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Orientation Handbook for VA Affiliated Personnel

1. Keep cables and cords protected from oil chemicals liquids or sharp objects to prevent damage Arrange equipment cords and cables away from traffic keep them off of the stairs and out of aisles Extension cords are prohibited unless they have a GFI circuit AND ARE APPROVED by MARS IN Engineering BEFORE USE AT NO TIME ARE EXTENSION CORDS TO BE DAISY CHAINED Unless specifically part of your job assignment never open panel boxes reset circuit breakers or change fuses Page 9 Make sure electrical cords do not pose a trip hazard To prevent electrical shocks and fires check for damaged plugs and or pinched wires Do not allow equipment or beds to roll over power cords If an instrument or piece of equipment is malfunctioning has been dropped or has had liquid spilled on it disconnect the power cord from the wall outlet and report it to Biomedical Engineering extension 5215 or MARS extension 5138 Also enter an electronic work order and label the equipment as unsafe until it has been serviced Equipment Used in the Patient Care Vicinity Prior to using equipment that may come in contact with a patient check inspection sticker to verify that the inspection due date has not expired If the date has expired or there is no inspection sticker notify Biomedical Engineering extension 5215 or MARS extension 5138 as soon as possible and enter an electronic work order EWO to have the equipment inspected XII UTILITY SYSTEMS
2. conditional or future Harassment as it relates to workplace violence is defined as menacing or threatening behavior or communication designed or intended to intimidate menace or frighten another employee Property damage is defined as and includes behavior or acts which contribute to the destruction or damage of private or government property Response Workplace violence and threats of violence by any employee will not be acceptable Acts of violence and threats of violence will be treated as conduct violations and will be met with a response that is compatible with the seriousness of the act in question In less serious cases a Page 21 simple apology or clarification will be needed In very serious cases appropriate disciplinary action even removal will be called for In each case due process will be followed and employee rights will be honored Reporting An employee experiencing or witnessing such acts shall report these acts to his her immediate supervisor Human Resources or the VA Police They may also report the incident to your supervisor EAP or EEO Program Manager If immediate danger exists direct intervention by the VA Police will be sought Resources The Employee Assistance Program EAP represents a major resource for employees who might be troubled Courses are offered available through EAP on stress management anger management and conflict resolution These courses are available to all employees Let s
3. 09 043 Use of Cell Phones The following areas are currently defined as restricted areas Operating Rooms Recovery SICU MICU CCU Telemetry ECU monitored rooms Cardiac Catheterization Labs Special Procedure Rooms in Imaging Gamma camera rooms in Imaging Waiting rooms in Imaging Dialysis Definition These restrictions apply to cellular phones two way communication devices such as FRS radios walkie talkies two way pagers wireless personal data assistants wireless LAN Local Area Network laptops RF barcode scanners and any other device that is designed to operate as a communications device via emission of radio frequency energy Applicability This policy applies to all hospital staff Paid employees and VA affiliated personnel Exceptions Use of radios or cellular telephones during emergencies or to conduct essential VACCHS business when no feasible alternative is available is permitted Operation in close proximity to medical equipment should be minimized as much as possible Contact If you are unsure if a device omits RF energy contact the Biomedical Engineer at extension 4451 for clarification Do not make assumptions that could endanger our patients XXIII PATIENT RIGHTS AND PATIENT ABUSE POLICY It is the policy of VA Central California Healthcare System to ensure patients are provided quality health care in a respectful and courteous manner and receive the benefits and rights for which they are
4. Utility systems at this medical center include HVAC hydronic and mechanical system components medical gas domestic and sanitary plumbing natural gas and electrical power supply systems For problems with any of these systems please contact Maintenance and Repair Section at 5455 If after hours please contact the Utility Systems Operator on duty at 5403 or direct dial 559 241 6430 If at any time there is an Engineering related causality and you are unable to contact personnel at ext 5455 there is a Utility Systems Operator on duty 24 hours a day in the Boiler Plant The medical gas systems include oxygen vacuum medical air nitrous oxide and nitrogen The oxygen system is the only valve that can be shut off by the nursing supervisor but doing so will affect multiple patient care rooms Vacuum and Medical Air are systems controlled by pumps and compressors in the associated buildings penthouse or basement mechanical rooms The Nitrous Oxide and Nitrogen are specialized systems located in isolated areas of the medical center All medical gas system monitoring devices are continuously monitored by the Utility Systems Operator on duty in the event of a level or pressure alarm they have a Standard Operating Procedure to follow to ensure safety and reliability of the affected system Emergency power outlets are the red outlets located in every building These are to be accessed only for operating equipment that must not sustain interruption in the e
5. correcting any deficiencies e Standardized note titles facilitate the retrieval of patient information Appropriate note titles must be matched to note content and credentials of the author e Authors must respond promptly to Notifications that alert them to documents requiring authentication unsigned orders lab results or consults Page 16 Copy and Paste Cloned Notes The electronic function of copy and paste is a powerful tool However this functionality must be used with caution Clinical financial and legal problems may result when text is copied in a manner that implies the author or someone else obtained historical information performed an exam and or documented a plan of care when the author or someone else did not personally do it Plagiarized data in the patient record is prohibited Copying information from other documents in the patient record is unnecessary duplication of information that does not assist those reading the record Repeating information found in other parts of the health record does not provide any clear advantage but instead makes reading the charts more difficult and time consuming Copied portions of notes and other data are overwhelming to the reader and dwarf the remaining unique and relevant information within the note Copy and Paste Tenets Never copy the signature block into another note Never copy data or information that identifies a healthcare provider as involved in care that the he
6. entitled Upon admission patients or their designated representative will be provided with VHA Form 10 88 Patient and Nursing Home Resident Rights and Responsibilities dated September 2006 PROCEDURES PATIENT RIGHTS Patients receiving care in this health care system are assured of the following subject to legal or safety limitations Page 19 e The right to be treated with dignity courtesy and respect in a humane environment that affords both reasonable protection from harm and appropriate privacy with regard to personal needs e The right to receive to the extent of eligibility under the law prompt and appropriate treatment for any physical or emotional disability e The right to the least restrictive conditions necessary to achieve treatment purposes The right to hold and to dispose of property except as may be limited by applicable state law e The right to execute legal instruments e g wills e The right to enter into contractual relationships e The right to register and vote e The right to hold a professional occupational or vehicle operator s license e The right to counsel with the Patient Advocate regarding concerns and treatment at the facility e The right to be informed about the care received e The right to participate in care decisions treatment and services and accept or refuse care treatment and services in accordance with law and regulations e The right to know the names of caregiver
7. health problem characterized by the use of a drug in a manner or to a degree which interferes with the individual s health interpersonal relations economic functioning or social standing Biopsychosocial problems A term encompassing an individual s physical mental and social status For the purpose of this policy biopsychosocial may include physical emotional financial marital family legal or vocational problems that are adversely affecting the employee s job performance and or conduct Physical illness An illness pertaining to the body in which normal or appropriate functioning of the body is impaired in some manner Professional Standards Board Responsible board for determining the physical and or psychological fitness for appointment or retention in VA employment and for recommending action based on examination of findings What keeps impaired professionals from receiving treatment Denial Self treatment Occupational success General distain and lack of knowledge of substance abuse and psychiatric conditions Here are some statistical findings 15 of all physicians will become markedly impaired during their careers ANA estimates that approximately 6 8 of nurses have a problem with substance abuse 8 and 12 of health care professionals have chemical dependencies according to the National Institute on Drug Abuse NIDA Warning signs Deterioration of personal hygiene High rates of absenteeism for implausible
8. 2012 VA Central California Healthcare System ORIENTATION HANDBOOK for VA Affiliated Personnel This handbook is mandatory training for VA Affiliated Personnel Fee Basis Appointees Consultants Attendings Residents Interns Without Compensation WOC and Contract personnel who provide direct or indirect ancillary health care services Human Resources Management Service August 2012 PROVI DI NG A SAFE AND SECURE ENVIRONMENT FOR HEALTH CARE Individuals appointed to the VACCHS as VA Affiliated Personnel Fee Basis Appointees Consultants Attendings Residents Interns Without Compensation WOC and Contract personnel who provide direct and or ancillary health care services must be compliant with mandatory training required by The Joint Commission the Occupational Safety Health Administration and the Veterans Administration This module addresses general safe practice requirements measures policies and procedures which every VA Central California Healthcare System staff member need to know and use in performing patient care and or ancillary health care services Upon the completion of this module participants should be able to 1 Cite examples of a safe and secure environment of care the VA Central California Healthcare System provides its patients employees and WOC staff 2 Identify the standardized emergency codes and describe how to activate these codes at the VA Central California Healthcare System 3 Lo
9. ED Automated External Defibrillator if available and stand by to assist the emergency response team upon their arrival VII GOOD HOUSEKEEPING Slips and falls are often caused by poor housekeeping habits To help eliminate slips and falls all employees and VA affiliated personnel should observe the following Do not block doorways elevators or entrances with equipment Mopping and waxing is done on only one side of a corridor at a time leaving one side for safe passage Wet Floor signs are posted to indicate Caution Take personal responsibility to alleviate slipping or tripping conditions anywhere on the floor or stairways or report to Environmental Management Service Principal hazards may include liquids flower petals rubber bands paper clips cigarette butts and other small objects Do not use chairs boxes or other items for climbing Always use a ladder or step stool Approach corridor intersections and elevators slowly Report unsafe conditions immediately For example spills to Environmental Management Service and damaged or broken equipment to Engineering Services and Emergency Boiler Plant VIII INFECTION CONTROL Basic Hygiene Everyone is responsible for preventing and controlling the spread of hospital acquired infections Protect yourself and others with the practice of these basic hygienic measures 1 Always cover your coughs and sneezes An easy way to do this is to cough or sneeze into you
10. VACCHS EAP Program is contracted through Federal Occupational Health at www FOH4You com Treatment Outside of VA Most professional organizations have peer assistance programs within the community that provide support confidentiality and strict on the job monitoring The goal of these programs is to return the affected professional to work as soon as they are Safe to practice XXVIII AGE POPULATION AND CULTURAL COMPETENCE Page 25 The Aging Veteran In the VA approximately 40 of the patient population is over the age of 65 The fastest growing age group in America is those over the age of 80 Because of this the goals of healthcare are changing prevention changes to postponement cure changes to maintenance disease changes to decreased function Special issues faced by healthcare providers in caring for the older veteran are medication management cognitive impairment depression and end of life concerns Over 20 of the elderly population in the United States has a speech or language disorder that prevents them from expressing themselves or hinders their ability to understand others Tips for communicating with the elderly include Get the person s attention before you speak Maintain eye contact and keep your mouth visible Reduce background noise Eliminate glare Speak loudly enough for the person to hear you do not shout Use facial expressions and gestures Use simple words and sentences Ask one question at a
11. Work with ozone depleting substances Use large amounts of electricity or water Purchase chemicals medical or other supplies Your job activities could impact the environment by e Causing a spill of hazardous chemicals that could pollute the air soil or water e Incorrectly storing or disposing of waste that could pollute the soil and water e Not recycling when possible which creates more waste in landfills We need Environmental Programs to prevent air water and land pollution that could create EPA fines for non compliance Chemical resistant pest populations Negative impacts of chemical management Toxic effects of chemical management Excessive use of water resources Loss or degradation of wetland resources Contamination of soil and water Page 28 Our current environmental programs include Hazardous Waste Lead Asbestos Mercury Hazardous Material Water and many others Each of us is responsible to Use recycled products Conserve energy and water Prevent pollution use green products Prevent unplanned spills Make sure we follow organizational and VACCHS guidelines on environmental issues You can help by Following medical center environmental policies and procedures Participating in campus wide recycling efforts Using public transportation or participate in a car or van pool Conserving energy Turn off lights computers appliances radios and fans before leaving work e Submitting your suggestio
12. all work together to decrease the possibility of workplace violence and to assure that the VACCHS is a safe place to work XXVI STANDARDS OF ETHICAL CONDUCT PRINCIPLES OF ETHICAL CONDUCT FOR GOVERNMENT OFFICERS AND EMPLOYEES Includes WOC EMPLOYEES Executive Order 12674 of April 12 1989 By virtue of the authority vested in me as President by the Constitution and the laws of the United States of America and in order to establish fair and exacting standards of ethical conduct for all executive branch employees it is hereby ordered as follows Part Principles of Ethical Conduct Section 101 Principles of Ethical Conduct To ensure that every citizen can have complete confidence in the integrity of the Federal Government each Federal employee shall respect and adhere to the fundamental principles of ethical service as implemented in regulations promulgated under sections 201 and 301 of this order e Public service is a public trust requiring employees to place loyalty to the Constitution the laws and ethical principles above private gain e Employees shall not hold financial interests that conflict with the conscientious performance of duty e Employees shall not engage in financial transactions using nonpublic Government information or allow the improper use of such information to further any private interest e An employee shall not except pursuant to such reasonable exceptions as are provided by regulation solicit or a
13. althcare provider is not involved in Do not copy entire laboratory findings radiology reports and other information in the record verbatim into a note Data copied into the record needs to be specific and pertinent to the care provided Do not re enter previously recorded data Authors are liable for the content of copied items within the notes they authenticate Authentication identity and professional discipline of the author date and time signed Different signatures on the same electronic document in the health record have distinct separate purposes depending on the role of the signer Currently there are three types of signatures in the electronic health record A signer is the author of the document A co signer is the attending staff or supervising clinician who may edit and authenticate a document if the author has not already signed the document Identified signer and additional signer are synonymous This is a communication tool used to alert a clinician about information pertaining to the patient and for the recipient to acknowledge receipt of the information Being identified as an additional signer does not constitute a co signature Reference VHA Handbook 1907 1 Health Information Management and Health Records For more information regarding documentation of patient care please contact our Health Information Management Department XXI BOMB THREATS How to handle bomb threats Bomb threats ar
14. apy and a variety of surgical interventions Transsexual female to male FTM individuals who are female sex at birth but self identify as male and often take steps socially or medically to transition to male again can include hormone therapy and a variety of surgical interventions Intersex individuals who are born with reproductive or sexual anatomy and or chromosome pattern that doesn t seem to fit typical definitions of male or female These individuals often are assigned male or female gender by others at birth although later on in life the individual may not identify with that assigned gender Key Points e VHA Directive 2011 024 dated June 9 2011 entitled Providing Health Care for Transgender and Intersex Veterans states that respectful delivery of health care will be delivered to all transgender and intersex veterans who are enrolled in the Department of Veterans Affairs health care system or are otherwise eligible for VA care e Refers to the medical benefits package Title 38 Code of Federal Regulations SFR Section 17 38 VA provides care and treatment to veterans that is compatible with generally accepted standards of medical practice and determined by appropriate health care professionals to promote preserve or restore the health of the individual e VA will provide health care for transgender patients including those who present at various points on their transition from one gender to the next This includes th
15. be used to verify identities in order to enter federal buildings or gain access to federal computer networks Veterans Affairs VA Handbook 0735 provides in conjunction with the policies and responsibilities defined in VA Directive 0735 Homeland Security Presidential Directive 12 HSPD 12 Program and facility policy the guidance regarding the use administration and governance of VA identity credentials Lost PIV Badge Procedures For other ID Badges contact HR Personnel Security Make every attempt to find the badge and after 1 hour you are still unable to locate the card report loss as follows Page 29 z Report to Police Services and obtain report 2 Report loss to HR Personnel Security section so card can be suspended then notify your Service PIV Manager Sponsor 3 Report loss to Facility ISO and obtain incident 4 Record all above information on HCS Memo 05 12 025 and submit to HR Personnel Security office Upon receipt of report applicant can then report to designated PIV Service Manager Sponsor for further badge processing Operating Hours Bldg 10 Room 19 Monday Wednesday and Friday OPEN 8 00 AM 4 30 PM Tuesday OPEN 12 30 4 30 PM Thursday CLOSED except for general questions General Contact Number 559 225 6100 ext 5005 5300 All PIV transactions related to issuance are BY APPOINTMENT ONLY PIN resets and operational PIV Manager Sponsor issues card use etc assistance do not require an ap
16. cate departmental Policy Memorandums for a safe and secure environment of care 4 Demonstrate actions of a safe and secure environment of care in performing daily patient care 5 Review Principles of Ethical Conduct and VA Ethics Rules 6 Discuss age population and cultural competence specific to the VA patient population 7 Identify the key personnel to contact concerning the topics of a safe and secure environment of care The handbook Providing a Safe and Secure Environment for Health Care will take approximately 45 minutes to one hour to read review It is recommended that you view the handbook content from your computer rather than print the document as it is several pages in length However it can be printed for those who may have difficulty viewing it on the computer The referenced personnel Fee Basis Appointees Consultants Attendings Residents Interns Without Compensation WOC Contract personnel who provide direct and or ancillary health care services will be herein referred to as VA Affiliated Personnel or VA affiliated personnel throughout the handbook I MPORTANT INSTRUCTIONS FOR COMPLETING THIS HANDBOOK CERTIFICATION When you have completed your review of the handbook content print the Self Certification page located at the end of the handbook You will need to sign date and return the certification page to Human Resources 05 ATTN Daphne Cuyler for credit certification
17. ccept any gift or other item of monetary value from any person or entity seeking official action from doing business with or conducting activities regulated by the employee s agency or whose interests may be substantially affected by the performance or nonperformance of the employee s duties e Employees shall put forth honest effort in the performance of their duties Brief summary of the major ethics rules for government employees The secretary for your Service has the full text and you are strongly encouraged to take the time to review its contents The Library also maintains a copy of the full test on its reserved shelf for employees to review Page 22 e A Government employee must place loyalty to the public trust above anyone s private gain e Prevent conflicts of interest Don t serve two masters e Avoid the appearance of a conflict of interest Employees must be above approach e Restriction on gifts With some exceptions an employee must not accept a gift from a prohibited source or given because of the employee s official position Subpart B e Gifts or favors from patients is restricted e Acceptance of gifts from a pharmaceutical or medical supply representative or company is restricted including drug samples meals tuition travel or per diem e Meeting with pharmaceutical representatives must have prior approval and scheduled by Pharmacy e Gifts to official superiors are prohibited Subpart C
18. ckground of the call loud or quiet Are there other voices in the background Are there sounds in the background such as aircraft machinery street noises office equipment animals or music What to do after the call e DO NOT HANG THE PHONE UP LEAVE IT OFF THE HOOK UNTIL THE POLICE ARRI VE Remain calm Write down as many clues as possible Immediately notify the VA Police at ext 4444 Immediately complete the Bomb Threat Check Sheet Make yourself available to be interviewed by the VA Police or other Law Enforcement Officials Remember Never search suspicious packages LEAVE THEM FOR THE EXPERTS Reference Emergency Management Plan located on the VA Intranet Policies XXII CELL PHONE USE AND RESTRICTIONS It s all about Patient Safety Radio Frequency RF producing devices can interfere with medical equipment The intent of our cell phone policy is to restrict the use of cell phones and two way radios only in those areas where usage presents an unacceptable risk to our patients We recognize there are circumstances where cell phones and two way radios may be necessary to provide patient care We also do not want to unnecessarily restrict cell phone use for our patients and visitors Still cell phone use must be restricted in some areas to ensure patient safety Page 18 Restricted Areas Cell phones are to be turned off in restricted areas unless you formally request and receive a waiver You can reference HCSM 00
19. creening A Female to Male transsexual patient may require screening for breast and cervical cancer A diagnosis of Gender Identity Disorder or other gender dysphoria diagnoses is not a pre condition for receiving care consistent with the veterans self identified gender All other health services are provided to transgender veterans without discrimination in a manner consistent with care and management of all veteran patients All staff including medical and administrative staff is required to treat as confidential any information about a patient s transgender status or any treatment related to a patient s gender transition unless the patient has given permission to share this information The expectation for all employees and VA affiliated personnel is mandated diversity awareness to be maintained and a zero tolerance standard for harassment of any kind Page 32 You have now completed the review of the VA Central California Healthcare System s mandatory training program for VA Affiliated Personnel Providing a Safe and Secure Environment for Health Care Print the following Self Certification page Sign date and return this certification page with your packet CREATED August 2012 DOCUMENT REVIEW This handbook will be reviewed ANNUALLY or AS NEEDED Page 33 Sef Certifcatien of Comfletion ORIENTATION HANDBOOK for VA Affiliated Personnel Providing a Safe and Secure Environment for Health Care Requi
20. door The goal is to get the patient into an Airborne Infection Isolation Room All persons entering the room must wear an N 95 respirator mask for which they have been currently fit tested or a powered air purifying respirator PAPR NOTE Volunteers and Work Study Students are not allowed in the rooms Health Care Worker I nfectious Disease Exposure Follow up Definition of Exposure Puncture laceration abrasion of the skin with a needle or other sharp object which is contaminated with blood or other body fluid Splash of blood or body fluid onto the mucous membranes of the mouth nose or eyes Blood or body fluid contact with non intact skin Inhalation of air contaminated with airborne disease VA affiliated personnel who are accidentally exposed to blood or body fluids by any of the routes defined above or exposed to TB or any other communicable disease should immediately inform their supervisor and go to Employee Health during weekdays or Emergency Department during weekend for prompt treatment The Standard and Transmission Based Precaution System Exposure Control Plan Bloodborne Pathogen Standard the Exposure Control Plan Bloodborne Pathogen Standard and the Tuberculosis Exposure Control Plan can be found on the VA Central California Healthcare System Intranet under Infection Control SharePoint The supervisor is responsible to assure that VA affiliated personnel adheres to Standard and Transmission Based Precautions and t
21. e An employee must not take any official action that affects his her financial interest Subpart D e An employee should not take any official action in circumstances where a reasonable person would question the employee s impartiality in that action Subpart E e An employee must not take any official action that affects the financial interest of any person or entity with whom the employee is negotiating for employment Subpart F e An employee must not use his her public office including official time information property or endorsements for personal gain or the private gain of anyone Subpart G e An employee must not engage in any outside employment or outside activity which conflicts with his her official duties Subpart H e An employee must comply with all ethics laws and regulations Subpart I When in doubt seek advice from a VA ethics counselor or contact the Ethics Committee XXVII MANAGEMENT OF THE IMPAIRED LICENSED INDEPENDENT PRACTITIONER Purpose The purpose of this information is to address the prevention of physical psychiatric or emotional illness and to facilitate confidential diagnosis treatment and rehabilitation of those practitioners who suffer from a potentially impairing condition The process and procedure outlined in this policy pertains to all actively practicing licensed independent practitioners who care for patients in this healthcare system and its community based clinics This policy may also be appl
22. e correct patient gets the correct blood when they get a blood transfusion Improve staff communication NPSG 02 03 01 Get important test results to the right staff person on time Use medicines safely NPSG 03 04 01 03 05 01 03 06 01 Before a procedure label medicines that are not labeled For example medicines in syringes cups and basins Do this in the area where medicines and supplies are set up Record and pass along correct information about a patient s medicines Find out what medicines the patient is taking Compare those medicines to new medicines given to the patient Make sure the patient knows which medicines to take when they are at home Tell the patient it is important to bring their up to date list of medicines every time they visit a doctor Prevent infection NPSG 07 01 01 07 03 01 07 04 01 07 05 01 07 06 01 Use the hand cleaning guidelines from the Centers for Disease Control and Prevention of the World Health Organization Set goals for improving hand cleaning Use the goals to improve hand cleaning Use proven guidelines to prevent infections that are difficult to treat Use proven guidelines to prevent infection of the blood from central lines Use proven guidelines to prevent infections after surgery Use proven guidelines to prevent infections of the urinary tract that are caused by catheters Identify patient safety risks NPSG 15 01 01 Find out which patients are most likely to try to commit suicide P
23. e fire alarm by activating the nearest pull station and dial extension 5200 Contact the Boiler Plant to report the fire by dialing extension 5403 The following information should be reported to the Boiler Plant Operator who answers extension 5403 Your name exact location of fire including room number type of fire and size of fire Do not attempt to extinguish a fire until personnel in immediate fire area have been evacuated pull station has been activated the fire has been reported and open doors in fire area have been closed Do not attempt to extinguish a fire unless you know how to operate the extinguisher the fire is small and you can fight the fire with your back to the exit Be alert in recognizing fire hazards and fire prevention If you hear a fire alarm in your work area you should immediately check your area for smoke flames sprinkler system activation or any sign of fire If a fire or any fire symptoms are observed you should alert the other employees in your area by saying Code Red and the location of the fire After notifying your coworkers there is a fire in the area the R A C E procedure described below should be followed Know fire and evacuation plans for the work site Your supervisor will provide you with site specific fire safety procedures Fire Procedures R A C E Rescue Rescue anyone who is in immediate danger from the fire Remove these people to the closest safe area Simultaneously notify other s
24. e more likely following the discovery of a suspicious package Stay calm be courteous to the caller listen and do not interrupt Use a pre arranged hand signal to warn others that the call is a bomb threat Have someone notify VA Police ext 4444 Record the time and date of the call Try to make note of the exact words the caller uses these can help identify the nature of the threat Page 17 Some questions to attempt to ask bomb threat callers e When is the bomb going to explode e Where is the bomb right now e What kind of bomb is it e What does the bomb look like e Why did you place the bomb Verbal clues to a bomb threat caller s identity e Is the caller male or female e Is the caller an adult or juvenile How old does the caller appear to be from the sound of his voice Does the caller sound local Does he have an accent Is the caller s language good or poor Does he use slang obscenities or foul language Is the caller s voice notably loud or soft Deep or high Raspy or pleasant sounding Does the caller s voice have a nasal sound a stutter a slur or a lisp Does the caller speak fast or slow Is his speech distorted or distinct Is the caller angry or calm Irrational or deliberate Emotional or self righteous Is he laughing Verbal clues to a bomb threat caller s disposition and location Does the caller appear to be under the influence of alcohol or drugs Is the caller incoherent Is the ba
25. e present at all times and are a natural part of life Understanding radiation and putting radiation into proper perspectives is a complex undertaking A tremendous amount is known about radiation and research is ongoing to better understand low levels of exposure and medical exposures Any questions about radiation radiation exposure contamination or radioactive spills can usually be answered by the trained staff in the appropriate area If you need or want additional information ask to speak to the Radiation Safety Officer XI ELECTRICAL SAFETY Many equipment hazards that eventually result in an electrical shock are visible for a period of time prior to the accident Frayed or damaged electrical cords should not be used until repaired or replaced Report defective or damaged equipment immediately to your supervisor tag as unsafe and remove equipment from use service by placing in appropriate designated area If a tingle or shock is felt unplug the equipment and report it to Biomedical Engineering extension 5215 or MAINTENANCE AND REPAIR SECTION MARS in Engineering at 5138 and enter an electronic work order Label the equipment as unsafe until it has been serviced When disconnecting equipment from the wall outlet grasp the cord cap and tug gently Don t grab the power cord and yank it Report any electrical problem with the wall outlet to the supervisor of the Electrical Shop in the MARS Service Center extension 5138
26. enance if required by regulatory bodies e g JCAHO CAP etc Electrical Safety Tags Electrical equipment that is used in the patient care vicinity should have a green tag indicating that it has been tested and is safe for use If this tag is out of date then a work order should be entered to have it inspected Work Orders Equipment users should be familiar with Electronic Work Order system and enter an electronic work order whenever they have equipment that needs maintenance or repairs Backup procedures If critical equipment fails all operators must be knowledgeable about the backup procedures in their department and what clinical interventions should be initiated in the event of equipment failure Machines Each of us comes in contact with electrical and mechanical machines including power and hand tools The following are general practices to reduce accidents Never operate a machine or a piece of equipment until instructed in safe operation Make absolutely certain that all personnel are clear of the machine or equipment before it is started Walk around it if necessary and or give the proper warning signal before starting Do not operate machines without appropriate guards Machine guards have been installed for safety Keep them in place when the machine is operating and replace any missing guards that have been removed for repair or adjustment Missing or inadequate guards should be reported to the supervisor immed
27. ent care activities within VHA is CPRS Computerized Patient Record System All staff is responsible for the accuracy of the health record for each patient under the physician s care Documentation of each patient care event must be entered into the health record The practitioner who treats the patient is responsible for documenting and authenticating the care provided Scope of Documentation Emphasis is placed on relevant day to day entries Each patient event must include or provide reference to The chief complaint and or reason for visit Relevant history Examination findings and prior diagnostic test results Assessment Clinical impression or diagnosis Plan for care Medical necessity for the care The scope of documentation must be comprehensive enough to e Provide continuity of care e Be concise and complete e Reflect any treatment for service connected conditions including agent orange ionizing radiation military sexual trauma or external contaminants e Support reported workload e Bill for services CPRS Computerized Patient Record System e Entries must be timely relevant necessary complete and authenticated electronic signature e All entries must be recorded and authenticated immediately after the care event or observation has taken place to ensure that the proper documentation is available to ensure quality patient care e The author of the entry is responsible for completing authenticating and
28. ess and non employees while conducting business in the VA workplace Definitions Sexual harassment is a form of employee misconduct that undermines the integrity of the employment relationship All employees must be allowed to work in an environment free from sexual overtures Sexual harassment debilitates morale and interferes in the work productivity of its victims and co workers Sexual harassment is deliberate or repeated unsolicited verbal comments gestures or physical contact of a sexual nature which are unwelcome Page 20 Any employee who participates in deliberate verbal comments gestures or physical contact of a sexual nature which interferes in work productivity is also engaging in sexual harassment Within the VACCHS a supervisor who uses implicit or explicit coercive sexual behavior to control influence or affect the career salary or job of an employee is engaging in sexual harassment Similarly an employee of the VACCHS who behaves in this manner in the process of conducting agency business is engaging in sexual harassment The VA Central California Healthcare System supports a zero tolerance for anyone who engages in sexual harassment Response An employee experiencing or witnessing such acts shall report these acts to his her immediate supervisor the EEO Program Manager at 228 5318 Human Resources at extension 5075 or the AFGE Representative at extension 6402 Resources The Employee Assistance Prog
29. iately Turn off the equipment before machine repairs or adjustments are made There are no exceptions to this practice Personal protective equipment such as gloves safety glasses ear protection hard hats safety clothing and other applicable items may be required in certain operations The supervisor will provide the personal protection equipment necessary for each job XIV COMPRESSED GAS CYLINDER SAFETY Gases are stored in cylinders under high pressure Follow these basic rules when handling gas cylinders Safe cylinder cracking detects flaws and protects us from injury Check cylinders in an area away from patients Open cylinder valves slowly to allow heat of compression to dissipate Make certain the cylinder regulator is turned off before opening the main cylinder valve When cylinders are not in use bleed all pressure off of regulators Cylinders with broken regulators should be taken out of service and reported to Biomedical Engineering via the Work Order System on the VISTA Computer System Secure cylinder at all times Chain to wall or other stable object like a patient bed or stretcher Never leave a cylinder freestanding regardless of the cylinder contents Damage to a cylinder via a fall or mishandling can cause a stem or valve rupture A stem or valve rupture can cause a cylinder to become airborne or act as a deadly missile Compressed gas cylinders Page 11 must be stored in approved racks as these rac
30. ic Brain Injury TBI and other similar to Gulf War All Conflicts PTSD Post Traumatic Stress Disorder Fearful of unknown hospital experience hospitalization during conflict negative associations same smells hyper vigilant sleep disorders anxiety restlessness fearful of anesthesia not in control combative and disoriented safety issues Page 26 Cultural Competence Why Does It Matter Cultural competencies involve understanding and respecting patients and staffs cultural values beliefs and practices Cultural competence starts with understanding our own biases and learning more about the many cultures of the world If we just remember two important points 1 treat all individuals with respect and dignity 2 listen carefully and respectfully to your patients beliefs about his her illness we will be on a sure path to cultural competence XXI X THE JOINT COMMISSION PATIENT SAFETY GOALS VACCHS is committed to providing our patients with the highest quality of care in a safe and secure environment The purpose of the National Patient Safety Goals is to improve patient safety The goals focus on problems in health care safety and how to solve them Identify patients correctly NPSG 01 01 01 01 03 01 Use at least two ways to identify patients For example use the patient s name and date of birth This is done to make sure that each patient gets the correct medicine and treatment Make sure that th
31. ices is mandatory Published procedures are available on the unit and Unit Educators can provide an orientation to their use VI CARDIAC AND RESPI RATORY ARREST Cardiac arrest or respiratory arrest is a life threatening event and it must be recognized and treated quickly Once a patient is found unresponsive the hospital code team or local EMS system must be activated and CPR begun Depending on where the arrest is located on the VA campus will determine what system should be activated To activate a Code Blue 1 Dial 5200 it will go directly to the operator 2 State the following e Cardiac arrest or respiratory arrest e Building number e Unit Location e Room number Location 3 Continue CPR stand by to assist the code team upon their arrival It is important to note that some of the nursing care areas have a code button located in patient rooms This code button can be used to activate a Code Blue however it is still necessary to activate the code by dialing 5200 and following the activation sequence as mentioned previously Patients found in cardiac or respiratory arrest in all other buildings trailers and VA grounds the EMS system will be activated To activate the EMS system 1 Dial 911 or 9 911 using VA phone 2 STATE THE FOLLOWING Page 5 e Your name e Your exact location and location of victim e Victim s name if Known Nature of the emergency 3 Continue CPR initiate the A
32. ied to all members of the credentialed medical staff who care for patients In this document credentialed medical staff LIPs will also be referred to as providers For detailed policy and procedures refer to Healthcare System Memorandum No 11Q 11 031 Definitions e Impairment The inability or immediate impending inability of a health professional to provide care in a manner that conforms to the standards of acceptable and prevailing practice for that health profession due to the following substance abuse chemical dependency physical or mental illness e Self referral The employee recognizes that he she has a physical psychiatric or emotional illness and needs assistance in correcting the problem Page 23 Formal referral A referral of an employee by a supervisor or other staff member where there is reasonable cause to believe that a licensed independent practitioner is providing unsafe care and treatment Mandatory referrals The referral of an employee who has been found to be using illegal drugs as mandated by the VA Drug Free Workplace Program Alcoholism A behavioral disorder characterized by repeated excessive drinking which interferes with the individual s health interpersonal relations or economic functioning An alcoholic is an individual who is alcohol dependent His her drinking is out of control A problem drinker is any employee whose use of alcohol frequently affects him her adversely Drug Abuse A
33. in TMS Talent Management System within 30 days of receipt of this handbook The following is a list of topics addressed in this handbook I Safety Program Il Accident Report Treatment lll General Safety Practice IV Material Handling V How to Life and Save Your Back VI Cardiac and Respiratory Arrest VII Good Housekeeping VIII Infection Control IX Hazardous Materials Management X Radiation Safety Xl Electrical Safety XII Utility Systems XIII Medical Equipment Management XIV Compressed Gas Cylinder Safety XV Live Safety and Fire Prevention XVI Emergency Management and Disaster Planning XVII Office Safety XVIII VA Police Services XIX Information Security Program XX Standards for Documentation of Patient Care XXI Bomb Threats XXII Cell Phone Use and Restrictions XXIII Patient Rights and Patient Abuse XXIV Sexual Harassment XXV Workplace Violence XXVI Standards of Ethical Conduct XXVII Management of the Impaired Licensed Independent Practitioner XXVIII Age Population and Cultural Competence XXIX The Joint Commission Patient Safety Goals XXX Green Environment Management System GEMS XXXI HR Personnel Security ID Badges XXXII Women Veterans Primary Health Care Services XXXIII Transgender and Intersex Veterans Primary Health Care Services Additional information regarding these topics can be found in the HCS Memorandums located on the VA Cent
34. ipment and office supplies Put away sharp objects when they are not in use Do not cover sharp objects such as kitchen knives or tools that are on a desk table or workbench Page 4 Needles and other sharp objects are a source of infectious disease Immediately dispose of such objects in the nearest needle disposal sharps container Contaminated needles should not be recapped prior to disposal Needle stick injuries require immediate follow up See II Accident Reporting Use proper safety devices when breaking glass ampoules Do not reach into general or biohazard waste containers with unprotected hands V HOW TO LIFT AND SAVE YOUR BACK Provide a good base of support by broadening stance one foot slightly ahead of the other wear non slippery low heeled supportive shoes Keep the load close to your body and waistline Use handles when available Lift slowly and smoothly not fast and jerky like a weight lifter Do not twist your back as you lift Bend your knees and hips to avoid putting all the stress on your back when you are lifting or getting down performing a procedure Lift using the muscles of your legs and buttocks With large or bulky loads use good common sense and either get help with the lift from another person or by using lifting equipment Use carts to transport items Break lifting tasks into several small loads versus one large load when possible When lifting patients the appropriate use of lift dev
35. irements are met by following the guidelines listed above If you need help with something or have a question about the program please call Kelli Johnston at x5447 Page 30 Women Veteran Primary Care Services Located on the 4 floor West Primary Care is also provided in the primary care clinics on the first floor and CBOCs Community Based Outpatient Clinics XXXIII Transgender and Intersex Veterans Primary Health Care Services This is not a change in existing policy but rather clarifies the current best practices in the VA system regarding the provision of health care to transgender and intersex veterans VHA Directive 2011 024 dated J une 9 2011 Policy VHA policy is that medically necessary care is provided to enrolled or otherwise eligible intersex and transgender veterans including hormonal therapy mental health care preoperative evaluation and when medically necessary post operative and long term care following sex reassignment surgery Sex reassignment surgery cannot be performed or funded by VHA or VA Definitions Transgender is a term used to describe people whose gender identity Sense of themselves as male or female or gender expression differs from that usually associated with their sex assigned at birth Transsexual male to female MTF individuals who are male sex at birth but self identify as female They often take steps to socially or medically transition to female this can include hormone ther
36. ks are required by OSHA These racks also protect the cylinder from damage Transport cylinders in pressure gas cylinder carts or correct holder Always store with cylinder caps Bleed disposable cylinders before replacement Continue to bleed the cylinder until pressure is reduced to O PSI Non recyclable cylinders may be disposed of via crushing If there is any pressure left in the cylinders they could explode during crushing Empty cylinders should be marked as such and stored separately from full cylinders Keep petroleum based products combustibles and spark producing equipment away from oxygen Contact your supervisor regarding any questions you may have about cylinder safety XV LIFE SAFETY AND FIRE PREVENTION Fire extinguishers are available in designated areas Learn the location and proper use of fire extinguishers and fire alarm pull stations in your work area Passageways and work areas around fire extinguishers and pull stations must be kept clear at all times The fire alarm pull stations are frequently located near exit doors and exit stairwells Extinguishers that appear to have been used or tampered with should be reported to the Fire Safety Officer extension 6331 No open flames or smoking are permitted except in designated areas Exit doors will not be obstructed Know the nearest exit in your work area Report fires by activating the nearest pull station Once the pull station has been activated sound th
37. l assist you in completing the necessary Workers Compensation paperwork and understanding your benefits under the Federal Employee s Compensation Act Page 3 After normal business hours and on weekends you should report directly to the Emergency Department after notifying your immediate or shift supervisor that you have been injured You should contact Employee Health by 9 00 AM the next normal business day Needlesticks and other blood exposures must be reported as soon as possible to Employee Health at ext 6978 during normal business hours After normal business hours you should report directly to the Emergency Department Employees may be asked to remain on station until appropriate risk assessment and blood testing can be obtained by either the Employee Health or Emergency Department staff Complete electronic paperwork If your injury requires medical treatment beyond first aid care you must complete an OWCP form CA 1 Federal Employee s Notice of Traumatic Injury and Claim for Continuation of Pay Compensation This form is completed electronically on the Medical Center s internal computer system Your supervisor will assist you in completing this form Ill GENERAL SAFETY PRACTICE Report any unsafe conditions or acts that you observe to your supervisor Report any foreign material on the floor to the Environmental Management Service or remove it at once to prevent injury to others Report defective or damaged eq
38. n Users are also responsible for loss or damage to or unauthorized use of Government property Responsibilities As members of this Medical Center s staff you are tasked with certain information security oriented responsibilities They include but are not limited to the following obligations You may use the VA computer only in fulfilling your duties as a VA employee non paid employee student or resident Upon receiving a computer access code and or password you must keep this code confidential and must not share it with any other employee or non employee under any circumstances In the event an access code is inadvertently disclosed to another party you must request a new code through the computer liaison person for your Care Service Center Unauthorized distribution of access codes to other persons allowing other persons to use information available once you have accessed it or disseminating confidential information obtained through the computer system may be grounds for disciplinary or adverse action Once you have signed on the computer system you must also sign off prior to leaving your workstation Turning the monitor off is not an acceptable way to sign off the system since this can result in the next person using this monitor entering data with your access code That person may not have the same level of authorization as you do You are held accountable for data input with your access code The Privacy Act provisions apply t
39. ns for conservation to the GEMS Coordinator at ext 3669 XXXI HR Personnel Security 1D Badges Oversight and Management HR Personnel Security is responsible for the oversight and management of three areas of concern that all incoming employees and VA affiliated personnel are required to be in compliance with before during and after their association with the facility These areas are as follows Personnel Security and Reliability Personal Identification Verification PIV and Facility Badging The following paragraphs will cover each are in a concise and brief manner More detailed information can be obtained from the HR Personnel Security Program Specialist Badges 2 Types Facility I dentification Badge It is VHA policy that all VA affiliated personnel who have to conduct official duties here at the primary facility or any of its satellites are required to have a Facility Identification badge This badge will be worn as required in conjunction with the PIV badge in preceding section so all patients and visitors to the facility will be able to identify you by name service and position This section explains the badging process here at the facility PIV Badge Personnel Identification Verification HSPD 12 directs all federal agencies and departments to issue identity cards to provide government workers contractors and affiliates with a credential that provides the attributes of security authentication trust and privacy and can
40. nse against the spread of infection is meticulous hand hygiene Standard Precautions In the hospital setting some diseases such as HIV and hepatitis B and C spread by blood exposure Microorganisms such as Clostridium difficile and methicillin resistant staphylococcus aureus are spread by exposure to body substances other than blood To provide a work environment free of exposure to infectious diseases employees and VA affiliated personnel must practice Standard Precautions When you follow standard precautions it means you protect yourself from all body substances and non intact skin of all patients All patients are considered equally potentially infectious The following pieces of personal protective equipment are to be worn to prevent possible exposure to blood borne pathogens 1 Wear gloves for touching blood and moist body substances mucous membranes or non intact skin of all patients for handling items or surfaces soiled with blood or moist body substances and for performing venipuncture and other vascular access procedures 2 Change gloves between contacts with each patient 3 Wash hands or sanitize with an alcohol gel immediately after gloves are removed Wash hands and other skin surfaces immediately and thoroughly if accidentally contaminated with blood or moist body substances 4 Wear a dust mask and protective eyewear if aerosolization or splattering is likely 5 Wear gowns if splattering of blood or body substance
41. o all information in the database Computer privileges are given to you based on the nature of your position Any further modifications to them must be requested by your Care Service Center Director who will authorize these in writing along with justification for the variances If you have any questions regarding the Information Security Program please contact Information Resources Management IRM at extension 5334 XX STANDARDS FOR DOCUMENTATION OF PATIENT CARE General Health record documentation is required to record pertinent facts findings and observations about an_individual s health history including past and present illnesses examinations tests treatments and outcomes The health record documents the care of the patient is an important element contributing to high quality care and facilitates The ability of the physician and other health care professionals to evaluate and plan the patient s immediate treatment Monitoring of the patient s health care over time Communication and continuity of care Accurate and timely claims review and payment Page 15 Appropriate utilization review and quality of care evaluations Collection of data that may be useful for research and education Documentation Principles amp Standards The electronic health record is subject to the same medical and legal requirements as hand written information in a patient health record The primary medium for documentation of all pati
42. o provide training about the location of personal protective equipment IX HAZARDOUS MATERIALS MANAGEMENT Purpose To provide a safe environment for patients visitors employees VA affiliated personnel and the surrounding community by initiating the proactive management of hazardous and potentially hazardous materials wastes or conditions through written policies and procedures regarding their safe handling storage use disposal and related educational and training programs You have the right to know about the hazardous materials with which you work Initial information on hazardous material management is given during New Employee Orientation This includes an overview of the federal and state requirements along with the Hazard Communication Program Description MSDS Your director Supervisor is to ensure you have received site specific chemical hazard training Training includes notification of the hazardous properties of the chemical used in the work area This training will also include potential health hazards handling storage and emergency procedures You can obtain MSDSs Material Safety Data Sheets on the facility SharePoint or by dialing 1 800 451 8346 Examples of common hazardous materials are copier fluids cleaning chemicals sanitizing agents and other applicable items X RADIATION SAFETY General radiation safety guidelines include Radiation Safety rules need to be observed by all employees and VA affiliated pe
43. office doors and desks are locked when you are not there Log off of all computer equipment when the application that you are running is no longer needed Secure all personal items of clothing day planners purses backpacks and other items that are subject to pilferage Do not allow yourself to become complacent with your own physical security needs stay alert and be observant of your working environment All VA affiliated personnel must process through the VA Police Service at their time of hire to register their privately owned vehicle Should you require special reserve parking or you wish to participate in a carpool ride share program contact the VA Police Service at extension 6400 If you have any non emergency questions regarding station security or police matters contact the VA Police Service at extension 5845 The VA Police is here to protect and serve you XI X INFORMATION SECURITY PROGRAM NOTE 1 All users must complete TMS 10176 Privacy and Information Security Awareness and Rules of Behavior prior to being given network accounts Page 14 NOTE 2 If you require a VistA account or will be working in areas where you might be exposed to patient information you will need to complete TMS 10203 Privacy and HIPAA training Statement The purpose of the Information Security Program is to ensure procedures that protect automated functions and resources All users are responsible for safeguarding confidential data or informatio
44. ong health care professionals adds to the incentive of the depressed professional to go to great lengths to try to mask his her signs of depression When Impairment is Suspected and No Action is Taken If it can be proven that person had knowledge of a chemically dependent coworker and chose not to act to safeguard patients the non reporting individual could face disciplinary action When I mpairment is Suspected and Enabling Occurs When people cover up mistakes of impaired coworkers or attempt to assume the role of counselor while not disclosing possible substance abuse they enable impaired professionals to continue in their problem These counselors become accomplices and barriers to definitive treatment Self Referral Any health care professional may begin the process to self report and seek care for their perceived impairment through their supervisor Service Chief Nurse Executive or Chief of Staff When I mpairment is Suspected How Should It Be Reported Report the suspected behavior to the practitioner s supervisor Service Chief or Chief of Staff Document accurately and completely any suspicious behaviors or incidents that have occurred Be supportive not judgmental Substance abuse is an illness Treatment will be offered through the Employee Assistance Program or Employee Health Employee Assistance Program EAP at VACCHS The EAP Program is available 24 7 365 days a year at 1 800 222 0364 TTY 1 888 262 7848
45. ose who have had sex reassignment surgery outside of the VHA those who might be considering such surgical intervention and those who do not wish to undergo sex reassignment surgery but self identify as transgender Intersex individuals may or may not have interest in changing gender or in acting in ways that are discordant with their assigned gender e Patients will be addressed and referred to based on their self identified gender Room assignments and access to any facilities for which gender is normally a consideration Page 31 i e restrooms will give preference to the self identified gender irrespective of appearance and or surgical history in a manner that respects the privacy needs of transgender and non transgender patients alike Where there are questions or concerns related to room assignments an ethics consultation may be requested The documented sex in the medical record should be consistent with the patients self identified gender There are two VHA governing policies that provide guidance on making changes They are Identity Authentication for Health Care Services and Data Quality Requirements for Identity Management and Master Patient Index Functions Sex reassignment surgery will not be provided or funded Non surgical supportive care for complications of sex reassignment surgery will be provided Screenings A Male to Female transsexual patient over the age of 50 may require breast cancer screening and prostate cancer s
46. pointment Until otherwise posted XXXI I Women Veterans Primary Health Care Services HealthCare Services for Women Veterans revised and distributed May 21 2010 Directive 1330 01 PRIVACY SAFETY SECURITY Access to Provider and Benefits We fee base out for pregnancy and any procedure that we do not have the physical equipment for or personnel trained available If you are part of the clinical team please ensure that you have a standby assistant for any physical exam for a woman veteran The standby should be female unless the patient specifically requests a male standby This preference needs to be documented in the patient chart If you are part of the clinical team or any other service that has contact with a female patient please be respectful of the patient s privacy Exam rooms should have locks on them and curtains Please ensure that they are used Please knock on the door and announce yourself prior to entering any patient room Women Veterans need to have access to bathrooms that are in close proximity to the exam room or inpatient room that they are assigned to Women Veterans need to have gowns that fit them correctly or tops and bottoms that fit them correctly These can be obtained from EMS Women Veterans need to have access to female specific personal hygiene products These can be accessed through SPD Please help to ensure that Women Veterans receive excellence in care and that the program requ
47. r Safety Committee The Safety Committee serves as an advisory body to the hospital Administration Medical Staff and the Governing Board in the recommendation formulation and adherence to the safety policies in the hospital It develops implements and maintains a comprehensive hospital wide safety program The committee chair and the Safety Manager have the authority to take any and all necessary actions to eliminate any hazardous conditions which could result in personal injury or damage to equipment buildings or the environment Il ACCIDENT REPORTING MEDICAL TREATMENT The following steps should be taken following a work related injury or illness this includes blood exposures needle sticks and exposure to TB or any other communicable disease If there is a life threatening injury you should contact your supervisor security or safety The supervisor is a member of the response team Refer to VA Central California HCS Policy HCSM No 001 09 026 Accident Reporting Get appropriate medical treatment You have the right to your choice of Workers Compensation physicians both for first aid treatment and other follow up care During normal business hours Monday through Friday from 7 30 AM to 4 00 PM you should call Employee Health at extension 6978 Arrangements will be made for you to be seen by the Employee Health provider or in the Emergency Department if the Employee Health provider is not available Employee Health wil
48. r sleeve 2 Don t touch your own eyes nose and mouth except with freshly washed or sanitized hands 3 Always wash hands before eating 4 Wash hands after using the bathroom or performing any personal grooming for yourself such as blowing your nose 5 Stay home from work if you have a fever above 100 4 especially if it is accompanied by a cough diarrhea or rash If there is ever any question check with Infection Control at extension 4487 or Employee Health at extension 5327 Use alcohol based hand rub or soap and water 1 Before and after direct contact with each patient 2 After handling objects or touching surfaces near the patient 3 Before moving from a contaminated body site to a clean body site on the same patient 4 After contact with body fluids excretions and non intact skin if hands are not visibly soiled 5 Before donning gloves to perform invasive procedure 6 After removing gloves Page 6 Use antimicrobial soap if hands are visibly soiled with blood or other proteinaceious material or after interacting with a patient or waste with Clostridium difficile Use 1 Warm water 2 Soap Enough to work up a good lather 3 Friction At least fifteen seconds of friction is needed to remove organisms that cause infection 4 Free flowing water Let it flow freely enough to adequately rinse off soap and soil 5 Use paper towel to turn off water and open bathroom door Remember The best defe
49. ral California Healthcare System SharePoint Page 2 SAFETY PROGRAM Statement The goal of the Central California Healthcare System is to continually develop promote and enforce safe work practices and provide a hazard free working environment consistent with generally recognized standards and or established federal state and local regulations In order to meet this goal the Medical Center provides an efficient and effective Safety Program along with a safe working environment and assurance that VA Affiliated Personnel is aware of their responsibilities regarding safety Responsibilities Management All levels of management will consistently and constantly enforce all rules and regulations be alert for unsafe practices and conditions and take immediate and appropriate action to correct any irregularities they find The responsibility of making the work place as safe as possible rests with management This is accomplished through training and ensuring that VA affiliated personnel follows proper safety procedures Supervisors must consider accident prevention as a normal part of their role Employee The responsibility for safety must rest on each VA staff member and VA affiliated personnel Each shall follow safe practices in their assignments abide by all rules and regulations be constantly alert for health and accident hazards and report them to their supervisor Safety Officer or Safety Committee Members Medical Cente
50. ram EAP represents a major resource for employees as well as the EEO Program Manager These programs are provided to assist employees to report incidents and support a zero tolerance Let s all work together to decrease the possibility of sexual harassment and provide an environment that supports and quality work environment free of sexual harassment XXV WORKPLACE VI OLENCE Statement As private citizens we have all become aware of the apparent increase in violence in our society Sadly violence also appears to be increasing in our workplace These violent acts can occur for a number of reasons and can involve outsiders as well as co workers The VACCHS is dedicated to providing a quality work life for our employees A major component of a quality work life is safety on the job No one can ensure absolute safety from violence at the workplace There are simply too many factors involved in these events However we can each do our part in decreasing the possibility of workplace violence See HCSM 132 11 012 Definitions Physical attack is defined as an unwanted or hostile physical contact such as hitting fighting pushing shoving or the throwing of objects Threat is defined as the expression of a present or future intent to cause physical or mental harm An expression constitutes a threat without regard to whether the party communicating it has the present ability to do harm and without regard to whether the expression is contingent
51. reasons Inability to meet deadlines or achieve goals that others can easily accomplish Increased incidence of professional errors l e prescriptions dictations clinical judgment non responsive to pages or telephone calls Sloppy or incorrect patient documentation Decreased concern for patient well being and unexplained personal problems to mask his her deficits in concentration and or patient care Increased patient complaints about quality of care and bedside manner Health care professionals tend to obtain drugs through legal channels such as legitimate prescriptions that are written for them or diversionary measures on the job rather than purchasing them illegally on the street Page 24 e In spite of narcotic dispensing machines such as PYXIS workplace theft has been identified as the most frequent source of illegally obtained narcotics Watch for these drug diversionary behaviors e Frequent reports un witnessed wasting of drugs or broken containers e Administration of maximum PRN doses when others do not e Patients report a variance in pain relief when no change has occurred in drug dosage or frequency e Requests to transfer to night shift Depression Depression can impair a person s ability to deliver adequate health care There are no lab assays to diagnose depression The added social stigma of depression embedded into our society as well as the poor understanding of the pathophysiology of depression even am
52. red for FEE BASIS APPOINTEES CONSULTANTS ATTENDINGS RESIDENTS INTERNS WITHOUT COMPENSATION WOC and CONTRACT PERSONNEL WHO PROVIDE DIRECT OR INDIRECT ANCILLARY HEALTH CARE SERVICES Sign date and return this certification page to HUMAN RESOURCES 05 Attn Daphne Cuyler HR Specialist within 30 days of receipt of handbook aR PRtAt EARS te ot OEE RNAP NE nr ee E E Seer hereby certify that have reviewed Print Type Name all content in the ORIENTATION HANDBOOK Providing a Safe and Secure Environment for Health Care for VA Affiliated Personnel and am knowledgeable as to who to contact for questions see handbook for reference For HUMAN RESOURCES MANAGEMENT ONLY Date Certification Received Date Recorded in TMS
53. revent mistakes in surgery UPSG 01 01 01 01 02 01 01 03 01 Page 27 Make sure that the correct surgery is done on the correct patient and at the correct place on the patient s body Mark the correct place on the patient s body where the surgery is to be done Pause before the surgery to make sure that a mistake is not being made For more information and to access an easy to read document the exact language of the goals can be found at www jointcommission org XXX GREEN ENVIRONMENT MANAGEMENT SYSTEM GEMS What is a Green Environmental Management System GEMS is a management tool used to ensure compliance of environmental regulations and to improve environmental performance It is accomplished by the identification of roles responsibilities and procedures for achieving prevention compliance and continuous improvement The purpose of GEMS is to e Enhance our compliance and management of our programs e Commit to being good stewards of the environment e Comply with all regulations e Utilize practices that eliminate or minimize negative environmental impact So what does all this mean to me How does your job impact the environment at the Medical Center In your job do you Use dispose and or store paint or solvents Use paper computers and batteries Repair Operate motor vehicles Store waste hazardous radiological or solid Operate a boiler Manage construction projects Work with asbestos
54. rsonnel Page 8 1 Nuclear Medicine maintains a restricted area where radioactive materials are used for diagnostic imaging and a few therapies An escort is required to enter Nuclear Medicine 2 X ray rooms have a lighted radiation sign over the doorway that indicates DO NOT ENTER when the x ray is turned on Care must be taken whenever entering an x ray room do not enter unless escorted If the x ray turns on while trying to enter exit the room immediately It is important to understand and be familiar with these areas before trying to enter these rooms Discuss the proper ways to enter safely with staff who works in the area In general you should not enter an x ray room unless being escorted 3 Patients who have had x ray or CT scans are NOT radioactive Patients who have been administered a Nuclear Medicine radiopharmaceutical are radioactive but the levels of radioactivity emitted are below the limits that are allowable for the general public 4 Employees working directly with radiation emitting machines or radioactive materials follow special safety procedures which do not apply to general hospital employees 5 Women employees who work with radiation are allowed to declare a pregnancy and receive a fetal dosimeter 6 Radiation exposure is lowered by limiting time close to a radioactive source increasing distance from the source or by shielding as with lead walls doors and other applicable items Low levels of radiation ar
55. s e The right to receive safe care e The right to have pain treated e The right to know when something goes wrong with their care e The right to an up to date list of all current medications e The right to be listened to e The right to be provided interpretation and translation services as necessary e The right to receive a copy of patient rights upon admission e The right to allow a family member friend or other individual to be present with the patient for emotional support during the course of stay e The right to be free of discrimination based on age race ethnicity religion culture language physical or mental disability socioeconomic status sex sexual orientation and gender identity or expression For more information regarding Patient Rights and Patient Abuse refer to HCSM No 11Q 11 027 Patient Rights and Patient Abuse dated March 18 2011 XXIV SEXUAL HARASSMENT Statement It is the policy of the VACCHS that sexual harassment is unacceptable conduct in the workplace and will not be condoned Personnel management within the VACCHS shall be implemented free from prohibited personnel practices and consistent with merit system principles as outlined in the provisions of the Civil Service Reform Act of 1978 All VACCHS employees should avoid conduct which undermines these merit principles This policy applies to all employees and covers employees outside of the workplace while conducting government busin
56. s is likely 6 Use a disposable resuscitation bag or ventilation device for cardiopulmonary resuscitation 7 Wear gloves to clean up all blood body substances spills promptly with a hospital approved disinfecting solution Never pick up broken glass by hand 8 Consider all patient specimens as infectious and place in a sealed bag for transport to the lab 9 Use instruments with built in safety mechanisms whenever available Immediately discard uncapped needles syringes and other sharps in puncture resistant sharps containers provided for this purpose Do not overfill sharps container The container is to be changed when it is 3 4 as indicated by fill line and arrow 10 Be aware of the location of personal protective equipment in your department i e sharps containers resuscitation masks gloves masks and other applicable items 11 Items saturated with blood and containers of blood or bloody body fluid are to be discarded in the Infectious Waste Bin Know the location of the Infectious Waste Bin in your area Other waste products which must be handled as infectious are microbiology and pathology waste animal carcasses and bedding Airborne Precautions When a patient is suspected or known to have a disease transmitted by the airborne route such as tuberculosis chickenpox or disseminated shingles the patient will be placed in a private room Page 7 and a AIRBORNE PRECAUTIONS sign will be placed on the outside of the
57. taff of the fire by stating Code Red and the location of the fire Page 12 Alarm Sound the fire alarm by activating the nearest pull station dialing 5200 and following the fire reporting procedures listed in above Confine Confine the fire by closing all the doors in and around the fire area Do not turn off the lights Extinguish Extinguish the fire by using a portable fire extinguisher if safe to do so If it is not safe to extinguish the fire you should follow site specific evacuation procedure when directed to do so The evacuation of any area would be at the direction of the most senior person in charge Operating Portable Fire Extinguisher P A S S Pull Pull the pin Aim Aim the nozzle or cone at the base of the fire Squeeze Squeeze the handle Sweep Sweep the nozzle from side to side at the base of the fire P A S S will work for most fire extinguishers However one must become familiar with all fire extinguishers in the work area Standardized Emergency Codes Cardiac arrest and Respiratory arrest Dial 5200 Dial 9 911 for all other buildings trailers and VA grounds Fire Activate pull station and dial 5200 Follow fire reporting procedures described above Disruptive behavior requiring professional assistance Dial 4444 VA Security Police XVI EMERGENCY MANAGEMENT AND DISASTER PLANNING It is the responsibility of each employee and VA affiliated personnel to become familiar with the Facili
58. time to minimize confusion O DOr U1 US a A Who Are Our Veterans Approximately 25 million veterans live in the United States and Puerto Rico Although most veterans are white males our veteran population today represents diverse cultural and ethnic backgrounds as well as an increasing number of women Healthcare providers should be aware of the following conditions associated with the veteran s time of service World War II WWII Pacific Europe Africa infectious disease wounds exposure to nuclear weapons nuclear clean up frostbite cold injury mustard gas testing mostly physical Korea K cold injury lasting effects the forgotten conflict Cold War CW nuclear testing nuclear clean up Vietnam V Agent Orange infectious diseases anger and distrust of government unfairly blamed for war fought in good faith unsupported Gulf Wars GW Desert Storm Iraqi Freedom Increased survival rate with devastating injuries triple amputation face blown off torso intact Exposure to smoke Leishmaniasis immunizations chemical or biological agents depleted uranium DU infections debilitating undiagnosed illnesses military experience wasn t as expected life changing consequences on career education and marriage Peace Keeping Missions PK missions in Bosnia Haiti Kosovo and other locations Peace Time PT time of no conflicts Operation Enduring Freedom Operation Iraqi Freedom OEF OIF Traumat
59. ttom drawer up to prevent tipping Office equipment and appliances shall be maintained free of slivers burrs and other conditions which might cause an accident or personal injury Do not operate office equipment without proper instructions Report all unsafe conditions to the supervisor immediately Include chairs with broken wheels arms or back connections Remember that chairs with wheels can be hazardous Always use care when sitting to ensure the chair is under you Hold onto armrests on the chair seat to prevent the chair from rolling out from under you XVIII VA POLICE SERVICES Statement The success of this Medical Center s Police posture largely depends upon the watchful eyes of everyone Whatever immediate action you do in the early phase of an incident or situation may well determine whether the final outcome has a positive or negative nature Responsibilities As members of this Medical Center s staff you are tasked with certain security oriented responsibilities They include but are not limited to the following circumstances Should any crisis or emergency situation arise contact the VA Police immediately at extension 4444 or 9 get an outside line then 911 When reporting any incidents or situations to the VA Police be prepared to give the data ina who what when where why and how format This will assist responding officers in their response to your request for assistance Ensure that
60. ty Emergency Preparedness Plan In particular each should know what role their specific department plays what the internal traffic flow is to be where the main areas of Disaster Control are and how they can get into the hospital if they are called from home The Emergency Preparedness Plan includes action plans specific for each department in the hospital The action plan describes each department s responsibility whenever the Emergency Preparedness Plan is implemented It must be noted that the action plans provide a framework for response and are not necessarily written to limit the activity of the department In fact all individuals responsible for the implementation of the Emergency Preparedness Plan must remain flexible in managing their areas of responsibility during the disaster Over the years the VA facilities have experienced a variety of disaster events such as floods and tornados but the most likely natural event that would affect our medical center would be an earthquake Due to all of these types of natural disasters in our area our Emergency Preparedness Plan and your knowledge of this plan is very important XVII OFFICE SAFETY Do not use a chair box desk table or unstable material in place of a ladder or step stool The drawers of desks and file cabinets should be closed when left unattended Page 13 No more than one file drawer should be opened at any time File cabinets should be appropriately loaded from the bo
61. uipment immediately to your supervisor tag as unsafe and remove equipment from use service by placing in appropriate designated area Walk do not run especially in halls and on stairs Keep to the right using special caution at intersecting corridors Know the fire safety plan Know the location of fire alarms and extinguishers and how to use them Become familiar with relevant work procedures and safe work practices Open doors slowly using the handle or push plate make sure the other side is clear before opening doors The work place is no place for horseplay and practical jokes that may endanger others No one is expected to take chances or endanger themselves or others in the performance of job duties Do not take chances or guess When in doubt ask your supervisor to explain any job IV MATERIAL HANDLING Avoid containers with protruding nails jagged edges burrs or rough surfaces Have them repaired or get rid of them Keep fingers away from pinch points in setting down materials passing through doorways or closing drawers and doors Also when handling long objects keep hands away from ends Wipe off greasy wet slippery or dirty objects before trying to handle them Keep hands free of oil and grease Wear protective gloves Use caution around operating machinery Get help for lifting heavy equipment or use hand trucks and dollies to handle heavy bulky or loose materials Use utility carts for moving patient equ
62. vent of a power outage Emergency power is supplied to these outlets by emergency electrical generators within ten seconds when the need occurs The generators are tested monthly to ensure proper operation For the safety of staff and patients please do NOT alter isolate or adjust utility systems without expressed written permission from the Chief Maintenance and Repair Section or designee Additionally do not take emergent matters into your own hands unless otherwise trained or instructed to do so XIII MEDICAL EQUIPMENT MANAGEMENT PROGRAM Supervisors are responsible to work with their employees to develop a list of equipment and machines that requires operational training Supervisors are responsible for providing the training and documenting its completion VA affiliated personnel must inform their supervisors if they are not properly trained to operate a piece of equipment or machine Medical Equipment All operators of medical equipment are required to meet the following requirements Training Be properly trained and knowledgeable about the proper and safe use of the equipment they operate Inform your supervisor if you are not familiar with a piece of equipment Page 10 Operators Manual Have a user s manual readily available for reference All employees who operate the equipment must know the location of the manual and have access to it User Maintenance Perform all user specified maintenance and document the maint

Orientation Handbook for VA Affiliated Personnel

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