Hill Country Memorial Volunteer Handbook

WELCOME!

This is your HCM VOLUNTEER HANDBOOK

Hill Country Memorial Volunteer Services 1020 South Highway 16, P.O. Box 835 Fredericksburg, TX 78624 830-997-4353 www.hillcountrymemorial.org

Updated January 2016 Hill Country Memorial Volunteer Handbook

INTRODUCTION Vision, Mission and Value Statements HCM Hospital and Volunteer History HCM Operating Elements AIDET

ABOUT BEING AN HCM VOLUNTEER Volunteer Services Orientation Ethics Standards of Behavior Benefits and Recognition for Volunteers Service Holidays Some Common Hospital Abbreviations and Meanings

VOLUNTEER PROCEDURES HIPAA Criminal Background Check Drug and Alcohol Use Equal Opportunity

EMERGENCY MANAGEMENT AND SECURITY Hazardous Materials Handling Infection Control Medical Staff Relationship On-site Weapons Sexual and Racial Harassment Tuberculosis Testing Flu Shots Transporting Wheelchair Patients Workplace Violence Emergency Operations Plan Disaster Preparedness Security at HCM Facilities

JOINT COMMISSION REQUIREMENT

JOB DESCRIPTION INTRODUCTION

Hill Country Memorial Vision Empower Others, Create Healthy.

Hill Country Memorial Mission Remarkable Always.

Hill Country Memorial Values Others First – commit to remarkable care with each life we touch Compassion – care for others with a kind heart Innovation – integrate new ideas with courage Accountability – responsibility for our actions Stewardship – uphold our responsibility for lives and resources

A Brief History of Hill Country Memorial Hospital, the HCM Auxiliary and Volunteer Services

Hill Country Memorial Hospital (HCM) is a not-for-profit organization noted for excellence in 24-hour emergency care, medical/surgical services, diagnostic capabilities, obstetrics and rehabilitation. All these services were established without support from local, state or federal taxes.

HCM is a tribute to the generosity and community spirit of the people of Gillespie and surrounding counties. The hospital opened on February 22, 1971 after four years of planning, organizing and construction. In fact, the Hill Country Memorial Hospital Auxiliary was established four years before the completion of the hospital and raised $6,000 to fund advertisements for the construction of the new hospital. Citizens of the Fredericksburg area contributed the funds to build the hospital. The hospital remains the community’s largest volunteer effort.

Located on a 14-acre site and serving eight counties, Hill Country Memorial has seen much growth from the original 49-bed hospital building. In 1999, a 42,000-square-foot professional building, named Perry-Feller for the founding physicians, opened with 20 medical and dental offices and a retail pharmacy. This building is connected to the hospital via an enclosed all- weather walkway. In 2012, the three volunteer organizations that supported Hill Country Memorial – Hospice Volunteers, Thrift Shop Volunteers and Hospital Auxiliary – joined under one name as the Hill Country Memorial (HCM) Volunteers.

Throughout the years, the Volunteers have been a mainstay within the hospital organization, supporting it with time and monetary gifts. Fundraising is done through various Volunteer- sponsored sales and proceeds from the hospital gift shop, Whimsies. Volunteers work in 20 different departments within the hospital system.

The hospital celebrated 45 years in 2016 as it, with the Volunteers, continues to provide remarkable service to our community.

Hill Country Memorial Operating Elements

Fredericksburg HCM Facilities

Hill Country Memorial Hospital – HCM is dedicated to providing and fulfilling access to the preventative, restorative and palliative health care needs of the eight counties it serves. Personalized, high-quality and cost-effective health care is delivered with compassion, dignity and respect throughout all phases of life.

Home Care Services – Skilled professionals provide quality health care where the patients are most comfortable – in their own homes.

Hospice – Hospice patients receive special end-of-life care in the comfort of familiar surroundings in their homes or in a nursing home.

Hospital Foundation – The Foundation’s purpose is to build relationships between the hospital and the individuals and communities it serves to ensure the financial future of health care in the Texas Hill Country.

Medical Office Buildings – These two on-campus facilities are the Perry-Feller Professional Building and the Eckert-Smith Office Building, each of which provides offices for physicians and other medical specialties.

Rehab Clinic – The fully licensed staff of trained physical therapists, occupational therapists, speech therapists, exercise physiologists and cardiac rehab nurses emphasize a personal and hands-on approach with individualized attention. Wellness Center – This state-of-the-art facility provides a range of health education as well as land and aquatic fitness programs.

Go Clinic – This convenient clinic offers services such as minor emergency care, radiology and bloodwork.

Regional HCM Clinical Facilities

Boerne and Marble Falls Specialty Clinics and the HCM Kerrville Clinic – These regional clinics provide access to a selection of medical specialties and services for local patients.

WIC Program Clinics in Blanco, Boerne, Gillespie, Kendall and Kerr Counties – HCM administers this federal/regional special supplemental nutrition program for women, infants and children (WIC) to safeguard the health of low-income women and children up to age 5.

AIDET® – In the Medical Practice: More Important than Ever Studer Group’s Five Fundamentals of Communication is AIDET, an acronym that stands for Acknowledge, Introduce, Duration, Explanation and Thank You. Those who utilize AIDET consistently find it to be a tremendously valuable tool for organizing patient communication and providing patients with information and caring relationship that they want and need.

The keys to effective patient and customer communication include:  A - Acknowledge Acknowledge the patient by name. Make eye contact, smile and acknowledge everyone in the room (patient and families).  I - Introduce Introduce yourself, your skill set, your professional certification and experience.  D - Duration Give an accurate time expectation for tests and identify/communicate next steps. When this is not possible, give a time in which you will update patient on progress.  E - Explanation Explain step-by-step what will happen, answer questions and leave a way to contact you. Use language a patient can understand.  T - Thank You Thank the patient. You may thank them for choosing your medical practice, and for their communication and cooperation. Thank the family for assistance and being there to support the patient. Why is AIDET important now more than ever? We frequently hear that there is “no time” for AIDET given the increasing complexity of patients, the perceived decrease in the amount of time of an office visit and a variety of other challenges. On the contrary, incorporating AIDET into conversation does not require additional time, rather slight modifications during interactions. If fact, AIDET is proven to save providers time because patients are well informed and better understand their plan of care.

AIDET does not need to be robotic, scripted or time consuming. Include the five components in your encounters, but make it your own. Those who have done so report better relationships with their patients, adherence to recommendations and greater fulfillment with their work. ‒ Written by Richard Rubin, MD, MBA, CPHQ, Studer Group

ABOUT BEING A VOLUNTEER

Volunteering A person must be at least 16 years old to be a volunteer. All adult volunteers apply through the standard volunteer application and may serve as a short- or long-term volunteer. Teens, who complete a separate form, typically volunteer for the summer session, fall session or both.

The Volunteer Services Office presents volunteer orientation each month. The number of new volunteers fluctuates depending upon a number of factors such as the time of year and the start dates for certain programs and/or services.

Volunteer Placement Each applicant must complete an interview and screening process before being accepted into the Volunteer Services Department. It is important to note that not all who apply are accepted. Because of the seriousness of our mission and our responsibility to those who rely upon us for care, we must base our decision to accept volunteer applicants on many factors. Appropriate communication skills, experience and background, knowledge of and interest in the health care environment and custom-orientation are some of the factors that must be kept in mind at all times.

The requirements for admission into the Volunteer Program are:  Completion of a volunteer application  Completion of an interview given by the Volunteer Services Department  Criminal background check for adult volunteers  Volunteer reference check  Tuberculosis and immunization screening  Formal acceptance into the Program  Orientation given by Volunteer Services Department  Departmental training for volunteer assignments

In order to continue their service, Volunteers must comply with the following:  All required continuing volunteer education and competency assessments  Annual volunteer education  Annual flu shot  HCM Policies and Procedures  Standards of behavior  Meeting Volunteer Performance Expectations

Volunteer Services Orientation During the training program, Volunteers are oriented on the following topics:  Safety  Code of Ethics  Confidentiality  Emergency codes, responsibilities and procedures  Infection control  Mission, Values and Vision  Joint Commission  Patient transport safety

Ethics Volunteers are subject to the Code of Ethics as established at Hill Country Memorial Hospital. It is important, therefore  To respect all information as confidential  To be dignified, pleasant and quietly efficient  To follow instructions meticulously and accept supervision graciously  To remember that you represent the hospital while you are in the volunteer uniform, and to act in a manner commanding public respect for yourself and for the hospital  To not take advantage of your association with the hospital to seek free medical advice for yourself and others  To not seek favors for your family or friends  To be loyal to your organization as well as to the hospital

The greatest discretion must be used in mentioning anything pertaining to patients. Avoid criticism of the hospital, its staff or its patients. Criticism should be discussed only with the Volunteer Program Coordinator – not with other hospital staff members or with other Volunteers.

Standards of behavior This is a guide to help provide remarkable service to our HCM patients, guests and hospital staff.

While on HCM duty, you must practice the standards set forth below and encourage your co-volunteers to do the same.

Appearance You must maintain a professional appearance at all times by:  Wearing your name badge appropriately  Maintaining a neat and modest appearance and adhering to the HCM Volunteer dress code  Practicing good personal hygiene  Limiting use of perfume, colognes, aftershave, fragrances, scented lotions and makeup.

Communications You should listen attentively to the needs of all HCM patients, guests, physicians, employees and co-volunteers, understand and respond appropriately.

You must maintain patient confidentiality at all times.

You can maintain good communications by:  Promptly notifying the Volunteer Program Coordinator of any change of address, email or phone number  Bringing any assignment-related issue to the attention of the appropriate person  Responding in a friendly and appropriate manner  Smiling and maintaining eye contact (10/5 Rule: at 10-foot distance, make eye contact; at 5-foot distance say “hello”)  Introducing yourself and your role at HCM  Escorting patients, family members and guests to their destination when required. Make the family part of the patient experience.  Inviting questions and comments when communicating with patients and guests, being sensitive to cultural differences. You should use proper telephone etiquette by  Identifying your duty station and yourself with a pleasant greeting using this script: Duty station, this is Volunteer (your name). How may I help you?  Asking permission to place the calling person on hold, assuring them of a minimal hold time  Giving the caller the extension to which you are transferring them before transferring them  Informing the receiving person of the nature of the call and the caller’s name.

You can practice good communication skills by  Checking and responding to Volunteer emails and calls daily when at your home.  Answering the telephone quickly and following the scripted greeting shown above.  Using a quiet, respectful tone of voice, being aware of your surroundings and of others who may overhear.

Hands-on patient care Regular volunteers never perform any “hands-on” patient care services, regardless of any licensure, certification, etc. they may hold.

Teamwork You should work as an HCM Volunteer team member with pride and take responsibility for your membership.

You can take responsibility as a proud volunteer team member by:  Attending General and Special membership and other meetings.  Adhering to the policies and procedures of HCM and HCM Volunteer Services  Cooperating with the HCM staff  Attending two (2) continuing education classes each calendar year  Representing HCM and Volunteer Services positively by not openly criticizing, complaining or speaking negatively of your co-volunteers or HCM.

Service attitude You should do your best to maintain a positive, caring attitude that demonstrates empathy and concern for others at all times as you practice a service-oriented attitude while striving to provide remarkable service to all with care, compassion and understanding. You can perform your service area responsibilities by  Being amenable to suitable assignments with consideration for personal preferences and requesting clarification when needed  Maintaining a satisfactory standard of work performance  Finding a substitute Volunteer for your assignment if you anticipate an absence  Notifying your Department Manager of any planned absence  Giving a minimum of 100 hours of service per year to maintain an Active Status  Recording your service hours appropriately  Being punctual and behaving in a professional manner.

You should treat colleagues (employees, physicians, volunteers) with a professional attitude by  Being courteous, honest and respectful  Speaking positively about one another  Being a team player – helping when possible  Openly discussing concerns and issues when they arise  Treating all people like you want to be treated.

Hospital telephone usage  Telephones and telephone lines are necessarily a very important working tool within the hospital. Therefore, whenever permission is granted by the HCM department in which you are working, Volunteers may make phone calls using HCM telephones provided they are short in duration.  Personal cell phone use should be limited and take place outside of the building or at least outside of your work area.

Benefits and Recognition for Volunteers

These are the current benefits of volunteering at HCM: Cafeteria food services – Coffee and tea are available in the hospital’s cafeteria without charge to you. Daily specials are also available to you at a discounted price. These benefits are only available when you are identified by wearing your uniform.

Whimsies Gift Shop – Volunteers receive a 20% discount on everything except sale items.

TB test – A TSpot test for tuberculosis is provided free of charge to you during your enrollment process and thereafter as required. Injury treatment – If you are injured while on the job, HCM will provide treatment. If a Volunteer is hurt while serving at HCM, you are covered by the hospital's special supplemental insurance policy. This volunteer coverage is not mandated under State laws, but HCM provides it as a courtesy to our volunteers who donate their time to benefit HCM.

At the time of injury, the Volunteer should proceed to the HCM Emergency Department after informing the Volunteer Services Department of their injury, where an “incident report” will be completed. In this injury case the Volunteer’s own insurance will be the primary carrier for the injury and the HCM insurance will be strictly the supplemental.

Once the Volunteer has submitted their applicable bill(s) to their insurance carrier and the carrier has advised them of their payment, the volunteer should submit their bill(s) to the Volunteer Program Coordinator for submittal to the supplemental carrier. Any charges not covered by the volunteer’s insurance will be covered by HCM.

Annual Appreciation Luncheon – HCM provides an Annual Appreciation Luncheon as a token of its thanks and to recognize service and accomplishments of each of you.

Wellness Center – Membership discount applies to active members of Volunteer Services.

Rehab Clinic – Membership discount applies to active members of Volunteer Services.

Free Uniform – Your first uniform will be provided free of charge.

MVP Award – This award is given to up to five volunteers each year who have gone above and beyond their volunteer commitment for the betterment of the organization.

Service Holidays These are the official HCM service holidays when you are not expected to perform your usual service functions. However, if requirements dictate working on these holidays (or on regular weekend days) you may record double time.

Holiday Date New Year’s Day January 1st (*) Independence Day July 4th (*) Labor Day First Monday in September Thanksgiving Day Fourth Thursday in November Next Day after Thanksgiving Fourth Friday in November Christmas Eve December 24th (**) Christmas Day December 25th (*) (*) If the date falls on a Saturday, then the day before (Friday) is taken off. If the date falls on a Sunday, then the day after (Monday) is taken off. (**) In the case of December 24th (only) falling on Sunday, then the previous Friday is taken off.

Some Common Hospital Abbreviations and Meanings Bed Rest ...... May not be up Bed Rest c BRP ...... May go to bathroom Bio-Med ...... Department that fixes all the medical equipment BRP ...... Bathroom privileges C ...... With C.S. (SPD) ...... Central Supply (Sterile Processing Department) DNR/AND ...... Do Not Resuscitate/Allow Natural Death D.R...... Delivery Room E.R/E.D...... Emergency Room/Emergency Department Environmental Services ...... Housekeeping H2O ...... Water Infusion ...... Location where IV treatments are given I.C.U...... Intensive care unit I&O ...... Intake & Output I.C.U...... Intensive Care Unit I.V...... Intravenously LVN ...... Licensed vocational nurse N.P.O...... Nothing by mouth O2 ...... Oxygen OB ...... Obstetrics OP ...... Outpatient/also referred to as Out Patient Surgery OR ...... Operating room Palliative Care ...... Symptom control for chronic illness Pedi ...... Pediatrics Post-op ...... After surgery Pre-op ...... Before surgery P.R.N...... When required Pt ...... Patient Radiology/Xray/Imaging ...... Different names for the same department Rec. Room (PACU) ...... Recovery room R.N...... Registered nurse S ...... Without S.C.U...... Special Care Unit Stat ...... At once

VOLUNTEER PROCEDURES

HIPAA HCM is governed by and adheres strictly to a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). The hospital’s policy on confidentiality speaks directly to patient privacy; however, consideration must be given to exactly who and what the statement includes.

You are not permitted to disclose any information concerning the following:  Patient condition or diagnosis  Any aspect of patient’s treatment  Patient’s physician name  Other patient care providers  Patient’s billing information

To divulge or seek such information, unless specifically authorized, is cause for immediate dismissal.

Only individuals directly involved with patient care are authorized to discuss patient information. Volunteers must be aware of their surroundings when discussing a patient or any confidential discussions.

Personal information relating to another Volunteer, any patient care provider, physician, therapist or any employee, is confidential and must not be discussed either in or away from the hospital.

Internal and external disclosure of information regarding a patient, a care provider, physician or any hospital employee can result in legal action against the person disclosing the information as well as the hospital or physician.

Breach of these confidentialities will result in immediate dismissal!

Criminal Background Check

In order to screen volunteer candidates to identify those who have engaged in criminal conduct, Hill Country Memorial Volunteer Services has implemented the following procedure:  Application – Each candidate must provide written consent for a criminal background check conducted by the HCM Volunteer Program Office by completing the Consent for Criminal Background History Check and the Volunteer Criminal History Records Check Statement.  Personal interview – Each applicant will undergo an interview with an appropriate HCM staff or HCM Volunteer Services member

Grievance Process Each applicant may review the criminal history transcript but may not have a copy. If the applicant has been disqualified from placement with HCM Volunteer Services based on the criminal information received, and, if on reviewing the information the applicant feels the information is incorrect or is not his/her record, the applicant may request a fingerprint check from the Texas Department of Public Safety as a method of positive identification unless the applicant can prove by other means that he/she is not the person on the criminal information record.

Drug and Alcohol Use Volunteers are prohibited from the unlawful use, possession, transport, promotion or sale of drugs, drug paraphernalia or look-alike (simulated) drugs, or the use of alcoholic beverages at any time when on HCM property or elsewhere while on volunteer duty.

Volunteers may not report to their shift under the influence of any drug, alcoholic beverage, intoxicant or other substance (including legally prescribed drugs and medicines) that may affect their ability to work safely and efficiently.

HCM is a smoke-free facility. Use of cigarettes, cigars, pipes, smokeless tobacco and e- cigarettes is prohibited.

Equal Opportunity The HCM Volunteer Services accepts volunteers on the basis of merit, qualifications and competence. Race, color, national origin, religion, gender or qualified physical or mental handicap shall not influence any aspect of volunteering. Acceptance decisions will be made on the basis of individual qualifications as related to the requirements of the position to be filled.

EMERGENCY MANAGEMENT AND SECURITY

Hazardous Materials Handling What HCM Volunteers should know about handling hazardous materials:  Know the hazards of any product you work with. The hospital Operator maintains a reference copy of all Material Safety Data Sheets (MSDS) for hazardous hospital chemicals for anyone to inspect at any time.  Read hazardous material container labels before using  Use any required personal protective equipment  Handle, store and dispose of hazardous materials safely  Notify immediate supervisor, Security and Environmental Services of any spill or release.

REMEMBER: There is no such thing as safe chemicals – only safe ways to use them.

Infection Control

Hand hygene Current studies show that the direct correlation between hand hygiene and reduced risk of transmission of pathogens is stronger that the correlation between many other accepted practices and reduced risk of infection.

Frequent hand washing is the single most important and effective way to control the spread of infection.

When to wash your hands  Upon arrival at work  When transporting a patient by wheelchair at the time of admission, dismissal or to or from medical departments  If a Volunteer is going to touch a patient in their room, he/she should “Gel-in” and “Gel- out” using the antibacterial gel at the patient’s door  Frequently following a delivery to patient rooms  Before and after serving food or drink to visitors  Before and after using the restroom  Before leaving work area for home  After removing protective equipment (i.e., gloves) after carrying specimens to the lab

CAUTION: Do not transport specimens that are not in closed plastic containers. Gloves are recommended.

How to wash your hands  Thoroughly wet hands  Apply a hand washing agent  Rub all areas of hands and fingers with friction for 20 seconds, paying close attention to the areas under the fingernails and between fingers. (Sing the happy birthday song to yourself twice and when you are finished…clean hands.)  Rinse hands thoroughly  Dry hands with paper towels  If sink does not have foot control or automatic shut off, use a paper towel when turning off the water.

What if there is no running water? In cases where there is no running water available or facilities are not convenient, an alcohol-based gel is appropriate.

Alcohol-based gel  Alcohol-based gel for hand hygiene is considered the standard of care if hands are not grossly soiled  Alcohol-based gel does not remove gross soil and organic material  Soap and running water should be used to wash hands periodically during the day – about once for every 10 washings with waterless hand wash or when hands are visibly soiled  Rub enough product to completely cover hands  Rub solution vigorously until hands are dry (usually about 30 seconds). Remember that alcohol-based products do not remove dirt and organic material – so hands must be free of these before applying alcohol-based gel if it is to be effective.

Bloodborne Pathogens Bloodborne pathogens are infectious materials in the blood that can cause disease in humans. Workers exposed to these pathogens risk serious illness and possible death.

Any person who has been diagnosed with Hepatitis B, Hepatitis C or human immunodeficiency virus (HIV) can carry bloodborne pathogens. Bloodborne pathogens are transmitted by contact with infected blood or any other bodily secretions, as well as needles, razors or any other sharp instrument that has been contaminated. Mothers can also pass the infectious material to their newborns.

There is a vaccine for Hepatitis B. If you are interested in receiving this vaccine please let your supervisor know and arrangements can be made. There is no vaccine for Hepatitis C or HIV. All patient blood/body fluids will be treated as if infected. Appropriate personal protective equipment will be worn as needed including masks, eye protection, gloves, gowns, etc. If a volunteer has a question as to what appropriate protective equipment is needed, they are to always ask the patient care person.

A “Respirator Alert” or “Isolation” sign will be posted outside a patient’s room if there is a suspected presence of a disease that is transmitted by the airborne route. WARNING – A volunteer must not enter such a room. Make any delivery to an appropriate nurse’s station

Medical Staff Relationship Volunteers must maintain an ethical and professional relationship with the HCM medical staff at all times. Solicitations of free medical advice or prescriptions are considered discourteous. Although a volunteer might know a physician on a first-name basis outside the hospital, please give the doctor professional respect by addressing him/her by the proper title (e.g., Dr. Smith) when in the hospital.

On-site Weapons HCM prohibits any and all Volunteers from bringing weapons such as firearms, bombs, chemical dispensers and other items into any HCM facility or onto any of its properties while engaging and conducting volunteer work on behalf of the HCM.

If an HCM Volunteer observes a weapon on any person (except official security officers), he/she should call the Operator immediately so that the proper code may be activated and the perpetrator may be apprehended without causing undo commotion.

Sexual and Racial Harassment HCM does not tolerate any form of sexual or racial harassment in its workplace. If a Volunteer believes such harassment has taken place, the Volunteer must contact the Volunteer Program Coordinator or Human Resources Department immediately for assistance.

Any HCM volunteer or employee who is found guilty of sexually or racially harassing others may be dismissed.

Tuberculosis Testing To promote the health of our community and to prevent the spread of epidemiological diseases, HCM conducts a tuberculosis (TB) TSpot test on all new candidate Volunteers and as needed thereafter. There is no charge to the Volunteer for this service.

If a Volunteer’s test is positive for TB, the Volunteer should then further expect to also have a chest x-ray (for a more definitive result) for which there is also no charge. Flu Shots Annual flu shots will be made available at no charge to Volunteers each year when the flu season arrives. Flu vaccination is mandatory. If you get your shot somewhere other than HCM, please bring proof that you have been vaccinated.

Transporting Wheelchair Patients Volunteers will receive advanced wheelchair training and will be certified in that training if they are expected to transport a patient alone. The Volunteers will be taught how to protect the patient and how to protect themselves from possible injury.

Based on nursing judgement, a patient may walk out unescorted if they are able.

The Volunteer should first ask the requesting nursing staff if a “wide” wheelchair is required for the patient. For patients in a wheelchair, the responsibility of the Volunteer is to deliver them to the vehicle that is waiting at the door to pick them up.

It is vitally important that the wheelchair brakes are set before anyone sits down in/or arises from the chair because these wheelchairs roll easily and can slide out from beneath a patient. In addition, the Volunteer should stand behind the wheelchair.

Here are a number of helpful techniques used in transporting patients via wheelchair:  Always back in and out of elevators since the swiveling front wheels can become stuck in the elevator door’s threshold  The elevator next to the HCM cafeteria entrance is the only elevator that has a “STOP” or “HOLD” button – a less stressful option with a wheelchair  It is also helpful to back over a small rise, such as a door threshold, using the large wheels first to easily negotiate the obstacle.

When receiving a patient, the Volunteer should ask the patient if they are able to get out of the chair without assistance. A steadying hand may be offered. For those patients not able to exit the wheelchair unassisted, the Volunteer should call the Nursing Station that released the patient and have them come and assist.

In cases where the patient is being delivered to the hospital (particularly through Outpatient) and cannot exit the vehicle unassisted, Volunteers should have the Operator call the Emergency Department, the Patient Care Coordinator (House Mom) or Physical Therapy for assistance.

At no time should a Volunteer attempt to transport a patient that they feel uncomfortable handling. Workplace Violence HCM has adopted a zero-tolerance policy regarding actual or threatened violence by a Volunteer against any person in HCM facilities within the course of their duties.

The forms of prohibited violent or threatening behaviors include:  Threats of violence  Use of abusive language  Making annoying/threatening telephone calls, emails or other communication  Displaying or threatening the use of unauthorized weapons  Harassment  Throwing or destroying objects or HCM property  Using or attempting to use actual physical violence against another person  Any other conduct, which in the judgement of HCM and its Volunteer Services, may endanger the safety and well being of any other person on the premises who may have contact with a Volunteer in the course of their duties.

Any Volunteer who engages in any conduct listed above may be subject to disciplinary action up to and including immediate dismissal.

Truthful reporting of suspected violations by Volunteers to the Volunteer Program Coordinator will not subject the reporting Volunteer to any retaliation, discipline or reprisal of any kind.

Although Volunteer Services encourages Volunteers to report all threatening or violent conduct, Volunteers must not make false reports and those who intentionally make a false report, pursuant to procedure, may be subject to disciplinary action up to and including immediate dismissal from Volunteer Services.

Violence in the health care workplace often begins with an aggressive threat made in frustration. The situation can be calmed with early and appropriate intervention. However, it can also escalate to an actual act of violence. Although HCM has a policy prohibiting anyone from bringing a weapon into its facilities, our environment contains many objects that could be used as weapons so it is important for Volunteers to know how to be safe.

The following listed factors may contribute to the potential for violence: The nature of the work and the health care system itself such as  A confusing array of highly specialized personnel  Highly technical work, not always interpreted for patient/family  Significant delays as the sickest is cared for first  Because each patient situation is different, outcomes cannot be guaranteed. Patients/Families are in situations characterized by:  High stress, often an unexpected emergency  Circumstances beyond their control  Uncertain but highly significant (perhaps life-altering) outcomes  Outpatient/emergency areas that may be aggravated by use of alcohol/drugs.

The above factors can be a volatile mix with a high potential for frustration!

What should a volunteer do? A Volunteer may not be able to control the situation, but they can control themselves.  Have someone call the Operator if any type of a threatening weapon is involved  Keep a calm and caring attitude  Avoid giving orders (“Sir, you just have to calm down”) – this is not helpful  Avoid arguing – just listen  Don’t match their threat with one of your own – it can escalate the situation quickly  Keep a safe personal distance so that a quick exit is possible  Use your judgement about whether to use these tactics or just exit the situation.

Emergency Operations Plan HCM has prepared an Emergency Operations Plan for the hospital to provide for an all-hazards response in the event of an emergency or disaster in the community or at any of the hospital campuses. This plan provides an environment that is safe, effective and functional for patients, visitors, staff, physicians and volunteers. The plan is designed to assess and minimize risks and to develop, evaluate, coordinate and manage activities during actual or potential emergency situations affecting the hospital.

How does this impact you, the Volunteer? Please make yourself aware of the Emergency Code System and your response to each: Code Blue – Cardiac or respiratory arrest. No response Code Red – Fire. Remember RACE – Rescue, Alarm, Contain, Extinguish Code Purple – Evacuation. Follow manager’s instructions in all cases Code White – Armed intruder/shooter. Protect yourself and do not confront intruder Code Green – Combative person. Get to a safe place and report to an employee or your supervisor Code Black – Bomb threat. Notify supervisor and/or follow supervisor’s instruction Code Pink – Infant abduction. Be alert to unusual persons or vehicles Code Silver – Missing or eloped adult. Be alert and observant of people surrounding you Code Gray – External/Internal event that may affect normal hospital operations Code Orange – Hazardous material spill or contamination. Follow manager’s instructions Code Yellow – Equipment system failure/out of service. Follow manager’s instructions

Disaster Preparedness Volunteers are free to leave the premises when a Disaster Code is announced. To ensure personal accountability, Volunteers should notify the staff person they report to in their department that they are leaving.

If the Volunteer chooses to stay and help, individual departments may utilize the Volunteers on assignment for their services in the functions of their Disaster Plan. Volunteers who are not needed in their assigned service area may report to the Main Lobby for direction if they choose to stay and assist during the Code. The Volunteer Program Coordinator will orchestrate the utilization of Volunteers with other departments in the hospital.

It is very important that safe conditions are maintained for patients, visitors, staff and volunteers in health care settings. Volunteers have a responsibility to help ensure that safe conditions are maintained so that accidents are prevented from occurring. Sometimes accidents are seemingly unavoidable but they often occur as the result of careless behavior resulting in unsafe acts as well as unsafe conditions. Hospital staff may even become accustomed to an unsafe condition or act to the point that they fail to recognize it as dangerous.

For a safer HCM, Volunteers should:  Be aware of their surroundings and if they see potential hazards report them to the person in charge  Practice common safety sense  Help with enforcement of the no-smoking policy  Practice personal safety when volunteering: wearing protective equipment such as gloves and practice good technique when performing physical tasks  Always follow the direction of the staff person in charge with regard to safety  In case a Volunteer has an accident of any kind while working, report it to the Department Supervisor for assistance in completing the Incident Report. Be sure the Volunteer Program Coordinator is alerted and receives a copy of the Incident Report.

Security at HCM Facilities Here are some reasons a Volunteer might report an emergency to Security  Suspicious person with no apparent reason for being at an HCM facility  Vehicle accidents in the parking lot  Infraction of HCM safety procedures by staff, patients, volunteers or visitors  Situation of conflict that is escalating  Theft of hospital or personal property  A bomb threat  Report a safety hazard

JOINT COMMISSION REQUIREMENT

The Joint Commission (TJC) is a private, not-for-profit organization that sets performance and compliance standards, evaluates and accredits health care organizations nationwide.

The Joint Commission’s voluntary evaluation process is based on a three-to-five day on-site survey of facilities. The process includes physicians, nurses, health care administrators, staff, volunteers, contractors, agency personnel and any additional individuals who provide services to patients within the organization.

The Joint Commission monitors performance standards and services with the expectation that each accredited organization remains in compliance with the standards on a continual basis. The Joint Commission specifies that all elements of performance must meet compliance standards.

Joint Commission Requirements: Volunteers may be part of the Joint Commission survey process. Joint Commission surveyors have been known to review the following:  Volunteer files and records  Volunteer applications  Volunteer training records  Volunteer qualifications for special assignments  Volunteer documentation of orientation  Volunteer job descriptions  Volunteer communication processes  Volunteer preparedness  Volunteer education  Volunteer safety  And the list goes on ……

The Volunteer Services Office diligently works to ensure that this documentation is completed and that Volunteers are prepared for Joint Commission surveys. There may be instances when user departments are asked to assist with volunteer competencies, job descriptions or documentation of volunteer training to fulfill Joint Commission requirements. JOB DESCRIPTION

A description of your duties and responsibilities follows. Please speak with the Volunteer Program Coordinator if you have questions or suggestions on how your assignment can be improved.