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Focus On: The Employee Newsletter

Batter Up

The 2007 EOW season got off to a great start with the official kick-off on March 1. The first day participation winners were the Los Angeles Dodgers and the St. Louis Cardinals in a National League tie, and the Detroit Tigers for the American League. All members from these teams won $10 Safeway gift cards and bragging rights for the highest first day participation rate. The prizes kept coming with the Los Angeles Dodgers and the Detroit Tigers hitting home run after home run to score 100 percent participation by day thirteen of the series and earn a $25 American Express gift card for each of their members. Not to be left out, members of all teams achieving 90 percent participation rate earned $5 Starbucks gift cards.

Now that the season has ended, two prizes await us. First up is the tailgate party for successfully reaching 90 percent participation. All shifts at each campus will have a great time celebrating this victory with great food and great teammates. Second is the awarding of the very first EOW champion trophy for the campus with the highest participation rate. Look for the official announcements on the tailgate party and trophy soon.

But first, what would a tailgate party be without hot dogs, mustard and ketchup? You may have seen this trio in the units, cheering teams on to victory and showering players with ballpark treats. Now that both leagues successfully reached 90 percent participation, employees can vote for who they want to see donning the fashionable – and figure flattering – hot dog, mustard and ketchup attire during the tailgate party. Just like the EOW survey, we want to know what you think!

JCAHO Preparation: Continued Readiness – Unannounced JCAHO/CALS Survey

By Bryan Daylor, Vice President of Ancillary and Support Services, Eden Campus; and Debbie Hendrickson, Director of Risk and Medical Staff, Eden Campus

Like in all other accredited hospitals, Eden Medical Center’s employees, medical staff and management team are expected to perform their respective responsibilities in accordance to JCAHO, DHS, CMS and other regulatory guidelines and standards.

The Medical Center’s accreditation is dependent upon our demonstrated compliance with the hundred of performance standards the regulatory agencies review and inspect. This year we will experience our first unannounced JCAHO/CALS survey. This is a significant change from years past when we were scheduled for our surveys with 60-90 days advance notice.

Although we have the best intentions of always being in compliance with the requirements, hospitals are a dynamic organization with frequent changes and new processes being adopted each month. This is why we must be vigilant in knowing our various individual responsibilities as well as the organization’s rules and standards for accreditation.

In order for us to have a successful JCAHO/CALS survey we must be ready at all times. Whether we are medical staff members, management team or employees, we are responsible for knowing and understanding the information provided to us through our annual education, training, and preparation participation.

We know that the unannounced JCAHO/CALS survey will occur between next week and the end of the calendar year. We have learned that four other Sutter affiliates have already been surveyed with various degrees of success. We also know that due to Eden Medical Center’s size we will have a five day survey. Most likely, the survey will begin on a Monday and end on a Friday. Otherwise, we do not know what week they will arrive.

The JCAHO/CALS Unannounced Survey Readiness Plan (distributed to each department) outlines responsibilities for placing the organization in a positive position when the surveyors arrive. The management team is responsible for organizing and preparing the appropriate documentation (reports, policies, etc.) for the surveyors to review. Staff employees play a key roll in seeing that patient records are current, accurate and void of discrepancies or missing information. Likewise, each of us has responsibilities for maintaining the facilities in a clean and safe condition. To assist in maintaining the physical environment we have created unit checklists that describe specific items that must be adhered to at all times and checked upon learning our surveyors have arrived. These are the same items that create a potential safety hazard, or violate a Life Safety Building Code such as items blocking egress, fire alarms or fire doors that are on magnetic hold openers, oxygen bottles not stored or transported correctly, inappropriate storage of medication, staff not familiar with emergency response codes etc.

As in previous surveys, we expect employees to be interviewed and asked questions regarding understanding of hospital policies and procedures. We are confident in our employee’s knowledge and understanding of their respective job responsibilities. However, as a reminder, when answering questions for the Surveyors, remember to listen closely to the question, if necessary ask them to repeat the question or clarify. Be calm and answer to the best of your ability. Don’t provide more information than is requested. If needed, you may refer to a resource such as a policy manual, a help checklist or information on your identification badge.

If surveyors request copies of materials or policies please refer them to your supervisor or the medical center’s escort who will be in the vicinity of the surveyor. Remember to thank them for their time when you have finished.

We look forward to demonstrating to our survey team that Eden Medical Center provides excellent quality care in a patient safe environment.

Who's News

Please welcome Phyllis Moroney, R.N., N.P., on board as the new marketing manager for Eden Medical Center. Phyllis has taken over several ongoing marketing projects, including the Sutter East Bay Neuroscience Center, the Birthing Center, EdenFit, the 20th anniversary of the trauma center. She has also taken over marketing our ancillary services, working directly physicians to increase referrals. Well-known in this community, Phyllis has worked with us before, at Laurel Grove Acute Rehab. She lives here in Castro Valley and is active in several organizations in the Hayward community.

Phyllis will based at the San Leandro Hospital Campus, in the office formerly occupied by Chuck Prosper, however her work between the two campuses and with physicians will keep her "on the road" quite a bit. Mary Garcia will continue to be our main public relations contact at the San Leandro Hospital Campus.

Please also welcome Sophie Taylor, R.N., BSN, PHN, MSHCA, who has accepted the position of clinical transformation director at Eden/San Leandro. Sophie most recently held the position of senior quality project manager for the Department of Quality and Resource Management at Kaiser Permanente in Oakland. In that role, she assisted and advised the Kaiser Foundation Hospitals/Health Plan Board of Directors Quality Improvement Committee in carrying out their fiduciary responsibilities to perform their quality oversight role covering 8.5 million members in regions spanning from the Mid-Atlantic States to Hawaii. Sophie also identified and made recommendations pertaining to quality issues throughout the KP program, as well as JCAHO accreditation, credentialing and quality processes. She served as the sentinel event coordinator for the KP nationwide program, lead multiple inter-regional groups to facilitate the spread of best practices and ensure compliance with regulatory and accrediting requirements, and participated as an observer in the formal research project known as “Highly Reliable Surgical Teams.”

Prior to her role at Kaiser Permanente Regional Offices, Sophie was the director of risk management at Kaiser Richmond. Before working in a leadership role, Sophie was a surgical nurse at Eden Medical Center for four years and this is an opportunity for her to “return home” to the facility where she worked as an operating room nurse.

Sophie has completed the AHA Institute for Patient Leadership and holds a Fellowship from this program which is a year long intensive program on Patient Safety.

Female Knee Implants

Did you know that the majority of knee replacement patients are female? In fact, according to the National Center for Health Statistics, nearly two-thirds of the more than 400,000 annual knee replacement patients are women and that number increases each year. As word about the female knee implant spread, female patients have been demanding it.

“In my years in practice, this is one of the few things patients come in requesting,” says Dr. Gregg Pottorff, orthopedic surgeon on staff at both the Eden and San Leandro Hospital campuses.

In the past, female patients used the same implants as male patients, only smaller. However, women’s bones are aligned differently then men – women have wider hips to accommodate for childbirth. This caused implants to hang too loosely, by a quarter inch on either side, often resulting in tendonitis and stiffness for the patient.

The Gender Solutions Knee™ is the first and only knee shaped and sized to optimally fit the female knee. It was developed by Zimmer Inc., a leader in designing, developing and manufacturing reconstructive and spinal implants, trauma and related orthopedic surgical products. Zimmer incorporated both existing research and new data about gender differences and was able to addresses three key shape-related anatomical differences of a woman’s knee: 1) thinner profile in front to feel natural and not bulky, 2) more natural movement when bending and walking, and 3) contoured shape from side to side for a more precise fit that more closely matches the narrower anatomy of a woman’s knee.

The knee joint is composed of three bones: the end of the femur (thighbone), the top of the tibia (shinbone) and the patella (kneecap), which are all held together by tendons and ligaments and cushioned by cartilage. Factors such as arthritis, injury and infection can cause the cartilage to deteriorate and lead to painful knees. When the cartilage is gone, the knee bones grind against each other, wearing away and typically causing severe pain. Total knee replacement involved removing the portion of the bone that is damaged and resurfacing the knee with metal and plastic implants.

There have been other advancements in knee replacement surgery over the years. In the past, incisions were 12 inches long. However, now, with minimally invasive surgery, they’re only 3-4 inches long,” And now, a knee that better meets the needs of two-thirds of the knee replacement populations is a logical next step.

The procedure itself and recovery are still the same. Patients are still walking by the next day, using a walker or cane for the next 6-12 weeks and going through physical therapy for 3-6 months.

Your Health on TV

Catch the latest episode of Your Health when it airs on KPIX Channel 5 on Sunday, April 1, at 3:30 p.m., and learn more about the following topics:

Why are trans fats so dangerous to your health?
You may have seen the headlines: trans fats banned from city restaurants. But why are people taking such serious steps to remove these preservatives from food?

Nearly 1 in 5 Americans affected by Arthritis!
Arthritis is a common problem that refers to more than 100 diseases and afflicts nearly 1 in 5 Americans. But sadly, many people with chronic joint problems don't seek treatment from a physician.

Back problems affect your sleep, your mood, your concentration...
And you might think big pain like this requires equally big treatment. But one tiny invention - a titanium wedge - is making a huge difference for many people who've been suffering.

What would it be like to take a virtual tour of your own body?
What would you see? A heart that beats strong? Healthy bones? Doctors now have a new tool that's allowing them to view the body in detail never seen before.

Sutter Scholar Deadline

There is still time to submit an applications for the Van R. Johnson Sutter Scholars Program for the 2007-2008 academic year. Applications can be downloaded from MySutter or picked up at your local Human Resources Department.

Applications and all supporting documents must be postmarked by March 30, 2007. Late or incomplete applications will not be accepted.

Should you have any questions, program eligibility information is included on pages 1–4 of the application. For any additional questions, please leave a message on the message line at (800) 500-0114 or e-mail your question to sutterscholars@sacregcf.org. All inquiries will be responded to within two business days.

Patients' Rights

Did you know that every patient who is admitted to the hospital or uses our services is informed of their rights as patients? Are you aware of your role in honoring these rights? Take the time to review the Patients Rights and understand how you help make our patients' experience here the best it can be.

Patients’ Rights

Eden Medical Center and its medical staff have adopted the following list of patients’ rights. Eden Medical Center will honor these rights without regard to sex, economic status, educational background, race, color, disability, religion, ancestry, veteran status, national origin, sexual orientation or marital status or the source of payment for care. Patients, as well as the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient, have the right to:

1. Be informed of your rights, in advance of providing or discontinuing care, whenever possible.

2. Know the name of the physician who has primary responsibility for coordinating the care and the names and professional relationships of other physicians and non-physicians who will see you.

3. Have a family member (or other representative of your choosing) and your own physician notified promptly of your admission to the hospital.

4. Considerate and respectful care, and to be made comfortable. You have the right to respect for your personal, cultural, psychosocial values, and have access to pastoral services and other spiritual services.

5. Receive care in a safe setting that is free from all forms of abuse or harassment. You have a right to be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff.

6. Receive information about your health status, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand.

7. Participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life-sustaining treatment.

8. Participate actively in decisions regarding medical care including development and implementation of your care plan. However, you do not have the right to demand inappropriate or medically unnecessary treatment or services.

9. Request or refuse treatment, to the extent permitted by law, including the right to leave the hospital even against the advice of physicians.

10. Receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse this course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in this treatment, the likelihood of achieving the desired results, alternate courses of treatment or non-treatment and the risks involved in each and to know the name of the person who will carry out the procedure or treatment.

11. Formulate advance directives and have staff and practitioners who provide care comply with these directives or be informed if the hospital is unable to honor your advance directive wishes.

12. Identify a surrogate decision maker who can make health care decisions for you should you become unable to do so, and have all the patients' rights apply to this person or others who may have legal responsibility to make decisions regarding medical care on your behalf.

13. Full consideration of personal privacy and privacy concerning the medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be advised as to the reason for the presence of any individual. You have the right to have visitors leave prior to an examination and when treatment issues are being discussed.

14. Confidential treatment of all communication, recordings/films and records pertaining to the care and the stay in the hospital. Written permission shall be obtained before the medical records and/or films can be made available to anyone not directly related with the care, unless otherwise authorized or permitted by law.

15. Access information contained in your medical record within a reasonable time frame, and to request an amendment to and receive an accounting of disclosures regarding your health information.

16. Examine and receive an explanation of the hospital’s bill regardless of the source of payment.

17. Reasonable responses to any reasonable requests made for service.

18. Reasonable continuity of care, and to know in advance the time and location of appointment as well as the identity of persons providing the care.

19. Be advised if hospital/personal physician proposes to engage in or perform human experimentation affecting care or treatment. You have the right to refuse to participate in such research projects without fear of compromise to your care.

19. Examine and receive an explanation of the hospital charges regardless of source of payment.

20. Know which hospital rules and policies apply to your conduct while a patient.

21. Designate visitors of your choosing, if you have decision making capacity, whether or not the visitor is related by blood or marriage, unless: no visitors are allowed; it is determined that health or safety would be compromised; you do not wish a person to visit; or you lack decision-making capacity, at which time your wishes will be considered for purposes of determining who may visit.

22. Request a list of and assistance with accessing protective or advocacy services in the community, including notifying government agencies of neglect or abuse.

23. Appropriate assessment and management of pain, information about pain, pain relief measures and to participate in pain management decisions.

24. Be informed of any continuing health care requirements following discharge from the hospital. Be informed that, with your authorization, the hospital may provide a friend or family member with information about your continuing health care requirements following discharge from the hospital.

25. Be involved in the development and implementation of your discharge plan.

26. Have complaints/concerns voiced by you or your representative addressed in a respectful manner, as soon as possible.

27. File a complaint, concern or grievance. If you want to file a grievance with this hospital, you may do so by writing to Eden Medical Center Administration, 20103 Lake Chabot Road, Castro Valley CA 94546, by contacting the Nurse Manager or Administrator, or by calling (510) 727-2712 (or 667-4510 at the San Leandro Hospital Campus). Your actions will in no way adversely affect your care or access to care.

28. Report concerns about the safety or quality of care provided in the hospital to the Joint Commission after efforts to resolve the concerns through the hospital’s management have been unsuccessful.
Contact the Joint Commission’s Office of Quality Monitoring by calling 1-800-994-6610 or e-mailing complaint@jcaho.org

29. File a complaint with the California Department of Health Services, regardless of whether you use the hospital’s grievance process, 850 Marina Bay Parkway, Building P: 1st Floor, Richmond, Ca. 94804-6403, (510) 620-3900.

PTO Payment

The first of two payments for any employee having paid time off (PTO) hours above the “cap” will be added to the April 6, 2007, paychecks. The cap amount will be based on the ending balance from the March 23, 2007, paychecks. Here are the PTO maximums according to employee category:

Exempt: 450 Hours

Local 6: 350 Hours

Local 39: 280 Hours

Local 250 Service/Clerical: 400 Hours

Non-Exempt: 350 Hours

RN: 500 Hours

Kudos

Eden Medical Center’s emergency departments at the Eden and San Leandro campuses achieved a 2006 hospital-wide goal of having 80 percent of pneumonia patients receiving antibiotics within four hours of hospital arrival. They celebrated their success with well-deserved pizza parties for all three shifts last month. Congratulations to the ER staff at both hospitals for their outstanding accomplishment!

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