Highland Hospital, John George Psychiatric Hospital, Fairmont Hospital, Ambulatory Wellness

Medical Staff Medical Executive Committee (MEC)

Report to the Quality Professional Services Committee of the Board

March 28, 2019 A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows:

 4 Initial Appointments  18 Reappointments  2 Proctoring Activity  2 Leave of Absence / Staff Status Change  6 Additional Privilege Request/Staff Status  9 Voluntary Resignations  1 vRad Proctoring Activity

Medical Staff Provider Clinical Privileges (Exhibit 1) The following privilege form and multi-facility privilege form were approved.

 Clinical Nurse Midwife  OB/GYN Multifacility

Provider Education Competency Module 2019 (Exhibit 2)  The 2019 provider education competency module was approved which incorporates the 2019 Joint Commission National Patient Safety Goals and other regulatory requirements.

B. Professional Services/ Contracting The non-physician contracts report was approved.

C. Quality and Outcomes  Wings (A&B) Seismic Update o Assessment of the buildings against the building code requirements o Concerns were expressed regarding the lack of engagement by the County regarding maintaining the integrity of the building

 Surge Report for “Surge Red”/Patient Flow o Performance presented; question raised about occupancy triage beds in the ED. More data is needed

 True North Metric Dashboard March o Highest patient satisfaction scores we have seen o Quality efforts continue to improve patient care

 SAPPHIRE Report – Electronic Health Record o Training sessions are ramping up over the next four months

Page 1 of 2

Alameda Health System MEC Report to the Board of Trustees March 28, 2019

D. Other Issues  AHS and SLH Medical Staff Merger o Medical Executive Committee from the Core and San Leandro have reached an agreement and are prepared to move forward with Bylaws revisions.

Medical Staff Medical Executive Committee (MEC)

Report to the Quality Professional Services Committee of the Board

March 28, 2019

A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows:

• 7 Initial Appointments • 2 Temporary Privileges • 11 Reappointments • 4 Proctoring Activity • 1 Additional Privileges and/or Staff Status Requests • 3 Voluntary Resignations

• 1 Proctoring Activity

Additional Credentialing Actions:

Medical Staff Provider Clinical Privileges (Exhibit 1) The following multi-facility form was reviewed and approved. This privilege form will be used for providers who apply for clinical privileges at Alameda Hospital and/or Alameda Health System.

• OB/GYN Multifacility

Provider Education Competency Module 2019 (Exhibit 2) The 2019 provider education competency module was approved.

B. Professional Services/Contracting The Non-physician contracts report was presented.

C. Quality and Outcomes True North Metric Dashboard March • Overall performance is at 75%; QIP goal is 98.29% - 100% o Incrementally meeting goals and achieving metrics

• PRIME and QIP measures are all at or above goal

Specialty Coverage • Neurology o Stroke Diversion 3/15/19 – 3/25/19 o Phone coverage from Highland Neurologist o Stabilization needed of the Stroke Program

• Gastroenterology o System level solution being explored for coverage and care o Request shorter term solution to expand the call coverage with other GIs on staff

Page 1 of 2

MEC Report to the Board of Trustees March 28, 2019

• Cardiology o AH physician is retiring July 1st

• Hospitalist o Contracting group is recruiting

D. Other Issues System transfers from Highland to Alameda Hospital • Expand the process and workflows for all transfers; including other non-AHS hospitals o Centralize the process local and communication o Remove burden from the physicians • Transfers are occurring to the Hospitalists beyond the CAP • Reports that there are continued issues with the process • Transfers for ERCP procedures from SLH; we are the only facility that does ERCPs o Recommendations to look at this information • Epic transfer modules will be reviewed for optimization

Chief Operating Officer / Patient Care Services Report • Report on the January 2019 Financial expenses o Expenses are well managed and out performance is within target o Project meeting EBITA target this fiscal year • FY20 Budget is being worked on at this time o Final budget May 28th o Gap of $100,000,000 being driven by the following: . Total revenue is going down in supplemental programs . GME funding is reduced o Leadership is looking at areas to revisit and close the gap while supporting mission o Capital equipment o $120M in liabilities in the balance sheet that are due by December 2019 • Facility specific projects were provided • Upcoming community events were shared

Sapphire Project • Updates were shared on training, testing, order sets

Medical Staff Medical Executive Committee (MEC)

Report to the Quality Professional Services Committee of the Board

March 28, 2019

A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows:

• 3 Initial Appointments • 2 Reappointments • 4 Proctoring Activity • 3 Resignations • 1 vRad Proctoring Activity

Provider Education Competency Module 2019 (Exhibit 2) The 2019 provider education competency module was approved which incorporates the 2019 Joint Commission National Patient Safety Goals and other regulatory requirements.

B. Professional Services/Contracting The Non-physician contracts report was presented.

C. Quality and Outcomes • The FY 2019 True North Metric Dashboard reviewed; San Leandro Hospital is doing well on the FY19 YTD quality pillars

• Public Hospital Redesign and Incentives in Medi-Cal (PRIME) and Quality Improvement Programs (QIP) and the 9 metrics that are being monitored were presented o Our dashboard for February demonstrates 42 PRIME metrics were green, March 43. February 14 QIP green, in March 15 are green

• Patient Experience is focusing on implementation of G.I.F.T. (greet, introduce, for, thank) which aims to improve communication amongst staff and patients

D. Other Issues

• Case Management and Social Services o Concerns were raised regarding understaffed and we are/ may be losing some extremely skilled and competent staff as a result. o CM leadership is focusing on recruiting, developing skillsets of the team, and relationship building.

Page 1 of 2

MEC Report to the Board of Trustees March 28, 2019

• San Leandro medical staff integration with the Alameda Health System medical staff Bylaws Revision(s) o We have come to an amicable agreement with AHS medical staff leadership on representation of SLH medical staff on the AHS MEC. We continue to work with AHS medical staff leadership to revise the AHS Bylaws.

• SAPPHIRE Report o Go-live will be focused on patient safety and care of the patient o Project Process including the training, testing of charges, orders and documents is underway, go-live decisions for the EHR inbasket

Chief Operating Officer / Patient Care Services Report • Report on the January 2019 Financial expenses o Total Expenses under budget o Project meeting EBIDA target this fiscal year • FY20 Preliminary Budget efforts underway to achieve the final budget date of 5/28/19 o Gap of $100,000,000 being driven by the following: . Significant reduction in supplemental revenues/programs . Legislative changes are impacting us i.e. $14million in Medicare GME funding . Operating expenses in labor are increasing within MOU agreements • Facility specific acute rehab project o Project tracking toward completion by June 30, 2019 o Planning continues for move and licensing process o Projected Move–in, November 2019 • Alameda Health System Foundation is supporting fundraising for capital equipment Mammography o $300,000 funding received for new digital mammography; completion 2/2020

Fundraising continues for the following: o 2 Mobile X-rays o Fluoroscopy Equipment o Nuclear Medicine Equipment • Blue Cross contract negotiations are be actively worked on. • Concerns were raised regarding ambulance diversion of patients who reside in the community to other facilities.

• Emergency Medicine Department Report

o Team from Stanford, CHO and EMS was on site 3/14/19 to assess SLH preparedness for pediatric emergencies, including staffing and equipment – part of Alameda County Disaster Preparedness efforts and ultimately assign designations for hospital EDs (assessment will affect ambulance traffic) o The newly added clinical nurse supervisor roles in the ED have been helpful. There continues to be concerns regarding staffing shortages in the ED resulting in closure of 4 ED beds for up to 8 hours per day. This ultimately impacts patient throughout and flow in the ED. Page 2 of 2

Certified Nurse Midwife - MCH - AHS Delineation of Privileges

Applicant's Name:

Instructions:

1. Click the Request checkbox to request a group of privileges such as Core Privileges or a Special Privileges. 2. Uncheck any privileges you do not want to request in that group. 3. Check off any special privileges you want to request. 4. Sign form and submit with any required documentation.

Required Qualifications Licensure Current California Board of Registered Nursing 1) Registered Nurse license, 2) Nurse Midwife license, and 3) Furnishing license. Current BLS certification from AHA approved provider. Current DEA registration with schedules 2, 2N, 3, 3N, 4, 5.

Education/Training Successful completion of a program leading to licensure as a registered nurse. Successful completion of a nurse-midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME) Division of Accreditation (DOA).

Continuing Education Evidence of thirty (30) hours of continuing education in areas that fall within the scope of practice for nurse midwives for the past two (2) years.

Certification Current certification as a Certified Nurse Midwife from the American Midwifery Certification Board (AMCB)

Clinical Experience Recent training and/or clinical experience is required for all applicants for appointment and (Initial/Reappointment) reappointment. Recent clinical experience is defined as having performed at least 40 inpatient care activities relevant to inpatient practice prerogatives requested and/or 200 clinical services or procedures in a Joint Commission accredited hospital or hospital based ambulatory setting in the last two years. The variety and type of clinical services must be sufficient to cover the scope of obstetric/gynecology practice prerogatives requested.

Additional Qualifications Written Supervising Physician Agreement AND Provider must submit documentation of successful completion of an AWHONN or ACOG endorsed class that includes current NICHD fetal monitoring nomenclature prior to, OR within 3 months of date of initial employment and annually thereafter. All documentation will be reviewed by the Department Chair of Obstetrics and Gynceology. AND Provider must submit documentation of successful completion of Baby Friendly training prior to, OR within 6 months of date of initial appointment. All documentation will be reviewed by the Department Chair of Obstetrics and Gynecology.

Published: 3/14/2019 Certified Nurse Midwife - MCH - AHS Page 1 of 4 [applicant]

GENERAL COGNITIVE PRACTICE PREROGATIVES

Description: Privileges available to the generalist NP.

Request Request all privileges listed below. Div Dept Uncheck any privileges that you do not want to request. Chief Chair Rec Rec

Obtain the patient's medical history and perform a physical examination. Management of the normal Obstetric Patient: Inpatient Management of the normal Obstetric Patient: Outpatient Manage the normal Gynecology Patient Conduct an initial and ongoing assessment of the patient's medical and physical status Order, conduct, and interpret lab tests and other diagnostic studies Counsel patients and their families on health promotion, diagnosis and management options. Facilitate and initiate referrals to appropriate health care agencies and arrange community resources. Administer, provide, or transmit drug orders or devices according to the requirements in the AHP Rules and Regulations.

FPPE Requirements First five (5) clinical activities include first three (3) H&Ps

PROCEDURAL PRACTICE PREROGATIVES

Request Request all privileges listed below. Div Dept Uncheck any privileges that you do not want to request. Chief Chair Rec Rec

GYNECOLOGY Minor GYN Procedures including: Pelvic Exam including Pap Smear Minor GYN Procedures including: Family Planning Services (Diaphragm Fitting, Wet Prep Exam for Vaginitis, IUD Insertion and Removal) Endometrial Biopsy Management of normal labor and vaginal delivery, (gestation 36 - 42 weeks), including: Amniotomy Management of normal labor and vaginal delivery, (gestation 36 - 42 weeks), including: Episiotomy Management of normal labor and vaginal delivery, (gestation 36 - 42 weeks), including: Fetal Monitor (Insertion, Placement) Management of normal labor and vaginal delivery, (gestation 36 - 42 weeks), including: Laceration Repair, 1st and 2nd degree Limited Obstetrical Ultrasound Examination SURGICAL Cesarean Section surgical assist

Published: 3/14/2019 Certified Nurse Midwife - MCH - AHS Page 2 of 4 [applicant]

Surgical Wound Care including changing of dressings, removal of sutures and clips, and treatment of superficial wound separations Insertion and Removal of Contraceptive Implant

FPPE Requirements Concurrent evaluation by a privileged CNM of the first 5 deliveries (for a CNM with > 1 year of hospital-based midwifery experience) or 10 deliveries (for a new graduate CNM). Concurrent evaluation of the first 4 first assist c-sections (for a CNM with > 1 year of hospital-based midwifery experience) or 10 first assist c-sections (for a new graduate CNM).

Acknowledgment of Applicant

I have requested only those privileges for which by education, training, current experience, and demonstrated competency I believe that I am competent to perform and that I wish to exercise at Alameda Health System and I understand that:

A. In exercising any clinical privileges granted, I am constrained by applicable Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation.

B. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws or related documents.

Practitioner's Signature Date

Department Chair Recommendation - Privileges

I have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s):

Privilege Condition/Modification/Deletion/Explanation

Published: 3/14/2019 Certified Nurse Midwife - MCH - AHS Page 3 of 4 [applicant]

Division Chief Recommendation - FPPE Requirements

Signature of Division Chief/Designee Date

Signature of Department Chair/Designee Date

Published: 3/14/2019 Certified Nurse Midwife - MCH - AHS Page 4 of 4 Obstetrics and Gynecology Delineation of Privileges

Applicant's Name:

Instructions:

1. Click the Request checkbox to request a group of privileges such as Core Privileges or a Special Privileges. 2. Uncheck any privileges you do not want to request in that group. 3. Check off any special privileges you want to request. 4. Sign form electronically and submit with any required documentation.

Required Qualifications Basic Education M.D. or D.O.

Education/Training Completion of an ACGME or AOA accredited Residency training program in Obstetrics and Gynecology.

Continuing Education Applicant must have [25] Category I CME credits per year (waived for applicants who have completed residency training during the previous 24 months). OR Applicant must be active in the MOC (maintenance of certification) program in obstetrics/gynecology.

Certification Current certification or active participation in the examination process leading to certification in Obstetrics and Gynecology by the American Board of Obstetrics and Gynecology or in Obstetrics and Gynecology by the American Osteopathic Board of Obstetrics & Gynecology.

Clinical Experience Recent clinical experience for initial appointment and reappointment is defined as having (Initial/Reappointment) performed at least 100 clinical services, procedures, or clinical consultations in a TJC-accredited hospital or hospital-based ambulatory setting in the last two years. The variety and type of clinical services must be sufficient to cover the scope of obstetrics/gynecology privileges requested.

Additional Qualifications 1) Provider must submit documentation of successful completion of an AWHONN or ACOG for Providers Requesting endorsed Fetal Heart Monitoring class that includes current NICHD nomenclature prior to, OR for Obstetric Privileges within 3 months of date of initial appointment and annually thereafter. All documentation will be reviewed by the Department Chair of Obstetrics and Gynecology. AND 2) Provider must submit documentation of successful completion of Baby Friendly training prior to, OR within 6 months of date of initial appointment. All documentation will be reviewed by the Department Chair of Obstetrics and Gynecology.

Published: 3/12/2019 Obstetrics and Gynecology Page 1 of 9 [applicant]

Core Privileges in Gynecology

Description: Evaluate, diagnose, provide consultation, treat and provide surgical and non-surgical management of reproductive health and pregnancy of female patients.

Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Admit to inpatient care or other level of care Perform history and physical examination Evaluate, diagnose, provide consultation and non-operative management of reproductive health and genitourinary system, including non-surgical treatment of injuries and disorders of the mammary glands. Moderate Conscious Sedation in Adults (current ACLS certification required) OR assisting for gynecologic surgery Procedures Minor GYN procedures including but not limited to: IUD insertion and removal, endometrial biopsy, Word catheter placement, and insertion and removal of contraceptive implants. Paracervical or pudendal block Marsupialization or excision of Bartholin's cyst or abscess Soft tissue biopsy of the genital-urinary tract or incidental biopsy of other lesions encountered in the course of a gynecologic procedure Simple vulvectomy Hymenotomy Dilation and curettage Dilation and evacuation (2nd trimester) Colpotomy, culdocentesis Colpocleisis Colposcopy Hysterectomy, abdominal, total or subtotal with or without BSO Hysterectomy, vaginal, with or without BSO Myomectomy via laparotomy Salpingectomy, salpingo-oophorectomy, salpingostomy, oophorectomy and/or resection of ovarian cyst Cold-knife conization of the cervix and or LEEP Amputation of cervix with colporrhaphy (Manchester Procedure) Colporrhaphy for urethrocele, cystocele, or rectocele Repair of enterocele Excision of vaginal/vulvar mass Vaginal myomectomy Cystoscopy as part of a gynecologic procedure Elective termination of pregnancy (1st trimester) Laparoscopy (diagnostic) Hysteroscopy (diagnostic)

Published: 3/12/2019 Obstetrics and Gynecology Page 2 of 9 [applicant]

Basic Operative Laparoscopy including treatment of endometriosis; assisted vaginal hysterectomy of uteri (anticipated to be less than 12 weeks gestational size); salpingectomy; salpingostomy; salpingo-oopherectomy; lysis of adhesions; myomectomy (pedunculated myoma); and ovarian cystectomy. Basic Operative Hysteroscopy including polypectomy; removal of IUD, incision of mild type 1 adhesions; resection of submucous myomas; resectoscopic endometrial ablation; global endometrial ablation; and hysteroscopic tubal sterilization. Incidental appendectomy Incidental bladder repair Incidental hernia repair (umbilical, incisional, ventral) Abdominal paracentesis Advanced Laparoscopy and Hysteroscopy Advanced Operative Laparoscopy including urethropexy (e.g. Burch); enterocele repair; vaginal vault suspension (sacrocolpopexy, utero-sacral ligament fixation); subtotal hysterectomy; assisted vaginal hysterectomy of uteri anticipated to be greater than 12 weeks gestational size; myomectomy (intramural, subserosal); presacral neurectomy; tubal reanastomosis; and total hysterectomy. Advanced Operative Hysteroscopy including the following procedures and other procedures that are extensions of the same techniques and skills: incision of uterine septum; incision of moderate to severe (type 2-3) intrauterine adhesions. Use of CO2 laser- requires successful completion of an approved residency in a specialty or subspecialty that included training in laser principles OR provide documentation appropriate to the specific laser to be utilized. Practitioner agrees to limit practice to only the specific laser types for which they have documentation of training and experience. Gynecologic Oncology Vascular access including placement of central venous lines and arterial lines Use of a laparoscope in a procedure where the applicant is a concurrent privilege holder Urethrolysis Presacral neurectomy Urogynecology Mid-urethral sling Vaginal suspension of the vault (to include but not limited to paravaginal repair, sacrospinous, high utero-sacral, vaginal mesh kits) Abdominal suspension of the vaginal vault (to include but not limited to sacrocolpopexy and paravaginal repair) Repair of vesico-vaginal or rectovaginal fistulas Cystotomy Cystoscopy ureteral catheter/stent placement Cystoscopy including but not limited to hydrodistention, intradetrusor injection Cystourethroscopy Proctoscopy Vaginal reconstructive surgery Laparoscopic reconstructive surgery in an area where the applicant has concurrent privileges for open procedures Colpectomy, partial or complete Suprapubic catheter placement Abdominal retropubic urethropexy (Burch; Marshall-Marchetti-Krantz, etc.) Vaginal trachelectomy Vaginal mesh excision Revision or removal of mid-urethral sling

Published: 3/12/2019 Obstetrics and Gynecology Page 3 of 9 [applicant]

FPPE (Proctoring) Requirements AHS Core AH

Retrospective evaluation to include pre-operative work-up, surgical plan and post-operative course of events of 5 surgeries representative of the scope and complexity of privileges granted. Concurrent observation of 3 cases representative of the scope of privileges granted.

Special Privileges: Female Pelvic Medicine and Reconstructive Surgery (Urogynecology)

Description: Evaluation, treatment, consultation and care of women with complex pelvic floor conditions including urinary and fecal incontinence, pelvic organ prolapse, genitourinary fistulas, and congenital anomalies.

Qualifications Education/Training Completion of a Fellowship program in Female Pelvic Medicine and Reconstructive Surgery approved by the American Board of Obstetrics and Gynecology (ABOG)

Clinical Experience (Initial) Applicant must provide documentation of provision of clinical services (20 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed fellowship training during the previous year).

Clinical Experience Applicant must provide documentation of provision of clinical services (20 cases) representative of (Reappointment) the scope and complexity of privileges requested during the past 24 months.

Additional Qualifications Applicant must be granted primary privileges in gynecology.

Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Procedures Anal Sphinchteroplasty Urodynamic testing Fascial grafts and biological grafts Sacral neuromodulation procedures Urethrolysis Urethral bulking for incontinence

Published: 3/12/2019 Obstetrics and Gynecology Page 4 of 9 [applicant]

FPPE (Proctoring) Requirements AHS Core AH

5 retrospective case reviews chosen to represent a diversity of major surgical procedures and management challenges.

Special Privileges: Gynecologic Oncology

Description: Evaluation, treatment, consultation and care of women with gynecologic cancer, including those diagnostic and therapeutic procedures necessary for the total care of the woman with gynecologic cancer or complications resulting from them.

Qualifications Education/Training Completion of a Fellowship program in Gynecologic Oncology approved by the American Board of Obstetrics and Gynecology (ABOG) or by the AOA

Certification Board eligibility or current certification in Gynecologic Oncology by the American Board of Obstetrics and Gynecology or in Gynecologic Oncology by the American Osteopathic Board of Obstetrics & Gynecology.

Clinical Experience (Initial) Applicant must provide documentation of provision of clinical services (10 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed fellowship training during the previous year).

Clinical Experience Applicant must provide documentation of provision of clinical services (10 cases) representative of (Reappointment) the scope and complexity of privileges requested during the past 24 months.

Additional Qualifications Applicant must be granted primary privileges in gynecology .

Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Procedures Placement of intraperitoneal access catheters Placement of thoracostomy tube and thoracentesis Select, initiate and administer chemotherapeutic agents for the treatment of cancer via all therapeutic routes Radical hysterectomy with/without lymph node dissection including laparoscopic assist Lymphadenectomy of the inguinal, femoral, pelvic and para-aortic areas Inguinal-femoral lymph-node dissection Incision and drainage of abdominal or perineal abscess Published: 3/12/2019 Obstetrics and Gynecology Page 5 of 9 [applicant]

Intercavitary brachytherapy insertion Pelvic exenteration (anterior, posterior or total) Ureteral anastomosis Ureteral resection and reconstruction Ureterolysis Urinary diversion, including pouch Ileal conduit or continent urinary diversion Large or small bowel resection Colostomy, cecostomy, gastrostomy Ileostomy Vaginectomy or vulvectomy - simple and radical Neo-vaginoplasty and vulvar reconstruction Interstitial perineal template Gastroenterostomy Resection of upper abdomen tumor metastases involving omentum, diaphragm, spleen or liver Resection of metastatic tumors involving the abdominal wall or skin Abdominal sacrocolpopexy Endoscopic exam of the rectum and colon with or without biopsy Local tissue rearrangement flaps for closure of perineal defects Laser ablation of vulvar, vaginal and perineal lesions

FPPE (Proctoring) Requirements AHS Core AH

5 retrospective case reviews chosen to represent a diversity of major surgical procedures and management challenges.

Core Privileges in Obstetrics

Description: Evaluate, diagnose, provide consultation, treat and provide surgical and non-surgical management of reproductive health and pregnancy of female patients. To be granted OB privileges, applicant needs to show a minimum of 6 shifts per year or 12 shifts in two years.

Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Admit to inpatient care or other level of care Perform history and physical examination Evaluate, diagnose, treat and medically manage reproductive health, pregnancy, and medical diseases or problems that are complicating factors in pregnancy. OR assisting for deliveries Published: 3/12/2019 Obstetrics and Gynecology Page 6 of 9 [applicant]

Procedures 3rd trimester amniocentesis OB Ultrasound Normal labor and delivery with/without episiotomy Local anesthesia, pudendal and paracervical blocks Induction and augmentation of labor Operative delivery including the use of forceps and vacuum External cephalic version Repair of vaginal, cervical and perineal lacerations including 3rd and 4th degree lacerations Post vaginal delivery tubal sterilization Cesarean section including hysterectomy and tubal sterilization Cervical cerclage Management and delivery of multiple pregnancy Specialized Obstetrical Procedures Vaginal delivery only Cesarean section assist only

FPPE (Proctoring) Requirements AHS Core AH

Concurrent observation of 3 cesarean deliveries Retrospective review of 5 vaginal deliveries Review of data collected for OPPE for physicians in this specialty

Special Privileges: Maternal-Fetal Medicine

Description: Evaluation, treatment, consultation and care of women with complicated pregnancies. This cluster includes privileges specific to Maternal-Fetal Medicine that were not previously referenced in the cluster for Primary privileges in Obstetrics.

Qualifications Education/Training Completion of a Fellowship program in Maternal-Fetal Medicine approved by the American Board of Obstetrics and Gynecology (ABOG) or by the AOA

Certification Board eligibility or current certification in Maternal and Fetal Medicine by the American Board of Obstetrics and Gynecology or in Maternal and Fetal Medicine by the American Osteopathic Board of Obstetrics & Gynecology.

Clinical Experience (Initial) Applicant must provide documentation of provision of clinical services (20 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed fellowship training during the previous year).

Clinical Experience Applicant must provide documentation of provision of clinical services (20 cases) representative of (Reappointment) the 20scope and complexity of privileges requested during the past 24 months.

Request Request all privileges listed below. Published: 3/12/2019 Obstetrics and Gynecology Page 7 of 9 Page 8 of 9 Date [applicant] Obstetrics and Gynecology FPPE (Proctoring) Requirements Uncheck any privileges you do not want to request. do not want to any privileges you Uncheck to Request all privileges. blue check box Click shaded - Currently granted privileges Intrauterine fetal therapy (fetal thoracentesis, paracentesis and administration of fetal medications, Intrauterine fetal therapy (fetal thoracentesis, or injection) intrauterine umbilical vessel aspiration Provide genetic counseling for commonly recognized disorders for commonly recognized Provide genetic counseling Procedures Amniocentesis, genetic at all stages of pregnancy Ultrasound examination, all types and Chorionic villus sampling Intrauterine transfusion Outpatient diagnosis and management of obstetric patients Outpatient diagnosis and management of obstetric patients Inpatient consultation linked genetic, or possibly genetically treat and provide consultation regarding Evaluate, diagnose, or birth defects diseases or disorders 5 retrospective case reviews chosen to represent a diversity of procedures and management challenges. 5 retrospective case reviews chosen to AH AH

AHS Core AHS Core Department/Service Chair Recommendation - Privileges Acknowledgment of Applicant I have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s): I have reviewed the requested clinical privileges and supporting documentation Published: 3/12/2019 Practitioner's Signature

B. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions B. Any restriction on the clinical privileges granted to me is waived in an emergency are governed by the applicable section of the Medical Staff Bylaws or related documents. A. In exercising any clinical privileges granted, I am constrained by applicable Hospital and Medical Staff policies and rules A. In exercising any clinical privileges granted, I am constrained by applicable applicable generally and any applicable to the particular situation. I have requested only those privileges for which by education, training, current experience, and demonstrated competency I which by education, training, current experience, and demonstrated competency I have requested only those privileges for that: and that I wish to exercise at Alameda Health System hospital(s) and I understand believe that I am competent to perform [applicant]

Privilege Condition/Modification/Deletion/Explanation

Department/Service Chair Recommendation - FPPE Requirements

Signature of Department/Service Chair or Designee Date

Published: 3/12/2019 Obstetrics and Gynecology Page 9 of 9

Provider Education / Competency Module 2019

Alameda Health System-AHS (Highland Hospital, John George Psychiatric Hospital, Fairmont Hospital, Ambulatory Wellness Clinics) San Leandro Hospital- SLH Alameda Hospital- AH

Table of Contents

*The Joint Commission National Patient Safety Goals (NPSG)…………………. 3 Universal Protocol …………………………………………………………………………………. 4-6 Do Not Use Abbreviations ……………………………………………………………………… 7 Medication Safety …………………………………………………………………………………. 8-11 *Pain Management ……………………………………………………………………………….. 12 HIPPA Privacy and Security ……………………………………………………………………. 13-15 Emergency Operations Plan / Emergency Management …………………………. 16 *Emergency Codes ………………………………………………………………………………… 17 Restraints ……………………………………………………………………………………………… 18 Infection Prevention……………………………………………………………………………… 19 *Hand Hygiene ………………………………………………………………………………………. 19-22 *Antimicrobial Stewardship……………………………………………………………………. 23 *Blood borne Pathogen ………………………………………………………………………… 24-25 *Tuberculosis …………………………………………………………………………………………. 26-27 *Radiation Safety……………………………………………………………………………………. 28-30 Ethics and Compliance……………………………………………………………………………… 31-33 Domestic Violence California Mandatory Reporting Law…………………………. 34 Workplace Harassment …………………………………………………………………………… 35-37 Workplace Violence Prevention ………………………………………………………………. 38-39 Physician Well Being / Provider Wellness ………………………………………………… 40-41

*Per regulatory requirements, the modules listed above with an (*) are required annually.

Page 2 of 41 2019 Hospital National Patient Safety Goals The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them.

Identify patients correctly NPSG.01.01.01 Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. NPSG.01.03.01 Make sure that the correct patient gets the correct blood when they get a blood transfusion.

Improve staff communication NPSG.02.03.01 Get important test results to the right staff person on time.

Use medicines safely NPSG.03.04.01 Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. NPSG.03.05.01 Take extra care with patients who take medicines to thin their blood. NPSG.03.06.01 Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

Use alarms safely NPSG.06.01.01 Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

Prevent infection NPSG.07.01.01 Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. NPSG.07.03.01 Use proven guidelines to prevent infections that are difficult to treat. NPSG.07.04.01 Use proven guidelines to prevent infection of the blood from central lines. NPSG.07.05.01 Use proven guidelines to prevent infection after surgery. NPSG.07.06.01 Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.

Identify patient safety risks NPSG.15.01.01 Find out which patients are at risk for suicide.

Prevent mistakes in surgery UP.01.01.01 Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.

UP.01.02.01 Mark the correct place on the patient’s body where the surgery is to be done. UP.01.03.01 Pause before the surgery to make sure that a mistake is not being made.

This is an easy-to-read document. It has been created for the public. The exact language of the goals can be found at www.jointcommission.org.

The Joint Commission’s (TJC) National Patient Safety Goals (NPSGs) You play a critical role in ensuring our patients’ safety at Alameda Health System. You are the eyes and ears of the organization, and you can quickly recognize a patient safety issue and help get it resolved. TJC has developed patient safety goals based on patient events that have happened across the country. Be familiar with these goals. To ensure the safety of our patients, know what your role is in implementing these goals.

Identify patients correctly: Two unique identifiers are required prior to providing care. The two identifiers for inpatients and outpatients are:

A. Patient name (first and last name) B. Date of birth (month, day, and year)

For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

Make sure that the correct patient gets the correct blood when they get a blood transfusion. • Acknowledge your presence to patient by addressing them by name; introduce yourself to the patient and explain your purpose in the room. Patient identifiers are: • Name and date of birth • Name and date of birth for outpatient areas in which there is no armband (i.e. lab) • Ask the patient to identify him or herself if able. Do NOT state the patient’s name and ask if that is correct. • Before collecting a specimen or performing a procedure, compare the name and date of birth on the armband to a document with the identifiers (MAR, requisition, etc.). • Label blood tubes or specimen containers AT the bedside with patient’s two identifiers, date and time of collection, your initials. • When administering blood or blood products, two qualified staff members must conduct a review of the patient’s identity and match it with the document accompanying the blood product. One of the qualified staff must be the person administering blood or blood product. A physician may serve as a “qualified staff member” in this process.

Improve staff communication: Get important test results to the right staff person on time.

1. For telephone orders / telephonic reporting of critical tests results, verify the complete order or test result by having the person receiving the order or test result “read back” the complete order or test result and the patient name.  When communicating the telephone order, you should require the nurse to read back the order to verify the information given and the patient name.  When you receive a critical value, you should also read this back to verify the information given and the patient name.  Note: Verbal orders are ONLY allowed in emergency situations.

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Use medicines safely: Before a procedure, label medicines that are not labeled. For example: medicines in syringes, cups and basins. Do this in the area(s) where medicines and supplies are set up.

Take extra care with patients who take medicines to thin their blood – Use printed MD Anticoagulation order sheets i.e. Heparin, argatroban when applicable.

Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their updated list of medicines every time they visit you or the hospital.

Note: Ensure that a complete list of home medications is documented on admission on the Home Medication List (HML) and that you review and sign the form.  Update the list if you are aware medications are missing or have been discontinued or changed.  Refer to the HML (medication reconciliation list) when writing admission, transfer or discharge orders so NO medications are missed.  When transferring patients between units, review the current list of medications and reorder as appropriate.  Reconcile medications on discharge, giving the patient a complete and accurate HML (medication reconciliation list). Do not use any abbreviations on this list.  At the time of discharge, the patient is instructed to give a copy of the HML to their next provider of healthcare.

Use alarms safely: The physician has authority to set alarm parameters based on their goals for the patient’s treatment. Alarm settings can only be changed from default alarm settings based on a written MD order.  Heart rate must never be set below 35  Blood pressure it actively treating may use 20-25% above or below current reading until intervention completed  Respiratory rate lower limit never below 8  Pulse ox never below 90% unless specifically ordered by MD  When applicable write patient specific parameters for alarm settings Prevent infection:  Use the hand cleaning guidelines from the Centers for Disease Control and Prevention. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.  Use proven guidelines to prevent infections that are difficult to treat.  Use proven guidelines to prevent infection of the blood from central lines.  Use proven guidelines to prevent infection after surgery.  Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.

Identify patient safety risks: Find out which patients are most likely to try to commit suicide.

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Prevent mistakes in surgery – Universal Protocol: Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.

Mark the correct place on the patient’s body where the surgery is to be done. Pause before the

surgery to make sure that a mistake is not being made.

 Pre‐operative/pre‐procedure verification will include verification of the correct person, procedure and site during the following:  At the time the procedure or surgery is scheduled  At the time of admission or entry  Anytime responsibility of care is transferred  With the patient awake and involved, when possible  Before the patient leaves the pre‐op area

 Review the following before procedure:  Relevant documentation (H&P, anesthesia assessment, informed consent, etc.)  Relevant images and reports  Relevant biopsy/pathology reports  Any required implants, blood products or special equipment

 Physician to mark the site using only their INITIALS or “YES” at or near the incision site. The process must be documented on the checklist.  Have all members of the health care team pause and participate in a TIME OUT led by the physician immediately prior to the procedure. During a Time Out, everyone is to pause and verify the correct patient, procedure, site and position.  If clinically possible, have the patient awake during the time out.

Other Important Information

Implement a standardized approach to “hand‐off” communications:

 Include an opportunity to ask and respond to questions. (Examples: Unit‐to‐Unit transfers, Anesthesia to PACU, Unit to Procedural Area, Physician‐to‐Physician)  Use SBAR (Situation, Background, Assessment and Recommendation) for patient care handoffs. Ensure recipient has an opportunity to ask questions.

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Do Not Use List of Abbreviations These DNU abbreviations include:

 NO unapproved abbreviations are allowed in ANY medical record documentation.

Abbreviatio n/ Dose Prone to Error Misinterpretation Recommendation Expression

U or u Heparin 5000 u Read as a zero (0) or a Write out “units” Do Insulin 10 u 4 four (4), causing a 10 fold not abbreviate “u” u packed cells overdose or greater (4u seen as 40 or 4u seen as 44)

IU For International Mistaken as IV Write “International Unit” Unit (intravenous) or 10 (ten)

Q.D and Q.O.D. Latin abbreviation Mistaken for each other. Write “daily” and “every other for once daily & The period after the Q day” every other day can be mistaken for an I and the O can be an I

Zero after Ativan 1.0mg Misread as 10 mg if the Do not place a decimal followed decimal point decimal point is not seen by a zero to the right of a whole (1.0) number (1 mg)

No Zero before Ativan .5mg Misread as 5mg Always place a zero followed by a decimal dose decimal to left of a fraction (0.5 (.5mg) mg)

MS, MSO4 or Confused for one Can mean morphine Write “morphine” or MgSO4 another sulfate or “magnesium” magnesium sulfate

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Medication Safety

SOUND A LIKE LOOK ALIKE MEDICATIONS

 Clearly identify and distinguish Sound‐Alike / Look‐Alike (SALAD) medications. The table below is a list of SALAD medications. Look for “TALL‐MAN” lettering on medication labels. For example: HYDROmorPHONE vs. morPHINE to help differentiate between Sound Alike Look Alike medications.

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HIGH RISK HIGH ALERT MEDICATIONS High Risk High Alert medications are those that have been identified by the Institute of Safe Medication Practices to bear heightened risk of causing significant patient harm when used in error. As a result, these medications have been identified to have special procedures for handling to prevent errors.

Antineoplastics  Double check all chemotherapy orders for regimen, doses, calculation, (Chemotherapy) concentration and infusion rate by two pharmacist prior to distribution of antineoplastic agents  Double check all chemotherapy orders for regimen, doses, calculation, concentration and infusion rate by two nurses prior to administration.  Only chemotherapy or specially trained/certified nurses will be permitted to administer anti-neoplastics.  NO verbal orders are accepted.

Epidural, PCA,  Standardized concentrations for PCA, epidural and narcotic infusions. Fentanyl patches  Patients will be monitored for level of pain relief and signs and symptoms of over and narcotic sedation and side effects. infusions  Based on dosing equivalence, fentanyl patches will be approved by pharmacy prior to administration Insulin  All insulin doses are double checked by two licensed nurses for accuracy on dose, time and order of insulin.  Insulin vials are kept in the Automatic Dispensing Machines, on all nursing units (except Fairmont). Vials are kept in separate containers, clearly labeled and away from other floor stock vials.  Units are spelled out and printed in all orders and medical care plan and diabetic flow sheet. No abbreviations as “u” or “U” are allowed.  Standardize insulin drip concentration. Bag label & pump rate must be double- checked by two nurses.  Use infusion pump for all insulin drips to safeguard against potential overdose.  Patients will be monitored for signs and symptoms of hyper/hypoglycemia per standardized insulin protocol. Antithrombotics  Utilize standardized premixed heparin infusion bags when available by (Anticoagulants, manufacturer. Factor Xa  Limit the number of concentrations available to floors and stored separately. inhibitors)  Use smart infusion pump for all intravenous heparin infusions.  Limit the number of Low Molecular Weight Heparin (LMWH) syringes and dosages in the emergency department.  Pharmacist protocol for warfarin  DOAC’s will only be available for patient specific administration Magnesium  Magnesium sulfate is printed and spelled out on order. No abbreviations allowed. sulfate  Premixed magnesium bags in minimal quantities for all patient care areas. All quantities will be kept in Automatic Dispensing Machines. Potassium  Concentrated vials of potassium are not permitted in any patient care areas chloride,  Only premixed bags of KCL are allowed in patient care areas. Potassium  Intravenous drips shall require a pump. phosphate,  Pharmacists will review potassium order prior to dispensing (except for ED) Potassium acetate

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Sodium chloride  No NaCL with a concentration > 0.9% are available in patient care areas in those 24 concentrations hour pharmacies. > 0.9%  For those non 24 hour pharmacies, concentrated Sodium Chloride can be available through the ADM in locked cubie and can only be accessible through a pharmacist verified ordered. No override ability will be available for concentrated NaCL.  A pharmacist dispenses concentrated NaCL in 24 hour pharmacies per patient- specific order after review and will delivered by pharmacy to unit.  Warning labels are placed on the pharmacy bins containing NaCL > 0.9%. Total parenteral  A dedicated infusion line for TPN only. nutrition (TPN)  Established standard TPN Protocol for central and peripheral administration.  TPN therapies are monitored per pharmacy for appropriateness. Thrombolytics  Developing standardized protocols/ ED screens for AMI and stroke.

ADVERSE DRUG REACTIONS  According to the FDA, An adverse drug reaction (ADR) is defined as a response to a drug which is noxious and unintended and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for modification of physiological function.  If an ADR is suspected, the reaction should be reported in the AHS Safety Alert.  A pharmacist will review the report and start an investigation to evaluate causality and assess the probability of a reaction using standardized criteria.  Pharmacists may also report suspected ADR’s for a new drug (typically within 3 years of entering the market) or a suspected severe ADR for any drug to the FDA Medwatch program.  ADR’s reported to the FDA can act as signals which are then investigated to determine their clinical significance and potential public health impact. This may lead to regulatory action, including mandatory warnings and label changes, manufacturer-sponsored post marketing studies, journal publication, modified indications, or rarely product withdrawal.

MEDICATION ERRORS  Medication errors are mishaps that occur during prescribing, transcribing, dispensing, administration or monitoring of a drug.  Examples of medication errors include misreading or miswriting a prescription, a medication not administered at the time it was due, wrong dose ordered and duplicate therapies. Medication errors that are stopped before harm can occur are sometimes called “near misses.”  Not all prescribing errors lead to adverse outcomes. Some do not cause harm, while others are caught before harm can occur. If a medication error is suspected, it should be reported in the AHS Safety Alert to allow for tracking and trending.

More information on Medication Safety:  For written orders, write orders legibly and print your name so staff knows who to call for questions.  Do not carry medications in your pockets or hip pouches! The temperature is not appropriate.  Label all syringes, basins and medication cups PRIOR to the procedure with the name of the medication (i.e. normal saline, sterile water, Lidocaine, etc.), strength, amount and expiration date when not used within 24 hours.)  Label only ONE syringe ‐ basin, etc.‐ at a time.  Hospital has a policy for safe administration and monitoring of patients on anticoagulation therapy.  Obtain baseline and ongoing lab results for patients on anticoagulation agents such as

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heparin and warfarin (Coumadin®) to monitor effects.  A black box warning is a notice on the packaging of a prescription drug which warns patients and prescribers that the drug has potentially dangerous side effects. This warning system is primarily used by the Food and Drug Administration (FDA).

Example: Fentanyl patch BBW: should ONLY be used in patients who have demonstrated Opioids tolerance. Tolerance: taking Opioids for ≥ 7 days, ≥ 60mg Morphine oral/day, ≥ 30mg oxycodone/day, ≥ 8mg Dilaudid oral/day, or any other equianalgesic doses.

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Pain Management Pain management is considered a basic right for all patients. Pain assessments and remedies must be tailored to the individual patient’s age, abilities, personal, cultural, spiritual, and/or ethnic beliefs.

The assessment of pain is an interdisciplinary process including input from physicians, nurses, pharmacists, physical therapists and other clinical disciplines involved with the patient’s care.

The Registered Nurse will interact with the physician when it becomes evident that current pain management regimens are ineffective.

Pain is  assessed on admission  Reassessed every four (4) hours as necessary OR  When indicated by verbal or non-verbal signs and/or symptoms of pain  Within 60 minutes of administration of pain medication using the:  Modified Wong Baker 0‐10 Pain Intensity Scale  Nursing Assessment of Pain Intensity Scale (NAPI) for preverbal children and cognitively impaired adults  The Riles Infant Pain Scale/Assessment Tool for newborns to two (2) months of age

 Consider possible reduced dosing of pain medications for patients with body weight less than 50 kgs., and patients with chronic respiratory, kidney or liver impairments.  If pain is still present at discharge, physicians must address pain management as part of the discharge instructions.

Patients who do not achieve satisfactory pain management report less satisfaction with their care in the hospital.

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HIPAA Privacy and Security Every person working in a health care facility must be familiar with general confidentiality procedures and practices. The following is a brief guideline on patient privacy and security at Alameda Health System.

HIPAA is a federal law that requires AHS to: • Protect the privacy of patient information • Secure patient health information (physically and electronically) • Adhere to the “minimum necessary” standard for use and disclosure of patient health information • Specify patients’ rights for access, use and disclosure of their health information

Fines and Penalties

HIPAA Civil/Criminal Penalties • Up to $1.5 million per violation • 10 years in Jail

State Penalties • Individuals and Entities • Up to $250,000 • 10 years in Jail All physicians and workforce members of Alameda Health System may have access to confidential patie nt information. Any information identifying a patient (“Protected Health Information” or “PHI”) legally must be used only for patient care, billing, and quality improvement and other healthcare operations. Having this information kept private is the legal right of patients, including employees and physicians who are patients. Below are recommendations to help maintain security, privacy, and confidentiality of patient information at Alameda Health System:

Protecting Patient Privacy

Verbal Exchanges • Be aware of your surroundings when talking • Lower your voice • Do not leave PHI on answering machines

Know Where You Left Your Paperwork • Double check! When mailing or handing documents to patients/family members, slow down and verify that each document belongs to the patient. • Check printers, faxes, and copier machines when you are done using them. • Do not leave paper PHI laying on your desk; lock it up at the end of the day.

If you must take PHI with you, follow these tips to reduce the risks of theft or loss of PHI: • Do not leave any PHI in your car; even if you lock up your car. Your car can be burglarized. • Double check that you have your belongings before leaving a coffee shop, restaurant or public transportation.

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Text Messaging

• Do not communicate PHI via text messaging since AHS does not have a secure platform to send text messages. • The only recognized secure mechanism for the electronic transmission of PHI data is via encrypted email.

Sending AHS Emails Securely

• When emails are sent internally within AHS Outlook, our email system is secure and can be used to transmit patient information. • If you are using email to send patient information external to AHS Outlook, you will need to ensure that PHI is processed securely by using AHS’ Secure email.

DO THE FOLLOWING: • Enter SECURE:(space) at the beginning of the Subject Field. • Continue typing your Subject line as you normally do but do not include PHI. • Compose and send the email.

It is your responsibility when communicating to send all PHI securely.

When your job requires you to work from home or Follow transport PHI between sites, follow best practices:

Access Access PHI remotely via Virtual Private Network (VPN)

Ensure all devices used to access ePHI or AHS email are Ensure encrypted

Never leave PHI unattended in your bag, briefcase or your Never car (even if it’s locked in the trunk!)

Remember, this applies to all types of PHI – paper, films, Remember photos, cameras, CDs and ePHI stored on laptops

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Media Inquiries and Authorization for Records • Send all media requests for information regarding a patient to Corporate Communications and Marketing (510) 437‐4732. • Written permission (authorization) must be obtained from a patient before the medical record can be made available to anyone not directly involved with the care of the patient, billing, or operations. • Contact Medical Records Department at Highland Hospital (510) 437-4469, San Leandro Hospital (510) 667-4575, or at Alameda Hospital (510) 814-4304 for forms. • Contact the Compliance Department (510) 535-7788 if you have questions or believe patient privacy has been compromised .

Page 15 of 41 Emergency Operations Plan In the event of a disaster, an announcement will be made overhead calling a Triage Code and the number of expected casualties the medical center can expect. Medical Staff within our facilities are asked to report to the Labor Pool (if activated) otherwise remain on the unit. Physicians who are out of the hospital and responding to our call for assistance should report to the campus specific locations. Providers should report to their Department Chair and follow their Department's Emergency Plan to receive instructions about clinical assignments. The Labor Pool is established by the site's Hospital Command Center. Department Leaders will be notified via the Hospital Command Center regarding essential assignments and potential staff deployment. Please remember to bring your identification badge.

Alameda Health System has implemented a comprehensive all hazards Emergency Operations Plan in order to assure the most appropriate hospital response to the medical needs of the community in the event of an emergency/disaster situation or a mass casualty incident. This all hazards plan complies with the elements of the National Incident Management System (NIMS) and incorporates the Hospital Incident Command system (HICS) and addresses the six critical areas mandated by the Joint Commission standards. The approval process includes review and approval by the Chiefs of Medical Staffs.

A complete Hazard Vulnerability Analysis (HVA) is conducted annually to identify potential emergencies (natural and man‐made) that could increase the need for the organization's services, or its ability to provide those services. A multidisciplinary committee, including physicians, annually updates the HVA. The completed document is reviewed by the Medical Executive Committee.

During a disaster demand for care may exceed the ability to deliver healthcare. Disaster privileges may be granted to Volunteer Licensed Independent Practitioners after presenting documentation and completing a verification process by the Medical Staff Office. A temporary badge will be presented and they will be paired with credentialed Medical Staff members.

In a healthcare surge, the focus may shift from patient‐based care to population‐based outcomes as determined by the California Department of Public Health. Appropriate standards of care may also vary based on the availability of resources, patient needs and environmental factors. Medical Care is coordinated and guidance is provided by the Medical Staff Specialist in the Hospital Command Center and implemented by the Medical Care Branch Director (HICS identified positions).  When you hear a Triage Code overhead or receive a call from the hospital letting you know that our Emergency Management plan has been activated: o Go to the site specific Labor Pool (if activated) or to the unit you are assigned o Bring your ID badge  We have an up‐to‐date Emergency Operations Plan in place and practice using it twice per year. o A committee consisting of a physician liaison and persons from a variety of disciplines perform an annual update to the Hazard Vulnerability Analysis  The Medical Staff Office facilitates disaster privileges to volunteer licensed independent practitioners who present proper documentation. These practitioners are then paired with credentialed Medical Staff members  When shifting to population‐based care, medical care is: o Coordinated by the Medical Staff Specialists in the Hospital Command Center o Implemented by the Medical Care Branch Director

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Emergency Codes You may hear the following emergency codes announced overhead in Alameda Health System facilities.

Know the significance of every code.

YOU may activate Codes Red, Gray, Yellow, Pink, Silver, Purple, Blue or Stroke by calling ext. 55555

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Restraints 1. Always consider alternatives to the use of restraint such as reorienting, diversion items, safety education, and/or personal alarms

2. Assess for the underlying cause of the behavior necessitating restraints, (i.e., medication, oxygenation, infection, electrolyte imbalance, etc.)

3. Restraint orders shall never be written as standing orders or PRN (as needed) orders. If the need for medical‐ surgical restraint use extends beyond 24 hours, the physician must reassess the patient daily, before writing new daily order. The physician must complete orders, date, time and sign.

4. Alameda Health System will limit the use of restraints for behavioral management only for management of violent or self‐destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. This type of restraint use requires a face‐to‐face evaluation of the patient conducted by a physician trained in conducting a n evaluation, within 1 hour of the initiation of the restraint.

5. The face‐to‐face session must evaluate the following: a. The patient’s immediate situation/condition or symptoms that warranted the use of restraints. b. The patient’s reaction/response to the intervention c. Alternatives or other less restrictive interventions attempted (if applicable) d. The patient’s medical and behavioral condition e. The need to continue or terminate the restraint.

6. Orders for Restraints for violent or self‐destructive behavior are limited to 4 hours for adults. The patient must be reassessed for continuation of restraints and a new order obtained at that time. The RN can reassess and obtain T.O order at 4, 12 and 20 hours. The Physician must reassess at 8, 16 and 24 hours.

7. The order for use of Restraints for management of violent or self‐destructive behavior must be limited to:  Four (4) hours for adults  Two (2) hours for children 9 – 17  One (1) hour for children under 9

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Infection Prevention Infection prevention is everyone's job. Each of us has an important role to play in keeping patients safe from infection.

Hand Hygiene Hand hygiene is the practice of properly cleaning your hands with soap and water or with an alcohol- based hand rub.

According to the Centers for Disease Control and Prevention (CDC), performing proper hand hygiene is the single most important method for preventing and controlling the spread of germs from person to person. Observational studies show that healthcare workers washed their hands an average of five times per shift, with some as many as 30 times per shift. Certain nurses washed their hands approximately 100 times per shift. Despite these statistics, a great deal of research shows that healthcare workers generally do not cleanse their hands according to the required guidelines. In fact, only about 40% of healthcare workers cleanse their hands appropriately. Transmission of Germs Research shows certain patients are likely to be carriers of a germ called Staphylococcus aureus on areas of intact skin. Likely carriers are patients who:  Have chronic dermatitis  Have diabetes mellitus  Are undergoing dialysis for chronic renal failure

You can contaminate your hands by touching the patient’s: . Gown . Bed linens

. Side rails . Bedside furniture . Call light

These germs are shed daily from a patient's skin onto items close to the patient, such as the patient's gown, the side rails of the bed, and the call light. You can contaminate your hands performing such activities as:  Taking blood pressure or temperature  Removing the meal tray  Lifting the patient

When germs are transferred to the hands of healthcare workers during these activities, and if hand hygiene is not done correctly, the hands of the healthcare worker spread harmful germs to other patients.

When to Perform Hand Hygiene Healthcare workers should perform hand hygiene before and after specific activities, as well as any time hands are visibly dirty. Before  Eating and handling Food.  Handling medication.  Putting on gloves to perform invasive procedures.  Handling an invasive device for patient care regardless of whether gloves are used

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After  Removing gloves.  Having any contact with blood or bodily fluids.  Having contact with a contaminated body site and before moving to a clean body site during patient care.  Touching inanimate (nonliving) objects, including medical; equipment in the immediate patient surroundings. Before and After  Having direct contact with patients.

Using Alcohol-Based Hand Rubs Proper hand hygiene, whether washing with soap and water or using an alcohol-based hand rub, is an important way to prevent health care-associated infections. According to the CDC, the ideal method for hand hygiene is the use of a hand rub that contains 60% to 95% alcohol.

Using Soap and Water When hands are visibly dirty, the CDC recommends washing your hands with soap and water instead of using an alcohol rub. Wet your hands, apply the correct amount of soap, and rub vigorously for at least 15 seconds. Be sure to rub all surfaces of the hands and fingers. Rinse your hands and pat them dry with a clean towel. Use the towel to turn off the water if needed. You are also required to wash your hands with soap and water before eating and after using the restroom.

 Hand hygiene is the practice of properly cleaning your hands with soap and water or with an alcohol- based hand rub.

 Hand hygiene is the single most important method for preventing and controlling the spread of germs from person to person.

 Based on research conducted by the CDC, hand hygiene noncompliance among healthcare workers is the leading cause of health care–associated infections.

 The Joint Commission requires hospitals to develop hand hygiene policies and improve hand hygiene compliance.

 Research shows that some patients, such as those with chronic dermatitis, diabetes mellitus, or those undergoing dialysis for chronic kidney failure, are more likely to be carriers of a germ called Staphylococcus aureus on areas of intact skin.

 Healthcare workers must perform hand hygiene before and after direct patient care. Perform hand hygiene before eating or putting on gloves, after removing gloves, or after coming into contact with a contaminated item, as well as any time hands are visibly dirty.

 Studies show alcohol-based hand rubs quickly decrease the number of germs on the hands of healthcare workers.

 When hands are visibly dirty wash your hands with soap and water instead of using an alcohol rub.

 Always perform hand hygiene after you remove your gloves.

 Don’t wear artificial nails if you work directly with patients. Keep natural nails clean and short.

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The table below provides specific requirements and prevention methods.

SPECIFIC PREVENTION METHODS REQUIREMENTS Hand Hygiene ● The number one method to prevent the spread of infection. ● Performed upon entry into and exit from patient rooms. ● Should also be practiced before and after contact with each patient. Influenza and ● All healthcare workers are required to have Influenza vaccination or sign a declination. Pneumococcal Vaccinations ● During influenza season a mask is required to be worn in patient care areas if the influenza vaccine is declined. ● Every patient should be assessed for Influenza and pneumococcal vaccination status and receive vaccinations needed before discharge Multi‐Drug Resistant  All patents should be screened for MRSA based on hospital specific criteria. Organisms (MDRO)  Per California regulations physicians will discuss positive results and document that the patient or the patient representative was informed.  Patients diagnosed with an MDRO are placed on Contact Precautions.  Highland and San Leandro Hospital require patients colonized with MRSA to be placed on Contact Precautions . Alameda Hospital MRSA - colonized patients alone are not placed on Contact Precautions unless signs of active infection (see transmission based precautions) Foley Catheters  The use of a Foley catheter should be limited to patients who meet specific criteria and removed as soon as possible. The need for the Foley catheter should be assessed daily.  The patient/or family member should be educated about the risk of Foley catheter and ways to prevent infections.   Alternatives to consider are intermittent catheterization using a bladder scanner and male or female external catheters when possible. Clostridium  difficile C. diff is a spore forming bacteria that is a difficult organism to control, (C diff /CDAD)  Patient with diarrhea (not medication related) should be placed in Enteric/Enhanced Contact Precautions - a type of Contact precautions that requires hand washing with soap and water and use of bleach to clean equipment and patient rooms.  Patients should be placed in a private room and a stool specimen be sent by nursing.  Antimicrobial stewardship is a very import measure to prevent C diff, prescribing target therapy to pathogen, using appropriate dose and therapy.  Do not perform “test for cure” following a positive test since patients may carry toxigenic C. diff for months after treatment  Hand Hygiene must be performed using soap and water. Alcohol-based hand sanitizers are ineffective at killing C diff spores. Hospital  Report to the Infection Preventionist any patient who may have a HAI. If a patient dies, or Associated Infection (HAI) has a permanent loss of function due to an HAI, it is considered a Sentinel Event, requiring immediate action. Reporting  For patients seen in the Emergency Department, the physician is responsible for completing a Communicable Confidential Morbidity Report for reportable conditions. Diseases  For admitted patient’s Infection Prevention is responsible for completing a Confidential Morbidity Report for reportable conditions.  The Infection Preventionist should be notified for cases in which a communicable disease requires immediate intervention or reporting to Public Health.

SPECIF IC PREVE NTION METHODS REQUIREMENTS Page 21 of 41

C entral Li nes  Th e majority of hospital-acquired blood stream infections are associated the use of Central venous catheters.  Orders should be placed prior to insertion. The need for the central line should be assessed daily and should be discontinued if no longer need.  The patient/or family member should be educated about the risk of Central Line catheters and ways to prevent infections.  The Central Line Insertion Practice bundle form should be completed for all insertions. It requires hand hygiene, hair covers, sterile gowning/gloving, maximum barrier drapes, and masks and sterile technique  Catheters into the femoral vein should be avoided unless other sites are not available. Femoral lines MUST be assessed for removal within 24 hours of insertion. Surgical Procedure  Infections remote to the surgical site should be identified and treated before elective procedures.

 Patients having elective procedures should shower or wipe with a Chlorhexidine product the night before and the morning of the procedures.  When hair removal is necessary, clippers should be used only, outside the OR in the PACU  Patients and family members should be educated about surgical site infection prevention.  Use the correct prophylactic antibiotic for the procedure being done. Note: Vancomycin is the prophylactic antibiotic used prior to hip and knee joint replacements and CNS shunt placement.  Prophylactic antibiotics should be given within 1 hour of surgical incision. Vancomycin should be given within 2 hours of surgical incision.  Prophylactic antibiotics should be discontinued within 24 hours after the surgical incision is closed unless a post‐op infection is documented.

Standard Precautions  Standard precautions are to be taken with ALL patients to prevent the spread of infection. Assume blood and body fluids of all patients are infectious.  Gloves should be worn when hands are likely to come into contact with blood and body fluids.  Protect clothing with fluid resistant gowns when clothing is likely to be soiled with body fluids.  Wear a mask and goggles/shield when eyes/mucous membranes will be splashed. Transmission based  Patients may require isolation based on symptoms or positive culture for pathogens. precaution Precaution signs posted by the patient’s door. Patient should place an order for the type of precaution and the order to discontinue.  Contact Precaution applies to organisms transmitted by direct or indirect contact. Gloves and Gowns must be worn. Examples of organisms that require Contact precautions are MRSA, VRE, ESBL, scabies, lice, and Multi Drug Resistant organisms.  Droplet Precaution applies to respiratory diseases transmitted through the respiratory tract. Mask and Eye protection should be worn. Examples of when Droplet precautions should be applied include:” rule out bacterial meningitis, influenza and pertussis.  Airborne precautions applies to organisms that can be transmitted by airborne nuclei that can be dispersed by air current over long distances. Examples include TB, varicella (chicken pox), and measles, and disseminated herpes zoster. PPE required includes N95 or PAPR while performing High Hazard procedures. Eye protection should be worn when creating aerosols.  Enteric precautions (enhanced contact) apply to patients with unexplained diarrhea suspicious for C.diff or norovirus. Gloves and gowns must be worn. Soap and water is required for hand hygiene.

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Antimicrobial Stewardship Antimicrobial Stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.

In Alameda Health System we have customized Antimicrobial Stewardship programs approved by each Pharmacy and Therapeutics Committee for Alameda Health System, San Leandro Hospital and Alameda Hospital.

Alameda Health System (AHS) Annual Empiric Antibiotic Therapy Guide (ETG).

Evidence-based, consensus-driven recommendations customized to AHS based on the Annual Antibiogram and in alignment with CMS Core Measures and national guidelines.

Recommendations  Perform an “antibiotic time-out” after 48-72 hours when culture and susceptibility data can direct appropriate therapy.  Streamline to narrow-spectrum, directed against the organism(s) recovered from culture.  When possible, convert parenteral antimicrobials to comparable oral antimicrobials  Treat for the shortest duration that is clinically effective. If there is low suspicion for infection at 48-72 hours, consider discontinuing antibiotics, especially if fever has persisted despite appropriate antibiotics.  “Foam in, Foam out” – wash your hands or use antimicrobial hand sanitizers each time you enter and exit a patient's room.  There are situations when recommendations in this ETG are not clinically appropriate. In these situations, document the justification for a different treatment regimen.

Alameda Hospital (AH) Empiric Antibiotic Therapy Guide.

Evidence-based, consensus-driven recommendations customized to AH based on the Annual Antibiogram and in alignment with CMS Core Measures.

San Leandro Hospital (SLH) Annual Empiric Antibiotic Therapy Guide (ETG).

Evidence-based, consensus-driven recommendations customized to SLH based on the Annual Antibiogram and in alignment with CMS Core Measures.

Recommendations  Perform an “antibiotic time-out” after 48-72 hours when culture and susceptibility data can direct appropriate therapy.  Streamline to narrow-spectrum, directed against the organism(s) recovered from culture.  When possible, convert parenteral antimicrobials to comparable oral antimicrobials  Treat for the shortest duration that is clinically effective. If there is low suspicion for infection at 48-72 hours, consider discontinuing antibiotics, especially if fever has persisted despite appropriate antibiotics.  “Foam in, Foam out” – wash your hands or use antimicrobial hand sanitizers each time you enter and exit a patient's room.  There are situations when recommendations in this ETG are not clinically appropriate. In these situations, document the justification for a different treatment regimen. Page 23 of 41

Blood Borne Pathogens Blood borne pathogens are bacteria and viruses carried in the blood that can cause disease. They are spread when the blood or body fluid of an infected person comes into contact with the blood, open skin, or mucous membranes of another person. As a healthcare provider, you are at risk for exposure to blood borne pathogens.

Exposure Control Plan The Occupational Safety & Health Administration (OSHA) developed blood borne pathogen standards for healthcare workers to decrease their risk of accidental contact with blood borne pathogens.

Personal Protective Equipment Alameda Health System provides personal protective equipment to you if you are at risk for exposure to blood borne pathogens. Under normal conditions of use, and for the time that it is used, personal protective equipment should prevent blood and other possibly infectious materials from passing through to your: • Work clothes, street clothes, and undergarments • Skin, eyes, mouth, and other mucous membranes

Standard Precautions Use standard precautions when providing patient care or while handling items that may be contaminated with blood and body fluids. The table below lists the recommendations from the Centers for Disease Control and Prevention for the use of standard precautions for the care of patients in all healthcare settings.

Standard Precautions Hand hygiene Perform after touching blood, body fluids, secretions, excretions, and contaminated items; after removing gloves; and between patient contacts. Gloves Use when touching blood; body fluids; secretions; excretions; contaminated items; mucous membranes; and skin with cuts, abrasions, or other openings. Gown Use during procedures and patient care activities when contact of clothing or exposed skin with blood, body fluids, secretions, or excretions may occur. Mask, eye Use during procedures and patient care activities that are likely to cause splashes or sprays of protection blood, body fluids, or secretions, especially during suctioning and endotracheal intubation. (goggles), face shield Soiled patient care Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear equipment gloves if visibly contaminated; and perform hand hygiene. Environmental control Routinely care for, clean, and disinfect environmental surfaces, especially frequently touched surfaces in patient care areas. Material and laundry Handle in a manner that prevents transfer of microorganisms to others and to the environment. Needles and other Do not recap, bend, break, or hand-manipulate used needles. sharps If recapping is required, use a one-handed scoop technique only. Use safety features when available. Place used sharps in a puncture-resistant container. Patient resuscitation Use a mouthpiece, resuscitation bag, and other ventilation devices to prevent contact with mouth and oral secretions.

Patient placement Make it a priority to place a patient in a single-patient room if the patient is at increased risk for spreading an infection to others, does not maintain appropriate hygiene, or is at increased risk for acquiring infection or developing an adverse outcome following an infection. Respiratory hygiene Instruct symptomatic persons to cover their mouth and nose when sneezing or coughing, use and cough tissues and dispose of them in a no-touch receptacle, perform hand hygiene after soiling of hands etiquette with respiratory secretions, wear a surgical mask if tolerated, or maintain separation greater than 3 feet of space if possible.

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Putting on and Removing PPE

Order for Putting on Personal Order for Removing Personal Protective Equipment Protective Equipment

1. Isolation gown 1. Gloves

2. Mask or respirator 2. Face shield or goggles

3. Goggles or face shield 3. Gown

4. Gloves 4. Mask or respirator

Blood Borne Pathogens Exposure Incident An exposure incident happens when you have direct contact with blood or body fluid through: • Splash or spray to your eyes, mouth, or other mucosal surface • Needle stick, laceration, or other piercing of the skin by an object contaminated with blood or other body fluids • Contact with contaminated blood or body fluid that enters a cut, abrasion, or other lesion on your skin

What to Do if You Are Exposed Alameda Health Systems exposure control plan describes specific steps to follow if you are exposed to contaminated substances in the workplace. The exposure control plan should tell you about the free post exposure evaluation and follow-up care. The post exposure evaluation and follow-up are confidential.

Exposure Incident What to Do Hands or skin Immediately wash the area with soap and water. Mucous membranes Flush the exposed area with water. Any exposure incident Notify your supervisor of the exposure incident immediately. In some cases, preventive treatment may be necessary and must be started within only a few hours of the exposure. The patient involved in the exposure may require testing.

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Tuberculosis The Centers for Disease Control (CDC) states healthcare organizations must complete a risk assessment to decide how often TB testing is needed. Alameda Health System has determined that we are at Medium risk per the guidelines they recommend a 2 step process for all healthcare workers. All Alameda Health System providers, employees, volunteers and contractors provide a 2 step TB Test upon starting at AHS.

References https://www.cdc.gov/tb/publications/slidesets/infectionguidelines/default.htm

https://www.cdc.gov/mmwr/PDF/rr/rr5417.pdf

Local, state, and federal laws require confidentiality for all healthcare workers and patients who have latent TB infection and active TB disease.

Latent and Active TB Patients can have one of two types of TB. Some patients have a form of TB called latent TB infection, while others may have active TB disease.

Latent TB Infection

Patients with latent TB have the TB germs in their bodies, but the germs do not actively attack the tissue or organs within the body. Therefore, these patients do not get sick or have signs or symptoms of the disease and cannot spread the germs to others. A patient with latent TB may develop TB disease in the future.

The table below describes the medical course of action for patients who have latent TB infection to help diagnose and prevent the development of active TB. Actions Taken for Patients with Latent TB Testing A simple tuberculin skin test or Interferon-gamma release assay (IGRA) blood test can be used to detect the presence of the TB germ. The tests do not identify whether the patient has TB disease.

TB skin testing in older adults is not a good method of finding out whether they have TB infection. Skin tests of older adults often show a false-negative result because the immune systems of older people are 6 weaker and cannot react to the skin test.

A chest x-ray and samples of sputum—material coughed up from the lungs and spit out through the mouth—are needed to tell if the patient has active TB disease. Medication To prevent patients who have latent TB infection from developing active TB disease in the future, doctors may prescribe medications for them. Precautions in the When caring for patients with latent TB, follow standard precautions. Healthcare Setting Click Standard Precautions for more information.

Active TB Disease Patients develop active TB disease when the immune system is weakened and cannot fight off TB germs. In patients with active TB disease, TB germs: • Grow and multiply inside their bodies. • Attack the body and kill living tissue. The attack can happen anywhere in the body, but usually TB germs infect the lungs. • Can create a hole in lung tissue. If TB is not treated, the patient can die. Remembering Your Patient's Language and Cultural Differences Healthcare workers must teach patients and their families about: • The cause of TB. Page 26 of 41 • How to prevent it. • How to treat it. • Why airborne infection precautions and isolation rooms are used. Provide patients and their families with written material that is easy to read and understand. According to the CDC, teaching should be done in the patient's own language. A medical interpreter can help. The local and state health departments can also help with language interpretation. Interpretation resources can be found at: http://www.atanet.org; http://www.languageline.com; and http://www.ncihc.org. Providing Care to Patients with TB Hospitals must use special methods for treating patients who are suspected of having or are known to have active TB disease.

The Airborne Infection Isolation (AII) Room The airborne infection isolation (AII) room used to be called a negative pressure room. The air flow in these rooms is controlled. Contaminated air from the patient's room is not shared with other patients and staff, but is either vented directly outside or sent through a high-efficiency particulate (HEPA) filter before it re-circulates through the air system.

Airborne Infection Precautions Place a sign at the entrance of the patient's room so everyone knows to use airborne infection precautions. ALL staff who enter the patient’s room MUST use a fit-tested N95 respirator Door MUST remain closed to maintain negative pressure ONLY INFECTION PREVENTION’s TB COORDINATOR (or IP representative) CAN DISCONTINUE AIRBORNE ISOLATION.

Employee Use of Respirators The use of respirators is another way hospitals prevent the spread of TB. Respirators and Fit Testing The Occupational Safety & Health Administration (OSHA) requires facilities to develop and use a respiratory- protection program for healthcare workers who use respiratory protection devices. They must be fit-tested for the respirator and taught how to make sure their mask fits properly. Fit testing should be done during initial employee training and periodically afterward according to federal, state, and local laws. The minimum level of protection required by OSHA is an N95 filtering respirator. Laboratory workers, radiology workers, and other hospital employees who use respiratory protection should also be trained to use the N95 respirators and they should be fit-tested for them. Follow the AHS protocol on fit-testing and fit-checking N95 respirators.

Page 27 of 41 Radiation Safety As a healthcare worker, you can be exposed to radiation while at work. Because you cannot see or feel radiation, it is critical that you practice recommended precautions to ensure your safety and the safety of your patients.

Healthcare professionals, especially diagnostic imaging professionals, are responsible for safeguarding patients, other healthcare workers, and the public from unnecessary exposure to radiation. Unnecessary exposure is any contact with radiation that does not provide essential diagnostic information or does not enhance the quality of a particular study.

What is Radiation? Radiation is the emission of energy, rays, or waves. A simpler definition is "energy in transit from on location to another." There are many different types of radiation, such as ultraviolet and electromagnetic waves. X-rays, visible light, and microwaves are all examples of electromagnetic waves.

Standards for Safety Radiation safety is governed by standards from the Environmental Protection Agency (EPA), the Occupational Safety & Health Administration (OSHA), Food and Drug Administration (FDA), and the Nuclear Regulatory Commission (NRC). The Joint Commission also provides standards that address patient safety in its Comprehensive Accreditation Manual for Hospitals.

Limits for Radiation Exposure

Healthcare organizations are required to maintain records of radiation exposure and advise employees of their individual exposure at least once a year. Other requirements state that organizations must provide a report of radiation exposure records to current and former employees when requested.

The table lists the Occupational Safety & Health Administration's recommended dose limits for an employee working with radiation.

OSHA Recommended Limits for Radiation Exposure Area Exposed to Rems Per Calendar Radiation Quarter Whole body; Head 1 1/4 and trunk; active blood-forming organs; lens of eyes; or gonadsHands and forearms; 18 3/4 feet and ankles Skin or whole body 7 1/2 Courtesy of Occupational Safety and Health Administration

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Safety Management Plan

In addition to radiation exposure records, organizations must develop a safety management plan that describes:

 How the organization will effectively manage hazardous materials and waste, including radioactive materials  Safety risks related to radiation exposure  Safety policies and procedures to minimize or eliminate the risk of exposure to radiation  An inventory system that reviews how the hazardous materials and wastes are used, stored, or generated  Emergency plans to address spills and exposure

ALARA The ALARA principle, as described by the United States Nuclear Regulatory Agency (NRC), states that radiation exposure should be kept "as low as reasonably achievable (ALARA)." The acronym ALARA is synonymous with "optimization for radiation protection (ORP)." Both acronyms represent a common- sense approach to keeping radiation doses lower than the regulation limits for patients and healthcare professionals

Your organization should have policies and procedures that explain how to keep exposure to radiation as low as reasonably achievable. Imaging procedures that increase exposure risk include:

 General fluoroscopy  Interventional procedures that employ high-level-control fluoroscopy (HLCF)  Mobile examinations  General radiographic procedures  C-arm fluoroscopy

Dosimeters A dosimeter is a device worn to measure the radiation dose to which an individual has been exposed. A dosimeter is designed to record the level of exposure received in the area of the body where it is worn. The manager of the area in which radiation is used is required to maintain an accurate and up-to-date roster of employees who need to be monitored. Dosimeter monitoring is required for employees who are routinely exposed to ionizing radiation and have the potential to exceed recommended dose limits. Page 29 of 41

Organizations are required by The Joint Commission to periodically check employee radiation exposure levels. Additionally, organizations are required to document the dates of the monitoring checks and the amount of exposure received by employees. There are several different types of dosimeters. The dosimeter looks like a badge or a ring and should be consistently worn on the outside of a lead apron in the same location

Dosimeter Placement The diagnostic procedures that produce the highest level of occupational radiation exposure are:  Fluoroscopy  Special radiographic procedures

During such procedures, wear a lead apron and place your dosimeter outside the lead apron at collar level. Such placement provides a reading of the approximate equivalent dose of radiation to your thyroid and eyes. These measurements are essential because the head, neck, and lenses of the eyes receive 10 to 20 times more exposure than the shielded trunk of the body.

Storage and Disposal of Radioactive Material Radioactive materials are stored and disposed of in several areas within healthcare organizations. For example, radioactive isotopes may be administered to patients in an interventional cardiology department. in such cases handling and disposing of these materials must be done according to regulatory requirements.

Radiation Policies To ensure the safety of healthcare workers within your organization, only authorized personnel should have access to areas where radioactive materials are disposed of, used, or stored. In addition:  Each area of the organization that uses or stores licensed radioactive material must have a sign on the door bearing the radiation caution symbol and words that indicate that material is radioactive.  Radioactive waste must be placed in special radioactive waste containers and labeled appropriately.  Radioactive waste must never be placed in public areas.  A radioactive spill must be contained and cleaned up according to policy and federal guidelines

Additionally, The Joint Commission has updated diagnostic imaging requirements in 2015 for the hospital and ambulatory care programs to include:  imaging equipment testing and maintenance  annual education for staff supporting CT and MRI services  minimum qualifications for medical physicists  managing MRI safety risks  data collection on MRI incidents and CT radiation dose data  CT protocol management  documentation of CT radiation dose

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Ethics and Compliance Doing the right thing is everyone’s responsibility. Knowing how to detect, correct and prevent non-compliance through training helps you in this effort. You play an important role in ensuring we are compliant.

You are a vital part of the effort to prevent, detect and report non-compliance.  First: You are required to comply with all applicable laws and rules that govern your professional duties.  Second: You have a duty to report any violations or potential concerns you may be aware of.  Third: You have a duty to follow the AHS policies and the Code of Conduct.

PATIENT BILLING LAWS AND REGULATIONS Healthcare providers who provide care to Medicare and Medi-Cal beneficiaries must follow the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation including standards for quality of care. Healthcare providers must also adhere to rules and regulations for submitting claims for payments.

Medicare and Medi-Cal rules can be complex. As providers who provide care or engage in billing or coding related activities, you must understand the rules applicable to your work. AHS has many resources available to assist employees in understanding these rules. Providers with questions may ask their Medical Staff or Human Resources Department for clarification. Compliance and Legal can also provide guidance on complying with applicable laws and regulations.

FALSE CLAIMS ACT The False Claims Act (FCA), 31 U.S.C. 3729-3733 states that a person who knowingly submits a false or fraudulent claim to Medicare, Medicaid or other federal healthcare program is liable to the federal government for three times the amount of the federal government’s damages plus penalties of $11,000 to $22,000 per false or fraudulent claim. False Claims Act is commonly known as the “Lincoln Law” because it was first enacted to counter fraudulent activities involving military procurement during the Civil War. This establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. Government for payment.

Health care fraud examples include: • Billing for services not actually performed • Falsifying a patient’s diagnosis to justify a test or other procedures that are not medically necessary • Misrepresentation of the individual rendering the service • Up-coding – Knowingly billing for a more costly service than the one actually performed • Unbundling – Knowingly billing separately for services that should be a single service • Accepting kickbacks for patient referrals

Tips to prevent fraud and abuse: • Stay up to date on new laws and regulations applicable to your department unit • Educate yourself about payer rules • Ensure billing is both accurate and timely • Verify information provided to you • Be on the lookout for suspicious activity

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CONFLICT OF INTEREST A conflict of interest occurs if an outside interest or activity may influence or appear to influence an employee’s ability to exercise objectivity and to meet their job responsibilities. A healthcare provider has a duty of loyalty to always act in the best interests of AHS. Any potential conflicts of interest should immediately be disclosed to the employee’s supervisor.

When can a Conflict of Interest occur? • Purchasing and other business relationships • Gifts • Employment • Research • Technology licensing • Activities of family members

A Conflict of Interest may occur in one of three ways: • When an individual has the opportunity to use his/her position for personal financial gain or to benefit a company in which the individual has a financial interest. • When an outside financial or other interest may inappropriately influence the way in which an individual carries out his/her responsibilities. • When an individual’s outside interest otherwise may cause harm to AHS reputation, staff, or patients.

Tips to remember: While a vendor may offer you something for ‘free’, the truth is….. In most cases, the cost of that ‘free gift’ is being passed on to AHS through their contracted rates for service. If you are unsure about accepting something from a vendor, STOP and ask someone in your chain of command.

STARK AND ANTI-KICKBACK Stark Statute (Physician Self-Referral Law) Prohibits: A physician from making a referral for certain designated health services to an entity in which the physician (or a member of his/her family) has an ownership/investment interest or with which he/she has a compensation arrangement (42 United States Code, Section 1395nn). The Anti-Kickback statue prohibits the soliciting, receiving, offering or paying any remuneration in return for referral of patients or inducing purchases, leases or orders. Remuneration includes kickback, bribe, or rebate, cash or in kind, direct or indirect. The Statute is broad and applies to anyone.

Stark Key Points: • Applies only to physicians and immediate family members of physicians. • Applies only when a financial relationship exists between a physician (or immediate family member of the physician) and an entity furnishing designated health services (DHS)

ELDER ABUSE AND NEGLECT LAW The Elder Justice Act (EJA) was signed into Law by President Obama on March 23, 2010, as part of the Patient Protection and Affordable Care Act (PPACA). It provides federal resources to “prevent, detect, treat, understand, intervene in and, where appropriate, prosecute elder abuse, neglect and exploitation”.

Requirements of EJA (Elder Justice Act) Section 1150B - establishes time limits for reporting a reasonable suspicion of a crime depending on the seriousness of the event. 1. Serious Bodily Injury – 2 Hour Limit: If the event results in serious bodily injury to a resident, the

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individual must report the suspicion immediately, but not later than 2 hours after forming the suspicion; 2. All Others – Within 24 Hours: If the events do not result in serious bodily injury to a resident, the individual must report the suspicion not later than 24 hours after forming the suspicion. Any employee failing to meet the reporting obligations of Section 1150B of the Social Security Act is subject to civil monetary penalty and exclusion sanctions.

Who must report? Individuals who must comply with this law are: owners, operators, employees, managers, agents or contractors of health care facilities. Individuals who fail to report, are subject to a civil monetary penalty of up to $300,000 and possible exclusion from participation in any Federal health care program as an “excluded individual”.

You must report a reasonable suspicion of a crime to at least one law enforcement agency and to the State Agency • Adult Protective Services (APS) 24 hours/7 days a week (866) 225-5277 • District Attorney’s Elder Abuse Unit (510) 569-9281 • Ombudsman (abuse in a nursing home or residential care setting) (510) 638-6878 • Local Police Department

REPORTING CONCERNS Activities or conduct that you believe violate a state or federal law or AHS policy should be reported. This includes violations of fraud, privacy, contracts and grants, financial reporting, health care billing, coding, documentation practices, human resource issues, Medical Staff grievances, and other compliance violations of any kind. • First Reporting Step: Report knowledge of suspected or alleged compliance concern to your supervisor or manager first. • Alternative Option (including Anonymous Reporting): If you wish to remain anonymous, you may use the Compliance Hotline at: 1-844-310-0005. Alternative Reporting Option: If you are uncomfortable about raising concerns directly to your supervisor, or if a concern has already been raised and not addressed, report the concern to the Compliance Officer, Rick Kibler at 510-895-7271.

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Domestic Violence California Mandatory Reporting Law

WHEN TO REPORT: Any provider is required to make a report if he or she “provides medical services for a physical condition to a patient whom he or she knows or reasonably suspects is”: (1) “suffering from any wound or other physical injury inflicted by his or her own act or inflicted by another where the injury is by means of a firearm”, and/or

(2) “suffering from any wound or other physical injury inflicted upon the person where the injury is the result of assaultive or abusive conduct.” “Assaultive or abusive conduct” is defined to include a list of 24 criminal offenses, among which are murder, manslaughter, torture, battery, sexual battery, incest, assault with a deadly weapon, rape, spousal rape, abuse of spouse or cohabitant, and an attempt to commit any of these crimes.

THE REPORT: The report shall include, but not be limited to: (A) The name of the injured person, if known. (B) The injured person’s whereabouts. (C) The character and extent of the person’s injuries. (D) The identity of any person the injured person alleges inflicted the injury.

A report must be made even if the person has died, regardless of whether or not the injury contributed to the death, and even if evidence of the conduct of the perpetrator was discovered during an autopsy.

Please note the above is a summary and does not include all provisions of the law.

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Workplace Harrassment Harassment is unwelcome conduct that is based on race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability, or genetic information. Harassment can include “sexual harassment” or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. Harassment becomes unlawful where these actions may affect a person's ability to work, such as when the person has to put up with the offensive behavior as a condition to keep his or her job or the behavior is so severe that a reasonable person would consider it intimidating, hostile, or abusive. As a result, the employee may not be able to concentrate and do his or her work. Employees may be afraid of losing their jobs if they report the harassment, or if they do not respond to requests made by a supervisor.

Identifying Sexual Harassment Sexual harassment is illegal. It is a form of sex discrimination. Sexual harassment includes:  Comments about sex from colleagues/coworkers that you and other people do not want to hear  Touching by colleagues/coworkers that is not appropriate and you do not like  Being asked to do a sexual act by a colleague/coworker, boss, or employee  Sexual cartoons, photos, or items hung in the workplace that you or others do not like

The Civil Rights Act of 1964 protects workers from sexual or other types of harassment in the workplace.

Identifying Other Types of Harassment Other types of illegal harassment that can interfere with another person’s work performance include:

 Using offensive jokes, slurs, epithets, or name-calling  Physically assaulting or threatening another colleagues/coworkers  Using intimidation, ridicule, or mockery  Insulting a colleagues/coworkers or using “put-downs”  Displaying offensive objects or pictures

Why Is Workplace Harassment an Issue?

In recent years, we have heard more about harassment and sexual harassment in the workplace, partly because of several changes in the environment of the workplace.  Many different people with different backgrounds and cultural and social beliefs work together.  Work schedules are more flexible.  There are more chances for promotion and more career challenges.  Men and women may not agree about what actions are appropriate in the workplace.  New court rulings make it clear that people do not have to accept behaviors that may have been allowed in the past.  Organizations know that they can be held responsible for a provider’s inappropriate behavior.

Providers must learn how to prevent harassment and sexual harassment. They also must learn what to do if it happens.

The Joint Commission has specific standards about harassment in the workplace. These are in the Code of Conduct manual and are called ethics in the workplace.

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Examples of Sexual Harassment in the Workplace These are examples of sexual harassment workplace:  Promises of a promotion or wants to give you more money in return for sex.  Threats to fire or demote you (move you to a lower position) if you don't do a sexual act.  A colleague/coworker touches or hugs you when you do not want to be touched. This can include hugging coworkers when greeting them if they do not want to be hugged.  A colleague/coworker calls you "honey" or "sweetheart" and you or your colleague/coworker does not like it.  A colleague/coworker makes comments or jokes about sex, or asks personal questions about your sexual likes and dislikes.  A colleague/coworker asks if you are gay.  A colleague/coworker hangs pictures, calendars, or cartoons in the workplace that offend you or your coworkers.  A colleague/coworker sends you texts or e-mails about sex, or writes sexually explicit graffiti in the workplace.

Examples of Workplace Harassment that can create a hostile work environment:  telling jokes about race, sex, disability, or other protected bases  using demeaning or inappropriate terms or epithets  using indecent gestures and/or using crude language  sabotaging someone’s work such as withholding important information  engaging in hostile physical conduct

Who May Be Involved in Workplace Harassment? Sexual harassment can happen between people with many types of relationships. They can be total strangers or close friends. They can be healthcare workers and patients.

Sexual harassment may happen at any job position in the organization. It may happen with executives or volunteers.

Men can harass women or other men, and women can harass men or other women.

Many people think that sexual harassment applies only to the person who, for example, is called "sweetheart" or who is told a dirty joke. But, in fact, other people may be involved. For example, if a colleague/coworker makes sexual comments about a coworker, the behavior creates what is called a hostile working environment. The colleague/coworker who heard the comment about the other person may be offended.

What Is Not Workplace Harassment? Not all teasing, offhand comments, or sexual behavior in the workplace is harassment. For example, if a colleague/coworker says an offhand remark or tells a sexually explicit joke to another colleague and that individual is not offended, it is not harassment. Also, if you and a colleague both like to hug each other when you see each other in the hallway, it is not sexual harassment.

Harassment laws that are specific to the workplace do not apply to actions between you and people who do not work in your organization. Although the law does not prohibit simple teasing, offhand comments, or isolated incidents that are not very serious, harassment is illegal if it is so frequent or severe that it creates a hostile or offensive work environment, or if it results in an adverse employment decision (such as the victim being fired or demoted).

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What Should You Do if You Are Harassed? If someone is harassing you, tell him or her to stop because you do not like it. Be very clear. For example, say, "Mr. Smith, I do not want to hear about what you do on your dates. It makes me feel uncomfortable. Please stop." Sometimes the other person does not realize that his or her behavior offends you or your colleagues.

Report the Incident or Behavior

If the person continues the same actions after you have asked him or her to stop, tell your Department/Service Chair, Division Chief or Chief of Staff.

Follow the policy for reporting the incident. You can get information about how to file a complaint from Medical Staff Services Department or the Human Resources Department. After you file your complaint, an investigation will take place.

Document Incident or Behavior

Keep a record of what happened, when it happened, where you were and who was involved. If possible, write down the names of anyone else who was there.

You may keep a copy of in appropriate drawings, cards, letters or e-mail that you received if you want to support a claim of harassment. However, do not remove business documents from the organization.

Retaliation Is Not an Option A Department/Service Chair, Division Chief or Chief of Staff or others within the organization cannot retaliate, or take revenge, against you for filing a claim of harassment. You are protected by law if you file a claim or if you testify or participate in an investigation.

Retaliation, if it happened, might include:  Being ignored by colleagues/coworkers  Being demoted or fired from your job  Having personal belongings ruined or destroyed

Workplace Harassment Summary  Harassment is unwelcome conduct that is based on race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability, or genetic information.  Harassment includes “sexual harassment” or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature.  The law does not prohibit simple teasing, offhand remarks, or isolated incidents that are not very serious.  Harassment becomes unlawful where the offensive actions affect a person's ability to work, such as when the person has to put up with the offensive behavior as a condition to keep his or her job, or the behavior is so severe that a reasonable person would consider it intimidating, hostile, or abusive.  If you are harassed, tell the harasser to stop the behavior. Be very clear.  If the behavior continues, tell your Department/Service Chair, Division Chief or Chief of Staff, or immediately file a complaint with Medical Staff Services and/or the Human Resources Department.  AHS is responsible for reacting and responding to complaints of workplace harassment.  Keep a journal, make copies of inappropriate emails, pictures, jokes, or behaviors that are offensive.  If you are not satisfied with actions taken, appeal to the U.S. Equal Employment Opportunity Commission.  Department/Service Chair, Division Chief or Chief of Staff or others within the organization cannot retaliate, or take revenge against you for filing a claim of workplace harassment.  You are protected by law if you file a claim or if you testify or participate in an investigation.

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Workplace Violence Prevention

Our purpose for providing this information is to protect the safety and security of all personnel, patients and visitors at Alameda Health system..We would like to advise you and make you aware that Alameda Health System has zero tolerance for violence

Our facilities include:  Highland Hospital  John George Psychiatric Hospital  Fairmont Rehabilitation and Wellness  San Leandro Hospital  Alameda Hospital  Park Bridge Rehabilitation and Wellness  South Shore Rehabilitation and Wellness  Creedon Advanced Wound Care  Marina Wellness and Surgical Associates  Eastmont Wellness  Hayward Wellness  Highland Wellness  Newark Wellness

Workplace violence is defined as: The threat or use of physical force against an employee, patient or visitor, that results in, or has a high likelihood of resulting in, injury or psychological trauma, or stress, regardless of whether the employee and/or visitor sustains an injury; An incident involving the threat or use of a firearm or other dangerous weapon, including the use of common objects as weapons, regardless of whether the employee and/or visitor sustain an injury. Workplace violence includes abusive behavior toward authority, intimidating or harassing behavior and threats. Workplace violence includes four workplace violence types:

Workplace Violence Categories 1. Type 1 violence means workplace violence committed by a person who has no legitimate business at the work site, and includes violent acts by anyone who enters the workplace with the intent to commit a crime. 2. Type 2 violence means workplace violence directed at employees by customers, clients, patients, students, inmates or visitors or other individuals accompanying a patient. 3. Type 3 violence means workplace violence against an employee by a present or former employee, supervisor or manager. 4. Type 4 violence means workplace violence committed in the workplace by someone who does not work there, but has or is known to have had a personal relationship with an employee.

If you are involved in an unsafe or threatening situation at Alameda Health System, it is important that you contact Security Services (at internally x55555 or directly at 510 437-4800) and remove yourself from the area as quickly and as safely as possible.

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Physician Wellbeing / Provider Wellness The Medical Staffs at Alameda Health System, San Leandro Hospital and Alameda Hospital provide a resource to our providers for wellbeing. We are available for support in the following ways:  Confidential resource to you  Non-disciplinary support for you  Promote a culture consistent with quality and safety of patient care   Increase retention of care givers  Provide informal conversations to discuss concerns

All people are vulnerable to illness, illness that can result in impairment in one’s personal, social or work life. As physicians, we are no exception. Indeed, we may be even at higher risk to certain types of impairment than the general public.

The American Medical Association defines an “impaired physician” as one who is unable to practice medicine with reasonable skill and safety because of physical or mental illness or excessive use or abuse of drugs, including alcohol. Physicians can become impaired because of four major problems  Substance abuse  Psychological problems  Physical illness  Cognitive impairment

Warning Signs? The physician who is impaired often acts in an unusual manner and exhibits behaviors that can serve as warnings if they are recognized and understood. These indicators may include, but not limited to the following:  Loss of enthusiasm  Negative attitude  Changes in work habits  Missed appointments and meetings  Complaints from staff, patients, families  Looks tired (insomnia)  Personal hygiene changes

Symptoms of burnout can include exhaustion and depersonalization. These symptoms can affect physicians’ health, quality of patient care, and engagement. Early intervention is critical. When left alone, problems caused by impairment tend to worsen and can lead to divorce, financial disaster, loss of employment, or suicide. Severely impaired physicians may be endangering the safety of patients and colleagues as well as themselves on a daily basis.

The following personal strategies can be used as preventive measures for burnout.  Self Awareness and mindfulness training  Exercise  Hobbies  Philanthropy  Work-life Balance

Our Medical Staffs continue to focus on the development of a Physician Support Services Program to alleviate

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burnout, support health and wellbeing.

According to the American Journal of Medical Quality, turnover can cost an organization approximately $250,000 when a physician leaves, and up to $1 million by the time the physician is replaced.

How can you help?

Generally, impaired physicians do not seek help on their own. In fact, like other impaired persons, they usually deny that there is a problem. Because denial is so common in situations of impairment, it is even more critical that you, the concerned colleague, take some action to see that help is made available to the physician who may need it. There are several steps to consider:

First: Approach your colleague. Mention the specific behaviors you have noticed that have caused your concern. Inquire directly whether there is a problem.

Second: If your colleague denies there is a problem but you still suspect one, wait a while for him or her to resume the conversation. If the topic isn’t brought up again, and you still fear that a problem exists, call a reliable resource for advice.

Third: Based on the above information, advice from reliable sources, and your own observation, decide if you still think there’s a problem.

Fourth: If you are convinced your fellow physician does have a problem, consider making a call for help. Remember that this kind of problem it is likely to worsen, but if caught early the prognosis improves.

Well Being / Wellness Resources  Alameda - Contra Costa Medical Association (ACCMA) contact (510) 654-5383 and ask for information regarding the Physicians Advisory Committee  Mindfulness: HelpGuide's self-help tools https://www.helpguide.org/harvard/benefits-of-mindfulness.htm  Stress: Mental Health America Stress Screen  http://www.mentalhealthamerica.net/stress-screener  Work-Life Balance: Work-life balance: Tips to reclaim control Mayo Clinic http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/art-20048134

Alameda Health System San Leandro Hospital Alameda Hospital (Highland Hospital, John George Psychiatric Hospital, Fairmont Hospital, Ambulatory Clinics) Eastmont Wellness Center Winton Wellness Center Newark Wellness Center

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