Summer Staff BBQ!

Bulletin #11 – Emergency Preparedness

EMERGENCY PREPAREDNESS THEME

Emergency Preparedness is one of our Accreditation 2018 Quality and Safety themes. It focuses on ensuring that Menno Place services and staff are prepared for emergencies and that an effective disaster response system in place. Although there are no Required Organizational Practices (ROPs) in this theme, it contains a number of high priority standards concerning staff and resident/patient safety. This theme covers four components of our organization’s emergency management processes, infrastructure and plans, including:

  1. Emergency Colour Code Response Plans
  2. Disaster Response Plans
  3. Fire Safety Plans
  4. Pandemic Plans (i.e. H1N1)

Quality and Safety Themes

In addition to Emergency Preparedness, the other Quality and Safety themes we have reviewed to date at Menno Place are:

  • Infection Prevention and Control Theme – Reduce the risk of health care associated infections and their impact across the care continuum.
  • Safety Culture Theme – Create a culture of safety.

Our remaining themes which we will review before our October 2018 survey include:

  • Work life/Workforce Theme – Create a work life and physical environment that supports the safe delivery of care/service.
  • Communication Theme – Improve the effectiveness and coordination of communication among care/service providers and among our recipients of care/service.
  • Ethics Theme – Ensure processes are in place to support resident/patient safety efforts related to ethics, privacy and data management.
  • Medication Use Theme – Ensure the safe use of high-risk medications.
  • Risk Theme – Identify safety risks inherent in our resident/patient population.

Meeting Our Emergency Preparedness Priorities

The Emergency Preparedness theme covers emergency response plans, disaster plans, fire safety plans and pandemic outbreak plans. Ensuring everyone is familiar with these plans helps us adequately care for staff, residents and visitors in the event of an emergency.

Menno Place has detailed disaster response plans that provide guidance and instruction for identifying, activating and managing all levels of response situations.

  1. EMERGENCY RESPONSE PLANS

Menno Place uses two main systems for identifying and responding to emergency situations: Emergency Colour Code Response Plans and the Emergency Command Centre.

 

Through our Emergency Colour Code Response Plans, we identify and respond to emergency situations using the resources at hand. For more complex emergencies, we activate our Emergency Command Centre to coordinate and manage response requirements.

Emergency Colour Code Response System

Menno Place uses a standardized colour code system to declare and respond to emergencies such as hazardous spills, evacuations, fires or missing residents. The colour codes allow people to convey essential information quickly and clearly, and to help prevent stress among residents and visitors. There are nine codes in total.

Our colour codes are:

  • Code Blue: Medical Emergency (can include cardiac arrest)
  • Code White: Aggressive/Violent Act
  • Code Red: Fire
  • Code Yellow: Missing Resident
  • Code Brown: Hazardous Spill
  • Code Black: Bomb Threat
  • Code Green: Evacuation
  • Code Orange: Disaster/Mass Casualty
  • Code Grey: Air Exclusion

For each emergency colour code, Menno Place has response protocols. Together, the colour codes and their associated protocols form our Emergency Colour Code Response system that provides us with guidelines for responding to a variety of situations. The Emergency Colour Code Response procedures are available in a number of formats throughout our organization including:

  • Binders – a manual book with the comprehensive colour code emergency response procedures that include step by step guidelines, as well as a one page quick reference sheet.
  • Wallet size stickers – colour code stickers are available to be attached to the back of your security ID badge for quick reference.
  • Flip chart – emergency response plan flip chart that provides a more detailed quick reference of managing emergencies.
  • Sharepoint – an electronic repository of the emergency response procedures found in the binders.

Isolated or small internal emergencies can be managed with the resources on site and response protocols are outlined according to the colour code protocols. A colour code situation can quickly escalate and may require additional resources. In some cases, it may become so complex that it requires activation of the Emergency Command Centre. Menno Place has a system to practice responses to these colour codes.

Emergency Command Centre

If an event is beyond an employee and/or the work area’s ability to manage, a Command Centre may be activated. Through the Emergency Response structure, the Command Centre is established to manage large, complex events that may require additional resources and coordination. Specifically the Command Centre provides:

  • Policy and management support and direction
  • Information collection, evaluation and display
  • Coordination of site services
  • Priorities and objective setting
  • Resource management
  • Communications
  • Information and warnings

Activating a Command Centre

The Chief Safety Officer or delegate has the authority to activate a Command Centre and to direct the use of staff for emergency response. The Chief Safety Officer on site works with external partners such as first responders, local authorities, utility companies and government as needed.

  1. DISASTER RESPONSE PLANS

Menno Place has put a number of measures in place to support staff and residents through a disaster including disaster response plans, supplies, specialized resources and drills.

Preparing for a Disaster

Employees should be familiar is our Emergency Response Plan which includes planning for a disaster such as an earthquake.

To ensure you are prepared you should know:

  • The location of your department’s emergency supplies
  • The location of the site Command Centre
  • Your department responsibilities in an event
  • Any specific duties assigned to you or which may be assigned to you
  • That your contact information in payroll is correct for fan-out
  • Designated disaster routes to your workplace
  • What your personal or family preparedness plan is

Employee Fan-Out Lists

Staff call back lists (Fan Outs) are in place in the event that we may require assistance when you are off duty or unscheduled. Fan Out lists are accessible for leaders to activate from outside the workplace.

Disaster Supplies

Disaster supplies are available in different locations on campus. Please ask your supervisor where they are at your site. Supplies include:

  • Food and Water
  • Search and Rescue items (hard hat, reflective vest, flashlights, candles, masks, etc.)
  • First Aid
  • Site Maps

Disaster Response Routes

Within the Lower Mainland, there is a network of pre-identified roads that will be used to move emergency supplies and services in the event of a major incident such as an earthquake. These routes are deemed priorities for clearing of debris so emergency vehicles and responders can gain access to impacted areas. Staff need to show their Menno Place picture ID security badge to access these routes.

Personal Preparedness

Just as every employee and department should know how to mitigate the consequences of a disaster and where to go for support, so should you and your family. Among other things you should:

  • Ensure you have critical supplies that will last 72 hours
  • Have an out of town contact
  • Have a family meeting place
  • Know your neighbours
  1. FIRE SAFETY PLANS

Menno Place has a fire safety plan that is approved by the municipal fire department. Our fire safety plans include information about how to prevent, mitigate and respond to fires. They outline what to do in the event of a fire or fire alarm, how to use a fire extinguisher, general evacuation procedures and other fire safety information. We practice fire drills monthly.

Discovery of smoke or fire

In the unlikely event smoke or fire is discovered, staff should follow the ICE process. ICE stands for Investigate, Communicate, Evacuate.

  • Investigate what is going on. What and where is the hazard?
  • Activate the fire alarm and designate emergency call centre to call 911
  • Move everyone away from hazard past fire doors or into another unit.

Responding to a fire alarm

If you hear the fire alarm or Code Red announcement the process is:

  • Report to a nursing unit (use stairs not elevators)
  • Check your work area for signs of smoke or flames
  • Check fire panels for location of fire or listen for announcement
  • Reassure residents and visitors
  • Direct residents and visitors to stay in their rooms or a safe area
  • Ensure hallways are unobstructed
  • Prepare residents for evacuation
  • Know where gas shut off (or oxygen shut offs) are located
  • Provide direction to fire responders
  • Know exit routes from work area

Evacuating or Relocating Due to Fire

All sites have an established Code Green procedure for evacuation. In the event of a Code Green due to fire staff should:

  • Evacuate residents, staff and visitors from a danger area
  • Move horizontally through a set of fire separation doors, moving from a danger area to a safe area
  • If danger persists, move horizontally again
  • Move vertically to a lower floor if there are no safe horizontal routes
  • Move out of the building if necessary and gather at the pre-planned location for your site.
  1. PANDEMIC PLANS

Pandemic Planning is part of our overall emergency preparedness plan. We follow pandemic protocols set by the health authority and the provincial government. We work with our partners in the health authority and other residential care homes on pandemic preparedness.

HOW WILL OUR EMERGENCY AND FIRE SAFETY PREPAREDNESS BE EVALUATED?

Surveyors will tour Menno Place and will gather information by:

  • Reviewing documentation such as policies and fire drill records
  • Talking and listening to leaders, staff, students, volunteers, residents and families
  • Observing what takes place
  • Recording what they read, see and hear

YOUR ROLE

During the on-site survey, surveyors will tour Menno Place and speak to staff, residents, students, volunteers, and family members. You may be interviewed and/or observed as surveyors gather information about how we plan for emergencies. Please ensure you take the time to review the location of emergency response supplies, location, binders and information. Prepare yourself by thinking through some of the questions that a Surveyor may ask you prior to the survey. Questions may include:

  • Is there a plan for staff response in the event of an emergency or disaster?
  • How are you trained?
  • Have you participated in any drills or exercises?
  • Are debriefings held following drills or exercises to identify areas to improve?
  • When was the last fire drill you participated in?
  • Are you aware of any exercises to test the Evacuation Plan?

 

If you have any questions, please ask your manager. If you are asked a question but you do not know the answer, please feel free to refer the surveyor to the appropriate person in your work area or to your supervisor.

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Bulletin #10 – Worklife – Workforce Theme

Worklife-Workforce is one of the Quality and Safety themes that we need to be aware of and knowledgeable about as we approach our Accreditation survey from October 22 – 25 2018. It focuses on creating a worklife and physical environment that supports the safe delivery of care/service. Within this theme, there are four Required Organizational Practices (ROPS) that Menno Place must meet to successfully complete Accreditation. A fifth standard under Worklife-Workforce does not apply to Menno Place. Additionally, there are other important Accreditation Standards that assist in ensuring staff are up-to-date in safety training.

The Worklife – Workforce ROPs are:

  1. Client Flow – Does not apply to Menno Place.
  1. Client Safety: Education and Training – Client safety training and education addresses specific client safety focus areas and are provided at least annually to leaders, team members and volunteers.
  1. Client Safety Plan – A client safety plan is developed and implemented at Menno Place.
  2. Preventative Maintenance – An effective preventative maintenance program for medical devices, medical equipment, and medical technology is implemented.
  3. Workplace Violence Prevention – Implements a comprehensive strategy to prevent workplace violence.

ROP 2    Client Safety: Education and Training

Surveyor Question: Tell me about the annual resident/client safety education you receive related to your work area.

Evidence:   We deliver client safety training and education at least annually to the leaders, staff, service providers and volunteers.

  • Policies and procedures are reviewed at each unit meeting
  • Staff sign that they are aware of the policies and where to access them
  • Staff sign commitment to safety
  • Emergency code/ fire drills
  • Hand Hygiene audits with immediate coaching
  • World Hand Hygiene Day Road Show

As part of our performance review process, all staff review safety policies and procedures such as fire safety, hand hygiene, emergency response plans, WHMIS, our Staff Safety Brochure, Immunization policy, and specific educational updates in their work areas such as safe Lifts and Transfers (No Lift policy) and prevention and management of aggression. We provide training at orientation and annually for a number of these topics. Our electronic system (SURGE) keeps a database which monitors which staff have taken courses and when. Staff can ask for a printout of the education they have taken. Nurses participate in a peer review system as part of their validation for licensure yearly.

ROP2     Client Safety Plan

                Surveyor Question:  Tell me about the Menno Place’s Safety Plan.

Evidence:

Our organization has developed Quality and Safety Plans that incorporate client safety measures and practices which are designed to address and evaluate safety issues. Some of the components of our plans are:

  • Safety Huddles (by staff teams and leaders)
  • Hand Hygiene audits and education
  • Trending of incidents and near misses and initiating improvement projects
  • Medication Reconciliation on admission and during transfers

We monitor and report a variety of indicators to the health authorities and share them cross-site. We look at such things as:

  • # of residents who have a fall
  • # of residents with a new fracture
  • # of residents with a facility acquired pressure ulcer
  • # of residents screen on admission for pain
  • # of medication errors requiring emergency intervention or treatment

Our Safety Plan includes provincial and national practices from the BC Patient Safety & Quality Council, Patient Care Quality Office, Provincial Licensing, Institute for Safe Medication Practices, Canadian Patient Safety Institute, Safer Healthcare Now and Accreditation Canada.

ROP3     Client Safety Roles and Responsibilities

Surveyor Question:  Can you please describe what roles and responsibilities staff and leaders have in resident/client safety? 

Evidence:

Everyone has a role in contributing to resident/client safety. All staff must be aware of all policies and procedures in the Sharepoint system or Administration Manual. All job descriptions include a role in safety. Our strategic plan has a goal to provide safe care/service.

Our organization is committed to a culture of safety, we have a number of safety policies which we teach our staff, students and volunteers including:

  • Health Care Consent
  • Immunization and Screening
  • Prevention and Management of Aggressive Behaviour
  • Incident Reporting and Tracking (Residents & General, Staff Injuries, Assisted Living) with Disclosure
  • Infection Control Program
  • Security
  • No Manual Lift
  • MSIP
  • Non/Least Restraint
  • Missing Resident
  • Smoke-Free Premises
  • Emergency Response
  • Workplace Inspections

ROP4     Preventative Maintenance Program

Surveyor Question: Is equipment regularly checked to ensure it is in good working order?

Evidence: Menno Place has a preventative maintenance system in place. Our maintenance (and rehabilitation) departments maintain lists of all medical and rehab equipment. Each piece has a serial number and a date for the next preventative maintenance inspection. The frequency and method of inspection depends on the equipment. We have an electronic system (Worxhub) and manual logs to track repairs and inspections.

ROP5     Workplace Violence Prevention

Surveyor Question: Please describe the strategy that Menno Place has in place to prevent workplace violence.

Evidence: We have a policy in place and provide training and education to staff.

Menno Place provides staff training throughout the year on Code White.  Staff who work with residents are expected to complete the 8 Violence Prevention modules provided through HEABC.  Menno Place has also had an HCA trained in the “Train the Trainer” program through SafeCare BC to present the 8 hour workshop on the Provincial Violence Prevention program.  There are 8 training sessions set up from March 2018 through February 2019 for staff to take part in.

Signage is located throughout Menno Place campus in the form of a red octagon with the words inside; “Violence, foul language, and abusive behaviours are not acceptable. Verbal threats or acts of violence will not be tolerated and may result in removal from this care home and/or prosecution.”  It is provided by SafeCare BC. Visitors are made aware that violence is not tolerated at Menno Place by reading the statement at each front door and signing in upon entry.

Menno Place has a bullying/harassment, code of conduct and respectful workplace policy that are introduced at orientation and reinforced with safety education.

Contractors go through a Contractor Safety Orientation prior to each job which notifies them of the Violence Prevention guidelines as well.