section i: site information

Created date: 11-6-2017 Created by: Nursing Education & Professional Development

Reviewed / Revised Date: 3-5-2019

Clinical Affiliations

Orientation Handbook

2019



Table of Contents

About Advocate Health Care p. 3 - 4

Mission and Philosophy, Our Purpose, Our values p. 5

Advocate Experience, Organizational Structure p. 6

Advocate Behaviors of Excellence p. 7

Service Excellence:

• AIDET; Service Recovery; Personalized Care, Key Words at Key Times; Purposeful Hourly Patient Rounding

p. 8 - 9

Culture of Safety: Behaviors and Tools p. 10

Patient Safety Initiatives p. 11-16

Plain Language Emergency Alerts p. 13

Limitation of Emergency Treatment (LET) / No CPR Policy p. 14-15

Risk Management and Reporting Patient Safety Events

• Purpose, Your role, Reporting Safety Events

• Documentation Tips

• Medical Device / Electrical Safety

• MRI/Radiation Safety

p. 16-18

Infection Control Practices and other Safety Concerns p. 18-21

Other Key Issues and Clinical Experience Requirements Identification, Restraints, HIPAA, Access to EMR, Helpful Hints, Dress Code/Professional Appearance, Cell Phone Use, Ethical Issues, Cultural Diversity and Awareness, Workplace Violence, Business Conduct

p. 21-24

Computer Reference Guide:

How to access Policies, Procedures, and other clinical Resources

p. 25-30

Advocate GSAM-Site Specific Handbook p. 31-43



Mission & Philosophy

It’s not uncommon for an organization to have a mission statement. Advocate Health Care’s

mission, values and philosophy are grounded in more than 100 years of caring for individuals,

families and communities.

Advocate Health Care is so uniquely committed to our mission, values and philosophy that we have

a dedicated Office for Mission and Spiritual Care. One of the functions of this office is to ensure that

the mission, values and philosophy are understood and integrated into all aspects of our health care

ministry.

Mission

The mission of Advocate Health Care is to serve the health needs of individuals, families and

communities through a wholistic philosophy rooted in our fundamental understanding of human

beings as created in the image of God.

Philosophy

The care we provide is wholistic. This philosophy means we understand people have physical,

emotional and spiritual needs and their relations to God, themselves, their families and society are

vital to health and healing. Finally, we believe all people are created in the image of God. All human

beings live under God's care and must be treated with dignity and respect.

Advocate Aurora Health

Our Purpose

We help people live well.

Our Values

Excellence We are a top performing health system in all that we do and continually

find new and better ways to improve.

Compassion We unselfishly care for others.

Respect We treat people in a way that values their unique needs and

preferences.



The Advocate Experience

An Experience without harm

An Experience of excellence

An Experience of engagement and trust

Always



Five Fundamentals of Service: AIDET To interact with each customer in a way that reduces their anxiety and is respectful and informative. When you talk with a patient or family member, use AIDET:

Service Recovery

We are all responsible for Service Recovery! ACT for Service Recovery:

• Apologize: No Excuses

• Correct: Fix the problem or find out who can

• Take Action: Communicate

Personalized Care

The goal is to identify the top one or two areas of concern for patients and/or families during hospitalization. Upon admission, all patients will be asked the following question:

“We want you to have an excellent stay. Can you please tell us one or two things that are of most concern to you while you are here in the hospital?”

Those concerns are then highlighted on the white boards in the patient rooms under the category “Personalized Care”. The goal is to increase all associate’s awareness and sensitivity to patient needs, proactively address issues, and avoid potential problems.

A Acknowledge the patient, family or significant other

I Introduce: Introduce yourself, share your credentials (include professional certification/education & training)

D Duration: Inform the patient of the length of time required to complete a test/procedure/obtain results etc.

E Explanation: Explain rationale for processes / procedures / next steps. Connect key words with safety and excellent care.

T Thank you! Thank the patient and family for allowing us to care for them.



Key Words at Key Times

To determine key communication points with our customers and develop key words that convey consistent and caring messages. In health care, patients are distracted, frightened, and many times in pain. We may think we have communicated something, but in reality, what we thought we were communicating may not have been heard. Key words are simple. They help the patient understand his/her care better, and they align the behavior of the staff to the needs of the patient. When we talk about key words, we are really talking about building a relationship with our patients.

Examples of Key Words at Key Times

• I am closing the curtain for your privacy. • I will get you a warm blanket for your comfort. • Do you have any questions before I leave? • We are very committed to managing your pain. What is your current pain level?

Purposeful Hourly Rounding

Anticipate patients’ needs – ask patients what they need before they need to use the call light. The results of consistent hourly rounds will increase patient satisfaction, improve patient safety, and increase time saved for nursing staff. PLEASE NOTE: Rounding may be modified or not utilized at some locations.) Patients will be “rounded on” every hour on days/evenings/nights (shared by UAPs & RNs):

1. AIDET – (see page 8) Use the five fundamentals when you interact with our patients.

2. Scheduled Tasks

3. Focus on and address the four “P’s” (Potty, Position, Pain, Pump) during rounding

4 & 5. Address additional comfort needs and complete environmental assessment prior to leaving

room o Call light, phone, and remote within reach

o Bedside table next to bed

o Room service menu on bedside table

o Kleenex box and garbage can next to bed

o Urinal within reach (if applicable)

o Fill water pitcher (if applicable)

o Straighten sheets/linens

6. Ask “Is there anything else I can do for you before I leave?”

7. Inform the patient that another member of the nursing staff will be back in about an hour to

round on them again

8. Document the Round

Created date: 11-6-2017 Created by: Nursing Education and Professional Development


Be Safe Behaviors and Tools for a Culture of Safety Behavior One: Attention to Detail

Too

ls

Stop: Think:

Act: Review:

Pause for 1 to 2 seconds Focus on the act to be performed Perform the act Check for desired results

Behavior Two: Communicate Clearly

3-Way Read/Repeat Back:

• Sender initiates communication

• Receiver documents and reads back

• Sender acknowledges accuracy by saying, “That’s correct”

Phonetic & Numeric Clarifications:

• For sound-alike words, say the letter followed by a word that begins with the letter:

• Example: o A= ALPHA o B= BRAVO

Too

ls

Clarifying Questions:

• Ask 1 to 2 questions to ensure understanding o ... when in high risk situations o ... when information is incomplete or

unclear

SBAR Situation:

• What is the situation? Background:

• What is the important information? Assessment:

• What is your read of the situation? Recommendation:

• What is your recommendation?

Behavior Three: Questioning Attitude

Too

ls

Q V V

Qualify – the source, is it credible & reliable? Validate – consistent with my info & knowledge? Verify – check with credible & reliable source.

Red Rule: Absolute compliance, meet the conditions or “stop the line.” (Time Out Procedures)

Behavior Four: Effective Handoffs

Too

ls 5 P’s: Patient/Project

Plan Purpose Problems Precautions

Behavior Five: Never Leave Your Wingman

Too

ls

Peer Check: Watch out for each other Peer Coach: 5:1 Positive feedback

Speak up with ARCC: Ask a Question Make a Request Voice a Concern Chain of Command



Patient Safety Initiatives

Advocate Health Care is extremely dedicated to our patients and their safety. We follow the appropriate standards for reducing risk and improving patient safety and would like to share them with you. As a student in one of our facilities, we ask that you also follow these standards as they apply to your education experience. As always, if you have any questions with these standards please ask any associate for more information.

DNV

Advocate hospitals are accredited by DNV which ensures that we comply with Centers for Medicare and Medicaid (CMS) regulations. Advocate At Home is accredited by The Joint Commission and Dreyer by AAAHC. DNV Healthcare Inc. (DNVHC) is an operating company of Det Norske Veritas (DNV) and is the leading accreditor of US hospitals integrating ISO-9001 quality compliance with Medicare Conditions of Participation. This accreditation platform helps organizations achieve constant readiness, eliminate survey shock and inspire staff. The corporate purpose of DNV is safeguarding life, property and the environment. In 2008 US Centers for Medicare and Medicaid (CMS) approved DNVHC by granting it deeming authority for hospitals.

There are 3 fundamental objectives of ISO called the 3Cs: • Consistency in Service delivery and performance to ensure that the patient experience is safe,

high quality, and efficient every time, always.

• Continual Improvement ensures we reach our expected outcomes through process improvement and process redesign.

• Customer/Patient Satisfaction ensures patients' expectations are met…or exceeded

As a student, you may be asked about processes such as assessment, medication administration, patient identification, infection control, hand-offs, coordination of care between disciplines, or quality initiatives that improve the care of the patient.

IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION • Always use at least three identifiers

o Inpatients: Name, Date of Birth, Medical Record Number o Outpatients: Stated Full Name and Date of Birth

• Use the Universal Protocol o Pre-procedure verification o Marking of the procedure site o Performing a time-out immediately prior to the starting procedures

• Eliminate transfusion errors o Follow collection and specimen labeling procedures o Strict pre-administration verification (2 RNs)



Steps to Patient Identification • ASK the patient to state their full legal name and date of birth.

• The information provided by the patient, should be checked against their ID band.

• The inability to communicate with a patient should never be a barrier to proper patient

identification. If the patient is unable to state their full name and birth date, the information is

available on the ID band.

• The ID band is then compared to the record to match three identifiers.

• The identifiers used for all patients include:

1) Full legal name 2) Date of birth 3) Medical record number

• Never state the patient’s name and date of birth and ask for confirmation, as a confused, hard-

of-hearing or limited English speaking patient might respond ‘yes’ to incorrect information. For

example:

Correct: Can you please tell me your full name and date of birth? Incorrect: Are you Margaret Jones, born 11/8/57?

As per POLICY Patients will be accurately identified at the time of intake into an Advocate facility and prior to the delivery of care. Patients will have their identification on their person and visible throughout their course of stay or treatment.

DEFINITIONS

White identification band –– in-patient or out-patient upon admission or registration The patient ID band contains the following information at most Advocate sites: (Some items listed below are not on Patient ID bands at BroMenn and Eureka facilities).



Plain Language Emergency Alerts Standardization • Please refer to site orientation handbook for specific emergency notification dial numbers

• There are 4 plain language CATEGORIES that will serve as the CORE ANNOUNCEMENT for all

emergency notifications (e.g. pager, test, overhead announcement)

• Following the Core Announcement, the type of actual emergency (in plain language) and location

will be communicated.

o Example: “Medical Alert – Rapid Response Team – Unit 40 – Room ----"

Implementation March 1, 2019

Event Plain Language of Initial Notification

Faci

lity

Ale

rt Utilities Interruption (formerly Code Green) Facility Alert: Affected Utility ‐ Location

IT/IS Interruption Facility Alert: (Affected System)

Communication Interruption Facility Alert: (Affected System)

Internal Flooding Facility Alert: Internal Flooding ‐ Location

Hazardous Material Spill (Internal or External)

Facility Alert: Hazardous Spill ‐ Location

Evacuation (Internal or External)

Facility Alert: Internal Evacuation ‐ Location Being Evacuated

Facility Alert: External Evacuation

Fire Alarm (formerly Code Red) Facility Alert: Fire Alarm ‐ Location

Mass Patient Decontamination Facility Alert: Decon Response Team ‐ Location to Respond

Establish Incident Command Facility Alert: Initiate Incident Management Team

Me

dic

al A

lert

Patient Surge/Mass Casualty Medical Alert: Patient Surge ‐ (Internal/External)

Potential Patient Surge/Mass Casualty

Medical Alert: Patient Surge‐Standby ‐ (Internal/External)

Trauma (Adult/Pediatric) (formerly Code Yellow) Medical Alert: Trauma ‐ Adult/Pediatric

Medical Code Team (Adult/Pediatric/Nursery) (formerly Code Blue)

Medical Alert: Medical Code Team ‐ Adult/Pediatric/Nursery ‐ Location

Rapid Response Team (Adult/Pediatric/OB/Nursery) (formerly Rapid Response Team)

Medical Alert: Rapid Response Team – Adult/Pediatric/OB/Nursery – Location

Behavioral Health Response Team Medical Alert: Behavioral Health Response Team ‐ Location

NICU Medical Alert: NICU to L&D ‐ Location

Anesthesia STAT (Adult/Pediatric) Medical Alert: Anesthesia STAT ‐ Adult/Pediatric ‐ Location

Sepsis Alert (formerly Sepsis Alert) Medical Alert: Sepsis Alert

Stroke Alert (formerly Stroke Alert) Medical Alert: Stroke Alert

Cath Alert Medical Alert: Cath Alert

Cool Team Alert Medical Alert: Cool Team Alert

ED Critical Response Pediatric Medical Alert: ED Critical Response ‐ Pediatric

Code Help/Family RRT – (Adult/Pediatric) (formerly Code Help)

Medical Alert: Help Response – Adult/Pediatric ‐ Location

Secu

rity

Ale

rt Bomb Threat/Suspicious Package Security Alert: Bomb Threat ‐ Location

Missing Person ‐ (Infant, Child, Teen) (formerly Code Pink)

Security Alert: Missing Person ‐ (Male/Female), (Infant/Child/Teen)

Lockdown Security Alert: Lockdown

Active Threat Security Alert: Active Threat ‐ Location

We

ath

er

Ale

rt Severe Weather- Tornado, snow/ice storm, etc. Weather Alert: (Type of Weather)

Weather Emergency ‐ Hold Staff (formerly Code White)

Weather Alert: (Type of Weather) ‐ Hold Staff



BLOOD Bank BANDS: Are utilized at BroMenn and Eureka facilities only. All other Advocate locations use the

white patient identification band for administration of blood products.

• Purple identification band – LET (DNR band used @ BroMenn and Eureka facilities)

• Pink identification band – Limb precautions

• Yellow identification band – Falls risk

• Red identification band – Allergy

Limitation of Emergency Treatment (Advocate System Policy)

In the event of a cardiac arrest or other pre-arrest emergency, emergency treatments up to and including cardiopulmonary resuscitation (CPR), as medically indicated, will be provided to a patient unless a No CPR Order and, if indicated, other Limitation of Emergency Treatment Orders (LET), are entered in the patient’s medical record. In general, CPR should not be attempted in cases of terminal, irreversible illness, where CPR would serve only to prolong the dying process. This policy applies to all inpatient units of Advocate Health Care except BroMenn and Eureka. Refer to the site specific (ABMC) policy regarding this topic.

• LET Orders: A physician’s set of orders which limit the provision of medical treatment which will be provided to a patient during a cardiac arrest or pre-arrest emergency. 1. LET Orders must include a No CPR Order in the event of a cardiac arrest and may include

orders which limit intubation, cardioversion, antiarrhythmic medication and/or vasoactive medications in the event of a pre-arrest emergency.

2. The decision to write a LET Order is that of the Responsible Physician after discussion with the patient or the patient’s Substitute Decision Maker (if patient is decisionally incapable).

• Types of LET Orders 1. No CPR Order. A No CPR Order applies only in the event of a cardiac arrest. 2. Orders Related to Pre-Arrest Emergencies. LET Orders for pre-arrest emergencies shall not be

written unless a No CPR Order is entered in the medical record by the responsible physician. a. No Intubation: In the event of respiratory distress or failure, the patient will not have

an endotracheal tube placed for the purpose of providing assisted ventilation. b. No Electrical Cardioversion: In the event of a life-threatening dysrhythmias,

electrical cardioversion will not be provided for the purpose of re-establishing a stable cardiac rhythm.

c. No Antiarrhythmic Drugs: In the event of significant cardiac dysrhythmias, antiarrhythmic drugs will not be given for the purpose of reestablishing a stable cardiac rhythm.



d. No Vasopressor Drugs: In the event of hemodynamic compromise or hypotension, vasopressor drugs will not be given for the purpose of reestablishing a stable hemodynamic status.

3. All patients with a LET Order shall have a purple LET identification arm band to alert caregivers of the existence of LET Orders.

4. For further information, please refer to the policy and procedure.

IMPROVE THE SAFETY OF USING MEDICATIONS • Prevent errors related to look-alike/sound-alike medications

• Labeling of ALL medications that are not labeled

• Utilizing site Medication Scanning Device

• Processes to reduce patient harm associated with the use of anticoagulation therapy

ACCURATELY RECONCILE MEDICATIONS ACROSS THE CONTINUUM OF CARE • Compare current medications with those ordered

• Communicate reconciliation to next or known provider upon transfer or discharge

• Provide and explain to the patient/family the reconciliation upon discharge

• Modified reconciliation process for minimal settings

IDENTIFY PATIENTS AT RISK FOR SUICIDE • Screen patients at risk for suicide

• Implement “suicide precautions” for those identified

FALL PREVENTION • RNs assess upon admission, at a minimum of every 12 hours, or as the patient’s condition

changes

• Morse Fall Scale documentation

• ABC’s of Falls ▪ A-Age: Is the patient elderly or frail? ▪ B-Bones: Osteoporosis, previous fractures, etc.? ▪ C-Coagulation: Anti-coagulants? ▪ S-Surgery: Recent surgery?

• Implement Standard or High-Risk Prevention measures

• High Risk Measures include: Fall Risk signs, yellow socks, Fall risk bracelet, possible bed alarm

• Do not leave High Risk for Falls patients unattended while toileting

• Utilize “Teach Back Method” for patient education to ensure patient’s and family members understanding of falls prevention



PRESSURE ULCER PREVENTION • Assess and reassess risk and implement prevention measures

o Thorough head-to-toe skin assessment upon admission and daily o Eliminate moisture, promote hydration, and frequent repositioning

Risk Management

Purpose/Role of Risk Management • Partner with all associates and medical staff to promote and ensure patient safety

• Explore “Patient Safety Events” and “Near Misses”.

• Design activities to proactively prevent future patient safety events.

• Facilitate legal process and claims management.

What is a “Patient Safety Event”? Any unusual event not consistent with the routine operation of the hospital, or the routine care of a particular patient, which may, or may not, have resulted in a patient/visitor injury.

What is a “Near Miss”? Any safety event that did not reach the patient, but only because of chance or just in time intervention.

What is your role in Risk Management? Everyone is a risk manager!

1. Collaborate with Risk Management to ensure a Culture of Safety 2. Report unusual events to an Advocate team member. Injuries should be reported immediately. The Patient Safety Event Form should be completed with an Advocate team member. 3. Recognize Risk Management as a RESOURCE to all. 4. Service Recovery

Examples of Patient Safety Events

Adverse Drug Reactions Conflict/Security Events Fall Events Pregnancy Events

Adverse Outcome Events Consent Events Infection Control Events Property Loss Events

AMA Events Diagnostic Events Injury Events Surgical Events

Anesthesia Events Dietary Events IV Related Events System Failure Events

Code Arrest Events Equipment Events Medical Record Events Treatment/Procedure Events

Complaints Facilities Events Medication Error Events Other Events

http://luth3523/MidasWeb/LUTH3523/MAA/RDE/RDE.aspx?FormID=475



























Purpose of a Patient Safety Event Form

• To provide objective and factual documentation of unusual or untoward events.

• May facilitate manager follow-up.

• May facilitate Risk Management follow-up or investigation.

• Protects hospital and staff by providing information necessary to appropriately respond to claims and lawsuits.

Patient Safety Event Forms are not to be used:

• In lieu of communication or adequate documentation

• To antagonize another department or individual

Documentation Tips: Word Usage in Charting

• Provide concise, complete, clear, factual and objective information in the medical record

• Avoid words that create some doubt about what you actually observed, such as: (i.e., apparently, appeared, seems to be, or believed to be)

• Avoid the use of “slanted” words which reflect judgment or place blame/fault: erroneous inadvertently terrible unexplainably unfortunately unintentionally mix-up regretfully somehow sorry

Medical Device / Electrical Safety

• If incident occurs with a medical or electrical device, tend to the immediate health and well-being of the individual and protect from electrical shock.

• Remove the device from service along with all materials and peripheral equipment. Do not clean or change any settings on the equipment. If the medical examiner or proper authorities must be notified do not alter the scene or the incident in any way. Throw nothing away.

• Report the incident to your instructor, preceptor, and unit leadership.

• Complete a Patient Safety Event Form ASAP with unit leadership.

• Use electrical equipment, power cords, and outlets properly to help prevent electrical accidents.

MRI/Radiation Safety Radiation and radioactive materials may be essential in medical diagnostics and treatment, but they do create some hazards.

• Staff are the only ones authorized to be in radiation restricted areas without supervision.

• If you believe there are conditions present that could result in unnecessary radiation exposure, please contact your instructor and the unit leadership.

• If you believe there is equipment malfunction, leave the area immediately and contact your instructor and unit leadership.



• Radiation Therapy: There are 3 methods to limit your exposure to radiation: 1. Time: Limit your time spent in restricted areas. 2. Distance: Increase your distance from the radiation source. 3. Shielding: Use lead or other shielding to decrease radiation exposure.

• MRI safety: Please do not go into MRI department with any metal!!!

Infection Control

REDUCE THE RISK OF HEALTHCARE ASSOCIATED INFECTIONS (HAI) • Comply with hand hygiene guidelines

• Guidelines to prevent HA infections due to multiple drug-resistant organisms

• Guidelines to prevent central line associated bloodstream infections

• Guidelines to prevent surgical site infections

• Implement evidence-based practices to prevent indwelling catheter associated urinary tract infections (CAUTI)

HAND WASHING is the single most effective way to prevent the spread of infections. If hands are visibly soiled use soap and water. Waterless hand antiseptic may be used for all other times. For further information, please refer to system wide policy.



Infection control is extremely important to our patients and health care works at the hospital. The following guidelines should be closely followed to ensure continued safety.

There are several methods that are used to reduce the risk of exposure. • Standard and Transmission based Precautions

• Work Practice Controls

• Personal Protective Equipment

• Engineering controls

Standard Precautions Standard precautions are an approach to infection control in which ALL body fluids are treated as if known to be infectious for HIV, Hepatitis B, Hepatitis C, or other blood borne pathogens.

Transmission Based Precautions Disease specific precautions used in a suspected or confirmed case.

• Contact Isolation-2 types This is identified with a contact isolation sign outside the patient’s door. Follow instructions specified on sign. Differences related to type of hand hygiene when leaving room and cleaning of room upon discharge.

• Droplet Isolation This is identified with a droplet isolation sign outside the patient’s door. For droplet isolation, a mask must be worn when you are within three feet of the patient.

• Airborne Isolation This is identified with an Airborne Isolation sign outside the patient’s door. Employees must wear an N95 respirator when entering a patient’s room. Students are not allowed to enter an airborne isolation room.

• Combination Isolation – 2 types

Follow instructions specified on each type of sign. Differences related to type of mask and patient placement.

o Droplet and Contact o Airborne and Contact

Work Practice Controls Eating and drinking in non-designated areas is prohibited. Artificial nails may not be worn by associates or students providing patient care.



Personal Protective Equipment Personal protective equipment should be worn any time you feel there is a potential for exposure to blood or body fluids as well as any time there is a posted sign on a patient’s door. PPE consists of gloves, goggles, masks, gowns, etc.

Engineering Controls

• All sharps are to be placed in a sharps container. Never recap a needle.

• Discard waste in the appropriate colored waste container. All blood and body fluids that have the potential to leak, splash or flake should be place in red biohazard bags or containers.

• All linen should be placed in designated linen bag at your site.

Information for Exposures to blood and body fluids: • Immediately and aggressively wash the wound with soap and water for 10 minutes.

• Splashes in mucous membranes should be irrigated with water for 15 minutes.

• Notify your instructor and unit leadership if exposed

• Report immediately to Employee Health or the Emergency Department after hours.

• Prophylactic treatment must be given within 2 hours of exposure for maximum effectiveness.

Hazardous Materials

• A hazardous material is one that is a physical hazard (flammable, explosive) or a health hazard (Produce reactions in the body, such as a rash)

• Always take time to read the label on materials for a quick reference on hazards

• Refer to Material Safety Data Sheets (MSDS) for information on handling, storing, chemical identification, fire and explosive data, health hazards, reactivity data, spill/leak procedures, special protection and precautions info, which can be found in Advocate Online.

• Protect yourself: o Utilize Personal Protective Equipment such as gloves, goggles, gowns, etc. o Work practice: including hand washing, labeling containers o Disposal: Dispose in an approved manner

Waste Disposal REGULATED INFECTIOUS WASTE (“Red Bag”):

• Any liquid or semi-liquid blood or body fluid removed from a human body • Any tissue or organ removed from a human body • Any item that is covered with dried blood or body fluids • Any item that is saturated with enough blood or body fluids to release it if the item is

compressed. This contributes most to the generation of red bag waste.



NON-REGULATED WASTE (Clear or Black liners): • Paper items • Tissues • Gloves not visibly contaminated with blood or other body fluids • Plastics • Items that have blood or body fluids on them but will not release the fluid when

compressed (for example, a band-aid with a drop of blood on it can go into clear bag waste)

• Styrofoam cups or other products • Wrappings from gauze, procedure trays, etc.

Back Safety: Proper Care Healthcare workers who lift and move patients are at especially high risk for injury. Ergonomic best practices are:

• Use proper posture and body mechanics when sitting, standing, or lifting. • Hold the load close to your body, to avoid reaching, twisting, and bending. • Bend at the hips and knees, and keep your head up. • Lift with the muscles of the legs. • Avoid lifting without using proper devices or equipment. • Avoid forceful exertions.

Injury at the clinical site A student who is injured at the clinical site should fill out an Employee Occupational Injury report and note “student status” on the report. They should be given the option of going to the Employee Health Service, Emergency department or their own physician. All costs incurred are the responsibility of the student.

Flu immunization

The flu is a significant safety concern for our patients. Advocate Health Care has implemented mandatory annual influenza vaccinations for all associates, physicians, volunteers, students and contractors that physically work at a site that provide clinical care.

Other Key Issues and Requirements Student Identification

• Wear your school ID badge and hospital issued student badge card (If applicable at your site) above your waist, in a visible location at all times.

The following requires Direct Supervision (With Staff RN/Clinical Instructor)

• Medication Administration (preparation, patient identification, administration & documentation)

• Nursing Interventions (i.e. nursing assessment, dressing changes, tube insertions, etc.)

• Nursing Documentation



Health Insurance Portability & Accountability Act (HIPAA) & Confidentiality

• REMEMBER: Respect the privacy of others as you want your privacy respected.

• Please be aware of the environment before you engage in patient conversation.

• Ensure that all patient specific information is kept private and confidential.

• Please be aware of visitors in the room before disclosing any patient information.

• Do not make copies, print, photograph, or save patient pages from the medical record.

• Do not disclose any information regarding patients or clinical experience on social media.

• Refer media inquiries to Marketing dept.

• A signed confidentiality agreement is required.

Access to the Patient’s Electronic Medical Record (EMR) & Medication Supply Cabinets (Pharmacy & Supplies) etc.

• Access will be coordinated by the Clinical Affiliations Coordinator and Instructor as appropriate

• Please print clearly on all forms using your full legal name

• If you are a current Advocate associate, you will still need to complete the forms to obtain a separate student account.

Other Helpful Hints

• Be cognizant of the noise level on the units

• Share your Student Clinical Information Card with the staff you will be working with (i.e. tasks you can do independently, tasks that must be performed with the faculty, or tasks you are NOT permitted to do, etc.)

• Rather than spending prolonged time at the nurse’s station/computer, offer assistance or seek out additional learning experiences during your down time

• When in doubt, look up the Policy and Procedure

The following may NOT be performed by students under any circumstances:

• Blood Administration

• Airborne Isolation rooms

• IV push medications

• Central Line Access

• Restraints: No application, administration or documentation regarding restraints

• Point of Care testing such as blood glucose, urine dip sticks, etc.

• Pediatric clinical rotations (Oak Lawn and Park Ridge campuses) and pediatric community sites may NOT perform the following skills:

• Indwelling urinary catheter insertion

• Specimen collection from indwelling urinary catheter

• Urinary straight catheterization

• Urinary catheter discontinuation



Dress Code / Professional Appearance Uniforms

• General clinical areas – School Uniform – Professional appearance

• Specialty areas (i.e., OR, PACU, POCU, L&D, ASC, NICU) may require hospital issued scrubs • Refer and adhere to site specific and school policy.

Cell Phone Use

• Refer and adhere to school and site-specific policy

• Limit use of personal phones to areas away from patient and family view

• Follow your instructor’s lead regarding their use

• Exercise discretion in using cell phones/texting during clinical especially in patient care areas: make personal calls/texts on non-clinical time, unless circumstances demand immediate attention

• Camera and camera phone usage is not permitted

Ethical Issues • If an ethical concern is unresolved, a patient, family member, or employee may request a

consult from the ETHICS Committee

• Consultation is advisory, educational, and supportive

• Patient’s primary physician is notified by the committee of the consult

• See your specific hospital site for contact details

Cultural Awareness/Diversity • Cultural diversity should be considered when we assess the needs of our patients and plan

their care

• Interpretation services are available when needing to communicate with patients in their native language or those having other communication impairments

• Family members should not serve as interpreters for our patients who do not speak English as their primary language unless appropriate waiver is signed

• Refer to your site for: Interpreter Resources

Refer to site specific info regarding:

• Parking requirements

• Maps

• Obtaining student/faculty ID badges if applicable



All staff and students need to

• Know evacuation procedures and routes

• Know location of fire extinguishers and how to report and respond to a fire

• Use stairs whenever possible during emergencies

R.A.C.E. To Use a Fire Extinguisher – P.A.S.S.

Rescue – All person in danger Pull the Pin between the handles

Alarm – Pull the nearest Pull Station Aim the Nozzle at the base of the fire

Contain – Close all doors Squeeze the handles

Extinguish – If safe to do so Sweep from side to side

Workplace Violence

• Nurses and nursing aids are at highest risk of hospital violence. This is because they have the most direct patient contact

• Risk of healthcare violence is increased when there is a lot of activity and patient contact. Risk is also high when patients feel frustrated, vulnerable, or out-of-control.

• Within hospitals, violence is most common on psychiatric wards, in emergency departments, in waiting rooms, and on geriatric units.

• Violence in the healthcare setting can have serious consequences.

Business Conduct (Code of Conduct)

Provides guidance to all Advocate colleagues and associates and assists us in carrying out our daily activities within appropriate ethical and legal standards. These obligations apply to our relationships with patients, affiliated physicians, third-party payers, subcontractors, independent contractors, vendors, consultants, and one another. The Code of Business Conduct is available in the Advocate Document System via the Advocate Intranet (AdvocateOnline). All Advocate colleagues and associates have the duty to report any perceived violation of applicable laws, regulations and professional standards to management or the Business Conduct Hotline.

BUSINESS CONDUCT HOTLINE NUMBER: 630.929.5755 (internal 55.5755)



Computer Reference Guide

Help Line x52-7000 or 49-5555 at BroMenn and Eureka Facilities

This reference guide will

show you how to access the following resources through our hospital intranet

(Only available using a computer onsite)

Resource Page

Accessing Online Policies 27-28 Procedures through Lippincott 29 Education Resources 30

Other Healthcare Resources 31



Accessing Online Procedures

What is Lippincott:

• On-line resource for over 1200 procedures that provides nurses with accurate, up-to-date information and detailed visuals, including full-color art and video clips, which let you see proper technique first hand!

Why are we using Lippincott?

• Standardizes procedures/care across Advocate sites of care

• Provides annual review by national clinical experts

• Ensures that hospitals procedures are documented and available to all nurses at all times • Provides skill lists and competency tests for each procedure

How do I access Nursing Procedures in Lippincott?

From HOME PAGE for Advocate, scroll down to Applications and select Lippincott Procedures

Created by: Elvira Stawarski, Clinical Development Specialist

Created date: 11-6-2017; Reviewed / Revised Date: 03-5-2019

Good Samaritan Hospital Clinical Affiliations

Orientation Handbook

2019

GSAM Site Contact Information for Clinical Affiliations

Elvira R. Stawarski, MS, RN-BC Clinical Development Specialist

Clinical Affiliations Liaison Phone: 630-275-1811

Email: [email protected]

Fax: 630-275-2944

mailto:[email protected]



Table of Contents

About Advocate Good Samaritan Hospital p. 33 - 34

Organizational Structure p. 35

Hospital Emergency Notification System p. 36

Directions to Advocate Good Samaritan Hospital p. 37

Campus Map p. 38

Ground Floor Map p. 39

First Floor Map p. 40

Using the Phone System & Key Extensions p. 41

Other Clinical Experience Requirements p. 42

*** Acceptance of Clinical Affiliations Handbook form p. 43

***This form must be returned prior or on the first clinical day***



Organizational Structure



Hospital Emergency Information (Dial 31-3333 or 31-4444)

Plain Language Emergency Alert Standardization

• There are 4 plain language CATEGORIES that will serve as the CORE

ANNOUNCEMENT for all emergency notifications (e.g. pager, test, overhead

announcement)

• Following the Core Announcement, the type of actual emergency (in plain

language) and location will be communicated.

o Example: “Medical Alert – Rapid Response Team – Unit 40 – Room ----

Facility Alert (may include but not limited to) Utilities Disruption Fire Alarm Electricity Disruption Hazardous Spill Decontamination Evacuation Incident Command Health Informatics & Technology (HIT/IS)

Weather Alert (may include but not limited to) Severe Thunderstorm Tornado Snow Storm Ice Storm

Security Alert (may include but not limited to) Missing Person: Adult/Child/Infant with description /last location Suspicious Package/Bomb Threat Security Assist Active Threat Perimeter Control/Lock Down

Medical Alert (may include but not limited to)

Patient Surge-Stand By Patient Surge Trauma - Adult/Pediatric Medical Code Team - Adult/Pediatric Rapid Response Team - Adult/Pediatric Stroke Alert Behavioral Health Response Team Sepsis Alert

STEMI Alert Help Response



Directions to Advocate Good Samaritan Hospital

3815 Highland Avenue Downers Grove, IL 60515

(630) 275-5900

Chicago – Eisenhower (I-290) west to I-88 west towards Aurora. Continue on I-88 west. Exit at

Highland Avenue Southbound. Go 1 mile south and the hospital is on left (east side of Highland). There is a traffic light in front of it.

Chicago (South Side) – Take I-294 north to Wisconsin. Exit Ogden Avenue West. Turn right

(north) on Main Street. It becomes Highland Avenue. Continue on Highland Ave and the hospital is half a mile north of Ogden on the right (east side of Highland).

Chicago (North Side or O’Hare Airport) – Take I-294 south to I-88. Take I-88 west towards

Aurora. Exit at Highland Avenue southbound. Go one mile south and the hospital is on left (east side of Highland). There is a traffic light in front of it.

East-West Tollway – Take I-88 west and exit southbound on Highland Avenue. Go one mile

south and the hospital is on the left (east side of Highland). There is a traffic light at the entrance.

Stevenson Expressway – Take I-55 south to St. Louis. Exit at I-55 south at Lemont Road north

exit. Go north on Lemont Road. It becomes Main Street and then becomes Highland Avenue. Continue north on Highland (cross Ogden Avenue) and the hospital is half a mile north of Ogden on right (east side of Highland). There is a traffic light at the entrance.

From Joliet & Lockport Area – Take Rt. 53 north to I-55 north towards Chicago. Exit at

Lemont Road northbound. Proceed north on Lemont Road and it becomes Main Street. Proceed north on Main Street crossing Ogden Avenue. Main Street becomes Highland Avenue. Continue north on Highland Avenue. The hospital is half a mile north of Ogden Avenue on the right side (east side of Highland). There is a traffic light at the entrance.

Route 83 North – Exit on 31st Street and head west. At Highland Avenue turn left (south). Go

one mile south and the hospital is on the left (east side of Highland Ave). There is a traffic light at the entrance.

Route I-355 – Exit on Ogden Avenue heading east to Main Street (also called Highland Avenue).

Turn left on Highland (north) and the hospital is half a mile north of Ogden Avenue on the right (east side of Highland).



FACULTY & STUDENT PARKING

NOTE: Students/Faculty on day or evening shifts should park in the last two rows of the Wellness Center Parking Lot as designated below. Access Badges to Door by the Cancer Care Center will be issued on first clinical day.

Entrance Door

Campus Map



Alcatel Telephone System Quick Reference Guide

The telephone number for Advocate Good Samaritan Hospital is 630-275-5900 If you know the extension, it may be direct dialed at 630-275-(extension number) To Make an Internal Call or Transfer a Call: Dial “31” then the 4 digit extension To Make an External Call: Dial 9 for the outside line, then the number To Page: Dial 31-1300 and follow instructions For an Emergency: Push the Emergency button or dial 31-3333

Other Important Extensions

Department Unit Nurses

Station Location

Behavioral Health Behavioral

Health 31-6300 North Pavilion - 3rd Floor

Birth Center / L & D Unit 31 31-3192 Classic Tower – 3rd Floor – North Elevator

Cardiovascular CV H.A.R.T. 31-1600 LL Atrium South-Ground Floor

CCU Stepdown CC-Pod 2 31-7200 West Tower - Middle Pod - 1st Floor

Construction Unit 43 31-4300 Classic Tower – 4th Floor – South Elevator

Construction Unit 44 31-4400 Classic Tower – 4th Floor – South Elevator

Critical Care Critical Care 31-7100 West Tower – 1st Floor

Critical Care CC-Pod 1 31-7300 West Tower – 1st Floor

Critical Care CC-Pod 3 31-7300 West Tower – 1st Floor

Detox Unit 54E 31-5450 Classic Tower – 5th Floor – South Elevator

Dialysis (inpatient) 31-4677 Classic Tower – 1st Floor Center Hall

Emergency Room 31-1116 Hospital – 1st Floor South

Endoscopy Center 31-7900 West Tower – Ground Floor

Family Focus Unit 33 31-3300 Classic Tower – 3rd Floor – South Elevator

Human Resources 31-1916 North Pavilion, Ground Floor

Information Technology 52-7000

Infusion Center 31-2300 Bhorade Cancer Center

Intermediate Cardiac Care Unit 30 31-3050 West Tower – 3rd Floor - North Elevator

Intermediate Neuro Care Unit 40 31-4050 Classic Tower – 4th Floor – North Elevator

Oncology Unit 42 41-4200 Classic Tower – 4th Floor – North Elevator

Overflow Unit 52 31-5200 Classic Tower – 5th Floor – North Elevator

Patient Overflow Unit 41 31-4100 Classic Tower – 4th Floor – North Elevator

Pediatrics Unit 54W 31-5400 Classic Tower – 5th Floor – South Elevator

Pharmacy 31-1042 Ground Floor – Center Hallway

Post-Surgical Unit / Ortho Unit 50 31-5050 West Tower – 5th Floor – North Elevator

Post-Surgical Unit / Ortho Unit 53 31-5300 Classic Tower – 5th Floor – South Elevator

Public Safety 31-1166

Special Care Nursery /

Neonatal Unit 32 31-4400 Classic Tower – 4th Floor – South Elevator

Surgical Care Pavilion 31-7600 Classic Tower – 1st Floor – Center Hall

Surgical Services 31-1100



Other Clinical Experience Requirements

Student/Faculty Parking & Entrance into the Hospital – see attached maps

• All students/faculty are to park in the last two rows of the Wellness Center Parking lot. If coming after 7pm, you may park in the Employee/East Parking deck on the 4th floor.

• Access badge cards will be issued on first clinical day by the Clinical Affiliations Coordinator and must be returned on last clinical day.

• All badge cards are the property of Good Samaritan Hospital. Lost or damaged cards can be replaced for $10 each by contacting the Clinical Affiliations Coordinator.

Student Identification

• Wear your school ID badge and hospital issued student badge card above your waist, in a visible location at all times.

Restraints (Physical and/or Chemical)

• Students do not apply, administer, or document regarding restraints.

• Notify staff members for assistance.

Health Insurance Portability & Accountability Act (HIPAA) & Confidentiality

• Ensure that all patient specific information is kept private and confidential.

• Do not make copies or print from the medical record.

• A signed confidentiality agreement is required.

Access to the Patient’s Electronic Medical Record (CareConnection)

• Access will be coordinated by the Clinical Affiliations Coordinator and Instructor as appropriate.

• Please print clearly on all forms using your full legal name.

• Read all directions carefully before completing.

• When entering an end date, use the day after the last clinical day.

• Department and cost center questions can be left blank.

• If you are a current Advocate associate, you will still need to complete the forms to obtain a separate student account.

Other Helpful Hints

• Be cognizant of the noise level on the units

• Communicate with the staff you will be working with (i.e. tasks you can do independently, tasks that must be performed with the faculty, or tasks you are NOT permitted to do, etc.)

• Offer assistance or seek out additional learning experiences during your down time

• When in doubt, look up the Policy and Procedure

The following requires Direct Supervision (With Staff RN/Clinical Instructor)

• Medication Administration (preparation, patient identification, administration & documentation

• Nursing Interventions (i.e. nursing assessment, dressing changes, tube insertions, etc.)

• Nursing Documentation



Acceptance of Clinical Affiliations Handbook

As a student/faculty member practicing under the clinical affiliation agreement between Advocate Health Care and my School/University, I agree to abide by all hospital policies and procedures.

In addition, I am aware of the key issues and clinical experience requirements listed in the Advocate System Handbook, and those specific to Advocate Good Samaritan Hospital regarding:

• Advocate Behaviors of Excellence

• Patient Safety Initiatives and Customer Service Processes

• Student /Faculty Parking

• Identification and Student ID Badges

• Direct supervision requirements for medication administration, nursing interventions, and documentation

• Restraints

• HIPAA & Confidentiality

• Access to patient’s electronic medical record

• Dress Code and Professional Appearance

I have also reviewed the content in both the System and Good Samaritan Hospital Clinical Affiliations Handbook prior to or during my first clinical day. I have had the opportunity to ask questions and I declare my understanding of the content.

School/University _______________________________

Instructor___________________________________

Printed Full Legal Name __________________________

Signature_______________________ Date___________

section i: site information

Documents