General Orientation Manual Non Associates & Clinical Affiliations

A member of Purpose & Introduction to STVHS & Ascension General Orientation Manual Non-Associates & Clinical Affiliations

Purpose of the General Orientation Manual About St. Vincent’s Health System and Ascension Welcome to the St. Vincent’s Health System. This Health manual is your guide to the St. Vincent’s Health System Ascension Health is the nation’s largest Catholic and policies. We believe that understanding the St. Vincent’s largest nonprofit health system, serving patients Health System and how it works is an important step through a network of hospitals and related health in developing and maintaining positive and productive facilities providing acute care services, long-term relationships. care, and community health services, psychiatric, rehabilitation and residential care in 25 states and the This manual is your orientation to the St. Vincent’s District of Columbia. Health System. It replaces the traditional classroom General Hospital Orientation. The St. Vincent’s Health System arm of Ascension Health consist of five facilities. About St. Vincent’s Health System and Ascension Health Our healthcare ministry currently provides its special St. Vincent’s Health System includes the longest-serving brand of Christ-centered quality care to people in as hospital in Birmingham, a not-for-profit health care many as 40 different zip codes. Together, we are creating provider founded by the Daughters of Charity National care you can believe in. Health System (DCHNS) in 1898. DCHNS is now a member of Ascension Health. • St. Vincent’s, Birmingham

Ascension was formed in November 1999, when DCNHS • St. Vincent’s East, and the Sisters of St. Joseph Health System entered into a co-sponsorship to strengthen their health care • St Vincent’s Blount, ministries. In 2002, Ascension Health welcomed Carondolet Health Care System and today Ascension • St Vincent’s St. Clair, Health employs more than 100,000 associates. • One Nineteen Health and Wellness In 2007, St. Vincent's Health System expanded to include the facilites of Easter Health System, Inc. , another long standing not-for-profit heatlh organization.

Page 01 Care You Can Believe In HEALTH SYSTEM Introduction to STVHS & Ascension Health General Orientation Manual Non-Associates & Clinical Affiliations

Philosophy Mission Statement We believe that each person is created by God in His own Rooted in the loving ministry of Jesus as healer, we commit image and likeness. We further believe that each person ourselves to serving all persons, with special attention to as a unit of body, mind, and spirit has been endowed those who are poor and vulnerable. Our Catholic health with unique human dignity, rights, and responsibilities. ministry is dedicated to spiritually centered, holistic care that sustains and improves the health of individuals and We believe that the dignity and rights of each person communities. We are advocates for a compassionate must be protected and promoted with the utmost care, and just society through our actions and words. from the moment of conception through life and death. Vision Statement We believe that in caring for the whole person, the We envision a strong, vibrant Catholic health ministry in the meaning of suffering may be recognized in light of the United States which will lead to the transformation of health suffering and death of Christ. care. We will ensure service that is committed to health and well-being for our communities and that responds to We believe that healing is ultimately the work of God and the needs of individuals throughout the life cycle. We will that our involvement in health care is a participation in expand the role of the laity, in both leadership and spon- healing ministry of Christ, a mission that we share with sorship, to ensure a Catholic health ministry in the future. all those who assist us in this work.

We believe that the health care ministry provides a means of witnessing to the work of Christ as healer; the teaching of the Catholic Church concerning mercy and justice; and the founders’ spirit of humble, simple and loving service.

Page 02 Care You Can Believe In HEALTH SYSTEM Purpose & Introduction to STVHS & Ascension General Orientation Manual Non-Associates & Clinical Affiliations

Values Rights and Responsibilities We are called to: In recognizing and accepting its responsibility to provide those services necessary to assure quality patient Service of the Poor care and to contribute to the health care needs of the generosity of spirit, especially for persons most in need local community, St Vincent’s Health System maintains the responsibility and the right to determine the extent Reverence and type of work which must be performed. In keep- respect and compassion for the dignity and diversity of ing with its core values, it also recognizes its responsi- life bility to establish and maintain efficient procedures and methods to achieve this work, and set forth the stan- Integrity dard of performance to realize the Hospital’s objectives inspiring trust through personal leadership Equal Employment Opportunity Wisdom The concept of Equal Employment Opportunity is consis- integrating excellence and stewardship tent with St. Vincent's Health System's philosophy and is in accord with the principles of Christian social justice, Creativity which affirm that all persons should receive recognition of courageous innovation their personal dignity and work. In keeping with this belief, St. Vincent's Health System provides equal opportunity Dedication without regard to race, color, sex, religion, national origin, affirming the hope and joy of our ministry age, or disability. This policy relates both to the public and to all phases of employment including, but not limited to, recruitment, hiring, placement, promotion, demotion, transfer, layoff, recall, rates of pay and other forms of compensation, selection for training, and use of facilities.

The Human Resources Department should be informed of any perceived violation of this policy.

Page 03 Care You Can Believe In HEALTH SYSTEM Purpose & Introduction to STVHS & Ascension General Orientation Manual Non-Associates & Clinical Affiliations Harassment reported to Protective Services. If immediate threats It is the policy of St. Vincent's Health System that un- or acts of violence occur, associates should follow their welcome conduct of a nature which causes an intimidat- facility specific emergency code. (See facility specific ing, hostile, or offensive working environment or unrea- emergency code policy for threat of violence). sonably interferes with an individual’s work performance will not be tolerated, and such conduct will be subject- Solicitation and Distribution ed to disciplinary action up to and including discharge. Non-associates are prohibited from distributing literature and/or soliciting on Hospital premises at An associate who feels that he or she has been subjected any time. to harassment (including sexual harassment) should immediately report the incident to his or her supervisor, to Associates are not permitted to distribute literature in the next higher level manager, or to Human Resources. patient care areas or during work time. Patient care St. Vincent's Health System assures prompt, thorough in- areas include patient rooms, operating rooms and vestigation and resolution of any allegation of harassment. any other place where patients receive treatment, corridors and sitting rooms adjoining or accessible to An associate who has had a harassment complaint filed patient rooms and treatment rooms, and elevators or against him or her may not retaliate against the individ- stairways used to transport patients. Exceptions may ual who filed the complaint or anyone who participated only be permitted in cases of charitable or Hospital in the investigation. activities with the prior approval of the President/COO.

Violence in the Workplace Performance / Competency Assessment St. Vincent’s Health System, in keeping with its phi- Staff members are assessed at the time of placement/ losophy and values, strives to provide a safe envi- contract/utilization on whether they are competent to ronment for associates, patients, visitors and other perform the responsibilities outlined in their job de- customers by taking a proactive stance towards the scription. They are given a copy of their job descrip- prevention and control of violent behavior on its cam- tion during their orientation period and asked to sign puses. Workplace violence typically involves custom- an acknowledgment statement. The job description ers or associates, or both, but can be stranger vio- outlines the task, responsibilities, performance stan- lence that involves the workplace only incidentally. dards and required competencies necessary to perform the essential functions of the position. In addition, each Concerns about potential threats of violence involving department may utilize other internal manuals, check- other associates should be reported to the HR Manager lists, etc, to assist in job performance measurement. in Human Resources. Concerns about potential threats of violence involving non-associates should be

Page 04 Care You Can Believe In HEALTH SYSTEM Corporate Responsibility General Orientation Manual Non-Associates & Clinical Affiliations

Corporate Responsibility Quality Care - Provide competent and compassionate care, respect and safeguard the dignity of the patient and allow patients’ access to all the medical and ethical information necessary to make decisions about their care.

Laws and Regulations – Operate in accordance with all laws and regulations.

Human Resources – Cultivate a work environment where all associates are highly regarded.

Business and Ethical Practices – Not purposely defraud anyone of money, property, or services and preserve and protect the organizational assets: physically, electroni- cally and intellectually.

Conflicts of Interest– Not use my position or status at St. Vincent’s Health System to profit personally or to assist others in profiting in any way at the expense of the organization

Confidentiality – Maintain the confidentiality of medical Corporate Responsibility Plan and Ethical Practices records and other patient information, known as Protect- Corporate Responsibility is a process, dependent upon a ed Health Information (PHI); as well as keep confiden- culture, which builds and nurtures a zero-tolerance atti- tial information about other associates and proprietary tude. St. Vincent’s Health System (STVHS) is committed business practices of the organization to include the se- to carrying out its health ministry in a manner consistent curity of information and electronic systems, known as with the mission of Ascension Health and the mission, Proprietary Information. vision and values of STVHS. STVHS is dedicated to the highest standard of moral and ethical excellence. STVHS requires its associates to maintain a high standard of Cor- porate Responsibility:

Page 05 Care You Can Believe In HEALTH SYSTEM Corporate Responsibility General Orientation Manual Non-Associates & Clinical Affiliations HIPAA False Claims Act Information - January 2007 The Health Insurance Portability and Accountabil- As recipients of federal health care program funds, includ- ity Act (HIPAA) of 1996 reinforces St. Vincent’s Health ing Medicare and Medicaid, Ascension Health’s hospitals System ethical principle of confidentiality and expands are required by law to provide all associates, agents and the scope of Protected Health Information (PHI). As contractor’s information regarding the federal False Claims an associate or agent employed by or associated with St. Act, the federal Program Fraud Civil Remedies Act, and any Vincent’s Health System, I must be increasingly vigilant applicable state laws intended to prevent and detect fraud, and self-enforce the nondisclosure of patient informa- waste and abuse in federal health care program. STVHS tion including medical treatment, payment information will not tolerate making or submitting false or misleading or disposition, either in part or whole. Exceptions to con- claims or statements to any government agency, health fidentiality may occur only under the following circum- care program or payer. It is the policy of STVHS that its stances: associates, medical staff and vendors adhere to the stat- • I may disclose PHI to the appropriate individual or utory requirements of federal and state False Claims Act. entity only if necessary for the treatment of a pa- What is the False Claims Act? tient The False Claims Act is a federal law that makes it a • I may disclose PHI to the appropriate individual or crime for any person or organization to knowingly make entity to the minimal extent necessary to facilitate a false record or file a false claim with the government payment or hospital operations for payment. “Knowingly” includes having actual • I may disclose PHI at the direction of the patient’s knowledge that a claim is false, or acting in “deliberate primary care physician ignorance” or “reckless disregard” as to whether a • I may disclose to the patient, or the patient’s desig- claim is false. Examples of possible false claims include nee, his or her own PHI billing Medicare and/or Medicaid for services that were not provided, billing for a higher-level service than As part of Ascension Health’s Mission, Vision and Values the service actually furnished (upcoding), or billing for it is important that we maintain high standards around services that were not ordered by a physician. corporate responsibility and ethics. Concerns about integrity, compliance and ethics can be reported confi- The False Claims Act contains provisions that allow in- dentially and without fear of retribution. The following dividuals with original information (i.e., information not are avenues for reporting: already the subject of legal proceedings or activities that • First step, talk with your supervisor or manager have already been publicly disclosed) concerning fraud • Values Line - 1.800.707.2198 involving government programs to file a lawsuit on behalf • Corporate Responsibility Office 205.939.7742 of the government and, if the lawsuit is successful, to receive a portion of recoveries received by the government.

Page 06 Care You Can Believe In HEALTH SYSTEM Corporate Responsibility General Orientation Manual Non-Associates & Clinical Affiliations Penalties for Violating the False Claims Act pay, solicit or receive kickbacks, bribes, or rebates for Financial penalties to the organization for submitting a services. Conviction for any of these felonious actions false claim can total as much as three times the amount of could result in a fine of $10,000 or imprisonment for one the claim plus fines of $5,500 to $11,000 per claim. In ad- to five years for each violation. dition to fines and penalties, an individual or organization that violates the False Claims Act is subject to exclusion Our Commitment to Corporate Responsibility from participation in federally funded healthcare programs. Ascension Health is committed to fully complying with all laws and regulations that apply to our health Protections under the False Claims Act care ministry. We have established the Corporate Re- The federal False Claims Act protects employees from sponsibility Program (CRP) as evidence of our com- being fired, demoted, threatened or harassed by his or mitment to operating with the highest degree of inher employer for filing an FCA lawsuit or providing infor- tegrity. The CRP includes the Standards of Conduct, mation in good faith relative to a False Claims Act inves- policies and procedures, training and education, audit- tigation or lawsuit. ing and monitoring, and mechanisms for individuals to raise issues and concerns without fear of retaliation. Program Fraud Civil Remedies Act The Program Fraud Civil Remedies Act (“PFCRA”) pro- STVHS Policy and Procedures for Detecting and vides federal agencies, including the agencies respon- Preventing Fraud, Waste and Abuse sible for federally funded health care programs, with As stated in STVHS Corporate Responsibility Plan Sec- administrative remedies against individuals and organi- tion VI A. Identification of High Priority Areas, STVHS zations that knowingly submit a false claim for payment, is aware of specified levels of exposure within compli- or knowingly make or use a false record or statement ance activities. STVHS annually performs an assessment to get a false claim paid. The PFCRA is limited to situ- of its Corporate Responsibility Program which includes ations where a false claim, or a group of related false ensuring appropriate audits i.e. baseline coding audits, claims, does not exceed $150,000. The PFCRA provides PEPPER (Program for Evaluating Payment Patterns Elec- civil penalties up to $6,000 per false claim, plus an as- tronic Report) reviews, as well as internal audits i.e. sessment equal to twice the amount of the false claim. charge capture/reconciliations are routinely conducted as part of the system’s audit and corporate responsi- State of Alabama Law bility plans which take in account the Office of the In- Rule No. 560-X-4-.04 of the State of Alabama Program spector General’s Work Plan as well as areas of con- Integrity Division under Code of Alabama 1975 Section cerns identified by the Corporate Responsibility Officer. 22-1-11 makes it a felony offense to falsify a claim or application for payment of Medicaid benefits or offer,

Page 07 Care You Can Believe In HEALTH SYSTEM Corporate Responsibility General Orientation Manual Non-Associates & Clinical Affiliations Whether you are an associate, contract worker, ation, in any form, against an individual reporting an issue or medical staff member, vendor or other business concern in good faith. Please contact the Corporate Respon- partner with Ascension Health and/or STVHS, you sibility Office at 205.939.7742 if you have any questions. are reminded to:

• Act with honesty and integrity in all your business activities • Follow all laws and regulations that apply to your work activities, including requirements of the Medi- care, Medicaid and other federal health care programs. These requirements generally include maintaining complete and accurate medical records, and submitting only complete and accurate claims for services provided. • Report any violation or suspected violation without fear of retaliation.

Contact one of the following resources available within STVHS if you have knowledge or concern regarding a potential false claim:

• The Corporate Responsibility Office at 205.939.7742 • STV Associates, Medical Staff and Vendors: Val- ues Line – 1.800.707.2198 or www.AscensionHealthValuesLine.org. The Values Line is staffed 24 hours a day, 7 days a week by an outside organization. You may choose to remain anonymous when filing a report.

You can obtain a copy of STVHS Corporate Responsibility Plan and False Claims Act Information Sheet from the Corporate Responsibility Office and from www.stvhs.com.

Ascension Health and STVHS policies strictly prohibit retali- Page 08 Care You Can Believe In HEALTH SYSTEM Corporate Responsibility General Orientation Manual Non-Associates & Clinical Affiliations Diversity and Equal Employment Opportunity Health and Safety No one shall discriminate against any individual with St. Vincent’s Health System (STVHS) facilities must a disability with respect to any offer, or term or condi- comply with all government rules and regulations that tion, of employment. STVHS will make reasonable ac- promote the protection of workplace health and safety. commodations to the known physical and mental limita- Associates must become knowledgeable of and abide by tions of otherwise qualified individuals with disabilities. the Hospital’s health, safety and contingency policies and procedures. Associates are expected to help prevent injury to themselves, other associates, patients and visitors. Drug Free Workplace It is the expectation of St. Vincent’s Health System (the System) that associates will engage in behaviors and performance levels that meet the generally accepted expectations of patients, fellow associates, and customers. Associates who are not meeting these expectations will be coached and assisted in developing a plan of action that will allow them to meet expectations. Associates who continu- ally choose not to meet expectations will be addressed by the positive redirection process (STVHS HR Policy #002). Included in these expected behaviors, and not limited to, reporting to work free of the influence of alcohol or illegal drugs, or prescription drugs, which impair performance.

Page 09 Care You Can Believe In HEALTH SYSTEM General Information General Orientation Manual Non-Associates & Clinical Affiliations Appearance and Dress Badges To maintain the hospital’s favorable image and the con- In keeping with the Core Values, St. Vincent's Health Sys- fidence of its patients and visitors, associates must tem associates, volunteers, temporary personnel, and keep themselves neat, clean and well-groomed, and health affiliates, students and vendors performing work at must present a professional appearance at all times. St. Vincent’s Health System are required to wear hospital- Moderation and good taste must be observed in re- issued identification badges while on hospital premises. gard to clothing, shoes, hosiery, hair, fingernails, fra- grances, jewelry, and make-up. Uniforms are re- Non-associate badges: Students are required to quired for specific job classifications and must be worn wear their school badges. Volunteers, temporary per- while on duty as specified by the department head. sonnel, and health affiliates and vendors are issued badges by Protective Services according to established **Clinical students in the hospital facility for busi- guidelines and upon request from the supervisor of ness related to school activities must wear your the area in which they will be preforming their duties. uniform and/or lab coat and school ID badge. Other badge tips: **Fingernails must be kept clean and well groomed. For • If you find a badge or lose your badge, contact secu- associates giving direct patient care, fingernails rity at the site. may not extend more than ¼ inch beyond the fin- • If you see someone without a badge, you have the gertip. Nail polish is acceptable, if it is neat and smooth. responsibility to question them. No chipped or cracked nail polish may be worn. Artificial • You should never loan your badge to anyone. nails, including wrapped, overlays, and acrylics may • When on and off duty, keep your badge secure. not be worn by associates giving direct patient care. Some departments may have more stringent guidelines regarding nail length and artificial nails, as approved by the department head or as specified by outside agencies.

HEALTH SYSTEM Page 10 Care You Can Believe In General Information General Orientation Manual Non-Associates & Clinical Affiliations Parking Confidentiality Refer to facility specific information provided in supple- A patient’s condition or other information concerning ment packet. the patient’s illness, hospitalization, or records should not be discussed with anyone except those involved in Smoking the care of the patient, and only as necessary to per- In keeping with the objectives of promoting good form this job. health and providing a quality environment, all St. Vin- cent’s Health System facilities are smoke-free hospitals. Special care should be exercised in regard to casual Smoking is not allowed in the hospital. Smoking is al- conversation in elevators, hallways, dining areas, and lowed in designated areas only. Please see your im- other places where comments may be overhead. mediate supervisor or staff member for directions. Patients, their care and treatment and other informa- Telephone and Facsimile Machines tion, should never be discussed outside of the hospital. The hospital telephone system and facsimile machines are intended for official hospital business and for use by Media our patients. Personal phone calls/faxes are discour- Contacts from the news media requesting information aged and should be limited to emergency reasons. should be referred to your immediate supervisor, staff resource and/or the Marketing and Communications Personal cell phones should only be utilized dur- Department. ing breaks and meal periods in areas that do not interfere with the delivery of services. Performance Improvement To enable associates and other health care team members to deliver services most effectively, the St. Vincent Health System has adopted the PDCA model for improv- ing performance. Quality is the focus at every level of the organization. Each and every associate can identify and report performance improvement opportunities to the department manager. Every associate should be an active participant in the performance improvements initiatives specific to their department.

Page 11 Care You Can Believe In HEALTH SYSTEM Performance Improvement General Orientation Manual Non-Associates & Clinical Affiliations

Page 12 Care You Can Believe In HEALTH SYSTEM Performance Improvement General Orientation Manual Non-Associates & Clinical Affiliations Service Excellence • Adhere to hospital policies regarding tardiness, break, and time-off: • Report to work when scheduled • Report to work on time • Avoid unscheduled call-ins • Utilize work time appropriately • Complete assignments by established due dates • Account for time worked honestly and accurately

Professionals • Appearance should reflect professionalism: • Adhere to the dress code at all times • Wear name badges appropriately displayed • Maintain good personal hygiene • Treat co-workers with courtesy, compassion, and respect Standards of Behavior • Report to work as scheduled and on time “A-SPARC” • Offer assistance to co-workers and ask for help when needed Attitude • Welcome and be supportive of new associates • Smile and introduce yourself when you greet a co- offering any assistance in the workplace worker, customer, patient or visitor. When using the elevator: • Acknowledge patients by surname unless otherwise • Smile and speak to fellow passengers directed, • Step aside, hold the door and let patients and visitors • Knock and ask for permission to enter a patient room enter/exit first • Provide positive recognition (verbal and written re- • Position wheelchair-bound patients towards the door wards) to co-workers for outstanding service. • Give priority to patients. Consider taking the next elevator or the stairs to provide ample space for patients Stewardship and visitors • Safeguard resources: • Be sensitive and respectful of each person’s unique • Take care of equipment beliefs and cultural customs • Use resources wisely • Take ownership of problems and address or report to • Conserve the use of supplies the appropriate person • Recycle when possible

Page 13 Care You Can Believe In HEALTH SYSTEM Performance Improvement General Orientation Manual Non-Associates & Clinical Affiliations Advocacy • Provide encouragement and hope for patients Communication • Utilize available resources to promote the healing process • Practice Key Words at Key Times (What to Say When) • Proactively look for ways to improve delivery of ser- • Practice proper telephone etiquette: vice and/or the use of resources • Identify yourself and your department followed by • Discuss the patient’s personal health information with “How may I help you?” only those individuals who are involved in the pa- • Speak slowly and clearly tient’s medical care • Ask permission to place a patient on hold and fre- • Avoid discussion of patient information in elevators, quently update the status of their wait time hallways, or other inappropriate areas • Answer the phone with a SMILE…Your attitude can • Safeguard the privacy of medical records be heard in your voice • Provide a safe, functional, supportive environment for • Acknowledge others with eye contact patients, associates, and visitors • Remember, most patients are not medical experts. • Maintain a work environment that is clean and orga- Use simple language that is easily understood nized at all times • Listen while other are speaking • Collect and dispose of litter • Assure that the patient and/or family are secure in • Properly clean up any spills or debris to maintain a their understanding of treatment and follow-up care safe environment • Encourage, praise and affirm. (Do not criticize, con- demn, or complain.) Responsiveness • Initiate contact with those who appear to be lost or need direction, and escort them to their destination • Anticipate the needs of patients. Meet their needs before they ask • Respond to call lights, phone calls, and requests promptly any with a positive attitude • Provide an accurate time frame for when a patient’s request will be met if unable to meet the request immediately • Ask, “Is there anything else I can do for you?” as a final comment when leaving the patient’s presence • Address all complaints in a timely manner using a calm, positive and non judgmental appropriate

Page 14 Care You Can Believe In HEALTH SYSTEM Performance Improvement General Orientation Manual Non-Associates & Clinical Affiliations Telephone Etiquette Risk Management - Organization-wide Patient • Answer incoming calls by the third ring. Apologize to Safety the guest if there is a delay. • Answer the phone with a pleasant, polite and clear Emergency Assistance tone of voice. • Answer with a greeting (‘good morning, good after- EMTALA noon, or good evening’), identify yourself, identify E= Emergency Care your department or location, and provide an offer of M= Medical Screening/Medicare assistance (‘may I help you?’) T= Treat/Stabilize • Take complete messages. A= Active Labor Act • Ask the customer/guest if they may hold the line for L= Level of Care/Cobra Law a moment if a second line rings while you are on the A= Assist to Emergency Department phone. Handle the call immediately if the guest in- dicates the call is urgent. Do not place calls on hold Access to Emergency Care for longer than one minute without explanation or an • State and Federal Laws offer to call back. • Emergency Medical Treatment and Active Labor Act • Transfer calls only after giving the number to the • Offer emergency service to those seeking emergen- caller in case of disconnection. Stay on the line until cy care, regardless of the ability to pay, race, color, the party you are transferring to answers the phone. creed, religion, nationality Explain the call and provide the customer’s/guest’s • Any patient on the medical premises seeking emer- name when appropriate. gency care Dealing with Difficult Situations • Listen to the guest without interruption. Medical Screening • Make certain you fully understand the concern. Must be performed on all persons seeking emergency • Apologize for the situation and assure the guest that medical care on the hospital premises. you will work with them to rectify or address their concern. A medical screen includes tests, x-rays, consults and • Avoid blaming other departments or personnel. ancillary services routinely available to the emergency • Take action and follow up to make certain the cus- department in order to determine if a medical tomer/guest is content with the resolution. emergency exists. • Thank the customer/guest for bringing the concern to our attention and for giving us the opportunity to improve our services. • Contact the Guest Relations Coordinator to assist or follow up as needed. Page 15 Care You Can Believe In HEALTH SYSTEM Risk Management & Patient Safety General Orientation Manual Non-Associates & Clinical Affiliations Risk Management To help prevent healthcare errors, patients are urged to “Speak Up”: SPEAK UP: Help Prevent Errors Everyone has a role in making health care safe-physicians, Speak up if you have questions or concerns, and if you healthcare workers, nurses and technicians. Healthcare don't understand, ask again. It's your body and you organizations across the country are working to make have a right to know. healthcare safety a priority. You play a vital role in making your patient’s care safe by becoming an active, in- Pay attention to the care you are receiving. Make sure volved and informed member of the healthcare team. you're getting the right treatments and medications by the right health care professionals. Don't assume any- An Institute of Medicine (IOM) report has identified thing. the occurrence of medical errors as a serious problem in the healthcare system. The IOM recommends, Educate yourself about your diagnosis, the medical among other things, that a concerted effort be made tests you are undergoing, and your treatment plan. to improve the public’s awareness of the problem. Ask a trusted family member or friend to be your advo- The “Speak Up” program, sponsored by the Joint cate. Commission, urges patients to get involved in their care. Such efforts to increase consumer aware- Know what medications you take and why you take ness and involvement are supported by the Centers of them. Medication errors are the most common health Medicare and Medicaid Services. This initiative pro- care errors. vides simple advice on how the patient can make his care a positive experience. After all, research shows Use a hospital, clinic, surgery center, or other type that patients who take part in decisions about their of health care organization that has undergone a healthcare are more likely to have better outcomes. rigorous on-site evaluation against established state- of-the-art quality and safety standards, such as that provided by Joint Commission.

Participate in all decisions about your treatment. You are the center of the health care team.

HEALTH SYSTEM Page 16 Care You Can Believe In Risk Management & Patient Safety General Orientation Manual Non-Associates & Clinical Affiliations Incident/Event Reporting An incident/event is any occurrence (with or without in- Do not: jury and/or damage) which is not consistent with the • Use the report to punish, blame or accuse other indi- routine operations of the hospital, especially relating to viduals or departments patient care, but also affecting visitors, physicians, vol- • Document in the patient’s record that you have com- unteers and associates in non-clinical areas. Examples pleted a report are wrong medication administered, patient or visitor fall, equipment malfunction with patient/staff injury. Sentinel Events Sentinel Event – Any event which is an unexpected St. Vincent’s Health System supports a non-punitive re- occurrence involving death, physical or psychological in- porting of medical/healthcare errors and near misses. jury, or risk thereof. Serious injury specifically includes lost of limb or function. The phrase “or the risk there- There are four event categories: of” includes any process variation of which recurrence Category would carry a significant chance of a serious adverse outcome. 1. Patient • The event should be reported to Risk Management 2. Visitor/Physician/Other immediately 3. Property/Equipment/Narcotics Count • The Joint Commission requires that all healthcare 4. Employee Illness/Injury organizations report sentinel events • A Root Cause Analysis (RCA) and action plan is When an event occurs: completed • Inform immediate supervisor or House Supervi- • An RCA identifies the most basic causal sor (for students contact faculty advisor and/or unit factor or factors for the event and focus- charge/resource staff nurse) es primarily on systems and process, • The individual who knows the most about the event and not the individuals performance completes the form or ensures that the report is done When completing a report: • Do it as soon as possible after the event • Write objective, accurate, thorough and concise statements • Maintain confidentiality (Need-to-Know) both inside and outside the hospital • Document the event on the patient record, if applicable Page 17 Care You Can Believe In HEALTH SYSTEM Risk Management & Patient Safety General Orientation Manual Non-Associates & Clinical Affiliations Patient Safety Patient Safety is freedom from accidental injury. It Quality and patient safety are the focus of care encompasses those actions undertaken by individuals and treatment provided to patients cared for by St. and organizations to protect health care recipients from Vincent’s Health System facilities. being harmed by the effects of health care services. Anyone having concerns about the quality of care “Medical errors most often result from a complex or patient safety provided by St Vincent’s Health interplay of multiple factors. Only rarely are they System facilities, that the hospital has not addressed, due to carelessness or misconduct of single indi- is encouraged to contact the hospital’s management viduals” through the Patient Representative Office. Lucien Leape, MD Hospital Contact Number Harvard School of Public Health St. Vincent's Birmingham 205.939.7599

Each of us can improve Patient Safety by: St. Vincent's East 205.838.3167 • Watching - really looking at situations and potential St. Vincent's Blount 205.274.3055 for error. St. Vincent's St. Clair 205.814.2106 • Listening - to patients, families, and to co-workers. One Nineteen Health & Well- • Asking - There are no stupid questions! ness • Acting - Point out your observations and make rec-

ommendations for Improvement Hospital associates who may have concerns with • Reporting - Develop a proactive not just a reactive quality or patient safety may contact TJC directly. approach. Continuous reporting of not only errors No disciplinary action or retaliatory action will be but of near misses will enable the use of Failure taken by the hospital against associates who report Mode and Effects Analysis (FMEA) and Root Cause concerns to TJC. If the concerns cannot be resolved Analysis (RCA) to change systems and Improve through the hospital management and/or the Patient Patient Safety. Representatives office, TJC can be contacted to express these concerns related to quality or patient Get Involved! It is everyone’s job... safety. TJC office of Quality Monitoring may be

contacted to report any concerns or register complaints JCAHO Standard: Accreditation Participation about TJC accredited organizations by either calling Requirements (APR) 17 1.800.994.6610 or contact TJC via their web site at St. Vincent’s Health System is accredited by The Joint www.jointcommission.org and follow the link at the Commission. The Joint Commission standards address bottom of their web page. an organization’s compliance with the care, services and treatment provided to patients in their care. Page 18 Care You Can Believe In HEALTH SYSTEM Risk Management & Patient Safety General Orientation Manual Non-Associates & Clinical Affiliations 2007 National Patient Safety Goals (NPSG) Goal 1 Improve the accuracy of patient identification. 1A Use at least two patient identifiers when providing care, treatment or services. Name and Birthdate are the St.Vincent’s patient identifiers. Goal 2 Improve the effectiveness of communication among caregivers. 2A For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. Monitored by observation on all units. Remind your peers if you do not see this process being followed. 2B Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. DO NOT USE abbreviation policy is posted in all departments and on the intranet. Monitoring of the use of these abbreviations is in place across the organization. 2E Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. Hand off tools are in use throughout med-surg, surgery, and OB departments. These tools are useful to promote communication and patient safety. Goal 3 Improve the safety of using medications. 3C Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. 3D Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. All of the above are labeled in all surgical areas. Be sure and do the same for procedures on units and in departments. 3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. Full implementation by Janu- ary, 2009. Goal 7 Reduce the risk of health care-associated infections. 7A Comply with current Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO) hand hygiene guidelines. Infection Control follows and teaches these guidelines. Department monitoring is reported to the Infection Control manager. 7B Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. In the event this occurred we would follow our Sentinel Event Policy and Root Cause analysis process. HEALTH SYSTEM Page 19 Care You Can Believe In Risk Management & Patient Safety General Orientation Manual Non-Associates & Clinical Affiliations Goal 8 Accurately and completely reconcile medications across the continuum of care. Policy and process are in place for ad- mission, any change in the level of care and at discharge. 8A There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. 8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. Goal 9 Reduce the risk of patient harm resulting from falls. 9B Implement a fall reduction program including an evaluation of the effectiveness of the program. Bear Tracks is our fall prevention program. We use green ID bands and door signs which indicating the patient is at risk for fall. All patients are assessed utilizing the Hendrick II model of risk assessment for fall. Goal 13 Encourage patients’ active involvement in their own care as a patient safety strategy. 13A Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. Remind patients to ask questions of the nurses and physicians. Explain the importance of keeping up with all of their medications. Encourage them to write down all of their medications and keep this list with them at all times. With each physician visit, update the list. Add to this list the immunization history. This is important related to pneumonia and flu vaccines and will be asked when they are admitted to a hospital. Goal 15 The organization identifies safety risks inherent in its patient population. 15A The organization identifies patients at risk for suicide. 16 Recognition and Response to change in Patient’s Condition 16A The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. Example RRT team

Each facility has specific programs and processes in place to meet each goal. Please refer to deartment specific activities for details.

Page 20 Care You Can Believe In HEALTH SYSTEM The Joint Commission - High Risk Abbreviations

Official "Do Not Use" List Do Not Use Potential Problem Use Instead U (Unit) Mistaken for "0" (zero), the number "4" Write "unit" (four) or "cc" IU (International Unit) Mistaken for IV (intravenous) or the num Write "International Unit:" ber 10 (ten) Q.D., QD, q.d, qd (daily) Mistaken for each other] Write "daily" Q.O.D., QOD, q.o.d., qod (every other Period after the Q mistaken for "I" and the Write "every other day" day) "O" mistaken for "I" Trailing zero (X.0 mg)* Decimal point is missed Write X mg Write 0.X mg MS Can mean morphine sulfate or magnesium Write "morphine sulfate" sulfate Write "magnesium sulfate" MSO4 and MgSo4 Confused for one another Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre- printed forms.

*Exception: A "trailing zero" may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results. Imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

Page 21 Care You Can Believe In HEALTH SYSTEM The Joint Commission - High Risk Abbreviations

Additional Abbreviations, Acronyms and Symbols (For possible future inclusion in the Official "Do Not Use" List) Do Not Use Potential Problem Use Instead > (greater than) Misinterpreted as the number "7" (seven) Write "greater than" < (less than) or the letter "L" Write "less than" Confused for one another Abbreviations for drug names Misinterpreted due to similar abbrevia- Write drug names in full tions for multiple drugs Apothecary units Unfamiliar to many practitioners Use Metric Units Confused with metric units @ Mistaken for the number "2"(two) Write "at" cc Mistaken for U (units) when poorly writ- Write "ml" or "milliliters" ten pg Mistaken for mg (milligrams) resulting in Write "mcg" or "micrograms" one thousand-fold overdose

Refer to facility policy for detailed information regarding “Do Not Use” abbreviations

Page 22 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Employee Responsibilities Infection Control Working safely is part of expected performance at all The purpose of an Infection Control policy is to provide levels of the St. Vincent Healthcare System. By observ- guidelines in order to minimize the risk of transmission ing safe work practices, associates will ensure their and/or acquisition of infectious diseases. safety and the safety of our patients, and visitors. All associates are required to report and take action on any Personal Health & Practices slip, trip, or fall hazards, or anything that could cause • Do not report to duty if you are sick! an accident or injury. • Eating and drinking are prohibited in patient care areas. Work tasks shall not be considered effectively complet- • Any individual with active, suspect, or exposure to ed unless an associate has followed every precaution a communicable disease will not be permitted to and safety rule to protect themselves, fellow associates, serve as a volunteer pending a medical evaluation or patients and visitors. clearance.

Wearing of prescribed protective equipment is manda- Handwashing tory. Handwashing is the single most important means of preventing the spread of infection. Seat belts MUST be worn by all associates while travel- • Hands should be washed when coming on duty and ing in a vehicle on St. Vincent’s Health System's busi- upon leaving duty; ness, whether in your own vehicle or a St. Vincent’s • Before and after patient contact Health System vehicle. • Before and after glove use • After handling contaminated equipment Please do NOT talk on cell phone while driving. This is • After using the toilet required in St. Vincent’s’ Health System's owned ve- • Before meals and breaks hicles, and while traveling on St. Vincent’s Health Sys- • As a general rule, when in doubt, healthcare workers tem's business. should wash their hands

Unsafe equipment, medical devices, or products must be removed from service immediately and safely kept secure for Biomedical Engineering, Risk Management, or Facilities Engineering, as appropriate.

Page 23 Care You Can Believe In HEALTH SYSTEM General Orientation Manual Non-Associates Environment of Care - Providing a Safe Environment & Clinical Affiliations Handwashing Procedure: Isolation Precautions 1. Under stream of tepid water, wash hands with soap Below is general information only, on the types of iso- and water for at least 10 to 15 seconds. lation precautions, refer to the facility specific infec- 2. Rub together vigorously all surfaces, fingertips, and tions control policies for listing of diseases and isolation between fingers. required: 3. Rinse hands thoroughly under running water, holding elbows higher and allowing water to flow from the Standard Precautions wrist to the fingertips. Standard Precautions are designed to reduce the risk 4. Dry hands with a paper towel. of transmission of microorganisms from both recog- 5. Use a paper towel to turn off faucet and discard in nized and unrecognized sources of infection in hospitals. trash receptacle. Proper barrier precautions should always be taken when coming in contact with a patient’s body fluids regardless Handwashing with waterless antimicrobial handwash: of their diagnosis or presumed infection status. Stan- 1. Apply a bubble gum ball size amount to palm of one dard Precautions apply to all body fluidsexcept sweat: dry hand. 2. Rub hands together, covering all surfaces of hand 1. Blood and fingers, until hands are dry. 2. Any other body fluids, secretions, or excretions NOTE: If hands are visibly soiled, more time may be 3. Non-intact skin required 4. Mucous membranes 5. Articles/Equipment contaminated with blood or body Glove Use fluids • Gloves should be the appropriate size for the wearer. • Gloves are to be removed immediately upon comple- Airborne Isolation tion of task regardless of whether or not visibly A mask is always required. If patient is being transport- soiled. ed, then the patient must wear a mask. Use for patients • Hands are to be washed upon removal of gloves with TB, chickenpox, measles (gloves may become perforated and bacteria can multiply rapidly on gloved hands) Contact Isolation • Volunteers with identified tasks will receive instruc- Gloves must always be worn when entering the pa- tion from the department personnel for specific tient’s room. Used for patients with ‘c. difficle’, multi- glove use drug resistant organisms such as MRSA or vancomycin resistant enterococcus (VRE).

Page 24 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Tuberculosis (TB) All employed and non-employed staff are evaluated for This is called TB infection. Your immune system traps tuberculosis prior to working in the hospital environ- TB germs with special germ fighters. Your germ fighters ment (See TB Skin Test next page). Employees must be keep TB germs from making you sick. fit tested and wear a Respirator particulate N95 mask (only for TB) if entering airborne isolation. Droplets But sometimes, the TB germs can break away and exhaled by the infectious disease person (coughing, spread. Then they cause TB disease. The germs can at- speaking, sneezing, singing or shouting) spread tuber- tack the lungs or other parts of the body. They can go culosis. N95 Respirators must always be worn in the pa- to the kidneys, the brain, or the spine. If anyone has TB tient’s room. The door to a TB isolation room should be disease, they need medical help. If they don’t get help, kept closed to prevent the airborne bacteria from enter- they can die. ing the hallway. Employees must be fit tested and wear a Respiratory particulate N95 mask when entering the How do I know if I have TB infection? patient’s room. If the patient is being transported, then A skin test is the only way to tell if you have TB ex- the patient must wear a regular mask. (For additional posure. This test is usually done on the arm. A small information refer to infection control and TB policies) needle is used to put some testing material, called tu- berculin, under the skin. In two or three days, a health Droplet Precautions worker will check to see if there is a reaction to the Droplet transmission involves contact of a susceptible test. The test is “positive” if a bump about the size of a person with large-particle droplets generated from a pencil eraser or bigger appears on your arm. This bump person who has a clinical disease. Special ventilation is means you probably have TB exposure. You may need not required and a regular mask is to be worn within medicine to keep from getting the disease. three (3) feet of the patient. Note: If you have ever had a “positive” reaction to a TB The TB Skin Test skin test or if you have been treated with TB drugs in What is TB? the past, tell the health worker. “TB” is short for a disease called tuberculosis. TB is spread by tiny germs that can float in the air. The TB germs may spray into the air if a person with TB disease of the lungs or throat coughs, shouts, or sneezes. Anyone nearby can breathe TB germs into the lungs. TB germs can live in your body without making you sick.

Page 25 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Infections and Biohazards Occupational, Safety & Health Administration (OSHA) Gloves, masks, goggles, gowns and aprons are all con- has issued regulations to protect workers from blood- sidered Personal Protective Equipment (PPE). borne pathogens, such as Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV). These diseases Hazardous Materials & Waste Management Bio- are caused by pathogenic microorganisms that are hazard Waste: present in the blood. These are not airborne viruses. Biohazard waste is any body tissue or bloody waste, You can only become infected by direct contact with such as gauze, pads, diapers, empty blood transfusion blood or body fluids, or materials such as unfixed tis- bags, or suction canisters containing bloody drainage. It sue, or organs (other than intact skin) containing the also includes all sharps. viruses, or cell or tissue cultures or solutions containing HIV, HBV, or other bloodborne pathogens. All infectious / biomedical wastes (any item with blood or body fluids on it) are placed in red bags at the point Because you do not know who might be infected with of origin and are securely sealed to prevent leakage. any of these bloodborne diseases, OSHA mandated Volunteers should not touch or transport these bags. “Universal Precautions.” Anyone in an occupation that Patient’s rooms and procedure rooms have puncture re- exposes him or her to the blood or body fluids of oth- sistant containers that are used for disposing of needles ers must protect himself or herself from the possibility and other sharp items. of becoming infected. To take “Universal Precautions” means to treat all patients as if they are infected with Sharps containers must be closed when full. A sharps HIV, HBV, or other bloodborne pathogens. container is considered full when materials placed into it Some Universal Precautions include: reach the designated fill line or three quarters ¾ capac - 1. Hand washing, the single most effective infection ity of the container. control procedure. 2. Wearing gloves when exposure to blood or body Red bags must be handled with care, avoid touching fluids is anticipated, especially if you have cuts, bag against body, and assume red bag may contain skin abrasions, chapped hands or dermatitis. Gloves sharps in error. The biomedical symbol shall be securely should be the appropriate size for your hands and attached or permanently printed on each RED bag, should be changed between patient contact. sharps container, and outer holding container, and be 3. Masks/goggles should be used to protect the mu- clearly legible. cous membranes of the eyes, nose and mouth from splashes of contaminated blood or body fluids. Volunteers should not touch these containers. 4. Aprons/gowns should be worn in case soiling/splash- ing of blood or body fluids occurs to skin or clothing.

Page 26 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Linen Handling: Exposure to Biohazards: All linen goes into the blue bags. Linen is treated as if If you are exposed to any biohazard, wash immediately infectious and proper barrier precautions are used when and report the exposure to your clinical instructor and/ coming in contact with a patient's body fluid. or staff resource person, Infection Control nurse or Em- ployee Health nurse; fill out an incident report/form and Laboratory Specimens: go to the Emergency Department. Lab specimens and blood bank bags should be securely sealed in a clear, plastic, disposable bag at the point Miscellaneous: of origin. The use of Special Precaution labels on the 1. Hepatitis B can be more contagious than Acquired specimen tubes and containers is not necessary, as all Immune Deficiency Syndrome (AIDS). However, specimens should be considered potentially infectious. there is a vaccine available that prevents HBV. 2. A person may be HIV positive and not have AIDS; Blood and Body Fluid Spill however, the person is contagious during this stage. To inactivate potential infectious pathogens as a result 3. Tuberculosis, chicken pox, mumps and measles are of a blood or body fluid spill apply premixed Coverage airborne. HBV Spray cleaner, or prepare a solution of one part 4. Respiratory Isolation precautions are used for per- bleach obtained from Environmental Services. Use sons with tuberculosis. They must be cared for in a gloves, and dispose of gloves and clean up materials as room with negative pressure, which means the room biohazard waste in RED bag. Be sure to soak area for is vented to the outside. 10 minutes before cleaning up. 5. Volunteers should not be in any situations where they are exposed to bloodborne pathogens, but it is Biological Hazards: extremely important that volunteers serving in nurs- Warning labels with the biological hazard symbol or the ing areas of the hospital be aware of the possible word “biohazard” is used to identify potentially con- biological hazards. taminated or infectious items. They could be on bags, equipment, containers, rooms, etc., that contain or are contaminated with biohazardous materials, i.e., blood, body fluids, or infectious materials.

Page 27 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Special note: When you are sick with a communicable Chemical Labeling Guidelines illness, we ask that you let us know what you have so Most chemicals utilized will be in the original container we can report it to the Infection Control nurse or Epide- with the manufacturer’s label intact. miologist for tracking purposes. You should not come to work or volunteer if you have any kind of infection, When you transfer a chemical from its original container i.e., sore throat, fever or undiagnosed illness; or open to another you should consult the information in the lesion, i.e., impetigo, rash or oozing cold sore. Material Safety Data Sheet (MSDS) to create your label for the new container. Observe the recommended pre- If more in-depth training in infection control and safety cautions, warnings and PPE. is needed in a certain area or department, this is provided on an individual basis on the unit by the unit manager/resource staff.

Tuberculosis (TB) Tuberculosis is carried on airborne particles that can be generated when persons with the disease sneeze, cough, speak, or laugh. Air currents keep these particles airborne and can spread them throughout a room or building.

TB isolation practices include the following: • Patient education – about transmission of TB and reasons for isolation and good protection techniques by patient when coughing or sneezing • Door to isolation room - closed at all times; room in negative air pressure • N95 or PAPR - respirator worn by staff while in room • Appropriate signage - affixed to patient door and chart • Transportation of patient - the patient will wear an appropriate mask during transportation. The personnel transporting the patient do not need to wear a mask outside of the isolation room.

Page 28 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Ergonomics Product Recall and Removal Ergonomics helps to fit the job to the person and helps St. Vincent’s Health System has a pro-active program to prevent strain that can lead to pain and discomfort. in place for notification of recalls to monitor, identify, Individual employee awareness of the prevention of communicate, repair and/or remove all stated products. bodily stressors and back injury is critical. Early report- These recalls may involve various affected products, ing will provide you with the help you need to rearrange tools, equipment, devices, or drugs that impact pa- your work station or teach you back injury prevention. tients, staff, or property. If you identify a faulty item, To prevent injuries to the back you are encouraged to tag and take out of service. have regular and moderate physical exercise. Radiation Safety Notification of Work Related Injuries Any occurrence of illness or injury on the job, no matter A radioactive material can be ei- how slight, must be reported. ther a sealed source such as the types used for radiation therapy Steps to take: treatment, implanted seeds, or it 1. Notify your supervisor immediately can be a liquid given to a patient 2. Go to the Personnel Health or Emergency Depart- for a Nuclear Medicine procedure. ment, if necessary In each case, the patient becomes 3. If the incident occurs before or after work hours, a radiation source. notify the Nursing House Supervisor 4. Complete an incident report in the DOERS (Dynamic On-line Reporting System) Within Radiology, Nuclear Medicine, Radiation Therapy, and the room of a patient containing radioactive materials, we will see a caution sign that will make us aware NOTE: Employees may not self-direct or refer of the possibility of radiation exposure. themselves to any medical provider for care associated with a work-related injury or illness. The sign will have a proper written description of its meaning. There are three basic types of radiation caution signs, (normally a magenta or purple radiation symbol or a yellow background). If the Caution Radioactive Material sign is posted on a patient’s room, instructions will be posted on the door, and anyone who wants to enter the room must read and follow them.

Page 29 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Radiation Protective Practices MRI Safety The three principles of radiation protective practices The Magnetic Resonance Imaging (MRI) equipment lo- are: Time, Distance, and Shielding. cated in your facility uses a large and powerful magnet Every individual within the hospital is responsible for that is always producing a magnetic field and therefore keeping his or her radiation exposures as low as pos- attracts metallic objects at all times. sible by observing three basic principles: 1. Perform your duties as quickly and safely as possible Any metallic object, including oxygen cylinders, wheel- following posted instructions, if available. This is the chairs or stretchers, can be subjected to the strong “Time Principle.” Exposure is directly related to the magnet’s pull and could become projectiles if brought amount of time spent near a radiation source. into magnetic zone. 2. Keep maximum distance between you and the potential or known radiation source. This is the “Dis- • Only MRI compatible equipment may be allowed into tance Principle.” The farther away from the radiation the MRI Magnet room at any time. source the smaller the exposure is going to be to • Non-compatible metal objects will cause severe you. damage and injury. 3. The “Shielding Principle” is the third method to mini- • Get permission from the MRI staff before entering mize employee exposure. Shielding means contain- area ing the source of radiation within a barrier that will block the radiation. This material is usually lead. Shielding of radiation sources sometimes is not possible and therefore the “time and distance principles” are the best protection.

Laser Safety Lasers are used in the OR. Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. The beams of lasers can cause burns to the skin and damage to the retina of the eye, therefore training, isolation of room where laser is in use, and use of protective equipment is mandatory. Heat generated can cause fire. Keep away from combustibles (paper, cloth), and flammable liquids (alcohol).

Page 30 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Medical Equipment Electrical Safety Guidelines Before using biomedical equipment look for the biomed- Report ALL electrical hazards to your supervisor imme- ical inspection sticker and the next inspection due date. diately, such as: If Biomedical Equipment starts malfunctioning, take • inoperative electrical/electronic equipment equipment out of service, tag as defective and contact • intermittent operation of electrical/electronic equip- the Biomedical Engineering Department. ment designed for continuous operation • improper extension cords, frayed or damaged power Testing Intervals – All biomedical equipment used in cords, wires or leads patient care areas shall be tested before it is first put • bare or exposed electrical wire into service, after any repair or modification, and re- • loose wiring on plugs or equipment tested at lest annually thereafter. • broken, cracked, damaged switches or plugs • broken pins on equipment plugs Operator’s Manuals – Operator’s manuals for all Bio- • damaged wall outlets, receptacles, plates or switch- medical Equipment shall be kept in the area where the es equipment is located and used. • three-wire to two-wire “cheater” adapters • burned out indicator lights Inspection Tag (sticker) – Biomedical Equipment, • equipment with a damaged case, switch, cord or including authorized extension cords, is inspected and a plug sticker with the date of the inspection is placed on the • liquid that has spilled into electrical equipment equipment. • any electrical shock you have received—no matter how small • meters, scopes, or displays that don’t seem to be working properly • excessive heat or smoke rising from equipment

Page 31 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Utility Systems Material Safety Data Sheet (MSDS) The Utilities Management Program addresses safe op- MSDS is the Material Safety Data Sheet. Every depart- eration, maintenance and emergency response proce- ment in the St. Vincent Health System has a Material dures for critical operating systems, as well as evalua- Safety Data Sheet or MSDS Manual, which outlines the tion, assessment, and improvement processes. chemicals you are exposed to in that department and health and safety concerns associated with the chemi- All critical elements of utility systems used for life sup- cal and how to store and handle them safely. A typical port, infection control, environmental support, equip- MSDS is divided into nine major sections: ment support, and communications are included in the 1. Chemical and Manufacturer name, address and program. emergency telephone number. 1. Electrical Distribution Systems 2. Hazardous ingredients and percentages contained 2. Heating, Ventilation, and Air Conditioning Systems therein. 3. Domestic Water Systems and Sewage Removal Sys- 3. Physical/chemical characteristics – appearance/odor, tems pH and vapor pressure. 4. Medical Gas Systems, and vacuum Systems 4. Fire and explosion hazard data – flammable limits of 5. Elevators – Vertical Transport Systems the chemical. 6. Communications Systems 5. Reactivity date – information on the chemical’s sta- 7. Steam Distribution Systems bility and materials, which are incompatible. 8. Fire Alarm Systems 6. Health hazard information – symptoms related to exposure to the product. MSDS (Medical Safety Data Sheet) 7. Precautions for safety handling, use, spill response OSHA, MSDS, and “The Right to Know” and disposal. The Occupational Safety and Health Administration 8. Control measures – personal protection information. (OSHA), mandates laws to protect workers on the job. 9. Special precautions – appears on some MSDSs. OSHA says workers have the “Right to Know” about potential chemical hazards they are exposed to in the work place.

Page 32 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations In the event of a chemical emergency, you should no- Protective Services (Security) tify your supervisor immediately and In the event of a THREAT OF VIOLENCE chemical emergency, you should notify your supervisor Acts or threats of physical violence which includes in- immediately and obtain the MSDS. Your staff supervi- timidation, harassment or coercion, and which in your sor will notify personnel responsible for the appropriate judgment affects your safety will not be tolerated. As- clean up procedure. sociates should be reported to the HR Manager in Hu- man Resources and non-associates should be reported Some Potential Hazards in a Hospital: to Protective Services. Radiation used in x-ray Chemotherapy used to treat cancer If immediate threats or acts of violence occur, associ- Ethylene Oxide used to sterilize hospital equipment ates should follow the procedures outline in your emer- Chemicals from bleach to white-out gency code for threats of violence. Medical Gases include oxygen and anesthetic gases Hospital Number Refer to facility for additional information regarding MSDS St. Vincent's Birmingham 939.7799 St. Vincent's East 838.3911 St. Vincent's Blount 625-4351 St. Vincent's St. Clair 781 - page Security One Nineteen Health & 408-6546 or Wellness 541-8441

Page 33 Care You Can Believe In HEALTH SYSTEM Environment of Care - Providing a Safe Environment General Orientation Manual Non-Associates & Clinical Affiliations Fire Response & Life Safety Fire Plan – Code Red Elevators should never be used during a Code Red. If there is a fire is in your area: stay calm, don’t shout “fire,” use the following procedure: Use of Fire Extinguisher You must be trained before using a fire extinguisher. R.A.C.E. When using, know your immediate exit route, alert for R – RESCUE Immediate action may be needed to save help, start back at least 8 feet from the fire, and follow a life. Move patients if immediate danger and close that PASS rules. door. A – ALERT Alert by pulling down the fire alarm pull PASS: station and notify switch board of exact fire location and P PULL the safety pin on the handle dial: A AIM at the base of the fire Hospital Number S SQUEEZE the handle to discharge agent S SWEEP from side to side St. Vincent's Birmingham 205.939.7223 St. Vincent's East 205.838.3500 Fire Response Plans (in house only) Each patient care unit and support service has a current St. Vincent's Blount 205.838.3300 fire response and evacuation plan developed. The plans St. Vincent's St. Clair 781 describe the steps that must be implemented to minimize immediate danger from a fire, removal of patients One Nineteen Health & Well- 911 to areas of refuge, evacuation to another level or sec- ness tion of the building, and evacuation of the building.

C – CONFINE Close doors and windows, to prevent smoke spread and to cut off air supply to fire. E – EXTINGUISH With fire extinguisher, if trained and safe to do so.

The steps to be used in the R.A.C.E. plan for fire safety may vary in sequential order depending on the immediate situation. For example, if you discover a fire in an empty room, the first thing to do would be to confine the fire by closing the door and then sound the alarm. If the fire is discovered in an occupied room rescue efforts should be implemented immediately.

Page 34 Care You Can Believe In HEALTH SYSTEM The Patient General Orientation Manual Non-Associates & Clinical Affiliations The Patient Patient responsibilities: At St. Vincent’s Health System, each patient has the • Provide information about your health following rights: • Ask questions when you do not understand • Tell your doctor if you cannot follow through with • Considerate and respectful care treatment • Be well informed about your illness, treatments and • Be considerate of other patients and hospital staff outcomes • Work with the hospital to arrange payment • Know the names and professional status of those • Recognize the effect of lifestyle on your health providing your care • Consent to or refuse a treatment If you or your family has any concerns or complaints • Have an advance directive while in our care, please contact the Patient • Personal privacy Representative. • Confidentiality • Review your completed medical record Unresolved Medicare grievances may be reported to: • Be free from restraints and seclusion of any form as a means of coercion, discipline, convenience or The Alabama Quality Assurance Foundation retaliation by staff Two Perimeter Park South, Suite 200W, • Know about hospital rules that apply to your conduct Birmingham, AL 35243. as a patient (?) 1-800-760-4550 • Appropriate and medically-indicated care • Appropriate assessment and management of pain The Joint Commission’s Office of Quality • Consent or right to refuse care that involves re- Monitoring search 1-800-994-6610 • Be involved in discharge planning [email protected] • Receive explanations about your hospital bill • Request assistance regarding ethical issues • Know your relationship with outside parties that may influence care, (i.e. educational institutions or insurers

Page 40 Care You Can Believe In HEALTH SYSTEM Cultural Differences General Orientation Manual Non-Associates & Clinical Affiliations Cultural Differences 5. Communicate and encourage feedback. Con- Understanding cultural beliefs and the variety of ethnic tinually evaluate the patient’s level of understanding backgrounds, regardless of age, can help you under- and ability to follow through with instructions re- stand a patient’s behavior, actions and responses in the garding his/her health care and plan of care. health care setting. Knowing all the customs and practices of the variety of cultures is not practical. However, In summary, be understanding and respect other peo- there are some key areas to focus on that can have an ple’s health care beliefs. Beliefs vary, such as: immediate impact on patient care and effect outcomes. • Illness may be viewed as a punishment or being evil Five (5) Key Areas to Address in Caring for a Patient of • Patients may view themselves as powerless over the a Different Culture: illness • Patients may believe greatly in alternative remedies, 1. Respect for personal space. Stay at arm’s length healing potions, biofeedback, acupuncture, and initially and observe the patient’s reaction and inter- herbal remedies action with other family members. For Example: In • Patients may not believe in taking medications or some cultures, physical closeness is preferred, i.e., have a fear of overmedication. Keep in mind that Spanish or Italian heritage. In other cultures person- if the family remedies or alternative remedies are al space and privacy are highly valued. not harmful to the patient or anyone else, and they 2. Tune into voice volume, eye contact, and ges- don’t interfere with your plan of care, then be willing tures. Speak clearly and in a soft tone. For Exam- to compromise. This may go a long way to improve ple: In some cultures, speaking loudly is considered the patient outcome. Reducing stress can improve rude and reflects anger, and in other cultures, direct the overall psycho-physiological response. eye contact may be viewed as being disrespectful. 3. Determine the primary caretaker. Ask the patient and/or family who will be responsible for providing the care. For Example: In Asian families, the oldest son is traditionally responsible for making decisions and carrying out instructions. So if instructions are given to the oldest daughter, she may understand but she may not have the authority to carry them out. 4. Respect your patient’s perspective of time. Be attentive to the perception of time. What may seem important to some may not be to others.

Page 41 Care You Can Believe In HEALTH SYSTEM Other Mandatory Topics General Orientation Manual Non-Associates & Clinical Affiliations Diversity Practitioner Health What is diversity? How does diversity affect our lives? The St. Vincent’s Health System and all St. Vincent’s Diversity means recognizing that each individual is Health System associates share a mutual responsibility unique and possesses unique gifts. It can also be de- to provide a safe and healthy environment for fellow as- fined as “otherness”. By otherness we mean that we see sociates, students and patients. people and groups as different from us. How we react to these differences in human qualities will influence It is the responsibility of each associate or student who both our personal and professional lives. observes another associate or student in an impaired condition to report this fact to his/her supervisor. It is important to distinguish between the primary and Students will report this to their clinical instruc- secondary dimensions of diversity. The primary dimen- tor. Clinical instructors will report this to the unit sions of diversity are broad categories of human nature manager. that can not be changed. Primary dimensions include age, ethnicity, physical abilities/qualities, and sexual orientation.

The secondary dimensions of diversity may be changed. They can include educational background, geographic location, income, marital status, military experience, parental status, religious beliefs, and work experiences. Diversity adds a vital texture to our lives. We must learn to embrace diversity in individuals and groups. When we value diversity, we help to create a stronger more compassionate society.

Our goal at St. Vincent’s Health System and Ascension Health is to celebrate the rich dimensions of diversity that are an integral part of our community and our workplace.

Page 42 Care You Can Believe In HEALTH SYSTEM Age Specific Needs General Orientation Manual Non-Associates & Clinical Affiliations Age Specific and Developmental Care Issues Preschoolers (3 to 5 yrs) - have imaginations that As caregivers, we must be aware that patient needs don’t stop. They are curious for factual information vary depending on their age and development level. --“Why” is their favorite word. They retain magi- The following is a summary of the major health care cal thinking and egocentrism. They feel that a “bad” issues, including physical, psychosocial, and safety thought can cause a “bad” event and often see illness needs, and appropriate age specific interventions. as “punishment”. They fear mutilation and bodily injury, losing control, and separation from family and friends. Newborns/Infancy (0 to 1 yr) — are dependent on They benefit from clear, simple explanations of proce- their caregivers to meet all their physical and emotional dures allowing them to “handle” equipment when pos- needs. They are developing a sense of trust. They are sible. sensitive to loud noise and develop anxiety towards strangers and unfamiliar environments. Preventing sen- School age (5 to 12 yrs) - start to have logical think- sory overload, limiting caregivers who come in contact ing; understands concepts of time and space. They are with the infant, and allowing parents to participate in concerned with modesty and privacy. Peer groups are their care are essential aspects of their care. important and accomplishments lead to improved self- esteem. Often concerned about death and hospitaliza- Toddlers (1 to 3 yrs) – are developing a sense of tion is seen as a loss of control. While caring for this autonomy. Caregivers should encourage their sense age group, allow and encourage discussion of feelings, of independence whenever possible —e.g., allow them offer choices and encourage decision making. Provide to help dress themselves. Promoting safety is a major privacy and allow peer interaction whenever possible. concern as toddlers are more mobile and are continu- ously exploring their environment. Additionally, tod- Adolescent (12 to 18 yrs) - are struggling for a sense dlers develop “magical thinking”, are egocentric, and of identity, however, they don’t want to be seen as dif- often blame themselves for events. Caregivers should ferent. Peer pressure may create problems with preg- provide simple, truthful explanations of procedures and nancy, sexually transmitted diseases, substance abuse, treatments. and Motor Vehicle Accidents. Health promotion should include these topics. Additionally, adolescents need reassurance about normal changes in body appearance/function.

Page 43 Care You Can Believe In HEALTH SYSTEM Age Specific Needs General Orientation Manual Non-Associates & Clinical Affiliations Adults(18 to 45 yrs) – move from dependency to responsibility. Often responsible for the care of children or parents. Major health risks are obesity, hypertension, heart disease, cancer, stroke, STDs, and smoking.

Middle Adults (45 to 70 yrs) - experience a slowing of reflexes, visual changes especially farsightedness, noticeable loss of taste and hearing, decreased balance and coordination, and decreased short term memory or recall. Need to individualize safety needs— need for adaptive equipment to prevent injury (e.g., handgrip at bathtub). May need to repeat information or adjust lighting when providing written materials.

Geriatrics (70+ yrs) – have decreased tolerance to heat/cold, decreased peripheral circulation, decreased functioning of major organs, and decreased response to stress and sensory stimuli. Decreased skin tone, decreased bone density, and loss of teeth occur. Provide support for coping with any impairments—avoid making assumptions about loss of abilities. Ensure safe environment and utilize measures to maintain/promote skin integrity.

In summary, incorporating simple, age-specific interventions enables health care providers to provide the most appropriate care to our patients.

Page 44 Care You Can Believe In HEALTH SYSTEM Additional Regulatory Mandatory Topics General Orientation Manual Non-Associates & Clinical Affiliations Minimizing the Use of Restraints—Know your To help minimize the use of restraints, it is important Role! to understand the underlying causes of behaviors As health care providers, we have increased our aware- exhibited by patients. Often patients demonstrate ness and emphasis on patient rights, individualized care aggressive or unsafe behaviors because they are and ethical considerations. In order to minimize the use confused, disoriented, angry or overwhelmed. of restraints, we must first understand the definitions. Sometimes a patient’s behavior is related to a medical rather than an emotional condition (for example, According to The Joint Commission (TJC): threatening or unsafe behaviors resulting from delirium in fevers). Seclusion is the involuntary confinement of a patient in a room or an area where the patient is physically Lastly, remember our behaviors affect the behaviors prevented from leaving. of the patient. Always use a non-threatening approach to try to defuse the behavior. For more information on Restraints are any method (chemical or physical) of these approaches, staff may attend the Non-violent restricting a patient’s freedom of movement, physical Crises Intervention classes. activity or normal access to his or her body. (Refer to facility specific policy for detailed information Alternative measures to deal with threatening behaviors regarding restraint use) or safety issues must be attempted and documented prior to the utilization of restraints. These measures may include assessment of patients comfort level, assessment of physical needs (is the patient hungry or thirsty, does the patient need to use the bathroom, etc); verbal re-orientation, de-escalation, mediation, and or decrease of environmental stimuli. Restraint alternative products can be used as well, such as: • Activity apron • Skin sleeves • Freedom splints

Page 45 Care You Can Believe In HEALTH SYSTEM Other Mandatory Topics General Orientation Manual Non-Associates & Clinical Affiliations Effective Pain Management Nursing care of the dying patient will be performed in What are some barriers to effective Pain Management? a holistic manner, focusing on the whole person in an • Pain is not assessed or inadequately assessed/reas- attempt to meet the physical, emotional, spiritual, and sessed. social needs of the patient approaching death, as well • People have fears about addiction. as the needs of the family. • Patients and families are not involved in planning for their pain management. Terminal illness clearly affects more than just the pa- • Tendency to under medicate (remember, pain is tient’s body; care for the dying patient requires a mul- “whatever the experiencing person says it is, exist- tidisciplinary team working together in concert to ade- ing whenever he says it does” - McCaffrey, 1968). quately address all aspects of that person and the many • Failure to use non-pharmacologic interventions. forms of suffering that may present. • Besides medications, the following measures can be used to relieve pain: The family will be supported and consoled and the pa- • Application of heat, cold, positioning, or tient kept as comfortable as possible at all times to be elevation. provide for the most peaceful passing in an atmosphere • Humor, distraction, guided imagery, self- that honors each individual’s needs and preferences hypnosis, relaxation, or music therapy. during this most sacred process. • Therapeutic touch, massage, or acupuncture. Other team members who can be to consulted regard- BE A PATIENT ADVOCATE - be proactive NOT reac- ing the care of the dying patient are; Palliative Care, tive! Pastoral Care, Socials Services and Ethics Committee. (Refer to facility specific policy for detailed information on pain management) (Refer to facility specific policy for detailed information on Care of the Dying Patient) End of Life Care—Meeting the Unique Needs of Pa- tients and Their Families

St. Vincent’s Health System Core Value of Reverence and consistent with the Ethical and Religious Directives for Catholic Health Care Services of the United States Conference of Catholic Bishops, the rights and dignity of every patient and family will be honored and protected.

Page 46 Care You Can Believe In HEALTH SYSTEM Other Mandatory Topics General Orientation Manual Non-Associates & Clinical Affiliations Organ Procurement—How much do you know? • Donation costs the donor family nothing Did you know that… • Giving the family an opportunity to donate is a kind and caring act. It can provide comfort and long term • An average of 77 organ transplants takes place consolation to family members every day in the U.S.; however, an average of 18 • Donation does not disfigure the body patients die every day while waiting for an organ • Donation occurs within a few hours of the family they need that did not become available in time giving consent • Today, a single organ donor can theoretically benefit • It is a crime to sell organs under the Federal more than 60 individuals if bones, eyes and organs National Organ Transplant Act (Public Law 98-507). are donated • A person becomes eligible to receive a donated • The number of organ transplants nation wide organ or organs by getting on the National List of recorded by the United Network for Organ Sharing Transplant Candidates. (UNOS) since 1988, is 400,291 • Geographical proximity is a key criterion in organ • As of June 22, 2007, the UNOS recorded 96,364 distribution. If a qualified recipient is not found candidates on their awaiting lists for organ locally, the search then turns to the national list. donations. This number has steadily increased over • Signing a donor card combined with family the years due to monumental advancements in the discussion of donation, is the most certain method of care and treatment of patients with end stage organ having one's wishes carried out. disease • Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi and Puerto Rico are the states that make up “Region 3” of the UNOS, as of June 22, 2007: • the UNOS recorded 49,825 candidates on their list awaiting an organ donation in Region 3 • the UNOS recorded only 25,773 organ donors in Region 3

• Federal and state law require that families be given the opportunity to donate their loved one’s organs/ tissues at the time of death, based on medical eligibility • Most major organized religions support donation as a humanitarian act in keeping with religious doctrine

Page 47 Care You Can Believe In HEALTH SYSTEM Other Mandatory Topics General Orientation Manual Non-Associates & Clinical Affiliations In keeping with St. Vincent’s Health System's Core Referral of Potential Donor Values, every effort will be made to comply with all ap- • The attending physician will determine prognosis of plicable federal and state laws/regulations regarding patient and discuss with the family and document in the procurement of organs and tissue while maintaining the progress notes. the dignity of the patient and compassion for the family. • Once the determination is made by the physician We will extend the healing ministry of Christ through an that death is imminent, or when death occurs, the active organ and tissue procurement program in associ- Alabama Organ Center (A.O.C.) at 1.800.252.3677 ation with the Alabama Organ Center and Alabama and Alabama Eye Bank at 1.800.424.7811) is noti- Eye Bank. fied to determine definite suitability for organ procurement • Refer to the Organ and Tissue Procurement for Donation policy for detailed guidance

Your notification to the Alabama Organ Center (A.O.C.) is a small role but the implications and potential benefits are tremendous!

The United Network for Organ Sharing (UNOS) information and data was obtained from www.OPTN.org.

Page 48 Care You Can Believe In HEALTH SYSTEM Other Mandatory Topics General Orientation Manual Non-Associates & Clinical Affiliations Identifying Victims of Abuse B. Neglect – The failure of a parent or caretaker to In keeping with the Core Values of St. Vincent’s Health provide basic needs such as food, shelter, clothing, and System, associates are committed to identifying, treat- health care for the child or adult unable to care for him- ing and referring victims of human abuse. Such victims self/herself; or the failure of the person to provide basic may be victims of abuse, neglect, exploitation, or do- needs for himself/herself when the failure is the result mestic violence. of the person’s mental or physical ability. C. Exploitation – An unjust or improper use of anoth- St. Vincent’s Health System cooperates with Alabama er person or another person’s resources for one’s own agencies to report or cause a report to be made by profit or advantage. practitioners of the healing arts and any other persons D. Domestic/Partner Violence – Characterized as having reasonable cause to know or suspect that a child a pattern of coercive behaviors that may include re- under the age of nineteen years or any person who is peated battering and injury, psychological abuse, sexual aged or disabled and has been the victim of abuse, ne- assault, progressive social isolation, deprivation, and glect, or exploitation. intimidation. These actions are perpetrated as a method of coercion, control, revenge, or punishment upon a Child/Elderly – Aged or disabled persons or children person with whom the partner is in a intimate relation- under the age of nineteen years arriving at the emer- ship. An imitate relations his defined as a relationship gency department, outpatient areas, or inpatients of the between spouses, former spouses, past or present un- hospital suspected of having been abused, neglected or married couples, or persons who are both the parents exploited, will be reported to the Department of Human of a child, regardless of whether the persons have been Resources of the State of Alabama (Title 27, Code of married or lived together at any time. Alabama, 197, Section 26-14-1 through 26-14-13 and Adult Protective Services Act of 1976, Section 38-9-1 As an associate, what do I do if I suspect abuse? through 38-9-11). Any person who reports a case of abuse will be immune from any liability, civil or criminal, • Notify the Charge Nurse/Manager and Case that might otherwise be incurred. Management during regular shift hours, after hours, notify the House Supervisor Definitions: • Refer to facility specific policy and/or unit A. Abuse – The willful, non-accidental inflection of manager for detailed information on reporting physical pain, injury, mental anguish, or sexual abuse abuse. or the willful deprivation by parent, caretaker or other person of services necessary to maintain mental and physical health.

Page 49 Care You Can Believe In HEALTH SYSTEM Other Mandatory Topics General Orientation Manual Non-Associates & Clinical Affiliations A Key Part Of Patient Safety One way to address these issues is to establish good communication and teamwork. In 1999, the Institute of Teamwork Medicine (IOM) published a landmark report on patient TJC Standard HR 2.30 safety titled, “To Err Is Human”. They estimated that up St. Vincent’s Health System and The Joint Commission to 98,000 people die annually from patient safety is- (TJC) believe that teamwork has a direct impact on sues. This has cost the nation approximately 29 billion patient care. TJC standard for team training reads as dollars. These errors are often made by highly skilled follows: individuals and are generally the result of system fail- • Ongoing education, including inservices, training, ures, not substandard individual performance. Despite and other activities, maintains and improves com- our best intentions, mistakes happen, and the individual petence. involved is often blamed for the error. Element 5: Ongoing in-services, training, or other education incorporate methods of team In July 2004, The Joint Commission (TJC)) noted in a training when appropriate. Sentinel Alert, that most cases of death and injury are caused by problems with an organization’s culture and Teamwork is more important today than ever! miscommunication. This prompted TJC to recommend In a world where healthcare is changing daily, team- that organizations conduct team training to teach staff work is more important than ever before. We are all to work together and communicate more effectively. struggling to manage a complex system that has inherent dangers such as: O’Brian & Keefe (2006), reported that nurses rate • Complicated equipment, teamwork and attitude as what is most important for • Biohazardous waste, them to remain in a particular job. While most hospital • Radiation, employees feel they already work in teams, the truth • Acutely ill patients, is that they don’t. We confuse working in groups with • Nosocomial infections working in teams. Webster’s defines a group asa num- The list could go on. ber of persons or things gathered together forming a unit; cluster; band. Teams are groups that have united Lack of teamwork or functioning in a vacuum can have for a common purpose (i.e. sports teams playing to- adverse effects on: gether to win a national championship, super bowl, or • Patient safety, hospital process improvement teams to initiate a new • Financial outcomes, and change in clinical practice or new policy). • Staff and customer satisfaction.

Page 50 Care You Can Believe In HEALTH SYSTEM Other Mandatory Topics General Orientation Manual Non-Associates & Clinical Affiliations A team has one common goal…All partners must work Service of the Poor toward one common goal. Every interaction matters. • acknowledging that every staff member is an advo- Striving for a common goal means that everyone needs cate and a servant made in God’s image to work together and everyone understands their value • building relationships and collaborating with other to the team. John Donne, a 17th Century English poet, for the common good spoke of teams in his famous quote: … “no man is an Reverence island, entire of itself; every man is a piece of the con- • being sensitive to the goals and needs of co-workers tinent, a part of the main.” Thus, can any of us say • listening when others are speaking, showing respect that we work alone? Working together in collaborative for their opinions and concerns relationships is essential to delivering a seamless con- Integrity tinuum of care and ensuring the best possible patient • working diligently to make the workplace more just, outcomes in a safe environment. more spiritual, and more ethical • providing a professional work environment that is Teams need to acknowledge the need for each and free from harassment every member of the team and the diverse contribution Wisdom each member brings to the team. Teams acknowledge • holding high expectations of myself and others; no the need for Interdependence. A team has the ability one ever rose to low expectations to connect across common divides. For example: across • recognizing and affirming excellence of associates, departments, job functions and assignments. Team physicians and volunteers members need one another’s knowledge, skill, and re- Creativity sources to produce something together that they could • being flexible and willing to assist when another’s not have accomplished alone. • workload is excessive • being open to the possibility of change with a posi- St. Vincent’s Health System recognizes the importance tive attitude of teamwork. Our mission and vision embrace team- Dedication work concepts and our core values outline how associ- • demonstrating commitment to accomplishing the ates and non-associate should demonstrate teamwork. goals of my unit/department and the organization The following are some examples of teamwork outlined • using teamwork to solve problems in our core values: Through teamwork we can reach Ascension Health’s Call To Action Healthcare That Works Healthcare That Is Safe Healthcare That Leaves No One Behind

Page 51 Care You Can Believe In HEALTH SYSTEM