
Wear mask prior to entering the room
Remove mask without touching front of mask
Patient wears mask when leaving the room
MEADOWLANDSHOSPITAL.ORG
Airborne Precautions
• Diseases with very small microorganisms can travel
long distances on air currents and be inhaled
• Requires a negative pressure room with doors closed
• Ball in the wall device alert for functioning of negative
pressure
• Examples: Tuberculosis, Varicella (chicken Pox),
Measles, and Disseminated Herpes Zoster (Shingles).
• Requires N 95 particulate respirator mask and
annual fit test
• Patients wear a surgical mask when leaving the room.
Pulmonary Tuberculosis
• Location of negative pressure rooms: 374, 375, ICU 11,
12, ED, PP, and 445 Peds.
•R/O TB 3 consecutive days of sputum for AFB culture
and smear is required.
•Samples must be dated and timed for 3 consecutive days.
•Sputum for induction can be used
• AFB smears are sent out to Quest and usually released
the following evening.
•The culture report takes about 55 days.
•Employees involved with patient contact need annual skin
test or symptom inventory form annually
Pulmonary Tuberculosis
•If the patient has a positive AFB smear, the Hudson
County Chest Clinic is to be notified immediately on
Monday through Friday.
•Call infection control nurse or nursing supervisor to
make aware.
•Patient cannot be discharged until 3 negative AFB
smears at least 8 hrs apart.
•DOH must visit patient in the hospital and do a home
assessment to evaluate people in contact that will need
testing for TB.
•TB /Chest clinic deliver meds daily to the patients
house to observe them taking meds.
Hand Washing
•
•
•
•
•
Most effective deterrent to the spread of infection
Instruct patients, family, and visitors about hand
hygiene and to
remind their healthcare providers to wash their hands
if they do not see them do so
Let the patient see you wash your hands
We follow CDC guidelines with 20 second hand wash
Fingernails for direct care givers- No artificial nail
products. Nails to be well manicured, and length < ¼”
above the finger tip.
When to wash your hands
•
•
•
•
•
•
Before and after glove application
Before and after touching a patient
After touching patient environment
Before and after a clean / aseptic procedure
After body fluid exposure
When you enter and exit the room.
Soap and Water
• For visibly soiled hands and C- difficile precautions
• Wet hands, apply soap, and wash all surfaces of your
hands for 20 seconds; dry with towel, then rinse (sing
(Happy Birthday) twice).
•Use paper towel to turn off water.
Alcohol Based Gel (Purell)
• Routine decontamination of hands
• When no hand washing facilities are available
• Directions- Apply alcohol based gel to the palm of
one hand and rub hands together covering all
surfaces until it is dry
C- difficile Precautions(Deadly Diarrhea):
•Use contact precautions
•Pink sign to cover alcohol based gel dispenser,
stating not to use this product, advising to use soap
and water
• Alcohol based gel has no effect on c-difficile
• Call EVS for terminal cleaning with Yanex Machine
for air and surface disinfection
• Spores live for months on surfaces waiting for
someone new to infect
Prevention of Multidrug Drug Resistant Organisms (MDRO).
• MDROs are increasing world wide
• Increases the risk of morbidity, mortality; and cost.
• Problem is that antibiotics are used incorrectly,
leading to antibiotic resistance
• Not able to develop new antibiotics to treat these
infections
• Careful use of antibiotics and following isolation
precautions is crucial to prevent the transmission
• MDRO Alerts posted on EMR cover page.
Urinary Catheter Orders
USE Order set under Procedure section on each department order menu
[ ] External condom catheter
[ ] Straight Cath Drop down menu for this selection
[ ] for urine sample
[ ] other: _____________________
[ ] RN to Insert Indwelling Foley Catheter (selection includes a drop down field for foley indication):
[ ] Strict Intake and Output measurements in the Intensive Care Unit Only
[ ] Urinary retention including obstruction and neurogenic bladder
[ ] Short perioperative use in selected surgeries (less than 24 hours)
and for urologic studies or surgery on contiguous structures.
[ ] Assist healing of perinea and sacral wounds: stage (3 or 4) in incontinent
patients
[ ] Required immobilization for trauma or surgery
[ ] Hospice/comfort care or palliative care, if requested by patient
[ ] Chronic indwelling urinary catheter on admission
[ ] Other reason: ________I_________
******INCOTINENCE ALONE
IS NOT AN ACCEPTABLE INDICATOR******
[ ] Urologist to Insert Indwelling Catheter (Name of urologist): _____________________________________
(Exclude from nursing protocol for the nurse to remove the Foley when no longer indicated)
__________________________________________________________________________________
RN TO EVALUATE THE INDICATION DAILY
IF THE FOLEY IS NO LONGER INDICATED, DISCONTINUE IT
USE ORDER SET TO KNOW THE INDICATION (located under procedure section in dept. order menu)
BLADDER SCAN PRIOR TO INCERTION OR REINCERTION
DISCUSS IN REPORT THE INDICATION FOR THE FOLEY
IF TRANSFERRING FROM ICU AND STRICT I&O IS THE ONLY INDICATION THEN DC THE FOLEY
Latex Allergy
•Skin reactions to latex can start as an irritant dermatitis
• Can develop into severe life threatening allergic
reaction.
• Read labels on products
• Examples of products that may have latex: Ace
bandages, airways, bite blocks, BP cuffs, breathing bags,
electrode pads, and stethoscope tubing etc.
•Non-medical products containing latex: Adhesive tape,
air mattress, balloons, chewing gum, condoms,
telephone cords, and pacifiers.
Employee Blood/Body Fluid Post Exposure Resource Guide
If an exposure occurs, immediately wash the area, notify your supervisor
and go report to the ED.
Labs to be done:
EMPLOYEE:
Rapid HIV
CBC with differential
Syphilis Screen
Hep B Ag
Total Cholesterol Hep B surface Ab
Triglycerides
Hep C Ab
UA
CMP
UCG (females)
SOURCE PATIENT:
Rapid HIV (If source is positive, complete on misc slip HIV resistance test to
Truvada and Insentress; genotype and phenotype viral load.
Hep B Ag, Hep C AB, and Syphilis Screen
Must follow up with employee health nurse for all injuries / incidents The
employee health nurse will follow up with any pending results not completed
at the time of your ED evaluation.
MRSA Screening and Chlorhexidine Gluconate (CHG) Bathing
Reduces bacteria on the skin to prevent infections (SSIs and CLABSIs).
CHG bathing is done:
Once daily on all ICU patients
Adults on Med-surg units with central lines.
Inpatient and outpatient pre op procedures: Spinal fusion cases; and
podiatry and orthopedic cases requiring implants.
Nasal Swab for MRSA (screening) is done preoperatively on
inpatient and outpatient surgical procedures listed above.
Mupericin nasal treatment is needed for positive MRSA tests for at
least 5 days before surgery. This is to reduce nasal colonization of
MRSA, to reduce risk of transmitting this bacteria from the nose to
the surgical site. If results are known less than 5 days pre op, it
must be continued to complete 5 days of treatment.
Cleansing of Equipment: Always use dedicated equipment for isolation rooms
when possible. All equipment (including stethoscopes) going from patient to patient
should be cleaned and decontaminated after each patient use. Always follow
manufactures recommended disinfection chemicals/agents and wear gloves.
PDI Sani-Cloth Germicidal wipes.
Contact time – is the amount of time the surface is wet when wiping equipment. The
amount of contact time is printed on the label. Bacteria and viruses are being killed
during the drying time.
Super Sani Cloth Germicidal Disposable Wipe (Purple top)
Disinfects in 2 minutes contact time (wet time) .
Ideal for daily use fast-paced environments that require the shortest contact time.
High touch surfaces such as bed rails, countertops and carts
Effective against 27 microorganisms
Sani Cloth Bleach Germicidal Disposable Wipe (Orange top) for Glucometer ,
norovirus, MDROs and CDI
Disinfects in 4 minutes contact time (wet time) .
Sani Cloth AF3 (Grey Color) is ALCOHOL FREE
Use for computers
Contact time 3 Minutes
ISO
DOCUMENT CONTROL, RETIEVAL & VERIFICATION
&
Organization Structure
Felicia Karsos
CEO
International
Organization for
Standardization
ISO Standards
◦ ISO = International Organization for Standardization
◦ ISO standards – are generic standards (can be
applied to all types of industries)
◦ The ISO 9001 standard is used for quality
management of the entire hospital.
Quality Management
 Quality
management means what the
hospital does to ensure that its products or
services satisfy the customer's quality
requirements and
 comply with any regulations applicable to
those products or services.
Quality management (cont.)
 Quality
management also means what the
hospital does to:
 enhance customer satisfaction, and
 achieve continual improvement of its
performance.
DNV, ISO, NIAHO
 Det
Norske Veritas (DNV) (hospital’s
accreditation body) uses ISO 9001
standards and NIAHO standards during
their annual survey visit for accreditation.
 ISO
9001 gives the requirements for what
the organization must do to manage
processes affecting quality of its products
and services (delivering healthcare).
DNV, ISO, NIAHO
 NIAHO
= National Integrated
Accreditation for Healthcare Organizations
 NIAHO standards – are more specific, only
for healthcare.
 NIAHO standards - based upon the Centers
for Medicare and Medicaid Services (CMS)
Conditions of Participation and State
Operations Manual Regulations.
What are processes?
 The
processes that the hospital uses to
carry out the standards are the hospital’s
policies and procedures.
 The current versions of all policies are
found on the homepage of the intranet.
 5 main manuals and separate
department folders.
Document Control
The intranet contains the most up-todate version of all policies and
procedures.
 All policies printed from the intranet are
verified as the most current version.
 Once a policy is printed, it is considered
an “uncontrolled document” and is no
longer considered the most current
version.

EXAMPLE – Process Medication Management

Policy & Procedure for Medication Management is located on the intranet
Patient Care Manual (ISO)

Collect data on the compliance with the P&P (ISO)

Collect and analyze data on medication errors and develop corrective
action plan (ISO)

P&P addresses administration of pain medication as well as effectiveness of
pain management. (NIAHO)

Medications administered within 2 hours of time schedule for routine
medications and 60 minutes for critical medications. (NIAHO)

Organization identifies critical medications. (NIAHO)

The P&P is reviewed at least every 3 year or more frequently as required
(NIAHO & ISO)
In Summary
 ISO
Standards are the backbone. Can be
applied to many industries.
 NIAHO standards – for healthcare.
 DNV uses both standards as a way to check
that the hospital is following hospital policy
and the standards/regulations in everyday
functions.
Organizational Structure
Governing Board
Quality Mgt Oversight Comm.
Patient Safety & Quality Comm.
Felicia Karsos, CEO
-Ancillary depts
-Marketing
-General Counsel
-CFO
-Revenue Cycle
-Finance
Stanley Galichenko, VP
-Security
-Facilities
Dr. Alan Rimmer
-Lab
-Emergency Department
-Registration
M. Bellifemine, CMO
-Medical Staff Office/GME
E Garrity,VP, HR
-HR
-Food & Nutrition
-Environmental Services
D. Ortiz, CNO
-Nursing units
-Infection Control, Emp Health
-Pharmacy, Respiratory
-EMS
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Vision, Mission,Values
&
Evidence Based Management
Felicia Karsos
Chief Executive Officer
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
VISION
To be the destination of choice when your
loved one needs care in the Hudson/
Meadowlands region.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
MISSION
Our mission is to provide exceptional
patient outcomes through our
commitment to safety. We do this with
service excellence and sophisticated
information technology to bring
evidence-based medicine and evidencebased best practices to our patients.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
CORE VALUES
Medicine with compassion
Evidence based practices
Accountability
Dignity for our patients
Open and transparent communication
Welcoming to our community
MEADOWLANDSHOSPITAL.ORG
Drama drains our energy
Drama reduces innovation
Drama depletes our passion for
our work
Drama contributes to disease
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Everything in life is perception.
There is no reality.
The only thing we want to hear is: “Who
Said what” or “Did what”
Everything else is your opinion.
We use EVIDENCE ……
not EMOTION
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
•Everything in life is perception.
•There is no reality.
•The only language we want is:
• “Who said what” and
• “Who did what”
•Everything else is your opinion.
•MHMC uses EVIDENCE ……
•It’s safer for our patients
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
MHMC wants engaged employees
MHMC wants evidence, not
emotion
CONNECT instead of BLAME
CREATE instead of COMPLAIN
COACH instead of CRITICIZE
of
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
MEADOWLANDSHOSPITAL.ORG
Workplace Etiquette & Professional Conduct
Patient Safety
Dona Ortiz
Acting Chief Nursing
Officer
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Patient Safety
Actions undertaken by individuals and
organizations to protect healthcare recipients
from being harmed by the effects of healthcare
services.
MEADOWLANDSHOSPITAL.ORG
Patient Safety
•
Increase Focus on the Human Factors:
• Memory lapse,
• Failure to communicate,
• Poorly designed Equipment,
• Exhaustion, Ignorance,
• Noisy working conditions,
•
•
other personal and environmental factors.
GOALS
• Design safer process- Barriers or safeguards can prevent untoward
events.
• Reduce Harm Caused By Mistakes- People must be able to quickly
recognize the adverse event and take action.
MEADOWLANDSHOSPITAL.ORG
Implementing a Patient Safety Program
•Consider
safety improvement recommendations
made by external groups (DNV, CDC, IOM,
HRET)
•Share safety improvement ideas.
•Focus attention on high-risk processes
•Incident reports and other information are used
to identify risk-prone patient care processes
MEADOWLANDSHOSPITAL.ORG
Implementing a Patient Safety Program
•Redesign
our processes so that simple mistakes
don’t end up harming patients
•Eliminate opportunities for errors – Failure
Modes and Effects Analysis (FMEA)
•Build better safeguards to catch and correct
errors before they reach the patient
•Establish a Culture of Safety
MEADOWLANDSHOSPITAL.ORG
Safe Patient Handling

“Safe Patient Handling Act” N.J.S.A. 26:2H-14.8 et. seq.,
requires hospitals to minimize unassisted patient handling by utilizing
assistive patient handling technology.





Safe patient handling program
Assessment of patient’s need for assisted
patient handling
Evaluation of assistive devices available within
the facility
Education and Training of Personnel
Review of work related injuries
MEADOWLANDSHOSPITAL.ORG
Risk Management
•Incident: any
unusual occurrence or mishap
•Incident reports: Tool used to track and trend
incidents
•Health Care Incident Report: Patient/visitor incident
•Employee Incident Reports: For EMPLOYEES ONLY
•Examples of Incidents: Accidents, Lost/Damaged
Property, Equipment (Damage/Malfunction), Exposure to
Infectious/Hazardous Material, Medication Error
MEADOWLANDSHOSPITAL.ORG
Abuse/Neglect
•Abuse:
physical, sexual, or psychological attack or
assault on the elderly or vulnerable adult/child.
•Vulnerable: Any adult/child who, due to physical or
mental incapacitation, is at risk for abuse/neglect
•Neglect: Any omission of care which results in harm to
the health or welfare or risk of harm to the elderly or
vulnerable adult/child.
•Exploitation: Financial or material gain as a result of
acts of trickery, threat or in any way taking advantage of
an elderly or vulnerable adult.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Alexis Joseph, Director
CORPORATE
COMPLIANCE PROGRAM
MEADOWLANDSHOSPITAL.ORG
Compliance Program

The Compliance Program provides an
overview of key legal and regulatory
requirements

System that lays the foundation of ethical
behavior composed of:
◦ Individuals
◦ Polices and procedures
◦ processes
Compliance Program
 MHMC
is committed to providing high quality
care in compliance with all applicable laws, rules,
regulations and standards
 Employee: act
with the highest level of integrity
 Management: support/carry
out objectives
 Compliance
Officer: ensures that compliance program is
being properly operated and implemented
 Governing
Board: provides vision, guidance, and support
Combating Fraud and Abuse

Medicare Fraud: making false statements or
representations to material facts to obtain
some benefit or payment for which no
entitlement exists

Medicare Abuse: occurs when doctors or
suppliers do not follow good medical practices
that lead to
◦ unnecessary costs to Medicare
◦ improper payment
◦ services that are not medically necessary
HIPAA (Health Insurance
Portability and Accountability Act)
•
Patient confidentiality
– ALWAYS protect/secure paper & electronic health information
– Only accessible through need-to-know basis
– Can only be released upon written consent from patient
•
PHI (Protected Health Information)
–
–
–
–
Demographic information
Medical data/results/records
Account handling/Billing Management
The Privacy Rule protects all individually identifiable health
information
EMTALA (Emergency Medical
Treatment & Labor Act)

Ensures public access to emergency services
regardless of ability to pay

Requires hospitals to provide an
examination and needed stabilizing
treatment without consideration of
insurance coverage/ability to pay
Whistleblowing
Federal Whistleblower rule allows anyone
who knows about a person or entity
submitting false claims to bring a lawsuit
on behalf of the government.
 NJ Law-Conscientious Employee
Protection Act (CEPA)
 You are protected by law from retaliation
relating to any report made in good faith.

Chain of Command
 Duty
to report suspected wrongdoing or
misconduct
 Compliance
Office is located on the 2nd
floor of MHMC with the Administration
suite
 Compliance
Office phone #: 201-392-3262
 Anonymous
Compliance Hotline: 201-392-
3191
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Liz Garrity
Vice President
HUMAN RESOURCES
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Rules of Conduct
MHMC provides a safe environment for employees, patients and visitors
The following are examples of behaviors that will not be permitted:
Theft
Falsification of information
Destruction of property
Insubordination
Disclosing confidential information
Being under the influence of alcohol or illegal drugs while at work
Smoking on Hospital property
Violence in the Workplace
Please see the HR Rules of Conduct Policy for additional information and details.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
ANTI - HARASSMENT POLICY
MHMC is dedicated to providing a workplace that is free of all forms of employment discrimination,
including sexual and other unlawful harassment.
Any conduct that creates an intimidating, hostile or offensive work environment is not tolerated.
Some examples of sexual harassment are unwelcome behaviors such as:
Sexual advances, propositions, off color jokes, touching, physical assault, sexually explicit
conversations ,suggestive pictures, etc.
Some examples of other forms of harassment are:
Verbal or physical conduct relating to an individual’s race, religion, creed, color, national origin,
citizenship, disability, age, military status, marital status, sexual orientation, ancestry, or veteran
status.
Please see the HR Anti Harassment Policy for additional information and details.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
DRESS CODE
All employees are expected to dress appropriately and professionally.
Employees whose position requires that they wear a uniform must wear the correct uniform and
footwear.
Employees working in other areas of the hospital must dress in a professional business manner.
Examples of items of clothing such as flip flops, shorts, jeans, tee shirts, leggings, hats, etc. are not
appropriate or permitted.
Please see the HR Dress Code Policy for additional information and details.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
ATTENDANCE POLICY
It is vital that all employees are at work on their scheduled times and dates.
It is every employee’s responsibility to adhere to their schedules.
It is also every employee’s responsibility to find out what their own department’s policy is when
calling in an absence ,or lateness., how much time prior to the beginning of their shift is required
and who to contact .
Excessive ( three or more occurrences in a three month period) absences or lateness may lead to
disciplinary action up to and including termination of employment.
No call no shows, excessive missed clock ins/outs, or forgotten clock ins/outs and patterned
absences will be reviewed and may lead to disciplinary action up to and including termination of
employment.
Please see the HR Attendance Policy for additional information and details.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
HR SERVICES
HR Online – Information System for Employees
•View
and Print Paystubs, W2 forms, change demographic information, etc.
MystaffingPro – Applicant Tracking
•View
and apply for open positions via hospital website/careers section
Benetrac – Online Benefits System
•Enroll, or
waive benefit coverage and view and manage your personal benefit plans
Kronos – Timekeeping system
•Manage
your time at work online and submit time off requests
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Glenn Berchtold,
Director EMS &
Emergency Management
&
Safety Officer
MEADOWLANDSHOSPITAL.ORG
EMPLOYEE SAFETY
RESPONSIBILITIES:
Safety at Meadowlands Hospital is every employee’s
responsibility.
Every employee is expected to follow hospital safety
policies. Policies can be found on the Intranet under Main
Manuals
Employees are expected to make recommendations for
safety improvements.
Familiarize yourself with policies
related to CODES & DRILLS
90
REPORTING SAFETY PROBLEMS:
A life threatening situation requires immediate
action.
 Report any safety issue or incidents/occupational
injuries to your Supervisor or, if after hours, the
Nursing Supervisor on duty.
 Always call the Safety Officer at ext. 3219


Dial 8 for any emergency
91
Prevention of Injury

Bending and Lifting
◦ Avoid lifting when possible, use patient
handling equipment
safe
◦ Bend your knees to let your legs do the work ,keep
abdominal muscles tightened
◦ Store heavy objects at waist level
◦ Ask for help when necessary.

Pushing and Pulling
◦ Push rather than pull, avoid leaning over the object and
move with the object
◦ Use whole body to push and not just your arms, and get
help when you need it.
92
You work on a
SMOKE FREE CAMPUS!
Emergency Preparedness
HOSPITAL WIDE DRILLS
The purpose of disaster planning and drills is to prepare
all personnel and members of the medical staff to cope
with real incidents when they occur.

We conduct 2 drills per year

Drills help us to assess our effectiveness in the case of
a disaster.
The command post (EOC) is located in the 2 Center
Conference Room

Check with your Supervisor for your assigned duties
during a drill.
94
Emergency Codes
Code Triage - External Mass Casualties/Internal
Emergency
Code Red – Fire
Code Blue – Adult Medical Emergency/Cardiac Arrest
Code White – Pediatric Medical Emergency
Code Amber - Infant/Child Abduction
Code Yellow- Bomb/Bomb Threat
Code Gray –Patient Elopement
Code Silver –Threat of Violence (Active Shooter)
Code Orange – Hazmat Situation/Decon-Needed
Code 9 – Utility Failure
Code Clear – The Situation/Emergency is now cleared
Emergency - Dial 8
95
Code Response for
Terroristic Actions



Bioterrorism
IED’s (explosives)
Bomb Threats

Protective Measures
◦ Report anything suspicious to Supervisor and/or Security
immediately.
◦ Utilize Standard Precautions and Hand Washing
◦ Avoid direct contact with suspicious items
◦ Contain the affected area by closing doors and shutting
down ventilation system.
◦ Possible evacuation plan implementation
◦ Safety Officer or Security will contact proper local
authorities.
96
Emergency Preparedness

Meadowlands Hospital
provides
◦ Trained staff for decontamination
◦ Personal protective equipment and detection equipment
◦ Decon tent & trailer for showers-back of the hospital

Emergency Backup
Communications Systems
◦
◦
◦
◦
Portable radios
State Police radio system
Cell phones
EMS dispatch center-4th fl
97
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Gary Patterson
Director of
Environmental
Services
MEADOWLANDSHOSPITAL.ORG
Hazardous Materials/Waste
Management (Right-to-Know)


This section covers health risks, routes of entry
with exposure, and procedures for clean-up
related to hazardous materials.
Hazard Communications
◦ OSHA Requirements
 Written plan by employer, labeling by manufacturer
 Labeling by employee, training and education

Types of Hazards
◦ Flammables, Corrosives, Toxins, Reactive
Hazardous Materials/Waste
Management

RECOGNIZE HAZARDOUS SUBSTANCES BY THEIR:
◦ Signs (to an area)
◦ Color Coding (usually red or yellow)
◦ Container Labels (always read the label BEFORE using a hazardous
substance)

ROUTES OF ENTRY:
◦
◦
◦
◦

Inhalation (lungs)
Absorption (skin)
Ingestion (digestive system)
Injection (puncture or open wound)
HEALTH HAZARD:
◦ Acute = immediate effect
◦ Chronic = long term effect
HAZARDOUS MATERIALS/WASTE
MANAGEMENT - SPILLS
WHAT DO I DO IF THERE IS A HAZARDOUS MATERIAL SPILL?

Should an incident occur that involves the spill of a hazardous substance, your first concern will
be for the protection of yourself, your co-workers in the area, patients or visitors. “Isolation
and evacuation of the immediate area by all persons who are in danger should be your
first priority”

After evacuation, refer to your Material Safety Data Sheets/MSDS to determine the hazards
present, and PPE/personal protective equipment. Report spill by calling the hospital emergency
line. Dial 8 and explain to the operator that you are reporting a possible CODE ORANGE

Additionally, a hospital or employee incident report will be completed and forwarded to Risk
Management or Employee/Occupational Health respectively.

For large hazardous materials spills you should contact the Operator at *8 and report a
CODE ORANGE. Specify the hazardous material that was spilled and the exact location.
Role of Safety Data Sheets in
the Harmonized System - SDS
Safety Data Sheets (SDS)
Safety Data Sheets are an essential component of the GHS and are intended to provide comprehensive information
about a substance or mixture for use in the workplace chemical management.
Minimum Information for an SDS
1. Identification of the substance or mixture and of the supplier
a)
GHS Product Identifier
b)
Other means of Identification
c)
Recommended use of the chemical and restrictions on use
d)
Supplier’s details (including name, address, phone number etc.)
e)
Emergency phone number
2. Hazard identification
8. Exposure controls/personal protection
3. Composition/information on ingredients
9. Physical and chemical properties
4. First aid measures
10. Stability and reactivity
5. Fire-fighting measures
11. Toxicological information
6. Accidental release measures
12. Ecological information
7. Handling and storage
13. Disposal information
14. Transport information

What is the Globally Harmonized System (GHS)?

GHS stands for the Globally Harmonized System of Classification and Labelling of Chemicals. GHS defines and classifies the hazards of
chemical products, and communicates health and safety information on labels and safety data sheets). The goal is that the same set of
rules for classifying hazards, and the same format and content for labels and safety data sheets (SDS) will be adopted and used around
the world. An international team of hazard communication experts developed GHS.

SDS FORMS ARE AVAILABLE ON THE HOSPITAL INTRANET. MAIN SECURITY DESK, and ED
Why is global harmonization
necessary?

Currently many different countries have different systems for classification
and labelling of chemical products. In addition, several different systems can
exist even within the same country. This situation has been expensive for
governments to regulate and enforce, costly for companies who have to
comply with many different systems, and confusing for workers who need
to understand the hazards of a chemical in order to work safely.

GHS promises to deliver several distinct benefits. Among them are:
Promoting regulatory efficiency.
Facilitating trade.
Easing compliance.
Reducing costs.
Providing improved, consistent hazard information.
Encouraging the safe transport, handling and use of chemicals.
Promoting better emergency response to chemical incidents.
Reducing the need for animal testing.








What is a pictogram?

Pictograms are graphic images that immediately show the
user of a hazardous product what type of hazard is present.
With a quick glance, you can see, for example, that the
product is flammable, or if it might be a health hazard.

Most pictograms have a distinctive red "square set on one of
its points" border. Inside this border is a symbol that
represents the potential hazard (e.g., fire, health hazard,
corrosive, etc.). Together, the symbol and the border are
referred to as a pictogram. Pictograms are assigned to
specific hazard classes or categories.

The graphic below shows hazard pictograms. The bold type is
the name given to the pictogram; the words in the brackets
describe the hazard.
Personal Protective Equipment

EYES
Safety Glasses

Splash Goggles
SKIN
Gloves

Face Shield
Boots
Protective Apron
Full Suit
Respiratory
Dust Respirator
Vapor Respirator
Mask or Hood
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Michael Acquaviva
Facilities Supervisor
MEADOWLANDSHOSPITAL.ORG
Utility Systems


Utilities
◦ Electric
◦ Water
◦ HVAC (Heating/Ventilation/Air Conditioning)
User Failure Plan
◦ Notify Plant Operations/Emergency Operator if
failure occurs
◦ In the case of a power failure, use emergency
electrical outlets (in red)
108
Electrical Safety

Emergency Power
◦ Automatic within 10 seconds.
◦ Daisy chains are prohibited on
Hospital property.
◦ Power will only be provided by the RED outlets.
Essential lighting in main corridors and patient care
areas will remain lit.
◦ Always use Emergency outlets RED for critical
patient care equipment (you cannot predict an
outage).
109
Medical Equipment

Safety Considerations
◦ All medical equipment must be inspected prior to use & with a current sticker
◦ Never use equipment without proper inservicing
◦ Use three prong/grounded equipment only & avoid use of extension cords
◦ When unplugging grasp the body of the plug to prevent damage to the prongs
◦ All electrical equipment brought by employees, vendors or physicians must be
checked for electrical safety by the Biomedical Engineering Department before
use.
◦ Do not touch patients while touching medical or electrical devices.

Employee Responsibilities
◦ Ensure all equipment is checked and tagged prior to use
◦ Remove malfunctioning equipment from service
◦ Complete incident report for and report problem to Supervisor
110
Facilities Dept-Landport

Landport is a work order management system that was implemented to provide a more efficient way
to send and monitor maintenance requests. ALL maintenance requests are to be submitted through
Landport and will be addressed within 2 days.


1. Go to the company intranet page: Select Landport work order log-in icon. The main login page should
appear


2. Type in your user ID and password:



User ID: mead-staff
Password: mead2013


3. Press the "Login" button to access your personal account.


4. Click the link "Create Request" and follow the directions to describe and submit your maintenance
request.


It's easy to use. You may track maintenance request progress at any time by simply logging in.


If you have any questions or need help, I can be reached at macquaviva@meadowlandshospital.org or
extension 3162.
WHAT TO DO IF EQUIPMENT
MALFUNCTIONS:

Immediately remove the equipment from service.

Fill out a healthcare incident report and report to the Nursing
Manager/Supervisor or Biomed department immediately.

Tag the equipment so that anyone can identify that the equipment
cannot be used.

Essential equipment that is needed, and not functional for patient care
during off hours, can be handled by having the operator contact the
Biomedical Engineering Technician on-call, who is available 24 hours a
day by dialing 0.
112
Medical Equipment
EMPLOYEE OR PATIENT HARM BY A
MEDICAL DEVICE:
◦ A device that has been identified as causing patient harm, or in
some way brings into play the “Safe Medical Devices Act of 1990:
must be handled in the following manner:
 Immediately respond to the individual’s clinical needs.
 Remove the equipment from service, saving all attachments, and tag
the equipment with a service tag or label.
 Notify your supervisor immediately. If an incident occurs after
normal working hours, notify the Nursing Supervisor or
Administrator-On-Call who will contact the appropriate individuals.
113
CROTHALL HEALTHCARE
Biomedical Engineering Department

Manager on Site:- Venugopal Kalathur

Current Office Room:- 406

Phone Extension:- 3149

Standard Hours at Hospital :-

Week Days :- 8.30 AM to 5.00 PM

Time is Flexible based on the need.

After Office Hours On Call for Emergency Needs.

For Emergency needs contact Hospital Switch

Board. They will reach him on his mobile.

Response Time :- 2.00 Hours.
114
Stanley
Galichenko
Director of
Security
Security Management
The Overall Goals of the Security Management Plan are to:
◦ Safeguard hospital and personal property from damage or theft.
◦ Maintain an environment conducive to the health and safety of patients,
visitors, and employees.
◦ Identify and correct security and safety hazards.
◦ Maintain order throughout Meadowlands Hospital and to prevent
disruptions to the hospital’s operations by persons or groups behaving in
an improper manner.
IDENTIFICATION
◦ All employees and volunteers are required to wear identification badges
issued by the Security Department.
◦ Wear your identification badge where patients and visitors can see it and
identify all our employees by name. We also expect all of our employees
to introduce themselves when interfacing or communicating with patients
or visitors.
116
Employee Responsibilities
Wear your identification badge at all times
Maintain patient confidentiality
Secure patient valuables, & your personal
valuables
Report all security incidents to Ext. 3269
Dial “8” for all emergencies!!!
MHMC Practices to Promote
Safety
 Limit access to facility (direct all visitors and
vendors to Security desk when accessing the
building)
 We conduct 1 fire drill/month. Be prepared
and know your responsibilities.
 Have your code card attached to ID at all
times so you know your responsibility.
 See something; say something (such as
unattended bags/packages or suspicious
objects/persons) report to ext 3269.
118
Life Safety Fire / Evacuation
Plan

Fire Alarm System
◦ Use the pull station to activate the fire alarm during smoke or
a fire condition .
◦ Dial “8” to notify Customer Services to announce the Code
for a fire (CODE RED)
◦ Close the doors & Clear the corridors

Compartmentation
◦ Fire & smoke doors close automatically.
◦ Close all patient room doors

Employee Responsibility
◦ Complete required education & Attend drills
◦ Know locations for pull station; fire extinguishers; & fire and
smoke doors. Contact your manager for these locations.
119
At the Scene of the Fire (RACE)
In the event of a fire emergency or a drill, Meadowlands
Hospital used the R.A.C.E. procedure, which stands for:
◦ Rescue/move patients to a safe area
◦ Alarm: pull Alarm AND notify Operator
by dialing “8” to provide location of fire
◦ Confine by closing all doors
◦ Extinguish (extinguish small fires)
120
At the Scene of the Fire (RACE)
In the event of a fire emergency or a drill, Meadowlands Hospital
used the R.A.C.E. procedure, which stands for:
Evacuation
◦ Horizontal/Initial Evacuation:
From one fire compartment to another
compartment (through the fire doors).
◦ Vertical Evacuation: Going from
one floor to the floor below and is only
done when a horizontal evacuation is
not possible.
Know the location of your
department's oxygen shut-off
valve
These are clearly labeled in each
patient care area.
121
EMPLOYEE RESPONSIBILITIES FOR FIRE
DRILS OR EMERGENCIES
Patients, visitors, & others will be looking to you for
guidance and direction.
 Make sure all doors, windows and fire doors are closed in
your area.
 Listen for instructions over PA system or directly from
your supervisor.
 Do not use the elevators. Restrict travel of visitors and
staff (moving through doors allows smoke through).
 Remove all guests or visitors from the corridors
immediately and return patients to their rooms.
 Keep all corridors clear for emergency personnel.
 Evacuate patients horizontally from the area in their beds
and disconnect all mechanical devises.

122
FIRE Extinguishers
TYPES OF FIRES
◦ Class A – ordinary combustibles (ash)
◦ Class B – flammable liquids (boiling liquids)
◦ Class C – electrical fires (current)
FIRE EXTINGUISHERS
◦ ABC
◦ Type K
(Portable Extinguisher for Cooking Hoods)
FIRE EXTINGUISHER OPERATION (PASS)
◦ P
Pull the Pin
◦ A
Aim the extinguisher at the base of the flames
◦ S
Squeeze the trigger while holding the extinguisher upright
◦ S
Sweep the extinguisher from side to side
123