NEO Orientation Paper Packet 2011 - School of Nursing

NEO Orientation
Paper Packet 2011
DIRECTIONS FOR :
NEW EMPLOYEES, VOLUNTEERS, AGENCY AND
CONTRACTORS
1. Read all the material.
2. Sign pages
109, 111, 113, 115,
117, 119.
Return to Providence St. Peter
Hospital Human Resources.
3. Keep remaining pages for your personal file.
DIRECTIONS FOR:
STUDENTS AND JOB SHADOW PARTICIPANTS
1. Read all the material.
2. Sign pages
109, 111, 113, 115,
117, 119, (121 students
only)
Return to Providence St. Peter
Hospital Human Resources.
3. Keep remaining pages for your personal file.
8/2010 1

Note Page
2 8/2010

New Hire Paper Packet Orientation
Purpose
The purpose of this packet is to give you the initial orientation information
you need to successfully and safely enter the workforce as a new employee,
volunteer, agency worker, or other affiliate of Providence. This
packet is not intended to cover everything you need to know about your
specific role, but rather an awareness and understanding of topics that are
important to all.
It is our expectation that you will read this packet thoroughly, ask questions
if any section is unclear, and save this reference material for future
review and information.
At the end of this packet are several items that need to be completed by
you:
A comprehensive quiz about the material covered in this packet
An orientation checklist
A Confidentiality and Non-disclosure Statement
Acceptable Use and Confidentiality Agreement
Welcome
Welcome to Providence St. Peter Hospital (PSPH). As an employee, volunteer
or contract worker, you play an important role in helping to provide
quality service to those who choose us for their medical care. PSPH employees,
volunteers, and contract workforce provide high quality professional
expertise, delivered in a caring and compassionate environment.
As an organization, we are committed to providing you with a safe, fair,
enriching and interesting work environment. With this commitment in
mind, we would like to provide you with the following information you will
need to work effectively, efficiently and safely at PSPH. If you have further
questions, please ask your PSPH supervisor.
Who We Are
Providence St. Peter Hospital is a Catholic, not-for-profit health care provider
sponsored by the Sisters of Providence. Providence St. Peter Hospital
was founded by Mother Joseph in 1887, two years before Washington
became a state! This first hospital stood on the grounds of what is now
the Capital Campus. PSPH is a 390-bed community hospital and regional
medical center offering a broad range of services to Thurston, Lewis,
Grays Harbor and Pacific Counties. PSPH is part of the Sisters of Providence
Health System, one of the largest health care systems in the West,
with facilities in Washington, Montana, Oregon, California, and Alaska.
8/2010 3

THE PROVIDENCE COMMITMENT
MISSION
As People of Providence
we reveal God’s love for all,
especially the poor and vulnerable,
through our compassionate service.
CORE VALUES
Respect
All people have been created in the image of God
Genesis 1:27
We welcome the uniqueness and honor the dignity of every person
We communicate openly and we act with integrity
We develop the talents and abilities of one another
Compassion
Jesus taught and healed with compassion for all
Matthew 4:24
We reach out to people in need and give comfort as Jesus did
We nurture the spiritual, physical and emotional well-being of one another and those we serve
We embrace those who are suffering
Justice
This is what the Lord requires of you: act with justice, love with kindness
and walk humbly with your God
Micah 6:8
We believe everyone has a right to the basic goods of the earth
We strive to remove the causes of oppression
We join with others to work for the common good and to advocate for social justice
Excellence
Much will be expected of those who are entrusted with much
Luke 12:48
We set the highest standards for ourselves and for our ministry
We strive to transform conditions for a better tomorrow while serving the needs of today
We celebrate and encourage the contributions of one another
Stewardship
The earth is the Lord’s and all that is in it
Psalm 24:1
We believe that everything entrusted to us is for the common good
We strive to care wisely for our people, our resources and our earth
We seek simplicity in our lives and in our work
4 8/2010

Mission Leadership and Spiritual Care Services
Contact Information
Ext 37236
Providence/St. Peter Hospital
Connie Walker
Director, Mission Director
Thoughtful Questions
Why did you choose Providence?
Why do you feel called to minister in a faith
based institution?
What does this mean?
International Mission
The mission and core values of PH & S are the
guiding force for all actions, decisions and policy
development.
Assists clinics/ hospitals in developing countries
with donated medical supplies and volunteers;
Equipment donated;
Opportunities for employees to work and volunteer
here and in other countries;
Warehouse is located in Lacey;
Interested employees call 43025
How to reach a chaplain
When do I call a chaplain?
Pager--971-2187
Dial (0)
Call Spiritual Care Service ext 37240
–Prayer or other rituals are needed.
–Staff need
–Death or when a patient is actively dying.
–Request by a patient or a family.
–Physician consultation.
–Physician request.
–Nurse/physician/Care Management believe
that a visit would be of benefit to the patient or
family.
–Services of a specific minister, priest, rabbi,
Imam or other resource are needed.
–All Code Blues ( 8 a.m.-8 p.m. Off hours by
need or request.)
–Decision-making regarding DNR, withdrawal
from treatment, life support.
–Ethical issues arise.
–Issues regarding the grief process.
8/2010 5

Ethics Committee-Olympia
Providence Ethics Committee–Olympia
Basic Principles of Ethics
Purpose of the Ethics Committee
As a health care organization, Providence strives
to conduct patient care and business operations
within a consistent ethical framework as defined
by our mission, strategic plan and core values.
Is an interdisciplinary advisory group that addresses
medical issues of importance to patients,
staff and the community.
The patient‘s values, beliefs and stated wishes
are respected regarding medical care decisions.
The patient‘s best interest directs the ethical decision-making
process.
Patients have the right to make informed decisions
regarding their medical care. For those who
do not comprehend these decisions, staff will
work with their surrogate.
When making appropriate treatment decisions,
the medical treatment‘s potential benefit is
weighed against its potential burden.
The health care institution must assure that its
business operations are consistent with ethical
standards.
All information is confidential.
Provides a forum for discussion of ethical questions
for Providence health care facilities in
Olympia.
Provides consultation to caregivers, patients,
families and physicians regarding ethical issues of
medical care, including the appropriate use of life
support and artificial nutrition/hydration.
Supports the development of ongoing education
on ethical issues affecting the ability to serve the
Providence community and the common good.
Explores conflicting issues that may impact an
institution, caregiving team or family‘s decision
regarding medical treatment or non-treatment in a
specific case.
Addresses organizational issues related to patient
resources, personal behavior, business practices,
marketing service plans and professional integrity.
Functions as an advisory council on issues related
to organ donation.
6 8/2010

Ethics Committee-Olympia continued...
―Ethics committees do not remove ambiguity or conflict, but help responsible, moral people
make informed, conscientious decisions.‖
Monsignor Charles Fahey Fordham University
Case Review
The Ethics Committee reviews the important facts of a
case using an established method that sorts the data
into relevant categories for analysis and
discussion.
Recommendations are based on accepted principles of
medical and organizational ethics.
Case review discussion is documented and confidential
and in consultation with physicians and
consultants.
―Ethics committees do not remove ambiguity or conflict,
but help responsible, moral people make informed, conscientious
decisions.‖
Accessing The Ethics Committee
If you as a physician, nurse or employee need an ethics
committee consultation, or if you have an educational
need please contact:
Providence St. Peter Hospital
360.493.7360
Providence Mother Joseph Care Center
360.493.7236
Providence SouthHome Care Hospice
If you are a patient, family member or legal guardian and have a concern, please contact your
physician, nurse or a health care team member and they will help you contact the appropriate
person.
8/2010 7

Employee Health and Infection Control
Contact Information
493-4341 (Department number)
Infection Control Contact Information
493-7179 (Department number)
Providence/St. Peter Hospital
Employee Health
Benita Akins 493-4392 (Presenter)
Diana Mills 493-5892
Joan Harrod 493-5518 (Presenter)
Lou Hilken 493-5519
Bloodborne Pathogens Topics -Hepatitis B Virus (HBV) -Hepatitis B
-Hepatitis C Virus (HCV) -Hepatitis C
-Human Immunodeficiency Virus (HIV)
-AIDS
What Bloodborne Pathogens are
present in
1. Blood
2. Other
Potentially
Infectious
Materials
OPIM
Types of OPIM (Other Potentially
Infectious Materials)
Transmission of Bloodborne Pathogens
•Semen
•Vaginal secretions
•Body fluids (such as cerebrospinal, synovial, and
amniotic fluid)
•Any body substances visibly contaminated with
blood
•Tissues such as biopsy samples and organs
•Saliva in dental procedures
Bloodborne Pathogens can enter your body
through:
•a needle stick or sharps injury
•a break in the skin (cuts, rash, dermatitis)
•contact with mucus membranes
•sexual contact
•other modes depending on the organism
Risk of infection depends on several factors at the
time of exposure:
which pathogen
route of exposure: splash vs. needle stick
the amount of infected blood / OPIM in the
exposure
the amount of virus in the blood / OPIM
whether or not there was post-exposure
treatment
8 8/2010

Employee Health and Infection Control Continued…
Viral Hepatitis - General Overview
The word hepatitis means
inflammation of the liver
Hepatitis is also the name of a
family of viral infections that
affect the liver
inflammation, enlargement,
and tenderness
acute and chronic infections
possible liver damage ranging
from mild to fatal
Symptoms include:
Flu-like symptoms
Fatigue
Abdominal pain
Loss of appetite
Nausea / Vomiting
Joint pain
Jaundice
Dark urine
HBV - Hepatitis B-General Overview
-Hearty - can live for 7+ days in dried blood
-100 times more contagious than HIV
-Approximately 60,000 new infections per year
-Highest rates in 20-39 year olds
-1.25 million chronically infected
-5,000 deaths/year
-Preventive vaccine available
-Post exposure prophylaxis
8/2010 9

Employee Health and Infection Control continued...
HBV-Hepatitis B—Clinical Features
HBV - Hepatitis B-Transmission
HCV - Hepatitis C-General Facts
Incubation period = 6 weeks – 6 months the
average is 60-90 days
Acute Illness (jaundice) = ~90%
Chronic Infection (carrier) = ~10%
Immunity possible after acute infection
Unprotected sex with multiple partners
Sharing needles during injecting drug use
From infected mother to child during birth
Sharps/needle sticks
The most common chronic bloodborne infection
in the U.S.
3.9 million (1.8%) Americans infected
~20,000 new infections per year
Leading cause of liver transplantation
Most prevalent among those born 1945-65
8,000-10,000 deaths from chronic
disease/year
No broadly effective treatment
No vaccine available
HCV-Hepatitis C-Clinical Features
HCV-Hepatitis C-in Washington State
Incubation period = 2 weeks – 7 months; if
symptoms do occur, they do so an average of
6-7 weeks after
exposure
Acute Illness (jaundice) = ~ 20%
No signs or symptoms = ~75%
Chronic Infection (carrier) = 75-85%
No protection from future infection
-66% of the people infected in our state do not
know it
-8X as many cases of HCV as cases of HIV/AIDS
-about 80% of people who have ever injected
street drugs or shared drug ―equipment‖ are
infected
10 8/2010

Employee Health and Infection Control continued...
HCV - Hepatitis C-HCV Transmission
Health Care Workers and BBPs-
Occupational Transmission
HIV / AID Definitions
How AIDS is defined
Injecting drug use
Hemodialysis (long-term)
Blood transfusion and/or organ transplant before
1992
From infected mother to child during birth
Occupational exposure to blood - mostly needle
sticks
Not efficiently transmitted sexually
Household exposures - rare
Risk of infection following needle stick / cut from a
positive (infected) source
HBV: 6%-30%
HCV: 1.8%
HIV: 0.3%
HIV– Human Immunodeficiency Virus
AIDS- Acquired ImmunoDeficiency Syndrome
By a specific set of clinical conditions caused by
HIV
HIV attacks the immune system damaging the
body‘s ability to fight disease
Fragile – few hours in dry environment
Everyone who has AIDS has HIV, but not everyone
who has HIV has AIDS
Medical treatment can delay the onset of AIDS
Human Immunodeficiency Virus (HIV)-
HIV Transmission
Transmission for HIV Conditions
Sexual contact
Sharing needles and/or syringes
From HIV-infected women to their
babies during pregnancy or delivery
Breast-feeding
Needle sticks
HIV is not spread by casual contact, it must
be acquired
Three conditions must be met in order for
HIV to be transmitted
1. HIV source
2. Sufficient dose of the virus
3. Access to the bloodstream of another person
8/2010 11

Employee Health and Infection Control continued...
Human Immunodeficiency Virus (HIV)
HIV Infection AIDS
How Prevalent is HIV?
Many have no symptoms or mild flu-like symptoms
Most infected with HIV eventually develop AIDS
Incubation period »10-12 yrs from HIV progression to
AIDS without treatment
Opportunistic infections & AIDS-related diseases -
TB, Kaposi‘s sarcoma, many others
Treatments are limited / No cure
In the United States:
The CDC estimates that about 1 million people in the
U.S. are infected with HIV
~25% of these people are undiagnosed and
unaware that they are infected
In 2007 there were 42,655 new HIV infections in the
U.S.
74% of those were males
In Washington State:
First case of AIDS in WA state reported in 1982
As of December 31, 2008:
-there were a total of 10,121 persons living with HIV
disease in WA state
-57% of these people with HIV disease have AIDS
85% of all HIV cases diagnosed 2003-07 were male
There are an average of 560 new cases of HIV disease
each year in WA state
Most people with HIV disease diagnosed 2003-08
were between the ages of 30-39
Testing
Anonymous Testing
Client doesn‘t give their name
Confidential Testing
Client gives their real name and information is kept in
medical records
Results are confidential
Informed Consent
With rare exceptions, HIV testing can only be done with
the person‘s consent
12 8/2010

Employee Health and Infection Control continued...
Reporting Requirements
AIDS and HIV are reportable conditions in Washington
State (statute WAC 246-101)
HIV+ results obtained through anonymous testing are
not reported until this person seeks medical care for
conditions related to HIV/AIDS.
Federal Law requires that states take action to notify
all spouses/ ex-spouses of HIV-infected persons going
back 10 years
-State law requires health depts. to offer HIV partner
notification services
Disability and Discrimination HIV / AIDS are considered disabilities under :
the Washington State Law Against Discrimination
the Federal Americans with Disability Act of 1990
the Rehabilitation Act of 1973.
Difficulty Realities
Personal Impact of HIV/AIDS
In 2007, the largest number of new HIV/AIDS diagnoses
was for persons aged 40-44
Infections & malignancies that accompany AIDS as
well as certain medications can disfigure the body
Men who have sex with men and injected drug users
may already be subject to social discrimination and
may encounter even more social discrimination
Loss of :income / savings,
health insurance
emotional support
housing
Facing :premature death
infections / malignancies/ disfigurement/
social discrimination
Family and Care Providers
Often feelings of family members and caregivers will
mirror those of the patient:
Sadness, anger, vulnerability, helplessness, isolation
Stages of Grief and
Psychological Suffering
Chronic Grief:
Before the grieving process for one death is
complete, more people have died.
-people who work with and care for people with AIDS
-people living with HIV/AIDS
8/2010 13

Employee Health and Infection Control continued...
Special Populations
Health Care Workers and BBPs
Occupational Transmission
Exposure Control Plan
Exposure Control-
Reducing Your Risk
Exposure Control
Standard Precautions
HIV infection affects people from all ethnic groups, genders,
ages, and income levels, but some groups have
been significantly affected by the AIDS epidemic.
•Men who have sex with men
•IV drug users
•People with hemophilia
•Women
•People of color
#1 is needle sticks
#2 is cuts from other contaminated sharps (scalpels,
broken glass, etc.)
#3 is contact of mucous membranes or broken skin with
contaminated blood
Location of the plan-Employee Health
To Eliminate/minimize your risk of exposure:
•Identify employees who are most at risk
•Training and Education
•Hepatitis B Vaccine
•Post exposure evaluation & follow-up
•Review equipment and practices
•Record keeping
Standard Precautions
Safer Medical Devices
Personal protective equipment
Everything properly labeled
Hazardous material disposal
Practice safe work habits
TREAT ALL BLOOD AND
OPIM AS IF KNOWN TO BE
INFECTIOUS WITH A
BLOODBORNE
DISEASE
Hand Hygiene is part of Standard
Precautions. Use alcohol
based hand sanitizer or wash
with soap and water for 20
seconds.
14 8/2010

Employee Health and Infection Control continued...
Exposure Controls
Equipment and Safer Medical
Devices
Sharps Disposal Containers
Old
20% of HIV infections
due to needle sticks
involved disposal of the
needle
PSPH has implemented
new sharps
containers
Exposure Controls
Safer Medical Devices and Practices
Sharps with engineered
sharps injury protections
(SESIP)
Needleless systems
Plastic IV capillary tubes
Don‘t bend, recap, or remove
needles or other
sharps
Place contaminated,
reusable sharps immediately
in appropriate containers
Exposure Controls
Personal Protective Equipment
(PPE)
You must wear all required PPE. PSPH provides you
with PPE at no cost:
Gloves, lab coats, gowns, shoe covers, face shields
or masks and eye protection, Powered Air Purified
Respirator (PAPR)
Exposure Control
Safe Work Practices
Clean-up spills, biohazard waste, and broken glassware/sharps
Clean the area with hospital approved disinfectant.
(We use a quaternary cleaner in most areas)
Saturate the spill area with disinfectant. Follow directions
on bottles for contact time
Know where to find plans & policies related to
hazardous waste materials in Docushare.
8/2010 15

Employee Health and Infection Control continued...
Special Populations
Health Care Workers and BBPs
Occupational Transmission
Exposure Control Plan
Exposure Control-
Reducing Your Risk
Exposure Control
Standard Precautions
HIV infection affects people from all ethnic groups, genders,
ages, and income levels, but some groups have
been significantly affected by the AIDS epidemic.
•Men who have sex with men
•IV drug users
•People with hemophilia
•Women
•People of color
#1 is needle sticks
#2 is cuts from other contaminated sharps (scalpels,
broken glass, etc.)
#3 is contact of mucous membranes or broken skin with
contaminated blood
Location of the plan-Employee Health
To Eliminate/minimize your risk of exposure:
•Identify employees who are most at risk
•Training and Education
•Hepatitis B Vaccine
•Post exposure evaluation & follow-up
•Review equipment and practices
•Record keeping
Standard Precautions
Safer Medical Devices
Personal protective equipment
Everything properly labeled
Hazardous material disposal
Practice safe work habits
-Labels attached
securely to any containers
or items containing
blood/OPIM
-Red bags/containers
may substitute for
labels
-Signs posted at entrance
to specified
work areas
16 8/2010

Employee Health and Infection Control continued...
Management of Occupational
Exposure PSPH Responsibility
Hand Hygiene Policy
Important
Exposure Controls-
Hand Hygiene and Glove Use
Hand Hygiene
Provide immediate post-exposure medical evaluation
and follow-up to exposed employee:
At no cost
Confidential
Testing for HBV, HCV, HIV
Preventive treatment when indicated
Test blood of source person if HBV/HCV/HIV status
unknown (if possible)
•Use proper hand-washing technique before eating
and after using the restroom. (20 seconds! And use a
towel to turn off water and grab door handle)
•Use alcohol hand-rub (Purell) when hands are not
visibly dirty.
•Proper Nail Care – keep nails short and clean.
No artificial nails for patient care providers.
´If you wear gloves, do you still
need to perform hand hygiene?—YES
´Do you perform hand hygiene before you
put the gloves on or after you remove the
gloves?—BOTH
The nurse uses Purell after taking Mr. Smith‘s blood
pressure.
As she leaves the room she answers a call from the
lab on her portable phone.
Does she need to do hand hygiene again before she
takes Mrs. Jones‘ blood pressure?—YES
Stay Home When You Are Sick Fever >100
Diarrhea / Vomiting
Cough (if > than 3 weeks, see Employee Health)
Keep vaccinations current
Annual Influenza vaccination
Chickenpox
Hepatitis B
Tetanus
Do you have what many of your coworkers have?
8/2010 17

Infection Infection Control Control: Additional Information
Additional Information
Star on the patients’ identification labels: The star means that we have identified the
patient as having a history of MRSA, VRE, or ESBL (Extended Spectrum Beta Lactamase
producing organism). These are multi-drug resistant organisms or MDROs. These
patients require Contact Precautions on admission. Use the pre-printed nursing order for
transmission based precautions (nursing isolation order) to make sure that both the RN
and the HUC complete all the steps necessary for placing the patient on precautions.
Isolation Stop Signs: We use 4 different stop signs to communicate that a patient is on
infection control precautions. Most of our patients require contact precautions for VRE
(Yellow), MRSA (Green), or C. difficile (Orange) so we have designated colored stop
signs for this purpose. There is also a stop sign which can be customized by checking
the appropriate boxes. This sign would be used for patients that may have chickenpox,
lice, ESBL, bacterial meningitis, etc. (anything but MRSA, VRE, and C. difficile).
You must leave the orange C. difficile isolation sign on the door so housekeeping
knows to clean the room with bleach after patient is discharged.
Infection Control Policies: You can access all hospital policies, including infection
control policies by clicking on ‗Docushare‘ found on St. Peters Hospital intranet
homepage. You can also find ‗Infection Control‘ resources under Department Sites A-L.
18 8/2010

Infection Control
Initiating Precautions
8/2010 19

20 8/2010

CONTACT PRECAUTIONS
MRSA
VRE or ESBL
Clostridium difficile
Lice/Scabies
RSV
DROPLET PRECAUTIONS
INFLUENZA
Bacterial meningitis
(until 24 hr after starting abx)
Pertussis
AIRBORNE PRECAUTIONS
Tuberculosis
Primary Chicken pox Or
Disseminate Herpes Zoster
Measles
SARS
Infection Control: Precautions Guidelines
Patient Management
Infection Control: ext. 37178
Isolation Precautions
Standard Precautions X X X X X X X X X X X X
Contact Precautions X X X X X
Airborne Precautions (negative pressure room
and PAPR or N 95 masks for all individuals
X X X X
entering the room)
Droplet Precautions (surgical mask) X X X
Required PPE
Gloves X X X X X
Gown X X X X X
Mask X X X X
Eye protection (goggles) X X
N95 / PAPR X X
Immunity (had disease or vaccination) X X
Patient Placement
Private Room or separate care area X X X X X X X X
Negative Pressure Room (turn alarm on) X X X X
Door closed at all times X X X X
Hand Hygiene
Alcohol based hand rub X X X X X X X X X X X
Antimicrobial Soap X X X X X X X X X X X X
Regular soap and water X X X X X X X
Patient Transport
Limit movement to essential medical purposes
only (supervised)
X X X X X X X X X X X X
Place mask on patient to minimize dispersal of
droplets when outside the room
X X X X X X X
Cleaning, Disinfection of Equipment
Daily disinfection of high touched surfaces with
hospital approv. disinfectant and routine
X X X X X X X X X X X
terminal upon discharge
Terminal clean with bleach/water sol. 1.9 (10% sol.)
X
Dedicated equipment (disinfect prior to leaving room) X X X X
Linen management as with all other patients X X X X X X X X X X X X
Vis Visitors
Instructed on Hand hygiene X X X X X X X X X X X No
Gloves if patient contact X X X X X visitors
Mask (surgical) within 3 ft of pt. X X X No
Mask or N 95 (for airborne)
X
Immunity (had disease or vaccination) X X visitors
Gown for patient contact X X X X
Discourage children from visiting X X X X X X X X X X
Yellow = VRE Green = MRSA Orange = C.diff.
8/2010 21

Central Line Care Bundle
Preventing Infection
22 8/2010

Aseptic Technique with VADs‘ and IV Lines
Evidence Based Practice
8/2010 23

Security Department
Security Department Contact Information
Providence/ St. Peter Hospital
Fred Millius
Manager, Security and Communications
Location:
Next to the Emergency Center Admitting desk.
Phone Numbers:
Office: Inside-hospital Ext. 37918
Outside-360.491.9480
O-Operator
111 Emergency
Car Safety
Keep vehicles locked
Keep valuables out of site
Park in the secure garage
ext. 37918 or O-operator
Escort Service
Escorts are available for:
Patients
Visitors
Employees
Inmates
Anyone deemed a ―risk‖
When calling for an escort please stay on the
phone line with the operator until Security is
reached
Lost and Found
Motorist Assists
Contact Security-ext. 37918 or O-operator
Vehicle unlock
Jumpstart
Reports and picture on damaged vehicle for
insurance
Phone:
ext. 37918 or O-Operator
When calling for motor assist please stay on
the line with the operator until Security is
reached.
24 8/2010

Unusual Occurrences
Contact Information
Providence/St. Peter Hospital
Karen Lindsey-37612
Risk Management Specialist
For questions on Quantros or reporting events
Definition
Purpose of Reporting
Examples of When to Complete an
Unusual Occurrence Report (UOR)
Definition of Sentinel or Adverse
Events
Electronic Reporting
Policy Highlights
Any event placing patients and/or others at unplanned
risk of harm or possible harm should be considered an
unusual occurrence
Any happening which is not consistent with routine operation
of a healthcare system or routine care of a particular
patient.
Core value of Excellence
Identify opportunities to improve the quality of patient
care
Identify events or unsafe conditions
To collect data on frequency
To advise Risk Management
Medication errors or adverse drug reaction
Patient or visitor fall
Equipment failure that could have resulted in injury
Breach of confidentiality
Delay in Treatment
Sentinel Event = Joint Commission
Adverse Event = State DOH (Department of Health)
Examples:
Wrong site surgery
Infant discharged to wrong parents
Patient Suicide
Requires immediate response
See policy for complete listing of Joint Commission
and DOH defined events.
Quantros – commercial product
SRM = Safety & Risk Management
Training tutorial on-line
If patient-related
Don‘t mention UOR in chart
Document facts in patient‘s record
Culture of patient safety
Person who observes - reports
Manager investigates
Reviewed by Quality or Pharmacy
SE or AE – report right away
8/2010 25

Patient Safety Program page 1 of 3
Contact Information
Providence /St. Peter Hospital
Quality Department
Ext 37179
Medical Errors
Prevention Strategies
National Safety Goals
Medical errors can result in increased costs and
additional days in the hospital for patients.
Many of these errors are considered preventable
utilizing concepts from the Joint Commission National
Patient Safety Goals.
For patient safety, regulatory bodies and other professional
organizations have set expectations for hospitals
to follow.
The JC has developed National Patient Safety
Goals (NPSG) to promote specific improvements
in patient safety.
Goal 1-Improve the accuracy of patient
identification.
Use at least two patient identifiers when providing
care, treatment or services
It is our hospital policy to use the patient‘s name
and date of birth.
Goal 2-Improve the effectiveness of communication
among caregivers.
Report critical results of tests and diagnostic procedures
on a timely basis.
Use the SBAR format for all ―hand off‖ communication
S-situation
B-background
A-assessment
R-recommendation
26 8/2010

Patient Safety Program page 2 of 3
Goal 3-Improve the safety of using medications
Label all medications, medication containers and
other solutions on and off the sterile field in
preoperative and other procedural settings.
Reduce the likelihood of patient harm associated
with the use of anticoagulant therapy.
Goal 7-Reduce the risk of health care-associated
infections
Comply with either the current CDC or WHO
hand hygiene guidelines.
Implement evidence-based practices to prevent
health care-associated infections
Goal 8-Reconcile patients medications while in
the care of the hospital.
We need to verify to help avoid errors of transcription,
omission, duplication of therapy, and possible
interactions
There is a process for comparing the patient‘s
current medications with those ordered for the
patient while under the care of the organization.
Upon discharge, the patient is given an updated
list of their medications to take home with them.
Goal 15– The organization Identifies safety risks inherent
in its patient population.
Universal Protocol
The Organization meets the expectations of the universal
protocol
Conduct a pre-procedure verification process.
Mark the procedure site.
A time-out is performed before the procedure.
8/2010 27

Notes
28 8/2010

Patient Safety Program page 3 of 3
Patient Safety Principles
Our Role
–First ―Do No Harm‖
–Take Nothing For Granted
–Safety Is Everyone‘s Responsibility
–Communicate With the Team
–Learning Is the Goal
–Engage the Patient in Partnership
No matter what your role at PSPH, It is every
employee‘s responsibility to keep our patient‘s
safe
8/2010 29

Facility Safety
Contact Information
Providence/St. Peter Hospital
Pam Long
Facility Safety Officer
Ext 37387
New color codes effective 6/17/2009
Facility Safety
Safety Programs
Emergency Contacts
Emergency Codes
•All workplace injuries and illnesses are preventable by
working safe.
•Use the proper Personal Protective Equipment (PPE) for
your job tasks
Check Material Safety Data Sheets (MSDS) for
recommended or required PPE on chemicals you
may use.
•Play an active role in creating a safe and healthy work
environment for you, your coworker and patients.
Safety Components
1. Safety Policies and procedures:
are located within ―Docushare.‖ Docushare is on
the Providence Home page .
2. Safety Committees
3. Safety and Hazard Inspections
4. Safety Trainings and Exercises
Healthstream/Department Specific Safety Training
5. Department Meetings
Are an opportunity for process improvements
Openly discuss safety
Report any Hazard immediately!
Employees must understand how to call for Emergency
Assistance.
Inside the facility Hospital Emergency call 111
Outside Non Hospital dial 9 then 911
RRT- Rapid Response Team
CODE BLUE-Medical Emergency
CODE AMBER - Newborn/Pediatric Abduction
CODE GRAY - Verbally Escalated Person/Person
Harming Self/Others
CODE BLACK - Adult Patient Elopement
CODE RED - Smoke/Fire Response
CODE ORANGE -Hazardous Material Spill
CODE BROWN - Internal or External Disaster/Disruptive
Event
CODE YELLOW - Bomb Threat
ROSE TEAM- Obstetrical Emergency
FALL TEAM-Person falls outside a patient room
30 8/2010

Facility Safety continued...
Red Team
Response to Fire
Rescue, and Remove if safe
Alarm, or Alert
Contain, or Close
Extinguish, or Evacuate
Assume it is real
Use stairs
Wait for ―ALL CLEAR‖
Fire Protection Basics
No material can be stored within 18‖ of the sprinklers
or ceilings
Maintain clear access to exits
Smoke outside in ―Designate Smoking Areas‖
ONLY!
Do not block fire extinguishers or electrical panels.
It is your responsibility to know the locations of:
How to Use a Fire Extinguisher
Steps
Fire alarm pull stations
Fire Extinguishers
Fire Exits
Department evacuation meeting locations
1. Pull
2. Aim
3. Squeeze
4. Sweep
8/2010 31

Facility Safety continued…
Hospital Evacuation
CODE BLUE
RAPID RESPONSE
CODE ORANGE
Evacuation is extremely rare in hospitals.
1st – horizontal evacuation Defend in Place
2nd – vertical evacuation
3rd – complete evacuation
Response to Medical Emergencies
• Heart Stops, no Respiration
You need more in depth assessment and
evaluation of your patient, or immediate assistance with a
patient.
Response to Chemical Safety
Right to Know Standard
OSHA Requirement-You have the right to know: what
your working with and the protective equipment
needed to use the products, proper use and storage of
the products, and what to do if you have been
splashed or exposed to the product.
Know this before you use the product the first time for
your own safety and the safety of others.
Know the hazards of material before you use it. Know
the location of the Material Safety Data Sheets (MSDS)
MAX COM-Online link to MSD
If a spill occurs:
Only authorized and trained personnel shall handle
hazardous materials
Dial 111-provide the exact location
Secure the area, move personnel, stay out until you
hear- ―All Clear.‖
Waste Products at PSPH-Chemicals (Lab,
Chemo Waste)
Sharps and biological-(needles, bodily
fluids, etc.)
32 8/2010

Facility Safety continued...
CODE BROWN
Hospital Incident Command
Response to Disasters
Internal Disasters: Fire, bomb threat, power failure, water
or communications are down.
External Disasters: Mass Casualty Incidents, earthquake,
flood, bio terrorism, weather, industrial hazmat.
CODE YELLOW
Responds to Bomb Threats
Report telephone threats immediately – dial 111
Never touch a suspicious object, secure area, move people
away, wait for ―ALL CLEAR.‖
ROSE TEAM
CODE GRAY
Response Obstetrical Surgical Emergency Team
When a pregnant mother or fetus requires emergency
Cesarean Section.
When a person (patient, co-worker or visitor) becomes verbally
aggressive. and or displays physically aggressive behavior.
To respond to CODE GRAY you need to have training in
the ―Management of Assaultive Behavior,‖ (MOAB). This is
a requirement for Security, Psychiatry and Crisis Services.
Person harming self or others-displays physically
aggressive behavior.
CODE SILVER
Person with a weapon or hostage.
Do not run to the area where the incident is happening; you
may put yourself or others at risk for injury.
8/2010 33

Facility Safety continued…
CODE BLACK
CODE AMBER
Responds to Adult Missing Patient
Look at all exists/entrances for the missing person. Usually
they are wearing a patient gown and could just be outside
smoking. Sometimes a patient will leave against
medical advice.
Responds to Newborn/ Infant Abduction
Newborns are tagged with a transponder upon delivery.
Doors lock whenever a transponder comes with in a predetermined
distance from the doors.
Fall Team
MRI Safety
Safety Summary
The pediatric area is a locked unit so you have to have a
proximity badge to enter or exit. You can also use the
phone for to ask for entrance.
Responds to falls outside of patients room
Call 111 – give exact location
•Special Team of Transporters, Security and nurse(s)
bring mobile lift equipment to safely lift patient/visitor from
floor to gurney or wheelchair.
MRI - uses an extremely powerful magnetic field, the
magnets are ALWAYS ON. It can draw any metallic items
into it without warning. Metal items become projectiles
and anyone in the path may sustain bodily injury or death.
See MRI safety presentation on Providence Home Page.
It is very informative and interesting video to educate staff
on MRI safety.
Safe workplaces prevent injuries, illnesses and save lives.
Safety is everyone‘s responsibility!
Safety promotes a successful, team oriented work culture
and greater employee satisfaction.
34 8/2010

Workplace Violence
Workplace Violence
―More assaults occur in the health care and social services industries
than in any other.‖ – Occupational Safety and Health Administration;
1998
Examples of Workplace Violence:
Threats or threatening body language
Physical assault, i.e. Slapping, beating, spitting, grabbing, use of
weapons.
Most Common Locations for Violence:
Crisis Services Center
Emergency Center
Psychiatric Building
Telemetry/Surgical Recovery floors
If a Person Becomes Violent:
Call Security (Via ―111‖. Announce that a Code Gray is needed and
your location).
Avoid confronting the person
Avoid trying to stop the person physically
Get yourself and others to safety
How to Contact Security:
Dial ―111‖ Hospital Operator will answer. Emergency Only
Office Telephone: 360-493-7918. Expect Voicemail. Non-Emergency
Hospital Operator ―0‖ or ―111‖ or 360-491-9480. Non-Emergency
Reporting Requirements:
It is a state requirement that all instances of workplace violence be
reported.
An Unusual Occurrence Report must be completed.
A Security Incident Report must be completed.
Follow-up with your supervisor to see if other action needs to be
taken.
8/2010 35

Hospital Security
Hospital Security
To contact security
For emergencies, dial ―111‖
Non-emergency dial operator ―0‖ or call 3-7918
Outside the hospital, dial 360-491-9480
Security:
Is available 24/7
Located next to the emergency room admit desk
A phone is located outside of door if no one is in the office.
Pick-up to speak to an officer.
ID Badges:
Wear picture facing out, between neck and waist.
Do not put pins or labels on badge
If lost, contact security for a new badge.
If broken or damaged, come to security office for replacement.
Bring old badge for destruction.
Door access badges are available for after hour entry into hospital.
If lost, report immediately so badge may be disabled.
Motorist assistance:
Contact security for help with dead battery jump starts, door
unlocks, flat tire assists, and vehicle damage investigation.
Parking:
Parking lots are designed in alpha/numerical order
Alphabetical lots are assigned to visitors of patients and patients
only.
Numerical lots are assigned to staff
Physicians have their own lot
Emergency department lot is only for patients of that area
Evening shift lots are chained until 12:45pm, then available to
evening shift workers.
Night shift (2100-0700) may park in alphabetical lots if they are
out by 0800.
36 8/2010

HIPAA, Integrity and Compliance 1 of 4 pages
Contact Information
Providence/St. Peter Hospital
Sharon Cockrum, SWSA Compliance Manager
Interpretive Services
Ext. 37677
HIPAA Privacy and Security
These regulations give patients more access to and control over who accesses
their healthcare information.
As a workforce member, you need to know that access to medical information
on patients is on a need to know basis only. This includes looking at
your own record.
Remember, access to medical information on patients is a privilege.
HIPAA holds violators accountable, and civil and criminal penalties can be
imposed if they violate the privacy rights of any patient.
Providence has sanctions policies to hold our workforce members accountable
(see below summary).
System access to electronic medical information is tracked and/or audited.
The Privacy and Security rules increase our accountability to safeguard
medical information.
Always limit the use or disclosure of medical information to the minimum
necessary.
Avoid discussions using patient names or identifiable information in public
areas.
When talking to or about patients, always be aware of others within earshot.
Safeguard healthcare information that is stored or communicated in any
manner (oral, written or electronic).
Integrity
Computer Network Security
You are accountable for the integrity of your decisions and actions on the
job.
You are responsible for protecting Providence‘s assets
This can include things like supplies or the use of your time
The Providence Code of Conduct guides integrity, compliance, and ethics in
our work
It is available on both the Providence intranet site and the internet site.
Please review the ―Code of Conduct‖ handbook provided with this training.
Be sure you understand the standards and ask questions about anything
you are not clear about!
The people of Providence (including contract workforce) are expected to
follow these standards as well as the policies and procedures pertaining to
your own work unit.
Providence takes patient privacy very seriously – a key part of this is protecting
the security of our computer network.
There are several things you must know and practice to keep the Providence
computer network secure
Know the policies and standards on the Information Security web site and
how they apply to you. (http://grace.providence.org/Sites/Security/
PoliciesStandards/Home)
8/2010 37

HIPAA, Integrity and Compliance 2 of 4 pages
Computer Network
Security
Keep computer and voicemail passwords private.
If you work at your own desk, your PC should be
―locked‖ (Ctrl Alt Delete | K) when unattended.
Confidential information should be stored in a secure
folder on the network whenever possible.
Never download confidential information onto a home or
non-Providence PC.
Always store portable devices and electronic media in a
secure location.
Confidential information stored on portable devices
must be encrypted, so the data is not accessible if the
device is lost or stolen.
Only send confidential information (whether by fax,
email, or other means) to people who need to know.
Use secure mail when sending confidential information
via e-mail to a recipient outside Providence. You can
send a secure e-mail by going to: https://
securemail.providence.org/mc10/login.aspx?
ReturnUrl=%2fmc10%2finbox.aspx. (See the Information
Security web site for more information.)
Keep personal information you may see or hear confidential.
If you have a question about privacy or data security,
please e-mail the PHS Security Questions mailbox (in
the Providence Global Address List in Outlook).
38 8/2010

HIPAA, Integrity and Compliance 3 of 4 pages
Contact Information
Providence/St. Peter Hospital
Sharon Cockrum, SWSA Compliance Manager
Interpretive Services
Ext. 37677
Violations
Recognizing a violation of the Code of Conduct or Providence
policy isn‘t tattling.
Workforce members are the eyes and ears of Providence –
you need to tell management of your concerns because they
don‘t have access to the same information and knowledge that
you do.
Examples of what to report:
Theft or fraud
Violation of privacy of employee/patient records
Inappropriate gifts and entertainment
Code of Conduct and policy violations
Billing and coding concerns
Retaliation
If you encounter an issue that violates the Code of Conduct or
a Providence policy, or you think an issue might be unethical
or illegal, you need to speak up.
There are a number of people you can talk to about your concerns,
including:
Your manager or a higher-level supervisor.
Compliance Manager (x37677) or another department such
as Human Resources or Security.
Regional or System Integrity Officer.
Call the Integrity Line at 888-294-8455.
Available 24 hours a day, 7 days a week
All calls are strictly confidential and anonymous
Providence has a non-retaliation policy that prohibits anyone
from being punished or treated unfairly just because they
asked a question or reported an issue. Retaliation is a negative
action against a workforce member for reporting good-faith
concerns.
If you suspect that a workforce member is committing fraud
against the government, such as improper billing, you are required
to report this concern to the Integrity and Compliance
Program.
It is also important to report any retaliatory behavior that you
are aware of – we can‘t correct what we don‘t know about!
8/2010 39

HIPAA, Integrity and Compliance 4 of 4 pages
In Summary
To maintain Privacy and confidentiality:
Access only the health information needed to do your work
Protect patient confidentiality at all times, and be alert to possible
risks to patient confidentiality.
All workforce members are expected to follow the Code of Conduct.
Take responsibility for protecting your computer password.
Ensure safeguards for protecting patient confidentiality.
Log off every time you leave your work station
Don‘t download software from the Internet or install unlicensed copies
of programs.
Soliciting or accepting a gift is prohibited. We do not accept gifts of
cash from any source, including vendors.
Question and report issues that seem unethical or illegal. Management
is committed to resolving and addressing issues, but they rely
on you to report.
Our Code of Conduct states that retaliatory behavior is not tolerated.
If you witness such behavior, we expect you to check it out
and make a report.
Other Privacy
Information
Requests to use patient information for research must be routed to
the Research Manager 360-486-6445
Opt-Out = if someone calls or visits and asks for the patient by
name PSPH cannot release information. Standard responses are:
―We do not have information on a patient by that name‖ or ―I do not
have a patient by that name listed in the directory.‖
If a patient is opted out a sticker will appear on the patient chart and
the symbol ―>‖ will appear next to their name in the census.
Opt-In = PSPH can only release patient name, location and a oneword
status (there is a specific list)
40 8/2010

Privacy and Compliance page 1 of 2
Protecting Patients Privacy: HIPAA DO’S and DO NOT’S
Contact Information
Providence/St. Peter Hospital
Sharon Cockrum, SWSA, Compliance Manager
Interpretive Services
Ext. 37677
HIPAA DO‘S
How To Report
Violations of
Confidentiality
Ask yourself, ―Do I need this patient information to do my job?‖
Only discuss patient information with team members who need
information and others the patient has identified.
Honor a patient‘s request if they have opted-out of the Patient
Directory by not telling anyone their location.
If a patient is opted out a sticker will appear on the patient
chart and the symbol ―>‖ will appear next to their name in the
census.
Close the door during patient care and when talking to the patient.
Close the curtains and speak softly in semi-private areas.
Ask the family if they would like to speak in a more private setting
than the hall or waiting area.
Ask the patient or their representative/family member to identify
a family communicator to speak with after the patient‘s procedure/surgery.
If you go to a waiting room and are greeted by a large crowd of
―interested persons,‖ determine who is the patient representative
or family communicator and ask them to accompany you to
a more private location.
Use Shred-It bins for waste that contains patient information.
Lock your computer station when away and log out when you
are done.
Sign and return your Acceptable Use and Confidentiality
Agreement.
Wear your photo ID face out and above the waist so patients
and visitors can easily identify you as a workforce member at
PSPH.
Contact the Compliance Manager : 360-493-7677
Or contact your manager
8/2010 41

Notes
42 8/2010

Privacy and Compliance page 2 of 2
Protecting Patients Privacy: HIPAA DO’S and DO NOT’S
HIPAA
Do Not‘s
Don‘t talk about patients in public places, the elevators or cafeteria.
Don‘t talk about patient information with someone who does not have
a need to know.
Don‘t walk away from open medical records in unattended or easily
accessible areas.
Don‘t place full patient names on white boards in public view.
Don‘t leave patient information unattended or lying about.
Don‘t ask for overhead pages of patients or family unless absolutely
necessary.
Don‘t leave phone messages with patient information on answering
machines or with another person without patient permission.
Don‘t choose computer passwords that are easily guessed.
Don‘t share or post your computer password.
Don‘t send confidential information via electronic mail outside of
Providence without ―securing‖ it. Type ―ProvSecure‖ in the email
subject line to secure an email.
Don‘t download unapproved software, when in doubt ask IS.
Don‘t leave your laptop or other electronic media or confidential information
unattended (i.e. do not leave your laptop in your car).
8/2010 43

Interpretive Services
44 8/2010

Interpretive Services
Contact
Information
Providence/St. Peter Hospital
Sharon Cockrum, SWSA Compliance Manager
Interpretive Services
Ext. 37677
The Program
Tools
Interpretive Services are required to be offered to patients at no
cost to the patient.
The program is developed based on the needs of our community.
Our top four languages are: Spanish, Vietnamese, Cambodian
and Sign language.
Interpretive Services Resource Guidebook
Telecommunication Device for the Deaf (TDD)
Request from Transporter
Useful for ―over the phone‖ conversations
Speakerphones
Request from Transporter
There are three in Emergency Center
DeafTV
Visual sign language provided via videoconference unit
Interpretive
Services
Provided
The patient has a right to refuse our offer
Ensure they understand (use interpreter as needed)
Document their refusal
The patient can use their friend, family member or themselves in
place of a hospital interpreter
No one under 18 can be used
Document that patient wants this person to interpret
Use care provider professional judgment for efficacy of
interpretation
Consider that a family or friend may not understand
the terminology they are interpreting
The importance of exact transmission of your questions/ answers
or the patient‘s questions/ answers
-There may be cultural/social issues that hinder accurate
communication
-Your duty is to ensure effective and accurate communication
If you need to have an interpreter involved for your side of the
conversation, you can do that also.
8/2010 45

Employee Relations
Contact Information
Providence/ St. Peter Hospital
Mary Mertens, Manager, Employee
Relations ext.37146
Chyrran Slama, HR Generalist ext.37445
Provide support to both management
and employees regarding:
Key policies for new employees
Coaching and counseling
Conflict resolution and facilitation
Investigations
Contract administration
Team building
Policy interpretation
It is your responsibility to familiarize
yourself with hospital and department
policies located on Docushare. Your
manager will also be a good resource.
Types of Policies:
Equal Opportunity
Tobacco Free Campus
Attendance Policy
Personal Appearance Policy
Employee Counseling & Discipline Policy
Harassment / Sexual Harassment
Electronic Communications System Policy
See specific policies on following pages
Harassment / Sexual Harassment
Every employee has the right to work in an
environment free of harassment
Two Kinds of harassment
1. Quid Pro Quo
2. Hostile Work Environment
Report inappropriate behavior.
There will be a confidential investigation and
disciplinary action if necessary.
46 8/2010

Equal Employment Opportunity page 1 of 1
8/2010 47

Tobacco Free Campus 1 of 2
48 8/2010

Tobacco Free Campus 2 of 2
8/2010 49

Attendance Standards Page 1 of 2
50 8/2010

Attendance Standards page 2 of 2
8/2010 51

Personal Appearance Standards page 1 of 3
52 8/2010

Personnel Appearance Standards page 2 of 3
8/2010 53

Personal Appearance Standards continued page 3 of 3
54 8/2010

Employee Counseling and Discipline page 1 of 3
8/2010 55

Employee Counseling and Discipline page 2 of 3
56 8/2010

Employee Counseling and Discipline page 3 of 3
8/2010 57

Harassment 1 of 3
58 8/2010

Harassment 2 of 3
8/2010 59

Harassment page 3 of 3
60 8/2010

Electronic Communication page 1 of 6
8/2010 61

Electronic Communications pages 2 of 6
62 8/2010

Electronic Communications pages 3 of 6
8/2010 63

Electronic communication page 4 of 6
64 8/2010

Electronic communication page 5 of 6
8/2010 65

Notes
66 8/2010

Electronic Communication page 6 of 6
8/2010 67

Commitment to Excellence
Contact Information
Providence/St. Peter Hospital
Danielle Jackson
Manager, Organization Development
Ext. 37634
Rev. 1-3.2010-DJ
SWSA Operating Commitments
In 2006, Providence St. Peter Hospital and
Providence Centralia Hospital joined together
in a pursuit of excellence toward their annual
goals. Each facility identified its strategic priorities
and has taken steps to achieve the measures
associated with these goals. Since its onset,
employees have been asked to find ways
to support the Commitment to Excellence
goals in their daily work.
Our goals are aligned with our six operating
commitments, they include:
Mission Inspired
Service Oriented
People Centered
Quality Focused
Growing to Service
Financially Responsible
Quality Focused Goals
Quality Focused Goals
•Clinical Reliability Index: Patients will receive the
treatments and services they need every time; our
goal is to score 92 percent on the clinical reliability
index.
•Patient Safety Index: We will increase patient
safety; our goal is to score 85 percent on the patient
safety index.
68 8/2010

Commitment to Excellence Continued...
Mission Inspired Goals
ProvVoice Survey question ―My work supports the
mission‖ TARGET – 85%
Charity Care TARGET – 4.89%
People Centered Goals First year voluntary turnover TARGET – 23.5%
ProvVoice Survey question ―Recommend Providence
as a great place to work‖ TARGET – 81%
Financially Responsible Goal Visionware Productivity TARGET – 104%
Department, cost per unit of service TARGET –
0% variance
Growing to Serve Goals CMAA TARGET – 100% (38,758)
Department specific goal to be developed with VP
as appropriate
Service Oriented Goals
Press Ganey – ER likelihood of recommending
TARGET – 60th percentile
Press Ganey – In-patient likelihood of recommending
TARGET – 70th percentile
Press Ganey – In-patient, service specific question
TARGET – TBD with 1-up leader
Out-patient unit specific goal to be developed with
VP
8/2010 69

Commitment to Excellence continued…
What is your role
as a PSPH Employee?
Commitment To Excellence Must
Haves
Rounding for Outcomes
Be aware of the annual goals and operating commitments.
Understand how your work affects the annual goals and
operating commitments
Use the Commitment to Excellence ―Must Haves‖ to help
PSPH achieve annual goals and objectives
Attend Town Hall Meetings
Pledge to commit to the Service Area Standards of Behavior
Organizations that achieve great results have six key behaviors
in common. Called "Must Haves," these specific
actions can help hospitals improve patient, employee and
physician satisfaction. They include the following:
•Rounding for Outcomes
•Employee Thank You Notes
•Check in During the First 30 and 90 Days
•Discharge Phone Calls
•Key Words at Key Times
Rounding is all about gathering information in a structured
way. It‘s proactive, not reactive. It‘s a way to get a
handle on problems before they occur and also to reinforce
positive and profitable behaviors‖
What can you expect from your manager?
Your manager will meet you informally weekly or monthly
to discuss what is working well, and what immediate
needs you may have. Your manager may ask:
What is working well today?
Are there any individuals/physicians whom I should
be recognizing?
Is there anything we can do better? (Process or system
problems that need to be fixed)
Do you have the tools and equipment to do your job
safely (employee safety and patient safety)?
Rounding is a great opportunity to catch up with your
manager, however, it is not intended to be the only opportunity
you have to seek out guidance or discuss concerns
with your manager.
Please take this opportunity to share with your manager,
your thoughts and insights are important.
70 8/2010

Commitment to Excellence continued…
Employee Thank You Notes
Check in at the first 30 & 90 days
Key Words at Key Times
AIDET
•At PSPH it is important for us to recognize the things employees
are doing well. By taking the time to show appreciation
for a job well done, we demonstrate our commitment
to making St. Peter hospital a great place to work, as
well as recognizing you for your efforts
•You may receive a personal thank you note from
someone at PSPH, thank you notes are generally sent to
employee‘s home address.
•At PSPH we routinely check in with all new employees
during the first 30 and 90 days
•This routine process helps everyone reconnect, and ensure
that there are no outstanding issues
AIDET and Managing Up are two tools that make up Key
Words at Key Times.
AIDET is a communication tool that provides patients with
an explanation of services and the duration they expect to
wait.
It is expected to be used by employees during all patient
Interactions.
Managing Up is a process of sharing positive information
about your co-workers to others: patients, colleagues,
and/or managers.
A = Acknowledge
Acknowledge and greet your patients
I = Introduce yourself
My name is Jane, I am your nurse today
D = Duration
Provide a timeframe of the expected duration
of the patient‘s wait
E = Explanation
Explain what is going to happen next
T = Thank you!
Thank your patient
This is also a great time to Manage Up your
colleagues
8/2010 71

Commitment to Excellence continued…
Manage up
Managing up is about positioning hospital staff and
employees.
Present a positive and focused message about others in
the unit that will be providing care, e.g., Mary will be your
evening nurse. Mary has been a nurse with Providence
for 25 years – she is a great nurse and will take very
good care of you!
Town Hall Meetings
Behavior Standards
Why Manage Up?
Provides patients with a sense of security about
the care they are receiving
the hospitals commitment, and
increases their comfort level, reduces anxiety,
blood pressure, and heart rate
Are a fun way to learn about more about our goals and
recent achievements.
You are expected to attend.
The SWSA Standards of Behavior are detailed guidelines
for how employees should behave at work.
They are based on our core values and identify specific
behaviors so employees understand what the hospital
expects of them.
All employees -- regardless of job title or position -- will
be held to the same standards.
Tools and Resources
You received a copy of the Behavior Standards at New
Employee Orientation, you are expected to adopt them
during your PSPH tenure.
PSPH offers a variety of tools and resources to assist
you with understanding the hospital operating commitments
and Commitment to Excellent Visit the Commitment
to Excellence intranet website to learn more:
http://swsa.wa.providence.org/excellence/psph/
72 8/2010

Employee Health, Wellness and Injury Management Services
Workers Compensation page 1 of 2
Contact Information
Worker Compensation
413 Lilly RD NE, Olympia, WA 98506-5165
Tel 360-493-7762
Fax 360-493-5417
8/2010 73

Employee Health, Wellness and Injury Management Services
Workers Compensation page 2 of 2
Workers' Compensation Filing Information
IF A JOB INJURY OR DISEASE OCCURS:
Providence St. Peter Hospital is subject to Washington industrial insurance laws and has been
approved by the state to cover its own workers' compensation benefits. Self insured employers
must provide all benefits required by the laws. The Department of Labor and Industries regulates
your employer's compliance with these laws. If you become injured on the job or develop
an occupational disease, you will be entitled to industrial insurance benefits. Your claim will be
handled and your benefits paid by your employer.
IN CASE OF INJURY OR DISEASE:
REPORT YOUR INJURY OR DISEASE to your supervisor (listed below).
Your employer will provide you with a "self insured accident report" (SIF-2). You must
complete this form with your employer if you seek medical treatment.
GET MEDICAL CARE. You have the right to go to the doctor of your choice.
Complete a "Physician's Initial Report" form at your doctor's office. Have your doctor mail this
form to your employer's claims administration address listed below. The claims administrator
will evaluate your claim for benefits. All medical bills that result from an allowable on the job
injury or occupational disease will be paid by your employer. You may be entitled to wage replacement
or other benefits. Your employer will explain this to you.
IMPORTANT:
Your employer cannot deny you the right to file a claim, and your employer cannot penalize
you or discriminate against you for filing a claim. Every worker is entitled to workers'
compensation benefits for any injury or illness that results from his/her job.
Any false claim filed by a worker may be prosecuted to the full extent of the law.
If you have any questions or concerns, contact your employer's representative (at the claims
administration address or phone number below), or call the Department of Labor and Industries,
Self-Insurance Section (360) 902-6901.
EMPLOYER MUST COMPLETE THE FOLLOWING
Report your injury to: Norma Gravlin, RN, CCM
Worker Compensation Coordinator
(360) 493-7762
Claims administration address:
Added 2/12/09-Gravlin
Revised Donahue 12/09
Sedgwick Claims Management Services, Inc.
P O Box 14518
Lexington, KY 40512-4518
Fax: 206-621-9749
74 8/2010

Employee Health, Wellness and Injury Management Services
Information By Karla Meyer, 5-6-2010
Highlights of Washington State Safe Patient Handling Law
Employers Must:
1. Have a safe patient handling committee made up of 50% direct
care staff
2. Write your own facility Safe Patient Handling Policy
St. Peter Hospital has one in place and have a right of refusal
clause in it
3 Purchase equipment equivalent to 1 device for every 10 inpatient
acute care beds by Jan 2010
4. Provide annual training on the components of the policy and use
of equipment.
PSPH Inpatient Safe Patient Handling Policy
1. Assess mobility and post mobility status level
2. Annual Mandatory Education on Law and Patients Lifts
3. Unit Charge Nurse is responsible for lift equipment readiness
4. Right of Refusal to lift patient in non-emergent situation
5. Disciplinary process will be stated if you refuse or choose not to
use ergonomic lift equipment and techniques.
As Part of the Law-Right of Refusal
A. All PSPH staff have the right to refuse to manually lift or handle a
patient and will not be subject to disciplinary action.
B. However, if any employee in a non-emergent situation chooses to
not use the patient handling equipment, ergonomic techniques or
willfully disregards components of the safe patient handling policy
they will be subject to disciplinary action.
8/2010 75

Employee Health, Wellness and Injury Management Services
Information by Karla Meyer, 5-6-2010
76 8/2010

Employee Health, Wellness and Injury Management Services
Commute Trip Reduction
Contact Information
Stephanie Kerr
X37630
email stephanie.kerr@providence.org
Added 7/2010
Know Your Options
There are several options to make your commute easier and less expensive. In addition to saving
you money, benefits include:
reduced stress, reduced wear and tear on your vehicle, reduced traffic congestion and air
pollution
Carpool
A carpool is two to six people who regularly share the ride to work in a private vehicle. Because
a carpool can operate every workday, or only on certain days, it is one of the most flexible and
convenient ways to commute. One person may do all the driving with riders contributing to the
cost of the commute, or the commuters may share driving and not exchange money. Prior to
starting your carpool, you should develop a simple set of rules for your group, including policies
for tardiness, smoking, music, etc. In addition to saving money, the benefits of carpooling include:
convenience and flexibility, reduced wear and tear on your vehicle, reduced stress, tax incentives,
reduced traffic congestion and air pollution
If you‘d like to carpool, but don‘t know anyone to share the ride, go to www.rideshareonline.com
and click on ridematch. Also, you can contact Intercity Transit at (360) 786-8800 or commuterservices@intercitytransit.com.
Vanpool
A vanpool is a group of five to fifteen people who commute together in a passenger van. Sharing
a ride can be cheaper and faster than driving alone. See a list of current Vanpools to join, or you
can start a new one. If you don't find a Vanpool in place for you, it's very simple to start one:
5 people are all it takes to form a new Vanpool! Find 4 other people besides yourself
with similar commute and work hours
Contact Intercity Transit's Vanpool Coordinator at 360-786-8800 to request a Starter Kit
3 Volunteer Drivers within your group will need to attend Intercity Transit's Defensive Driving
Class
Once the above steps are completed, you can hit the road in a beautiful Intercity Transit
Vanpool vehicle
8/2010 77

Return to Human Resources
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Employee Health, Wellness and Injury Management Services
Commute Trip Reduction continued...
Transit
Riding the bus is convenient and cost-effective for many commuters. Intercity Transit serves
stops near most major employers and schools in Olympia, Tumwater and Lacey. Intercity Transit
carries about 9,300 riders each weekday on its bus system of 24 routes. IT‘s Transit Guide lists
all the routes and schedules and provides information about all their services. IT also works with
other Puget Sound transit systems to provide service for travel along I-5. The Olympia Express
provides service between Olympia and Tacoma, and service between Tacoma and Seattle is
provided by Sound Transit. You pay the fare when you board the bus or you can save money
with a daily or monthly pass. Pass programs are available through many area employers. You
can purchase Half-Price Bus Passes through Employee Health and Wellness. Regular priced
bus pass is $30.00 a month. Call x34341 for more information. See your ETC for a copy of the
Transit Guide or for more information. Routes and schedules are also available online at
www.intercitytransit.com or call Intercity Transit at 360-786-1881.
Teleworking
Described as the use of telephones, computers, or other technology to permit an employee to
work from home (eliminating a commute trip) or from a workplace closer to home (reducing the
distance traveled in a commute trip by at least half.). Benefits may include:
Increased productivity, Improved morale, Reduced absenteeism, Higher quality work at a lower
cost, Improve air quality and reduce traffic congestion
Not every job or person is suited for a teleworking arrangement. Successful telecommuters must
be self-motivated, responsible, and results oriented. Jobs best suited for telework are those in
which:
Face-to-face interactions can be scheduled on specific days, Internal and external clients‘
needs can be met by teleworking, Clear work objectives can be set, Productivity would be increased
by quiet or uninterrupted time. (e.g. data entry, planning, editing, reading, research,
word processing)
Walking and Bicycling
These two options are the most inexpensive and efficient forms of transportation for short trips
around town and commuting to work. It‘s not just about staying fit and healthy. When you ride
your bike or walk, you‘re also:
Reducing traffic congestion, Reducing wear and tear on the roads, Reducing the need for
more roads and parking, Helping keep our air clean, Saving gas
If you‘re interested in walking or bicycling to work, but live further than five miles, consider combining
your trip with transit.
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Mandatory Online Education
Due 30 days
(after date of
hire)
Due 90 Days
(after date of
hire)
Due Dec. 1 st
(each year)
INFORMATION SECURITY
TRAINING
This training is regarding the
safety of electronic information.
It covers how to help
keep our computer system and
information secure. Mandatory
for All Staff
WORKPLACE VIOLENCE
This training is designed to
help employees prevent and
handle workplace violence.
Mandatory for All Staff
INTEGRITY TRAINING
This training is provided to foster
compliance with applicable
federal and state laws and
regulations. Mandatory for
Direct Patient Care Staff
Examples include but are not
limited to:
Fraud and Abuse
Nursing Documentation
Allied Services Radiology
Physician Documentation
Core
ENVIRONMENT OF CARE
TRAINING
This training consists of multiple
modules regarding yearly
requirements on the various
aspects of safety in the workplace.
Mandatory for All Staff
Examples include but are not
limited to:
Emergency Preparedness
Hazard Communication
Sexual Harassment
Patient Privacy
General Safety
Electrical Safety
Back Safety
What is HealthStream?
HealthStream is the electronic platform that Providence uses to house our online
training.
Additional training will be added to this platform on a Quarterly basis.
If any training is added outside the Quarterly assignment it is considered to be of
great importance to the organization.
Important Information regarding HealthStream
Online training must be completed at work if you are an hourly employee
You may complete online training from any site if you are a salaried employee
The attached pages will show you how to access HealthStream and take your
training.
8/2010 81

Diversity page 1 of 2
Just as our country is referred to as a melting pot, diversity is a concept that describes the mosaic
of people who bring a variety of backgrounds, styles, perspectives, values, beliefs and assets
to the groups and organizations with which they interact. Today‘s workforce is a collection
of people with many differences. Some of these differences include: age, race, religious beliefs,
sexual orientation, military experience, ethnicity, geographical location, parental status,
marital status, income, physical qualities, gender, education, and work background.
Diversity does not exclude anyone, it is inclusive. It includes and applies to everyone. Diversity
revolves around treating people the way they want to be treated. Valuing diversity is a
celebration of humanity. It speaks to:
Our individual uniqueness
Group commonality
Appreciation of ourselves and others for who we are
Laughing at our own strengths and weaknesses
Openness
Discovery of joining together
Creating a strong and united team
Workplace diversity is profitable because it fosters teamwork, and helps organizations
identify and meet the needs of their customers.
Workplace diversity relates to people‘s values. It encourages people to question social
conditioning and encourages them to develop a broader perspective. Some individuals
relate values to religious beliefs. Valuing diversity is a personal decision, but one that
the organization supports and views as a strength.
Workplace diversity is also a behavior. The behavior is valuing the uniqueness of those we
work with. It is productive to place a high value on diversity, since a positive and inclusive environment
enables people to work more effectively.
Respecting diversity involves an attitude that a person holds toward other people who may be
viewed as similar or different. It does not attach positive or negative attributes to those differences
and similarities, and does not interfere with a person‘s right to be different.
Diversity valuing helps employees and volunteers to:
Develop successful working relationships across the lines of differences.
Build effective organizations that focus on all the strengths of each person.
Understand, value and use the differences in each person to make the whole stronger.
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Diversity continued 2 of 2
Understand diversity to help avoid stereotyping, prejudging, discrimination, intimidation,
harassment, and collusion.
Stereotypes are generalizations that we form growing up. It involves an oversimplified concept
or belief about a group of individuals, and it does not take the ―here and now‖ into account.
Prejudice is the strong feeling for or against something formed before the person knows the
facts. It often takes the form of ethnocentrism, or belief that one‘s group is superior to all others.
It is also the tendency to see differences and weaknesses.
Discrimination is the unfair treatment of a person or a group on the basis or prejudice of preconceived
notions.
Intimidation occurs when a person belittles, frightens, discourages or inhibits others, especially
those they perceive to be weaker. Harassment is unwelcome behavior that disturbs or
irritates others.
Collusion is a form of exclusion. It involves cooperation with others, knowingly or unknowingly
to reinforce stereotypical attitudes, prevailing behaviors and norms. Silence is the most common
form. By saying nothing when people tell jokes that involve ethnic groups, the ―status
quo‖ is reinforced.
In summary, it is illegal for organizations to discriminate in any aspect of employment including:
Hiring and firing
Compensation, assignment, or classification of employees
Transfer, promotion, layoff, or recall
Job advertisements
Recruitment
Testing
Use of company facilities
Training and apprenticeship programs
Fringe benefits
Pay, retirement plans and disability leave
Other terms and conditions of employment
8/2010 83

Patient Rights & Responsibilities page 1 of 4
As a patient, you have a right:
• To receive a written statement of your rights.
To have family member(s), a representative or support person(s) of your choice
participate in your care decisions.
• To exclude any or all family members from participation in your care decisions.
• To receive considerate and respectful care in a safe setting.
• To an environment that preserves dignity and contributes to a positive self-image.
• To be free from mental, physical, sexual,
and verbal abuse, neglect, and exploitation.
• To participate in the development and implementation of your plan of care.
To have your cultural, psychosocial, spiritual and personal values, beliefs, and
preferences respected.
• To supportive social and spiritual services of the hospital that will enhance your
decisions for treatment and recovery.
• To make informed decisions regarding your care.
To have any restrictions on communication determined with your participation,
evaluated for therapeutic effectiveness, and fully explained.
• To appropriate assessment and management of your pain.
To formulate advance directives, and to have hospital staff and practitioners who
provide you care, and your family, comply with these directives.
• To know the names of all providers involved in your care, and to know which physician
is coordinating that care.
• To obtain from the physician or hospital staff, in your language of preference whenever
possible, complete information concerning your care and, your continuing health care
requirements in advance of that care, or in discontinuing care.
• To be informed of the reasons for any procedure or treatment before giving consent.
The information supplied usually includes a description of the procedure or treatment,
the significant risks involved, reasonable medical alternatives and the probable length
of time for recuperation.
To be informed of your health status and to be involved in care planning and treatment,
including pain management, and be able to request or refuse treatment. This right must
not be construed as a mechanism to demand the provision of treatment or services
deemed medically unnecessary or inappropriate.
Continued next page...
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Patient Rights & Responsibilities continued... page 2 of 4
As a Patient You Have The Right:
To be informed about the outcomes of care, including unanticipated outcomes.
To have a family member or representative of your choice and your own physician
notified promptly of your admission.
To be free from restraints of any form that are not medically necessary or are used as
a means of coercion, discipline, convenience, or retaliation by staff.
To be free from seclusion and restraints, of any form, imposed as a means of coercion,
discipline, convenience, or retaliation by staff as related to seclusion and restraint for
behavior management.
To refuse treatment and to be informed of the medical consequences of refusal.
To personal privacy, which includes personal hygiene activities
(e.g., toileting, bathing, dressing), during medical/nursing treatments, and when
re quested as appropriate.
To confidentiality in regard to the discussion and performance of health care, in
compliance with laws.
To confidentiality in regard to your medical and clinical records, and
communications regarding your care.
To access information contained in your clinical or medical records within a reasonable
time frame. The hospital must not frustrate the legitimate efforts of individuals to gain access
to their own medical records and must actively seek to meet these requests as quickly
as its record keeping system permits.
To be informed by the doctor, before transfer to another health care facility, of the need for
the transfer and the alternatives to it.
To refuse to participate in research projects, and not have your refusal compromise your
access to services.
To be informed of the following when asked to participate in research projects: expected
benefits, potential discomforts and risks, description of alternative services that might also
prove advantageous, and a full explanation of the procedures to be followed, especially
those that are experimental in nature.
To examine all bills and have an explanation of those bills, regardless of the payment
sources.
To change physicians.
To information regarding hospital policies, mission, and practices that relate to patient care,
safety, treatment and responsibilities.
To keep and use personal clothing and possessions, unless this infringes on others‘ rights
or is medically or therapeutically contraindicated.
To prompt resolution of disputes, concerns, complaints, conflicts, and grievances, and to
be informed on the procedure for filing a grievance.
To be involved in resolving dilemmas about your care decisions.
To effective communications.
To forego or withdraw life–sustaining treatment.
To care at the end of life.
To be informed in advance if your care is being furnished or discontinued.
To access protective and advocacy services.
5.2010

Patient Rights & Responsibilities page 3 of 4
As a patient, you have a responsibility:
To actively participate in decisions about your health care.
To be as accurate and complete as possible regarding medical history and treatment.
To let the physician or nurse know if you are concerned about a treatment, or if you
cannot, or will not follow a certain treatment plan.
To ask your physician or nurse what to expect regarding pain and pain management.
To discuss pain relief options with your physicians and nurses.
To work with your physician and nurse to develop a pain management plan.
To ask for relief when pain first begins.
To help your physician and nurse assess your pain.
To tell your physician or nurse if your pain is not relieved.
To tell your physician or nurse about any concerns you have about taking pain
medication.
To follow the physician's advice regarding the level of activity, diet and other health
care requirements.
To be considerate of other patients and staff.
To use hospital property and equipment only for intended purposes.
To examine your bill and ask any questions regarding charges or method of payment.
To leave your valuables at home, whenever possible, or to take responsibility for
them, if you choose to bring them to the hospital.
Continued next page...
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Patient Rights & Responsibilities page 4 of 4
Patient/Customer Concern Process
Providence St. Peter Hospital hopes to make your stay at our facility as pleasant as possible.
We welcome your feedback. We cannot address issues of concern if we do not know they exist.
Should you have a concern, complaint or grievance, please let us know.
You may utilize any or all of the following resources:
Inform a staff member, for example your nurse or care technician, of your concern. If we
can address the issue immediately, we will.
Ask to speak with the supervisor, manager or director of the department.
Contact a Quality Services representative Monday through Friday 8 a.m. to 4 p.m. at
360/493-7352 or 1-888-492-9480, and ask for the Customer Concerns Action Line.
After 4:00 p.m. and on weekends, dial 1-888-492-9480 and you will be connected to the
nursing supervisor.
Contact Risk Management at 360/493-7612.
These individuals will begin the process to have your concern addressed in a timely manner by
the appropriate person. You may send a written concern to:
Risk Management – Mail Stop 04H17
Providence St. Peter Hospital
413 Lilly Rd. N.E.
Olympia, WA 98506
We welcome the opportunity to address any issue you raise. As a health consumer, you also
have the right to contact any of the following agencies:
Washington State Department of Health
P.O. Box 7901
Olympia, WA 98504-7901
800/633-6828
The Joint Commission
800/994-6610
Washington Medical Quality
Assurance Commission
360/236-4700
Patient Rights & Responsibilities
We believe each patient, and when appropriate his/her representative or family member(s),
possesses certain rights with regard to his/her care, and shares in the responsibility of that
care. We feel you can best exercise and protect your rights and responsibilities by establishing
an open line of communication with those caring for you during your stay. We encourage you
to participate in decisions regarding your care and treatment.
8/2010 87

Notes:
88 8/2010

PROVIDENCE HEALTH & SERVICES
PROVIDENCE ST. PETER HOSPITAL
VALUE-BASED CUSTOMER SERVICE STANDARDS AND BEHAVIORS
Our values serve to guide us in all that we do,
including our commitment to the provision of exceptional customer service.
RESPECT:
AFFIRMING THE
GOD-GIVEN DIGNITY AND
WORTH OF EACH PERSON.
I am attentive to the individual’s
right to privacy.
• I always knock before
entering a patient’s room.
• I ask my patient if they
would like the door or curtain
shut for their privacy.
• I maintain strict confidentiality
with patients, visitors,
co- workers, and physician
information.
• I protect confidential,
personal patient information
from loss or theft.
• I coach co-workers in private,
commend them in public.
I listen to the needs of others
and respond patiently and
respectfully.
• I acknowledge the customer
with a greeting, attentive
posture, and eye contact.
• I introduce myself to the
customer by giving my
name and where I work.
• I inform the customer about
the duration of the activity in
which I will be engaged.
• I explain to the customer
what I will do and what they
can expect, in clear
language that avoids
technical jargon and
acronyms.
• I always thank the customer
at the end of every
interaction.
I follow through on my
commitments.
• I arrive to work on time and
return from break on time.
• I agree to comply with
hospital standards and
policies.
• I ask for help when I need it.
• I am accountable for meeting
deadlines.
COMPASSION:
CARING FOR EACH
PERSON AS PART OF OUR
FAMILY.
I offer assistance to those who
appear in need.
I approach people who appear
lost, and when possible,
I offer to escort them to their
destination.
• I utilize good telephone
etiquette, including “Good
Morning/Afternoon,” my
name and department name.
• I welcome customers in
a warm, friendly manner,
including an offer of
assistance.
• I find ways to allow my
patients to actively participate
in decision-making about their
care.
I respond to concerns and
complaints.
• I acknowledge concerns
without blaming or making
excuses.
• I apologize for unmet needs
or frustrating experiences.
• I take corrective action and
follow up with the customer.
I do all in my power to alleviate
suffering.
• I address physical pain by
working with physicians to
provide pain control.
• I address spiritual and
emotional pain by listening,
comforting, and offering to
find specialized assistance.
JUSTICE:
WORKING FOR A FAIR
AND EQUITABLE SOCIETY.
I resolve conflicts in a respectful
way.
• I address difficult, interpersonal
issues directly and privately,
without assigning blame.
• I listen to the other person’s
perspective in an objective
fashion.
I honor diversity in the
workplace.
• I show respect to all without
regard to race, religion,
culture or orientation.
• I value all team members
and their opinions.
I appropriately advocate for
the rights and needs of others.
I protect the safety of the
vulnerable.
• I respectfully share fairness
concerns with my supervisor.
EXCELLENCE:
CONTINUALLY
IMPROVING
ALL THAT WE DO.
I seek opportunities for growth
and learning, and share what I
gather with others.
• I continue to grow in skill
and competence, and encourage
others to do the same.
• I share information that
people need to do their jobs
in a constructive manner.
I actively participate in
committees, projects, and teams.
I am fully engaged in work activities
when I am on the job.
• I balance my personal
agenda with team and
organizational goals.
• I value the contributions
and opinions of all team
members.
• I offer to assist co-workers
whenever I am able.
I recognize excellence in others.
• I acknowledge co-workers
when they do an excellent job.
• I thank others who are
helpful to me.
• I share positive experiences
with others on the team.
I present a professional image
when I represent Providence.
• I keep my appearance neat,
clean, and consistent with
hospital policy.
• I keep my employee badge
visible and appropriately
placed.
• I use appropriate language
and tone when at work.
STEWARDSHIP:
WISELY CARING FOR
AND SHARING HUMAN,
ENVIRONMENTAL, AND
FINANCIAL RESOURCES
HELD IN TRUST.
I do my part to maintain a
neat and orderly environment.
• I return equipment to the
proper place.
• I pick up litter and throw
it away.
I manage my time effectively.
• I limit personal phone
calls to only those that
are necessary.
• I only utilize the internet
in accordance with
Providence policy.
I correct or report any safety
hazard I observe.
• I wash my hands before
and after leaving any patient
treatment area.
• I ensure all spills are cleaned
up properly.
• I promptly report any jobrelated
injury.
I wisely utilize hospital
resources to minimize waste.
• I recycle whenever
it is practical.
• I utilize equipment per
specifications.
8/2010 89

Notes
90 8/2010

Code of Conduct
PATIENT STANDARDS ■DISRUPTIVE BEHAVIORS
Disruptive Behaviors
Our Core Value of Compassion leads us to nurture the spiritual, physical, and emotional
well-being of those we serve. We apply this value to our work with each other and to the care
and service we provide to our patients.
In keeping with this Core Value, medical staff members and allied health professionals are held
to the same conduct standards as other employees, and are expected to treat others with respect
and courtesy, and to conduct themselves in a professional manner. Expected behaviors
that contribute to a positive patient care environment include:
Speaking in a respectful manner to patients, families, nurses, physicians, hospital
personnel and others in private and public places;
Responding to requests for information in a timely and supportive manner whether related
to clinical care delivery, collegial and professional interactions, or to patients and families;
Handling conflicts, disagreements and other differences of opinion through appropriate
administrative channels;
Offering constructive feedback to improve patient care and operations; and,
Practicing in a manner consistent with medical staff bylaws and regulations.
Disruptive behavior is a style of interaction with physicians, hospital personnel, patients, family
members, or others that interferes with patient care. Examples of disruptive behaviors may
include, but are not limited to:
Threatening or abusive comments;
Profanity or similarly offensive language;
Demeaning behavior such as name-calling;
Criticizing other caregivers in front of patients or other staff;
Racial or ethnic jokes or comments;
Inappropriate physical contact, sexual or otherwise;
Sexual comments or innuendo;
Refusal to cooperate with other staff members;
Refusal to abide by Medical Staff bylaws, and other organizational policies, rules and
regulations or to perform patient care responsibilities.
For non-employed members of the medical staff, medical staff governance documents should
address disruptive behaviors, educate on these behaviors, and provide a process for reviewing
and acting on allegations of disruptive behaviors within the patient care environment.
References
Joint Commission, Sentinel Event Alert, Issue 40, July 9, 2008.
American Medical Association, Current Opinions of the Council on Ethical and Judicial Affairs, E-9.045, Physicians with
Disruptive Behavior. American Medical Association, Current Opinions of the Council on Ethical and Judicial Affairs,
E-9.031.
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Notes
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Page two
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Name__________________________________
Department_____________________________
Date___________________________________
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College Advisor and Student:
Student completes the top half and the college advisor confirms the
bottom half.
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