BRG 2007 Worksmart 1

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					          Orientation Packet
  PRN Employees, Short Term Contract or
               Vendors

                                WELCOME!!
      The Baton Rouge General Medical Center is proud to have you
      on our team! One of the responsibilities of the organization is to
      provide an orientation for all new employees. Because you will
      probably only work with us for a short time or on a limited basis,
      this orientation packet has been prepared for your special needs
      as a short term contract or PRN employee.
      Instructions:

          1. Please read through this information on critical hospital
             procedures and safety information. If you have any
             questions, please contact the person that provided you with
             the packet.
          2. After reading the information, please complete the form on
             the last page of the booklet and return the form to Human
             Resources or your supervisor.
          3. It is very important that you do this on the first day
             that you work here. You should keep this orientation
             booklet handy for future reference.

      Again, welcome to the Baton Rouge General Medical Center!




Revised on 9/17/2007
                        Table of Contents
Section Title                               Page Number
Everyday Excellence – Our
Culture                                              3
(Team Dynamics/Collaboration)
Code of Conduct                                      7
HIPAA                                               10
Discrimination/Harassment                           16
Performance Improvement                             17
Patient Safety                                      18
Ethics Committee                                    20
Pain Management                                     20
Abuse/Violence In Hospital                          21
Security Program                                    24
Safe Baby Site                                      26
Electrical Safety                                   27
Ergonomics                                          28
Employee Safety & Health                            32
Infection Control & Prevention                      34
Emergency Situations (Codes)                        36
Incident Reporting                                  41
Medical Gas Shutoff                                 42
Confidentiality Statement                           43
Acknowledgement                                     44
Post-test                                           45




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                        Everyday Excellence – Our Culture

We as individuals – and together as an organization that cares for our community – share
values and a code of conduct that guides our actions and decisions. These values include: a
caring environment, excellence, respect, integrity, innovation, stewardship, and illness
prevention and healthful living. These values shape how we treat each other, our patients and
their families, physicians, and our community. We call these customer groups our Heartbeat.

At Baton Rouge General/General Health System, we are guided in our day-to-day activity by our
Vital Signs, the behaviors that exemplify our values. Our Vital Signs include: attitude,
professionalism, safety, expertise and accountability. In addition we have a Code of Conduct
that further clarifies our ethics.

Living up to this code, and behaving in a way that demonstrates our values is more than a goal
– it is our responsibility and obligation. Our commitment to Teamwork and Collaboration as
employees sets us above all other organizations.

Our Mission
We exist to improve the quality of life of the people we serve by promoting principles of
healthful living and participating in the process of bringing healing to the sick.

Our Vision
Caring for our Community with Everyday Excellence.

Our Heart
The Heart of our organization: People, Service, Quality and Resources

Our Values
A Caring Environment
We recognize and meet the needs of the people and families we serve and those who work with
us to achieve our mission, in an atmosphere of kindness, compassion and understanding.

Excellence
We will exceed the standard of the healthcare industry and the expectations of the people we
serve.

Respect
We value the diversity of our patients, employees, business colleagues, visitors and all who
interact with us, and are committed to treating them with respect, dignity and kindness
regardless of their race, religion, culture or socioeconomic background.

Integrity
We conduct our business fairly and ethically, communicating responsibly and honestly, creating
an environment of trust.

Innovation
We recognize the needs of the changing market circumstances and encourage professional
development through adaptation, continuing education, problem resolution and process
improvement in order to meet the needs of the people we serve.

Stewardship
We are accountable stewards of the human and material resources entrusted to us and will
utilize them safely, wisely, efficiently and responsibly.
Illness Prevention and Healthful Living

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We commit time, talent, and financial resources to educate our customers through screenings,
wellness programs, and educational opportunities throughout our community.

Our Heartbeat - Our Customers
These are the promises we make to each of our customers. They are our Heartbeat.

Each Other
1. I will greet you with a warm smile and friendly hello.
2. I will never say, “It’s not my job.” We all share the same goal–patient care.
3. I will celebrate your successes and support you in trying times. I will not let you be in need.
4. I recognize that we are all experts in our fields. I will listen to your opinions, as you may see
         the situation in a different light.
5. I will leave my problems at the door and maintain professionalism at all times.
6. I will be a part of the solution, not the problem.

Patients and Their Families
1. I know you may be scared and in pain. I will do my best to ease these fears.
2. I am sensitive to your loss of control, lack of privacy and need for information. I will do my
         best to comfort you.
3. I recognize that you may experience some embarrassing moments during your hospital visit.
         I will treat you with dignity and maintain confidentiality.
4. I will empower you and your family members to make safe and informed healthcare
         decisions by keeping you and your family aware, involved and educated about your
         care.
5. I will give you the opportunity to verbalize your feelings and fears concerning your illness.

Physicians
1. As physicians, you have a choice where you practice. Baton Rouge General wants to be
       that choice.
2. We will not label your patients as a room number or diagnosis. We will treat each as a
       unique person with distinctive needs.
3. We depend on you to direct the care of your patient. You can depend on us to deliver that
       care.
4. We are advocates for our patients and we ask that you seek our input.
5. We know you can’t be with your patients all the time, but we are. We promise to care for
       them as you would.
6. We know your time is valuable. We will learn your preferences so your patients receive
       efficient care.
7. Your trust of us is not automatic. We know we must earn it.
8. Recognizing that there are risks and liabilities in healthcare, we will ensure that your patients
       are safe in our care.

Community
1. We are in touch with the needs of our community and will meet those needs by healing,
      preventing and teaching.
2. We celebrate the different cultures that make up our community and it is reflected in our
      employees and those we serve.
3. We do not just serve the community, we are the community.
4. We are your church members, scout leaders, customers, neighbors, educators, volunteer
      firefighters and we are your healthcare providers.



Our Vital Signs
These are the expectations of our employees to fulfill the promises we make to our customers.

Revised on 09/17/2007                                                                                  4
Attitude – Our Vital Sign
We are committed to providing excellent service to our customers, which include: our patients
and their families; physicians; members of our community; and each other. We will provide
excellent customer service by sharing an attitude that is welcoming and demonstrates our
sincere concern. We will meet all of our customers’ needs by treating each and every interaction
as an opportunity to serve. We acknowledge that true feelings shine through in attitude; we will
express our desire to care and heal.

Expectations of Attitude
1. Greet everyone with a smile.
2. Introduce yourself.
3. Rudeness is NEVER acceptable.
4. Seize the moment to make the customer feel welcome.
5. Answer the phone promptly with a pleasant voice. Respond to the caller’s needs.
6. Customers are not interruptions; they are why we are here.
7. Show the customer; don’t tell them.
8. Maintain enthusiasm.
9. Show compassion. Remember, people visit us in their time of need.

Professionalism – Our Vital Sign
We are committed to providing excellent service by exemplifying professionalism. We respect
our customers’ dignity, comfort, and will treat each with consideration, courtesy and respect.
We recognize our customers’ time is valuable and so we will provide them with prompt service,
always keeping them informed of delays and making them comfortable while they wait. We will
demonstrate sensitivity and responsiveness to our customers by listening attentively and
patiently in order to fully understand their needs, including the recognition and acceptance of
diverse backgrounds. We will ensure our customers’ right to privacy by creating and
maintaining a secure and trusting environment. We will treat all customer information
confidentially. Discussion of this information will be restricted to situations where the
information is necessary to meet the customer’s needs.

Professionalism Expectations
1. Be on time and ready to work wearing your ID badge.
2. Take pride in your appearance. Always come to work neat and clean.
3. Speak to everyone with respect and discuss differences discretely.
4. Respect the privacy of others. Do not engage in gossip.
5. Respond to each other’s needs.
6. Communicate with everyone in a manner they will understand.


Safety – Our Vital Sign
We maintain an environment where the health, safety, privacy and comfort of each other,
patients/families, physicians and the community come first. We understand that the appearance
of our facility and grounds reflect the attitude, competence and compassion that characterizes
our organization. We will consistently exceed customer needs and expectations by maintaining
all aspects of our environment in a clean, safe, orderly and attractive manner. We will inspect
our workplace daily to ensure this objective is met. We will adopt work practices and behaviors
that contribute to sustained excellence in the appearance of our facility and grounds. We will
take personal ownership in the appearance of our work environment; when we see a problem,
wherever it is, we will take the necessary steps to fix it immediately.

Safety Expectations
1. Respond to call lights immediately, even if it is not your area of expertise.
2. Always refer to patients by their name, not their room number.
3. Pick up litter and dispose of it appropriately.
4. Prevent slips, trips and falls. If a problem exists, fix it.
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5. Identify hazards and report them to the proper department.
6. Know and follow policies and procedures.
7. Communicate effectively with all disciplines.

In addition to these environmental safety expectations, at Baton Rouge General/ General Health
System, patient safety is given the highest priority. Each employee is expected to live the
National Patient Safety Goals and Requirements for JCAHO’s Hospital Accreditation Programs.


Expertise – Our Vital Sign
Baton Rouge General/General Health System supports a culture that taps the full potential of
employees and builds an environment that allows all people to feel appreciated, included and
valued.
Professional growth, career development and individual empowerment are actively encouraged
and rewarded.

Expertise Expectations
1. Participate in educational opportunities offered by the Baton Rouge General/General Health
       System.
2. Take every opportunity to share your knowledge with others.
3. Be an expert in your field. Be a life-long learner.
4. Be innovative. Think of new and better ways to do things.

Accountability – Our Vital Sign
Every Baton Rouge General/General Health System employee must feel a sense of ownership
toward his or her job. By this we mean taking pride in what we do, feeling responsible for the
outcomes of our efforts, and recognizing our work as a reflection of ourselves. We look beyond
our assigned tasks. Our responsibility does not end where our co-workers’ responsibilities
begin. In most situations, responsibilities merge and blend.

Accountability Expectations
1. Take ownership in your work.
2. If you hear about a problem, you own it. Be a part of the solution.
3. Create a just culture.
4. Follow through with what you say you will do.
5. Lead by example. Live our Heartbeat and our Vital Signs.

Measuring Our Culture
One way we measure the impact of our Heartbeat and Vital Signs is by monitoring patient
satisfaction. Our vendor, Press Ganey, mails surveys out to our patients following discharge.
Monthly, departmental patient satisfaction data is posted on the “Community of Caring” bulletin
board in each department.

To get as much information about our care and services as possible, it is very important for us
to get each patient to respond to the survey, if they are randomly selected to participate. A
good time to ask patients to participate is during discharge.




Revised on 09/17/2007                                                                             6
                              OUR CODE OF CONDUCT
At General Health System, we have developed a Code of Conduct to guide our everyday
actions.

We/I shall:

1.      Comply with all applicable federal, state and local laws and regulations, being guided by
        the basic principles of honesty and fairness.

2.      Deliver medically necessary healthcare in a compassionate, respectful and ethical
        manner without regard to race, creed, color, religion, national origin, gender or disability;
        treat patients with dignity and respect at all times; provide each patient with information
        regarding their rights and responsibilities, endeavoring to protect those rights throughout
        their care and treatment.

3.      Maintain accurate and reliable patient and organizational records; and prepare corporate
        records honestly and in accordance with established finance and accounting
        procedures.

4.      Maintain contacts with government officials and personnel in a professional manner,
        affirming the high integrity of the organization.

5.      Provide patients with understandable explanations of services rendered; hold
        responsible parties financially accountable only for care rendered; and seek to resolve
        business conflicts in a fair and equitable manner.

6.      Carry out our organization’s public and commercial communications in a manner
        consistent with our mission; and ensure that our marketing and advertising statements
        are accurate and sensitive to community culture without false or misleading statements.

7.      Continually examine our practices to identify, avoid or eliminate potential conflicts of
        interest.

8.      Reference Corporate Compliance Guidelines through the Corporate Intranet.




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                              CONFLICT OF INTEREST

Because conflicts can occur in any organization, we continually examine our practices to
identify, avoid or eliminate potential areas of difficulty.

We/I shall:

1.      Avoid the appearance of favoritism; and not give or accept any benefits (seen as a gift or
        favor or value) in business relationships with government officials, commercial firms or
        others with whom the company or its subsidiaries does business, unless the nature,
        value and circumstances are generally regarded as reasonable, proper and customary in
        light of prevailing ethical business practices, and giving or receiving the benefit does not
        violate the law.

2.      Treat fairly and impartially all persons and firms with whom we have business
        relationships.

3.      Enter only into business relationships that will not conflict or appear to conflict with our
        Baton Rouge General/General Health System responsibilities.

4.      Participate only in appropriate outside activities and not render services to, represent or
        act for any outside or competing concern, whether for compensation or not, unless it is
        determined that these activities will not create a conflict.

5.      Reference Corporate Compliance section through the Corporate Intranet for specific
        Conflict of Interest Guidelines.

MAINTAINING ACCURATE RECORDS
We are committed to ensuring accurate and reliable patient and organizational records.

We/I shall:

1.      Prepare records honestly and in accordance with established policy and procedures.

2.      Require accurate bills, which include only services rendered, and use billing codes that
        accurately describe the services.

3.      Take every reasonable precaution to ensure that all charge recording, billing, and coding
        is accurate, timely, and in compliance with our policies.

4.      Report to management any transaction that is not recorded in compliance with our
        policies and procedures.

5.      Reference Corporate Compliance Guidelines through the Corporate Intranet.

Am I Doing the Right Thing?

When faced with a problem or situation, asking yourself these questions can help you decide if
you’re doing the right thing.

1.      Am I following the law?

2.      Am I treating others, as I would like to be treated?

Revised on 09/17/2007                                                                                  8
3.      Am I setting a good example?

4.      Will I feel good about my actions tomorrow?

5.      Would my actions look good in print or on the 6 o’clock news?


Also, if you find yourself, or another employee, saying any of the following, you should consider
it a “warning sign” and should consider whether you have a potential issue you may want to
report.

Warning Signs

“Well, maybe just this once….”

“We didn’t have this conversation.”

“Everyone does it.”

“What’s in it for me?”

“No one will ever know.”

DORIGHT Line
DoRight is General Health System’s compliance program designed to guide each of us toward
the highest possible standards. The DoRight Line is a helpline where you can share concerns of
a legal or ethical nature.

The DoRight Line is available to take your important calls regarding:

• Patient Care Issues
• Conflicts of Interest
• Business Courtesies/Gifts
• Customer/Supplier Relations
• Competition and Antitrust
• Safety, Health and Environmental Matters
• System Property, Technology and Confidential Information
• Discrimination/Harassment
• Accounting and Recordkeeping
• Billing Issues
• Admissions, Treatment and Referrals, etc.
• Community Involvement/Political Activities
• Relations with Government Officials/Regulatory Agencies
• Marketing/Media Inquiries
Other Concerns You May Have

The DoRight Line is confidential and available 24 hours a day. You may call toll-free to 1-866-
73RIGHT (737-4448) or email the DoRight Line through the DoRight link on the General Health
System Intranet home page.




Revised on 09/17/2007                                                                               9
Health Information Portability and Accountability Act HIPAA

In 1996, Congress enacted legislation commonly referred to as HIPAA. HIPAA was passed in
order to standardize healthcare financial transactions and to ensure privacy and security of
patients’ protected health information. It has taken awhile for the government to finalize the
standards and actual regulations under HIPAA. The government still has not released some
HIPAA regulations.


What is Protected Health Information – PHI?

PHI is individually identifiable health information. It includes information that relates to:

           past, present or future physical or mental health conditions of an individual
           the provision of health care to an individual
           the past, present, or future payment for the provision of health care to an individual
                                                 -and-
           any information that identifies the individual, or there is a reasonable basis to believe
            that the information can be used to identify the individual.

The following information is considered PHI:
         Names
         Addresses
         Dates relating to the patient (including birth date, admission date, discharge date,
           date of death)
         Telephone numbers
         Fax numbers
         Electronic email addresses
         Social Security numbers
         Medical record numbers
         Health plan beneficiary numbers
         Account numbers
         Certificate/license numbers
         Vehicle identifiers and serial numbers, including license plate numbers
         Device identifiers and serial numbers
         Web Universal Resource Locators (URLs)
         Internet protocol address number
         Biometric identifiers (fingerprints and eye scans)
         Full face photographic images and any comparable images
         Any other unique identifying number characteristic or code, such as diagnosis.

So you see, not only are patient charts PHI, but anything containing patient information (billing
information, phone messages, letters, emails, memos, schedules, packing slips, patient labels,
etc.) is considered an identifier.

Our employees and workforce should remember that although we should limit the disclosure of
the information defined as PHI, the HIPAA regulations allow us to disclose PHI for treatment of
the patient, payment of the patient’s bill and health care operations of GHS/BRGMC and its’
entities, subject to the minimum necessary requirement, which is discussed below.




Revised on 09/17/2007                                                                              10
Privacy
While GHS/BRGMC has always worked to ensure patient privacy, the regulations require
increased efforts on our part. As they relate to most employees and workforce, these
regulations focus primarily on the following areas:

           Notice of Privacy Practices
           Business Associates
           Minimum Necessary
           Release and Accounting of Disclosures of Protected Health Information
           Amendment of Protected Health Information
           Required Training for Workforce
           Sanctions

The following is an overview of these areas. Additional details and information on how HIPAA
affects your department can be obtained from your manager or by contacting the Privacy
Officer.

Patient Rights and the Notice of Privacy Practices
Upon registration in any GHS/BRGMC facility, each patient will receive a Notice of Privacy
Practices. This document will explain to the patient how we will use and disclose his/her PHI.
In addition to providing this information, the patient, or their legal representative, will have to
sign an acknowledgement that he/she has received the document prior to receiving services,
when practical. This acknowledgement must be retained for six (6) years.

The Notice of Privacy Practices will give the patient instruction on how to access several rights
concerning his/her information:

   Right to request limited access and/or disclosure of his/her information
   Right to inspect or receive a copy of his/her information
   Right to receive an accounting of disclosures made of his/her information
   Right to request amendments to his/her information

In order to receive these rights, however, a patient or his/her legal representative must complete
a form requesting these rights. These forms are located on the GHS/BRGMC Intranet or can be
received by contacting the Privacy Officer at 237-1589.



What is Minimum Necessary?
Under the HIPAA regulations for privacy, a concept has been adopted and put into the
regulations regarding Minimum Necessary. As it relates to employees, this term is defined that
as an employee, you can only access the Minimum Necessary patient information in order to
perform your job. Prior to April 14, 2003, job descriptions were amended to include the
Minimum Necessary requirement. Although it is often difficult physically to limit information
provided to an employee, each employee must understand that he/she should only access the
Minimum Necessary.

Minimum Necessary also relates to information requested and provided to others. All requests
for information by non-employees should be routed through appropriate channels and only the
minimum necessary should be provided.

Although the Minimum Necessary requirement is a key concept in privacy, patient safety and
well-being should always be considered first. If information disclosed is above the typical
minimum necessary for whatever reason, appropriate documentation should be completed and
retained.
Revised on 09/17/2007                                                                                 11
Business Associates
PHI can be shared, as appropriate, with GHS/BRGMC’s Business Associates. Business
Associates are non-GHS/BRGMC companies that perform services for payment, treatment or
healthcare operations on behalf of GHS/BRGMC. Business Associates must have a written
Business Associate Agreement in place, which holds them responsible for the privacy of
information that we provide them. If you are working with a new vendor, please contact the
Compliance Office so that it can be determined whether a Business Associate Agreement is
needed. Remember, only provide the minimum necessary in order for them to perform their
duties.

Required Education
In order to comply effectively with the HIPAA regulations, GHS/BRGMC requires that all
members of our workforce receive general awareness training for patient privacy. This packet
serves that purpose. However, different employees will have different specific education needs
relating to privacy. This additional training will be on-going, using different means of
communication and education, including, but not limited to, newsletters, department meetings
and additional Worksmart modules. If you have any question regarding department-specific
policies or training, contact your supervisor or the Compliance Department for additional
information.


What happens if I, or someone I know, violates the HIPAA Policy?
There are specific consequences if the privacy policies are not followed. This would include
disciplinary action, which could lead up to or include termination from employment. Here are a
few examples that could lead to sanctions from the government, as well as from GHS/BRGMC:

           Discussing a patient, his/her condition, or PHI with one of your friends or family
            members is a violation. This could be often an unintentional or well meaning
            disclosure, but is still inappropriate and not allowed.

           Using the computer system to check the status of a patient (regardless if they are
            friend or family) is also considered a violation. An example could be checking to see
            if your co-worker or neighbor had her baby or checking the status of friend’s lab test
            results.

           If you pretend to be someone else in order to get patient information, your actions
            could result not only in disciplinary action by your employer, but also a fine or jail
            time by the government.

           Looking through patient charts, or allowing someone to look through charts, in order
            to sell information to a vendor who may market to the patients is a major violation.
            This could result in a fine of up to $250,000 and up to 10 years in jail.

                        As you can see, Patient Privacy is serious business!


So what does all this mean to GHS/BRGMC Employees?
You should see the effects of HIPAA in your everyday life at GHS/BRGMC. Reasonable efforts
should be taken not to disclose accidentally patient information, such as:

           Don’t leave charts unattended or where they could be seen inappropriately by others
           Never leave a computer logged on while away from the computer station
           Conduct discussions concerning patients discreetly and appropriately
           Utilize appropriate document destruction methods

Revised on 09/17/2007                                                                                12
           Limit vendor access
           Refer to and follow the GHS/BRGMC HIPAA Policies

Additionally, all employees and workforce members should:
        Review the Notice of Privacy Practices to be familiar with the GHS/BRGMC official
            position on handling patient information
        Have a signed Confidentiality Statement on file in the Compliance Department
        Make sure a Business Associate Agreement is on file before information is
            exchanged with a Business Associate
        Ask questions and be familiar with the policies that affect your areas


                Remember PHI is everywhere, not just in patient charts!


Security
As with privacy, General Health System has always worked to ensure the security of electronic
PHI (“ePHI”). However, the regulations regarding security require increased efforts on our part.
The security rule covers any of PHI stored on hard drives, removable or transportable digital
memory (such as magnetic tape or disk), and information being transported electronically via
the Internet, email, or other means. As they relate to most employees and workforce, these
regulations focus primarily on the following areas:

       Protecting PHI
       Protecting Your System from Outside Threats
       Access Control
       Taking Data Offsite
       Sanctions

Protecting ePHI
Although it is the role of the Security Officer to ensure that General Health System has
implemented policies and procedures that are compliant with HIPAA regulations, everyone in
the organization must follow these policies and procedures in order to keep information secure.
Properly maintaining your password, preventing the spread of viruses, and properly disposing of
materials that contain PHI are all important ways to contribute to information security.

Password Management
Choosing a strong password, one that is not easily guessed, is essential to maintaining
information security. Your password should be in accordance with General Health System
policy. Here are some recommendations on creating for effective password management:

       Do not use passwords such as team names, personal names, or dates of birth.
        Computer hackers use software systems that have been specifically designed to guess
        common passwords.
       Use passwords that consist of letters and numbers and are at least six characters long,
        when the application is able to support these features.
       Create a password that represents a subject that interests you.
       Never put your password in your desk or on your computer. If you cannot remember you
        password, write it down and store it in a secure location that only you can access.
       Change your password on a regular basis in accordance with organizational policy.
       Never share your password, and immediately report anyone outside General Health
        System asking for your password.



Revised on 09/17/2007                                                                          13
Physical Security
The HIPAA security regulation requires security measures that limit physical and electronic
access to PHI, but still allow staff to do their jobs properly. The following are some tips to ensure
physical security:

       Protect your computer screen if you work in a public area, you may use a privacy filter or
        simply relocate your computer screen.
       Lock up laptops and all other portable devices when not in use.
       Do not disable security devices such as; screen saver passwords and keyboard locks.
       Keep all appropriate doors, deck drawers, and filing cabinets locked when they are left
        unattended.

Destruction of PHI
A computer file is not permanently removed from a computer when you delete it. The file will still
remain on the hard drive of a computer until it is overwritten or removed. For this reason, never
take a computer or disk from the property of General Health System for use elsewhere until it
has been appropriately cleared by PHNS.

Protecting Your System from Outside Threats
Computer hackers cause millions of dollars of damage each year, but there are precautions that
you can take to minimize the chance of being vulnerable to an outside threat.

Viruses and Other Malicious Software
A computer virus is a program that makes copies of itself and infects diskettes or files.
Computer viruses can spread to other computers and files whenever infected diskettes or files
are exchanged. Often infected files come as email attachments, even from people you know.
The email senders have no idea that they are passing on a file with a virus in it. Protecting our
computer systems from viruses and malicious software is a very important responsibility.
Remember the following tips to guard against malicious software:

       Never open anything that is attached to an email unless you were expecting the
        attachment and you know the exact contents of that file.
       If you receive any suspicious email, report it immediately to the Security Officer (237-
        1589) or the PHNS Help Desk (381-6440).
       Do not use personal email accounts unless they have been properly approved by PHNS.

Unauthorized Software and Hardware
Software or hardware that is installed without the approval of PHNS is another example of a
security threat. These threats could possibly disable your computer, General Health System’s
network, and could even allow someone else to gain access to your computer. Do not install
any software such as games, music sharing software, remote access software, and other
programs without proper approval from the General Health System Security Officer or the PHNS
help desk.

Email Use and Transmission of Electronic Data
If you or your department emails or electronically sends ePHI outside of the General Health
System, you should contact the Security Officer to ensure proper protocols are in place to
protect the information.

Access Control
Borrowing or sharing ID’s is prohibited under the HIPAA Security Rule. Your user ID has been
created to provide you with the access level you need to do your job. If you login using a
different ID, then you may not have the appropriate access level you need to properly do your
job.

Revised on 09/17/2007                                                                               14
Taking Data Off-site
Personal Digital Assistants (PDA’s) and Laptops:
Many healthcare workers use PDA’s and laptops. If you use one of these devices and it
contains PHI, contact the Security Officer or PHNS help desk to ensure it is compliant with
General Health System’s policies and procedures. The largest risk of using these wireless
devices is they can easily be stolen due to their portability. This equipment should always be
locked in a drawer or briefcase when not in use. Here are some tips for using PDA’s and laptops
safely:

       Never save PHI on a portable device unless the data is protected by a password.
       If you write down your password to your portable device, keep the password in a secure
        location that only you have access to.
       Remember that these devices are vulnerable to viruses and ensure that anti-virus
        protection is in place and it remains current.

Sanctions
As with Privacy, General Health System takes seriously the responsibility of securing PHI in our
care. Failure to properly follow policies and procedures in compliance with the new security
standards can result in disciplinary action, up to and including, termination.

                           HIPAA Privacy & Security - On-going

HIPAA is here to stay. In order to ensure that we continuously strive to meet not only the
government’s minimum standards, but also our own internal standards, GHS/BRGMC has
appointed a Privacy & Security Officer. The Privacy & Security Officer will work with the
Compliance Department in order to provide on-going education to all employees and provide
on-going auditing and monitoring to ensure that all employees are aware of and abide by the
privacy and security policies which are in place. The Privacy & Security Officer can also serve
as a resource or advocate for privacy and security issues or concerns you may have. You may
call the Privacy & Security Officer directly by calling 237-1589 or you may use GHS/BRGMC’s
anonymous reporting line, The DoRight Line, at 1-866-737-4448 (1-866-73RIGHT).




Revised on 09/17/2007                                                                         15
                         Discrimination & Harassment
At the General Health System and Baton Rouge General Medical Center, we strongly believe in
providing all employees with a positive work environment free from any form of discrimination or
harassment. It is company policy that all employees be treated fairly without regard to race,
color, religion, sex, national origin, veteran status, disability or age in matters of internal
recruitment, job assignments, pay, training, promotion, participation in programs or activities,
and terms and conditions of employment.

The organization also strictly prohibits sexual harassment of employees, patients, guests or any
associate.

Sexual harassment includes such behavior as:

         Abusing the dignity of an individual through insulting or degrading sexual remarks or
          conduct.

         Threats, demands, or suggestions that an individual's work status is contingent upon
          the individual's toleration of or acquiescence to sexual advances.

         Retaliation against an individual for complaining about the behaviors described above.

Any employee who believes that he or she is the victim of discrimination or sexual harassment
or believes he/she have witnessed discrimination or sexual harassment should immediately
notify his/her Supervisor or Human Resources.

Any reported allegations of discrimination or harassment will be investigated promptly.
Confidentiality will be maintained throughout the investigation process to the extent that is
consistent with appropriate investigation and corrective action.

Any individual who wishes to file an appeal in regards to discrimination or harassment should do
so with the Vice President of Human Resources or a Senior Executive of the organization.


Cultural Sensitivity and Diversity:

We provide care and services to a very culturally rich and diverse community. Respect for this
diversity is critical to our mission. By embracing people’s differences we gain the value of each
individual’s unique ideas and perspectives. We also foster a secure and healthy atmosphere for
patient care and healing.

Diversity transcends race and gender, affirmative action, and Equal Employment Opportunity. It
means respecting and valuing differences such as those based on age, disability, ethnicity,
gender, language, race, and socio-economic status, as well as respecting each individual’s right
to privacy in areas such as religious faith, politics, and personal beliefs.

All employees are expected to be respectful and accommodating of diversity and cultural
differences.




Revised on 09/17/2007                                                                             16
                           Performance Improvement

At BRGMC, we are always looking for ways in which we can improve our services. In an effort
to provide our staff with a simple, user-friendly method of identifying and addressing
improvement opportunities, we have adopted the PDCA (Plan-Do-Check-Act) Performance
Improvement model.

In the PDCA model, the letters indicate the actions that are to be taken when making a change
in a process, service, or system.

Plan the Change
        First, identify the area for improvement and then plan what changes you will make and
        how you will make them. Decide how you will measure your improvement.

Do the Change
        During this stage, you will implement the new process, system or service.

Check the Change
        Here, you examine the changes that have been implemented and decide if they have
        indeed improved the process, service, or system. Measure your improvement.

Act to Hold the Gains
        Once the changes have been made and the process is working correctly, continue the
        improvements so that the new gains are not lost. Celebrate and report your success. If
        the changes made did not result in improvement, begin the cycle again (Plan a new
        change).

This system of continuous quality improvement can be used in any setting of our hospital and
for any process. If you would like more information or need help in getting started on a PDCA
effort in your department, check with your manager or contact the Quality Management
Department at 387-7805.




Revised on 09/17/2007                                                                           17
                                     Patient Safety
Patient Safety is the responsibility of ALL employees at the BRGMC. Our goal is to create an
environment in which all employees, as well as patients and their families, work as a team to
identify and manage actual or potential risks to patient safety.

Important steps to make this happen are:

   1.   IDENTIFY and REPORT these risks. If you identify a risk or a possible risk or have a
        concern regarding patient safety, it is important that you report this to the Safety Hot
        Line 237-1SFE (237-1733). Any event that has or could have resulted in patient harm
        should also be reported You can also report directly to JCAHO.
               Any immediate risk that you identify should be reported to appropriate
                  personnel as soon as possible. For example, if you see a spill in the hallway,
                  please be sure to call Environmental Services (EVS). Stay at the sight of the
                  spill until EVS has arrived.
               Important phone numbers:
                       o EVS: x7620 (Mid-City) or x4115 (Bluebonnet)
                       o Facilities Maintenance x6285 (Mid-City) or x4188 (Bluebonnet).

   2.   Baton Rouge General promotes a “Just Culture” that encourages an atmosphere where
        any employee can openly discuss errors, concerns, process improvements and/or
        systems corrections without the fear of individual blame. Most errors that occur result
        from complex processes and systems, and not from one individual action. Reporting
        events and concerns allows the system to learn where shortcomings exist and to make
        the necessary changes to improve performance.

   3.   Encourage patients and families to participate in their care. BRGMC has implemented
        the ASK ME, ASK US campaign to encourage patients and families to ask questions
        about medications or treatments that they do not understand.

   4.   Follow the JCAHO Patient Safety Goals as they apply to your job. These goals are
        recommendations based on actual problems other hospitals have experienced.

   5.   Practice Everyday Excellence in your efforts to improve Patient Safety.

   6.   Each year JCAHO recommends patient safety goals based on actual problems other
        hospitals have experienced.

        The 2006 Patient Safety Goals include:

                   Improve the accuracy of patient identification.
                   Improve the effectiveness of communication among caregivers.
                   Improve the safety of using medications.
                   Reduce the risk of health-care associated infections.
                   Accurately and completely reconcile medications across the continuum of
                    care.
                   Reduce the risk of patient harm resulting from falls.




Revised on 09/17/2007                                                                           18
JCAHO recently announced to new Patient Safety Goals in addition to the 2006 goals listed
above.

Effective January 1, 2007 and includes:
               Encourage patients’ active involvement in their own care as a patient safety
                 strategy. (Patients and their families are educated on methods available to
                 report concerns related to their care, treatment, services, and patient safety
                 issues.)
               The organization identifies safety risks inherent in its patient population.




                                     Remember:
 Patient Safety is everyone’s responsibility! If you identify any risks or potential
              risks, it is important that you report this immediately.
               Patient Safety Hotline Number: 237-1SFE (237-1733)
                   EVS: x7620 (Mid-City) or x4115 (Bluebonnet)
                   Plant Operations: x6285 (Mid-City) or x4188 (Bluebonnet)




Revised on 09/17/2007                                                                             19
                            BRGMC Ethics Committee

The Ethics Committee is both a policy-making and consultation committee. It makes
recommendations and works with physicians and hospital staff when necessary in their
teaching, education, research and clinical care activities. The committee is also available
to assist patients and their family members with difficult issues.

HOW TO ACCESS THE ETHICS COMMITTEE

The attending physician, hospital staff members, the patient or the patient’s family may
seek an ethics consultation. Nursing and other hospital staff can access Ethics
Committee through their immediate supervisor, who in turn refers the case to a staff
member of Pastoral Care (Ext. 7742) or Medical Social Work (Ext. 7738).




                                   Pain Management

Pain is "an unpleasant sensation that results from injury, disease, or an emotional disorder".
Margo McCaffrey, RN states "Pain is whatever the experiencing person says it is, existing
whenever he or she says it does." Pain can have a negative impact on a patient's well-being;
therefore, the patient's report of pain must always be assessed. If we do not assist the patient
with ways to relieve or tolerate the pain, it may effect their sleep and cause feelings of fear,
anxiety, and hopelessness.

Direct patient-care employees receive pain assessment and management training during
Patient Care Services Orientation. There may be times that non-direct patient care staff
encounters a patient that expresses feeling pain. Should this occur, contact the nurse on duty
immediately. The nurse and other direct patient care staff will be able to assess and address the
situation to ease the patient's pain as needed.

Controlling the patient’s pain is a team effort. Everyone must work together to alleviate
unnecessary patient suffering.




Revised on 09/17/2007                                                                              20
                        Abuse Throughout the Life Cycle

Recognizing/reporting abuse/neglect/exploitation is everyone’s responsibility. When staff
suspects a patient may be the victim of Abuse/Neglect, Medical Social Work is notified. The
social worker will assess the situation and make the appropriate recommendations.

Be alert for these conditions:

High Risk Conditions and Stressors may promote abuse and neglect:

    Abuser may be: young, immature, unemployed or without sufficient funds; poor self-
   image; forced to care for the patient due to circumstances; does not know how to care for
   the patient/and has numerous demands on his/her time.
    Victim may be: demanding, overly critical, never satisfied, disoriented, confused,
   depressed, totally dependent, disabled. Most often they may be female, child or elderly
    Abuser and/or victim may be: socially isolated, alcohol and/or drug abuser, mentally ill
   and used to violence being used to solve problems in the family.
“Red Flag” Behaviors for the Victim of Abuse:
    Unwilling to discuss problem/injuries if caretaker is present
    Fearful of caretaker
    Fearful of outside contacts
    Overly passive/quiet
    Looks to caretaker to provide the “right answers”
    Unable to relate financial information
    Isolated from family and friends
“Red Flag” Behaviors for the Abuser:
    Demanding
    Critical
    Accusing towards victim
    Doesn’t allow victim to speak for himself/herself
    Attempts to isolate victim from family/friends
    Lacks physical/eye contact with victim
    Unwilling/reluctant to comply with planning/delivery of care for the victim

Signs and Symptoms of Abuse and Neglect:
     Child:
        Nail biting, thumb sucking, bedwetting
        Repeated injuries and visits to the emergency room for unexplained accidents
        Soiled clothes, insufficient/inappropriate clothing for the weather
   Preteen/Adolescent:
        Underweight and not on schedule developmentally
        Withdrawal, depression, prolonged interval between injury and treatment
        Lacks medical attention and appropriate interventions
        Running away, trance, stealing, substance abuse
   Elderly:
        Underweight, sudden weight loss, bedsores, other physical changes
            Lacks eyeglasses, hearing aide, false teeth, walker, wheelchair or other needed
           prosthetic devices
        Medication not properly taken or not taken at all
        Lacks awareness of personal financial affairs; failure to meet basic needs




Revised on 09/17/2007                                                                           21
Signs and Symptoms of Domestic Violence:
    Repeated injuries or injuries that are difficult to account for as accidental
    Strokes in young adults (blow to the head)
    Isolation of the victim, no access to money, transportation, family friends, jobs or school
    Frequent referral to partner’s “anger” or “temper;” fears being harmed by partner
    Reluctant to speak/disagree in the presence of the abuser; reluctance to speak to those
   in authority because of reprisals from the abuser
Signs and Symptoms of Sexual Abuse:
   Children:
           Sexual behavior/knowledge that falls far above the child’s development;
          unexplained abdominal pain; increased attention to private body parts; acting out or
          overly withdrawn; behavior problems at school.

    Children/Adolescents:
            Depression, isolation from peers; drug, alcohol use/abuse; chronic runaways,
           sudden drop in academics/work performance; sexual promiscuity/child prostitution;
           repeated truancy; overly seductive behavior.

                                    Remember:
    At Baton Rouge General Medical Center, when abuse/neglect is suspected, notify
                               Medical Social Work.




Revised on 09/17/2007                                                                          22
                              Violence in the Hospital

Hospitals experience violence from a variety of sources – unhappy employees, transients or
domestic violence. Most often, assaults come from patients, family and friends. Many
individuals who demonstrate the assault cycle have mental impairments and/or a violent past.

                                       The Assault Cycle




                                 Explosion


        Triggering
        Event
                                                                     Shame and
                                                                       Guilt




How do you recognize the warning signs?

Physical signs:

            Person shows “nervous behaviors:” finger tapping, pacing, clenching of fists and
              frequently changing positions.
Verbal signs:
            Person uses a raised voice, angry tones and unreasonable demands.
            Confused thinking can also be an early earning sign that someone is becoming
              upset.



What do I do?
   If you feel that you or others on staff are threatened, keep your distance.
   Do not allow yourself to become distracted by what is happening around you.
   Keep your eyes on the individual who is angry while you get help from others on staff.
   If the situation continues to escalate, and it is obvious that you will not be able to defuse
      the situation, your first priority is to get out of the danger zone. Your safety is paramount.
   Keep yourself a safe distance from the person who is becoming angry.


Know How to Use Hospital Security Systems
Our hospital has put various security systems and procedures in place to protect all of our
employees, patients and visitors. Keep these things in mind as you arrive at our hospitals, go
through your workday, or as you leave at the end of your shift.
Revised on 09/17/2007                                                                             23
    1. Be aware of your surroundings.

    2. Safety systems prevent unauthorized individuals from entering sensitive areas. When
       you enter a secure area, do not allow unauthorized people to follow you.

    3. If you are using a code to unlock a door or open an area, never let others see these
       codes as you enter them.

    4. If you see an unauthorized person in a secure area, help him/her find his/her way out.
       This sends a clear message that our employees are security conscious.

    5. Know the hospital procedures for handling assaults. If you are assaulted, you will be
       provided with support.

    5. Your best protection from assault is conduct yourself in a professional manner and to be
        alert to what is going on around you always.

                                  Assaults can be prevented!




Security Practices

It is the Baton Rouge General Medical Center’s intent to safeguard all employees while on the
job, as well as protect company property. Therefore, every employee is encouraged to report to
any Supervisor any concern regarding personal or property security.

           Be familiar with your work area, emergency exits, closets, fire extinguishers, fire
            alarms and locations of phones.
           Be familiar with the people who work with you. Look for identification badges or ask
            those who do not have identification who they are and where they work. Do not
            allow unauthorized persons into restricted work areas.
           Keep personal items locked in a desk, cabinet or locker.
           Minimize the number of personal items you bring to work. Personal items of value
            should be locked in your vehicle when possible and out of sight.
           Report lights that are not working or other safety hazards to Facilities
            Maintenance.
           Appropriate ID badges are to be worn visible above the waist at all times while on
            GHS property. All contract workers are to obtain an ID badge from the appropriate
            department.
           Security Services should be contacted in the event of any accident, suspicious or
            potentially violent individuals, and unusual circumstances or for escorts. Contact
            Security Dispatch.
           All contract workers and vendors are to park in the appropriate parking areas; i.e.,
            parking garage, loading dock and designated lots. No vendor will be allowed to park
            on the front drives except to unload.

Baton Rouge General Medical Center will not be responsible for any loss or damage to the
personal property or valuables of employees or others using the premises.

           Inspection of Parcel and Vehicles - Employees are discouraged from bringing
            personal items to work. Baton Rouge General Medical Center may, from time to
            time, search and/or require employees to allow searches of parcels, bags (including

Revised on 09/17/2007                                                                           24
            handbags and briefcases) and/or other personal items, and/or personal vehicle
            brought onto property.

           Company Property - All Baton Rouge General Medical Center property, including
            but not limited to, lockers (whether secured by employees’ locks or otherwise),
            desks, file cabinets and vehicles used by employees, is subject to being searched
            and the contents held by company personnel at any time.

           Theft - Most of the Baton Rouge General Medical Center’s buildings are open at all
            times during normal business hours. Due to the nature of our business, public use is
            frequent and the security staff challenges only persons acting suspiciously.
            Employees are urged to be alert to the entry of unauthorized persons in any area.
            Every employee is encouraged to report to security and their Supervisor any
            suspicious individual or happening on or near Baton Rouge General Medical Center
            property.

The cooperation of all employees is essential if the problem of theft is to be minimized. There
are several ways as employees you can help: always wear your name badge. Be sure supplies
and equipment are stored in approved areas and the appropriate security measures are
observed. Employees should not bring excessive amounts of money or valuables with them to
their work areas. Baton Rouge General Medical Center will not be responsible for loss or theft
of personal items. Baton Rouge General Medical Center property may not be removed from the
premises except by written authorization in advance from your supervisor.

Parking Lot Security – Employees are encouraged to be particularly observant of their
surroundings when walking to and from their automobile. A security representative is available
to escort employees leaving work after normal working hours or upon request. Contact security
for arrangements. To discourage theft of articles inside automobiles, packages and other
articles should be placed out of sight or in the trunk.




Revised on 09/17/2007                                                                           25
                                  Safe Baby Site

             As a designated emergency care facility, Baton Rouge General and its employees are
             Safe Haven providers, where parents can relinquish the care of an infant less than 30
             days old in safety, anonymity and without fear of prosecution. The intent of the parent
             is to forego all parental responsibilities for that child.

The facilities within GHS and BRGMC include Mid City, Bluebonnet, the Diabetes Center,
Occupational Health, Pediatric Rehabilitation, Bluebonnet Rehabilitation, Sleep Center, Family
Health Center, First Care Physicians, and Advanced Medical Concepts.

If an infant is relinquished to the care of an employee at any of the GHS/BRGMC sites noted above,
and the parent does not indicate that they intend to return for the infant, GHS will comply with the
Louisiana Safe Haven Law. The infant must be released to an employee of GHS. The person
leaving the infant is not required to give his/her name, however, he/she does have the option of
providing medical or genetic history to assist in caring for the infant. This policy covers infants that
are transferred by EMS from another designated emergency care facility (i.e., fire station) that has
dialed 911 to transport the infant to the hospital.

This policy does not apply if the infant is left unattended or has been abused (for example, if the
baby is left in a bathroom).

When an infant is relinquished:
    GHS employee should immediately transport the infant to the nearest BRG Emergency
    Department (ED). It is not appropriate to direct the individual to the ED; the employee should
    accompany the individual/infant or receive the infant and take to the ED personally.

     Make an attempt to provide the individual relinquishing the infant with a card containing the
     GHS name, address and contact number as well as a toll free number (1-800-CHILDREN)
     where he/she can call to find out more information about his/her rights and also anonymously
     give information about the infant’s medical/genetic history. These cards should be attached to
     each employee’s name badge holder so it is readily available at all times.

     Maintain patient confidentiality.

     If the infant is relinquished at any other department/entities within GHS, immediately call 911.

     Work with EMS to transfer the infant to the nearest BRG ED, notify the ED and the Medical
     Social Worker on call (the GHS appointed representative).

The act of relinquishment by law constitutes parental consent for the purposes of examining and
testing procedures conducted by GHS hospital staff and for the purposes of providing medical
treatment and care of the infant. Once custody of the infant is assumed by the Louisiana
Department of Social Services, they will provide these consents.




   Revised on 09/17/2007                                                                              26
                                       Electrical Safety

Don’t let Electricity be a shocking experience! Follow these tips to keep yourself safe.

                                                ALWAYS:

       Use only extension cords that have been checked by the Biomedical Engineering
        Department or Facilities Management Department.

       Use only 3 wire plug heavy-duty extension cords.

       Unplug electrical cords by gripping the plug, not by pulling on the cord.

       Avoid holding or touching metal or wet objects with your free hand or body when using
        electrical equipment.

       Inspect electrical equipment, cords, plugs and receptacles for damage prior to using.

                                                 NEVER:

       Use electrical equipment or cords in water or wet conditions.

       Test an electrical wire by touching it to see if it is live.

       Ignore a tingling sensation when you touch electrical equipment—sure sign of a
        problem!

       Use electrical equipment in areas that may have flammable, explosive or hazardous
        atmospheres.

BRGMC Environment of Care Policy states that malfunctioning or improperly working equipment
should be considered "out of service" until it can be evaluated for safety. The Biomedical
Engineering department will assist in the completion of reports to manufacturers and FDA as
appropriate and will determine whether or not equipment should be thrown away. In addition,
this policy also states an incident report when equipment malfunctions should be made and that
the staff in Biomedical Engineering is responsible for completing the investigation and
appropriate forms thereafter.




Revised on 09/17/2007                                                                           27
                                           Ergonomics
Ergonomics is the science of fitting jobs to the people who work in them.
   The goal of an ergonomics program is to reduce work-related muscle and bone
   (musculoskeletal) disorders (MSDs) developed by workers when a major part of their jobs
   involve reaching, bending over, lifting heavy objects, using constant force, working with
   vibrating equipment and doing repetitive motions.

Management and Employee Involvement:
Both managers and employees will participate in ergonomics training including
    Identifying hazards, risk factors, and controls available to prevent muscle and bone
      disorders. MSDs (musculoskeletal disorders),
    Following proper work practices
    Identifying and reporting to Employee Health Nurse, early signs and symptoms of
      muscle and bone disorders. (MSDs).

What causes MSDs?

Workplace MSDs are caused by the following risk factors:

       Repetition. Doing the same motion over and over again places stress on the muscles
        and tendons. The severity of the risk depends on how often the action is repeated, the
        speed of the movement, the number of muscles used and the required force.

       Awkward Postures. Posture is the position your body is in and affects muscle groups
        that are involved in physical activity. Awkward postures include repeated reaching for
        long periods of time, twisting, bending, kneeling, squatting, working above your head
        with your hands or arms, or staying in positions for long periods of time.

       Contact Stress. Pressing the body against a hard or sharp edge can result in placing
        too much pressure on nerves, tendons and blood vessels.

       Force Exertion. Force is the amount of effort needed to do a task (such as heavy lifting)
        or to maintain control of equipment or tools. The amount of force depends on the grip,
        the weight of an object, body position, and the type of activity and the length of the task.


       Vibration. Operating tools such as sanders, grinders, chippers, routers, drills and other
        saws can lead to nerve damage.


What are signs and symptoms of MSDs (muscle and bone disorders) that you should
watch out for? Workers suffering from MSDs may have less strength for gripping, less range
of motion, loss of muscle use and are not able to do everyday tasks. Symptoms include:

Painful joints                                 Pain in wrist, shoulders, forearms, knees

Pain, tingling or numbness in hands or feet
Shooting or stabbing pains in arms or legs     Fingers or toes turning white
Swelling or inflammation                       Back or neck pain
Burning sensation                              Stiffness


Symptoms should be reported to Department Manager and Employee Health Nurse.
Revised on 09/17/2007                                                                             28
The Back and Spine

Keeping your back healthy reduces the risk of injury. It is important to understand how the back
is built, and how it is made to be used.

The back consists of a column of single bones (vertebrae) separated by cushions (discs) and
held together by joints, ligaments, and muscles. A healthy back has three natural curves
(cervical/neck, thoracic/upper back, and lumbar/lower back), strong flexible muscles, flexible
joints, and healthy discs. It supports your upper body, protects your spinal cord, and allows you
to move freely.

Proper position of the three natural curves of the spine makes you less likely to injury your self.
To keep proper body position the ear, shoulders and hips should be in a straight line.



Body Mechanics for a working back.

Body mechanics- the way you move your body and back can also help prevent back injury.

Good body mechanics includes lifting loads close to your body to reduce strain on your back
and keep your three natural curves to help your back stay in balance.


Good Body Mechanics
By lifting the load close to your body, you
give yourself leverage that reduces strain
on your lower back. Keeping your body
straight helps you distribute the weight of
the load evenly.




Poor Body Mechanics

Lifting even a slight weight can put a lot
of strain on your lower back.
So don’t reach and bend from the waist.
That forces your back to support your
upper body plus the load. Poor body
mechanics over time can cause disc
damage and pain and lead to a
disc problem (herniation).



Chair and Workstation Considerations:



Revised on 09/17/2007                                                                             29
Proper body position at each workstation is very important to stay in good physical health. To
make sure each persons workstation is ergonomically correct please check the following.

   Monitor screen should be at eye level.
   Elbows rest at side.
   Elbows are bent at a 90 degree angle.
   Wrists are in a neutral (straight) position.
   Wrists rest on rounded tabletop edge.
   Knees are level with or slightly lower than
    hips.
   Seat edge by knees should be soft.
   Feet rest either on floor or ona footrest.
   Low and middle back is supported.
   Seat width is 18"
   Seat depth is 15" - 17"




Sitting
Most people think of sitting as a resting position. Most of the time the exact opposite is true.
Many of the sitting postures put more strain on the body that standing does. Backaches,
headaches, muscle stiffness and soreness are common symptoms of poor sitting posture.


Prolonged Over-bending
Sitting in a forward bent or “hunched” position causes a lot of strain on the back. It squeezes on
the internal organs and slows down their normal function. This poor posture will usually cause
lower back pain and fatigue.


Prolonged Extension of the Arms and Back
Sitting with the arms extended in a non-supported position will cause a lot of strain on the
muscles of the neck and shoulder area. Sitting for a long time in this position can cause neck
and shoulder pain, and headaches.


Prolonged Forward Bending of the Head
Sitting in an over bent posture with the head in a forward bent position will cause strain on the
lower back, neck, and shoulders. This will cause stiffness and pain in the lower back, shoulders,
and the neck.

Stretching and Strengthening Exercises
The following stretching and strengthening exercise program will help you reduce muscle
tension, increase range of motion and warm-up prior to beginning work or following a prolonged
period of inactivity. Anytime you exercise, make sure you

       Keep you feet at shoulder width apart and hold onto a stable item for support.

       Do the exercises slowly and smoothly- holding the stretch for 3 to 5 seconds. Repeat
        each exercise 5 times.



Revised on 09/17/2007                                                                              30
       Do not bounce or stretch to the point of pain. If you are trying to improve your muscle
        length, stretch slowly until you feel tension in the muscle. Then attempt to go a little
        further. Hold this position for 5 to 7 seconds, repeating 5 to 7 repetitions 3 to 4 times a
        day for 6 to 16 weeks.

       Never hold your breath while exercising.

       For stretching or strengthening exercises, controlled movements are better than
        numerous, quick movements.



Wrist/fingers
Hold one hand with fingers upward. Gently push fingers and wrist back with the other
hand. Hold for 3 seconds. Repeat 5 times for each hand.



                                                           I




Thumb
Hold one hand with fingers upward. Gently pull back the thumb with the fingers of the other
hand. Hold for 3 seconds. Repeat 5 times for each hand.




Whole Hand
Spread the fingers of both hands apart and back while keeping your wrist straight. Hold for 3
                  seconds. Repeat this exercise 5 times for each hand.




        It’s your job to follow this program. It is very importance for you to allow time each day to
                                 exercise regularly and as often as instructed.




Revised on 09/17/2007                                                                                 31
                        Employee Safety & Health Procedures

Baton Rouge General Medical Center intends to provide a safe and healthful work environment
for all employees. It is expected that employees will comply with safety and health requirements
established by management or by federal, state, or local law.

        (1)      Each Supervisor shall be constantly alert to protect the safety and health of
                 his/her employees. The Supervisor’s responsibilities under this policy include
                 inspection of the work area under his/her control, familiarity with safety and
                 health procedures, and training of employees in matters of health and safety.

        (2)      Baton Rouge General Medical Center complies with the following:
                 (a) Assuring compliance with the applicable safety and health standards
                     established pursuant to the Occupational Safety and Health Act of 1970 by
                     investigating, correcting, and eliminating unsafe and unhealthful working
                     conditions
                 (b) Assuring compliance with the applicable hazardous and or toxic substance
                     law
                 (c) Conducting periodic informal safety and health inspections of all work areas
                 (d) Representing Baton Rouge General Medical Center during investigations
                     conducted by Occupational Safety and Health Administration (OSHA)
                     personnel
                 (e) Training and retraining employees as required by OSHA
                 (f) Assuring compliance with the various requirements established by OSHA
                     relating to record keeping and retention of records; and
                 (g) Posting notices and records as may be required by OSHA.

Employees are encouraged to submit suggestions to the GHS Risk Management
Department concerning safety and health matters.


                                     Employee Health

Working in healthcare can be risky. Nasty bugs like Hepatitis B, HIV and Hepatitis C are just
some of the blood borne pathogens that you may deal with while at work. Baton Rouge has the
second highest AIDS rate in the nation and our Hepatitis C rate is 15% of inner-city males.
These pathogens can be transmitted from the patient to you by contact with blood or other body
fluids known as “other potentially infectious materials” (OPIM).

Do you know how these pathogens can be transmitted (how you can get them)?

             Needle sticks

             Cuts, scratches or abrasions with sharps

             Direct contact between broken or chapped skin and blood or OPIM

             Splash to mucous membranes such as your eyes, nose or mouth

BRGMC has an Exposure Control Plan that is designed to reduce or eliminate your risk of being
exposed. The plan is made up of these parts: exposure prone tasks, engineering controls,
work practices and the Hepatitis B program.



Revised on 09/17/2007                                                                               32
What kind of tasks are we talking about?

Tasks that put you at risk for exposure to blood or OPIM; like starting an IV, emptying trash or
drawing blood.

What are engineering controls?

You’re probably already using them and you don’t realize it:
            Needle-less or safety devices
            Puncture resistant sharps containers
            Personal protective equipment (PPE) like gloves, impermeable gowns, face
             masks or goggles

Here are some tips:
            OSHA requires the use of needle-less and safety devices whenever they are
             available.
            Don’t beat on the sharps container; it is puncture resistant, not puncture proof!
            And even if you don’t think you look good in personal protective equipment, use it
             any time you think you may be exposed to blood or OPIM.
            Eye Splashes are our fastest growing exposure type, WEAR GOGGLES IF
             THERE IS ANY RISK OF SPLASHING.

What are the work practices that I can use to protect myself?

Use Standard/Universal Precautions when caring for any patient regardless of his/her diagnosis:

       Treat all blood and OPIM as though they contain blood borne pathogens
       Wash your hands or use waterless hand rub as often as possible
       Never recap, bend or break a needle
       Dispose of all wastes and sharps in the proper receptacles:
           •   Biohazard waste in red bags
           •   Linen in blue bags
           •   Sharps in sharps containers
           •   All other trash in clear bags

Do I really need to take the Hepatitis B shots?

               It’s free to all employees AT RISK for blood or OPIM exposure, and it could save
                your life!
               Call the Employee Health Department (381-6811) for more details.

Where can I get an Exposure Control Plan?

               It is available any time day or night, just go to the GHS INTRANET under
                BRGMC Policies & Procedures.
               Call the Employee Health Department (381-6811) for more details.

Okay, so what happens if I do all those things, and I still get exposed to blood or OPIM?

       Get first aid.
       Tell your supervisor about the incident.
       Call in the incident on the Incident Report Line.
       During normal business hours call the Employee Health Department. After hours, go to
        the Emergency Department.
       If you have been exposed to blood or OPIM, the Employee Health Department may
        monitor you for several months if indicated.
Revised on 09/17/2007                                                                              33
       If you have had an exposure and you have any of the following symptoms call the
        Employee Health Department as soon as possible:
                           Fever
                           Feeling tired
                           Flu-like symptoms
                           Rash
                           Muscle pain

    The Exposure Control Plan was written to address issues related to occupational exposure
    to blood or OPIM in accordance with OSHA’s Blood Borne Pathogen Standard, Part
    1910.1030, Title 29 of the Code of Federal Regulations. (A copy is available by contacting
    the EHD.)

       The Standard was updated in April 2001 and now mandates that healthcare facilities
        must evaluate and select safer medical devices. These evaluations and selections (if
        appropriate) must involve front-line or non-managerial employees.



Infection Control & Prevention

Protecting our patients and our staff from acquiring infections is a major focus of the Baton
Rouge General. All staff and physicians are expected to comply with infection control and
prevention policies and procedures, which can be found on the BRG Intranet.

Here are some facts relating to hospital-acquired infections in the United States:
    There is an estimated 1.7 million hospital-acquired infections each year.
    Nearly 100,000 patients die as a result of these hospital-acquired infections.
    Most hospital-acquired infections are preventable.

Infections can be spread in several ways:
     From an infected patient to another patient on the hands of healthcare workers.
     From contaminated environmental surfaces to a patient on the hands of healthcare
        workers.
     In the air, when an infected patient coughs or sneezes.

Hand Hygiene:
       The use of waterless hand sanitizer is the preferred method for hand hygiene, unless
        your hands are visibly soiled.
             o Make sure you rub your hands until they are dry.
             o Include your fingernails and wrists.
       If your hands are visibly soiled you should wash them with soap and water, using friction,
        for at least 15-30 seconds.

                        Protect Your Patient and Protect Yourself

Clean hands are the single best way to prevent the spread of infection
    Clean your hands immediately before providing any care to a patient. Do this in the
      patient’s room or area where the patient is being treated.
    Clean your hands after touching any environmental surfaces in the patient’s room or
      treatment area.
    Clean your hands as soon as possible after you remove any personal protective
      equipment such as gloves, gowns, or masks.

A clean environment is a safe environment
Revised on 09/17/2007                                                                           34
       Make sure that all reusable equipment is cleaned after being used on a patient.
       Use disinfectant wipes to clean any used equipment or environmental surfaces. The
        surface must remain wet with the disinfectant for at least 5 minutes.
       Never reuse disposable equipment or supplies.

Identify and appropriately isolate patients with suspected or confirmed infections that
can be spread by contact or in the air
    Practice Standard Precautions when providing care to any and all patients regardless of
       their age or diagnosis.
    Nursing can use the Isolation Assessment Tool as a guide to determine if a patient
       needs to be placed in isolation.
    Follow all the instructions listed on the isolation precautions sign that is posted on the
       patient’s door.
    If you have any questions regarding isolation of patients, contact the Infection Control
       Department at 387-7852.




Revised on 09/17/2007                                                                        35
Emergency Situations
There is an Emergency Code Flip Chart posted conveniently in each department at BRGMC.
These charts are reference tools in the unlikely event an emergency situation or disaster should
occur within our facilities or our community. During such a situation, the emergency code will be
announced overhead so that all employees will know how to react accordingly. Locate the
Emergency Code Flip Chart in your area, and if such an event should occur – refer to the chart
immediately.

Another resource for you is the Emergency Staff Hotline. If you are not able to get in touch with
your manager/supervisor during an emergency event, this hotline will give you information on
the event and instructions for responding to the event. The Emergency Staff Hotline number is
763-4600. Program this number into your cell phone for easy reference.


CODE RED
Called when there is a fire

What is the first thing I need to do if there is a fire in my area?
Refer to the Emergency Flip Chart located in your area.

What should I do next?
Practice the RACE plan:
 Rescue anyone in immediate danger.
 Alarm others by activating the nearest fire alarm pull station.
 Find out where the pull alarm is in your work area before there is a fire!
 Confine the fire by closing all doors.
 Extinguish the fire if you can or Evacuate the area.


What if I want to put the fire out?
Get the nearest extinguisher and follow the PASS plan:
            Pull the pin.
            Aim the nozzle at the base of the fire
            Squeeze the handle.
            Sweep from side to side at the base of the fire.

What should I do if the fire is not in my area?
  Follow the PAUSE plan.
   Pay attention to overhead paging of the location of the fire.
   Await instructions from Command Center. Evacuation may be necessary.
   Use your senses:
          Look for proper function of fire doors and strobe lights
          Listen for proper function of alarm and paging systems
          Smell for possible smoke.
          Report any problems to Security or Maintenance Dept.
   Stay clear of the fire area.
   Ensure patient care and “business as usual” except in the area of the fire.




Revised on 09/17/2007                                                                           36
        CODE YELLOW – MASS CASUALTY / INFLUX
        Called in the event we will be receiving a large number of patients following an external
        accident. This code is called indicating number of patients expected: Code Yellow 10, 20, or 50.

        What should I do in the event of a Code Yellow?
           Follow instructions from your supervisor/manager.
           Each Department will provide assistance to ensure the Emergency Room staff receiving
              patients is not overwhelmed. The department supervisor/manager will designate staff
              members to respond on behalf of their department.
           The chart below outlines the initial assistance provided by each department

                                                    MID-CITY
  TREATMENT AREA                    CODE 10                        CODE 20                        CODE 50
            RED           RN                           2 RN                           4 RN                          8
  Life/limb threatening   Respiratory                  1 Respiratory                  2 Respiratory                 4
Supervised by: ED Staff   Registration Clerk           1 Registration Clerk           1 Registration Clerk          1
Staff Supplemented by:    PCA                          1 PCA                          1 PCA                         1
ICU and Burn Staff        Runner                       1 Runner                       1 Runner                      1
         YELLOW           RN                           2 RN                           4 RN                          8
      Urgent, not life
        threatening       Radiology Tech               1 Radiology Tech               1 Radiology Tech              1
Supervised by: ED Staff   Registration Clerk           1 Registration Clerk           1 Registration Clerk          1
Staff Supplemented by:    PCA                          1 PCA                          1 PCA                         1
2E, 2W, 3E, 5E, PACU
Staff                     Runner                       1 Runner                       1 Runner                      1
          GREEN           RN                           1 RN                           2 RN                          4
   Walking wounded,
           stable         Registration Clerk           1 Registration Clerk           1 Registration Clerk          1
Supervised by: ED Staff   PCA                          1 PCA                          1 PCA                         1
Staff Supplemented by:    Runner                       1 Runner                       1 Runner                      1
5W, 3W, Oncology Staff
                          Pastoral Care                1 Pastoral Care                1 Pastoral Care                1
                          RN                   as needed RN                   as needed RN                   as needed
        BLACK
                          Social Work          as needed Social Work          as needed Social Work          as needed
     Terminal Care
                          Security                     1 Security                     1 Security                     1

Peds/PICU Staff - respond and assess need for PEDS/PICU assistance in Treatment Areas
Psych Unit - standby
Same Day Surgery/Cath Lab/Specials - If electives cancelled, respond to Yellow Treatment Area




        Revised on 09/17/2007                                                                                      37
                                                      BLUEBONNET
      TREATMENT AREA                       CODE 10                         CODE 20                        CODE 50
             RED                RN                             2 RN                           4 RN                            8
    Life/limb threatening       Respiratory                    1 Respiratory                  2 Respiratory                   4
Supervised by: ED Staff         Registration Clerk             1 Registration Clerk           1 Registration Clerk            1
Staff Supplemented by:          PCA                            1 PCA                          1 PCA                           1
ICU Staff                       Runner                         1 Runner                       1 Runner                        1
           YELLOW               RN                             2 RN                           4 RN                            8
 Urgent, not life threatening   Radiology Tech                 1 Radiology Tech               1 Radiology Tech                1
Supervised by: Tele Charge
Nurse                           Registration Clerk             1 Registration Clerk           1 Registration Clerk            1
Staff Supplemented by:          PCA                            1 PCA                          1 PCA                           1
Oncology and Telemetry Staff    Runner                         1 Runner                       1 Runner                        1
            GREEN               RN                             1 RN                           2 RN                            4
  Walking wounded, stable       Registration Clerk             1 Registration Clerk           1 Registration Clerk            1
Supervised by: ED Staff         PCA                            1 PCA                          1 PCA                           1
Staff Supplemented by:          Runner                         1 Runner                       1 Runner                        1
Postpartum and Med/Surge
Staff
                                Pastoral Care                 1 Pastoral Care                 1 Pastoral Care                1
                                RN                   as needed RN                     as needed RN                   as needed
          BLACK
                                Social Work          as needed Social Work            as needed Social Work          as needed
       Terminal Care
                                Security                      1 Security                      1 Security                     1

NICU - Respond and assess need for NICU staff assistance in Treatment Areas




           CODE PINK
           Called in the event of a child/infant abduction

           What should I do if a Code Pink is called?
              Refer to the Emergency Code Flip Chart located in your area.
              Listen carefully to the description of the infant or child.
              Close all entrances and exits.
              Be on the lookout for ANYONE carrying a child/infant fitting the description.
              Search your area, surrounding areas and any large bags, boxes or packages.

           What should I do if I find out that a child/infant is missing?
              Refer to the Emergency Code Flip Chart located in your area.
              Dial 20 and tell the operator/dispatcher that a child/infant is missing.
              Give a detailed description of the child/infant.

           What should I do if I see someone carrying a child/infant that may be the missing
           child/infant?
                Ask the individual if they will accompany you to Security because someone has reported
                   a child missing.
                                                                      st
                Escort the individual to the Security office on the 1 Floor or the nearest Security Rep.
                If the individual refuses, call the Incident Command Center at 387-7767 and wait for
                   Security.
                DO NOT let them leave the facility



           Revised on 09/17/2007                                                                                         38
CODE BLACK – BOMB THREAT
Called when there is a bomb threat

What should I do if a Code Black is called?
   Refer to the Emergency Code Flip chart located in your area.
   Discontinue the use of all cell phones
         (Cellular phones could actually activate the bomb)
   Look in your area and surrounding areas for any unfamiliar or suspicious looking items.

What should I do if I find a suspicious looking item?
   Do not touch the item!!!
   Call the Command Center to let them know what you have found.
   If the local authorities arrive in your area, follow their instructions.

NEVER evacuate patients unless instructed to do so by your supervisor/manager.

CODE GRAY
Called in the event of bad weather such as hurricanes, tornadoes and floods

What should I do at work to prepare for a hurricane or a tornado?
   Refer to the Emergency Code Flip Chart located in your area.
   When Code Gray is activated, your manager/supervisor will ask for current contact
      information from you in the event you will need to be contacted to come to work outside
      of your normally scheduled time.
   You will also be asked if you will need child care or pet care in order to report to work for
      the emergency. This is available to you if you are unable to arrange for childcare or pet
      care with family or friends.
   Follow instructions from your supervisor/manager and the Incident Command Center.


CODE ORANGE OR CODE GREEN
Code Orange: chemical contamination event
Code Green: radiological contamination event

What should I do when I hear a Code Orange or Code Green called overhead?
   Refer to the Emergency Code Flip Chart located in your area.
   If you have been trained in chemical/radiological decontamination, report to the
      Emergency Department.
   Follow instructions from your supervisor/manager or the Incident Command Center.
   Care for the patient should be administered only after the patient has been
      decontaminated.




Revised on 09/17/2007                                                                          39
CODE EVACUATE
Called in the event of patient/staff evacuation is required.

What should I do if a Code Evacuate is called?
   Refer to the Emergency Code Flip Chart located in your area.
   If the evacuation is needed from one part of the hospital to another, the affected area
      where the emergency is occurring will need wheelchairs, stretchers and assistance to
      evacuate their patients.
   Assistance must be provided in an orderly fashion, therefore, a staging area will be
      set up for all personnel, equipment and supply resources to wait until they are needed.
   The location of the staging area will be paged overhead when the Code Evacuate is
      called.
   If the entire facility must be evacuated, each department will prepare their patients for
      evacuation, ensuring that the patient’s medical record remains with them, the patient has
      an armband on and that the situation has been explained to them.
   Follow instructions from your supervisor/manager or the Incident Command Center.

CODE WHITE
Called in the event of a violent individual or hostage situation.

What should I do if a Code White is called overhead?
   Refer to the Emergency Code Flip Chart located in your area.
   Stay away from the area where the situation is taking place.
   Conduct “business as usual” and follow instructions from your supervisor/manager and
      the Incident Command Center.

What should I do if I encounter a violent individual?
    Dial 20 to report.
Do not attempt to handle the situation yourself.

What should I do if I am in the area where a person has been taken hostage?
   Dial 20 and tell the operator/dispatcher that a person has been taken hostage.
   Clear the area of all staff, visitors and patients if this can be done without presenting
      additional risk.
   Don’t let anyone else into the area.
   Follow instructions of Security and Law Enforcement officers.


CODE BLUE
Code Blue is the BRGMC’s code for cardio-pulmonary arrest.

What should I do in the event of a Code Blue?
   Dial 20
   Tell the operator to call a “Code Blue” and identify the location of the event
   The operator is responsible for activating the Code Blue Team pagers.

OUTAGES

What should I do if the hospital loses power?

       Make sure all essential patient care equipment is plugged into the “red” outlets.
       Call the Facility Management Department to report the outage.
       Follow instructions from your supervisor/manager or the Incident Command Center.

What should I do if the phones go out?
Revised on 09/17/2007                                                                           40
       Listen to the overhead page for instructions.


SPILLS

What should I do if blood or body fluids (OPIM) are spilled?

       Keep people from coming into the area where the spill has occurred.
       Get a “Blood Spill Kit” and follow the instructions in the kit (for spills greater than two
        cups use two spill kits).
       After you have cleaned up the spill, call Environmental Services for final cleaning.

What should I do if I spill a chemical or hazardous material?

       Keep people from coming into the area where the spill has occurred.
       Call Facilities Management to report the spill.
       Call 1-800-451-8346 for the Materials Safety Data Sheets (MSDS).
       Follow the instructions you will receive from the company.
       The company will also fax you a copy of the MSDS sheet.

What should I do if a mercury spill occurs?

       Keep people from coming into the area where the spill has occurred.
       Call the Facilities Management Department to report the spill.
       Do not attempt to clean up the spill.


                                INCIDENT REPORTING

                          It is an important part of your job, and it is easy!

How do I know when to call in an incident report?

       Anytime you think there was an incident (example: medication variance, patient incident,
        employee incident, visitor incident.)

       Anytime you have to notify your supervisor or administrator-on-call.

How do I report incidents?

       Call 237-1SFE (1733) anytime day or night.

       Follow the instructions.

Will I get into trouble for reporting these incidents?         NO!




Revised on 09/17/2007                                                                                 41
                                 Medical Gas Shutoff

In the event of an emergency, our staff must be aware of the procedures related to the shutoff of
Medical Gases. The Medical Gases specifically are Oxygen, Vacuum and Compressed Air.
These Shutoff Valves are found on the wall of each Nursing Unit and are labeled with the
specific room numbers or areas that they control. If you are unsure of the location of the valves
in your area, ask your manager to point them out to you and explain which areas they control.

Emergencies Outside Your Immediate Area: if the emergency situation is not in your immediate
area and you have time to plan for the safety of your patients, call the Respiratory Therapy
Department with a list of all patients on oxygen. The Respiratory Therapist will convert these
patients to portable oxygen.

Emergencies In Your Immediate Area: if the emergency situation is in your immediate area
and there is little or no time to plan, have the Charge Nurse for your unit shut off the valves.
Under direct orders from the designated person in charge, Respiratory Therapy and/or Facilities
Maintenance can also shut off the valves.


To shut off the valves, pull the metal ring on the valve’s cover. Then, grasp the valves and turn.
The pressure gauge for each of the gases will drop to zero. Be sure to shut off all three valves
(Oxygen, Vacuum and Compressed Air).




Revised on 09/17/2007                                                                           42
     Worksmart Post Test

Name: ___________________________                  Employee ID: ____________________
Date: _________________________ _

         1. The vital sign “Expertise” includes:
               a. Sharing your knowledge with others
               b. Participating in educational opportunities
               c. Being a life-long learner
               d. Being innovative
               e. All of the above

         2. When living the vital sign, “Accountability”, you:
              a. Take ownership in your work
              b. Follow through with what you say you will do
              c. Live our Heartbeat and Vital Signs
              d. Are part of the solution
              e. All of the above

         3. “Seize the moment to make the customer feel welcome” is part of which vital sign?
               a. Accountability
               b. Attitude
               c. Expertise
               d. Professionalism

         4. To measure the patient experience at BRG, Press Ganey surveys our patients within 1
            week after discharge by:
               a. Calling them on the phone
               b. Mailing a survey to their home
               c. E-mailing a survey to their home computer

         5. To get the patient perspective of our care and services, we want to encourage patients
            to complete the survey. The best way to do this is to:
                a. Talk about the survey and ask patients to complete it, if they receive one at
                    home.
                b. Write a personal note.
                c. Give them a copy of the survey to fill out.

         6. The HIPAA laws were created to protect and secure patient information.
               a. True.
               b. False.

         7. It is ok to place patient information in the regular trash instead of using the shred bins.
                 a. True.
                 b. False.

         8. Computer monitors that are used to display patient information should be secured and
            not easily viewable by others.
                a. True.
                b. False.

         9. I should not use my birthday as a password because it is easy to remember.
                a. True.
                b. False.


     Revised on 09/17/2007                                                                                43
Worksmart Post Test

Name: ___________________________                Employee ID: ____________________
Date: _________________________ _

         10. I can anonymously contact the DoRight Line (1-866-73RIGHT) if I have knowledge of a
             HIPAA violation.
                 a. True.
                 b. False.

         11. Sharing my ID and password so that a co-worker can access information is OK because
             they have one, but forgot their password.
                a. True
                b. False

         12. It is OK to bring copies of Medical Records home to work on, because it’s easier to work
             on them from home.
                  a. True
                  b. False

         13. Computer monitors that are used to display patient information should be secured and
             not easily viewable by others.
                 a. True
                 b. False

         14. When it is absolutely necessary to communicate via email, it is OK to send emails
             regarding a patient to outside agencies as long as you contact PHNS to properly secure
             the email before sending it, which will ensure only the intended party views the email.
                 a. True
                 b. False

         15. Copying medical records at the request of a patients family is OK since you have seen
             them in the room visiting the patient.
                a. True
                b. False

         16. What performance model does the BRGMC use?
               a. CEA
               b. FMEA
               c. PDCA
               d. RACE

         17. During the Plan stage, you decide how your improvement will be measured.
                a. True
                b. False

         18. Which of the following should be done if the change you made did not result in
             improvement?
                a. Stop trying altogether.
                b. Call the Quality Management Dept crying
                c. Plan a new change based on what you learned in this cycle




     Revised on 09/17/2007                                                                           44
Worksmart Post Test

Name: ___________________________                   Employee ID: ____________________
Date: _________________________ _


         19. Who is responsible for Patient Safety at our hospital?
               a. Manager only.
               b. Nurses only.
               c. All BRGMC employees.
               d. Safety Officer only.

         20. BRGMC employees work as a team to identify and manage patient safety risks.
               a. True.
               b. False.

         21. You see a smashed banana on the floor in the hallway. What should you do?
                a. Call a Code Red.
                b. Walk away and hope somebody else cleans it up.
                c. Go back to your desk or unit and call EVS.
                d. Find the nearest phone, call EVS, and stay near the mess until it has been
                   cleaned.

         22. The Patient Safety goals are based on:
                a. A book
                b. Things we think are important.
                c. Actual problems hospitals have experienced.
                d. Education team findings.

         23. Pain has no impact on a patient’s well being.
                a. True
                b. False

         24. If a patient expresses feeling pain to you, you should tell the nurse on duty immediately.
                  a. True
                  b. False

         25. It is only the nurse’s job to alleviate unnecessary patient suffering.
                  a. True
                  b. False

         26. Medical Social Work should be notified if abuse or neglect of a patient is suspected.
               a. True.
               b. False.

         27. “Red Flag” Behaviors of the Abuser include:
                a. Critical towards victim.
                b. Demanding or accusing towards victim.
                c. Attempts to isolate victim from family/friends.
                d. Unwilling/reluctant to comply with planning/delivery of care for the victim.
                e. All of the above.




     Revised on 09/17/2007                                                                            45
Worksmart Post Test

Name: ___________________________                  Employee ID: ____________________
Date: _________________________ _

         28. Children who are sexually abused will show increased attention to private body parts
             and unexplained abdominal pain.
                 a. True.
                 b. False.

         29. Bedwetting and frequent trips to the hospital for unexplained injuries are “red flags” for
             physical abuse of children.
                a. True.
                b. False.

         30. When faced with a situation that may turn violent, pay very close attention to what’s
             going on around you.
                 a. True.
                 b. False.

         31. According to the Louisiana Safe Haven Law, Safe Baby sites are designated emergency
             care facilities where parents can give up the care of an infant without fear of being
             prosecuted.
                a. True.
                b. False.

         32. The facilities within GHS are designated safe baby sites.
                a. True.
                b. False.

         33. In order to comply with the law, the infant must be released to an employee of
             BRGMC/GHS.
                 a. True.
                 b. False.

         34. Which one of the following does not comply with BRGMC policy or Safe Baby law?
                a. Infant left with BRG security officer making rounds at the BB Plaza.
                b. Infant left on floor in any BRG restroom.
                c. Infant left with Groundskeeper outside of parking garage.
                d. Infant left with EVS employee in lobby restroom.

         35. An attempt should be made to give the person relinquishing the infant a card containing
             the BRGMC address and contact number to find out more information about his/her
             rights or to give information about the infant’s medical history. These pre-printed cards
             can be obtained from your manager and should be readily available at all time by
             keeping it:
                 a. In your vehicle
                 b. In your desk drawer.
                 c. Attached to your nametag.
                 d. In your locker.




     Revised on 09/17/2007                                                                                46
Worksmart Post Test

Name: ___________________________                  Employee ID: ____________________
Date: _________________________ _

         36. You should always inspect electrical equipment, cords, plugs and receptacles for
             damage prior to use.
                a. True.
                b. False.

         37. It is acceptable to use electrical equipment in water or wet conditions when it is
             necessary.
                  a. True.
                  b. False.

         38. Gripping the plug, not pulling on the cord, unplugs cords.
                 a. True.
                 b. False.

         39. Broken or damaged medical equipment should be reported directly to the Biomedical
             Engineering Department as soon as possible.
                a. True.
                b. False.

         40. All of the following are true regarding BRGMC policy (EOC 405) for safe medical device
             reporting (SMDA) except:
                 a. If a device malfunction or equipment related incident occurs, an incident report
                      shall be made and forwarded to Biomedical Engineering
                 b. Biomedical staff are responsible for completing the investigation and if it is a true
                      device problem completing the Medical Device Reporting Form 3500 A.
                 c. Biomedical staff will take any malfunctioning device and send directly to the
                      manufacturer without permission/instruction from Risk Management.

         41. The goal of ergonomics is to reduce work related muscle and bone disorders(MSDs)
             developed by workers when a major part of their jobs involves reaching, bending over,
             lifting heavy objects, using constant force, working with vibrating equipment and doing
             repetitive motions.
                   a. True.
                   b. False.

         42. A healthy back supports your upper body, protects your spinal cord and allows you to
             move freely:
                a. True.
                b. False.

         43. Good body mechanics includes lifting loads close to your body to reduce the strain and
             load on your back and to retain the three natural curves of the back in order to help your
             back remain in balance.
                 a. True.
                 b. False.




     Revised on 09/17/2007                                                                             47
Worksmart Post Test

Name: ___________________________                 Employee ID: ____________________
Date: _________________________ _

         44. When sitting and working at a desk or table, it is important to make sure that elbows rest
             at the side, are bent at 90 degrees, wrists are in a neutral or straight position and are
             resting on a rounded tabletop edge. This will reduce your chance of injury
                 a. True.
                 b. False.

         45. When using waterless hand sanitizer:
               a. Use even if hands are visibly soiled
               b. Rub hands together briskly until hands are dry
               c. Use if contact isolation sign states hand washing
               d. Use only if you think you have touched something contaminated

         46. Standard Universal Precautions should be practiced on every patient regardless of
             his/her diagnosis.
                 a. True.
                 b. False.

         47. OSHA requirements under the Blood Bourne Pathogen Standard include:
               a. Use of Personal Protective Equipment
               b. Required Use of Needle-less and safety sharps
               c. Organizations having an Exposure Control Plan
               d. All of the above.

         48. If you are exposed to blood or OPIM, you should clean the area, call in an Incident
             Report at 237-1733 (or 237-1SFE) and go to Employee Health or Emergency
             Department (after hours).
                  a. True.
                  b. False.

         49. What is the single best way to prevent the spread of infection?
               a. Wear personal protective equipment
               b. Avoid taking care of patients who are infected.
               c. Perform hand hygiene.
               d. Rinse your hands with water after caring for any patient.

         50. Emergency Code Flip Charts are found
               a. In the main lobby of each hospital.
               b. On the GHS Intranet.
               c. In every department.

         51. What is the Emergency Staff Hotline Number?
               a. 763-6900
               b. 763-4600
               c. 381-4600
               d. 387-7767




     Revised on 09/17/2007                                                                           48
Worksmart Post Test

Name: ___________________________                  Employee ID: ____________________
Date: _________________________ _

         52. What number do employees dial to report emergency situations?
                a. 387-7767
                b. 763-4040
                c. 0
                d. 20

         53. In what situation would you RACE/PASS & PAUSE?
                 a. Code Black - Bomb Threat.
                 b. Code Yellow - Mass Casualty.
                 c. Code Pink - Infant Abduction.
                 d. Code Red - Fire.

         54. What committee can be contacted to assist patients and families with difficult decisions?
               a. PI Committee
               b. Ethics Committee
               c. NEC
               d. Everyday Excellence Communications Team.

         55. Medical Gas shut off valves are located….?
               a. In each patient room.
               b. Within or adjacent to each unit.
               c. In Human Resources.
               d. In Administration.




     Revised on 09/17/2007                                                                          49

				
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