Intermountain Healthcare Healing Commitments Form – Fill Out and Use This PDF

General Orientation Booklet

Contingent Workforce

Clinical Facility

Revised: January 2015

Table of Contents

Introduction

I n t e r m o u n t a i n H e a l t h c a r e

Intermountain is a premiere, not-for-profit healthcare system of doctors, hospitals and health insurance plans dedicated to providing high quality healthcare. Intermountain combines the financial, administrative and delivery aspects of healthcare into one integrated network that is nationally renowned for providing high quality, low cost care. Intermountain was created as a charitable, nonprofit, nondenominational system governed by community leaders who serve as volunteer, unpaid trustees.

As part of a nonprofit system, Intermountain’s facilities provide care to all those with a medical need, regardless of their ability to pay. Intermountain provides millions of dollars in charitable assistance to people who need healthcare but are not able to pay for it.

Intermountain employees, volunteers, students and contingent workers are expected to exhibit behaviors consistent with company Mission, Vision and Values.

M i s s i o n , V i s i o n a n d V a l u e s

O u r M I S S I O N

Helping people live the healthiest lives possible.

O u r V I S I O N

Be a model health system by providing extraordinary care and superior service at an affordable cost.

The Dimensions of Care include:

Clinical Excellence: We deliver outstanding clinical care in a consistent, coordinated way—always improving through evidence-based practice.

Patient Engagement: We provide a compassionate healing experience, fully involving patients in clinical and financial decisions about their healthcare and encouraging them to take responsibility for healthy life choices.

Operational Effectiveness: We are wise and innovative stewards of our resources and maintain the financial stability necessary to meet our high standards of quality and affordability.

Physician Engagement: We respect the professional and clinical skills of our physician colleagues and engage them in teams that help us deliver optimal outcomes and best serve our patients.

Community Stewardship: We help meet the diverse healthcare needs of our communities by providing excellent care at the lowest appropriate cost, regardless of the patient’s ability to pay. This is an important part of our strong not-for-profit heritage.

Employee Engagement: We honor the noble cause that inspires us as Intermountain colleagues. Together, we create a workplace that is built on our values, attracts and rewards caring and talented individuals, and engages us to live lives that are connected, balanced, secure, and healthy.

O u r V A L U E S

Integrity: We are principled, honest, and ethical, and we do the right thing for those we serve.

Trust: We count on and support one another individually and as team members.

Excellence: We perform at the highest level, always learning and looking for ways to improve.

Accountability: We accept responsibility for our actions, attitudes and health.

Mutual respect: We embrace diversity and treat one another with dignity and empathy.

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Contingent Worker Requirements

Contingent workers must meet the following requirements prior to beginning their work assignment at Intermountain Healthcare.

V e r i f i c a t i o n a n d D o c u m e n t a t i o n

The employer of the contingent worker must have verification or documentation of the following items:

Measles (Rubeola), Mumps and Rubella requirement. One of the following is required:

-Proof of two (2) MMR vaccinations.

-Proof of immunity to Measles (Rubeola), Mumps, Rubella through a blood test.

Tuberculosis screening requirements. One of the following is required:

-2-step TST (two separate Tuberculin Skin Tests, aka PPD tests) within twelve months of each other. The last TST should be completed at the time the healthcare worker begins their assignment at an Intermountain facility.

-One (1) Quantiferon Gold blood test with negative result.

If positive, or previously positive, to any TB test, the healthcare worker must complete a symptom questionnaire and have a chest x-ray read by a radiologist with a normal result. If chest x-ray is abnormal, the worker needs to be cleared by their physician or local health department before beginning a work assignment at an Intermountain facility.

Varicella (Chicken Pox) requirement. One of the following is required:

R e a d t h e C o n t i n g e n t W o r k f o r c e O r i e n t a t i o n B o o k l e t

This orientation booklet provides a list of responsibilities allowed by contingent workers at Intermountain facilities. Contingent workers are subject to general rules, policies and regulations of Intermountain specified herein.

Contingent workers will be provided facility and department specific orientation independent of this booklet.

C o m p l e t e a F o r m s P a c k e t

Along with this booklet, workers should receive a contingent workforce forms packet (or clinical instructor forms packet if applicable). The following items are provided in the packet.

This packet must be completed and returned to the facility Human Resources department or the assigned department supervisor before services are provided. Clinical instructor packets are returned to the assigned student placement coordinator.

R e c e i v e a N a m e B a d g e

Once the forms packet is completed, workers can obtain an ID name badge. The Human Resources department, department supervisor, or student coordinator (for clinical instructors) will assist with ID badging. The ID badge must be worn at all times when on-site at an Intermountain facility. At the end of the work assignment, the badge must be returned to Human Resources, the department supervisor, or student coordinator.

Contingent workers are not provided with proxy access on their ID badges. Exceptions are:

Affiliated physiciansConditionswho have pr vileges at I termountain hospitals and clinical sites. Campus Inter ountain volunteer staff, who serve in secured areas.

Contractors who provide facility operati nal support.

P a r k i n g

All workers must follow facility specific parking guidelines. These guidelines insure enough parking for all who need access to Intermountain facilities at any given time of the day.

Workers who do not comply with facility parking guidelines will be ticketed and fined accordingly.

Facility specific parking requirements are found in the Facility Information booklet for Contingent Workforce.

T o b a c c o F r e e

Intermountain Healthcare maintains smoke and tobacco-free, or partially smoke-free facilities in order to provide a healthy environment for our patients and customers and to comply with applicable laws. Tobacco products include cigarettes, cigars, pipes, spit tobacco and any lighted or heated plant product intended for inhalation such as hookah, e-cigarettes or other electronic devices.

In facilities that permit smoking, it is not allowed in patient rooms, places of public access, common areas, common work areas, or other areas except in designated smoking areas.

Facility specific information is found in the Facility Information booklet for Contingent Workforce.

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Roles & Responsibilities

I n t e r m o u n t a i n F a c i l i t y R o l e / R e s p o n s i b i l i t y

The Intermountain facility will:

Accept any contingent worker otherwise qualified without discrimination on the basis of any protected class under state or federal law.

Orient contingent worker to Intermountain’s mission, philosophy, and general physical structure. Inform worker of facility rules, policies and regulations with which they are expected to comply.

C o n t i n g e n t W o r k f o r c e R o l e / R e s p o n s i b i l i t y

Contingent worker will:

Act professionally and refrain from making comments, gestures, or acting in any manner, which can be construed as harassment towards other employees, patients or guests.

Wear an appropriate ID badge, which includes job title.

Refrain from soliciting employees, patients, or visitors for products, memberships, or any other reason, nor may they distribute literature for any purpose. (See Intermountain’s Solicitation Policy for additional information.)

Adhere to general rules, policies, and regulations of Intermountain.

In addition to the roles noted above, contingent workers, who are patient care providers, will:

Adhere to all policies and protocols pertaining to clinical operations.

Receive patient information and provide care as appropriate.

Perform patient care functions within the assigned department and within clinical expertise and scope of practice. Clinician must have an appropriate, current license (or healthcare certification) for the state the care is performed.

Professional - Know of and f llow f ci ityImagesecurity, safety, and infection control procedures.

Clinical in tructors assisting with student activities must meet requirements noted in the Instructor Guidebook f r Stud nt Practicum.

Intermountain workers create and present a professional image which helps our patients and visitors feel safe, confident and comfortable during their hospital experience.

P e r s o n a l I d e n t i f i c a t i o n

An Intermountain name badge must be worn in a visible location on the upper torso area at all times while at work.

ID badges are to be free of pins, stickers, or any other material that might interfere with the visibility of the photo or the identification of the person wearing the badge.

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Patient Rights & Responsibilities

Intermountain Healthcare outlines the rights afforded to each person who is a patient in our facilities. This Patient Rights and Responsibilities document discloses Intermountain’s commitment to an environment of trust where patients can feel comfortable and confident with the care they receive.

The Patient’s Rights Policy has been adopted to promote quality care with satisfaction for the patient, the family, the physician, and the staff, regardless of age race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression. Patient Rights and Responsibilities signs are posted in English and in Spanish throughout Intermountain facilities.

Some areas within Intermountain have slightly modified versions of the rights and responsibilities that are more specific to their patients, residents, or members. Questions regarding these modified versions may be directed to the department

Culturaldirector or he facility complianceDiversitycoo dinator. & Sensitivity

Workers are responsible to locate the Patient Rights and Responsibilities sign posted in the Intermountain facility they are assigned and assist with Intermountain’s commitment to pati nt rights.

Culture is the values, beliefs and practices shared by a group of people. Intermountain has an obligation to be respectful and sensitive to another’s belief system (co-workers, patients, families, guests).

C u l t u r a l C o m p e t e n c y

Workers should consider these questions:

Acquire basic knowledge of the cultural values, beliefs and practices of customers or patients served:

Ask questions

Listen

Account for language issues

Be aware of communication styles

B e s e n s i t i v e t o p e r s o n a l h e a l t h b e l i e f s a n d p r a c t i c e s

How does the patient stay healthy?

-Special foods, drinks, objects or clothes

-Avoidance of certain foods, people or places

-Customary rituals or people used to treat the illness

What are the expectations for medicine usage?

-Past experiences with medicine usage

-Will the patient take medicine even when he/she doesn’t feel sick?

-Is the patient taking other medicines or anything else to help them feel well?

Family and community relationships:

-Are illnesses treated at home or by a community member?

-Who in the family makes decisions about healthcare?

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Environmental- Wealth or social statusSafety - Presence of a disability

- Sexual rientation

S a f e t y i s E v e r y o n e ’ s C o n c e r n

Workers should call Security when they:

See any criminal activity

Need to report visitor accidents or visitor needs

See any suspicious circumstances

Need escort or vehicle assistance

Need to access lost and found items

Each Intermountain facility has a number to contact security directly. These numbers are found in the Facility Information booklet for Contingent Workforce.

E m e r g e n c y C o d e R e s p o n s e

In an emergency situation, it’s the responsibility of the worker to recognize an emergency and respond appropriately. Workers should know the facility specific phone number to call, be respectful to the responding code team and assist as needed.

The emergency codes listed below are standard for all Intermountain facilities:

Code RED: Fire

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Some Intermountain facilities have additional codes. These are found in the Facility Information booklet for Contingent Workforce.

F i r e P r e v e n t i o n a n d R e s p o n s e

Promoting fire safety by recognizing and correcting fire hazards, and appropriately responding to any fire incident at work is a shared responsibility of everyone.

Workers can apply simple safety measures that will help prevent fires:

Intermountian hospitals are designed to contain a fire behind closed doors for a period of time to allow fire-fighting efforts to occur. Closed fire doors allow areas of the facility away from the fire to remain functional. Do not block or prop doors open in any way.

C o d e R E D

Code Red is the term used for a possible or actual fire. “Code Red” and the location of the fire will be announced (overhead paging system). Alarms and strobe lights are used to identify the scope of the fire emergency. Fire drills will be announced as a “Code Red Drill”.

R A C E R

R – Rescue

Rescue anyone (including patients, visitors, employees and yourself) in immediate danger from flames or smoke.

NOTE: Many patients are connected to oxygen tanks and monitoring equipment. These items need to be moved with the patient whenever possible.

A – Alarm

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Activate the nearest fire alarm pull box and call your facility emergency number or 911. Take the time before a fire emergency to locate the fire alarm pull boxes in your work area.

C – Contain

Keep the smoke and fire from spreading to other locations within the facility by closing any open doors or windows. If the fire is in a patient’s room, turn off the oxygen flow meter and remove from the wall.

E – Extinguish

Take time before an emergency to locate the fire extinguishers in your area. If a fire is small and manageable, use the nearest fire extinguisher. Follow the steps in PASS to help you properly extinguish a fire.

Follow the facility’s evacuation procedure and move everyone to a safe location. Use an evacuation route that leads way from the fire. Do not use elevators!

E M T A L A

The Emergency Medical Treatment and Labor Act is a federal law that requires hospitals to treat all people who request emergency care.

W o r k e r R e s p o n s i b i l i t y

Provide assistance to all people (adults and children) needing emergency care.

If help is required to transport the person, call the hospital operator. State the problem and the location. Request Security to help transport the patient.

Initiate a Code Blue, if appropriate.

Never direct a person seeking emergency care to go to another hospital or facility if a patient requiring treatment for an emergency medical condition refuses to stay at the hospital.

Do not force individuals to receive treatment.

Employee- If the individual insistsHealthon le ving or going elsewhere for treatment, it is important to give them information regarding the possible risk nd benefits involved in staying or leaving.

- It is vital to document the individual’s refusal of treatment.

I n f e c t i o n P r e v e n t i o n a n d C o n t r o l

The purpose of an infection prevention and control program is to prevent the transmission of infections within a healthcare facility. Workers can protect themselves and patients by adhering to basic infection prevention and control principles. Standard precaution procedures should be used routinely when caring for patients, regardless of their diagnosis.

S t a n d a r d P r e c a u t i o n s

Standard Precautions is the name of the isolation system used within Intermountain Healthcare, and is used for every patient, regardless of diagnosis. The aim is to minimize risk of exposure to blood or body fluids. To accomplish this, personal protective equipment (PPE) (i.e. gloves, gowns, masks, and goggles) is used for potential contact with body fluids from any patient.

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Precautions include:

Place patient in a private negative pressure room. Keep door closed except to enter / exit.

Wear an N-95 respirator mask, which requires a fit test, or a Powered Air Purifying Respirator (PAPR) when entering the room. Contingent workers will not be assigned these patients due to OSHA’s medical evaluation and fit testing requirements for the use of respirators.

Use proper hand hygiene. Wash or sanitize your hands upon entering patient room, removing gloves, and when leaving the patient room.

O t h e r I n f e c t i o n P r e v e n t i o n a n d C o n t r o l C o n c e r n s i n c l u d e

Artificial Nails Policy

Workers in patient care areas, including those who handle food, medications, or laboratory specimens cannot wear artificial nails, wraps and nail jewelry. Gel and shellac nail polish is not allowed. Regular nail polish is permitted but must be chip free.

Workers assigned to surgical areas are prohibited from wearing artificial nails, wraps, nail jewelry and any type of fingernail polish.

Sharps Containers

All sharps should be placed in a sharps container after use. These containers are placed throughout clinical departments. Containers should be changed before full (pay attention to the “fill line” on container).

Waste

Red bags are used for bio-hazardous waste and must be used if blood or other body fluids can be squeezed or crushed out of the container.

Yellow bags are used for hazardous drugs. Drugs are classified as hazardous if studies in animals or humans indicate that exposures to them have a potential for causing cancer, developmental or reproductive toxicity, or harm to organs. Workers who have not been trained and authorized should not handle hazardous drugs or anything containing a hazardous drug due to the potential for surface contamination. If hazardous drug waste (yellow bag) is found in an unsecured area, notify your Intermountain supervisor/preceptor and facility chemical safety officer immediately.

Black disposal containers are used to dispose of EPA / RCRA regulated pharmaceuticals and bulk hazardous drugs.

Linen

All soiled linen is considered contaminated and should NOT be carried so that it touches the body or clothing of the person transporting it. Wet linen must be wrapped with dry linen or placed in a plastic bag before putting into linen bag to prevent seep-through. If the linen bag is leak proof, no special handling of wet linens is necessary.

E r g o n o m i c s

Ergonomics focuses on creating an environment in which workers would not experience physical problems associated with their work assignment.

Examples of work design that may lead to physical stress include:

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Improper work design can cause repetitive force or movement of the body without an adequate rest period for tissues to recover. Over time, this may lead to damage of tendons, bones, nerves or muscles, typically in the hands, elbows, shoulders, neck and back. An example would be tendonitis progressing to carpal tunnel syndrome.

Certain workers are more at risk for developing problems than others. Examples include those who:

Symptoms that may appear include pain, swelling, numbness, tingling, restricted range of motion, or weakness in the affected body part, with varying degrees of severity.

Obesity, pregnancy, recent weight gain, smoking, lack of general physical condition, and emotional stress may contribute to the development of these disorders. Additionally, activities and hobbies at home can contribute to these symptoms.

At the first sign of discomfort, the worker should discuss medical treatment options with his/her family care provider.

B a c k S a f e t y

Every year many healthcare workers suffer back injuries. Even the simplest activity, if done incorrectly, can strain a back and cause permanent injury. Some of these injuries lead to permanent loss of work. Prevent injuries by following these simple safety guidelines.

L i f t i n g

Use additional staff and mechanical equipment as needed to safely transfer, reposition or lift patients. Never attempt to reposition a patient without help. Don’t overestimate the weight you can lift. (See Intermountain’s Safe Patient Handling policy for more information)

Feet should be kept apart, with one foot next to the object being lifted and one foot slightly behind. This gives greater stability and upward thrust.

Let your legs do the work, not your back. Backs should be straight with knees bent, keeping the knees in line with your feet.

Use your entire hand when lifting. Fingers alone have very little strength. Wrap fingers around the object, with firm pressure from the palm.

Bring the load in close to the body with arms and elbows tucked in close.

Position your body so that weight is distributed inside the feet. This gives better lifting strength and better balance. Lift by using the strength of the legs and not the back.

Never twist your body from side to side when lifting or transferring. This is a major cause of back injuries. Move your feet if a change direction is needed.

Don’t lift or carry objects above shoulder level.

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I d e n t i f i a b l e I n f o r m a t i o n

The following is considered identifiable information by HIPAA and must not be accessed or shared for any purpose other than patient care.

While this section primarily addresses the requirements of the HIPAA Privacy Rule, additional protections and requirements may apply to certain types of sensitive information, such as substance abuse records, genetic test results, social security numbers and credit card numbers. If your work assignment includes accessing or disclosing these types of information, ask the department manager for relevant policies and procedures.

A d d i t i o n a l s t e p s t o p r o t e c t a p a t i e n t ’ s p r i v a c y

Close room doors when discussing treatments and administering procedures.

Close curtains and speak softly in semi-privacy rooms when discussing treatment and performing procedures.

Avoid discussions about patients in public areas such as hallways, the cafeteria/cafe, waiting rooms, restrooms and elevators.

Do not discuss patients with family or friends.

Do not leave patient charts, schedules, or computer screens containing patient information in plain view.

Do not allow visitors or patients in staff areas, dictation rooms, chart storage areas, etc.

Do not hold telephone conversations or conduct dictation in areas where confidential patient information can be overheard.

Call out the patient’s name only in waiting rooms, not their diagnosis or procedure.

Do not share your Intermountain computer systems access code or password with anyone. Take precautions to prevent others from learning your access code and password.

Do not access systems you are not authorized to access. Access only information needed to do your job.

Before discarding any patient-identifiable information, make sure it is properly shredded or locked in a secure bin to be destroyed later. Do not leave information intact in a trashcan.

Do not use cell phones or other electronic devises to take or send photographic images and audio/video recordings of patients and/or medical information.

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the patient’s permission, information necessary for the treatment or payment activities of another healthcare physician or provider if both entities have a relationship with the patient.

Examples of permitted uses and disclosures include:

When sending a specimen to a lab for testing, the physician’s office may send the laboratory the patient’s health plan information so that the laboratory may be reimbursed by the patient’s health plan for services rendered.

A physician’s office may send health information to another physician’s office for the treatment of a patient. As long as both have a relationship with the patient, physicians and other providers may share health information as needed for treatment purposes.

A physician’s office may send health information to a pharmacy so that pharmacy may fill a prescription for a patient. The physician’s office may also send the patient’s health plan information so that the pharmacy may be reimbursed for filling the prescription.

A health plan may share certain member information with another health plan to coordinate benefits.

A health plan may collect data directly from paneled physicians’ medical charts for purposes such as completing HEDIS performance measures or other Quality Improvement studies.

A hospital’s Quality Management department may abstract data from charts at the facility to conduct a study designed to improve patient care.

D i s c l o s u r e s t o P a t i e n t s ’ F a m i l y & F r i e n d s

Only Intermountain employees may disclose health information to a family member, other relative, close personal friend of the patient or any other person identified by the patient.

I n f o r m a t i o n P r i v a c y a n d S e c u r i t y I n c i d e n t s

If a situation arises where patient health information has been shared with the wrong person, or the privacy and/or Qualitysec rity of pa ient healthAssessmentinformation has be n compromised in any way and regardless of whether it was intentional or accidenta , mmediately report the ituation to your supervisor/preceptor or call the Intermountain Compliance Hotline

Performance(1-800-442-4845).Improvement

Intermountain Healthcare is committed to providing quality care and strive to meet customer needs through using a quality assessment performance improvement (QAPI) approach. The QAPI I model used is: Plan, Do, Study, and Act. (PDSA). This model is used to answer the question: What changes can we make that will result in improvement?

P l a n

The planning part requires that Intermountain:

Defines quality. Intermountain defines quality as: meeting or exceeding the customer’s expectations 100% of the time. Quality is delighting the customer.

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D o

Do is the action part of the process; collecting and analyzing data or meeting with involved parties.

S t u d y

Intermountain Healthcare believes that teamwork is the best way to improve processes. A team consists of a small number of people with complementary skills who are committed to a common purpose. Each team member holds him/herself accountable for the team’s success. Teams test new ideas and continue to improve quality.

In a QAPI culture, 80-90% of an worker’s time is spent in day-to-day tasks. The remaining 10-20% of the worker’s time should be spent improving quality of work.

This may involve the following:



NationalDoing quality controlPatientmonitor ngSafety GoalsLearning about quality improvement

Poor quality costs the organiza ion mo ey. However, ach person can m ke a difference. Workers are responsible to look for ways to improve d ily work processes, custom r satisfaction, nd quality outcomes.

Intermountain Healthcare hospitals follow National Patient Safety Goals established by The Joint Commission to improve patient safety. The goals focus on problems in health care safety and how to solve them.

I d e n t i f y P a t i e n t s C o r r e c t l y

Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to ensure each patient receives the correct medicine and treatment.

Ensure the correct patient receives the proper blood during a transfusion.

I m p r o v e S t a f f C o m m u n i c a t i o n

All critical test results must be reported to the patient’s physician.

U s e M e d i c a t i o n s S a f e l y

Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.

Take extra care with patients who take medicines to thin their blood.

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Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicine to take when they go home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

U s e A l a r m s S a f e l y

Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

P r e v e n t I n f e c t i o n

Use hand cleaning guidelines established by the Centers for Disease Control and Prevention or the World of Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

I d e n t i f y P a t i e n t S a f e t y R i s k s

Determine which patients are most likely to try to commit suicide.

P r e v e n t M i s t a k e s i n S u r g e r y

 Ensure the correct surgery is done on the correct patient and at the correct place on the patient’s body. Event Mark the correctReportsplace n the patient’s/bodyIncidentwhere the surgery isReportsto be done.

Pause before the surgery to en ure a mistake is not b ing made.

An incident is any event that is not consistent with the normal, routine operation of a department, which may result in or have potential for injury and/or property damage. The person discovering the incident should report the event via the electronic event reporting system. This report should be submitted within 24 hours of the event.

Event reports are used for the improvement of the quality of patient care and the reduction of any circumstances, which might cause the event to be repeated. When used in this manner, event reports become a tool for the QAPI process.

R e p o r t F a c t s

The event report is used as a means of gathering data to identify repeated events, possible preventative actions, and educational needs. Event Reports are to be filled out electronically via the web event system.

The event report is not part of the medical record and should never be printed and placed in the chart. The medical record should, however, state the pertinent facts and responses about the event, without the mention of an event report being filed. When documenting an incident in the medical record, state the objective facts only, i.e., what you actually saw or heard when you discovered the incident.

Event reports are confidential documents and are protected from disclosure by Utah or Idaho code. Do not mention event reports in the medical record.

According to the Safe Medical Devices Act, event reports must be filled out if there is a malfunction of a piece of medical equipment. The FDA requires healthcare facilities to report when circumstances “reasonably suggest” that a medical device has caused or contributed to the death, serious injury, or serious illness of a patient. This type of event must be reported to the manufacturer and/or the FDA.

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W h e n t o C o m p l e t e a n E v e n t R e p o r t

Breach of department policy, patient injury, delays dealing with anesthesia/surgery/delivery

Behavioral actions and attitudes dealing with AWOL, AMA, violent/agitated behavior or communication problems

Patient care management problems dealing with consents or patient misidentification

Complications of diagnosis and/or treatment, delays, or omissions of diagnostic tests/procedures

Falls of patients and/or visitors

Patient/staff/hospital property missing or damaged should be reported to Security

Medication errors as in, incorrect dose/ patient/ medication/ time/route. IV related and pharmacy related errors

Incidents occurring when using equipment as in equipment failure, user error, etc.

Thefts, vandalism or other criminal activity should be reported to Security

“Near Misses” are events that could have caused serious damage to the patient or staff, but were discovered and averted prior to reaching the patient

S e n t i n e l E v e n t

Sentinel events, as defined by Joint Commission, require immediate notification of Risk Management. A sentinel event, in most cases, is an event that results in unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition.

Additional sentinel event categories include:









 Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities





 Unintended retained foreign object Workplace Ne natal hy erbilirubin miaViolence

Pr longed fluoroscopy or radiati n th rapy to the wrong body part

Workplace violence is conduct which is sufficiently severe, offensive, intimidating or disruptive to cause an individual to reasonably fear for his/her personal safety or the safety of his/her family, friends or property. Intermountain has a number of measures in place to help keep employees and patients safe from workplace violence (e.g. emergency phones in parking lots, reinforce visitation policy, etc.).

Workers can assist by learning:

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W h e n P r e v e n t i o n D o e s N o t W o r k

Remember these important points:

Remain calm.

Secure personal safety.

Call security and/or nursing supervisor so they can follow up.

Cooperate fully with security and law enforcement.

Inform security and law enforcement of restraining orders.

P a t i e n t C a r e A r e a s

Set limits and boundaries.

Limit the number of visitors and define visiting hours.

Define staff space versus visitor space.

Contact security if someone is becoming worrisome.

When confront is necessary, kindly ask the offending person to “please come talk with me out here”—then step out of the room to a more public place.

HarassmentR e p o t i n g W o r k p l a‐cFreee V i o l n c e

Report all workplace viol nce i cidents no matt r how insignificant they may seem. Record the event electronically via the web event y tem or call the compliance hot line, 801-442-4845.

Treating individuals with mutual respect is one of Intermountain Healthcare’s core values. A key component of this value is ensuring all workers are treated in a manner in which each individual’s unique talents and perspective are valued, and providing a work environment in which they feel safe.

Harassment also includes sexual harassment, which is unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when submission to or rejection of this conduct affects an individual’s work performance or creates an intimidating, hostile or offensive work environment.

Examples of harassment or inappropriate behavior may include:

Oral or written communications that contain offensive name-calling, inappropriate sexual connotations, jokes, slurs, negative stereotyping or threats including those that target individual groups based on age, disability, gender, national origin, ethnicity, race or color, religion, sexual orientation or veteran status.

H o w t o R e p o r t H a r a s s m e n t

Contact the facility Human Resources department. The Human Resources department is responsible for conducting a prompt, thorough and confidential investigation. All investigations surrounding incidents of harassment will be conducted confidentially to the extent reasonably possible. Only individuals with a “need to know” will have access to confidential communications resulting from the receipt and investigation of a complaint.

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