Non-Nursing Student
&
Faculty
Orientation Packet
2016-2017
2016-2017
Non-Nursing Student & Faculty Orientation
Table of Contents
Topic
EvergreenHealth 2016-2018 Strategic Plan Summary
EvergreenHealth Campus Map
Emergency Codes and Staff Response
Patient Bill of Rights
EvergreenHealth Art of Caring
Cultural and Linguistic Awareness in Healthcare
A Communication Guide
Hand Hygiene
SBAR Communication
Fall Prevention Fact Sheet
Personal Protection Equipment
EvergreenHealth Policy Review
• Code of Conduct
• Exposure to Blood and Body Fluid Management
• Immunity/Vaccination and Tuberculosis Screening Requirements
• Transmission based Isolation Precautions
• Specimen Labeling Flow Chart
• Work Restriction Policy
• Dress Code Policy
• Cell Phone Usage and Requirements Policy
Page
1
5
8
9
11
12
14
18
20
21
27
29
IT Overview
30
Orientation Attestation Form (Signature Required – to be turned in with paperwork)
32
2016-2018 Strategic Plan Summary
Thriving in the Transition from
Volume to Value-Based Care
PURPOSE - Our brand promise
CORE PILLARS – Areas of strength and core competency
Working together to enrich the health and
well-being of every life we touch
•••
MISSION - Why we exist
EvergreenHealth advances the health of the
communities it serves through dedication to
high quality, safe, compassionate, and cost-
I. CLINICAL OUTCOMES & ABSOLUTE SAFETY – Attain local and
national recognition for our commitment to absolute safety and
consistent top decile clinical outcomes
II. CUSTOMER ENGAGEMENT – Create exceptional customer
experiences that foster meaningful and active engagement,
resulting in absolute loyalty
effective health care
•••
VISION - What we aspire to fully become
EvergreenHealth will create an inclusive
community health system that is the most
trusted source for health care solutions
•••
III. PEOPLE & PROCESSES – Create a culture and environment that
enables all employees and medical staff to perform at their best every day, and fulfill their potential
IV. GROWTH & ACCESS – Deliver innovative and accessible
solutions for the growing and changing health care needs of the
community
VALUES - Shared beliefs that define our culture
Compassion, Excellence, Respect,
Collaboration, Accountability
V. FINANCIAL STEWARDSHIP – Continually improve our financial
performance to advance our ability to serve the community
•••
STRATEGIC IMPERATIVES – Strategies that achieve market
advantage and distinction
I. CARE TRANSFORMATION – We deliver the right care, for the
right person, at the right time, in the right place, at the right
value– every time – now and in the future
II. ECONOMIC TRANSFORMATION – We excel under today’s clinical
and financial models while strengthening our position to thrive
under tomorrow’s reimbursement models
III. INTENTIONAL GROWTH – We improve access and grow
intentionally and innovatively to meet the needs of our
community and to successfully transition to value-based care
IV. CONSUMERISM – We are known as the place to go for care and
health information through personalized experiences and tools
that equip our community with the ability to easily navigate
the system and the knowledge to meaningfully engage in their
health care choices, including health and wellness
1
GOALS & STRATEGIES – What we want to achieve & how we will achieve it
I.
CLINICAL OUTCOMES & ABSOLUTE SAFETY
• Demonstrate superior clinical quality and outcomes
− Adopt best clinical and safety practice standards using
the Safety Management System framework
− Advance nursing practices through Magnet principles
• Deliver the right care, at the right time, in the right place,
at the right value
− Transform care by excelling at population health
management
• Achieve Absolute Safety
− Elevate a culture of transparency and achieving
absolute safety
− Reduce human error and improve quality by effectively
leveraging IT
II. CUSTOMER ENGAGEMENT
• Exceed each customer’s expectations
− Deliver consistent service behaviors that mirror patient
expectations
− Create unique, breakthrough customer experiences
and products
− Become the preferred source for help, information
and referral
− Inspire health and wellness in those we serve
III. PEOPLE & PROCESSES
• Become an employer of choice
− Recruit and retain the best staff
− Create and sustain a fully engaged workforce that finds
joy in their work
− Cultivate high-performing leaders
− Inspire a healthier workforce
• Be the best place to practice medicine in the Puget Sound
Area
− Recruit and retain the best medical staff
IV. GROWTH & ACCESS
• Be the community’s provider of choice
− Leverage strategic partnerships
to advance business and market
performance
− Promote and drive targeted growth in
primary care, cancer, cardiovascular,
neuroscience, surgery, musculoskeletal,
women’s & children’s and home care
services
• Improve access to care
− Build virtual medicine capabilities
− Improve ease of access to convenient care
options
− Improve ease of access across specialties
• Foster innovation in the delivery of
value-based care through collaborative
partnerships
− Increase physician alignment through
EvergreenHealth Partners
− Expand geographic reach through the
Puget Sound High Value Network
− Foster direct-to-business relationships
V. FINANCIAL STEWARDSHIP
• Deliver affordable and value-based health
care
− Control and lower the costs of health care
− Ensure strong value-based contracting
− Advance pricing transparency
capabilities, services, and education
• Be accountable to our community
− Demonstrate differentiated community
benefit
− Engage the community in philanthropy
and the stewardship of donated funds
− Enhance the ability of all medical staff to manage both
the professional and personal challenges of practicing
medicine
• Integrate process improvement principles into day-to-day
behavior and culture
− Eliminate waste in our processes
− Model standard work at all levels of the organization
EvergreenHealth | 2016-2018 Strategic Plan Summary
2
2016 TOP 15 INITIATIVES – How we will achieve our strategies
I.
CLINICAL OUTCOMES & ABSOLUTE SAFETY
1. Hardwire absolute safety into our systems and processes
− Team-based simulation
− Mandatory critical event assessment and clearance
best practices
− Safety event reporting, response, and communication
− Physician documentation
− Mpages created for early detection and warning of the
deteriorating patient
− Expand ambulatory EMR to additional practices
− Medication reconciliation
2. Systemize population health management mechanisms
across the continuum
II. CUSTOMER ENGAGEMENT
3. Launch customer engagement innovations
− Loyalty and affinity system and outreach
expanded (call center, CRM, push emails, inpatient
communications, service standards)
− Navigation services and journey mapping for ideal
customer experience
− Appointment reminder system
4. Implement e-innovations
− e-patient registration and check-in
− e-home health
− e-visits/telehealth
− Online appointment for primary care and
mammography
IV. GROWTH & ACCESS
7. Enhance partnerships
8. Strengthen EvergreenHealth Monroe’s
market position through integration,
service, growth, and financial
sustainability initiatives
9. Grow surgical services, including
neurosurgery, musculoskeletal, and
bariatrics
10. Explore retail and virtual health
opportunities
11. Launch the Master Space Plan, including
the capital campaign
12. Continue to secure and execute on valuebased contracts for EvergreenHealth
Partners and the Puget Sound High Value
Network
13. Pursue new payer markets, including
preparing for Medicare Advantage and
contracting directly with businesses
V. FINANCIAL STEWARDSHIP
14. Formulate a plan to achieve a 2% operating
margin in 2017
15. Pursue pricing innovations
− Bundled payment programs for Total
Joint Replacement and OB
− Direct-to-consumer pricing tools
exploration
− Price information at point of service
III. PEOPLE & PROCESSES
5. Grow capacity and fully develop the
EvergreenHealth Medical Group
infrastructure
6. Drive waste out of our processes to
maximize value to our customers and
staff that deliver care
3
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Customer
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People & Process
Growth &
Access
Financial
Stewardship
Patient & Family
Centered
STANDARD WORK
PEOPLE
PROCESS
STRUCTURE
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LEADERSH I P PRI NCI PLES
Compassion
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Respect
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VALUES
Excellence ɜ Collaboration
ɜ
Accountability
Mission
Purpose
To advance the health of communities
nities
we serve through our dedication to
high quality, safe, compassionate,,
and cost-effective health care.
• We are the stewards of our culture.
How we embrace and live our values and
• We are “teachers and
coaches” supporting the
these principles cultivates a consistent
professional growth of our staff,
and intentional culture.
and helping our teams achieve
• We are accountable for achieving
exceptional outcomes, and for
applying the learning’s from our successes
and failures to help us improve every day.
• We are committed to continuous,
incremental improvement to eliminate
waste, inefficiency, ineffective
their highest potential.
W
Working
together to
enrich
enr the health and
well-being of every
w
life we touch.
• We are consistently responsive
and timely to those we serve.
• We are inclusive and
transparent in our decision making
and communications.
• We find opportunities every
day to genuinely recognize and
celebrate the excellent work of our
staff, physicians, and volunteers.
• We listen and communicate
effectively, always seeking
• We are committed to learning
and growing as leaders in the
application of these principles.
• We role model healthy and
rewarding personal lives that
communication, and variations in
first to understand and then to
are in balance with the demands of
our care processes.
be understood.
our work.
4
LEGEND
EvergreenHealth Medical Center Campus
Parking Lot
EvergreenHealth
Human Resources &
Technology Center
EvergreenHealth
Administrative
Services Building
EMERGENCY PARKING
ENTRANCE
Building Entrance
Information Desk
Cafeteria/Deli
www.evergreenhealth.com
Restroom
Stairs
NE 130th Lane
EMERGENCY
ENTRANCE
(Underground)
General Information: 425.899.1000
Nurse Navigator & Healthline: 425.899.3000
Parking Lot
Elevator
Ambulance
Entrance
Only
Escalator
Telephone
Family
Maternity
Center
CENTRAL ENTRANCE
EvergreenHealth Surgery
& Physicians Pavilion
DROP-OFF AREA
Central Registration
Chapel
Green Zone
WEST
ENTRANCE
(underground)
EA
AREA
Education
Center
Tan
Zone
FF
P-O
DROP-OFF
Breast
Health
Center
Registration
Halvorson
Cancer Center
Silver
Espresso
Deli on Two
DRO
120th Avenue NE
Café 128
Gift
Shop
Courtyard Deli
and Espresso
op
t Sh
Gif
Silver Zone
Inpatient
Units
ay
lkw
Wa
F AR
um
Galleria
Purple
Zone
WEST PARKING
ENTRANCE
nd
rou
erg
Und
F
P-O
ori
DRO
dit
Patient Registration
Red Zone
ATM
Blue Zone
Au
EMERGENCY
Department
AR
EA
Pharmacy
Baby & Family
Boutique
Coral Zone
Evergreen
Professional
Center
Vending Area
Waiting Area
Gene and
Irene Wockner
Hospice Center
CENTRAL PARKING
ENTRANCE
EAST
ENTRANCE
Central
Parking
(lower levels)
EAST PARKING
ENTRANCE
East
Parking
(top deck)
Parking Lot
Parking
Lot
(lower levels)
124th Avenue NE
NE 128th Street
Central
Parking
Parking Lot
DEYOUNG PAVILION
ENTRANCE
Parking Lot
SS
BU
PW
TO
AI
TIN
G
AR
EA
DeYoung Pavilion &
Sound Transit Center
DeYOUNG PARKING
ENTRANCE
CENTRAL PARKING
ENTRANCE
Parking
Lot
Parking Lot
5
Central Entrance and Central Parking
TAN, Floors 1‐4
Floor 1 Floors 2‐4 Education Center – Training rooms for employees and community members Outpatient Provider Offices BLUE Floor Floor 2 Floor 3 Floor 4 Floor 5 “Galleria”, Employee Health, Diagnos ic Imaging (DI), Cardiac Cath Lab Family Maternity Center (FMC), Gift Shop, Outpatient Pharmacy (EPC) Surgery NICU & Pediatrics Progressive Care Unit (PCU) CORAL Floor 1 Floor 2‐5 Floor 5 Mammography, Wound Care Center, Microbiology Lab Outpatient Provider Offices PacLab East Entrance and East Parking TAN, Floor 5
Floor 5 EvergreenHealth Surgery Care, Tan
West Entrance and West Parking SILVER Basement Floor 1 Cafeteria Chapel, Administration Offices Floor 6 Floor 7 Floor 8 Oncology Unit Ortho, Spine, Neuro Unit (OSN) Med/Surg Unit GREEN Floor 1 Floor 2 Floor 3 Floor 4 Central Registration, Cancer Support Services & Therapy, Gift Shop Education Offices Education Skills Lab Comprehensive Procedures Center (CPC) PURPLE
Floor 1 Floor 2 Inpatient Lab (Blood Bank inside) Cardiovascular Short Stay, Inpatient Pharmacy Floor 3 Floor 4 OR Waiting Room Acute Rehab Unit (ARU) EMERGENCY Entrance and EMERGENCY Parking
RED Basement Floor 1 Medical Records Emergency Department, Security Floor 2 Critical Care Unit (CCU) 6
EvergreenHealth Medical Center
DIRECTIONS
405
12040 NE 128th Street | Kirkland, WA 98034
NE 132nd St.
NE 132nd St.
124th Ave. NE
120th Ave. NE
HOV
Exits
NE 130th Lane
EvergreenHealth Medical Center is conveniently located just off I-405 in the
Totem Lake area (north Kirkland).
Northbound on I-405 Take the NE 124th Street/Totem Lake Boulevard Exit (20B); stay
to the right and follow the Totem Lake Boulevard Exit, and proceed straight from the
light, up the hill on 120th Avenue NE to NE 128th Street. Follow the signs to campus and
adjacent parking.
NE 128th St.
NE 128th St.
em
Tot
La
NE 124th St.
1
20
ke
B
lvd
.
th
Ave
. NE
ve
0th A . NE
12
116th Ave. NE
EXIT
20
Southbound on I-405 Take the NE 124th Street Exit (20); turn right onto NE 124th Street,
turn right onto 116th Avenue NE, turn right on NE 128th Street and proceed straight past
Totem Lake Boulevard until you reach 120th Avenue NE. Follow the signs to campus and
adjacent parking.
EvergreenHealth
Medical Center
(see inset)
New Parking Entrance Names Starting Nov. 2, 2015
Central Parking If your destination is the Blue Zone (Diagnostic Imaging;
EvergreenHealth Surgery Care, Blue; Family Maternity Center; Patient Registration); Coral
Zone (Breast Health Center; Evergreen Professional Center; PACLAB; Pharmacy) or the Tan
Zone (Education Center; EvergreenHealth Surgery & Physicians Pavilion), follow signs to
the Central Entrance and nearest parking entrance on either NE 128th Street or NE 130th
Lane. From Central Parking, proceed to Level A, using the tan-colored elevator if needed,
for destinations in the Tan Zone. Use the blue-colored elevators if needed for destinations
in the Blue Zone and the Coral Zone. Follow signs to your location.
NE 1
24th St.
KIRKLAND
EXIT
20B
NE 132nd St.
120th Ave. NE
NE 130th Lane
EMERGENCY
Entrance
Central
Entrance
124th Ave. NE
NE 116th St.
East
Entrance
West
Entrance
NE 128th St.
DeYoung
Pavilion
Map Inset
East Parking If your destination is EvergreenHealth Surgery Care, Tan, follow the signs to
the East Entrance on 124th Avenue NE and park in East Parking located on the top deck.
West Parking If your destination is the Green Zone, the Halvorson Cancer Center, the Purple
Zone or the Silver Zone, follow the signs to the West Entrance on NE 128th Street and park in
the underground West Parking. Follow signs to your location.
EMERGENCY Parking If your destination is the EMERGENCY Department (Red Zone),
follow the signs to the EMERGENCY Entrance on NE 130th Lane and park in the surface lot
or underground in EMERGENCY Parking.
DeYoung Pavilion Parking Follow the signs to the DeYoung Pavilion (Booth Gardner
Parkinson’s Care Center; EvergreenHealth Rehabilitation Services; Heart & Vascular
Wellness Services; Multiple Sclerosis Center; Neuropsychological Services) on NE 128th
Street. Park in the surface lot or underground parking.
Free parking is available campus wide.
7
EMERGENCY CODES & STAFF RESPONSE
HOW TO CALL A CODE
Dial x1199 (Inside Hospital) Dial 9-911 (Outside Hospital)
State the Code, Location, Color Zone and Name
CODE
BLUE
Arrest or Medical Emergency
CODE
RED
An adult, child, or infant’s heart has stopped or they are
not breathing.
ADULT
NEONATES
PEDIATRIC
•
Initiate Basic Life Support.
•
Hospital: Dial x1199 or press Code button
CODE BLUE Adult arrest or medical emergency
To Utilize a Fire Extinguisher (P.A.S.S.)
P-Pull the pin twist as you remove it
A-Aim at the base of the fire
S-Squeeze the handle
S-Sweep from side to side
CODE BLUE NEO Neonates arrest or medical emergency
Combative or Out of Control Person
In the event a person is combative or exhibit out of
control behavior, Dial x1199 and report a Code Gray
with the following information.
CODE
SILVER
Early Identification (Prior to Code Gray)
A person’s aggressive behavior is escalating Dial x1199 and
requests Security STAT. Security staff will initiate a response and
make an effort to de-escalate the situation prior to reaching a
Code Gray status.
CODE
BLACK
(Internal Triage)
CODE
ORANGE
Bomb Threat / Suspicious Package
To report a bomb threat or suspicious package Dial
x1199 and request Security to respond “STAT”
providing the following information:
1.
Your location and/or the location of the incident
(Your name, floor #, wing color & location).
2.
Wait for Security to respond to your location after
Security arrives; provide the officer with the
situational information.
Hazardous Materials Spill
A significant hazardous material spill, release or odor
CODE
ONE
Non-Life Threatening Event
Response required by clinical and security staff for a nonlife threatening event. (example: Slip,Trip, Fall)
In Case of Fire Perform R.A.C.E:
R-Rescue anyone in immediate danger
A-Activate alarm and call x1199
C-Contain fire and smoke by closing doors
E-Extinguish the fire if possible
Emergency Number: Hospital Dial x1199
Emergency Number: Other Dial 9-911
CODE BLUE PALS Pediatric arrest or medical
emergency
CODE
GRAY
Fire or Smoke
Weapon or Hostage Situation
Code Silver 1 = Weapon
At risk or confronted by a person with a weapon
Code Silver 2 = Hostage situation
To activate the Code Silver Dial x1199
Security and Emergency personnel will respond.
CODE
INTERNAL
/
EXTERNAL
TRIAGE
CODE
AMBER
ALERT
RAPID
RESPONSE
TEAM
External Event
An event that impacts services
To activate the Event Alert Team Dial x1199
EVENT ALERT, level 1,2,or3
Level 1 = Full Activation, response by all 1-2 staff person to
the Labor Pool.
Level 2 = Partial Activation, 1-2 staff person to
the Labor Pool when requested.
Level 3 = Alert/Standby – Await further instructions from
Management
Infant/Child Missing
An infant or child is missing or abducted.
•
If Infant – Code Amber Alert
•
If Child – Code Amber Alert + age of child
Medical Team Required
A patient’s medical condition is declining and needs an
emergency medical team at the bedside.
(Prior to heart or respiration stopping)
8
Methods for Expressing
Your Concerns
Patients, clients, families and visitors
are encouraged to express complaints
or concerns about any aspect of their
care or experience with EvergreenHealth
Medical Center.
Concerns or complaints may be directed to any
Evergreen staff member or to:
Patient Relations
EvergreenHealth Medical Center
12040 NE 128th St., MS #8
Kirkland, WA 98034
Telephone: 425.899.2267
Please be assured that expressing a complaint or
a concern will not compromise your care. We will
promptly investigate all complaints and grievances
and work to resolve them in a timely, reasonable
and consistent manner.
Patient and Client
Bill of Rights
You may also lodge a grievance directly with the
Washington State Department of Health and/or
The Joint Commission.
Department of Health
Health Systems Quality Assurance –
Complaint Intake
1.800.633.6828 (complaints only)
Calls are received from 8 a.m. to 5 p.m.,
Monday through Friday.
Department of Health
P.O. Box 47857
Olympia, WA 98504-7857
[email protected]
The Joint Commission
1.800.994.6610
[email protected]
12040 NE 128th Street
Kirkland, WA 98034
www.evergreenhealth.com
9
Patient and Client Rights
• Know the name of your physician and others As a patient or client, you have the right to:
• Effective written and verbal communication that is
• Be notified of your rights and exercise your rights in regard to your care.
• Receive safe, private, high-quality and respectful care.
• Be provided impartial access to care.
• Receive medical services in a life-threatening
emergency.
• Have a family member or representative of your
choice and your physician notified promptly of
your admission to the hospital.
• Receive visitors designated by you or your support
At EvergreenHealth Medical Center,
every effort is made to provide you with the
best possible health care. While we are known
for providing advanced medical solutions, it is
our belief that the power to heal comes from
many places. That knowledge is still the most
powerful tool — yours and ours. That’s why we
have adopted these Patient and Client Rights
and Responsibilities to help guide our actions.
The statement of rights and responsibilities is
for those who receive services from Evergreen.
In addition to these rights, we make every effort
to protect your privacy and the privacy of your
health information. For more information about
Evergreen’s privacy practices and your rights
regarding privacy, please read our Notice of
Privacy Practices. If you have questions about
Evergreen’s privacy practices, please contact
our privacy officer at 425.899.5599.
person; these include, but are not limited to, a
spouse, domestic partner, other family member
or friend. You have the right to withdraw or
deny your consent at any time. Evergreen will
not restrict, limit or deny visitation on the basis
of race, color, national origin, religion, sex,
gender identity, sexual orientation or disability.
Visitors are restricted from most treatment and
procedure areas and may be limited based on
your medical condition.
• Have your comfort needs addressed through
appropriate pain assessment and management.
• Be informed of aspects of your condition to
help you make informed decisions regarding
your care.
• Request medically necessary and appropriate
services or refuse treatment or services to the
extent permitted by law, and be informed of the
potential consequences of such an action.
• Receive detailed information, in terms you
can understand, about your care, your illness, your treatment or other services that you may be receiving.
who care for you.
appropriate to your age, understanding and language.
• Actively participate in decisions involving your care,
including the consideration of ethical issues, and be
informed in advance of any change in your plan of care.
• Receive care from personnel who are properly trained
• Be informed of the reasons for impending discharge,
transfer to another facility and/or level of care,
ongoing care requirements, and other available
services and options as appropriate.
• If you are a Medicare patient, you have the right to
receive a notice of your discharge rights as well as a
notice of your non-coverage rights, and to be notified
of your right to appeal premature discharge.
to perform assigned tasks and to coordinate services.
• Courteous and respectful treatment of person and
property, privacy, and freedom from abuse and
discrimination.
Patient and Client
Responsibilities
• Receive spiritual care, if desired.
As a patient or client, you have the responsibility to:
• Confidential management of your patient records • Participate in decisions involving your care.
and information.
• Access information in your own patient record within
a reasonable amount of time following your request.
• Be informed of the process for submitting and
addressing any complaints to the hospital facility
or a state agency.
• Receive an explanation of your bill and our policy con-
cerning billing and payment for services, and the right
to inquire about the possibility of financial assistance.
• Seek a second opinion or choose another caregiver.
• Freedom from the use of seclusion or restraint in of any
form unless medically necessary for your well-being.
• Receive adequate information to help you make an
informed decision whether to participate or refuse
to participate in experimental treatment or research.
• Be informed that refusing to participate in research
will not compromise your access to care, treatment
and services.
• Sign an advance directive such as a living will or
durable power of attorney for health care and have
hospital staff and your providers comply with your
directives to the extent permitted by hospital policy
and state and federal laws.
• Provide a complete and accurate medical history
to the best of your knowledge, and to provide
information about current medications or
treatments.
• Ask questions and seek clarification of your
diagnosis, course of treatment or care plan.
• Provide information about complications or health
symptoms.
• Follow the proposed course of treatment or care,
recommendations and advice upon which you and
your provider have agreed.
• Be considerate of the rights of other patients and
clients, and care personnel, and to be respectful
of property.
• Provide accurate and timely information about
sources of payment and your ability to meet
financial obligations.
• Make it known whether you understand what is
expected of you, and whether you are able and
willing to comply.
Parents and guardians may represent or assist a patient
or client in fulfilling these rights and responsibilities.
10
Art of Caring Warm welcome •
•
•
establishing initial rapport identifying the reason(s) for the visit orienting to call light / room Gathering information •
•
•
exploration of problems understanding the patient’s perspective providing structure to the visit Building the relationship •
•
developing rapport involving the patient Explanation and planning •
•
•
providing the correct amount and type of information aiding accurate recall and understanding achieving a shared understanding that incorporates the patient’s perspective and shared decision making Fond Farewell ‐ Closing the session 11
C u l t u r a l a n d L i n g u i s t i c Aw a r e n e s s
According to the Census Bureau the U.S. is projected to become a
majority-minority nation for the first time in 2043.
Our obligation is to ensure that the programs and services provided in English by EvergreenHealth are accessible to
Limited English Proficient (LEP) individuals, as well as people with hearing problems and to all people of diverse
cultural background.
Only DSHS certified interpreters from one of EvergreenHealth contracted agencies may interpret for providers/
patients. Bilingual employees, friends, family members may NOT interpret during any clinical communication.
Interpreter Services Department
evergreenhealth
Federal Legislation & Policies
2001 -
CLAS Standards
2000 -
Executive Order 13166
1985 -
Establishment of Federal Office of Minority Health
1964 -
1946 -
They aim to improve health care quality and advance health equity by establishing a framework for
organizations to serve diverse communities.
Requires all federal financial assistance recipients to uphold Title VI.
Civil Rights Act—Title VI
Prohibits discrimination on the basis of race, color, and national origin in programs and activities
receiving federal financial assistance. It is the legal foundation for language access services.
Bill-Burton Act
It was designed to provide federal grants to improve the physical plant of the nation’s hospital system.
EVERGREENHEALTH Interpreter Services Guidelines
For more info:
http://employees.evergreenhealthcare.org/departments/Interpreter%20Services/Pages/
default.aspx
EH Interpreter Services
Shahzina Karim,
12 Director
Ana Balducci-Curtis, Coordinator
10/2015
Culture
Globalization brings a wide range of cultures into closer interaction than ever before. Culture and language are vital factors in how
health care services are delivered and received. Cultural awareness in health care is the ability to provide culturally sensitive patient
-centered care mutually respecting beliefs and values.

The United Nations defines culture as “the complex whole which includes morals, beliefs, customs and other capabilities and
habits acquired by a human as a member of society.”

Diversity refers to the co-existence of a difference in behavior, traditions and costumes.

Intercultural competence are abilities to perform “effectively and appropriately when interacting with others who are
linguistically and/or culturally different from oneself” (Fantini & Tirmizi, 2006) -learning to co-exist, recognizing and
tolerating difference.
developing
CULTURAL
AWARENESS
Cultural and linguistic awareness is the ability of healthcare providers to understand and effectively respond to the cultural, sensory,
and linguistic needs brought by patients. This type of awareness begins at two levels; the individual and institutional level:
1) At the individual level it is a set of behaviors, attitudes, and knowledge that enables a person to interact effectively with different types of people by being aware of their own cultural values and understanding the “dynamics of difference.”
2)
At the institutional level it is a set of behaviors, attitudes and policies that enables an organization to appropriately serve people
of different cultures in a respectful manner.
The Joint Commission provides guidance for organizations assessment of patient’s cultural needs:
 Ask the patient if there are any cultural, religious, or spiritual beliefs or practices that may influence his/her care.
 Ask the patient if the hospital environment is welcoming to their cultural and religious or spiritual beliefs.
 Respect the patient’s needs and preferences for modesty.
 Determine if the patient uses any complementary or alternative medicine or practices. Consider incorporating these into the patient’s care, if appropriate.
 Consult a professional chaplain, if available, to complete a spiritual assessment.
 Provide an area or space to accommodate the patient’s need to pray.
 Note any cultural, religious, or spiritual needs that influence care in the medical record and communicate these preferences to staff.
To develop appropriate cultural and linguistic awareness we must let patients know that we want to make sure they are comfortable
by asking them questions in order to learn their views on health beliefs, misconceptions and treatment plans.
In order to alerting the care team we must identify and record patient’s primary language, interpreter, cultural, physical, or/and
sensory needs.
13
A Communication Guide
Compiled by Melissa Tiesel, RN, BSN, CNE
Working with the Albanian population:
 Prefer to be addressed formally (Mr./Mrs. + last name)
 The eldest member of the group generally makes decisions
 Handshakes, smiles, and eye contact are culturally appropriate
 Remaining composed is very important
 Often use expressive hand gestures and body language
 Direct eye contact often signals trust
 Nodding and shaking the head have different meanings than they do in America. Answers
should be verified orally
 Personal space may be closer than is typical between Americans
 Touching is common, except between strangers
Working with the Chinese population:
 Bowing is a traditional greeting and a simple head nod is an appropriate response
 Traditionally, the Chinese are addressed by their family name/title, but some variations do
exist. It is especially important with this population to ask how they prefer to be addressed
 Older people are venerated and viewed as very wise
 Raised voices during conversation may be understood as anger
 Smiling is considered very personal and used for special circumstances
 Touching and eye contact should be avoided during conversations
 Sitting and/or standing side by side is preferred for conversations
 Pointing should be done with the whole hand rather than just with the pointer finger
 Putting your hands in your mouth for any reason is considered offensive
 The Chinese do not speak with their hands. Large hand movements can be distracting
 Negative queries and complex sentences are difficult to understand. Use simple, affirmative
phrases when giving instructions.
 *Those who speak Chinese at home have been identified as having one of the lowest levels of
English proficiency. Please be aware of an increased risk for language barriers.
Working with the Deaf or Hard of Hearing population:
 Ask patients what their preferred method of communicating is: ASL interpreter, lip reading,
pen and paper, other SL interpreter
 For patients who prefer speech or lip reading, the patient’s attention should be ensured before
speaking
 Eye contact should be maintained while speaking
 Speech should be slow and clear
 Over-enunciation should be avoided as it can distort words and make them more difficult to
understand
14
08/09/16 Working with the Filipino population:
 Prefer to be addressed formally in order of age
 Handshakes, smiles, and eye contact are culturally appropriate, although eye contact is often
not maintained with authority figures
 There are varied meanings for “yes” and “no.” Use open-ended questions when possible and
verify yes/no responses
 Nodding the head has many different meanings such as, “Yes, I hear you,” “Yes, we’re
interacting,” do not automatically take it for comprehension
 Most individuals are comfortable with silence and allow the other person to begin speaking as a
sign of respect
 Any pointing gesture with the fingers can be insulting
 Standing with your hands on your hips is considered an aggressive posture
Working with the French population
 The last name is often stated first
 Handshakes, smiles, and eye contact are culturally appropriate
 Rudeness during impersonal interactions is common
 Prefer to chat about general topics rather than their personal life
 Strong eye contact, large gestures and excited tones often indicate interest and involvement
 Set times are often viewed as flexible and it is acceptable to be “fashionably late”
 It is considered rude to chew gum or talk with hands in your pockets during conversation
Working with the German population:
 Prefer to be addressed formally
 Often very literal and blunt in conversation
 Decisions are based on facts and require detailed information
 Information is long reviewed and decisions may take awhile
 Punctuality, orderliness, and structure are highly valued
Working with the Hispanic/Latino population:
 Prefer to be addressed formally (Mr./Mrs. + last name)
 Spokesperson and decision- maker is usually father or oldest male
 Often bring multiple family members with them to appointments
 Greeting all family members present (even children) is important
 Elders may avoid eye contact with healthcare workers as a sign of respect
 Often stand close to one another during conversations, even with strangers
Working with the Hmong (Laotian) population:
 Spokesperson and decision- maker is usually father or oldest male
 Verbal communication is preferred to telephone or written communication
 Direct eye contact is often avoided as a sign of respect
 Personal cleanliness and lack of body odor are very important; may be offended by strong
perfumes
 It is considered dangerous to comment on the appearance of a child due to religious beliefs that
spirits may take away the child’s soul
 Small talk is considered polite and important in building relationships
 The use of silence is usually a strong indicator of a negative response
 There are varied meanings for “yes” and “no.” Use open-ended questions when possible and
verify yes/no responses
15
08/09/16 
In Laos, the Hmong do not have calendars and clocks. Therefore, many do not know how old
they are. They also may have a difficult time with understanding set appointment dates and
times
Working with the Japanese population:
 Prefer to be addressed formally, especially by their last name. A slight bow or handshake is also
acceptable
 Prefer written communication. Comprehension and speech of English is often poorer
 It is embarassing for a native born citizen to be taken for a foreigner
 Presenting oneself as educated and knowledgeable is expected and will gain trust and respect
 Saying “no” especially to authority figures is considered extremely impolite.
 Considerable control over body language is often exhibited
Working with the Khmer (Cambodian ) population:
 Prefer to be addressed formally according to societal rank
 Often communicate indirectly (body language, use of silence)
 Public touching between men and women is strictly forbidden
 If an interpreter is needed, most prefer a same-sex interpreter
 *Those who speak Khmer at home have been identified as having one of the lowest levels of
English proficiency. Please be aware of an increased risk for language barriers.
Working with the Korean population:
 Prefer to be addressed formally
 Spokesperson and decision- maker is usually father or oldest male
 Respect to everyone is highly valued
 Tend to stand close to one another while conversing
 Often do not maintain eye contact
 Touch in the realm of healthcare is readily accepted: also common among friends and social
equals
 Punctuality is valued
 Small talk is commonly viewed as pointless and insincere
 Communication of feelings through facial expressions is uncommon
Working with the Persian (Iranian) population:
 May prefer to be addressed by their last name
 Greeting every family member is important; shaking hands with children shows respect to the
parents
 Intense eye contact is common; often smile and use hands and arms to help convey expression
 Spokesperson and decision- maker is usually father or oldest male
 Handshakes, a slight bow, and standing when someone enters the room are common greetings
 The concept of family is very private: It is considered rude to ask about an Iranian’s wife or
other female relatives
 Rarely discuss private matters outside of the family. Require time to “warm up” before
approaching personal subjects
 An individual should never be given bad news alone.
 Extending the thumb (“thumbs up”) and showing the soles of one’s feet are considered
offensive
Working with the Russian population:
16
08/09/16 





Handshakes, smiles, and direct eye contact are culturally appropriate
The whole hand should be used for pointing
Most individuals accept touch regardless of age and gender
Punctuality is the cultural norm
Tone of voice tends to be loud, do not interpret as anger
Shaking hands or passing items across a threshold should be avoided
Working with the Somali population:
 Somalis appreciate formal introduction of everyone in the room (name and purpose)
 Elders are highly respected and addressed as “aunt” and “uncle” even if strangers
 Often touching the opposite sex is forbidden, even shaking hands with the opposite sex in a
healthcare setting
 If an interpreter is necessary, a same-sex interpreter is preferred
 It is considered dangerous to comment on the appearance of a child due to religious beliefs that
something evil will occur (like illness)
Working with the South Asian population:
 Prefer to be addressed formally
 Strangers are often greeted with folded hands and a head bow
 Spokesperson and decision- maker is usually father or oldest male
 Direct eye contact and touching between men and women should be avoided
 Tilting the head back and forth is a common way of saying, “I’m listening”
 Punctuality is not highly valued
 Any gesture using the fingers is considered rude
 Personal space is important. The acceptable conversation distance is 3 to 3.5 feet apart.
 Winking has vulgar implications
 Strong body odors are common
Working with the Vietnamese population:
 Prefer to be addressed formally according to age/importance
 Respect is shown to authority figures by giving a gentle bow and avoiding eye contact
 Direct eye contact or standing over someone is considered impolite
 Often nodding or saying “yes” reflects that the person is listening, not that they understand
 Respect is very important and questioning or defiance is considered offensive
 Self-control is highly valued and voicing pain or concerns is generally not done
 The head is a sacred part of the body which should not be touched
 *Those who speak Vietnamese at home have been identified as having one of the lowest levels
of English proficiency. Please be aware of an increased risk for language barriers.
17
08/09/16 18
Your 5 Moments
RE
O
ASEPT
EF EAN/
IC
L OCEDURE
C R
2
P
B
for Hand Hygiene
4
1
2
3
4
5
Y
E
3
AFTER
TOUCHING
A PATIENT
D
AF
T E R BO U
FLU
OS
P
I
D
X
E
RIS
K
R
1
BEFORE
TOUCHING
A PATIENT
5
AFTER
TOUCHING PATIENT
SURROUNDINGS
BEFORE TOUCHING
A PATIENT
WHEN?
Clean your hands before touching a patient when approaching him/her.
WHY?
To protect the patient against harmful germs carried on your hands.
BEFORE CLEAN/
ASEPTIC PROCEDURE
WHEN?
Clean your hands immediately before performing a clean/aseptic procedure.
WHY?
To protect the patient against harmful germs, including the patient's own, from entering his/her body.
AFTER BODY FLUID
EXPOSURE RISK
WHEN?
Clean your hands immediately after an exposure risk to body fluids (and after glove removal).
WHY?
To protect yourself and the health-care environment from harmful patient germs.
AFTER TOUCHING
A PATIENT
WHEN?
Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient’s side.
WHY?
To protect yourself and the health-care environment from harmful patient germs.
AFTER
TOUCHING PATIENT
SURROUNDINGS
WHEN?
Clean your hands after touching any object or furniture in the patient’s immediate surroundings,
when leaving – even if the patient has not been touched.
WHY?
To protect yourself and the health-care environment from harmful patient germs.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind,
either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.
May 2009
19
SBAR
SBAR is a communication method used to frame any conversation to be
used whenever crucial information is transferred between staff, services
or patients and families.
SBAR is the communication standard at EvergreenHealth.
S
B
Situation
A concise statement of the problem
What is the headline?
Background
Pertinent and brief information related to the
situation
What has happened?
A
Assessment
R
Recommendation
Revised 9/3/14
Analysis of the problem
What is going on?
Requested action, order or change
What is needed?
20
Falls 1
Fall Prevention
A fall is defined as an unplanned descent to the floor with or without injury. Patient falls
contribute to mortality and increased morbidity in the general patient population.
Implementation of a falls/injury risk assessment and prevention program targets those at risk
due to such factors as environmental challenges, functional limitations, and patient and family
educational deficits. However, all patients may be at risk for falls.
General precautions that are in place for all patients include:
• Orientation to surroundings and use of call light
• Keeping bed in low, locked position
• Keeping floors obstacle free
• Keeping personal belongings and call light within patient's reach at all times
• Intentional rounding
• Use of non-skid footwear
• Adequate lighting
• Encouraging patient and families to call for assistance when needed
Safety huddles are held at the beginning of each shift with all staff for the purpose of going
over recent falls and current fall risks on unit. Because of increased risk of injury with a fall,
information about fall risk will include the "ABCS" - Age 85 or greater, Bones (Osteoporosis,
recent fracture or other bone disorder), Coagulopathy (on anticoagulants or with a bleeding
disorder) and Surgery (during current admission). This information will be passed on in shift
report and documented on whiteboard along with patient's fall
risk assessment.
Acute Care Inpatient (ONC, OSN, MED/SURG, CCU, PCU, ARU)
The following list of equipment may be used to prevent patient falls:
1. Call light within reach for patient and/or family
2. Alarm systems for doors, chairs, toilets, or beds as appropriate
3. Lift equipment to provide safe patient movement and prevention
of falls
4. Gait belt or appropriate assistive devices (walker, cane, etc.)
5. Yellow socks or yellow arm band
6. Visual doorway identifier
7. In-room patient white boards designating fall risk assessment as Low,
Mod, or High
8. Fall risk alert on Medical Record or bed board
9. Omnibelt as a reminder for patients with impulsive behavior
9/2015
21
Falls 2
Frequency of Fall Assessment:
• Assess patient fall risk using the Modified Morse Fall Scale
• Assess patient risk of injury with fall using the ABCS Risk Assessment
1.
2.
3.
4.
5.
Upon admission
Upon transfer from one unit to another
Following any change of patient status that may affect fall risk
Following a fall
Every shift
a. Document the assessment in the medical record
b. Document on patient white board as LOW, MOD, or HIGH risk
c. In addition to the risk assessment tool, the nurse is expected to apply her/his
clinical judgment about the patient's risk for falls
Fall Risk Interventions:
•
Implement basic fall prevention interventions as listed in supportive data for ALL patients.
•
Add the following interventions when designated Moderate Risk:
1. Provide assistance with toileting during rounds
2. When assisting patient to bathroom, stay nearby
3. Evaluate effects of medications that increase the individual’s risk of falling with
assistance from pharmacy, as appropriate
4. Determine if appropriate to move patient closer to nurse’s station or constant care room
5. Partner with patient to determine which side of the bed they usually get out ofconsider placing tethers (IV pump, Foley bag, etc.) on that side of the bed
6. Consider implementing use of appropriate equipment as in equipment list above
•
Add the following interventions when designated High Risk:
1. Implement yellow identifier at patient room entrance
2. Place yellow socks and/or yellow bracelet on high fall risk patient
3. Assure patient is able to be visualized from hallway if staff not present
4. When assisting patient to the bathroom, stay in the bathroom, within arm's
reach, to monitor and assist patient
5. Use of chair, toilet and bed alarms are highly recommended
6. Consider use of constant observer
7. Implement "no-passing" zone on high fall risk patients: After reviewing high risk patients
at safety huddle, all staff on unit are aware that these patient's call lights are highest
priority. All staff will accept responsibility to assure call light is answered immediately.
EMERGENCY DEPARTMENT
•
The following list of equipment may be used to prevent patient falls:
1. Light within reach for patient and/or family
2. Lift equipment to provide safe patient movement and prevention of falls
3. Gait belt or appropriate assistive devices (walker, cane, etc.)
4. Yellow socks or yellow arm band
9/2015
22
Falls 3
5.
6.
7.
8.
9.
Yellow/visual doorway identifier
Room curtains to remain open if patient is alone
In-room patient white boards designating fall risk assessment as Low, Mod, or High
Fall precaution icon added to ED tracking board
Additional interventions as ordered by MD
WOMENS AND CHILDREN'S
•
Moderate and High Risk Nursing Interventions (over the age of 8 yrs):
1. Provide distraction to the patient as appropriate
2. Assist moderate risk fall patients to the bathroom, staying close to the bathroom door
to listen to patient activity
3. Determine if appropriate to move patient closer to nurse’s station
•
Moderate and High Risk Nursing Interventions (under the age of 8 yrs):
1. All Infants and children up to the age of 8 years are considered at minimum a Moderate
Risk
2. Side rails, crib rails, and side walls are always in the ’up’ position unless care is provided
3. Families are educated on proper falls prevention techniques when holding,
feeding, snuggling, bathing, carrying, and other activities that take place when
the infant or child is not in their bed
EDUCATION OF PATIENT AND FAMILY
•
Using Teach Back method, educate the patient/family about fall prevention to include:
1. Reasons for precautions (i.e. recent fall, impaired mobility, medications, recent
surgery, use of anticoagulants)
2. Assistive devices (i.e. walkers, gait belts, lift equipment)
3. Fall prevention precautions (i.e. yellow socks, yellow flag, bed or chair alarm)
4. How to request assistance
POST FALL PROCEDURE
•
•
•
Fill out fall event/post fall assessment in ad hoc charting
Document fall in the Progress Notes
Assure SafelinQ report is completely filled out by person witnessing fall
Documenting Morse Fall Scale in Cerner:
• Found in AdHoc
9/2015
23
Falls 4
•
Or on Care Compass
Morse Fall Scale in QS:
Maternal Chart:
Maternal falls usually occur post-delivery, first or second time getting out of bed.
• Assess vital signs, sensory/motor of legs prior to getting out of bed.
• Assist out of bed first and second time out of bed post-delivery.
9/2015
24
Falls 5
Newborn Chart:
Newborns at risk for falling out of adults arms and off day bed or patient bed
• Recommend adults don’t hold baby when they are at risk of falling asleep
• Recommend baby doesn’t lay on day bed or patient bed without being held.
Morse Fall Scale Reference Text
https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:29072
Initial Assessment or Re-assessment:
1. Initial: admission, first scale done in hospital
2. Re-assessment: any thereafter
History of Falling:
1. If the patient has a history of falls within 3 months of admission – this value may change if they fall
while they are here, YES = 25 points
2. If no falls w/in last 3 months, and no fall during hospitalization, NO = 0 points
Secondary Diagnosis:
1. If only one diagnosis is listed on the patient’s chart, score as NO = 0 points
2. If more than one medical diagnosis is listed on the patient’s chart, score as YES = 15 points
9/2015
25
Falls 6
Mobility Aid:
1. If a patient walks independently with no assistance of any kind, score 0
2. If a patient walks without a walking aid (even if does walk with a nurse assist), or is on bedrest and
does not get out of bed at all, score 0
3. If the patient uses crutches, a cane, walker, or wheelchair, score 15
4. If the patient ambulates clutching onto furniture for support, score 30
IVF Infusion/Narcotics/Diuretics:
1. If no infusing IV, no narcotics, no diuretics, score NO = 0 points
2. If patient has an infusing IV or is taking any narcotics or diuretics, by any route, score YES = 20
points
Gait/Transferring:
1. Normal gait = walking with head erect, arms swinging freely at the side, striding without hesitation,
score 0
2. Bedrest/immobile = patient does not ever get out of bed and walk at all (by MD order or unable),
score 0
3. Weak gait = May be stooped in walking, but able to lift the head and walk without losing balance,
steps are short and may be shuffling, score 10
4. Impaired = May have difficulty getting out of a chair, head down, watches the ground, poor
balance, cannot walk without assistance or a walking aid, score 20
Mental Status:
This is based on patient’s self-assessment of their ability to walk. Ask the patient, “Are you able to walk to
the bathroom alone, or do you need help?”
1. If the patient’s reply judging their ability is consistent with their true ability and the MD activity
orders, the patient is scored 0 (oriented to own ability.)
2. If the patient’s response is not consistent with their actual capability and MD orders for activity,
then they are judged to be overestimating their abilities or forgetful of limitations = 15 points
9/2015
26
Procedure for Putting on and Taking off
Personal Protective Equipment (PPE)
Putting on PPE
1. SANITIZE HANDS (GEL OR WASH HANDS)
2. PUT ON GOWN

Fully cover torso from neck to knees, arms to end of wrists, and wrap around the
back.

Fasten in back at neck
3. PUT ON MASK OR RESPIRATOR

Secure ties or elastic band at middle of head and neck.

Fit flexible band to nose bridge.

Fit snug to face and below chin.

Fit-check respirator.
4. PUT ON GOGGLES/FACE SHIELD

Put on face and adjust to fit.
5. SANITIZE HANDS (GEL OR WASH HANDS)
6. PUT ON GLOVES

Use non-sterile for isolation.

Select according to hand size.

Pull glove up to cover wrist of isolation gown.
Revised: July 2016
Removing PPE
Remove PPE at doorway before leaving patient room
or in anteroom
1. REMOVE GLOVES




Outside of gloves are contaminated!
Grasp outside of glove with opposite gloved hand; peel off.
Hold removed glove in gloved hand.
Slide fingers of ungloved hand under remaining glove at wrist.
2. REMOVE GOWN





Gown front and sleeves are contaminated!
Unfasten neck
Remove gown using a peeling motion; pull gown from each shoulder toward the
same hand.
Gown will turn inside out.
Hold removed gown away from body, roll into a bundle and place in hamper.
3. SANITIZE HANDS (GEL OR WASH)
4. REMOVE MASK OR RESPIRATOR



Front of mask/respirator is contaminated – DO NOT TOUCH!
Grasp ONLY bottom then top ties/elastics and remove.
Discard in waste container.
5. REMOVE GOGGLES/FACE SHIELD






Outside of goggles or face shield are contaminated!
To remove, handle by “clean” head band or ear pieces.
Place in designated receptacle for reprocessing or in waste container.
PAPR hoods are recyclable. DO NOT write your name on the mask and DO NOT
throw in the trash.
When finished with your PAPR hood, wipe off with a Sani-Wipe and store in the
cabinet.
At the end of your shift place the PAPR hood in the blue recycling bag.
6. SANITIZE HANDS (GEL OR WASH)
Revised: July 2016
EvergreenHealth Policies for Incoming Students
Prior to starting your student placement, review each policy as it pertains to your role at
EvergreenHealth. Your signature on the Code of Conduct and Student Attestation form will
attest to the fact that you have read and reviewed each policy prior to your start date. To
access the policy, please click on the link below each policy title.
Code of Conduct
Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:10054
Exposure to Blood and Body Fluid Management
Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:12201
Immunity/Vaccination and Tuberculosis Screening Requirements
Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:20412.
Transmission based Isolation Precautions
Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:15955.
Specimen Labeling Flow Chart
Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:29818
Work Restriction Policy
Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:12203$6
Dress Code Policy
Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:29548
Cell Phones Usage and Requirements Policy
Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:15833$3
Last updated: 7/5/16
29
IT – Overview
Welcome to EvergreenHealth! Please review the IT information contained in this document and use as reference
material for the following key topic areas:
• Important Phone Numbers
• Information Security
• Appropriate Use of Computer Systems
• Prohibited Activities
• EverLink – The Evergreen Intranet service
Important Phone Numbers
•
•
•
•
•
Helpdesk
Human Resources
Security (non-urgent)
Healthline
Disaster Information
Extension 1740
Extension 2511
Extension 1300
Extension 3000
Extension 4111
or
or
or
or
or
(425) 899-1740
(425) 899-2511
(425) 899-1300
(425) 899-3000
(425) 899-4111
Information Security
Passwords must be a MINIMUM of 8 characters and contain at least 3 of the 4 following items:
• one UPPERCASE letter
• one lowercase letter
• one number (1, 2, 3, etc.)
• one special character (@#$! ,etc.)
Passwords will expire every 120 days (4 months). After five (5) unsuccessful login attempts, your account will be
locked. To unlock your account - Call the Helpdesk at x 1740
Keep your username and password private! Do not leave them in plain sight or put them on Post-It notes.
Do NOT allow anyone else to login to the system with your username and password. Do NOT be tempted
to login to the system as anyone other than yourself.
Always secure your workstation whenever you are going to be away from it, either by locking it or logging out.
Appropriate Use of Computer Systems
•
•
•
•
EvergreenHealth’s computing resources exist for company business.
EvergreenHealth reserves the right to inspect or monitor any company owned, leased, or controlled
computer, computer device, network, computer facility or storage device at any time for any reason
Access to personal e-mail (Hotmail, gmail, etc.) or social media sites (Facebook, Twitter, etc.) is restricted
Certain websites are restricted, depending on content. Contact your manager if you have a business need to
access a restricted website
Prohibited Activities
•
•
•
•
•
Personal activities that interfere with performance
Personal profit or non-profit business ventures
Political activity
Unlawful activities
Sending, posting or downloading sexually explicit or offensive messages, cartoons or jokes, ethnic slurs, racial
30
•
•
•
epithets or other statements or images that may be construed as offensive, harassment, disparagement or libel
Sending or posting EvergreenHealth’s non-public materials or communications to anyone not entitled to know
or possess such information
Making unauthorized use of a password or mailbox, or masquerading as another individual
Unauthorized destruction, deletion or dissemination of electronic communications
Everlink – Evergreen’s Internal Website
Everlink is the default homepage of every computer. Everlink is also referred to as the intranet or SharePoint site.
To navigate Everlink:
• Departmental information, i.e.:
o Emergency Room
o Diagnostic Imaging
• Applications, i.e.:
o LMS
o SafeLinQ
• Quick Links, i.e.:
o Order Patient Transport
o Lucidoc
• Clinical Information, i.e.:
o Up To Date
o Pharmacy/Drug
• Useful Links, i.e.:
o Education
o IT Helpdesk
•
Highlighted areas include:
• Policies (Lucidoc) (located on the right side on Everlink) – Used to search policies and procedures
•
Evergreen Information Kiosk (located on the bottom on Everlink) – Used to search department and
physician locations at Evergreen
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ORIENTATION and CODE OF CONDUCT ATTESTATION Student Name (Please PRINT): School: _ Date: Review and complete the following items from the Non‐Nursing Student Orientation Packet: ITEM LOCATION Initial to verify understanding EvergreenHealth Strategic Plan Summary
EvergreenHealth Campus Map Emergency Codes & Staff Response Patient Bill of Rights EvergreenHealth Art of Caring Cultural and Linguistic Awareness in Healthcare
Hand Hygiene SBAR Communication Fall Prevention Fact Sheet Personal Protection Equipment EvergreenHealth Policies: • Code of Conduct • Exposure to Blood and Body Fluid Management • Immunity/Vaccination and TB Screening Requirements • Transmission based Isolation Precautions • Specimen Labeling Flow Chart Policy • Work Restriction • Dress Code • Cell Phones Usage and Requirements Packet Packet Packet Packet Packet Packet Packet Packet Packet Packet Packet IT Overview Packet My signature indicates that I have read and will be held responsible for the information provided in the list above. I understand that completion of all items is required prior to the start date of my clinical experience. Code of Conduct Attestation: I am confirming my commitment to integrity and my responsibility for following Evergreen’s Code of Conduct 1. I will follow the organization’s Code of Conduct and will ask questions if I don’t understand my responsibilities. 2. I will report violations of the Code of Conduct and any other concerns to the Evergreen supervisor, the Corporate Compliance Officer or the Corporate Compliance Hotline (425.899.5599). 3. I know that the organization has the right to take immediate corrective action if I violate the Code of Conduct, up to and including termination of the use of its facilities. Signature: Revised: 10/20/16
Date signed:_ 32