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Safety Counts! a newsletter highlighting safety at Hallmark Health System

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Safety Counts March 2015 - Download entire PDF by clicking here. 

Vol 3, No. 3, March 2015

Weathering the storm: Disaster planning comes to life

The Boston area experienced record-breaking snowfall this winter! When weather or other emergencies strike, Hallmark Health System’s disaster plan is activated to ensure the safety of patients, visitors and employees.

That’s what happened during the two-day blizzard at the end of January when a “code alert” was called (see codes article on back) and the disaster plan kicked in. Its hub is an incident command center established at a primary site. The command center is both physical and virtual, so off-site leaders across Hallmark Health can call in via a bridge line. The administrator on call at the time the disaster is called serves as the incident commander. Comprising senior leaders and other key staff, the incident command group assesses the situation. Department heads give status reports and assignments are made – such as logistics, operations and finance – to ensure the hospitals maintain operations and the facilities can function.


“Having an incident command center ensures that everyone is on the same page and working together,” said Rick Westhaver, RN, BSN, a clinical educator who assists with setting up the incident command center and serves as liaison to the incident commander. The goal is to ensure operational flow so that patient care is not disrupted. Among the tasks covered during a snow emergency are the obvious such as shoveling as well as tasks such as cancelling elective surgeries and checking supply levels.

Disaster planning also extends to employees. “For example, we have a bed coordinator who makes sleeping arrangements for staff who cannot safely get home,” said Westhaver.

“Thankfully, we don’t need to activate our disaster plan very often, but when we do, everyone is willing to lend a hand,” said Westhaver. “And we are always ready. Each hospital has enough food, hot water, fuel and oxygen to last four days.”


The importance of policies and procedures

Every organization has them. Every organization needs them. But how many place policies and procedures among their overall goals? That’s what’s happening this
year for Hallmark Health System. The board of trustees has identified compliance with policies and procedures as an organization-wide goal for 2015. Having and adhering to up-to-date policies and procedures also is mandated by many government agencies and outside organizations, such as the Joint Commission.

Last summer, the federal Occupational Safety and Health Administration cited one Hallmark Health hospital for a violation of a potential employee safety hazard.

“One of the areas cited was in relation to our written policies. Had the policies and procedures related to the OSHA complaint been current, this issue never may have risen to this level,”said Tessa Lucey, MHA, CHC, CHPC, corporate compliance officer. “We take employee and patient safety very seriously and have resolved these particular issues.”


There are more than 50 manuals and 4,000 documents within Policy Manager, the Hallmark Health online policy and procedure manual. For example, all the activities described in this issue – codes, incident reporting, and weather emergencies – have policies and procedures detailed in Policy Manager. Updating this resource is one part of the overall initiative.

There are two main parts to the process: reviewing each written policy and making sure that staff know about it and put it into practice. A third element is ensuring that the practice and policy match. “Sometimes, new clinical best practices can overtake the old written policy,” said Lucey. “This is why it’s so critical that policies are updated and revisited at least every three years.”

Despite the volume of work involved, the process has some benefits for employee and patient safety. “For one thing, it makes us think about all our processes,” said Lucey. “Also, it can identify areas for improvement so they can be fixed before an issue arises.” She added that “policies need to be lived, not just read in a manual. Our ultimate goal is that they are so ingrained that they just become the way we do things.” 


Calling a code: Shorthand communication alert staff to emergencies

Anyone who has watched hospital-based dramas on TV is familiar with overhead pages, such as “code blue,” that signify an emergency. 


In general, emergency codes used by hospitals fall into three categories: facility, security and medical. Hallmark Health System employs a dozen codes to convey critical information in an emergency. 

Anyone can call a code; stickers with code names and phone numbers are affixed to phone handles throughout the system. Among the most frequent codes called are for fire, security and assistance in the emergency department. 

“When we have a sudden influx of patients in the ED and we need more resources, we call a ‘code help,’” said Chief Nursing Officer Pamela Duchene, PhD, APRN-BC. “This most often brings a response from nurses, supervisors and physicians, plus representatives from security, administration, transport and environmental services. Everyone comes together to ensure that patients are safe and cared for appropriately.” 

“Most ‘code help’ incidents involve the lack of beds,” said Chair of Emergency Services Alexander Walker, MD, MBA, FACEP. “Either all beds in the ED are in use or there are no available beds up on the inpatient floors for a patient who needs to be admitted. Having more hands on deck helps us with everything from bringing temporary beds to the ED area to facilitating the preparation of patient rooms on the inpatient units. This matters because studies show that the quicker a new patient can be brought into the ED to be worked up or an admitted patient can be moved out of the ED to an inpatient unit, the safer he or she will be.” 

‘Code help’ challenge met on Super Bowl Sunday
According to ED nurse Paul Champagne, RN, “…just after noon we got extremely busy, the waiting room started to fill up, ambulances were arriving fast and furious, and no one was being discharged or admitted fast enough to decompress the ED. We called a ‘code help’ and got support from the charge nurses from the floors as well as calls from Drs. Sbardella, Doherty and Walker. I was not at all surprised to see everyone working together and providing top-notch care to every patient in our overcrowded ED.”

From RMPro to RL6: A new generation of patient safety reporting

Coming soon to the computer screens of Hallmark Health System employees and staff is a new, streamlined and more user-friendly patient safety reporting system. The new software, called RL6, is made by the same company as RMPro; it is highly regarded and used by top hospitals around the country. 

RL6 has a number of advantages for users. “Most important is ease of use,” said Debra Wright, RN, MPH, CPHRM, system director of risk management. She cited a number of examples:


■ Clear and colorful icons help users navigate around the software and help define the various reporting categories.

■ Many forms have fields that autocomplete to reduce file-entry time. 

■ There is a sign-off function when a user’s follow up is completed. 

■ Users are able to search by keyword. 

Electronic patient safety reporting in general is an extremely useful tool for aggregating data, flagging potential problems sooner, and spotting trends that can improve patient safety. 

At Hallmark Health, the current RMPro system logs more than 5,000 reports annually. “We hope the new system’s ease of use will motivate staff to report even more potential patient safety issues,” said Wright. “Increased reporting is actually a good thing. Many organizations known for quality and safety recognize that reporting by their employees ultimately reduced potential errors and improved patient safety.” 

Transitioning to the new system is expected to be completed this spring. “Because any employee can submit a report, everyone will be trained – both in in-person sessions and through NetLearning,” said Wright.


Annual Report


Patient Handbook