Valley Health Non-Employee Modules

There are two main types of lower back injuries: Muscular injuries Can occur due to a strain or sprain because when you are trying to lift (especially if you're doing it quickly), your muscles become like a rope in a tug o' war and the fibers tear. These types of injuries will generally heal in 6-8 weeks. Disc injuries They occur when the fluid-filled center of the disc (the nucleus) gets displaced. This displacement can be so severe that the disc can bulge out from between the vertebrae. The bulge may even pinch a nerve and cause pain all of the way down your leg. The fluid-filled nucleus is the shock absorber and primary weight-bearing structure between the vertebrae. Without it, a person will lose motion and have back pain when trying to move at the spine.

Base of Support When you lift, how you position your feet is important. They should be approximately shoulder width apart. You can offset them (place one foot slightly more forward than the other) to add to your stability. Balance of Motion (BOM) For every motion our body makes we have an opposite motion. Most work activities require a person to stand straight or bend forward (over 80%). Rarely, in most jobs, do people bend backward to perform work tasks. Not using all of your back movements may cause you to lose those movements over time. By performing regular backward bending (every 1-2 hours for 30 seconds) you decrease the backward pressure on the disc and help to maintain all of your spine's motion.

Hepatitis B Vaccine VHS offers the Hepatitis B vaccine to employees who are at risk for exposure to bloodborne pathogens. The Hepatitis B vaccine is a series of three shots given over a 6-month period of time. You must complete the whole series to be protected. 6-8 weeks after you complete your series you will have a titer drawn to determine if the vaccine is effective.

Biohazard Waste Biohazard Waste Guidelines: •Handle laundry as little as possible, use PPE and carry bag away from you. •Laundry must be bagged or containerized at the location where it is used. •Do not sort or rinse laundry where used. •Soiled line must be placed and transported in labeled or color-coded containers. Warning labels are required on containers of regulated medical waste. •Refrigerators and freezers containing blood and other potentially infectious materials. •Other containers used to store, transport, or ship blood or other potentially infectious materials. •Red bags or containers may be substituted for labels.

Confidentiality

HR504 - Confidentiality Policy To ensure confidentiality of all medical, personal and financial information of the persons we serve, including both external and internal customers. IMPORTANT: All contracted employees and education focused visitors must sign a statement agreeing to maintain patient confidentiality.

Ethics Valley Health is committed to upholding laws, regulations and ethical behavior.

This includes: •Delivering compassionate, appropriate, effective quality care to our patients •Treating each other with respect, dignity and fairness •Displaying good judgment and high ethical standards in business decision making •Ensuring that bills are accurate and honest at all times •Accurately maintaining patient and VHS records according to law •Cooperating with legitimate government investigations •Competing fairly and in compliance with anti-trust laws •Representing VHS services and products fairly and honestly •Using VHS funds only for proper, legal activities •Protecting VHS confidential and proprietary information including patient, employee and copy protected information entrusted to us by others •Avoiding conflict of interest or the appearance of such •Providing a safe and healthy work place •Using VHS property for business purposes only

Integrity

We assume responsibility for the decisions we make and the actions we take. We inspire trust and confidence through personal and professional leadership. We are consistent in our values, beliefs, actions and relationships. Our quality service and care are sincere and consistent in all settings, regardless of audience. Integrity shines through in our actions and our words.

Cultural Diversity

"Cultural" is a name for all the beliefs and behaviors shared by a particular group of people. "Diversity" is another word for variety. So, "cultural diversity" means that a variety of groups with different beliefs and behaviors live and work together in the same place. There have always been a number of diverse cultures living together within the United States. But, our country is becoming more diverse every year. Everyone is born and raised in a "culture." Each culture has its own set of values, beliefs, assumptions and practices. One's culture comes from many influences including: •Where you live. •If you have a disability. •Your race or age and language you speak. •Your religious and political beliefs. •Your values. •Your sexual orientation. •Whether your male or female. •The foods you prefer. •The work you do. •Your socio-economic status. - Your political beliefs. - Your family traditions.

Access to a Bio-Ethics Committee

A Bio-Ethics Consult can be made by contacting: •WMC - Chaplaincy Services at 536-8181. •SMH - Pastoral Care at 459-2579 (on call community clergy) •WMH - Chaplaincy Services at 636-0276 •PMH, Contact the VPMA Dr. Greg Ross at 540-743-2887 Please note that WMC Chaplaincy Services services as a resource for all six VHS hospitals. Should an urgent Bio-Ethics consult be requested at 12PM weekdays or on the weekend, please page #1000 for the onsite/on call chaplain.

MSDS (Material Safety Data Sheet)

A Material Safety Data Sheet (MSDS) provides information on the physical and chemical properties, hazards, exposure risks, safe handling instructions and PPE required, treatment of exposures and spills or emergencies. To receive an MSDS call 1-800-451-8346 and provide your name, facility, department, chemical name, manufacturer and fax number.

Quality Sentinel Event

A Quality Sentinel Event is an event that is unanticipated and results in a patient death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition. It also includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Examples of a Quality Sentinel Event are: •Infant abduction or discharge to the wrong family •Rape by another patient or staff or any allegation of sexual misconduct by any VH staff toward a patient or visitor •Hemolytic transfusion reaction •Surgery on the wrong patient or body part •Suicide of a patient •Unanticipated death of a full-term infant •Identified case of death or permanent loss of function as a result of a nosocomial infection YOUR role in a Quality Sentinel Event? If you are involved in a Quality Sentinel Event, use the following guidelines. •Respond to patient's immediate clinical needs. •Notify patient's physician as appropriate. •Notify Area Manager, Department Director, Nursing Supervisor or designee. •Respond to family's needs (chaplain, SW, counseling, lodging, etc.); Do not leave patient or family alone. •Maintain strict confidentiality concerning event and protect patient's privacy. •Document facts of event in the medical record. •Complete Quality/Risk Report and submit to Risk Management before the end of the shift. •Remain accessible in unit until dismissed by nursing supervisor, manager or director. •Reporting actual variances that have already occurred (click image below) •Reporting potential variances that could lead to a problem if they are not corrected •Reporting "near-misses" - near misses are variances that have developed, but did not reach the patient or customer.

excellence

A commitment to exceed standards and achieve superior performance in everything we do. Excellence is the result of caring more than others think is wise, risking more than others think is necessary, and expecting more than others think is possible. Striving for excellence is a commitment to make positive differences by exhibiting these characteristics. Together, our hospitals, clinics and all other points of service can support one another by sharing resources and knowledge.

Medical Record Privacy

A patient's medical record is protected by the HIPPA privacy and security rules as well as state laws. Violations of the Privacy and Security Rules can results in civil and/or criminal penalties. Valley Health has systems in place to track individual users who access patient information electronically. Violation of the VHS confidentiality policy may result in corrective action up to an including TERMINATION. You should only access or disclose confidential patient information, on a "need to know" basis. If you do not need the information to perform your job, do not look at it. Confidential patient information is classified as ANY information that identifies the patient, such as, the patient's diagnosis, treatment and/or billing information. If you are caring for a patient, you may communicate with the patient's family and friends who are involved in caring for the patient about the patient's condition or treatment, unless the patient has objected to these disclosures. As a professional caregiver, you should exercise your professional judgement in restricting or disclosing information when you believe it is in the patient's best interest.

Religious Diversity

A person's faith beliefs are often critical in time of need. Religious beliefs will also help a patient decide about many life and death decisions that may confront them such as using ventilators or donating tissue and organs. What can you expect from a Chaplain? •Confidentiality •Good listening skills •Regular visits •Support for individuals and families •Linking individuals and families with staff •Religious services, sacraments and prayer •Information and guidance regarding medical ethics questions, living wills, life support decisions and other questions •Grief ministry in dealing with loss or death Valley Health hospitals Chaplains to provide spiritual support to patients and staff. Chaplains do not try to convert you to their faith beliefs.

Patient Safety

A world class regional health care system using innovation, partnership and empowerment of people to achieve service excellence. Serving our community by improving health. We are committed to safety, quality and minimizing risk! Promoting Safety and Quality is Everyone's Priority •Treat people with respect by consistently performing your best in whatever you do! •Assist in the improvement of processes, systems, and performance •Identify and report risks, errors, failures & breakdowns •Promote patient safety and a safe environment for all customers and staff •Adhere to regulatory and licensure requirements

Caring for the Bariatric Patient

According to the U.S. Department of Health and Human Services (DHHS), obesity is the first epidemic of the 21st century is a life threatening disease. It is important for Valley Health to be aware of this epidemic and the effects that obesity has on our patients and their families. It is equally important that a safe environment, both physical and nonphysical, be provided to meet our patients' needs. Obese patients suffer from: •Quality of Life Issues that include crippling isolation. Obese people feel that the "the larger they become, the smaller their world becomes" •Difficulty doing simple, everyday tasks that most people take for granted. For example bending over and tying shoes •Psychological Effects consists of low self-esteem, loneliness, and depression. Depression rates are very high among obese individuals •Social and economic discrimination occurs frequently. Obese people are looked over for jobs, promotions, and admission into schools and universities •Physical Limitations. Many obese people will refrain from travel because of the fear of not fitting into the seats on airplanes and buses. How can we help? •Addressing the Patient in an intelligent manner. Obesity is a disease not a character flaw. •Create a Supportive Environment by having available furniture and equipment that is appropriate for people of all sizes. •Be aware of your terminology. •Be aware of your body language. •Ask yourself "Do the patients and their families feel welcomed" •Attitude - Take a moment and reflect on your own bias towards the obese person. •Remember your STARS and Key Principles for maintaining self-esteem

Air-mate Hepa-12 Hood and Power Pack

Air-mate Hepa-12 Hood and Power Pack are worn by all staff entering the room. Each staff member has their own hood and it is stored in zip-lock baggies and labeled with their name. Hoods are not discarded unless they are structurally damaged, contaminated with blood or body fluids or used on a patient with multi-resistant TB. N95 Mask Initial and annual medical screening and fit testing must be performed prior to receiving and wearing the N95 Mask. Staff members who cannot wear the N95 mask should use the Air-Mate HEPA system. During visits, patients and visitors will wear a standard surgical mask.

Dress Code Policy HR-506

All contracted employees and education focused visitors are expected to present a neat, clean and well-groomed, professional appearance consistent with the traditional dignity of the healthcare professions. While on duty employees, contracted employees and education focused visitors should: PURPOSE: Personal appearance plays an essential role in the public's perception of healthcare workers and healthcare as a profession. In almost no other business are personal dress, cleanliness, conduct and appearance as relevant as they are in the healthcare field. Therefore, all employees of Valley Health are expected to maintain a well groomed, professional appearance which creates a favorable impression and consistently conveys to patients, visitors and colleagues the therapeutic role, professionalism and scope of responsibility. Whenever contracted employees and education focused visitors are at work photo ID badges shall be worn in the following manner: • Prominently displayed with photograph side visible; • Worn on the upper half of the body (above the waist); • Pins, stickers, etc. shall not cover any printed information or the photograph on the badge.

Special situations for TB patients •Visitors are limited for patients on AFB Isolation to reduce the risk of spreading the disease. •Visitors should talk to the patient's primary nurse before entering the room. •Isolation is used to prevent the spread of disease among patients, personnel and visitors. Transporting Patients When patients are on AFB isolation need to be transported to another department they shall wear a standard surgical masks until they return to their room. Discontinuing AFB AFB Isolation is discontinued when the patient is no longer considered contagious OR TB has been ruled out. Protecting Visitors The Isolation Caddy holding PPE is placed outside the patient's door with a sign, indicating what personal protective equipment is required to enter the room. Infection Control Policies Please visit the VH Intranet and review all Infection Control Policies for your entity.

Bloodborne Pathogens Working in a healthcare facility, you may encounter bloodborne pathogens such as HIV (Human Immunodeficiency Virus), HBV (Hepatitis B Virus) or HCV (Hepatitis C Virus). Bloodborne pathogens (BBP's) can cause serious even fatal diseases. The bloodborne Pathogens Standard, issued by the Occupational Safety and Health Administration (OSHA), describes how workers and employers can work together to reduce or even eliminate the risk of contracting bloodborne disease on the job. OSHA requires that employers have a written Exposure Control Plan which includes: •Identification of contracted employees and education focused visitors covered by the BBP standard •Specific measures in place to minimize your risk of exposure •Procedures to follow if there is an exposure incident

Routes to Safety

Each department has a defined route in case of evacuation. Know the path you should follow in an evacuation; you may relocate to an adjoining area beyond a fire barrier, to another level or the complete evacuation of the building. Evacuation Evacuation is the required movement of all persons away from an emergency incident to a place of safety. Follow these actions if you need to evacuate. •Notify everyone located in the evacuation area •Evacuate ambulatory, then wheelchair, then bed-ridden patients •Take medical records with patient •Report to appropriate area of refuge •Account for missing individuals •Report any missing or unaccounted individuals to supervisor or command center

Hazardous Materials

Each department keeps a chemical inventory of potential hazardous materials located on the VH Intranet. Report all spills and avoid contact with substances unless you have proper training and protective equipment. You can protect yourself from exposure to hazardous materials. In the event of a hazardous materials incident remember to S.I.N. •Safety - leave the area •Isolate - deny entry into the area •Notify - call the emergency operator •Know the chemical and precautions for handling and use-READ the label •Use proper PPE (Personal Protective Equipment) •Know proper procedures for "hazardous material" spills •Request a Material Safety Data Sheet (MSDS)

Three kinds of ethics

Ethics Ethics is a broad term that is applied to real life situations where people may have different values guiding their actions. There are 3 types of ethical situations that are commonly encountered in the hospital. Corporate Ethics Corporate ethics is the work standard of the hospital. It involves all the business transactions of the hospital and its affiliates. VH has written ethical guidelines for employees and educational visitors to use in the work place. Corporate ethics at VH are based on our values system: STARS Maintaining the high integrity of Valley Health is a responsibility of every employee--not just the staff in the business office. Corporate ethics complies with all federal and state regulations. Bio Ethics Bio ethics refers to situations involving patient care. Sometimes staff and caregivers will have one ethical (value) framework and the patient or family a different one. There is a potential for conflict and misunderstanding. Staff Ethics Staff ethics refers to situations when the staff may find a procedure or work practice objectionable on moral, ethical or diversity grounds. Staff have the right to refuse to participate in such work. The guidelines for such objections are found in HR Policy 515.

Parking

Every car you drive to work must be registered with Safety and Security and have a parking sticker located on the driver's side of the car, on the rear window or bumper. When you are working, you are required to park only in designated areas. Violations If you notice a parking violation call Security. If you violate parking regulations, the following warnings and/or fines will occur. Violations include: •First violation - written warning •Second violation - $10 fine •Third violation - $25 fine •Fourth violation - Corrective Action will be taken according to Policy HR500

HIPAA

HIPAA stands for the Health Insurance Portability and Accountability Act. It is a broad law dealing with a variety of issues. Its original goal was to make it easier for people to move from one health insurance plan to another as they change jobs or become unemployed. This means people must be able to move their medical records and information easily, to get the care they need. But as records become easier for providers to share, it also becomes easier for information leaks and abuses to happen. This is especially true as more and more information is shared by electronic means (Internet, e-mail, Intranet). Today with e-mail and electronic storage of information, in just a few minutes at a computer, thousands of records can be sent virtually anywhere. The more information that is put into computers, the easier it is to misuse information. Legislation Two important pieces of HIPAA legislation are the Privacy Rule and the Security Rule. The HIPAA Privacy Rule is a patient's rights law. It gives patients the right to control who may access, use or disclose their confidential information. The HIPAA Security Rule governs the security of patient information maintained or transmitted electronically. The HIPAA Privacy and Security rules affect all of us and can be confusing at times. However, it's good to remember that there are a few simple rules that can help each of us ensure that we protect our patient's right to privacy

Infection Control - Prevention

Handwashing is the single most important way to prevent the spread of infection. You may not even realize you have germs on your hands. Perform hand hygiene with an alcohol based hand sanitizer - if your hands are not visibly dirty and you are not near a sink to wash your hands - or soap and ater. Remember, hand hygiene is important for the safety of our patients, yourself and your family. Because our patients are so sick, they may not be able to fight off a "minor" infection that you would find an annoyance. Follow the policy on not coming to work when you have an infectious disease. Click on the Reportable Infectious Conditions button below to see these conditions. Wash your hands: •Before preparing and serving food •Before and after eating •After using the restroom •After contact with frequently touched surfaces (i.e. computer keyboards, elevator buttons, telephones and patient care equipment) •Before and after direct contact with patients •Before administering medications •Before putting on gloves and after removing gloves •Upon entry of the patient room (wash in/wash out) Hand Care: Frequent hand hygiene can lead to drying and irritation of the skin. Because the integrity of the skin on your hands is important to preventing the spread of infection, a hospital approved hand cream is provided and should be used. Artificial Nails: No artificial fingernails, nail enhancements, overlays, wraps, tips, or attached decorations should be worn by individuals whose responsibilities include direct "hands on" patient contact.

Work Practice Controls Sharps should be handled with caution: •DO NOT bend, recap by hand or break contaminated needles or other sharps •Dispose of contaminated sharps immediately in appropriate puncture resistant, leak- proof containers Personal Hygiene: •Do not eat or drink in work areas with potential risk for exposure •Do not keep food/beverages in areas (refrigerators, freezers, cabinets or on countertops) where there might be exposed to bloodborne pathogens

Housekeeping Good housekeeping protects everyone and is everyone's responsibility. •Follow Standard Precautions when handling line •Clean all equipment and surfaces that have contact with infectious materials Infection Control - Regulated Medical Waste RMW Guidelines: •Work surfaces must be decontaminated with an appropriate disinfectant after the completion of procedures, when surfaces are contaminated and at the end of the work shift. •Regulated medical waste must be placed in a closeable, leak proof container built to contain all contents during handling, storing, transporting or shipping and be appropriately labeled or color-coded. •Regulated medical waste must be double bagged according to procedure in order to protect all contracted employees and education focused visitors that will handle the waste.

ID and Smoking

ID Badges •Your photo ID badge must be worn at all times while on duty. If you lose your badge report it to HR immediately so that the old badge can be deactivated to prevent unauthorized use. Replacement cost for the badge is $10. •Badges must be worn and displayed above your waist. Picture, name and title must be visible at all times. •Students, faculty, and educational visitors are required to wear the photo ID badge from their school or facility Safety and Security Policies Complete information about Safety and Security Policies can be found on the Safety and Security Website on the Intranet Smoking This policy applies to employees, physicians, education focused visitors, patients, and contractors at all Valley Health facilities. The use of tobacco products - by anyone, anywhere on our campuses - is PROHIBITED.

Contracted Employee/Education Focused Visitor Exposed to a Workplace Violence Incident on the Job

If you are exposed to a workplace violence incident on the job, the following procedure should occur, the contracted employee or education focused visitor should: •Inform their manager/supervisor of the workplace violence incident, which occurred on or off-site, involving another individual, which may impact the workplace. The contracted employee or education focused may also contact the Human Resources Representative at their facility. •Provide their manager or supervisor with a complete description of the workplace violence behavior or actions, the name of the employee(s) and the department of the threatening individual, if known, as well as any other identifying information. •Contracted employees or education focused that experience workplace violence from a non-employee should contact Safety and Security or the local police department. •Contracted employees or education focused experiencing workplace violence from their supervisor should contact their facility Human Resources Representative or AOC who will determine the next step in the process. •Contracted employees or education focused injured on the job need to follow the HR600 policy for reporting an injury to EOHS and obtaining medical care as appropriate.

RACE

If you observe Fire or Smoke, call your facility's emergency number and alert the Switchboard Operator by announcing " Code Red". Be sure to give the Operator the following information; Your Name, Location of the "Code Red", Is anyone injured Note the location of telephones, fire alarms, fire extinguishers and exits in your work area. If you discover a fire follow the RACE steps. •Rescue people in immediate danger •Alarm by activating pull stations and dial the designated emergency number •Confine the fire by closing all doors •Extinguish the fire if it is a small fire OR Evacuate the area If you need to use a fire extinguisher remember these steps: •Pull the pin •Aim at the base of the fire •Squeeze the handle/trigger •Sweep from side to side The extinguisher will empty in 10-15 seconds - that is why they are used only for small fires!

Isolation Caddy

Isolation Caddy If a patient is on any type of isolation an Isolation Caddy is needed. •Send order to Dispatch and specify type of isolation. •Place signage on door and on chart. •Give proper notification of appropriate ancillary departments. •The caddy can be cleaned with disinfectant if visibly soiled. Patient with Antibiotic Resistant Organisms The Infection Control Department maintains a database of patients with Antibiotic Resistance where Contact Isolation is required. Upon any ER visit, O.P. Procedure, or Admission, when the patient's medical record number is entered into Valley Health's AS400 program a pop-up screen will appear. These patients must be placed in Contact Isolation until cultures return negative.

Lean

Lean is a concept that centers on waste elimination in any process. Waste is something not adding value to the process.

Pulling Examples •Always use your legs to begin a pull. •NEVER pull with only one arm. •Limit pulling to no more than 10 feet. •DO NOT twist your body while you pull.

Lifting Examples Floor Lift - bend at the knees keeping your back straight. Lift straight up using your knees to bring you back up to a full, upright position.

Lifting Example - Waist Lift •Waist Lift- hold object close to the body. •Use a wide balanced stance with one foot ahead of the other.

Lifting Examples - Overhead Lift •Test weight by pushing on object. •Stand as close as possible to the load. •Grasp object firmly, sliding it down your body. •Avoid twisting motion as you move object.

M.TB

M.TB A person can be infected with M.TB but NOT have active TB disease. •Bacteria is present in the body but not active •Probably will have a positive PPD, however no other symptoms •Persons with TB infection are not contagious. When the M.TB bacteria are active, a person has TB disease. They may exhibit symptoms such as: •Persistent cough (longer than 2 weeks) •Bloody sputum •Night sweats •Weight loss •Anorexia •Fever •Chest x-ray with pulmonary cavitation •Hilar/ediastinal adenopathy with or without pleural/pericardial effusion •Significantly positive PPD These populations are at high risk for TB •Medically under served low-income population. •Foreign-born persons from areas where TB is common (Asia, Africa, Latin America, Eastern Europe, Russia). •Ethnic minority populations (Hispanic, Asians, Pacific Islanders, African Americans, Native Americans). •Migrant farm workers or homeless persons. •Residents of long-term care facilities, correctional institutions, mental institutions. •Persons who use illicit drugs.

The Joint Commission (TJC)

Mission: To continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations. Evaluations: TJC evaluates and accredits nearly 15,000 healthcare organizations and programs in the United States. An independent, not-for-profit organization, TJC is the nation's predominant standards-setting and accrediting body in healthcare. TJC's comprehensive accreditation process evaluates an organization's compliance with these standards and other accreditation requirements. TJC accreditation is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. Joint Commission will make unannounced visits at any time, so be continually prepared!

HIPPA Consequences

Privacy and Security Rules The Privacy and Security Rules are federal laws and violations can result in civil and/or criminal penalties. Civil Penalties Civil penalties are usually fines and may result from "inadvertent violations." These penalties can be up to $100 for each violation. For example, if a hospital inadvertently released 100 patient records because someone used the wrong e-mail address, it could be fined $100 for each record, for a total of $10,000. Criminal Penalties Criminal penalties for "wrongful disclosure" can include not only large fines, but also jail time. The criminal penalties increase as the seriousness of the offense increases. Selling patient information is more serious than accidentally letting it be released, so it brings stiffer penalties. These penalties can be as high as fines of $250,000 or prison sentences of up to 10 years.

Safe Lifting/Handling Close Open Gaps/Center of Gravity (COG) •Keep objects as close to your body as you can when lifting and carrying. •Holding objects at waist height brings the object closest to your Center of Gravity, which is located right where the buckle on a belt is, at your waist. •Use the combination lift bend at the knees and hips when reaching for your load. •Size up the load and determine if mechanical or other physical help is needed. •Push don't pull whenever necessary. You decrease your chances of back and shoulder strain. •DO NOT pull with only one hand and only pull if you are going no farther than 10-feet. •DO NOT twist your body when you lift. If you have to turn to place the object where it is going, then turn with your feet. Seek Assistance with Larger Loads

Pushing Examples •Push don't pull whenever necessary. •You decrease your chances of back and shoulder strain. •Always use your full body to begin a push.

Corporate Ethics

Reporting Process: •First discuss the issue with your immediate supervisor or assigned preceptor. If you are not comfortable discussing the issue with your supervisor; discuss the issue with a higher manager such as a director or Vice President. •Discuss the issue with other company resources, such as, but not limited to, Human Resources, Risk Management, Internal Audit, Safety and Security, the Bioethics committee, or the VH compliance officer. REMEMBER: It is always better to raise a question before taking any action that may be improper.

Sensitivity

Some of the ways we seek to work within the tapestry are: •Providing bi-lingual signs •Providing language interpreters •Being non-discriminatory in our hiring practices •Providing TDD phones •Blue Language Line Phones •Accessing a Cyracom interpreter by dialing 71536 on any Cisco phone. Guidelines when there is not an interpreter present: •Be polite and friendly •Use the patient's last name •Take your time •Speak slowly (but not loudly) •Speak about one item at a time •Try to get a response •Avoid slang terms

Access to a Patient Advocate

The Patient Advocate can be reached at 536-8122 for WMC; 636-0399 for WMH; 459-1126 for SMH; 304-822-4938 for HMH. At PMH they handle it a little different - "We all serve as patient advocates at PMH.

The Safe Medical Device Act (SMDA)

The SMDA is a federal law, enforced by the Food and Drug Administration (FDA), designed to protect patients from device failures and malfunctions. It involves two components: •Reporting - by reporting these failures to the FDA and manufacturers, designs will be changed to prevent future failures and malfunctions. •Tracking - tracking devices makes it possible to locate patients on or in which the device may have been utilized. If recall of the device occurs, this allows for proper notification to those patients. Types of Medical Devices Covered in the Regulation •Infusion pumps •Defibrillators •Monitors •Pacemakers •Prostheses •Grafts •Anything used in treatment or diagnosis that is not a drug including implants, disposables, components, reagents, etc. Malfunctions must be reported if: •The injury or illness caused by the failure is life threatening •The injury or illness results in permanent impairment of a body function or permanent damage to a body structure •The injury or illness necessitates medical or surgical intervention to prevent permanent impairment of a body function These situations must be reported even if the injury was a result of user error.

Preventing Back Injuries The Occupational Safety and Health Administration (OSHA) has reported that back injuries are the nation's number one safety problem. More than one million workers suffer back injuries each year, and back injuries account for one in five workplace injuries or illnesses. Back pain is a symptom that can arise from many causes. It can range from a dull, annoying ache to absolute agony. It is important to learn proper back safety techniques. You may be straining your back. Many cases of back pain are caused by stresses on the muscles and ligaments that support the spine. •Jobs requiring strenuous work and challenging physical tasks •Sedentary jobs and lifestyles •Obesity, which increases both the weight on the spine and the pressure on the discs •Have poor posture •Use improper lifting techniques All of these strains on the back add up and often give you no warning until it is too late.

The Spine Your spine consists of 24 interlocking bones called vertebrae. Between each bone you have a joint that is called a disc. These discs allow your spine to bend and rotate. They also act as "shock absorbers" between the vertebrae.

Infection Control

The human body has multiple defenses in order to protect itself from infection. The physical barriers, the skin and mucous membranes are the first line of defense. If an organism gets into the skin or mucous membranes, the body activates secondary defenses through the inflammatory response and immune system. The Four types of organisms that can invade the body's defenses are: •Viruses: ie., the common cold, hepatitis, HIV, cold sores, chicken pox •Bacteria: strep, staph, pseudomonas •Fungi: thrush •Parasites: tapeworms Not all organisms cause illness. If an organism causes an illness, it is called a pathogen. An infection is the body's response to a pathogen.

Workplace Anti-Violence Policy HR527

The purpose is to provide a safe and secure workplace and an environment free from physical violence, threats and intimidation. Valley Health is committed to providing a safe and secure workplace and an environment free from physical violence, threats and intimidation. Contracted employees and education focused visitors are expected to report to work to perform their jobs in a nonviolent manner. Valley Health believes that violence is a form of serious misconduct that undermines the integrity of the employment relationship. Conduct and behaviors of physical violence, threats or intimidation by an employee may result in disciplinary action up to and including termination. Valley Health will not permit employment-based retaliation against anyone who, in good faith, brings a complaint of workplace violence or who speaks as a witness in the investigation of a complaint of workplace violence.

Staff Conflict Management Policy HR528

The purpose of this policy is to provide a process to resolve conflict among healthcare professionals in order to promote a culture of safety and quality. Conflict between staff members may occur when there is personal or professional difference of opinion that may affect safety and quality of patient care.

Sexual Harassment Policy HR513

The purpose of this policy is to provide an environment free from all forms of sexual harassment and intimidation, whether it is visual, physical or verbal. Definition: Sexual harassment is defined by the Equal Employment Opportunity Commission as: unwelcome sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature when: •Submissions to such conduct is made either explicitly or implicitly a term or condition of an individual's employment; •Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual; •Such conduct has the purpose or effect of substantially interfering with an individual's work performance or creating an intimidating, hostile, or offensive working environment.

Patient Rights VHS uses the American Hospital Association Patient Bill of Rights

These Rights include: •Right to Privacy and Confidentiality •Personal Safety Information The physician is responsible for providing information about the medical plan of care and obtaining Informed Consent. The patient has the right to refuse any medical treatment. Billing Information The Finance Department is available to counsel the patient or family about the hospital bill. Advance Directives Patients have the right to a living will or durable power of attorney so that if they are unable to give informed consent about life-prolonging procedures, their wishes will be followed. Three examples of life-prolonging procedures are ventilators, feeding tubes or CPR. Any medical intervention could be refused by the patient. Transfer and Continuity of Care Patient and families may request that the patient be transferred to another health care facility

Acid Fast Bacillus (AFB) Isolation

This is the primary protection against the spread of TB and is required for: •Pulmonary TB •Laryngeal TB Patients with suspected or confirmed TB disease shall be placed in AFB Isolation. AFB Isolation Guidelines: •Patients on AFB Isolation must be in a special room. •The air in this room is filtered to the outside of the hospital and TSI monitor for negative pressure in the room. •These rooms also have an ante-room (for entering and exiting) and storage of isolation supplies. •Gowns and gloves are used based on Standard/Universal Precautions. •A physician's order is required; however, the resource or primary nurse may initiate AFB isolation.

Tuberculosis and Airborne-AFB Precautions

Tuberculosis (TB) is a disease caused by the bacteria Mycobacterium tuberculosis which usually affects the lungs but can be found in other parts of the body such as the spine, kidney and bladder. Mycobacterium Tuberculosis (M. tb) is carried through the air by small airborne particles. These particles are introduced into the air when someone with TB of the lung or larynx, coughs, laughs, sings, sneezes or speaks. Symptoms of TB •Persistent cough (longer than 3 weeks) •Bloody sputum •Night sweats •Anorexia (loss of appetite) and weight loss •Fever Precautions Patients with active TB disease are placed in Airborne-AFB Precautions and in special isolation rooms. The air in this room is filtered to the outside of the hospital. These rooms also have an ante-room for entering and exiting the room. If your job duties require you to enter an Airborne-AFB isolation room you must wear an Air Mate Hepa-12 Hood and Power Pack. Follow these guidelines: •Hoods are fitted to an individual and labeled with their name •Discard hood only if it is damaged or contaminated with blood or body fluids •Gowns and gloves are used based on Standard Precautions •Patients should only leave their rooms for medically essential purposes •During transport the patient will wear a standard surgical mask •Visitors are limited to immediate family or previously exposed individuals •During visits, patients and visitors will wear a standard surgical mask, N95 respirator if ordered by MD

Utilities, Breakdown, and Fire Alarms

Utilities The Utilities Management Program addresses the safe operation, maintenance and emergency response procedures for critical operating systems. Includes systems used for life support, fire alarms and response, medical gases, elevators, infection control, environmental support, equipment support, communications, and generators. Breakdown If a localized breakdown occurs with one of these utilities, contact the facilities department for repairs. Take the time - in advance- to become familiar with Valley Health's Utilities Management Program on the VHS Intranet. Red outlets and switches are connected to the generator so they will work during power failures Fire Alarms A fire alarm should be activated when fire, smoke, or the odor of something burning is detected. A fire alarm system can contain any or all of the following parts: Fire alarm pull stations; smoke detectors; strobe lights and bell annunciators.

Contacting an Interpreter

Valley Health Policy (and good practice) requires that we use an interpreter for any encounter with a patient whose first language is not English. Information about how to contact an interpreter is on the intranet under the Interpreter icon on the scroll bar at the top. This policy includes using sign language interpreters for the deaf. Please click the image below and take a moment to visit the Interpreter website on the Valley Health Intranet.

Employee TB Exposure Plan

Valley Health has a tuberculosis (TB) exposure plan in order to identify, isolate and prevent the transmission of TB in the health care setting. As part of the TB exposure plan, employees are required to have an annual Tuberculin skin test (TST) or possibly a chest X-ray. In the event of an exposure to TB in the workplace, employees will receive follow-up through Employee Occupational Health Services. Students, faculty and education focused visitors will have at least TWO TST/TB tests within the past 12 months and annually thereafter if continuing clinical education rotations beyond the first semester as part of the immunization history documentation on file at VHS.

values

Values are the ideals and principles Valley Health embraces, and serve as the basis for the behaviors and performance of staff. Values are those things that really should matter to each of us. Values form a foundation for Valley Health, providing a basis for decisions about within the organization.

Transmission of Pathogens BBP's may be present in blood and other body fluids. To cause an infection the pathogens need to get inside your body. This can occur from: •An accidental injury by a sharp object contaminated with infectious material •Direct contact between broken (open cuts, nicks and skin abrasions) or chapped skin and infected body fluids •Direct contact between mucous membranes (mouth, eyes and nose) and infected body fluids •Indirect transmission by touching contaminated environmental surfaces without appropriate PPE and then transferring the contaminate to mucous membranes or open skin. Infection Control - Ways to Protect Yourself The number one way to protect yourself from exposure to Bloodborne pathogens is by using Universal/Standard precautions. Standard Precautions Any individual can have a bloodborne disease without visible symptoms or knowledge of their infection. Standard precautions are used by all contracted employees and education focused visitors whenever you are at risk for exposure to blood or other potentially infectious such as gloves, gowns, eye and face protection are available.

Ways to Protect Yourself (continued) Another way to protect yourself is to use the Engineering and Work Practice controls that are provided by Valley Health for your health and safety. Engineering and Work Practice Controls are methods used to control the transmission of Bloodborne pathogens. Examples: •Self sheathing IV catheters are one example of a work practice control to protect yourself. Do not bend, break or recap needles. •If the workplace practice and engineering controls can protect you while you perform the task, then you must use personal protective equipment (PPE). Examples: •gloves •gowns •face shields •eye protection •mouthpieces •resuscitation devices. It is important to remember to wash your hands after wearing gloves and change gowns and other PPE as soon as possible if they are visibly contaminated.

compassion

We demonstrate a visible attitude of kindness and empathy and see the value of each person. Healthcare is a service with a central focus on compassion. We strive to provide compassionate care and service to members of our community. We must focus on the feelings and attributes of our customers, both internal and external. We must assess their needs and strive to exceed them. We can best fulfill these needs by asking questions and understanding the feelings and preferences of those we serve and with whom we work. We seek to develop trusting and respectful relationships with each other.

The Language of Caring - continued

We explain to patients and families how our actions are intended to benefit them—"I'm getting some water for you." This feels very different from"I'm getting water because I'm supposed to refill the container every two hours." •We apologize without blaming others or the hospital. "I'm so sorry you have had to wait" is sufficient. Never tell the patient, "You had to wait because we are short staffed," or "The nurse was supposed to take care of that." •Whenever possible, we express our appreciation to patients and their families for everything they are doing to help their own recovery and healing. "I'm so glad you finished your lunch. That's great. It will help you build up your strength." These simple practices can make all the difference to a patient. Remember, our patients are here because there is something wrong. They are sick and vulnerable. Treating them with kindness, compassion, and respect will help them feel better and may even help them get better.

courage

We have strength and conviction to do the right thing regardless of opposition or fear. Our customers count on us to take care of their needs by keeping them safe. We must have the courage to communicate problems and concerns without fear and to propose solutions. We set high standards for ourselves and others to act ethically and professionally, and dedicate ourselves to do the right thing even if it is not the easiest thing.

collaboration

We recognize and value the input and effort of every person involved with the care and service provided to our customers. This includes direct caregivers, physicians, support staff, volunteers, and administrative staff within Valley Health. We also include our colleagues and partners in care and service delivery such as outside provider organizations and vendors. Coordination of efforts for the good of every customer is essential to our work. Everyone in this organization relies on others and is accountable to others. Through collaboration and mutual respect, we take advantage of the knowledge and contributions of everyone so that combination of our efforts increases the talents of any one person.

innovation

We use creativity, problem solving, imagination and the acceptance of new ideas to improve our results/performance and to extend our resources. Great ideas for new products, services and processes happen all the time. We push ourselves to view problems from different points of view, and encourage initiative in others and ourselves, while keeping the customer's best interests in mind. Innovative organizations take, develop, and adopt these new ideas, making improvements that previously did not seem possible.

Workers Compensation

Workers Compensation is for any employee that is injured while performing their work duties. Follow these guidelines if you have been injured on the job. •Every injury, no matter how small should be reported. •Report must be completed within 24 hours of occurrence. •Report your injury to your immediate supervisor and report to the Employee Health Department during regular office hours. Evening/Night Shift or Weekend Guidelines: •On the evening/night or weekend shift check with your supervisor who will direct you to the Nursing Administrative Coordinator for care. If you must see a doctor: On occasion, Employee Health will request that you see a doctor as a follow-up. If this is the case you will be given a form titled "Panel of Physicians". You can receive a copy of this panel from Employee Health. VH will pay all expenses related to accepted workers' compensation claim as long as you have followed protocol. If you choose to see your own private physician, that is your right, but VH will not be responsible for these bills.

The Language of Caring

alley Health is committed to providing a warm, supportive environment for our patients and visitors. We expect all those who interact with patients and visitors to demonstrate genuine empathy and caring, and to do whatever we can to alleviate their anxiety. Here are some of the ways in which we strive to do this: •We express caring for the patient before and after we provide information or treatment—a technique called the "Heart-Head-Heart" Sandwich. •We practice presence—being fully in the moment with our patients. We maintain eye contact while interacting. We do not shuffle papers, check text messages, do e-mail, or glance at our watches. If family members are in the room, we acknowledge them and connect with them. They are important participants in the patient's care. We listen. And we listen well. •We acknowledge others' feelings. If they are distressed, we display concern. If they are sad, we display care. We never discount their feelings by saying, "You shouldn't feel that way," or, "Don't worry about that, you'll be fine." •We learn to align our nonverbal behavior with the words we say. Our words and facial expressions must match. If they don't, the patient doesn't hear our words—they read our faces and body language.

What is Waste? TOM D. WIP

transportation: moving things unnecessarily overproduction: making more than needed motion: needless movement defects: mistakes to fix or replace waiting: in any situation inventory: keeping too many processing: doing more than needed

excellence key behaviors

• Contribute above and beyond job descriptions. • Be responsible and take ownership. • Surpass performance expectations in Service, Safety, Quality, and Outcomes. • Promote a positive image of Valley Health through professional appearance and behavior. • Show eagerness for personal goals and organization success. • Become an expert in chosen field through continuous learning and education, or regularly strive to exceed expectations. • Prioritize time and talent to produce the biggest impact with exceptional results.

Integrity Key Behaviors:

• Exercise good judgment and high ethical standards in decision-making. • Represent self and organization fairly and honestly to customers, stressing Valley Health's mission, vision and values. • Take ownership and be personally accountable to self and the organization; be courageous to report risks and unethical business operations at all times. • Demonstrate trustworthiness and consistency by following all guidelines, policies, laws and regulations that apply to Valley Health and its operations. • Keep commitments to others, thereby establishing trust and confidence. • Be committed to performance improvements that best serves the customer and our organization. • Treat customers with respect, dignity and fairness. • Maintain confidentiality of patient, employee and corporate information.

Courage Key Behaviors

• Hold self and others accountable for actions and behaviors. • See the value in appropriate risk-taking. • Speak up for the right thing to do. • Mentor and coach others to make appropriate choices - words, approach, process, conflict management. • Commit to speak and listen to the truth respectfully with peers and superiors even when it is difficult and without fear of retaliation. • Seek out and welcome feedback about personal job performance and offer feedback to others when needed.

innovation key behaviors

• Listen carefully to fully understand a problem, change, or opportunity. • Embrace change, come forward with recommendations, and assist with making change. • Seek and share knowledge, and actively participate. • Focus on continuous improvement. • Be positive, optimistic, flexible, and believe in possibilities. • Proactively remove barriers and/or provide resources. • Research best practices and support bringing them to Valley Health. • Challenge the status quo and do not settle for "the way we've always done it" or "that just isn't possible." • Encourage others to bring forward new ideas and creative solutions

collaboration key behaviors

• Promote effective two- way communication; respect others' ideas and opinions. • Share responsibility, resources, and knowledge with others inside and outside of Valley Health counting on all parties to assist with goal achievement. • Commit to working with and involving others to do what is best for our customers and Valley Health. • Support decisions of the organization; be willing to compromise while showing support for final decision(s). • Become part of solutions, not a complainer; share ownership of problems. • Remain positive and be fully cooperative with others for better outcomes.

When You Hear Code Silver or You See the Event In Progress:

•Clear personnel and patients from view •Seek immediate shelter behind locked doors •Dial your facility's emergency number from a land line or 911 from a cell phone to identify your location if safe to do so •Turn off lights and hide •Keep away from windows •Turn OFF or SILENCE all electronic devices - Phones, radios, etc. •Remain in place until given the "all clear" by a page, e-mail or identifiable police or security officer When the Police arrive at your location: •Listen carefully •Do exactly what the officer is stating •Follow instructions •Be quiet: no pointing, screaming, yelling •Put down any items you may be holding •Raise hands and spread fingers •Keep hands visible at all times •No quick movements toward the officers

How to Secure Patient Information

•Do Not share passwords or security codes. •Always log out or password protecting your computer screen when you leave your workstation. •Always lock paper records in a file cabinet or desk drawer when you leave your work area. •Dispose of confidential waste in accordance with your facilities waste disposal policy or shredding the documents if you have access to a shredder. •Verify fax numbers BEFORE you hit the "SEND" button. •Never remove medical records from the premises--this includes printing out patient information from the computer. •When in doubt, obtaining the patient's consent before disclosing confidential information.

compassion key behaviors

•Fully focused and present with active listening, not just hearing; use good eye contact and facial expressions that demonstrate care and genuine interest, and non-verbal behaviors match words. •Honor and respect the uniqueness of each individual. •Treat all individuals as equal regardless of perceived differences. Be non-judgmental and accepting of other's appearance, culture, etc. Respect cultural diversity by recognizing individual differences and support those differences. Be considerate and respond to the diverse needs of the people we serve. •Prioritize work based on the needs of the customer.

Why is Lean Important?

•Lean is important because it provides a more consistent process that adds quality to the patient and employee experience. •Lean is not cutting resources but determining the best way to utilize the resources we have. This allows us to improve efficiency and quality.

Risk Management and Performance Improvement Responsibilities

•Monitor and report quality and safety measures - what we do and how effectively we complete it •Assist with policies, procedures, protocols, and best practice •Monitor and report patient and environmental safety measures •Monitor patient satisfaction •Facilitate meeting regulatory and licensure requirements •Educate Risk Management •Dedicated representatives for each entity •Track and trend variances to identify opportunities for improvement •Respond to regulatory or legal inquiries •Support with legal concerns and subpoena's •Educate and provide resources Performance Improvement •Dedicated personnel for each entity •Monitor and report processes and outcomes measures •Perform process evaluation to identify root causes of failures •Develop, implement, and monitor improvement action plans •Educate and provide resources

2014 National Patient Safety Goals

•Use two patient identifiers when giving medications or blood, or providing a treatment or procedure. •Get important test results to the right staff person on time. •Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines to thin their blood. •Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. •Make improvements to ensure that alarms on medical equipment are heard and responded to on time. •Use the hand cleaning guidelines from the Centers for Disease Control and Prevention. •Use proven guidelines to prevent infections that are difficult to treat. •use proven guidelines to prevent infection of the blood from central lines. •Use proven guidelines to prevent infection after surgery. •Use proven guidelines to prevent infections of the urinary tract that are caused by catheters. •Find out which patients are most likely to try to commit suicide. •Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body. •Mark the correct place on the patient's body where the surgery is to be done. •Pause before the surgery to make sure that a mistake is not being made.

Employee's, Contracted Employees and Education Focused Visitors Responsibilities

•View quality, safety and minimizing risk as your #1 priority. •Work collaboratively with Risk Management and Performance Improvement personnel in initiatives to: - Promote a culture of safety - Promote customer satisfaction - Consistently exhibit STARS behavior •Report actual or potential errors by the end of your shift •Know and understand the regulatory and legal requirements for your position Examples of What to Report: •Unresolved complaints •Environmental related occurrences •Equipment related occurrences: - Always provide lot # or serial # or VHS sticker for easier identification •Falls: Patients and guests/visitors •Errors involving the medication process •Errors involving deviations from Policy/Procedure and Practice Helpful Things to Remember: •You make a difference by reporting variances - If in doubt....report - Submit a Risk Report within 24 hours •Maintain a clear focus on safety and minimizing risk •Patient, Employee, Physician Satisfaction: we work together to exceed our customer's expectations •Know your resources and how to access them - Departments policies, protocols, rules and regulations