ROP HANDBOOK - Los Angeles Valley College Pres Volunteer/2018... · Web viewValley Presbyterian...

Volunteer Services OfficeHours: 9:00 a.m. to 6:00 p.m.(818) 902-2932 – Director

Dear Volunteer:

Welcome to Valley Presbyterian Hospital's family of health care providers. By becoming a volunteer you have joined a very special group of dedicated people. We welcome you warmly and hope that your association with us will be a satisfying and rewarding experience. You have assumed the responsibility of serving Valley Presbyterian Hospital as a very valuable member of our health care team. Through your generous donation of time and talent, you will support and supplement the work of the hospital staff in providing quality care and services to our patient and family members.

As a volunteer, you will learn new skills, gain a sense of pride and accomplishment, and know that you are a very needed and important member of the hospital "team." At the same time, the staff of the Volunteer Services office assumed the obligation of giving you the assistance and support you will need to be a valuable volunteer. You have assumed the responsibility of making a difference in the lives of our patients and staff. This entails, among other things, consistent and friendly service in a timely manner.

Our goal for you as a Volunteer is that you have a unique experience that fulfills your needs and expectations, and that you are challenged to your greatest potential.

This Volunteer Handbook was written for you. We hope it will give you a better understanding of the value and importance of your position as a volunteer. Occasionally, policies may change or information will be updated. The Volunteer Services staff will advise you of any changes and we ask that you update your Handbook so it will remain current.

Sincerely Volunteer Services,

Virginia Rivero NapolesDirector Volunteer Servicesvirginiarivero.napoles@valleypres. org

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mailto:virginiarivero.napoles@valleypres.

VALLEY PRESBYTERIAN HOSPITALVOLUNTEER HANDBOOK

TABLE OF CONTENTS

WELCOME LETTER......................................................................................................................1TABLE OF CONTENTS.................................................................................................................2VPH FACTS....................................................................................................................................3VPH MISSION STATEMENT, GOALS & LEADERS TO KNOW………………………………4CORE Values & REGULATORY AGENCIES IMPACTING PATIENT CARE OPERATIONS...5VOLUNTEER GUIDELINES......................................................................................................6-9VOLUNTEER RULES & REGULATIONS....................................................................................9VOLUNTEER CONDUCT……………………………………………………………………….10VOLUNTEER CODE……………………………………………………………………………..10VPH CUSTOMER SERVICE Initiatives, Goals & Expectations..............................................11-13TELEPHONE CUSTOMER SERVICE& NAME RECOGNITION SOFTWARE...................13-14BODY MECHANICS & WHEELCHAIR TECHNIQUES …………………………………..15-16CULTURAL DIVERSITY.............................................................................................................16EMTALA..................................................................................................................................16-17ELEVATOR PROTOCOL.............................................................................................................18ENVIRONMENT OF CARE, EMERGENCY CODES & ASSISTANCE...............................18-21FIRE EXTINGUISHERS..........................................................................................................22-23GENERAL DISASTER & FIRE PROCEDURES..........................................................................24POLICY AGAINST HARASSMENT............................................................................................25HAZARDOUS MATERIALS and HOW TO LOG ON ………………………………………25-26HIPAA & PATIENT RIGHTS ………………………………………………………………….27INFECTION CONTROL, STANDARD PRECAUTIONS & BLOODBORNE Pathogens 28-

30SAFETY and MEDICATION SAFETY ………….......……………………………………..30-32SERVICE FILES & SIGN IN & OUT …………… …………….…………….

………………...32TRAINEES/ASSIGNMENTS/TERMINATIONS…………………………………………….33-34INTERPRETERS FOR PATIENTS...............................................................................................34HELPFUL HINTS……………………………………………………………………………...…34HOSPITAL TERMINOLOGY …………………………………………………………..……35-36VOLUNTEER AGREEMENT ACKNOWLEDGEMENT………………………………………37CONFIDENTIALITY PLEDGE ACKNOWLEDGEMENT……………………………………38Behavior Norms for VPH Core Values Acknowledgement & Agreement……………………..39REPORTING CONCENCERNS RELATED TO PATIENT SAFETY Acknowledgement…….40


POST TEST…………………………………………………………………………..………41-44

Valley Presbyterian Hospital F A C T S

15107 Vanowen Street Van Nuys, California 91405 (818) 782-6600 www valleypres.org

Valley Presbyterian Hospital in Van Nuys, California, is a 350-bed, full-service, not-for-profit, acute care hospital. It has been serving the residents of the San Fernando Valley and beyond since its establishment in 1958.

Hospital Services« Breast Diagnosis & Treatment Center« Cancer Care« Cardiac Rehabilitation & Fitness

Center« Cardiac Care« Emergency Services« GI-Laboratory« Outpatient Services« Women's and Children's

Services:- Maternity Centers- Neonatal Intensive Care Unit- Obstetrics- Pediatrics- Pediatric Intensive Care Unit- Perinatology

Medical StaffMore than 500 physicians, each carefully reviewed and screened, belong to the Valley Presbyterian Hospital medical staff. The hospital’s Physician Referral Service provides information on these highly qualified physicians, who represent more than 50 specialties.

The FacilityValley Presbyterian Hospital is located on 16.3 acres at 15107 Vanowen Street in Van Nuys. The healthcare campus includes a new 127,500 square-foot, six-floor, 188-bed inpatient tower, which accommodates the needs of patients, visitors, and hospital staff in a hotel-like environment. The patient-friendly rooms offer natural lighting, a private bathroom, personal closet, dressing table, television, and comfortable seating and resting area for visitors. Also

on the campus is the seven-story hospital building; two-smaller patient towers; an ancillary services wing; the freestanding Health Education Center that contains the Henry X. Jackson Auditorium, classrooms and the Richard O. Myers Medical Library; three medical office buildings and two multi-level parking structures.

EmployeesValley Presbyterian Hospital has more than 1,500 full and part-time employees. Our employees, many of whom are active in community affairs, have a major impact on the central San Fernando Valley economic community.

VolunteersVolunteer Services has more than 360 part-time Adult and Student Volunteers. Our Volunteers assist in the Escort Office, Gift Shop, Information Desk, Admitting, Nursing Units and Visiting Patients and Families.

Community Benefit ProgramsBenefits for At-Risk Populations

Asthma Education, Infant Care Seat Program, Maternity Centers, ONEgeneration Stroke Management Collaborative, Flu Clinic, Perinatal Outreach, Senior Health Lectures, Senior Exercise Programs, TLC Palliative Care & Bereavement Program

Benefits for the Broader CommunityCommunity Health Fair, Golden Vitality Senior Program, Heart Healthy Check-Up, Health Screenings, Community Health Education & Newsletters, Community Sponsorships, Physician Referral, Transportation, Volunteer Services

Health Research & Education

Family Ties – Maternal Health Education Programs, Self-Help & Support Groups, Regional Occupational Program Training, CPR Classes, Parenting Classes, Moms in Touch Support Group, Student Nurse Education

Educational Affiliations The hospital works closely with the following institutions on medical & nursing educational programs: University of Southern California, University of California at Los Angeles, Northwestern University, California State Universities at Los Angeles & Northridge, Mount St. Mary's College, Pierce College, Los Angeles Valley College, College of the Canyons, Casa Loma College and Glendale Career College. Individual hospital departments also offer internships to college students throughout Southern California.

Professional AffiliationsValley Presbyterian Hospital is a member of Voluntary Hospitals of America (VHA), Healthcare Association of Southern California, California Healthcare Association, American Hospital Association, Valley Industry and Commerce Association and Mid Valley Chamber of Commerce.


Board of DirectorsGreg Kay, MDDavid W. FlemingPeter Koetters, MD, David Adelman

Alex Guerrero, Treasurer Daniel Chandler Ruth Garcia-Corrales Dianne F. Harrison, PhD Luca Jacobellis Matthew Mischel, MD Todd Moldawer, MD Ganesa Pandian, MD Barbara Romero

Munaf Shamji, MD Sukshma Sreepathi, MD Tony Tartaglia Gustavo Valdespino Vladimir Victorio

VALLEY PRESBYTERIAN HOSPITALMISSION STATEMENT

All successful organizations have a focus. Whether called a common purpose or mission, it describes the direction all the energies in the organization are pointed toward. Valley Presbyterian Hospital’s Mission Statement describes what we intend to be and distinguishes us from other organizations: “To improve the quality of health in the San Fernando Valley.”

The Vision Statement: “Excellence in all we do.”

The hospital is focused upon making these statements a reality. These ideals will be achieved by your understanding, supporting, and cooperating to do these in your volunteer tasks. Together we can help this institution make the mission and vision statements a reality.

Shared Values and Volunteer Department Goals

In the pursuit of excellence, Valley Presbyterian Hospital’s employees, physicians, Board of Directors, and volunteers work as a collaborative team. Our goals are to deliver the highest quality health care, outstanding customer service; to create a positive work environment and to foster an enriched work life.

The Volunteer Department Service Strategy is: Volunteers are dedicated to providing the highest quality of service to our patients and assist in freeing staff to give optimum patient care. Volunteers pledge to support the programs and departments by giving quality service to insure customer satisfaction. Volunteer’s goal is to help Valley Presbyterian Hospital meet the healthcare needs of our community. Volunteers become an integral part of the hospital team. Teens have the opportunity to learn from this introduction to an environment of commitment and responsibility.Students gain experience for college, resumes and employment applications, and accrue the volunteer hours needed to meet school course requirements.Homemakers, a vital part of Volunteer Services, share their compassion, skills and expertise on behalf of patients, families and staff.Employed Adults volunteer for personal growth, job advancement, career change or social commitment.Retirees gain personal satisfaction and reward by offering their time and experience to the hospital. The goals for each volunteer are to...Assist medical center staff, releasing them for essential duties that only they can perform.Bring a greater personal dimension to the delivery of health care.Serve as vital ambassadors between the medical center and the community.Participation as volunteer provides opportunities to...Acquire new skills and knowledgeMake new friendsDevelop new interestsLearn to be more compassionate and understandingExperience satisfaction in helping others.

LEADERS TO KNOWEveryone who comes to Valley Presbyterian Hospital should be treated with utmost kindness and respect. VPH Leaders are Gustavo Valdespino, President and Chief Executive Officer (CEO); Lori Burnell, Senior VP/Chief


Nursing Officer (CNO); Lori Cardle, Senior Vice President and Chief Operating Officer (COO); Dr. Clyde Wesp, CMF (Chief Medical Office); Janice Klostermeier, Senior VP Finance/CFO; Jeff Allport, VP Chief Information Officer and Deborah Gac VP of Human Resources

VALLEY PRESBYTERIAN HOSPITALCORE VALUES

Our Mission: To improve the quality of health in the San Fernando ValleyOur Vision: Excellence in all we doCore Values:

▪ Demonstrate dignity and respect for all individuals▪ Deliver compassionate and patient-centric care that addresses diverse cultural needs▪ Create and maintain a quality environment that allows physicians, employees and

volunteers to succeed▪ Show pride in providing community-based health care▪ Promote trust and transparency▪ Encourage collaboration in the workplace

REGULATORY AGENCIES IMPACTING PATIENT CARE OPERATIONSValley Presbyterian Hospital is accredited by DNV Healthcare, the leading accreditation company of hospitals in the U.S. DNV integrates ISO 9001 quality compliances with the Medicare conditions of participation. For more information, visit www.dnvglhealthcare.com☛ DNVHC Accreditation Program ☛ Centers for Medicare and Medicaid Services (CMS)☛ California Department of Public HealthAs a business entity, DNV Healthcare is part of Det Norske Veritas, a global, independent, tax-paying foundation whose purpose is safeguarding life, property and the environment. DNV Healthcare Inc. was granted deeming authority for hospitals on Sept. 26, 2008, by the US Centers for Medicare and Medicaid Services (CMS). DNV Healthcare is managed by a dedicated group of degreed professionals, each with many years of experience in their respective fields of expertise including hospital management, clinical services, health law, ISO certification and engineering.

Valley Presbyterian Hospital received ISO 9001 certification for three (3) years from (DNV) Healthcare. Hospital staff, physicians and volunteers assisted in receiving certification by complying with the: 5 C’s of ISO9001:

1. CUSTOMER Satisfaction2. CONSISTENCY3. CONTINUAL Improvement4. COMMITMENT from management5. CONTRIBUTION to departmental and organizational goals

6 Required Policies:1. Document Control2. Record Control3. Internal Audits4. Control of Nonconforming Products5. Corrective Action6. Preventive Action

National Integrated Accreditation for Healthcare Organizations (NIAHO) is the name of DNVHC’s hospital accreditation program. The NIAHO® standards integrate requirements based on the CMS Conditions of Participation (CoPs) with the internationally recognized ISO 9001 Standard for the formation and implementation of the Quality Management System. ISO 9001 is the infrastructure of quality that infiltrates every aspect of your organization – it enables an organization to reach maximum effectiveness and efficiency in


its processes that leads to improved outcomes, both clinically and financially. These two sets of standards form the basis of DNVHC’srevolutionary Integrated Accreditation concept in NIAHO®.

Why should a healthcare organization commit to the “accreditation” survey process?▪ To assess compliance and educate hospitals in best practices▪ Offers the organization “deemed status” in meeting certain certification requirements▪ Enhances the confidence of the community in the organization▪ Enhances the recruitment of direct patient care staff

Centers for Medicare and Medicaid Services (CMS) is a Federal government agency that performs announced and unannounced surveys.

Special Focus: To improve the quality of health care provided to Medicare, Medicaid, and Child Health insurance Program beneficiaries by:1. Developing and enforcing standards through surveillance2. Measuring and improving outcomes of care3. Educating health care providers about quality improvement opportunities4. Educating beneficiaries to make good health care choices.

Why should a healthcare organization commit to the “accreditation” survey process?▪ Set forth the minimum requirements that hospitals must meet in order to participate in the Medicare and

Medicaid programs.California Department of Public Health is a State government agency that performs announced and unannounced surveys.

Special Focus: To promote the highest quality of medical care in community settings and facilities, through the licensing and certification program, by:1. Operating a responsive, uniform enforcement program in accordance with state licensing and federal

certification requirements2. Encouraging provider-initiated compliance and quality of care improvement activities3. Promoting the use of practice guidelines to improve the quality and effectiveness of medical and other

interventions.

Why should a healthcare organization commit to the “accreditation” survey process?▪ Set forth the minimum requirements that hospitals must meet in order to stay in business.

Staying in a State of “Ongoing Survey Readiness”1. Follow the practice act established for your profession2. Follow the policies and procedures established for your department3. Document your activities well

VALLEY PRESBYTERIAN HOSPITALVOLUNTEER GUIDELINES

Application, Group Meeting/Orientation and TrainingA hospital is a unique, challenging and exciting environment, which offers tremendous opportunities for personal achievement and satisfaction. We have designed our application, group meeting/orientation, and training process to fulfill the needs of the departments and support the overall goals of hospital.

Acceptance in the volunteer program at Valley Presbyterian Hospital does not suggest or guarantee employment here.

To become a volunteer, an application must be completed and submitted to the Volunteer Services Department with a medical form filled out and signed by a physician or nurse practitioner. The medical form includes a current TB skin test, which has been administered in the last 6 months or a chest x-ray in the last 5 years. The Director of Volunteer Services


or Volunteer Coordinator will then conduct the group meeting/orientation.

Orientation provides an overview of the hospital’s history, mission, safety procedures, and rules, which all volunteers must follow. All volunteers will then shadow in the Escort Office in order to obtain practical experience within the hospital. Once the two previous steps are completed, training will occur within the assigned department. Continuing in-services/meetings are provided and required in order to keep volunteers current on hospital procedures and policies.

Volunteer Commitment and Service Hours All volunteer schedules are arranged by the Volunteer Services Department and communicated to the department volunteer will be assigned to. VPH expects consistent and reliable service from all the volunteers. Volunteer dependability is essential to effective performance. Accepting a volunteer position is a serious commitment to VPH.

Volunteers are expected to clock in at the beginning of their shift and out at the end of each shift at one of the Volunteer sign in computers located at Main Information Desk and Volunteer Escort/Dispatch Office. Volunteers are expected to serve a minimum of 4 hours per week and be in proper uniform when reporting to work.

The volunteer department requests a commitment of at least 120 hours of service from any individual accepted into the volunteer program. Modifications to assigned schedules need to be done by a Volunteer Services Department employee. Any letters of recommendation or verification letters will be written upon request once 120 volunteer hours have been completed not before.

AbsenteeismIn the event that a volunteer is unable to work their assigned shift, the Volunteer Services Department at 818.902.2932 must be notified at least four hours prior to the beginning as well as the assigned unit, of the shift. If the volunteer’s assignment is a nursing unit, admitting, the business office or the gift shop, notification to the assigned department is also required. Continuous or frequent absences will be reviewed. In the event that the policies are not honored, email notice of termination will be mailed to the volunteer.

Excused absences are illness, family emergency, bereavement, vacation and medical appointments. In the event that an illness is more extensive, such as surgery and the recovery period after, the volunteer will be placed on a medical leave of absence. The volunteer may resume volunteering after a medical leave of absence once a written notice has been provided by the attending physician. A leave of absence will be granted to a volunteer when they have a family member with an illness, bereavement, extended vacation or urgent personal business requiring immediate attention.

Vacations: Please provide sufficient advance notice of planned vacations to the Volunteer Office, as well as the assigned area.Holidays: The Volunteer Escort/Dispatch Office is closed on recognized holidays that include Easter, Memorial Day, 4th of July, Labor Day, Thanksgiving Day, Christmas Day and New Year’s Day (7 holidays).Volunteer Time: The times allowable for volunteers are from 7 a.m. to 11 p.m. No volunteers are allowed to work before 7 a.m. or after 11 p.m. No students under 18 yrs. old may work after 8 p.m.Resignation: If you are no longer able to volunteer, report it to the Director of Volunteer Services or Volunteer Coordinator/Assistant. You are required to turn in your badge and proxy card.Inactive: Volunteers who are inactive due to medical leave or emergencies for more than one month may not retain their assigned shift and hours. Inactive volunteers may return when they are able to participate on a regular basis. Must contact the Director of Volunteer Services when you are ready to return.

Unexcused AbsencesAfter 2 unexcused absences, a volunteer may be dismissed from volunteering. Unexcused absences occur when a volunteer does not come to work, does not call in advance to advice of the pending absence, or does not report in the correct uniform.

Uniform and Grooming (Cost for is $10.00 for burgundy Polo shirts (students) & $20.00 for navy blue smocks (adults), must be paid prior to receiving items.) The following is required uniform for volunteers:

Adult female volunteers - The navy blue volunteer smock, a plain white or light colored blouse or shirt /tt/file_convert/5f3db3c122bcaa27674c7300/document.docx\05/22/23 7

underneath the smock, white, khaki or black slacks/pants or a skirt below or at the knee, socks or stockings, white, black or color close-toed shoes (tennis shoes allowed) that matches with uniform.

Adult male volunteers - The navy blue volunteer smock, a plain white shirt or polo shirt, black, khaki or white slacks/pants, socks, black or white color closed-toed shoes (tennis shoes allowed)that matches with uniform. The pant color could correspond with the shoe color.

Student volunteers - The burgundy volunteer polo shirt, khaki or black slacks/pants, white or black socks, white or black close-toed shoes (tennis shoes allowed) that matches with uniform. The slack/pant color could correspond with the shoe color.

Student Volunteer Leaders - Selected students are issued a royal blue volunteer polo shirt, worn with black/khaki slacks/pants, white or black socks, white, black or color that matches close-toed shoes (tennis shoes allowed). These students worked under the Director’s supervision and direction to supervise other volunteers and develop action plans to run a more efficient volunteer program.

Other hygiene requirements:Females and males with shoulder length hair or longer must have it pulled back in a ponytail, bun or braid.

Make sure that hair is kept cleaned and combed at all times. Post earrings or small hoops only. No excessive perfume or cologne. No extreme coloring of the hair. Beards, moustaches, sideburns and hair must be kept trimmed and neat at all times.

Clothing that is not allowed No large, dangle earrings. No jeans of any kind, no Capri pants, no skinny pants of any kind, no sweats, no nylon pants, no leggings

(unless wearing skirts/dresses over them), no overly baggy pants, no shorts or no overalls. No boots of any kind, platform tennis shoes, high-heeled shoes, platforms, clogs, sandals or thongs. No large facial piercing. No extreme coloring of the hair (e.g., purple, pink, green, etc.) Do not bring or use IPods during volunteer assignment Cell phones to be kept in silent or vibrate, to be used for emergency purposes only and no texting during shift No extreme coloring of the hair (e.g., purple, pink, green, etc.)

If any volunteers wear inappropriate attire or do not follow the Hospital Volunteer Services Dress Code this could be cause for verbal, written warnings and final termination.

Identification BadgesThe photo I.D. badge is for patient, employee and volunteer security and protection. All hospital personnel are required to wear the hospital photo identification badge while on duty. All personnel must wear and display the photo I.D. badge while on duty. Failure to do so will lead to disciplinary action. Photo I.D. badges are not to be defaced or mutilated in any fashion or worn backwards so that the photo is not displayed. Any personnel with a damaged I.D. badge must seek a replacement.

If the I.D. badge is lost or stolen, the volunteer must report it to the Volunteer Services Department as soon as possible to arrange for a replacement photo badge. There will be a $5.00 replacement charge for a new badge.Volunteers are required to return their identification badge and proxy card to the Volunteer Services office upon com-pletion of volunteer service at Valley Presbyterian Hospital. Uniforms are yours to keep. If you do not return your identification badge and proxy card, you will not receive any verification of completion of volunteer hours.

Meal BenefitsMeal benefits are provided by the Hospital to its Volunteers, Adults wearing navy blue Smocks and Students wearing burgundy polo shirts only. Volunteers donate a minimum of 4-hours of volunteer service on their scheduled day therefore, are permitted in the cafeteria and eligible for a $7.00 meal to be used for either a breakfast, a lunch or a dinner – not all three. The, Hospital Director of Volunteer Services will take appropriate action against any volunteer that fails to comply with any Hospital policies such as the meal benefit.

Hospital Cafeteria Hours and MealsCafeteria Hours are: Monday through Friday, 6:30 am to 7:00 pm and 10:00 pm to 01:00 am


Saturday and Sunday 8:00a-7:00pClosed on Hospital Observed Holidays, unless otherwise posted

Smoke-Free Facility: Valley Presbyterian Hospital is dedicated to creating a healing environment for our patients and visitors. A smoke-free campus environment supports this mission and enables us to provide the highest quality, safest health care possible. Therefore, smoking pipes, cigars, cigarettes, or e-cigarettes of any kind in the hospital, parking structures or on the hospital campus is prohibited. Volunteers are not allowed to transport patients to smoke or for fresh air.

Injury or Accident While On DutyIn the event that you are injured while performing a volunteer duty, please use discretion. For example, if you have slipped while performing a hospital errand and are unable to get up, have someone nearby call a Code Green by dialing x4444. A Code Green, you may remember, is a non-patient medical emergency. Allow the response team to attend to you. Other situations arise which are less severe, but still deem the need for medical attention, for example a cut from a filing cabinet. We hope that you are never hurt while performing your volunteer responsibilities. In the event that you are, and whether it is similar to the fall or the cut, there are some steps that we want you to follow.

If you are hurt while performing a volunteer duty, please notify a Volunteer Services Staff person. Please communicate to those assisting you that you are a volunteer here at the hospital, and that you are on duty. Whether you are mobile to go yourself or need to be escorted in a wheelchair, proceed Monday through Friday, 7:30a-3:45p to Occupational Heath Office, other days or after hours go to the Emergency Room Department located on the first floor. The Hospital’s General Liability Insurance will cover the care you receive if your injury is incurred while performing a volunteering task during your shift. If your injury were more severe and needed greater attention, the appropriate level of care would be administered. Let's take these same examples, and alter them a bit to clarify accidents that would not be covered by the Hospital’s General Liability Insurance. A volunteer is on their way in to report for their shift. While getting out of the car, they cut themselves on the door. The cut is serious enough that a thorough washing and a band aid is not enough. This volunteer should go to the Emergency Room, have them tend to the cut in case stitches are needed. The volunteer's medical insurance would be billed, because the injury was not incurred while performing one of their volunteer responsibilities.

Similarly, a volunteer comes to visit a patient. While visiting, they slip and fall while walking to the elevator. Once again, a Code Green (x4444) should be called. However, because the volunteer is not on duty, they should be taken to the Emergency Room and their medical insurance will be billed. In this situation, the volunteer was here on their own time, and the injury was not related to any of their volunteering responsibilities.

If you are injured while on volunteer duty at VPH, you should:1. Report the accident or injury to the Director of Volunteer Services (x2932) and proceed to Occupational Heath

Office during business hours, and to the Emergency Room Department on the 1st floor, after hours and Saturday -Sunday.

2. The Director of Volunteer Services or designated person must fill out an Unusual Occurrence Form that is on the computer system.

3. Page the nursing supervisor if the injury occurs after 5:00 p.m. and then go to the Emergency Room for treatment, if needed.

4. Always inform the Director of Volunteer Services and /or the Volunteer Coordinator/Assistant, as soon as possible.

These procedures must be followed in order for VPH to cover medical expenses resulting from your injury.We are well aware that accidents do happen even when one is properly trained and diligent. We will provide you with appropriate care. You can assist in the processes by making sure that Volunteer Services is notified, and proceed to Emergency Room Department.

ParkingFree of charge for all active volunteers. On first day, will receive Proxy Key card which gives access to parking lot when you receive Hospital ID. If this card is lost or stolen, the volunteer must report it and arrange for a replacement. The cost to replace this card will be $15.00. All volunteers may park in the Noble Parking Structure located corner of Noble/Vanowen or Campus parking 1st entrance on Vanowen. Do not park in the Valet Parking in front of the


hospital, this is a “visitor only” lot and you will be charged the normal visitor rate.

VOLUNTEER RULES AND REGULATIONSFor your health and safety and the health and safety of our patients certain standards of cleanliness and behavior are required of all hospital personnel. As a volunteer you will be expected to comply with the following standards.

General Regulations 1. Bathroom breaks may be taken as workload permits or if needed.2. You are not allowed to eat at volunteer assignment or have drinks in any of the nursing units.3. Please clock in when reporting for your shift and clock out when you leave.3. Punctuality and dependability are important in volunteer work.4. If you take an extended leave of absence you cannot be guaranteed the same assignment if you decide to

return.5 Please notify the Volunteer Office of any change of address, telephone number or emergency contact.6. All volunteers are accountable to the supervisor of the department to which they are assigned.7. VPH is not responsible for personal property you bring to the hospital. Please leave valuables at home and

bring only the amount of money you will need.8. Not permitted on Hospital premises are: digital cameras, portable radios, MP3s, I-Pods, CD players and

headphones, cellular phones, hand-held electronic games (Game Boy, DS, etc.) or the like. Hospital is not liable for any personal effects that are lost or stolen and therefore volunteers are encouraged to not bring any valuable items on campus.

9. Accepting tips from patients or witnessing signatures is against hospital policy.10. No loitering in the hospital lobby, stairwells, Volunteer Escort Office or in and around the hospital campus.11. Smoking is allowed in the designed huts located outside of the hospital only. Smoking in the rooms,

corridors, or elevators is strictly forbidden and will be cause for dismissal from the volunteer program.12. No Texting While Walking. WALKING + TEXTING = WEXTING

VOLUNTEER CONDUCTWhenever people are required to work together for any purpose, certain guidelines are necessary to govern their personal conduct and relations. The hospital considers work rules to be an important responsibility. They are a necessary part of managing our business so that volunteers can be treated fairly, and work safely and effectively. These rules apply to all employees and volunteers. Either the volunteer or the hospital has the right to terminate the volunteer relationship at will.

Violations of the rules listed below may call for some form of disciplinary action up to and including immediate termination. Although it is not possible to provide an exhaustive list of all types of unacceptable conduct and performance, the following are some examples.1. Insubordination, including improper conduct toward a supervisor or refusal to perform tasks assigned by a

supervisor.2. Possession or use of alcoholic beverages or illegal drugs on hospital property or appearing for duty under the

influence of alcohol or drugs.3. Release of confidential information about the hospital or its patients or employees.4. Theft, unauthorized removal of, destroying or damaging property of the hospital, fellow volunteers,

employees, patients, visitors, or anyone on hospital property.5. Falsifying or making material omission on a volunteer application or making erroneous entries or material

omissions on the hospital's record.6. Frequent tardiness or absence from work and 2 unexcused absences.7. Possession of firearms, explosives or other weapons on hospital property.8. Failure to comply with safety, fire or sanitary regulations.9. Fighting on hospital property.10. Unsatisfactory performance.11. Sleeping on duty under any circumstances.12. Non-compliance or disregard of any established safety rule.13. Harassing, threatening, intimidating or coercing any other employee or volunteer.


14. Using iPods, iPads, texting, surfing the net during volunteer shifts.

VOLUNTEER CODEAll hospital workers, Adult and Student volunteers, are bound by the same code of ethics. The patients need and expect ethical and professional behavior from their caregivers. The following guidelines are designed to clarify the sorts of activities that are appropriate for you to undertake and your obligation concerning patient confidentiality. If a situation arises which is not covered by these guidelines or about which you are uncertain, talk to your supervisor before taking any action. VPH Volunteers should ALWAYS : 1. Accept the guidance of staff members in charge of the area in which they are working.2. Maintain and support the hospital’s policies on privacy and confidentiality.3. Refer all questions regarding a patient's health status to the nurse in charge. Billing questions should be

referred to the VPH Business Office.4. Clear any requests for food, drink, etc., with the charge nurse.5. Be pleasant, helpful, and adaptable. Let the patients see you smile.6. Refrain from excessive noise in the halls.7. Take any problems or suggestions to the Volunteer Services department.VPH Volunteers should NEVER : 1. Discuss a patient's name, illness, or personal affairs with other personnel.2. Read a patient's chart or records.3. Inquire about a patient’s diagnosis or facts from personnel.4. Offer opinions concerning diagnosis or treatment.5. Offer advice or counsel to patients. Refer such requests to the charge nurse or the VPH Patient Relations or

Risk Manager.6. Recommend or criticize a physician or hospital staff member to a patient.7. Discuss politics or religion with a patient. 8. Agree to run errands or transport patients off the hospital grounds. 9. Accept tips from patients or their families.10. Feed patients, transfer patient from bed to chair, give medications, change diapers or dress patient.11. Leave your department without signing out.13. Obtain a patient's signature for treatment.14. Smoke or chew gum on duty.15. Should never have iPod, iPad on or use cell phones (no texting) at any time during volunteer shift.16. Transport any patients or visitors to smoke or for fresh air.


VOLUNTEER CUSTOMER SERVICE at VPHValley Presbyterian Hospital is a Customer Service Driven Organization. Excellent Customer Service is a MUST for all employees and volunteers at VPH. The image YOU, as a volunteer give our patients and visitors at Valley Presbyterian Hospital is made by the attitude you display. Very often the first impression is the lasting impression. Remember that Patients are VPH first priority. Everyone must practice the basic universal common sense courtesies to everyone; be courteous, friendly and helpful.

We measure the results of our service by surveying our patients. Patient satisfaction is our number one focus at Valley Presbyterian Hospital we depend on their thoughts and opinions. After their hospital discharge the patients may receive a survey or telephone call from the consulting firm Press Ganey. The patients are asked of their entire hospital experience and if they would recommend hospital to others and rate services from Always to Never, Very Good to Very Poor and from 1 to 10. Many patients acknowledge hospital staff members who made their visit more pleasant, in which area, and what was done. In the event of a patient complaint, the appropriate hospital employee follows up as soon as possible to hopefully have a service recovery. Patients depend on hospital staff for all their personal needs. Patients expect care, concern and courtesy from all staff and volunteers. Exceed the patients’ expectations by using and abiding by the following customer services initiatives:

1. To create consistent service throughout VPH all hospital staff and volunteers use the acronym AIDET

2. which are five behaviors to use with every patient/family encounter to anticipate, meet and exceed the expectations of the customer and reduce the anxiety.

a. Acknowledge by using positive body language, speaking with friendly tone to make an excellent first impression. Communicate to customers "You Are My Focus" - (even if just passing in the hall). They will remember that first impression.

b. Introduce yourself “My name is … I am a volunteer and I am here to … ” Customers will want to know “Who You Are You and What You Want”(whether in person or by phone/email)

c. Duration- Give the Roadmap to "When" (be specific about duration and apologize for delays). People do better when they are informed, even if the wait is long!

d. Explanation "Do your Work Out Loud" (remember to include safety and ask if they have?) Why you are there (engaging with patients is key in keeping them informed)

e. Thank You- For Trusting Us To Be a Part of Your Healthcare Team (Thank the families for their assistance and support and don't forget to thank internal customers)

3. All staff and volunteers that have any interaction with patients in their rooms, should always: Knock before you enter a patient’s room or draw a curtain

Use the acronym AIDET and the behaviors standards Smile – a friendly smile will make people feel more at ease

Verify the patient’s name and date of birth on the patient’s ID bracelet (prior to a procedure or transporting them)

Always Make eye contact and use Positive Body Language Before leaving the room, make sure that all essential items are within the patient’s reach

(call light, bed side table and telephone) Before leaving the room always say “Is there anything else I can do for you?”

3. All hospital staff and volunteers must answer the telephone in the following manner: Pick up the phone at first ring and no more than three rings Greet the caller and identify yourself and your department (i.e., Name, Escort Office) Always say “How may I help you?”


Finish the call by thanking them and asking “Is there anything else I can do for you?”4. All employees and volunteers will stop and assist patients on the nursing units.

The “No – Pass – Zone Program” is: a room when a call light is on or patient asking/yelling for assistance. All will follow number #1 expectation (above) when helping patients. All hospital staff and volunteers needs to be involved and work as a team to Improve the Patient’s Hospital Experience.

Assist to keep the noise level down throughout the hospital. Remember to be quiet in patient areas, keep voices down in elevator and work areas.

TIPS to help us have Service Recoveries with our customers. Use the C.A.R.E. model:C = Connect and critically think. Seek to understand everything that is going on with the situation.A = Apologize with empathy (be genuine). Take responsibility and focus to enhance the experience forward.R = Repair and respond. Initiate the problem solving process. Empower staff to problem solve or use chain of command. E = Evaluate and exceed expectations. Determine success and ask if additional actions needed. Follow-up and close loop with the patient/family.

We want all our internal and externals customers (patients, visitors, physicians and each other) to feel welcome and confident of the kind of service we provide. Following is the Behavioral Standards that all employees and volunteers must adhere by. No excuses. This will help us to build a collaborative partnership with all our customers to build commitment to provide the best possible service in this community. The Behavioral Standards are for all hospital staff, volunteers and physicians to display with all our customers. At VPH all employees and volunteers have signed Acknowledgement and Agreement, and new employees and new volunteers will sign at orientation agreeing to follow this pledge. Everyone is accountable. Excellence in all we do!

VPH Behavioral Standards VALLEY Presbyterian Hospital - Excellence in All We Do

Demonstrate Dignity and Respect for all Individuals Welcome Everyone-make eye contact, greet with a smile and say “Hello/hi/good morning Protect patient privacy-be mindful of PHI (protected health information), close curtains

and doors, speak softly Be courteous-say “please/thank you/ anything else I can do for you? Be respectful Present yourself professionally at all times Speak English in all work related areas Keep those we serve informed about delays Show concern for our patients by minimizing noise level throughout our organization

Deliver compassionate and Patient-Centric Care that Addresses Diverse Cultural Needs Respect cultural difference and honor individual preferences Use your eyes, ears and heart when listening Make compassionate connection with each patient and their family members Express empathy and provide explanations – say “I understand / I am sorry / I am here to

help you” Respond to patient needs immediately – prioritization of the patient’s needs and timely

follow through are the expectations Answer the telephone promptly with our name, department, and greeting of “How may I

help you?”

Create and Maintain a Quality Environment that Allows Physicians, Employees and Volunteers to Succeed Be committed to patient safety and quality improvement


See it. Own it. Act on it – personally guide visitors who need assistance, call for repairs, report broken equipment, and report patient safety concerns immediately

Keep VPH clean – pick up trash, assist with overall cleanliness Identify opportunities and seek solutions – if something needs attention, notify the

appropriate department(s) (EVS, Engineering, Biomedical, Transportation, etc.) Round regularly on those we serve, making certain that we have met and exceeded their

needs

Show Pride in Providing Community-Based Health Care Take full responsibility for behavior – positive attitude, adhere to the dress code, avoid

using your personal cell phone while at work, show respect for everyone Speak positively about VPH – this is expected in and outside of the hospital and at all

times, discourage negativity by not acknowledging it Be honest, reliable and prompt – be transparent and truthful, be on time Be committed to excellence and encourage it in others – do your best and role model

positive behavior

Promote Trust and Transparency Be honest with everyone and treat others as I want to be treated Be open to constructive feedback – welcome new ideas, be open to suggestions Speak up to protect our patients and ensure their safety – use the chain of command, be

a patient advocate Respond to all forms of communication including call lights, pages, emails, voice mails and

text in a sensitive manner

Encourage Collaboration in the Workplace Work with others to create an excellent experience for patients, families and co-workers

and co-volunteers – let’s make it better! Help other meet their goals – we are ONE team! Speak positively about everyone throughout the organization

TELEPHONE CUSTOMER SERVICEAs members of the health care team, we believe in providing an environment, which encourages and supports all members of the health care team in their efforts to adhere to professional standards. This is consistent with Valley Presbyterian Hospital's commitment to foster cooperative and positive relationships within the community for the benefit and enrichment of all. One way to fulfill this philosophy is proper use of the telephone. Telephone communication is a vital link in any organization. Good telephone techniques are learned skills, and each member of the health care team is encouraged to learn and use these skills.

Telephone Etiquette Basics: CUSTOMER SERVICE begins when the telephone rings

o Prepare your PHONE VOICE (use a positive/friendly tone)o Take a deep breath before you pick up the telephoneo Be prepared before you respondo Put a SMILE - callers can ‘see’ a SMILE over the telephone

Answer the telephone by the 3rd ring. Do not leave anyone on hold for more than 1 min.

Offer your standardized greeting that includes your department name and your name. Some examples are:

o “Volunteer Escort Office, Mary speaking, how may I help you?”o “Good morning, Gift Shop. This is Mary, how may I assist you?”

Address the caller by their name; avoid patronizing words such as “honey”, “sweetie”, and “dear”.

BE PRESENT with your caller; your CENTER OF INTEREST is on the caller/tt/file_convert/5f3db3c122bcaa27674c7300/document.docx\05/22/23 14

Clear your mind of all but the task at hand – RESPONDING to the callero FOCUS your attention on the callero Turn away from distractions such as reading materials, computer, etc.

Be a good LISTENERo Do not interrupt when caller is speakingo Stay calm and show sincereness when speakingo Do not rush the callero Avoid placing callers on speakerphones or on HOLD for more than 1 minute

Before ending the call, ask the caller “Is there anything else I can do for you?”Other Telephone techniques for providing quality service to the public:Transferring a Call

Tell the caller what you are going to do. Let the caller know the name and extension of the person they need to call in case they get disconnected.

Placing a Call Keep a directory of frequently called numbers handy. Be ready to talk, have all the necessary information right at hand. When your call is answered, start by identifying yourself, your organization, and the purpose of your call.

Asking a Caller to Hold Tell the caller what you plan to do and how long it will take. Ask to wait, or have you call back. Try not to keep a caller on hold any longer than three minutes. Thank the caller for waiting.

Taking a Message Be prepared to take notes. Repeat key information to ensure accuracy. Be sure your message includes the following: date of call, time of call, name, telephone number, organization

and job title of the caller. Leaving a Message

Give your name, your organization, and your telephone number. Give details, so that when your call is returned, the caller can be prepared with proper information. Ask for the name of the person taking the message so you will know who handled your call.

These are basic guidelines to help you use good telephone techniques. Sometimes your voice is the only contact the public has with Valley Presbyterian Hospital. What you say and how you say it can make or break the connection between Valley Presbyterian Hospital and the community. It is important that you train your telephone voice to project a confident and capable image. Do not ever argue with any caller!

Art & Science of Service Recovery C.A.R.E. C: Connect and critically think A: Apologize with empathy R: Repair and respond E: Evaluate and exceed expectations

C.A.R.E. Service Recovery Model • Connect and critically think – Seek to understand everything that is going on with the situation. – Determine what can be handled right away. –• Encourage staff to handle situations at the time and the best of their autonomy before escalating to the situation to their supervisor.

Apologize with empathy (be genuine) – Take responsibility and apologize for the patient’s /

family’s experience. • Apologizing does not mean that it is your fault, it means

we missed the mark, or did not meet an expectation. – Focus on what we can do to enhance the experience

moving forward. Repair and respond


– Initiate solving the problem to the best of your ability and in a timely manner.

• Initiate the problem solving process even if you cannot complete it.

– Empower staff to problem solve and not be discouraged for inability

• Tell the patient what you will do and when you will update the patient.

• If you do not know the appropriate resolution, ask the patient.

Evaluate and exceed expectations – Determine success of the actions taken and if the resolution was appropriate. – Ask yourself: • Do any additional actions need to be taken? • Has the situation been closed? – Follow-up and close the loop with the patient/family.

TELEPHONE NAME RECOGNITION SOFTWAREPlease be advised that we have a business tool that will allow you to contact anyone at Valley Presbyterian Hospital with an assigned phone number by simply saying his or her name or department.

Dial x5555. This service will allow you to access the office phone, pager, and cell phone of all employees and departments listed in the hospital directory. The attached instructions will explain how to use this feature. The service is available 24/7, and eliminates the need to search through printed directories (which may be not be available), or dial the switchboard to transfer your call. We have included the “common name” of the employee. We have also added some additional names for many employees. For example, if your full name is Susan Davis-Jones, but most people call you Sue Davis, or Sue Davie-Jones, you will be listed under these other options. By utilizing this service, you will reduce the workload on the switchboard and allow us to provide better service to our patients and families.

FREQUENTLY ASKED QUESTIONSWhat if there is another call?

The calls are handled as they were before. What if two people have the same name?

The Name Connector will tell a caller that there is more than one person with that name, and will instruct the person to say the name with the “tiebreaker” attached: “There is more than one listing for John Smith. Please say John Smith in Sales or John Smith in Finance.”

BODY MECHANICS

What are good body mechanics? Body mechanics refers to the way we move during everyday activities. Good body mechanics may be able to prevent or correct problems with postures (the way you stand, sit or lie). Good body mechanics may also protect your body, especially your back, from pain and injury. Using good body mechanics is important for everyone. Wear appropriate shoes for your work duties. Shoes should protect your feet from injury, give a firm foundation and keep your from slipping.

Body Mechanic Basics1. Reaching for records, files or supplies, especially in high places, can strain your back. Reach only as high as your

shoulders. Use a stepladder if you need to get closer to the load. Test the weight of the load by pushing up on a corner before lifting. If it is too heavy, get help.

2. Bending requires special precautions for the safety of your back. When you are bending to reach or lift, move /tt/file_convert/5f3db3c122bcaa27674c7300/document.docx\05/22/23 16

your whole body to protect your back. Bend your knees and hips, not your back. Kneel down on one knee if necessary. Your bottom should always stay even with your knees or lower than your knees. Get as close to the object as you can, so you will not reach with your arms.

3. Lifting incorrectly is a common cause of back injury. Get a firm footing and bend at your knees, not your waist. Keep the load close to your body. Tighten your stomach muscles to support your back when you lift. Lift with your legs, not your back.

4. Pushing larger objects rather than pulling is safer for your back. Push with both arms, keeping your elbows bent. Stay close to the load without leaning forward. Tighten your stomach muscles as you push.

5. Avoid twisting your back when you reach or bend. These combined movements can injure your back even with the slightest loads. Use your legs and get close to the object. Move your feet during the transfer and lift with your legs, not your back.

6. Sitting incorrectly contributes to poor posture, stiffness and fatigue. These guidelines should be followed to sit correctly:a) Hold your head upright so that the top of your text or project is just below eye level and at least 12-18

inches from your face.b) Sit up straight. Do not slouch or hunch forward.c) Rest your arms comfortably so they are level with your workspace.d) Rest your feet on the floor or on a footrest.

7. There are many other simple activities to do throughout the day to decrease physical stress. Take the stairs instead of the elevator. Walk or cycle to work or after work. Take a brisk walk at lunchtime. Take periodic stretch breaks if you sit for long periods of time.

WHEELCHAIR TECHNIQUES1. Position the chair as close to the patient's bed as possible.2. Always set the wheelchair's brake when loading or unloading a patient.3. Move the footrest to the side and out of the patient's way.4. Be attentive to the patient while nursing staff is assisting patient in the wheelchair. Position the leg and foot

rests comfortably. 5. Push the wheelchair at a slow and steady pace. Be particularly careful when rounding corners.6. Patients should sit well back in the chair to avoid tipping.7. Use the main service elevators to move from floor to floor.8. Always back the wheelchair into the elevator, so that patient is facing elevator doors.9. Upon arrival at your destination, caution the patient not to attempt to leave the chair until you set the brake.10. Set the brake, move the leg and foot rests aside, staff or family member are to help the patient to exit the chair.11. NEVER ATTEMPT TO ASSIST A NON-AMBULATORY PATIENT INTO OR OUT OF A CHAIR.

CALL FOR A NURSE.12. Be sure to collect the patient's glasses, chart, tissues, etc. These items are often left behind during treatments

and procedures and are easily lost. This is particularly important if the patient is being discharged.13. If the patient you are transporting is to be discharged, be prepared to transport their luggage, as well. DO NOT

PLACE LUGGAGE ON THE PATIENT'S LAP.14. Ask the families of discharged patients to meet you at the discharge area and to have their vehicle parked as

close to the door as possible.15. DISCHARGES AREAS #1 in back of ICU (cult de sac and #2 at the front main entrance of hospital lobby. Only

when requested may use Emergency Room entrance.16. For a challenging discharge (e.g. an overweight patient or special needs) coordinate with Transportation

department by calling x4000. We do not want any of the volunteers to hurt themselves or patient.

CULTURAL DIVERSITYIn a desire to fulfill our hospital mission statement, Valley Presbyterian Hospital advocates a set of skills, behaviors, and policies that enable individuals to work respectfully and effectively with patients and each other in a culturally diverse work environment. Culture defines the values, beliefs, customs, knowledge, and practices shared by a group and can affect an individual’s perception of health care providers, as well as the many types of services related to the provision of care. In the delivery of health care services, we must be sensitive to and knowledgeable of the relevance of a patient’s


cultural background in any component of service delivery. At VPH it is expected for all staff and volunteers to demonstrate respect, honor cultural preferences, and accommodate requests regarding these preferences in a reasonable manner. Very important to assess and to avoid any type of stereotyping.

Emergency Medical Treatment and Active Labor Act – EMTALAThrough revisions in the statute, the regulatory agencies as well as the court systems have defined the primary focus of the statue as ensuring access and prohibiting discrimination in the provision of emergency services to patients presenting with similar types of conditions. In other words, the statue mandates access to emergency services to all patients regardless of financial status.

By federal law….A hospital offering emergency services must provide an appropriate medical screening examination, within the

capability of the emergency department, to any individual who “comes to the emergency department” and who requests an examination or treatment for a medical condition in order to determine if the individual has an emergency medical condition.

If a hospital determines that the individual has an emergency medical condition, it must provide treatment to stabilize the condition or provide for an appropriate transfer to another facility.

State law….The state emergency medical service requirements are similar to the federal laws with some exceptions…The state laws apply to hospitals that are “licensed” to provide emergency services. The federal laws apply to

“all” hospitals, which provide emergency services, even if they do not have licensed emergency departments.Federal law focuses on the stability of a patient for transfer or discharge; state law primarily focuses on the

transfer of a patient for non-medical reasons.

By state law….Emergency services and care must be rendered without first questioning the patient in light of his or her ability to

pay.A county hospital must accept a patient whose transfer will not create a medical hazard… and who is determined

by the county to be eligible to receive health care services…, unless the hospital does not have appropriate bed capacity, medical personnel, or medical equipment required to provide care to the patient in accordance with accepted medical practice. When a county hospital is unable to accept a patient whose transfer will not create a medical hazard…, it must make appropriate arrangements for the patient’s care.OBLIGATIONS:Transferring Hospitals

The statutory obligations begin when a person “comes to the emergency department.”Key Definition: “Comes to the emergency department…”

▪ On the hospital campus▪ In any facility or department of a hospital that is located off-campus and is considered to be

provider-based under federal regulations▪ In a hospital-owned ambulance, regardless of the location of the ambulance▪ In a non-hospital-owned ambulance on hospital property

Key Definition: “Hospital property….”▪ Main hospital facility at points of entry for patient-care examination (i.e. emergency department;

labor/delivery unit; ambulatory services)▪ On-campus services (freestanding) located within 250 yards of the main hospital buildings…

but ultimately determined on a “case-by-case” basis by the regional office (CMS)▪ Off-campus services operated under the hospital provider number▪ Parking lots, driveways, and sidewalks that access the inpatient facility and other on-campus

buildingsThe statutory obligations continue if it is determined that the patient has an emergency medical condition. If a patient has an emergency medical condition, a hospital is obligated to provide necessary stabilizing treatment and further examination within the capabilities of the


staff (including on-call physicians) and facilities available at the hospital.

If the hospital does not have the capability to provide necessary stabilizing treatment or upon the informed request of the patient, the hospital may transfer the patient to another hospital. If an un-stabilized patient is transferred for medical reasons, the transferring physician must certify that the medical benefits reasonably expected from the treatment at the receiving facility outweigh the increased risks to the patient secondary to the transfer. A patient with an un-stabilized or unresolved emergency medical condition may be transferred only if the hospital complies with all four of the following standards:

1. The transferring hospital provides medical treatment within its capacity to minimize the risks to the health of the individual and, in the case of a laboring woman, the health of the unborn;

2. The receiving hospital has: (a) available space and qualified personnel for treatment of the patient; and (b) agreed to accept the patient and to provide appropriate medical treatment;

3. The transferring hospital sends to the receiving facility all medical records (or copies thereof) available at the time of transfer related to the emergency condition of the patient, including:a. Records related to the emergency condition, preliminary diagnosis, treatment provided, test results, and

vital signs at the time of transfer;b. Informed consent of the patient or certification by the physician for transfer;c. Name and address of any on-call physician who has refused or failed to appear within a reasonable time

to provide necessary stabilizing treatment;4. The transfer is achieved using proper personnel and equipment, as well as necessary and medically appropriate

life-support measures.

The medical record should reflect the evaluation of a patient prior to transfer. In cases where the condition of the patient deteriorates during the transfer or upon arrival at the receiving facility, the regulatory agencies will look closely at the ongoing monitoring and care provided prior to the transfer to determine whether the patient was stable for transfer.Receiving HospitalsA hospital that has specialized capabilities or facilities (such as a neonatal intensive care unit, pediatric intensive care unit) may not refuse to accept an appropriate transfer of a patient with an un-stabilized emergency medical condition, who requires specialized capabilities or facilities, if the receiving hospital has the capacity to treat the individual.A receiving hospital may refuse to accept a transfer of a patient with an emergency medical condition in two circumstances:1. The receiving hospital does not have the present capacity or capability to provide the emergency medical services

required for the patient. If the specialized services of the receiving hospital are at capacity or otherwise unavailable, the regulatory agencies will examine whether the receiving hospital has historically created additional capacity for patients by opening additional beds, moving patients, calling in staff, etc., in order to admit patients in similar circumstances.

2. The transferring hospital has the present capacity and capability to provide the emergency medical services required for the patient. However, if a transferring hospital is operating beyond its capacity (i.e. no intensive care beds) or with an equipment malfunction, then a receiving hospital may be obligated to accept a transfer.

ELEVATOR PROTOCOLThere are three sets of elevators on the main building at VPH, which serve three distinct purposes. The visitor elevators #5 & #6, closest to the main lobby, should be reserved for patients and visitors only. The main service elevators #3 & #4, down the main hall from the visitor elevators, run from the basement all the way to the fifth floor. These should be used for transporting carts, specimens and patients in wheelchairs. The back service elevators are generally quicker than the other two but run only from the basement to the fifth floor.

ENVIRONMENT OF CARE – Culture of SafetyThe goal of EOC program is to provide a safe, functional and effective environment for patients, staff members and other individuals in the hospital. VPH has adopted the Hospital Incident Command Systems (HICS) as a method to handle a disaster. The HICS is a flexible system that can be expanded or scaled back to meet the particular needs of a


specific crisis.

The HICS module gives the hospital: Responsibility oriented chain of command; Prioritization of duties with the use of Job Action Sheets; Applicability to varying types and magnitudes of emergency events; Thorough documentation of action taken in response to emergency; and Expeditious transfer of resources (mutual aid) within a particular system or from one facility to another. HICS is the method by which the hospital will operate when a disaster is declared not the entire plan.

Everyone’s responsibility to report unsafe conditions. Examples of Unsafe Conditions Environmental Hazards: slippery or uneven floor surfaces, cluttered work areas, cabinets or furniture with

sharp or protruding areas. Fire Hazards: Obstructed corridors and fire exits, missing fire extinguishers, accumulated trash and smoking

in designated “no smoking” areas.” Electrical Hazards: frayed cords, exposed wires, ungrounded plugs, extension cords, or electrical appliances

from the home being used in patient care areas (i.e., portable space heaters, radios, electric razors.) Hazardous Substances: the generation of strong, unpleasant fumes or improper handling of disposal or toxic

substances. Unsafe Acts or Procedures: improper use of equipment or instruments, failure to wear appropriate protective

apparel, or attempts to bypass mechanical safety switches or other equipment safety guards.

ELECTRICAL SAFETY:1. Regularly inspect work area for frayed electrical cords. Keep electrical cords away from heat and water.2. Use only 3 prong plugs.3. Never disconnect an electrical appliance by pulling the cord. Remove by pulling plug at its base from the wall

outlet.4. Always send any electrical equipment that has been dropped to be checked, even if it does not appear

damaged.5. In the event of a power outage, use red wall sockets. Essential life support equipment should be connected to

these outlets even for routine use.

EMERGENCY CODESWhen an emergency occurs, an announcement is made over the public address system. A shorthand system of codes is used to save time and avoid confusion. The Hospital Association of Southern California has recommended for standardized codes in an effort to standardize Emergency codes in all hospitals. You should be familiar with the implications of all the codes.

Emergency Notification Codes: In the event of any emergency, remain calm; Dial 4444 from any telephone; State CODE….. and room number or location.

Code Red = FIRE In Case of Fire, Smoke or Smoke OdorWhen the alarms sounds – Remain Calm –Think SAFES – Save Save the victim if the fire is in an occupied room. Close ALL doors in the

area. A – Alarm Pull the nearest alarm, AND Notify PBX by dialing 4444, give location.

Do that which is closest first. Remember DO BOTH! Clear the hallways of equipment/supplies.

F – Fight If safe to do so, fight the fire with a fire extinguisher or fire hose, under direction of hospital staff, but preferably for volunteers to get to safety.

E – Evacuate If there is danger from a spreading fire evacuate occupants from adjoining area. (See evacuation plan for details).

If the area has oxygen supply, know location of medical gas/suction shut off valves, and what area those values supply. The oxygen should not be turned off until the Incident Commander, Safety Officer, Safety Director and/or the Fire Official instruct the staff to do so or the staff identifies an immediate danger.

IF THE FIRE IS NOT IN YOUR IMMEDIATE AREA:/tt/file_convert/5f3db3c122bcaa27674c7300/document.docx\05/22/23 20

1. Shut ALL doors in your immediate area. Even if you are not in your normal work area, close the doors.2. DO NOT use elevators. Advise those waiting for an elevator they must not use elevators until a Code Red

is cleared.3. One hospital staff member from each department above and below the fire area will respond to the fire

location with an extinguisher.4. These measures must be maintained until the Code Red is cleared and this is announced through the

overhead paging system.

Code Blue = CARDIAC ARREST When a patient suffers a cardiac arrest a Code Blue is announced. A team of specially trained medical personnel will respond immediately. Please stay out of their way.

Code Triage Internal = DISASTER plan activation internal due to a disaster within the hospital.

Code Triage External = Disaster plan activation, external: This signifies a disaster in which normal operations may be significantly altered. It could be called in the event a major earthquake, plane crash, freeway catastrophe, or a major emergency within the hospital itself. Unless otherwise instructed, you should report to the supervisor on your floor and if needed report to the hospital triage area in the cafeteria for further instructions. If the disaster is an earthquake or similar disaster: Save yourself first. Assess injuries and damages. If it is NOT safe to leave your area, remain there. Runners will be sent to units that are unaccounted for. If you are home when there is an earthquake/disaster, tune into KNX news radio (AM 1070) for VPH bulletins. If you want to come in to help during an emergency, make sure you bring your ID badge (it may be needed to pass through barricades). Report to the cafeteria, not to your regular work place.

Code Pink = INFANT ABDUCTION This is paged if an infant is removed from the maternity unit without authorization. Your role is to help identify anyone leaving the hospital with a large bag, bundle or blankets, towels or anything that can possibly hide or camouflage an infant. Let security know the person’s route, identifying features, description of car, license, etc. Do not touch the person or attempt to remove the “suspected bundle”.

Code Purple = CHILD ABDUCTION This is paged, all staff and volunteers are to immediately stop all non-critical work. Working in pairs, personnel are to cover all interior stairwell doors, elevator areas and doors that exit anywhere near their area.

When a pediatric patient is discovered missing, Pediatric staff is to immediately search the entire unit including locker rooms, restrooms, waiting areas, empty rooms, etc., and the charge Nurse or other responsible party is to dial “4444” to page a Code Purple.

Security upon hearing the code purple, will communicate with others via hand-held radios to facilitate transmission of information and coordination of the response effort.

The crimes scene is to be protected; if parents of the abducted child are present, they are to be moved to a private room off the pediatric unit (but not their belonging as they are part of the crime scene) and arrange for the Risk Manager or a single social services representative to act as a liaison between the parents and the health care facility.

Call National Center for Missing and Exploited children at 1-900-843-5678 for technical assistance in handling ongoing crisis management.

Notify via the Reddinet system other facilities about the incident and provide a full description of the child and the suspected abductor, if known.

When the incident has been resolved, “code Purple all Clear’ is announced three times and all employees are to return to normal assignment duties.

Code Green= NON-PATIENT MEDICAL EMERGENCY Code Green will be used when an individual (non-patient) needs immediate medical attention. Examples include: a visitor passing out in the surgery waiting room; a patient goes into labor in the lobby or a family member falls and can’t get up. To activate, dial 4444 from any campus phone. Tell the operator your name, the type of emergency and the location of the emergency. If you hear Code Green announced over the P.A. system, please keep the area clear and avoid the hallway near the Emergency Room, as this is where the response team will be coming from.


Code White =Cardiopulmonary Arrest (Pediatric) When a child suffers a cardiac arrest a Code White is announced. A team of specially trained medical personnel will respond immediately. Please stay out of their way.

Code STEMI = ACUTE MYOCARDIAL INFARCTION Code STEMI will be used when a patient in the Emergency Department has been diagnosed as having an acute myocardial infarction (heart attack). The Code STEMI Team, a multi-disciplinary team, will respond.If you hear Code STEMI announced over the P.A. system, please remain off the elevator and avoid the hallway near the Emergency Room, as this is where the response team will be going.

Code Gray = COMBATIVE PATIENT/VISITOR Code Gray is called when there is an indication that there may be assaultive behavior by a patient or visitor. Any volunteer confronted with or witnessing a combative situation should initiate a Code Gray by contacting the operator by dialing “4444” and identify that a Code Gray is in progress and give the location of the incident and number of people involved. The operator will overhead page “Code Gray” three times to initiate the response team, which consists of Security, an engineer, a charge nurse and a facility Administrator. Volunteer does not become involved only may initiate (call) the code. To safely restrain someone under these circumstances, it is recommended that five trained individuals participate in the process.

Code Silver = WEAPON OR HOSTAGE SITUATION Assault with a Weapon. Prepare to provide assistance to staff, volunteers and/or visitors who are confronted by an individual brandishing a weapon, or who has taken hostages within the Facility or its property. To ensure a safe and secure environment for patients, visitors and staff. This type of situation must be approached calmly, carefully and thoughtfully in order to reduce danger to patients, staff, volunteers and visitors. Anyone encountering a person brandishing a weapon should:

Seek cover/protection and warn others of the situation. Dial 4444 and report the code Silver including: The hospital operator will overhead page “code silver” with the location to immediately alert Security of the

situation and serve as a bulletin for all employees to stay away from the area and secure their own departments.

Security will obtain pertinent information from PBX, secure the area, and contact LAPD. When the situation has been announced as “Code silver all clear”, anyone in need of medical or need the

assistance of a licensed social worker will get help as needed.Code Yellow = BOMB THREAT If you receive a bomb threat over the phone, do NOT hang up or put the caller on hold. Take all such calls seriously. Take written notes immediately. (For example, try to ascertain background noises, reason, timing, location, type of bomb, or if the caller is a former patient or relative of a patient.) Have someone alert PBX, ext. 4444, while you remain on the line with the caller. Do not touch or move suspicious packages or envelopes. Avoid alarming patients by stating we are testing our disaster plan. Try to clear the area of visitors, stating this is part of the test. Never say BOMB in earshot of patients or visitors.

Code Orange = Hazardous Material released (page 26 more details on response). This is paged if a hazardous material has been released.

Code Rapid Response Team = Change in patient status This is paged when a patient has a change in status and immediately needs the response team. Code HERT = Hospital Emergency Response Team This is paged and the name of the unit that this team of specially trained medical personnel is needed for them to respond immediately. Please stay out of their way.

Reporting an Emergency /tt/file_convert/5f3db3c122bcaa27674c7300/document.docx\05/22/23 22

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Dial ext. 4444 from the nearest telephone. This call is answered immediately. Give:1. Your name2. Location of emergency (department or room number)3. Type of emergency

For example: This is Mary Smith, there is a fire in the Volunteer Escort Office.

Types of Fire Extinguishers--Use the Right ExtinguisherLook for the symbol(s) on the fire extinguisher to choose the correct type of extinguisher for the fire:

Types of Fire Extinguishers

Look for the symbol(s) on the fire extinguisher to choose the correct type of extinguisher for the fire:

H o w T o U s e A F i r e E x t i n g u i s h e r

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AA

B

C

Common CombustiblesUse on wood, cloth, paper, and trash fires

Not on electrical fires or burning liquids

One way to remember:A = use on fires that produce Ashes

Extinguisher is comprised of pressurized water, multi-purpose dry chemical and halon.

ElectricalUse on electrical equipment fires such as motors, switchboards, etc.

One way to remember:C = use on fires resulting from electrical Current.Extinguisher is comprised of dry chemical, carbon dioxide and halon. C

A multipurpose fire extinguisher (ABC) can be used on all 3 types of fires, and is highly recommended for your home as well as work.

B

23

LiquidsUse on gasoline, oil, grease, pane, acetone and flammable liquid fires

One way to remember:B = use on fires resulting from things that could Boil

Extinguisher is comprised of dry chemical, carbon dioxide and halon.

GENERAL PROCEDURES1. Avoid Delay and Panic. The greatest dangers of most fires are delay and panic. Be calm and move

with assurance. Patients look to you for protection. Don’t alarm patients and visitors by excited motions and loud conversation.

2. Prevent Fires. Good housekeeping is the best guarantee against fire. Make it a habit to watch for fire hazards.

3. Be alert for signs of a fire. If you see or smell smoke, you pull the alarm. Report it to the hospital operator immediately for investigation. Early detection means prompt extinguishing of the fire. Form habits of watchful care. Above all, be alert at night for help is least available at this time.

4. Know the location of fire extinguishers and fire hoses in you area. Use the right extinguisher on the fire. Instructions for use are printed on the extinguisher.

5. Learn the Emergency Procedures. Know your duties exactly. Memorize locations of exits.6. Learn the significance of all code numbers.7. Do not use elevators.8. Do not call the telephone operator in an attempt to obtain additional information of instruction. Use

telephones only for reporting vital information.9. When the supervisor’s area of responsibility is secured, provide assistance at the scene of the fire in

accordance with the mutual support plan.

Brief Review of Valley Presbyterian Hospital Disaster & Fire ProceduresThe following are important points found in the Emergency Operations Plan and Fire Manuals located on the hospital intra-net under Policy and Procedures. The

• Volunteers’ responsibility is to wait at assigned department for assignment from manager/supervisor of department.

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Hold upright.

P = Pull the ring pin at top of the

extinguisher

A = Aim the nozzle atthe base of the fire

S = Squeeze the lever

S = Sweep from side to

Common MetalsUse on magnesium, sodium, aluminum and phosphorus fires

Extinguisher is comprised of special agents.

24

D

• Volunteers in Escort/Dispatch Office wait for directions from Director Volunteer Services. Stay alert, focus and follow instructions of evacuation for emergency or fire!

If you have any questions about fire safety or observe a potential hazard, please do not hesitate to contact the Risk Manager or engineering. Working together, we can ensure this Hospital remains safe for all patients, visitors, employees and volunteers.

1. Be alert to the possibility of fire at all times. They almost always occur when we least expect them.2. We must do everything possible to safeguard our patients. They depend on us. Remove any patient

in immediate danger as instructed by hospital staff.3. Your ability to ensure safety of others as well as yourself depends on your knowledge of Hospital

Safety Policies and Procedures.4. All volunteers must participate in fire drills and practice sessions. Remember: These can occur on

any shift.5. Volunteers must know the locations of fire alarm boxes and fire extinguishers near their work area,

and know the difference between the various types of extinguishers.6. Volunteers must know evacuation routes from their work area.7. Know how to call Code Red and what to do when you hear it.8. Know your role during disaster or fire incidents. There is no time to learn it “on the run.”9. Report any blocked exit doors, fire alarms or extinguishers10. Do not use any elevator during a fire.11. Know that invisible, toxic fumes rise. So, stay as low to the ground as possible.

POLICY AGAINST HARASSMENTValley Presbyterian Hospital maintains a strict policy prohibiting all forms of unlawful harassment, including sexual harassment, and harassment based on race, color, age or any other characteristic protected by state or federal law. This applies to all employer agents, employees, and volunteers including supervisors and non-supervisory employees. Furthermore, it prohibits unlawful harassment in any form, including verbal, physical and visual harassment.

An employee or volunteer who believes he/she has been harassed by a co-worker, supervisor, or agent of the hospital should promptly report the facts of the incident and the names of the individuals involved to his/her supervisor and Human Resources. Supervisors, too, shall immediately report an incident of harassment to Human Resources. Human Resources will investigate all claims and take appropriate action. Please do not hesitate to immediately contact Director of Volunteer Services and/or Human Resources to report any type of harassment.

Sexual harassment in employment violates the provisions of the Fair Employment and Housing Act, specifically Government Code sections 1294(a), I), and (k). See enclosed Definition of Sexual Harassment.

HAZARDOUS MATERIALSAlthough you should not have contact with hazardous materials, you should be aware that they do exist in the hospital. Unsafe conditions related to hazardous materials should be reported immediately to your supervisor or (x2932) and engineering (x3968).

A hospital is a complex environment in which many chemicals can be found. For this reason, it is important that each volunteer know what materials may be encountered in his or her workplace. In general, volunteers at VPH may be exposed to:


Body substances and sharps; Chemotherapy and nuclear medicine agents; Chemicals, such as formaldehyde and glutaraldehyde Compressed gases; Cleaning compounds and Heavy metals, such as mercury

Detecting Hazardous Substances Hazardous substances are often readily detected by their odor. Other ways to detect chemicals are by taste, appearance of vapors, fumes, or smoke, alarm or measuring equipment, and/or by physical symptoms induced by the chemicals.Your Right to Know Every person has the right to know about the chemicals they work with and the risk from exposure to these chemicals. The first source of information should always be the chemical label on the container. All hazardous materials (as defined in CCR Title 8) must provide:

Identity of the hazardous substance(s) A hazard signal word -- Danger, Warning, Caution A description of health and physical hazards Exposure control measures, such as needed personal protective equipment (PPE) Emergency and first aid procedures

HAZARDOUS MATERIALS INCIDENT RESPONSE -DEPARTMENT LEVEL

IF THE SPILL IS MINOR: This will apply in special departments such as Oncology, Lab, Pharmacy, Engineering were proper training has been already given to staff on how to respond. REVIEW the MSDS for the material. CONTAIN the spill, and begin cleanup wearing appropriate personal protective equipment and using

proper absorbent materials (per the MSDS). CONTACT Environmental Services to proper disposal of the material. COMPLETE a hospital report.

IF THE SPILL IS MAJOR: (S.I.N.) IMMEDIATELY

SECURE the spill area; evacuate to a safe distance, and do not allow re-entry. IDENTIFY the product (if possible) without re-exposing anyone. NOTIFY dial 4444 to the PBX operator to page CODE ORANGE (give location, NOT the

name of the spilled material). The hospital HAZMAT team will respond. DO NOT ATTEMPT TO CLEAN UP SPILL YOURSELF.

WHEN IN DOUBT, TREAT THE SPILL AS MAJOR!REMEMBER: Do not return to the site of a major spill. Unless you are formally trained in Hazardous Materials spill clean up response, do not attempt to rescue victims…you may become the next one!

NEED MSDS Information? LOG ON!

Material Safety Data Sheets are at your fingertips in these few steps:

1. Start the hospital Intranet (if not already started).2. On the lower half of the page, click the “Prosar / MSDS” button to open the Prosar website,

http://www2.prosarcorp.com/valleypres. 3. A new window will open that says “Prosar.” (It may take a minute to load.)4. There are two primary ways to look-up an MSDS.

For emergencies, or if the link is not available, call the number below. 1) Search by Product Name or Type: In the “Trade Name” line, enter the name of the item.


http://www2.prosarcorp.com/valleypres

Names can be exact or general (i.e., Baby Bath, drain cleaner) Click the bottom button that says “Find MSDS.” The next page lists MSDS sheets. Locate the correct vendor / item. On the far right, click on the page icon to open the MSDS. Click the printer icon for a hardcopy. 2) Search by Vendor: Select using the “Vendor” menu’s alphabetical list. Type the first letter to jump ahead, or scroll down. Click on the correct vendor. Click the bottom button that says “Find MSDS.” The next page lists MSDS sheets. Locate the correct product. On the far right, click on the page icon to open the MSDS. Click the printer icon for a hardcopy.

If you are unable to log in, call PROSAR: (800) 291-7661 or Poison Control: (800) 876-4766.

Report exposures and spills to your Supervisor. Treat injuries in Employee Health or the E.R.

Another source of information on the chemicals you work with is the Hazardous Materials Management Manual. This manual was designed to provide broad information on chemicals in use in the hospital. The manual has a section that lists the hazardous materials found in an individual department and then provides a Material Safety Data Sheet (MSDS) for each of the chemicals listed.



HIPAA & PATIENT RIGHTSThe HIPAA (Health Insurance Portability and Accountability Act) regulations became effective on April 14, 2003. VPH developed Privacy Policies and Procedures to outline directives to maintain the patient privacy of Protected Health Information (PHI). PHI is any individually identifiable patient information, communicated orally or recorded in any form. VPH policies provide guidance for its employees and volunteers to be informed of penalties ($10,000 to $50,000 fines or one year jail sentence) for not complying with the privacy requirements.HIPAA Objectives: It is the duty of every employee and volunteers to protect the confidentiality and privacy of patient health information

Examples of personal identifiers:NameAddresses: home, e-mail, URL, IPNumbers: Social Security, medical record, account, insurance, license, biomedical devicesFull facial photos

These regulations cover use or disclosure of Protected Health Information for oral communications, written documents and electronic transactions. Employees/volunteers are prohibited from looking at records unless they have a need to know the information and patient information kept out of sight from public. Reasonable efforts are taken to determine how much information is used, disclosed or requested to serve the intended purpose. What this means to all staff and volunteers:

FaxingAlways use a cover sheetVerify fax numbers

Proper disposal of PHIShredders

Proper storage of PHI Lock filing cabinets Do not leave PHI in plain view

Telephone requests for PHI Know who you are talking to

Oral PHI Lower your voice Use separate room

Computer access Log off computers DO NOT SHARE PASSWORDS

Report Privacy Breaches Examples:

Misdirected mail, email, voicemail containing PHI Lost or stolen PHI Accessing PHI of a patient you are not involved in the care of

Where to report breaches to: Your Supervisor Privacy Officer

VPH distributes to each patient a Notice of Privacy Practices (NPP) that outline an overview of VPH’s organizations privacy practice to protect patient’s health information. Also, the California Law, Title 22, Section 70707 specifies patient rights. Volunteers will promote patient rights. Specific areas appropriate to the Volunteer Department include

Considerate and respectful care Full consideration of privacy or restrict access to their medical records Rights without regards to background, race, color, religion, ancestry, national origin, gender, economic status,

educational sexual orientation, or marital status Reasonable response to any reasonable requests made for service.

Permitted uses of PHI are Treatment, Payment and Health Care Operations.▪ Treatment – Anyone involved in the care of a patient▪ Payment – Anyone who needs to know so that services may be billed and payment collected▪ Health Care Operations – Quality improvement per review, business planning and management disclosure of PHI must

be limited to what is reasonably necessary to accomplish the purpose for which the request is made. It does not apply to disclosures to treatment purposes. The hospitals HIPAA policies, found on the intranet, contain charts that identify persons and departments who need access to PHI to carry out their job.

INFECTION PREVENTION/CONTROLInfection Control is everybody’s business. Infection Control is a team effort. In order to minimize risk of infection

in-patients, employees, and volunteers, the hospital wide infection control program will be followed including prevention, surveillance, reporting and education. As a member of Valley Presbyterian Hospital’s team you should constantly be aware that they could easily carry bacteria in and out of the hospital. It is our responsibility to help provide a safe environment for our patients, visitors, staff, physicians, other volunteers and you by reducing the incidence of Hospital Acquired Infections (HAI’s). Hospital Acquired Infections(HAI’s) are those acquired in the hospital. National studies indicate that between 5 to 8 percent of all patients admitted to hospital will develop hospital acquired infections(HAI’s); and these infections will in turn add greatly to the length of hospital stay and to the expenses incurred by the patient.

1. Please do not come to work if you are experiencing symptoms of illness such as a sore throat, fever, or diarrhea.2. Volunteers with infectious skin conditions; boils, infected pimples, or fungus infections should also not report for

work.3. Your hands and fingernails must be kept absolutely clean at all times. NO ARTIFICAL NAILS OR WRAPS.4. If you are taking any medication on a regular basis you should inform your supervisor. If you take tranquilizers

or other medications on a short-term basis please call and cancel your shift for that day.5. Any infractions of these infection control procedures should be reported to your supervisor immediately. Your

health and the health of our patients depend on them.6. An annual TB test is mandatory and/or Employee Health Screening form must be complete at Employee Health

Office.

The incubation period for influenza is 1-4 days, possibly as long as 7 days. The clinical features of influenza are well known and include: sudden onset of fever (greater than 100 degrees), headache, extreme tiredness (malaise), dry cough, difficulty breathing, sore throat, runny nose, muscle aches, nausea, vomiting and diarrhea. VPH has enacted a temporary seasonal influenza visitor policy. Visitors who have signs and symptoms of an influenza-like illness (ILI) are asked not to visit and are asked to return to visit when they are well. Patients who are presenting for treatment of an ILI will be asked to wear a mask and follow respiratory cough etiquette recommended by CDC. Visitors under the age of 16 are not allowed to visit inpatient care units. All staff and visitors are asked to follow good hand hygiene practices including the use of alcohol-based hand sanitizers.

STANDARD PRECAUTIONSHANDWASHING is the best method to prevent infections and protect yourselves. Wash Hands before and after patient contact and after gloves are removed. Immediately wash hands and skin surfaces if contaminated with blood and/or body fluids.

Hand Washing Procedures The purpose of hand washing:

To prevent and control the spread of infectious microorganisms. Hand washing is the most important factor in infection control.Hand washing must be faithfully practiced by all hospital personnel without exception.

When hands should be washed:When coming on duty.When hands are obviously soiled.Before and after any patient contact, and after delivering patient’s personal belonging bags.Before and after removing gloves.After making deliveries of body fluids to and from the lab. (Remember all body fluidsmust be transported in zip-locked plastic bags).Before serving meals or other related duties.After sneezing, coughing, blowing or wiping nose.Before and after personal use of the toilet.


After coming in contact with contagious or hazardous materials.Between handling an individual patient.

Standard Hand Washing Procedures at Valley Presbyterian Hospital shall include: Use of running water and soap. Applying vigorous friction to all surfaces for at least ten (15-20) seconds*. Thorough rinsing under a stream of water. Drying. Turning off the tap with a paper towel.

*More than ten (15-20) seconds may be required, if hands are visibly soiled.An antimicrobial agent shall be used for hand washing when washing hands before caring for newborns or severely immuno-compromised patients or patients with resistant organisms.

Hands shall be washed, when gloves are used immediately after glove removal.Procedure Key Points

1. Stand well away from the sink and turn on water to a comfortable temperature.

Leave water running for entire procedure if using hand-operated faucet.

2. Wet hands and wrists thoroughly, holding hands downward over the sink.

Allow water to flow off fingertips.

3. Take 2 to 4 cc of soap (antiseptic agent is preferred from the dispenser)

Use enough soap to work up a good lather.

4. Wash up to two or three inches above the wrists, applying as much friction as possible.

Scrub backs and palms of the hands using rotary motions. Interlock fingers to get between the fingers.

5. Work up a vigorous lather for at least fifteen (15) seconds, rubbing together all surfaces.

Sudsing and friction loosen “dirt” and microorganisms.

6. Rinse thoroughly with running water. Allow water to flow off wrists or fingertips.7. Dry hands and wrists well with paper towels. If using a hand-operating faucet, use a dry paper towel to

turn of the water. Gloves: Gloves shall be used when contact with blood, body fluids containing visible blood, and other fluids to which universal precautions apply is anticipated. Gloves reduce the incidence of hand contamination, but cannot prevent penetrating injuries due to needles or other sharp instruments.Gloves should routinely be worn when:1. Hands are likely to touch any moist body substance, mucous membranes or non-intact skin.2. Handling surfaces, instruments or linen contaminated with blood and/or body fluids.3. Performing or assisting in any invasive procedure.

Gloves must be changed if they develop holes or tears and MUST BE CHANGED BETWEEN PATIENTS. Gloves are NOT a substitute for HANDWASHING!!! Hands MUST be washed following removal of gloves.

Blood borne Pathogens: A needle stick or cut from a contaminated scalped can lead to infection from Hepatitis B (HBV), HIV (the virus that causes AIDS or Hepatitis C (HCV). You can be considered a risk for exposure to these blood borne pathogens because you volunteered in a healthcare setting. Your level of risk will be increased if you are involved in specific healthcare or patient care activities.

Hepatitis BHepatitis B is a virus that can cause inflammation of the liver. Many people infected with HBV never feel sick, while others can experience a mild flu-like illness. Other may get jaundice (yellowing of the eyes and skin) dark urine, nausea, abdominal pain, fatigue r loss of appetite. These symptoms last up to six months. Most infected people completely recover, however a small number of individuals can carry the virus for a long time without symptoms. These chronic carriers are infectious and can potentially spread HBV to others. Carriers are at increased risk for developing liver diseases like cancer and hepatitis. How is it spread: Through contact (infected needles or sharps, splashes to mouth, eyes or nose or open skin) with blood, semen, vaginal secretions and saliva (bites) or other infected body fluids breast milk, tears and


urine.)

HIV: The Human Immunovirus (HIV) is the virus that causes AIDS. HIV destroys your body’s ability to protect itself from a number of diseases and infectious illnesses. A person with HIV infection can have the virus for years without feeling sick. They are not sick. They are infectious and can still spread the infection to others. How is it spread: Through contact (infected needles or sharps, splashes to mouth, eyes, or nose or open skin) with blood, semen, vaginal secretions and saliva (bites) or other infected body fluids (breast milk, tears and urine.)

Hepatitis C:Hepatitis C is a virus that can cause inflammation of the liver. It is the most common cause of non-alcoholic liver disease in the U.S. and Canada. Hepatitis C is responsible for 90% of cases of transfusion-associated Hepatitis. Acute illness with Hepatitis is usually less severe than that with Hepatitis B with 75% of HCV cases having no signs/symptoms. How it is spread: How is it spread: Through contact (infected needles or sharps, splashes to mouth, eyes or nose or open skin) with blood, semen, vaginal secretions and saliva (bites) or other infected body fluids (breast milk, tears and urine).

PREVENTION:The best way to prevent cuts and sticks is to minimize contact with sharps. All needle safe devices are to be used wherever available. Volunteers SHOULD NEVER handle any contact with any used needles, any kind of sharps or any items with exposure to blood and body fluids.

Key Points: Treat all blood and body fluids as if they were infectious. Use Standard Precautions for the care of all patients. Hospital staff should not recap, bend or shear any needle or improperly disposed of sharp. Report all sharps containers that are over ¾ full to EVS. Containers must have the biohazard

emblem. Employees must properly dispose of all sharps. Specimens must be transported using biohazard plastic bags. Personal protective equipment (gowns, gloves, masks, face shields, respirators) are worn at all times

where contact with blood or body fluids can be anticipated. All blood and body fluids are cleaned up immediately using approved disinfectant. All reusable

medical equipment is cleaned between patients or when visible soiling occurs. Hospital staff should never pick up by hand sharps or glass, even if you are wearing gloves. Report all blood or body fluid exposures to your supervisor and go immediately to your designated

employee health services.

CULTURE OF SAFETYTo ensure that there is minimal risk to patients, personnel, volunteers, visitors, and the community environment of the hospital, volunteers will:

Participate in annual safety training and re-orientation. Participate in hospital fire and disaster drills. Adhere to the follow general safety guidelines: Be fit for work through good health habits, proper diet, sufficient rest, and cleanliness. Wear proper clothing and shoes. Report any unsafe conditions, including defective or broken equipment. “If your SEE something SAY

something.” Heed all warning signs


Walk and not run. Be cautious in congested areas and at blind corners. Never climb on chairs or boxes to reach overhead items. Pick up any foreign matter found on the floor and place in the proper receptacle. Do not use or possess alcohol or drugs. Report any unsafe conditions, including defective or broken equipment. Report to EVS (housekeeping) at x2359 any spills and use appropriate signage Report all unusual events affecting the well being of patients, visitors, employees, or other volunteers. Never lift or carry anything heavy. Obtain assistance. Close all files and desk drawers when unattended. Report all damaged electrical cords, plugs, or receptacles to Engineering. Receive appropriate training to operate equipment. If unsure how to operate specific equipment, seek

guidance. Use good body mechanics. Consider yourself a member of the Safety Committee – it is everyone’s job. To enhance patient safety at VPH standardized color patient arm bands within the facility are as

follows: Red Band = allergy; Yellow band = Fall Risk; Purple band = Do Not Resuscitate and Orange Band = No blood products.

Know meaning of Door Magnets: ACTIVATE BED ALARM FOR FALL PREVENTION The Bed Alarm should be active (Green on the door = Green lights on the floor) The light shine from under the foot of the bed. If you see the lights are not on notify the nursing staff or if you provide direct patient care please turn the alarm on.

CAUTION – CHECK BEFORE ENTERING This sign indicates that the patient in this room is known to be aggressive or at times out of control. Please check with the nursing staff prior to entering this room.

Please do not disturb When an adult patient is near death or has died we will assist all staff by providing the blue dove magnet on the door. Patients and their families should be afforded the utmost respect, dignity, and privacy. Please do not disturb them at this time.

* Please do not disturb When an infant has died or a death is anticipated we will assist all staff by providing the purple butterfly magnet on the door. Patients and their families should be afforded the utmost respect, dignity, and privacy. Please do not disturb them at this time.

Medication Security• It is a requirement in our hospital that ALL medications be locked.• In addition to medications being stored behind a locked door, this standard is interpreted to mean that access

to these locked areas is restricted to ONLY those employees who need to access them in order to perform

their routine job duties. • The handling and distribution of medications is the responsibility of the Pharmacy Department.• In some instances, the Pharmacy Department may delegate this responsibility to other departments, provided

they ensure proper training and periodic process review.• Medications Include: Traditional prescriptions

Over-the-counter medications Intravenous solutions Irrigation solutions Oral Contrast Media Intravenous Contrast Media Medical kits that contain a medication as one component.

• Items Not Considered As Medications Include: Nutritional Products


Medical gases purchased in their gaseous form (some anesthetic gases are purchased in liquid form and are, therefore, considered medications

• Medications are most commonly stored in the Pharmacy Department or medication rooms that are located in patient care areas of the hospital.

• Other points of use areas Supply Rooms, Anesthesia Rooms, Materials Management Department, Radiology Department and

Point-of-Use (POU) Rooms• When job duties require that you access secured areas, it is important that you ensure the security of

medications by NEVER leaving the area unlocked when you are leaving. (Note: None Pharmacy volunteers should never have access or go into any Medication room or noted secured areas.) NEVER: Share the door combination to rooms where medications are located with other staff. Or, allow

individuals to access these areas unless you are sure they are authorized to be there.• Medication Storage:

Storage requirements of medications vary from product to product and manufacturer to manufacturer. Storage parameters such as temperature, humidity, etc. can be found printed on the package. When adding a new item to inventory, it is important that the storage requirements match the storage

conditions of the location in which it will be stored. When storing medications, standard life safety guidelines apply. Do not store medication items on the floor or within 18 inches of the ceiling. Medication Handling: 1) In the process of handling or restocking medications, check the expiration

dates. 2) Expiration dates should be observed to ensure that adequate time remains for the product to be used. 3) Remove products that have expired dates from stock immediately and return to the Pharmacy. 4) During any process in which medications are being stocked or returned to a department, medication security must be maintained at all times. 5) NEVER leave medications unattended for any reason.

SERVICE FILESService files are maintained for each volunteer in the Volunteer Office (basement). Files will contain copies of all documents relating to health, orientation, competency, and performance. You may review your file by scheduling an appointment with the Director or Coordinator. You may wish to add letters of thanks from patients, etc. to your file. Service files are confidential and may not be reviewed by any other volunteer or unauthorized individual.

SIGN IN AND OUT / CLOCK IN AND OUTIt is important to know who is on the premises in case of an emergency and for authorization for appropriate insurance coverage. Volunteers are required to clock/sign in when reporting for duty and to clock/sign out when they have completed their assignment.

All Volunteers may clock/sign in at the Lobby/Information desk and/or at Volunteer Dispatch Office. When you arrive for your shift, please clock/sign at the computer located at either noted location. You will be assigned volunteer number and trained on first day how to clock/sign in to computer. You need to clock/sign in when you arrive and at end of shift. Computer will keep track of your volunteer hours. In case of emergency, the supervisor or Director will be able to see which Volunteers are here and where they are working. Should a fire or other disaster occur, all Volunteers who have signed in would be accounted for. There is no way of finding a Volunteer in an emergency is we do not know you are here. Do not jeopardize your safety—clock/sign in. This system allows us to track your total hours on a yearly basis for the purpose of awards at the Annual Volunteer Recognition or for school verification purposes. Because the clock/sign-in process are legal documents of the hospital, each volunteer is required to clock/sign-in individually. No one may clock/sign-in or out for another person, if you are caught clock/sign-in or asking someone else to clock/sign-in for you - this will be cause for termination.

TRAINEES/INTERNSIn certain instances a person may become a volunteer for the specific reason of participation in a trainee or internship (not paying), which requires clinical or “hands-on” experience, or for acceptance into a certified program.

* Trainees or interns are interviewed by the appropriate department for acceptance.* Trainees or interns cannot be part of the volunteer team and placed with Education department.


* Trainees or interns must have an established outline or curriculum from their school and deal directly with the education department or department.

* Trainees or interns must have a person from their school that is available to communicate directly with the department’s Director for full approval.

* Trainees or interns must have a VPH Supervisor appropriate to their trainee or internship—e.g. Physical Therapist to supervise P.T. Trainees, Central Supply supervisor to supervise Central Supply trainees.

* Trainees or interns must attend house-wide orientation and receive a department-specific orientation prior to beginning duties and not under the volunteer program.

* Competency testing by direct observation and documentation of successful performance must be performed before trainee or intern is able to perform such activities on her/his own.

* The supervising department will document hours of service.* It is up to the supervising department to validate parking.

TRAINING/ASSIGNMENT TERMINATIONTRAINING: Every new volunteer is expected to be part of a comprehensive orientation and training program to become familiar with the hospital, its rules, regulations, policies and procedures. The orientation will last approximately one hour and will be followed by a tour of the hospital. On the job training will be provided when the volunteer starts its assignment.

ASSIGNMENT: This will be determined by the skills, needs and special interests expressed during the volunteer interview. The volunteer will be scheduled as to time and day, per request. Volunteer assignments are not permanent, but are expected as four hours per week on a regular schedule. Volunteers may volunteer more than one day per week or more than four hours per day, with the approval of the Director Patient Relations & Volunteer Services and Volunteer Coordinator.

If the volunteer assignment does not meet with the desires or needs, after a reasonable trial period, reassignment will be considered. An appointment with the Director Volunteer Services or the Volunteer Coordinator should be made to discuss the matter.

The volunteer will work under the direct supervision of the person in charge of volunteers in the department in which the volunteer has been assigned. The volunteer will always be under the supervision of the Director Volunteer Services and/or Volunteer Coordinator. Any problems should be discussed with the Director or Coordinator.

The first month is the initial period, during which time the volunteer adjust to, and become familiar with the job assignment. The supervisor and the Director of Volunteer Services and/or Volunteer Coordinator will evaluate the job performance. Knowledge of the hospital rules, regulations, attendance, job skills, flexibility and performance of assigned duties, as well as the ability to get along with other volunteers and staff members. Also, the attitude demonstrated toward patients and physicians are evaluated and feedback will be given. Annual Evaluations and Competencies are done during volunteer anniversary month.TERMINATION: We reserve the right to terminate a volunteer whose behavior or performance is unsatisfactory and detrimental to the operation of the hospital and the volunteer program. Volunteers will be verbally counseled and warned and given every opportunity to make necessary improvements before being terminated.Written Counseling & Termination: The hospital adheres to the three strikes you’re out policy. The third written counseling will result in immediate dismissal from the Hospital. Involvement in any of the following actions will result in your immediate dismissal from the Hospital:

Causing, attempting to cause, or threatening to cause physical injury to another person. Causing or attempting to cause damage to Hospital property. Stealing or attempting to steal Hospital property (including Meal Tickets). Possession, use, sale or attempted sale of any controlled substance, alcoholic beverage, or drug paraphernalia. Possession or use of any firearm, knife, explosive, or other dangerous object. Smoking anywhere on the Hospital campus. Committing obscene acts or gestures or engaging in habitual profanity or vulgarity. Wearing inappropriate attire (see Hospital Volunteer Services Staff member for specific dress code).

Engaging in disruptive or dishonest behavior while on the hospital campus, or willfully defying the valid /tt/file_convert/5f3db3c122bcaa27674c7300/document.docx\05/22/23 34

authority of any hospital staff member. Violating computer software licenses/agreements/copyrights or tampering with computer hardware/software

configurations. Committing acts of sexual harassment, which are defined as, “unwelcome sexual advances, request for sexual

favors, and other verbal, visual and physical conduct of a sexual nature.” Violation of hospital rules and regulations* Unsatisfactory work performance* Behavior that is not in the

best interest of patient care* Difficulty in getting along with the hospital staff and other volunteers* Stealing* Repeated excused absences* Intoxication and unauthorized use of drugs or narcotics.

These actions could seriously impair the efficiency of volunteer services with the hospital and cannot be tolerated.

INTERPRETERS FOR PATIENTSVPH provides language assistance services to patients with language or communication barriers, in compliance with Senate Bill #1840.

This includes provisions of readers for the visually impaired, and sign language providers for the hearing impaired. The employees who are listed as able to translate have the ability to translate names of body parts to describe symptoms and injuries in both English and the second language. VPH is committed to provide this service for our patients.

Tools for translation: Each nursing unit has dual translation phones that may be used by patient and nurse or doctor to assist with translations. Hospital staff will dial for translation services and request for language required and be connected to certified translator. Also hospital staff have access to video translation computer system (like Skype) to connect with certified translators as needed by patient.

Note: Volunteers are not supposed to translate for doctors or nurses for any medical information or to consent forms to be signed by patients. Hospital may be liable if translation is incorrect. This is why certified translators are required.

Helpful Hints to the New Volunteer

1. Never be afraid to ask a question. A question is never considered unnecessary and it is better to be safe and ask. Bring a small notebook with you to keep track of your questions and the answers you receive.

2. It is very natural to feel uncomfortable when in new surroundings. Try to be patient at becoming familiar and comfortable on your unit.

3. Hospital nursing units can be unpredictable. Some days will be very busy and hectic -- and others may be very slow.

4. On busy days, a staff member may not have as much time to spend with you. Try to remember not to take situations as personal.

5. On slow days, try to find things to keep you busy -- making charts, straightening up, asking for additional activities or training. You should not do the following at your assigned area, nursing unit or department: DO NOT READ A NEWSPAPER OR BOOK, DO NOT DO YOUR HOMEWORK, DO NOT EAT YOUR MEALS OR SNACKS, DO NOT USE THE TELEPHONE TO MAKE PERSONAL TELEPHONE CALLS, or BE TEXTING or SURFING THE NET or be taking pictures.

6. If a situation should ever arise that makes you uncomfortable, always communicate it. This is the only way we can work together. Remember you are a part of a team effort.

7. Discuss routinely -- with the Director of Volunteer Services - your experiences on your assignment. We are interested in continually upgrading this service and can more easily do so with your help.

8. Attitude has everything to do with how well your day will go. Don’t expect someone else to make it successful for you

9. Keep in mind that your job responsibilities may increase as you continue to volunteer. New challenges will come with commitment.


HOSPITAL TERMINOLOGY FOR VOLUNTEERS

ACUTE Short, severe illness

ADMISSION The act of admitting a patient to a hospital, which legally binds the hospital for the care of the patient until she/he is discharged from the hospital.

AMBULATORY Able to walk from place to place; strong enough to walk

ANCILLARY Supportive, assisting in the performance of a service; subordinate or supplementary to professional services.

B/P Blood Pressure

CARDIAC Of or pertaining to the heart

CHRONIC Of a long duration or frequent occurrence

CNA Care Nursing Assistant; assists nursing with bed baths, linen changes, monitoring vital signs, etc.

DNVHC DNV Healthcare Inc. (DNVHC) is an operating company of Det Norske Veritas (DNV) that uses NIAHO (National Integrated Accreditation for Healthcare Organizations) survey program to inspect annually the hospital from top to bottom to guide safe patient care practices to maintain the highest standards and service.

COMATOSE Unconscious

DISCHARGE The act of legally releasing a patient from hospital responsibility

EEG Electroencephalogram

EKG Electrocardiogram

EMG Electromyogram

ER Emergency Room

GERIATRIC Pertaining to treatment of the aged

GURNEY A stretcher for transporting patients

HEAD Charge Nurse The nurse responsible for that nursing unit

HIPAA Healthcare Insurance Portability and Accountability Act – federal law to protect patients’ health information.

ISOLATION The complete separation from others of a patient suffering from contagious or infectious disease or for the protection of that patient from outside infection or contagion

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INPATIENT Patient receiving medical treatment within the hospital as a result of her/his legal admission to the hospital; a patient remaining overnight

I.V. Intravenous, through the veins

IN-SERVICE EDUCATION Educational services taking place within the hospital

ICU Intensive care unit; unit designed for patients requiring the most constant care or monitoring

I'S AND O'S Intake and output. Measurement of all liquids that the patient may eat or drink

LVN Licensed Vocational Nurse

MEDICAL STAFF The physicians qualified to admit patients

NPO Nothing by mouth--nothing to eat or drink

O.R. Operating Room

OUTPATIENT One who received treatment in a hospital clinic, ambulatory area, or emergency room but who is not remaining overnight

P.T. Physical Therapy. The treatment of disease by physical and mechanical means rather than by medication

R.N. Registered Nurse

SHORT STAY UNIT Where patients are treated who need a surgical procedure that does not require an overnight stay

STAT Needed immediately, as soon as possible

VITAL SIGNS Temperature, pulse, respiration, blood pressure

VOLUNTEER/INTERN One who offers service without a salary; a terrific person


Valley Presbyterian HospitalVOLUNTEER AGREEMENT ACKNOWLEDGEMENT

As a Volunteer at Valley Presbyterian Hospital, I agree by signing the following:

1. It is known that I must complete the following training required by Volunteer Services: Shadowing in the Escort Office and training in my assigned department.

2. While volunteering at Valley Presbyterian Hospital, I understand I am responsible and it is my duty to protect the confidentiality and privacy of all patient health information and the patient's family and friends. I will not discuss or release any information learned while volunteering at Valley Presbyterian Hospital with anyone outside of the hospital nor with fellow volunteers or hospital staff members. I understand that discussion or release of patient information, unless a responsible staff person gives specific authorization, is grounds for dismissal and penalties may arise ($10,000 to $50,000 fines or one year jail sentence) for not complying with the privacy requirements and HIPAA regulations. I have read, signed, and understand the Confidentiality Pledge.

3. I attest that I am in good physical and emotional health.4. I understand Volunteers are expected to report to the hospital dressed in the prescribed uniform the

Burgundy polo shirt or navy blue smock that the hospital will issue after paying a $10.00 or $20.00 and/or white, black or khaki pants. I will wear conservative clothing when reporting to and leaving the hospital. My identification badge will be worn and be visible at all times.

5. Failure to wear the proper uniform can result in no volunteer duty for the day or being asked to return home to put on the correct uniform.

6. I agree to volunteer a minimum of 4 hours per week. I also agree to volunteer for a commitment of a minimum of 120 hours. Verification by Valley Presbyterian Hospital, of working hours, will be given after 120 hours of volunteer service, if requested.

7. I agree to an annual TB test. 8. Adults born after 1957 must receive appropriate immunizations to include the MMR (Measles,

Mumps and Rubeola) test at your own expense, to initiate your volunteer services, if necessary.9. If I am unable to come to work as scheduled, I agree to notify the Volunteer Services office (x5704)

and the department manager where I am assigned, as soon as possible. (You can report this information by telephoning the office, the department or by completing an absence slip in the Volunteer Escort office).

10. Valley Presbyterian Hospital and the Department of Volunteer Services are not responsible for lost or stolen personal property.

11. I will be held responsible if ID badge is lost or stolen, there will be a $5.00 charge for a new badge. Also, if assigned a Proxy Card which gives access to the parking garage structure and the main west tower is lost or stolen; there will be a $15.00 charge.

12. I am familiar with the Volunteer Agreement issues that are listed for all volunteers and I agree to abide by them.

13. I have received a Volunteer Services Handbook and I agree to abide by the policies listed therein.

_____________________________________________ __________________________Signature of Volunteer (print legibly beside signature) Date

______________________________________________ ________________________Signature of Parent or Legal Guardian (print legibly beside signature) Date


Valley Presbyterian HospitalCONFIDENTIALITY PLEDGE ACKNOWLEDGEMENT

Valley Presbyterian Hospital is in the business of caring for patients and their families and other “customers”, we regularly have information that they consider to be very intimate and private. We also have business information that belongs to VPH or others we work with and therefore considered confidential.

As a volunteer, it’s very important that you put yourself in the shoes of our patients. You would not want information about your treatment, your family or intimate personal details told to anyone, without your permission or the permission of someone you trust. This is why keeping certain information private and confidential is part of your job.

This is so important, that every volunteer must sign this pledge to honor privacy and confidentiality. The goal is to protect Valley Presbyterian Hospital and its mission, and most importantly, the people we serve.

Confidentiality Pledge

I understand that I may hear and see information that is private and confidential. Examples of such information are: Patient information both medical and financial.

Private employee information such as salaries, disciplinary action, etc.

Business information that belongs to Valley Presbyterian Hospital or those we work with including: internal reports copyrighted computer programs business and strategic plans contracts, financial reports and other internal documents

Keeping this kind of information private and confidential is so important that if I fail to do so I understand that I could lose my volunteer position or otherwise be disciplined if I fail to keep the following promises:

I promise that:1. I will use confidential information only as needed to do my job.2. I will not share confidential information with anyone unless authorized to do so.3. I will not handle confidential information in a careless manner and will protect any access codes,

computer passwords or other such things so that unauthorized persons cannot access confidential information. I understand that Valley Presbyterian Hospital may access any computer or electronic mail files.

4. I will report to management if I think private or confidential information is being accessed or shared improperly. I understand that any such reports and my name will be kept confidential to the extent possible.

5. I understand that any confidential information that I work on as part of my volunteer position belongs to Valley Presbyterian Hospital, not me.

6. I understand that these promises carry over even if my volunteer position with Valley Presbyterian Hospital should end.

_____________________________________________ __________________________Signature of Volunteer (print legibly beside signature) Date

______________________________________________ ________________________Signature of Parent or Legal Guardian (print legibly beside signature) Date


VALLEY Presbyterian HospitalExcellence in All We Do

VPH BEHAVIORAL STANDARDS, CORE VALUES and AIDETACKNOWLEDGEMENT AND AGREEMENT

PURPOSE

Valley Presbyterian Hospital’s “Behavioral Standards and AIDET” provides an overview of the behaviors required by all members of management council, employees, physicians and volunteers.

ACCOUNTABILITY

Individual commitment is required and will be evaluated on an annual basis in concert with the performance appraisals.

As a VPH volunteer, I am committed to consistently demonstrating the Behavioral Standards, the VPH’s CORE Values and AIDET to improve the patient hospital experience. I understand agree to be held accountable to uphold these behavioral standards.

I understand and agree that my personal commitment is required.I agree to treat all co-workers, patients, visitors, volunteers and physicians with dignity and respect.

_________________________________ _______________________Signature of Volunteer Print Name


REPORTING CONCERNS RELATED TO PATIENT SAFETYVOLUNTEER ACKNOWLEDGEMENT AND AGREEMENT

PURPOSE

It is the goal of Valley Presbyterian Hospital to provide high quality service and respond promptly to any employee, patient and family concerns related to patient safety, care, treatment, and/or services. Valley Presbyterian Hospital provides education to employees and patients on how to report these concerns internally and externally.

ACCOUNTABILITY

I have a professional commitment to report any concerns related to patient safety, care, treatment, and/or services and to encourage patients and their family to become actively involved in their own health as a patient safety strategy.

By signing I understand and agree that I have received education on how to report concerns related to patient safety, care, treatment, and/or services, and that I may contact the appropriate agencies without fear of retaliation.

_________________________________ _______________________Employee/Volunteer Signature Date

_____________________________Print Name

Below is a list of the reporting agencies:

Valley Presbyterian Hospital Resources External Reporting Agencies*Please address concerns to the nursing or California Department of Public Healthdepartment director. If your concerns are 3400 Aerojet Avenue Suite 323Not resolved satisfactorily, please contact El Monte, CA 91732The Patient Relations Office at ext. 3975 1.626.569.3740or 1.818.902.3975Monday-Friday Health Services Advisory Group (HSAG - Medicare beneficiaries with concerns and coverage) 9 am – 5 pm 1.800.633-4227

Or ask the Concierges at Information Desks toContact AdministrationOr the Nurse SupervisorWeekdays, Weekends, and Holidays5 pm – 9 am


Valley Presbyterian HospitalVolunteer Orientation Test (complete prior to group meeting/orientation)

Printed Name Signature

Date: _________________________ Please circle the answer or fill in the answer:

1. In a case of work-related injury, the volunteer will:a. Immediately report your injury to your supervisor or the House Supervisor.b Supervisor fills out the Internal Report of Job Related Injury or Illness.c. Submit the Internal Report with all the appropriate documentation and signatures

to the emergency room.d. All of the above.

2. Patient Confidentiality is protected by a. Patient Rights & HIPAA privacy ruleb. Advance Directives

3. The single most important thing you can do to prevent infection is .

4. What is the name of the President/Chief Executive Officer at Valley Presbyterian Hospital? ________________________________________________________________

5. In the event of a disaster, the volunteer should:a. Go home without telling anyone.b. Report to supervisor in your unit/department for an assignment.c. Go to the cafeteria for an assignment.

6. “Code Pink” meansa. Infant Abductionb. Violent Situation/Security Distress Call

7. When carrying any item, it is best to keep it close to your body because:a. Carrying it close to your body will minimize the stress on your back.b. Carrying it at arms-length will help clear your path.

8. When picking up an object it is OK to bend at the waist.True ____________ False ________

9. It is mandatory that all volunteers wear clean/pressed volunteer smock, ID badge and proper attire (which exclude open toe shoes, sandals, jeans, nylon pants, sweats, baseball caps, spaghetti strap blouses, mini-skirts or any unprofessional dress attire. NO IPods or cell phones)

True _________ False _________

10. What is the telephone extension number you dial to initiate a code i.e., a fire or disaster within the hospital? ________________

11. It is the duty of every employee/volunteer to protect the confidentiality and privacy of patient health information? (HIPAA privacy rules-Protected Health Information)

Yes ____________ No _________


12. Under HIPAA privacy rule, it is illegal to (two (2) answers):a. Obtain information from a patient during treatment.b. Share information obtained from a patient with the patient’s physician.c. Snoop in the patient medical chart and transmit via any computer device or verbally

disclose to anyone.d. Fail to adequately protect health information from release.

13. Which of the following protects the confidentiality of patient information?a. Medical record file cabinets and file room doors are kept lockedb. Passwords to access computerized medical records are not sharedc. There are rules that prohibit employees/volunteers from looking at records unless they

have a NEED to know the information.d. All these answers are correct.

14. Does PHI (Protected Health Information) give disclosure of what patient information (oral, written, e-mail and faxed) may be disclosed?

Yes __________ No __________15. In the event of a disaster or fire, you may not use the elevator until the code has been clear

True ____________ False _________16. Only people with special training may respond to Code Gray.

Yes ____________ No _________ 17. What is the first thing you do if there is a fire in your area?

a. Close the door and walk to nearest exit (if patients/visitors in area have them follow you or assist to evacuate them.)

b. Fight the fire.18. It is a requirement in our hospital that all medications:

a. Are secured c. Are availableb. Are under constant supervision d. Are locked

19. Hospital employees are the only ones that must practice Infection Standard precautions.True __________ False ____________

20. Match the following definitions:CODE GRAY______ A) Non-patient Medical EmergencyCODE PINK______ B) Person with weaponCODE SILVER______ C) Violent SituationCODE GREEN ______ D) Bomb ThreatCODE YELLOW______ E) Infant AbductionTriage Internal ________ F) Disaster plan activation-internal

21. What does the acronym AIDET mean and (five behaviors)? ______________________________________________________________________________________________________________________________________________________________

22. The acronym AIDET are five behaviors used by all staff and volunteers with every patient/family encounter to anticipate, meet and exceed the expectations of the customer to help reduce anxiety. a. Yes ________ b. No ______________

22. All employees and volunteers are accountable for providing excellent customer service to all its customers: patients, visitors, physicians and co-workers?True ___________ False _______________

23. Circle all of the hazardous and infectious materials:a) Blood & Body Fluids b) Toxic Chemicalsc) Infectious substances d) Flammable liquid & gases


24. It is allowable for volunteers to handle infected needles and sharps?True _________________ False __________________

25. What is the initiative and program called in which all employees and volunteers are supposed to stop and assist patients on the nursing units?

a. NO PASS ZONE b. AIDET

26. What must you do every time you come in and finish your volunteer assignment?_______________________________

27. Who are Valley Presbyterian Hospital customers (internal and external)?

________________ _______________ ______________ ____________

28. Even when distributed by other departments, ALL medications are the responsibility of the pharmacy department.

A. True B. False

29. Always turn equipment off before pulling the plug from the outlet?True _______ False __________

30. If you need to access Material Safety Data Sheets (MSDS) where can you go to:a. MSDS Manualb. Hospital intranet and click the Propar/MSDS button to open websitec. All of the above

31. In order to maintain the security of medications, It is important that I:a. Never allow unauthorized individuals to enter into areas where medications are

stored.b. Never leave areas where medications are stored unlockedc. Never share medication room combination locks with other staffd. All of the above.

32. On delivering medications to nursing stations, it is OK to leave medications on counters:a. True b. False

33. Confidentiality of information includes all medications and medication therapy:a. True b. False

34. All of the following are examples of a privacy breach except:a. Discussing patient’s condition at bedside in a room with more than one patientb. Accessing the medical record of a patient you are not caring forc. Sending a fax with patient information to a restaurant

d. Losing a flash drive which contains patient names and diagnoses

35. The Quality Management System is aligned with VPH’s mission, vision and the 5 C’s and 6 Required Policies to be ISO 9001:2008 certified.

a. True b. False


Thank you for completing pages 37 to 44. Next step to complete volunteer packet is to answer the following questions that will assist us on how to utilize your goals and talents at Valley Presbyterian Hospital. Please provide as much detail information for each question. We are look forward to meeting and discussing how we could make your volunteer experience at Valley Presbyterian Hospital as rewarding as possible!

1. Why do you want to volunteer at Valley Presbyterian Hospital? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. How do you plan to make a difference at Valley Presbyterian Hospital? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. What talents do you have that could be applied as a hospital volunteer? (i.e., play an instrument, paint or write or etc.?) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. What are you grateful for and what do you value the most? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Describe yourself in the following space. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for interest in volunteering at Valley Presbyterian Hospital!


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