The document provides an overview of annual education for medical staff and residents at Sibley Medical Center. It discusses the hospital's values of compassionate service, professionalism, teamwork, and continuous quality improvement. It then outlines the hospital's performance improvement plan, focusing on safe, effective, patient-centered, timely, and equitable care measures. The document also reviews general safety protocols, health information management, infection control, influenza prevention strategies, patient safety, quality improvement, and medication safety practices.

1. Annual Education for
Medical Staff & Residents
Presented by: Medical Executive Committee

2. OUR VALUES
• Personal and Compassionate Service
• Professionalism
• Teamwork
• Trust and Respect
• Continuous Quality Improvement
• Confidentiality and Privacy
• Honesty, Integrity, Flexibility and Selflessness
OUR VALUES ARE AT THE CENTER OF
EVERYTHING WE DO

3. CIRCLE OF EXCELLENCE
• Basic Expectation: Courtesy and Respect
We value and respect one another’s unique areas of
expertise.
• Remember to always:
– Wear your Sibley ID Badge
– Promote a Safe and Clean Environment
– Maintain Privacy and Confidentiality
– Protect Dignity
– Keep Patient and Family Informed
– Be Responsive

4. 2011-12
Performance Improvement Plan
1. Safe Care Measures
a. Sibley Red Rules (100% Compliance Expected)
- Patient Identification
- Final Time Out before surgery or bedside procedure
b. Surgical site infection monitoring
c. Hospital acquired infection monitoring
- Eliminate Central Line Associated Blood Stream Infections
- Decrease Catheter Associated Urinary Tract Infections
- Decrease Clostridium Dificile Infections
d. Improving hand hygiene
- GEL IN / GEL OUT

5. 2. Effective Care Measures
a. Core measures (Medicine/Cardiology/Critical Care)
-Acute MI, Heart Failure, Pneumonia
b. IP Psychiatric core measures (Psychiatry)
c. Perinatal bundle measures (Obstetrics)
d. Surgical Care Improvement Program (Surgery)
e. Hospital Acquired Conditions (HACs)
- Capture and Document patient conditions that are
present on admission.
f. Decrease unplanned readmissions.

6. 3. Patient-centered Measures
a. Patient satisfaction scores
b. HCAHPS patient satisfaction scores
4. Timely Care Measures
a. Emergency Department patient flow measures
5. Efficient Care Measures
a. On-time starts in OR
6. Equitable Care Measures
a. Pneumonia care

7. General Safety & Security
• ID Badge
– Wearing of your Sibley issued ID badge is required and
it must be displayed while on hospital premises
• Fire or Smoke:
– Code Red: get a fellow team member to help, pull the fire
alarm AND dial 4600
– “RACE”: Rescue persons; pull Alarm; Contain fire;
Extinguish if possible.
• To extinguish: “PASS” - Pull, Aim, Squeeze, Sweep

8. • Hazardous Materials/Spill
Isolate the affected area as much as possible
Notify a hospital employee who will arrange for appropriate care
and treatment of the accident.
• Waste Containment
– Place all waste in proper containers:
• RED- medical waste
• YELLOW – chemo
• PURPLE/BLUE/BLACK – pharmaceutical
• GREEN – recycling
• Locked – HIPAA/Confidential papers
• Security
– Violence Free Work Place – Report All Violent Actions or
threats immediately
– Observe and report (x4674) suspicious activity

9. Codes:
• Code Blue: Cardiac Arrest
• Code Purple: Neonatal Resuscitation
• Code Pink: Infant/Child Abduction
• Code Yellow: Incident on the grounds
• Code Orange: Hostage situation
• Code Strong: Disruptive or Combative person
• Code Silver: Active shooter incident
• Code Stork: Precipitous Delivery
• Code Red: Fire
• Code 100: Internal /External Disaster
• Status E: Pre-Diversion Alert
• Security: Report bomb threat
• Rapid Response: Rapid Response Team
• Stroke: Stroke Response Team
• Command Ctr: Command Center/EOC

10. Information Technology
• All practitioners are encouraged to use the electronic patient
information system .
• Practitioners are responsible for maintaining compliance with the
security and integrity of patient information (HIIPA).
• Secured passwords are updated every six months.
• Improper and unlawful use of Sibley‟s information systems may be
cause for immediate dismissal from the Medical Staff.

11. Health Information Management
• Information documented in any manner (dictated, created on-
line, via email, written on paper, etc.) about the treatment of a
patient constitutes the medical record, must be accessible to all
care providers no matter where the care is provided or by what
specialty.
• All entries into the Electronic Medical Record (EMR) must
be signed electronically.
– History & Physical (work type 70)
– Operative Reports (work type 71)
– Discharge Summaries (work type 72)
– Progress Notes (work type 73)
– Consultations (work type 74)
• Transcriptions are available to edit and sign electronically
within 24 hours of dictation.

12. Health Information Management
• SIGN / DATE / TIME / PHYSICIAN ID#
• REQUIRED FOR ALL ENTERIES IN THE MEDICAL
RECORD (ORDERS, PROGRESS NOTES, etc.)
• COUNTERSIGN Telephone Orders ASAP, or
within 48 hours.
• Use Legible Handwriting or Dictate your notes

13. BASIC MEDICAL RECORDS REQUIREMENTS
• Every patient requiring admission or having an outpatient procedure
MUST have a written or dictated History and Physical Exam.
– Within 24 hours of an admission, a complete H&P examination
and admission note MUST be recorded.
– Outpatient procedures may use a focused H&P on the chart prior
to the procedure (see Short Stay Record)
• The attending physician MUST countersign the H&P when recorded
by non-credentialed qualified licensed practitioners.
• TO CORRECT AN WRITTEN ENTRY IN THE MEDICAL
RECORD, cross thru the entry with a SINGLE LINE; Initial and
Date adjacent to the correction

14. Infection Control
HAND HYGIENE – is Sibley‟s primary initiative for controlling hospital
acquired infections. GEL IN - GEL OUT!
• Before and after patient contact
• After removing gloves
• After touching inanimate objects (such as computers, phone, etc…,)
in between caring for patients
• Use soap and water (15-20 seconds) after caring for patients with
C.difficile and if hands are visibly soiled
PREVENT SPREAD OF MULTI-DRUG RESISTANT ORGANISMS
(MDROs)
• Contact Precautions for patients known or suspect for MDROs
• Gown & glove when touching anything in the room
• Disinfect equipment between patients (i.e. stethoscope)
• Avoid taking chart into the room

15. INFECTION CONTROL (continued)
PREVENTION OF CENTRAL-LINE ASSOCIATED BLOODSTREAM
INFECTIONS (CLA-BSI)
• Use the central line insertion checklist
• Avoid femoral site for central lines
• Perform hand hygiene, use full body drape; wear mask, cap, sterile gown
and sterile gloves, use CHG skin prep
• Hand hygiene & gloves before changing dressing or accessing port---Scrub
the hub before all access
• Remove central lines as soon as possible
PREVENTION OF SURGICAL SITE INFECTIONS (SSI)
• Educate patients about SSI prevention
• Perform proper surgical scrub on hands
• Use proper antibiotics for prophylaxis at right time
• If hair removal needed , use clippers
• Ensure proper surgical site scrub
• Minimize traffic in OR during surgery
• Do not flash sterilize equipment
• Hand hygiene before and after caring for wound

16. INFLUENZA STRATEGIES
Every Sibley Medical Staff Member and Resident must obtain an
influenza vaccination annually. Dispensations are given on a case-by-
case review.
• Employee Health(EH) provides the following to facilitate vaccinations through the
flu season:
· Seasonal Influenza vaccination clinics
· Schedule a vaccination appointment in EH
· Vaccine information Statements(VIS) available on the Sibley intranet
• Restrictions during the Influenza season:
• Limitation of number of visitors during flu season
• Placing masks on patients with signs & symptoms of flu
• Inpatients being ruled out or diagnosed with the flu are placed on droplet
precautions
• Restricting visitors and Sibley employees with signs & symptoms of the flu
from the hospital
• Age restrictions for visitation may apply
• Facility access restrictions may apply

17. Patient Safety
• Sibley provides a safe environment for patients in the hospital
based on the patient‟s assessed needs.
• Red Rule is a practice that is done 100% of the
time by all physicians and staff.
• Red Rules for 2011-12
Conducting a team “time out” prior to any surgery or
procedure. The time out is to validate right patient, right
procedure and right site. Any disagreement among the team
requires stopping of the activity until the red rule is in
compliance.
Use of 2 identifiers to ensure right patient with right
medication or treatment

18. Quality Improvement
Sibley‟s Quality Council is the hospital‟s quality improvement
oversight committee. It‟s a multidisciplinary team that:
– meets monthly to monitor the progress of hospital ,
– quality/performance improvement teams,
– reviews data on the hospital‟s dashboard (scorecard)
– reviews patient and staff satisfaction survey results
• CORE MEASURES
– AMI (Acute Myocardial Infarction)
– HF (Heart Failure)
– PN (Pneumonia)
– OP (Outpatient AMI and Surgical Patients)
– SCIP (Surgical Care Improvement Project)
– IP HBIPS (Inpatient Psychiatric Core Measures )
• This data is used exclusively for internal benchmarking
and not reported.

19. Medication Safety
• Use proper format when writing medication orders:
– Medication/Dose/Route/Frequency/Indication(For PRN Meds)
• No Ranges for dose or frequency
• Unique indication for Each PRN medication
• Use 10-point Pain Scale for PRN Pain Medication
Orders
– PRN Mild Pain (1-3)
– PRN Moderate Pain (4-6)
– PRN Severe Pain (7-10)
• Review your patients Medication Administration Record
(MAR) daily for accuracy

20. Medication Safety
• Medication Reconciliation: Perform on
Admission, Changes in level of care, and
Discharge
• Verify patients home medications are accurate.
• Resume home medications when appropriate during
hospitalization.
• Provide patients with a complete and legible list of
medications on discharge that includes clear indications for
medications.
• Highlight any change in doses of home medications as well
as new prescriptions on discharge.

21. Diversity Awareness
Sibley Memorial Hospital is made up of patients and staff who
come from every corner of the world, creating a very diverse
environment. Patients and staff have different
beliefs, customs, communication styles and dress that we
must acknowledge and respect.
GOLDEN RULE:
• Treat others as you would want to be treated.
• Demonstrate respect and honor for their differences.

22. Communication - SBAR
• SBAR is a communication tool that provides a quick, concise
explanation of the purpose of the conversation, a background and
assessment of the patient's condition and a recommendation for the
next step of care.
• SBAR stands for "Situation, Background, Assessment,
Recommendation/Request
• Responsibility for professional communication with our internal and
external customers is a two-way street. We must be sure that we our
doing our part as far as communicating effectively by having our
information organized in an accurate and concise format. Using the
SBAR format consistently will ensure the completion of this step in
the communication process.

23. Compliance
• Sibley Memorial Hospital is committed to the
prevention, detection and resolution of fraud, or any instances of
conduct that do not conform to federal, state and private health
care program requirements. Sibley and its Medical Staff values
honesty, integrity and high ethical standards in the conduct of its
business by:
– Ordering only those services or tests that are believed to be
medically necessary;
– Only performing services or tests on a patient with evidence
of a written order.
– Prohibiting any activity that violates the anti-kickback statute;

24. Citizenship
• Good citizenship is an important facet of professional conduct.
Citizenship on our staff includes participating in medical staff
activities and committees, and being a mentor, teacher, and
lifelong learner.
• It means upholding one‟s mutually agreed-upon responsibilities
to the Medical Staff, the Hospital, one‟s Department and
Division, our patients, our colleagues, and our community.
• It means making prudent use of the resources available to
us, and accepting our stewardship for those resources. It
means conducting ourselves with dignity, integrity, and
honesty, and accepting responsibility for our actions.

25. Confidentiality
Physicians agree to maintain complete confidentiality of patient
care information at all times, in a manner consistent with
generally accepted principles of medical confidentiality.
We recognize that, physicians have the right to have certain
personal and professional issues dealt with in a confidential
manner, including such things as performance problems and
concerns about competency.
Physicians agree to maintain this confidentiality and to seek the
proper, professional, objective arenas in which to deal with
these issues.

26. Professional Behavior
and Conduct
It is the policy of Sibley, that all individuals within it be treated with
courtesy, respect and dignity. To that end, all members of the
Medical Staff & Residents staff shall conduct themselves with
dignity and professionalism at all times.
Offensive, insulting language, or inappropriate physical behavior
toward colleagues, nurses, employees, patients, their families or
visitors will not be tolerated.
It is recognized that stressful situations may arise constituting a
challenge for the Medical Staff member or Resident.
Nonetheless, the response must always be expressed with
dignity, patience, insight, and professionalism.
Performance critiques should be discussed in an appropriate
setting and directed toward a positive learning experience.
MS Policy & Procedure: Professional Behavior

27. Behavior and Conduct (continued)
Unprofessional behavior is defined as conduct that adversely
affects the Hospital’s ability to accomplish the objectives
stated above including, but not limited to, the following:
– Verbal attacks, including the use of hostile, angry or confrontational voice
– Physical attacks of any sort or behavior threatening a physical attack
– Destruction of property
– Denigrating or inappropriate comments or illustrations made in patient medical
records or other official documents that impugn the quality of care in the hospital
or attack particular physicians
– Abusive language or criticism directed at the recipient in such a way as to
ridicule, humiliate, intimidate, undermine confidence, or belittle
– Derogatory comments that go beyond differences of opinion that are made to
patients or patients‟ families about caregivers. (This does not prohibit comments
that deal constructively with the care given.)
– Refusal to follow required departmental, hospital, or medical staff policies in a
professional and appropriate manner
– Sexual harassment
– Behavior demonstrating or promoting discrimination

28. Practitioner Health
• Sibley Memorial Hospital and its Medical Staff require all
practitioners who have been granted privileges to maintain
continuous adequate health status to carry out those privileges.
• Any Medical or Allied Health Staff Member whose health status
changes in such a manner as to jeopardize his/her ability to
provide quality patient care shall notify the Department
Chair, the Director of Medical Affairs, the President of the
Medical Staff, or CEO in a timely manner. The physician may
request consultation with the Practitioner‟s Health Committee.
• Any Medical Staff member should report concerns about a
colleagues health, as per medical staff policy - MS Policy &
Procedure: Practitioner Health

29. Informed Consent
• Informed consent is a process of communication between a patient and
physician that results in the patient's authorization or agreement to
undergo a specific medical intervention.
• As the physician providing or performing the treatment and/or
procedure, you are expected to disclose and discuss with your patient:
– The patient's diagnosis, if known;
– The nature and purpose of a proposed treatment or procedure;
– The risks and benefits of a proposed treatment or procedure;
– Alternatives (regardless of their cost or the extent to which the
treatment options are covered by health insurance) and the risks
and benefits of the alternative treatment or procedure; and
– The risks and benefits of not receiving or undergoing a treatment or
procedure.
• In turn, your patient should have an opportunity to ask questions to
elicit a better understanding of the treatment or procedure, so that he or
she can make an informed decision to proceed or to refuse a particular
course of medical intervention

30. INFORMED CONSENT (continued)
• This communications process, or a variation thereof, is both an ethical
obligation and a legal requirement spelled out in statutes and case law in
all 50 states.
• The PROCEDURE PHYSICIAN must sign the attestation
statement on the consent, noting they have had a discussion with
the patient regarding risks and benefits of the proposed procedure
• Incomplete Informed Consent = no procedure .

31. The Medical Record

32. The MEDICAL RECORD
• LEGIBILITY- it is the expectation that all handwritten documents
are legible. Sibley Medical Staff believes that legible documents
are critical to maintaining a safe and efficient environment for each
patient.
• AUTHENTICATION: is the use of a legible identifier to follow your
signature on any order/documentation. Approved methods of
authenticating your signature:
– Use your Sibley ID following your signature (e.g. John
Doe, MD - ID:55555)
– Use of a personal stamp behind your signature. The stamper
must have your full name and Sibley ID number. Note: A name
stamper alone may not be use in lieu of a signed order.
– Electronic signature
Failure to authenticate an order or entry shall render the
record as incomplete and be handled accordance with
Medical Staff Rules and Regulations X. MEDICAL
RECORD, PRACTITIONER RESPONSIBILITY

33. The Medical Record (Continued)
• The attending practitioner shall be responsible for a complete
and legible medical record for each patient.
• Its contents shall be pertinent and current.
• Symbols and abbreviations may be used only when they have
been approved by the Medical Staff.
• Do Not Use Abbreviations:
• Always use a leading zero with decimals, (i.e. 0.5 mg.)
• Never use a trailing zero with decimals, (i.e.5.0 mg.)
• Spell out the word „unit‟; do not use „u‟
• Spell out „international units‟; do not use „iu‟
• Spell out „microgram‟ or „mcg‟; do not use „μg‟
• Spell out „greater than‟ and „less than‟; do not use < or >
• Spell out Magnesium Sulfate; do not useMgSO4.
• Spell out „Morphine‟; do not use „MSO‟ or“MS‟.
• Eliminate period between drug names and sig
• Spell out „Daily‟ or „ Every other day‟; do not use Q. D. or Q.O.D.
• Spell out „3 times weekly‟ or „three times weekly‟; do not use T. I. W.
• Spell out „Left ear, Right ear, Both ears‟; Do not use „A.S., A.D., or A.U.‟
• Spell out „Left eye, Right eye, Both eyes‟; Do not use „O.D, O.S. or O.U.

34. All entries must include
SIGNATURE, AUTHENTICATED ID, DATE & TIME
of the ordering/writing practitioner
Failure to complete any element constitutes an
incomplete medical record.

35. ADMISSION ORDERS AND DOCUMENTATION
• Orders shall be on the medical record within 2 hours of a
patient‟s admission.
• Within 24 hours of an admission, a complete history and
physical examination and admission note shall be recorded.
These records shall include all pertinent findings.
• If a history and a physical examination has been performed
within 30 days before admission, a durable, legible copy of this
report may be used in the patient‟s medical record, provided
any changes that may have occurred are recorded in the
medical record at the time of admission. Failure to comply will
be reported to the attending physician by the floor head nurse
or to the chairperson of the department if there is further delay.

36. GENERAL ORDERS
• Orders shall be written in detail on the order sheet of the patient‟s
record, dated, timed, signed and authenticated by the practitioner.
• A verbal/telephone order shall be considered as a written order if the
physician provides his ID number and it is dictated to a registered
nurse, registered pharmacist or respiratory therapist functioning
within his or her sphere of competence and signed by the
responsible practitioner.
– ALL VERBAL ORDERS AND TELEPHONE ORDERS SHALL
BE SIGNED OFF (signature, ID, date & time) BY AN AUTHORIZED
PRACTITIONER WITHIN 48 HOURS OF SUCH ORDER.

37. PROGRESS NOTES
• Pertinent progress notes shall be written legibly and recorded at
the time of observation, sufficient to permit continuity of care and
transferability.
• Whenever possible each of the patient‟s clinical problems should
be clearly identified in the progress note and correlated with
specific orders as well as results of tests and treatments.
• Progress notes shall be written daily on critically ill patients and
those where there is difficulty in diagnosis or management of the
clinical problem.
• SIGNATURE, ID, DATE & TIME of the Progress Note by the
writing practitioner is required.

38. POST OP NOTE
• Immediately following any procedure, a post op note is
to be written in the medical record prior to the patient
leaving the procedure area.
• Required elements for the post-op note :
- Name of Surgeon
- Name of Assistants
- Description of Procedure
- Findings of Procedure
- Estimated Blood Loss (even if it is “zero” or “none”)
- Any specimens removed
- Post op Diagnosis

39. DISCHARGE NOTES
• A written or dictated discharge clinical resume is recommended
at the time of the patient’s discharge to support the continuum
of care post hospitalization. All summaries shall be authenticated
(signature, ID, date & time) by the responsible practitioner.
• The attending practitioner is required to document the need for
continued hospitalization after specified periods of stay as
identified by the Clinical Resource Management Committee of the
hospital. (R&R IX: Medical Record General)
• The final diagnoses shall be recorded in full, without the use of
symbols or abbreviations and authenticated (signature, ID, date &
time) by the responsible practitioner

40. Restraint and Seclusion
Hospital Policy 01-31-12
• Each patient‟s safety needs are individually evaluated and the
least restrictive type of restraint is utilized.
• Alternative measures are attempted and documented before
resorting to restraints or seclusion.
• Restraints or seclusion must be discontinued at the earliest
possible time regardless of the length of time specified in the
order.
It is the responsibility of the physician / LIP who initiates
use of restraints and seclusion to be familiar with and
comply with every aspect the hospital’s policy and
procedure.

41. Conditions for Using Restraint or Seclusion:
– For the Purposes of Promoting Medical-Surgical Healing
(e.g.: to prevent a patient from pulling out a tracheostomy tube).
• time-limited order of no more than 24 hours,
• defines the specific type of restraint, and
• the reason for implementation
– For Violent or Self-destructive Behavior that is an immediate threat
to the patient, staff, or other‟s physical safety
• A face-to-face evaluation is required within 1 hour of initiation.
• Restraints or seclusion orders must be renewed every:
– Four (4) hours for adults (over 18);Two (2) hours for ages 9-17;One (1)
hour for under age 9.
• Restrained or secluded patient is re-evaluated face-to-face by an LIP
every:
– Eight (8) hours for patients who are 18 or older; Four (4) hours for patients
who are 17 and under.; One (1) hour for patients under 9.

42. Sibley – Becoming Certified as a
Stroke Center of Excellence
• Evidence-based, best practice methodologies are
used promote consistent stroke care. Stroke centers
must also have excellent standards of program
management, clinical information and self-
management
• Target date for certification is first quarter 2012.
• To activate stroke team at Sibley call 4555. Medical
Office Building above the first floor needs to call 911.

43. Every Minute Counts…
Act F.A.S.T

46. The Physician’s Role
• All patients admitted with a primary diagnosis of TIA
or stroke will be admitted to the Telemetry or ICU
depending on acuity and need for TPA.
• Physicians must utilize the stroke order sets for all
stroke/TIA patients in order to insure best practice
• Stroke order sets can be accessed on the Sibley
intranet under stroke response and are titled Acute
stroke/TIA order set (MR02822).

47. Thank you for completing the Medical Staff
Orientation for Sibley Memorial Hospital on
10/25/2011.
Copy the above statement and paste it into an email
text box.
Email to one of the following addresses
jrein@sibley.org cfried@sibley.org
jbarnett@sibley.org tlucas@sibley.org
To earn CME from this activity, you must complete a
CME Evaluation Form. Open and complete the
attached Word document and include with your email