House Staff Manual - Winthrop University Hospital

PROCEDUREImmediate Action:1. Clinical judgment must be used in determining what concerns, problems, and emergencies requireescalation, and appropriate time frames for response. Escalation policies exist for clinical andadministrative concerns.2. If the healthcare provider has a concern, problem, or emergency that requires initiation of theescalation process, it is her/his responsibility to escalate the matter to the person to whom theyreport (see Diagram 1 for sample-refer to department specific policy for further clarification).3. If in the judgment of the healthcare provider the appropriate response is not then achieved orobtained in a reasonable amount of time the healthcare provider must escalate the problem,concern or emergency to a higher level in chain of command, and continue the escalation processuntil resolution is achieved.Follow up Reporting/documentation:1. Documentation in the patient record will be factual, objective, complete and accurate. If aproblem or emergency is identified, documentation will reflect date and time matter wasidentified, actions taken to resolve them and the patient’s response and outcome.2. Documentation of a concern, problem, emergency or initiation of the escalation process on anIncident Report must reflect a comprehensive description of the event. Complete documentationmust include specifically the time of the event, time of notification, name of person who wasnotified, the information communicated the response and outcome.3. If the healthcare provider initiating the escalation process does not perceive the resolution of theconcern, problem, or emergency as satisfactory, a request for review should be submitted toQuality Management.ESCALATION FLOWCHART for PATIENT CARE (Diagram 1)Clinical Issue Identified By HealthCare ProfessionalAction Taken to Resolve IssueIssue ResolvedYesNoSenior Resident/Nurse Manager – Notified of IssueIssue ResolvedYesNoRev. 1/08