MANDATORY ANNUAL TRAINING MANUAL - UC Davis …

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.

2 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 .. 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.

3 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) .. 30 Teamwork .. 31 CODE RED .. 31 Smoke Barriers .. 31 Fire Drills .. 31 FIRE EMERGENCY .. 31 Classes of Fire .. 32 USE OF FIRE EXTINGUISHERS.

4 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?

5 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).. 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.

6 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 .. 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.

7 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 .. 89 Protection from Retaliation .. 90 Important Compliance Standards.

8 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.

9 102 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 .. 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).

10 111 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 .. 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).