Samples of Hospital Vision Statements - PDF

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					                Welcome to Henrico Doctors’ Hospital!
This orientation packet has been prepared to assist you with your educational
experience. Please read the following instructions, and if you have questions
regarding the contents of this packet contact Deavin Kates, RN Clinical Rotation
Coordinator @ 289-5618 or

  1. Please review and sign one copy of the “Clinical Affiliate Orientation Agenda”
      provided in this packet.
  2. Read and review the information in the Education Study Guide and the Patient
      Privacy & Confidentiality Packet.
  3. Complete both tests.
  4. Read, sign and initial where indicated Exhibit A and B
  5. Return the following to your clinical supervisor;
            The original copy of the signed agenda
            Return both tests
            Exhibit A and B

Your clinical supervisor will forward your completed orientation packet to Deavin
Kates, RN in the Clinical Education Department located on the Forest Campus.
Completed orientation packets must be on file prior to the start of your educational

Welcome again to Henrico Doctors’. We hope that your learning experience is a
rewarding and productive one.
          Annual Review
           Study Guide

Values Awareness    Environment of Care
  Employee Focus          General
  Patient Focus


   Mission and Vision Statements (pgs. 5-6)
   Information Management (HIPPA Level II Packet)
       o HIPPA
   Patient Rights (pg. 10)
       o Statement of Patient Rights and Responsibilities
   General Safety (Environment of Care)(pg. 14)
       o Risk Management Notification (Occurrence Reporting pgs. 15-16)
       o Security Management Plan (pgs.16-17)
       o Hazardous Materials/Waste Management Plan (pgs. 17-18)
       o Material Safety Data Sheet (MSDS)(pg.19)
       o Radiation Safety (pg. 20)
       o Emergency Preparedness Management Plan (pgs. 21-22)
       o Emergency Codes (pg. 23)
       o Life Safety Management Plan (pg. 24)
       o Fire Safety (pgs. 24- 25)
       o Fire Extinguishers & Evacuation (pg.25)
       o Smoking Policy (Refer to Administrative Policy & Procedure Manual on your
           assigned unit for the designated employee smoking areas.)
       o General Safety Guidelines (pg. 26)
       o Electrical Safety (pg. 26)
       o Body Mechanics (pgs. 27-28)
       o Equipment Management Plan (Medical) (pg. 29)
       o Safe Medical Device Act (pg. 30)
       o Utilities Management Plan (pg. 31)
   Infection Control (pgs. 32-43)
       o Standard & Transmission Based Precautions
   Parking Policy (Students @ the Forest Campus are required to park in the off-site
                    parking lot adjacent to Westpot Convalescent.)
   Patient Safety Initiatives
       o Falls Program (FEAT)
       o Medication Safety
       o POC Testing (AccuChek)
       o JCAHO Standard for Pain Assessment

Signature of Clinical Affiliate:_________________________________Date

                                   Table of Contents

I.    VALUES AWARENESS                                 3
      HCA Mission & Values                             4
      Diversity & Cultural Awareness                   5
      Standards of Behavior & Service Excellence       8
      Patient Rights                                   11
      Information Security & Confidentiality           12
      Performance Improvement                          13
      Patient Safety                                   14

II.   ENVIRONMENT OF CARE                              17

      Safety Management Plan                           18
      Occurrence Reporting                             18

      Security Management Plan                         20

      Hazardous Materials/Waste Management Plan        20
      Material Safety Data Sheet (MSDS)                22
      Employee Rights                                  22
      Radiation Safety                                 23

      Emergency Management Plan                        24
      Emergency Codes                                  26

      Life Safety Management Plan                      27
      Fire Safety, Extinguishers & Evacuation          27
      General Safety Guidelines                        28
      Electrical Safety                                29
      Body Mechanics                                   29

      Equipment Management Plan (Medical)              31
      Safe Medical Device Act                          32

      Utilities Management Plan                        33

      Infection Control                                34
      Bloodborne Pathogens Standard                    35
      Reducing Risk of Exposure                        36
      Tuberculosis (TB) Standard                       38
      Regulated Medical Waste                          40

Employee Focus

                   HCA – Our Mission & Values
         Above all else, we are committed to the care and improvement of human life.
       In recognition of this commitment, we strive to deliver high-quality, cost effective
                             healthcare in the communities we serve.

     In pursuit of our mission, we believe the following value statements are essential and

          We recognize and affirm the unique and intrinsic worth of each individual.

                 We treat all those we serve with compassion and kindness.

        We act with absolute honesty, integrity and fairness in the way we conduct our
                           business and the way we live our lives.

     We trust our colleagues as valuable members of our healthcare team and pledge to
                      treat one another with loyalty, respect and dignity.

Mission and Values
The mission of a company is its purpose statement! It is to be shared and accepted by
employees to successfully drive it and for the organization to reach its goals. At HCA our
mission is the foundation of all we do. It is important to us that our employees are involved
in helping achieve our mission, in fact, more than 10,000 employees participated in the
development of the HCA mission statement.

Values are the principles and standards that guide people’s behavior as they work to
achieve results. HCA’s values guide how we will achieve our mission. They include
respect, honesty, and fairness. It is not enough to just talk about the values; we must keep
them alive through our actions, and through the choices we make every day.

Paramount to our mission and values is “patients first.” That’s our work and our focus. We
do this with our
     Hearts: Caring, or the human element of our work.
     Hands: Our physical contact with patients.
     Minds: The brightest and best people to serve our patients.

HCA’s founders included Dr. Frist Sr. and Tommy Frist, Jr. M.D.-- physicians with a vision
to build an organization solely around patients. That is the vision that still guides us today.

Diversity Awareness & Honoring Differences
Values, norms, and personal experiences contribute to our beliefs about ourselves and
Working in Healthcare means caring for and coming in contact with people from every walk
of life. These encounters and experiences require us to recognize that each person is
unique, with diverse beliefs, cultural backgrounds, experiences and needs. When we focus
on diverse populations we must be sure to encompass a wide range of differences

        Ethnicity                   Family relations             Disability
        Religion                    Life experiences             Attitudes
        Language                    Learning styles              Gender
        Communication               Age                          Education
        Sexual Preference           Politics

Honoring and responding to individual differences through understanding and stronger
relationships creates a positive environment where we can:
       Provide the most appropriate care and service to patients, family, physicians, visitors
        and co-workers.
       Improve communication channels for more positive interactions.
       More accurately understand other people’s point of view and customs.
       Effectively blend cultures, traditions and individual needs with the best care possible.

Remember the Golden Rule? “Do unto others as you would have them do unto
you. ”An even better approach is to follow the Platinum Rule:

             “Do unto others as they would have you do.”

                         Culturally Competent Care

Culture is a set of characteristics shared by a group of people. It includes their values,
beliefs and practices that are passed from generation to generation. Culture affects all
areas of life, including beliefs about health, nutrition, communication, birth and death.
Examples of some cultures include people who are:
   Native American – North American Indians or Alaskan natives
   Hispanic – from areas such as Spain, Portugal, South America and Central America, or
   African – American – from Africa or the Caribbean countries
   Asian – having roots in China, Japan, Korea or other Asian countries
   European – from countries such as England, France, Germany, or Italy
   Certain religious faiths – such as Catholic, Protestant or Jewish

What is Cultural Awareness & Sensitivity?

The population in the United States is becoming much more diverse... there are many
people of different cultures. This means that you will often have the opportunity to care for
patients and work with people who have cultures different from your own. It is important to
show respect and develop an understanding of their cultural beliefs and practices.

What is Cultural Competency?

The first step to becoming culturally competent is to examine your own values and beliefs.
Then you need to learn about those that are different from you.

Do you need to learn all of the cultural beliefs and practices of every cultural group? Of
course not, for two good reasons:
 There are too many groups and cultural practices. You could never learn them all!
 And more importantly, just because a person is of a certain background does not mean
   he or she shares all of those beliefs and practices. Never make assumptions!

Use these guidelines when working with others from different cultures:

   Treat all patients and their families with respect. Call adults Mr. or Mrs. unless asked to
    do otherwise.

   Never act shocked or make fun of anything the patient or family does or requests.

   If English is not their first language, make sure that what you tell them is understood by
    having them say it back to you in their own words. Do not ask questions they can
    answer yes or no. Some people, especially Asians, may smile, nod and say yes to
    everything. They do this so as not to appear rude. If communication is difficult, consider
    using the AT&T Language Line, getting a translator or looking on the HDH Intranet
    under Transcultural Resources.

   Accept and respect their beliefs, even if you don’t agree with them. A Middle Eastern
             wife may run to meet her husband’s every need and take orders from him
             without question. Do not judge their culture – it is not your role and it isn’t

             When you respect and appreciate someone’s culture, you show respect for
             him or her as a person. Your patient is much more likely to meet his
             healthcare goals if care is planned in harmony with important cultural beliefs and
practices. You will also work better with people when you take an interest and try to
understand cultural differences rather than judging them for being “different”.

Employee Recognition
The benefits of consistent recognition are far reaching, including improved teamwork,
collaboration, retention and job satisfaction, as well as overall higher performance.

Frist Humanitarian Award
At the corporate level, there is an award given to an HCA employee and a volunteer from
each facility who make significant contributions to their hospitals and communities called
the Frist Humanitarian Award. It is the most prestigious recognition in HCA.

360 Degree Recognition
EVERY day at our hospital people are doing good work and they should be recognized for
their efforts and accomplishments. 360 degree recognition comes from a variety of
sources including letters, phone calls, E-mails, manager feedback and “Recognizing
Excellence” forms. Every two weeks feedback is collected then shared with Administration
and Department Leaders. Finally, and most importantly, the recognition is presented to
employees to share the positive feedback and congratulate them on a job well done!

People who are consistently recognized for excellence take PRIDE in their work, PRIDE in
our hospital and PRIDE in the organization. They regularly go above & beyond and they
put the following concepts into practice:

  Patient & Customer Focus
  Consistently anticipates and exceeds expectations. Follows up to resolve complaints;
  develops ways to prevent future problems. Works to ensure safety of others; puts
  patients & customers first.
  Respect for Others
  Provides care and service with compassion & kindness. Courteous; professional in all
  communications. Shows respect for the rights, privacy & dignity of each individual. Role
  model for others.
  Integrity in Action
  Represents organization with honesty & trustworthiness. Ownership; takes responsibility
  for actions & consequences. Ethical behavior in work activity & personal conduct.
  Developing Partnerships
  Builds & sustains positive alliances with patients, family, physicians, co-workers &
  community. Team player; encourages collaboration. Cooperative spirit extends beyond
  immediate unit or department.
  Excellence is the Standard
  Consistently goes above & beyond. Remains focused on quality & continuous
  improvement. Innovative; shares ideas; initiates & supports change at all levels.

Standards of Behavior & Service Excellence
Patients are the reason for our existence. Because of this, it is critical that we all believe in
and share a commitment to service. Make no mistake, while we have a great deal of high
tech equipment, it is our staff who make the greatest difference in the lives of our patients
and other customers. Below are some of the expectations we have for all staff members.

Focus on Our Customers
Our sole purpose for being is to provide an important service to our patients, their families,
and our community. We cannot forget why we are here... “The care and improvement of
human life.” This must be done with the highest technical competence along with a good
measure of care and compassion. We cannot become complacent to what our patients
and their families are experiencing.

If your job is not taking care of patients directly, you are somehow supporting someone who
does. Your customers may be patient families, visitors, physicians, other departments, staff
members, vendors, volunteers, or community members. Your outstanding service to them
positively impacts the overall service to our patients. Every position at our hospital plays an
important part in ensuring our mission is complete.

Assertive Friendliness
We expect you to seek out and initiate positive interactions with our customers. This
means that you are expected to greet, smile, and approach our customers regularly. No
matter what you do, where you work, or where you find them, you are expected to offer
assistance to customers (without being asked) by providing directions, escorting them to
their destination, finding answers to their questions, or providing a caring touch or smile. It
is often the little things that leave a lasting impression.

We have an obligation to behave in a professional manner at all times in front of our
customers. This means that we must be “on guard” in any area where a customer might
have the opportunity to hear or observe us. We call this an on-stage area. While on-stage,
we must carefully monitor our conversations, emotions, and behaviors making sure that
what we say and do are appropriate for our audience.

Positive Attitude
Your attitude has a tremendous impact on those around you. Therefore, it is imperative that
you choose to make today (and everyday) a good day. Of course, all of us have bad days
or experience things that frustrate us however, we cannot let this impact how we treat
others. The sign of a true professional is the ability to maintain consistent, high quality
service no matter what one may be experiencing personally.

Commitment to Co-workers
Most full time staff members spend more waking time with the people they work with than
with their families at home. Therefore, it is crucial that we take care of each other.
Teamwork, cooperation, and respect are necessary in order to create a positive, healthy
work environment. In addition, we must be good role models for our co-workers by being
knowledgeable, resourceful, and positive to one another. We also need to warmly
welcome and be patient with new staff members.

Professional Appearance
Like it or not, people use appearance to make judgments about our ability to do our job. Unless
they’re extremely knowledgeable, most people do not have the ability to adequately judge technical
competence. Instead, they use things such as personality, attentiveness, and appearance to form
their opinions.

We are all expected to adhere to our professional appearance guidelines. Some employees wear
uniforms while others are in professional dress. Regardless, we expect clothing and grooming to be
conservative and not cause undue attention. Below is a broad overview of our guidelines:

 Clothing must be neat, clean, well fitting, and in good repair.

 Photo identification badges are to be visible, readable, & worn near the face. This will help
  coworkers and patients identify you and are required by the Security Management Plan as well
  as Human Resources.

 Hairstyles must be clean, well-kept, and conservative. Mustaches, beards, and sideburns are to
  be kept neat, clean, and trimmed at all times.

 Jewelry and cosmetics should be tasteful and conservative. Pierced jewelry may be worn in the
  ears only. Facial cosmetics are permissible in moderation. Tattoos must be covered. No
  cologne or any type of body or hair fragrance is allowed for staff in patient care areas. All other
  staff are encouraged to use fragrances in moderation.

 Footwear must be clean, polished, in good repair, and of a type providing safe and secure footing
  and protection. Material should be appropriate for the type of the uniform worn or for a business
  environment if staff is non-uniformed. Socks or hosiery must be worn at all times. Sandals,
  thong-style shoes, and flip-flops are not permitted anytime. Shoes in patient care areas must be

 Nails must be moderate in length and clean at all times. Under no circumstances will patient
  care providers be permitted to wear acrylic nails. This is one more way that we take care to
  provide the patient with a safe environment.

Keep Our House Clean
This is our house. Most of us spend a great deal of time here. Because of the hospital’s large size
and the great number of people coming in and out daily, it is virtually impossible for the
housekeeping department to keep it clean by themselves. You are expected to help. This means
you are expected to keep your own work area neat and clean, to pick up trash you see on the floors
or other places, and to straighten up common areas without being asked. It also means helping
housekeeping by reporting areas that may need their special attention. Just as we want to keep our
own home clean for our guests, we want to keep the hospital clean for its guests.



Patient Focus

Patient Rights, Privacy, Security and Confidentiality
HDH is committed to the HCA philosophy of “Patients First.” To this end, we endeavor to make the
patient’s stay as stress free, informative, safe, secure, and confidential as possible. We provide
them with their rights, our pledge to protect their personal health information, and our obligation to
honor their confidentiality through HIPAA.

Patients Rights
Every patient who comes into HDH receives a folder providing important information that will: help
create a positive experience, help them to make informed decisions, and give them a sense of
caring, privacy, and security. One of the key items is the Patient Bill of Rights, which is posted in
every room.
Here are some excerpts from that document:
 Considerate and Respectful Care—such as the right to quality treatment, to be treated with
   dignity, the right to ask all personnel involved in their care to introduce themselves, and the right
   to participate in the development and implementation of a plan of care.
   Information about Treatment – such as the right to be informed of any and all procedures
    involved in their treatment, as well as the right to refuse to participate. Patients have the right to
    request assistance if they are non-English speaking.
   Participate in Decisions about Care – such as the right to informed consent and, in
    partnership with the physician, to agree to treatment based on a full explanation of the disease,
    risks, and benefits of the proposed treatment, as well as the right to refuse a diagnostic
    procedure or treatment.
   Pastoral Counseling – such as the right to request pastoral/spiritual counseling from either a
    staff member of the clergy or one of their choosing.
   Advance Directives – such as the right to request information about advance directives (living
    will and/or Durable Power of Attorney for Health Care). The patient can give directions about
    future medical care or assign another person to make medical decisions in case they are
    incapable of so doing.
   Ethical Decisions – such as the right to make individual decisions based on personal beliefs
    and values and to be involved in the consideration of all ethical issues involved in the their care.
   Reasonable Response to Requests and Needs – such as the right to the assessment and
    management of pain, the have a family member or personal physician notified of their
    admission, the right to be assisted in transfer to another health care facility if the service is not
    provided by HDH, and the right to examine their hospital bills and have them explained.
   Privacy – such as the right to make decisions pertaining to: closing the door for privacy,
    restricting visitors, protecting identity, transferring to another room, and the right to a safe and
    secure environment.
   Confidentiality – such as the right to expect that all medical records are confidential and that
    patient information is only used or released as permitted by law.

Information Security
Information security includes the proper use and storage of patient’s personal health information,
computer access, and awareness of any breaches of security. Information security is everyone’s
responsibility. Each employee is responsible to:
A. Use only systems they are authorized to use
B. View only the information that they need to do their job.
C. Lock sensitive and confidential information in a cabinet, drawer, or other safe place when not in
D. Share confidential information only with people who need the information to perform their job.
E. Log off and shut down computers before leaving work each day
F. Never share their User ID and Password even in an emergency
G. Call the Local Security Coordinator (LSC) – Dan Patton or the Security Help Desk for suspected
    breaches of security.
H. For Meditech issues, contact the CPCS Coordinators, Chris Karstens and Alpheus Pope.

Health Insurance Portability and Accountability Act (HIPAA) reinforces the role we play in creating
and maintaining organizational integrity, ethics and compliance. This act affects the entire
healthcare industry. Its purpose is to protect patient information, health insurance coverage, improve
access to healthcare, reduce fraud and abuse, and reduce healthcare administrative costs.

HIPAA establishes regulations for the use and disclosure of Protected Health Information (PHI). PHI
is any information about health status, provision of health care, or payment for health care that can
be linked to an individual. This includes any part of a patient’s medical record or payment history,

   A patient’s diagnosis
   Personal identifiers, such as name and address, etc.
   Photographic images
   Individually Identifiable Health Information
Employees should not discuss, copy, send, or share any confidential information about a patient
unless the person with whom it is shared has a need to know in order to perform his/her job.

Reasonable safeguards should be put into place to protect the patient’s information at all times. This
means that the information may not be left in the patient’s room, exposed at the nurses’ station, or
anywhere else that it might be seen by anyone except those who have a need to know or those with
direct care responsibility for the patient.
In order to release information about a patient in the hospital to a family member, we must verify the
requestor has authorization to receive the information by asking for the password, which is the last
four digits of the patient’s Account Number.

Privacy questions or concerns should be addressed to Lou Canulli, Facility Privacy Officer.

                                             Performance Improvement

 Henrico Doctors’ Hospital strives to fulfill its mission to its patients, physicians, personnel, and the community and is
committed to designing, measuring, and improving performance/processes in order to meet this mission. Using the
following two models helps us better understand Performance Improvement.
         Find a Process Improvement Opportunity
             What situation needs improvement?
             Which processes should be addressed?
         Organize a team that knows the process
             Are there staff who work closest to the customer?
         Clarify the current knowledge of the process
             Is the process well defined?
             Do our perceptions of the process relate to the process?
             What is the baseline of our current situation?
             Have we clarified our initial opportunity?
         Uncover root causes of process variation
             Are these root causes or symptoms of the problem?
             What root causes have greatest priority?
         Start improvement cycle based on theory
             What new knowledge has been acquired about the process?
             What change needs to be made to improve the process?


        The Process Improvement
            Who, what, where,
             when and how                                    Implement the
            The Data Collection                              improvement

        On the process
                                                          The results
            Test the theory                                 Do they match
                                                             What was learned?

Patient Safety is a vital concern for all healthcare providers. The 1999 report from the Institute
of Medicine, To Err is Human, triggered significant action at HCA. In February of 2000, HCA began
an in-depth analysis of patient safety issues within hospitals. This analysis lead to a company-wide
commitment to assuring patient safety practices are implemented in every HCA hospital.

Patient safety is our culture

The HCA mission statement affirms that “Above all else, we are
committed to the care and improvement of human life.” This simple
statement is the foundation of our culture and our passion for patient

Thomas F. Frist, Jr., MD, a co-founder and former chairman, is fond of
saying “putting patients first” is the secret of success in healthcare.

Jack Bovender, CEO and Chairman of HCA, describes the patient
safety initiative as a response to the “sacred trust” that healthcare
providers have with their patients.

“Every day each one of us, no matter what our job, makes a difference
in the safe care of our patients,” says Dave Williams, CEO. “It is
important that we all realize how even our simplest actions can impact
our patients.”

Patient Safety Goals for Henrico Doctors’ Hospital

Our goal is to create a culture of patient safety as a tangible expression of HCA’s commitment to
putting patients first.

   Establish patient safety as a visible commitment to our "putting patients first" philosophy

   Move from blaming people to improving processes

   Improve use of technology to prevent and detect error

   Use data to identify and measure improvements

Patient Safety in Action
  Emar Implementation
  eICU Implementation
  Core Measures
  JCAHO National Patient Safety Goals
  ED Risk Reduction Initiative
  Perinatal Safety Initiative
  Kernicterus Screening
  Anthem QHIP Project
  Institute for Healthcare Improvement Initiatives
National Quality Forum Safe Practices

2008 JCAHO National Patient Safety Goals
1      Improving the accuracy of patient identification
1A     Use two identifiers when providing care, treatment or services.

2      Improve effectiveness of communication among caregivers
2A     Reading back all verbal and telephone orders, and test results.
2B     “Do Not Use Abbreviations” – such as QD, QOD, U, u, IU, MgSO4, MSO4, MS
2C     Reporting critical test results in a timely manner.
2D     Implementing a standardized approach to “hand off” communications.

3     Improve the safety of using medications.
3C    Take action to prevent errors involving look-alike/sound-alike drugs.
3D    Label all medications, containers and solutions on and off the sterile field.
3E    Reduce the likelihood of patient harm associated with the use of
      anticoagulation therapy.

7      Reduce the risk of health care-associated infections.
7A     Comply with the CDC hand hygiene guidelines or World Health Organization
       (WHO) Hand Hygiene Guidelines
7B    Manage as sentinel events all cases of death associated with a health care-
      associated infection.

8     Accurately and completely reconcile medications across the continuum of care.
8A    There is a process for comparing patient’s current medications with those ordered while
      patient is in hospital.
8B    A complete list of the patient’s medications is communicated to the next provider and is
      provided to the patient on discharge.

9      Reduce the risk of patient harm resulting from falls
9A     Implement a fall reduction program

13   Encourage patients’ active involvement in their own care as a patient safety strategy
1 3A Communicate to patients and their families how to report concerns about safety.
15    Identify safety risks inherent in the patient population
15A   Identify patients at risk for suicide.

16  Improve recognition and response to changes in a patient’s condition
16A A method is in place to allow healthcare care members to request additional assistance from
    a specially trained individual when patient’s condition appears to be worsening.

**Bold font indicates goals that are new for 2008


The management team and staff at Henrico Doctors’ Hospital are committed to achieve good
outcomes through the provision of quality patient care at our facilities. The goal is to maintain a safe,
functional, supportive, and effective environment for patients, staff members, and other individuals
who work at or visit our facilities.

Plans, and related policies/procedures, are located in the red Safety Policies and Emergency
Procedures manual and on the HDH Intranet. They are:

1.    Safety Management Plan
2.    Security Management Plan
3.    Hazardous Materials/Waste Management Plan
4.   Emergency Preparedness Management Plan
5.   Life Safety Management Plan
6.   Equipment Management Plan (Medical)
7.   Utilities Management Plan

     The Plan is designed to establish, support, and maintain a safe, accessible, and
     functional environment of care at Henrico Doctors’ Hospital Forest and
     Parham Campuses. The environment is free of recognized hazards and maintained, based on a
     system of monitoring and evaluation of facility specific organizational
     experience, applicable laws and regulations, and accepted practice. Each campus
     has an assigned Safety Officer to address safety questions/concerns: Forest Campus – Sharon
     Lapkin 289-4857; Parham Campus – Joan Recher 747-5650.
     There is an Environment of Care Committee with multidisciplinary representation. The five
     subcommittees that cover the 7 EOC standards under JCAHO are as follows: Safety
     Management, Emergency Management, Hazardous Materials Management, Employee Safety,
     and the Fire Safety, Security, Equipment and Utilities. The Environment of Care Committee and
     subcommittees are responsible for the overall monitoring of the Environment of Care program

Risk Management Notification System (Occurrence Reporting)
                                 Patient/Non Patient/Employee
Occurrence reporting is everyone’s responsibility. Instructions for “how to” complete an Occurrence
Report can be found in the Meditech Library under “Occurrence Reporting” or you may receive
training from your supervisor, preceptor or Risk Management. Serious occurrences, such as an
unexpected death or serious injury, must be reported to Risk Management immediately. The Director
of Risk Management can be reached by pager round the clock and the Risk Manager/Coordinator
from 8-5.
What do you report?

Refer to the Safety Policies and Emergency Procedures manual, Series 100,

File 100-4, “Occurrence Reporting” for reporting requirements. Below are some examples:
        •   ASSAULT               ASSAULT ISSUES
        •   FALL                  FALL
        •   HAZ SPILLS            HAZARD SPILLS/LEAKS
        •   ILLNESS               ILLNESS
        •   INJURY                INJURY
        •   LEGAL                 LEGAL ISSUES
        •   MATERNAL              MATERNAL AND INFANT
        •   MED EVNTz             MEDICATION EVENT
        •   OTHER                 OTHER ISSUES
        •   TREATMENT             TREATMENT ISSUES
   When reporting, focus on the facts of the occurrence; avoid subjective commentary.
   All reports are to be referred to employee’s manager.
   All Patient/Non Patient Occurrence Reports go directly to Risk
    Management and Employee Reports go directly to Employee Health

What do you do if a patient or non-patient is injured?
       Patient Injury – Document the facts in the medical record. Complete an Occurrence Report
       in Meditech within the same shift, if possible, and refer it to your Department Manager. The
       occurrence report is not to be copied or referenced in the medical record.
       Non Patient Injury - Complete a Non-Patient Notification (Occurrence Report) in Meditech
       within the same shift, if possible, and refer it to your Department Manager. The occurrence
       report is not to be copied.
       Call Security for all visitor occurrences or for any fall that occurs in common areas.

What do you do if you or an employee is injured?
       Injury Requiring No Medical Treatment – Report the injury to his/her immediate supervisor
       before the end of the shift and complete an Employee Occurrence Report in Meditech.

       Injury Requiring Medical Treatment – Report the injury to his/her
       immediate supervisor before the end of the shift and complete an Employee
       Occurrence Report in Meditech. If medical care is desired/needed, contact the
       Employee Health nurse for assessment. If the nurse is unavailable, go directly to the
       Emergency Department.
        Failure to report, as specified above, may result in claim denial and disciplinary action.

   The objectives of this plan are to reduce the risk of injury to patients, visitors, and
   personnel and to ensure patient confidentiality. Important functions include:
   A.  A process in place for addressing security issues re: patients and visitors,
   B.   Reporting and investigating security incidents involving all of the above.
   C.   Providing identification, as appropriate, for all of the above.
   D.  Controlling access to sensitive, secured areas.
   E.   Providing vehicular access to urgent care areas.
   F.   Protecting patient confidentiality with proper information security in the use of
      the telephone, faxes and computers.
   Monitoring security of the facility is by:
   A. Security officers conducting internal and external patrols.
   B. Employees reporting suspicious looking individuals to security officers.
   C. Proper identification of employees by their I.D. badge.
   D. Requiring volunteers, patients, and contract/construction workers to wear identification
   E. Safe keeping of personal belongings in a locked desk drawer or locker.
   Remember: You have the right to ask someone who he or she is if they
   are not wearing identification.
   Secured/Sensitive Areas – Certain areas in the facility are classified as ensitive areas. This
   means both staff and visitors have limited access. Appropriate persons may gain access by
   swiping their ID Badge.

   Examples of sensitive areas are: Obstetrics (Forest), Emergency Department, Cashier,
   Pharmacy, Laboratory, and Out Patient or Same Day Surgery Centers. These areas are
   equipped with cameras, panic alarms, and have increased patrols every shift by Security.

   The Hazardous Materials Management Plan objectives are to reduce the risk of injury to
   patients, visitors, and personnel by promoting a safe, controlled, comfortable environment of
   care. Important functions include:
   A.     A process for selecting, handling, storing, using, and disposing of hazardous material
          and waste from receipt or generation through use or final disposal.
   B.     Written criteria consistent with applicable law and regulation to identify, evaluate, and
          inventory hazardous material and waste used or generated.
   C.      Procedures for managing chemical waste, chemotherapeutic wastes,
          and regulated medical waste.
   D.      Process to monitor and dispose of hazardous material and waste.
   E.      Provision of space and equipment for safe handling and storage of hazardous material
           and waste.
   F.      Investigation of all hazardous materials or waste spills, exposures, and other

As required by OSHA/other regulatory agencies, there is a “Hazard Communication Program” in
the red Safety Policies and Emergency Procedures manual, located behind tab 300, Hazardous
Materials/Waste Management. The Hazard Communication Program requires employees to be
trained on hazardous materials and waste; the training begins with classroom orientation and
continues in the department orientation, and throughout the employee’s employment. Medical
Waste – Spill Containment and Clean Up – Information is located in the policy “REGULATED
MEDICAL WASTE” File Number: 403, located behind tab OSHA IC 400, in the INFECTION
CONTROL MANUAL. Hazardous Leaks and Spills Response - Information is located behind the
Haz.Materials/Waste tab in the policies 300-5, 300-7, 300-8, 300-9, 300-11, 300-12, and behind the
CODE H “Haz. Spills” tab, policy 400-15 CODE H –HAZARDOUS SPILL/LEAK PROCEDURES.

-     Drugs and chemicals are safe and useful if handled properly. However, many can be
      hazardous if not treated with caution. Always follow recommended procedures and protocols.

-      Read all warning labels and Material Safety Data Sheets (MSDS).

-      Never open or use an unlabeled container. Notify and give the container to your supervisor.
-     A large chemical spill that requires the activation of the Code H policy is usually a spill of 1
      gallon or more.

-     As cleaning solutions often contain hazardous chemicals, do not handle them if it is not part of
      your job. Special training in their use and the required personal protection equipment (PPE)
      is necessary before you use the chemical.

-     Wear lead aprons/shields and gloves if you work with x-rays. Your film badge will be checked
      regularly to make sure you are not being overexposed to radiation.

-     Follow all drug and chemical procedures carefully. Wear appropriate PPE and wash your
      hands thoroughly after completing the job. Also, remember that hazardous chemicals require
      special clean up for spills. Each department has a chemical inventory that outlines all
      chemicals in your department. If any of those chemicals spill, the emergency Code H is to be

How do you detect chemical leaks or spills?
You may see it or smell it. Some chemicals, however cannot be seen or have no odor. It is for this
reason that you must look up the chemical in the MSDS so that you will know how to detect it. If you
do suspect a chemical spill, immediately consult MSDS.

Hazard Warning Symbol
The Biohazard Symbol below is black and red. It is used on containers that hold blood or other
infectious material.

Material Safety Data Sheet - MSDS

OSHA (Occupational Safety and Health Administration) developed the MSDS form as part of the
Hazard Communication Standard or the Right-to-Know regulation.

The MSDS is an easy reference for information on a hazardous substance. Many chemicals that
you use contain substances that could be harmful if used improperly. Each department is
responsible for maintaining and updating their department specific MSDS manual.
The MSDS contains the following parts:
         Identity of the chemical
         Name, address and phone number of the manufacturer
         Hazardous ingredients, chemical I.D. and common names
         Chemical’s physical/characteristics
         Recommended safe exposure limits
         Effects of over exposure
         Fire and explosion risks and the types of extinguishers to use
      Specific safety precautions to take when using the chemical and/or disposal of the

Employee Rights:
    The right to know the listed toxic substances present in the workplace.
     The right to obtain a copy of the MSDS for each listed toxic substance present in the
      immediate work area by submitting a written request.
     The right in limited circumstances, to refuse to work with a listed chemical, if not provided an
      MSDS within five working days after submitting a written request.
     The right to protection against discharge, discipline, or discrimination for exercising these

Chemicals are to be inventoried in all departments annually. MSDS sheets for applicable
chemicals in the department should be available in the department manual. MSDS sheets for
chemicals that are no longer present in the department must be sent to Risk Management for

If you cannot locate a MSDS sheet or are unable to read the information, you or a co-worker can call
CHEMTREC at 1-800-424-9300. You will receive first-aid information, or clean up procedures over
the phone.
Radiation Safety

The Facility Management is committed to keeping radiation exposures As Low As Reasonably
Achievable (ALARA). The hospital’s Radiation Environment of Care Committee is responsible for
our ALARA program and meets quarterly to review exposures and operational problems. The
Hospital’s Radiation Exposure plan is in the Red Safety and Emergency Procedures Manual in your

The Radiation Safety Officer for HDH is Dr. Julius Hurwitz.

The Radiation Symbol (below) is usually maroon text on a yellow background. It warns people that
radioactive materials are in the container or room, which is posted. Do not enter a room or open a
container with this symbol unless you know how to protect yourself and others from exposure to
radioactive materials.

If you see a radiation symbol and are not sure what to do – contact your Supervisor.

Any radiation safety incidents or issues should be reported to the Radiation Safety Officer at your
facility (you can call the operator and have them paged).

The three elements that are associated with exposure to radiation are the amount of time exposed,
the distance from the source and proper shielding. Universal precautions must be used for all
patients administered with radioactive material.

Time:         The less time you spend around radiation – the less you will receive.

Distance:    The farther you are from the source, the less your exposure. If you double your
             distance from a source of radiation you will cut exposure to one fourth.
             Taking ONE step back reduces your exposure.

Shielding: When possible, place a shield – such as a lead apron – between you and the source of

The Emergency Management Plan objectives are to reduce the risk of injury to patients, visitors, and
personnel. The following represents a limited list of important functions, the complete list can be
found in the Plan:
a.     Implementation of specific procedures in response to a variety of disasters.
b.     Defining and integrating the role of the organization with the community
       Emergency Preparedness efforts.
c.     Notifying personnel when emergency response measures are initiated.
d.     Managing patients during emergencies; including scheduling, modification, or discontinuation
       of services, control of patient information, and patient transportation.
e.      Managing space, supplies, and security.
This plan is reviewed yearly and updated as needed based on an HUA – Hazard Vulnerability

Emergency Management includes natural disasters as well as fire, bomb threats, and other internal
situations. Because our goal is the safety of our patients and staff/visitors, emergency preparedness
is high on our priority list.

Knowing your role at the time of a disaster can save lives.
 Stage Alert is used to notify departments that something has happened and we may be
   receiving casualties; departments should be on ‘stand-by’ OR this may be used as a test of the
   callback response process. Internal staff should follow exercise procedures as appropriate.
 Stage One is used by the hospital to mobilize staff within the hospital and initiate appropriate
   department callbacks if instructed by the Command Center. This stage is used when casualties
   are expected from an incident, but the Command Center feels that resources within the hospital
   can handle the situation.
 Stage Two is used by the hospital to notify departments that we will be receiving mass
   casualties from an incident. Departments will initiate callbacks for their staff and bring
   employees on site, at which time they will report to the Personnel Pool.

During all emergency situations, the telephone should be used for urgent communications only. This
will free the telephone lines to be used for the emergency. If the phone rings in your area, answer it!
Walkie-talkies will also be used for communication by designated staff and security. In addition,
walkie-talkies will not be used during bomb threats and should never be used in critical care areas
or within 10 feet of patient care equipment, due to the possibility of equipment malfunction.

Cellular phone use is prohibited within 10 feet of patient equipment. During emergency situations
cell phones may be used with discretion. Spectralink phones are also available for use if they are

Employee Responsibilities
All staff/volunteers are expected to be familiar with their department’s role when participating in
emergency situations. There will be a minimum of two disaster exercises per year. All staff (if on
duty) are expected to participate in accordance with the plan.
The purpose of the exercise is to increase familiarity of the protocols. This will reduce some of the
stress and anxiety of the situation, allowing operations to function with a sense of purpose and
optimal outcome. It will also identify parts of the plan that may be improved.

Refer to Series 400, Code D tab, File 400-1 2, “Emergency Preparedness Plan” for more detailed

Call System
A “call system” has been established to obtain additional staffing during a disaster/mass casualty
incident. Each department manager and employee will maintain a “call roster” of their area.

Fire, Bomb Threat, Emergency Assistance
All employees/volunteers will be expected to be prepared, at all times, to:
       activate and initiate all emergency codes
       report all emergency codes by dialing:
               5111 if onsite.
               911 if offsite.
       not use elevators during a Code Red (fire).
       respond to area of code as appropriately instructed.
       follow directions by administrative/fire/police personnel in charge.

A bomb threat is always treated like a real threat and not an exercise!

Emergency Codes - Dial 5111
Refer to your emergency I.D. badge or phone stickers for a quick reference. Your red Safety Policies
and Emergency Procedures Manual contain the actual policy.

      CODE BLUE                  ADULT Cardiac and/or Respiratory

      CODE 99                    PEDIATRIC Cardiac and/or Respiratory

      CODE RED                   FIRE
      CODE ATLAS                 COMBATIVE PERSON

      CODE A                     ABDUCTION

      CODE B                     BOMB THREAT

      CODE C                     CRIMINAL ATTACK

      CODE D                     DISASTER

      CODE E                     EVACUATION

      CODE H                     HAZARDOUS SPILL

      CODE N                     NUCLEAR CONTAMINATION

      CODE U                     UTILITY FAILURE

      CODE W                     WEATHER RELATED

The Fire Safety Management Plan objectives are to reduce the risk of injury to patients, visitors, and
personnel by promoting a safe, controlled, comfortable environment of care. The following
represents a limited list of important functions. The complete list can be found in the Plan:
       a.     Inspect, test, maintain fire alarm/detection system; quarterly testing required.
       b.     Inspect, test and maintain fire protection and life safety systems, equipment
              &components on a regular basis in accordance w/JCAHO.
       c.     Minimize smoke transmission by controlling designated fans and dampers in air
              handling and smoke-management system.
       d.     Transmit fire alarm to local fire department.
                                    FIRE PLAN
                              R-A-C-E TO SAFETY!

What you do during the first two to three minutes of a fire is more important than what you do over
the next two or three hours. To respond rapidly and effectively, use “R-A-C-E.”

R        Rescue                            Remove from danger.
A        Activate/Alarm                    Pull the alarm and call the emergency number*
                                                        5111 if onsite.
                                                        911 if off-site.
C        Confine/Contain Fire              Close doors and seal area off.
E        Extinguish and/or Evacuate        Use extinguisher on fire or evacuate patients.
        When you see fire or smell smoke, no matter how minor it appears, report it!
        Pull handle on fire alarm box-this automatically notifies the fire department.
        Dial 5111/911 and tell operator the exact location of fire/smoke.
        Under no circumstances should you use the elevators in the event of a fire!

Fire Extinguishers
Look around your work area and know the placement of the fire extinguishers. It is important to
locate these now as you are doing this module. Once you know the location of fire extinguishers,
using them is as easy as “P-A-S-S.”

P        Pull the pin between the two handles.
A        Aim at the base of the fire.
S        Squeeze handles together.
S        Sweep from side to side.


Fire is fast. When fire breaks out, it may take just minutes to go from a tiny flame to a raging, all-
consuming inferno.

Fire is hot. As frightening as flames are, you may face greater danger from a fire’s intense heat
that can sear lungs and fuse clothing to skin. Also, heat rises.

Smoke can kill. Fire can fill your workplace with thick, black, binding smoke.
Smoke contains toxic gases that can kill within minutes. This is especially hazardous to vulnerable
patients. Smoke rises to the ceiling, forming a dense cloud that slowly descends. Below it you can
still see and breathe.

O Locate the extinguisher(s) in your area and know how to use it.
O Apply extinguishing agent even after the fire is extinguished.
O Never leave an extinguished fire unattended.
O Stay until the fire department arrives.

If the fire department/administrative personnel determine that evacuation is required, “Code E” will
be paged over the hospital intercom.
Move people horizontally. Get patients out of their rooms, through the next set of fire doors and into
a safe area on the same floor (next smoke compartment).
Never use elevators to evacuate.
Be prepared to transport patients. Use wheelchairs if available, and stretchers if needed. Patients
may be left in bed to transport only when necessary.
Learn a variety of rescue techniques.


General Safety Guidelines
Don’t get tripped up by a slip or fall. Pay attention to where you are going and how you are going to
get there.
      Walk–don’t run!
      Wear shoes with non – skid soles.
      Watch out for, avoid, clean up, and/or report wet, slippery floors.
      Change directions slowly, especially if you are carrying something.
      Don’t leave drawers open.
      Report any loose floorboards, tiles or carpets.
      Don’t carry things in a way that blocks your vision.

Electrical Safety Guidelines
** Use common sense around electricity! Electrical Safety is everyone’s responsibility.
      Don’t place cords near heat or water
      Don’t touch anything electric with wet hands
      Make sure electrical equipment is properly guarded/grounded, usually with a 3 prong plug.
      Check patient care equipment for inspection stickers.
      Don’t pull out any cord from the wall outlet by the cord itself.
      Keep cords out of walking paths that might cause someone to trip.
      Electrical cords that are frayed should be removed from service and tagged as defective.
      Notify engineering whenever power cords are frayed.

Body Mechanics and Posture
FACT: 8 out of 10 people have back problems according to the National Institute for Occupational
Safety and Health (NIOSH), 2002.

Most back disorders are the result of...........
     Poor posture
     Faulty body mechanics
     Awkward postures are used, such as twisting, when lifting or handling patients
     Stressful living habits
     Loss of flexibility
     General decline of physical fitness
With few exceptions, back problems are the result of months, even years of stress to the spine.
These factors accumulate throughout one’s lifetime at both work and home activities.
One of the keys to having a healthy back is maintaining the curves of your spine in a balanced
position. If one of the curves is either flattened or excessive (too much curve), the balance and
mobility of the spine may be altered and stress is placed on the back.
If at any time you feel you require specialized inservice (education) on lifting techniques, please
contact Physical Therapy.
Three methods to prevent back injury are:
      - keep the load as close to your center of gravity as possible (your waist).
      - manipulate your environment so you can use proper body mechanics.
      - perform pre-shift and pre-lifting stretches.

For further information contact the Employee Health Office at Forest Campus -
Ext. 289-4507 or Occupational Health at the Parham Campus – 747-5627.

Following are tips in practicing good Body Mechanics.
             Plan the lift in your head
             Check your environment/path
             Test the load – get help if needed
             Spread feet for wide base of support
             Bend at knees and hips
             Move and keep the load close to your body
             Keep back and neck in line
             Tighten abdominal muscles
             NEVER twist or pivot with feet or try to lift while in an awkward posture/position
             Use your legs
             When two or more persons are involved in the lift, one should be the leader to count
              and initiate the lifting process and provide direction
2.      SITTING
      Reduce unnecessary strain with proper ergonomics:
             Proper adjustment of the chair is related to the proper placement of the monitor,
              keyboard, mouse, and work surface
             Set seat height so feet are flat on floor and knees level with hips
             Sit close to your desk
             Use a lumbar roll (or rolled up towel) for support
             Computer monitor at eye level (or just below)
             Hand/elbow height relative to keyboard (same level)
             Vertical book stand for data entry
             Stand up to stretch at frequent intervals (at least once per hour)
          When possible, raise or lower work station to relax neck and shoulders.
          Rest one foot on a low box or stool to reduce strain to low back.
          Intermittently switch feet.
          When convenient, stretch at frequent intervals.
           Proper rest is important.
           Firm mattress to support the three natural curves of the spine.
           Sleeping on back – use 1-2 pillows under knees and one pillow under head/neck.
            Side sleeping: one pillow between legs and one in front of body to hug.
            For patients who find it difficult to stand, can get off of the bed more easily if it is
             raised a few inches.

If we practice some of these simple tips in back care, we may be able reduce the risk of injury. In
turn, this can reduce the cost of workman’s compensation claims and improve our overall health and
performance whether at work or at home. Each new employee should have viewed a “Backsafe”
video during his or her orientation. They should also have received a handbook with “Backsafe”
information and instructions on pre-shift stretching. If you have not received these, please contact
the Employee Health Office at Forest Campus - 289-4507 or Occupational Health at the Parham
Campus – 747-5627.

The Equipment Management Plan objectives are to reduce the risk of injury to patients, visitors, and
personnel. Important functions include:
      a.      Processes for selecting and acquiring medical equipment.
      b.      Written criteria for identifying, evaluating, and taking inventory of
              medical equipment to be included in the program before equipment is used.
      c.     Developing emergency procedures that address: steps to follow in event of equipment
             failure; interventions to implement when equipment fails; availability of backup
             equipment; how to obtain repair services.

Biomedical Equipment
Biomedical equipment is defined as any equipment that is directly involved in patient care and is
monitored through the Biomedical Equipment plan.
You will note that each piece of equipment has a small Preventative Maintenance (PM) label with
inspection dates on it. This equipment has been checked upon entry into the hospital and must be
re-inspected at certain time intervals (determined by either regulations or manufacturer’s
recommendation and risk scoring), and repaired as needed by the Biomedical Department.

An identification tag is placed on the equipment.

If equipment fails to work properly:
1. Take it out of service immediately.
3. Affix an orange “Defective – DO NOT USE” sticker ON the equipment.
     CLEARLY STATE on the sticker how the equipment is malfunctioning. Also list your department
     and phone extension.
4. Submit a biomedical work order through Meditech; complete the information
     requested on the work order (department name, your name, phone # and description of the
     problem); then attach the work order to the equipment.
5. If the equipment is portable – clean it and take it to the Biomedical Department.
6. If the equipment has come through Central Sterile (such as IV pumps), tag it for Biomedical as
     previously described and send it to Central Sterile for cleaning. Central Sterile will then send
     the equipment to Biomedical.
7. For emergencies – between the hours of 7am-4pm call the Biomedical
     Department at Forest Campus - 289-4558 or at the Parham Campus – 747-5798. After hours,
    call the hospital operator (0).

Biomedical Equipment
Failures/user errors/preventative maintenance are reported monthly to the Environment of Care
Committee. This ensures that equipment is being checked, repaired, and used properly by staff.

If a piece of medical equipment causes a patient illness/injury, remember to follow the
“Medical Devices-Incident Reporting and Investigation Policy 600-3” in the Safety and
Emergency Procedures Manual.

Radio Frequency Interference - Cellular phone use is discouraged inside the facility. Cell phones
are not to be used within 10 feet of patient care equipment. Cell phones are restricted in the
following areas:
             a. OR (Forest/Parham)
             b. PACU (Forest/Parham)
             c. L&D C-Section OR (Forest)
             d. Cardiac Cath Labs (Forest/Parham)
             e. NICU (Forest)
             f. PCN (Forest)
             g. Newborn Nursery (Forest)
             h. Post Partum (at unit entrance/exit doors)
             i. NVICU (Forest)
             j. SICU(Forest)
             k. CSICU (Forest)
             l. CCU (Forest/Parham)
             m. PCU (Parham)

Safe Medical Devices Act (SMDA)
Congress passed the Safe Medical Devices Act (SMDA) in 1990. The intent of this law is to track
medical devices and report incidents that may result in patient illness/injury or death.

Federal law requires that these incidents be reported to the Food and Drug Administration (FDA),
using a MedWatch report. Each employee has an obligation to report these incidents. This
responsibility also includes physicians and allied health contract staff.

What should be reported? An Occurrence Report is to be completed if a medical device contributes
to or was thought to contribute to a serious illness/injury that is life threatening or requires surgery or
medical treatment.

Which equipment is included?
     Any and all medical equipment, which may include, but is not limited to: IV pumps, monitors,
     defibrillator, beds, syringes, dressings, and catheters. If lab results are inaccurate due to
     equipment malfunction-that in turn contributes to patient illness, this becomes a reportable
     occurrence under SMDA.

What do you do in event of an injury?
      Take care of the patient first. Notify physician and immediate Manager.
      Remove equipment and secure it. (So that it will not be used again.) Risk Management
        must be contacted to obtain the equipment for sequestering.
      Save any materials that are connected with the equipment (e.g. box, tubes) for Risk
      Do not change any settings on machine.
      Complete a Patient Notification (Occurrence Report) in Meditech.

What happens to equipment?
     Equipment and all accessories shall be secured in Risk Management, or Engineering, or
     BioMed. Do not allow equipment to leave the hospital without the permission of Risk

The Utilities Management Plan objectives are to reduce the risk of injury to patients, visitors, and
personnel by promoting a safe, controlled, comfortable environment of care. The following
represents a limited list of important functions, the complete list can be found in the Plan:
      a.       The Process for assessing utility failures and minimizing risks that affect operational
               reliability of utility systems.
      b.       Written criteria for identifying, evaluating, and taking inventory of critical operating
               components of systems that are included in the program.
      c.       The Process for developing, and maintaining current utility system operational plans to
               promote reliability, minimize risks, and reduce failures.
      d.       Emergency procedures for utility system disruptions or failures.

 All equipment is assigned an equipment maintenance number that is used to track purchase date
     and repair history. Monthly reports on utility maintenance, failures, and repairs are given to the
     Environment of Care Committee.

   If you are in a patient care area, know the location of your medical gas shut off valves and what
      rooms they affect. Know who is authorized to turn off the oxygen in your area in the event of an
      emergency. A nursing supervisor or head nurse is responsible for turning off the oxygen to the

Part of the Utility Plan includes our electrical source. Remember that the red receptacles are
connected to emergency power. Life support equipment should be plugged into these at all times.

Infection Prevention and Control programs exist in health care facilities for the protection of patients,
staff, and visitors. Every department has infection control responsibilities from basic hand hygiene to
specific policies and procedures unique for particular departments or work areas. This section will
address some of these responsibilities plus things you can do to make the performance of your job

Infection Control activities are influenced by multiple agencies including the Joint Commission on
Accreditation of Health care Organizations (JCAHO), the Occupational Safety and Health
Administration (OSHA), the Centers for Disease Control and Prevention (CDC), the Centers for
Medicare and Medicaid Services (CMS), and Virginia laws related to hospital licensure, environmental quality,
and regulation of medical waste. Excerpts from these agencies will be discussed.

Infection Control Manuals are located in every department, on each nursing unit and on the Hospital
Intranet. You should become familiar with the location of these manuals and review information in
the sections of General Policies, Isolation, Employee Health, OSHA, Departmental Guidelines, and
facility specific policies.

The OSHA Bloodborne Pathogens (BBP) Standard and the CDC TB prevention guidelines require
education on hire and annually. Information is included here that summarizes key provisions of
these publications. OSHA also requires a written plan of action related to each standard. The
Exposure Control Plan (for Bloodborne diseases) and the TB Control Plan (for tuberculosis) are
located in the OSHA section of the Infection Control Manual.

A. Bloodborne Pathogens Standard
The Bloodborne Pathogens Standard (BBPS) is an OSHA law passed to promote protection of
employees from Bloodborne diseases such as hepatitis B (HBV), hepatitis C, syphilis, and Human
Immunodeficiency Virus (HIV). The three most significant are HBV, HCV, and HIV. You are covered
by the BBPS if it is reasonably anticipated that you could be exposed to Bloodborne pathogens as a
result of performing your job duties.

Hepatitis B infection is an inflammation of the liver. It is the number one infectious Bloodborne
hazard you face on the job. Hepatitis B can survive dried on hard surfaces for at least one week.
Infection with hepatitis B can either cause no symptoms or one may have flu-like symptoms that
could be severe enough to require hospitalization. Long-term effects of hepatitis B infection, includes
other severe liver diseases. Once infected with hepatitis B, a person’s blood, and other body fluids
may be infectious. Infection may also be spread to sexual partners, family members, and unborn
infants. Because of the risk of exposure to hepatitis B, a vaccine is offered to all employees to
prevent contracting the disease.

Hepatitis C virus causes liver disease. Hepatitis C is the most common liver disease in the United
States and is a leading reason for liver transplant. Between 50 and 80 % of individuals positive for
hepatitis C will develop a chronic infection. Of these persons, about 50% will eventually develop
cirrhosis or cancer of the liver. 1.8% of blood exposures to patients with Hepatitis C is known to
cause infection. There is no vaccine available to prevent the disease.

Human Immunodeficiency Virus (HIV) attacks the body’s immune system and can cause the
disease known as Acquired Immune Deficiency Syndrome (AIDS). There is no vaccine to prevent
this infection. HIV is transmitted through sexual contact or contact with blood or some body fluids.
HIV is not transmitted by touching, feeding, or working around patients who carry the disease.
HIV could affect the unborn infant.
HBV and HIV and other Bloodborne pathogens may be present in:
    Body fluids such as saliva, semen, vaginal secretions, cerebrospinal fluid, synovial fluid,
     pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, and any other body fluids visibly
     contaminated with blood
    Saliva and blood contacted during dental procedures
    Unfixed tissue or organs
    Cell or tissue cultures
Bloodborne pathogens could enter your body and infect you:
    By accidental injury by a sharp (needle, scalpel, broken glass, etc.) contaminated with
     infectious material
    Through open cuts, nicks and skin abrasions, and the mucous membranes of your mouth,
     eyes, or nose
    By touching contaminated objects/surfaces, then touching your mouth, eyes, nose or open
The Exposure Control Plan identifies employees covered by the standard,
outlines specific measures for you to take in order to minimize risk of exposure, and gives
procedures to follow if an exposure does occur.
Standard (formerly Universal) Precautions require the health care worker to treat all human blood
and body fluids as if they were known to be infected with HIV, HBV, or other Bloodborne pathogens.
By using Standard Precautions, you are protecting yourself from Bloodborne diseases of all patients,
even if the patient is undiagnosed.

Reducing Risk of Exposure to Bloodborne Pathogens
You can reduce your risk of exposure to blood borne pathogens on the job by using:

ENGINEERING CONTROLS are physical or mechanical systems your employer provides to
eliminate hazards at their source. Engineering controls depend on YOU utilizing the system
Examples: Self-sheathing needles and sharps containers.
WORK PRACTICE CONTROLS are procedures you must follow on the job to reduce your exposure
to Bloodborne pathogens.
Prevention of Needle Sticks:
    Do NOT bend, hand-recap, or break contaminated needles or other sharps;
    If a contaminated needle must be recapped, use a mechanical device or a one-handed
    Contaminated sharps must be placed in an appropriate puncture-resistant leak-proof
     container immediately after use;
    Report any sharps containers that are mounted too high or are not easily accessible.

Hand Hygiene (see detailed Hand Hygiene Policy (# 105) in Infection Control Manual):
    Sanitize with alcohol-based hand rub or wash your hands every time you remove your gloves.
    Sanitize with alcohol-based hand rub or wash your hands before and after patient contact.
    Wash your skin as soon as possible after coming in contact with blood/body fluids.
    Flush mucous membranes with water as soon as possible after coming into contact with
     blood/body fluids.
    Artificial nails are not permitted for those having patient contact or working in food service.
    Finger nails should be 1/4 inch or less and be kept clean.

Personal Hygiene:
    Do not eat, drink, smoke, apply cosmetics or lip balms, or handle contact lenses where you
     may be exposed to blood and/or body fluids.
    Do not use petroleum-based lubricants as hand creams.
    Do not mouth pipette.
    Do not store food and drinks in any area where blood and/or body fluids may be present.

PERSONAL PROTECTIVE EQUIPMENT is any equipment that protects you from contact with blood
and/or body fluids. These items may include gloves, masks, gowns, aprons, lab coats, face shields,
protective eyewear, mouthpieces, and resuscitation bags. Personal protective equipment must not
allow blood and or body fluids to come into contact with your skin or mucous membranes. The type
of personal protective equipment you wear depends upon the task you are completing and the
amount of exposure you anticipate. (The use of personal protective equipment is a Work Practice

            You must be trained to use the equipment properly.
            The personal protective equipment must be appropriate for the task.
            You must use appropriate personal protective equipment each time you perform a task.
            The equipment must be free of flaws that could compromise safety.

If the personal protective equipment is penetrated by blood and/or body fluids while wearing it,
remove it as soon as is feasible. Remove all personal protective equipment when leaving the work

The exception to using PERSONAL PROTECTIVE EQUIPMENT is as follows:
Only if you believe that using personal protective equipment would prevent proper delivery of health
care or jeopardize your safety or a coworker’s safety. After this incident, your employer must
investigate the circumstances to determine if such a situation could be prevented.

Gloves are the most widely used form of personal protective equipment.
            You must wear gloves when anticipating hand contact with blood and/or body fluids. If
             allergic to latex/vinyl gloves or powder, use nitrile gloves.
            Bandage any cuts before applying gloves.
            If gloves are contaminated, torn, punctured, or damaged, replace as soon as possible.
            Sanitize with alcohol based hand rub or wash your hands after removing gloves.


Utility gloves may be decontaminated and reused if there is no damage to them.

The proper steps for glove removal are:
1.    With both hands gloved, peel one glove off from top to bottom and hold it in the gloved hand.
2.    With the exposed hand, peel the second glove from the inside, tucking the first glove inside
      the second.
3.    Dispose of the entire bundle promptly.
4.    Wash hands thoroughly.

GOOD HOUSEKEEPING: Good housekeeping is everyone’s responsibility!
      Clean all equipment and working surfaces as soon as possible after contact with blood and/or
       body fluids.
      Do not pick up broken glass with bare hands. Use forceps or a brush and a dustpan.
      Place contaminated sharps in designated sharps containers.
      Do not allow containers to over-fill.
      Handle contaminated laundry as little as possible and with minimal agitation.
IMMUNIZATION: If you may be exposed to HBV on the job, the HBV vaccination is offered at no
cost to you through Employee Health. The vaccine is administered by three injections over a six-
month period.

B. Tuberculosis (TB) Standard
The TB Standard is guided by CDC, however, the general duty clause gives OSHA the authority to
inspect and levy fines based on standards in progress. Tuberculosis is a respiratory infection that
can be contagious if there is prolonged exposure in small areas of inadequate ventilation. There is
concern today about strains of TB that are resistant to usual drugs of treatment. See the TB
Exposure Control Plan in the Infection Control Manual.
Tuberculosis (TB) is a disease that is spread from person to person through the air. TB usually
affects the lungs but can affect other parts of the body, such as the brain, kidneys, or the spine.
TB germs get into the air when someone who has TB sneezes, coughs, speaks, laughs or sings.
The most common way to get TB germs is by spending a lot of time indoors (sharing same confined
air space) with someone who has TB disease.
General symptoms of TB may include a feeling of weakness, weight loss, fever, and/or night sweats.
Symptoms of TB of the lungs may include cough, chest pain, and/or coughing up blood. Other
symptoms depend on the particular part of the body that is affected.
Anyone can get TB, but some people are at a higher risk. Including:
    people who share the same breathing space (crowded living conditions)
    homeless people
    people from countries that have a lot of TB
    nursing home residents
    alcoholics and IV drug users
    people with certain medical conditions (diabetes/cancer) and
    persons with HIV infection (virus that causes AIDS).

People with TB infection (without disease) have the germ that causes TB in their body (usually have
a positive TB skin test). They are not sick because the germ lies inactive in their body. They cannot
spread the germ to others. Medicine is often prescribed for these people to prevent them from
developing TB disease.

People with TB disease are sick from germs that are active in their body. They usually have one or
more symptoms of TB. These people are often capable of giving the infection to others. Medicines
which can cure TB are prescribed for these people.

A skin test (PPD) can help show if there are TB germs in your body. A small needle is used to put
some testing material, called tuberculin, just under the skin on the inside of your arm. (Skin should
not be scratched where test was applied.) This skin test is done before you start to work and at least
annually thereafter. Certain high-risk areas are tested more frequently.

TB test results:
Negative or Not Significant - This means that you probably do not have TB germs in your body.
Positive or Significant - This means that you have TB infection - TB germs got into your body at
some time. A positive test result does not show that you have TB disease or that you can infect
others. Skin tests should be read by people knowledgeable in accurately measuring them.

All personnel with newly recognized positive PPD tests or PPD test conversions will be promptly
evaluated for TB disease with a chest x-ray and clinical evaluation. Based on the clinical judgment
of the evaluation, the employee may require further follow-up such as medication.
Employees with pulmonary or laryngeal TB shall be excluded from work until they are no longer
If you are exposed to a person who has suspected/confirmed TB your name will be included on a
contact list. If the person has TB disease, you will be contacted by Employee Health to have follow-
up PPD skin testing.
There are options for severely immunocompromised employees to voluntarily transfer to areas and
activities in which there is the lowest risk of exposure to TB. This is a personal decision for the
employee after being informed of the risk by the Employee Health Department and evaluating their
own job commitment and satisfaction. Reasonable attempts shall be made to offer alternative job
assignments to an employee with a documented immunocompromised state who works in a high risk
setting for TB.

The infection control practices that must be instituted for a patient with suspected/confirmed
TB are:
     patient must be placed in a special (negative pressure) isolation room;
     the door must remain closed at all times;
     an Airborne Precautions sign should be displayed on the door to the room;
     all persons entering the patient’s room must wear an approved respirator;
     the patient must wear a surgical mask over their nose and mouth at all times when out of their
     instruct the patient to cover their mouth and/or nose with a tissue when coughing or sneezing
      (be sure to keep adequate supply tissues available).
     during period Airborne Precautions are in effect, Engineering will check for negative pressure
      in the room daily.

C. Regulated Medical Waste (Reference: Infection Control Manual policy #403)
Regulated medical waste is waste capable of producing an infectious disease. In order to produce
an infectious disease the following factors must be present:
      presence of a pathogen of sufficient virulence
      dose (sufficient number of organisms)
      portal of entry (a way for organisms to get into host)
      resistance of host (host with decreased resistance/susceptible to infection)
Richmond area HCA facilities have designated the following as regulated medical waste:
      all cultures and stock of microorganism and biologicals;
      all pathological waste (human tissue, organs, body parts, or body fluids);
      human blood and blood products (serum and plasma);
      needles, syringes with needles, scalpel blades, Pasteur pipettes, and other sharps;
      blood tubes and other items containing blood or body fluids;
      dressings, sponges or other disposable items visibly contaminated with free flowing or caked
       on blood or body fluids;
      any residues of spill clean up from regulated medical waste (includes waste solidified with
Detailed laminated lists of specific RMW items are posted in each soiled utility area.
All regulated medical waste should be contained in red plastic bags or bins bearing the biohazard
symbol. Virginia law mandates that red-bagged medical waste closure be leakproof. Be familiar
with your hospitals specific policy and procedure for compliance with this regulation.

All free flowing liquids should be contained in leak-resistant plastic containers. Commercial products
such as Isolyzer, Primasorb, etc. may be used to solidify these liquids.

All sharps should be placed into designated sharps containers red in color or bearing the biohazard
symbol. When the container is 3/4 full, the lid should be securely closed and placed into a red bin
labeled reusable sharps only that is properly closed. Reusable sharps boxes cannot be placed in
Schaefer carts.

Transportation of Waste
1.     The Environmental Services personnel should not pick up regulated medical waste that is not
       packaged according to this policy.
2.     Person transporting regulated medical waste should wear heavy neoprene gloves (or
       equivalent) and other items of personal protective equipment (i.e. rubber puncture resistant
3.      Regulated medical waste should be transported to the storage area by Environmental
      Services personnel in the re-usable cart supplied by the contracted pickup vendor.
      Transportation of regulated medical waste is scheduled by the Environmental Services
      Department. The vendor is responsible for cleaning carts.

Spill Containment and Cleanup (Reference: Infection Control Manual policy #403.2)
Spill containment kits are located in areas where large amounts of regulated medical waste are
accumulated to provide for rapid and efficient clean up of spills within the area. Vehicles transporting
regulated medical waste are required to carry a spill containment clean-up kit in the vehicle
whenever regulated medical waste is conveyed.

1.    Units should clean up small spills by:
     a. Utilizing personal protective equipment;
     b. If no sharp objects are involved, blotting the area with a paper towel;
     c. Applying hospital approved disinfectant to the affected surface for appropriate contact time
         (usually ten [10] minutes);
     d. Wipe off the surface
     e. Disposal of clean-up items into regulated medical waste receptacle.
2.   Clean up of spills of less than thirty-two (32) gallons or one (1) quart of spilled free flowing
     a. An employee discovering the above spill should notify the Environmental Services
         supervisor for clean up. After hours, the nursing supervisor should be notified and
         designate a person to clean up the spill.
     b. The employee discovering the spill should post someone at the spill site until personnel
          arrive to clean up the spill.
     c. The following clean up procedure should be followed:
         1) notify the environmental services supervisor;
        2) place a sign around the spill;
        3) put on appropriate personal protective equipment (PPE);
        4) if no sharp objects are involved, blot the spill with a paper towel or sprinkle a solidifying
           agent on the spill;
        5) a dust pan and broom should be used to avoid unnecessary contact with spills;
        6) For infectious waste spills on carpets, spray a hospital-approved disinfectant directly on
           the spill and allow the recommended contact time (usually [10] minutes). Extract and
           rinse (3) times then implement the Bonnet system to remove any residue. Place the
           bonnet in a plastic bag and return to Environmental Services for disinfecting and
        7) For infectious waste spill on a tile floor, spray a hospital-approved disinfectant directly
           on the spill and allow the recommended contact time (usually [10] minutes). Saturate
           the area with the disinfectant. Use mop head to scrub the area and place the mop
           head in a plastic bag; return to Environmental Services for disinfecting & laundering;
        8) clean equipment with the hospital approved disinfectant;

        9) Place used gloves in red bags. Wash hands with antiseptic soap.

3.   Clean up of spills of thirty-two (32) gallons or more (thirty-two [32] gallons is equivalent to one
     [1] large red bag) or greater than one (1) quart of spilled free flowing liquid.
     a. The employee discovering the above spill should report the spill as a "Code H" (see also
        Emergency procedures), and notify the Environmental Services supervisor. After hours,
        the employee should notify the Nursing Supervisor, who should designate a person to
        clean up the spill.

     b. The employee discovering the spill should post someone at the spill site until personnel
        arrive to clean up the spill.

      c. An Employee Notification should be completed by the Director of Environmental Services
         and/or designee and should include documentation of the following:
          1) Location of the spill (room number, etc.)
          2) Identification and type of regulated medical waste
          3) Cause of spill, and amount spilled
          4) Method of cleanup
          5) Protective equipment worn
          6) Name of person(s) performing cleanup
          7) Name of person completing the report
          8) Name and signature of the Department Manger.

      d. The following is required for cleanup of a spill of the above quantity and is housed in an
         appropriate cart in the Environmental Services Department:
             1)      Absorbent material designated to pick up spill of at least ten (10) gallons;
             2)       One (1) gallon of hospital approved germicide in a sprayer capable of dispersing
                      in a mist and in a stream at a distance;
             3)       Red plastic bags that meet the ASTM 125 pound drop test to enclose the
                      regulated medical waste housed on a unit;
             4)       Two (2) sets of liquid impermeable and disposable coveralls;
             5)       Gloves made of heavy neoprene or equivalent;
             6)       Rubber boots;
             7)       Surgical masks and caps
             9)       First aid kit;
             10)       Fire extinguisher;
             11)      Flashlight;
             12)      Boundary marking tape;
             13)     Small rigid container for broken containers and/or spillage contents.
4.     Following a spill of regulated medical waste the following procedure
      should be implemented:
             the "Clean-up Team" should put on the personal protective equipment (PPE) as
              described above;
             if broken containers are involved, disinfect them with a hospital approved disinfectant
              and place container and spillage in the designated rigid container;
             clean and disinfect non-disposable items with a hospital approved disinfectant;
             after completion of clean up, discard disposable personal protective equipment (PPE)
              into a red bag;
             with a hospital-approved disinfectant, disinfect boots and gloves before removal;
             replenish containment equipment and clean-up kit with items used.

 *** Should you have any questions related to Infection Control, please contact your supervisor or the Infection Control
                           Professional, Marsha Kemp on the Forest Campus - 289-4690
             or Bonita Allen at the Parham Campus – 747-5740,or check in the Infection Control Manua

                                              IT&S Security Access Form (Non Corporate)

    Henrico Doctors’ Hospital                                                                               Date of Birth (DOB) and Social Security Number (SS#) are not necessarily required
                                                                                                            to grant access, depending on the system. Look below to see if DOB and/or SS# is
    1602 Skipwith Road/7700 E. Parham Road                                                                  required for the system for which you are requesting access.
    Telephone (804) 289-4500

Section 1: To be completed for all Security Access Requests:
Applicant Last Name X             Applicant First Name X                                                     MI or "NA" X            Date of birth (MM/DD/YYYY) (see below)

Work Address                                                                                                                         City, State, Zip code

Work Phone Number
                                                                  Work Fax Number (required for GHX/MediBuy)                         Social Security Number (SS#) (see below)

User Type oHCA          o Contractor     oVendor                  Company Name and Phone (required for Contractor or Vendor)                                           E xp Dat e for
                                                                                                                                                                       Contractor or Vendor

Expiration date must be supplied for “Contractors” and “Vendors”. The expiration date should be the end of the contract or engagement period.
Facility ID (CO-ID)                  Facility/Company Name                                                                           Facility Type (Hospital, Division, Etc.)
                   34634                           Henrico Doctors’ Hospital                                                                    Hospital
Department #/Primary Cost Centers               Department Name                                             Job Title                                                   Universal ID/3-4 ID
                                                                                                            Student Nurse
Section 2: To be completed for Meditech Security Access Requests only:                                                              Meditech (Clinical Patient Care System-CPCS)

Facilities6HDH             oOther                                                                                                                Effective Date:
                                                                  Action            oNew oChange oInactivate
Cost Center Number/Name:                                            Access to Confidential Patient             Check if other than an HCA Employee:
                                                                    oData           o Information              oAgency Nurse oContract Employee oVendor oTemporary Employee
oRestrict by Nursing Dept/Location                                                                             Expiration Date (req’d for non-HCA Employees):
Copy User’s Menu and Access same as UserID:                                             Copy User First and Last Name:
(User must already have CPCS access)

Special Instructions and/or Custom Menus:

Section 3: To be completed for all Security Access Requests:
I acknowledge and agree to adhere to the rules and regulations stated herein, and in Company Policies and Procedures.All information I will have access to is confidential and should be
treated as such. I am responsible for all entries and inquires using my individual Access Code. A breach of this Confidentiality Agfreement is grounds for disciplinary action that can result in
termination. I also understand that willful disclosure of my, or any other user’s password, misuse of my password, or of another’s password will be considered grounds for termination from the
Companty or cacellation of Agreements in the case of Physicians, consultants, contract employees or any other vendors.
Applicant (Employee/Physician/Consultant/Vendor) Signature:                            E- Ma il Addr es
                                                                                                                                                Date: x

                                              By signing this request I am stating that I have reviewed the above information for completeness and it is accurate
Authorizing Security                          to the best of my knowledge. Also I have reviewed the Information Security Agreement and verified that it has been
Coordinator Statement                         completely filled out and signed. Also that I verify this request and authorize its processing. 2 signatures required.
Managers Signature    x (instructror)                                                Managers Printed Name    x                                Date   x

Security Coordinator Signature                                                       Security Coordinators Printed Name                        Phone Number of HDIS / LSC
                                                                                                     Daniel L. Patton                                          804-289-4881

o    o Applicant has Information Confidentiality & Security Agreement on file Action: o New o
                                     Change o Delete Effective Date: ____________________________ X
                                     Access Granted By HDIS/LSC
              o Collections (neither reqd)   o SMART (neither reqd)               o G HX/MediBuy (neither reqd)
              o HOST/PY/HR/GL (SS#reqd)      o PLUS (SS#reqd)                     o iKronos (SS#reqd)
              o NT (DOB&SS#reqd)             o Remote Access/SecurID (SS#reqd)    o Misc. Application
              o   Outlook (DOB&SS#reqd)      o ViewDirect/Document (Reports) (DOB&SS#req)
            NOTE: Systems sharing the same logon (3-4 ID): HOST, NT, Outlook, PLUS, iKronos & Meditech

•   Patient Assessment:
       – A patient will be considered HIGH RISK for falls when they are
           RESPONSIVE and have one or more of the identified risk elements listed
              • Confused at times
              • Fall history (last three months)
              • Impulsive behavior
              • Lethargic/Sedated

       –   A patient will also be HIGH RISK if the patient is NOT following fall
           prevention directions AND has one or more Addition Risk Elements:
              • Cane/Walker/Crutch
              • Dizzy/positive orthostasis
              • Incontinent
              • Decreased muscle coordination
              • Tethered device
              • Unsteady gait
              • Urgency/frequency

•   Global Fall Interventions are part of the standard of care for every patient in the
    hospital. These interventions include:
       • Evaluating sleep habits and toileting routines
       • Education of patients and families
       • Observation (hourly rounds, family presence, open door, 4 Ps – pain,
           potty, positioning, personal items)
       • Environment of Care (call bell within reach, lighting, room free of clutter,
           bed low/locked)

•   Generic Interventions are part of the standard of care for all patients identified as
    high risk of falling. These are in addition to the Global Interventions:
       – Alert (sign on door, yellow arm band)
       – Non-slip footwear
       – Assist in mobility
       – Assist in ADLs
       – Assist to toilet
       – Move poles to exit side of bed, secure tubes and cords when ambulating

•   Specific Interventions are specific for the high risk element identified for the
    patient and are designed to specifically address the identified element. These
    interventions are in addition to the Global and Generic Interventions:
        – Confused at times – bed alarm, diversional activities
        – Impulsive behavior – bed alarm
        – Lethargic/Sedated – bed alarm
        – Cane/Walker/Crutches – bed alarm
        – Dizzy/Orthostasis – assist; minimize effects of orthostatic hypotension;
           consult PT
        – Incontinent – bed alarm
        – Decreased muscle coordination – consult PT
        – Unsteady gait – consult PT
        – Urgency/frequency – bed alarm

We have reduced the risk of patient
harm resulting from falls with the
help of our FEAT program.

  • F all
  • E limination
  • A ction
  • T eam
Together we can keep our patients


 What is eMAR? ..................“Electronic Medication
 Administration Record”

 It assures the 5 rights of medication administration.
    Right Patient
    Right Medication
    Right Time
    Right Dose
    Right Route

If you will be administering medications you will receive additional
training on the eMAR System.

Whole blood glucose testing at the point-of-care is used to monitor glucose concentrations for adjustments to
treatments, not for definitive diagnostic purposes. Please refer to the written procedure, available on all patient units.
for this test.

The test system and supplies consist of:

       Accu-Chek Inform " meter, battery operated by rechargeable batteries
       Accu-Chek " Base unit for docking the meter and recharging the batteries
                 TM                 ,
       AccuChek Comfort Curve® test strips (with corresponding Code Chip)
       Accu-Chek " Comfort Curve® Quality Control Solutions, Level I and II
                   T           r
       Accu-Chek " Safe-T-Pro " Lancets
      Alcohol Squares
      Cotton Balls or Gauze squares
      Gloves

Supplies are ordered by the floors and obtained from Materials Management. Meters are assigned to the units.
Loaner meters are available in the laboratory in the event a floor meter is broken or malfunctioning. The laboratory
repairs or replaces broken meters for the floors.

      The test strips are good to the stated expiration on the bottle provided the vial is kept tightly capped, except
       when removing test strips.

     The quality control solutions are good for 90 days after opening. They should be dated with the open date.

 Quality Control:

Quality control must be performed every 24 hours that patient tests are performed. Every 24 hours a Level 1 (low)
and Level II (high) control test must be performed prior to testing patient samples. This process helps to insure the
test strips used for patient care are viable and will provide accurate patient test results. 24 hours after the last quality
control tests are performed, the Inform " meter will disallow patient tests to be performed until the appropriate
controls have been tested again.

The test result from each level of the quality control must fall within a specified range to be satisfactory. The ranges are
programmed into the meter. In the event a quality control test result is out-of-range, the meter will advise you and prompt
you to enter a comment code for any corrective action.

 If a quality control test is out-of-range, rerun the test. Most of the time that will solve the problem. If the quality
control result is still out-of-range, obtain new strips and or quality control solution and perform the test again Verify
the lot numbers you are using are the lot numbers programmed into the meter If the quality control tests are out-of-
range after testing with new quality control solution and new test strips, take the meter to the laboratory for servicing
and obtain a loaner.

Test Strips:

The Comfort Curve® test strips are "touch" strips. A very small "V" notch on the side in the curved portion of the strip
is the area that will accept blood or quality control solution into the strip. Avoiding "wiping" the strip on the patient's
finger tip; merely touch the strip to the finger to obtain the specimen. Likewise, blood from a syringe or quality control
solution can be gently squeezed into the "V" notch for dosing. Once dosed, the yellow area on the strip should be
completely covered with blood or quality control solution. If any yellow is still showing after sample application, you
have 15 seconds to add more to obtain an accurate result. Insufficient sample can cause a false low result.

Code Chip:

A code chip imprinted with the test strip lot number comes with every new vial of test strips. Get in the habit of
replacing the code chip every time you open a new vial of strips, even if the lot number does not change. Code chips
wear out and this can be avoided by replacing it with each new bottle.

On/Off/Reset Button:

If the meter does not turn on with the purple button on the front, it may need to be reset Turn the meter over and
insert the tip of a paperclip into the hole on the bottom right to press against a recessed button. The meter should
"reset" and be ready for use in a few seconds. If not, take it to the laboratory for troubleshooting


Capillary, venous, arterial, neonatal (including cord blood) whole blood may be used for testing on the Accu-Chek "
 system. The test requires 9 ul of blood for satisfactory dosing, however, only 4 ul of blood is used in the strip to
 determine the glucose concentration.

Normal Glucose Ranges and Critical Values:

Newborn Intensive Care Unit (NICU)                                  Newborn Nursery
         Normal            35– 125 mg/dl                                   Normal               40– 110 mg/di
         Critical        <34 or> 150 mg/dI                                 Critical             <39 or >400 mg/dl

All Other Patients:
         Normal                          70 -110 mg/dl
         Critical                        <50 or> 400 mg/di

The above ranges are programmed into the meter. The meter will advise you if the test result is "out of the normal
range" or "a critical value". Most of your patient tests will be "out of the normal range", but not critical. If a test
is critical, you will be required to enter a comment code depicting the action taken.
O erator ID and Ongoing Certification:

An operator ID is required for any test performed, quality control or patient, for the record. Your operator ID is
your social security number. Never give out your ID for others to use. Your certification will be programmed into
the glucose system upon completion of the glucose test training done on your assigned unit. You will not be able
to perform glucose tests if the training is incomplete. As part of the continuing glucose test competence
assessment, you will need to perform, at minimum, a satisfactory level I and Level II quality control test each year.

Patient ID

The patient ID is the account number (AR number). This can be entered manually or by scanning the patient's
Comments ap ended to test results:

 Critical values and quality control results out-of-range require a comment to be entered. The meter will prompt you
through the preprogrammed choices. For other tests, a comment is optional. Up to 3 comments may be
appended to a test result. You may also customize a comment by typing in remarks you want attached to the test
result for your patient.

Fingerstick, Heel stick, and Lancet:

Adhere to standard precautions and guidelines for disposal of sharps. Follow protocols for finger and heel
sticks. The lancets are one-use devices. Clean the area with alcohol and allow to air dry to avoid any dilutional
effect from the alcohol on the skin. Place the lancet gently on the skin and fire. Do not push until the skin blanches
before firing the lancet. Wipe away the first drop with a little abrasion to cause a second drop to form. The first
drop is full of tissue factors, the second is a purer drop of blood for your test result.


Clean the meter with the alcohol squares and allow to air dry. NEVER SPRAY THE METER WITH
DISINFECTANT. The meter is a palm-pilot technology computer and excess moisture will damage it. You can
spray a cloth with disinfectant and wipe the meter down.


The meter should be docked at least every night to transmit test data and recharge the batteries. It can be kept in
the dock anytime when not in use, or in a case with other supplies closer to patient's rooms. The battery is not
replaced by unit staff. When the meter is turned on for use, a battery icon will depict the amount of power
remaining. A warning note will appear on the meter screen if the battery is getting low. If the meter has not been
docked in 24
hours, a warning note will remind the user to dock it. If the meter has not been docked in 72 hours, the user will be
locked out from using it until it is placed on the docking station and data transmission occurs. When the meter is
docked, watch for a bright green light on the base to illuminate indicating the connection of the base and meter are

            JCAHO Standard for
            Pain Assessment

When Pain is identified, the patient is assessed and treated by the
hospital or referred for assessment and treatment.
   A comprehensive pain assessment is conducted as appropriate to
     the patient's condition and the scope of care, treatment and services
   Elements of a Comprehensive Pain Assessment
         Pain intensity – use a pain intensity rating scale
         Location – where is the pain located?
         Quality- including patterns of radiation
         Onset, duration and variation
         Alleviating and aggravating factors
         Pain management history
         Effects of pain – impact on sleep appetite concentration etc.
         The individual's pain goal
         Physical examination/observation of the pain site
    Frequency of Assessment
          Assess pain as a 5th vital sign as often as you do your physical
             assessment and...
          Before Surgery
          After Surgery
          After a Procedure
          Each time pain is reported

                                                 54Level   II HIPAA Privacy Training

     Located next to Westport Convalescent Center on
   Forest Ave. between Skipwith Road and Glenside Drive

There are two phones with direct links to the hospital in mounted black
metal boxes near the front and rear entrances. Please fill the lot starting
from the Forest Ave. entrance/exit and progress toward the rear. Between
6am and 10am buses remain in the off-site lot between runs to provide faster
service to the hospital. If you need to go to the off-site lot during those hours
call extension 4501 to request a bus to the shuttle entrance.
Please do not park in the front of the Hospital or
in front of MOB III office building. There is ample
parking beside and behind the hospital. To reach
the designated parking enter via the second
entrance off Parham Rd next to the MOB II office
building. You can enter the hospital via the cafeteria
or loading dock.

                                           56Level   II HIPAA Privacy Training
                        PATIENT PRIVACY AND
At the completion of this study packet, the participant will:
   Have a basic understanding of HIPAA Privacy Standards
   Be able to provide examples of patient privacy protection
   Be able to define Protected Health Information (PHI)
   Have a basic understanding of the role of the Facility Privacy Official (FPO)
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act of 1996 deals with patient privacy,
security, and other requirements that includes punishment for anyone caught violating this law.
Prior to HIPAA, our healthcare Code of Ethics included patient privacy. The HIPAA privacy
regulations go into effect April of 2003, but that doesn't mean that we should wait until then
because patient privacy is of utmost importance to everyone!
This federal law has both civil and criminal penalties. Criminal penalties can be up to $250,000
and/or up to 10 years in prison.

Privacy and Confidentiality
All patients within our hospital have a Right to Privacy. With the new HIPAA regulations
regarding patient privacy, confidentiality is being taken a step further. Regardless of your role in
the healthcare setting, all employees must receive training about the obligations we have
regarding privacy of health information. It is important to understand confidentiality and
Privacy and confidentiality means that patients have the right to expect that their protected health
information remains private and limited to those with the need to know. The information should
remain private whether spoken aloud, written or saved on a computer.

Protected Health Information (PHI)
PHI includes, but is not limited to:
   > Name
   > Address
   > Why the patient is being treated
   > Medications
   > Notes written about the patient
   > Past health conditions
   > Account number
   > Unit/medical record number
   > Social security number
   > Photographs
   > Birth date

All duplicate papers/forms that display patient information must be shredded. All original
papers/forms must be returned to the HIM department.

                                                                  57Level   II HIPAA Privacy Training
Protecting Patient Privacy
Much of this is common sense! Knock on doors, pull the curtains when talking to a patient, and
don't talk about patients in public areas (elevators, cafeteria). If visitors ask about a patient,
direct them to the patient information desk. The patient information desk will have access to
information contained in the hospital directory. This information includes the patient name,
location, and condition in general terms. This information is available to anyone who asks for
the patient by name, unless the patient chooses to restrict that information.

Even the trash! Patient information should be disposed of in proper containers not in the regular
trashcan. If you suspect a violation notify your supervisor and/or the Facility Privacy Officer

Facility Privacy Official (FPO)
Each facility is required to have an FPO. This person not only is responsible for making sure
that the rules and regulations are followed but also responsible for facility wide training and
development, and enforcement of policies and procedures. Our FPO is Lou Canulli. He can be
reached at 289-4687 or through pager number 759-0998.

Patient Complaints/Concerns/Grievances
The patient has the right to voice complaints without compromising care concerning Quality of
Care, Customer Service, Timeliness of Service or Privacy. Concerns should always be taken
seriously and addressed as soon as possible. Privacy questions and concerns should be directed
to your supervisor or the FPO. Information obtained from concerns/complaints/grievances is a
vital part of the facility’s efforts to improve patient care and enhance customer satisfaction. It is
our policy of this Hospital to promote quality care and patient satisfaction by analyzing
concerns/complaint/grievances from patients, family members or other responsible parties
involved with patient care.

Breaches in Confidentiality
Breaches in confidentiality may occur in many situations. Help protect confidential medical
information by paying close attention to what you say or read, why you say or read the
information, and where you say or read the information. The most common ways patient
confidentiality is violated are:
       1. Discussion of patient information in public places, or with inappropriate or
           unauthorized individuals.
       2. Print or electronic patient information that is left exposed where visitors or
           unauthorized individuals can view it.
       3. Records that are accessed without the need to know in order to perform their job
       4. Unauthorized persons hearing patient-sensitive information.

Need to Know
A very important question you need to ask yourself is "Do I need to know this type of
information in order to do my job?" If the answer is NO, stop what you are doing! Access only
what you need to know.

                                                                   58Level   II HIPAA Privacy Training
Patient Privacy Protection:
All information is confidential in any format, paper, oral and electronic communication. Each
user is given appropriate access to the Clinical Patient Care System (CPCS) also known as
Meditech, according to their job duties. Each staff member with access to CPCS is responsible for
maintaining compliance with appropriate access and Privacy Policy Procedures.

Appropriate Access:
Appropriate access to clinical information is defined as providing a CPCS user timely access to
patient-specific information, which is necessary to perform his/her professional responsibilities.
Access will be granted for an individual to provide and/or support quality patient care processes,
as defined by an individual’s professional responsibilities to the patient and the facility.
Employees will collect, dispose, process, view, maintain and store patients’ clinical and financial
information in an honest, ethical and confidential manner. It is every employee’s responsibility
to maintain patient confidentiality. Again, you need to ask yourself is "Do I need to know this
type of information in order to do my job?" If the answer is NO, then it is not appropriate to
view the information.

Appropriate Access Policies prohibit employees from accessing their own records in CPCS.
Employees may, however, fill out the appropriate authorization in HIM and obtain a copy of
their records. Everyone is responsible for following the Release of Information policy and

If a patient or family member would like access to the medical record during their hospital stay,
notify the attending physician and then consult with HIMS Director. The HIMS Director or
designee will verify which forms/authorization will need to be completed and ensure verification
of requestor (see Release of Information Policy and Procedure in MOX library).

Notice of Privacy Practice:
All patients will receive a copy of the Notice of Privacy Practices upon registration. They will
be required to initial a section in the Conditions of Admission to indicate receipt of the brochure.
Our Notice of Privacy states we may use or disclosure patient health information for treatment,
payment and healthcare operations. Patients have specific health information rights, which

      Right to Access
      Right to Amend
      Right to an Accounting of Disclosure
      Right to Opt out of the Directory
      Right to Request Restrictions
      Right to Request Confidential Communications
      Right to Obtain our Notice of Privacy Practices

                                                                 59Level   II HIPAA Privacy Training
Right To Access
A patient has the right to access/copy their health information. The patient/requestor must
complete/sign an authorization before information can be copied/accessed. This information is
contained in the Release of Information policy. Before records are released the requestor must
be verified. The patient’s physician can deny access to the patient if in his/her opinion, the
furnishings to or review by the patient of such records would be injurious to the patient or well
At this time we do not allow access online via Meditech. The Health Information Management
Services department handles requests for release of information. There is a fee for copying
medical records. Virginia State law requires us to process written requests for release of
information within 15 days.

Right To Amend
A patient has the right to request an amendment to their health information in the designated
record set (DSR). This might include the addition of information, or an explanation of
information already contained in the DSR. The right to amend does not permit deletions or
removal of information from the DSR. Requests to amend should be forwarded to HIMS
department for processing. The request must be in writing from the patient/responsible party.
We must respond to the patient request within 60 days. We can deny the request for amendment
if it meets specific requirements.

Right to an Accounting of Disclosures (AOD)
A patient has the right to an accounting of disclosures for protected health information made by a
hospital except for disclosures to carry out payment, treatment, and healthcare operation or
pursuant to an authorization. The hospital has 60 days to comply with the written request for
accounting of disclosures by the patient. The first accounting of disclosures is free of charge
within a 12-month period. The hospital must keep documentation of AOD for 6 years. The
compliance date for AOD is April 14, 2003. Facility Privacy Official, Lou Canulli, must be
advised of patient requests for AOD. Appropriate staff will require additional training for
documenting disclosures. Several examples of AOD are reporting of births, deaths, congenital
anomalies, cancer registries, or communicable disease, etc.

Right to Opt Out of the (Hospital) Directory
When a patient is admitted to the hospital s/he will be notified via the Notice of Privacy Practices
that we include certain limited information about them in the hospital directory. The information
may include their name, location in the hospital, general condition (e.g., fair, stable, etc.) and
religious affiliation. This information may be provided to members of the clergy and, except for
religious affiliation, to other people who may ask for them by name.

If a patient wishes not to be listed in the hospital directory s/he may opt out by completing the
Directory Opt Out Form. The Directory Opt Out Form will notify the patient by invoking this
patient right that phone inquiries and visitors will be told I have no information about this
patient, and that no deliveries will be forwarded to the patient including cards or flowers. The
patient is then placed in “Confidential Status” in Meditech In the event that a patient chooses to
opt out of the directory after registration a Directory Opt Out Form must be completed and a
copy forwarded to Patient Registration for action. Patients who Opt Out of the Directory will
appear in Meditech as Confidential patients.

                                                                 60Level   II HIPAA Privacy Training
Right to Request Restrictions
A patient can request a restriction o the uses their PHI. These requests must be in writing and
forwarded immediately to the Facility Privacy Officer for review. Only the FPO or his designee
may review and act on a request for restriction.

Right to Request Confidential Communications
A patient has the right to request Confidential Communications by alternative means or to
alternative locations. Requests for Confidential Communications must be accommodated by the
hospital if reasonable. Confidential Communications pertains to all future correspondence and
communications related to the specific visit(s) stated in the request.

Verify Requestor
It is every employee’s responsibility to verify the identity of any person or entity outside the
facility that is unknown to the employee and who is requesting protected health information
(PHI) either in person, verbally or via written request. Each patient will be notified at
registration that the hospital will use a password to verify that the individual calling is authorized
to receive information beyond that which is available in the directory. The password will be the
last four digits of the patient’s Account Number. This number is readily available to the patient
and all clinicians. Family/friends requesting updates on a current patient must give the patients
last four digits of the Account number. It is the patient’s responsibility to give this information
to family/friends.

The exceptions to the verification requirement are:
      Release of information from the hospital directory to visitors requesting the patient by
         name (the patient has opted in our facility directory).
      Release for disaster relief purposes; and
      Release for purposes of care and notification purposes, which may include:
             a. Use or disclosure of protected health information to notify a family member, a
                  personal representative of the individual, or another person responsible for the
                  care of the individual, of the individual's location, general condition, or death;
             b. In the event of an emergency or the patient’s incapacity, professional
                  judgment should determine whether the disclosure is in the best interests of
                  the patient’s and, if so, disclose only the protected health information that is
                  directly relevant to the person's involvement with the patient's health care
                  without verification of the requestor.

Approved methods of identity verification are any one of the following three options:
         1. Valid State/Federal Issue Photo ID (i.e.: passport, driver license, etc)
         2. Requestor is able to provide a minimum of three information items from the
             “acceptable identifiers” list. The information can be provided in written or
             verbal fashion.
                   Patient Social Security (required) and
                   Patient Date of Birth (required) and
                  Any one of the following: Account Number, Street Address, Insurance
                  Carrie, Insurance Policy Number, Medical Record Number, Birth
                  Certificate, Insurance Card

                                                                   61Level   II HIPAA Privacy Training
3. Positive match of signature to a signature on file e.g., request received from patient via
   fax or mail and signature is compared to patient signature on conditions of admission.

Unacceptable forms of identification for requestor verification are:
                     Employment ID
                     Student ID
                     Membership ID Cards
                     Generic Billing Statements (utility bills)
                     SSI Card
                     Credit Cards (photo or non-photo)

In the event that there are insufficient acceptable identifiers available for verification of
requestor, individuals releasing the PHI should use their professional judgement to determine
whether or not to permit the release. The HIMS department can be contacted for assistance. The
actions taken and the reasons for that action should be documented.

                                                                   62Level   II HIPAA Privacy Training
Henrico Doctors’ Hospital

Name:                                          School:
            (sign)                                                     (print)


1) Who is our Facility Privacy Official?
     A. Thomas Frist
     B. Bill Caldwell
     C. Lou Canulli
     D. Ron Buchanan
2) Protected health information includes all of the following except:
       A. Patient financial information
       B. Clinical information
       C. User ID
       D. Patient birth date

3) Who is responsible for protecting patient's individually identifiable health information?
     A. CEO
     B. ECO
     C. FPO
     D. Everyone

4) It would be appropriate to release patient information to:
       A. The patient's (non-attending) physician brother
       B. The transferring hospital's personnel checking on the patient
       C. The respiratory therapy personnel doing an ordered procedure
       D. A retired physician who is a friend of the family

5) What is the standard for accessing patient information?
     A. A need to know for the performance of your job
     B. If a physician asks you the diagnosis of the patient
     C. Just because you are curious
     D. You are a relative of the patient

6) The acronym for HIPAA stands for:
      A. Health Information Protection and Accountability Act
      B. Health Insurance Portability and Accountability Act
      C. Health Information Publication and Accumulation Act
      D. How I Protect Patient Access

7) It is appropriate to place a yellow "post it" note with a patient's medical record number
   written on it in the trashcan.
         A. True
         B. False

8) It is inappropriate for family/patient/employee to view/access their own medical record
  online via Meditech.
        A. True
        B. False

9) Employees are given access to Meditech according to their professional responsibilities.
     A. True
     B. False

10) The patient has the right to voice complaints without compromising care concerning:
     A. Quality of Care
     B. Customer Service
     C. Timeliness of Service
     D. Privacy
     E. All of the above

11) It is against hospital policy for a patient to read their medical record.
       A. True
       B. False

12) It is your professional responsibility to maintain the security of the chart, even while
  transporting the patient from one location to another.
       A. True
       B. False

13) How do you find a patient location for a visitor?
      A. Contact the information desk
      B. LookupinPCI
      C. Call the nursing unit
      D. Call Patient Access

14) Confidential Information must not be shared with another unless the recipient has:
     A. An OK from a doctor
     B. The need to know
     C. Permission from Human Resources
     D. All of the above

15) A visitor who asks for a patient by name may receive the following information except:
     A. Patient name
     B. Patient condition in general terms (e.g. stable, critical, etc.)
     C. Patient location
     D. Patient diagnosis
16) How long must the hospital keep accounting of disclosures?
      A. 1 year
      B. 6 years
      C. 6 months
      D. 10 years

17) What is the time frame for responding to a patient request for accounting of disclosure?
     A. 7 days
     B. 25 days
     C. 30 days
     D. 60 days

18) An Accounting of Disclosures must include all releases of information for the patient.
      A. True
      B. False

19) The patient’s right to amend their Protected Health Information (PHI) includes:
      A. Patient’s right to add PHI in the designated record set
      B. Patient’s right to delete PHI from the designated record set
      C. Patient’s right to remove PHI from designated record set
      D. None of the above

20) The facility has a right to deny a request to amend their PHI.
      A. True
      B. False

21) The facility must act on a written request to amend no later than:
      A. 24 hours
      B. 15 days
      C. 60 days
      D. Within 7 business days

22) The hospital directory may contain all the following information except:
      A. Patient name
      B. Patient condition in general terms (e.g. stable, critical, etc)
      C. Patient location
      D. Patient Social Security number

23) If a patient invokes their right to opt out of the hospital directory they will be able to receive
   cards and flowers.
        A. True
        B. False

24) If a patient has opted out of the Hospital Directory, it is okay to tell a family member the
   patient’s room number or location as long as you can verify that the person inquiring is a
   family member.
25) Patients do have a right to request a copy of their health information.

         A. True
         B. False

26) There is no fee to copy health information
       A. True
       B. False

27) An acceptable ID to verify a requestor for PHI when the patient is no longer in-house is:
      A. Valid drivers license
      B. Credit Card
      C. Membership ID card
      D. Ukrops Card

28) In order to release information about a patient in the hospital to a family member we must
   verify the requestor has authorization to receive the information by asking for the password
   which is:
       A. Date of Birth
       B. Last four digits of the Account Number
       C. Street address of the patient
       D. AphotoID

29) Request for privacy restrictions of a medical record must be made in writing to the:
       A. Facility Privacy Official (FPO)
       B. Ethics and Compliance Officer (ECO)
       C. Director of Health Information Management (HIM)
       D. Attending Physician

30) A Notice of Privacy Practices must be given only to those patients who ask for it
      A. True
      B. False

                  True               False
Revised 11/2007                                                                                   66
                            Student Education Review Test
Please circle the best answer then return your test to your instructor.
1.        Three ways of serving that help us put ‘patients first’ are:
        A. Work, patience, time
        B. Hearts, hands, minds
        C. Caring, sharing, giving
        D. People, place, equipment

2.       Identify which statement below is false:
        A. “Values” determine how we will achieve our mission.
        B. Our core values include honesty, fairness, and respect.
        C. Integrity is one of our “cornerstone” values
        D. The way to keep our values alive is to constantly talk about them.

3.       It is acceptable to wear sandals and other comfortable shoes without hosiery or socks
         when working in the hospital.
                 True                   False

4.      Which of the following is acceptable for employees / students who work in patient care?
        A. Canvas shoes
        B. Tattoos
        C. Artificial nails
        D. Jewelry piercing other than in the ears
        E. Neatly trimmed beards, moustaches, and sideburns

5.       Patients have the right to considerate and respectful care, to participate in decisions about
         care, privacy and confidentiality.
                True                     False

6.       Who is responsible for information security?
         A. Administration
         B. IT&S
         C. Everyone
         D. Noneoftheabove

7.       Practicing good information security helps ensure confidentiality.
                True                   False

8.       In case of an emergency it is OK to give someone your User ID and Password to access
         the computer system.
                True                    False

9.       Computer viruses can cause an interruption of service to our patients.
              True                    False

10.      It is not necessary to ‘log off’ and shut down your PC before leaving the clinical area
         each day.

Revised 11/2007                                                                                          67
11.       Each person is responsible to:
         A. Use only systems you are authorized to use.
         B. View only the information you need to do your job
         C. Share confidential information only with people that need the information to perform
              their job.
         D. Lock sensitive and confidential information in a cabinet, drawer, or other place when
             not in use.
         E. All of the above

12.       One thing you should not do if you are practicing good security measures is:
         A. Use only your own User ID and Password
         B. Keep your password in an easily accessible place near your computer
         C. Create a hard to guess password and never share it.
         D. Activate your password protected screensaver with a timeout from 5 minutes (public
             area) to 20 minutes (private office)
           E. Call you Local Security Coordinator (LSC)—Dan Patton, or the Security Help Desk
             for suspected breaches of Security.

13.       Which of the following is an important aspect of Patient Safety:
         A. Fall Prevention
         B. Accurate Documentation
         C. Effective Leadership
         D. Proper Nutrition and Menu Selection
         E. Performance Improvement
         F. All of the above

14.      Communication, Collaboration, Education, and Accountability are part of creating a
         positive, pervasive environment of safety.
                 True                 False

15.     Completion of Notifications (Occurrence) Reports is everyone’s responsibility.
              True                    False

16.      When completing the Notification (Occurrence) Report in Meditech, the description of
         the event should include:
         A. What the patient had for lunch
         B. Why the patient is in the hospital
         C. The facts of the occurrence
         D. How the occurrence could have been avoided

17.      Personal belongings should be:
         A. Left in work area but hidden under a desk or counter
         B. Left in break area
         C. Locked in locker or desk drawer
         D. Not worried about. The hospital will reimburse the employee.

18.        If you notice someone you don’t know in your department, you should:

                  True                  False
Revised 11/2007                                                                                 68
         A.   Ask “May I help you” and if not at ease with their response, call for Security.
         B.   Ask for an ID badge if you think they are an employee or vendor.
         C.   Make a note of description, color of clothing, estimated height/weight.
         D.   All of the above

Revised 11/2007                                                                                 69
19.       On an MSDS you will find all of the following EXCEPT:
         A. Manufacturer
         B. Disposal information
         C. Exposure information
         D. How to make the chemical

20.     General Safety Guidelines are in place to decrease your risk of injury, such as falling and
        they include:
         A. Wearing non-skid soled shoes
         B. Walking, not running
         C. Cleaning up and/or reporting wet slippery floors
         D. Reporting loose tiles, torn carpet
        E. All of the above

21.     What is the phone number that staff / students should call if there is a fire or other life-
        threatening emergency in the clinical area?
         A. Dial5111
         B. Dial911
        C. Dial 0 for operator

22.      What does RACE stand for?
         A. Run Around Calling Emergency
         B. Radius of Area Covered by Extinguishers
         C. Rescue, Alarm, Contain, Extinguish
         D. React, Announce, Cover, Evacuate

23.      Electrical safety is the responsibility of the Engineering Department only.
                True                     False

24.      For equipment that has a frayed electrical cord, you should:
         A. Tape with adhesive tape
         B. Remove equipment from service and tag as defective
         C. Continue to use, but call Engineering/Plant Ops
         D. Nothing as ground fault outlet will protect user and Maintenance will repair during
             next Preventative Maintenance Inspection.

25.     Patient life support equipment is to be plugged into emergency power at all times. What
color receptacle/outlet would you use?
        A. Orange
        B. White
       C. Red

26.     Increased potential for employee / student injury exists if awkward postures are used,

                  True                    False
Revised 11/2007                                                                                        70
        such as twisting, when lifting or handling patients.

Revised 11/2007                                                71
27.  Patients who find it difficult to stand can get off the bed more easily if it is raised a few
True                                   False

28.    When lifting,
       A. Position yourself as close to the load as possible
       B. Assume a wide base of support with legs shoulder width apart, one foot slightly
          ahead of the other
       C. Keep your stomach muscles firm
       D. All of the above

29.     When prolonged standing is required
       A. Use a foot support/elevated surface to relieve the demand on your legs and back
       B. Stand with your legs in a locked position
       C. Anti fatigue mats and/or soft-soled shoes do NOT help

30.       When staying motivated by exercising and reducing stress:
       A. The mind will be more alert when performing job tasks
       B. IT helps to have more energy
       C. It helps you to relax
       D. It prom ot es a pos i t i ve at t i t ude and
       l i ft s m oral e E. All of the above

31     Sharps containers should be closed and locked when they are 3/4 full.
             True                   False

32.    Standard precautions protect you from:
       A. HIV diagnosed patients only
       B. Hepatitis B diagnosed patients only
       C. All patients – with diagnosed or undiagnosed communicable/contagious diseases
       D. None of the above

33.     In healthcare – Bloodborne infection could enter your body through:
       A. Casual contact
       B. Eyes, nose, throat, non-intact skin
       C. Unknown
       D. All of the above

34.     My resources for infection control related questions are:
       A. The Infection Control Manual
       B. Meditech Library
       C. My supervisor / clinical instructor
       D. The infection control nurse
       E. All of the above

35.     Regulated medical waste goes into:
       A. Regular trash bags
       B. Red trash bags with the biohazard symbol

36.   Hepatitis B (HBV) dies as soon as it leaves the body and comes into contact with the air.
             True                  False

37.   Where should you look for policies on regulated medical waste?
      A. Infection Control Manual
      B. MSDS Manual
      C. Safety & Emergency Procedure Manual
      D. Any of the above

38.   When entering the room of a patient on Airborne Precautions for known or suspected TB,
      which is necessary?
      A. A mask that loops over your ears
      B. An N95 respirator in size specifically fitted to you
      C. Hold a tissue over you nose and mouth

39.   Which of the following items would be considered Regulated Medical Waste (RMW)
      according to hospital policy?
       A. Paper cups, newspapers, food waste
       B. Soiled dressings
       C. Empty Biohazard Bags
       D. Foley, leg, and/or urostomy bags (if not empty)
      E. B,C,andD

40.    Symptoms of TB are:
      A. Weight loss and fatigue
      B. Coughing or hemoptsis (coughing up blood)
      C. Temperature and night sweats
      D. All of the above

41.     Patients who must be isolated for known or suspected TB,
      A. Should be housed in an intensive care unit
      B. May be in a semiprivate room
      C. Require a private room with negative pressure ventilation

42.    Patients with HIV, Hepatitis B or Hepatitis C infection require:
      A. Airborne precautions
      B. Contact precautions
      C. Standard precautions

43.    TB is spread from
      A. Drinking after a person who has TB
      B. Person to person through the air
      C. Walking by a patient’s room who has TB

44.    When properly closed, sharps containers should be:
      A. Placed in a red bag, tied securely and labeled before being placed in the Regulated
           Medical Waste container
      B. Closed securely and placed directly into a Regulated Medical Waste container
      C. Placed on the floor or counter in the Dirty Utility Room

45.       Hand washing is required
         A. Before and after patient contact
         B. Upon removal of gloves
         C. BothAandB

46.       To avoid needle sticks
         A. Always recap
         B. Do not recap
         C. Remove needle from syringe

47.       HIV and Hepatitis B are the only Bloodborne threats you face.
                True                   False

48.       When an emergency code is called, students should report to their clinical instructor for
                 True                 False

49. Match the following emergency codes with the correct definition:

Code              Blue                               a. Abduction

Code              99                                 b. Bomb Threat

Code              Red                                c. Adult Cardiac Arrest

Code              Atlas                              d. Criminal Attack

Code              A                                  e. Pediatric Cardiac Arrest

Code              B                                  f. Fire

Code              C                                  g. Nuclear contamination

Code              D                                  h. Evacuation

Code              E                                  i. Combative Person

Code              H                                  j. Disaster

Code              N                                  k. Utility Failure

Code              U                                  l. Weather Related

Code              W                                  m. Hazardous Spill

Revised 11/2007                                                                                       74
                                           EXHIBIT A


For and in consideration of the benefit provided the undersigned in the form of
experience in a clinical setting at: Henrico Doctors' Hospital (Hospital), the
undersigned and his/her heirs, successors and/or assigns do hereby covenant and
agree to assume all risks and be solely responsible for any injury or loss sustained by
the undersigned while participating in the Program operated by:

 _______________________________________________________ (School) at
Hospital unless such injury or loss arises solely out of Hospital's gross negligence or
willful misconduct.

Signature of Program Participant/Print Name            Date

Signature of Parent or Legal Guardian                  Date
(If Program Participant is under 18 years old)

Revised 11/2007                                                                           75
                                                        EXHIBIT B

                  Protected Health Information (PHIL includes patient information based on examination, test
                   results, diagnoses, response to treatment, observation. or conversation with the patient. This
                   information is protected and the patient has a right to the confidentiality of his or her patient care
                   information whether this information is in written, electronic, or verbal format. PHI is
                   individually-identifiable information that includes, but is not limited to, patient's name, account
                   number, birthdate, admission and discharge dates, photographs, and health plan beneficiary
                  Medical records, case histories, medical reports, images, raw test results, and medical dictations
                   from healthcare facilities are used for student learning activities. Although patient identification is
                   removed, all healthcare information must be protected and treated as confidential.
                  Students enrolled in school programs or courses and responsible faculty are given access to patient
                   information. Students are exposed to PHI during their clinical rotations in healthcare facilities.
                  Students and responsible faculty may be issued computer identifications (IDs) and passwords to access
         Initial each to accept the Policy
              Initial                                                               Policy
                         1   It is the policy of the school/institution to keep PHI confidential and secure.
                            Any or all PHI, regardless of medium (paper, verbal, electronic, image or any other), is not to be
                            disclosed or discussed with anyone outside those supervising, sponsoring or directly related to the
                            learning activity.
                        3 .Whether at the school or at a clinical site, students are not to discuss PHI, in general or in detail, in
                            public areas under any circumstances, including hallways, cafeterias, elevators, or any other area
                            where unauthorized people or those who do not have a need-to-know may overhear.
                            Unauthorized removal of any part of original medical records is prohibited. Students and faculty
                           may not release or display copies of PHI. Case presentation material will be used in accordance
                           with healthcare facility policies.
                            Students and faculty shall not access data on patients for whom they have no responsibilities or a
                           "need-to-know" the content of PHI concerning those patients.
                        6 A computer ID and password are assigned to individual students and faculty. Students and faculty
                           are responsible and accountable for all work done under the associated access.
                        7. Computer IDs or passwords may not be disclosed to anyone. Students and faculty are prohibited
                            from attempting to learn or use another person's computer ID or password.
                        8. Students and faculty agree to follow Hospital's privacy policies.
                        9. Breach of patient confidentiality by disregarding the policies governing PHI is grounds for dismissal
                           from the Hospital.

              I agree to abide by the above policies and other policies at the clinical site. 1 further agree to keep PHI
              I understand that failure to comply with these policies will result in disciplinary actions.
              I understand that Federal and State laws govern the confidentiality and security of PHI and that
               unauthorized disclosure of PHI is a violation of law and may result in civil and criminal

Signature of Program Participant/Print Name                                             Date

Signature of Parent or Legal Guardian                                                  Date
(If Program Participant is under 18 years old)

Revised 11/2007                                                                                                              71

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