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2013Mandatorymanual.Pdf University of Rochester Medical Center Strong Memorial Hospital 2 Highland Hospital 0 MANDATORY IN-SERVICE EDUCATION 1 MANUAL 3 This manual and accompanying test are available for viewing or printing on SharePoint at: http://inside.mc.rochester.edu/sites/Inservice/default.aspx. An online, interactive version of the manual and tests is available on Blackboard. Self-enroll at: http://bb.rochester.edu/enroll/user_enroll.cfm?enrollmentID=2a2j Or, you can take your copy card to the URMC Copy Center on the ground floor of SMH to request copies of the manual. TABLE OF CONTENTS 2013 Mandatory In-Service Education Manual Introduction Table of Contents ........................................................................................................................ i Preface ....................................................................................................................................... v Section 1: General Topics for Everyone, Regardless of Duties/Position AMBER Alert ..............................................................................................................................1 Bloodborne Pathogens Standard ...............................................................................................3 Code of Organizational and Business Ethics (SMH specific) ...................................................5 Compliance: Everyone’s Responsibility ......................................................................................8 Disaster Preparedness ...............................................................................................................9 Disruptive Event Education ......................................................................................................11 Diversity and Inclusion ..............................................................................................................13 Electrical Safety in Health Care Facilities .................................................................................14 Emergency Page Codes ..........................................................................................................15 eRecord Downtime Procedure .................................................................................................17 False Claims Prevention (False Claims Acts) ..........................................................................19 Firearms/Weapons ...................................................................................................................20 Fire Safety ................................................................................................................................21 Hand Hygiene—Simple, But Effective ......................................................................................23 Hazard Communication Standard (NEW OSHA STANDARD) ................................................25 HIPAA Privacy and Security, and Confidentiality of Information ..............................................29 HIV/AIDS Confidentiality Requirements ...................................................................................30 Infection Prevention ..................................................................................................................31 Influenza—What You Should Know .........................................................................................33 Interpreter Services ..................................................................................................................34 Joint Commission Readiness ...................................................................................................36 Lifting and Transfers: Posture and Body Mechanics ................................................................37 Management of Suspected Abuse and Neglect ......................................................................38 Meal and Rest Breaks ..............................................................................................................39 Obtaining Security Services ...................................................................................................................40 Occurrence and Claim Reporting .............................................................................................41 Patient Prisoner Population (SMH specific) ...........................................................................43 …..continues….. URMC Mandatory In-Service Manual 2013 Page i Compiled and edited by Human Resource Development and HH Dept. of Ed. TABLE OF CONTENTS for 2013 Mandatory In-Service Education (continued) Patient Rights/Ethics/Complaint Process .................................................................................44 Patient Safety, Team Communication, and Medical-Health Care Error Reduction .................45 Policy Against Discrimination and Harassment .......................................................................47 Professional Misconduct Reporting and the Impaired Professional .........................................48 Quality, Safety, Performance Improvement ..............................................................................49 Smoke-Free Campus, Inside and Out ......................................................................................50 The Strong Commitment (SMH specific) ................................................................................51 Waste Management .................................................................................................................52 Workplace Violence / Defusing Potential Violence ...................................................................53 Your Role in Quality / Performance Improvement ....................................................................54 Section 2: Topics for Faculty and Staff With Patient Care Responsibilities or Who Enter a Patient’s Room (Nurse Practitioners, Physician Assistants, and Physicians also read “Provider Only” topics listed on next page) Anticoagulation Safety ..............................................................................................................59 Care of Patient Personal Belongings and Valuables ................................................................61 Conflict of Care .........................................................................................................................63 Continuity of Care Through Interdisciplinary Communication ..................................................64 Do Not Resuscitate (DNR) .......................................................................................................65 End of Life Care ........................................................................................................................66 Ensuring Comprehensive Handoff (ECHO) ..............................................................................68 Health Care Proxy ....................................................................................................................70 Information for Clinical Decision Making ............................................................................... 71 Medical Equipment ...................................................................................................................72 Medical Orders for Life-Sustaining Treatment (MOLST) ..........................................................74 Medical Record Documentation for Clinical Staff ....................................................................75 Medication Reconciliation/Adverse Drug Reaction (ADR) Reporting .......................................77 Organ and Tissue Donation......................................................................................................79 Pain Management ....................................................................................................................81 Patient Identification ................................................................................................................82 Patient Self-Determination Rights ............................................................................................83 Prevention of Surgical Site Infections ......................................................................................84 Radiation Safety .......................................................................................................................86 Rapid Response Team .............................................................................................................87 Restraint Use .............................................................................................................................................89 Write Down and Read Back for Verbal Orders or Critical Results ...........................................93 …..continues….. Page ii URMC Mandatory In-Service Manual 2013 Compiled and edited by Human Resource Development and HH Dept. of Ed. TABLE OF CONTENTS for 2013 Mandatory In-Service Education (continued) Section 3: Highland-Specific Topics Code of Organizational and Business Ethics (HH specific) ....................................................97 Forensics (HH Specific) ..........................................................................................................98 Highland Promise Standards and Global Behaviors (HH specific) .........................................99 Security/Safety Management Programs at Highland (HH specific).......................................100 Section 4: Provider Only Topics (Nurse Practitioners,
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