November 2014

Welcome Welcome to Deepa Abraham, Reg. N., who will join the Inpatient Unit staff and to Lynda Amorim, who is now working in our pharmacy It is Almost Time! Yes, it is almost here… our once a year day….the much anticipated silent auction that is sponsored by our WHGH Managers! Our Managers have kindly agreed to donate items to be auctioned off as a Foundation Fundraising event. All proceeds will go towards new hospital equipment. The auction will occur on Tuesday December 16th, 2014 in our front lobby from 10:00 am to 3:00 pm. As always there will be lots of great items and a chance to do some Christmas shopping.

Let’s Keep Our Photocopy Room Neat Helping to keep our hospital neat and tidy is everyone’s business – photocopy rooms included. When using the copiers, please take a look around – are the interdepartmental envelops in the slot on the wall where they belong? Scrap paper in the blue box? Toner cartridges stacked neatly in the corner? With you help we can keep our hospital a neat, safe place to work.

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MIND BODY SPIRIT ~ Christmas 2014 Secret Santa 2014 Program 1. Participation by individual choice ~ Ballots and

instructions attached to November 20th pay-stub or contact Cindy Knaus 2. Complete and submit your Secret Santa ballot to Cindy Knaus by December 10th

MBS Christmas Door Decorating Pick a door in your department and decorate it for the holidays by Friday, December 5th. This is a fun event to spread some Holiday Cheer through out the building.

MBS … Expanded “Fill the Crib" Campaign As in the past our Crib will be available for food and toy donations in the main lobby. However, the MBS is encouraging departments to participate by decorating their own donation box and collect donations within their department. If you need a box … see Cindy. The focus is our community and supporting families in need this holiday. All donations to be in by December 17th.

Mocktail Event Join us on Thursday, December 11th in the cafeteria for our annual “Mocktail Event” …. Alcohol free beverages and holiday snacks provided by your MBS committee. MBS Christmas Basket Raffle Tickets will be available for purchase on a lovely basket at the Mocktail Event or from Judy, Ellen or Cindy … Draw will be made at the annual Physio Potluck on Thursday, December 18th

On behalf of the Mind Body Spirit Committee … we wish everyone a wonderful Holiday and a

Happy and Healthy 2015

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LABORATORY ACCREDITATION What is OLA?

Ontario Laboratory Accreditation (OLA) is the authoritative body of the Institute of Quality Management for Healthcare (IQMH), previously known as Quality Management Program of Laboratory Services (QMPLS) which is operated by the Ontario Medical Association.

OLA assesses the Laboratory staff’s ability to perform their scope of licensed tests, provides formal recognition of competence and provides a tool that enables standardized processes and assists in setting quality benchmarks. How the Assessment Process works:

The Organization receives notification 120 days prior to pending assessment visit. In response the laboratory staff submits a pre-visit questionnaire and their Quality Systems Manual.

On site Peer Visit – Peers, consisting of trained, pre-certified discipline specific technical experts, will assess on the basis of comprehensive and process-based pre-defined standards provided on standardized checklists. They will determine if the laboratory conforms to the requirements by means of document review, interviews and observation. They will share their findings of all minor and major non-conformances with Administration and all Laboratory staff. In November 2012, West Haldimand General had the peer assessment with 17 minor non-conformances identified.

Corrective action plans and supporting documentation was submitted to OLA within 90 days of the accreditation visit.

Regular Self assessments are completed at mid cycle – every two years. This stage of the assessment process helps ensure that laboratory staff continue to monitor their own conformances to accreditation requirements. West Haldimand General laboratory staff have recently completed their self-assessment using the same standardized checklist that peers had used during the on-site visit. Frontline staff were engaged in the process and had identified three minor non-conformances. Follow up status from the previously identified non-conformances were reported to OLA.

The Self-Assessment is reviewed by the OLA team at the next scheduled accreditation visit.

Specimen I.D./Labelling Errors the Lab’s Perspective Main Issues: - Specimens are being delivered to the Lab with

no label - Specimens may be delivered with a proper

label but missing a site of origin on the biopsy and / or requisition

- Samples collected do not match the test ordered in Meditech. For example: A virus culture is ordered in Meditech however, the sample collected is in Amies transport media. The sample should be collected in a virus culture transport media. (This is important because the test will be cancelled due to the incorrect media. The sample would have to be re-obtained)

How does the Lab become aware of an error? Upon receiving specimens the laboratory staff reviews all details on the specimen label and verifies to the requisition label. If any detail does not match the specimen is rejected. Laboratory staff call the department where the sample originated from to notify that the specimen is rejected and a new sample must be collected. The specimen is cancelled with an explanation in Meditech. The incident is reported in RMPro. How do we work together to minimize these occurrences? 1. When collecting samples, consider employing

a consistent routine of practice. E.g. Order the required test in Meditech, obtain Meditech generated label, conduct two patient identifier process with patient and label, collect sample, label sample, send sample to the lab

2. Departments not utilizing Meditech order entry have the necessity to visually verify details such as site of origin on the sample as well as the requisition. Ensure the number of specimens to be processed match the number of specimens on the requisition.

3. Utilize the electronic lab manual or “ELM” this link is located on the desk top. The ELM has the most current Meditech mnemonics and specimen collection information. This is a great standard of practice tool that is easy and convenient.

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COMING EVENTS

WHGH FLOAT PLANNING MEETING

Volunteers are needed Thursday, December 4th, 2014 @ 1330 hours in the Cafeteria

Manager’s Auction WHGH Lobby

Tuesday, December 16th, 2014 – 10:00 a.m.

Mind/Body/Spirit Mocktails Event Try an alcohol-free Christmas beverage

And Seasonal Snacks In the cafeteria

Thursday, December 11th, 2014 – 12:00 noon

Hagersville Chamber of Commerce Christmas Parade Friday, December 12th, 2014 – 6:00 p.m.

Physiotherapy Christmas Pot Luck Lunch

In the Physio Department Thursday, December 18th, 2014 – 12:00 noon

Come and Join the Fun Sandy Emslie is again leading our Parade Committee – the WHGH will be participating in the Hagersville Chamber of Commerce Christmas Parade on Friday, December 12 at 6:00 p.m. And we need your help! Laughter is the best Medicine is the theme for this year’s float and it is going to be lots of fun – we still need people to ride on the float and to hand out candy canes along the route. Decorating will be done in the Ambulance building on December 10, 11 & 12 – let Sandy know if you can help. Doug Vanderburg has very generously loaned us his wagon to use and volunteered to drive in the parade. So let’s all get behind this great fun event!

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Good News on the Patient Safety Front In keeping with our patient safety focus, with the generosity of the West Haldimand Hospital & Healthcare Foundation and the WHGH Auxiliary, the WHGH have been able to purchase 21 new beds for the our inpatient unit. The new beds are here and in use. They come with many features that contribute to patient safety. The beds are fully adjustable for patient comfort but also for patient safety. A nurse can put the bed flat at the touch of a button to assist with resuscitation. The head of the bed can be raised to alleviate choking and the foot can be raised to assist in blood flow.

The beds can be lowered close to the floor for patients at risk of falls. Each bed comes equipped with a built-in weigh scale so patients can be weighted without needing to stand. All beds are also equipped with an alarm to alert staff when a patient who needs assistance is leaving the bed. The side rails run the full length of each side of the bed and can be folded down to safely move patients from the bed. The controls are easily accessed by the patient but can also be locked out so only staff can access them if necessary. They also come with emergency battery backup in case of a power failure. The inpatient unit staff would like to thank the Foundation and Auxiliary for their generous donation and their contributions to patient safety. Improvements in Patient Safety – Medication Administration Congratulations to the staff on the Inpatient Unit and the Pharmacy for improving the safety of our patients! In the summer of 2013, the nursing staff on the Inpatient Unit and in Pharmacy implemented a number of changes to the medication administration process. This included new equipment such as four medication carts, and an automated dispensing cabinet. Process changes included having the medication record (MAR) be printed through the pharmacy instead of nurses developing handwritten, frequently recopied MARs. Since the new initiatives were implemented the number of medication and fluid errors has decreased significantly from over 1.26 incidents per 1000 patient days to less than 0.1 incidents per 1000 patient days. The team has made a significant positive impact on patient safety with these changes.

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A heartfelt THANK YOU!!!! To all of our Support Departments who invested their time and energy to create story boards and/or conduct presentations at our Patient Safety Week (PSW) celebration October 27 – October 30. It was very important and informative to share patient safety issues faced by our Support Departments.

Thank you as well, to everyone who attended and to our Patient Safety Advisory Committee and Management Team for their support of this week. The 2014 Key Patient Safety Week themes included: Communication and Isolation Communication Breakdown - Physiotherapy shared all of their actions taken to

ensure patient safety. - Diagnostic Imaging spoke to Falls and Injury

Prevention. - Dietary shared information concerning Food Allergy

processes. - Housekeeping was very enlightening as we learned

about “terminal cleaning” - The Lab spoke of proper Patient Identification and

proper Specimen Labeling. - The Pharmacy was available for Accudose tips and

Q&A on the IPU. - Occupational Health addressed communication and

employee health.

A survey completed during PSW determined that 100% of respondents found the storyboards very effective. Thank you and Way-To-Go especially to: Elaine A., Karen, Tracy! Everyone appreciated hearing directly from you about your patient safety focuses.

Survey respondents stated that they learned a great deal about our support departments that they didn’t know before this week such as: - How important interdisciplinary communication is - How much extra everyone does for patient care - General processes for each area - How involved it is to take a blood sample - Laboratory labeling & processes - The steps & procedures Dietary goes through

everyday for patient care - How long a terminal clean takes and a better

understanding of what is involved in Housekeeping

- The Falls Risks faced in Diagnostic Imaging Survey respondents felt we could improve our PSW by

….. - Higher attendance from all departments if possible,

because it is so informative - Others thought PWS is great just as it is! We have

been celebrating PSW since 2010, 100% of respondents feel celebrating PSW at WHGH is a worthwhile event.

- Future PSW topics staff would like to see include: Hospital statistics and Infection Control. Staff felt some of the following were their “highlights” of PWS:

- Overall, focusing on the support staff was nice - Understanding other department interactions and

breakdowns - I thought that hearing everyone’s input and

participation was great. I felt like it was a safe place to have discussions

- Presentations by new managers - Excellent interaction and well presented information

Patient Safety Week 2014 Another Unanimous Success!!!

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