UCLA MEDICAL CENTER加州大學(xué)洛杉磯分校醫(yī)療中心.doc

UCLA HealthcareNeuropsychiatric HospitalSelfStudy Orientation Guide and Staff Information Handbook TABLE OF CONTENTSChapter One: Overview1. Mission32. Vision33. Values34. Leadership3Chapter Two: Medical Center Plans, Programs and Initiatives1. Plansa) Staff Education Plan3b) Information Management Plan4c) Institutional Plan for the Provision of Patient Care4 2. Programs and Initiativesa) Performance Improvement4b) Patient and Family Education5c) Patients Evaluation of Performance5Chapter Three: Key Medical Center Policies and Highlights1. Patient Rights and Responsibilities52. Code of Ethics63. Corporate Compliance64. Patient Confidentiality65. Advance Healthcare Directives76. Pain Management87. Staff Rights88. Abuse Recognition and Reporting99. Research Involving Medical Center Patients10Chapter Four: Age Specific Guidelines for Patient Care1. Neonates112. Infants 113. Pediatrics 114. Adolescents115. Adults116. Geriatrics11Chapter Five: Environment of Care1. Emergency Management112. Fire Safety133. Hazardous Materials144. Safety and Body Mechanics155. Security176. Utilities177. Medical Equipment188. Social Environment19Chapter Six: Patient Safety1. Patient Safety Overview192. Event Reporting203. Medication Use214. Medical Gas Safety225. Bed Rails226. Infection Control23Post Test24 REVISED July, 2003Chapter One: OverviewUCLA Neuropsychiatric Hospital (NPH) is a 136 bed acute psychiatric hospital with outpatient services located in 300 Medical Plaza. The NPH is licensed by the State of California and accredited by the Joint Commission on Accreditation of Health Care Organizations. 1. MISSIONThe mission of the Neuropsychiatric Hospital, in association with the Department of Psychiatry and Biobehavioral Sciences at the UCLA School of Medicine, is to develop and maintain an environment in which education and research are integrated with exemplary patient care. 2. VISIONThe vision of the UCLA Neuropsychiatric Hospital is to serve the health care needs of our community, our patients and their families through excellence in research, education and the provision of Neuropsychiatric and behavioral health services. 3. VALUESThe NPH staff and faculty are dedicated to providing quality care in a service oriented and cost effective manner, teamwork and an interdisciplinary approach to process improvement, and participation of staff in all aspects of performance improvement. 4. LEADERSHIPThe Regents of the University of California serve as the governing body for UCLA Medical Center. Authority to lead UCLA Healthcare (including the Medical Center, Medical Group, and the Medical School) is delegated to the Provost, Medical Sciences (Dr. Gerald Levey). The Provost delegates the responsibility for the quality and integration of patient care services for the NPH to the Physician-In-Chief (Peter Whybrow, MD) who is also the Chair of the Department of Psychiatry at the UCLA School of Medicine. The Medical Director of the NPH (Fawzy I. Fawzy, MD) is delegated the responsibility for the administrative and clinical operations of the hospital. The Hospital Advisory Committee, chaired by the Provost or his designee, assumes the governing body functions. The Professional Staff (physicians and psychologists) are led by a self-governance process and elect a Chief of Staff, who works closely with the Medical Director and NPH leadership to achieve the hospitals mission. Chapter Two: Medical Center Plans, Programs, and Initiatives1. PLANSNPH leadership develops plans to guide how the institutional mission and values are carried out in specific situations. Key institutional planning issues are summarized below.a) Staff Education Plan The UCLA Medical Center Education plan includes the NPH and is a two-year plan, which was created, to address formally assessed learning needs across the organization. The purpose is to provide an effective and efficient process that builds the requisite skills for optimum performance at all levels of staff. The ultimate purpose of the plan is to provide a learning environment that supports progressive learning and optimum performance in providing exemplary patient care. The goals of the plan are to ensure that employees are provided with an adequate orientation, to provide an environment that is conducive to continuous learning, and to ensure the effective collection and aggregation of data related to education, training and development. Education, training and development is an ongoing process rather than a single event, that occurs at any time or any place. Each employee, together with their manager, is responsible for ongoing achievement of competencies and learning objectives.b) Information Management Plan Information management means many things in a hospital, from paperbased processes like medical records to telephone, fax and e-mail communications, to computerbased activities. Information management links research, teaching, and patient care activities as well as administrative and business functions. A Clinical Enterprise Information Technology committee exists to assess information needs, develop and plan the current and future use of technology. In addition, the NPH has an Information Management Committee that coordinates local issues and approves forms for the hospital. The goals of information management are to: Develop and maintain an integrated information and communication network linking research, academic and clinical activities Provide computer-based patient records with integrated clinical management and decision support Support administrative and business function with information technologies to improve quality of services, cost-effectiveness, and flexibility Build an information infrastructure that supports the continuous improvement initiatives of the organization Ensure the integrity and security of information in order to protect patient confidentiality Protecting patient confidentiality is everyones responsibility so all employees who access patient data must sign confidentiality statements. To assure security of computerized information, individual passwords are required for all employees who use a computer. c) Institutional Plan for the Provision of Patient CareThis plan guides the NPH in providing excellent patient care. Four important factors guide patient care planning: Patient focused care Services are decentralized at the unit level whenever possible for greater efficiency, cost savings, and increased staff and patient satisfaction. Consideration of special patient populations Patient care plans consider the patients age, language, cultural background and special needs and circumstances. Single level of care All patients with similar health care needs receive the same level of care regardless of the department providing the care, the discipline of the health care practitioner, or the patients ability to pay. Continuity of care Patient care is coordinated as patients move from one level of care to another, i.e., from admission, through hospitalization and to ambulatory or home care. Each department/unit has a written Scope of Service which highlights its functions and services. It also identifies and provides a summary of its standards and staffing to meet the needs of its patients and/or other customers. 2. PROGRAMS AND INITIATIVESAs a way to continually improve the NPHs performance, the following initiatives and programs have been established to provide structure, formal process improvement, and to support quality patient care activities. a) Performance Improvement In keeping with the NPHs mission to provide high quality patient care and support the teaching and research programs of the School of Medicine, a Performance Improvement (PI) Program continuously plans, measures, assesses, and improves processes, systems and outcomes to assure exemplary performance. This includes quality assessment which refers to systematic monitoring activities. The systematic methodology used to conduct Performance Improvement activities is “FOCUSPDCA,” which stands for the following: Find a Process to Improve Organize a Team that Knows the Process Clarify Current Knowledge of the Process Understand the Source of Improvement Select the Improvement Process Plan the Improvement Do Improvement, Collect Data, and Analyze it Check and Study the Results Act to Hold the Gain and to Continue to Improve the ProcessPerformance Improvement includes evaluation of clinical effectiveness to improve patient care and achieve efficiency of treatments and cost effectiveness. The program also incorporates the institution-wide PI Program that is organized to integrate NPH PI activities into a comprehensive, interdisciplinary program. All employees are responsible for assuring patient safety by identifying unsafe practices, participating in root cause analyses, and understanding the relationship between Performance Improvement and Risk Management. Employees work with Risk Management to identify, reduce and eliminate risk exposures. This process provides the opportunities for improvements in process and practice of care. b) Patient and Family Education improves health outcomes by promoting healthy behavior and involving patient/family in their own care and care decisions. Patient and Family Education is specific to patients assessed needs, abilities, and readiness to learn. Educational resources are available to patients and their families. The patient and family educational process is collaborative and interdisciplinary, as appropriate to the plan of care. When health professionals understand one anothers contributions to patient education, they can collaborate more effectively. Collaboration, in turn, ensures that the information that patients and families receive is comprehensive, consistent and effective as possible.c) Patients Evaluation of PerformancePatients evaluate our performance continuously through ongoing patient surveys. Patient feedback from these surveys in both inpatient and outpatient settings is shared with staff to identify opportunities to improve our service.Chapter Three: KEY MEDICAL CENTER POLICIES AND HIGHLIGHTSAll Medical Center staff must be aware of key policies that guide appropriate and quality patient care as well as provide a safe working environment for staff. 1. PATIENT RIGHTS AND RESPONSIBILITIESThe NPH respects the rights of the patient and recognizes that each patient is an individual with unique health care needs. The NPH has adopted a Patients Bill of Rights and Responsibilities. Employees should be aware of these rights, which include, but are not limited to individualized care, knowledge of roles of the physicians, making decisions about medical care, information about diagnosis, treatment and prospects for recovery, effective pain management, privacy and confidentiality, billing explanations, filing a grievance, and reasonable requests for services. In addition, psychiatric inpatients have additional rights specified under California law that may not be waived by the persons parent, guardian or conservator. These include the right to wear ones own clothes, to keep and spend money, to see visitors, to have access to the phone and letter writing materials, to have storage for personal belongings, and the right to refuse certain treatments. Patient responsibilities include the expectation to treat providers and others with courtesy and respect, to follow hospital policies, to provide necessary medical information, and to cooperate with the delivery of care.A detailed description of all of the patient rights are given to patients on admission and are found in NPH policies and posted on inpatient units. 2. CODE OF ETHICSThe “Statement of Organizational Ethics” describes the values and guiding principles on which the UCLA NPH bases its decisions and actions and affirms the NPHs commitment to meeting its responsibilities in an ethical manner.The UCLA NPHs staff and faculty are dedicated to building and sustaining an ethical environment supported by basic values. These basic values are incorporated into all daily activities through the NPH policies and processes.The code of ethics as adopted by the American Medical Association and by the American College of Surgeons governs the professional conduct of members of the Medical Staff. A Professional Staff Ethics Committee also exists at the Neuropsychiatric Hospital, which identifies and clarifies ethical issues. Posters situated throughout the hospital invite anyone including staff, faculty, trainees, and patients to call, to write, or to email the Chair of the Ethics Committee in confidence to discuss an ethical issue. The Chair can be reached at 310-825-6962 or by letter to the Chair, NPH Ethics Committee, c/o NPH Ombuds Office, NPH B8-257, Campus Mail 175919.3. CORPORATE COMPLIANCE The Regents of the University of California and the UCLA Healthcare Enterprise have developed a Compliance Code of Conduct to provide guidance to Medical Center and NPH personnel in carrying out their daily activities. The rules governing the provision of healthcare have become more complex, and it is often difficult to know which choice is the right one. The Corporate Code of Conduct serves as a guide in helping staff to make the correct legal and ethical decisions. The UCLA NPH and UCLA Medical Center adhere to the Code as a foundation of commitment to ethics, integrity, prevention and detection of fraud and abuse, and compliance with all regulatory and legal requirements. As set forth in the Code, all faculty and staff should adhere to all applicable standards of professional practice and ethical behavior in carrying out their duties and should not feel forced to take part in unethical, improper or illegal conduct. A Confidential Compliance Hotline is available for staff to anonymously report compliance concerns, and the hotline can be accessed by calling 1-800-296-7188.4. PATIENT CONFIDENTIALITYEvery patient has a right to privacy and it is every employees responsibility to protect that confidentiality. This means keeping information about patients health care private. Both federal law (the Health Insurance Portability and Accountability Act or “HIPAA”) and California state law require the protection of all Patient Identifiable Health Information, including all identifiers, images and other information which could be used to determine of the identity of a patient. The privacy laws apply to all forms of patient health information including, paper, electronic and verbal information.Staff are required to only use or access that amount of patient information that is minimally necessary to complete a task, responsibility or function. Staff are responsible to only use and access information on patients for whom they are providing care, or which they need the information to complete a task that is part of part of their responsibilities. Failure to comply may lead to disciplinary or legal action against the employee and the hospital. Confidential information includes a wide variety of information about a patients health care. Examples of confidential information include: Patient identifiers such as medical record number, name, date of birth, Social Security Number, address, phone number, contact information, photographic images and any other unique code or characteristic that could be used to identify an individual patient Details about illnesses or conditions (particularly AIDS, psychiatric conditions, genetic testing or alcohol/drug abuse) Information about treatments Healthcare providers notes about a patient Patient billing information Conversations between a patient and a healthcare providerThe NPH has special rules regarding when to release information. These guidelines are available in NPH policies and procedures. We do maintain all patient information with appropriate confidentiality controls.At the time of admission or at the first outpatient direct service encounter, each patient receives a “UCLA Healthcare Notice of Privacy Practices” which explains how the hospital uses patient information, and the rights the patients have over their own health information. Patients have certain rights granted under federal and state law to control their protected health information, including the right to access and receive a copy of their health information, request addendums to or changes to their health information, request restrictions on how and to whom their information is used or disclosed, request alternate methods for communicating with them, and to obtain a list of individuals or organizations to whom the hospital has provided access to their information. These rights apply to both the patients medical and billing records.Privacy Policies and ResourcesUCLA Healthcare policies and procedures, and University of California policies, relating to the protection of patient privacy can be found on the “Privacy Management