WELCOME!!!
Welcome to Memorial Hospital.
Welcome to Memorial’s On-boarding experience.
We are pleased that you chose to join us!
We are a mission, vision and values driven provider of
exceptional quality service. During our 60-year
history as a community hospital, we have played a
significant role in enhancing the quality of life in the
Yakima Valley.
You have joined a team of engaged colleagues who do
amazing work…every day! We focus upon creating the
healthcare experience of choice for our patients and
customers, and we look forward to creating an
exceptional experience for you as well.
Russ Myers, CEO
Core Purpose
To inspire people to thrive
Vision
Creating healthy communities one person
at a time
Mission
Achieving health with you in new ways
Values
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Respect
Accountability
Teamwork
Stewardship
Innovation
Values Defined
 Respect: Recognizing our differences as strengths, affirming
each other, and valuing each other’s contributions.
 Accountability: Taking responsibility for our actions, being
trustworthy and demonstrating integrity.
 Teamwork: Healthcare is best delivered by a team working
together, sharing unique talents, perspectives, ideas and
efforts to achieve our Vision.
 Stewardship: Effective and efficient use and preservation of
resources (human, environmental, financial, and community).
 Innovation: Creating and implementing original, visionary,
inventive solutions in pursuit of excellence.
Core Purpose reflects the heart of an organization over
several decades. Though it is never completely fulfilled, it is
something that continually guides us.
Vision is an inspiring, realistic picture of what we want to
look like over the next 10 years or so.
Mission is what we do.
Values describe the shared beliefs of our organization –
those things that really matter to us – and help us to
achieve our Vision.
About Memorial
Memorial is a 226-bed community hospital that was founded in
1950. We are a private, not-for-profit organization governed by a
board of directors. Each year we admit approximately 14,600
patients and serve over 77,000 patients in our Emergency
Department. We are delighted to welcome over 3,000
babies each year.
Our 2500 employees and 327
medical staff (representing 35
specialties) continually strive
for improvements in health care
quality and safety.
Ethical Considerations
Memorial has established a *Code of Ethical Business Conduct, and
Corporate Compliance Plan to underscore its commitment to ethical and
legal conduct throughout the organization. In addition, there are topic
committees which focus attention in specific areas of Memorial, including
Business Conduct, Compliance, Privacy/HIPAA, Consultative/Clinical
Ethics, Performance Improvement/Quality Assurance and Patient Rights.
These committees and officers report directly to the CEO and work with
each Memorial-affiliated organization to coordinate and implement a
vigorous plan to promote a positive and ethical work environment.
Memorial maintains an anonymous, 24-hour ethics violation report line.
Please contact them at 1-877-648-8658
*The Code of Ethical Business Conduct is found on Memorial’s Intranet
home page/About Us/Our Culture
Conflict of Interest
A conflict of interest is defined as a situation or activity from
which an employee stands to receive financial or personal
gain from any decision or consideration made during the
course of employment. Direct or indirect competition with
the hospital, or any use of information acquired during the
course of engagement with Memorial
is considered inappropriate and a
conflict of interest.
Identifying an Ethics Issue
 It could endanger someone’s life or health.
 It is against the law.
 It is against Memorial policy.
 It is contrary to Memorial’s vision, mission and values.
 You would not want others to know about it.
 It makes you feel uncomfortable.
Code of Conduct Motto: Do Right!!!
The safest course is to think and ask before you act.
Everyone has a responsibility for:
Appropriate disposal of materials containing identifiable
health information following the process for reporting
patient and employee concerns regarding privacy.
There are penalties for violating
confidentiality. If you need further
clarification about this policy or
have questions, please talk with
your supervisor.
Confidentiality
One of our primary accountabilities in health care is
confidentiality. We have access to a variety of information
about patients, their care, and their financial situations.
They trust us to ensure their privacy.
It is not to be shared with people who
are not involved in the direct
treatment of the patient or
supervision of the employee.
If you receive inquiries from
relatives and friends about patients,
ask them to speak with a shift nurse or supervisor.
HIPPA-Your Role in
Protecting Patient Rights
The Health Insurance Portability and Accountability Act
(HIPAA) is a privacy rule that creates national standards to
protect individuals’ personal health information (PHI) and
gives patients increased access to their medical records.
Health information covered:
Any information, whether spoken, electronic or written that
relates to the health of the individual, the health care
provided to that individual or payment for health care
provided, is considered protected.
Patient Rights Include:
 Knowledge of who has access to
his/her health information
 Ability to access his/her medical
record and/or amend incomplete or
incorrect information
 Requirement of authorization before
information is given, except as
allowed by HIPPA
 May request an accounting of all
disclosures in a six-year period
 Recourse if his/her rights are violated
Patient Rights continued…
Disclosure:
Any information that relates to a patient’s health cannot be
disclosed unless authorized by the
patient or someone acting
on the patient’s behalf or
unless permitted by HIPPA
regulations. The facility
must limit access to only
those individuals who need
the information for a
legitimate purpose.
Patient Rights continued…
What to Disclose:
Any information that is shared should be limited to the minimum
necessary, the least amount of information to accomplish the
purpose of the request. However, this does not apply to the sharing
of medical records for treatment purposes. The new law requires us
to not only identify and investigate HIPAA breaches, but also notify
patients when such breaches occur and report breaches to the US
Department of Health and Human Services.
 Protect all forms of Protected Health Information (PHI)
 Only access patient protected health information (PHI) for which
you are authorized to perform your duties. Do not access PHI of
family members, friends or anyone else for which you don’t have
a direct purpose.
Patient Rights continued…
What to Disclose:
Report any observed or suspected HIPAA breaches immediately
to the Ethics/HIPAA/Privacy Line (877-684-8658) or your facility’s
Privacy Officer.
YVMH Privacy Officer: Director of Health Information
Management
Memorial Physicians Privacy Officer: Safety Manager
Memorial Family of Services Security Officer: Vice-President,
Chief Information Officer
Ethics / HIPAA / Privacy Line
877-684-8658
The Customer Experience
At Memorial, Above and Beyond is the creation
and maintenance of an environment that
produces superior patient and client satisfaction
with our quality, services and people.
Why is Patient/Family Satisfaction important?
It is consistent with our vision, mission, and demonstrates
our values/behaviors.
Acknowledge
Introduce
Duration
Explanation
Thank You
Key words used by Memorial
Family of Services Staff:
 A.I.D.E.T.
For the convenience of our guests and staff, Memorial offers the following
services.
Located on the Main Campus outside the Memorial Café
Hours of operation are:
Monday—Friday
Saturday & Sunday
6:00 am—6:15 pm
8:00 am—4 pm
Two locations ~ Main Campus and ‘Ohana
Flowers, Sundries, Fine Gifts, Health related
merchandise, Lifestyle/spa products
Proceeds from sales at Into the Brew and The Memorial Gift Shop benefit
vital community health programs through the Memorial Foundation
Located on the Main Campus
Hours of operation are:
Breakfast
Lunch
Dinner
Late night grill
7:00am- 9:30am
11:00am-1:30pm
5:00pm-7:30pm
12:30am-3:00 am
The Memorial Café uses a Badge Pay system for employees and
volunteers. Volunteers are eligible for a $5.25 daily credit in the
Café that is accessed with the ID badge. The intent is to
be used the day of volunteering, however with a large
number of volunteers at off-site locations, volunteers
may use it on a more convenient day. If a purchase
exceeds the maximum benefit of $5.25, the volunteer
is asked to pay the difference. There is a set weekly
and annual maximum.
Parking
There are designated parking areas/lots at each Memorial facility
for our safety and convenience. Volunteers are given the benefit
of parking in visitor or employee areas. A campus map is on the
next slide.
Visitation Policy
Memorial Hospital supports family-centered care for patients and
strives to balance patient safety and quality of care with the need
for family support. Our visitation policy has been developed to
find the balance between keeping families together and involved
in the care of their loved ones, while still assuring the best
possible patient care. Please check with your supervisor for the
specifics of visiting hours.
Non-Smoking Work Environment &
Substance Abuse
Memorial and its family of services are smoke
free environments. Employees and visitors may
smoke in designated smoking areas outside the
buildings and utilize the waste receptacles for
debris. Smoking is permitted in your personal
vehicle in employee parking lots.
Memorial Hospital recognizes responsibility to
maintain a work place that is safe, healthful and
productive. The possession, dispensing, or use
of alcohol or illegal drugs, or the abuse of legal
drugs is prohibited.
Because Memorial provides a variety of services to a diverse population in
our community, we want to present a healthy and professional
appearance. While we recognize and respect that each individual has his
or her own personal style, the most important thing at work is your safety
and comfort, and the safety and comfort of our patients and their families.
Badges
Wear your badge at all times during your scheduled shift. Visible badges
immediately distinguish your identity as having a defined role with
Memorial Family of Services, making patients and visitors feel
more comfortable asking questions or requesting assistance.
In certain cases, your badge also provides access to restricted
areas. Wearing badges at or near eye level helps ensure you
can be recognized quickly and easily. No slogans, pictures,
advertisements, and/or other materials may be placed on
a badge or its attachments.
Pride in our Premises
The appearance and neatness of all hospital buildings and
grounds are a source of pride.
Please do your part!
We ask you to tell your
supervisor if you see any
neglect or abuse so we may
continue to maintain at the
highest level of beautiful
setting for patients, visitors,
and employees.
Hygiene:
Please maintain an acceptable level of cleanliness, which includes:
– Wearing deodorant
– Remain odor neutral; no fragrances are to be worn
– Artificial nails are prohibited
Footwear:
Footwear is particularly important for your safety and comfort.
Where applicable, we adhere to OSHA guidelines as related to
protective equipment. Again, depending upon your position, your
manager may ask you to wear or refrain from wearing specific kinds
of footwear. For example, an open toed sandal may present a safety
issue if part of your job is to use or move equipment.
Clothing and Accessories
Please make sure you discuss specific uniform
or appearance guidelines with your manager.
We want you to feel and project pride while
working for Memorial and clean clothing in
good repair is one way to ensure this.
Please make sure your clothes and
accessories are not so large or loose they
will catch or tear on nearby equipment or
furniture. Conversely, clothing that is too tight or small may
restrict ease of movement.
In general, well-fit clothes that are appropriate to your position,
ensure your best performance, safety and professional image.
Clothing and Accessories continued…
Please refrain from wearing the following while on your shift:
 Facial or tongue jewelry
 Sweatshirts, tank tops,
 Ear lobe expanders
miniskirts, and jeans
 Flip flops; closed toed shoes,
socks or stockings are to be
worn if assigned to a clinical
area
 Cologne, perfume, or
aftershave lotion; make-up
should be used moderately
 Political pins, religious and
holiday pins
 Artificial nails of any kind.
Fingernails are to be trimmed
short; if nail polish is worn, it
must be in good repair
 All tattoos must be covered
 Refrain from chewing gum while on your shift
Clothing and Accessories continued…
Clothing is to be free of slogans, pictures, and/or
advertisements unless specifically approved by Memorial
As this applies to badge pins and lanyards, you are asked to
wear only those provided
you by Memorial. These
should remain free of
decoration such as stickers
or pins, to maintain the
consistent, professional
appearance.
Media Relations
Because Memorial enjoys a
strong presence in the
community, there are times
when members of the media
may be in the hospital or one
of our facilities.
Any interviews or inquiries from the media (radio, television,
print, or internet) are to be referred to the Marketing and
Communications department.
Information Systems
Memorial has a vast network of technology for patient care, financial
accountability and employee recordkeeping and communication. These
technologies include:
– Software
– Email
– Internet and intranet capabilities
These technologies are company resources and are provided for business
purposes. These technologies, including the internet and email systems,
are hospital property and are subject to monitoring by the Hospital.
Your communications on these systems are not private. Therefore, use
them in a manner that reflects values and standards including Harassmentfree and Discrimination-free environment policy.
You are expected to utilize these systems responsibly and continue to abide
by the IS policy you agreed to.
Harassment
We strive to provide an environment that is free from all forms of
discrimination and harassment based on an individual’s race, religion,
creed, color, age, sex, marital status, national origin, sexual orientation,
disability or veteran status, or any other status protected under law.
“Harassment” includes unwelcome hostile or offensive remarks,
gestures, or physical contact of a severe or pervasive nature; display or
circulation, including email, or unwelcome written materials or pictures
to one’s race, religion, creed, color, age, sex, marital status, national
origin, sexual orientation, disability or veteran status, or basing
personnel decisions on a person’s response to sexually oriented
requests. Harassment is improper, can be illegal, and may be grounds
for immediate dismissal depending on the circumstances. Harassment
may come from people other than hospital managers and supervisors,
employees, interns or volunteers, such as doctors, patients, contractors,
or visitors in the workplace.
Complaint Process: If you witness, or believe you are a victim of
sexual or other forms of harassment or discrimination based on
protected status, you are to immediately report the circumstances to
your supervisor. If this is uncomfortable, or if the situation is not
satisfactorily resolved, you are to immediately notify
Human Resources. Memorial hospital is committed
to protecting your rights. We prove this commitment
to you through our “ZERO TOLERANCE” policy. All
incidents are taken seriously and, where appropriate,
effective action will be taken to address the problem.
No Retaliation: The hospital respects you for bringing to light any
behavior not in alignment with our vision and values. We will protect
you from retaliation for your efforts. Talk with your supervisor or
human resources if you have questions.
Non-solicitation
Memorial Family of Services ‘No Solicitation’ policy is
designed to be applied to all Memorial employees, contract
staff, volunteers, students, and visitors. Memorial prohibits
solicitation by, and of, its employees, contract staff,
volunteers, and students (collectively, individuals), except as
expressly set forth in the policy.
Solicitation on Memorial premises
by visitors is prohibited, unless
expressly otherwise stated in
this policy.
Infection Control
For your safety, and the safety of all, abide by the employee
health and infection control policies.
These policies are altered periodically
based upon policies of regulatory and
advisory bodies.
It is your obligation to report any
communicable diseases or
significant infections to either
the Employee Health Nurse or
Infection Control.
Hand-washing continued…
Specific infection control guidelines are sometimes trained at the unit or
department level, but all workers need to have a basic understanding of
Universal Precautions for preventing the spread of infection.
The single most effective way of preventing the spread of germs is hand
washing. Wash your hands before, during and after your shift, before
handling equipment and/or supplies, before eating, and after using the
bathroom or combing your hair. Be especially cautious about touching
anything above the neck (eyes, ears, nose).
Hand Washing Procedure: When washing hands with soap and water, wet
hands first with warm water, apply a generous amount of foam soap, and rub
hands together vigorously for at least 15 seconds, covering all surfaces of the
hands, fingers and wrists. Rinse hands with water and dry thoroughly with a
disposable towel. Use a dry disposable towel to turn off the faucet. Avoid
using hot water, because repeated exposure to hot water may increase the
risk of dermatitis.
Incidents & Injuries While at Memorial
 If you are involved in an unusual incident relating to
patients, personnel or visitors, or you are injured, please
report the incident immediately to your supervisor.
 If you are injured while on duty, inform your supervisor
and then proceed to HealthyYou for non-urgent
treatment or the Emergency Department for urgent
treatment.
Incidents & Injuries continued…
Memorial Hospital provides immediate first aide through
HealthyYou or our Emergency Department for staff,
volunteers, and students while on duty. No expenses will incur
for a clinic or Emergency Department visit when being treated
for an injury while on duty.
Safety Vision:
We create the safety
culture that achieves
zero events of harm.
Safety & Well Being
Safe conditions for employees,
volunteers, patients and visitors are of
primary importance in the hospital.
Employees are expected to be
knowledgeable of, and observe
all hospital and departmental
policies and practices related
to safety.
Workplace Violence & Campus Security
Memorial is committed to providing you with a safe
environment. It is with this goal in mind we prohibit
threatened or actual violence. Some examples of these
behaviors include:
 Inflicting or threatening injury or damage to another
person’s life, health, wellbeing, family or property
 Possessing a firearm, explosive or other dangerous
weapon anywhere within our Family of Services
 Abusing or damaging Memorial or employee property
 Using obscene or abusive language or gesture, or raising
your voice in a threatening manner
Workplace Violence & Campus Security
continued…
 Memorial Hospital has trained
security employees 24 hours a
day, 7 days a week. We want
you to feel safe and know that
help is available.
 Should you need help, dial
SAFE, 7233, from any phone in
the hospital and Security will
answer 24/7. If you are outside
the hospital, dial 494-7233.
Workplace Violence & Campus Security
continued…
If you witness suspicious behavior, and if you feel safe doing so,
you have the authority to question those involved and/or call
Security at your discretion.
Additional security measures:
 Follow safe practices at all times!
 Identify evacuation routes in
your assigned area
 Be alert for safety hazards and report
them to your supervisor or the Safety Officer
 Wear your photo ID Badge
Workplace Violence & Campus Security continued…
Phone Numbers:
Operator, for emergencies
Emergency-off site locations
Safety Officer
Facilities Management (8am-4pm, M-F)
7233
911
575-8054
575-8052
Report unauthorized visitors and staff members to:
Nursing Supervisor
Vocera or extensions 5660
Security (24 hrs, 7 days)
Vocera or 731-7339
If no answer, contact:
Engineer on duty (24 hrs, 7days) Pager 173-443
The hospital Phone Directory includes all pagers and numbers
Safety Imperative
As employee, volunteer, or student at Memorial Hospital it is
important to review the safety of our organization.
We believe that SAFETY involves taking responsibility for
oneself and others to practice tools to ensure safety for all.
Memorial recognizes that as humans we are prone to make
errors and we strive to prevent them by teaching error
prevention tools.
These tools focus around critical thinking, compliance,
communication, teamwork and attention on task.
All members at Memorial are responsible for helping to
“Create a Safe Day” for our patients, visitors, staff, volunteers,
and students.
Emergency Codes
Code Red: Fire
Seeing smoke or fire; smelling smoke or other burning material;
feeling unusual heat on wall, door or other surface; told by
someone of a fire.
Code Blue: Heart or Respiration stops
If in the vicinity announced, move out of the way of emergency
staff that will be in rapid response.
Code Orange: Hazardous Spill
Hazardous material spill or release; unsafe exposure to spill. Do
NOT clean up a spill yourself. Mark and isolate; call
Environmental Services at 575-8049 during the day and
evenings. A summary of hazardous chemicals found in your
department is in the Max.Com manual.
Emergency Codes continued…
Code Gray: Combative Person
Combative or abusive behavior by patients, families, visitors,
staff or physicians. Able bodied male staff will respond rapidly
to provide assistance.
Code Silver: Weapon/Hostage Situation
If at risk, or confronted by person with weapon, or a hostage
situation, call 911 and then call ext. 7233 and/or Security
External Triage: External Disaster
External emergencies impacting hospital, including: mass
casualties, severe weather, massive power outages, or nuclear,
biological and chemical accidents. Gives advance notice to
emergency clinical staff of possible incoming patients.
Emergency Codes continued…
Internal Triage: Internal Emergency
Internal emergency in multiple departments, including: bomb or
bomb threat, computer network down, major plumbing
problems, power or telephone outages.
Amber Alert: Infant/Child Abduction
An announcement will include: gender, age
and last known location. If the age is not
announced, the child is less than 18 months
old. Be an extra set of eyes, watching hallways and exits. If a
person matching the description is seen, ask them to please wait
until the Amber Alert is announced “all clear.” If that person
refuses to wait, get a good visual description and the direction
they go, relay this information to Security.
Emergency Codes continued…
Rapid Response Team: Medical Team needed at bedside
A patient’s medical condition is declining and needs an
emergency medical team at the bedside.
“Code (name) Clear”:
Announced when emergency is over.
To Call a Code:
When you’re on campus: Dial SAFE (7233)
Off campus: call 494-SAFE (7233). Security personnel
will answer the line 24/7.
In the Event of Fire
Follow the steps set forth in the acronym RACE
R - Remove from danger (patients, staff, visitors, self)
A - Activate the alarm, using a pull box and call a code RED
KNOW the location of the nearest pull box
C - Contain the fire (close doors and windows)
E - Extinguish the fire using PASS
The acronym PASS gives the steps for
correct use of a fire extinguisher.
P - Pull the pin
A - Aim at the fire
S - Squeeze the nozzle
S - Sweeping motion
KNOW YOUR
RESPONSIBILITY
IN A CODE!!!
Appreciating Our Differences
We live in an ever increasing diverse community. At Memorial we
encourage our employees, volunteers, students, physicians,
patients, vendors, and visitors to learn about and honor the many
ways in which we are alike, as well as the ways in which we are
different.
Thoughtfulness in Dealing with Others:
There are many factors to take into consideration when dealing
with others:
Age/Generation
Religion
Social-economic status
View about illness/death
Sexual orientation
Gender
Temperament
Physical status
Martial status
Spiritual beliefs
Language
Family relationships
Cultural background
Geographic location
Food preferences
Principles in Developing Cultural Competency
 1st principal: Know your own culture
 Healthy working relationships are based on:
self-awareness, ability to build functional
 trust, and willingness to perspective-shift
 (to see another’s point of view)
 Every interaction is multicultural
 There is no “one way” to treat any racial

or ethnic group, or any group classified by a
diversity factor
 Cultural understanding is a constant work in
progress
 Stereotyping is…a stopping point. It is a way to
define a person or a group (often in a negative
manner) without learning more about them.
Principles in Developing Cultural
Competency continued…
• Generalization is…a starting point. It is a way to apply what
you know to a person or a group as a way to figure out how to
learn more about them.
• Important intergenerational differences exist within any
group, and diversity is often greater with groups than
between them.
• “Culture” is not stagnant, but is continually evolving,
developing, and changing.
• Skills and awareness are needed to challenge and confront
racism, sexism, ageism, classism and other forms of
prejudice and discrimination that occur.
Patient Care
Developing strategies that address culturally appropriate care is
consistent with our vision, mission, and values.
 Demonstrates respect and compassion for every individual
 Increases our ability to adequately meet the needs of specific
populations
 Improves the quality of service
 Recognizes that the attitudes and beliefs of patients, families
and healthcare providers influences the health-related
behaviors of patients, leading to better outcomes
 Promotes documentation of patient care and interaction
without personal value judgments
 Shows accountability for patient rights
The Joint Commission Standards State:
 The patient has a right to, and receives care that is
considerate and respectful of his or her personal
values and beliefs.
 The assessment of patients considers not only
physiological status, but also psychological and
social concerns.
 A patient’s cultural and family contexts, and individual background are
important factors in response to illness and treatment.
These standards require:
 Staff to support the patient’s expression of value and beliefs, within the
limits of our mission and philosophy
 The patient to be allowed to exercise cultural and spiritual beliefs that do
not interfere with the well-being of others or the planned course of
medical therapy for the patient
 Patient care to demonstrate awareness of the spiritual aspects of patient
care
Your Personal Beliefs
We attempt to accommodate your religious and/or cultural
beliefs, but sometimes conflicts arise regarding specific
clinical intervention.
It is your responsibility to discuss with your supervisor any
potential conflicts within the normal scope of your duties.
Our primary goal as an organization is to provide the highest
quality patient care. In the event an unexpected conflict
occurs, meet with your supervisor as soon as possible
following the event to assess the situation and discuss your
options in future situations.
As a hospital volunteer, student or intern,
your responsibilities include:
1) Respecting patient confidentiality and privacy
2) Extending courtesy to all visitors and outpatients
3) Offering assistance whenever you see someone in
distress, lost or confused
4) Promoting a positive work environment to your fellow
volunteers, students and employees
Please remember…
Patients are the most important part of our work.
Patients are the Most Important
Part of Our Work
They are the incentive that directs us through the day.
They are our purpose, and their care and comfort deserve
first priority.
As a volunteer, your responsibilities include:
1. Respecting patient confidentiality and privacy
2. Extending courtesy to all visitors, patients, and staff
3. Offering assistance whenever your see someone in distress,
lost or confused
4. Promoting a positive work environment to your fellow
volunteers and staff
5. Following safe practices at all times
Safety
To aid in the safety of everyone,
know the location of the nearest
 fire extinguisher
 alarm pull box
 primary & secondary
evacuation routes in your
assigned area.
If you see a SPILL
 Mark and Isolate
 call Environmental Services at
ext. 8049
Infection Control & Hand Washing
Volunteers perform such a variety of functions for our hospital,
specific infection control guidelines are sometimes trained at the
unit or department level.
 All volunteers need to have a basic understanding of Universal
Precautions for preventing the spread of infection.
The single most effective way of preventing the spread of germs is
HAND WASHING
 Wash your hands before, during, and after your volunteer
assignment, before handling equipment and/or supplies, before
eating, and after using the bathroom or combing your hair.
 Be especially cautious about touching anything above the neck
(eyes, ears, nose).
Hand Washing Procedure
 When washing your hands with soap and
water, wet hands first with warm water,
apply a generous amount of foam soap and
rub hands together vigorously for at least
15 seconds, covering all surfaces of the
hands, fingers, and wrists.
 Rinse hands with water and dry thoroughly
with a disposable paper towel.
 Use a dry disposable towel to turn off the
faucet.
 Avoid using hot water because repeated
exposure to hot water may increase the
risk of dermatitis.
Infection Control continued…
Volunteers with an active,
infectious disease or
process are not to
report to their shift.
Notify Volunteer Services
and your assigned
department that you
will not be at your shift.
Suspicious
Host
Portal of
Entry
Infectious
Agent
Chain of
Infection
Mode of
Transmission
Reservoir
Portal of Exit
Report active or infectious diseases to:
 Supervisor of your assigned area
 Infection Control Nurse or Employee Health Services
 Volunteer Services
Latex Allergy
Due to increased use of latex in the healthcare environment,
latex allergies are on the rise. People who are allergic to
avocado, banana, kiwi, cherry or peach (stone, seedy and tropical
fruits or nuts) tend to be at high risk for having latex allergy.
Let your supervisor know if
you are allergic to these foods.
Any employee, volunteer or
student who suspects they are
experiencing a latex sensitivity
should report to the Employee
Health nurse.
Precaution Signs
Yellow Arrows are placed on the doorway of a patient’s room
to identify that patient as at risk of falling. Two other fall risk
identifiers are a yellow wristband and yellow socks. If a patient
is transported to another department for treatment, this alerts
staff to be watchful.
Volunteers who are on the patient floors are given the
responsibility to glance into the room
with the yellow arrow, observe if the
patient is up, or trying to get up, without
assistance. If so, report immediately
to the nurses station.
Precaution Signs continued…
Door Signs: Do not enter a patient
room that has signs posted indicating
special precautions. In many cases,
protective clothing is required to
enter those rooms. If you have been
asked to make a delivery to a room
that is posted, either leave the item(s)
in the rack at the patient’s door,
or go to the nurse’s station and
ask them to make the delivery.
HIV/AIDS
HIV is one of the most important health threats of our time.
Volunteers do not have direct patient contact, so are not at risk
for exposure to the virus. However, all healthcare professionals
need a basic understanding of the virus (HIV) and the disease
(AIDS) caused by the virus.
HIV and AIDS are NOT the same!
 HIV is a virus that affects the
human immune system
(Human Immunodeficiency
Virus)
 AIDS is the disease that the
virus can cause (Acquired
Immune Deficiency
HIV/AIDS continued…
With AIDS, a person’s natural immune system breaks down,
leaving it unable to fight off infection.
A person infected with HIV can spread the virus to others through
certain bodily fluids. The following bodily fluids are known to
spread HIV.
 Blood
 Semen (men)
 Vaginal secretions (women)
 Breast milk (lactating women)
Transmission of HIV can occur when an infectious bodily fluid
comes into contact with certain vulnerable areas of the
uninfected person’s body. In general, these areas include:
 Non-intact skin
 Mucous membranes
 The blood stream
HIV/AIDS Important Points:
 HIV is found in blood, semen, vaginal secretions, and breast
milk.
 HIV can be spread through high-risk behaviors. This includes
unprotected sex and sharing injection-drug equipment.
 An HIV-positive mother can spread the virus to her child
during pregnancy, labor and delivery, or breastfeeding.
 Healthcare workers are at risk for occupational exposure to
HIV (needle-stick or other sharps injury, splashes, sprays, or
other sources of patient bodily fluids).
 Many bodily fluids do not contain HIV (sweat, saliva, tears).
 HIV cannot be spread through casual contact (shaking hands,
hugging).
In addition, a person cannot get (or give)
HIV infection from:
 Clothing
 Public drinking fountains,




phones, or toilets
Sharing a meal
Insect bites or stings
Donating blood
Kissing with closed mouth
HIV/AIDS Exposure – Reducing Your Risk
To help protect workers from HIV and other bloodborne
infections, the Occupational Safety and Health Administration
(OSHA) issued the Bloodborne Pathogens Standards (BPS).
The BPS mandates the use of Standard Precautions. According
to Standard Precautions, healthcare workers should:
 Assume that all blood and other bodily fluids are infectious
 Use barrier protection (gloves, face shield, protective clothing, etc) as
needed to protect skin and mucous membrane from contact with
blood or other bodily fluids
 Wash hands and other skin surfaces immediately and thoroughly
after contact with patient blood or other bodily fluids
 Wash hands immediately after glove removal
 Avoid accidental injury from needles, scalpel blades, and other sharps
Latex Allergy: Screening and Diagnosis
• Latex allergy results from hypersensitivity to specific
proteins or chemicals in the latex product.
• Latex allergy is becoming more and more common.
Most reactions to latex are mild, but some can be life
threatening.
• Screening questions provide good tools for identifying
patients at risk for latex allergy. This can help prevent
future problems.
• Review the questions in the table to the right.
• If a patient answers “yes” to one or more of these
questions, the patient may be at risk for latex allergy.
• A careful and thorough medical history and physical
exam should be performed.
• For a more definitive diagnosis of latex allergy, tests
that measure blood levels of anti-latex antibodies
[glossary] may be ordered.
Latex Allergy: Management
• Anyone who is allergic to latex
should avoid latex products.
• To help protect a patient from
exposure to latex in the healthcare
• setting:
• Clearly indicate “latex allergy” in the
medical record.
• Do not use any latex products,
including latex cleaning
gloves, in the patient’s room.
• Before entering the patient’s room,
remove latex gloves.
• Wash hands thoroughly with soap
and water.
• Healthcare facilities should maintain
a latex-free cart or tray for patients
with latex allergy or sensitivity, if
feasible.
Latex Allergy: Management
Healthcare workers are at elevated
risk for latex allergy.
If you are allergic to latex:
• Avoid all contact with latex.
• Wear a medical alert bracelet or
necklace.
• Inform your employer.
• Encourage your facility to provide
as many latex-free
• products as possible.
• Use silk or plastic tape instead of
adhesive tape.
• Use non-latex gloves only.
Hazard Communication
Under its Hazard Communication Standard,
OSHA requires all employers to develop
written hazard communication programs.
To protect workers from exposure to
hazardous chemicals, the following groups of
people have hazard communication duties:
Manufacturers
Employers
Employees
Manufacturers
Manufacturers of hazardous chemicals must:
•
Research, create, and distribute a Safety Data Sheet (SDS), which lists
the specific hazards of the chemical
•
Label all containers of hazardous materials
OSHA’s Hazard Communication Standard specifies the information that has to
be on the safety data sheet, but does not require any specific format. OSHA has,
however, developed and recommended a 16-section format.
1. Identification
3. Hazard(s) identification
4. Stability and reactivity
5. Composition
6. Toxicology information
7. First-aid measures
8. Ecological information
9. Fire-fighting measures
Click on each for a review of key duties.
Note:
GHS is the Globally Harmonized System of
Classification and Labeling of Chemicals
adopted by the United Nations. OSHA’s
Hazard Communication Standard is aligned
with the GHS. As of June 2015, all facilities
that use hazardous materials use this
system.
2. Physical and chemical properties
11. Accidental release measures
10. Disposal considerations
12. Transport information
13. Handling & storage
14.Regulatory information
15. Personal protection
16. Other information
Employers
Employers whose employees work with hazardous chemicals must:
•
Maintain a file of SDSs for all hazardous chemicals used by workers.
•
•
Inspect incoming chemicals to verify proper labeling. If a chemical is transferred to an unlabeled container at
the facility, the new container must be labeled appropriately.
Train employees in the use of hazardous chemicals
Employees
Employees who work with hazardous chemicals must:
• Know which hazardous chemicals are used in their work area
• Know where SDSs are located on their unit
• Know how to read an SDS
• Read all relevant SDSs before starting a job that may require the use of a hazardous chemical
• Read product labels carefully. Follow all instructions. Heed all warnings.
• Attend all required hazardous chemical training sessions
Introduction
Welcome to the lesson on infection control
Lesson 4: Infection Control
Healthcare-associated infection
Hand hygiene
Environmental hygiene
Antibiotic use
Bloodborne pathogens
Airborne precautions
Contact precautions
Droplet precautions
Personal protective equipment
Personal responsibility
Healthcare-Associated Infection: Impact
Healthcare-associated infection (HAI) is an
infection that develops after contact with
the healthcare system It:
• Is not present or incubating at the time
healthcare services are delivered
• Presents symptomatically 48 hours or
more after admission or provision of care
HAI can be very costly in terms of:
• Patient life and health
• Healthcare dollars
HAI: Cause
HAI may be caused by bacteria, viruses,
fungi, or parasites.
These infectious organisms may come
from:
• Environmental sources (dust, etc.)
• Patients
• Staff members
• Hospital visitors
Depending on the agent, infection may be
transmitted person-to-person via the:
• Contact route
• Droplet route
• Airborne route
Infection control for each of these modes of
transmission will be discussed in greater
detail later in the lesson.
HAI: Prevention
Preventing HAI is an important focus of The Joint
Commission.
The Joint Commission emphasizes that:
“The activities of infection prevention and control
should be
practical and involve collaboration between staff.
Everyone
who works in the organization should have a role and
hold
each other accountable.”
The Joint Commission requires accredited hospitals to
implement
evidence-based practices to prevent HAI. These
practices must
focus on:
• Central line–associated bloodstream infections
• Infections due to multidrug-resistant organisms
• Surgical site infections
• Catheter-associated urinary tract infections (CAUTI)
HAI: Best Practices
• Best practices for preventing HAI are
related to:
• Hand hygiene
• Environmental hygiene
• Invasive procedures
• Antibiotic use
• Bloodborne pathogens
• Airborne Precautions
• Contact Precautions
• Droplet Precautions
• Personal protective equipment
• Personal responsibility
Let’s take a closer look at each.
Hand Hygiene: When and What
The single most important factor for preventing
the spread of infection is proper hand hygiene.
Hands should be washed or decontaminated
before and after each direct patient contact.
Hand hygiene also should occur after gloves are
removed.
Current guidelines from the Centers for Disease
Control and
Prevention (CDC) recommend the use of:
• Soap and water for washing visibly soiled
hands
• Alcohol-based hand rubs for routine
decontamination of hands between patient
contacts
Follow CDC or World Health Organization
(WHO) guidelines for hand hygiene.
Hand Hygiene: How Do you know how to
appropriately use soap and water or an
alcohol rub for hand hygiene?
Soap and water
When using soap and water to wash hands:
1. Wet hands with warm water. Use warm, but not hot, water. Hot water can contribute to skin
irritation. Wetting the hands before applying soap reduces the likelihood of skin irritation.
2. Apply soap. Use enough soap to give a good lather.
3. Rub hands together vigorously for at least 20-25 seconds. You can use the “ABC” song and “Happy
Birthday” to estimate 20 seconds.
4. Lather all surfaces of the hands and fingers. Do this away from the running water so that you do not
wash the lather away. Remember to scrub between your fingers and under your nails.
5. Rinse hands with water. Keep arms angled downward in the sink, so that water from your hands
goes down the sink, not down your elbows.
6. Dry with a disposable towel.
7. Use the towel to turn off the faucet.
8. Dispose of the towel in an appropriate bin.
Alcohol rub
When using an alcohol rub:
1. Apply the rub to the palm of one hand. Use the volume of product recommended by the
manufacturer. You should have enough to wet all surfaces of the hands.
2. Rub hands together until they are dry*. Be sure to rub over all surfaces of the hands and fingers.
Do not wash hands after using an alcohol rub. This step is not necessary nor is it recommended.
*Note: Rubbing the hands together until they are dry ensures that the flammable
alcohol in the product has evaporated and is no longer a fire hazard.
Environmental Hygiene
Environmental hygiene also can help prevent
HAI.
Best practices for environmental hygiene are:
• Maintain a visibly clean environment (no
visible dust or soiling).
• Clean, disinfect, or sterilize medical
equipment after each use.
• Safely dispose of clinical waste.
• Launder used and infected linens safely and
effectively.
• Follow appropriate guidelines for kitchen and
food hygiene.
• Maintain an adequate pest-control program.
Invasive Procedures
Many HAI are related to invasive
procedures, especially:
• Catheterization
• IV line placement
The most common type of HAI is urinary
tract infection (UTI) associated with
indwelling urinary catheters.
Therefore:
• High-risk procedures such as
catheterization should be performed only
when absolutely necessary.
• Catheters should be removed as soon as
possible.
• Instruments and equipment used for
invasive procedures should be properly
sterilized before use. They should be
used with aseptic technique.
Antibiotic Use: Antibiotic Resistance
Widespread use of antibiotics began in the 1940s.
Penicillin and
other antibiotics were hailed as miracle drugs. They
were able to cure previously untreatable bacterial
illnesses.
However, bacteria are very adaptable. They have the
ability to
change genetically to resist the effects of antibiotics.
The more antibiotics are used, the more common
resistant strains of bacteria become.
Clinically important examples are:
• Methicillin-resistant Staphylococcus aureus
(MRSA)
• Vancomycin-resistant Enterococci (VRE)
• Drug-resistant Streptococcus pneumoniae (DRSP)
• Multidrug-resistant Mycobacterium tuberculosis
(MDR-TB)
Antibiotic Use: Impact of Resistance
Antibiotic resistance is a significant health
problem.
It adversely affects:
Drug choice
Patient health
The healthcare system
Click on each for a brief review of key
points.
Drug choice
When an infection is resistant to the antibiotic of choice,
other antibiotics must be used instead. These
secondchoice drugs are typically:
• Less effective against the bacteria
• More toxic to the patient
• More expensive
Patient health
Patients with resistant infections tend to have:
• Lengthier illness
• Higher medical bills
• Greater risk of death
Antibiotic-resistant infections cost at least twice as
much
as antibiotic-susceptible infections.
The healthcare system
• Antibiotic-resistant strains contribute significantly
to HAI.
• More than 70% of all bacteria that cause HAI are
found to be resistant to one or more commonly
used antibiotics.
Antibiotic Use: Prevention of Resistance
Healthcare professionals must take an
active role in preventing the spread of
antibiotic resistance.
Strategies include:
Preventing infection
Diagnosing and treating infection
effectively
Using antibiotics prudently
Preventing spread of infection
Prevent infection
One of the best techniques we have to prevent infection is
vaccination.
• Patients should be current on appropriate vaccinations.
• Healthcare workers also should receive appropriate
vaccinations.
Diagnose and treat infection effectively
• Effective diagnosis means identifying the cause of
infection so that the right treatment may be given.
• Effective treatment includes using specific antibiotics when
antibiotics are necessary. A specific antibiotic is targeted to
the identified infectious agent. Use of broad-spectrum
antibiotics or multiple antibiotics should be avoided.
Use antibiotics prudently
• An important part of using antibiotics prudently is NOT giving
in to patient demands for antibiotics for viral illnesses (colds,
flu, etc.).
• Patients must be educated accordingly.
Prevent spread of infection
• Remember: The single best method for preventing spread of
infection is hand hygiene. This makes proper hand hygiene
an important tool in the fight against antibiotic resistance, as
well.
• Appropriate Isolation Precautions (as discussed later in the
lesson) should also be used to prevent spread of infection in
the healthcare setting.
Bloodborne Pathogens
Bloodborne diseases are spread from person to person as a result
of unprotected exposure to:
• Infected blood
• Other bodily fluids
• Non-intact skin
• Moist body tissues
Important bloodborne diseases include:
• HIV infection/AIDS
• Hepatitis B
• Hepatitis C
Other potentially infectious materials (OPIM) include:
• Saliva (during dental procedures)
• Semen
• Vaginal secretions
• Pleural fluid
• Cerebrospinal fluid
• Amniotic fluid
• Peritoneal fluid
• Pericardial fluid
• Any fluid that is contaminated with blood
• Any fluid that is not easily identifiable
Bloodborne Pathogens: Bloodborne
Pathogens Standard
The Bloodborne Pathogens Standard (BPS)
helps protect workers from exposure to HIV
and other bloodborne pathogens.
The Bloodborne Pathogens Standard:
• Covers any worker who might come in
contact with blood or other potentially
infectious materials (OPIM) as part of his or
her job
• Requires employers to take certain steps to
help protect these workers
One of the key parts of the Bloodborne
Pathogens Standard is to require the use of
Standard Precautions.
Bloodborne Pathogens: Standard Precautions
Standard Precautions should be used in the
care of all patients, regardless of their diagnosis.
These precautions apply to patient:
• Blood
• Body fluids
• Secretions and excretions (except sweat)
• Non-intact skin
• Mucous membranes
The major provisions of Standard Precautions
are summarized in table form on the next
screen.
Note: In the table, the term “bodily fluids” is used
to indicate all patient fluids to which Standard
Precautions apply (i.e., blood, body
fluids, secretions, excretions).
Bloodborne Pathogens: Standard Precautions
Handwashing
Wash or decontaminate hands:
Standard Precautions are to be used in the
• Before and after each work shift
care of all patients— whether or not you think
• Before and after physical contact with each patient
• Before donning sterile gloves when inserting a central intravascular catheter
or know the patient has a bloodborne disease
• Before inserting indwelling urinary catheters, peripheral vascular catheters, or other
invasive devices that do not require a surgical procedure
• When moving from a contaminated body site to a clean body site during patient care
• After handling contaminated items such as bedpans, dressings, or urinary drainage bags
• After removing gloves
• After using the toilet, blowing the nose, covering a sneeze, etc.
• Whenever hands become visibly dirty
• Before eating, drinking, or handling food
Gloves
• Wear gloves when touching blood, other bodily fluids, or contaminated items.
• Put on clean gloves before touching mucous membranes or non-intact skin.
• Change gloves between “dirty” and “clean” tasks on the same patient.
• Remove gloves promptly after use (before going to another patient). Perform hand hygiene immediately.
Mask, Eye
Protection, Face
Shield, Gown
• Use personal protective equipment (PPE) as necessary to protect against splashes or
sprays of blood or other bodily fluids.
• Use masks for catheter insertion or injection into spinal or epidural spaces.
Patient Care
Equipment and
Linens
• Equipment and linens soiled with blood or other bodily fluids should be handled in a way
that avoids cross-contamination.
• Clean and reprocess reusable equipment appropriately before use on another patient.
• Discard single-use items appropriately.
Environmental
Control
• Environmental surfaces should be cleaned and disinfected on a routine basis.
Continued…
Bloodborne Pathogens
• Use sharps (needles, scalpels, etc.) carefully and
appropriately. For example, do not bend
• or recap needles.
• Use safe injection practices.
• Take care to prevent accidental sticks.
Patient Placement
• Patients who contaminate the environment should be
placed in private rooms.
Bloodborne Pathogens: Needlestick
Prevention
The BPS has rules to protect against
sharps injury:
• Facilities must adopt the use of safer
needle devices.
• Contaminated needles and other
contaminated sharps should not be bent
or recapped.
• Shearing or breaking of contaminated
needles is prohibited.
• Contaminated sharps should be placed
in appropriate
containers. These containers must be
puncture-resistant,
appropriately labeled or color-coded, and
leak-proof on the sides and bottom.
Airborne Precautions: Background
Airborne diseases are transmitted from
person to person via infectious droplet
nuclei.
These tiny particles:
• Are produced when an infected person
sneezes, coughs, or talks
• Can remain suspended in the air for long
periods of time
• Can travel long distances on air currents
Transmission occurs when a healthy
person inhales an infectious particle.
Infection and disease symptoms then may
occur.
Airborne Precautions: Diseases
Important airborne diseases include:
• Chickenpox and shingles (disseminated)
• Measles
• Tuberculosis (TB)
Other diseases that may be spread by the
airborne route include:
• SARS [glossary]
• Smallpox
To prevent the transmission of airborne
diseases in the healthcare setting, Airborne
Precautions are used, as summarized
briefly in the table on the next screen.
Chickenpox
Measles
Tuberculosis
Airborne Precautions: Summary Table
Airborne Precautions are to be used, along with Standard Precautions, in the
care of all patients with a diagnosed or suspected airborne-transmitted
disease.
Patient Placement
Patients on Airborne Precautions are isolated in private rooms with special air
handling and ventilation systems. If a private room is not available, patients
are cohorted [glossary].
Respiratory Protection
Healthcare staff must wear personal respirators whenever they enter an
airborne isolation room. N95 respirators are most commonly used. A surgical
mask will not protect against airborne transmission.
Patient Transport
Patient transport should be limited as much as possible. During necessary
transport, the patient should wear a surgical mask, if possible.
Airborne Precautions: Tuberculosis
TB is an airborne disease.
Therefore, Airborne Precautions apply.
In addition, both the CDC and OSHA have specific
guidelines for
preventing transmission of TB in the healthcare
setting.
Click on the following links to access more
information:
• CDC Guidelines
(http://www.cdc.gov/tb/publications/guidelines/infecti
oncontrol.htm)
• OSHA TB Enforcement Policy (link to
OSHA_TB.pdf)
• OSHA Hospital eTool Healthcare Wide Hazards
(http://www.osha.gov/SLTC/etools/hospital/hazards/t
b/tb.html)
Contact Precautions: Background
Contact transmission of disease occurs via
direct or indirect person-to-person contact.
This form of transmission is the most
important and common cause of HAI.
Contact Precautions: Diseases
Hepatitis A
Examples of contact diseases are:
• MRSA
• Hepatitis A
• Respiratory syncytial virus infection
• Impetigo [glossary]
• Conjunctivitis [glossary]
• Viral hemorrhagic infections
• Many others
To prevent contact transmission of
diseases in the healthcare setting, Contact
Precautions are used, as shown in the
table on the next screen.
Respiratory Syncytial Virus
Impetigo
Contact Precautions: Summary Table
Contact Precautions are to be used, along with Standard Precautions, in the care of all patients with a
diagnosed or suspected contact-transmitted disease.
Patient Placement
Patients on Contact Precautions are isolated in private rooms or cohorted.
PPE
Healthcare staff must don a gown and gloves when entering the room of a patient on Contact
Precautions.
Hand Antisepsis
Hands should be decontaminated immediately after removing gloves.
Patient Transport
Patient transport should be limited as much as possible.
Patient Care Equipment
Non-critical equipment should be dedicated to a single patient or cohort on Contact Precautions. If this
is not possible, equipment should be cleaned and disinfected between patients.
Droplet Precautions: Background
Droplet transmission happens via large
respiratory droplets.
These droplets:
• Are generated during coughing,
sneezing, talking, etc.
• Travel a short distance through the air
(up to three feet)
Droplets may land on the mucous
membranes of a nearby
person’s eyes, nose, or mouth. Droplets
may also contaminate surfaces.
Disease transmission then may occur.
Droplet Precautions: Diseases
Examples of droplet diseases are:
• Mumps
• Rubella
• Influenza
• Many others
To prevent the transmission of droplet
diseases in the healthcare setting, Droplet
Precautions are used, as shown in the
table on the next screen.
Mumps
Rubella
Influenza
Droplet Precautions: Recommendations
Droplet Precautions are to be used, along with Standard Precautions, in the care of
all patients with a diagnosed or suspected droplet-transmitted disease.
Patient Placement
Patients on Droplet Precautions should be isolated in private rooms or cohorted. If a
private room is not available and cohorting is not possible, patients should be
placed at least three feet away from the nearest other patient or visitor.
PPE
Healthcare staff should don gloves and a mask when entering the room of a patient
on Droplet Precautions. A gown and eye protection also may be needed.
Hand Antisepsis
Hands should be decontaminated immediately after removing gloves.
Patient Transport
Patient transport should be limited as much as possible.
Personal Protective Equipment
Personal protective equipment (PPE) is an
important component of infection control.
PPE helps to prevent the spread of
microorganisms both:
• From patient to healthcare worker
• From healthcare worker to patient
Review the screens describing Standard
Precautions, Airborne Precautions, Contact
Precautions, and Droplet Precautions for
appropriate use of key items of PPE.
Note the use of:
• Gloves
• Masks
• Goggles
• Gowns
• Respirators
Personal Responsibility
As a healthcare worker, you have personal
responsibilities for infection control in your
facility.
Maintain immunity to vaccine-preventable
diseases such as:
• Hepatitis B
• Measles
• Varicella (chickenpox)
• Rubella
• Mumps
• Influenza
Report all unprotected exposures, such as
accidental needlesticks.
Stay home from work when you are sick.
Glossary
Term
aerobic exercise
antibody
cohort
conjunctivitis
electrically conductive loop
ferromagnetic
HBV
HCV
HIV
impetigo
MRI
MRSA
PPE
projectile
SARS
ventricular fibrillation
Definition
continuous activity that requires the use of increased oxygen to maintain the function of
the body’s cells
protein produced by immune cells to fight infection
to group together patients with the same active infection, but no other infection
an infection and/or inflammation of the inner lining of the eyelid, commonly called “pink eye”
complete circuit through which electricity is able to flow
able to be attracted by a magnet
Hepatitis B virus
Hepatitis C virus
human immunodeficiency virus; the cause of AIDS
a bacterial skin infection with pus-filled blisters
magnetic resonance imaging
methicillin-resistant Staphylococcus aureus
Personal Protective Equipment
an object that is thrown, sent, or cast forward
severe acute respiratory syndrome
an ineffective heart rhythm that if not corrected will lead to cardiac arrest and death
Documentation of Volunteer Hours
Volunteers are required to sign in and
out for hours served at Memorial.
Documentation of hours is needed for:
 insurance purposes
 accounting statistics
 volunteer recognition
 RSVP programs
 job reference
 request for school admission
Most departments have a RED folder containing GREEN
sign-in sheets. Check with the supervisor of your assigned
department for their location.
Volunteer Records
Volunteer Files
– All Volunteers have access to their file
– Volunteer files are kept in Volunteer Services
– All health records are kept by Employee Health Services
Minimum Age Requirement
– Minimum age requirement for a volunteer is 16 years of age
• Certain departments mandate a minimum age of 18 years
of age
– Volunteers under the age of 18 are required to have a parent
or guardian permission form signed prior to beginning
Records Update
– Report change of name, telephone number, address or
availability to the Volunteer Services Department in a timely
manner.
Volunteer Records continued…
Resignation/Termination
Volunteers are asked to provide at least 2 weeks notice
when resigning from their volunteer position. This gives
Volunteer Services the opportunity to recruit and train a
replacement. Volunteers are asked to return photo ID
badge and uniform to Volunteer Services.
 The manager of Volunteer Services may remove a volunteer
from the program for any reason.
Sick, Vacation or Time Off
Volunteers are requested to call Volunteer
Services and their assigned department
(in advance) to report any time off.
Holidays
Volunteer Services Department is
closed on the following holidays:
 New Years Day
 Presidents Day
 Memorial Day
 Independence Day
 Labor Day
 Thanksgiving Day
 Christmas Day
Volunteer Services will be closed on a Friday or Monday when a
holiday falls on a weekend. Volunteers are not expected to
report for duty on a holiday.
Volunteerism
Research shows that volunteering leads to better health, that
volunteer activities can strengthen social ties, and the
experience of helping others leads to a sense of greater selfworth and trust.
Memorial volunteers receive a monthly newsletter, free
parking, free or discounted educational offerings, a holiday
meal in the Café (December) and a volunteer appreciation
event (April).
Other advantages include:
 Café Privileges
 Gift Shop Discount
Privileges
The Memorial Café uses a Badge Pay system for employees and
volunteers. Volunteers are eligible for a $5.25 daily credit in the Café
that is accessed with the ID Badge. The intent is to be used the day
of volunteering, however with a large number of volunteers at offsite locations, volunteers may use it on a more convenient day. If a
purchase exceeds the maximum benefit of $5.25, the volunteer is
asked to pay the difference. There is a set weekly and annual
maximum.
Specific guidelines of use:
 Identify yourself to the cashier as a volunteer
 Have your ID badge out, visible to the cashier and ready to use
 Some volunteers are issued a uniform (smock or jacket). It is
preferred the volunteer is in uniform to assist with identification.
The Gift Shop at Memorial
The Gift Shop at Memorial and ‘Ohana are Auxiliary-led,
volunteer-driven shops that provide a service to patients, visitors,
employees, and volunteers. Proceeds from the sales at the shops
are donated back to support programs of Memorial Hospital.
Volunteers are eligible for a discount in the gift shop after
completing the 3-month probationary period. Volunteers and
employees are eligible to purchase “over-the-counter”
medications at a discount.
Annual Requirements
Memorial policy and The Joint Commission mandate the
following two requirements be met annually by volunteers
with one or more years of service. Completion is documented
in the volunteer’s file.
Evaluation: Written evaluations are completed by a
qualified staff person who supervises the volunteer. This is
an appraisal of the volunteer’s performance of assigned
tasks and competence in their position.
Safety Review: This is a review and test
of the information in this orientation.
Contact Phone Numbers:
Branden Johnson
Manager
575-8053
Joyce Scott
Volunteer Services Secretary
577-5062
Deb Gorman
North Star Lodge Volunteer Supervisor
574-3441
Mary Lynne Brewington
Children’s Village Volunteer Supervisor
574-3209
Cindy Fiscus
Hospice Volunteer Coordinator
574-3600
Pam Edwards
Retail Sales Program Coordinator
(Gift Shop)
585-8309
Nancy Roehr
Ohana Manager
574-3873
Tammy Oswalt
Ohana Volunteer Supervisor
574-3872