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MENDOCINO COAST DISTRICT HOSPITALADMINISTRATION POLICY AND PROCEDURE STATEMENT

NUMBER: 100.1012 PAGE: 1 OF 27

TITLE: FACILITY PLAN FOR THE PROVISION OF CARE

PURPOSE: The facility plan for the provision of care provides a broad description of the manner in which Mendocino Coast District Hospital (MCDH) plans and delivers care to the patients and customers we serve.

The plan is developed using a multi-disciplinary approach, revised as needed, approved by the Board of Directors, and used as a communication tool to facilitate congruence among all providers and stakeholders in developing an understanding of the way we provide care to patients.

The plan is organized in format to align with the important activities and functions identified by Joint Commission that significantly influence patient outcomes.

While the plan is not intended to provide the detail required to deliver specific care, key supporting information is included in the appendix as indicated.

The Plan includes the following items:

I. DESCRIPTION OF THE SETTING

II. PATIENT FOCUSED FUNCTIONSA. Patients right and organizational ethicsB. Care, Treatment and Services to include:

a. Assessment of patientsb. Care of patients:

1. Where care is provided2. Nursing care defined3. Anesthesia Care4. Medication Use5. Pain Management6. Nutrition7. Operative and Invasive procedures8. Rehabilitation9. Respiratory Care10.Laboratory & Transfusion Services11.Spiritual Care12.Psychiatric Care13.Volunteer Services

c. Education:1. Patient and Family2. Community

d. Continuum of Care



e. Accounting & Business Services

III. ORGANIZATIONAL FUNCTIONSA. Improving organizational performanceB. LeadershipC. Management of the environment of care and safetyD. Management of human resourcesE. Management of informationF. Surveillance, prevention, and control of infectionG. Medication Management

IV. STRUCTURES WITH FUNCTIONSA. GovernanceB. ManagementC. Medical staffD. Nursing

V. APPENDIX1. Organizational Chart2. Mission - Philosophy Statement

I. DESCRIPTION OF THE SETTING

A. MCDH is a critical access hospital (CAH), public facility, originally established by the citizens of the District in 1971. Major building expansions and service additions have resulted in a modern 25 bed facility and a broad continuum of care to provide health care services to the communities served by the District from Westport on the North to Comptche on the East and to Elk on the South of the Mendocino Coast.

B. The District represents a population of 23,738, of which 86.2% are White, 13.3% are Hispanic, 2.4% American Indian, .9% Asian-Pacific, and 0.5% Black. (4/2004).

C. MCDH recognizes the responsibility of being an active participant in the greater health care delivery system. Cooperative endeavors link our organization with the medical community, service clubs, other allied health care professionals, schools, as well as community, county, regional, state, and federal service agencies. MCDH has linkages with Tertiary Care Centers to ensure provisions of services not available at MCDH.



II. PATIENT FOCUSED FUNCTIONS

A. Patient Rights and Organizational Ethics. 1. MCDH respects the rights of all patients. We recognize that each

patient is an individual with unique health care needs and that each patient deserves considerate, respectful, non-discriminatory care, focused on individual needs. Patients with comparable needs receive the same standard of care throughout the organization.

2. We accomplish this through multiple methods and mediums and continuously strive to improve our performance of this important function.

3. The following non-inclusive list of activities affirms our organizations’ commitment to respecting patient’s rights and resolving ethical issues:a. Adopting and providing a patient brochure packet that gives

the patient specific information about the hospital and their use of the facility.

b. Adopting, publishing, posting, and discussing Patient Rights and Responsibilities.

c. Developing policies, procedures, and protocols that:1) Support the use of advance directives.2) Provide direction in withholding resuscitation.3) Provide direction in forgoing life sustaining treatment.4) Provide confidentiality and security in release of patient information.5) Protect patient privacy.6) Constantly working to improve patient safety7) Address and resolve patient complaints.8) Address and resolve decision conflicts.9) Ensure informed decision-making.

10) Provide interpretive services. 11) Provide consent forms and instructions in English and in Spanish.

12) Involve patients and families in patient care. 13) Protect patients from medically unnecessary restraints. 14) Address sensory impairment. 15) Address cultural and religious diversity.

16) Ensure participation in the Organ Procurement Network.

d. Providing a smoke-free environment.



3. MCDH, with the medical staff, and with the support of an Organ Procurement Service (California Transplant Donor Network), honors patient/family requests to donate organs and tissues. The services of a trained coordinator are available to MCDH patients and staff twenty-four hours a day by contacting the Nursing Supervisor.

4. The institution, through the Hospital and medical staff structure, has a mechanism for administering and monitoring investigative treatments when applicable.

5. MCDH has developed and adopted stated values and a Code of Respect. It is our expectation that these values will be applied in all our interactions and we will look for incongruities and opportunities to align our practices with our values.

6. We recognize the complexity of the environment in which we work and provide care and have developed multiple means to resolve conflicts as they arise. Some of the resources available include but are not limited to the following: a. Chain of Command Policy.b. Ethics Committee consultation.c. Grievance procedure.d. Practice training (customer service, resolving conflicts,

telephone communication, management skills.)e. Case conferences to include all parties (patient, family, care

giver).f. Court orders.g. Access to expert resources.h. Corporate Compliance Program.i. Health Insurance Portability and Accountability Act (HIPAA)

B. Care, Treatment and Services provided to include:1. Assessment of patients that occurs throughout the organization

whenever someone has contact with the patient or processes key information related to the patient. The assessment may be as basic as the housekeeper assessing the patient satisfaction with the timing and cleaning of the room, or the phlebotomist assessing the patient’s ability to cooperate with a blood draw. Skilled and/or licensed professionals provide complex assessments.



2. Medical staff by-laws and patient care standards describe the type, frequency, and necessity for initial assessments and reassessments.

3. Professional staff roles and assessment functions are outlined on the following grid.

ASSESSMENT MD RN PHAR DIET RT PT OT STCaseMgt

Biophysical X X X X X X

Psychosocial X X X X X

Nutritional X X X X X

Functional X X X X X X

Treatment Effect X X X X X X X X X

Pre-Op X X X X X X

Education X X X X X X X X X

Discharge X X X X X X X X X

4. Diagnostic testing and procedure results are critical to the assessment function of patient care. Diagnostic departments and services provided by MCDH or through contracted services include:

a. Radiology:1) CAT scan; mammography; ultrasound; MRI;

fluoroscopy.b. Nuclear Medicine:

1) Metabolic imaging.c. Clinical Laboratory:

1) Hematology; chemistry; microbiology; serology; coagulation; blood gas analysis, microbiology, pathology, and blood and tissue bank.

d. Cardiovascular:1) Ultrasound; stress testing; echocardiogram;

EKG.e. Respiratory:



1) Pulmonary function.f. Neurology:

1) EEG; EMG.g. Nursing:

1) Point of care testing; skin testing.h. Rehabilitation:

1) Physical/Occupational Therapy (strength, endurance, flexibility, mobility, function).

2) Speech/language pathology (swallowing, cognitive communication, speech language, hearing).

i. Audiology1) Hearing testing

5. Skilled professionals with demonstrated competency, state of the art functional equipment, and quality controls assure accurate, timely diagnostic results upon which treatment decisions are based.

6. Care of the Patients:a. Patient care at MCDH occurs through organized and

systematic processes designed to ensure safe, effective, and timely care and treatment. Patient care occurs whenever patients are evaluated and treated. Providing the delivery of patient care requires special knowledge, judgment, and skills derived from education and training. Patient care is planned, coordinated, provided, delegated, and supervised by professional health care providers who recognize the unique physical, emotional, cultural, and spiritual needs of each person. Patient care recognizes both the processes of disease and maintenance of health. Physicians and other allied health professionals, strive for greater collaboration as a multi disciplinary team to achieve positive patient outcomes.

b. Patient care is provided in the following areas:1) Emergency Department.2) Critical Care Unit.3) Medical/Surgical Unit.4) Swing Bed Unit.5) Obstetrics/Maternal and Child Care Unit.6) Operating Suites.7) Post Anesthesia Care Unit.8) Ambulatory Care Unit.



9) Endoscopy Suite.10) Rehabilitation Department.11) Diagnostic Imaging Department.12) Nuclear Medicine Department.13) Cardio-Pulmonary Laboratory.14) EEG Procedure Room.15) Yag Laser Procedure Room.16) Hematology/Oncology/Infusion Center17) North Coast Family Health Center

c. Additionally, patient care is provided both in the patient’s place of residence by Home Health and Hospice and by the hospital based Ambulance Service.

7. Nursing care is defined as providing those functions which help people cope with the difficulties associated with illness and injury problems, or the treatment thereof; with the process of birthing and dying; and, with the coordination and provision of patient care services necessary to implement a physician directed treatment regimen. Nursing care is also provided to assist patients in maintaining health, wellness, and self independence. Nursing care is or may be provided in all of the above named patient care areas as required by patient need and nursing licensure practice. Detailed information about the provision of nursing care can be found in each nursing unit structure standards and in the Plan for the Provision of Nursing Care Policy (Nursing Administration Policy Manual).

8. Patient care is guided by standards, policies and procedures. Each patient care unit/department has defined structure standards which include:a. The types and ages of patients served.b. The types of services available.c. The hours of operation.d. The staffing plan to meet the needs of the department.e. Staff roles and responsibilities.

9. Anesthesia care is provided in the form of general, regional, local and/or monitored anesthesia care. The Anesthesiologist directs and provides anesthesia services. Anesthesia initiates epidural and/or spinal anesthesia for obstetrical services and postoperative pain control. A certified nurse anesthetist provides anesthesia under the direction of the anesthesiologist. Anesthesia services provide oversight to the hospital-wide moderate sedation policies and procedures. Other Medical Staff members also administer regional, local, and monitored drug anesthesia in accordance with hospital policy.



a. Anesthesia administers & monitors patient controlled analgesia (PCA) programs;

b. Anesthesia performs specific pain treatment procedures on a referral basis in the Outpatient Center.

10.Standardized procedures, developed and approved by the Medical Staff provide the guidelines for nurses to maintain anesthesiologist initiated epidural anesthesia and administer local anesthesia for the following procedures:a. IV starts.b. Insertion of urinary catheters.

11.Medication use is determined by prescribing physician orders, with the Pharmacist serving as consultant. Medications are prepared and dispensed under the direction of the Pharmacist. Administration of medications is determined by licensure and Hospital policies utilizing a unit dose system. Medication administration is limited to physicians, registered nurses, and licensed vocational nurses (LVN’s are excluded from administering IV medications), except in the following:a. Respiratory therapists may administer inhalant medications

prescribed for pulmonary treatment.b. Physical and Occupational therapists may apply topical

agents.c. Nuclear Medicine Technologists may administer prescribed

radio-pharmaceuticals.d. Radiology technologists with IV certification may administer

IV contrast for CT exams.12. Medication is available for patient administration as determined

by the Hospital formulary; is distributed by the pharmacy, and stored in the pharmacy, in a night locker, and in-patient care areas. Controlled substances are maintained under lock and carefully accounted for per protocol. The pharmacist participates as a member of patient care teams as indicated.

13.Pain management is an important function of medication use. Patient Controlled Analgesia (PCA) is one method of managing post-operative pain, promoting self-management.

14.Nutrition care is provided by the Dietary Department under the direction of a registered dietician. The Dietary Department is responsible for preparing and delivering attractive, nutritious, high-quality meals within operational limits and dietary restrictions. Patient trays are delivered to patient care units at scheduled meal times and as requested. Nourishments are available in unit based pantries as delivered by Dietary. Trays and nourishments are delivered to the bedside by unit



personnel. Inpatients are offered a selective menu when permitted by their diet. The Dietitian participates in the multi-disciplinary patient care teams.

15.Pharmacy, Dietary, and Nursing collaborate with the Physician to address and resolve food and drug interactions, and provide the patient with information and education to assist the patient in managing medications after discharge.

16.Operative and other invasive procedures are performed according to the privileging and credentialing process of the Medical Staff. Privileging and credentialing files are kept in and are accessible to patient care units and nursing administration. Other departments have access to credentialing information pertaining to their departments. Patient care provided prior to, during, and after operative and invasive procedures is guided by Medical Staff and nursing standards and members of the Department of Surgery.

17. Rehabilitative care is provided at the bedside, on the nursing units, in the Rehabilitation Department, and in the place of residence. The Physical Therapist (PT) and Occupational Therapist (OT) prescribe and evaluate therapies to assist individuals with physical dysfunction secondary to disability, disease, or injury. They assist the patient in learning to perform activities of daily living in the presence of the disability, and help the patient improve strength and regain function. The Speech Therapist (ST) evaluates speech, language, cognitive, oral, and pharyngeal sensori-motor competencies. Rehabilitation Therapists are members of the multi-disciplinary team. Nursing personnel support the therapy goals and provide and promote rehabilitative care to minimize the functional loss associated with illness, injury, and loss of mobility.

18.Respiratory care is provided collaboratively by Respiratory Therapists (RTs) and nursing personnel. RTs administer prescribed treatments, including oxygen, aerosol, ultrasonic mist, and percussion therapies. The RTs provide management of ventilator care, which may include suctioning of the patient to accomplish therapy goals. RTs respond to all codes as able, providing assistance with CPR. The RTs are members of the multi-disciplinary patient care team when appropriate. The RTs instruct the patient in the use of the incentive spirometer. Nursing personnel are responsible for routine coughing and deep breathing exercises and for routine prescribed treatments during the absence of the RT.


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19.The Clinical Laboratory provides testing and specimen collection services along with microbiology and pathology services. The laboratory also processes transfusion services after obtaining the blood products from a licensed blood bank. MCDH ensures compliance with the Paul Gann Blood Act by patients reading the Blood Act literature and signing a blood consent form, and by physicians obtaining informed consent with their patients.

20.North Coast Family Health Center (NCFHC) is a rural health care clinic owned and operated by MCDH. NCFHC provides medical care in an outpatient setting, operating Monday through Friday.

21.Hemodialysis Care, either chronic or acute is not provided on site. Peritoneal Dialysis Care may be provided by the licensed nursing staff if ordered.

22.Spiritual care is provided by patient’s own clergy, Hospital volunteer chaplains, and staff.

23.Patients requiring psychiatric care are evaluated, stabilized, and referred to psychiatric facilities and services as needed.

24.Volunteer Services are available to greet visitors, escort patients upon discharge, run errands, deliver flowers, mail, newspapers, manage the gift shop, and provide broad support to the Hospital staff.

C. Education:1. Patients, family members, and significant others (S.O.) as

appropriate, are provided with information and training to increase their knowledge and understanding of specific illnesses and treatment needs. Patient education is provided through multiple means including:a) One-on-one question and answer encounters.b) Group presentations.c) Leaflets, pamphlets, booklets, admission packets.d) Videos.e) Consent forms.f) Written discharge instructions.g) Computer generated information and instructions.

2. Education is intended to facilitate informed decision making by the patient, family, and/or care giver to promote recovery, and to improve function and self care. Education is provided specific to the patient’s assessed needs, considering their abilities and readiness to learn, including spiritual, cultural and religious


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beliefs, emotional barriers, physical and cognitive limitations, age, education and language barriers.

3. Patient, families, and/or care givers receive information, as appropriate, about the following:a) Disease processes.b) Medication use.c) Medical equipment use.d) Food and drug interactions.e) Rehabilitation techniques.f) Diets.g) Safe and healthy lifestyles.h) Advance Directives.i) Treatments, tests, procedures.j) Rights and responsibilities.k) Risks, alternative, benefits of treatment options and the risks

and benefits of the alternatives.l) Community Resources.m) Self care and care-giver responsibilities.n) When and how to obtain further care.o) Placement options for continued care.

4. MCDH’s patient care staff are involved in providing health-related educational services to the community as well. These efforts include:a) Prenatal care and OB tour.b) Breast feeding care.c) Advance Directives.d) Support groups.e) First Aidf) CPR.g) Child restraint compliance.h) Smoking cessation.

D. Continuum of Care:1. MCDH’s leaders consider the needs of the population served, the

resources available, access to care, and the appropriate care settings, to provide for a broad continuum of care. Ambulatory care services, home care services, skilled nursing services (Swing Bed Unit) and primary care services for publicly-funded recipients (California Perinatal Services Program) represent major services added to the critical access facility to broaden the continuum of accessible care provided by MCDH.


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2. Criteria define the information needed to determine appropriateness for the individual’s entry to the settings of care and services provided. As the patient’s care requires and as assessments determine the need for another level of care, processes assist the patient in moving throughout the system. Additionally, when patient needs exceed the capability of MCDH, arrangements are made to access the necessary care at tertiary or special care centers. Services not provided by MCDH include:a) Cardio-thoracic surgery, angiograms, catheterization.b) Neurosurgery.c) Burn treatment.d) High risk Perinatal.e) Neonatal Intensive Care.f) Pediatric Intensive Care.g) Radiation Therapy.h) Psychiatry.i) Hyperbaric treatment.j) Organ transplantation.k) Hemodialysisl) Spine Surgery

3. Health care professionals ensure continuity of care whenever the patient’s care is transferred from one individual to another, from one department to another, from one setting to another, from one facility to another, and at the time of discharge through communication, information, and an appropriate means of transportation.

4. The Hospital-wide Utilization Management Plan outlines the processes for evaluating and monitoring the appropriate utilization of resources and provision of care. Decisions regarding the provision of care are based on patient needs, not by an external entity, or third-party payer who denies care, services or payment. MCDH complies with COBRA and EMTALA regulations in regard to the provision of emergency care.

5. Post discharge and follow-up phone calls are made to ambulatory care patients routinely and home care and emergency department patients as needed to ensure patient well-being.

E. Accounting and Business Services:1. Departments are established that accurately reflect the billing to

third party payers and private individuals for the care and services


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the patient receives in any of MCDH’s departments/units.2. All accounting and billing transactions are monitored and audited

through the Board of Directors Finance and Auditing functions to assure the charges are correct and the transactions are accurate and appropriate.

III. ORGANIZATIONAL FUNCTIONS

A. Improving Organizational Performance:

1. There is a Hospital-wide performance improvement plan. Each department also has a plan that aligns with the Hospital plan, identifying key processes, important aspects of care and key indicators to monitor. Hospital staff work together cross departmentally to improve our services. We use the principles of performance improvement and the use of tools and methods to achieve sustained improvement.

2. Medical Staff define criteria by which patient care staff identify and initiate the peer review process. The Quality Review Report (QRR) is used to note and collect data regarding untoward patient outcomes, process and system failures, unusual incidents and substandard performance by anyone.

3. Notification in the Patient Information Pamphlet, informing patients/family members during the admissions procedure, and discussions during bedside visits from the Nurse Manager or Nursing Supervisor are methods we use to internally collect information to identify situations that have a negative impact on customer satisfaction. Information is also derived from the Patient Perception of Care Survey conducted by a contracted service for the In-patient and Emergency Department patients. Follow-up phone surveys are made from the Out-Patient Departments as well to determine customer satisfaction of care and services.

4. Reviewing progress toward improved performance occurs at all levels of the organization. The Integrated Quality Management Committee (IQMC), comprised of medical staff, key department managers and administrative staff, focus on overall facility performance, identifying improvement opportunities and allocating resources for improvement teams. Unit/department meetings


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review findings of ongoing monitoring, seeking input and participation from staff. Nursing Management Team meetings combine all nursing unit managers/clinical coordinators, nurse educator, HR staff, and shift supervisors to target areas for cross-departmental, multi-disciplinary improvement and review progress toward improved performance. The IQMC monitors performance and reviews progress of improvement efforts for the entire facility. The IQMC as a committee of the Medical Staff, reports through the Medical Executive Committee to the Board of Directors.

B. Leadership:1. MCDH leadership provides the framework for planning,

directing, coordinating, providing, and improving health care services. This framework is formed by the following:

a. Mission, vision and values statement.b. Code of Respectc. Strategic plan.d. Operating budget.e. Organizational chart.f. Medical Staff By-laws.g. Department structure standards.h. Policies, procedures, protocols.i. Operational Plans.j. Utilization Review.k. Infection Control.l. Quality and Risk Management.m. Human Resource Management.n. Safety Management.o. Health Information Management.p. Provision of Care.q. Corporate Compliance.

2. All plans are developed by and with appropriate leaders of the organization, revised to reflect changes, reviewed annually/periodically when indicated, and approved by the Board of Directors, Administration, and Medical Staff as required.

3. Each department has effective leadership with the following responsibilities:

a. Integrating the service into the organization and other departments and services.

b. Developing policies and procedures.c. Recommending qualified number of staff.d. Determining the qualifications and competence of

department personnel.


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e. Continuously assessing, improving, and reporting performance.

f. Maintaining quality controls, as indicated.g. Orienting and providing training and education of all persons

in the department.h. Recommending space and other resources needed by the department.i. Participating in the selection of sources for services not provided by the department or organization.

4. All staff with assigned managerial responsibilities participate in cross-organizational activities which may include but are not limited to:a. Safety Committee.b. Infection Control Advisory Committee.c. Blood Transfusion and tissue reviewd. Policy and Procedure reviewe. Pharmacy and Therapeutics Committee.f. New Employee Orientation.g. Bio-Ethics Committee.h. Nursing Management Teami. Integrated Quality Management Committee.j. Hospital Management Team.k. Administration Team.l. Risk Management Activities.m. Task forces and work groups.n. Medical Staff department meetings

5. Patient care department managers/clinical coordinators collaborate with medical staff leaders, (medical directors, and committee chairpersons) to identify and accomplish goals and objectives for each service area.

3. Patient care department managers/clinical coordinators establish goals and objectives consistent with strategic planning efforts.

4. The leaders of the organization, to include department managers, Nursing Supervisors, Chief Clinical Officer and/or the CEO will be available to deal with patient flow issues throughout the organization as they occur.

5. There are mechanisms in place to handle overflow of Emergency room patients or patients in need of specialized care within the facility (eg: CCU/PACU, L&D) per departmental policies.

6. Transfers are arranged to other facilities whenever care can not be provided at MCDH due to lack of specialized medical care or resources.


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11. In the event of a large influx of patients and the possibility of diverting patients exists, the Chief Clinical Officer, and the CEO or his designee along with the Chief of Medical Staff will be contacted to discuss diversion. If decision is made to divert patients proper notification will be made to the appropriate authorities per Nursing Administration Policy “Staff during High Census/Personnel Shortage/Disruption of Services”.

12. Diversion will only occur when:1. All available resources have been utilized

13. The use of contracted services to provide clinical care will be provided based on the following criteria:a. hospital approves the servicesb. medical staff advise or recommend the servicesc. services are agreed upon in writingd. services meet Joint Commission standardse. services are evaluated to determine whether they are

meeting expectationsf. hospital retains overall responsibility and authority over the

services

14. Contracted services for clinical care at MCDH include:a. MRIb. Audiologyc. Transfusion Servicesd. Reference Laboratoriese. Pathologyf. Radiologist on site and back-up coverageg. Anesthesiah. Transcription Servicesi. Dental Servicesj. Temporary Staffing Services

C. Management of the Environment of Care 1. MCDH supports the provision of a safe and supportive environment

for patients and other individuals served by or providing services in the organization. This is accomplished by a myriad of activities, with everyone having responsibilities to assist in carrying out this function.

2. There is a Hospital wide Safety Committee that addresses the safety/environment of care management program for the organization. The CEO/Administrator appoints a Safety Officer who assists with the Safety Committee. The Safety Committee has the responsibility for designing, implementing, measuring,


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assessing and improving the status of the environment. The Safety Committee has Hospital-wide representation, clerical support and meets monthly and addresses such areas as:a. Patient, visitor, employee environmental events/injuries.b. Equipment management/failures/device tracking.c. Drug and supply management/recalls.d. Utility management/failures.e. Hazardous materials management/spills/exposures.f. Life Safety/fire alarms/drills/events. g. Emergency preparedness.h. Security/infant abduction drills.i. Patient safety programsj. Employee Safety Programs

3. There is a Radiation Safety Subcommittee (Imaging Manager) responsible for monitoring: a: the use and handling of radio-nuclides and radio-pharmaceuticals; b. individual film badge readings. The film badges are processed by an outside contracted service.

4. Hospital staff receive education and training at the time of hire, annually, and periodically to ensure a proper process of interacting with the environment of care. New employee orientation and annual training include:a. Physical safety associated with lifting and moving patients

and equipment.b. Electrical safety.c. Infectious disease control principles/blood borne

pathogens/work related injuries.d. Hazardous materials use and handling.e. Fire Management.f. Emergency preparedness and protocols.g. Security and Workplace Violence.h. Corporate Compliance program.i. Department specific safety training.j. Reporting of Abuse and Sexual Harassmentk. HIPAA Training

5. Employees, patients, families, and care givers are instructed in the safe operation and use of patient care equipment, medical and assistive devices. Training and education are accomplished through:


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a. Interactive videos.b. Demonstration and return demonstrations.c. Written policy and procedure reviews.d. Lecturese. Discussionsf. Postersg. Leaflets, memos, flyers

6. MCDH endeavors to provide state-of-the-art equipment, supplies and support services to ensure a safe environment for the delivery of quality patient care. Hospital departments that support the delivery of care include:a. Purchasing and Stores: acquire, receive, distribute and store

approved purchases, order, stock, sticker and distribute non-reusable patient supplies via an exchange system.

b. Housekeeping, Janitorial and Linen Services: clean physical plant, collect and dispose of waste and disposables, collect soiled and distribute clean linens.

c. Maintenance Services: maintain and repair equipment, provide maintenance to the facility plant, grounds, and utility systems.

d. Biomedical Engineering Services: inspect, maintain and repair technical patient care equipment.

e. Security Services: patrol and secure grounds, facility plant, and high volume service areas.

D. Management of Human Resources:1. This function focuses on human resources planning,

orientation, training and education of staff, competency assessment, and employee benefits.

2. Human Resources planning occur with each department manager/clinical coordinator defining job qualifications and job expectations in written job descriptions for each position in their respective area. Job descriptions are refined through HR support. Department managers/clinical coordinators monitor employee performance to ensure job expectations are met.

3. MCDH provides an adequate number of staff whose qualifications are commensurate with defined job responsibilities and applicable licensure, law and regulation, and or certification. This is accomplished through the HR department and department managers/clinical coordinators. Competitive wage and salary administrations, satisfying working conditions, fair application of policies and procedures,


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and advancement opportunities are some of the strategies that assist in assuring adequate staff to carry out the mission of the organization. License verification and back-ground checks are accomplished through HR. The HR department verifies all patient and non-patient care staff licensure and hospital systems are in place to ensure there is ongoing monitoring of these licenses. There is also verification that ambulance drivers have a safe driving record.

4. Each patient care department has a staffing plan defined in unit specific structure standards. This plan includes the type and number of staff needed to carry out the function of the department, as well as the mechanisms used to adjust the staffing to meet patient care needs.

5. Processes are designed to ensure that the competence of all staff members is assessed, maintained, demonstrated, and improved upon on an ongoing basis. These processes include:a. Verification of education, training, experience.b. Interview of applicant by manager.c. Successful completion of orientation.d. Annual performance appraisal.e. Demonstration of knowledge through exam and skills lab.f. Mandatory training/in-service attendance.g. Performance Improvement processesh. Diagnosis, population served assessment, which

includes age specific and cultural diversity training, and restraint monitoring as appropriate.

i. Coaching and counseling by manager or supervisor.j. Competency assessment.

6. MCDH has established methods and practices that encourage self development and learning for all staff. Methods and practices include:a. Paid time off for continuing education.b. Compensation for advanced education and certifications.c. Multi-disciplinary education conferences.d. Off site tuition/fee payment for key trainers.e. Board of Registered Nurses and EMT/Paramedic

continuing education provider status.f. Courses/classes presentations.g. Medical libraryh. CPR, ACLS, NRP, provider statusi. Preceptor assignmentsj. Internet access


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7 Staff orientation processes provide initial job training and information, including an assessment of an individual’s capability to perform specified responsibilities. All new employees attend a Hospital-wide orientation. Each employee receives a department specific orientation that includes orientation to policies, procedures, standards, safety, compliance program, performance improvement, infection control, and performance responsibilities and expectations. Records of orientation and training are maintained in each employee file. Aggregate data and information from the organization’s improvement activities are used to identify and respond to staff learning needs. Registered nurses receive additional assessment and training in the following:a. Medication administration.b. Blood administrationc. Fluid and electrolyte managementd. Nursing process (assess, plan, implement, evaluate).e. Documentationf. Organ/tissue donationg. Cultural diversity care needsh. Restraint monitoringi. Pain managementj. Point of Care Managementk. Central Line Managementl. Falls Preventionm. Waive Testing

7. An individual’s ability to achieve job expectations as stated in the job description are assessed and documented annually by the department manager. The assessment tool reflects the special needs and behaviors of specific age groups of patients for staff who have regular contact with patients. Staff members who are assessed as not competent to perform certain tasks are provided additional training to include established goals to meet expected competency.

9. MCDH has an established policy and mechanisms to address any request by a staff member not to participate in an aspect of patient care, including treatment. All requests are handled between the manager/coordinator and the employee, in consultation with HR, as appropriate. Every effort is taken to manage a patient’s care needs while meeting the request by


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the staff member.

E. Management of Information1. Providing patient care is a complex endeavor that is highly dependent on

information. Because of this dependence on information and the need to coordinate and integrate services, MCDH treats information as an important resource to be managed effectively and efficiently. There is a Hospital-wide goal to greatly expand the ability to better integrate services through enhanced information technologies.

a. The Hospital Information System is a Meditech application system, which includes the following applications:

1. General Ledger/Accounts Payable2. NPR report writing3. Materials Management4. Payroll/Human Resources5. Admitting6. Abstracting7. Billing and Account Receivables8. Blood Bank 9. Laboratory10. Medical Records11. Order Entry12. Pathology13. Pharmacy14. Radiology

b. Dictaphone is the dictation system in use at MCDH.

2. Departmental computers support multiple information management functions, through open architecture, including:a. Word processing ( M/S Word).b. Database (SQL,Visual Basic).c. Spreadsheet (Excel).d. Computerized patient instructions (Exit Writer).e. E-mail (Outlook Express).

3. Individuals throughout the organization participate in generating, collecting, and analyzing data and information.

4. MCDH initiates and maintains a medical record for every individual assessed or treated. The medical record incorporates information from subsequent contacts and contains sufficient


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information to identify the patient, support the diagnosis, justify the treatment, document the course and results accurately, and facilitate continuity of care among health care providers. Specific requirements for monitoring the required medical record documentation are defined in Medical Staff By-Laws, as well as hospital and department policies and procedures. This function is assessed quarterly and reported to the Integrated Quality Management Committee.

5. Aggregate data is defined, captured, analyzed, transmitted and reported. Aggregate data and information include such items as:a. Pharmacy transactions.b. Safety management issues.c. Quality management issues.c. Risk management issues.d. Infection control surveillance e. Patient demographics.f. Patient diagnosis and procedures.g. Financial information.

6. Record keeping is defined by policy, including such items as: records of radio-nuclides and radio-pharmaceuticals, quality control functions, and required maintenance records.

7. Accessible knowledge-based information resources include clinical and management literature, and is available in multiple formats.

8. The organization uses and contributes to external reference databases on a local, system, regional, state, and national level.

F. Surveillance, Prevention and Control of Infection1. MCDH has a functioning, coordinated plan in place to reduce the

risks of endemic and epidemic nosocomial infections in patients and health care workers. This plan is defined in writing and is managed by a trained Infection Control Coordinator, and along with input from the Infection Control Advisory Committee is managed by the Integrated Quality Management Committee.

IV. STRUCTURES WITH FUNCTIONS

A. Governance1. MCDH is governed by a five member board. Members are elected

by the general public and serve three year terms. Other at-large


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non-board members include the CEO, the CFO, the Chief Clinical Officer, and the Chief of Staff.

2. The Board of Directors is responsible for the following functions:a. Meeting needs of the community.b. Development of a Strategic Planc. Ensuring appropriate quality of care.d. Adopting by-laws.e. Privileging and Credentialing of appropriate medical stafff. Obtaining appropriate medical staff participation in

governance.g. Selecting a chief executive officer.h. Ensuring adherence to relevant statutory and regulatory

requirements.i. Requiring organizational leaders to collaborate in developing

necessary policies and procedures.j. Developing mechanisms for resolving conflict.k. Establishing policy, promoting performance improvement

and organizational safety programs and providing for organizational management and planning.

l. Approving operating and capital budget, and resource allocation.

m. Responding to needs of the community by operating District in a fiscally responsible manner.

n. Providing for an annual independent audit.

3. The Board carries out its responsibilities and oversees the organizational activities through monthly meetings. Committees for Finance, Planning and Audit report to the full Board. Board members also attend medical staff meetings, and special purpose meetings as needed.

4. Members of the Board as well as the CEO attend the MCDH Foundation meetings as needed. The Foundation’s mission is to facilitate the development of a hospital community that is healthy, active and has high self-esteem. The Foundation carries out its mission by:a. Developing resources, funding and community support, to

benefit not-for-profit health care organization.b. Soliciting, receiving, maintaining, and distributing gifts of

money and property.c. Engaging in and conducting charitable, and educational

activities with MCDH.


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B. Management1. The Chief Executive Officer (CEO) is appointed by the Board and

is responsible for operating the Hospital in a manner commensurate with the authority conferred by the Board.

2. The CEO is qualified by education and experience appropriate for fulfilling the responsibilities of the position and takes all reasonable steps to provide for compliance with applicable law and regulations. The CEO promptly reviews and acts on reports and recommendations from authorized planning, regulatory, and inspecting agencies.

3. The CEO, through the management and administrative staff, provides for the following:a. The implementation of organized management and

administrative functions throughout the organization, including the establishment of clear lines of responsibility and accountability within departments and between managers and administrative staff.

b. The establishment of internal controls to safeguard physical, financial, information, and human resources.

4. Management and administrative staff are organized per the organizational chart and as stated under the Leadership Function.

C. Medical Staff1. There is a single organized Medical Staff that has overall

responsibility for the quality of the professional services provided by individuals with clinical privileges, as well as the responsibility of being accountable to the Board.

2. The Medical Staff organization has established mechanisms for appointing and reappointing of medical staff members, and for granting, renewing or revising privileges as defined in the by-laws. Medical staff member’s status (active and affiliate), and the associated privileges granted, are available to patient care units/departments.

3. The Medical Staff develops and adopts bylaws and rules and regulations to establish a framework for self-governance of medical staff activities and accountability to the Board of Directors.


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4. The Medical Staff is organized to accomplish its required functions. There is a Medical Executive Committee (MEC), whose members are selected by the medical staff and appointed according to their department/committee chairperson roles. The MEC is responsible for making recommendations directly to the Board for its approval. The MEC receives and acts on reports and recommendations from Medical Staff committees, clinical departments, and assigned activity groups. The CEO serves as a ex-officio, non-voting member of the Committee

5. There is a Department of Medicine which includes the following divisions:a. Medicineb. Family Practicec. Emergency Medicined. Gastro-enterologye. Neurologyf. Radiology.g. Pediatrics.h. Psychiatry.i. Cardiologyj. Hematologyk. Endocrinology & Metabolisml. Medical Oncology.

6. There is a Department of Surgery which includes the following divisions:a. General surgeryb. Anesthesiologyc. Obstetrics and Gynecologyd. Pathologye. Ophthalmologyf. Orthopedic surgeryg. Podiatryh. Dentistry

7. Additional committees include:a. Integrated Quality Management.b. Continuing Medical Education.c. Bioethics.d. Well-Being.e. Medical Staff Bylaws.f. Pharmacy and Therapeutics


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g. Credentials/Interdisciplinary Practice Committeeh. Infection Control Advisory

8. The Medical Staff participate in developing standardized procedures for advanced practice via the respective clinical department and making recommendations to the MEC/IPC.

9. The Medical Staff’s role in the care and/or appropriate referral of patients who are emotionally ill, who become emotionally ill while in the hospital, or who suffer the results of alcoholism or drug abuse is defined in writing.

10. The Medical Staff, with other appropriate hospital staff, developed and use criteria that identify deaths in which an autopsy should be performed. Autopsies are performed at the local mortuary by the pathologist, as arranged by administration, mortuary, and Pathology services.

11. All individuals with delineated clinical privileges participate in continuing education.

12. Medical staff members participate in organizational activities, for example:a. Medication formulary development.b. Clinical effectiveness.

D. Nursing1. Nursing services are organized under the direction of the Chief

Clinical Officer (CCO). Nursing services and nursing care are available on a continuous basis as appropriate to the department.

2. The CCO actively participates in the organization’s leadership functions and collaborates with other organization leaders in designing and providing patient care services. Participation includes:a. Board Meetings.b. Medical Staff Committees.c. Strategic Management.d. Strategic Planning retreats.e. Nursing Management Team.f. Integrated Quality Management Committee.g. Safety Committee (designee).h. Association of Northern California Nurse Leaders.


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i. Community based groups as necessary.

3. Position qualifications responsibilities and accountabilities are described in a written job description.

NEW: 04/00, REVISED: 8/05, 2/08

REVIEWED AND APPROVED:

ORIGINAL SIGNATURE ON FILE _________ Director, Quality & Risk Management Date

ORIGINAL SIGNATURE ON FILE_________________________________________ _________Chief Clinical Officer Date

ORIGINAL SIGNATURE ON FILE _________ Chief Executive Officer Date

ORIGINAL SIGNATURE ON FILE _________ President, Board of Directors Date

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