Orientation/Reorientation Handbook 2011 - …

1 Nursing Department Orientation/Reorientation Handbook 2011 . This Handbook was prepared as collaborative effort of many individuals. We appreciate their contributions. CONTRIBUTORS. Calvin Kwan Hospital Administrator Susan Black, RN QA/Resource Management Nancy Lefcourt, RN, MSN Risk Management Thresia Nayagam, RN Nursing Administration Paula Siler, RN Nursing Administration Grace Chacon, RN, MBA Nursing Education Robin Watson, RN, MN, CCRN Nursing Education Jenelle Zambrano, RN, MSN Nursing Education Vince Jugo, RN, MSN Nursing Education Sreedevi Warrier, RN, MSN, MA Nursing Education Olivia Piedad, RN Materials Management Erika Sweet, RN, NP Employee Health Services Julie Rees Compliance Officer Clinton Coil, MD Patient Safety Officer Yvette Ruiz Hospital Administration Patrick Brady Facilities Management Sandy Mungovan Information Systems Valeriea Caesar Health Information Management Loren Miller, MD, MPH Infection Prevention and Control Monica Murphy, RN Infection Prevention and Control Alma Belis, RN Infection Prevention and Control Wesley Kamikawa, Pharm D.

2 Pharmacy Donna Samuels Health Information Management Dana Denis, RD Nutrition Services Larry Schneider, LCSW Clinical Social Work SECTION REVIEWERS. James Freeman Facilities Management Essence Wilson, RN, BSN Hospital Administration Alma Belis, RN Infection Prevention and Control Patricia Strayer, RN, MSN Nursing Administration Theresa Carnes, RN, BSN Nursing Education Monique Eriksen, RN, MSN, CNOR Nursing Education Elizabeth Leon, RN, MSN Nursing Education Maria Morales, RN, BSN Nursing Education Susan Ulit, RN, MSN, CCRN Nursing Education Jo Ann Williams, RN, MN Nursing Education David Applebaum, MS Radiation Safety Publication Support: Francisco Acevedo, Intermediate Typist Clerk TABLE OF CONTENTS. I. Harbor-UCLA Medical Center a. Welcome .. 1. b. Introduction .. 2. c. Coastal Cluster History and Highlights .. 2. d. Harbor-UCLA Medical Center 3. e. Mission, Vision, & 5. f. Customer 5. g. Teamwork: Communication, Collaboration, Coordination of Care & Conflict 6. II.

3 The Joint Commission a. The Joint Commission's Shared Vision, New Pathways .. 9. b. Survey Process .. 9. c. Other Survey 9. d. The Joint Commission Accreditation Participation Requirement (APR ).. 10. III. Patient Safety a. Patient Safety 11. b. Safe and Just Culture .. 12. c. National Patient Safety Goals .. 12. d. Deteriorating Patient Condition .. 15. e. Fall Prevention and 15. IV. Staff Rights and Responsibilities a. DHS Workforce Emergency 18. b. Staff 18. c. DHS Compliance Program and Code of Conduct .. 18. d. Procurement 22. e. Training & Competency .. 22. f. Medical Professionals License/Registration/ 23. g. Criminal Background 24. h. Attendance/Tardiness .. 24. i. Health Screening .. 25. j. Employee Assistance Program (County Employees) .. 25. k. Sexual Harassment Prevention .. 25. l. Cultural Competence .. 27. m. Abuse Prevention, Sexual Abuse, Sexual 28. n. Workforce Behavior 29. o. Threat Management Zero Tolerance .. 30. p. Reporting of Abuse/Neglect 31.

4 Q. Safe Haven/Safely Surrendered Baby Law .. 32. r. Americans with Disabilities Act (ADA) .. 32. V. Patient Rights and Services a. Patient 34. b. Patient Advocates .. 35. c. Interpreter 36. d. Spiritual Needs of 36. e. Advance Health Care Directives .. 36. f. Americans with Disabilities Act .. 37. g. Service Animals .. 37. h. Organ/Tissue Donation .. 38. VI. Clinical Social Work a. Scope of Services .. 39. i VII. Performance Improvement a. Improving Organizational Performance .. 40. b. Performance Improvement c. Performance Improvement Activities ..41. d. ORYX Initiative / Core Measures .. 41. VII. Risk Management a. The Office of Risk Management .. 43. b. Reporting Near Miss, Adverse and Sentinel c. Reportable Unusual 44. d. Timely Reporting .. 45. e. Documentation A Key 45. f. Subpoena and Summons .. 46. g. Contacting Risk 46. VIII. Environment of Care a. Workforce Safety 47. b. Emergency 48. c. Security .. 49. d. Safety Awareness .. 50. e. Bomb 50. f. Weapons .. 50.

5 G. Workplace Violence .. 50. h. Evacuation ..51. i. Reporting Work Related j. Injury and Illness Prevention Program (IIPP)..51. k. Ergonomics and Body ..52. IX. Infection Prevention & Control a. Infection Prevention and 54. b. Bloodborne Pathogen Control Plan ..55. c. 56. d. Airborne Transmissible Disease Plan ..56. e. Pandemic Influenza Plan .. 57. f. Waste Disposal .. 58. X. Management of Information a. Confidentiality of Patient Information (HIPAA).. 59. b. Hospital Information Management..62. XI. Key Points to Remember (ALL STAFF).. 64. CLINICAL orientation (CLINICAL STAFF ONLY). XII. Patient Care Practices a. Population-Specific Guidelines and Care of Special Patient Populations .. 68. b. Patient Food Services/ Nutrition XIII. Patient Safety a. Read-Back Requirements .. 70. b. Universal Protocol .. 70. c. Deteriorating Patient Condition .. 71. d. Fall Reduction and 71. e. Medication 73. f. Dangerous Abbreviations: Do Not Use .. 74. g. Look-Alike/Sound-Alike Medication h.

6 Medical Record Requirements for 76. ii XIV. Key Points to Remember (CLINICAL STAFF) .. 77. XV. Addendum a. Rapid Recognition and Response to Changes in Patient Condition .. 78. b. Emergency Medical Treatment and Active Labor Act (EMTALA).. 81. c. Infant/Child 81. d. Hazardous Materials Communication and Safety 82. e. Radiation Safety 82. f. Emergency Preparedness .. 83. g. Fire/Life Safety .. 83. h. Medical Equipment and 84. i. Hand Hygiene .. 85. j. Tuberculosis (TB) Control 86. k. Pain Assessment and Reassessment .. 87. l. Use of Restraint and 88. m. Baby Friendly .. 92. iii Welcome to Harbor-UCLA Medical Center and the Metrocare Regional Health Network! We are pleased that you have chosen to join our healthcare team and made the commitment to help us provide quality, patient-centered healthcare services to our family, friends, neighbors and everyone who comes to us for care in their time of need. When you join Harbor-UCLA Medical Center or Long Beach Comprehensive Health Center, you also join the Metrocare Regional Health Network of Los Angeles County.

7 The Metrocare Regional Health Network encompasses Harbor-UCLA Medical Center, Long Beach Comprehensive Health Center, Wilmington Health Center, Harbor-UCLA Family Health Center, and Bellflower Health Center, as well as Martin Luther King, Jr., Multi-Service Ambulatory Care Center (MLK-MACC), Hubert H. Humphrey Comprehensive Health Center and Dollarhide Health Center. Ours is the only public medical care network providing services to the indigent and underinsured in the South Bay areas of the County of Los Angeles, as well as South and Central Los Angeles. Our responsibility is great and clear: Provide services to everyone in a caring manner. You have chosen an organizational network that includes Harbor-UCLA Medical Center, which for more than half a century has been recognized nationally as a provider of high- quality health care, a renowned academic medical center affiliated with the School of Medicine at UCLA, a major medical research institution, and an integral part of the healthcare safety net in the County of Los Angeles.

8 We welcome your creativity and desire to make a difference. You will have this opportunity every day. Take this opportunity and be counted as one of our leaders in our quest for excellence. This Handbook provides you with information regarding the Harbor-UCLA, Metrocare Regional Health Network and County policies. Please take time to thoroughly read and review these policies. If you have any questions or need additional information, you may discuss them with your supervisor or contact Human Resources for assistance. 1. INTRODUCTION. This section provides a broad organizational overview of the Coastal Cluster's service delivery. Included is the history, its Mission, Vision, Values and customer-service philosophy. As a vital resource for the delivery of healthcare, Harbor-UCLA Medical Center and its affiliated Coastal Cluster Health Centers are committed to achieving the goals and objectives of the Los Angeles County Department of Health Services (DHS), improving service-delivery systems to our community and enhancing the quality of patient care provided by the Cluster's healthcare facilities.

9 We also are committed to meeting our Mission, Vision, and Values. In addition, we must meet quality standards established by accrediting agencies as they evaluate our programs and services by way of surveys, reviews, and other indicating tools. We are providing this informational Handbook to you as a responsible and vital member of our service-delivery team so that together we can achieve excellence by meeting regulatory standards and the healthcare needs of our patients. It is important that you understand -- whether you are a healthcare practitioner, technician, clerical or housekeeping member of our team -- that you make an important contribution to the delivery of quality healthcare. We have designed this Handbook so that important information about the Coastal Cluster facilities is readily available. It provides you with general information about Coastal Cluster Harbor-UCLA and can be used as a quick reference guide to key policies and procedures. You are expected to know the material in this Handbook and you may be tested on the information contained herein.

10 COASTAL CLUSTER HISTORY AND HIGHLIGHTS. Harbor-UCLA Medical Center For more than half a century, Harbor-UCLA Medical Center has been a prime provider of high-quality, cost- effective health care to insured and uninsured Los Angeles County residents, alike. Harbor-UCLA is an integral part of the County's healthcare safety net, a world-class academic medical center, and a major medical research site. The medical center began as a military station hospital for the Los Angeles Port of Embarkation. In June 1946, the US Army sold the facility as war surplus to the County's Department of Charities. Opening one month later, Harbor General Hospital - as it was then known -- had 60 beds and a 70-person staff. Since then, Harbor-UCLA's physical plant has evolved. Following the passage of a bond issue in the mid 1950's, an 8-story replacement facility opened in 1963. The Emergency Department has been enlarged, and wardrooms have been converted to a number of specialty care units.