Encourage front line supervisors to promote hand hygiene with their staff throughout the day. STRATEGIC PERFORMANCE EXCELLENCE Emergency Management Responsible Party: Robert Patnaude, Emergency Management Coordinator Measure Name: Communications Equipment/Two-way radios Measure Description: The Joint Commission states the following in EM.02.02.01: part of its Emergency Operations “As Plan, the hospital prepares for how it will communicate during emergencies. The hospital maintains reliable communications capabilities for the purpose of communicating response efforts to staff, patients, and external organizations.” In the event of an unforeseen emergency which could impact the safety and security of patients, staff, and visitors, communications equipment, more specifically, two-way radios are a major solution to getting accurate information to and from staff in a timely manner. The objective of the Emergency Management Communications PI is to ensure compliance with The Joint Commission standard with the overall objective of ensuring that the two-way radio system is fully functional and that staff are proficient in its use. Type of Measure: Performance Improvement Methodology: Each month, the Emergency Management Coordinator or designee will perform a combination of partial and hospital-wide radio drills. Such drills will utilize a specific form to track the drills (see attached). In conjunction with the drills, environmental rounds will be conducted for the purpose of inspecting communications equipment. Any deficiencies shall have the appropriate corrective measure immediately instituted until compliance is met. The numerator is the number of timely and appropriate responses by staff utilizing the two-way radios by assignments. The denominator will be the total number of two-way radios by assignments. Baseline Data: To assure that critical emergency information is disseminated in a timely and accurate manner, a minimum of 90% compliance has been established. This data will be reported monthly to the Emergency Management Committee, IPEC, and the Environment of Care (EOC) Committee. Areas that fail to meet the threshold will be immediately reported to the aforementioned committees. STRATEGIC PERFORMANCE EXCELLENCE
Encourage front line supervisors to promote hand hygiene with their staff throughout the day. STRATEGIC PERFORMANCE EXCELLENCE Emergency Management Responsible Party: Robert Patnaude, Emergency Management Coordinator Measure Name: Communications Equipment/Two-way radios Measure Description: The Joint Commission states the following in EM.02.02.01: “As part of its Emergency Operations Plan, the hospital prepares for how it will communicate during emergencies. The hospital maintains reliable communications capabilities for the purpose of communicating response efforts to staff, patients, and external organizations.” In the event of an unforeseen emergency which could impact the safety and security of patients, staff, and visitors, communications equipment, more specifically, two-way radios are a major solution to getting accurate information to and from staff in a timely manner. The objective of the Emergency Management Communications PI is to ensure compliance with The Joint Commission standard with the overall objective of ensuring that the two-way radio system is fully functional and that staff are proficient in its use. Type of Measure: Performance Improvement Methodology: Each month, the Emergency Management Coordinator or designee will perform a combination of partial and hospital-wide radio drills. Such drills will utilize a specific form to track the drills (see attached). In conjunction with the drills, environmental rounds will be conducted for the purpose of inspecting communications equipment. Any deficiencies shall have the appropriate corrective measure immediately instituted until compliance is met. The numerator is the number of timely and appropriate responses by staff utilizing the two-way radios by assignments. The denominator will be the total number of two-way radios by assignments. Baseline Data: To assure that critical emergency information is disseminated in a timely and accurate manner, a minimum of 90% compliance has been established. This data will be reported monthly to the Emergency Management Committee, IPEC, and the Environment of Care (EOC) Committee. Areas that fail to meet the threshold will be immediately reported to the aforementioned committees. STRATEGIC PERFORMANCE EXCELLENCE
Section-13-Riverview-Report-FY16Q1.docx