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N.E.W. Orientation Packet

Novant Health Orientation

Self Study 2008

For Non-Employed Workers

Completing this Orientation Self Study will satisfy

the requirements and objectives for Novant Health Orientation.

This Orientation is suitable for:

Contract Personnel, Students, Interns, Agency employees,

and Consultants in our organization.

Contents

Table of Contents 2

Orientation Self Study Instructions 3

Objectives For Orientation 4

Novant Mandatory Information

Mission, Vision, Values 5

The Joint Commission 7

*Service Excellence 8

Service Recovery 11

Corporate Compliance 12

*Confidentiality 13

Communication Aids 14

Foundation of Safety 15

Patient Safety 16

Ergonomics 22

*Public Safety 23

Fire Safety 24

Electrical Safety 25

Hazard Communication 26

Emergency Preparedness 29

*Infection Control Basics 31

*Standard Precautions 32

*Transmission Based Precautions 32

*Bloodborne Pathogens 33

*Tuberculosis 36

Self-Study Questionnaire 37

Questionnaire Answer Key 44

Orientation and Corporate Compliance Roster 45

*Information Confidentiality Agreement 46

Orientation Checklist 47

Participant Evaluation Form 48

This Self Study needs to be completed

before you begin working in your department.

Observers are to complete only those items listed above that are marked with an asterisk (*)

Orientation Self Study Instructions

1. Review the Orientation Self Study material.

2. Complete the Orientation Questionnaire.

3. Sign the (a) Orientation and Corporate Compliance Roster, and the (b) Confidentiality Form.

4. Complete the (a) Orientation Evaluation Form and the (b) Orientation Checklist.

5. The following documents need to be submitted and kept on file:

Orientation and Corporate Compliance Roster

Signed Confidentiality Form

|Group |Submit To: |

|Consultants, contract and agency personnel |Novant Health Corporate Education and Training for the location in which you are working: |

| | |

| |For Brunswick Region (choose one): |

| |interdepartmental envelope |

| |fax to 910-755-1049 |

| |mail to Human Resources, Brunswick Community Hospital, 1 Medical Center Drive, Supply, NC 28462 |

| | |

| |For Southern Piedmont Region (choose one): |

| |interdepartmental envelope |

| |fax to 704-384-5626 |

| |mail to Corporate Education and Training, Novant Health, P.O. Box 33459, Charlotte, NC 28233-3549|

| | |

| |For Triad Region (except Thomasville Medical Center) (choose one): |

| |interdepartmental envelope |

| |fax to 336-277-1890 |

| |mail to Corporate Education and Training, Novant Health, 1901 S. Hawthorne Rd, Suite 360, |

| |Winston-Salem, NC 27103 |

| | |

| |For Thomasville Medical Center (choose one): |

| |interdepartmental envelope |

| |mail to Jo Ella Waugh –Human Resources, Thomasville Medical Center, 207 Old Lexington Road, |

| |Thomasville, NC 27360 |

|On-site contract groups |Department Manager |

|Student and intern groups |Students also need to give copy to faculty |

6. Send the completed Evaluation Form to Corporate Education and Training (see options above).

7. Contact the Department Manager for Department Specific Orientation.

If you have any questions about this self study, contact Corporate Education and Training.

Brunswick Region: Call Sheila Gerald at 910-755-1147

Southern Piedmont Region: Call Ann Lampron at 704-384-7289

Triad Region: Call Connie Hedrick at 336-277-1891

Objectives For Orientation

After reviewing the following information, learners will be able to:

Describe Novant Health’s mission, vision, and values.

Discuss service excellence expectations.

Identify infection control and safety principles related to the environment of care.

Mission Statement

Novant Health exists to improve the health of communities, one person at a time.

Vision Of Novant Health

We, the employees of Novant and our physician partners, will deliver the most remarkable patient experience, in every dimension, every time.

Statement Of Values

COMPASSION

We treat our customers and their families, staff, and other healthcare providers as family members, with kindness, patience, empathy, and respect.

PERSONAL EXCELLENCE

We each strive to grow personally and professionally. Honesty and personal integrity guide all we do. We approach each service opportunity with a positive, flexible attitude.

TEAMWORK

We support each other and collaborate in our efforts to better serve our customers.

DIVERSITY

We recognize every person is different, each shaped by unique life experiences; this enables us to better understand each other and our customers.

Novant Health facilities, grounds and parking areas are tobacco free environments (as of April 2, 2007). This applies to all employees, non-employed workers, patients, visitors and other guests on Novant Health premises.

Novant Health Vision 2010 and Beyond

Everything we do should support our Vision of delivering the most remarkable patient experience. It’s every staff member’s #1 job responsibility. The six themes, shown in the diagram below, provide that support.

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The Remarkable Patient Experience includes three focus areas shown below.

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Fulfilling Vision 2010 will make Novant a better place to work,

a better place to receive healthcare and a better community citizen.

The Joint Commission

1. Representatives from:

1. The American College of Surgeons

2. The American Medical Association

3. The American College of Physicians

4. The American Dental Association

5. The American Hospital Association

2. Accreditation Importance

6. Important public statement of accountability

7. Required by most third-party payers

1. Medicare/Medicaid

2. Managed Care

3. Employers

4. Other Third-Party Payers

8. Recruitment of high-quality staff

9. Bond ratings and financial options enhanced

10. Fulfills State licensure requirements

3. Worker’s Role

11. Know and abide by the organization’s Policies and Procedures

12. Comply with Federal Laws and Regulations

13. Be able to talk about your role in the organization

14. Participate in improvement efforts

15. Perform appropriately during emergencies

16. Prompt report of:

4. Equipment failures

5. Errors

6. Non-properly functioning equipment

7. Spills

Service Excellence

Achieving excellent levels of service at Novant Health includes the daily practice of living our service standards.

Through Service Excellence We:

□ Provide exceptional levels of customer service to all customers

□ Communicate our commitment to respect, kindness and compassion

□ Show people that excellent service is as important as quality care

Standards of Service Excellence

Service standards translate our mission, vision and values into specific behaviors. Through these standards, we are accountable for building a strong and respectful relationship with all our customers.

Achieving our vision of service excellence means you know and apply the standards every day. This shows our commitment to quality healthcare.

COURTESY

We treat people with the respect we want our loved ones to receive

DIRECTIONS

We make sure people get where they need to go

CUSTOMERWAITING

We minimize waits as much as possible

PROVIDING INFORMATION/COMMUNICATION

We listen first and communicate clearly and simply second

ENVIRONMENT & CLEANLINESS

We are relentlessly committed to a trash and clutter-free environment

PRIVACY, RESPECT, & DIGNITY

We purposefully protect our patient's privacy and dignity at all times

PROFESSIONALISM

As owners of Novant Health, each of us will do whatever it takes to

ensure an excellent patient experience

TELEPHONE COURTESY

We meet the needs of our callers quickly and accurately

PEER RELATIONSHIPS

We treat each other with respect and courtesy at all times

SERVICE RECOVERY

When things don't go perfectly, we work quickly to make things right

Standards of Service Excellence

Sample Behaviors

Courtesy

• Make eye contact with and acknowledge each person you pass in hallways and public areas.

• Immediately acknowledge customers in your work area.

• Allow customers to exit and enter doorways and elevators first, and hold doors open for them.

• Never use endearing names such as Baby, Darling, Honey, or Sugar. Many customers find these names offensive.

Directions

• Be familiar with the physical layout of the campus and the location of departments and services.

• Approach anyone who looks lost or hesitant and ask, “May I help you?”

• Always attempt to escort customers to their destination.

Customer Waiting

• Respond to call lights, doorbells, intercom systems, and telephone requests immediately.

• Provide customers with estimates of expected wait times and regular status updates.

• If delays occur, take responsibility and apologize.

• Keep waiting areas clean and comfortable with access to reading materials.

Providing Information/Communication

• Always introduce yourself by stating your full name, role and department.

• Ask questions to better understand and restate your understanding of what has been said.

• When sharing information, communicate in terms and language that the customer can understand.

• If you don’t have the information the customer needs, follow-up with someone who does.

• Appreciate the emotional state of our customers.

• Learn about Novant Health facilities and services so that you can provide better information to others.

• Learn your facility’s procedure for requesting interpreting services.

Environment & Cleanliness

• Never walk past trash on the floor – stop and pick it up.

• Report immediately to Plant Facilities any broken furniture, non-functioning equipment, repair needs, or poor lighting.

• Clean up spills and/or report them to Environmental Services.

• Keep work area clean, neat, and orderly.

Privacy, Respect & Dignity

• Knock and wait for an answer before entering a patient’s room, an exam room, or a workspace.

• Close curtains and doors when examining or treating patients, or interviewing or counseling patients and families.

• Provide patients and families with privacy to deal with emotions, spiritual needs, and decisions regarding care.

• Be culturally sensitive to the needs of a diverse population.

Professionalism

• Keep your promises.

• Speak positively of our facilities, fellow employees, physicians, and support services.

• Acknowledge each member of the patient care team as a valuable.

Telephone Courtesy

• Answer phones within 3 rings.

• Use your most pleasant voice.

• Offer a greeting (good morning/afternoon), identify yourself, your department, and offer assistance.

• Ask for permission and wait for an answer before placing a caller on hold.

• Provide updates every 30-45 seconds for callers on hold.

• Tell the customer where they are being transferred and the extension.

• Confirm that you have written messages accurately.

Peer Relationships

• Respect and appreciate cultural differences among fellow staff members.

• Remain open-minded and listen to each other’s points of view.

• If disagreements occur between staff members, take them to a private area.

• Address issues with each other in a direct, prompt, and timely manner.

• Recognize and acknowledge the individual expertise of all team members.

Service Recovery:

The Art of Making Things Right

Service Recovery restores trust and goodwill and creates a loyal customer.

The Four A’s of Service Recovery

Anticipation

▪ Identify recurring problems/situations

▪ Develop plans to respond to specific problem situations

▪ Use what worked before

▪ Develop skills to communicate, manage conflict, apologize and be empathetic

Acknowledge

▪ Admit a problem has occurred

▪ Thank the person for letting you know about the problem

▪ Use listening skills (reflective listening, open questions)

Apologize

▪ Be empathetic and sincere

▪ Be flexible

▪ Show interest

▪ Establish your intention to help

▪ Don’t blame others or make excuses

Amend

▪ Use fixed solutions

▪ Respond immediately if possible

▪ Consider asking, “What would you like for me to do for you right now?” or “What would you like me to do with this information?”

▪ Explain what you are going to do

▪ Provide follow-up info

You…As a Service Champion

▪ Learn and apply the Service standards.

▪ Don’t settle for anything less than excellence…even when it’s uncomfortable.

▪ Never wonder whether or not you have a service impact.

▪ Excellence doesn’t come easy! Be a part of RAISING THE BAR.

▪ Be Predictably excellent.

Corporate Compliance

Corporate Compliance involves:

1. helping employees apply laws and regulations to our workplace

2. a way to prevent, detect, and report “wrong doing”

3. disciplinary action for failure to follow requirements

Your Role:

1. take responsibility for what you do

2. follow policy and procedure

3. ask questions

4. report problems

5. participate in compliance education programs

6. follow the Code of Ethics

The Code of Ethics

4. Defines what is appropriate behavior for employees

5. Includes information related to Conflict of Interest, Information Confidentiality, Business Conduct, Fraud, and Patient Issues

You will find the Code of Ethics located on the Intranet.

Reporting concerns or potential “wrong doing”:

Contact your leader or

Contact the compliance department or

Call the anonymous confidential 24-hour/day toll free phone line service.

The Alert Line 1-800-350-0094.

This phone line helps you to:

7. Forward concerns for review so appropriate action can be taken

1. Report any Code of Ethics issues like employee relations, patient rights, discrimination, sexual harassment, conflicts of interest, theft and fraud, compromised professional standards of practice, billing and/or coding problems

Confidentiality

Information Confidentiality

You may have contact with confidential (private) information about patients, employees, doctors and/or Novant.

Examples of confidential information include:

• Details about illnesses or conditions

• Conversations between a patient and health-care provider

• Patient demographics – name, address, phone number

• Patient insurance and financial information

Protecting Confidentiality:

Here are some guidelines to keep information secure and confidential:

✓ Don’t talk about patients in public.

✓ Be careful not to put confidential information in the trash.

✓ Use a cover sheet when faxing confidential information.

✓ Don’t leave files with confidential information in open view.

Remember: If you think that certain information might be confidential, treat it as such.

Access to and Requests for Confidential Information

Access to confidential information (medical record, on-line laboratory, x-ray, financial, addresses, phone numbers, etc.) is limited to employees who need the information in order to perform their job duties.

Computer Use:

✓ Never let others use your computer log-on or password.

✓ Never write down or post your password.

✓ Never display confidential information on a computer screen in public view.

Confidentiality Violations:

• Failure to follow Novant’s privacy or security policies and procedures can lead to disciplinary action, including termination.

• Anyone who witnesses a breach of confidentiality should report the incident to the Novant Health Privacy Official or The Alert Line.

What is HIPAA (Health Insurance Portability and Accountability Act)?

HIPAA is a federal law enacted to protect patient health information in all forms which includes written, verbal (what is spoken and heard) and electronic.

Why was HIPAA created?

❖ To protect the privacy and security of all health care information.

❖ To provide our patients with a series of rights for their health information.

What happens if privacy rights are violated?

Patients have the right to complain if they feel we’ve violated their privacy rights.

❖ All privacy complaints should be reported to the Novant Health Privacy Official.

❖ The Privacy Official has been designated to respond to privacy complaints.

❖ If you have questions about HIPAA, call the Privacy Official at 1-800-473-6610

Ext 49829.

Communication Aids

Novant Health strives to facilitate communication among patients and/or families who have special communication needs to ensure the same level of care for all patients. This includes sign language for the deaf and hard of hearing, as well as foreign language interpreters. Interpreter services are provided at no charge to the patient and may be refused by the patient.

The need for interpreting services will be addressed based on the level of complexity and the expertise of the interpreter. In all cases, patient rights will be protected.

Level I -- Customer Relations

Provide simple non-medical interpreting to assure positive customer relations. Includes giving directions, assisting with phone calls, translating food menu

Level II -- Basic Medical Communication

Involves gathering information from clients. Includes services such as a simple history, or reading informed consent forms for treatment if no medical explanation is needed.

Level III -- Medical Counseling and Teaching

Provides for complex, sensitive medical interpreting. Includes services such as gathering in-depth history, discussing the treatment plan, discharge instructions.

Services Available

The following services are examples of communication aids available to our patients and families:

Interpreter Services are available from our staff, telephone interpreter services and on-site contractual interpreters

Telephone Devices for the Deaf (TDD/TTY)

Communication Boards

Amplified telephone handsets

Televisions with closed captioning capability

Copiers to enlarge print on teaching materials/handouts

Modified call systems

Bells

Hearing Aid Batteries

For a complete listing of communication aids refer to the Intranet.

Administrative Policies and Procedures

NH-RE-RI-300 – Guide to Interpreter Services

NH-RE-RI-150 -- Communication Needs of Patients and Families

Foundation of Safety

Novant Health strives to provide an environment free from recognized hazards, which may cause physical harm to our employees, patients, and visitors.

Safety Culture

Our Safety Culture is the way we work and live within the company that influences our safe behavior. It consists of shared beliefs, practices, and attitudes. It is the way we act when no one is around.

In a strong safety culture, everyone feels responsible for safety, pursues it on a daily basis, goes beyond “the call of duty” to identify unsafe conditions and behaviors, and intervenes to correct them.

Benefits

□ Provides the best and safest patient care

□ Reduces injuries and illnesses to staff, patients, others

□ Provides a safe environment to work in

□ Improves employee morale and retention

□ Improves productivity

□ Meets regulatory compliance standards

Safety Principles:

□ Each worker is responsible and accountable for their safety and the safety of others

□ Care/service is delivered only in a safe manner

□ Safety takes precedence in all decisions

□ All safety issues need to be resolved

□ Our safety performance is a measure of effectiveness as an organization

Accountability:

□ Safety education provided

□ Safety assessment completed

□ Investigation of incidents and actions taken

□ Incident rates

Responsibilities of Staff

□ Learn and observe all safety policies and procedures

□ Exercise care for the safety of yourself and others at all times

□ Develop, maintain, and demonstrate good safety habits in performing all job duties

□ Use all safety devices and personal protective equipment as trained

□ Seek information or advice regarding hazards and procedures before carrying out new or unfamiliar work

□ Report unsafe conditions, practices, or processes to your leader. You can also use The Alert Line for confidential reporting.

Patient Safety

Patient Safety means freedom from injury or illness as a result of a health care process.

Includes

□ Commitment from every level of employee and Physician

□ Continually improve processes to reduce and eliminate medical/healthcare errors

The Joint Commission 2008 National Patient Safety Initiatives

Goal #1 Improve patient identification

* Always use your facility’s two patient identifiers (i.e. name, date of birth) when administering medications or blood products, collecting specimens, or providing treatments or procedures. Note: room number is not a patient identifier.

* When taking blood samples or clinical specimens, label them in the presence of the patient.

Goal #2 Improve communication among caregivers

* Never use unapproved abbreviations.

* Write down verbal or phone orders, read them back, and assure they were correct.

* Critical test results need to be handled in the time frame defined by facility policy.

* Hand off communication requires health care professionals to share pertinent patient information. Limit interruptions and ask questions as needed. SBAR-Q is a method used to organize the information.

Goal #3 Improve the safety of medications

* Concentrated medications (like potassium chloride) have been removed from patient units.

* Review look-alike, sound-alike drugs to prevent mix-ups.

* Label all medications and medication containers in peri-op and other procedural settings including syringes, cups, and basins.

* Reduce the likelihood of patient harm with the use of anticoagulants with the use of order sets

Goal #7 Reduce the risk of health-care associated infections in our patients

* Use appropriate hand hygiene at all times.

* Report hospital acquired infections that result in prolonged hospitalization, death, or loss of body function to Risk Management or Infection Control.

Goal #8 Reconcile medications across the continuum of care.

* Obtain an accurate list of all home medications upon admission.

* Compare the patient’s home medications with those medications ordered while he/she is in the hospital.

* A complete list of medications is provided to the next provider of care and the patient on discharge from the facility.

Goal #9 Reduce the risk of patient harm from falls

* Evaluate a patient’s risk to falls and take appropriate actions to keep the patient safe.

* Diuretics, sedatives, and pain medications can increase the patient’s risk for falls.

Goal #10 Reduce the risk of influenza and pneumonia in older adults (Centers with Joint Commission Disease Specific Certification and LTC only)

* Follow established protocols for the administration of flu and pneumonia vaccines

* All employees should receive the influenza vaccine annually.

Goal #13 Involve patients in their care as a patient safety strategy.

* Listen to the concerns of patients and families.

* Encourage patients and families to communicate concerns about safety.

Goal #15 Identify safety risks within our patient population and intervene.

* Identify patients at risk for suicide.

* Provide information such as crisis hotline to patients and families as needed.

Goal #16 Improve recognition and response to changes to a patient’s condition.

* Participate in proactive rounding to identify any changes in patient’s condition.

* Notify your rapid response team according to facility policy.

* Encourage patients and families to participate.

Note:

✓ Make sure clinical alarms are set correctly and can be heard in the area where they are used.

✓ Surgical/Procedural Wrong Site Universal Protocol – Assure the entire team present always completes a purposeful pause (“time-out”) before a medical and surgical procedure to make sure the patient, procedure, side/site, equipment and position are correct.

*Missing Goal numbers are not applicable

What is Chain of Command?

A way to communicate up to the next higher level of supervision when you believe a patient’s clinical needs aren’t being met.

• Licensed healthcare providers contact Physicians first to clarify orders or treatment issues.

• The Supervisor is contacted if they are unable to reach the physician or have concerns about the plan of care.

• Continue up the chain until a resolution for patient care is obtained.

Medical/Health Care Errors

A medical/health care error occurs when one:

✓ Fails to follow the correct plan as expected

✓ Uses the wrong plan to achieve an outcome

Reasons for medical/health care errors:

✓ Failing to follow policies and procedures as written

✓ Forgetting to communicate important information to the next caregiver

✓ Not speaking up when something isn’t right/correct

✓ Failing to recognize the effects of fatigue, stress, and distractions

✓ Making assumptions

✓ Making wrong decisions that impact patient care

Some actions/methods that can help reduce medical/health care errors:

✓ Following policies and procedures

✓ Using a checklist to communicate critical information to the next caretaker.

✓ Documenting care provided in the appropriate location

✓ Working as a team

✓ Supporting staff/peers who stop a process that has error potential

Tip: SBAR-Q is a communication technique for passing on information.

S – Situation - provide a brief reason for the call/about the event

B – Background - give any information/data you have about the situation

A – Assessment - state the problem

R – Recommendation - give your recommendations about what needs to

be done

Q – Question – opportunity to ask questions

Patient Bill of Rights and Responsibilities

Patients receive a copy of the Patient’s Bill of Rights and Responsibilities when they are admitted or sign consent for treatment.

They are posted at various locations within Novant Health facilities.

Each employee has the responsibility to be aware of and support patients in meeting their specific needs.

The Bill of Rights and Responsibilities contain a list of state and local agencies where concerns can be addressed.

Patient’s Rights include:

Considerate and respectful treatment during care

Knowing about and participate in decisions about their care

Knowing about diagnosis, prognosis, and treatment options including their risks and benefits

Personal privacy and confidentiality of information

Access to protective services

A truthful and compassionate explanation (disclosure) of an unexpected medical outcome

Having his or her complaints/grievances about care resolved

Routine Complaint – can be resolved promptly by staff present

• Concern about general care and/or support service (food, billing, staff attitudes, cleanliness)

• Requires minor change in a timely manner

Grievance – patient issue cannot be resolved promptly by staff present

• Verbal or written account

• Violation of a patient’s right to quality care

Ethics Committee

Consists of nurses, physicians, administration, lawyers, and lay people

from the community

Fosters communication and understanding of ethical concerns

May be called by staff, patients, physicians or family members

Will meet at any time as needed

Risk Management

The role of risk management is to identify, reduce, and eliminate actual or potential risks to the quality of patient care or visitor safety.

Doing the Right Thing, at the Right Time, in the Right Way

Remember – patients depend on you for safety. It’s your responsibility to provide a safe, secure environment for their recovery. Speak up when something is not correct or right.

1.

Prevention of Patient Abuse and Neglect

Novant Health is committed to take reasonable measures to prevent patient abuse, neglect and misuse of patient property by anyone in a Novant facility.

Assessment Includes:

□ Verbal reports

□ Patient behavior

□ Reliable witness

□ Injury or bruise

□ Unexplained lost property

If Abuse Is Suspected

□ Each worker is responsible for reporting suspected patient abuse, neglect or misuse of property to his or her manager.

□ Immediate medical attention will be provided if needed.

□ Protection and emotional support will be provided.

Discipline and Reporting

□ Suspension, reinstatement or termination dependent on investigation

□ Cooperation with authorities as required

□ Licensed personnel will be reported appropriately to licensing agency

Safe Medical Device Act

Requires that any person who witnesses, discovers, or otherwise becomes aware of information that a piece of equipment has caused, may cause, or contributes to the injury, illness, or death of a patient, is responsible for:

1. Immediately assessing the patient

2. Reporting the incident to Risk Management

3. Completing a QAR report

4. Removing the equipment from service

5. Tagging and sequestering the equipment and notifying Risk Management by QAR

6. Sequestering the equipment in the designated area for the facility

7. Maintaining all settings on the equipment or documenting the original settings when possible

8. Attaching the original packaging and all parts that belong to the equipment when it is available

If a department receives a recall or alert notification, immediately route it to the Purchasing department. Fax the notice, then send by interdepartmental mail.

Incident Reporting

Fill out a Quality Assessment Report (QAR) to report any Incidents

Fill it out legibly

Be brief, factual, and objective

Do not attach written statements from staff

Avoid judgments and opinions

REMEMBER!

The Reporting Form…

1. is confidential

2. is NOT part of the medical record and should not be

referenced in the medical record

3. Is never copied/printed

4. is not placed in an employee’s personal record

• Be sure to appropriately report adverse reactions to the Pharmacy.

• If something happens to a visitor, notify Public Safety/Security (completes appropriate form) and ensure a QAR is complete.

About Sentinel Events

Definition

Unexpected events involving death or serious physical or psychological injury or risk. They are called sentinel because they signal a need for immediate investigation and response.

Examples

• Unanticipated death or permanent loss of function not related to the

patients condition

• Unanticipated death of a full-term infant

• Abduction of anyone receiving care, treatment or services

• Discharge of an infant to the wrong family

• Surgery on the wrong body part or wrong patient

• Rape

• Suicide of a patient in a setting where the patient receives around the

clock care or within 72 hours of discharge

• Hemolytic transfusion reaction

• Unintended retention of a foreign object in a patient after surgery/procedure

• A death or serious injury believed to be related to a hospital acquired infection

Disclosure

❖ Providing a truthful, compassionate explanation to the patient and or family about the long term and short term effects of an unexpected outcome. This discussion should be documented in the medical record.

Ergonomics

Ergonomics is the science of fitting jobs to the people who work in them.

The Goal of Ergonomics is to reduce work related musculoskeletal disorders (MSD’s).

MSD’s (Musculoskeletal Disorders)

□ Injuries and illnesses that affect muscles, nerves, tendons, ligaments, joints, or spinal discs.

□ Possible Signs and Symptoms

← Painful joints

• Pain in wrists, shoulders, forearms, knees

• Tingling or numbness

• Burning sensation

• Shooting or stabbing pains in arms or legs

• Back or neck pain

• Swelling or inflammation

• Stiffness

MSD Risk Factors

Repetition

1. Doing the same motions over and over

Forceful Exertions

2. Amount of physical effort needed to do a task

Awkward Postures

3. Body position during work

4. Risk depends on what is done and repetition of awkward postures

Contact Stress

5. Pressing a body part against a hard or sharp surface

Vibration

6. Operation of vibrating tools

Avoid Sustained Postures

Vary position and activities frequently

Take stretch/movement breaks every 30-60 minutes

Proper Lifting

Plan the move

Keep weight close

Use a wide base of support

Maintain curve in low back and neck

Bend knees and lift with legs

Avoid twisting or jerking

Get help when needed (co-worker, instruct patient)

Use devices when needed (mechanical patient lift, dolly, cart)

Transporting Heavy Objects

Use wheels when possible

Push instead of pull

Roll or slide instead of pull

Ergonomic Computer Workstation Design

Monitor placed in front of keyboard and chair with top of screen at eye height

Documents and monitor at equal distances

Phone on non-dominant side – do not cradle phone between shoulder and ear

Keyboard, mouse, and phone placed so elbows are close to side during use – do not reach away for these items

Sit back in chair to get low back support

Adjust seat height so knees are at the height of hips or slightly lower

Public Safety

Novant Health strives to provide a safe and secure environment for its customers and staff. Workers take an active role in the security program to ensure its success.

Tips For Staying Safe

9. Be aware of your surroundings

10. Recognize potentially dangerous situations

11. Lock your vehicle and keep valuables out of sight

12. Walk to parking areas in groups

13. Leave valuables at home or secured at work

14. Property should be secured or attended

Security Is Everyone’s Responsibility

15. Wear your I.D. badge

16. Report visitor problems

17. Do not prop exterior doors open

18. Report theft or incidents

19. Report suspicious persons, vehicles, and activities

Novant Health strives to maintain a work environment free from intimidation, threats, or violent acts. Disciplinary measures and/or legal action will be taken when appropriate.

No violent act will be tolerated.

Weapons of any type are prohibited from Novant Health properties.

Signs are posted for visitors and staff

Notify security if you suspect anyone is carrying a weapon

An employee who violates this policy will be terminated

Do not tolerate threats. They may be the first step before action is taken!

Family Domestic Violence

Some signs that may indicate violence or abuse include but are not limited to:

|Children |Criminal Domestic Violence |

|Overly quiet or passive behavior |Choke marks on throat |

|Bruise pattern on arms, back |Suicide attempt |

|Frequent visits to ED for trauma |Defensiveness, anger |

|Multiple dislocations/broken bones |Lack of or fearful eye contact |

|Lack of supervision | |

|Inappropriate clothing |Disabled Adults/Elderly |

|Poor hygiene |Pressure ulcers |

| |Medication misuse |

| |Hunger, soiled clothing, malnutrition |

Report any neglect, abuse or suspicion to your manager, social worker, or local agency.

Fire Safety

We Are the First Line of Defense!

Know…

✓ The location of fire pull stations, emergency exits, and fire extinguishers

✓ How to report a fire

✓ The emergency number to call in case of fire

✓ How to respond to a fire alarm

✓ The policies and procedures for fire safety located in the Safety Manual

Fire hazards include:

✓ Smoking

✓ Oxygen, compressed gases

✓ Flammable substances

✓ Faulty electrical equipment or wiring

✓ Improper use of extension cords

✓ Patient’s appliances from home

✓ Combustibles (i.e., rubbish, latex gloves, rags, linens)

✓ Grease from cooking

✓ Lint from laundry

Prevention

✓ Do not leave microwave cooking unattended, especially popcorn

Inspect your work area for hazards regularly

✓ Report hazards to your supervisor or Safety Department

✓ Help enforce the tobacco free environment

✓ Use of personal and portable electric heaters are prohibited

✓ Fire/smoke doors must not be blocked, propped, or obstructed in any way

✓ Follow policy for surgical procedures involving oxygen and a heat source

✓ Keep equipment that can spark away from areas with oxygen

Suspect a fire? Smell smoke? Perform R.A.C.E.

Rescue

1. anyone in immediate danger

Activate Alarm

2. pull the red fire alarm pull box

3. call the emergency # and give exact location of fire

Contain the fire

4. close doors & windows

Extinguish

5. get closest fire extinguisher

6. use only if safe to do so using the PASS method:

Pull the pin on the fire extinguisher

Aim the fire extinguisher hose at base of fire

Squeeze handle

Sweep hose/nozzle from side to side

Electrical Safety

Everyone shares the responsibility of electrical safety to reduce shocks, burns, fires, and outages.

Workers should follow the following electrical principles:

23. Equipment in patient care areas should be grounded (i.e. a plug with 3 prongs), and UL-listed.

24. In patient care areas, extension cords are to be used for emergency situations only.

Turn equipment off before unplugging.

26. Disconnect cord from outlet by grasping and pulling the PLUG.

Biomedical (patient care) Equipment

• All employees must be in-serviced prior to using.

• If the power goes out, ensure that all essential equipment is plugged into the emergency outlets.

• When equipment is identified as a potential hazard or problem, be sure to turn the equipment off, unplug, mark or label as out of service, and report it to engineering.

Problems may include:

✓ cut or frayed wires or plugs

✓ feels or smells like overheating

✓ shock felt during use

✓ dropped or physically damaged

✓ liquid spilled on electrical components

✓ any other equipment problems or failures

Cell Phones and Walkie Talkies

There is an increased need to control use of these devices within critical patient care areas. Medical Equipment such as Ventilators, Infusion Pumps and Cardiac Monitors may pick up radio wave interference.

✓ Use only hospital approved communication devices

✓ Personal wireless devices must be essential to patient care when used in patient care areas

✓ Maintain a ten foot distance between Medical Equipment and wireless devices

Hazard Communication

Your “right to know” protects you as a worker.

Inventory List of Chemicals

An inventory list of all current chemicals (including gases and products containing chemicals) is available in each department. Be familiar with your list and chemicals.

Material Safety Data Sheets

Material Safety Data Sheets must be readily available to you. They are provided by the manufacturer and describe the chemical composition, characteristics, potential health, physical hazards, and other information on their product.

MSDS online – web-based library of material safety data sheets

➢ Website is accessible through the Novant Health Intranet

➢ Allows for management of department-specific chemical list

Labeling

Labeling is required on all hazardous chemicals entering our facilities.

This includes:

□ Name of the chemical

□ Physical and health warnings

□ Name and address of the chemical manufacturer

Re-label containers when removing chemicals from the original.

□ Name of the chemical

□ Hazard of the chemical

□ Date transferred

□ Name of person who transferred the material

Label All Containers – even water. No one should guess what’s inside.

The National Fire Protection Association’s (NFPA) diamond is used for quantities of dangerous chemicals. The danger is identified by the number inside the color diamond on the sign. The higher the number, the greater the hazard (between 4 and 0). The type of hazard is identified by the color.

Other Health Hazard Symbols:

Identifies materials that are Radioactive.

Identifies hazardous Biological materials.

Gas Cylinders

Many gases, such as nitrogen and oxygen, are used in our facilities. In order to transport, store and use these gases, they are "bottled" under great pressure in tanks called gas cylinders.

□ Store in the approved rack or cart at all times

□ Handle carefully to prevent damage when moved or used

□ Read the warning label and the MSDS for safe handling

Controlling Physical and Health Hazards

Product Substitution: Less toxic chemicals can be substituted to do similar jobs. For example, the replacement of mercury containing products.

Engineering Controls: Well-designed work areas minimize exposure to materials that are hazardous. Examples are exhaust systems and fume hoods.

Safe Work Practices: Use safe work practices to insure that chemicals are used correctly and safely.

Personal Protective Equipment: Masks, eye protection, gowns, gloves, aprons, and other protective equipment/clothing are designed to protect you while you work.

Training and Communication: You have a “right to know”, but you also have a responsibility to use the knowledge and skills to work safely!

Environmental Monitoring: Some departments perform environmental monitoring to ensure hazardous chemicals do not exceed established exposure limits.

Personal Monitoring: Some departments perform personal monitoring. You can also monitor yourself by watching for physical symptoms that indicate overexposure to any hazardous chemical. Symptoms, such as skin rashes, dizziness, eye or throat irritations, or strong odors, should be reported to your supervisor.

Personal Awareness: Make an effort to know the location of an Eye Wash Station close to or within your area. In case of a personal injury, eye wash stations are provided in your area if applicable.

Hazardous Spills Procedure

❖ Contain the spill if it can be done safely

❖ Check the MSDS before taking additional steps

If you don’t know how to handle the spill, don’t try. Report it to your supervisor. In addition, all chemical spills must be reported to the Safety Department using the Chemical Spill Report Form.

Common Chemicals at Novant Health

|Office: |Copier toners, white out, cleaners |

|Clinical Areas: |Disinfectants, alcohol, chemotherapeutic agents, medical gases |

|Central Supply: |Ethylene oxide, chemosterilants, disinfectants |

|Environmental Services: |Cleaners, disinfectants |

|Laboratory: |Acids, bases, solvents, toxic materials |

|Plant Engineering: |HVAC chemicals, degreasers, paint, mercury in broken fluorescent bulbs |

|Radiology: |Film fixer, developers |

|Surgery: |Anesthetic agents |

|Nursing/Pharmacy |Chemotherapeutic drugs and other hazardous drugs |

Emergency Preparedness

Novant Health is a vital member of the community emergency management system. We need to be ready for various hazards like water outage, a hurricane or pandemic influenza that may affect Novant Health and the communities it serves.

Emergency Codes

➢ When information needs to be shared quickly, emergency code information helps workers know how to respond.

➢ Review the Code Information below for your facility and job role response.

➢ If you are unsure about your function during these events, contact your supervisor.

To report an Emergency

1. Dial the designated emergency number.

2. State your name, title, and location. (if 911 -- street address)

3. Give the nature of the emergency situation. (if 911 -- fire, medical, police)

Emergency Numbers

|Off-Site Facilities & Physician Practices |Dial 9-911 or 911 |

|SPR – PH, PHM, POH, PHH |Dial 45555 |

|Brunswick Community |Dial #0 and state the type of code and location 3 times. You are speaking |

| |directly over the loud speaker when you do this. |

|Triad - FMC, MPH, HSC |Dial 22 |

|Triad - TMC |Dial 2224 |

Emergency Codes

|Code |Plan |Action |

|Code Red |Fire Threat Activation |RACE and PASS |

| | |Close doors and clear hallways if needed |

| | |Evacuate if appropriate or as directed. |

|Code Blue |Medical Emergency |Perform CPR if needed as trained |

| | |Code Team and Cart responds |

|Code Pink |Infant/Child Abduction |Monitor all exits and stairwells. |

| |Can specify age, gender |Report suspicious people. |

|Code Triage Stand-By |Stand-By for a Mass Casualty Event |Prepare for a potential influx of patients. |

|Code Triage |Mass Casualty Event |Respond to a mass casualty event |

|Code Black |Utility Failure |Follow appropriate department process |

|Code Outlook |Dissemination of Information |Leaders check email for information. |

| |Severe Weather Warnings, Reg. Agency on campus, etc. | |

|Code Gray |Security Alert |Immediate security assistance. |

| |Radio announcement only | |

|Code Silver |Hostage Situation with weapon(s) |Use caution with approach. |

| |Radio announcement only | |

|Code Orange |Hazardous Materials Response |Follow appropriate initial action. |

| | |Response Team to staging areas. |

|Code Yellow |Bomb Threat |Report to work area and wait for search assignment. Report |

| | |suspicious activity/packages. |

|Tornado Warning, Watch, |Use current National Weather Service Guidelines |Follow appropriate department procedure. |

|Flood, Hurricane, etc. | | |

*Note: You may work in a facility where codes are not paged. Respond appropriately to the above situations as trained in your Department.

Newborn Safe Surrender Policy

➢ Allows infants under seven days of age to be received at any North Carolina facility by any individual working at the facility.

➢ There will be no criminal prosecution to the parent.

Hospital Incident Command System (HICS)

➢ When emergency events occur, normal decision making and communication methods may not be effective.

➢ Novant Health has adopted the hospital incident command system (HICS), to overcome these issues.

➢ HICS provides a fast, efficient, and safe way to respond to incidents.

➢ It uses special job roles, command structures, documents and response guides.

➢ To learn more, contact your emergency preparedness committee.

Home Preparedness

➢ The employees of Novant Health are our most important asset in caring for the community.

➢ During disasters, our families, pets and those we care for must be safe.

➢ The home preparedness of employees is a vital part of an organization’s ability to perform under the stress of a disaster.

➢ Please plan for your loved ones needs during these emergencies. Their safety is your first priority, serving the community with Novant Health will hopefully be your next.

Steps to home preparedness:

Visit

1. Get a Kit – Gather supplies

2. Have a Plan – Know what to do

3. Be Informed – Know local hazards and readiness plans

Infection Control Basics

In the healthcare setting, patients, employees, and visitors are at risk for infections.

Infection Control and Prevention…

Measures are set to minimize the risk of the spread of infections including:

12. Proper Hand Hygiene

13. Staying healthy

Definitions

Hand Hygiene – a general term for washing with soap, antiseptic agent, or using an antiseptic handrub (waterless product)

Hand Antisepsis – refers to either antiseptic handwash or antiseptic handrub

Handwashing – washing hands with plain soap and water

Guidelines for use:

• Routine use of waterless antiseptic products is recommended if hands are not visibly soiled.

• When visibly soiled, wash hands with soap and water.

• Use waterless products when time or access to handwashing facilities is an issue.

Routinely Practice Hand Hygiene

• When the hands are visibly soiled.

• After performing personal hygiene activities (i.e., toileting, sneezing, coughing, and combing hair).

• Before eating, drinking, or handling food.

• As outlined in Standard Precautions.

|How To Wash Your Hands |How To Use The Waterless Product |

|Turn on water to comfortable temperature. |Apply the product to the palm. |

|Have paper towel available. |Rub hands together, covering all surfaces of hands and |

|Wet hands. |fingers until hands are dry (15-25 seconds). |

|Apply soap. |Do not touch equipment or source of electricity until dry |

|Use friction rubbing for at least 10-15 seconds. | |

|Rinse hands well under running water. | |

|Dry hands thoroughly with paper towel. | |

|Use paper towel to turn off faucet and discard. | |

No artificial fingernails or extenders permitted in direct patient care. Nails should be trimmed within ¼ inch of the fingertip.

Do not report to work if you have any communicable disease.

Standard Precautions

are designed for the care of all patients, regardless of a known infection status

are to be followed for contact with: blood, all body substances, non-intact skin, mucous membranes, contaminated items

are used in all healthcare settings

are used for known and unknown infection sources

Standard Precautions Include:

□ Hand hygiene or Hand antisepsis

There are additional times to use hand hygiene in the patient care areas.

Use the provided hospital approved lotion to prevent chapping and drying of hands.

Gloves are an adjunct to, not a substitute for hand hygiene

□ Wearing Personal Protective Equipment (PPE)

Wear the appropriate PPE for suspected exposure.

□ Equipment Handling and Cleaning

□ Environmental Controls

□ Preventing exposure to Bloodborne diseases

Transmission-Based Precautions

Used in addition to Standard Precautions for patients who have important healthcare associated infections, highly contagious infections, or patients with weak immune systems.

There are three categories of precautions:

✓ Contact Precautions

▪ Most of these diseases are spread when healthcare workers fail to perform hand hygiene!

✓ Airborne Precautions

✓ Droplet Precautions

What is my role in helping to prevent the spread of these infections?

FOLLOW INSTRUCTIONS POSTED ON THE PATIENT’S DOOR.

Bloodborne Pathogens

18. Bloodborne pathogens (BBPs) are disease-causing germs carried by blood and other body fluids and can cause disease in humans.

19. Human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) are the most common bloodborne pathogens.

Bloodborne Pathogens are Spread by:

2. puncture wounds/needlesticks

3. splash to mucous membranes or open areas of skin

4. sexual contact

5. mother to baby

6.

HIV

The virus that causes AIDS

The average risk for healthcare workers after exposure to HIV is about 1 in 300.

Symptoms include:

flu-like symptoms

fever

diarrhea

fatigue

swollen lymph nodes

night sweats

Hepatitis B Virus

17. Is the greatest risk to healthcare workers after exposure

18. May cause severe illness, liver damage, and death

Symptoms include:

fatigue

jaundice

abnormal liver tests

nausea

abdominal pain

loss of appetite

Hepatitis B virus can live up to 7 days at room temperature

on an environmental surface in dried blood.

Hepatitis C Virus

25. Recognized as an important BBP in healthcare workers

26. Previously known as non-A, non-B hepatitis

Symptoms include:

anorexia

vague abdominal discomfort

nausea

vomiting

jaundice

Exposure Control Plan

To comply with OSHA and the Bloodborne Pathogen Standard, Novant Health has a written exposure control plan (located in the Infection Control Manual) that includes:

Exposure determination

Every job has been assigned a risk category according to your risk of exposure to bloodborne pathogens.

Standard Precautions

Treat ALL blood and body fluids NOT PATIENTS as potentially infectious.

Engineering Controls

Controls that isolate or remove the bloodborne pathogens hazard from the workplace include:

27. Hand HygieneFacilities

28. Sharps Containers

29. Needleless IV Systems

30. Recapping devices

31. Safety needles, syringes and vaccutainers

32. Specimen Transmittal Bags

33. Splash guards

34. Regulated Waste Containers Emergency Eyewash Stations

Work Practice Controls

Controls (i.e. specific policies and procedures) that workers follow to reduce their exposure to Bloodborne Pathodgens include:

35. Use proper hand hygiene procedure after contact with blood or body substances

36. Handle sharps carefully and dispose in sharps containers appropriately

37. Do NOT recap needles.

38. Use approved safety sharp devices and always activate the safety mechanism.

39. Eating, drinking, applying cosmetics, smoking, or handling contact lenses are prohibited in work areas where blood exposure could occur

40. Perform procedures to minimize splashing or spraying

41. Do not store food or drink in areas where blood or body substances are present

42. Follow procedures for routine cleaning and disinfection of the environment.

43. Handle soiled equipment in a way to protect you, your patients, and the environment from the spread of germs.

44. Clean, disinfect, or sterilize reusable equipment between patients.

45. Place specimens in appropriate containers during collecting, handling, processing, storing, transporting, or shipping. Use biohazard labeling.

46. Remove broken glass by mechanical means such as tongs, forceps, or dust pan and brush

47. Do not reach into a container with bare hands

48. All soiled linens are considered contaminated:

Personal Protective Equipment (PPEs)

PPE = Special clothing or equipment worn by an employee for protection against a potential hazard.

Use PPE when there is a “potential” for exposure.

Remember:

20. If PPE is penetrated by blood or body substances, remove it immediately or as soon as possible.

21. Remove all personal protective equipment prior to leaving the work area.

Hazard Communication

□ The universal biohazard symbol is used to identify bio hazardous materials.

□ Workers need to place material with potential bloodborne disease in containers marked with the biohazard symbol.

Inadvertent Exposures

EXPOSURE INCIDENT: Specific eye, mouth, other mucous membrane, non-intact skin, or parental contact with blood or other potentially infectious materials (OPIM) that result from the performance of an employee’s duties.

Steps to follow for a Suspected Exposure

1. Immediately wash the affected area with soap and water.

2. Notify Leader.

3. Complete Exposure Incident Form.

4. Report to appropriate area (Employee or Emergency Department) as soon as possible to start recommended treatment when indicated.

There will be a confidential medical evaluation after exposure.

Immunizations – Hepatitis B Protection

□ It is safe and effective against Hepatitis B.

Call the Infection Control Department if you have any questions.

Tuberculosis

TB is primarily a lung disease caused by the Mycobacterium tuberculosis bacteria.

Spread by:

22. Coughing, Sneezing, Talking, Singing, etc.

23. Carried in airborne particles

24. Air currents can keep them in the air

People who are at risk for TB include:

• Close contact with a TB infected person

• AIDS/HIV Infected Persons

• Elderly persons

• Alcoholics and IV Drug Abusers

• Long term care and correctional facility residents

• Foreign born persons from high prevalence countries

• Medically underserved, low income population, high risk minorities

TB Infection means that an individual has inhaled the TB germ and has become infected. However, the body fights the bacteria to stop them from growing. The infected person:

• Cannot spread TB to others

• Has a positive TB skin test

• Does not have symptoms

The bacteria may become active later and cause TB Disease.

TB Disease means an individual has inhaled the TB germ and has become infectious. The infectious person:

• Is contagious and can spread TB

• Has a positive TB skin test

• Has an abnormal chest X-ray

• Has bacteria (Mycobacterium tuberculosis) in sputum

• May have any of the following:

21. Night sweats

22. Cough (which can sometimes bring up blood)

23. Fever and Chills

24. Weight Loss

25. Fatigue

Treatment

Differs for persons with active or inactive disease. There are strains of TB that are drug resistant. People with these are more contagious and difficult to cure.

The TB exposure Control Plan protects you against exposure to TB and includes:

49. Early recognition and identification

50. Management of TB patients

51. Engineering controls

52. Respiratory protection

53. Healthcare worker screening/counseling

Self-study Questionnaire

|Name: |Date: |

|Novant Department/Unit/Facility |Agency/Employer/School |

Directions:

3. Complete the statements below by filling in the blanks or selecting the best multiple choice answer.

4. Check your answers by referring to the answer key.

5. This answer sheet DOES NOT need to be turned in to Corporate Education.

1. The mission of Novant Health states

2. The values of Novant Health are _____________________, ______________________,

__________________________, ___________________________.

3. Service Excellence Standards include ___________________, ____________________,

_________________, __________________, ____________, _________________, _____________, _____________________ and ___________________.

4. It is my responsibility to understand and abide by the Code of Ethics. If I need to report a problem, I can call the anonymous Alert Line at _______________.

5. The number I would dial in the event of a fire is _______________.

( Mission, Vision & Values POST TEST

1. You are describing Novant Health’s Mission, Vision and Values to a co-worker. You know that our four core values include all the following except:

a) Personality

b) Personal Excellence

c) Compassion

d) Diversity

2. Working together at Novant Health under the same Mission, Vision, and Values, means we…

a) Support one another and collaborate in our efforts to better serve our customers.

b) Utilize resources sensibly to ensure high quality and cost effectiveness.

c) Work to improve the health of communities, one person at a time.

d) All of the above.

( Service Excellence POST TEST

1. When service breakdowns happen, we apply….

a) Professionalism

b) Service Recovery

c) Pressure

d) For a loan

2. When staff send consistent messages and use service behaviors…

a) We achieve our vision of service excellence.

b) We build trust and loyalty among patients and customers.

c) Satisfaction increases.

d) All of the above.

3. We meet the needs of our callers quickly and accurately by remembering to do all but which one of the following?

a) Smile to create a pleasant tone on the phone.

b) If you are unable to assist in the caller’s request, politely end the call.

c) Ask for permission before placing the caller on hold.

d) Provide updates every 30-45 seconds while the caller is on hold.

(Corporate Compliance POST TEST

1. Another worker is confused about Corporate Compliance. You tell him….

a) It’s not important for doing your job.

b) It is a process for preventing, detecting, and reporting wrong doing.

c) It is the organization’s mission, vision, and values.

d) It is something only the leaders of the organization need to be concerned about.

2. When discussing your role in compliance, you could say:

a) I have a responsibility to ask questions and report problems.

b) I have to take responsibility for what I do.

c) I must follow the Code of Ethics.

d) All of the above.

(Confidentiality POST TEST

1. You and your friend that works in the Emergency Department go to lunch. You heard there was a shooting victim brought in yesterday and ask what your friend knows about it. Your friend…

a) Doesn’t want to talk about it in the cafeteria but tells you to call her at home later that evening.

b) Changes the conversation and tells you about her new puppy.

c) Fills you in on the details since you will be reading about it in the paper anyway.

d) Reminds you that she cannot talk about it since you do not have a need to know the information in providing appropriate care.

2. Your neighbor comes into the hospital for tests. She is not on the floor where you work but you want to know how she is doing. You…

a) Access the information to see what is going on.

b) You do not access her information because you do not have a need to know.

c) Reassure the family that you’re sure the results are within normal range.

d) Ask your co-worker who works on your neighbor’s floor to check her information.

3. Another worker in your department asks why HIPAA is so important. You explain that….

a) HIPAA is the government’s way to control health care.

b) HIPAA protects an individual’s right to privacy and the confidentiality of medical information.

c) It’s not a big deal since our processes are well protected anyway and the medical records couldn’t fall into the wrong hands.

d) Protected Health Information (PHI) does not include patient identification numbers and billing information.

(Foundation of Safety POST TEST

1. The best way for you to explain our Culture of Safety to a new employee is to say it is….

a) A “way of working and living” within the company that influences safe behavior.

b) The job of the safety officer in the organization.

c) Performed in the microbiology lab.

d) Only important when someone gets injured.

2. Throughout your work day, you appreciate everyone’s efforts in keeping the environment safe because you know it……

a) Reduces injuries and illnesses to staff, patients, and others.

b) Improves employee morale and retention.

c) Provides the best patient care.

d) All of the above.

3. As a worker, you have a safety responsibility for all the following except:

a) Reporting unsafe conditions, practices, or processes to the department head or supervisor.

b) Developing, maintaining and demonstrating good safety habits in performing job duties.

c) Using the safety information covered in mandatory education, department training sessions, and policies/procedures.

d) Working with an attitude of carelessness and apathy.

(Patient Safety POST TEST

1. What is the term used to disclose the facts about a sentinel event to the family?

a) Tattle telling

b) Blaming others

c) Disclosure

d) There is no such term because we don’t talk about sentinel events.

2. A QAR should contain:

a) Your professional opinion about what happened

b) Your speculation about what happened

c) What was witnessed

d) Only the facts

e) C and D

3. Behaviors that reduce medical/health care errors are:

a) Working as a team

b) Speaking up when something is not right/correct

c) Using checklists so you do not rely on memory

d) None of the above

e) All of the above

4. Devices believed to have contributed to a patient event should be sequestered.

a) True

b) False

(Ergonomics POST TEST

1. There is a box on the floor that you need moved to the table. You should:

a) Shove it under the table to get it out of the way.

b) Plan your move, stand close to the object, squat with bent knees, lift while maintaining normal curves, and keep the object close to your body.

c) Ask a co-worker to do it instead.

d) Pick the box up and place it on the table without giving thought to your action.

2. Everyone in your office is talking about Ergonomics and MSD’s.

a) They are concerned about injuries and illnesses that affect muscles, nerves, tendons, ligaments, joints, or spinal discs.

b) They have been educated on the science of fitting jobs to the people who work in them.

c) They are aware of the risk factors that lead to musculoskeletal disorders.

d) All the above.

(Public Safety/Security POST TEST

1. You are walking to your work area when you see a suspicious person in the hallway. You….

a) Ignore them.

b) Report them.

c) Run!

d) Ask them if they are concealing a weapon.

2. A visitor to the Emergency Room is angered over waiting for treatment. He kicks the counter, slams his fist, raises his voice, and threatens physical harm to the employee unless he gets seen right away. You are passing by and witness this event.

a) You think of your safety and quickly get out of the way.

b) You immediately report the incident to public safety/security.

c) You go get a scalpel in case you need a weapon.

d) You report to your work area and tell all your co-workers.

(Fire Safety POST TEST

Knowing that prevention is the key to fire safety, you…

a) Inspect your work area for hazards regularly.

b) Help enforce smoking rules.

c) Dispose of rubbish properly.

d) All of the above.

2. A fire has started in a trash can in your work area. You have (RACE) rescued people in immediate danger, pulled the nearest fire alarm pull box, and reported the emergency. Next you should:

Close doors and windows.

a) Start evacuating bedridden patients.

b) Get a full water pitcher to toss on the trash can.

c) Find another trash can.

(Electrical Safety POST TEST

1. You use a desk lamp at your work space and you notice the wires are loose and frayed. You…

a) Get electrocuted and claim worker’s compensation.

b) Report it for repair.

c) Trade lamps with a co-worker on family medical leave.

d) None of the above.

2. While caring for a patient, a piece of equipment you are using malfunctions and injures the patient. You…

a) Assess the patient, report the incident, and remove the equipment from service.

b) Turn off the equipment and return the equipment, as is, to its usual storage place.

c) Blame it on managed care.

d) None of the above.

(Hazard Communication POST TEST

1. You need to review the chemicals you may be exposed to on your job. You find the information…..

a) When someone in your department spills a chemical.

b) On the inventory list of chemicals in your department.

c) When you notice a skin rash on your hands.

d) In your job description.

2. You find a container with a clear odorless fluid in it. The plant on your desk needs watering so you…..

a) Decide it must be water and use it on your plant.

b) Know all containers must have a label and report it to your manager.

c) Leave the container alone thinking someone will know what it’s for.

d) Put a water label on the container.

3. As a healthcare worker, you frequently encounter tanks (gas cylinders) of oxygen or nitrogen. You are alert to the safe handling of any cylinder including….

a) Propping it carefully in a corner when not in use.

b) Wearing a mask when in the storage room.

c) Storing it in the approved rack and avoiding damage when used.

d) Ignoring a strong odor since it won’t cause any immediate danger.

(Infection Control Basics POST TEST

1. You have learned as a healthcare worker to….

a) Find ways to sleep on the job.

b) Reduce the risk of infection with proper hand hygiene and by staying healthy.

c) Slip past the leader for a two hour lunch.

d) Reduce the risk of infection by wearing gloves all the time.

You sneezed and recognized the need to wash your hands. You should:

a) Apply soap, scrub, and dry your hands

b) Rinse hands and dry them.

c) Wet hands, apply soap, use friction for 10-15 seconds, rinse and dry your hands.

d) Rinse hands, scrub for 20 minutes, dry the faucet with the paper towel.

3. The use of an alcohol based hand sanitizer is recommended….

a) After finger painting.

b) When hands are not visibly dirty or when time and access to handwashing facilities is an issue.

c) Instead of wearing gloves.

d) For all hand hygiene.

(Standard Precautions POST TEST

1. To prevent the spread of infections, you use Standard Precautions:

a) With your patients that are diagnosed with contagious diseases.

b) With patients that you think have bloodborne diseases like AIDS.

c) When you care for all patients.

d) Only if the patient is going to surgery.

(Transmission-Based Precautions POST TEST

1. You need to deliver an important message to a patient in a private room. There is a sign posted on the door. Before you enter you….

a) Read the sign and follow the directions for wearing the appropriate personal protective equipment before entering.

b) Read the sign but ignore the directions since you will only be inside a short time.

c) Ignore the sign because you are in a hurry.

d) Ignore the sign because you’re sure it doesn’t apply to you.

(Bloodborne Pathogens POST TEST

If you have questions regarding this information, please call the infection control department.

1. Since you work in a healthcare facility, you know your greatest risk for exposure to HIV while at work is…..

a) Hugging your patients.

b) Getting pricked by a needle.

c) Touching dirty sinks.

d) Walking down the hallway.

(Tuberculosis POST TEST

1. TB can be spread by:

a) Coughing.

b) Sneezing.

c) Talking.

d) All of the above.

See your instructor to check your answers

Non-Employed Workers

2008 Orientation Roster

I have completed the orientation self study and am responsible for the content.

Date Signature_____________________________________

Novant Health Department & Facility________________________________

Agency/School/Employer_________________________________________

PRINTED NAME________________________________________________

Corporate Compliance

I have completed general education on the purpose, scope, and importance of the Novant Health Compliance Plan. I pledge to adhere to the Code of Ethics and the Compliance Plan. I understand that failure to comply with the Compliance Program may lead to disciplinary actions.

Date Signature____________________________________

Note: The following documents need to be submitted and kept on file:

Orientation and Corporate Compliance Roster

Signed Confidentiality Form

|Group |Submit To: |

|Consultants, contract and agency personnel |Novant Health Corporate Education and Training for the location in which you are working. See |

| |the table on page 3 for specific contact information. |

|On-site contract groups |Department Manager |

|Student and intern groups |Students also need to give copy to faculty |

Confidentiality Agreement

In consideration of new or continued employment, or my association with Novant Health, Inc. (“Novant”), I agree that:

I may have contact with confidential (private) information about patients, employees,

doctors and/or Novant. I agree to access and use this information only as necessary to do my job at Novant.

I will not discuss patient information with or around those who are not directly involved

in the patient’s care, obtaining payment for care or for Novant operations.

I will not leave confidential information (written or electronic) in view of those not

permitted to see this information, except in emergencies.

Any requests for patient information from persons who are not directly involved in the

patient’s care should be sent to the appropriate nursing or other supervisor.

I understand that the use of my computer password and the electronic use of my ID

badge are the same as my signature. I will not tell my computer password or lend my

ID badge to anyone. I will not put my computer password where others may have

access to it.

If I think someone else knows my password, I will stop using it. I will not try to learn or

use another person’s computer password. I will inform the Support Center immediately

if I think that any person’s password is being used improperly. I will use appropriate

sign-off procedures at the end of my computer session to prevent others from using the system under my name.

I will not try to access information that I do not need to perform my duties. This

includes accessing information about any patient, including fellow employee’s, family

members, or my own patient account information.

I will immediately tell Novant Security if my ID badge is lost or stolen. I will return my

ID badge when my relationship with Novant ends.

I will not tell unauthorized persons any non-public information about Novant or any of

our vendors/business partners.

I understand that all software, documentation materials and computer files are the

property of Novant and are not mine.

I understand that if I do not follow Novant’s confidentiality policies or this agreement

that I am subject to disciplinary action, including termination of employment/relationship and criminal charges.

I have reviewed this agreement, and agree to follow the requirements of Novant’s

confidentiality and information security policies and procedures.

_____________________________________ ___________________________

Name (please print) Agency/School/Employer

________________________________ ______________________

Signature Date

Orientation Checklist

I have reviewed the self-study pages and have asked questions if I did not understand the information.

I have directed any questions I may have on the Bloodborne Pathogen section to the Infection Control or Corporate Education Department.

I have completed the self-study questionnaire and checked my answers.

I have signed the Orientation Self Study Roster and Compliance Roster and submitted it as directed*.

I have filled out my evaluation of the self-study and returned it to Corporate Education and Training.

I have signed the Confidentiality Form and submitted it as directed*.

I wear my picture ID badge in the neck/chest area.

*The following documents need to be submitted and kept on file:

Orientation and Corporate Compliance Roster

Signed Confidentiality Form

|Group |Submit To: |

|Consultants, contract and |Novant Health Corporate Education and Training for the location in which you are working: |

|agency personnel | |

| |For Brunswick Region (choose one): |

| |interdepartmental envelope |

| |fax to 910-755-1049 |

| |mail to Human Resources, Brunswick Community Hospital, 1 Medical Center Drive, Supply, NC 28462 |

| | |

| |For Southern Piedmont Region (choose one): |

| |interdepartmental envelope |

| |fax to 704-384-5626 |

| |mail to Corporate Education and Training, Novant Health, P.O. Box 33459, Charlotte, NC 28233-3549 |

| | |

| |For Triad Region (except Thomasville Medical Center) (choose one): |

| |interdepartmental envelope |

| |fax to 336-277-1890 |

| |mail to Corporate Education and Training, Novant Health, 1901 S. Hawthorne Rd, Suite 360, Winston-Salem, NC 27103 |

| | |

| |For Thomasville Medical Center (choose one): |

| |interdepartmental envelope |

| |mail to Jo Ella Waugh –Human Resources, Thomasville Medical Center, 207 Old Lexington Road, Thomasville, NC 27360 |

|On-site contract groups |Department Manager |

|Student and intern groups |Students also need to give copy to faculty |

| | |

|Title of Activity: Orientation Self Study |Date: |

|for Non-Employed Workers 2008 | |

| |

|We are interested in your evaluation of this program. Your feedback is extremely important in planning future educational offerings. |

| |Strongly Agree |Agree |Disagree |Strongly Disagree |NA |

|I am satisfied with this educational activity. |

| |

| |

| |

| |

| |

| |

|What aspects of this learning experience were helpful? |

| |

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|What did you learn that you plan to use in your work setting? |

| |

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Send this form to Novant Health Corporate Education and Training

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Quality

and Safety

Questionnaire Answer Key

Participant Evaluation Form

The whole process was extremely smooth and straightforward

I felt like the people at Novant really listened and cared about me

I have absolute confidence that I got the best care available

Caring & Service

Access & Efficiency

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