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Bayhealth Educational Partners Faculty Manual
2017-2018
Bayhealth Medical CenterEducation Department640 South State StreetDover, Delaware 19901
302-744-7135
Table of Contents
Bayhealth Employee Contact Information…..…………………...………... 3
Welcome to Bayhealth 4Bayhealth’s Mission, Vision, and
Values……………………………… 5Planetree
Mission…………………………………………………………. 6Faculty
Qualifications……………………………………………………. 8Expectations………………………………………………………………
. 8Student
Qualifications……………………………………………………10
Expectations……………………………………………………………….
10
Parking Kent General Hospital…………………………………………………...
12
Milford Memorial Hospital………………………………………………
13
Clinical SystemsDocumentation……………………………………………………………....…..
14
Medication Administration…………….…………………………….….
14
Intellishelf……………………………………......………………………….
16
IV Medications and High Risk Medications ….………………………
16
Policies and Procedures…………………………………………………
17
Accessing Bayhealth Policies & Procedures……………...………………...
19
Patient Safety…………………………………………………………. 2Aab 1.25.18 2
….. 02017 Hospital National Patient Safety
Goals………………………...20
Accessing the Safety Variance Reporting System…...…………….
22
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Contact Information:
Director of EducationCatherine Salvato, EdD, MSN, RN, [email protected]
Student CoordinatorAndrea [email protected]
The Education Department is your first point of contact if you have questions, concerns, or comments about your clinical experience.
Welcome to BayhealthAab 1.25.18 4
Bayhealth’s mission is to strengthen the health of our community, one life at a time. As central and southern Delaware’s largest healthcare system, Bayhealth is comprised of Bayhealth Hospital, Kent Campus and Bayhealth Milford Memorial, the freestanding Emergency Department in Smyrna as well as numerous satellite facilities and employed physician practices encompassing a variety of specialties.
Bayhealth is a technologically advanced, not-for-profit healthcare system with more than 3,600 employees and a medical staff of 400 physicians.
Bayhealth is an affiliate of Penn Medicine in Heart and Vascular, Cancer and Orthopedics.
In Fiscal Year 2016, Bayhealth recorded 91,890 emergency department visits, 17,399 patients admitted to beds, 2,342 births, and provided $43.8 million in unreimbursed care to patients. For more information, please visit www.bayhealth.org.
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Bayhealth’s Mission, Vision and Values
Our PromiseWe are driven to bring the nation’s best healthcare to our communities here at home.
Our Mission To strengthen the health of our community, one life at a time.
VisionTo deliver the nation’s best healthcare to our communities here at home.
ValuesCompassion: We are kind and caring to everyone we encounter.
Accountability: Each of us is responsible for our words, our actions, and our results.
Respect: We value everyone and treat people with dignity and professionalism.
Integrity: We build trust through responsible actions and honest relationships.
Teamwork: We achieve more when we collaborate and all work together.
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Planetree
Patient Centered Care in Healing Environments
Bayhealth was awarded Planetree Bronze Recognition for Meaningful Progress in Patient-Centered Care in August 2015.
What distinguishes Planetree Recognition among other health care quality awards is its distinctive focus on patient-centered care, defined as a model of care delivery in which health care professionals partner with patients and families to identify and satisfy the full range of patient needs and preferences.
“The experience of Bayhealth Medical Center shows what can be accomplished when a team of deeply committed, supremely innovative and highly-driven caregivers take the courageous leap to re-define priorities and re-organize systems to put patients first,” quotes Susan Frampton, Planetree’s President.
As a Planetree affiliate, the achievement of Bronze Recognition by Bayhealth is a significant milestone in the organization’s culture change journey, evidencing that effective policies, practices, tools, and systems are in place to meet a broad range of patient, family, and professional health care giver needs and preferences.
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Criteria includes a shared medical record policy, nonrestrictive visiting practices, opportunities for patient and family input into health center operations, healthy and flexible meal options, recognition of the role of spirituality and the arts in healing, and a physical environment that facilitates privacy, promotes open communication between patients and providers, and is accommodating of family members’ involvement in their loved one’s care.
Bayhealth Nursing Philosophy: We, the professional nurses atBayhealth, are dedicated to providing a healing environment that encompasses mind, body and spirit without prejudice by:
Achieving the highest level of professional accountability through evidence-based practice, education and research.
Providing exceptional patient-focused care with respect, compassion, dignity, and integrity.
Fostering a safe and holistic approach to the provision of care. Recognizing that family is an integral part of the healing process. Supporting patient values and diversity. Improving patient outcomes through interdisciplinary and
innovative care Promoting an optimal level of wellness through the delivery of
health education
Above all, we are patient advocates.
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Faculty QualificationsBayhealth appreciates the role faculty fulfill in the education of tomorrow’s healthcare professionals. To maintain the highest quality of care for our patients, Bayhealth’s Education Department requires faculty to possess the following:
1. Academic credentials – Master level education or higher preferred2. Certification in specialty – Required3. Background check – No criminal history4. Drug Screen – No chemical substances5. Current CPR Certification through the American Heart Association or
Red Cross – BLS for Healthcare Provider status is required.
This is in accordance with the Affiliation Agreement between Bayhealth and your school: Section 3. Responsibilities, Item d and e.
All qualified/licensed instructors shall be subject to the credentialing requirements set forth by the Director of Education at Bayhealth. All faculty requirement forms can be found on Bayhealth’s Student/Faculty website (www.bayhealth.org/students-and-faculty) under Faculty Requirements.
Expectations of Faculty1. Faculty will facilitate the highest level of customer service between
the department managers, patients, family, and staff. 2. Faculty will introduce themselves to the Unit/Department Clinical
Coordinator and the Bayhealth employees in the area in which the student is assigned.
3. Faculty will introduce themselves to the patient and ask permission for a student to participate in their care.
4. Faculty will provide the unit/department with a list of student objectives each day on the assigned unit.
5. Faculty bringing students into any Bayhealth facility are not to leave the students unattended during clinical experiences. Staff cannot be responsible for students unless agreed upon in the Affiliation Agreement.
6. After the completion of the clinical experience, faculty will send student evaluations to Bayhealth’s Student Coordinator (c/o
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Education Department). This form, entitled Student Evaluation of Clinical Experience can be found on the following website: www.bayhealth.org/students-and-faculty.
a. The Education Department will then distribute summaries to the Nurse Managers.
7. Faculty will facilitate the submission of Safety Variance Reports and notify the following parties of all variances immediately:
a. Unit/Department Clinical Coordinatorb. Unit/Department Managerc. Education Department Managerd. For more information regarding Safety Variance Reports,
please refer to the Safety Variance Report section of this manual.
8. An annual orientation will be held for faculty and must be completed prior to accompanying students into the clinical setting.
9. Throughout the course of a school semester, we hope you will
develop a relationship with our nurse leaders. Questions will come up that you will want to discuss with staff on the unit. However; changes, edits and special requests for the clinical experience should be discussed with the student coordinator and/or Director of Education as written in our Agreement with your school.
a. per Affiliation: “The Director of Education, BAYHEALTH, shall represent BAYHEALTH in providing oversight management of the PROGRAM. The Director of Education shall be responsible for mediating any and all disputes, which may arise in the course of the externship PROGRAM. “
If you have additional questions, please contact Bayhealth’s Student Coordinator (c/o Education Department) at 302-744-6722.
Student Qualifications
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Government regulations and accreditation standards require us to maintain strict compliance with numerous standards.
Please refer to Bayhealth’s Externship and Observation Process for guidelines regarding completion of necessary forms for student clearance. Bayhealth’s Externship and Observation Process can be found at www.bayhealth.org/students-and-faculty.
Please make sure your students review the “Student Nurse” Job Description prior to the clinical externship as found on the Bayhealth website.
Expectations of Students1. Students will present a professional persona when on Bayhealth
property.2. Students will introduce themselves to the Unit/Department Clinical
Coordinator and employees serving the patients in the unit in which he/she is assigned.
3. Students will introduce themselves to the patient and ask permission to participate in their care.
4. Students will practice the highest level of customer service by displaying behaviors consistent with Bayhealth’s mission, vision, and values.
5. Students will adhere to all Bayhealth policies and procedures.6. Students will immediately report any variance to their clinical
instructor or preceptor.7. Students will ask questions and work as part of the Bayhealth
team.8. Students will park in the appropriate assigned areas and not in
areas for patients or visitors.9. Students will adhere to both school and hospital policy on dress
code. Students may not have any visible tattoos, facial piercing, excessive jewelry, make-up, abnormal hair color or styles.
10. Students will refrain from the use of tobacco products while at Bayhealth. Effective January 1, 2010, Bayhealth became a tobacco-free environment.
Parking
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Carpooling is recommended due to the limited number of parking spaces. Students and faculty are asked to park in designated areas only. They will be asked to move their cars if identified as having parked in restricted areas.
Please reinforce with your students that parking is reserved for patients and their visitors.
Students who are also employed by Bayhealth should only park in student-designated areas. Due to limited parking, the employee lot cannot be used during clinical experiences.
Kent General Hospital
Students and faculty are not permitted to park on any Bayhealth property including parking lots and parking garage.
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Milford Memorial Hospital
Students are to park in the large Employee Lot located on Foster Street,approximately ½ block from the hospital.
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Please contact Bayhealth’s Student Coordinator (c/o Education Department) at 302-744-6722 for appropriate parking guidelines.
Documentation Electronic Medical Record (EMR)
Bayhealth uses an electronic medical record (EMR) for a variety of patient care functions including physician orders, documentation, and Aab 1.25.18 14
medication administration. The EMR allows a variety of patient care areas to access and edit a patient’s record simultaneously. The EMR updates continuously so the information within the record is always as up-to-date as possible.
Patient Care and Assessment: A patient’s assessment and any care that was provided can be documented in the EMR.
Educational Requirement: Online modules pertaining to the EMR will be assigned to all faculty. This is only required once upon initial clinical assignment at Bayhealth. However, refreshers are available if needed. Please contact Bayhealth’s Student Coordinator (c/o Education Department) at 302-744-6722 for more information.
EMR Access: All faculty will need to contact Bayhealth’s Student Coordinator (c/o Education Department) for access prior to start of clinical assignment.
Medication AdministrationPer Bayhealth policy, the Pharmacy shall permit administration of medications by licensed physicians, licensed nurses, licensed nurse practitioners, licensed certified nurse anesthetists, and licensed physician assistants. Licensed physical therapists and licensed respiratory therapists may administer medications consistent within their scope of practices. Students of these disciplines may administer medications but must be under the direct supervision of a licensed professional.
All medication administrations are to be documented using the EMR or the associated downtime form when downtime is in progress. The EMR system provides a safe, efficient method for medication administration with the use of a barcoding system that will match the care provider, patient, and medication to reduce the chance of medication errors.
IV Medications and High Risk Medications:
Bayhealth does not permit student nurses to “push” IV meds. Students may observe staff or qualified faculty only.
Faculty whose license permits them to administer medication may administer IV “push” medications as long as he/she has successfully completed an annual Bayhealth competency skill validation test. IV Aab 1.25.18 15
push medications can only be administered in specific units per Bayhealth policy. See POLICY B6000.163
Individuals authorized to operate infusion pumps include Registered Nurses and Licensed Practical Nurses who are employed by Bayhealth Medical Center. Faculty members can operate IV pumps after receiving didactic education and completing a skill validation; listed medications and infusions that faculty are not permitted to administer via the infusion pump: see POLICY B6000.218.
Bayhealth has identified strict guidelines surrounding the proper identification, verification, and administration of High Risk Medications.
NOTE:
Policy numbers associated with Medication Administration and High Risk Medications are listed later in this manual. These polices should be reviewed and followed by all faculty.
Medication Cabinets: Bayhealth uses an automatic dispensing cabinet to house all medications. Each patient has his/her own profile within the cabinet. The cabinet is locked to unauthorized users.
Medication Cabinet User Authorization:
All faculty will complete the authorization form and submit the form to Bayhealth’s Student Coordinator (c/o Education Department) at the beginning of every semester. Bayhealth employees serving as a faculty member may NOT use his/her Bayhealth login information while serving in this role. Bayhealth employees must have a separate medication cabinet login for each of his/her statuses. The authorization form can be found at www.bayhealth.org/students-and-faculty under the “Faculty Requirements” link.
Educational Tutorial: On each medication cabinet, there is a computer touch screen. At the bottom of the touch screen is a tutorial that explains the following functions:
Login Inventory dispense Return Manual Admit
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Profile dispense Waste
If you have trouble operating the medication cabinet systems, please contact Bayhealth’s Student Coordinator (c/o Education Department) at 302-744-6722.
If there is any discrepancy with a narcotic count, the Clinical Coordinator must be made aware immediately.
Medication FAQ’s:
Yes, Students may perform saline flushes to peripheral IVs is permitted by students with faculty observation.
No, students may not attach syringes to IV pumps to push medications.
IntelliShelfIntelliShelf is a system for charging patient supply items to the patient’s hospital stay. Items taken from the supply room must be scanned to the patient/room by the person removing the supply. This system ensures that proper charging occurs.
Faculty members must have an Intellishelf sticker to scan. Employees who are faculty members CANNOT use their employee IntelliShelf code while on the premises as a faculty member.
Any item with a black dot on the scan sticker does not need to be scanned or charged to the patient. If a charged item is not used, it must be credited back to the patient’s account.
Policies and ProceduresYou may access the computers on the units to review any current policy or procedure via Bayhealth’s internal internet (intranet). Please ask the Unit/Department Manager or Clinical Coordinator which computers Aab 1.25.18 17
are available for your use. The policies listed in the table below should be reviewed and followed by all faculty.
Disclaimer: The policy reference table lists the most frequently used policies which are used during clinical experiences at Bayhealth. Not all Bayhealth policies are listed in the following table. We recommend that you review any policies associated with your program of study.
For more information on how to access Bayhealth’s policies and procedures, please contact Bayhealth’s Student Coordinator (c/o Education Department) at 302-744-6722.
Policy Name Policy Number
Tobacco-Free Environment B9000.73
Social Networking B9065.59
Cell Phone and Electronic Media Use
B9065.58
Patient Identification for Clinical Care and Treatment
B6000.62
Risk to Fall Program B9000.43
Control of Medications B7700.02
Adult IV Medication Administration
B6000.163
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Medication Administration and Documenting of Medication Orders
B6000.21
Medication Administration Record
B7700.21
Electronic Medication Administration Record and Medication Barcode Scanning
B6000.231
Adverse Drug Reactions B7700.03
High Alert Medications B7700.67
Look-Alike, Sound-Alike Medications
B7700.74
Hospital Infusion Pumps B6000.218
Accessing Bayhealth Policies and Procedures
Step 1: Open internet explorer from a Bayhealth computer.
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Step 2: Click Policies & Procedures.
Step 3: Click Policies and Procedures.
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Patient SafetyToday, patient safety is a hospital’s greatest challenge.
At Bayhealth, we take safety very seriously and have specific policies that address the process for achieving success. Please take the time to review these policies with your students. We appreciate your willingness to work with us to provide the highest quality care to our patients.
2017 Hospital National Patient Safety Goals
The purpose of the National Patient Safety Goals is to improve patient safety. The Goals focus on problems in health care safety and how to solve them.
Identify Patients Correctly: Use at least two ways to identify patients. For example, use the
patient’s name and date of birth. This is done to make sure that each patient gets the medicine and treatment meant for them.
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Make sure that the correct patient gets the correct blood type when they get a blood transfusion.
Operative/ Invasive Procedure Site Identification/Universal Protocol for Preventing Wrong Site /Procedure Surgery.
Improve Staff Communication: Get important test results to the right staff person on time.
Use Medicines Safely:
Before a procedure, label all medicines that are not already labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.
Take extra care with patients who take medicines to thin their blood.
Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
Use Alarms Safely:
Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Prevent Infection:
Use the Hand Cleaning Guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
Use proven guidelines to prevent infections that are difficult to treat.
Use proven guidelines to prevent infection of the blood from central lines.
Use proven guidelines to prevent infection after surgery.
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Use proven guidelines to prevent infection of the urinary tract that are caused by catheters.
Identify Patient Safety Risks:
Find out which patients are most likely to try to commit suicide. Prevent Mistakes in Surgery:
Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.
Mark the correct place on the patient’s body where the surgery is to be done.
Pause before the surgery to make sure that a mistake is not being made.
Resource: The Joint Commission
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Safety Variance ReportingClinical activity that falls outside customary or usual practice must be documented as a Safety Variance Report. Bayhealth uses an online program to assist in collecting this data quickly. At Bayhealth, it is expected that all variances are to be completed immediately.
Even if the situation could be classified as a ‘near miss’ or ‘no harm’ incident, a Safety Variance Report must be completed.
Please reinforce to your students that Safety Variance Reporting is viewed as a non-punitive action at Bayhealth. Safety Variance Reports are a critical component for providing the highest quality of care.
Safety Variance Reports are the sole property of Bayhealth.
Any questions related to the use of this tool should be directed to the Education Department Director/Manager at 302-744-7135 or the Risk Management Department at 302-744-7431.
NOTES:
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