Transcription of MANDATORY ANNUAL TRAINING MANUAL
1 UC Da vis Health MANDATORY A nnual TRAINING Ma nual 2 022 1 Version: January 2022 FINAL MANDATORY ANNUAL TRAINING MANUAL 2022 UC Da vis Health MANDATORY A nnual TRAINING Ma nual 2 022 2 Version: January 2022 FINAL Table of Contents TABLE OF CONTENTS .. 2 PURPOSE AND GOALS .. 7 OBJECTIVES .. 7 INTRODUCTION .. 7 ACCREDITATION .. 7 NATIONAL PATIENT SAFETY GOALS .. 8 emergency CODES .. 8 emergency MANAGEMENT .. 8 NOTIFICATION AND RESPONSE .. 9 CODE GREEN .. 9 Staff Roles and Responsibilities .. 10 Personal Preparedness .. 10 Evacuation Procedures .. 10 HIGH-QUALITY CARDIOPULMONARY RESUSCITATION (CPR) REVIEW .. 11 MANAGEMENT OF THE ENVIRONMENT OF care .. 13 WORKPLACE SAFETY .. 13 SAFETY 14 Hazard Identification and Reporting .. 14 INJURIES AND ACCIDENTS .. 14 Occupational Injury or Illness .. 14 Incidents Involving Patient or Visitor Injury .. 15 Indoor Trip and Fall Hazards .. 15 Outdoor Trip and Fall Hazards .. 15 SMOKE AND TOBACCO-FREE CAMPUS.
2 15 USE OF CELL PHONES .. 16 PROPER FOOTWEAR .. 16 SAFETY MANAGEMENT CONCLUSION .. 16 HAZARDOUS MATERIALS AND WASTE MANAGEMENT .. 17 SAFETY DATA SHEETS (SDSS) .. 17 How to Read a Safety Data Sheet (SDS) .. 17 HAZARDOUS MATERIAL LABELING ELEMENTS .. 21 PICTOGRAMS AND HAZARD CLASSES .. 22 SPILL RESPONSE .. 22 EXPOSURE CONTROL AND ENGINEERING CONTROLS .. 23 CANCER CAUSING MATERIALS .. 23 CODE WHITE: CHEMICAL SPILL RESPONSE .. 23 Managing Drugs Employee Exposure, Spills, and Waste .. 23 UC Da vis Health MANDATORY A nnual TRAINING Ma nual 2 022 3 Version: January 2022 FINAL CRYOGENIC LIQUID MANAGEMENT .. 24 OXYGEN AND OTHER COMPRESSED GAS CYLINDERS .. 25 HAZARDOUS WASTE, MEDICAL WASTE MANAGEMENT, AND BATTERY RECYCLING .. 25 Medical Waste Management .. 26 Battery Recycling Program .. 26 EYEWASH AND emergency SHOWER STATION .. 27 ASBESTOS .. 28 WILDFIRE SMOKE PROTECTION .. 29 FIRE PREVENTION MANAGEMENT .. 30 CAMPUS FIRE MARSHAL S OFFICE .. 30 INTERIM LIFE SAFETY MEASURES (ILSM).
3 30 Teamwork .. 31 CODE RED .. 31 Smoke Barriers .. 31 Fire Drills .. 31 FIRE emergency .. 31 Classes of Fire .. 32 USE OF FIRE EXTINGUISHERS .. 32 MEDICAL GAS SHUTOFF VALVES .. 32 BUILDING EVACUATION .. 33 ALCOHOL-BASED HAND-RUB DISPENSERS .. 33 MEDICAL EQUIPMENT MANAGEMENT .. 33 Clinical Engineering Information .. 33 TRAINING .. 33 Equipment Failure and Reporting .. 33 Equipment Caused Injury .. 34 Equipment Inspection .. 34 ELECTRIC SAFETY .. 34 Special Precautions for Electrically Sensitive Patients .. 35 RADIATION .. 35 MEDICAL LASERS .. 37 MAGNETIC RESONANCE IMAGING (MRI) .. 38 UTILITY SYSTEMS MANAGEMENT .. 39 Plant Operations and Maintenance .. 39 TRAINING .. 39 Utility System Failure and Reporting .. 40 Information .. 40 SECURITY MANAGEMENT .. 40 Identification Badges and Cardkeys .. 40 Personal Safety .. 41 What Do I Do in an emergency ?.. 42 TRAINING .. 42 UC Da vis Health MANDATORY A nnual TRAINING Ma nual 2 022 4 Version: January 2022 FINAL INFANT/CHILD ABDUCTION (CODE RAINBOW).
4 42 HUGS - Preventing Infant Abduction .. 44 emergency UNLOCKING OF PATIENT BATHROOMS .. 44 ONLINE INCIDENT REPORTING .. 45 REPORTABLE EVENTS .. 46 WORKPLACE VIOLENCE AND HATE INCIDENTS .. 46 WORKPLACE VIOLENCE .. 47 Ways to Prevent Potential Violence in the Workplace .. 49 Assault 50 REPORTING CRIMINAL, SECURITY, WORKPLACE VIOLENCE, AND HATE INCIDENTS .. 51 MANDATORY Reporting of Workplace Violence .. 51 Hate Incident Reporting .. 52 WEAPONS ON UC DAVIS HEALTH PROPERTY .. 52 ACTIVE SHOOTER/THREAT .. 53 HARASSMENT & DISCRIMINATION ASSISTANCE AND PREVENTION PROGRAM .. 54 CONFIDENTIAL RESOURCES .. 54 SEXUAL HARASSMENT .. 55 ERGONOMICS, BODY MECHANICS, AND SAFE PATIENT HANDLING .. 56 BODY MECHANICS .. 56 ERGONOMIC SELF-EVALUATION .. 58 SAFE PATIENT HANDLING .. 58 Safe Patient Handling Resources .. 59 PATIENT SAFETY .. 59 PATIENT RIGHTS .. 59 HOMELESS PATIENT DISCHARGE POLICY .. 60 LIGATURE RISK AND SELF-HARM .. 63 PATIENT IDENTIFICATION .. 64 INFORMED CONSENT.
5 65 PATIENT ADVANCE DIRECTIVES FOR HEALTHCARE .. 65 PRESSURE ULCER PREVENTION .. 65 RECOGNITION OF STROKES .. 66 care OF LVAD PATIENTS AT UC DAVIS .. 67 RESTRAINTS REVIEW .. 70 ELDER OR DEPENDENT ADULT ABUSE .. 74 CHILD ABUSE .. 76 BLOOD PRODUCT ADMINISTRATION AND TRANSFUSION REACTION .. 76 Licensed Personnel Responsibilities .. 77 BABY FRIENDLY HOSPITAL INITIATIVE .. 82 CYBER-SECURITY THREATS .. 83 ACCOUNT/PASSWORD PROTECTION .. 83 UC Da vis Health MANDATORY A nnual TRAINING Ma nual 2 022 5 Version: January 2022 FINAL PHISHING .. 83 MALWARE/VIRUS .. 83 RANSOMWARE .. 84 SECURING AND ENCRYPTING PORTABLE ELECTRONIC 84 PHOTOGRAPHY AND VIDEO RECORDING .. 84 SOCIAL MEDIA .. 85 COMPLIANCE AND PRIVACY SERVICES .. 87 UC DAVIS HEALTH COMPLIANCE PROGRAM .. 87 General Compliance TRAINING .. 88 UC Davis Health Code of Conduct .. 88 University of California Statement of Ethical Values and Standards of Ethical Conduct .. 89 Reporting Compliance Concerns.
6 89 Protection from Retaliation .. 90 Important Compliance Standards .. 90 Anti-Kickback Statute .. 91 Conflicts of Interest .. 91 Gifts .. 92 Vendor Access Program .. 92 Open Payments/Sunshine Act .. 93 UC DAVIS HEALTH PRIVACY PROGRAM .. 93 Important Privacy Topics .. 94 Reporting Privacy Incidents .. 95 RESEARCH COMPLIANCE PROGRAM .. 95 Clinical Research Billing (CRB) .. 96 Research Privacy .. 96 CODING AND BILLING COMPLIANCE .. 97 DOCUMENTATION/ELECTRONIC MEDICAL RECORD COMPLIANCE .. 97 Verbal Orders .. 97 Sharing Notes with Patients .. 99 Sharing Results with Patients .. 99 Copy and Paste Guidelines .. 99 Provider Responsibilities and Good Practices: .. 101 EMR Downtimes .. 102 Teaching Physicians: Billing Reminders and Resource Information on Documentation .. 102 UC Da vis Health MANDATORY A nnual TRAINING Ma nual 2 022 6 Version: January 2022 FINAL CONFLICT OF COMMITMENT AND OUTSIDE PROFESSIONAL ACTIVITIES .. 103 PROMOTING HEALTHCARE EQUALITY.
7 105 ORDERING MEDICAL INTERPRETERS FOR PATIENTS WITH LIMITED ENGLISH PROFICIENCY AND DEAF/HARD OF HEARING PATIENTS .. 106 CONTROLLED SUBSTANCE DIVERSION AND YOU .. 106 INFECTION PREVENTION/CONTROL .. 107 TIER 1 STANDARD PRECAUTIONS .. 107 Guidelines for Preventing Transmission of Infections in Healthcare Settings .. 107 TIER II TRANSMISSION-BASED PRECAUTIONS .. 108 Airborne or Aerosol Transmissible Diseases (ATD) .. 108 Control of Tuberculosis .. 110 MULTIDRUG RESISTANT ORGANISMS .. 111 Methicillin Resistant Staphylococcus Aureus (MRSA) .. 111 BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN (HEPATITIS B, C, AND HIV) .. 112 SHARP SAFETY- NEEDLE RESISTANT GLOVE EDUCATION .. 112 REPORTING BLOOD OR BODY FLUID EXPOSURES .. 113 ANTIBIOTIC STEWARDSHIP .. 114 HEALTHCARE-ASSOCIATED INFECTIONS (HAI) .. 114 Clostridioides difficile .. 114 DEVICE-RELATED INFECTIONS .. 115 HAND HYGIENE .. 115 To Glove or Not to Glove? .. 117 AGENTS OF CHEMICAL AND BIOTERRORISM .. 118 118 PHOSGENE.
8 118 ANHYDROUS AMMONIA .. 118 METHYL ISOCYANATE (MIC) .. 118 CYANIDE .. 119 ANTHRAX .. 119 BOTULISM .. 119 PLAGUE .. 119 SMALLPOX .. 119 120 APPENDIX A: 2022 NATIONAL PATIENT SAFETY GOALS .. 120 APPENDIX B: UC DAVIS HEALTH CODE OF CONDUCT STANDARDS .. 123 UC Da vis Health MANDATORY A nnual TRAINING Ma nual 2 022 7 Version: January 2022 FINAL Purpose and Goals This MANUAL updates and reviews ANNUAL TRAINING topics required for the Health Insurance Portability and Accountability Act (HIPAA), the Joint Commission on Accreditation of Healthcare Organizations (TJC), and Occupational Safety and Health Administration (OSHA). It also includes medical device reporting, patient s rights, Safety Data Sheets (SDS) and workplace safety. The MANUAL has links to associated UC Davis Health Policies as well as web sites. Objectives After reviewing this MANUAL , individuals should be able to: Identify patient rights. Identify components of a safe workplace.
9 Discuss environment of care . Discuss the importance of infection prevention. Introduction UC Davis Health is the only academic health system in the region that views healthcare on a regional, national, and even international level for areas that are vulnerable and need improvement. ANNUAL TRAINING is an opportunity to be current with topics of importance and polish skills that may not have been used recently. Reviews of personal skills and/or information deficits are assisted through regulatory agencies and accreditation organizations. Therefore, the UC Davis Health workforce should take the opportunity to benefit from the work put in by regulatory agencies and the UC Davis Health departments in identifying key areas of focus to provide person-centered care in the best way, at the best time, and in the best place UC Davis Health. Accreditation UC Davis Medical Center is accredited and surveyed by several regulatory and accreditation entities that are responsible for: providing oversight and monitoring of healthcare practitioners and facilities, providing information about changes within the healthcare industry, promoting patient safety, and ensuring regulatory compliance and quality services are rendered on behalf of patients.
10 Federal, state, and local regulatory and accreditation agencies establish rules, standards, or guidelines for healthcare facilities and mandate compliance to ensure a culture of safety for all patients, visitors, and healthcare employees. Accreditation entities such as The Joint Commission, an independent not-for-profit organization that accredits hospitals on behalf of the Centers for Medicare and Medicaid (CMS), are dedicated to raising UC Da vis Health MANDATORY A nnual TRAINING Ma nual 2 022 8 Version: January 2022 FINAL the level of quality and safety of healthcare provided through the accreditation or certification process. Accreditation or Program Certification is considered a symbol of quality within the healthcare industry, with the Joint Commission being considered one of the nation s predominant health standards-setting bodies. National Patient Safety Goals The Joint Commission is one of nine hospital and health services accrediting agencies accepted by CMS to provide deemed-status in the United States, providing oversight for hospitals and other healthcare facilities.
