Jordan Valley Orientation 2015

Jordan Valley Orientation 2015
To be completed by all New Hires,
Volunteers, Contractors, & Students
Policies and Procedures
Human Resources Policies & Procedures
are located online in I-REPP
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I-REPP is the best place to find information
regarding unit and hospital practices,
policies and procedure.
Do NOT discriminate
on
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Race
Color
Religion
Sex/Wages
National Origin
Disability
Age
Disability Status
Genetics
Employees Hired based
On
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Experience
Skills
Aptitude
Ability to fit into JVMC and
WVC culture
Equal Opportunity Employer
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Orientation period
◦ First 90 days of employment you should receive an
evaluation.
 Director should review with you your progress during
and at the end of the 90 day orientation period.
◦ Skills Check list and department orientation
 Must be completed by 90 days
 Ask
department director if you do not have
a 90 day orientation and Skills Check List
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ID Badges
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Must wear at ALL times
Worn above the waist
Human Resources creates the badges
Used for timekeeping and security doors
Glucometer
If LOST or STOLEN replacement badge cost
$20
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Dress Code (HR-A-7)
◦ Hair should be clean, well-groomed and controlled, and
appropriate to the job.
◦ Uniforms are to be worn if department requires them
◦ Open toed sandals are not appropriate in Clinical areas
◦ Flip-Flops/Sandals are never appropriate
◦ Jewelry must be conservative, non-offensive, and worn in
moderation. Two piercings per ear is allowed, all others must
be removed.
◦ All cosmetic products (including fragrances) should be worn in
moderation
◦ Tattoos are to be covered
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Clothing
◦ The following types of pants/skirts
are not appropriate:
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Denim pants
Leggings
Shorts (including walking shorts).
Sweat pants
Mini skirts
◦ The following shirts are inappropriate :
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Tank tops
T-shirts
Sweatshirts without collars
Souvenir T-shirts or sweatshirts (excluding
Jordan Valley Medical Center or Jordan-West
Valley)
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Problem Solving Procedures
1. Address issues or grievances with
A.
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Supervisor or Manager
Human Resources
VP over your department
CEO
2. Or IASIS Alert Line 1-877-898-6080 or
www.alertline.com
Employment Status
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Full Time
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36 hours/week - eligible for all benefits
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30-35 hours/week - eligible for medical,
dental, vision and small amount of PTO Accrual
Part Time
Less than Part Time/PRN
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Less than 30 hours/week - no benefits
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Registered Nurses only. Higher rate of pay, no
benefits
Per Diem
7 on 7 off
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Lab (MT’s only) All benefits, no accruals
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Employee Conduct and Work rules (HR.401& IASIS
Standards of Conduct)
◦ IASIS expects employees to follow rules of conduct that will
protect the interests and safety of all patients, employees and
the facility. Conduct that is offensive to patients or fellow
employees, discredits the company, interferes with business
operations, or any other conduct which in the facility's
judgment is adverse to the company's interest will not be
tolerated.
 Examples of unacceptable behaviors
 Fighting, intimidating or threatening violence in the
workplace
 Boisterous or disruptive activity in the workplace.
 Insubordination or other disrespectful conduct.
 Sexual or other unlawful harassment or discrimination
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Sexual Harassment (HR.402 & HR.401)
◦ Is unwelcome sexual advances, requests for
sexual favors and other verbal or physical
conduct of a sexual nature.
◦ When submitting to or rejecting this conduct, the
individual’s employment or work performance is
clearly affected. The result of sexual harassment
is an intimidating, hostile or offensive work
environment.
IASIS is committed to providing a work environment that
is free of discrimination and unlawful harassment.
Actions, words, jokes or comments based on an
individual’s sex, race, ethnicity, age, religion or any other
legally protected characteristic will not be tolerated.
It applies to all employees, including supervisors,
managers and department heads, directors, physicians and
vendors, whether or not employed by IASIS. Under
certain circumstances, the policy would apply to agents
and non-employees who interact with IASIS employees.
What is the Company’s responsibility?
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Act immediately and take every
complaint seriously
Conduct a thorough investigation
Keep accurate documentation of
the events and any action taken
Ensure non-retaliation
What should the victim of sexual harassment do?
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It is helpful for the victim to
directly inform the harasser that
the conduct is unwelcome and
must stop.
The victim should use the
employer’s complaint process or
grievance system in place.
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Non-Soliciting Policy (HR Policy HR.109)
◦ Employees shall not engage in solicitation for any
reason during his or her work time or to another
employee on their work time.
◦ The only exception will be for events sanctioned
by the hospital.
◦ The hospital’s electronic mail system is a
business system and not a personal
communications network or bulletin board.
◦ Off-duty employees of IASIS, or of an on-site
contractor who works at the hospital, are not
permitted access to any non-public working areas
of the hospital including the emergency area.
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Tobacco Free Environment (EOC-E-23)
◦ Jordan Valley and Jordan-West Valley prohibit
smoking or tobacco product use wile on any Jordan
Valley or Jordan-West Valley campus
 Tobacco use is defined as the burning of any type of tobacco
product, as well as the use of oral tobacco products.
 The policy applies to All employees, Patients, and Visitors
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Staff Rights Policy (HR.112)
◦ A way to address your rights not to participate in
certain aspects of patient care if it conflicts with
your cultural values, ethics, or religious beliefs.
◦ Notice Upon Hire
Examples
• End of life treatment
• Blood transfusions
• Organ donation
◦ Not Accepted Reasons
Refusal to treat patients based on:
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Nationality
Religion
Creed
Color
Sexual orientation
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Family Medical Leave Act (FMLA)
◦ Eligible after one year with 1250 worked hours
◦ Job Protected to:
• Care for child after birth or adoption
• Care for family member with Serious Health Condition
 Up to 12 weeks leave
• Military Leave
◦ 30 day Advanced notice if possible
◦ Apply for FMLA with Matrix Absence Management
• Information can be found on the intranet underISO Forms/Department Forms/ Human Resources
• Call 1.877.202.0055
• Website www.matrixeservices.com
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Lunch Breaks
½ Hour deducted after five hours worked
No lunches must be approved by Manager
Hospital must pay for missed lunches
Lunches – must be at least 30 minutes of
uninterrupted time
◦ Must punch out if you leave the hospital
◦ If you don’t have 30 minutes of uninterrupted
time for a lunch, you much punch a “no-lunch”
when you clock out at the end of your shift.
◦ If you forget to clock a “no-lunch,” you must
turn in a “no-lunch” form and enter a “nolunch” in API.
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Overtime
◦ Paid at 1.5 times average rate of pay
◦ Average rate of pay includes shift differentials
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Direct Deposit
Takes up to three pay periods to activate
Sign up at any time
Deposits in bank normally on Thursday
Any bank or credit union that has checking
On your check stub it will read “NON-NEGOTIABLE”
on signature line
◦ Overtime is based on a 40 hour workweek
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API
◦ Timekeeping system
 Track your own hours
 Log in and sign off on your hours each pay period
 Request PTO
◦ Must use badge to punch
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Benefits
o Benefit eligible employees have 30 days from their hire
date to enroll in benefits.
o To enroll in benefits you can:
o Call Melissa at 801-601-2361 for help
o Enroll online through Lawson on the intranet
o Fill out an enrollment form if online is not working
Attendance and
Punctuality
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“Scheduled Absences”
◦ A scheduled absence occurs when an employee
has arranged at least 24 hours in advance and
has been granted supervisory approval to be
absent from work.
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Unscheduled Absences”
◦ Any absence not requested and approved 24
hours in advance (e.g. call-in sick).
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No Shows
◦ Two consecutive shifts missed – hospital will
assume employee has quit
Caring Commitments
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We recognize that our talented and dedicated employees are our
greatest assets.
All patients, visitors, staff members, physicians and contractors
are encouraged to submit a STAR recognition card to recognize
any deserving individual within the organization.
The STAR Performance Recognition Program recognizes
individuals for demonstrating STAR behaviors. STAR behaviors
can be found within “Our Caring Commitments” & “It’s the Right
Thing to Do” pamphlet.
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I Commit to service through
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I Commit to accountability through
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Providing compassionate care.
Responding promptly to your needs.
Listening carefully to you.
Providing clear explanations.
Accepting ownership
Providing exceptional customer service
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I Commit to teamwork through
Working well with others
Promoting a positive attitude
I Commit to respect through
Being sensitive to the diversity of others
Treating everyone with respect and dignity
Acting with integrity
Respecting your time
Chris Rock
Risk Manager
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Overall claims against nurses or that involve nurses
continue to rise (CNA data)
60% from Med/Surge setting
Average paid settlement around 160K
Most frequent claims involve death (38%),
infection/sepsis (6.5%).
Most severe claims involve birth injury and
paralysis events
Claims involving wrong medication route have
the highest settlement among medication claims.
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We failed to adequately advocate for the
patient.
We failed to sufficiently disclose and
discuss while here to resolve the concern.
Studies have shown that patients sue
providers and hospitals they don’t
like more than ones they like, probably
based on their perception of how
their concerns were addressed.
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Who reports:
 Any individual (staff) at all locations who witnesses
or discovers and incident or unusual occurrence.
What is reported:
 Events where there is an unexpected outcome: falls,
medication errors, T/T/P (complications, delayed,
missed order), equipment failures, security threats,
blood complications, behavioral problems, skin integrity,
etc.
Why Report:
 To predict future risks and protect patients, visitors, and
staff
 To identify where P&Ps need updates
 To educate staff on potential risks
 To prevent & defend against lawsuits
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Do file incident report after pt. stable
and w/in end of shift.
Do record in the patient’s medical chart a factual
account of any outcome with pt. injury.
Do Not route incident reports through other
departs (okay notify your manager/sup).
Do Not indicate in the patient’s medical
record that a UOR was filled out
(liability protection).
Do Not assign blame, be judgmental,
or admit liability verbally or on the
UOR report. Stick to facts.
EMTALA (EM) concerns
 Sentinel Events (unanticipated death
or major permanent loss of function)
 Damage to IASIS property
 Loss of Patient property
 Birth related injury
Significant complaints (Customer Service
Champion or Risk Manager).
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 Goal is to try to resolve the patient’s concern
(while in-house, if possible), and before it becomes a
major risk issue.
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Right
Right
Right
Right
Right
Patient
Route
Dose
Time
Medication
Right Documentation
Standard Precautions
Estimated 1.5 million harmed each year;
7000 deaths/year.
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High Risk Medications: Heparin, Insulin,
Opiates, etc.
Familiarize yourself with medication
dosages, side effects, warnings,
contraindications.
Know how to obtain current reference
materials, or contact pharmacy when
available.
Adverse Drug Reactions
Communication: read back TOs, etc.
Document all medications administered and
response.
Document any wasted medications in
compliance with hospital Policy. Resolve
all narcotic discrepancies.
Document all errors as a UOR.
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A new study shows that as the number of
distractions/interruptions increases, so do
the number of errors and the risk to patient
safety.
For instance, four interruptions in a single
drug administration doubled the likelihood
that the patient would experience a major
mishap.
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Small lapses can lead to
big mistakes!
Read back TOs and labs
Make sure pt identifiers
are correct/consistent
Follow SBAR
Does the procedure sounds
right for the diagnosis?
Follow procedures for critical values reporting
Call the physician, to clarify if the order is not legible or
unclear!
24 hour nursing chart checks, important safety net!
Failure to document conversations with patients.
Failure to document medication response.
Abnormal VS documentation and follow-up.
Failure to notify physician of changes in
condition.
◦ Failure to indicate that the new nurse was made
aware of significant changes in patient condition
at shift change.
◦ Other mistakes include:
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Illegible handwriting
Generalizations
Overuse of abbreviations, or do not use
Spelling errors
Recording assumptions
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Medicare will not longer pay for following HAC
“never events”
 Retrieval of retained surgical devices left in patient
 Falls (Avg. cost of fall with injury = $4233, prob more)
 Blood Incompatibility
 Pressure Ulcers, hosp acquired III and IV (Stage II = $1119,
Stage II and III = $10,185
 SSI after CABG ($15-40K)
 Incompatible blood or air embolism
 Catheter associated UTIs
 Vascular catheter-associated infections
 Manifestation of poor glycemic control
 Surgical site infection
 DVT
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Additional proposals in works (gov and private)
SCIP
DNR - Purple
We have adopted the color
PURPLE for the Do Not
Resuscitate designation with
“DNR” embossed/printed on
the wristband or label.
Do we still need to look in the
chart?
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Yes!; and
Code designation can and
does change during a
patient’s stay.
Calling CODE BLUE!
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Recommended in the
Standardized Hospital
Emergency Code for the
State of Utah.
If Utah selected the
color blue for the DNR
wristband, the potential
for confusion exists.
“Does blue mean I code or
I do not code?”
Allergy - Red
We have adopted the color
RED for the Allergy Alert
designation with the word
“Allergy” embossed/printed on
the wristband or label.
Associated with other
messages such as STOP!
DANGER!
Easy Implementation
The transition to red for
Allergy Alert should be
easily achieved since the
majority of hospitals use a
wristband for allergies
already use red for Allergy
Alert.
Fall Risk - Yellow
We have adopted the color
YELLOW for the Fall Risk
Alert designation with the
words “Fall Risk”
Associated with “Caution” or
“Slow Down” for example: stop
lights and school buses;
American National Standards
Institute (ANSI) designates
yellow for tripping or falling
Falls account for more
than 70% of the total
injury-related
healthcare cost among
people 60 years of age
and older.
Color-coded “Alert” Wristbands
Risk Reduction Strategies
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1.Use wristbands with the alert message
pre-printed (such as “DNR”).
2.Remove any “social cause” colored
wristbands (such as “Live Strong”).
3. Initiate banding upon admission, changes
in condition, or when information is
received.
4.Educate patients and family members
regarding the wristbands.
6. Educate staff to verify patient colorcoded “alert” wristbands upon assessment,
hand-off of care, and transfer.
Preventing Patient Falls!
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1 in every 3 adults over 65 fall each year. Proportion
increases to 1 in 2 by the age of 80
◦ (“Falls Prevention Interventions in the Medicare
Population” available at cms.gov)
Falls exceed automobile accidents as the number one
cause of accidental death or persons over 75.
Thirty percent of hospital falls will result in injuries,
including 5% serious trauma such as hip fractures. Thus,
there are about 52,500 serious injury falls per year in
U.S. hospitals
Falls with injury and can have a large financial impact
and risk to the hospital & patient.
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The hospital employs a comprehensive Fall
Prevention Program aimed at reducing patient
and visitor falls. The following interventions
are important components of the Fall
Prevention Program for patients identified at
risk:
◦ Utilize the CareView virtual bed and chair rail
system where available and according to protocol.
◦ Complete a fall risk assessment upon admission,
every shift, and anytime there is a change in status.
◦ Communicate fall risk levels during shift report and
during other hand-off communications.
◦ Utilize additional prevention tools such as yellow
bracelets & signs, bed alarms, side rails, lap belts, no
slip socks, walkers, etc.
◦ Check the Four P’s during hourly rounding: Pain,
Potty, Position, and Placement.
◦ Place the patient in a room close to the nursing
station.
◦ Make sure the call light and other items the patient
may need are placed and left within easy reach of the
patient.
◦ Educate the patient and family about fall risk, and
remind patients to call for help prior to getting up,
particularly for toileting needs.
◦ If the patient is confused or wandering, discuss
concerns with the family and where appropriate evoke
their assistance with in room patient watches.
◦ After a patient falls, re-evaluate what changes are
needed to prevent repeat patient falls.
Cause of Inpatient Falls, May 12 through
Dec 12
25
100%
90%
80%
70%
15
60%
50%
10
40%
30%
5
20%
10%
0
Cause of fall
% of Total
Tioleting
Confused
patient
21
7
5
5
2
1
51%
68%
80%
93%
98%
100%
Environment Slip and fall
Therapy
related
Syncope
episode
0%
% of Total
# of Falls
20
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A restraint is defined as:
Any manual method, physical or
mechanical device, material, or
equipment that immobilizes or reduces
the ability of a patient to move his
or her arms, legs, body, or head freely.
Chemical: A drug or medication used
to control behavior or restrict a patient’s
movement and is not the standard
treatment or dosage for a patient’ s
condition. Note that PRN drugs is only
prohibited if med meets definition of drug.
If all 4 side rails are up, or if belts are being used
to keep a patient in bed or from getting up.
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Patient’s have right to be free from
restraints, including when necessary only
and not as coercion, discipline,
convenience, or
Medical = NV/NSD (non-violent, non-self
destructive)
◦ Prevent pulling lines
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Behavioral = V/SD (violent, self destructive
◦ Danger to themselves or others, after least
restrictive alternatives attempted.
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Forensic restraints: handcuffs, shackles, or
other restrictive devices by law
enforcement.
Orthopedic devices: surgical dressings,
bandages, protective helmets, etc.
Protective equipment: padded side rails,
padded mitts, etc.
Does not include methods that involve the
physical holding of a patient for the
purpose of conducting routine physical
examinations or tests (crying child for
example)
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Restraints or seclusion can only be used when less
restrictive interventions have proven ineffective &
they are needed to protect the patient, staff, or
others!
Alternatives to undertake first:
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These interventions must be documented!
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 Promote a safe environment; fall precautions, assist
devices, alarms, adjusting light/noise, patient location, 1:1,
toileting.
 Promote cognitive, psychological, and physiological well
being; orientate patient, ask family to help/stay, eliminate
unnec equip, medication assessment, toileting, re-position,
physical assessment to identify medical problems causing
beh change, diversion activities.
 Promote functional mobility; wear glasses, contacts,
hearing aids, strengthening activity, provide pain or other
comfort meds
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Americans with Disabilities Act (ADA) is a Federal
Law that prohibits discrimination against those
with disabilities.
The ADA includes those with hearing
impairments/deaf
◦ Assume nothing, take extra time to make sure
understanding is clear)
◦ Maintain good eye contact
◦ Be sensitive to visual environment – avoid bright
lights that create glare or make it difficult to read
lips
◦ Some deaf people do not read lips; consider and
use other methods to communicate.
◦ Family members/friends cannot reliably interpret
medical terms and procedures
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Interpretation machine is housed in the ER/ED
department
The nurse follows the procedure for start up
(laminated help sheet with the machine
Interpreter will ask for needs (desired services
needed language/physician etc.)
Connection is completed within minutes to begin
effective communication
Keep machine plugged in so battery does not
drain.
Contact Supervisor if you encounter problems.
Local sign language interpretation is available as
back-up.
TDY if needed.
Packets (resource materials) from State Office
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Other Languages (Medvix phone number with
code, >100 languages).
Meeting Needs of Disabled Patients
◦ Handicap stalls, ramps, other assist devices
◦ Increased risk for falls, interventions as noted.
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Hospitals must abide by ADA Laws!
If you encounter issues, you may use the Hotline
Number to call in the event: x3662
Sara Phillips
Quality Director
Sara Phillips
Director Quality Management
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Quality Like Beauty is in the Eye of the
Beholder. We must meet the needs of the 20
year old as well as the 90 year old.
 Quality means different things to different people. They
key to quality lies in communication and standardization.
The most frequent complaint from patients relates to the
lack of communication from staff and physicians.
 Treat every patient the same way you
would your family member (connect with
the patient, show them they are not just a
number)
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ISO is a set of standards that drive our Quality
Management System. We use them as our
Quality management system. The Core element
is standardization.
McDonald’s Hamburgers are the same all over the
world because they have “work instructions” for how
to cook a hamburger.
We have Standards, Forms, and Policies.
These three things provide directions on how to
perform certain processes.
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Patient/Client’s Satisfaction - Service Quality
Patient/Client’s Outcomes – Quality of Care (Do
the right thing, for the right patient, at the
right time)
◦ Both of these elements now affect our payments.
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Processes – Quality of Design
Staff and Physician Satisfaction – Quality of
Service, Design, and Care
 Quality
Improvement Designed to improve
outcomes or processes
 Quality Assurance –
Designed to keep things the
same.
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Decreasing the Number of Code Blue Cases by
Implementing Rapid Response Teams that
respond to emergency situations before the
patient’s breathing or heart stops.
Decreasing the Number of Nosocomial MRSA
Infections by Implementing Strong Hand
Washing Programs.
Define the Customer, their Critical to Quality (CTQ) issues, and
the Core Business Process involved.
 Define who customers are, what their requirements are for
products and services, and what their expectations are
 Define project boundaries the stop and start of the process
 Define the process to be improved by mapping the process
flow
Measure the performance of the Core Business Process
involved.
 Develop a data collection plan for the process
 Collect data from many sources to determine types of
defects and metrics
 Compare to customer survey results to determine shortfall
Analyze the data collected and process map to determine root
causes of defects and opportunities for improvement.
 Identify gaps between current performance and goal
performance
 Prioritize opportunities to improve
 Identify sources of variation
Improve the target process by designing creative solutions to fix
and prevent problems.
 Create innovate solutions using technology and discipline
 Develop and deploy implementation plan
Control the improvements to keep the process on the new course.
 Prevent reverting back to the "old way"
 Require the development, documentation and implementation of
an ongoing monitoring plan
 Institutionalize the improvements through the modification of
systems and structures (staffing, training, incentives) From GE's
DMAIC
This is the Process Tool Our Teams Use
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Airlines do a great job of error proofing. They use
three redundant systems for every critical element
of the airplane. Healthcare usually uses one – the
person performing the task.
Airline Flights
4000 X 365 = 1460000
A 1% error rate equals 14600 crashes
Annually there are normally 2 – 3 crashes a year.
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Healthcare
What is our error rate? (We often consider 99% to be excellent.)
How do we error proof our processes? (We need to learn to
standardize what we do and use technology to prevent harm to
patients.)
According to the Joint Commission's president, these "never events" are
becoming more common because of growing time pressures. He notes that
wrong-site errors have proven "more complicated to eradicate than anybody
thought" because it requires changing hospital culture and ensuring that
physicians collaborate and follow standardized protocols.
Peter Pronovost, the medical director of the Johns Hopkins Center for
Innovation and Quality Patient Care notes that physicians' "ritualized
compliance" is a key contributor to high wrong-site surgery rates. According to
KHN/Post, several wrong-site procedure studies have found that physicians
routinely fail to participate in pre-surgery timeouts. For example, in a 2010
study of 132 wrong-site and wrong-patient cases reported by Colorado
physicians between 2002 and 2008, 72% of error cases did not include a
timeout to confirm case details before the procedure.
The clinical director of the Pennsylvania Patient Safety Authority says physicians
who confirm details with patients before they are moved into the OR are less
likely to make an error. Similarly, physicians avoid mistakes when they stop to
ask team members if they have concerns. "There's a big difference between
hospitals that take care of patients and those that take care of doctors," he
says, adding, "The staff needs to believe the hospital will back them against
even the biggest surgeon."
We are fallible human beings. We live in an
inherently risky world where we create risk and
cause undesirable outcomes.
Fallibility vs. Culpability
The reckless driver model:
The drunk driver who kills someone is culpable, the
driver who kills someone who runs out in front of
him is fallible.
And the moral is:
Follow hospital standards and policies.
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National patient safety Goals were
developed as a result of harm to patients.
They are all important! Staff must know and
follow these standards. Your Unit Director
will review all of them with you. Three of
them and the reasons for them are listed
below on the next slide.

Improve the safety of using medications - standardize and limit the
number of concentrations – look alike, sound alike – physically
separated, reduce risk associated with anticoagulation therapy.
 Reason: Patients were harmed and some died when the wrong medication was
injected. Concentrated potassium accidently injected causes immediate cardiac
arrest.

Improve the accuracy of patient identification patient name
and date of birth
 Reason: Patients were permanently harmed when the wrong procedure was
performed, the wrong medication given, the wrong blood given, or laboratory tests
labeled and reported incorrectly.

Improve the effectiveness of communication between
caregivers – read back – do not use abbreviation – timeliness
of reporting critical values – hands off communication
 Reason: Patients were harmed or died as the result of being treated for an
incorrectly recorded laboratory result.
Questions?
Contact Sara Phillips
x3163
Mary Jordan
Infection Prevention/
Employee Health Nurse
New Hire Orientation
4-30-2013






Varicella (chickenpox)
MMR
Tdap
Hep B - if working in a clinical area
TB test – 2 step method
Flu shot – every year
Protects against acute and chronic
Hepatitis B disease,
the associated liver cancer & cirrhosis
3 shots and a titer
Very safe vaccine, only 1: 1,000,000 have
a serious complication
Best of all IT IS FREE for employees!




This is required for clinical areas.
OSHA requires annual fit testing
Fit testing is offered in clinical areas.
Your director will tell you how it is done on
your unit.



It means that you’ve been
exposed to TB some time in
the past.
It does not mean that you
have active TB.
It does mean that you will
have to visit with the
Employee Health
Practitioner
If you have a positive TB skin test
Do NOT receive future TB skin tests







Monitor for signs of active TB
Night sweats
Cough that lasts for weeks
Coughing up blood
Unexplained weight loss
Unusual (for you) tiredness
If any of the signs are apparent, contact
Employee Health immediately.








Work Practice Controls
Food and drinks in the workplace.
Refrigerators (food and specimen)
Specimens handling
Spills
PPE
Hand Hygiene
Infectious Waste



Can be found in I-REPP in Infection
Prevention Policies.
You can get a copy from Infection Prevention
if you do not want to pull one off of I-REPP.
Employee Health is available to answer any
questions you have about the plan.
It may be
Yellow,
Orange, or
Red.




Do not put regular trash
in the Biohazard (Red)
Trash.
Do not put Biohazard
trash in the regular
trash.
Do not store clean
supplies in a Biohazard
bag.
Do not put a Biohazard
bag in the regular trash
even if there is nothing
biohazardous in the bag






Bulk Blood?
Micro/Lab Waste?
Urine?
Other Body Fluids?
Sharps?
Contaminated or Saturated Dressings?
OSHA does not allow food or drinks in any area
specimens may be.
Food and specimens may not be in the same
refrigerator.
Staff food may not be stored in the patient
food refrigerator.
Breast milk is a body fluid and may not be
stored in a food or specimen refrigerator.
Patient food must be dated and the name of
the patient attached before it is placed in the
refrigerator.
Ask where you may keep your drinks during
unit orientation.



What do I do?
Who do I tell?
Do I go to the ER?
ER admitting at both campuses has
separate packets for Injury and Exposure.
 The injury packet is also on the intranet
under HR forms.
 Fill out all forms entirely!
 The drug screen must be done before you
leave from the shift on which you were
injured.
 Notify your supervisor and
Employee Health





Report injury to
supervisor and Employee
Health.
We can help determine
whether medical care or
simple first aid is needed.
Report to ER admitting
and get packet for
Workman’s Comp or print
it off the intra-net.
Report to Lab for drug
screen.



You need to report an exposure incident to
employee health or the house supervisor
immediately. Time is of essence in testing
and/or starting prophylactic treatment.
You will have tests for Hepatitis B, C, and
HIV.
Source patients and staff will have to sign a
consent for HIV testing. There is no charge
to the patient or staff member for postexposure testing.




Healthcare workers are at risk for exposure to bloodborne pathogens
including Hepatitis B and C and HIV. Certain populations of Healthcare
workers are more at risk than others. Those at high risk include staff who are
directly involved in patient care (physicians, nurses, nurse’s aides, therapists,
EMT’s), patient testing (lab, cath labs) and environmental services personnel.
The most common type of bloodborne pathogen exposure comes from
needlesticks or puncture and laceration wounds from an object contaminated
with an infected patient’s blood. Other exposures include splashes, splatters,
or sprays of blood that is contaminated with HIV, Hepatitis B or C.
Hepatitis B is the most common pathogen that HCW’s (Healthcare Workers)
could potentially be exposed to. The average risk from a single needlestick
or cut is 6-30% and depends on the immunity of the individual exposed and
the amount of the virus in the source patient’s blood.
Hepatitis C carries a risk level of about 1.8% for infection after an exposure
while HIV carries a risk of infection after exposure of about 0.3% (1 out of
300). For HIV infection risk after exposure to the mucous membranes, the
risk drops to 0.1% (1 in 1000) and the risk of infection after exposure to a
non-intact skin surface (such as a scrape or open skin lesion) is less than
0.1%.
The level of risk varies with such factors such as whether or not a pathogen
was present in the blood and what that pathogen is, the type of exposure,
the amount of blood involved in the exposure, how deep the exposure was
into the skin (percutaneous exposures) and the amount of the virus in the
patient’s blood at the time of the exposure.









Do not recap syringes.
Do not bend, break or shear needles
Handle sharps with medical devices such as forceps when
possible
Use only an approved sharps container to dispose of
sharps. Take care not to toss in patient trash.
Use appropriate barriers such as gloves, masks with eye
shields and non-permeable gowns when contact with
blood is anticipated.
Close and seal sharps containers when they are 2/3 full.
NEVER force a sharp into a container!!
Consider receiving the Hepatitis B vaccination series for
protection against Hepatitis B virus.
Note: This vaccination series will not protect you against
Hepatitis C or HIV.







Report the exposure incident to your supervisor immediately!! Time is of
essence to obtain tests and start prophylactic medication. Notify Employee
Health Nurse immediately.
Go to Emergency Department and get exposure packet from NURSING.
You will go to the LAB, give a drug screen and have blood drawn for baseline
Hepatitis B and C and HIV.
If the source patient is known, they will be interviewed for risk factors and
asked to sign a consent form and blood will be drawn from them for these
viruses also.
For some exposures the physician may opt to give you immunoglobulin to
help protect you against these viruses if you have no immunity to Hepatitis B,
or start you on oral medications prophylactically until the lab test results are
returned.
For the first 6 weeks after an exposure to HIV, it is suggested that you not
donate blood or other body fluids or be considered as an organ donor. Use
condoms with sexual intercourse. If you are a breast-feeding mother, stop
breast-feeding in the follow-up period. HIV can be transmitted through
blood and body fluids such as breast-milk or semen. HIV usually poses no
risk of transmission from sweat, tears or from skin-to-skin contact.
Testing for follow-up will be done on initial exposure (baseline), again
varying with the type of exposure.


How would you feel
if a co-worker
became infected
with HIV, Hepatitis
B or C and it was
due to your
carelessness?
How would you feel
if you were infected
as a result of
someone else’s
carelessness?



Must be done before you leave from the shift
in which you were injured.
If you do not do this you will be asked to
return for the drug screen.
Only current medications prescribed for you
are permitted.
What is Formaldehyde?
Formaldehyde is a colorless,
flammable, strong-smelling chemical
widely used to make resins, plywood,
particle board, pressed wood products,
glues and plastics.
It is also used as a preservative in
medical laboratories, mortuaries and
veterinary clinics.
It is mixed with water to make a liquid
called “formalin” which contains 37 %
formaldehyde and 6% - 13% methanol.
Only the lab may store formaldehyde

Regulated areas shall have danger signs posted at
entrances and access ways
Go to the lab to get the Formalin to be used that day.
All formalin that is not used must be returned at
the end of the day.
10
2

Exposure routes
◦ Inhalation
 Sore throat, coughing, shortness of breath
 Sensitization of respiratory tract
 25-30 ppm: pulmonary edema and pneumonitis
◦ Ingestion
 Severe abdominal pain, violent vomiting, headache,
diarrhea, unconsciousness and death
 Methanol used to stabilize the formaldehyde solution poses
additional toxic hazards Skin contact
 Irritation from vapors, pain, blurred vision
 May cause irreversible damage if splashed in eyes
 Irritation and/or burns; cracking, scaling, white
discoloration
 Can be absorbed through skin
◦ Eye contact
 May cause irreversible damage if splashed in eyes
 Irritation from vapors, pain, blurred vision
10
3
Engineering controls:
1.
Always use formalin in a properly functioning chemical fume hood or in a
properly ventilated area
2.
Use the smallest amount of formalin necessary
Protective clothing (lab coats, aprons, suits):
1.
Tychem® CPF2, SL, CPF3, F, CPF 4, BR, LV, Responder, TK, or Reflector all have
breakthrough times >480 min
Gloves (required when using >1% formaldehyde):
1.
Nitrile (>360 min) is the best choice
2.
Neoprene (105 min), or PVC (100 min) are ok
3.
Rubber or Neoprene/rubber are ok for short use (10-15 min)
4.
PVA gloves are not recommended
Eye protection
1.
For working with formaldehyde at any concentration greater than 1%, splashproof eye protection is required
Volunteers may not transport formaldehyde
10
4
 Specimens
in Formaldehyde
 Cerebral Spinal Fluid
 Specimens that are not tightly
sealed


Notify Employee
Health
An assessment of
the workstation will
be obtained and
suggestions for
improvements
discussed.



Take time to stretch.
If your position requires extended computer
time, rest your eyes.
Look away and focus on something on the
opposite wall.



Test the load before moving an object. Use
assistance if necessary.
Plan the move. Check the path of travel to be
sure that it’s clear.
Use a wide balanced stance with 1 foot ahead
of the other. This reduces the likelihood of
slipping and jerking movements





Keep the lower back in it’s normal arched
position while lifting. Bend knees or hips.
Bring the load as close to the body as
possible.
Keep head and shoulders up as lifting
begins. This keeps the natural arch in your
back.
Tighten stomach muscles as the lift begins.
Lift with the legs. Stand up in a smooth,
even motion.


Move the feet (pivot) if a direction change is
necessary.
Communicate if two or more individuals are
involved in the movement.
The CDC has included alcohol hand rubs in
their Hand Hygiene Guidelines for Health
Care Workers. Use of the alcohol hand rubs
has proven to be an effective measure to
improve hand hygiene and decrease the
spread of organisms within a healthcare
facility.




You must wash hands using alcohol based
hand cleaner or soap and water before and
after patient care.
You must wash hands after touching
something dirty on a patient before touching
something clean.
You must wash hands after removing gloves.
You must wash hands after using the
restroom.

A Reminder About What You Already Know
Use soap and warm water
Scrub hands for 10-15 seconds (pick a little song)
Don’t forget the backs
Don’t forget between your fingers
The thumb is the most forgotten digit
Scrub fingernails in the palm of your hands
Dry hands
Turn off faucet & open door with paper towel



No artificial nails
Natural nails must be kept short and clean
No large, bulky jewelry
Protect Yourself and Your Patients



For patients with TB,
measles, chickenpox,
and shingles.
Patient must be in
negative pressure room
at all times, with the
door closed.
Staff must wear special
N-95 mask and must be
fit-tested before use.
Droplet Precautions
• Use for patients
with influenza, RSV
and respiratory
illnesses
• Wear a regular
surgical mask
when within 3 feet
of the patient
Contact Precautions
• Use for patients with
open wounds with
drainage, skin infections
EXCEPT drug resistant
organisms.
• Wear gown and gloves
• Wear mask with eye
shields if splashes
might occur
VISITORS
Report to nurse before entering
Patient Placement
Private Room with door to remain closed
Gloves and Gown
 Must be donned before entering the patient’s room. No Exceptions!
 Must be removed before leaving the patient’s room. No Exceptions!

Remove PPE in a manner so as not to touch skin, clothes or environmental surfaces.
Mask with eye shields
 Must be donned before entering the patient’s room if infective material can be splashed or splattered into
eyes or mucous membranes.
 Must be removed before leaving the patient’s room. No Exceptions!
Wash
Strict Hand washing mandatory. May use Alcohol Hand Rub
Patient Transport
 Limit transport out of room to essential purposes only
 Place clean linen between patient and wheelchair, stretcher or lift.
 Communication to receiving departments re: precautions is mandatory.
Patient Care Equipment
 Dedicated or disposable equipment only.
 If using wheelchair, stretcher or lift, etc. thoroughly disinfect equipment after patient use.
VISITORS
Report to nurse before entering
Patient Placement
Private Room with door to remain closed
Gloves and Gown
 Must be donned before entering the patient’s room. No Exceptions!
 Must be removed before leaving the patient’s room. No Exceptions!
 Remove PPE in a manner so as not to touch skin, clothes or environmental surfaces.
Mask with eye shields
 Must be donned before entering the patient’s room if infective material can be splashed or splattered
into eyes or mucous membranes.
 Must be removed before leaving the patient’s room. No Exceptions!
Wash
Strict Hand washing mandatory. USE SOAP AND WATER
Patient Transport
 Limit transport out of room to essential purposes only
 Place clean linen between patient and wheelchair, stretcher or lift.
 Communication to receiving departments re: precautions is mandatory.
Patient Care Equipment
 Dedicated or disposable equipment only.
 If using wheelchair, stretcher or lift, etc. thoroughly disinfect equipment after patient use.

Remember the
best defense is
PROTECTING
YOURSELF by
strictly following
Standard
Precautions and
Transmission
Based Precautions.

The use of
personal protective
equipment is
MANDATORY.






Gowns
Gloves
Masks
Eye shields
Shoe Covers
Others


Everyone must
know & do this!
Read the following
policy carefully!
Cleaning of
Equipment
Terminal cleaning of equipment left in room.

◦
◦
Equipment cleaned and left in the room shall be identified as clean.
Equipment that needs to remain plugged in will be cleaned, positioned as close a possible to the power source, the
slack in the cord will be wrapped and tied with a blue zip tie.
Cleaning of equipment that does not remain in the room after patient discharge.

◦
Housekeeping will clean the equipment, wrap the power cord and secure it with a blue zip tie. The clean equipment
will then be placed in the equipment room or other designated place.
Cleaning of equipment that travels room to room.

◦
◦
Gait belts, BP cuffs and SVO2 probes that are reusable or disposable will remain in a single pt room, and be cleaned
upon patient discharge.
Blood pressure machines, thermometers, Xray plates etc. that move room to room shall be cleaned by the staff
member using the equipment upon leaving a pt’s room.
Rental Equipment

◦
◦
◦
◦

◦
All rental equipment will be cleaned upon arrival to the facility.
It is the responsibility of the staff member receiving the equipment to clean or to arrange for cleaning of the
equipment, prior to its being placed into use.
Equipment that is used immediately after cleaning does not need to be marked.
If use of the equipment will be delayed after cleaning, the power cord will be wrapped and tied with a blue zip tie.
Cleaning of broken equipment that may be removed from the room.
A work order will be generated and attached to the broken equipment. The equipment will be placed in the soiled
utility room. Nursing staff will clean the equipment, wrap the power cord and zip tie it with a blue tie. The clean
equipment with the attached work order will be placed in the equipment room, in a spot marked for broken
equipment. Biomed will pick up the broken equipment and repair it. Biomed will re-clean the equipment and mark
it with a blue zip tie. It will then be returned to service.
Broken equipment that can not be unplugged.

◦
◦

◦
This equipment will be grossly decontaminated. A work order will be attached, identifying it as broken. Biomed will
handle this equipment as bio-hazardous.
Housekeeping will clean the repaired equipment, mark it with a blue zip tie and return it to service.
Broken equipment that may be unplugged and has disposable or bio-hazardous pieces.
The equipment will be grossly decontaminated and placed in a clear bag. A work order will be attached to the bag.
The equipment will then be placed in the soiled utility room for pick up or taken to Biomed.
Questions?
Call Infection Prevention at 801.562.4266
Life Safety Orientation
This program covers safety
information related to…




Fire Safety
Electrical Safety
Security/Personal Safety
Life Safety & Environmental Safety
IF YOU TAKE AWAY ANY OF
THESE ELEMENTS, FIRE
CANNOT EXIST
There are four elements of fire…
FUEL: Any combustible material – solid, liquid or gas.
Most solids are liquids become gas or vapor before they will
burn.
OXYGEN: The air we breathe is about 21 percent
oxygen. Fire only needs the atmosphere to contain 16
percent oxygen
HEAT: The energy that causes the fuel to produce
vapors which, in turn, allows ignition to take place.
CHEMICAL REACTION: When fuel, oxygen and heat
come together in the proper amounts and under the right
conditions, a chemical chain reaction takes place and
causes rapid oxidation to occur. This rapid oxidation
results in fire.
How to Prevent Fires…







Electrical fires are the most common fires in
healthcare settings
Use only UL-rated electrical equipment
Keep electrical equipment and motors cleaned
and properly maintained
Check wiring and electrical fitting for wear or
damage. Report any wear or damage to your
supervisor
Never overburden electrical outlets or piggyback electrical cords
Do not use extension cords or tack cords to wall
or run under carpet
Investigate any unusual odors coming from
electrical device
How to Prevent Fires…






Keep storage and maintenance areas free of trash
and clutter
Keep combustible materials well away from any
source heat
Store gas cylinders away from patient area
Do not store cleaning fluids near any source of
heat, such as equipment electrical closets
Keep flammables away from any spark-producing
source
Use flammable liquids only in well-ventilated areas
A fire in any area of the hospital(s) is
an emergency, which must be
resolved quickly. Employees and
students are required to know and
implement the four basic steps in the
event of a fire using R.A.C.E.
R escue A larm C onfine E xtinguish
Rescue the patient(s) from danger.
Disconnect oxygen from the wall
outlet only for the patients in
immediate danger from the fire.
Close the door behind you.
R escue A larm C onfine E xtinguish
Activate the nearest alarm box and
call the Medical Center operator at
extension “ 0 ” or 4444. Give the
exact location of the fire by floor and
room number and the extent of the
fire. Remain on the line until the
operator has verified information
given. Never hesitate to sound the
alarm with ANY suspicion of fire.
R escue A larm C onfine E xtinguish
Close all doors and windows in the
area of the fire. This will limit
oxygen supply to the room.
R escue A larm C onfine E xtinguish
Extinguish only very small easily
controlled fires, or fires that prohibit
the removal of patients.
Proper use of Fire Extinguishers…
Use PASS method
P
A
PULL the pin
AIM the nozzle at the base of the flames
S
SQUEEZE the trigger while holding the
extinguisher upright
S
SWEEP the extinguisher from side to side
covering the area of the fire
Use of fire extinguishers can save lives and property by
putting out small fires before they spread
General Response of Employees…





Familiarize yourself with location of fire
alarm pull stations and fire extinguishers
Close all windows and doors
Reassure patients and visitors that
everything is under control
Prepare to evacuate if ordered by Fire
Department/Security
Stay close to the floor. Most fire deaths are
caused by smoke-related carbon monoxide
poisoning
Evacuation…






Evacuate only if directed to do so
Evacuate ambulatory patients first to
reduce confusion and create more room
Move patients horizontally, out of their
rooms, through next set of fire doors
If you can’t move horizontally, work your
way down to the next level
Do not use elevators
Bring patient record
When NOT to Fight a Fire…




The fire is spreading beyond the point
where it started
Smoke or flames threaten patients’
safety
You do not have proper equipment to
extinguish the fire
Flames are threatening to block your
path of escape
Fire Drills…
In an effort to provide on going fire safety education, the
Engineering Department conducts monthly fire drills
throughout both hospitals and campus buildings.
Immediately following these drills, staff are asked to
participate in a fire safety test & review. This test is a
useful tool to identify areas where more education may
be needed.
An employee from each department is required to
complete the Code Red Report Form (located on
Intranet) following a drill or actual event. This
information is required by DNV and is a useful tool to
identify any life safety issues that need to be
corrected.
Everyone has a role in keeping
the hospital a safe place.
Hospital security staff has the
responsibility to protect staff,
patients, visitors & property
Employee Responsibilities…






Report any suspicious activity or perceived
threats
Always be aware of your surroundings
Do not prop open doors
When leaving a secure area, do not allow
people to enter
Keep valuables out of sight. Do not leave
purse, phone, wallet out in areas where
people have access
For a security escort, please contact the
hospital operator and ask for security
Parking…


Employees may park in stalls lined in white.
Yellow parking places are visitor only
Do not leave valuables in your car
Security Codes…

CODE BLUE– MEDICAL EMERGENCY
◦ Call 4444
◦ Operator pages “Code Blue” overhead three times
◦ Operator initiates group pages to Respiratory, Lab,
Pharmacy, Radiology, House Supervisor
◦ All personnel return to your department if code blue in
your area
◦ Responding personnel:
bring crash cart
begin CPR if qualified
Patient's nurse to remain in room
Bring patient’s chart. In-patient area, bring patient’s chart
up on the computer
 Provide support to family




Security Codes…

CODE RED- FIRE



RESCUE patients in the immediate area
Sound the ALARM. Pull the alarm box or dial 4444
CONFINE the fire





Close all windows and doors
Shut off portable fans
Ensure automatic smoke doors are closed
If unable to move patient, place wet towel at bottom
of door
EXTINGUISH the fire if it is small and easily controlled
or prohibits the removal of patients
Security Codes…

CODE GREEN – SECURITY/SHOW OF FORCE
A situation that has the potential of becoming out of
control and requires security or assistance to prevent
injury to patients, visitors or staff.





Dial hospital operator at 4444 and designate the area and
problem
Hospital operator will page “Code Green” and location
overhead three times
Responding personnel will use non-threatening measures
to defuse situation
If further assistance is needed, the hospital operator is to
notify appropriate police departments
Complete Occurrence Report
Security Codes…

CODE ORANGE – HOSTAGE SITUATION
If you identify a hostage situation you should:
◦ Dial 4444, request a Code Orange, give the location and
stay on the line, Operator will call 911
◦ Secure the immediate area and remove all personnel to an
area that is safe and secure
◦ Write down everything, keep a log
◦ Do not talk with media
◦ Follow instructions from police, once they arrive
Security Codes…

CODE YELLOW – BOMB THREAT
The person receiving the bomb threat should:
 Keep the person talking
 Stay calm
 Get another employee to dial 4444 and tell the
operator to announce overhead three times “Code
Yellow”
 Give location
 Ask:






Where is it?
What time is it set to go off?
What does it look like?
What is the explosive?
Where was it placed?
Why was it placed?
Security Codes…

CODE PINK – INFANT ABDUCTION
There is a Security System (HUGS) in place and
newborns are banded at birth. Should a newborn be
removed from the unit without the band being
deactivated, an alarm will automatically trigger and the
hospital operator will call a “Code Pink”.




Nursing staff will immediately obtain a head count of all
babies
Question mother of the missing baby regarding possible
location
Hold all personnel until released by law enforcement
Other staff will go to their pre-assigned areas to watch
and check all people attempting to leave the hospital
Security Codes…

CODE PINK – INFANT ABDUCTION

Cautiously detain individuals:




(continued)
Carrying a baby
With large bags
Wearing baggy coats or anything else that could hide
a baby
If person insists on leaving, observe them from a
distance noting their description, direction of travel
and description of car and license number. Give this
information to the police or hospital security
Security Codes…

CODE ADAM – MISSING CHILD
When a
parent or guardian notifies an employee that
this/her
child, either a pediatric patient or pediatric visitor, is
missing in the hospital
◦ Obtain a detailed description of the child including:




Name and age
Hair and eye color
Weight and height
What the child is wearing, including shoes, as abductors
don’t usually change shoes if they redress the child
◦ Location where child was last seen
◦ Operator will announce “Code Adam” overhead three
times
Security Codes…

CODE ADAM – MISSING CHILD
◦ Staff will:
(continued)
 Completely search their immediate area and adjacent
area
 Monitor pre-assigned doors to make sure the child does
not exit hospital
 Other hospital staff will begin searching the other areas
of hospital
◦ Cautiously detain individuals who have a child fitting
the description
 Ask person to wait for management to arrive
 If person insists on leaving, observe them from a
distance noting their description, direction of travel and
description of car and license number
 Give information to police and hospital security
Security Codes…

CODE GREY – SEVERE WEATHER
The Safety Officer or designee will call the code when
information is received that severe weather is approaching
◦ Staff will do the following:





Draw blinds
Pull all drapes and curtains
Provide patients with pillows
Assist patients to safe areas
Move all visitors and other staff to interior hallways
Security Codes…

CODE SILVER - ACTIVE SHOOTER/KILLER
How to respond when an active shooter/killer is in your
area:
 Evacuate. Have an escape route and plan in mind.
Leave your belongings behind and keep your hands
visible
 Hide Out. Hide in an area out of the shooter’s view.
Block entry to your hiding place and lock the door.
Silence your cell phone
 Take Action. As a last resort and only when in
imminent danger, attempt to incapacitate the
shooter/killer. Act with physical aggression and throw
items at the active shooter/killer
 Upon arrival of law enforcement:


Immediately raise your hands and spread your
fingers
Allow law enforcement to take control of situation
Security Codes…

CODE BLACK – DISASTER
Code Black may be called if it is anticipated patients will
be arriving at the hospital in sufficient numbers or with
injuries of such magnitude that their care cannot be
handled within the context of normal hospital functions




A Code Black will be determined by Administration, House
Supervisor, ED Director or Charge Nurse
Dial 4444. Operator will announce overhead “Code
Black” three times
Unit Directors, Supervisors or Charge Nurse report to
command center
Prepare for evacuation
Security Codes…

CODE PURPLE – STROKE PATIENT
If you suspect stroke with a patient, look for the following:
◦ Facial droop – Ask patient to smile and look for unevenness
or drooping of one side of face
◦ Arm drift – Ask patient to lift both arms at shoulder level, if
one arm is hanging lower or drifts downward
◦ Inappropriate speech – Watch for confused garbled speech or
slurring of words
◦ Dial 4444, request a “Code Purple”
◦ Operator will announce overhead “Code Purple” and initiate
Group pages to team members
Security Codes…

CODE STEMI – STEMI
STEMI stand for ST segment elevated MI. This code is called
from anyone coming into the ED (or inpatient) having a
myocardial infarction. Because time is of the essence with
these patients, when a code STEMI is called, a designated
team is notified.
◦ Dial 4444, request a “Code STEMI”
◦ Operator will announce overhead “Code STEMI” and initiate
Group pages to team members
Security Codes…
Refer to the Disaster Reference Cardex in
each department for all code definitions.
Definitions can also be found on the back
of employee badge. Check with your
department director to know your role in
each code.
Equipment and Electrical Safety…





Grounding is the single most important
principle in electrical safety
Never use a piece of equipment that is not
equipped with a ground plug
Never use electrical equipment when the
ground prong is loose or broken.
Frayed or damaged electrical cords should
not be used
All electronic devices & equipment should
be visually inspected for any damaged
cords or parts





If a “tingle” or shock is felt, unplug the
equipment and report to your supervisor or
the Engineering Department
When disconnecting electrical cords from
wall, grasp the plug and gently pull. NEVER
grab the power cord and yank it
Arrange equipment cords and cables away
from foot traffic
Protect cords and cables from liquids and
sharp objects
Red electrical outlets provide emergency
power. Ensure critical equipment is
plugged into the RED emergency outlets




All hospital medical equipment is
maintained by the hospital’s Clinical
Engineering Department
All hospital mechanical equipment such as
HVAC, generators, electrical, plumbing,
stretchers and wheelchairs are maintained
by the Maintenance Department
To avoid patient harm, suspected problems
with equipment should always be reported
Never use water or a water fire extinguisher
to fight an electrical fire
Hospitals are challenged with maintaining a
safe building and environment. Employees
play a vital role in keeping the hospital safe.
Employees Responsibilities:






Keep hallways free of clutter and equipment
Do not use space heaters
Boxes are not to be stored on floor
Storage is to be kept at least 18” from ceiling
Dress for the weather to avoid slip and falls
Live trees and natural wreaths are not allowed in
hospital
Jordan Valley Medical Center/Jordan-West
Valley’s administration and staff members
recognize the health hazards caused by
tobacco products. As a healthcare campus,
JVMC/WVC is committed to the establishment
and enforcement of a healthier, tobacco-free
environment.

Initial Inspection of Equipment
◦ Includes ALL equipment that is used on a patient,
regardless of ownership.





Physician Owned
Rentals
Leases
Demonstration
Patient Owned Medical Equipment
◦ We Perform Electrical Safety checks to protect you
and the patient

During Preventive Maintenance Checks, we:
◦
◦
◦
◦
Inspect for damage
Inspect for proper operation
Calibrate the equipment
Replace worn parts

Perform Repair Services
◦ Common problems can include:





Equipment is unplugged
Equipment is turned off
User does not know how to use it
Using Bad probes and/or accessories
Equipment is actually damaged
The Magnet is always on

To report a Broken Piece of equipment:
◦ Use Web Link and/or
◦ Inform your supervisor
◦ Call the Service Coordinator (JVMC x 4213) or
Biomed (WVC x3801) with:
 Biomed Control Number or Asset Number
 YOUR name, so we can ask you questions
 Description of the problem.
 “Broken” causes delays
 Location of the equipment, where we will find it
 If you move it, we will come, but cannot fix it.
Clinical Engineering

Users Responsibilities:
◦ Verify equipment does not need to be inspected.
 Should have label:
◦ Inspect unit before use:
 Frayed cables
 Missing/Broken accessories
 Proper operation
Clinical Engineering

Users Responsibilities:
◦ Inform supervisor/Director if a problem is found.
◦ Call Biomed (x3153 or x3801), if in doubt.
Clinical Engineering

Equipment Failures:
◦ If there is patient harm caused by failed Medical
Equipment, it MUST be sequestered
 Leave unit plugged in, if possible
 Disconnect from patient, and keep any disposables
used
 Put sign on it “Do Not Use”
 Inform your supervisor
 Call the Service Coordinator (JVMC x4213) or Biomed
(WVC x3801) immediately
◦ An investigation of the state of the equipment will
be made
Clinical Engineering

Electrical Safety:
◦ EVERYONE is susceptible
◦ Frayed, Damaged cords can cause serious harm
◦ Requires periodic inspections


The Magnet is ALWAYS ON!!!
When in Doubt, Call Biomed!
Klay Kunz
Regional Compliance Director
IASIS’ Compliance Program
It is every employee’s responsibility and duty to report
possible or suspected wrongdoing that violates the IASIS’
Standards of Conduct or any regulation that governs our
organization.
IASIS’ Compliance Program
[DATE]
GC.009, Duty to Report Potential Compliance Violations, supports an
environment that encourages an obligation to immediately report
wrongdoing through the Chain of Command or IASIS AlertLine.
Individuals are protected from retaliation and retribution when
reporting potential compliance violations.
IASIS’ Standards of Conduct
We relate to people ethically and responsibly…
IASIS’ Standards of Conduct
Relating to fellow employees:
 Treat others with respect and dignity
 No tolerance for sexual harassment
 Communicate honestly
 Avoid discrimination in hiring practices
 Adhere to Standards of Conduct
 Follow appropriate chain of command
Relating to communities:
Relating to patients:
 Provide compassionate, prompt and
professional care
 Provide high quality healthcare
indiscriminately
 Treat all emergency medical conditions
 Protect patient confidentiality
 Uphold patient advance directives
Relating to vendors:
 Provide health education & resources
 Treat objectively, honestly & fairly
 Volunteer in community activities
 Select for objective business reasons
 Represent IASIS accurately & honestly
 Adhere to terms and conditions of
contracts; keep information confidential
 Refrain from fraudulent activities or
improper practices
IASIS’ Standards of Conduct
Examples of Gross Misconduct
 Socializing with prospective, current or
former patients
 Abusing a patient emotionally or physically
 Engaging in sexual activity
 Using abusive or provocative language in
the presence of the patient and/or family
members
 Using a form of restraint not physicianprescribed
 Failing to maintain confidentiality
 Accepting from or exchanging gifts with a
patient
 Offering unprescribed drugs or alcohol to a
patient
 Challenging physician orders or criticizing
physician care in the patient’s presence
IASIS’ Standards of Conduct
When to get help:
Where to get answers:
 Is the action legal?


Is it the right thing to do?


If I do it, will I feel bad?

Will it have a positive impact on
our patients, co-workers, or the
company?

Would I be proud to tell others
what I did?

How will it look in the newspaper?






Read our Standards of Conduct
Get on-line at iasishealthcare.com
Talk with your Supervisor
Talk with your facility’s HR personnel
Talk with your facility’s Regional
Compliance Officer
Contact the Corporate Compliance
Officer @ 615.844.2747
Contact the IASIS Legal Department
@ 615.844.2747
Call the AlertLine @ 1.877.898.6080
Employees and personnel will not be subject to retaliation or retribution for asking questions,
expressing concerns or sharing information about situations that may be in violation of the
IASIS Standards of Conduct. Anyone who engages in a deliberate act of retaliation or
retribution will be subject to disciplinary action, including termination if warranted.
A review of
HIPAA Privacy, ARRA, and HITECH
What is HIPAA, ARRA & HITECH?
• HIPAA is the Health Insurance
Portability and Accountability Act of
1996 (HIPAA).
– April 14, 2003 – federally mandated
deadline for privacy regulation compliance
• ARRA is the American Recovery and
Reinvestment Act of 2009
– Signed into law on February 17, 2009
• HITECH is the Health Information
Technology for Economic and Clinical
Health Act
– Title XIII in the ARRA

A Covered Entity may not use or disclose protected
health information (PHI) unless HIPAA allows it
◦ A patient’s individually identifiable health
information is protected
◦ PHI may be oral or written or in any form
◦ Information that identifies an individual and
relates to
 Physical, mental health or condition of the patient
 Care provided to the patient
 Payment for healthcare

A Business Associate may not use or disclose PHI
unless it is permitted by the terms of its business
associate agreement with a Covered Entity


A Covered Entity may use and
disclose protected health information
for treatment, payment and
healthcare operations purposes
without obtaining a patient’s written
authorization
Otherwise, a Covered Entity must:
◦ Have a signed authorization, or
◦ Meet a HIPAA exception
HIPAA Privacy
• Our hospitals, including
employees and physicians,
must continue to comply
with the HIPAA privacy rule
Breach Examples
• Inappropriate access of patient information
– Accessing paper or electronic records which are not required
to perform your job
– Accessing more than is required to perform your job
– Applies to employees, physicians, business associates, etc.
• Inappropriate use of patient information
– Uses which are outside of one’s job scope
• Inappropriate disclosure of patient information
– Misdirected faxes containing sensitive information sent
outside of the facility
– Incorrect PHI provided to a requestor or patient
– PHI removed or stolen from an office, briefcase, etc.
Timely Notification
• Appropriate notifications must occur within specific
timeframes; therefore, it is very important that
employees promptly report a known or suspected
HIPAA violation to any the following:
– Supervisor / Manager (chain of command)
– Regional Compliance & Privacy Officer
– IASIS AlertLine
Higher Civil Penalties
Violation category –
Section 1176(a)(1)
Each Violation
All such violations of
an identical provision
in a calendar year
Covered entity did not know
$100 - $50,000
$25,000
Covered entity had
reasonable cause
$1,000 - $50,000
$100,000
Covered entity acted with
willful neglect, corrected
$10,000 - $50,000
$250,000
Covered entity acted with
willful neglect, not corrected
$50,000
$1.5 million
Criminal Penalties Apply to
Employees
•
Criminal penalties
– Now apply to individuals (including employees), not just the
hospital or covered entity
HIPAA Privacy Practices
• Never obtain, access, or disclose patient information
unless you are authorized to do so.
– Being a hospital employee does not mean you are “authorized” to
access patient information – you must have a valid business
reason
– If you need access to your own patient records, you must go
through the same routes as any other patient of the facility
(request records from the H.I.M. Department or Business Office,
as applicable)
– Accessing or reviewing patient information without a valid reason
is a breach of the patient’s privacy
– If you are authorized to obtain, access, or disclose patient
information, do not share this information with unauthorized
individuals (hospital peers who do not have a “need to know” or
family members, friends, etc.)
– “Snooping” in a patient’s medical record is not tolerated by IASIS
and will be promptly addressed with strict corrective actions,
which may lead up to or include termination
HIPAA Privacy Practices
• Alleged abuse of any IASIS system is grounds for
suspension of an employee and deactivation of
systems access until a thorough investigation is
completed
• Confirmed abuse of any IASIS system is grounds
for permanent loss of access and/or other
immediate disciplinary actions, as deemed
appropriate
• In all cases, we must limit the amount of protected
health information we use, disclose or request to the
minimum necessary required to perform the task
Disciplinary Action
• You are personally responsible for the access of any
information using your login and password
• You are in violation of IASIS policies and subject to
disciplinary action if:
– you access information that you do not need to perform
your job, or
– allow someone else to access information using your
login information whether they are authorized to view
that information or not, or
– you fail to immediately notify the Regional Privacy
Officer or your Facility’s Information Security Officer /
I.S. Director if you are asked to share login or password
information
How Can You Protect Patient Privacy?
• Don’t discuss confidential patient information with coworkers in public areas (elevators, cafeteria, etc.)
• Do hold conversations with patients and families in
private areas, when possible
• Don’t assume someone else will report a known or
potential HIPAA violation…it is each employee’s
responsibility to report
• Do file medical records or patient information, in
patient care areas, in such a way to avoid observation
by patients, visitors, or unauthorized staff
How Can You Protect Patient Privacy?
• Don’t position computer monitors where the information
may be seen by visitors
• Do remember to lock your computer screen when it will
be left unattended
• Don’t leave confidential patient information on an
unattended printer, a copy machine, or a fax machine
• Do use limited patient information on departmental white
boards
• Don’t toss any paperwork containing patient information
in the regular trash, including reports, handwritten notes,
lab reports, patient labels, etc. -- dispose of this
information in a designated shredding bin
How Can You Protect Patient Privacy?
• Don’t release a patient’s medical record or medical
information unless you are authorized to do so
• Do check forms to be sure they contain the name and
other information pertaining to the correct patient for
which they will be used
• Don’t discuss confidential patient information with your
spouse, your neighbor, or your friends – what happens in
your facility, stays in your facility
• Do report misuse of confidential patient information to
your Supervisor, to the Regional Compliance & Privacy
Officer or to the IASIS AlertLine
How Can You Protect Patient Privacy?
• Don’t forget, it is your responsibility to maintain patient
confidentiality and privacy at all times (not just when you
are in the facility)
– Sharing information, descriptions, or pictures of patients, their
family members, etc., on Facebook, Twitter or other social media
is inappropriate and will result in appropriate sanctions
How Can You Protect Patient Privacy?
• HIPAA violations or breaches may be prevented if
employees will use caution when appropriately
accessing, using, or disclosing protected health
information (PHI)
• Additional HIPAA / HITECH information will be
presented by your Regional Compliance & Privacy
Officer in the near future, as we are currently awaiting
several updates from the federal government
• Do your part to protect our patients’ privacy…it’s the
right thing to do!
Information Security
Information Security, HIPAA Security, HITECH
H.B. 300
2012
Protection of the Confidentiality,
Integrity and Availability (CIA) of
sensitive and critical data against
unauthorized access,
modification and destruction




Personal information such as names,
addresses and social security numbers could
be at risk
Patients trust us to protect their health
information
Our reputation is on the line
It’s the Law – HIPAA/HITECH, Sarbanes
Oxley, PCI, etc.
…Corp. agreed to pay $1 million and take corrective action in a pair of
settlements with HHS' Office for Civil Rights involving violations of the
privacy provisions of HIPAA
…Corp. agreed to pay $2.25
million in HIPAA privacy
violations
Regulators fined a Hospital $250,000 for
failing to keep unauthorized employees
from snooping in medical records

The HIPAA Security Rule establishes national
standards to protect individuals’ electronic
personal health information that is created,
received, used, or maintained by a covered
entity. The Security Rule requires appropriate
administrative, physical and technical
safeguards to ensure the confidentiality,
integrity, and security of electronic protected
health information.

Our Hospitals must protect:
◦ Computer hardware, software and medical
equipment
◦ Buildings/areas that house computer hardware,
software and medical equipment
◦ Storage and disposal of data and the back-up of
data
◦ Who has access to data
 Special care and attention must be administered when
using medical equipment, computing systems, and all
portable media during and after accessing patient
information (i.e., Physician Portal, Star, HPF, etc.)

HITECH extends the complete Security Provisions of
HIPAA to business associates of covered entities
◦ Extension of civil and criminal penalties

Provides new breach notification requirements
◦ requires HIPAA covered entities to report data breaches
affecting 500 or more individuals to HHS and the media, in
addition to notifying the affected individuals





Unauthorized access to any system containing ePHI
Providing ePHI to non-workforce individuals
without proper authorization
Sending ePHI to your personal email account (i.e.,
gmail, yahoo, etc.)
Stolen unsecured laptop storing unencrypted ePHI
on hard drive
Stolen unsecured external media (i.e., PDA/Smart
Phones, Magnetic tapes, CD/DVD’s, USB External
Flash (thumb) Drive, Compact Flash/Secure Digital,
etc.) storing unencrypted ePHI

Criminal penalties now apply to covered
entities and workforce members!

Electronic Protected Health Information (ePHI)
is PHI created, received, stored or transmitted
electronically, such as:
Digital
Radiology
Electronic
Medical Record
Electronic Billing
Information

The HIPAA Security Rule covers all
electronic media including, but not limited
to:
◦
◦
◦
◦
◦
◦
◦
◦
Computer networks
Desktop computers
Laptop computers
PDA/Smart Phones
Magnetic tapes
CD/DVD’s
USB External Flash (thumb) Drive
Compact Flash/Secure Digital






PCs, mobile devices such as PDAs, Smartphone's, laptops, digital
cameras, flash drives or other devices containing confidential
information or electronic PHI must be kept secure
ePHI must be removed from these devices as soon as the need to
perform a required job function is complete
All confidential information is best kept on network storage space
provided by Information Technology (IT) and accessed only when
needed
Encryption and passwords must be used to protect ePHI
Personal devices are NOT approved for use in transmitting patient
information (i.e., texting between employees or physicians, taking
photographs of patients, etc.)
Contact your local IT department for assistance



Portable media with confidential information, such as:
◦ Laptop computers
◦ PDA/Smart Phones
◦ CD/DVD’s
◦ USB storage media (i.e., compact flash, multimedia, secure
digital, etc.)
Must be kept with you or locked up in a safe location (e.g.,
locked drawer or file cabinet)
If you MUST leave any of these items in your car, your trunk
is your best choice (store items prior to reaching your
destination)

Choosing a compliant password and keeping
it secure are two of the most important steps
you can take to protect electronic information

Passwords should be:
◦ A minimum of 7 alpha (upper & lower case) &
numeric selection
◦ Includes symbols or special characters when
possible
◦ Based on something besides personal information
so that it cannot be easily guessed or obtained
 Do not use names of family members or pets
 Do not use any word in the dictionary






Keep your password private
Do not share your password with anyone
Do not write your password on a sticky note
Do not reuse old passwords
Do not use your company passwords on web sites (e.g., bank
accounts, shopping, etc.)
Do change your password every 90 days


If you believe someone has inappropriately
used your user ID or password, change your
password immediately and notify your FSO or
Information Systems (IS) department
If you notice other security policy violations
contact your FSO or IT department

A incident is the act of
violating an explicit or
implied security policy, such
as:
◦Unauthorized access of
sensitive information
◦Unapproved file modification
◦Critical files deleted

Report any real or
suspected security incidents
to your FSO or IT
Department immediately


You are personally responsible for the
access of any information using your user
ID and password
You are in violation of IASIS policies and
subject to disciplinary action if you:
◦ access information that you do not need in order
to perform your job, or
◦ allow someone else to access information using
your user ID and password information whether
they are authorized to view that information or
not
Limit the amount of
patient information
included in e-mails to
the minimum
necessary
 Incoming and
outgoing e-mail, plus
attachments, are
scanned for malware
prior to delivery


Keep in mind:
◦ Be suspicious of messages appearing more than once
in your mailbox
◦ Be cautious about opening email and attachments,
giving out personal information, or altering computer
configurations based on message content
◦ Never respond to spam (do not try to unsubscribe!) as
this only verifies your email address as active and
more spam will be delivered
◦ Delete spam and other questionable email




IASIS installs virus
protection software on all
computers
Do not bypass or disable
the virus protection
software
Do not open e-mail
attachments with a
suspicious file extension
or from anyone you do
not know
Do not download
software from the
Internet to your computer

If you detect or
suspect malicious
software or a virus on
your computer,
immediately notify
your FSO or IT
Department

Is essential so that others cannot use the computer
under your user ID and password. This can result in
unauthorized access to confidential information,
such as, ePHI. (remember, you are responsible for
all access and activity logged to your user ID)

When leaving a computer unattended, you
must:
◦ Use “ctrl / alt / delete” and select “Lock
Computer” or “Log Off”, or
◦ Use the “Lock Workstation” icon on the desktop



IASIS computer systems must be physically secured at all
times
Rooms housing computer servers must be kept locked (badge
strike and biometrics locks provide entry auditing
capabilities)
Server location should be evaluated according to risk
associated with unauthorized access and environmental
threats and hazards (e.g., flooding, hurricanes, tornadoes,
etc.)


Electronic PHI, and other confidential
information, on computer system hard
drives and external storage media
(including copier, fax, scanning devices)
must be removed before hardware or
external media is disposed of or made
available for re-use
Contact your local IT Department regarding
additional information on ePHI data removal
and disposal of computer-related
equipment




Do lock portable media in a secure
receptacle with limited access to those with
a need to use in performing their job duties
Do keep your laptop with you or lock it in a
secure receptacle
Do keep your password a secret (only
known by you)
Do lock your workstation when leaving your
work area




Do notify the IT department prior to using
your personally owned computing device
Do ensure that the email address or fax
number is correct when sending sensitive
information
Do protect and handle ePHI as if it were
your own
Do report security incidents to your FSO (IT
Director)




Do Not allow other individuals to utilize your user
ID and password to access the network and
applications
Do Not allow unauthorized individuals to watch
over your shoulder while you are logging into the
network or working with ePHI
Do Not leave your laptop visible in your vehicle
(put it in the trunk PRIOR to arriving at your
destination)
Do Not allow physical or logical access to ePHI by
unauthorized individuals



YOU and your actions are the most important
part of keeping our sensitive information
secure!
Security & IT policies and procedures are
located on the I-REPP policy management
system under “IASIS Corporate Division” within
the “Security” & “Information Systems” manuals
If you have any questions regarding your part
in information security, contact your FSO or IT
Department
Thank you for your time and assistance!
Keith Poulsen
Radiology Director



Time – quicker exposure means less radiation
Distance – the greater the distance equals less
radiation
Shielding – lead aprons, thyroid shields

NRC Regulatory acronym for “as low as
reasonably achievable,” which means
making every effort to maintain exposures
to ionizing radiation as far below the dose
limits as practical.




Dosimeters – Badges that record radiation
exposure
Monthly/Annual reports
Pregnant workers – Fetal badges
Fetus is very radiosensitive




Education/Awareness
Warning Signs in MRI
No metal objects in restricted area
Ask the MRI Tech to answer any questions
or concerns
Scott Croft
Laboratory Director

Jordan Valley Medical Center and Jordan-West
Valley are working hard to protect you
against the dangers of hazardous materials.
In addition the Occupational Safety and
Health Administration (OSHA) have issued the
“Hazard Communication Standard.” This rule
states you have a “Right to Know” what
hazards you may face on the job and how to
protect yourself.
 Infectious
substances
 Flammable liquids and
gases
 Radioactive materials
 Toxic Chemicals
Hazard communication starts with the chemical
manufacturer. Each company that makes or
imports chemical must evaluate the possible
physical and health hazards of each substance
they make.
This information is found in two places: 1. The
container labels, and 2. Material Safety Data
Sheets (MSDS), information which can be
accessed by calling the phone number listed on
each phone through out the hospital. There is
one master copy of the MSDS for each facility
kept in the clinical laboratory departments.
The Laboratory Director is also the Hazardous
Materials Coordinator for the facilities.


The name of the chemical.
The name, address and emergency phone
number of the company that made or imported
the chemical.

The physical hazards.

Storing or handling instructions.



Identify the chemical or substance that was
spilled.
Secure the area as much as possible until
security can arrive.
Call the MSDS Faxback Service telephone
number 1-866-990-2522, to obtain a
MSDS and contain the spill following the
directions on the MSDS.

Alert the hospital operator who will notify
members of the Spill Assessment Team who will
assist with exposures and spill clean up.
members of the team will be contacted
accordingly:
- Security Officer: anytime weekends and
holidays
- Department Director where spill occurred:
M-F 0700-1900
- House Supervisor: 1900-0700 M-F, and
anytime weekends and holidays
- Housekeeping: anytime weekends and
holidays
- Hazardous Materials Coordinator (Lab
Director): anytime
- Safety Officer (Facilities Director): anytime



Remove patients and personnel exposed to
hazardous materials and assist them to the
Emergency Department if necessary.
Evaluate how to appropriately clean up the spill
as directed by the MSDS using appropriate
personal protective equipment and items from
the spill cart. Contact the Hazardous Materials
Coordinator and the Safety Officer to obtain
additional help for spills unable to be cleaned up
using the items on the spill cart. Dispose of the
substance as directed by the MSDS.
Document the incident on a Chemical Spill Report
Form and send the report to the Hazardous
Materials Coordinator.
Physical
 Neglect
 Emotional or psychological
 Sexual
 Exploitation – Dishonest use
of person’s resources such as
money or property





Children
Domestic partners both male and female
Elders
Other vulnerable adults (Those with mental
or physical impairments.)




More than 3,114 men, women, and children
entered shelters in FY 11 to escape domestic
violence
There has been an increase in the number of
days and the length of stay in shelters. .
Of the total number of Child Protective Services
cases (CPS) that include an allegation of
domestic violence in the presence of a child,
33% are substantiated/supported cases
Of the substantiated/supported CPS cases,
domestic violence is the most supported
allegation at 33% and sexual violence is the
second most supported allegation at 22% .
*Statistics from www.nomoresecrets.utah.gov.






Recent trauma history
Bilateral or multiple
injuries
Unexplained injuries
Delay in seeking medical
care
Physical injury during
pregnancy especially on
breasts and abdomen
Behavioral cues such as
depression, suicide
ideation, anxiety, sleep
disorders panic attacks,
symptoms of posttraumatic stress disorder,
substance abuse problem







Overly protective,
controlling partner, or a
partner who refuses to
leave patient
Direct or indirect
references to abuse
Defensive wounds such
as bruises/lacerations on
back of forearms, and,
etc.
Strangulation
Injuries caused by sexual
violence
Patient displays extreme
fear or apprehension
De-emphasizes the
extent of the injury
Infants:
Disrupted feeding routines
Failure to thrive
Developmental delays
Excessive screaming
School-aged:
Become aggressive
Poor school performance
Behavior problems
Have somatic complaints
Preschoolers:
Regressive behaviors
Clingy and anxious
Decreased willingness to
exert their independence
Adolescents:
Feel shame
Become aggressive
Exhibit high risk behaviors
Run away from home
Truancy
Lose impulse control

Persons who report suspected
cases of abuse, in good faith, are protected
from civil or criminal liability in the State of
Utah.
Reporting in “good faith” means the
reporting person has reason to suspect, to
the best of their knowledge, that the person
in question is a victim of abuse.
Report to immediate supervisor or
appropriate authorities based where you
work.
Find out your specific departmental
procedure for reporting.
Healthcare providers are classified as mandatory
reporters of abuse by the state of Utah
Child abuse – a mandatory reportable crime
Commission of domestic violence in the presence of
a child is considered child abuse and must be
reported
Elderly/disabled person abuse – a mandatory
reportable crime
Any assault (call local law enforcement or 911)
If an adult patient presents with an injury inflicted
by another person with a weapon , they are
required by law to report to the authorities


HIPAA permits covered entities to disclose
protected health information about whom
the covered entity believes to be a victim of
abuse, neglect, or domestic violence
After a report is made, health care providers
are mandated by HIPAA to inform the
patient of the report UNLESS in their
professional judgment, they believe
informing the individual would place them at
risk of serious harm.









Detailed description of persons involved
Findings – photos - take photos of all injuries- must obtain
consents
Label the photos with the patient's name, location of the
injury, date, time, and your signature.
Body maps are used to accurately document bruising, scars,
red marks, and other injuries. When completing a body map,
provide as much detail as possible, such as the size and color
of the injury.
Referrals made including to which Dr.
Treatments given
Reasons for suspecting abuse
Name and badge # of officer bringing in
Direct quotes from patient or family better than subjective
opinions
• Have the patient memorize a domestic abuse hotline number or
ensure
that she has it readily available.
• Help establish a safe place to go and a plan for how to get there.
• If the patient is living with the abuser, discuss how she can
prepare to leave home quickly when ready or when necessary.
• Tell the patient where medical care can be obtained if she is
injured or experiences pain after being attacked.
• Encourage the patient to notify police when subjected to
dangerous circumstances or domestic abuse.
• Instruct the patient on how to obtain a restraining order or a
protection from abuse order and to always have a copy of the
order readily available.
• Advise the patient to have the locks at home changed and to have
additional locks installed if extra security is needed.
• Notify your supervisor and the proper authorities, following the
protocol established by your facility and your state laws, if you
suspect that abuse has occurred.





Routinely screen female patients for
abuse. Intervening on behalf of
women is an active form of
preventing child abuse
Ask direct questions
Document your findings
Assess safety of victim and children.
Help the patient reduce the danger to
herself and her children when the
patient is discharged.
Review options and referrals. Take
time to talk about options available to
the patient and the patient’s family.
Give the victim written information if
she feels that it is safe to do so.
Lippincott’s Nursing Procedures and Skills
www.nomoresecrets.utah.gov.
At Jordan Valley Medical Center and
Jordan-West Valley, we care for and interact
with people of all ages.
Although needs and abilities vary from
person to person, there are some
commonalities in the various age groups.
Knowing what these are and understanding
them will be helpful in more fully meeting
the needs of the patients we serve,
regardless of what job is performed at the
hospital.
Infants like:
 Touch
 Talking
 Musical Toys
 Peek-a-boo/Patty
Cake (6 months-1yr)
 Being read to
(6 months-1 yr)
 Music
(6 months-1yr)
Diet:
 Breast milk or
formula 6-8 times/day
or on demand
 Begin solid foods at
4-6 months
 Teething begins by
6 months
 Doubles birth
weight by 6 months
 At risk for
dehydration
Pain:
 Remember painful
experiences after 6
months of age
 Need to be medicated
for pain when
appropriate
 Have faster
metabolism so pain
medications work more
quickly
Major Fear:
Separation Anxiety
 Encourage parents to
stay with infant
 Bring infant’s
favorite toy/blanket to
hospital.
 Newborn infants can
generally be soothed
with gentle touch and
sound
Interventions/Health
Maintenance:





Holding infants during
feeding provides warmth and
comfort.
Physical contact is very
important at this age.
Teach the parents the
importance of immunizations.
Encourage parents to seek
well child check-ups from
their Health Care Provider
Childproof hospital room




Instruct parents to
childproof home
Instruct parents on the
importance of knowing
CPR, the Poison Control
phone number, 911
The tongue is the most
common airway
obstruction.
Place infant on back to
sleep to prevent SIDS
Car seats – place child facing rear of
car until they reach 20 pounds.
Car seat placed in back seat
Observe for signs/ symptoms of child
abuse and report to Child Protective
services when appropriate
Toddlers like:








Push/pull toys
Dolls
Trucks
Being read to
Music
Videos/TV
To play by
themselves
Don’t like to
share
Diet:
Pain:
 Drink from cup
 Like finger foods
 Are finicky eaters
 Like small frequent
meals/snacks
 Like to feed self
 Are at risk for
dehydration
 Remember painful
experiences
 Need to be
medicated for pain
when appropriate
Major
Fears/Anxieties:
 Loss of control.
 Separation/Abandonment
 Body mutilation.
Allow the child as much
choice and control as is
safe and possible.
Maintain home routine







Keep normal daily routine if possible.
Teach parents the importance of
immunizations
Encourage parents to seek well child checkups from their Health Care Provider
Childproof hospital room
Instruct parents to childproof home
Instruct parents on the importance of
knowing CPR, the Poison Control phone
number, 911
Instruct parents in use of car seats placed in
back seat
Pre-School Age Child
likes:

Group play

Music

Videos/TV

To dress self

Vivid imagination
Diet:
 Like finger foods
 Like to choose own
food
 Are finicky eaters
 Like small frequent
meals/snacks
 Are at risk for
dehydration
Pain Management:
 Can verbalize pain
Distraction techniques
 Use Smiley Face
Scale to determine pain
severity.
Fears/Anxiety:
 Separation/Abandonment
 Body mutilation
 Dark, monsters
 Loss of control
Health Maintenance:







Involve patient in planning and carrying out selfcare
activities.
Set realistic limits.
Teach parents the importance of immunizations
Encourage parents to seek well child check-ups from
their
Health Care Provider
Instruct parents on the importance of knowing CPR,
the
Poison Control phone number, 911
Seat belts while in car
Bicycle helmets
School Age Child likes:

Board/Video
games

Books

Music

Art

Videos/TV

Friends

To maintain home
routine while in
hospital

Independence
Diet:
Allow school age child
to choose food according
to preference.
Interventions/Health
Maintenance:
Involve patient in
planning and carrying out
self-care activities.
 Give sincere praise.
 Set realistic limits
 Provide time for school
work
 Wear seat belts, booster
seats up to age 8
 Wear helmets safely
 Instruct about:
Illicit drugs
Abstaining from smoking
Protection from firearms
Fears/Anxiety:
 Bodily injury and
mutilation
 Loss of control
 Failure to meet
expectations of
important people.
An adolescent likes:
 Increased
sleeping/eating during
growth spurts
 To fit in with peer
groups.
 To develop own
identity
 To choose own values
 To be very
independent
 Privacy
 Is self-conscious
about physical
appearance
Diet:
 Reinforce good
food choices
Fears/Anxiety:
 Self image
 Acceptance
 Loss of control
 Failure to meet
expectations of
important people.
Intervention/Health Maintenance:
 Involve patient in planning and carrying
own self-care activities
 Give sincere praise when accomplishes
a task or responsibility
 Provide time for school work
 If a child is out of school for more than
2 weeks contact school for home tutoring
 Assess for and instruct in:
Auto safety
Sport/helmet safety
Alcohol, smoking and drug abstinence
Depression/Suicide
Eating disorders
Self esteem issues
The Adult has:
 Multiple roles,
look for signs of
stress
 Teach stress
management
Diet:
Reinforce high fiber, low
cholesterol diet
Fear/Anxiety:
 Family
 Loss of control
Health Maintenance:
 Women: Cervical Cancer
screening; Breast exams and
mammography.
 Men: Monthly selftesticular exams and PSA
 Both: Cholesterol checks,
Colorectal cancer screening;
Sexually transmitted disease,
Alcohol in moderation,
abstaining from smoking and
illicit drug use
The Elderly may have:





Poor skin turgor
Sensitivity to heat
and cold
Slower cognition
Short term memory
loss
Decreased hearing
and visual acuity
Diet:
 Balanced diet with attention
to food taste and texture.
 At risk for dehydration
Health Maintenance:
 Continue to seek guidance from
their health care provider
Assist with chronic disease
management, with special
attention to medication
The Elderly may have
difficulty adjusting to:
 Changes in family roles;
adjusting to retirement and
income constraints
 Death of spouse or friends
 Their own chronic illness.
Fear/Anxiety:
 Ability to live independently
 Financial concerns
 Loss in health, independence,
friends, and family
How We Communicate…
2012-2013 Compliance Training
What is the purpose of Cultural Diversity training?
 To learn how to communicate
with different races, religions
and backgrounds
 To learn what is normal
behavior for others unlike
ourselves
What is the purpose of Cultural Diversity training?
 To know the importance of treating co-workers,
patients, family members and visitors with respect
 To understand the beliefs, values and faiths of others
What is the purpose of Cultural Diversity training?
 To learn how cooperation
and patience can improve
the work environment
 To become sensitive to
others and help them feel
accepted and welcome
 To begin working as a team
that supports and
encourages our differences
What is the purpose of Cultural Diversity training?
 To include and acknowledge
everyone and put them at ease
 To encourage the retention of
employees by our inclusiveness
What is the purpose of Cultural Diversity training?
 To maintain a calm environment that
treats everyone equally
 To encourage creativity using
everyone’s talents and abilities
What is the purpose of Cultural Diversity training?
 To focus on individual attitudes that impact the well being of
patients and family members
 To accept the differences in behavior patterns and respond
What is the foundation for Cultural Diversity?
As little children, we were
taught The Golden Rule in a
variety of settings: “Do unto
others as you would have
them do unto you.”
REMEMBER: This shared value is quoted in countries all over
the world in many different languages and dialects and forms
the basis of countless religious doctrines. It speaks to us from
the world’s point of view.
Promoting Cultural Diversity help us in the hospital setting…
Cultural Diversity is NOT about promoting
ourselves. Cultural Diversity is about
showing respect for others.
* Every culture is important to our society.
Promoting Cultural Diversity helps us in the hospital setting…
If each of us treats everyone we meet with kindness and respect,
we will all have a part in improving our workplace and changing
lives for the better…and that’s good healthcare.





We may be different from co-workers, patients, visitors and
caregivers in:
What we believe
What we eat
What we say and express
What we think about
healthcare
What we do when a loved
one dies
Although our differences are more noticeable, there are also
subtle ways that we’re alike.
 We have basic beliefs.
 We enjoy familiar comfort
food.
 We thrive on relationships
and social time.
 We think family and friends
are important.
 We want to be healthy.
Working in a culturally diverse environment requires
open communication, sensitivity and a willingness to
accept our differences.
Summary
Regardless of your job, YOU and only
you are responsible for your attitude
and actions towards co-workers,
patients, families and visitors.
It is important that each of us
becomes more mindful of the feelings
of others and more accepting of their
beliefs, customs and social behaviors
so that we can work together and
serve each other within a culturally
diverse environment.
Cultural Diversity in the Workplace
The following web-sites may be helpful:
1.
Tanenbaum Center for Interreligious Understanding
www.tanenbaum.org
2.
Society for Human Resource
Management www.shrm.org
3.
Race Matters and America’s
Religious Diversity
www.racematters.org
4.
Bahai News: Cultural and
Religious Diversity
www.uga.edu/bahai/News
A culturally diverse environment depends on our communication…
Managing Workplace Violence
2012-2013 Compliance Guidance
The National Institute for Occupational Safety and Health defines
workplace violence as violent acts, including physical assaults and
threats of assaults, directed towards persons in the workplace.
It is the responsibility of healthcare professionals to
recognize a potential for workplace violence, risk factors,
preventative measures and techniques for managing
situations.
HEALTHCARE
IASIS
The most common forms of workplace violence:




Verbal and/or written threats
Body language used to threaten or intimidate
Physical attacks, either planned or impulsive
Use of weapons
Hospital areas that are high risk:

Emergency Departments

Waiting rooms

Behavioral Health Units

Chemical Dependency Units

Gero-Psych Units
IASIS
HEALTHCARE
Risk factors that may contribute to workplace violence:
1.
2.
3.
4.
5.
6.
7.
8.
Working with persons that have
history of violent behavior, mental
health problems or chemical
dependency
Inadequate security
Understaffed; working alone
Poor lighting or workplace design,
facility and grounds
Unrestricted public access to
buildings
Crowded waiting rooms; long
waiting times
Patients, family members and
visitors carrying handguns or other
weapons
Lack of trained staff to prevent,
respond and report
IASIS
HEALTHCARE
These are warning signs of suspect behavior:
 Past history of
workplace violence
and/or domestic
violence
 Discontent or disrespect
for authority; angry
comments or body
language
 Sudden withdrawal;
socially isolated
 Poor hygiene
 Paranoid; fanatic
behavior
 Resistance to change;
negative
 Poor attendance; chronic
tardiness
 Fixation with weapons
and violent acts
 Appears to stalk others;
enjoys intimidation
IASIS
HEALTHCARE
There are methods recommended to diffuse or resolve potentially
dangerous situations:
 Avoid sudden movements
or speaking aggressively

Keep a safe distance,
allowing physical space for
person

Suggest a move to quieter
area

Lay the ground rules –
calmly relate
consequences of violent
behavior
 Move and speak calmly
 Use relaxed posture; stand
at right angle - not directly
facing
 Encourage conversation
 Focus attention on the
person; appear interested;
listen patiently
 Acknowledge the person’s
feelings
IASIS
HEALTHCARE
The goal is to remain calm in all potentially dangerous situations.
Consider the following suggested responses to an encounter:
 Remain calm at all times;
avoid expressing anger or
impatience
 Encounter should be close
to accessible and
unobstructed exit
 Position yourself at an
equal level with person;
either sitting or standing,
etc.
 Never give orders or
commands, fight or argue
 Reassure person; point
out choices
 When complaint is true,
accept criticism positively
 When complaint is
unwarranted, ask
questions for clarification
 Ask for recommendations
to resolve the complaint
IASIS
HEALTHCARE
It’s important to recognize signs that a situation is escalating beyond the control of
persons involved. For the safety of all concerned, know how and when to react to
prevent harm and ensure everyone’s immediate safety.
 Obtain assistance from Security or Police, particularly if
weapon involved




If physically attacked, call for help as loudly as possible
If being pushed, pulled or dragged, drop to floor and roll
Activate security or fire alarm
Send a bystander for help or provide specific instructions
IASIS
HEALTHCARE
Employees and visitors are entering and leaving facility property at all
hours of the day and night. IASIS further protects the workplace from any
form of violence by providing physical security measures:
 Separate, secure restrooms for
 Monitor processes to decrease




employees with locks
Adequate lighting – inside and
outside facility, parking lots, etc.
Curved mirrors at intersecting
hallways and concealed areas
Sign-in procedures with visitor
passes; visiting hours policy


waiting times
Adequate training for Security
Officers
Ensure all hospital units are staffed
appropriately
Develop formal process for
reporting all incidents
IASIS
HEALTHCARE
Our Human Resources policy, HR.807, defines “workplace violence” as any
intentional conduct which is sufficiently severe, offensive or intimidating to
cause an individual to reasonably fear for his/her personal safety or for
others present in the work environment.
Employees should do their part by reporting such acts to an immediate Supervisor, to
Security Staff, Human Resources or Administrative Staff as appropriate in the situation.
IASIS
HEALTHCARE
IASIS will make the sole determination of whether, and to what extent,
the company will act upon threats or acts of violence.
IASIS
HEALTHCARE
Our STANDARDS of CONDUCT supports IASIS’ commitment to ensure a safe
workplace and communicates this responsibility to every employee:
 Immediately report any violence or threats of violence against a patient,
visitor, employees or other person
 Refrain from possession of firearms or any other type of weapon on company
property or any other locations where we may be present in relation to our
work
 Refrain from reporting to work impaired by drugs or alcohol, including drugs
prescribed by a physician and over-the-counter medications
 Refrain from using, selling, purchasing, transferring or possessing illegal drugs
or misusing legal drugs while on our property or while performing company
business
 Refrain from inflicting violent acts or making threats, either physical or verbal,
to co-workers, patients, visitors, vendors or others on or off our property
Do your part to maintain a safe work environment. It’s everyone’s responsibility.
IASIS
HEALTHCARE
Through its response procedures, training, and facility resources, IASIS strives
to protect its employees, patients, visitors and others on facility property from
all forms of workplace violence. IASIS’ strategy is firmly in place:
 Written, formalized program for Prevention
of Workplace Violence
 Goals and objectives for prevention
provided to employees
 Management’s communication of zero
tolerance for workplace violence
 Analyze worksite for greatest areas of risk
and risk factors and review security
measures in place
 Provide metal detectors
 Maintain alarms and security devices;
periodically test equipment
 Minimize stress in waiting rooms by
designing comfortable, non-crowded
areas
 Create two exits in all counseling
areas
Jordan Valley Medical Center
Jordan-West Valley Campus
The Language of
Caring
©2010; Wendy Leebov. All rights reserved.
www.quality-patient-experience.com
Heart-to-Heart
Head-to-Head
Feeling, Caring,
Empathetic
Thinking, Doing,
Explaining, Fixing
When you speak heart-to-heart:


Patients and families feel important,
cared for, and understood
They can hear the head-to-head part much better
When you speak head-to-head:


The patients and family get valuable information
They appreciate your answers and solutions



Busy-ness and pressure make people mainly
task-oriented.
Most communication is from the HEAD,
much less from the HEART.
The result: Patients and families may view
us as uncaring and not tuned in.
X
“I’m in terrible pain. I want more medicine
NOW!”
• “I’m so sorry you’re in pain. I want to
help.”
•
•
“Let me talk to your doctor and see if
there’s something that might work better
for you.”
“I really want to ease your pain.”
1.
2.
3.
4.
5.
6.
7.
The practice of presence
Acknowledging the person’s feelings
Showing caring nonverbally
Explaining positive intent
The blameless apology
The gift of positive regard
The caring broken record
It is critically important to quiet
your all other thoughts and focus
fully on the patient or family
member.
Acknowledge the patients’ feelings and build
concrete skills in communication with
empathy and responsiveness to people’s
emotion, anxieties and concerns.
Nonverbal behaviors can ease or increase
anxiety, earn trust and demonstrate caring.
Nonverbal behavior speaks louder than words.
We do what we do in order to have good patient
outcomes.
Shows how you can express sincere regret as a
way to demonstrate your caring – without
taking blame or blaming anyone else.
Reinforce the power of expressing thanks,
appreciation and admiration to patients and
other customers who are stressed, frustrated,
anxious or uncomfortable.
Handle a difficult, stressful interaction with
caring – without becoming defensive or
rigid and without losing our composure.



Combine the skills into one powerful caring
message, leaving our patients feeling safe,
relaxed, and willing to communicate, engage
and cooperate with their care.
Even though we are caring, the people we
serve don’t know it unless we COMMUNICATE
it.
By communicating our caring, we ease patient
and family anxiety and enhance their
experience.
If you had a bank that credited your account
each morning with $86,400-with no balance
carried from day to day-what would you do?
Well, you do have such a bank…time. Every
morning it credits you with 86,400 seconds.
Every night it rules off as “lost” whatever you
have failed to use toward good purposes. It
carries over no balances and allows no
overdrafts. You can’t hoard it, save it, store
it, loan it or invest it. You can only use it –
time. Spend it wisely……..
Your patient doesn’t care
how much you know, until
they know how much you
care .
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