WakeMed Systemwide Orientation

Summary Packet

Staff Development & Training

Table of Contents Instructions and Overview (Chapter 1) ..................................................................................................... 3

Summary Packet Description and Instructions ............................................................................... 4 Other Educational Requirements .................................................................................................... 6 Dr. Atkinson Welcome to WakeMed ............................................................................................... 7 WakeMed Health & Hospitals Overview ......................................................................................... 8 Mission, Vision, and Values .............................................................................................................. 9

Regulatory Content (Chapter 2) ..............................................................................................................11 General Information .......................................................................................................................12 WakeMed Facility List .....................................................................................................................12 Human Resources ...........................................................................................................................13 WakeMed Employee Related Policies ...........................................................................................17 WakeMed Code of Conduct ...........................................................................................................20 Corporate Compliance....................................................................................................................24 Performance Improvement ............................................................................................................27 Patient Safety/Risk Management ..................................................................................................28 TB Control Plan for Health Care Workers ......................................................................................30 Occupational Health and Safety Services ......................................................................................32 Infection Prevention .......................................................................................................................33 Environment of Care.......................................................................................................................41 Emergency Management ...............................................................................................................41 Hazardous Materials and Waste Management ............................................................................42 Life Safety Management ................................................................................................................44 Medical Equipment Management .................................................................................................46 Equipment Management ...............................................................................................................46 Safety Management .......................................................................................................................47 Utilities Systems Management ......................................................................................................49

WakeMed Facility Specific (Chapter 3) ...................................................................................................51 Environment Of Care Quick Response Guide ................................................................................52 Utility Systems Management .........................................................................................................59

SWO Summary Packet Test and Documentation (Chapter 4) ...............................................................61 Summary Packet Test .....................................................................................................................62 Summary Packet Test Answer Sheet .............................................................................................67 Human Resources Acknowledgement Form .................................................................................69 Confidentiality Agreement .............................................................................................................71

Educational and Technical Resources (Chapter 5) .................................................................................73 Lawson Login ...................................................................................................................................74 Kronos Login ....................................................................................................................................75 Systems Quick Reference Guide - Staff Level ................................................................................76 Systems Quick Reference Guide - Management Level .................................................................77 Accessing the WakeMedWeb on a non-WakeMed computer .....................................................79 Information Services Documents ...................................................................................................80 Wake Area Health Education Center (AHEC) Brochure ................................................................91

Frank Horton Employee Assistance Program (EAP) Brochure......................................................93

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Instructions and Overview Chapter 1

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WakeMed Systemwide Orientation Summary Packet Description and Instructions

The WakeMed Systemwide Orientation Summary Packet is designed to orient non-employees who will be working within the WakeMed System. On a limited case-by-case basis, the Packet may also be used to orient new employees who receive special approval by an HR Manager.

Independent Contract Workers, Agency Personnel, Observers, Students performing clinical rotations, Student Interns, Medical Residents, Medical Staff, Allied Health Professionals/Medical Office Staff who accompany and/or assist physicians with patients are encouraged to attend applicable portions of the employee orientation program. However, recognizing the inconvenience for those with short-term assignments, individuals intending to be at WakeMed less than 30 days, may be provided a Systemwide Orientation Summary Packet for review and completion.

The Packet includes all of the Joint Commission orientation information required for new employees, as well as non-employees, in addition to the WakeMed Systemwide Orientation Summary Test.

This packet may also be used for Non-WakeMed employees who do not have access to Learning Link to complete systemwide yearly mandatory requirements.

How to Access the WakeMed Systemwide Orientation Summary Packet

Department managers or supervisors can contact Staff Development & Training (SD&T) at 919-350-8306 to request a copy of the WakeMed Systemwide Orientation Summary Packet. An SD&T staff member will obtain information from the manager or supervisor for distribution of the Packet.

Upon approval from a HR Manager, the Packet (including test and answer sheet) will be sent to the manager or supervisor via interoffice mail or can be picked up at SD&T, located on the ground floor of the Medical Office Building. The most recent version of the Summary Packet can also be accessed under Systemwide Oreintation Resources on the Staff Development and Training SharePoint site.

How to Use the WakeMed Systemwide Orientation Summary Packet and Test

Managers, supervisors or an assigned staff member are required to administer the Packet to the user. The Summary Packet Administrator is responsible for the following items:

• Reviewing the content of the packet • Answering questions regarding packet content • Providing the test to the user and explaining the instructions • Reviewing the test answers with the user to make sure there is a clear understanding of the

packet content • Filing a copy of the following documents from Chapter 4 of this packet (copies will be filed in

different places dependent upon whether it is an employee or non-employee. See details below):

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o For Non-Employees = keep copies within the department (Remember – packet is to be administered annually to non employees that DO NOT have access to learning link to be compliant with Joint Commission). The following should be filed: Completed and graded test Signed WakeMed Confidentiality Agreement Form Signed Human Resources Acknowledgement Form

Contact Information

Please contact SD&T at 919-350-8306 between the hours of 8:00am–5:00pm, Mon.-Fri., if you are requesting a WakeMed Systemwide Orientation Summary Packet or if you have any general questions regarding the Packet.

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Other Educational Requirements

For Non-WakeMed Employees:

Independent Contract Workers, Agency Personnel, Observers, Students performing clinical rotations, Student Interns, Medical Residents, Medical Staff, Allied Health Professionals/Medical Office Staff who accompany and/or assist physicians with patients are required to complete this Systemwide Orientation Summary Packet. Completion of all other educational components is dependent upon your length of employment and is at the manager’s discretion.

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Welcome to WakeMed WakeMed Health & Hospitals welcomes you to our organization. The WakeMed Systemwide Orientation Summary Packet is intended to orient you to our system so that you can learn about the culture, organizational expectations and various department areas that promote and maintain a safe environment for everyone at WakeMed. After reading through these materials, you will complete the WakeMed Systemwide Orientation Summary Packet Test. The packet administrator will grade your test, review the answers with you and answer any questions you may have regarding the content. Respectfully,

William K. Atkinson, PhD, MPH President & Chief Executive Officer

WakeMed: The Power To Heal, A Passion For Care

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WakeMed Health & Hospitals’ Overview WakeMed’s Past, Present & Future WakeMed was founded in 1961 to serve all the people of Wake County and to provide the most advanced medical treatment and technology to everyone regardless of their ability to pay. Today, WakeMed is a private, not-for-profit, multi-facility health system currently operating two full-service acute care hospitals, one of which is a regional tertiary care center in Raleigh and the other a community hospital in Cary; a rehabilitation hospital; two hospitals providing skilled nursing care and outpatient services; several outpatient rehabilitation facilities; and three healthplexes which include full-service emergency departments and outpatient services. Many primary and specialty care physician practices are also affiliated with WakeMed Health & Hospitals. More than 1,000 affiliated physicians form the Medical Staff at our 870-bed hospital system. WakeMed has approximately 8,000 employees throughout the system.

Because WakeMed offers the largest off-site teaching program for The University of North Carolina at Chapel Hill School of Medicine, many of our physicians hold faculty positions at the UNC School of Medicine. This affiliation allows us to attract physicians from the finest training programs around the country with expertise in every aspect of modern medicine.

Over the years and through all the growth and expansion, WakeMed has continued to maintain its mission of treating everyone, regardless of their ability to pay. WakeMed’s third president and CEO William K. Atkinson II, PhD, who came to WakeMed in 2003, believes wholeheartedly that we are “the people’s hospital.”

Every year, thousands of people count on WakeMed for their health care. Several of WakeMed’s Centers of Excellence include Heart & Vascular, Rehabilitation, Neurosciences, Orthopedics, Pediatric & Neonatology, Emergency & Trauma Services (Level 1 Trauma Center) and Obstetrics & Gynecology. Visits to WakeMed’s six full-service emergency departments total more than 211,000 a year and the Women’s Pavilion & Birthplace staff in Raleigh and Cary helps bring more than 7,500 newborns into the world each year. It all adds up to a lot of people who depend on us.

Our system received re-accreditation by The Joint Commission (JC) in October 2009. After the 2009 survey, we are pleased to report that JC requested copies of several WakeMed processes because they were considered best practice. Additionally, for the past three years, WakeMed has achieved an outstanding patient satisfaction rating of 95 percent or higher for inpatient customer satisfaction (i.e. patients reporting that their experience at WakeMed was good, very good or excellent). Our work is to be continuously ready (every day) to provide quality and safe care for our patients. In addition, we need to be prepared for a Centers for Medicare and Medicaid Services (CMS) - the NC office is called the Department of Health Services Regulation (DHSR) - or the Joint Commission visit/survey. We can have JC and DHSR visits at any time. Our next scheduled Joint Commission triennial survey will be in 2012.

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Mission, Vision, and Values Mission WakeMed provides outstanding and compassionate care to all who seek our services. Vision WakeMed is the region's preferred health care system, providing high quality patient care and technological leadership. Our physicians, employees and volunteers represent the best minds and the biggest hearts in the business. Values • We provide a quality experience for those we serve, regardless of their ability to pay. • We partner with our physicians to provide safe, effective, compassionate care. • We are a leader in health care technology and education. • We empower employees and volunteers, recognize their achievements and encourage their

development. • We ensure financial viability and operate a well-managed, goal-directed, fiscally responsible

organization. • We value preventive health care and collaboration with others to improve the health of the

communities we serve. Strategic Plan Goals • Quality Outcomes • Unsurpassed Service • Workforce Excellence • Fiscal Responsibility • Market Development

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Regulatory Content Chapter 2

Review of this chapter is required for all users of the Systemwide Orientation Summary Packet.

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General Information Cellular Phones Because of their disruptive nature, personal cellular phones should only be used with supervisory permission while on duty. Employees, volunteers, contract employees, vendors and Medical Staff should also turn off their cell phones or switch them to vibrate status when on duty or in patient/visitor areas. Tobacco Use WakeMed is a tobacco-free campus. This policy, which supports WakeMed’s commitment to the promotion of health, prohibits the use of any tobacco products at all WakeMed campuses, facilities and office spaces (including parking lots, shuttles, sidewalks and other outside areas) and applies to anyone at these facilities, including employees, volunteers, medical staff, vendors, patients and visitors. Public Relations All media calls or inquiries should be referred to the Public Relations department. The main number for the Public Relations department is 919-350-8120. Internet Resources For internal information regarding policies, procedures, department information, campus and facility floor maps, and other topics, please refer to our internal Web site: http://wakemedweb/. Instructions for accessing WakeMedWeb from a non-WakeMed computer are in the last chapter of this Manual. For more information on WakeMed Health & Hospitals, employment opportunities and other topics, please refer to our external Web site: www.wakemed.org. WakeMed Facility List

WakeMed Raleigh Campus 919-350-8000 3000 New Bern Avenue, Raleigh, NC 27610

WakeMed Cary Hospital 919-350-2300 1900 Kildaire Farm Road, Cary, NC 27518

WakeMed North Healthplex 919-350-1301 10000 Falls of Neuse Road, Raleigh, NC 27614 Outpatient facility with a 24/7 stand-alone emergency department, day surgery, diagnostic imaging services, laboratory and physicians’ offices

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WakeMed Apex Healthplex 919-350-4301 120 Healthplex Way, Apex, NC 27502 Outpatient facility with a 24/7 stand-alone emergency department, diagnostic imaging services, laboratory and physicians’ offices

WakeMed Brier Creek Healthplex 919-350-9600 8001 TW Alexander Drive, Raleigh, NC 27617 Outpatient facility with a 24/7 stand-alone emergency department, diagnostic imaging services, laboratory and physicians’ offices

WakeMed Brier Creek Medical Park 919-350-0978 10208 Cerny Street, Raleigh, NC 27617 Outpatient facility with diagnostic imaging services and physicians’ offices

WakeMed Clayton Medical Park 919-350-4242 555 Medical Park Place, Clayton, NC 27520 Outpatient facility with diagnostic imaging services, laboratory, rehab and physicians’ offices

WakeMed Raleigh Medical Park

(919) 350-4185 23 Sunnybrook Road, Raleigh, NC 27610 Outpatient imaging, lab services and pre-anesthesia testing. Also home to the Capital City Surgery Center which is a joint venture between WakeMed and community physicians.

WakeMed Zebulon/Wendell Outpatient & Skilled Nursing Facility 919-350-4700 535 West Gannon Avenue, Zebulon, NC 27597 19-bed skilled nursing and outpatient facility

WakeMed Fuquay-Varina Outpatient & Skilled Nursing Facility 919-350-4646 400 West Ransom Street, Fuquay-Varina, NC 27526 36-bed skilled nursing and outpatient facility

WakeMed Wake Forest Road Outpatient Rehab Center 919-350-8550 3701 Wake Forest Road, Raleigh, NC 27609

WakeMed Home Health 919-350-7990 2920 Highwoods Boulevard, Raleigh, NC 27604

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Medicare- and Medicaid-certified, serving Wake County and several cities in Franklin County, Harnett County and Johnston County

Human Resources Desired Employee Interactions and Behaviors - The Wake Way: 1. Welcome and acknowledge every customer:

• Present a friendly and warm first impression. • Follow the 10/10 Rule: Greet/acknowledge customers within 10 seconds and/or 10 feet. • Focus on building or strengthening relationships with all internal and external customers. • Demonstrate a positive attitude and professional behaviors (i.e. onstage behaviors) at all

times. 2. Anticipate and clarify others’ needs:

• If you see someone who needs attention…give them your attention. • Engage patients and families and make sure they understand what is going on. • Actively participate in new ways to improve customer service. • Respond with empathy and ensure customers receive a sincere message of concern. • Respond in a timely and suitable manner. • Don’t wait until you’re asked – be proactive in providing information. • Use email communications appropriately and respectfully; recognize when face-to-face or

telephone discussions are more appropriate means of communication. 3. Keep our patients and others safe:

• Serve as a role model and encourage safe behaviors. • Avoid behavior or communication that is negative or disruptive. • Be aware of your environment, looking for things that could go wrong. • Does something not look quite right? • Question the events around you. • Immediately report concerns, errors, and policies not followed. Immediately report

disruptive, discriminating, bullying and intimidating behaviors, especially those that could have an impact on patient care.

• Decontaminate your hands before and after patient contact, 100% of the time. • Use gloves; change between patient contacts. • Introduce yourself and your role to the patient/visitor prior to taking any action with the

patient. • Confirm identification prior to any action involving a patient. • Identify unsafe practices and support/assist team members to assure resolution and safe

outcomes. 4. Ensure, respect and maintain privacy and confidentiality:

• Respect patient privacy and confidentiality – never discuss a patient outside the work environment/in an area where anyone else can hear.

• Maintain confidentiality of operational, departmental, financial and personnel information. • Be kind and respect others. • Treat everyone with courtesy and dignity. • Coach, take disciplinary action, and constructively correct staff in private when needed.

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• Give patients on stretchers the elevator in private; i.e. step off or wait for next one. 5. Work as a team. Take action and responsibility:

• If it’s broken…get it fixed, if it needs attention…attend to it. • If you can’t fix it, find someone who can. • Communicate clearly using SBAR. • Seek opportunities to exceed expectations and work cooperatively with other WakeMed

employees and departments to resolve concerns. • Treat each other with dignity and respect at all times. • Discuss concerns immediately with person(s) involved to resolve conflicts respectfully and

quickly, or report to management for guidance. • Coach, rather than criticize or blame. • Report disruptive behaviors. • Value each others' differences; look for the best in others.

6. Actively listen and respond with empathy: • Honor the golden rule: treat others as you would want to be treated. • Listen to your customer to find out what is really important to them. • Listen closely to concerns and feedback from patients/families. • Communicate clearly, respectfully and professionally.

7. You show pride in how you look and work: • Look good and follow dress code guidelines. • Interact nicely and respectfully with co-workers. • Be professional at all times. • Disclose any potential conflicts of interest. • Arrange for coverage when unavailable. • Address concerns with policy through proper channels. • Maintain proper credentials.

Always Inappropriate Behaviors/Communications Exhibiting any type of disruptive behavior, including but not limited to:

• Bullying, discriminating, demeaning or intimidating behavior - verbal, non-verbal and written • Yelling, shouting, or raising voice, especially in a hostile or frustrated manner • Exhibiting angry outbursts or temper tantrums • Being unnecessarily sarcastic or cynical • Demonstrating aggression/violence • Name calling • Gossiping and/or discussing issues/concerns behind someone's back • Starting, repeating and/or spreading rumors • Talking negatively about co-workers to others • Dismissing/disregarding/ignoring another person • Behaving uncooperatively; refusing to carry-out duties • Throwing things such as instruments, charts, etc. • Using profanity or disrespectful language • Making insulting comments and/or gestures

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• Exhibiting physically, sexually and/or verbally threatening/abusive behavior including any unwelcomed touching, pinching, patting, slapping, pushing, shoving, drawing on, etc.

• Reprimanding/criticizing/blaming in front of patient/co-workers or in an unprofessional/unproductive manner

• Making seductive/sexual advances, comments or jokes • Making racial, ethical or socioeconomic slurs or jokes • Arguing with or speaking negatively about a coworker, supervisor, and/or physician,

especially in the presence of a patient, visitor or other inappropriate person • Behaving rudely, unprofessionally, and/or disrespectfully to others • Repeatedly disregarding policies/procedures/rules • Publicly making derogatory remarks about quality of care • Ignoring a customer request or using the statement “it’s not my job” when responding to a

customer or co-worker • Refusing to communicate with or respond to others in the workplace • Displaying a lack of tolerance towards others because of differences • Deliberately undermining or sabotaging the work of others • Accessing and/or discussing confidential information, such as patient, employee or

operational information unnecessarily • Not reporting disruptive behavior. (See Disruptive Behavior & Harassment Policy)

Corporate Image First impressions are considered lasting impressions. WakeMed patients and their families are sensitive to the appearance of hospital employees and judge the hospital by the employees they see every day. Therefore, maintaining a professional, business-like appearance is very important to our overall success. Although dress requirements and uniforms may differ among departments, standard organizational guidelines regarding clothing are as follows: Appropriate Clothing • Clothing must be clean, neat, pressed, and non-tattered. • Shirts and blouses designed with shirttails must be tucked-in unless the apparel is designed to be

worn on the outside. • Business/office attire may be required due to level of public visibility, public representation,

and/or job duties. When required, business attire must be conservative. Examples include dress slacks, dress skirts, dress shoes, ties, business suits, blazers with coordinating skirt/pants, business dresses, dress shoes, etc. Also, feet must be clean and well-pedicured.

• Management staff, unless they are functioning in a staff role, should always wear business attire. It may be appropriate for managers in clinical departments to wear lab coats or scrub uniforms.

• Uniforms and dresses/skirts must be a professional length. • Hair must be clean, neat, dry, and well-groomed. (If required for infection control standards, hair

nets or other hair covering must be worn). • Cleanliness of body and good dental hygiene are to be observed at all times. • Clothes and shoes must be in good repair. Clean athletic shoes are acceptable when appropriate

for the type of work performed.

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• Visible tattoos are allowed as long as they are not offensive. • Any reasonable clothing or shoes may be worn into or from the organization by employees who

change into uniforms on-site.

Your manager will inform you of any deviations to the guidelines specific to your department’s requirements regarding uniforms, scrubs, or clothing. Inappropriate Clothing • Soiled, spotted, wrinkled or stained clothing. • Denim clothing of blue jean color, warm-up suits, sweatshirts/pants, t-shirts. • Transparent, see-through, low-cut, or revealing clothing. • Tight-fitting clothing that is revealing. • Shorts and skorts. • Hats or other head coverings except as required as part of a uniform or for religious purposes. • Apparel with advertising for other businesses. (This does not include clothing with brand

emblems, such as those with polo players, alligators, etc. Those are acceptable.) • Visible pierced accessories other than earrings. • Socks and athletic shoes with business attire. (These are acceptable when coming into/leaving

the organization or walking on a break period. They may also be acceptable due to the type of work that is being performed.)

• Visible undergarments. Drug Free Workplace /Fitness for Duty Anyone who works at WakeMed is subject to standards set forth in the WakeMed Human Resources Statement of Policies & Procedures regarding a drug free workplace. Illegal drugs or alcohol may not be possessed, used, or distributed on any WakeMed property, nor may any individual report to work at WakeMed under the influence of drugs or alcohol. WakeMed reserves the right to request and/or administer drug testing at any time. WakeMed has the right to require an employee to undergo a medical or psychological examination by an assigned physician at any time to ascertain whether or not the employee is physically and/or mentally capable of performing any and all job duties. Harassment and Other Disruptive Behaviors Anyone who works at WakeMed is subject to standards set forth in the WakeMed’s Harassment & Other Disruptive Behaviors Policy. WakeMed is committed to fostering an environment free from any form of intimidation, intolerance, discrimination or harassment based on an individual’s, race, religion, color, gender, gender identify/expression, genetics, sexual orientation, age, pregnancy, national origin, disability or veteran status. Harassing conduct in the workplace, whether physical or verbal is strictly prohibited. This also includes comments or conduct of a sexual nature. Any individual who feels harassed should immediately report the incident to their supervisor, manager or to Human Resources Department. All employees are expected to be fully cooperative with this policy at all times. Evidence of harassing behaviors or any behaviors that create a hostile work environment will be addressed immediately in accordance with Disciplinary Process Policy. For more detailed information about this subject refer to the Harassment & Other Disruptive Behaviors Policy located on the intranet at http://wakemedweb . Then click on Departments/Human Resources/Forms & policies/ Harassment & other disruptive behaviors.

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Holidays WakeMed observes the following holidays: New Years Day, Easter Sunday, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day. If a holiday falls on a weekend, the holiday will be the preceding Friday or Monday following the actual holiday. These may vary depending on your specific departmental closings. Solicitation Solicitation of the general public (patients, visitors, etc.) for any reason on WakeMed premises is prohibited. Solicitation/distribution of information/products by WakeMed personnel is prohibited. This is a summary of HR policies. A complete version of HR policies can be found on the Intranet under HR Policies and Procedures. It is everyone’s responsibility to know the organization’s policies and procedures in full. WakeMed Employment Related Policies

The following pages contain a list of WakeMed employment related policies that apply to both employees and non-employees who work at WakeMed facilities. Please access all the policies listed on the following sheet through the WakeMed Intranet. If you do not have access to a WakeMed computer, Instructions for accessing the WakeMedWeb from a non-WakeMed computer are in the last chapter of this packet. Sign the acknowledgement form to acknowledge that you have both read and understand the WakeMed policies. Every new person working at WakeMed is required to review and become familiar with each policy and procedure that applies to the individual’s employment classification.

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WakeMed Code of Conduct

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Corporate Compliance Health Insurance Portability and Accountability Act (HIPAA) HIPAA requires hospitals and healthcare providers to have privacy provisions in place that will protect patient's health and financial information. Healthcare organizations found in violation of this law can be subject to civil and/or criminal sanctions. WakeMed is required to provide all patients a privacy notice. WakeMed's Notice of Privacy Practices informs patients how we will disclose their information, and how they can access their records and request additions or amendments. In addition, this notice states that patients can request an accounting of disclosures and request restrictions of their protected health information (PHI). Patients requesting privacy restrictions will complete the "Request for Restriction of Health Information' form. Hospital staff interacting with patients can find information regarding privacy requests by checking with the patient’s caregiver, reviewing the patient record for the completed privacy form and/or by accessing the hospital electronic database. It is WakeMed policy to conduct health care communications with a patient in private and to include family members or others when the patient wishes us to do so or when family or another person is acting on behalf of a patient that is not able to make his or her own health care decisions. This means that staff should first ask the patient whether he or she wishes communication to occur in the presence of family or visitors and for staff not to assume that it is acceptable just because the person(s) is present. Health Information Technology for Economic and Clinical Health Act (HITECH) The federal law, the Health Information Technology for Economic & Clinical Health Act (HITECH) expanded the HIPAA Rules and requires notification of breaches of PHI. The notification requirement went into effect September 23, 2009. Breach Notification Requirements:

• To patients within 60 days of discovery • To Secretary of DHHS annually • To the media if 500 or more patients involved • Actions taken to decrease the potential damage caused by the breach must be included in the

report to DHHS When staff suspect a breach has occurred, they are required to immediately notify department management. Management will initiate and conduct an investigation to determine if a breach occurred; notify the Risk Assessment Team who will assist in determining if the breach poses a significant risk of financial, reputational or other harm to the involved individual and if reporting is required; log the breach in the Disclosures Database if determined that a breach has occurred; and provide education/retraining of staff. WakeMed Code of Conduct The WakeMed Code of Conduct is designed to safeguard the hospital's tradition of strong moral, ethical, and legal standards of conduct. It is applicable to all WakeMed personnel. This includes WakeMed's members of the Board of Directors, employees, medical staff, Providers of Supervised Privileges (PSPs), students, volunteers, Business Associates, contractors, and others within the WakeMed Organization. It is

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important for all WakeMed personnel to comply with all federal, state and local laws and government regulations. Anyone suspecting violations of WakeMed's Corporate Compliance Policy should contact Pandora Holloway, WakeMed’s Compliance and Privacy Officer at 919-350-8241. A Compliance Helpline number (1-800-379-0279) is also available if individuals do not feel comfortable talking with their immediate supervisor or other Management personnel at WakeMed about compliance issues. The Compliance Helpline number can be found in the Code of Conduct, on bulletin boards in each department, or by contacting the WakeMed operator. Compliance Reminders: • All workers at WakeMed are responsible for protecting WakeMed's assets, which includes time,

materials, supplies, equipment and information. • Be mindful of WakeMed's property. This includes not taking office or medical supplies home. • Personal use of WakeMed assets without prior approval of a supervisor is not allowed. • Use of WakeMed resources for personal financial gain is not allowed. • Do not accept payments or bonuses from organizations in which we refer our patients to after they

are discharged (nursing homes, rehab, etc.). • Ensure that WakeMed patients are billed only for services they receive. • All patients are to be treated with respect and dignity and provided care that is both necessary and

appropriate, regardless of a patient's ability to pay. • It is essential that all patient medical and financial information be safeguarded and not divulged to

anyone who does not use or need the information for direct health care. • Do not disclose information to unauthorized persons during and after employment at WakeMed. • Access charts/records on a "need to know" basis to carry out only WakeMed duties. • Log off all computer applications when leaving your workstation. • Maintain confidentiality at all times. Use caution when discussing patient information. • Individuals working for WakeMed shall not solicit or accept gifts from patients/family members or

visitors. Individuals wishing to make donations to WakeMed should be directed to the WakeMed Foundation.

• In no case should a WakeMed employee accept a gift of any cash or its equivalent (checks, stocks, etc) from a patient/family member, visitor, or third party.

• WakeMed personnel and their families shall not accept gifts or business courtesies with a value of $150 or more from a third party that does business with or may want to do business with WakeMed and/or its affiliates. Gifts/business courtesies may only be accepted on an infrequent basis. Gifts must not include paid expenses for travel costs or overnight lodging.

• Business meals may be provided by associates of WakeMed in conjunction with educational functions and/or business discussions as long as the meals are unsolicited, infrequently provided and reasonable in value.

Exception: For off-site education provided by members of the pharmaceutical industry, the meal must be open to other area practitioners. Meals at restaurants offered by pharmaceutical representatives only to a small group of targeted individuals may not be accepted, even if an educational component is included. • Entertainment and/or invitations to social events to further develop business relationships may be

accepted as long as the value of the event is less than $150. Political Activities No political activities may be conducted at WakeMed. Employees, contractors and affiliates are not to identify themselves as, or in any way imply they are, a representative of WakeMed in regards to individual political involvement.

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The WakeMed Human Resources Acknowledgement Form and Confidentiality Agreement are found in Chapter 4 of this packet. Please sign, date, and file them as instructed in Chapter 4.

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Performance Improvement Why are Quality & PI Important? Quality is the responsibility of everyone who works at WakeMed. The sole reason we exist is to provide quality services to our customers. As a hospital, our primary customer is the patient. However, our customers also include family, visitors, physicians, vendors, and fellow co-workers. Performance Improvement Methodology The DMAIC Method is used for all WakeMed PI Projects. PI Training Classes The Performance Improvement Department offers classes to educate staff on various PI methods and techniques. These classes can be found through Learning Link on the WakeMedWeb.

For further information contact the Performance Improvement department at 919-350-7519 or go to the PI website found on the WakeMedWeb.

D – Define …… the problem to be addressed

M – Measure … the performance

A – Analyze …. processes & data to determine improvement needs

I – Improve … the process by implementing solutions

C – Control ….. the process by establishing ongoing reviews of the performance

DMAICPerformance Improvement Method

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Patient Safety/Risk Management Risk management is a loss prevention program that identifies areas of risk, insures against these risks and continuously evaluates events to help prevent recurrence. Components of a Risk Management Program: • Detection: Identified via online incident reports, physician reported incidents, quality data

management, patient complaints, infection control, Center for Patient Safety, & compliance with Joint Commission standards

• Evaluation: Data analysis, investigation, committee review and safety rounds • Prevention: In-services, education and changes in protocols and procedures Potential Hospital Liability Areas: • Employees:

• Hospitals are liable for the negligent acts of their workers by the doctrine of respondent superior. This means an employer is responsible for wrongful acts by workers even if the employer did no wrong; however, this doesn’t relieve anyone of their legal responsibility.

• Equipment/Products: • A brief visual/functional check of equipment should be performed every day. • Defective equipment is to be removed from service, tagged, and sent for repair. • If equipment malfunctions or breaks and has the potential to cause an injury, or if an

injury actually occurs to a patient, the equipment must be secured and Patient Safety/Risk Management notified.

• Policies/Procedures: • Hospitals are responsible for providing the staff with policies and procedures, and staff

should be familiar with policies and procedures. • Facility/Premises:

• The hospital must be structurally sound and the surrounding premises maintained for the safety of everyone.

“Risk Events” That Can Result in Liability For example:

• Accidents involving patients, visitors or volunteers • Accidents resulting in property damage or loss • Situations or conditions which may result in injury or damage • Threats, complaints against the hospital • Unexpected/unintended patient outcomes

Joint Commission National Patient Safety Goals (These goals are updated every year – these are some examples of current and past goals.) • Improve the accuracy of patient identification • Improve the effectiveness of communication among caregivers using the SBAR format for

hand-off communications • Accurately and completely reconcile medications across the continuum of care • Reduce the incidence of healthcare-associated infections by washing your hands • Reduce the risk of patient harm resulting from falls

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Patients’ Rights and Responsibilities WakeMed is committed to providing a quality experience to those we serve. Care is focused on individual needs and provided in a manner considerate and respectful of each patient’s dignity. The patient is involved as a partner in the care process and has the right to participate in the development and implementation of his or her plan of care. Patient’s Rights and Responsibilities are posted in the main patient entryways of WakeMed patient care facilities. • Patient Rights include: Access to care and communication, respect and dignity, information

and participation in decision making, informed consent, conflict resolution and ethical decision making, security, privacy, and confidentiality, advanced directives, and pain management.

• Patient Responsibilities include: Respect and dignity, information and participation in decision-making, and pain management.

Patient Complaint/Grievance Procedures WakeMed encourages involvement of patients or their authorized representatives in all aspects of their health care experience. This philosophy extends to situations in which patients and/or their authorized representatives are dissatisfied with the services provided. The complaint process is described in the inpatient handbook and outpatient admission handout. Each department must keep a log of complaints and grievances that have been received by their unit. Employees, contractors and affiliates working at WakeMed need to know where the Patient Complaint Log is located within their department. It is imperative that complaints and actions be logged and management notified following each occurrence. Contact Information:

• Patient Safety/Risk Management Main Number: 919-350-8234 • Patient Safety Line: 1- SAFE (7233) or 919-350-1700, then ext. 7233 • Meera Kelley, MD, VP Quality & Safety BLOG on wakemedweb intranet • Janine Jones, RN, Patient Safety Resource Specialist at 919-350-8982 • Patient safety email: patientsafety@wakemed.org

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TB Control Plan For Health Care Workers

Developed by: WakeMed Occupational Health & Safety Services

Tuberculosis (TB) is a disease that most commonly affects the lungs. It is a type of bacteria that is spread through the air from person to person by a sneeze, cough, laugh, etc. Recently, certain types of TB have been resistant to drugs commonly used to treat this disease. In addition, the TB case rate in Wake County is higher than the state or national rates. It is, therefore, very important that healthcare workers learn all they can in order to protect themselves from exposure as well as to prevent the spread to others. This brochure will attempt to answer your questions about TB and help you to protect yourself from exposure. Q: What are the 2 types of TB?

A: The 2 types of TB are:

1. Active- usually causes symptoms: Lasting Cough, Fatigue, Fever, Loss of appetite, Weight Loss

a) TB Bacteria are multiplying in the body and can be spread.

b) Can almost always be cured.

2. Inactive - person has been exposed to TB but shows no symptoms. You have the TB germ in your body but it is not making you sick.

a) Only detected if tested.

b) Cannot be spread to others.

Q: Are there any times when I should not enter a TB isolation room or care for a patient with TB?

A. Yes. You should not risk exposure to TB if you have a medical condition that causes your system to be immunocompromised.

B. Only enter if you have been successfully fit tested for an N-95 respirator.

Q: What type of isolation does WakeMed use for patients with Tuberculosis?

A. Airborne Infection Isolation

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Q: What is a TB skin test?

A. A TB skin test consists of:

1. A small amount of fluid is placed under the skin with a needle to see if a reaction occurs. This tells you if the TB bacteria are in your body.

2. In 2-3 days after the test, you will need to have your test read. You must return to Occupational Health for your skin test reading. An appointment is not required for a skin test reading.

Q: What do the test results mean?

A. Negative results mean you probably don’t have TB bacteria in your body.

Positive results mean that you may have been infected with the tuberculosis bacteria. This doesn’t mean you have TB disease, you may have TB infection, or in other words, you have the TB germ in your body but it is not making you sick.

More tests such as a chest x-rays are needed to find out if you have TB disease.

Q: What should I do if I have had an exposure to someone with TB or have symptoms?

A. You should always report any exposure or symptoms to Occupational Health as soon as possible. Regardless whether you have TB disease or not, you must see a Health Professional for evaluation and treatment if needed.

Q: What type of personal protective equipment do I need to use when entering a room with Special Respiratory Isolation?

A. A NIOSH approved mask N95. “Fit testing” is required to make sure the mask fits you appropriately. “Fit-testing” is done by Occupational Health.

Q: After a patient is discharged who was diagnosed with TB and on Special Respiratory Isolation, how long does the room door need to remain closed?

A. The door to the patient room should remain closed for 45 minutes after a patient who has been on Airborne Infection Isolation is discharged. This will allow proper ventilation to occur and free the room of TB Bacteria. The isolation sign can then be removed.

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Occupational Health and Safety Services Raleigh – 1st Floor, Medical Office Building

• Office 919-350-8946; Injury Hotline 919-350--8155; Fax 919-350-7874 • Beeper: 919-393-5807 – An RN is on call when Occupational Health & Safety is closed • Office hours: Monday - Friday, 7:00 am to 4:00 pm • Appointments needed for respiratory fit tests only

Cary – 2nd Floor, Conference Center/WPBP

• Office: 919-350-2631, Nurse pager during normal operating hours 919-393-7007 • Beeper: 919-393-5807 – An RN is on call when Occupational Health & Safety is closed. • Office hours: Monday - Friday 7:00 am to 3:30 pm • Closed from 12:00 pm to 12:30 pm

TB Skin Test

Everyone is required to have a baseline TB screening upon hire and annually. Some areas of higher risk are tested more frequently. Contraindications for testing: +PPD skin test history and history of TB. Read by Occupational Health Nurse or their designee 48-72 hours after test administered. Two-step PPD testing is required.

Exposure to Blood or Body Fluids

• Needle sticks and exposures to potentially infectious material should be reported immediately to supervisor and OHSS.

• Red and Blue Exposure packets are available in all clinical departments. • Report to Occupational Health. After hours, call the nurse on call 393-5807.

Work-related Injuries

• Report work-related injuries immediately to your supervisor. • Complete an Employee's Report of Occupational Illness or Injury. • Report to Occupational Health. After hours, call the injury report line 919-350-8155

Back Injury Prevention Tips

• Establish a firm footing, bend at the knees, and not at the waist. • Keep back straight (head upright, shoulders back, small arch in low back). • Tighten stomach muscles and use your leg power to lift. • Follow the above tips when putting the object down. • Mechanical lifts are available in most nursing units.

Respiratory Fit Testing

• WakeMed requires respiratory fit testing upon hire and annually for staff who may be required to wear an N95 respirator as part of their normal work assignment.

WakeMed has a minimal lift policy! This means if it takes more than minimal assistance of 2 people to move a patient, a mechanical lift should be used! For more information contact Occupational Health at 919-350-8946.

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Infection Prevention (IP)

Regulatory Requirements

Centers for Medicare & Medicaid Services (CMS) – We are required to have a comprehensive IP program to receive reimbursement from Medicare and Medicaid

Conditions of Participation (COP)

Infection Control

“The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.” North Carolina General Statutes

• 10A NCAC 13B regulates hospitals

• Section .5100 requires the existence of an Infection Prevention program

• Mandates hospital construction and design

• Specifies sanitation requirements

The Joint Commission (TJC)

• Voluntary accrediting organization

• Standards for IP are used to establish a framework for an IP program.

• Standards help define the goal of surveillance, prevention, and control of infections.

• IP works to identify and reduce the risks of infections in patients and healthcare workers.

• National Patient Safety Goals (NPSG) were created in 2007 to promote patient safety.

National Patient Safety Goals (NPSG) Infection Prevention

1. Comply with Centers for Disease Control or World Health Organization hand hygiene guidelines

2. Implement evidence based practices to prevent healthcare associated infections due to MDRO’s

3. Implement evidence based practices to prevent central line associated bloodstream infections

4. Implement evidence based practices to prevent surgical site infections

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So….What does WakeMed do to comply with the requirements of the four NPSG’s directed at Infection Prevention????

Comply with CDC or WHO Hand Hygiene Guidelines

1. WM hand hygiene policy is based on CDC guidelines published in October 2002

2. Hand hygiene program is F.R.O.G.

3. Friction Rubs Out Germs

4. Key elements included from guidelines:

• Hand hygiene before and after patient care (total time: 15-20 seconds)

• No artificial nails on healthcare providers

• Alcohol products encouraged when appropriate (total time: 30 seconds)

Implement evidence based practices to prevent healthcare associated infections due to MDRO’s Prevention Measures Include

1. MRSA surveillance screening program in place in select areas based on IP risk assessment

2. Environmental cleaning protocols in place with hospital approved EPA registered disinfectants

3. Compliance w/isolation precautions evaluated

4. Staff education upon hire and annually regarding isolation

5. Surveillance data provided to key stakeholders

Multidrug-Resistant Organisms (MDRO’s)

• MDRO’s are bacteria that have become resistant to select antibiotics

• Emerging MDRO’s are concerning

• Several gram-negative organisms are developing resistance. Examples include Pseudomonas aeruginosa and Acinetobacter baumannii

• All MDRO’s require isolation when discovered

• All patients with history of VRE and MRSA are isolated upon readmission

• Help us stop the spread of these organisms---- Follow appropriate isolation protocols !

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Implement Evidence Based Practices to Prevent Central Line Associated Bloodstream Infections (CLABSI’s)

Prevention Measures Include

1. Education of staff upon hire and annually

2. Educate patient and families before lines are placed

3. Use standardized protocol for insertion

• Check lists, standardized all inclusive kit, no use of femoral vein in adults unless other sites unavailable

4. Perform hand hygiene prior to catheter insertion or manipulation

5. CLABSI rate data provided to key stake holders

Implement Evidence Based Practices to Prevent Surgical Site Infections (SSI) Prevention Measures Include

1. Education of staff upon hire and annually

2. Patient and family given education about preventing SSI

3. Hair removal with clippers before surgery (no razors)

4. Antibiotic prophylaxis within one hr of incision (2 hrs if using vancomycin or fluoroquinolones)

5. D/C antibiotics within 24 hrs after surgery

6. Follow evidence based guidelines

7. SSI rates for selected procedures provided to key stakeholders

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How Do You Prevent Infections? #1 Hand Hygiene

When Should I Use Hand Hygiene? Before and After Patient contact

Always WASH:

Before & after eating

After using the bathroom

After blowing/wiping your nose or hand to mouth contact

If your hands are visibly dirty

When caring for patients with diarrhea

When exiting Special Enteric Isolation Rooms

You may use GEL any other time, including:

Before donning & after removing gloves

After contact with surfaces surrounding patients

When your hands are not visibly dirty

Hand Health

• Avoid using oil-based hand lotions at work as they may not be compatible with our soap or gel

• Artificial nails are prohibited on direct care providers

• Nail length should be less than ¼ inch

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How Do You Prevent Infections? #2 Respiratory Etiquette

• Respiratory hygiene stations can be found at portals of entry to WakeMed facilities containing hand gel, masks, and tissues • Alcohol gel dispensers are placed throughout the facilities for employee and patient use • Patients and visitors should be taught to “Cover your Cough” • This is a requirement of the Joint Commission National Patient Safety Goals

How Do You Prevent Infections? #3 Standard Precautions

• Applies to everyone

• Consider all patients to be infectious

• Protect yourself and your patients

• Includes: gowns, gloves, masks and eye protection

• Remember: If it’s warm, wet, and not yours, wear a barrier

• Think… and wear appropriate PPE!

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How Do You Prevent Infections? #4 Transmission Based Precautions

• Requires a minimum of gloves on entering the room

• Requires a gown for direct contact with the patient or their immediate environment (bed rails, linens, bedside tables, etc.)

• Remove gown and gloves and perform hand hygiene when exiting the room

• Examples: MRSA, Shingles, Scabies

• Requires gown and gloves when entering the room

• Remove gown and gloves when exiting the room

• Wash hands with soap and water when exiting the room

• Clean any equipment with Dispatch before removing from the room

• Examples: C. difficile, VRE, Norovirus, or any patient with diarrhea of unknown & possibly infectious origin

• Requires a procedure mask to enter the room

• Patient must wear a procedure mask when out of the room

• Door does not need to be closed

• Examples: Meningitis and Influenza

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• Requires negative pressure room.

• Tissue test is required every 24 hours

• Requires use of a fit-tested N-95 respirator or PAPR for healthcare workers

• Visitors should be assisted to wear a fit checked N-95

• Patient wears procedure mask when not in room

• Door must remain closed at all times

• Examples: Tuberculosis, Chicken Pox, Measles

• Immediately notify Infection Prevention

• Requires gown, double gloves, N-95 respirator, goggles/face shield when entering the room

• Limited staff and visitors with log of all persons entering room

• Dedicated equipment

• Requires negative pressure room

• Check with the nurse before entering the room

• Examples: Avian Flu, SARS, certain bioterrorism agents

PPE holders • Throughout the WM system, we have rolling holders that can be placed

outside isolation rooms available in all nursing units In newer areas, we have PPE dispensers inserted in the walls between rooms with space for gloves, gowns and masks

PPE in the Hallways

• OSHA prohibits wearing PPE in the halls unless you could contaminate yourself while transporting an infectious patient

• CLEAN PPE is required in the hallways • You must remove PPE in the room prior to transport, perform hand hygiene, and put

on CLEAN PPE immediately before you leave the room • Shoe covers, masks, and eyewear must be removed before leaving the work area

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How Do You Prevent Infections? #5 Environmental Cleaning

• All multiuse equipment must be cleaned between patients (BP cuffs, stethoscopes, PT equipment)

• The keyboard, mouse and scanner must be cleaned every time they leave a patient room

• Dedicated equipment for isolation rooms

• #5 quaternary ammonium–10 minute kill time

• PDI Super-saniwipes- 2 minute kill time

• Dispatch- (hypochlorite) -1 minute kill time

Infection Control Website

Contains: • Policies

• Educational material for staff, patients, and visitors

• Audit tools

• FAQ’s

• Links to CDC documents

• Other Infection Control resources

Access via the WakeMedWeb Intranet: Departments Infection Control

QUESTIONS?

There are several ways to reach us:

• Call extension 919-350-2973

• Page the on-call ICP through the operator

• Smart Web online directory

• WakeMed Connect 919-350-6590

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Environment of Care Emergency Management Key Points to Remember • Be able to recognize emergencies. • Treat all emergency codes as if they are real events. Do NOT call the operator to confirm. • Know your responsibilities. • Get the required training for your position. • Look at the back of your badge frequently to learn codes. • Memorize your location’s emergency telephone number. Emergency Numbers • To report an emergency on the Raleigh and Cary Hospital campuses, call x-02222. • If you immediately need Campus Police for a security related emergency, call x-03333. • If you work at a non-hospital site, call 911 for all emergencies. • If you need to report a safety issue that you cannot solve in the department, call the Environmental

Health and Safety Office at 919-350-8080. Leave a voice message if nobody is available to answer your call and you will receive a call back shortly.

• When there is a disaster event that affects multiple departments or operations, the WakeMed Employee Alert Line is activated and will give you general information and instructions. The number is 919-350-5050. A good way to remember the number is that there is a 50/50 chance you will be called to work.

Hospital Incident Command System (HICS) • HICS is an internal structure to manage emergency events. • The Hospital Command Center (HCC) will be opened when there is an event that cannot be managed

through normal operations. • Key individuals are trained in HICS to lead emergency response teams. • The HCC team gives department guidance/direction regarding the event. WakeMed Emergency Response Teams • Key individuals are trained to serve on emergency response teams. The teams go to the event where

there is an emergency and take charge of the event. • If you are at a WakeMed off-site location, call 911 and the community’s emergency agency will

respond to you. Emergency Evacuation Plan • Evacuation occurs when there is an immediate threat of danger to persons/property and people need

to evacuate to a safe area. • The senior ranking employee at the location has the authority to start the evacuation. • Know your evacuation routes from the department. • Know your safe area location.

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Hazardous Materials and Waste Management Hazardous Chemical Exposure Health effects from exposure to hazardous chemicals depend on how the chemical enters your body, the exposure concentration, the exposure frequency, and the exposure length. Inhalation – Breathe in any material Inhalation is the most common way for chemicals to enter your body. You can breathe in dust, fumes and vapors from various hazardous chemicals like solvents and gases. Ingestion – Accidentally eat hazardous chemicals Chemicals can enter your mouth if you eat after handling chemicals, or you might accidentally swallow a chemical. Absorption – Chemicals contact skin and are absorbed Acids and alkalis can be absorbed into your skin if you touch or spill them. Injection – Unprotected sharp objects that have been in contact with x materials Needles, glass, or other instruments / objects with sharp edges may come in contact with hazardous materials. Always use proper precautions when using sharps. 10 Tips for Controlling Hazards • Recognize & understand chemical characteristics. • Only qualified workers may use hazardous chemicals. • Use only properly labeled containers. • Immediately report chemical spills, leaks, or accidents. • Use Personal Protective Equipment (PPE) when indicated. • Never use unidentified chemicals. • Store chemicals in approved areas. • Dispose of used chemicals & containers properly. • Get help from your supervisor if you don't understand the label information. • Know what to do in an emergency. Label Requirements: OSHA requires that all hazardous chemical containers have labels with: Product name Warning statement Safe use Name and address of manufacturer Chemical Transfers: Chemicals transferred from one container to another must be labeled with the same information as described above. NOTE: The only exception is when a secondary container is for immediate use, and it must be used by the same person during the course of one shift. Cytotoxic (Chemotherapy) Drug Safety • The only safe exposure level is NO exposure. • Only trained staff can work with these drugs. • Appropriate personal protective equipment (PPE) must be used when working with drugs. • There are policies that describe correct disposal of drugs and items used in chemotherapy

administration. Radiation Safety • Only properly trained individuals will handle or administer radioactive materials. • Radiation signage is posted in all rooms where radioactive materials are stored or used. • Do NOT enter these areas without proper supervision. • Eating or storage of food is not permitted in these areas.

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• Materials must be secured when unattended. RAFT-Chemical Spill Procedure Remove all persons from danger. Avoid contact with the chemical. Find and read the Material Safety Data Sheet (MSDS). Telephone the Operator, using the emergency number x-02222 and request the operator notify the Environmental Health and Safety Officer. Decontamination Alert A Decontamination Alert is called when the hospital receives patients from the community, who have been exposed to one of the following materials: nuclear, biological, or chemical. Decontamination procedures are required for patients and possibly for staff. WakeMed has an emergency response team that responds to this code, including a trained decontamination team. Stay away from the decontamination area unless you have assigned responsibilities regarding the Decontamination Alert. Your “Right-to-Know” You have a RIGHT-TO-KNOW about the hazardous chemicals you use in your job. There is a Hazardous Chemical Inventory for your department. If you have questions or concerns about hazardous materials, call WakeMed's Environmental Health and Safety Department at 919-350-8080. Material Safety Data Sheets (MSDS) • The MSDS is a good source of hazardous chemical information. • The chemical manufacturer writes the MSDS. • You have a right to see the MSDS for the chemicals you work with in your area. • An MSDS for each chemical listed in the chemical inventory on the WakeMed intranet. Go to the

Environmental Health and Safety web page. Click on MSDS Online and search for the MSDS you want to retrieve.

Regulated Medical and Biomedical Waste Regulated medical waste is waste that is potentially capable of causing disease in humans and may pose a risk to individuals or the community if not handled or treated properly. Biomedical Waste includes items containing volume blood and body fluid, discarded sharps, cultures, vaccines, etc. Personal Protective Equipment Personal protective clothing and equipment must always be used when there is an exposure risk from blood or body fluids or chemicals. To protect yourself from infectious materials or chemical exposure, there are specific pieces of equipment in healthcare you may need. WakeMed provides and maintains, at no cost to you, appropriate personal protective equipment such as, but not limited to, the following: • Gloves (utility, disposable) • Masks, eye protection and face shields • Gowns, aprons, lab coats, surgical caps or hoods, shoe covers, booties, etc. • HEPA or N95 respirators • Resuscitation bags/mouthpieces, pocket masks

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Life Safety Management Fire Prevention Practices • Make sure all storage is kept at least 18 inches from the ceiling in sprinkled buildings. • This measure allows the sprinklers to work properly in the event of a fire. • Storage must be kept at least 24 inches from the ceiling in non-sprinkled buildings. • Store and work with flammable materials properly. • Avoid a cluttered workspace. Hallways and Exits • Hallways must be kept clear of carts and equipment. • Any equipment in a corridor must be “in direct attendance” – in other words, it must be in use. • Take the time to get equipment moved when you see potentially dangerous situations. • Required fire exits are marked with exit signs. • Fire equipment must never be blocked. Fire Alarm System • Fire alarm pull stations are located by exit doors and exit stairwell doors. • Smoke detectors are located throughout the building. • Strobe lights and audible alarms are located throughout the building. • These devices activate to let persons know of the threat. Fire Alert/Confirmed and Department Responsibilities A Fire Alert is to be started when there is the smell of something burning. A fire confirmed is to be started when there is smoke or fire. You should know your department’s fire plan, evacuation routes, and safe area, as well as the location of fire emergency equipment, such as fire extinguishers and fire pull stations. Fire Drills/Events If you are in the area of the fire, you are to use: RACE/PASS Procedures Be ready to evacuate to the area of refuge (safe area) When you are in a department and you hear the fire alarm and the fire is NOT in your department: • Stop what you are doing unless you are in a life saving procedure. • Close all the doors in your department. • Stay alert to overhead announced instructions. • Follow the fire plan for your department regarding evacuation. RACE-Fire Response at Location of Fire Rescue all persons in danger. Alarm others. Pull the closest fire alarm and call the emergency number. Contain the fire by closing all doors and windows. Extinguish fire using a proper fire extinguisher. Evacuate if necessary. Fire Extinguishers You don't need to remember which extinguisher to use. The fire extinguisher appropriate for your area is placed there. For general areas, the ABC type fire extinguisher is available. It can be used on all types of fires.

ECAR ECAR is used when an individual is on fire and the environment is oxygen-enriched. ECAR is RACE done in reverse order. As part of confining the fire, make certain the oxygen source is turned off in the area.

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Fire Classifications: A – Ash Wood, Cloth & Paper B – Boom Combustible / Flammable Liquids such as Oil, Gasoline & Grease C – Current Electrical Equipment K – Kitchen Cooking Oils PASS-How to Use a Fire Extinguisher Use the word PASS to remember how to operate a fire extinguisher: Pull the pin Aim the nozzle at base of fire Squeeze the handle Sweep from side to side at base of fire Evacuation • The rule of thumb for healthcare facilities is to defend in place, which means to evacuate when there

is immediate threat of harm. • When it is necessary, evacuation needs to be performed in an orderly manner. • Move the people closest to the danger first. Then move in a horizontal direction away from the

danger. • If vertical evacuation (removal down the stairs to another floor) is required, the person in charge of

the hospital’s Fire Alert Emergency Response Team or the fire department will give instructions on how far down to evacuate persons.

Area of Refuge (Safe Area) • Know where the area of refuge (safe area) is for your department. • In the hospitals, the first area of refuge (safe area) is on the other side of fire and smoke doors. • If the fire continues to spread, a second area of refuge may be determined as the next step in the

evacuation process. • In business occupancy buildings, such as the Andrews Center or MOB, the area of refuge is generally

outside the building. • Check with your supervisor to confirm where the safe area is for your department.

Fire and Oxygen The more oxygen that is available, the more the fire will burn. The fire will continue to get hotter and get much larger if large amounts of oxygen are available. When should oxygen be turned off? • When there is danger that the fire may damage the wall oxygen valve in the room. • If unsure, the supervisor in the area should side with safety and have the valves turned off. • Know the location of oxygen shut-off valves for your area.

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Ignition Sources Do not bring the following to WakeMed: hotplates, space heaters, toaster ovens, and electric frying pans, etc. These items increase the likelihood of a fire and are not to be used at any WakeMed location. Electrical • Extension cords are not allowed except in very special circumstances. • Keep electrical cords away from heat-producing equipment. • Replace any electrical cord that is cracked, frayed, or otherwise damaged. • Never pinch an electrical cord against walls or furniture. • Do not run electrical cords under carpets or across doorways. • Don't allow equipment to rest on, or roll over electrical cords. • Check with Environmental Health and Safety if you have any questions. Interim Life Safety Measures (ILSM) When construction and/or other projects are taking place that may result in a compromised life safety environment and/or if there is fire system failure, Interim Life Safety Measures (ILSMs) will be put into place. Some of these include: • Areas under construction will always maintain exit routes. • There will be daily inspections of the area. • Staff may be required to have additional training. • Call Environmental Health and Safety at 919-350-8080 if you have any concerns when construction

and/or renovations are occurring in your area of work. Medical Equipment Management Medical Device Reporting Under the Safe Medical Devices Act (SMDA), WakeMed must report serious or potentially serious device-related injuries, illness or death of patients and/or employees to the manufacturer of the device. This is called a Medical Device Reporting (MDR) Event. Equipment Disruption or Failure A device may cause death or serious injury to a patient due to: device failure, malfunction, improper or inadequate device design, manufacture, labeling, or user error. The Patient Safety Services/Risk Management office will file the report(s) with the manufacturer of the device and/or the FDA. Since these reports must be filed with the FDA within 10 working days of the date of the incident, prompt reporting to Patient Safety Services/Risk Management is essential. Equipment Management Equipment Analysis Select medical equipment receives a Clinical Engineering tag, indicating it is approved for use. Equipment Training • All employees who are responsible for using or maintaining equipment must be trained each year, or

as often as necessary. • Equipment training includes emergency clinical interventions during failures.

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• If you are not sure how to operate a piece of equipment, you should ask your supervisor to provide you training.

Training Materials A copy of your equipment user/training material must be kept in your department. Equipment Problems If you notice anything that does not work correctly, or has loose or frayed wires, you should: Step 1: Report it to Clinical Engineering Either place it in the designated service area within your department for pick-up, or deliver it to Clinical Engineering. Step 2: Tag it Put a yellow Out-Of-Service tag on the equipment with your department, date and problem. Step 3: Get a back-up Get a back-up piece of the same equipment. NOTE: Do not use the equipment until checked or replaced by Clinical Engineering. Types of Labels Remember: ALL medical equipment, including outside equipment, must be checked by Clinical Engineering before it is placed into service or used on a patient. There are no exceptions!

• The yellow sticker is placed on WakeMed owned equipment that is inspected and receives

preventative maintenance annually. • The blue sticker is placed on WakeMed owned equipment that does not require annual preventative

maintenance. • The lavender sticker is used on equipment that is not owned by WakeMed. Safety Management Safety Management Goal Safety Management’s goal is to provide a safe and functional environment for all who come to WakeMed. Each employee is responsible for the safety of patients, visitors and co-workers. Slips, Trips, and Falls Learning to recognize and correct slip, trip, and fall hazards is important. Use fall precautions when working. a. Use adequate lighting. b. Wear shoes with good traction. c. Use handrails. d. Keep work areas uncluttered. e. When carrying objects, make certain you can see where you are going.

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Reporting Hazards As an employee, you have a responsibility to report workplace hazards to your supervisor. You must immediately report the following incidents to your supervisor: • Injuries • Potential hazards • Spills • Any other health and safety incident Circled below are the safety hazards in the pictured workspace.

MRI Safety An MRI is an extremely strong magnet that will attract certain metals toward the MRI unit. The MRI magnet is always on and attracts ferrous objects. On August 2, 2001 a child was killed in a hospital when a caregiver brought an oxygen tank into the MRI room. It flew into the center of the magnet where the child was lying and fatally injured the child. Do not enter the MRI area unless you are under the direct supervision of an MRI staff member. All equipment that enters the room must be MRI compatible.

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Utilities Systems Management Utility System Utility systems include: • Computer Systems • Electrical Systems • Elevators • Heating/Ventilation/Air Conditioning (HVAC) • Pneumatic Tube System • Sewer Systems • Telecommunications • Water Systems

This list is not all inclusive.

Numbers to Remember • Campus Police Emergency Line 919-350-3333 • Emergency Event Line 919-350-2222 • Employee Alert Line 919-350-5050 • Environmental Health & Safety Hotline 919-350-8080 • Information Services HELP Desk 919-350-8700 • Patient Safety Line 1-SAFE • Remote Site Emergency Events : 911 • Raleigh Campus Service Line; extension 12345 Resources to Remember • Environment of Care Intranet Page

– Environment of Care Checklists – Environment of Care Manual – Event / Drill Evaluation Forms – Incident Command Job Action & Forms – MSDS OnLine – Quick Response Guides

People to Remember Environment of Care Safety Officers Dr. Barb Bisset x07482 or (919) 350-7482 Nathan Funk x08375 or (919) 350-8375 Robert Maloney x05678 or (919) 350-5678 Linda Baker x05607or (919) 350-5607 Closing Thoughts • Not on my watch • Every standard, every day • There are no accidents – every event can be prevented • Details matter • The Wake Way is the Safe Way

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WakeMed Facility Specific Chapter 3

If you are an employee or non-employee assigned to a WakeMed facility, this chapter is required and provides additional WakeMed Facility specific information.

Environment of Care

Environment of Care Quick Response Guide

Initial Steps for the First Employee Who Discovers an Emergency Event

Emergency Management

Description Page/ Announcement Employee Responsibilities

Capacity Management

Activated when the bed census indicates the Gridlock Level (3), Diversion (4) or Disaster Level (5)

Announcement/Page: Level 5 will be announced. Refer to Mass Casualty information.

• Report to your supervisor for your assignment. • All departments should utilize the Capacity Management

Department Quick Response Guide and take the actions as written for the level that is activated.

Emergency Evacuation from an Area

Evacuation from an area due to an immediate threat of injury.

Announcement/Page: Staff, please perform an immediate evacuation

from, specify location(s)

• Remove persons in the hazard or danger zone first. • Calmly and rapidly follow the evacuation route(s) from

the affected department. to the department’s safe area of refuge.

• On arrival in the safe area, account for all persons. • If persons are missing, report this information to the first

responder on scene. Epidemiological (Emerging and/or Contagious Disease)

Biological event. Examples: SARS, anthrax, avian flu.

Announcement/Page: Event will not be announced.

• Report any suspicious infectious cases to your supervisor, who will notify Infection Prevention and Control.

• Report to your supervisor for specific instructions. • The Biological Assessment Team (BAT) will be activated

to evaluate the situation. Inclement Weather – Urgent

Tornado warning is given when an actual tornado funnel has been spotted in the area.

Announcement/Page: Weather Alert for Wake

County - Tornado Warning – Please report

to the department’s tornado safe zone.

Move all persons who can be safely and quickly moved to the tornado safe area designated within the department.

If patients cannot be moved, turn the head of the bed away from the windows; lightly cover the person with a blanket (to minimize injuries form shattered glass and debris.)

Inclement Weather – Not Urgent

High winds, floods, ice or snow

Announcement/Page: Event will not be announced. Communications will be made through e-mail, the Intranet and the Employee Alert Line 919-350-5050.

Confirm job duty assignment with the supervisor. specifying status on A (Active) or the R (Reserve Team.

Be prepared to perform assigned duties as requested. The weather radios/television and WakeMed

announcements should be monitored. Refer to the Personal Preparedness Quick Reference

Guide located in the Management of Employees in Emergencies and Disasters Plan.

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Emergency

Management Description Page/ Announcement Employee Responsibilities

Infant Deliveries Outside of Labor and Delivery

An infant is delivered outside of Labor and Delivery

Announcement/Page: Event will not be

announced.

Raleigh Campus & Cary Hospital: The Communications Center should be contacted at 02222 and request the Labor & Delivery Emergency Response Team.

North Healthplex should contact the Emergency Department.

All other sites should call 911. The infant should be accompanied until the team arrives.

Internal Flood (Liquid Damage)

There is some type of internal damage to the building due to liquids

Announcement/Page: will not be announced.

Remove all persons from immediate danger. Assistance should be requested; the Communications

Center should be contacted, who, in turn, will notify Facility Services for the affected building.

An inspection should be contacted for hazards, which might include electrical, chemical or slip hazards. Steps need to be taken to avoid and/or to reduce these hazards. Areas should not be entered if there are hazards. The flow of liquid should be detained, if it is possible and safe to do so.

The Chemical Spill Emergency Operations Plan is should be consulted if there is a chemical involved.

Mass Casualty

Mass casualty Event involves multiple victims arriving in the Emergency Department.

WakeMed has been notified there is the potential to receive multiple victims: Announcement/Page:

asualty Alert vent confirmed:

Announcement/Page: asualty Event Confirmed.

Report to your assigned role.

Pre-assigned role for mass casualty response should be filled, with preparations begun to assume that role when the alert is announced. Once event has been confirmed, employee should report to their assigned posts.

Hazardous Materials

Description Page/ Announcement Employee Responsibilities

Chemical Spill When a chemical is spilled internal to a WakeMed building. Minor Spill: Nontoxic chemical, less than 1 gallon or a toxic chemical, less than 20 ml. Major Spill: (non toxic chemicals, greater than 1 gallon and/or any toxic chemical spill)

Event will not be announced. Should another activity need to happen, related to a chemical spill, that activity will be announced. For example: Announcement/Page: Staff, please perform an immediate evacuation from, specify location(s)

Use RAFT Procedures R: Remove persons from danger. A: Avoid contact with the chemical. F: Find the MSDS data sheet and follow directions T: Telephone - supervisor for a minor spill. For a major spill, for Raleigh Campus and Cary Hospital, the Communications Center should be contacted and a request the activation of the WakeMed Chemical Spill Emergency Response Team made. Note: For minor spills, WakeMed staff that is trained to handle the chemicals should clean the spill using the appropriate PPE. For major spills, the WakeMed Chemical Spill Emergency Response Team will assume the lead role for the spill upon their arrival.

Decontamination

Nuclear, biological, or chemical event requiring decontamination

Announcement/Page: Decon Team, immediately report to the Emergency Department.

Employees who become aware of any such incident are to dial 02222 and report the situation. The operator will page the Decontamination Team.

Decontamination emergency response team members respond to the decontamination site.

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Life Safety

Description Page/ Announcement Employee Responsibilities

Fire, Smoke and/or Detecting the odor of Something Burning Fire, Smoke and/or Detecting the odor of Something Burning (continued)

Fire, Smoke and/or Detect the odor of Something Burning

When the call is received and/or the alarm system is activated: Announcement/Page: Fire Alert. The location will be specified. (If it is confirmed there is actual smoke or fire): Announcement/Page: Fire Confirmed –the location of the origin of the fire will be specified.

Department of Origin for Fire or Smoke Use RACE and PASS procedures R: Rescue persons from danger A: Activate nearest pull station; Call the emergency number for your site. Hospital Sites: call 02222. Other Sites: call 911. C: Contain the fire by closing all doors E: Extinguish the fire by using PASS procedures & Evacuate to safe area of refuge if there is an immediate threat of injury or harm. P: Pull pin A: Aim nozzle S: Squeeze handle S: Sweep and spray Departments Adjacent to the Department of Origin for Fire or Smoke If located in business occupancy rated building: employees should evacuate the building and report to the assigned reporting area outside. An immediate accounting for everyone should be undertaken, with immediate notification of the first responders if someone is missing. If employees are in an ambulatory or healthcare occupancy rated department: Efforts should be made to communicate with patients

and visitors, informing them know that there is a fire alert, Instructions will be offered regarding any further necessary actions that might be needed.

All the doors should be closed. All items should be cleared from the hallways. Efforts should be undertaken to receive persons from

the department of origin should an evacuation be necessary.

Employees should stay within their respective departments, unless it also becomes under threat of harm; if so, they should proceed to the department’s safe area of refuge.

Employees should stay alert to further announcements, until the event is cleared.

Medical Equipment

Description Page/ Announcement Employee Responsibilities

Medical Equipment Failure

Will involve a single device failure or a system failure.

If there is a system failure affecting more than two departments: Announcement/Page: Medical System Interruption –specify type of equipment and location. Downtime procedures should be initiated.

Clinical interventions (downtime procedures for equipment) should be initiated to minimize risk to patients.

Power status should be verified – is equipment plugged in?

Operator settings and accessory status should be confirmed.

Assistance from super user / supervisor should be requested.

If continued failure, the Clinical Administrator of the site should be notified.

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Failed equipment should be immediately removed from service. Notify Biomedical Engineering.

Security

Description Page/ Announcement Employee Responsibilities

Bomb Threat The threat of an explosive device has been received at a WakeMed site.

When indicated, Campus Police will request an announcement. Announcement/Page: Threat received, conduct search of your department.

Employee Receiving the Telephone Call: If possible, without arousing any attention, a second p

should be called to the telephone to listen. As much information as possible should be collected

caller The emergency number for the site should be contacted,

name, location and information gathered. Employee Receiving a Written Bomb Threat Message: Campus Police should be contacted at 03333. Employee Observing a Suspicious Object: The area should be calmly and immediately cleared of

people. The emergency number for the site should be

contacted offering the name, what is suspected and the location where the incident is taking place.

Upon their arrival, Campus Police will take the leading role for the response.

Immediate Threat to Person / Persons

Immediate threat of harm to persons due to escalation of another person’s behavior

Campus Police will request this announcement only when multiple departments need to be secured or the situation is not well contained. Announcement/Page: Staff Assist and Location Security Alert- Restricted Access and Location(s)

Panic alarms will be activated wherever available. The emergency number for the site should be

contacted. As much information as possible should be provided to

the Dispatcher. All persons in the immediate area of the threat should

be removed, if it is safe to do so. Staff, in the affected department who has been trained

in NonViolent Crisis Intervention (de-escalation techniques), should respond to the situation.

Once they arrive on scene, Campus Police (or local law enforcement for other sites) will assume lead role.

Civil Disturbance

Threat of harm due to a group of individuals demonstrating escalating behaviors and causing a near or actual riot.

Campus Police will request this announcement only when multiple departments need to be secured or the situation is not well contained. Announcement/Page: Security Alert-Restricted Access and Location(s)

Panic alarms will be activated wherever available. The emergency number for the site should be

contacted. As much information as possible should be provided to

the Dispatcher. All persons in the immediate area of the threat should

be removed, if it is safe to do so. The department should go into restricted access

procedures, verifying all persons in the department are authorized to be there.

Hostage Situation

An individual has taken physical control over another person(s) in an attempt to have their demands met.

Campus Police will determine if an announcement should be made. Announcement/Page: Security Alert-Restricted Access and the affected location(s)

When there is an immediate threat of harm: Panic alarms will be activated wherever available. The emergency number for the site should be

contacted. As much information as possible should be provided to

the Dispatcher. All persons in the immediate area of the threat should

be removed, if it is safe to do so. Campus Police (or local law enforcement for other

sites) will assume the lead role of the situation once on the scene

If not located in the affected area, employees need to 56

stay away from that area.

Security

Description Page/ Announcement Employee Responsibilities

Missing Infant Missing Infant: an attempt, suspected or actual removal of a newborn or infant, less than one year of age, without proper authorization.

Announcement/Page: Code Pink: Staff will immediately conduct a search of involved departments. When Campus Police have the description of the suspected abductor: Announcement/Page: Attempt to locate, description of person. Call Campus Police at 03333 when located.

The affected department should be immediately secured, assigning staff to all entrances and exits.

Unless providing life preserving patient care, employees should immediately stop what they are doing and initiate a search for someone carrying a bundle or any object that could conceal an infant, e.g. gym bag.

Linen carts, or wheeled containers, stairwells, waiting rooms, rest rooms, storage rooms, patient rooms and all space in/around the department should be inspected.

Missing Person Missing Person: a person greater than one year of age cannot be located

Campus Police will request the announcement if it is suspected the person in on a WakeMed campus. Announcement/Page: Attempt to locate, description of person. Call Campus Police at 03333 when located.

The supervisor should be immediately notified when a person cannot be located and/or someone has reported that they cannot locate a person.

“03333” should be dialed to report the situation. The Missing Persons Information form located in the

Missing Person Emergency Operations Plan should be completed as quickly as possible, and then given to Campus Police.

Utilities

Description Page/ Announcement Employee Responsibilities

Access Control System

Card swipe / controlled access

Announcement/Page: Generally not announced.

This issue should be reported to Campus Police at 08171.

Manual restricted access procedures should be undertaken.

Only authorized persons should be allowed into the department.

Information Technology

Desktop & Laptop Computers Pocket PC, Printer, Network Connectivity Failures

Announcement/Page: Information Technology Impairment, description of the type of equipment and the affected location(s). Staff should go to downtime procedures.

The Information Systems Helpdesk, at extension 08700 should be contacted.

Downtime procedures for the department with the affected equipment should be put into practice

Telecommunications

Telephone, cellular phone, IP phone, facsimile machine and pager failures

Announcement/Page: Telecommunications Impairment, description of the type of equipment and the affected location(s). Staff should go to downtime procedures.

The Information Systems Helpdesk, at extension 08700 should be contacted.

Downtime procedures for the department with the affected equipment should be put into practice

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Utilities

Description Page/ Announcement Employee Responsibilities

Utility Systems As listed below Announcement/Page: Utilities Impairment, description of the type of system and the affected location(s). Staff should go to downtime procedures. Additional instructions may be announced.

Safety measures to protect patients be should be implemented.

Downtime procedures for the department with the affected equipment should be put into practice. The Facility Services or Maintenance Group for the site should be notified.

o Raleigh Campus: 919-350-5111 o Cary Hospital: 919-350-2000

Other sites – the supervisor should be contacted, who will call Facilities Engineering Service Desk or the appropriate property management contact/landlord co. In addition: These instructions should be followed:

Utility System Impairment and/or Failure

Electrical

All critical equipment should be inspected to confirm being plugged into red outlets (Emergency generator).

Immediate measures should be taken to protect patients. Refer to Medical Equipment Interruption Clinical Quick Response Guide for details for patient interventions.

• Procedures in progress should be completed as quickly as possible; new patient procedures should not be initiated until authorized to do so.

• Flashlights should be used, as needed. • When time of expected disruption is established, the Hospital Incident Commander will make the

decision as to whether or not to continue operations in the building during the power outage. Elevator Impaired

When individuals are discovered in an impaired elevator: Communication should be initiated with the persons in the elevator. Attempt should be made to determine if anyone is injured or needs immediate medical attention. NO attempt should be made to rescue persons. Employees should stay at site until properly trained rescuers arrive. If elevators are out of service, alternate elevators should be used. If patients or equipment is not being

transported, stairways should be used. Vertical evacuation plans should be reviewed if there is a need to perform an emergency evacuation.

Fire System

If a fire system is down for more than four hours, a fire watch must be initiated in the affected locations. This fire watch must be conducted by persons who do not have other assignments.

(HVAC) Heat Ventilation Air Conditioning

If there is equipment that must be climate controlled, this should be reported to Facility Services. Infection Prevention and Control will authorize the use of fans in patient care areas. If there is limited heat, Facility Services must approve the type and use of space heaters. For heat loss, an effort must be undertaken to greatly increase the use of blankets.

Medical Gas

Effort must be undertaken to prioritize the patients needing oxygen; this finding should be reported to Respiratory Therapy.

Portable gas systems should be used. Patient procedures in progress should be completed; new procedures should not be undertaken, until

problem has been corrected. Medical Vacuum

Portable suctioning units should be used. Suctioning will be required for those patients requiring close monitoring. Patient procedures in progress should be completed; new procedures should not be undertaken, until

problem has been corrected.

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Utility System Impairment and/or Failure

Natural Gas If it is safe to do so, gas supplied equipment should be turned off.

The immediate area should be cleared of people. A match should NOT BE lit or spark producing devices, such as electric motors, be used. Windows should be opened to ventilate, if source is indoors. The windows should not be opened, if

source is outdoors. Preparation for an evacuation should be undertaken, if necessary. After the event, the gas should be turned on and the pilot lights re-ignited only by Facility Services

personnel. If a leak is suspected, the responding local fire department has the jurisdictional authority. They will

give instructions regarding evacuation from the area of threat. Nurse Call System

The close monitoring of patients should be undertaken, with increasing frequency of rounds. The nurse’s station telephone number should be placed at patients’ bedsides; if the patient has the

capability to do so, they should be told to use telephones to call the nurses station. Pneumatic Tube Stations that are not affected should be used.

Runners should be used. Sewer Stoppage

Flush toilets should NOT be used. Waste should be disposed of in red bags and placed in red plastic hazardous waste containers. Further

instructions will come from the emergency response team. Steam

Downtime procedures in affected departments should be put into effect. Sterile supplies should be conserved. Life saving procedures should only be undertaken. Extra blankets should be provided if patients are chilled.

Water Contamination

Water from fountains, the tap or ice machines should not be used, until official notice has been received that the water is safe to drink.

Bottled water for drinking should be substituted. Every attempt should be undertaken to conserve water.

Water – Non-Drinking

Every attempt should be undertaken to conserve water. Hand gels should be used for hand hygiene. Fire watches should be undertaken, if the fire system has been affected.

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WakeMed Specific Utilities Systems Management Reporting Utility Failures All work requested for maintenance needs to be referred to the work control center for your site. Contact Facility Services/Property Management, or the Information Services HELP Desk to report utility failures. • HELP Desk x08700 • Service Line for Raleigh Campus x12345 Emergency Generators Electrical Failure

• For buildings with emergency generators, power will be restored by emergency generators within a few seconds.

– Manually support ventilator patients; refer to the clinical interventions required in the Medical Equipment Emergency Operations Plan.

– Verify all electronically operated patient care equipment is plugged into emergency outlets.

– Emergency outlets and lights require 10 seconds for activation. – Report outages to the appropriate maintenance group for your facility. – Follow unit specific response as indicated.

Utilities Impairment Overhead page for Electrical Failure or Potential Electrical Problem is: Utilities Impairment • Manually support ventilator patients. • Check all electronically operated patient care equipment. • Emergency outlets and lights require 10 seconds for activation. • Report outage to Facilities Engineering. • Follow unit specific response as indicated. • In the event of extended electrical failure, notify the Hospital Emergency Operation Center (HCC) if

additional help is required.

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Systemwide Orientation Summary Packet Test and Documentation

Chapter 4

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WakeMed Systemwide Orientation Summary Packet Test 1. WakeMed is a tobacco-free campus and prohibits the use of any tobacco products at all WakeMed

campuses, facilities and office spaces (including parking lots, shuttles, sidewalks and other outside areas). a. True b. False

2. Information concerning WakeMed shall ONLY be released to the media by:

a. Physicians b. Public Safety c. Occupational Health & Safety d. CEO and Vice Presidents e. Public Relations

3. Bullying, discriminating, gossip and talking negatively about co-workers are described as disruptive

behaviors. a. True b. False

4. If an employee has knowledge of a harassing or disruptive behavior, it is their responsibility to:

a. Ignore the incident if it does not directly involve them b. Report the incident immediately to their manager or to Human Resources Department c. Notify the individual whose behavior they are reporting

5. The following are responsible for all WakeMed assets (which include time, materials, supplies,

equipment and information): a. Information Systems (IS) Department b. Administration c. All individuals working at WakeMed

This test will evaluate your competency with respect to the content you have just read in the WakeMed’s Systemwide Orientation Summary Packet. Please mark all your answers on the answer sheet. (Located in this chapter) Once you have completed the test, the packet administrator will grade the test and answer any questions you may have regarding the content. Note to Packet Administrator: To ensure your department is compliant with Joint Commission standards and the “Orientation to WakeMed” Policy, please either return the graded answer sheet, signed confidentiality agreement, and signed HR Acknowledgement form to the Staff Development & Training Office or file it in your department depending on whether they are an EMPLOYEE* or NON-EMPLOYEE*. *NON-EMPLOYEE’s: The signed, completed and graded answer sheet, along with the signed

WakeMed Confidentiality Agreement Form and signed Human Resources Acknowledgement Form will be kept and filed in your area by the packet administrator.

*EMPLOYEE’s: The signed, completed and graded answer sheet, along with the signed WakeMed

Confidentiality Agreement Form and signed Human Resource Acknowledgement Form will be sent to Staff Development & Training via interoffice mail, by email to sdregistration@wakemed.org, or by fax to 919-350-5337.

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d. Clinical staff

6. Our Code of Conduct is an explanation of WakeMed’s standards of ethics and it explains our obligation to comply with all federal laws and regulations. a. True b. False

7. Individuals working at WakeMed shall not accept gifts from:

a. Patients and their families b. Vendors, if greater than nominal value c. Friends d. Both a and b

8. The Compliance Helpline is to be used anytime an individual feels uncomfortable discussing a matter

of compliance with their immediate supervisor or other management personnel at WakeMed. a. True b. False

9. Select the correct statement(s):

a. WakeMed will try to honor all reasonable requests for restriction of health information. b. Health Information Technology for Economic and Clinical Health Act requires notification for

confirmed breaches of protected health information. c. Confidential information should not be disclosed to any unauthorized person. d. All of the statements are correct.

10. The Health Insurance Portability and Accountability Act of 1996 states:

a. Each patient is to receive a copy of the Notice of Privacy Practices b. Health care providers must inform patients of their right to privacy regarding their protected

health information c. Medical information can be released to any requesting agency without the patient’s consent d. Both a and b

11. Which statement best defines the Federal False Claims Act?

a. It is a federal statute that covers fraud involving any federally funded contract or program, including Medicare and Medicaid.

b. It established liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the government for payment.

c. It allows you to file claims directly with the government. d. The three statements listed above all correctly define the False Claims Act.

12. TB is transmitted through:

a. Blood and body fluids b. Air c. Needle sticks d. Water e. Surgical procedures

13. Patients with active TB are placed in a negative air pressure room with this type of isolation:

a. Special Enteric Isolation

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b. Droplet Isolation c. Contact Isolation d. Airborne Infection Isolation

14. If you experience a needle stick while at work you should:

a. Wash the site immediately with soap and water b. Complete a red exposure packet c. Report it to your supervisor immediately d. Report to Occupational Health and Safety or call the on call nurse e. All of the above

15. Artificial nails, of any type, are not allowed for any staff providing patient care.

a. True b. False

16. The proper length of time for hand washing is:

a. 5 –10 seconds b. 15-20 seconds c. 30 minutes d. 2 minutes

17. Guidelines recommend hand hygiene before and after patient care.

a. True b. False

18. OSHA prohibits wearing PPE in the halls unless you could contaminate yourself while transporting an

infectious patient. a. True b. False

19. The Hospital Command Center (HCC) will be opened when there is an event that cannot be managed

through normal operations. The purpose of this team is to: a. Evacuate all employees and visitors b. Give department guidance/direction through the event c. Clean up areas contaminated by a large spill

20. The ________________ has been established to give you information when an emergency event

affects multiple departments or operations. The phone number is 919-350-5050. a. Service Line b. Compliance Helpline c. Dispatch Office d. Employee Alert Line

21. Which of the following is a key point to remember in emergency management?

a. Memorize your emergency telephone numbers b. Knowing your responsibilities during an emergency c. Be familiar with employee responsibilities on the Quick Response Guide for Emergency Events d. All of these answers are correct

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22. Hazardous materials can enter your body in the following ways; Inhalation, ingestion, absorption, injection. a. True b. False

23. OSHA requires that all chemical containers have labels with:

a. Product Name b. Warning Statement c. Safe Use d. Name and address of the manufacturer e. All of the above

24. In case of a chemical spill, use the RAFT procedure. RAFT stands for:

a. Remove persons, Avoid contact, Find MSDS, Telephone b. Record incident, Act quickly, Find supervisor, Telephone c. Rescue, Alarm, File, Tell others

25. You have a “right-to-know” about the hazardous chemicals you use in your job.

a. True b. False

26. Which of the following is NOT an example of biomedical waste:

a. Human blood and human blood products b. Cultures and vaccines c. Unused disposable gloves d. Discarded used sharps

27. The acronym RACE is defined as:

a. Run And Call Engineering b. Record, Announce, Contact, Evacuate c. Rescue, Alarm, Contain, Extinguish

28. The acronym PASS is defined as:

a. Park, Assess, Shout, Send report b. Pull the pin, Aim at base of fire, Squeeze the handle, Sweep from side to side c. Pull pin, Aim at flames, Squeeze the handle, Stand still

29. ECAR is used when an individual is on fire and the environment is oxygen-enriched. ECAR is:

a. Extinguish, Close doors, Alert, Run b. Exit, Contain, Alarm, Report c. RACE done in reverse order

30. Select medical devices at WakeMed are inventoried, tracked and maintained by:

a. Patient Safety Services/Risk Management b. Clinical Engineering c. Property Management d. Facility Services

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Chapter 3 - WakeMed Facility Questions If you are an employee or non-employee assigned to a WakeMed facility, these questions are required and provide additional WakeMed Facility Environment of Care information. 31. When a Code Pink is announced, you should:

a. Secure all entrances/exits within and around your area b. Close patient room doors c. Pull fire alarm d. Move all patients away from windows e. Dial 2222

32. In the event of a power outage or electrical problem, the overhead announcement/page is:

a. Electrical Failure b. Equipment Emergency c. Utilities Impairment

33. Three key steps to consider when electrical power fails are:

a. Wait 10 seconds for emergency activation, check power-dependent patients, and report outage b. Call Engineering, pull fire alarm, and call 02222 c. Reboot computers, call supervisor, and discharge patients d. Check flashlights and call Public Safety

34. The most important task during a hostage situation is to:

a. Stay out of the hostage situation area and secure your unit b. Pull the fire alarm c. Get all patients away from windows d. Obtain a defibrillator STAT

35. Which of the following is a reason to pull the closest fire alarm and call the emergency number to

report a fire alert or confirmed fire? a. Smell of something burning b. Fire c. Smoke d. All of the above

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WakeMed Systemwide Orientation Summary Test Answer Sheet Name (Please print): ________________________________________________ Check one of the following: Employee: _____ Non-employee: _____ Student: _____ Department: ____________________________ Facility: ________________________________(i.e. Raleigh Hospital, North Healthplex, etc.) Packet Administrator’s Name: _____________________________________________ Instructions: Complete the personal information at the top and write answers on this page.

Note to Packet Administrator: To ensure your department is compliant with Joint Commission standards and the “Orientation to WakeMed” Policy, please either return the graded answer sheet, signed confidentiality agreement and signed HR Acknowledgement form to the Staff Development and Training Office or file it in your department depending on whether they are an EMPLOYEE* or NON-EMPLOYEE**.

*EMPLOYEE’s: The signed, completed and graded answer sheet, along with the signed WakeMed Confidentiality Agreement Form and signed Human Resource Acknowledgement Form will be sent to Staff Development and Training via interoffice mail, by email to sdregistration@wakemed.org, or by fax to 919-350-5337.

**NON-EMPLOYEE’s: The signed, completed and graded answer sheet, along with the signed WakeMed Confidentiality Agreement Form and signed Human Resources Acknowledgement Form will be kept and filed in your area by the packet administrator.

1. 13. 25. A B A B C D A B

2. 14. 26. A B C D E A B C D E A B C D

3. 15. 27. A B A B A B C

4. 16. 28. A B C A B C D A B C

5. 17. 29. A B C D A B A B C

6. 18. 30. A B A B A B C D

7. 19. A B C D A B C

8. 20. A B A B C D

9. 21. 31. A B C D A B C D A B C D E

10. 22. 32. A B C D A B A B C

11. 23. 33. A B C D A B C D E A B C D

12. 24. 34. A B C D E A B C A B C D 35. A B C D

Chapter 3 WM Facility Questions

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WakeMed Human Resources Acknowledgement Form

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Confidentiality Agreement

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