SCAHC
Your Weekly News Dose!
ISSUE 39, May 2, 2016
Quote of the week:
“Tell me and I’ll forget. Show me, and I may not remember. Involve me, and I’ll understand”
- Native saying...
Greeting’s everyone!
We are continuing to provide you information regarding the latest updates, messages from the department
managers as well as news from Vicki Began, Interim CEO of the San Carlos Apache Healthcare Corporation.
San Carlos Apache Healthcare
MISSION
Happy Medical Laboratory Professionals Week!
L-R Front: Theresa Parsons, Alexis Benally, Roberta Harris, Renna Clark,
L-R Back: Scott Taylor, Bill Thornton, James Clark, Shawna Pike
Also to all Administrative Professionals within our Corporation
April 24—30, 2016! Thank you for all that you do.
ANNOUNCEMENT
The SCAHC has established a dedicated 24 hour a day, toll-free
Compliance Hotline for use by employees, agents, or other persons
associated with the SCAHC wishing to report:
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suspicious conduct,
violations of law,
rules,
regulations,
SCAHC policies and procedures or
information the employee, agent, or other person feels cannot
be reported to a Supervisor.
The Compliance Hotline is 844-RPTSCAH (844-778-7224). Other alternative methods to report suspected compliance violations may also be
submitted in writing or directly calling the Compliance Officer.
The Mission of the Izeé Baa Gowah
is to heal, serve and empower the In
-deh (Apache people) while honoring the traditions through a caring,
compassionate and respective Patient-family centered team
VISION
The Vision of Izeé Baa Gowah is
Apache healing Apaches to achieve
a strong health community through
the delivery of quality healthcare
for current and future generations
VALUES
 Embrace and live the spiritual
value of healing in a harmonious
and peaceful environment
 Embrace the needs of the family
and community with confidentiality and accountability
 Promote and respect the well be-
ing of individuals by offering quality holistic healthcare
 Create and build trust in all our
relationships
FIRE PLAN:
GENERAL INSTRUCTIONS FOR ALL
EMPLOYEES:
POLICIES & PROCEDURES
ADMINISTRATION
1.16 CHAIN OF COMMAND- PURPOSE/EXPECTED OUTCOME:
 To provide a formalized mechanism for staff to follow in resolving administrative, clinical or other patient safety or service issues.
 To address issues where the quality of care or safety of a patient is in question.
 SCAHC does not allow retaliation against anyone who invokes the Chain of
Command/Communication Procedure.
 To present or report an issue of concern and pass it up the chain of command
(line of authority) until a resolution is reached.
II. Definitions: A. “Disruptive Physician/provider or healthcare professional"
means a healthcare professional who engages in any of the behaviors listed below
to the extent that it evidences of a course of conduct (track record), and either
actually interferes with the ability of others to perform their patient care obligations effectively OR threatens to endanger staff or patient health or welfare:
1. Non-constructive verbal attacks on others (oral or written) that are
inappropriate and that gratuitously discredit the competency of others
authorized to work in the Hospital;
2. Communication that is less likely to improve others' performance than
to intimidate, humiliate, degrade, offend, or belittle;
3. Disregard of rules necessary for the efficient operation of essential
Hospital functions;
4. Refusal to perform obligations agreed to in Medical Staff Bylaws and
Rules and Regulations or to follow SCAHC hospital policies.
III. Policy: A. The chain of command for resolution of clinical patient care issues
or operational safety issues is instituted when a Healthcare Professional (HCP)
becomes concerned about a specific patient’s care which may result in an adverse
patient outcome or when an operational safety issue is present in the organization. Below are example of when to evoke the chain of command:
1. In situations where impairment, unprofessional or disruptive behavior
of a practitioner is suspected or witnessed.
2.In clinical situations where a nurse or other practitioner believes a physician has not responded in a timely manner to fully address the issues
raised that may present an immediate risk to the patient.
3. When a nurse or other practitioner believes within his/her clinical
knowledge or judgment that implementing a physician order or plan of
care may potentially have an adverse effect on patient safety or condition.
4. When any operational situation has the potential to adversely affect
safe, quality patient care or organizational safety.
IV. Procedure/Interventions:
A. Staff Escalation of Concern:
1. To resolve: Immediately notify the physician, Director of Clinical area,
Charge RN and/or unit Nurse Manager/Supervisor of the concern. If resolution not reached go to 1st level of escalation.
2. 1st Escalation: Director of Nursing and/or Vice President of Clinical
Operations. If resolution not reached go to 2nd level of escalation.
3. 2nd Escalation: Administrator on-call, Chief Nursing Officer and/or
Chief Medical Officer.
B. Physician or Provider Escalation of Concern:
1. To resolve: Immediately notify the Nurse/Clinical Staff member or
Charge RN/Staff members Supervisor/Manage. If resolution not reached
got to the 1st level of escalation.
2. 1st Escalation: Director of Nursing or Department Director (including
after hours). If resolution not reached got to the 2 nd level of escalation.
3. 2nd Escalation: CEO or (after hours the Administrator on-call) or the
Chief Medical Officer.
V. Procedural Documentation:
A. Steps taken in resolving a patient care problem will be documented in the patient care record as appropriate by the Supervisor/Clinical Manager and/or
Clinical Director.
In the Event of a Fire: (Implement the R.A.C.E.
protocol – Rescue, Alarm Contain, Extiguish)
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Rescue - Patients or other personnel in
immediate danger.
Alert - Use pull box and use ALL PAGE
and announce location of the fire 3 times.
Contain - Smoke and flames by shutting
doors and sealing off the area.
Extinguish/Evacuate - Remove patients
and staff from area.
Attempt to extinguish flames if safe to do
so. Otherwise, assist in patient
evacuation if ordered to do so. Use P.A.S.S.
protocol to operate a fire extinguisher.
Announcement of Fire:
Upon notification of a fire, announce three
times:
CODE RED (Location), CODE RED (Location),
CODE RED (location)
Inpatient
1. Clear all hallways and corridors of equipment to make room for patient evacuation.
2. Prepare patients to move to alternate
smoke compartments (smoke wall is OB
wall)
3. Charge Nurse determines if O2 disconnection is advised.
4. Do not use elevators
Outpatient/Admin DepartmentsOutDepartmentsOutlying Buildings (Dental):
1. Secure all security sensitive locations
(Pharmacy, Med Recs)
2. Do not use elevators.
3. Check Restrooms in your area
4. Move patients and staff to rally points.
Stay 50 feet away from building;
5.(Flag Pole, Public Health Nursing Patio, fence
line by the Helipad, or West of Loading Dock)
6.Do not assemble in the parking lot or roadway. Seek shelter away from smoke.
Emergency Department:
1. Assess ED patient census
2. Clear all hallways and corridors of equipment to make room for patient evacuation.
3. Prepare patients to move (smoke wall is
exterior ED Wall)
4. ED Charge Nurse determines if O2 disconnection is advised.
All Employees: Employees are required to be
familiar with locations of exits, fire alarm boxes,
portable fire extinguishers and be able to operate
them safely. All employees must read and be
familiar with the written Fire Plan. Regular fire
drills will be conducted to evaluate staff skill in
reporting fires and demonstrating fire-fighting procedures.