WellStar Student Affiliations Orientation Handbook

WELLSTAR STUDENTAFFILIATIONS

ORIENTATION HANBOOOK

Welcome to WellStar!

The Organizational Learning staff welcomes you to WellStar. We hope that your clinicalexperience here will provide you with the knowledge and experiences necessary to prepare you foryour future healthcare career. Your presence in our hospital supports our commitment toeducation, patient care, and continued professional growth. We would like to take this opportunityto provide you with some valuable information regarding your time in our facilities. This bookletwas developed to welcome you and to acquaint you with WellStar.

Prior to beginning any student experience within a WellStar Facility, it is expected that anorientation to our system will be completed. This handbook will provide the information that isneeded to fulfill that requirement. Upon completion of this material, take the post-test that isprovided at the end and submit the post test to your school/faculty member or designated mentor.In compliance with regulating agencies and WellStar Policy, all students must also submit thecredentialing documents that are included with this booklet.

If you have any questions, please do not hesitate to contact Janice DeKlavon, Coordinator ofStudent Affiliations at: 770-956-6427 or e-mail [email protected]

WellStar is committed to providing a positive learning environment at every level.

Our Strategic GoalTo be the provider of choice by exceeding the expectations of the communities we serve.

Our VisionTo deliver world-class health care.

Our Mission To create and deliver high quality hospital, physician and other related healthcare services thatimprove the health and well-being of the individuals and communities we serve.

Section One: WellStar Health System Update 4Pillars of Excellence 4

Section Two: People 5What Employees Can Expect from WellStar and What WellStar Expects from You 5Fair, Equitable and Culturally Competent 5Great Leaders 5Your Opinion Counts and Communication is Encouraged 6Support for Balancing Work and Life 6Exceptional Contributions are Rewarded and Recognized 7Opportunities to Learn and Grow at Work 7Required Learning and Competence 7Safe, Ethical and in Compliance with Legal and Regulatory Requirements 8

Ethics and Compliance 8Reporting Problems and Concerns: The Compliance Hotline 9WellStar Code of Conduct for Quality of Care and Services 9Information Management Plan 10Confidentiality: Privacy and Security of Health Information (HIPPA) 11

Section Three: Service 13Our Service Expectations 13

Section Four: Quality and Patient Safety 14Environment of Care and Safety 14

Patient Safety 14Risk Management and Incident Reporting 14National Patient Safety Goals for 2008 15Emergency Codes and Responses 17

Infection Prevention 23The OSHA Bloodborne Pathogen Standard 23How Infections are Spread 24How to Prevent the Spread of Infections 24TB Control Plan - IC 25 26

Patient Needs 27Patient Rights 27Patient Responsibilities 28Staff Rights 28Ethics Committee 29Advanced Directives: Critical Conditions 29Care at the End of Life 29Eye, Organ and Tissue Donation 29

Meeting Patients Special Needs 30Age Specific Care 30Cultural Competence 31Spiritual Needs 32Language Translation Needs 32The American with Disabilities Act (ADA) 32Meeting the Needs of the Hearing and Speech Impaired 32

TABLE OF CONTENTS

Assessment of Patients 33Patient Screening 33Discharge Needs Screening 33Specific Assessment Parameters 33Pediatric Patients 34Waived Testing 34Victims of Abuse 34Nutrition (Inpatient) 34Safe Storage and Distribution of Food 34Diet Manual/Standardization of Practice 34Monitoring Nutritional Care 34Food/Drug Interactions 34

Patient and Family Education 34Assessment of Patients and Families Education Needs 34Resources for Patient and Family Education 34Documenting Patient and Family Education 35

Care of Patients 35Conscious Sedation 35Patient Restraints 35Medication Use 36Medication Errors 36Sentinel Events 36

Performance Improvement 37Accrediation and Certification 38Regulatory Organizations 38

Section Five: Financial 40Protecting the Organizations Assets 40WellStar Foundation 40

Section Six: Successful Growth 41Continuing to Learn and Grow at Work 41Finding Other Great Team Members 41Helping Retain Great People 41Improving WellStar through Ideas and Suggestions 41Promoting WellStar in the Community 41

Section Seven: Studeny Affiliations Orientation Exam 42Student Affiliations Orientation Exam Questions 42Student Affiliations Orientation Exam Answer Sheet

WellStar is an integrated healthcare delivery system withthe mission of delivering high quality hospital, physician,and other related healthcare services that improve thehealth and well-being of the individuals andcommunities we serve.

The People Pillar reflects our understanding of the value of our employees, leadership and physicians.Our people are our single greatest asset;

our most valuable resource. One of our key performance metrics is our employee engagement survey. We want to be an Employer of Choice, and weare seeking a variety of ways to meet and exceed ouremployees’ expectations.

The Service Pillar speaks to our commitment toservice excellence as a keydriver and component of WellStar’s success. Patients and customers come

first. We strive to build trust and loyalty with our customers. We are committed to reducing patient anxiety and creating an environment where every patientand family member feels confident that we are providingexceptional service.

The Quality and Patient Safety Pillar isthe center pillar. It defines us as a healthcare organization. Every great organization has the other four pillars, but

the center pillar differentiates WellStar in terms of whatkind of organization we are and what services we offerin the community. We have recently renamed this pillarQuality and Patient Safety. This was a direct result ofyour feedback on last year’s employee survey regardingyour concern for a greater focus on the quality of carewe provide our patients.

The Financial Pillar speaks to our commitment to being fiscally responsible.We are aggressive in our efforts to containcosts, utilize our financial resources so that

we can turn margins back into the organization and continue to serve our patients and community withworld-class healthcare.

The Successful Growth Pillar addressesour dedication to pursuing opportunities to provide new and innovative services, better access and new opportunities for revenue

stream that also serve our community. Obtaining cuttingedge technology and remaining mindful of the needs ofour community provides direction on the best way toensure we can offer optimal healthcare to our patients.

Our commitment is to deliver world-class care. To besuccessful, all pillars must have the same level of priorityin order to achieve the results we desire. By settingmeasurable goals under each of the pillars, monitoringto maintain optimal performance, and developing actionplans to keep us on track, we drive results.

“Our strategies for success will change over time tomeet the ever-changing environment of ourindustry. The pillars represent the core of our effortsand will remain constant over time.”

SECTION ONE: WELLSTAR SYSTEM UPDATE

WELLSTAR STUDENT AFFILIATIONS ORIENTATION HANDBOOK 4


What you can expect from WellStar and…what WellStar expects from you!WellStar is committed to being a great place to work andin helping all staff achieve their fullest potential. Webelieve that employees and affiliates of WellStar HealthSystem can expect and deserve a work environment

•That is fair, equitable and culturally competent. •With great leaders.•Where your opinion counts and open communication is encouraged. •Which supports work-life balance. •Where exceptional contributions are rewarded and recognized.

•That provides opportunities to “learn and grow at work”.

•That is safe, ethical and in compliance with legal and regulatory requirements.

It takes everyone at WellStar to create and maintain ourgreat place to work. WellStar has a system of processesand programs to support our success.

If you are interested in employment opportunities atWellStar – more information can be found at www..wellstar.org

Fair, Equitable and Culturally CompetentWellStar ensures that everyone is afforded equalemployment and advancement opportunities regardlessof gender, age, disability, race, color, religion or nationalorigin.

All employees have a duty to report any actual orperceived harassment, mistreatment, discrimination,safety issue, hostile activity, legal violation or other non-compliance issue occurring in the workplace. Employeesare encouraged to notify their supervisor, humanresources or any WellStar leader of any instances orconcerns of this nature. We conform to the standardsof our industry, professions and exercise reasonablejudgment and objectivity in the performance of ourduties.

Cultural CompetenceFor more information about Cultural Competence at WellStar,please contact Stephanie Taylor, Director of Cultural Competenceat 770-956-6419 or [email protected].

The world is becoming more global and our patients andworkforce reflect this diversity. Our vision to deliverworld-class health care can only be achieved when allmembers of our healthcare system create anenvironment which maximizes the full potential of eachperson and values differences as well as our similarities.

Our goal, to provide exceptional clinical outcomes, optimal patient experience, market leadership andbenchmark financial performance can be best achievedwhen we embrace the diversity of our employees, patients, and our providers.

WellStar provides tools, training and resources to all employees to encourage cultural competence. The resources that follow can be found on Esource. Thesetools are uniquely designed for managers, leaders, andfront-line workers to successfully build, manage, andthrive in our diverse organization and work groups.

Culture Vision is a robust database of theknowledge necessary for healthcare professionals to overcome the uncertainty

associated with cultural differences. It enables you tocare for people of varying backgrounds and assist,support, and facilitate the patient’s ability to regain ormaintain the highest levels of independence and wellness.

The Diversity Toolkit is a unique resourcedesigned for managers, leaders, and front-line workers to enable you to successfully

build, manage, and thrive in our diverse organization.

Great LeadersWellStar is committed to having strong, positive andskilled leaders throughout the organization. As part ofour journey to world-class healthcare, the seven leaderattributes below are expectations for all WellStar leaders.

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Seven Attributes of Leaders• Communicator• Innovator• Global Thinker • Goal Achiever• People Developer• Service Leader• Lifelong Learner

Your Opinion Counts and Communicationis EncouragedAt WellStar, your opinions count! All WellStaremployees are encouraged to share ideas, concerns andsuggestions through the following:

• Regular communication with their manager. • Employee Rounding• Department/unit meetings on an ongoing basis. • Town Hall Meetings• Nursing Shared Governance• Annual WellStar Employee Engagement Survey

Communication ToolsFor more information about employee communications, contact JanL. Taylor, Director of Internal Communications at 770-793-5185 or [email protected].

WellStar Health System is a busy, fast paced anddynamic environment. In order to understand what’shappening at WellStar and what it means for you, a variety of communication tools are used. These includethe following.

• Clinical Connection (Newsletter)• Communication Boards • Esource (Intranet)• Health and You (Community Wellness Newsletter)• Partners (Newsletter)• WellStar Learning Network Course Catalog

Resolutions of Problems and ConcernsPositive relations and morale can best be achieved and maintained in a working environment where ongoingand open communication exists among supervisors andpersonnel. This includes candid discussions of problemsand concerns. All team members have a responsibility toreport any significant actual or perceivedcommunication problem to management, HumanResources or the Compliance Hotline. In addition, allWellStar employees are encouraged and have aresponsibility to express

concerns and opinions on any issue regarding potentialviolation of laws, regulations, ethics, policies orprocedures including conduct. Initially, personnel should contact their own supervisor or human resourcesrepresentative or the compliance hotline to voice their concerns. If the concerns remain unresolved, personnelare then expected to raise the issues with individuals atthe next supervisory level, up to and including the highest level of management.

Support for Balancing Work and Life For more information about the WellStar Health System Work-Life Initiative, please contact Karen Mathews, Director ofWork-Life at 770-792-5010 or [email protected].

At WellStar Health System, we believe in helping eachand every employee balance work and life. WellStar has aWork-Life Initiative that is a system-wide collaborativeeffort between employee health, community education,organizational learning, human resources and others.The goal is to provide our WellStar family with work-lifeprograms, services and educational opportunities thatrepresent “best in class” among employers. Thefollowing model depicts our effort.


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Exceptional Contributions are Rewardedand RecognizedWellStar strives to recognize and reward employees andleaders who perform their jobs in an exceptional manner. In addition to unit, department and facilityrecognition efforts, the system-wide programs belowcreate opportunities to honor exemplary performance.

• Thank You Cards • Best of the Best• Leadership Attribute Recognition• Winners of WellStar (WOW)• Service Awards Banquet• Nursing Excellence Awards

Opportunities to Learn and Grow at WorkFor more information about learning at WellStar, please contactHelen Slaven, Chief Learning Officer at 770-956-6401 [email protected].

WellStar is committed to providing learning and careergrowth opportunities for all employees. Learning atWellStar starts with the onboarding/orientation process.The WellStar Onboarding Model is depicted below.

Required Learning and Competence Initial OrientationAll employees are oriented to the organization (NewEmployee Orientation), their facility (FacilityOrientation), their department/unit (Department/UnitOrientation), and their job (Job Specific Orientation).

Initial, Ongoing and Annual Competencies Allemployees at WellStar must demonstrate initial, ongoingand annual competencies. This is accomplished throughPatient Care Orientation and other job specific initialcompetence program, ongoing through departmentinservices and skills check-offs and annually throughGAMES (WellStar’s Annual Required EducationProgram)

Annual Required Education (GAMES)GAMES is the annual required education program ofWellStar Health System. GAMES provides remindersand refresher on key organizational information alongwith knowledge verification. All WellStar Employees arerequired to participate in GAMES.

The WellStar Learning Network(WLN)The WellStar Learning Network, thecorporate university of WellStarHealth System, assesses the learningneeds of the organization andsponsors development opportunities that meet the needs of

individuals and the organization. The WLN CourseCatalog contains a comprehensive listing of the learningopportunities offered throughout the WellStar HealthSystem. Courses are offered in a variety ofmethodologies including the following:

•Instructor-led•NetLearning (computer based learning and learning management).

•Video On-Demand (library of on demand videos)•On-site Medical Libraries.

Students and faculty are invited to register for any of theprograms which are offered on a as room allows basis.

In addition, WellStar offers tuition reimbursement,scholarships and other programs and services to assistemployees in maintaining and enhancing their competence and skill in their current role while pursuingtheir career goals. For more information about learningopportunities for you or to suggest programs, pleasecontact Organizational Learning at 770-956-6400.

SECTION TWO: PEOPLE


Safe, Ethical and in Compliance with Legaland Regulatory RequirementsSafe EnvironmentFor more information about safety at WellStar, contact, BrucePowell, Director of Safety and Regulatory Compliance at 678-331-6855.

WellStar is committed to providing a safe environmentfor all employees as well as patients, guests and others.We comply with all work and safety rules, regulationsand policies. All reasonable precautions are taken to ensure our overall safety as well as the overall safety ofpatients, visitors and other personnel. Programs andservices, like those described below help us create andsustain environment of care and safety.

Annual Health ScreeningEach year, all WellStar employees are required to complete an annual health screening. Students are required to fulfill the health requirements and documents for validating compliance are available fromyour instructor.

Smoke and Drug Free WorkplaceIn addition, we are committed to maintaining a smoke-free and drug-free environment.

Workers’ Compensation BenefitsWellStar Health System provides workers’ compensationcoverage for job related injuries/illnesses in accordancewith state law which sets forth requirements for theeligibility for benefits and the timely reporting of claims.

Remember…It is essential that every accident and/or occurrence, nomatter how small, be reported immediately to yourinstructor and/or the supervisor, who completes a greencolored report.

Report every injury immediately. Yourmanager will fill out a green coloredincident report. Follow the policy guidelinescompletely.

Ethics and Compliance Our Chief Compliance Officer, David Anderson, administersWellStar’s Compliance Program. For more information aboutEthics and Compliance at WellStar, contact John Reynolds, WellStar’s Director of Compliance at 678-331-6875.

WellStar Health System has adopted a Code of Conductthat emphasizes our values and our unwaveringcommitment to comply with all laws and regulations thatgovern our industry. These standards serve to promote aculture of ethical behaviors throughout the system andamong all staff members and affiliates. They were not developed out of concern regarding the integrity of ourstaff; instead, they serve as a reminder to each of us thatwe are an organization that values our employees, patients, providers, and the community.

We expect all our staff, contractors, and affiliates tohonor and adhere to these Standards of Conduct in addition to any departmental policies, system policymanuals or handbooks, or any Code of Ethics applicable to your licensed profession.

WellStar Health System must, at all times, comply withall laws and regulations, provide quality, cost effectivepatient care, treat our employees with respect, andprovide an environment that is free from discriminationand harassment.

If you have any questions about these Standards or anyWellStar policies or business practices, you can voicethese concerns without fear of retaliation. If yourconcern cannot be resolved through the normal chainof command, you may contact the Compliance Office atthe WellStar Administration Building or you can call theCompliance Hotline.

We each have a duty to conduct ourselves in a mannerthat reflects our commitment to maintaining the highestethical standards while accepting “nothing less thanexcellence in everything we do.” Together, we canachieve our goals through the vision we have setourselves. Doing so will undoubtedly make us theprovider of choice in all the communities we serve.

8WELLSTAR STUDENT AFFILIATIONS ORIENTATION HANDBOOK 5

SECTION TWO: PEOPLE

9WELLSTAR STUDENT AFFILIATIONS ORIENTATION HANDBOOK

Reporting Problems and Concerns: TheCompliance HotlineWellStar recognizes that there will be times whenconcerns cannot be properly addressed through thenormal chain of command. Under such circumstances,personnel are encouraged to report their concerns to theCompliance Office and/or by using the ComplianceHotline. To ensure that employees are comfortablereporting problems and concerns and that theiranonymity is protected, WellStar has contracted with anoutside entity to service its Compliance Hotline.

Our Commitment to Your RightsThe Compliance Office respects and protects the rightsof all personnel, including anyone who is the subject ofa Compliance Hotline complaint. All allegations will beappropriately investigated and verified before any actionis taken. Any disciplinary action or other response resulting from a call will be held confidential by the Hotline staff.

When to Use the Compliance HotlineThe Hotline should be used to report serious concernsabout suspected or known instances of fraud or violations of law. The Compliance Office will evaluateand respond to allegations of wrongdoing, concernsand/or inquiries made to the Compliance Hotline in animpartial manner.

More About the Compliance Hotline…Calls will not be traced or recorded and callers maychoose to remain anonymous. If callers choose toidentify themselves, their confidentiality will beprotected to the extent permitted by law.

WellStar has a non-retribution and non-retaliation policy.This means no action of retaliation or reprisal will betaken against anyone for calling the Hotline in goodfaith to make a report, complaint or inquiry. Calls to theHotline do not protect callers from appropriatedisciplinary action regarding their own performance orconduct.

Who is the Chief Compliance Officer for WellstarHealth System?

DAVID ANDERSON

WellStar’s Code of Conduct for Quality Careand ServicesWellStar is committed to quality, cost-effective patientcare. We have a duty to report any actual or perceivedquality of care issue to management, human resourcesor the Compliance Hotline.

Patient AffairsPatients and Communities ServedPatients will be provided with high quality services without discrimination due to their gender, age, disability, race, color, religion, national origin or ability topay. Patients will receive considerate and respectful carewith recognition of their dignity and right to privacy.Only personnel with proper credentials, experience, license and expertise shall be employed in meeting theneeds of our patient population.

Patient CommunicationPatients have the right to know the identity andqualifications of all personnel who provide services forthem. Patients have the right to receive informationregarding policies, procedures and charges. All questionsfrom patients will be answered promptly andcourteously, or referred to the proper source. Patientshave the right to participate in decision makingregarding their healthcare, to include refusing treatmentto the extent permitted by law and to be informed ofthe consequences of such action. Patients have the rightto voice their complaints about care and servicesprovided.

Confidentiality, Privacy and Security ofHealth Information and Medical RecordsAll WellStar personnel have a responsibility to ensure theprivacy, security and confidentiality of patient protectedhealth information at all times. It is also theresponsibility of all WellStar personnel, to read, understand and abide by WellStar Health System’s Policies and Procedures pertaining to the privacy,security and confidentiality of health system records,information and technology.

• WellStar shall maintain complete and accurate patient medical records. • WellStar shall ensure that all patient medicalrecords and related information remain strictly confidential, and disclosed for authorized purposesonly. Unauthorized access, use, release or disclosureof medical records, health system records and/or

SECTION TWO: PEOPLE

information systems is against WellStar policy andsuch violations will result in disciplinary action up to,and including termination of employment. Criminaland civil penalties may also apply particularly in vio-lations related to a patient’s protected health infor-mation.

Patient ReferralsAll agreements with an actual or potential patient referral source must be in writing and approved by management to ensure compliance with applicable laws,regulations, agreements with lenders and WellStar policies.

• WellStar shall not solicit or receive, or give or offerto give, anything of value to physicians or otherhealthcare professionals in exchange for the referralof patients or services. Kickbacks, bribes, rebates orflow of any kind of benefits intended to induce referrals are strictly prohibited. • Physicians will not refer Medicare or Medicaid patients to an entity with which the physician or animmediate family member has a financial relation-ship. (This standard, based on the Stark self-referralban, prohibits referrals related to specific designatedhealth services. For more information, contact theWellStar Director of Compliance.) • Contract payments or other benefits provided toclinicians and referral sources must be for the services and at the fair market value rates called forin the contract and must be specifically approved bymanagement. Payments must be supported byproper documentation that the services contractedfor were provided.

Employee AffairsConflicts of InterestWellStar will take all reasonable steps to avoid conflicts,or the appearance of conflicts, between the privateinterests of our personnel and the officialresponsibilities and performance of our duties. Thisincludes all situations that may create an actual conflictor the appearance of conflict, of loyalty or interest mustbe avoided. We have a duty to report any actual orperceived conflicts of interest to management, Human Resources or the Compliance Hotline. If in doubt, please consult.

GiftsWellStar prohibits the solicitation of any tips, gifts orpersonal gratuities from patients, vendors, and/or similar parties. Personnel are encouraged not to acceptgifts, favors or hospitality; however, the acceptance ofmodest gifts or entertainment of nominal value is notprohibited, but should be guided by policy. If aworkforce member is unsure about the appropriatenessof a gift, he/she should seek guidance from theirmanager, human resources or the ComplianceDepartment.

Protection of PropertyWellStar is committed to protecting the System’s assets,and the assets of others entrusted to us, includingphysical property and proprietary information, againstloss, theft or misuse. We have a duty to report any actualor perceived loss, theft or misuse of our organization’sproperty or the assets of others to management, HumanResources or the Compliance Hotline.

All students: • Have a duty to preserve our organization’s assets, property, facilities, equipment and supplies. • Have a duty to safeguard the property entrusted tous by patients, employees and visitors. • Will not disclose, misuse or take any confidentialor proprietary information or property of our organization.

Provider AffairsJoint Ventures with PhysiciansManagement must provide prior review and approval ofany joint venture, partnership or other risk-sharingarrangement with any potential or actual referral source.

Sanctioned ProvidersAs required by The Centers for Medicare and MedicaidServices (CMS), WellStar must ensure its vendors; staffand providers have not been sanctioned fromparticipating in federal health care programs.

Tax-ExemptionWellStar preserves its and its affiliate’s tax exempt statusby acting in a manner that furthers the charitable and educational mission of WellStar. WellStar’s resources areintended to benefit the community, rather than the private or personal interests of any individual withinWellStar.


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• WellStar will avoid compensation arrangements or other transactions in excess of fair market value, will accurately report payments to appropriate taxing authorities, and will file all tax and information returns in a manner consistent with applicable laws.

• Personnel or representatives of WellStar will not attempt to influence legislation that would disqualify WellStar for tax-exempt status.

• Personnel or representatives of WellStar will not participate in any political campaign for anycandidate for public office, and we will not contribute any WellStar money, property or services to any political candidate.

Compliance with Laws and RegulationsWellStar will operate in accordance with all applicablelaws and regulations in order to maintain the integrity ofour System. We have the duty to report any perceived violation of applicable laws, regulations and professionalstandards to management, Human Resources or theCompliance Hotline.

Environmental LawsWellStar shall promote sound environmental and safetypractices that will prevent damage to the environmentand enhance community resources. WellStar shall be responsible for the proper handling of medical or hazardous waste as well as radioactive materials.

Antitrust LawsThese State and Federal laws apply to virtually allindustries and are enacted to protect individuals andbusiness entities from monopolies and unfairrestrictions. In compliance with these laws, we shallavoid agreements or practices in restraint of trade suchas discussing prices with competitors, boycottingsuppliers or customers, market allocation, pricingintended to run a competitor out of business,disparaging, misrepresenting or harassing a competitor,stealing trade secrets, bribery and kickbacks.

Billing and CodingWellStar is committed to honesty, accuracy and integrityin all its billing, coding and documentation activities. Wehave a duty to report any actual or perceived false claim,misrepresentation, inaccuracy or problem in billing,coding or documentation.

• We will only submit for payment or reimbursement

claims for services actually rendered that are fully documented in patients’ medical records, using billing and classification codes that accurately describe the services provided.

• Submission of any claim for payment or reimbursement that is false, fraudulent, inaccurate or fictitious is strictly prohibited.

• All claims submitted for payment must be for services that are properly coded and supported by documentation and medical necessity requirements.

• We shall promptly refund any money received that is not due to us.

• We shall not use diagnostic information provided by a physician from earlier dates of services, unless conforming to approved standing orders.

• We shall take immediate steps to alert appropriate hospital or health system authorities if inaccuracies are discovered in claims that have been submitted for reimbursement.

Copies of the WellStar Code of Conduct are distributedduring New Employee Orientation and ComplianceTraining sessions. If you have suggestions for improvingcompliance at WellStar, please call the Compliance Office or write the Office of Compliance and InsuranceServices, Internal Mailing: WSR 11.01, WellStar HealthSystem, 531 Roselane Street, Suite, 600 Marietta, GA30060, Office Phone: 678-331-6870, Compliance Hotline: 1-888-800-5094.

Confidentiality: Privacy and Security ofHealth Information (HIPAA)All WellStar personnel have a responsibility to protectthe privacy, security and confidentiality of patient protected health information at all times. It is also theresponsibility of all WellStar personnel, to read, understand and abide by WellStar Health System’s Policies and Procedures pertaining to the privacy, security and confidentiality of health system records, information and technology. Unauthorized access,use, release or disclosure of health system recordsand/or information systems is against WellStar policy, as well as federal and state law. Such violations will result in disciplinary action up to, andincluding termination of employment. Criminal andcivil penalties may also apply particularly in violationsrelated to a patient’s protected health information.


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Guidelines for Protecting Privacy and the Securityof Health Information

• Patients should receive a copy of the Notice ofPrivacy Practices, at the first visit, or as soon as possible if it is an emergency situation. • Obtain patient’s permission before discussing patient information with the patient’s family, friends,etc who may be visiting. • Do not access any patient information regardingfamily, friends, neighbors, etc. unless you are directlyinvolved in the healthcare of that individual.• Patient information should not be used or disclosed without proper consent and/or authorization. A release form is available from Medical Records and Physician Office sites. Formore information, refer to WellStar’s SPP # IM-98or contact your supervisor for assistance. • Avoid work and patient related conversations inhallways, elevators and other public areas.Speak in low voices in private/appropriate areaswhen discussing patient protected health information. • Access and use only the information needed toperform your job responsibilities. • Use hard to guess passwords on computer devicesand applications, change them frequently and do notshare your passwords with anyone. • Ensure data on the computer screen is not visibleto others standing or sitting behind or beside you.When leaving your computer unattended, always logout or lock the computer with a screensaver password. • Do not load unauthorized/personal software onWellStar computers or connect unauthorized devicesto WellStar’s computers. • Beware of borrowed software, data, diskettes orCD’s. These may contain a computer virus designedto capture, alter or destroy data. Also be cautious ofunsolicited emails, emails with attachments or emailsthat come from outside the organization. • Dispose of confidential and/or protected healthinformation in accordance with WellStar SPP IM-65.• Do not leave printers/faxes unattended whenprinting/faxing confidential and/or protected healthinformation. • Lock up all removable media and equipment thatcontains patient medical information if left unattended. • Recognize, politely challenge and assist people whodo not belong in your area.

• Gently remind fellow students of computer etiquette and policies. • Be a good role model to fellow students concern-ing WellStar information systems usage. • Sign a new Confidentiality and Technology Acceptance agreement each year with student affiliation.• Routinely review and comply with all WellStar Privacy and Information Management Policies &Procedures located in the SPP manual.• Comply with all Federal & State Laws as well asother Regulatory and Accreditation Agency Stan-dards (i.e. JOINT COMMISSION, NCQA, CARF,CMS, DHHS, HIPAA, etc).

Suspected Violations/Incident Reporting:All suspected violations or complaints pertaining toinformation privacy, confidentiality and security shouldimmediately be reported to the WellStar PrivacyDepartment at 678-331-6880. If you wish to remainanonymous, please contact the WellStar Health SystemCompliance Hotline.

The Compliance Hotline can be reached bydialing…1-888-800-5094

Multilingual Hotline Reps are available 24 hours a day,365 days a year to take your call!

“Doing the right thing for all the right reasons.”

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Our Service ExpectationsWherever you work at WellStar, you have an important role in creating an environment that is positive, friendly andwelcoming for patients, physicians, guests, coworkers and others. Following WellStar’s Standards of Gold is part ofeveryone’s job and helps contribute to WellStar being a great place to receive care and a great place to work.

We believe in making positive first impressions our first priority.Behaviors you can practice to show this standard include…Eye Contact, Hospitality, Keep it Clean, Smile, YourProfessional Appearance, Offer to Help, Welcome, Apply the Ten-Foot Rule and Greet Everyone within 10Feet.

We believe in treating others as guests.Behaviors you can practice to show this standard include…Acts of Kindness, Be Positive, Golden Rule, Respect,Comfortable, and Timeliness.

We believe in developing service recovery.Behaviors you can practice to show this standard include…Acknowledge, Amend, Apologize, No Excuses, Empathetic,Reliable, and Be Proactive.

We believe in communicating effectively.Behaviors you can practice to show this standard include…Courteous, Body Language, Don’t Interrupt, Listen, Tone ofVoice, Be Sincere, and Identify Yourself.

We believe in serving others from a team-centered approach.Behaviors you can practice to show this standard include…Communication, Consistency, Cooperation, Share Solutions,Trust, All Accountable, and Support Others.

We believe in projecting a positive attitude.Behaviors you can practice to show this standard include…Body Language, Undivided Attention, Show Confidence andInterest, Self Responsibility, and Positive Thinking.

We believe in making excellence the goal in everything we do.Behaviors you can practice to show this standard include…Acknowledge Your Co-Workers, Listen, Think Positive, Respect People’s Differences, Pitch In, Admit Your Mistakes, Appreciate Others, and Live Up to Your End ofthe Job.


SECTION THREE: CUSTOMER SERVICE

Environment of Care and SafetyWellStar is committed to providing an environment thatis safe and focused on patient safety, evidenced-basedcare, and quality and performance improvement. TheEnvironment of Care function ensures that theorganization provides a safe, functional and effectiveenvironment for patients, staff and other individualsusing our facilities. Achieving this goal requires:1. Planning for safe and effective space, equipment andresources to support services. 2. Educating staff about their role in keeping theenvironment safe for patient care. 3. Implementing plans to manage the environment ofcare including:

• Safety • Security • Hazardous materials and wastes • Emergency preparedness • Fire safety • Medical equipment • Utility systems

4. Effectively managing the Environment of Careresults in; reducing accidents and injuries, andminimizing and controlling risks and hazards in theenvironment.

Patient Safety WellStar is a dynamic, complex system that strives toprovide safe patient care every day. We are committed tocreating a culture of safety. Patient safety is everyone’sjob and in order to continue providing safe patient carein our health system, we need to:

• Continuously learn about our system in order toimprove reliability and safety. • Investigate and understand the full story when errors occur in order to understand what’s working,what’s not working and how to make things better.

You can help WellStar’s create a culture of safety by… • Reporting all errors and potential errors (such as:patient falls, medication errors, wrongpatient/wrong site surgery) and hazardous conditions and near-misses by using the appropriatereporting forms or informing your supervisor. • Communicating with patients about unanticipated

adverse outcomes. • Including patients as active members of the careteam. • Practicing interdisciplinary teamwork.• Following processes and procedures.• Proactively preventing potential errors. • Actively participating in designing processes to en-sure safe care. • Giving suggestions to improve patient safety toyour peers and your supervisor.• Always thinking “safety first” when providing care.

The National Patient Safety Foundation definespatient safety as…

the avoidance, prevention and betterment ofadverse outcomes or injuries stemming from the

processes of health care. These events include errors,deviations and accidents.

Risk Management & Incident ReportingWhat is an Incident?“An incident is any event which is not consistentwith the routine operation of the system or theroutine care of a particular patient.” WellStar Health System’s SPP # EC-65Recognizing and reporting incidents is important for allWellStar Employees. In addition to being a regulatoryrequirement, this is one of the ways we continue toimprove and make the environment safe for patients,guests, physicians and employees.

Filling out incident reports EVERY TIME is critical.Two different forms are used. It’s important to select theright form.

Green Colored Incident Report Injury of employee/volunteer or employed physicianmay include but are not limited to:

• Exposure to blood or body fluids.• Exposure to hazardous chemical or substance.• Employee, volunteer or employed physician fall orinjury


SECTION FOUR: QUALITY & PATIENT SAFETY


CONTINUE YOUR COMMITMENT TO “SAFETY FIRST” BY LEARNING AND

FOLLOWING THE 2008 NATIONAL PATIENT SAFETY GOALS!


Orange Colored Incident Report Incidents involving patients, visitors, physicians oremployees (non-injury) may include, but are not limitedto:

• Medication and/or intravenous variances • Adverse drug reactions• Procedure, treatment or test issues• Consent issues• Leaving against medical advice issues • Equipment and/or implant issues • Patient care management issues • Medical management issues • Falls• Security issues• Missing or damaged property• Patient and/or family grievances • Disruptive physicians, employees, patients and/orvisitors • Any other adverse incidents which cause or havethe potential to cause injury.

The report should be completed immediately after theincident occurs by the person with knowledge of theincident. When this is not possible, it must be completedby the end of that person’s shift.

All information reported should be as factual and non-judgmental as possible. Risk Management should receivethe signed and completed report within 48 hours afterthe incident occurred.

Incident report forms are located in your unit ordepartment. For emergencies, a risk manager is oncall 24-hours, 7-days a week at 404-837-6170.

For further information or questions regarding riskmanagement call 678-331-6860.OAL REQUIREMENTSElectrical Safety Keeping yourself and others safe, while using electricaldevices, is important to having a safe environment. Thetips that follow can help you and others stay safe.

Using Cord and Plugs SafelyDO

• Keep cords away from heat and water• Pull on the plug, not the cord, when removing apluf from an outlet

DON’T• Run cords under rugs or through doorways, win-dows or holes in walls.• Use cords with insulation that is cracked, torn orrubbed off.• Use any cord or plug that appears broken or loose.• Use so-called “octopus” adapters.

Using Electrical Devices SafelyDO

• Get safety instructions before using electricalpower equipment, especially cleaning equipment thatwill be used with water• Make sure you, your clothes, your tools and yoursurroundings are dry.• Disconnect electrical equipment from the powersource before cleaning.• Be aware of tages indicating repairs are being madeon any machinery.• Report all shocks immediately - even small tingles.• Use pliers, screwdrivers and stripping tools with in-sulated handles.

DON’T• Use any electrical equipment or wall receptacle thatappears to be damaged or in poor repair.• Use any device that trips a circuit breaker or gives ashock. Have it inspected and reparied.



Overhead Announcement

Condition Initiate By Procedures Found

Plan F Fire Pull alarm and dial apporpriatenumber for facility and reportlocation.

Safety/Emergency PreparednessManual, Fire Plan Tab

Plan DELTA Disaster Initiated by Administration or HouseSupervisor.

Safety/Emergency PreparednessManual, Diaster Tab

Plan GREEN Bomb Threat Remain on phone line and get asmuch information as possible.

Safety/Emergency PreparednessManual, Bomb Plan Tab

CODE (location) Cardiac/Pulmonary

Dial appropriate number for facilityand report location.

Only CODE Team responds

Plan Weather Alert Tornado Warning Initiated by Administration or HouseSupervisor.

Safety/Emergency PreparednessManual, Tornado Tab

Plan Stork Infant Abduction Notify Nurse Manager or HouseCoordinator.

SPP#-ED 75

Plan ORANGE Hazardous MaterialsDecontamination

Notify PBX and Follow ProtocolSteps

Safety/Emergency PreparednessManual, RIN Tab

Emergency Codes and ResponsesWellStar Health System takes every precaution to ensure safety. Our planning process considers and plans for alltypes of potential catastrophes, both naturally occurring and manmade. This encompasses different types ofemergencies that could compromise the safety of patients, visitors and staff, and place an undue burden on thefacility’s ability to provide care. The following summarizes the most important codes along with the initial responseto take in the event they occur.

Hazardous Materials Decontamination (Plan ORANGE)The Hazardous Materials Decontamination Procedureensures that we take action and apply appropriatedecontamination techniques and processes during eventsinvolving suspected or confirmed hazardous materialscontamination. Notification of a hazardous event comesfrom EMS personnel, the on-scene commander at theevent, or when a patient arrives by private automobilefrom a probable event. All reports for an unknownsource are confirmed with the local fire departmentprior to activation of the Decon Team. When the event is confirmed, the Decon Team isactivated by overhead announcement (Plan Orange).Equipment is prepared at the designated Decon Station. The nature of the event, prior decontamination, andmethod of arrival determine patient management.

General Guidelines for Initial Response to Patients withProbable Contamination:

• Do not touch the patient until appropriate PPEs are in place.

• Do not stand down wind of the patient without appropriate PPEs.

• Limit patient care to Basic Life Support (BLS) even when the caregiver is appropriately protected by PPEs.

• Obtain as much information as possible about the event, i.e., substance, number of victims, symptoms, etc.

For more information about HazardousMaterials Decontamination (Code Orange),consult the Safety/Emergency PreparednessManual.

Recognition, Isolation and Notification (RIN)The RIN procedure guidelines assist WellStar employeeswhen they encounter a victim of suspected hazardousmaterials contamination. Staff members at WellStarmust anticipate the unexpected arrival of an individualor many individuals who may have been exposed to orare contaminated with a hazardous material or biologicalsubstance. When this occurs, it is important that we notbecome another “victim” by responding inappropriatelyto this situation. Our main focus should be to:

• Protect the facility from contamination• Protect ourselves and other staff from contamination



• Protect patients and visitors that are already in ourfacility• Render aid to the victim(s) of the contamination

Following the RIN Protocol provides you with thetools necessary to respond to situations of suspectedHazMat contamination:

1. Recognition of contamination through verbal,sensory and visual means.

2. Isolation of the contaminated individual(s).

3. Notification of Emergency Services, Security, theFacility Safety Officer or after hour’s on-call along withthe Administrator and/or House Supervisor.

For more information about RIN, consult the Safety/EmergencyPreparedness Manual.

Bomb Threat (Plan GREEN)In the event of a bomb threat, publicity must beminimal and search must be maximal. Personnel shouldremain in their work areas and function as search teams.Patients will not be moved unless approved by theHospital Administrator or designated alternate. TheControl Center will be established according to HICSprotocols. In most cases, the PBX Operator would mostlikely receive the threat, but if the threat is received byanother person, he/she will contact Security Servicesimmediately. Security Services will initiate the program.For more information about responding to bombthreats, consult your department/unit safety manual formore information.

Severe Weather/Tornado It is the intention of WellStar Health System to providefacilities that are safe from the dangers of tornadoes andsevere weather. The following describes WellStar’sSevere Weather/Tornado Plan.

Components of Severe Weather Plan Severe Thunderstorm Warning: Issued by the NationalWeather Service in Peachtree City when the followingcriteria have been met.

•Sustained wind speed 50 knots (58 mph) and hail3/4” in diameter or greater severe thunderstormsmove across a region with relative speed and pro-duce strong winds and dangerous lightening.

•Under the right conditions, these storms are con-ducive to the formation of tornadoes.• Dispatch/Communication Centers in WellStar fa-cilities monitor local broadcasts of the NationalWeather Service until the Severe ThunderstormWarning has expired. • Changes are communicated to the security man-ager/supervisor on duty.

Tornado Watch: Issued when conditions are favorablefor the development of tornadoes. Tornado Watches areusually issued for large regions and can last for severalhours.

• Upon issuance of a Tornado Watch by the Na-tional Weather Service that includes regions involv-ing WellStar facilities, the following actions will beimplemented:- All staff will remain vigilant to changingweather conditions and the dispatch/communicationcenter will monitor broadcasts of the NationalWeather Service or other media centers until theWatch is lifted.

Tornado Warning: Issued when an actual funnel cloudor tornado has been sighted or upon notification fromthe National Weather Service or County EmergencyManagement Agency. Today’s technology provides moreaccurate storm tracking and can identify embeddedtornadoes by use of Doppler Radar. Upon issuance of aTornado Warning that includes geographical regionsinvolving WellStar facilities, the following actions will beimplemented:

•Announcement: Security Services, Administrationor House Supervisor will contact PBX operatorand have the alert paged on the public address system.• Announcement shall be “Plan Weather AlertNow in Effect” at 30 second intervals and at a min-imum of three times each interval. • Dispatch/Communication center will continue tomonitor weather broadcasts of storm’s progress.

Staff Actions Patient Service Areas:

• Non-ambulatory patients are moved away fromwindows, covered with thick blankets/pillows, havewindow blinds and curtains drawn and privacy curtain pulled around their bed. • Close door to patient room upon exiting. Ambula-tory patients, visitors and staff should move to an



interior public corridor away from exteriorwindows, walls and doors.

• Off-site departments should move to the central most point of their facility, away from exterior windows, walls and doors. Seek shelter behind or beneath heavy furniture.

General Self Protection:• Remain calm. • Crouch on floor facing an interior wall away from windows. Cover head with arms and if time permits cover self with coats, blankets or other suitable articles.

All Clear will be announced only when the NationalWeather Service or County Emergency ManagementAgency issues the all clear for your region. At this timeupon notification of Security Services or administrativerepresentative, the PBX operator will page “PlanWeather Alert-All Clear.”

For More Information on Environment of Careand Safety Policies and Procedures check out thefollowing:

Safety Manual• Bomb threat procedures (Plan Green)• Disaster response (Plan Delta) • Hospital Incident Command System (HICS)• Emergency decontamination operations (Plan Orange) • Recognition, Isolation and Notification (RIN) (SRCM-20). Please refer to Safety Manual for detailed information on this protocol

• Evacuation plans • Fire safety plan (Plan F) • Severe weather response (Plan Weather Alert) • Utility failures

Standard Policy & Procedures ManualEC 05- Latex Allergy/Sensitivity EC 10- Smoking Policy EC 15- Reporting Medical Device/Product

Failure/RecallsEC 20- Radiation Protection and Badge Monitoring EC 21- Employee Pregnancy Declaration and

Radiation Safety EC 22 - Consent for X-Ray & Nuclear Medicine

Studies (Patient Statement of Pregnancy/Nursing Condition)

EC 23 - Fluoroscopic Radiation Dose Reduction EC 25 - Compliance Plan for Those Protected by

the Americans with Disabilities Act (ADA)EC 30 - Biomedical Waste Handling EC 35 - Use of System Vehicles EC 45 - External Signage and Traffic Control

Marking EC 50 - Interior Signage EC 60 - Sentinel EventsEC 65 - Incident Reporting EC 75 - Infant or Child Abduction Policy EC - 90 Clinical Alarm Testing, Training and Use EC - 95 Warming Cabinets EC - 96 Use of Fans in Clinical Areas

Fire Safety and Prevention According to the National Fire Protection Association,more than 8,000 fires occur in hospitals each year. Firespreads fast and can fill a room in as little as 3 minutes.Smoke rises forming a dense cloud that slowly descends.Smoke inhalation is a major cause of deaths from fire.Flashover occurs when the air is so hot that it ignitesevery combustible object in the room. Intense heat cansear lungs and fuse clothing to the skin. Not surprisingly,research shows that deaths and injuries are dramaticallyreduced when people are educated and trained on howto prevent and respond to fires.

Report all fire and safety hazards. Following the basicprecautions and steps below can save the lives ofpatients, coworkers and visitors.

Always Remember to…•Read the fire prevention plan for your facility (found in the Safety Manual).

•Know your facility’s emergency notification number to report a fire. REMEMBER: This number will differ from facility to facility.

•Know your evacuation plan to an area of refuge and out of the facility.

•Know the location of and how to operate alarm pull stations and fire extinguisher.

•Know the location of oxygen shut off valves and how to operate them.

•All staff are authorized to shut off oxygen valves during fire once all appropriate patients have been placed on portable oxygen supply.



Following the RACE procedure when a fireis involved can save lives. Take time toreview and remember RACE.

Remove all personsYour priority is to remove patients from immediatedanger. If you smell smoke from behind a closed door,be careful to first touch the door with the back of yourhand before opening. If the door is too hot to touch, donot open it. If you can touch the door, open it slowly,crouch low to the ground and approach the patient.

AlarmThere are two ways to call for help: activate the fire pullstations and dial your facilities emergency notificationnumber. When you dial the number you will reach thePBX operator. Let the operator know the type ofemergency (Plan F in this case) and where it is located.The red fire pull stations are located by exits, so that onyour way to an exit you can sound the alarm.

Contain Always close doors once you make sure the room isempty. They can help to contain a fire for up to twohours. In many WellStar facilities fire doors are designedto close automatically in the event of a fire. Don’t blockthem in any way at any time.

Extinguish or EvacuateIf a patient is on fire, wrap a blanket around him/her tosmother the fire. A fire in the trash can be smotheredwith a towel or rag. For small fires, use an extinguisher.Know the location of the fire extinguisher cabinetclosest to your work site.

Fire Extinguishers and the Types of Fires

Class A: Ordinary combustibles (paper, cloth, wood) Class B: Flammable liquids/gases (alcohol, grease, oil) Class C: Electrical components (computers, toasterovens) Class K: Kitchen fire (If you are a food serviceemployee, know the special operating features of thisextinguishing system.)

The RED ABC extinguishers will provide appropriateextinguishing media for all classes of fires listed above.

Use PASS to help you remember how to use a fireextinguisher, in the event of a small fire.Pull the pin between the handles.

Aim at the base of the fire. Squeeze the handles together.Sweep from side to side.

SmokingSmoking is prohibited inside all WellStar buildings.Visitors and staff who choose to smoke shall utilizedesignated outdoor smoking areas. (Refer to SPP # EC-10)

MRI SafetyFor more information about MRI safety, contact Shiloh Howell,PI manager at 678-581-5865 or [email protected] orthe site department manager.

MRI is a service offered in the Medical ImagingDepartment. There are many safety precautions thatneed to be followed by staff when in this area due to themagnet’s extremely strong force. The magnet is alwayson, no exceptions!

• Only MRI compatible metal items are allowed into the room. Un-approved metal items taken into the room can pose a safety hazard to patients and staff, causing injury and sometimes death.

• No patients or staff are to enter the room until they have been screened and approved by MRI per sonnel. This screening must take place prior to each entry. Please ask before entering and do not take any object into the room unless it has been cleared by the MRI personnel.

Personal ErgonomicsErgonomics is a science that studies work and homeenvironments to prevent all types of muscle and skeletalpain and disabilities. The following tips can help youwork safely and prevent injuries.

Lifting and Carrying• Assess the need for help from others to lift/carry • Get a firm footing• Stand close to the load; bend from the knees keeping back straight

• Get a firm grip of the load then lift with your legs • While carrying the load hold it close to your body to avoid strain to your back

• Slowly lower the load while bending with your knees



Reaching• Do not stretch for an object, use a stool or ladder. • Let your arms and legs do the work, not your back.

Sitting• Do not slouch. Sit firmly against the back of your chair.

• Avoid leaning forward and arching your back. • Arrange your desk area in a way to reduce reaching and twisting.

• Adjust your chair height so your feet are flat on the floor or on a stable footrest.

• Maintain ninety-degree angle or more between upper and lower legs.

• Maintain adequate back support when seated.

Tips for Computer Users• Relax arms and shoulders- sit at least an arms length away from the computer screen.

• Elbows to fingers should be in a straight line with your wrists in a neutral position.

• Avoid pounding the computer keys with excessive force.

• Rest your wrists on pads to reduce pressure.• Take breaks from constant typing.

Arranging Computer Equipment• Keep top of monitor at seated eye level.• Keep documents at eye level and near the monitor.• Keep keyboard at elbow height.• Arrange equipment appropriately. • Reduce glare on monitor. • Clean monitor screen often. • Take visual breaks and rest your eyes. • Have regular eye exams and use corrective lenses, if prescribed.

• Maintain appropriate distance from monitor. • Arrange keyboard and monitor in a straight line to avoid twisting of body to type and view monitor/screen.

Moving Patients Safely• Ask for assistance when moving patients.• Whenever moving a patient or object, always push rather than pull to avoid back injuries.

• Adjust bed to the proper height when turning patients or pulling them up in bed.

• Use your legs and not your back to avoid injury.

Latex Allergy (SPP #EC-05)

Due to continued prolonged exposure to the proteinsfound in natural rubber, the body’s immune systemidentifies the protein as a foreign invader and reacts to it.

Signs and Symptoms include: Burning eyes;Sneezing/nasal irritation; mild hand rash/irritation; andgeneralized itching.

Worsening Symptoms can include:Hives; wheezing, bronchial asthma; increased skinrashes/blisters/swelling; and tachycardia.

If you have these symptoms, fill out a green incidentreport and follow up with Employee Health forevaluation.

“Latex Free” carts are available at eachWellStar facility for latex sensitive patients.Questions or concerns? Contact Employee Health.

Oxygen Tanks: Safe Handling and StorageWe frequently see and handle oxygen tanks, but howoften have you thought about their potential danger?These tanks can cause great harm, explode, and evencause death if they are not handled or stored properly.

Handling:• Even though many oxygen tanks are green, always read the label. Never depend on color alone to identify agas.

• Never drag, drop or bang tanks against each other because doing so may cause sparks, fire, and/or ex plosion.

• Do not carry tanks by the valve cap. Do not carry tanks on your shoulders or head.

• Transport tanks in the brackets or carts made for this purpose.

Storage:• Tanks must be stored in secured carts or in divided storage containers.

• Tanks must never be stored near heat sources such as boilers, furnaces, or steam pipes or in the sun because heat can raise the internal pressure of a tank.

• Never let oil, grease, or fuel of any type come in contact with cylinder valves or regulators because

of the fire hazard.• Each tank should have a cap over the valve when it



is in use.• Tank valves should be turned off (closed position)when not in use, even if the tank is believed to beempty.• Notify the Respiratory Department if you see anytanks or regulators that are damaged or empty.• Tanks should be replaced when the contents readbelow 500 psi. • Any individual at a fire scene can be assigned tothe oxygen shut-off valve, should the valve need tobe cut off. This is coordinated with getting portableoxygen supply to the identified patients in the af-fected area.

Radiation SafetyFor more information about radiation safety, contact ShilohHowell, PI manager at 678-581-5865 [email protected].

Radioactive materials are primarily used and stored inthe Nuclear Medicine, PET and Radiation Oncology.Radioactive materials are to be kept locked or stored insupervised areas. If your duties require you to work inthe areas above, check with department personnelbefore entering the area. X-ray machines, such as thoseused to take chest X-rays and CT scans, are also a sourceof radiation exposure, but only when the machines areactually taking a picture. Even then, only a small amountof radiation scatters away from the patient. Also, thepatient does not become “radioactive” from this type ofX-ray.

Below are some simple guidelines that will help youavoid or minimize radiation exposure.

• If you must be in the room during a patient expo-sure, follow these three principles to reduce your ex-posure—time, distance and shielding (barrierprotection). Minimize the amount of time youspend in the area and whenever possible, increasethe distance (6-feet) from the source of radiation.

Right to Know: Hazard CommunicationStandard (MSDS)The Occupational Safety and Health Administration(OSHA) has developed legislation on an employer’sobligation to report on and distribute information toemployees regarding the use of hazardous substances inthe workplace. Information is available to all WellStarHealth System personnel regarding Hazardous Material

Handling through: • A written program in the safety manual • Material Safety Data Sheets (MSDS) • Container labeling• Education and training

ChemicalsHundreds of different chemicals are used daily inhealthcare settings. Every chemical has its own uniqueproperties. Here are tips for being safe with chemicals.

• Always be careful with any chemicals used in yourwork area. • If you have a question or a problem with anychemical, the information you need is available onthe Material Safety Data Sheet (MSDS) for that par-ticular product. • A comprehensive list of all hazardous materialsfound throughout the facilities in the office of theFacility Safety Officer. • Each department has access to a copy of the writ-ten program, an inventory unique to that depart-ment, and corresponding MSDS’s for each substancelisted on the inventory sheet.

What does a Materials Safety Data Sheet(MSDS) tell you?1. About the chemical product and companyidentification2. Hazardous ingredients including mixtures andpercentages of each chemical in the finishedproduct. 3. Hazard identification - key hazards to beaware of while working with the product. 4. First Aid measures if an exposure occurs.5. Safe handling and storage.6. Exposure controls and personal protection.7. Spill recovery and disposal considerations.

Where can you find a MSDS?On eSource by clicking theMSDSONLINE.com link.

Utility SystemsUsers must have a basic knowledge of operation for allutility systems in their work areas. Utility systemsinclude:




• Electrical (normal and emergency power) • Elevators • Heating, ventilation/air conditioning • Medical air, medical gas and vacuum • Telecommunication and data systems • Water

Emergency Power Emergency power is available throughout the hospitalsin the event of commercial power interruption. A red receptacle and/or light switch indicate emergencypower is available at that location. Critical patient careequipment should always be plugged into the red outlets. Details on emergency power for your location can beobtained from the Facilities Engineering Department.

Workplace ViolenceThe Facts about Violence Violence is the use of force or the threat of force tocause harm. Violence occurs when a patient, visitor oremployee demonstrates aggressive behavior that causesone to reasonably believe that he/she or another personis in immediate danger of serious bodily harm. Violenceincludes:

• Threats (verbal or written).• Stalking.• Bullying. • Robbery.• Hitting (slapping, kicking).• Using weapons, including fists.

Why do people commit violence?There isn’t one single cause. For example, violence maybe triggered by:

• Stress and frustration.• Revenge for being fired, laid-off, etc. • Family, domestic or money problems.• Fear or confusion.• Drug/alcohol reaction.• Invasion of privacy or personal space.

Basic rules for violence prevention• Spot trouble before it starts by being aware of your surroundings.

• Follow procedures and report every incident. • Trust your feelings.

Infection PreventionFor more information about infection prevention, contact LynnSharrer, Director of Infection Prevention at 770-956-6429 [email protected].

REMEMBER! When I have an exposure…contact EmployeeHealth. When I have questions about a patient’s infection or howto protect myself from infection…contact Infection PreventionInfection Prevention reduces the risk of acquiring andtransmitting (spreading) infections among patients,employees, medical staff, visitors and volunteers in thehealthcare setting.

The OSHA Bloodborne Pathogens StandardOSHA, the Occupational Safety and HealthAdministration, requires all health care institutions tohave a plan to prevent transmission of blood bornepathogens such as HIV, HBV and HCV. This plan iscalled the “Exposure Control Plan.” It describes job-specific procedures and policies to prevent exposure tothese illnesses. All employees with patient contact arerequired to review it annually and pay special attentionto any changes that may have occurred.

The Exposure Control Plan can be found inthe Infection Prevention Manual or SPPManual and on Esource.

Purpose and IntentAs with all OSHA regulations, the BloodbornePathogens Standard is intended to “protect employees”from potential workplace hazards. In this case, the intentis to: “Reduce occupational exposure to Hepatitis BVirus (HBV), Human Immunodeficiency Virus (HIV),Hepatitis (HCV) and other Bloodborne Pathogens.”

Bloodborne PathogensThey are viruses, bacteria and other microorganisms thatare carried in a person’s bloodstream and cause disease.If a person comes in contact with blood infected with abloodborne pathogen, he or she may become infected aswell.

Other body fluids may also spread bloodbornepathogens. These include: semen, vaginal secretions,fluid in the uterus of a pregnant woman, fluidssurrounding the brain, spine, heart and joints, fluids inchest and abdomen, other fluids containing visibleblood.


The three Bloodborne Pathogens of most concern tohealthcare workers are:

1. Hepatitis B Virus (HBV) which attacks the liverand can cause the following; Active Hepatitis B: flu-like illness that can last for months, a chronic carrierstate: the person may have no symptoms, but canpass HBV to others, Cirrhosis, liver cancer anddeath. Fortunately, specific vaccines are available toprevent HBV infection.2. Hepatitis C Virus (HCV) which also attaches tothe liver. HCV produces an illness that is usuallymilder than HBV initially, but persistent illness maylead to chronic liver disease and liver cancer morecommonly than HBV. Illness from HCV may notappear until years following infection with the virus.3. Human Immunodeficiency Virus (HIV) whichcauses AIDS. HIV attacks the immune system, mak-ing the body less able to fight off infections. Todate, there is not a HIV vaccine.

HBV, HCV and HIV can be spread when infected fluidsenter the body through:

• Needlestick injuries• Cuts, scrapes and other breaks in the skin• Splashes into the mouth, nose or eyes• Oral, vaginal or anal sex• Sharing infected drug needles•Infected pregnant women can pass the infection totheir babies.

There are other diseases caused by bloodbornepathogens, such as syphilis, malaria, arboviral infectionsand others listed in the policy. However you greatestrisks are from HBV, HCV and HIV.

How Infections are Spread1. A Source of an infection - Persons or things thathouse or carry the germ. This can be an employee, avolunteer, a physician, a student, a visitor, anotherpatient, an object or even the patient. The person whocatches or acquires an infection or organism that isspread from the source is known as the “host”.

2. A Mode or Means of spreading the infection:a. Contact -This can be direct contact, whichinvolves skin-to-skin contact between twopersons; or indirect contact, which involvescontact with another object, such as a dirtyinstrument or needle. b. Droplets- created when a person with the

germ coughs or sneezes and the germ ispropelled a short distance to the eyes, nose ormouth of another person. c. Airborne - Very small “droplet nuclei” or dustparticles with the germ are propelled into the airand then spread through the air long distancesand can be inhaled by another person in thesame room or even another area into which theair has moved. d. Common Vehicle - Germs spread throughcontaminated food, water, medications, devicesor equipment. e. Vector-borne - Germs spread through smallliving things like mosquitoes, flies, rats and othervermin.

3. Host – Person who catches or acquires an infectionor organism that is spread from the source.

How to Prevent the Spread of InfectionPractice Standard Precautions Along with hand hygiene, standard precautions are usedto reduce risk of spreading microorganisms (germs)from both known and unknown sources of infectionsfor all patients. These precautions are used for care ofall patients regardless of status, diagnosis, or disease.They apply to blood, all body fluids, secretions,excretions (regardless of whether blood is present ornot), non-intact skin, and mucous membranes (as inmouth, nose, eyes).

Hand Hygiene…The Best Way to Preventthe Spread of Infections!

Decontaminate YOUR HANDS! • Before and after your work shift. • Before and after patient care. • Before and after personal hygiene. •Before touching something clean. • After touching something contaminated or dirty. • After removing gloves.

How to Wash Your Hands1. Wet hands with running water. 2. Apply soap or hand washing agent. 3. Vigorously rub hands together for 10-15 seconds,washing all surfaces of hands, fingers, and wrists. 4. Rinse thoroughly with fingers pointing down. 5. Blot hands dry with paper towel. 6. Before discarding paper towel, use paper towel to



turn off faucets. 7. Dispose of towel in proper waste receptacle.

How to Use Alcohol-Based Hand Sanitizers1. Apply small amount into palm of hand (thumb

nail size) 2. Rub into all surfaces of hands until solution has

evaporated or hands are dry. 3. DO NOT USE if hands are visibly soiled.

Use Appropriate Personal Protective Equipment toStay SAFE!

Personal Protective Equipment includes gloves,gowns, masks and eye protection.

• Gloves are worn when touching blood, body flu-ids, secretions, excretions, non-intact skin and mu-cous membranes. Remove gloves and wash handspromptly after use. Put on clean gloves when touch-ing mucous membranes or non-intact skin. Glovesare changed and hands washed between patients andbefore touching clean items or the environment. Ifemployee is allergic to standard gloves, the employeewill be provided appropriate alternate gloves. • Gowns are worn when you think your clothingcould become soiled with blood, body fluids, secre-tions or excretions. Remember to wash hands afterremoving gown. • Masks are worn and Protective Eyewear (gog-gles/face shields) to protect eyes, nose and/ormouth from splashes or sprays of blood, body flu-ids, secretions or excretions. Do not touch front ofmask once applied.

Always remove personal protective equipmentimmediately after use, avoid contaminating hands,discard in appropriate container and wash hands.

Handling of Patient Care Equipment• Handle soiled patient care equipment in a mannerto prevent contact with your skin or mucous mem-branes. • Reusable patient equipment must be cleaned anddisinfected prior to use by another patient. • Cleaning and disinfection is a two step-processCLEAN the equipment with the disinfectant to re-move soil/dirt. DISINFECT the equipment by reap-plying the disinfectant and leaving the equipmentshiny wet.

• For contact time, follow the recommendations ofthe manufacturer.• Dispose of needles and other sharps immediatelyafter use in appropriate sharps disposal container.

Handling Linen and LaundryHandle and transport soiled linen in a manner toprevent contamination of your clothing and/or skin.Handle and transport clean linen in a manner to preventcontamination with dust, moisture or microorganisms.

Respiratory Etiquette• Provide surgical masks to patients with respiratoryillness symptoms, or tissues if patient unable to wearmask. • Instruct patient on use and disposal. Encouragepatients to use hand hygiene materials in waitingareas. • Move patients with respiratory symptoms out ofwaiting areas as soon as possible. Healthcare workersshould wear masks when within 3-5 feet of a patientwith respiratory symptoms. • Use Droplet Precautions for patients with respira-tory symptoms until cause is determined not to beinfectious.

Transmission Based Precautions• Used for patient suspected to be infected withhighly contagious germs/infections• Types of precautions Airborne, Special Airborne,Contact, Special Contact, and Droplet. • Signs are posted on door of room for patient re-quiring any of these precautions• For more information or a listing of diseases, referto SPP # IC- 03 located on Esource.

Biomedical WasteThe biohazardous sign identifies containers which haveitems soiled with blood or other infectious materials.Use solidifier for body fluids whenever possible.

Dispose of items such as the following in the “redbags”:

• Blood transfusion bag and tubing with spike • Sealed containers with pooled blood or body fluids(as hemovacs)• Dressings saturated (dripping) with blood or bodyfluids • Saturated, grossly contaminated disposable equip-ment



Dispose of items such as the following in the “sharpscontainers”:

• Disposable needles, • Syringes • Scalpels, blades or razor blades • Staples, wires • Lancets, pipettes• When sharps containers are 3/4 full, securely closethe container and insure removal/disposal as per fa-cility procedure

Dispose of items such as the following in the regulartrash:

• Paper, paper towels, wrappers, newspaper, etc. • Dressings with small amounts of blood, body flu-ids, emptied foley bags, used Band-Aids

Clean Up Of Blood SpillsSpills of blood or body fluid should be cleaned uppromptly. The process includes immediately cleaning upthe spill and then using a disinfectant. If using a spill kit,follow kit instructions.

• Put on disposable gloves and wear other personalprotective equipment (gowns, masks, faceshields/goggles) if needed.• Remove visible material by placing paper towels orother absorbent materials directly over the spill. Waituntil all the liquid is absorbed. Use more papertowels if needed.• Carefully remove paper towels or other absorbentmaterials and place in red bag. • Linen/cloth items are to be placed in appropriatelinen containers not red bags. • Clean the area with appropriate cleaner. • Disinfect using hospital approved germicide forblood/body fluid spills. • Remove gloves and dispose of appropriately. • Wash hands.

TB Control Plan – IC 25Protect Yourself and Others from TBTB can be spread from one person to another throughthe air. The mycobacterium (germ) is expelled into theair when a person coughs, sneezes or even with talking.Air currents can carry it. It enters the body through thelungs. Early identification and treatment of persons withTB is essential (this includes evaluation of signs-symptoms, diagnostic testing and initiation ofappropriate timely treatment). The signs and symptomsof active TB include fever, coughing up blood, weight

loss, night sweats, loss of appetite and fatigue.Diagnostic testing includes the PPD (TB) skin test, chestx-ray, AFB smear and culture.

Isolation of Hospitalized Patients Using SpecialAirborne Precautions

• Patients are placed in airborne infection isolation(negative pressure) rooms. • Doors should remain closed. • Patients should be instructed to cover nose andmouth when coughing and sneezing. • Employees entering these rooms must wear the N-95 respirator for which the employee has been fittested. Remember - If you have not been N-95 mask fittested then you cannot enter the room of a patient with TB.

Screening of Healthcare Workers • TST (tuberculin skin testing) skin testing of newemployees using the two-step method.• Annual TST of employees working in facilitiesclassified as medium risk of TB transmission.• TST positive employees must complete TB symp-tom questionnaire annually.• Follow up of employees potentially exposed to aperson with TB• Medical management of employees with active TB• NOTE: A positive TST skin test does not mean you willinfect someone else. It does mean that you have been exposedto TB and the TB germ has entered your body. It also meansyou should be evaluated for treatment. You can only infect oth-ers if you have symptoms of TB.

TB and HIVThere is a connection between TB and HIV/AIDS. Therisk of developing TB after exposure is much greater ina person who is also infected with HIV. Additionally, thesymptoms of TB may not be as apparent and the TSTmight not react the same. Treatment for TB in patientswith HIV will be longer. Antibiotic resistant TB hasdeveloped because some people have not complied withthe TB drug therapy. The TB germs are not killed andthese germs can change in such a way as to allow thegerm to survive the standard TB drugs.

If you are exposed to TBIf you are in healthcare long enough, you may beexposed to a patient or person with TB. Here is how theprocess works.

• Infection Prevention receives verification that a pa-tient has TB and determines if isolation was insti-



tuted and maintained. • A list is compiled of departments with employeespotentially exposed and a memo is sent to the man-agers of these departments/areas and EmployeeHealth.• The manager reviews the medical record to deter-mine which employees have been exposed, sends alist to Employee Health and also notifies all exposedemployees to see Employee Health. • Employee Health sets up dates for both baselineTB testing and 8-10 weeks post exposure testing. • POST EXPOSURE TB TESTING IS MANDA-TORY • Delay in notification of our employees occurs dueto the slow growth of the TB germ.• After the 8-10 week follow-up dates have passed alist of employees failing to comply is sent to the de-partment manager and to Human Resources. Employ-ees can be kept from working for failure to complete TBexposure follow-up.• If an employee tests positive (has a conversionfrom a negative TB skin test to a positive TB skintest), all employees that were initially exposed will berequired to have additional skin testing performed in8-10 weeks. • If an employee cannot have the TB skin test dueto allergy or previously testing positive, symptomsfor TB will be reviewed at baseline and again at 8-10weeks. If TB symptoms are present, the employee issent for a chest x-ray.

What Should Be Reported To InfectionPrevention and/or Employee Health? Any concerns regarding placement, removal orappropriateness of isolation for any patient. Any exposure to a COMMUNICABLE DISEASE thatcould be spread to fellow employees or patients. Anytime a healthcare worker has a fever, diarrhea,draining wound or any signs or symptoms of a possibleinfectious disease.Any needle/sharp injury or splash of blood/body fluidto eyes, nose, or mouth.

Detailed Information is located in yourInfection Prevention Manual. This manual

is located on the Wellstar eSsource site.

Patient NeedsPatient Rights and Organizational EthicsThe daily mission of WellStar Health System, its medicalstaff, employees & volunteers is to assure that patientrights are preserved for each of our patients.Information regarding patient rights and responsibilitiescan be found posted throughout all WellStar facilities. Inaddition, a list of patient rights and responsibilities canbe found in the information booklet in every inpatientroom. They are summarized below.

SUMMARY OF PATIENT RIGHTS AND

RESPONSIBILITIES AT WELLSTAR

FOR MORE INFORMATION, READ SPP #RI-02.

PATIENT RIGHTS

Quality Clinical Care• Treatment decisions are made based on healthcareneeds. • Clinical decisions are made independently of howthe staff is compensated for their services.

Access to Care• Impartial access to treatment or accommodationsthat are available or medically indicated regardless ofcolor, age, disability, race, creed, sex and national origin.

Respect and Dignity• Considerate, respectful care at all times and underall circumstances, including reasonable attempts torespect spiritual, religious or cultural beliefs andpractices and to make efforts to accommodatewhenever possible.

Privacy and Confidentiality • Be interviewed, examined and treated in surround-ings designed to provide reasonable privacy. • Have your medical record read only by those directly involved in your treatment, payment orhealthcare operations. • Review your medical record and to have informa-tion explained, except when restricted by law.• Request a transfer to another room if you feel apatient or visitor is compromising your right toprivacy and/or confidentiality.



Participate in Treatment Decisions• Be informed and to participate in decisions concerning your care. • Be given a clear and understandable explanation ofprocedures including the reason why a procedure isneeded, the risks and benefits, probability of suc-cess, and possible alternatives. • Complete an advance directive to indicate yourtreatment preferences should you become unable tomake your own decisions in the future. • Refuse treatment to the extent permitted by law. • Be informed of any research activities that affectyour care and to choose voluntarily to participate.Refusal to participate will not compromise care.

Personal Safety • Expect reasonable safety related to treatment andenvironment.

Access to Community Protective Services• Request and be assisted in the contact of advocacyor protective service agencies if you are being neg-lected or abused in your home and/or need outsidesupport.

Information • Be informed about your illness, possible treatmentsand likely outcome. • Know the names and roles of caregivers. • Know the relationships the hospital and/or physi-cians have with outside parties (such as health careproviders or insurers) that may influence your treat-ment and care. • Be informed of actual outcomes, including unan-ticipated outcomes.

Pain Management• Appropriate assessment and management of pain.

Ethical Standards• Expect that high ethical standards be followed inproviding your care. Whenever conflicts in carearise, a mechanism has been established to assistyou, your family and caregivers to help resolve anyethical issues surrounding care.

Transfer and Continuity of Care• Expect that the physician and/or the hospital will

provide necessary health services to the best of theirability. If a transfer is recommended, you will be informed of the benefits and alternatives. You willnot be transferred until the other institution and/orphysician agrees to accept you.

Understand Charges• Be billed fairly for those services provided.• Request an itemized bill for services rendered. • Ask questions and receive assistance in understand-ing charges and payment methods. • Receive timely notice prior to termination of youreligibility for reimbursement by any third party payerfor the cost of care.

Understand Rules and Regulations• Know about system rules that affect your treatment.

PATIENT RESPONSIBILITIES

• Provide caregivers with accurate and complete information about your health and convey under-standing of what is expected of you in regard toyour treatment. • Inform care providers of any safety issues thatneed attention. • Participate in planning your care (if able to do so). • Comply with instructions for your treatment plan.If you believe that you cannot follow through withtreatment, you are responsible for telling your physician.• Comply with hospital or office rules and regulations. • Meet your financial obligations as promptly as possible.• Be considerate of the rights of other patients andpersonnel in the control of noise, number of visitors and the respect of property.

Staff RightsWellStar has a policy that addresses a staff member’srequest not to participate in aspects of patient care. Thepolicy addresses:

• How the organization ensures that patient care ortreatment is not affected negatively if the requestnot to participate in aspects of care or treatment isgranted.• The process for staff to request to be excusedfrom participating in aspects of patient care due toconflicts with cultural values, ethics or religious be-liefs.



• For more information, see Personnel Policy #34.

Ethics CommitteeFor more information about Ethics at WellStar see SPP# RI-25Committee, or contact Charlene Bunts at 770-732-6770 [email protected].

The WellStar Ethics Committee offers support andconsultation to patients, families and staff in dealingwith issues related to end-of-life decisions and/or ethicaldilemmas. The committee is accessible from any facilitywithin the system. While the committee does not act in adecision-making role, the committee does offer optionsfor dealing with difficult decisions. In addition, thecommittee plays an active role in establishing systempolicy concerning patient rights and organizationalethics and in improving organizational performance inthese areas.

To Initiate an Ethics Committee Consult,Contact Administration, Patient Services orthe Medical Staff/Medical Affairs office.

Advanced Directives: Critical ConditionsAll adults over 18 years of age have the right to acceptor refuse medical treatment. An advance directive is alegal document that allows a person to indicate, inwriting, their wishes regarding medical treatment shouldthey become unable to state their preferences in thefuture. As addressing this for the first time on hospitaladmission is often frightening to our patients, WellStar isparticipating in a state-wide project through GeorgiaHealth Decisions called Critical Conditions. Thepurpose is to educate our communities prior toadmission regarding their right to execute an advancedirective and to provide resources to assist them incompleting a directive. A Critical Conditions PlanningGuide is provided and used in helping individuals tounderstand and to make these often difficult choices.Once a patient’s wishes are known, we must all work toensure that these wishes are carried out to the extentpermitted by law. Georgia recognizes the followingadvance directives: • Living Will: Person may indicate wishes regarding life-sustaining procedures, including respiratory support,nourishment and hydration as well as other treatments. • Durable Power of Attorney for Healthcare: Allowsperson to indicate their wishes and/or to designate anagent to speak on their behalf should they become

unable to do so in the future. • Directive for Final Healthcare: A form in which anindividual allows someone else a person to makehealthcare decisions on their behalf.

The law requires that we ask each patient on admissionif they have an advance directive and to provideinformation about advance directives if they do not.This is done by the admitting RN and documented onthe Admission Patient Data Base. Should the patientwish additional information or to complete an advancedirective, Social Services should be contacted.Whenever a patient indicates they have an advancedirective on admission, we must obtain a copy (patientto keep original) and place in front of chart. If copy isnot readily available, we should document generalcontent of directive on admission assessment and offerassistance (through Social Services) with completion ofnew directive if unable to obtain copy within 24 hoursof admission. Physician must be made aware ofdirective (label on front of chart, phone call, etc.). Acopy of advance directive should be sent with patientsupon discharge/transfer to another hospital, nursinghome, sub-acute unit, etc., and a copy kept as part ofthe permanent medical record.

Coming Soon… Recent changes to laws regarding AdvancedDirectives will effect how these are done and documented in thefuture. Watch for information and education.

For more information about Advanced Directives and WellStar’sprocess, read SPP# RI-10.

Care at the End of LifeAnyone approaching the end of life should becomfortable and have the option to be surrounded byhis or her family/loved ones, and supported by the staffin meeting their special needs. Emphasis is placed onensuring the patient’s comfort and dignity by:

• Managing pain effectively • Involving the patient/family in decision-making• Respecting the patient’s/family’s values, i.e., social,emotional, psychological, spiritual, cultural, religiousand personal wishes, i.e., advance directives, DNR,etc. For more information, read SPP# RI-15.

Eye, Organ, and Tissue DonationWellStar encourages and supports the donation of eyes,organs and tissue. Life Link and Georgia Eye Bank work



closely with the system to identify and approach allpotential donors. Based on recent changes, we must callto determine medical suitability for all deaths anddocument on the Death and Anatomical Gift Log.LifeLink and Georgia Eye Bank have taken on theresponsibility of offering the opportunity of donationto families of all suitable donors. Referrals are initiatedby call the Hospital Donation Referral Line at 1-800-882-7177. For more information, read SPP# RI-20.

Meeting Patients Special NeedsAge Specific CareThe majority of our patients are adults; however, wetreat people of all ages depending on the service anddepartment. Any employee who has direct patientcontact with patients who are younger or older thanadults must be educated about those age groups andevaluated yearly.

Employees who interact with patients and guests needto follow these guidelines:

Neonate/Infant • Involve the parents in education and planning. • Keep parents in the infant’s line of vision. • Provide protective environment by “baby proof-ing” the area. • Use distraction (pacifier, bottle, etc.).• Keep infants warm (use a blanket when bathing ortransporting infants). • If immobilization is required, include the parentsand/or use appropriate immobilization devices asdefined by departmental policy.• Use equipment specific to size and age of child.

Child

• Explain procedures and equipment to child usinglanguage and terminology that can be understood.Include the parents in teaching. • Provide for the safety of child. Do not leave unat-tended. • Keep side rails up on stretchers/cribs/beds. • Provide familiar objects and toys in order to pro-vide emotional support for the child. • Use equipment specific to size and age of child.

Adolescent

• Explain the procedure and equipment. Check forunderstanding. The self-conscious adolescent maybe reluctant to ask questions. • Keep patient covered with a gown and blanket.Adolescents are concerned about body image.

Older Adult (Geriatric)• Explain the procedure by talking and standingwithin the patient’s field of vision. Speak slowly anddo not shout. Do lower your voice and avoid excessbackground noise. • Assess the patient’s ability to safely ambulate, pro-viding assistance when in doubt. Use one-on-onephysical support for frail, elderly patients when walk-ing or moving them.• Use table pads, pillows and positioning sponges tosupport frail limbs and protect bony prominences. • Reassess patient status frequently during long anduncomfortable procedures, noting verbal and non-verbal cues for distress. • Maintain privacy and warmth by keeping patientcovered with a gown and blanket.

Safety Tips for ChildrenThe hospital provides compassionate quality medicalcare to a younger community too. Children are notsimply small adults; they have different needs, whichrequire additional safety considerations. Remember thatsmall children may express fear, pain, or sadness bycrying. Older children need explanations they canunderstand. Parents and families must be included in thedecisions made.

• Falls are the leading cause of injury. Some safetytips include: use bed and crib rails and keep toys outof walkways and paths.• Poisoning can occur accidentally because young children will put anything in their mouths – even ifit tastes bad. Keep the following items out of thereach of children: cleaning supplies, tools, paint,medications, and cords.• Choking is the fourth leading cause of accidentaldeath in young children. To help prevent chokingand suffocation, avoid the following foods for chil-dren less than five years: peanuts, grapes, popcorn,hot dogs, and hard candies. Check toys for small re-movable parts. Avoid giving small children balloons,especially latex, because of choking and allergic reac-tions.



• Clean floors of any small objects. Consult theChild Life Specialist as needed.• Scalds or burns can occur from hot liquids such ascoffee, soups, and even tap water. Remember toplace hot foods away from bedside tables and out ofreach.• Child safety begins with proper supervision.

Guidelines for Preparing Children andFamilies for Health Care ExperiencesAsk the parents and family what they understand andsolicit their concerns.

• Assess the child’s knowledge, understanding andconcerns about the situation before deciding whatinformation to share. • Determine any special needs or concerns of thechild or family that might affect the timing, style, orcontent of the preparation. • Select materials and style of presentation to matchthe cognitive, experience, and interest of the childand family. • Use non-threatening, developmentally appropriatelanguage. • Describe the procedure in terms of the child’s sen-sory experiences (what the child will feel, see, hear,taste, and smell), the sequence of events, and the an-ticipated duration. • Suggest a range of feelings that the child might ex-perience: “I don’t know exactly how it will feel foryou; it may hurt, sting, or just be uncomfortable.Perhaps you can tell us how it feels.” By using thisapproach, the child is not conditioned to automati-cally feel pain. • Describe the steps involved in the procedure,demonstrating with teaching materials and using ac-tual medical equipment when possible. • Encourage the child to handle and explore themedical equipment that he/she will directly experi-ence during the procedure. • Describe, draw, or demonstrate behaviors, such asa position, that are expected of the child during eachstep of the procedure (and after the procedure, ifappropriate). • Offer choices and describe options of how thechild might cope during the procedure. • Provide the child with opportunities to rehearse ef-fective coping behaviors (directly or with a doll). • Discuss with parents and family members howthey can support the child and family.

• Encourage the child and family to ask questionsand express their feelings. • Arrange for visits to areas associated with the treat-ment and, when possible, introduce the child to staffwho will be present. • Assess the child’s and family’s understanding ofand reactions to the information. • Allow time for follow-up after the preparation.• Document relevant information from preparationsession(s) in the child’s chart, including responsesand concerns.

Additional information to promote age specific competence can befound on NetLearning. Do a course search for one of thefollowing educational newsletter:

• Growing Families (Infant/Children)• Growing Up With Us (Adolescents)• Grown Up (Adults/Geriatrics)

Note: Adapted from Psychosocial Care of Children inHospitals: A Clinical Practice Manual from the ACCTChild Life Research Project (p. 95) by L. Generate et al.,1990, Washington, DC: ACCT.

Cultural CompetenceCultural Competence has been defined as “a set ofbehaviors, attitudes, and policies that enable a person towork effectively in cross-cultural situations.” Cultureinfluences a person’s beliefs, expression of pain andgrief, health-seeking behaviors and health relateddecisions.

Three Steps to Cultural Competence1. Practice Awareness and Sensitivity

•Be appreciative and sensitive to the values, beliefs,life ways, and practices, of other cultures. • Respect differences, knowing they are justdifferent, not better or worse.• Be aware of our own cultural values and identity. • Understand how our own culture influences ourbeliefs, human behavior, values, communication,biases, etc.• Understand how differences could impact orrelationships with patients and coworkers. • Listen without judgment. • Take care not to say things that might beinterpreted as judgmental, patronizing or ridiculing.



2. Become Knowledgeable about Cultures• Learn as much as possible about the values, andbeliefs, of coworkers and patients. • Ask questions that will help you understand what’simportant to patients.

3. Increase Your Cultural Competence Skills• To increase cultural skill, use cultural knowledge asa basis, practice the appropriate questions to ask andthe right words to use. • Care givers should learn to expand the questionson the patient assessment to get a good understand-ing of the patient. • Share your successes with coworkers and brain-storm how to handle difficult situations.

To enhance your cultural competence, use available WellStarresources. These include:

On Esource - Culture Vision and the Diversity Toolkit

On the Unit - Cultural Competence Resource (a 3-ring binder forquick reference located on the hospital units) and TransculturalHealth Care - a culturally competent approach (book) by LarryPurnell & Betty Paulanka

Spiritual NeedsMeeting patients and families spiritual needs can be animportant part of creating a healing environment. CallPastoral Services for assistance and/or spiritualcounseling. In addition, you can help meet spiritualneeds by…

• Asking every patient on admission if they havespecial preferences or needs related to spiritualissues.• Make every effort to accommodate these wishesunless they interfere with patient care or safety.

Language Translation Needs• Request a translator through Customer Service orPatient Services.• Contact Language Line Services for over thephone interpretations at 1-800-717-4435.• For document translation, call 1-800-763-3364 orfax 1-800-648-0170. To utilize the document transla-tion service, an order form must be completed andfaxed to the service. This form is an attachment topolicy SPP# RI-50. • For on-line in interpreters or information, the fol-

lowing website is also available.www.LanguageLine.com. Client ID# 213352. • Refer to information on the Americans with Dis-abilities Act in this document for further informa-tion.• For more information, read SPP# RI-50.

The Americans with Disabilities Act (ADA)SPP# EC-25The Americans with Disabilities Act (ADA) inaccordance with section 504 of the rehab act of 1973,and title III of the Americans with disabilities act, is thehealth system’s policy that: no program or activityadministered by WellStar health system shall excludefrom participation, deny benefits to or subject todiscrimination any individual solely by reason of his orher handicap.

Guidelines for ADA ComplianceListed are instructions and aids for you to use whenassisting a patient, family member or significant otherwho is hearing or speech impaired. The following termsare related to the ADA.

• TDD/TTY: Telecommunications for theDeaf/Text Telephone. A keyboard device used inconjunction with a telephone that allows communi-cation by telephone for persons with hearing/speechchallenges.• Relay Center: A third-party service that allows anon-TDD/TTY user hearing person to communi-cate by phone with a TDD/TTY using hearing orspeech impaired individual. The third-party readstext typed by the TDD using individual (Deaf/Hear-ing/Speech Impaired) and verbalizes the text overthe telephone to the non-TDD person. The hearingperson’s verbalization is then put into text by thethird-party so the TDD person on the other end ofthe telephone can read what is being spoken.

Meeting the Needs of the Hearing and Speech ImpairedThe initial assessment identifies patients having hearingor speech impairments who may need specialcommunication assistance. Communication with thehearing or speech impaired may include, but are notlimited to:

• Use of sign language and/or oral interpreter • Lip reading • Handwritten notes/communication boards • Amplified hand sets • Portable bedside telecommunication device for the



deaf (TDD) that provides a communication devicevia telephone• Dual relay services available through the GeorgiaRelay Center at (800) 255-0135. This service allowsincoming calls from hearing impaired individuals tobe received by the facility or outgoing calls to hear-ing impaired individuals using a TDD. • Closed–caption decoded televisions

Determining the Type of Interpreter When a request is made for a sign language interpreter,the staff member arranging the service must obtain thefollowing information from the speech or hearingimpaired individual to ensure effective communication:

• Determine if the patient or client wants a sign lan-guage interpreter or an oral interpreter.• Determine the discipline desired; ASL (AmericanSign Language) or Signed English. • Ask the patient, client or resident if they have aparticular interpreter or agency in mind. If so, takethe name and number from them to make arrange-ments. As an employee of WellStar Health System,if you are in contact with a patient, client, resident,family member requesting an interpreter or auxiliaryaids, you are authorized to make appropriatearrangements to effect communication. • Due to the sensitive nature of certain medical pro-cedures (OB/Gyn, urological, or gender specific), itis important that gender of parties be compatible.Ask if the patient, client, resident, or family memberwould prefer male or female interpreter.• Once these questions are answered, inform theparty that you will get back to them when interpret-ing arrangements have been made.

Resource List for Sign Language InterpretersAs needs arise either through outpatient appointment,admission to one of our hospitals or emergencydepartments, or if a patient or employee requests a signlanguage interpreter, the following agency can becontacted to fulfill this request: The agency is available24/7 and can respond usually within 30-90 minutes.

SIGN LANGUAGE INTERPRETING SPECIALISTS(770) 531-0700 (Voice)(404) 746-1253 (Pager)

The ADA/504 Coordinator for WellStar Health Systemis Bruce Powell. If you have questions on the ADA, orhave a patient or family member needing further

information, please direct your calls/requests to:

WellStar Health System Safety/Regulatory Compliance Management531 Roselane Street, Suite 600Marietta, GA 30060Phone: (678) [email protected]

Assessment of Patients (SPP #PE-05)Each patient receives an admission assessment thataddresses physical, psychological, pain, social, spiritualand cultural parameters. This includes data collectionwith identification and prioritization of needs. Barriersto learning are identified.

Patient Screening (SPP #PE-05)The time frame requirements for collecting admissiondata varies according to departments and specialties.Please refer to SPP # PE-05 for specific information onthese criteria.

• Admission data is obtained by an RN/LPN withinthe time frame specified for each unit. • Reassessment is done any time there is a change inthe patient’s condition or at specified intervals foreach area or discipline. Reassessment includes vitalsigns, pain, and other parameters as appropriate.

Discharge Needs Screening (SPP #PE-05)Determination of discharge needs begins on admissionand includes pain management, safety issues in thehome, financial needs, family needs (home health,private duty, meals on wheels, Social Servicesintervention), community referral information andknowledge deficit needs for self care. During the education process, if the patient is nearingdischarge and needs further teaching, Home Health canbe consulted with a physician’s order for visits to teachpatients.

Specific Assessment Parameters (SPP #PE-05)Nutritional screening identifies patients at nutritionalrisk. These patients are then referred for comprehensivenutritional assessment. Functional screening identifiespatients with a potential need for a rehab referral.



Pediatric Patients (SPP# PE-05)Assessment of an infant, child or adolescent is highlyindividualized. Development, immunization status, andpain are assessed for these patients. Verification ofimmunization may be obtained from a third party, i.e.,physician or school records.

Waived Testing (SPP# PE-15)Waived tests are screening tests performed outside thelaboratory, including BBG, gastric pH and gastric/fecaloccult blood. Control procedures are documented asappropriate for each test.

Victims of Abuse (SPP# PE-10)Victims of abuse may be male, female, children, elderlyor disabled adults. Georgia law requires the HealthcareSystem to report suspected abuse or neglect. SPP # PE-10 describes objective indicators of abuse or neglect andoutlines the procedure to make a report. If you suspectabuse, contact your supervisor or Social Services.

Nutrition (Inpatient) Initial Nutritional Screening Nutritional screening of thepatient is initiated by the nurse within 8 hours of arrivalto the inpatient area. Specific criteria are used to identifythe at-risk patient. Nursing is responsible for notifyingNutrition Services of patients at nutritional risk. Thedietitian completes a nutrition assessment on at-riskpatients within 48 hrs of referral.

Safe Storage and Distribution of Food (SPP #NC-32) Perishable food is stored in a refrigerator and dailyrefrigerator temperature monitoring is performed. Whenthe temperature falls out of the recommended range,actions are taken and these actions are documented onthe form. Each department is responsible formonitoring and disposing of out-of-date food items andenteral products within their department. Patient foodtrays are labeled with the date, product and patient’sname and room number for accuracy in delivery.

Diet Manual/Standardization Practice (SPP# NC-05)A diet manual describing WellStar’s standardizednutritional care practice is located at each hospital indesignated locations.

Monitoring Nutritional Care (SPP# NC-55)A patient’s response to nutritional care is monitored byan interdisciplinary team including a physician, nurse,clinical pharmacist and dietitian. Ways in which a

patient’s response to nutritional care is monitoredinclude documenting the %PO intake, calorie counts,monitoring lab values and weight changes.

Food/Drug Interactions (SPP# PF-10)Drugs with potential food/drug interactions areidentified on the Medication Administration Record(MAR). Pharmacy notifies Nutrition and Food Servicesof patients receiving specific target medications whichrequire modification of the patient food trays.

Patient and Family Education Questions regarding Patient-Family Education at WellStarHealth System may be directed to Organizational Learning. Call(770) 956-6400 for more information.

Patient/Family education is a need which must beaddressed by all members of the healthcare team. It isthe expectation of WellStar Health System that assertiveefforts be made to educate patients, as well as theirfamilies, to promote optimal health. Patient/Familyeducation involves an interdisciplinary approach, withinvolvement from all healthcare providers.Communication among members of the healthcare teamis critical.

Assess Patients and Families Education Needs (SPP # PF-05)

• Learning needs, abilities, preferences and readinessto learn• Barriers to learning• Cultural/religious beliefs

Always Educate Patients & FamiliesRegarding…

1. The disease process2. The safe and effective use of medications anddrug-food interactions 3. Effective pain management4. Nutrition interventions, modified diets or oralhealth, when applicable5. Discharge instructions 6. The safe and effective use of medical equipmentas well as rehabilitation techniques. 7. Available community resources. For more information consult SPP #PF-05

Resources for Patient & Family EducationThere are numerous resources available throughout



WellStar Health System to enhance patient familyeducation which staff are highly encouraged to use.Some of these include:

• WellStar Closed Circuit TV (CCTV) library ofhealth related videos. This is available to all inpatientrooms at WellStar Cobb, Kennestone, Douglas andPaulding Hospitals. (SPP #PF-15)• CareNotes System is a comprehensive teaching re-source available via Esource that contains 3000 cus-tomized, printable health and medicationdocuments. (SPP #PF-20)• Diabetes Educators and education for those pa-tients needing initial diabetes education or reinforce-ment of education.• Health Sciences Library at Cobb and KennestoneHospital has resources and materials to assist withpatient and family education. • WellStar Cobb & Kennestone Women’s Centerseach have a Women’s Resource Library available toall patients and staff for health & wellness relatedmaterials.

Documenting Patient & Family EducationIt is critical that healthcare providers document allpatient-family education planned, completed andevaluated. This promotes optimal education for ourpatients and their families. It is important thatdocumentation of all patient family education is presentin the patient record to promote effectiveinterdisciplinary communication.

Care of PatientsCare of patients includes use of medication, nutritioncare, operative/invasive/other procedures andanesthesia care, use of blood and blood componentsand rehab care and services. Standards related to thisfunction include:

• Planning care • Providing care • Monitoring and determining outcomes of care • Modifying care • Coordinating follow up

The goal of this is to address individualized care thatresponds to specific patient needs with respect forpatients’ choices.

The surgical process for operative, invasive and otherprocedures includes:

1. Selection of procedure 2. Pre-procedure preparation

3. Use of time out procedure to identify patientidentification, procedure to be performed and sitefor surgery/procedure. 4. Performance of procedure5. Post procedure monitoring 6. Patient education

Conscious SedationConscious Sedation is the administration of sedativesand/or analgesic medications that allow a patient totolerate unpleasant procedures without a loss ofprotective reflexes. The patient will maintaincardiopulmonary function and the ability to respondappropriately.

Patient RestraintsWellStar SPP #RI-40 outlines the policy and procedure relatedto patient restraint.

As a healthcare system committed to providingexceptional health services dedicated to personal serviceand quality, we have established a goal to reduce the useof physical restraint while maintaining a safeenvironment for our patients. The decision to place apatient in restraint is never to be made lightly and mustbe used only as a last resort when all other reasonableefforts to maintain patient/staff safety have failed.Alternative strategies to the use of restraint include:

• Educate patient/family regarding restraints and al-ternative strategies to avoid use• Implement Fall Prevention Protocol for high riskpatients -involve family/friends in visiting patientmore often, especially in evening hours • Increased patient observation and needs assess-ment by staff -evaluate for underlying cause of con-fusion, i.e., medications, pain, abnormal labs, etc.,and attempt to correct • Modify environment by placing all personal items,assistive devices, etc., within reach, evaluate use ofside rails (raising side rails may actually cause moreserious injury if patient attempts to get out of bed)• Utilize ancillary staff in attending the patient dur-ing periods of agitation & restlessness If restraint is necessary to prevent pulling at IV,tubes, etc., first evaluate need for continued use (he-parin lock vs. IV), and if necessary, attempt towrap/conceal tubes in such a way to prevent disrup-tion use bed/chair alarms for patient at risk for falls



• Utilize psychosocial interventions, i.e., reality orien-tation, verbal calming, active listening, etc.Evaluate usefulness of diversional activities, musictherapy, etc.

If restraint use cannot be avoided through use ofalternative strategies, the following guidelines should befollowed:

1. An explanation must first be given to the pa-tient/family regarding restraint use and the reasonwhy necessary. 2. The least restrictive device should be selected. 3. All restraints require physician evaluation/order atleast daily. 4. The nurse manager or designee must be informedof a patient placed in restraint within the next work-ing day and evaluate documentation for justificationand use of alternatives. 5. All of the above, as well as the reason for restraintuse (describing the behaviors that led to restraintuse) and alternatives implemented, must be docu-mented on the restraint physician order sheet.

Monitoring Restraint Use:1. Each patient care unit maintains a Restraint Logfor collecting data for each use of restraint. (NCRcopy of order sheet and flow sheet are forwarded tounit manager/resource nurse and used for enteringpatient data.)2. The data is aggregated for reporting by the PIdepartment quarterly.3. Data is reported at the WellStar hospital and unitlevel as appropriate.

a. All use of restraint requires physician evalua-tion/order at least daily.

b. Behavior management standards apply to acutecare settings when restraint is used to manageviolence or aggregated behaviors.

c. Acute care standards apply to behavioral healtsettings when restraint is used to promote healing.

Medication UseWellStar SPP #MU-55 outlines the policy and procedurefor reporting medication occurrence.

Adverse Drug Event (ADE)“An injury from a medicine (or lack of an intendedmedicine)”. These include the traditionally reportedAdverse Drug Reactions, such as allergic and

idiosyncratic reactions, as well as injury resulting frommedication error, accidental or intentional overdose, orunderdose of a medicine. Please report all ADE’s byutilizing the Adverse Drug Event Form. In hospitalsettings, reports are forwarded to the pharmacy. In non-hospital settings, forward reports to the departmentsupervisor or manager. Forms must be submitted by theend of the work shift.

Adverse Drug Reaction (ADR)ADRs include any unexpected, unintended, undesired orexcessive response to a medicine that requirediscontinuing the medicine (therapeutic or diagnostic),changing the medication therapy, modifying the dose(except for minor dosage adjustments), necessitatesadmission to a hospital, prolongs stay in a health carefacility, significantly complicates diagnosis, negativelyaffects prognosis or results in temporary or permanentharm, disability or death”

Medication Error“Any preventable event that may cause or lead toinappropriate medication use or patient harm while themedication is in the control of the health careprofessional, patient, or consumer. Such events may berelated to professional practice; health care products;procedures; and systems; including prescribing; ordercommunication; product labeling; packaging andnomenclature; compounding; dispensing; distribution;administration; education; monitoring; and use.”

Utilize the Medication Safety Form to report medicationerrors. A copy of the form should be forwardedimmediately to the pharmacy in hospitals, home health,or to the designated individual at your practice site. Theyellow copy is forwarded to the department supervisoror manager. Category E-I errors (as defined on theMedication Safety Form) must also be reported on theADE from. Forms must be submitted by the end of thework shift.

Sentinel Event (SPP # EC-60)A Sentinel Event is an unexpected occurrence involvinga patient death or serious physical or psychologicalinjury such as loss or use of limb or loss of organfunction.

Such events are called Sentinel because they signal theneed for immediate action and response. The following



events are expected to be handled as Sentinel Events• Suicide of an individual receiving care, treatment orservices in a staffed round-the-clock setting within 72hours of discharge (excluding Assisted Living,Emergency Department and Home Care)

• Unanticipated death of a full-term infant (unre-lated to a congenital condition in an infant having abirth weight greater than 2500 grams.) • Abduction of any individual receiving care, treat-ment or services.• Discharge of an infant to the wrong family.• Rape. (by another patient or family member)• Hemolytic transfusion reaction involving adminis-tration of blood or blood products.having major blood group incompatibilities• Surgery on the wrong patient or wrong body part.• Unintended retention of a foreign object in a pa-tient who has undergone surgery or other procedure.

Risk Management should be contacted immediatelyupon encountering a Sentinel Event. After hours andholidays please utilize the Risk Management on-callrepresentative at pager 404-837-6170.

Performance Improvement (PI)For more information about performance improvement atWellStar, contact Sharon Ellis at 770-792-5445 [email protected] or your facility PI coordinator.

Performance Improvement (PI) is a continuous processthat helps improve quality and safety. It focuses onimproving processes and systems that affect the way ourwork is done. PI involves measuring the functioning ofimportant processes and services within WellStar andeach of the departments. The measurement data is usedto identify changes that need to occur to improveperformance. Changes are then completed andmonitored (re-measured) in the current work process,service or product to ensure that improvementsoccurred and were sustained/maintained over time.

The result of a continuous performance improvementprocess is improved patient care, safety and customerservice for our patients, visitors and employees.Improving performance helps WellStar to achieve itsVision to provide world-class healthcare.Performance Improvement Opportunities are identifiedthrough customer service surveys, clinical outcomemeasures, financial measures, human resource measures,safety measures, and various operational measures.

The leaders of WellStar identify opportunities forimprovement through regular measurement systems.Each department of WellStar also has internalmeasurement systems to assist in identifyingopportunities for improvement.

WellStar’s Rapid Cycle Change ModelOver the last year, WellStar has adopted rapid cyclechange as its PI model. This Institute for HealthcareImprovement (IHI) Model for Improvement is based onthe idea that small tests of change with carefulmeasurement and observation can be used to developquality improvement interventions.

The model helps answer three questions that identify:1. What we are trying to accomplish?2. How do we know things improved? 3. What changes equal improvements?It also identifies when/how to carry out the change.

The Rapid Cycle Change Model for Improvement,depicted below, incorporates all three phases of thechange process that are necessary for sustainedperformance improvement. These include:

1. Developing change2. Testing change3. Implementing change

Resources for Performance Improvement PerformanceImprovement Coordinators at each hospital, whoorganize, educate and lead PI efforts at their facility.Departmental PI Notebooks maintained by the PI Reps. Bi-Monthly Meetings at each hospital to share projects,best practices and lessons learned from departments andfacilities across WellStar. PI education courses offeredacross WellStar on a regular basis and throughNetLearning. Departmental and facility PI DisplayBoards

Recognition of PIAt the end of each PI Bi-monthly meeting, participantswho presented department PI activities are selected for aspecial recognition for their department called “WeMake a Difference.” Some are recognized with a bannerto display in their department while others receive acertificate or have their picture featured on the PIDisplay Board.

Communication of PI ActivitiesIn addition to PI Display Boards, information about PIactivities is shared in staff meetings, Town Hallmeetings, and through various meetings and WellStar



publications. You can help to communicate by tellingothers what you are involved in and things that yourdepartment is doing to improve care and service thatmakes a difference!

Accreditation and CertificationFor more information regarding accreditation and certification,contact Brenda Miller, Manager of Accreditation at 770-792-5471 or your facility accreditation manager.

Regulatory AgenciesThere are many regulatory bodies that set performanceguidelines for healthcare. Joint Commission, OSHA,CMS, CARF, CLIA/CAP, and DHR are the largest.WellStar also pursues and holds other recognition andcertifications in specific departments or services. Thegoal of all these agencies is to ensure that we’reproviding quality and safe healthcare. Below is adescription of the major regulatory agencies employeesshould be familiar with.

Joint CommissionJoint Commission is a private organization that helpsensure quality patient care by setting minimumacceptable standards of care receive reimbursementfrom CMS and private insurance companies and ensureto healthcare consumers that we are a qualityorganization. Since January 1, 2006 all Joint Commissionsurveys will be unannounced. This means we do notknow the exact dates when our components will bevisited and surveyed. Staying “survey ready” is critical toWellStar’s success.

The tracer process is the method used during the survey.The following information describes this process.

• Joint Commission comes having pre-survey infor-mation very specific to each area they will visit. Thispre-survey information includes the previous surveyresults; complaints; CORE measures; trident data;state and federal complaints and periodic perform-ance review. • The surveyors review a patient’s record, possiblyinterview the patient, interview the bedside care-giver(s) and then TRACE the patient’s stay in the fa-cility. A typical tracer can take approximately 3 hoursto complete. In addition, every facility will have amedication management tracer and an infection con-trol tracer.• The reviewers also conduct a ‘data management’interview session. This session addresses perform-

ance improvement; data collection and how infor-mation is used to improve patient outcomes andsafety. Specific topics that are included are NationalPatient Safety Goals, CORE measures, medicationerror data, staffing effectiveness, etc.• The surveyors conduct surveys and direct observa-tion of staff when administering medication andblood or blood product • They observe to see that we are following our poli-cies and procedures including; handwashing, two pa-tient identifiers, etc.• While visiting the units and staff, the surveyorsmay ask to see policies; competence records; equip-ment preventive maintenance records; and perform-ance improvement documentation.• The survey team may include a nurse, administra-tor, and/or physician. Cobb and Kennestone Hospi-tals each have a Life Safety Code Specialist for oneday each to conduct the Building Tour.

How to Be Prepared! • Be familiar with the Joint Commission Standardsfor your job and your department. • Participate in educational offerings on PI, accredi-tation and survey readiness.• Know how a standard affects your work. • Be familiar with the mission, vision and values ofWellStar and your facility. • Know how your job helps meet the overall goalsof WellStar and your facility. • Know the standard policies and procedures as wellas your department to include: • Be sure all quality control data is current and a sys-tem is in place to check items such as(refrigerator/freezer temperature logs; gluteralde-hyde; code cart, etc.). • Know the performance improvement initiatives foryour department • Make quality and safety a part of what you doevery day.

When Talking With a Surveyor…• Think carefully before answering questions • Be honest • Refer to policies and procedures• Give examples



Always remember…You are the expert inyour job and are the best person to tell thesurveyor how YOU provide excellent care toyour patients and residents.

Occupational Safety and Health Administration (OSHA)OSHA is a division of the United States Department ofLabor that oversees laws and regulations designed toprotect employees and ensure that the workplace is safe.

Center for Medicare & Medicaid Services (CMS)CMS acts as a purchaser of healthcare services andquality and safety for Medicare and Medicaidbeneficiaries. WellStar must meet certain conditions ofparticipation to receive Medicare and Medicaid funds.

Department of Human Resources (DHR)The DHR licenses healthcare organizations in Georgiaand acts as the agents for CMS ensuring WellStar is incompliance with the Medicare/Medicaid Conditions ofParticipation. The DHR also investigates complaints bypatients, residents, family members, or employees whoreport concerns related to healthcare services.

Commission on Accreditation of Rehab Facilities(CARF)CARF is the recognized accrediting body for RehabUnits across the country. WellStar has two CARFaccredited Inpatient Rehab Units, Cobb Hospital andKennestone Hospital. They operate under CARFguidelines & regulations. This accreditation status isrecognized by JOINT COMMISSION.

CLIA (Clinical Laboratory Improvement Amendment)and CAP (College of American Pathologists)CLIA is the law that governs laboratory. It establishesquality standards for all laboratory testing to ensurereliability, timeliness and accuracy of patient test results,regardless of where the test was performed. CLIAspecifies quality standards for lab tests, patient testmanagement, quality control, personnel qualificationsand quality assurance. CAP is the surveying body forlaboratories to determine CLIA compliance.



As a not-for-profit institution, the revenue we generateat WellStar is put back into our community. It allows usto provide care, acquire new equipment, improve andexpand our facilities. The great news is that whateverour job, we can make an important contribution toWellStar’s financial well being.

Protecting the Organization’s AssetsWhile people are WellStar’s most important asset, wealso have beautiful facilities, equipment and materials.We can help by doing the following:

• Use supplies efficiently and avoid waste.• Avoid extra repair and replacement costs throughproper maintenance.• Safeguard against abuse and theft. • Recycle materials, where appropriate.

WellStar FoundationFor more information regarding the WellStar Foundation, call770-956-GIVE.

The WellStar Foundation’s mission is to buildrelationships that inspire charitable giving by individuals,foundations, corporations, and organizations in supportof WellStar’s mission to deliver world class hospital,physician, and other related healthcare services. Allemployees at WellStar have the opportunity toparticipate in the WellStar Foundation G.I.F.T. GiverProgram (Generous Individuals Funding Tomorrow).Through a simple tax-deductible payroll deduction,employees can help improve their home facilities andimpact the level of care we provide to our localcommunities. In addition, all employees can help bydirecting patients and families to the foundation so theycan give back.

SECTION FIVE: FINANCIAL


Each of us plays an important role in helping WellStargrow! The success of our organization depends on eachemployee’s commitment to providing and promotingquality care and service delivery. We can help WellStarcontinue to grow by practicing the following;

Continuing to “Learn and Grow at Work”• Maintaining and enhancing our clinical/technical,interpersonal and critical thinking competencies andskills. • Sharing new knowledge, skills and best practiceswith coworkers, other departments and across Well-Star facilities.

Finding Other Great Team Members• Promoting WellStar as a diverse, vibrant and excep-tional place to work and encourage others to con-sider WellStar as their “employer of choice”.• Helping new team members and students succeedby serving as preceptors, mentors and/or coaches.

Helping to Retain Great People • Helping create a positive work environment bycoming to work everyday ready to work, ready tohelp and ready to do your best. • Maintaining positive and professional relationshipswith coworkers, physicians and other WellStar de-partments and facilities. • Cultivating “best friends at work”, by creatingtrusting relationships that support us throughout ourwork day. • Embracing cultural competence in its entirety in-cluding; race, ethnicity, gender, generation, etc.

Improving WellStar through Ideas andSuggestions

• Providing feedback and suggestions for improvingyour workplace through, participation in depart-ment/unit meetings, Town Halls, the employee en-gagement survey and other opportunities.

Promoting WellStar in the Community• Choosing WellStar healthcare services for yourself,your loved ones and encouraging others to do thesame. • Being an ambassador for WellStar in your localchurch, school and community group by speakingpositively about WellStar and our commitment toproviding our community with world-class healthcare. • Consistently providing high quality care and serv-ices to patients, families, physicians, coworkers andothers.

Supporting Our Plan for Growth • Identifying and communicating opportunities andideas for growth.• Staying informed and being involved with local,state and federal healthcare issues that would impactour ability to continue to meet the needs of ourcommunity.

SECTION SIX: SUCCESSFUL GROWTH


Exam Instructions:

1. When assessing patient and family education needs, WellStar considers

a. Barriers to learning, Cultural religious beliefs c. Preferences and readiness to learn

b. Learning needs, abilities d. All of the Above

2. The P.A.S.S. acronym used when extinguishing a fire stands for

a. Point, at, squeeze, sweep c. Pull, aim, squeeze, sweep

b. Point, aim, side to side d. Plan, act, suddenly, sweep

3. Oxygen tanks can cause great harm, explode, and even cause death if they are not handled or stored

properly

a. True b. False

4. The WellStar Ethics Committee offers support and consultation to patients, families and staff in deal-

ing with issues related to end-of-life decisions and or ethical dilemmas

a. True b. False

5. The Emergency code you would hear in the event of an infant abduction is

a. Plan Delta c. Plan Green

b. Plan Stork e. Plan F

6. Emergency code and response Plan Green is the overhead announcement for a

a. Fire c. Tornado Warning

b. Bomb threat d. Disaster

7. Personal Protective Equipment (PPE) such as a gown, gloves, mask, and eye protection should be used

a. To protect eyes, nose and mouth from splashes or sprays of blood or body fluids

b. To prevent soiling of clothing or skin with blood or body fluids

c. When cleaning up a blood spill

d. All of the above

8. Reporting medical errors (such as patient falls, medication errors, wrong patient/wrong site surgery) is

one way to improve patient safety

a. True b. False

9. Standard Precautions to reduce the risk of spreading microorganisms (or germs) should be practiced

a. With all patients regardless of status, diagnosis, or disease

b. When touching blood and/ or body fluids

c. Only when a patient has AIDS

d. Both A and B

42WELLSTAR STUDENT AFFILIATIONS ORIENTATION MANUAL

SECTION SEVEN: WELLSTAR STUDENT AFFILIATIONS ORIENTATION EXAM


STUDENT AFFILIATIONS ORIENTATION EXAM

10. Emergency code and response Plan_____ is the emergency announcement to alert the staff of a

disaster

a. Delta c. Delete

b. Disaster d. Distant

11. A Sentinel event is an unexpected occurrence involving

a. A patient death or serious physical injury

b. A physical and/or psychological injury such as loss of use of limb or loss of organ function

c. Both A and B

d. None of the Above

12. The Ethics and Compliance standards adopted a Code of Conduct that emphasizes our _________

and unwavering ____________ to comply with all laws and regulations that govern our industry.

a. Concerns and Integrity c. Industry and Reminder

b. Values and Commitment

13. Which of the following statements is true regarding patient affairs and patient communications

a. High quality care is provided regardless of gender, age, race, religion, national, origin, or ability to pay

b. Patients will receive considerate and respectful care with recognition of their dignity and right to privacy

c. Patients have the right to know the identity and qualifications of all persons providing services for them

d. All of the Above

14. Effectively managing the environment of care and safety results in

a. Reducing accidents and injuries

b. Minimizing and controlling risks and hazards in the environment

c. Both A and B


15. The R.A.C.E. acronym used in the event of a fire stands for

a. Run, answer, carry, exit c. Rescue, assist, care, exit

b. Remove/Rescue, alarm, contain, extinguish d. None of the above

16. The OSHA Bloodborne Pathogens Standard requires all healthcare institutions to have a plan to pre-

vent transmission of bloodborne pathogens. This plan is called the:

a. Exposure control plan c. Purpose and Intent plan

b. Bloodborne pathogen plan d. None of the Above

17. Which of the following must be discarded in the biomedical (red bag) waste?

a. A dressing with a small amount of dried blood on it

b. Blood transfusion tubing

c. Dressing soaked with blood

d. Both B and C



18. What is the first step in Cultural Competence

a. Being aware and sensitive to the values, beliefs, life ways, and practices or other cultures

b. Knowing that my way is the right way

c. Being able to change what others believe

d. None of the above

19. Sentinel Events signal the need for immediate action and response

a. True b. False

20. The three bloodborne pathogens of most concern to healthcare workers are HBV, HCV, and HIV

a. True b. False

21. While in the room of a patient who has TB (Tuberculosis), it is necessary to follow special airborne

precautions including

a. Wearing a N-95 respirator c. Keeping the door closed

b. Not talking while in the room d. Both A and C

22. WellStar has adopted the Five Pillars of Excellence as a way to

a. Focus our strategic energies

b. Communicate effectively

c. Stay balanced in our effort to become a world class health system

d. All of the Above

23. Basic rules for workplace violence prevention include

a. Spotting trouble before it starts by being aware of your surroundings

b. Following procedures and reporting any incidents

c. Trusting your feelings if you or others are feeling a threat

d. All of the above.

24. Droplets, airborne, contact, and vector borne are all methods that describe how infections are spread

a. True b. False

25. Which of the following is not a National Patient Safety Goal

a. Reduce the risk of healthcare associated infections

b. Improve the safety of using medications

c. Improve the accuracy and effectiveness of communication


26. Which of these involves meeting our service expectations and is part of the WellStar Standards of

Gold

a. Treat others as guests. c. Project a positive attitude.

b. Communicate effectively. d. All of the above



27. What should be reported to Infection Prevention and/or Employee Health

a. Any exposure to communicable disease

b. Any healthcare worker who has a fever, diarrhea, draining wound, any signs or symptoms of possible

infectious disease

c. Any needle/sharp injury or splash of blood/body fluid to eyes, nose, or mouth

d. All of the Above

28. Which statements below describe how to prevent the spread of infection.

a. Wash your hands for 15 seconds using vigorous motion and washing all surfaces of your hands and wrists

b. Use an alcohol-based hand product (if hands are not visibly soiled) and rub into all surfaces of hand

c. Decontaminate your hands before and after patient care, your shift, and personal hygiene.

d. All of the above

Student: ______________________________ Date: ________________________________Faculty: ______________________________ Score: _______ Pass (>25) Fail (<24)

Please print off this answer sheet. Mark ONE answer per question. For True/False questions, mark A for TRUE or B for FALSE .

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True False True False

STUDENT AFFILIATIONS ORIENTATION EXAM ANSWER SHEET


WellStar Student Affiliations Orientation Handbook

Documents

Transcript of WellStar Student Affiliations Orientation Handbook