Incident Management (Policy 2.09)
This system is the centralized database use to record and track IMRs.
WaRMSS
True or False: Shorts or sweatpants/jogging suits are acceptable to wear to work.
False
Systemic and continuous actions that lead to measurable improvement in health care services and the health status of the targeted patient groups.
Quality Improvement
Patients at risk of suicide may require this type of monitoring.
A 1:1, 2:1, or Augmented Observation
All absences must be documented on this form.
The Absence and Additional Time Worked Report (DSH 0634)
Staff must complete both the Interdisciplinary Note (MH 5624) and Incident Management Report (DSH 2512) within this amount of time after an incident.
2 hours.
Which clothing colors are prohibited?
Khaki, Cocoa and Camouflage.
A standing body of clinical and administrative leaders responsible to provide oversight of hospital quality improvement activities and serves as the local governing body at DSH Patton.
The Quality Council
What is an Augmented Observation?
An Augmented Observations is one staff member observing more than one patient (1:2 or 1:3).
Employees must submit medical notes to this person, not HR.
The immediate supervisor
The previous terminology SIR is now IMR. What does this stand for?
Incident Management Report. Spread the word!
Personal hygiene is essential and necessary, it includes:
A bath/shower, deodorant, and mouth care.
An approach to improving the quality and safety of healthcare services by identifying the circumstances and opportunities that put patients at risk of harm and then acting to prevent or control/manage those "R**ks".
Clinical Risk Management
This individual is responsible for the policy on Enhanced Observation of Patients
The medical director
Is 7 minutes late considered a "Grace Period"?
No, Habitual tardiness of (6) minutes or less are NOT acceptable. Tardiness of (7) minutes or more shall be documented through the personnel system.
An SOC 341 is required for what types of IMRs?
Alleged Physical Abuse, Alleged Psychological abuse including a Patient Rights violation, Exploitation of Staff to Patient, and Alleged Sexual abuse by staff.
What happens if a DSH-Patton employee violates the clothing and grooming standards policy?
The employee will be sent home to change on their own time. Leave credits charged.
AN examination of a high-risk process in detail, sequencing of events, actual and potential risks, failure or vulnerability points, and prioritizes a logical process, to provide areas of improvement to impact of care, treatment, or services provided. How often must it be done?
Proactive Risk Assessment. Every 18 months.
This is the definition of enhanced observation
Any increase in staff observation or care of a patient that is not normally provided to all patients.
An employee must have 12 months of service and 1,250 hours worked to qualify for what types of leave?
FMLA/CFRA
Incident Management tracking and trending data with appropriate analysis, and recommendations is reported no less than quarterly to what committee?
Quality Council Quarterly & the Governing Report
This is the purpose of AD 4.26
To promote a professional appearance of all hospital personnel and to promote a safe and healthy environment.
SCD provides oversight of the hospital's regulatory compliance. Compliance activities include:
The Joint Commission, California Department of Public Health, CalOSHA, Sentinel Events, and regulatory reporting.
DTS and DTO are reasons for Enhanced Observation, what do they mean?
Danger to Self, Danger to Others
An employee shall provide sufficient documentation to support use of sick leave absences for more than how many consecutive workdays?
3 workdays.