Common Ground: Ebola update and Quality Operations Committee Corner news
Nov. 2, 2014
 WELCOME TO SALEM HOSPITAL
IN THIS ISSUE

 In the news:  

Coming events: 

TOP READSTop
SalemHealthSalem Health chooses not to be an Ebola Care Center
After careful consideration, Salem Health has not volunteered to become an Ebola Care Center in Oregon for a number of reasons, including our core commitment to provide quality care to the communities we serve. Read Norm Gruber's letter here.
 
QualityOperationsCommQuality Operations Committee (QOC) Corner: 
Who we are and what we do

The primary goal of the Quality Operations Committee (QOC) is to improve patient care through clinical improvement projects which are physician-led, patient-centered and data-driven. The committee has responsibility for prioritization and oversight of the quality, safety, cost and patient experience improvement projects at Salem Hospital, working together with the Executive Leadership Council (ELC) and Board of Trustees. Physician partnerships in strategic planning and leadership in quality improvement projects are critical contributions as we strive to improve health care for our patients. With this in mind, the QOC was launched in December 2012, as a standing committee of the Board of Trustees. Over the last two years, it has provided a unified approach to help physicians understand the key metrics that drive operational decisions, and has facilitated physician-led improvement work.

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MPRCGuidelinesMultidisciplinary Peer Review Committee guidelines for filing a patient safety alert
Salem Hospital and the medical staff leadership seek to ensure that problems involving patient care and safety are consistently reported, managed and resolved. Therefore, an effort is underway to standardize the following guidelines:
  1. The definition of quality and safety problems to be reported.
  2. How problems are managed and resolved.
The first step is foundational and involves building definitions around the types of problems to report using the Patient Safety Alert (PSA) system. The Patient Safety Division, with input from the Medical Executive Committee (MEC), Multidisciplinary Peer Review Committee (MPRC) and Physician Leadership Council, has revised a list of events which would be expected to generate a PSA. The list is not exhaustive and provides guidelines for filing a PSA. All Salem Hospital staff and medical staff should be aware of these guidelines so that the incident reporting system will be used more consistently and be widely accepted as a comprehensive and beneficial tool for quality improvement to enhance patient safety. See Event Management Policy, Guidelines for Patient Safety Alert Reporting - Attachment A, Category of Harm - Attachment B, Immediate Response Flow Diagram - Attachment C and Safety Assessment Matrix - Attachment D for further details.

PSA's reporting concerns about medical staff clinical care or professional conduct are forwarded to the Multidisciplinary Peer Review Committee. These occurrence reports are addressed through a standard process including the relevant section chief and the MPRC. See the PSA Referral Process flow diagram for more details.

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TwoWeeksFluTwo weeks left to get your flu shot

Don't delay! The NFHL comes to a close on Friday, Nov. 14, and there is no time like the present to get your flu shot.

 

As of Thursday, Oct. 23, "The Healers" (medical staff and medical staff office) were at a 55 percent participation rate, a 13 percent jump from Week 3 but still at the bottom of the NFHL standings. Total Salem Health NFHL participation is at a whopping 73 percent! Check out Week 3 (Oct. 17) video standings here

 

Egg-free, latex-free and flu mist vaccines are available at Employee Health on a first come, first served basis. You can get your shots at Employee Health, daily, from 7:30 a.m. to 4 p.m. on the second floor of Bldg. B, room 2414, or from a flu champion at the hospital. If you have received your vaccination elsewhere, please turn in or email your documentation to the medical staff office or Employee Health by Nov. 14.

 

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HandHygieneHand hygiene is a top priority

Increasing Salem Health's hand hygiene compliance rate has been established as a major goal under the Quality and Safety A3 for 2015. (Our four goals under Strategy Deployment are commonly referred to as A3s, named after the large paper size they're printed on.)
 
"We've had hand hygiene campaigns before and they've been successful," said Jaime Nichols, director of continuous improvement. "This new initiative is different because it creates a unified, consistent push throughout our organization as a critical priority with ambitious goals in our strategic plan."

Salem Hospital had 207 hospital acquired infections last year, all largely preventable through better hand hygiene. Our goal in the new Quality and Safety A3:  Improve hand hygiene compliance from 85 to 92 percent to reduce hospital acquired infections by 50 percent.  

New auditing (observation) methods are being created this year through Hand Hygiene Champions to measure progress at the unit level. You can learn more about how compliance will be measured from your champion or department leader.  

Awareness is being promoted throughout the hospital with a newly developed flier. The flier emphasizes how hospital acquired infections can be prevented in five critical moments: 

  1. Before patient contact
  2. Before performing a sterile task
  3. After body fluid exposure risk
  4. After patient contact
  5. After contact with patient surroundings  

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NewMedStaffEngMedical staff engagement survey coming in January
Members of the Medical Staff Engagement Committee, the Quality Operations Committee and Executive Leadership Council evaluated three nationally recognized survey vendors and Integrated Healthcare Strategies (IHS) has been selected as the new vendor for the annual medical staff engagement survey. IHS is an industry leader with 40 years' experience monitoring the opinions, attitudes and behaviors of our nation's physicians. IHS was chosen for their expertise in the measurement of engagement, survey design and methodology, advanced statistical analysis, predictive analytics, and post-survey action planning. Survey results will be nationally benchmarked against more than 200 health care organizations. The action plans created from the survey results will drive the Physician Engagement A3 strategy for 2015-2016.

The engagement survey will be emailed to the medical staff in mid-January.  For more information, contact Cort Garrison, MD, Maurice Collada, MD, or Mary Maberry.

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WELCOME TO SALEM HOSPITALWelcome
DmitryDmitry Dukhovny, MD - Neonatal - Perinatal Medicine
Oregon Health & Science University -
Pediatric Critical Care @ CDRCP
 

Medical
Education:

Boston University School of Medicine -
Boston, Massachusettes
Aug. 2000 to May 2004
Residency:
Pediatrics
Children's Hospital Boston
Medical Center -
Boston, Massachusettes
June 2004 to June 2007
Fellowship:
Neonatal Perinatal Medicine
Children's Hospital Boston
Medical Center -
Boston, Massachusettes
July 2007 to June 2010
Board
Certification:
American Board of
Pediatrics/Neonatal - Perinatal
American Board of Pediatrics


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CaseyLCasey L. Hazenberg, FNP - Family Nurse Practitioner

Willamette Health Partners - West Salem 

 

Medical
Education:
Idaho State University - Pocatello, Idaho
June 2011 to May 2014
Board
Certification:
American Academy of Nurse Practitioners

   

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NicoleNicole L. Kehrer, PA - Orthopedic Physician Assistant
Hope Orthopedics of Oregon 
     
Medical
Education:
Shenandoah University -
Winchester, Virginia
Aug. 2009 to Dec. 2011
Board Certification: 
National Commission on Certification of Physician Assistants

  
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CaseyShawCasey L. Shaw, PA-C - Orthopedics 

Hope Orthopedics of Oregon  

 

Medical
Education:
Oregon Health & Science University - Portland, Oregon
June 2012 to Aug. 2014

 

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TinaTina L. Vavro, DO - Pediatrics

Willamette Family Medical Center 

 

Medical Education:
College of Nova-Southeastern Osteopathic Medicine -
Fort Lauderdale, Florida
Aug. 2007 to May 2011
Residency:  Pediatrics
Baystate Medical Center -
Springfield, Massachusettes
July 2011 to June 2014
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IN THE NEWS...InTheNews
SHStaffTrainedSalem Health staff trained on new CDC guidelines for Ebola
The Statesman Journal recently published a story about new Ebola training at Salem Health. The story covers the work Salem Health has been doing to get key staff trained since the new CDC guidelines for personal protective equipment were published on Oct. 20. Training includes putting on and taking off protective equipment with a buddy to ensure it is done correctly and without any issues that might put the person at risk.
Salem Hospital Ebola drill with updated CDC guidelines
Salem Hospital Ebola drill with updated CDC guidelines.

The hospital is conducting the training sessions in phases for key staffers. Phase one prioritized the emergency room and ancillary services - including 49 staff nurses, 12 emergency physicians, nine environmental services staffers, five imaging employees, five patient transporters, three respiratory therapists and one member of the hospital's rapid response team, which covers the emergency room and the rest of the campus, as a backup. Additional training will continue.

On Thursday, Oct. 23, a small group conducted a drill in the Salem Hospital ED to help determine the preparedness of staff.  Watch a video of the drill here

Thank you to everyone who has been involved in Salem Health's Ebola preparedness work, in training staff and participating in the training.
 
Read the full Statesman Journal story.

Read the news release.

WhyWhy Salem Health isn't an Ebola Care Center
A recent story in the Statesman Journal states why Salem Health chose not to volunteer to become an Oregon Ebola Care Center. Norm Gruber is quoted in the article as saying,"Salem Health did not volunteer to become an Ebola Care Center in Oregon after determining that it would be detrimental to our ability to provide care to the communities we serve."  Read the full Statesman Journal story.

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COMING EVENTSComingEvents
CHECFor your patients, from the CHEC
The Smart Choice© Health Insurance Workshop
Presented by Oregon State University Extension Services, this workshop will help participants understand the basics of health insurance, learn strategies to help select a health insurance plan and increase their capability to make a Smart Choice© Health Insurance decision.
  • Thursday, Nov. 6
  • 2 to 4 p.m.
  • $5 per person

Read the flier

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Start Living Kidney Smart  

Participants will learn how kidneys function and the common causes of chronic kidney disease; how medications, diet and nutrition work together; and what treatment choices are available.  

  • Fourth Wednesdays and first Saturdays of each month
  • 10 to 11:30 a.m. 
  • Free

Read the flier  

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Alzheimer's Network Memory Screening  

For individuals concerned about unusual forgetfulness, or who are having more trouble than normal concentrating, remembering names or previous conversations.  Memory screenings will be conducted by a trained screener and will take approximately 15 minutes.  

  • Tuesday, Nov. 18
  • 9 a.m. to 2 p.m.
  • Free
Freedom From Smoking Support Group

For anyone who has completed the Freedom From Smoking course, this support group is led by a skilled facilitator and helps individuals learn from each other and discuss strategies to sustain the quit or to prepare for another attempt. 

  • Starts Nov. 12, Nov. 19, Dec. 10 and Dec. 17; then every second & fourth Wednesday of each month
  • 7:30 to 9:30 p.m.
  • Free
Read the flier  
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PRACTICAL MATTERSPracticalMatters
WHPWillamette Health Partners Neurology clinic to open Nov. 4
The new Willamette Health Partners Neurology clinic will be located in the Willamette Health Partners - Salem office at 966 12th St. SE, Suite 130. Doctors Sherif Al-Hawarey and Daniel Chen will be practicing at the new clinic and are now accepting
referrals.
966 12th St. SE, Suite 130
Salem, OR 97302
503-814-6387 Phone
503-540-5919 Fax 
                               

The clinic treats a variety of neurological diseases and conditions including: 
  • Seizure disorders such as epilepsy
  • Nerve and muscle diseases, diabetic neuropathy, neuromuscular disorders
  • Movement disorders, including Parkinson's disease and essential tremors
  • Multiple sclerosis
  • Headaches
  • Central nervous system infections and tumors
  • Stroke and transient ischemic attacks

Services will include: 

  • Medical Botox injection for migraines and muscle spasticity
  • Vagal nerve stimulation for epilepsy patients
  • Deep brain stimulation for Parkinson's disease patients
  • EMG/Nerve conduction studies
In preparation for the Nov. 4 go-live of the new clinic, the referral order "CON1030 Referral to Neurology" is now available. Scheduling for appointments began on Oct. 28. If you experience any issues with the order in Epic, please call the Solution Center at 503-561-4357.

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MagnetMagnet® champions lead the way
To achieve Magnet® designation takes a village or our entire hospital working together. To achieve redesignation is an even higher bar because not only is outperforming previous benchmarks expected but so is maintaining them.
Nurses Share Magnet Moments at Salem Hospital
Nurses share Magnet moments at Salem Hospital

"It takes a special group of people to keep Magnet top-of-mind and they are none other than the more than  80 Magnet champions at Salem Hospital," says Rick Kendall,  Kaizen cinical nurse consultant and Magnet specialty practice team coordinator. "They are the wind beneath our sails that touch every facet of what it takes to achieve Magnet status. If you have a question about Magnet, please don't hesitate to ask any one of these individuals."

To learn more about what it means to be a Magnet hospital, watch this Magnet Moments video.

Thank you for all you are doing:  every patient kindness, every LEAN project, every day you perform your job to the best of your ability, to help us attain this redesignation.

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MPRCRemindersMultidisciplinary Peer Review Committee:  Reminders when working with new nurses 
A large number of new nurses have recently joined our health care team at Salem Hospital making this a good time to review some important details. First, here are just a few statistics to give you some perspective on the new hirings: 
  1. In 2013, more than 200 new graduate nurses were hired. This was due to increased volumes as well as the fact that when our patient volumes dropped in the winter of 2011, we reduced hiring accordingly.
  2. Nearly 200 more nurses will have been hired during 2014. The next group starts this month.
  3. Typically, hirings take place twice per year, in February and August (to coincide with college graduations). Most years about 100 nurses are hired but the past two years have been exceptions. Due to increased volume and staff shortages, new graduate programs have been added in April and November, as needed.
In light of this significant and welcome influx of new nurses, the Multidisciplinary Peer Review Committee (MPRC) emphasizes these reminders:
  • The MPRC reminds all medical staff members of the importance of clear, proactive communication. New nurses may be reluctant to ask questions of physicians. It is important to promote open, direct, collaborative communication with all members of the health care team - regardless of level of experience.
  • It is important for physicians to enter orders directly into EPIC whenever possible. Verbal orders continue to be a source of potential error, and nurses are discouraged from accepting verbal orders if computer access is available.
  • Medical staff members are encouraged to take every educational opportunity to help our new nurses as they continue to develop skills for providing excellent, safe patient care.
  • Please be aware that nursing scope of practice is very clearly defined; medical staff members are responsible for all patient care decisions involving the practice of medicine.
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CardiacCardiac admission orderset for heart failure  
The heart failure affinity team has been working on improving evidence-based practice in caring for the patient. Learn more about the work this affinity group is doing including best practices and financial impact.

PPIDPositive patient identification system to go live Nov. 10 
The laboratory positive patient identification (PPID) system will go live on inpatient floors and prep/recovery on Monday, Nov. 10.  The rollout will occur is by building over several days as follows:
  • Monday, Nov. 10 at 8 p.m. - Bldg. B and Bldg. E
  • Tuesday, Nov. 11 at 8 p.m. - Bldg. A (excl. PACU)
  • Wednesday, Nov. 12 at 8 p.m. - Bldg. D; PACU and periop
There will be a 24/7 staffed command center effective Monday, Nov. 10 at 8 p.m. through Friday, Nov. 14, at 10 p.m. PPID superusers, IS and laboratory staff will also be on the floors supporting the rollout. The service desk will be available to receive calls at X1-HELP (4357), press 1 for PPID. 

Salem Hospital is implementing a PPID System for blood draws and eventually all specimen collection. This change brings our hospital practices in line with nationally recognized best practices that ensure patient safety. Salem Hospital's laboratory processes approximately 135,000 specimens annually and our hospital averages 350 patient safety alerts for mislabels annually.

The PPID system uses handheld scanning technology to confirm patient identity and print labels at the bedside. PPID eliminates rework and improves patient safety. Because the patient's identification bracelet will be scanned when samples are collected, the technology will raise patient satisfaction by reducing patient "sticks" through re-collections.  

The hospital's goal is to eliminate labeling errors, which can result in misdiagnosis and inappropriate treatment. The new technology is consistent with the hospital's system for dispensing medication.

For more information, contact Gordon Johnson, laboratory support services manager at 503-562-1110.     
 
RestrictionRestriction on use of C-1 Esterase Inhibitor (Berinet) 
At a recent pharmacy and therapeutics meeting, permission was given to restrict the use of C-1 Esterase Inhibitor (Berinert) to patients with an acute attack of laryngeal, facial or abdominal hereditary angioedema (HAE). As of Oct. 11, a question now appears in the order for Epic to reiterate this restriction. If you have any questions, please contact Matt Tanner in the pharmacy at 503-814-2048. 
 
SharpsSharps wound debridement considered surgical procedure 
It has been brought to the attention of the Infusion and Wound Care management team and the Wound and Ostomy Certified Nurses (WOCNs) that any debridement utilizing scissors or scalpels is considered a surgical procedure. Therefore, the WOCNs will not be allowed to do any cutting away of dead tissue until they complete a privileging process. During this transition your help is requested as follows:
  1. Be available as an advisor for the WOCNs in order for them to be signed off.
  2. Complete any sharps wound debridement until the process of credentialing the WOCNs can be completed.
It is hoped that the issue will be remedied as quickly as possible and your assistance in the meantime is appreciated. Thank you for your continued support of the great work the WOCNs do in providing specialized care for our patients.

For more information, contact Deanna Stein, MSN, RN, manager of infusion and wound care at 503-561-5567.
  
ConstConstruction soon complete on NW wing of Bldg. B,
floors 5 and 6  
The phase 2 remodel work in the 5NW and 6NW units of Building B is almost complete. The patient move date is scheduled for Tuesday, Nov. 11, when the general surgery unit will move from 6NE to 6NW and the oncology medical/surgery unit will move from 5NE to 5NW.   

Once patients are moved, the 5NE and 6NE units will have a staggered closure for about three weeks, when minor re-fix work will be done from the phase 1 remodel that ended in April of this year. This staggered approach will maximize the number of patient beds available and minimize the impact to patients as we work to provide a better environment for our patients, staff and physicians.  

Common Ground Newsletter Editorial Board 
For past issues of this newsletter, visit
Email us anytime with feedback, suggestions, or something for the next issue!  Dr. Ian Loewen-Thomas, Chair, Compact Implementation Committee
 

Salem Health

503-561-5200