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Orientation/Reorientation Handbook 2011 - …

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.

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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.

2 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. Pharmacy Donna Samuels Health Information Management Dana Denis, RD Nutrition Services Larry Schneider, LCSW Clinical Social Work SECTION REVIEWERS.

3 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.

4 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. 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.

5 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.

6 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. 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.

7 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.

8 B. Emergency 48. c. Security .. 49. d. Safety Awareness .. 50. e. Bomb 50. f. Weapons .. 50. 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).

9 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.

10 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.


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