EP - Exemplary Professional Practice

EP30: Culture of Safety-Describe and Demonstrate the structure(s) and process(es) used by the organization to improve workplace safety for nurses based on standards such as ANAs Safe patient Handling Movement.

The Health and welfare of our nursing staff is very important to this organization. Many processes have been initiated in order to insure that nurses have a healthy, safe environment in which to practice. One of our goals in our strategic plan is to reduce the incidence of employee injuries via the use of Safe Patient Handling devices. To this end, the Division of Nursing and the organization as a whole has supported the initiatives of the Environment of Care and Life Safety Committee, the Safe Patient Handling Committee, the Employee Health Team and the Sharps and Body Fluid Exposure Committee.

Environment of Care and Life Safety Committee

William Cook, Director of Facilities has the oversight to a comprehensive Environment of Care and Life Safety Committee. This program provides a functional, supportive environment for patients, nurses, other staff members and visitors. The Safety Management Plan is designed, implemented and evaluated in an effort to meet the needs of the individuals we serve and the employees who work at Jersey City Medical Center, (Appendix EP30-A). The Environment of Care and Life Safety Committee is essential to general safety management, security management, emergency management, life safety/fire prevention, medical equipment management and utility system management. These plans support organizational compliance with all related safety standards with the following regulatory authorities: The Joint Commission, Occupational Safety and Health Administration, Environmental Protection Agency, Department of Health and Senior Services, Food and Drug Administration and the Jersey City Fire Department.

Goals for the Environment of Care and Life Safety Committee for 2012 include:

  • Investigate the use of solar power to reduce electrical costs to the facility
  • Investigate an in-house Violence Prevention Program implementation
  • Planned project NICU-Nihon-Kohden installation
  • Increase the visibility of Biomedical personnel by performing daily department rounds
  • Continue participation in Emergency Preparedness Grant program
  • Continue community involvement and participation in regional drills
  • During Environmental Rounds monitor areas surveyed for life safety code compliance

Rita Smith DNP, RN, NEA-BC, in her role as Chief Nursing Officer, is a member of the Environment of Care and Life Safety Committee (EOCLS). The EOCLS includes mechanisms to identify environment of care risks within the organization which include: Incident reporting systems, product recall/alert systems, hazard surveillance, infection

control surveillance, preventative maintenance systems, quality management reviews, review of legal/regulatory requirements and support of the go green campaign.

The Security Department, as part of the EOCLS Committee, participates in the annual Safety Exposition which is sponsored by Brenda Hall MS, RN, NE-BC Senior Vice President of Safety, Quality and Regulatory Affairs. (See Reference EP30-A for the presentation used in Safety Exposition). The Expo is primarily related to patient safety, the Security Department utilizes this opportunity to demonstrate the use of fire extinguishers, review of R.A.C.E. (Rescue, Alarm, Contain and Evacuate) procedures, and the proper evacuation of patients.

Employee Health Team

Jessica Babich APN, NP-C and Ellen Brummer MS, RN participate in the annual Wellness Fair sponsored by Human Resources. They provide blood pressure screenings,
Ellen Brummer MS, RN and Jessica Babich APN-C, RN<br />Employee Health Team
 Ellen Brummer MS, RN and Jessica Babich APN-C, RN
Employee Health Team

lipid screenings, Prostate Specific Antigen screenings as well as counseling and educating the staff on various health topics.

The Employee Health Team successfully vaccinates the majority of employees against the Flu. They even utilize a mobile cart in the evenings so that staff nurses do not have to leave their unit. They also educate the staff routinely on the use of personal protective equipment hospital-wide.

Safe Patient Handling Program

The State of New Jersey was among the first states to respond to the call for legislation in 2003 in response to ANAs Handle with Care Program. Eight other states have enacted Safe Patient Handling legislation. The new law requires all health care facilities to implement a program.

Rita Smith DNP, RN, NEA-BC, Chief Nursing Officer and Ellen Brummer MS, RN Employee Health Nurse championed this program at the MedicalCenter. One of the first objectives was to establish an interdisciplinary Safe Patient Handling Committee. Ms. Brummer functioned as the chairperson of this committee. The committee members determined that each unit would have at least one (1) champion/super user in order to provide ongoing training and as a conduit between the committee and the unit. Team membership is listed below:

Safe Patient Handling Committee

EP30-Table 1

In order to demonstrate the need to commit organizational resources to this initiative, the team reviewed hospital-wide patient handling injuries.

The project team recommended a multi-tiered strategy to address patient handling issues which included: employee training, trial and purchase of equipment appropriate to unit specific lift needs and a process to insure ongoing appropriate use of lift equipment.

A Safe Patient Handling device fair was held in the hospital which allowed for the staff to view the devices and operate them as well. We then contracted with a company, Prevent, Inc. to help assure that the appropriate structures and processes for our Safe Patient Handling were sustained.
Yvette Bryant BSN, RN, 7E
 Yvette Bryant BSN, RN, 7E  

Equipment for the units was chosen based on the particular needs of the patient population on that unit. All units involved trialed equipment specific to their units. For example, the critical care areas trialed the ceiling lifts. Once the decisions were made, a quote was assembled for purchase of the equipment. The organization invested $380,000.00 in Safe Patient Handling devices.

In order to communicate Safe Patient Handling inpatient lift needs to the staff, the following methods are used:

  1. Whiteboards
  2. Placards next to the doorway of the room
  3. Sticker on patients identification bracelet

With the arrival/installation of the devices, training of employees began in earnest. Super users are a resource to staff on the units and received specialized training. Attendance in a total of three (3) classes was required to become a certified super user.

Liberty Intranet offers easy access to Resources and Competency for Safe Patient Handling

Liberty Intranet offers easy access to Resources and Competency for Safe Patient Handling

All units have a least one super user. The Prevent, Inc. nurses provided all the education regarding the Safe Patient Handling Program. Their education included a self-learning module on the internet, hands-on training and overall presentations. They also established patient scenarios in order to provide a hands-on review for the staff. Surveys were provided to the staff in order to determine the most effective methodology for learning. Brochures were developed and given to patients and their families in order to provide education for them as well (Appendix EP30-B).

Ms. Brummer further publishes information on the intranet entitled: Safe Patient Handling Corner: We are Watching your Back!! (Appendix EP30-C). Ms. Brummer provides educational information about the high rate of musculoskeletal disorders among healthcare workers and the costs related to treating these disorders. She further describes the Safe Patient Handling Act and the extent of our program at the MedicalCenter. As part of this education she includes a review of the Safe Patient Handling Policy and decision guide as well as an online learning module.

The Sharps and Body Fluid Exposure Committee

This committee, headed by Jessica Babich APN, NP-C is comprised of staff members that review sharp injuries, assess equipment and evaluate new products to protect employees from unnecessary needle sticks and body fluid exposures. Members of the Committee include:

EP30-Table 2

The Sharps and Body Fluid Exposure Committee

This committee has undertaken several initiatives in the recent past. One initiative is to reduce the sharps injuries in the Operating Room which will be described in EP30EO. They are currently reviewing an Intravenous needle and tubing which prevents the backflow of blood once inserted. Rosanna Vales BSN, RN, staff nurse from the Emergency Department is currently following-up with this product through

The Sharps and Body Fluid Exposure Committee
the Value Analysis Committee. Another recent intervention is the inception and implementation of the buddy card. This card can be added to your identification/security access card and is called the Employee Blood/Body Fluid Post Exposure Resource Guide. It provides instructions on how to proceed if you should sustain such an injury and be exposed to blood or body fluids.