Non-Employee Orientation Guide

Transcription

1 Non-Employee Orientation Guide S Y R A C U S E, N E W Y O R K

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3 Contents Section A: ID Badges... 7 Section B: Parking... 7 Section C: University Police Department... 8 Section D: The Globally Harmonized System... 9 Section E: Protecting Patient Privacy and Information Security Section F: Smoke-Free/Tobacco-Free Section G: Domestic Violence at the Workplace Section H: Drug & Alcohol Use Section I: Emergency Codes Section J: Fire and Life Safety Section K: Hazardous Materials & Waste Section L: Incident Command Section M: Infection Control Section N: Missing of an Infant/Child or Patient Section O: Patients And Families Rights Section P: Sexual Harassment Section Q: Workplace Violence Section R: Sexual Violence Section S: Workplace Diversity Section T: Gender Identity Awareness Section U: Emergency Medical Response Section V: Risk Management Section W: ISO

4 Our Mission, Vision & Values I. MISSION: The mission of Upstate Medical University is to improve the health of the communities we serve through education, biomedical research, and healthcare. II. III. VISION: To be a leading academic health center in New York State and a national leader in equitable and innovative health care. VALUES: We Drive Innovation and Discovery We Respect People We Serve Our Community We value Integrity We Embrace Diversity and Inclusion 4

5 Upstate Medical University NON-EMPLOYEE ORIENTATION GUIDE Completion Certificate Upstate Medical University non-employees should review the Non-Employee Orientation Guide and complete this certificate on an annual basis. Name: Upstate Badge ID#: Þ ID# is REQUIRED for entry into Self Serve Tracker *Please Note: If the non-employee is on campus 3-days or less, a badge ID # will NOT be issued; please then keep this form on file only, as completion cannot be entered into Self Serve Tracker. Department: My signature here confirms that I have read and understand the Non-Employee Orientation guide and that I have no questions at this time: Signature: Date: Enter in Self Serve Tracker with code: NONEMPORIENT The department hosting the non-employee should enter completion into Self Serve Tracker with code NONEMPORIENT and keep this form on file within the department. If the department is NOT able to enter into Self Serve Tracker, please send a COPY or fax the completed form for entry to: HR - Organizational Training and Development (OTD) JH Rm. 417 Fax (*Forms MUST have an Upstate Badge ID# to be entered into Self Serve Tracker. Please only submit forms with an Upstate Badge ID# to OTD.) Revised 9/14/16; Organizational Training & Development 5

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7 Section A: ID Badges Downtown: Payroll Office, Jacobsen Hall, 1st Floor (7:00am-4:30pm; Ph: ) Community Campus: Human Resources (HR), Hospital Main Entrance, 1 st Floor; Ph: All Upstate University Hospital employees, non-employees, students, temporary agency placements, and volunteers must wear an Identification Badge at all times when working throughout Upstate University Hospital Campuses, including both owned and leased areas. An approved individual expected to be on campus for a period of 3-days or more must obtain a plastic card-style ID Badge. These individuals must bring with them an additional form of photo identification and a social security number in order to obtain an ID badge (those without a social security number should consult Payroll or HR). Lost badges are replaced for a fee. When an individual leaves campus service, the ID badge must be returned and inactivated. An approved individual expected to be on campus for a period less than 3 days must be registered through the Passage Point system by the appropriate department and must receive a temporary sticker ID badge from Public Safety each day they are on campus. Badges are to be displayed so that the picture and the full name of the employee are visible during all work-related interactions. Forgotten badges must be replaced with a temporary ID from Public Safety. Section B: Parking Downtown: Parking Office, University Hospital, RM 1801 (7:00am-4:00pm; Ph: ) Community Campus: Parking Office, University Hospital Community, Basement RM 213 (7:30am- 4:00pm; Ph: ) All Upstate University Hospital employees, non-employees, students, temporary agency placements, and volunteers should pull a ticket to access the parking garage on their first day at Upstate. If here 3-days or less and not being issued a plastic card-style Upstate ID badge, you will pull a ticket each day and will be responsible for paying the posted parking rates. If being issued a plastic card-style Upstate ID badge, you should contact either campus s Parking Office to discuss parking options and register. You will need your plastic card-style Upstate ID badge and vehicle registration to register for parking. Downtown Campus should anticipate a fee due at parking sign-up. 7

8 Section C: University Police Department The University Police Department services are available at Upstate Medical University on a 24-hour basis, seven days a week. For the assistance of an Officer, call the University Police Department downtown at ; or at the Community Campus call 5511, or stop in their office located on the 1st floor at both campuses. Escort Service: The University Police Department provides escorts, upon request, for all personnel to and from campus locations. Personnel who must walk alone during the hours of darkness are encouraged to take advantage of this service. If you wish an escort, call the University Police Department downtown at ; or at the Community Campus call 5511, or stop in their office located on the 1st floor at both campuses, and arrangements will be made for an officer to assist you. Property Protection: Do not leave valuables unsecured. Keep your office, desk, locker and car doors locked when unattended. This is a precaution against intruders and thieves. Use available procedures for protecting patient property and valuables. Upstate Medical University cannot take responsibility for lost or stolen articles. Report all thefts or other crimes immediately to the University Police Department. No unauthorized solicitors or loiterers are permitted on Upstate Medical University property. Report any unfamiliar or suspicious persons or activities to the University Police Department immediately. Safety Procedures: Each person at Upstate Medical University is an essential participant in creating and maintaining a safe and healthy work environment. To this end, recognizing and reporting potential health and safety concerns is a responsibility shared by everyone. Non-employees should report any on-the-job injuries or illnesses directly to their Department Manager. 8

9 Section D: The Globally Harmonized System Development of a Worldwide System for Hazard Communication REV: 9/1/2015 GHS is an acronym for the Globally Harmonized System of classification and labeling of chemicals. The GHS is a system for standardizing and harmonizing the classification and labeling of chemicals. It is a logical and comprehensive approach to: Defining health, physical and environmental hazards of chemicals; Creating classification process that use available data on chemicals for comparison with the defined hazard criteria; Communicating hazard information, as well as protective measures, on labels and Safety Data Sheets (SDS). 9

10 Improvement of quality and consistency of hazard information in the workplace. Enhance worker comprehension of hazards: reduce confusion and safer use and handling of chemicals. Applicable Laws: OSHA s Hazard Communication Standard NYS Right-to-Know Law New look to labels New signal words, hazard statements and pictograms on labels. More standardized Safety Data Sheets(16 specific sections). Hazards are now communicated with labels and SDS. 10

11 Chemicals can only cause health effects when they come into contact with your body. Routes of entry Skin contact (absorption through the skin or damage on contact to skin or eyes) Inhalation Ingestion Injection Chemicals which pass through the skin are nearly always in liquid form. Solid chemicals and gases or vapors do not generally pass through the skin unless they are first dissolved in moisture on the skin's surface. Some products that can cause irritation or injury are; sulfuric acid, toilet cleaner, dishwashing detergents, household bleach, methyl ethyl ketone, drain cleaner. Wear appropriate Personal Protective Equipment. 11

12 Small amounts of chemicals may enter by dissolving in the liquid surrounding the eyes. Some products that can enter through eye contact are; acid, alkali, alcohol, bleach, ammonia, toluene. Wear appropriate Personal Protective Equipment. Contaminated air in the workplace can be inhaled. Air is drawn through the mouth and nose and then into the lungs. An average person will breath in and out about 12 times a minute. Each of the 12 inhalations brings in about 500 ml of air, corresponding to 6 liters of air per minute, together with any contaminants that the air contains. Some products that can enter through inhalation are; toluene, methyl ethyl ketone, alcohols, acid mists. Wear appropriate Personal Protective Equipment. 12

13 Chemicals can enter the stomach either by swallowing contaminated mucus which has been expelled from the lungs, or by eating and drinking contaminated food. Food and drink are most frequently contaminated by contact with unwashed hands, gloves or clothing, or by being left exposed in the workplace. Nail-biting and smoking also contribute. Some products that can enter through ingestion are; asbestos, lead. Wear appropriate Personal Protective Equipment and wash your hands. In some instances, chemicals may enter by accidental injection through the skin. Once in the blood stream, the chemicals can be transported to any site or organ of the body where they may exert their effects. 13

14 Labels Safety Data Sheets HMIS & NFPA Diamond Symbol pictogram Standard hazard statement Signal Word Danger (more significant) Warning 14

15 0 means almost no hazard 4 means extreme danger Explosive Flammables Oxidizers Carcinogen Acute Toxicity Corrosive Irritant Aquatic Toxicity! Gases Under Pressure 15

16 cause cancer. cause harm to fetuses. cause problems in pregnancy and/or getting pregnant (men and women). means you may have a heightened reaction on second exposure. is the organ that is most effected. means it irritates or harms when you inhale the liquid or solid. means vapors burn. Pyrophorics will ignite spontaneously when exposed to air. can sometimes form explosive compounds by themselves. get warm over time with access to air. 16

17 irritate. cause more severe second-exposure reactions. short term long term Gas under pressure can release pressure quickly causing mechanical hazards and releasing large volumes of gas that can displace air (suffocation potential) or be toxic. 17

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19 19 Oxidizers can cause or contribute to fire in other materials.

20 Danger or Warning Used to emphasize hazard and discriminate between levels of hazard. 20

21 Hazard Category Signal Word Hazard Statement Simple Asphyxiate Warning May displace oxygen and cause rapid suffocation Hazard Category Signal Word Hazard Statement Combustible Dust Warning May form combustible dust concentrations in air GHS label should include appropriate precautionary information. Should describe what the signal word means. The intent is to harmonize precautionary statements in the future. 21

22 Product Identifier Hazard Pictograms CODE Product Name Supplier Identification Company Name Street Address City State Postal Code Country Emergency Phone Number Precautionary Statements Keep container tightly closed. Store in cool, well ventilated place that is locked. Keep away from heat/sparks/open flame. No smoking. Only use non-sparking tools. Use explosion-proof electrical equipment. Take precautionary measure against static discharge. Ground and bond container and receiving equipment. Do not breathe vapors. Wear Protective gloves. Do not eat, drink or smoke when using this product. Wash hands thoroughly after handling. Dispose of in accordance with local, regional, national, international regulations as specified. Signal Word Danger Hazard Statement Highly flammable liquid and vapor. May cause liver and kidney damage. Supplemental Information Directions for use Fill weight: Lot Number: Gross weight: Fill Date: Expiration Date: In Case of Fire: use dry chemical (BC) or Carbon dioxide (CO2) fire extinguisher to extinguish. First Aid If exposed call Poison Center. If on skin (on hair): Take off immediately any contaminated clothing. Rinse skin with water. The SDS should provide comprehensive information about a chemical substance or mixture. Primary Use: The Workplace Employers and workers use the SDS as a source of information about hazards and to obtain advice on safety precautions. 22

23 1. Identification 2. Hazard(s) identification 3. Composition/information on ingredients 4. First-aid measures 5. Fire-fighting measures 6. Accidental release measures 7. Handling and storage 8. Exposure control/personal protection 9. Physical and chemical properties 10. Stability and reactivity 11. Toxicological information 12. Ecological information 13. Disposal considerations 14. Transport information 15. Regulatory information 16. Other information 23

24 The provisions for CBI protection should not compromise the health and safety of users. CBI claims should be limited to the names of chemicals and their concentrations in mixtures. Mechanisms should be established for disclosure in emergency and non-emergency situations. Option #1 1. Go to Upstate Medical University ipage 2. Click on Policies/Forms link 3. Click on Material Safety Data Sheet link on the left side of the page. You will get a Will open new window message. Click OK 4. Dolphin MSDS page will open 5. In upper right, in Find you can type the name of the chemical or product and hit Enter Option #2 Call the Environmental Health Office at

25 If you have a question you should first contact your supervisor. If your question has not been answered or you would like additional information you can contact Upstate Medical University, Environmental Health and Safety (EHS) at

26 Section E: Protecting Patient Privacy and Information Security WHAT IS HIPAA? HIPAA = The Health Insurance Portability and Accountability Act A Federal Law Created in 1996 Protects health information from unauthorized access & misuse Puts safeguards in place for health information collected, maintained, used or transmitted It is everyone s responsibility to secure and protect patient health information. WHAT IS PROTECTED HEALTH INFORMATION? All information about a patient is considered confidential, including information that: Is received, maintained or transmitted in ANY format Relates to the patient s past, present or future medical condition, treatment or payment for care Identifies the patient or could be used to identify the patient HOW CAN CONFIDENTIAL HEALTH INFORMATION BE SHARED? To protect a patient s privacy, confidential health information should be limited to the minimum necessary and only be accessible or shared with those who need to know in order to care for the patient or do their job. Use: The sharing of confidential health information within the organization Disclosure: The sharing of confidential health information with others outside the organization PRIVACY SAFEGUARDS Shred all paper containing confidential health information or place in closed receptacles When faxing, verify the fax number before sending Close doors or privacy curtains and lower your voice when having discussions of confidential health information Do not leave medical records unattended or in open areas Keep confidential health information you hear or see to yourself Before looking at patient information ask yourself Do I need to know this to do my job? and if not, don t look at anything Respect the privacy rights of employees who come here for care by affording their information the utmost confidentiality it deserves 26

27 SECURITY SAFEGUARDS It is your responsibility to be aware of these safeguards and follow them in everyday practices. Some examples of security safeguards include: Do not use or attempt to use another staff member s user ID and password to gain access to Electronic Protected Health Information (ephi) Never leave a workstation signed on/unattended with access to ephi Writing down or posting passwords on equipment for login purposes is not permitted Properly dispose of ephi on CDs, DVDs, or thumb drives Prevent theft of equipment housing ephi Never disable or remove virus detection software PASSWORD MANAGEMENT You are responsible for the management of all your passwords used to access ephi. The sharing of user accounts and/or passwords is prohibited on Upstate computer systems and could result in disciplinary actions. Some best practices for password selection include: Select a password that cannot be easily guessed Passwords must include a combination of number and letters (upper and lower case) Passwords must be at least 6 characters in length Passwords must be changed at least every 180 days Be sure your passwords meet the requirements outlined above! WORKSTATION USE AND SECURITY In order to access ephi, you will need to login using a workstation. Workstation use and security are crucial to the security and access to information. Workstation use and security practices include: Lock workstations when not in use, either using a password protected screen saver or logging off the workstation Workstations must be positioned or located in secure areas You are responsible for securing our workstations and protecting our ephi. SECURITY AUDITS AND MONITORING All systems at SUNY Upstate record all your activity. The information you view and access using your account leaves a digital trail of information where you go and what you do. SUNY Upstate audits and monitors access to ephi systems on a regular basis, therefore only access information that you need to do your job. If you have inappropriately accessed information, you have breached our security policies and practices! 27

28 THE SHARING OF SOME CONFIDENTIAL HEALTH INFORMATION REQUIRES EXTRA CAUTION! The sharing of confidential health information related to certain treatments and services are afforded a higher level of protection under New York State Laws, for example: Alcohol/Substance Abuse Child Abuse Mental Health Genetics HIV-Related Information Oral Disclosure Requires Written Authorization Do not share any confidential health information of this nature, unless you have checked with your immediate supervisor! PERSONAL CONSEQUENCES FOR INAPPROPRIATE ACCESS The penalties that can be levied against an individual for violating these rights can be severe, and include: Termination of employment at SUNY Upstate Charges of professional misconduct and loss of licensure by the NYS Education Department [NYS Education Law 6530(23)] Criminal and civil monetary penalties imposed by the Department of Justice Criminal and civil monetary penalties imposed by the New York State Attorney General INDIVIDUAL CIVIL MONETARY AND CRIMINAL PENALTIES UNDER HITECH FOR VIOLATING PATIENT PRIVACY Knowingly or wrongful uses or disclosures of PHI fined up to $50,000 and 1 year prison Offense committed under false pretenses fined up to $100,000 and 5 years prison Offense committed with intent to sell, transfer or use PHI for personal gain $500,000 and 10 years prison SOCIAL NETWORKING SITES Confidential Health Information about a patient should never be posted on a social networking site such as Facebook, YouTube, Instagram, Twitter, Snapchat, etc. for personal use even if the patient may be the only person who may be able to identify him or herself based on the description. Access to confidential patient information of SUNY Upstate is permitted so care and treatment can be provided to the patient, not for personal use! 28

29 WHO DO I CALL? Each organization must have a Privacy and Security Official to ensure compliance with privacy and security policies. If you observe or suspect that the confidentiality or security of a patient s health information has been violated, you must report it to your supervisor, or the SUNY Upstate Privacy Official or the SUNY Upstate Security Official at: nappac@upstate.edu (Privacy Official) Phone: oreillys@upstate.edu (Security Official) Phone: Hotline: (for anonymous reports) We cannot punish you for reporting suspected violations incidents, and in fact, it is considered your responsibility to make such a report! The relationship between a patient and a healthcare provider is based on trust. The healthcare provider must trust the patient to give full and truthful information and the patient must trust the healthcare provider to respect the privacy of such information. Section F: Smoke-Free/Tobacco-Free Smoking and tobacco use of any kind is prohibited to all persons, including employees, volunteers, students, patients, visitors, contractors, subcontractors, and others in or on Upstate campus s buildings, offices, parking lots, garages, ramps, and all other owned or leased facilities. The Upstate campus includes Sarah Loguen and Elizabeth Blackwell Streets and their associated sidewalks, the hospital circle and its sidewalks, and the Community Campus, including the Physicians Office Buildings and parking lots. This also applies to any vehicle that is on Upstate-owned and/or leased property and in all Upstate-owned or leased vehicles at anytime and any location. Smoking shall include cigarettes, cigars, pipes, electronic cigarettes or other similar items that emit smoke or vapors. Tobacco-free shall include use of tobacco in any form. In accordance with Onondaga County local law, smoking is prohibited on streets and sidewalks within 100 feet of property boundary of University Hospital Downtown Campus and University Hospital Community Campus, where signs are posted stating this restriction. Violators are subject to a fine of up to $ At University Hospital Downtown Campus Contact: Environmental Health and Safety at (during normal business hours) University Police at (after hours) At University Hospital Community Campus Contact: Environmental Services at or Plant Operations at (during normal business hours) 29

30 Section G: Domestic Violence and the Workplace Domestic violence permeates the lives and compromises the safety of thousands of New York State employees each day, with tragic, destructive, and often fatal results. Domestic violence occurs within a wide spectrum of relationships, including married and formerly married couples, couples with children in common, couples who live together or have lived together, gay, lesbian, bisexual and transgender couples, and couples who are dating or who have dated in the past. Domestic violence is defined as a pattern of coercive tactics, which can include physical, psychological, sexual, economic, and emotional abuse perpetrated by one person against an adult intimate partner, with the goal of establishing and maintaining power and control over the victim. In addition to exacting a tremendous toll from the individuals it directly affects, domestic violence often spills over into the workplace, compromising the safety of both victims and coworkers and resulting in lost productivity, increased health care costs, increased absenteeism, and increased employee turnover. Upstate Medical University to the fullest extent possible without violating any existing rules, regulations, statutory requirements, contractual obligations, or collective bargaining agreements, will take all appropriate actions to promote safety in the workplace and respond effectively to the needs of victims of domestic violence. Section H: Drug & Alcohol Use Upstate Medical University prohibits the unlawful manufacture, distribution, dispensing, use, possession, transport, promotion or sale of drugs, drug paraphernalia, or look-alike (simulated) drugs, or the use of alcoholic beverages, at any time when on the premises or elsewhere while on duty. Personnel may not report for duty under the influence of any drug, alcoholic beverage, intoxicant, or other substance (including legally prescribed drugs and medicines) which affects their ability to work safely and efficiently. 30

31 Section I: Emergency Codes EMERGENCY CODE: Code Red Code Amber Code Yellow Code Black Code Orange Code White Code Blue Code Silver Code Grey Code Clear DESCRIPTION: Fire, smoke, or the odor of something burning. Code Amber is activated when an infant/child is confirmed missing. Bomb Threat has been received or potential explosive device has been discovered. National Weather Service has issued a Severe Weather Watch or a Warning that potentially endangers the hospital. Contaminated patients are presenting to the Emergency Department from an external Hazardous Materials Spill. Pediatric Medical Emergency. Adult Medical Emergency. Person with a weapon and/or an individual is being held against their will by an unarmed/armed perpetrator. An adult patient is missing (Eloped, lost, or abducted) from the Hospital. Situation had been resolved. Code Stork (Community Campus Only) 1. Effective November 1, 2016, a Code Stork Team will be implemented at Community Hospital to respond to an Obstetrical Emergency outside of the Family Birth Center. This will include, but not be limited to: a. Imminent Delivery (crowning, bulging perineum, urge to push) b. Uncontrolled Obstetric Bleeding 2. To implement a Code Stork, any staff member or volunteer calls X-2211 and requests a Code Stork and gives the location. 3. Areas that the Code Stork team will respond to are the Community Hospital proper (outside of the Family Birth Center), including the ED, Golisano After Hours, and the Traffic Circle. For more information, you can contact Barbara LaCasse, RN, at or lacasseb@upstate.edu 31

32 Section J: Fire and Life Safety If you see smoke or flames, R A C E: RESCUE or relocate endangered people to a safe place ACTIVATE the fire alarm system and call x for Upstate Medical University and Upstate University Hospital (UUH); for Upstate University Hospital Community Campus (UUHCC) call ; for leased properties call Give fire location. STAY ON THE PHONE DO NOT HANG UP. CONTAIN fire by closing ALL doors and any open windows. DO NOT turn off oxygen unless told to note Oxygen Shut Off valves. Unplug any appliances touch the cord only if equipment appears to be overheating/ smoking. EVACUATE or extinguish. Evacuate the area as quickly as possible. Extinguish the flames with extinguisher if trained and the fire has not left its source. Fire Announcements CODE RED: Tells you a fire alarm has been activated. The operator will announce on the public address system the building and location of the alarm activation. Each department and nursing unit Close ALL doors that are open (patients, service room, fire, and smoke doors) Close ALL windows Clear hallway of ALL equipment Check EXIT areas for clear path Turn on hallway lights Tell visitors to stay in patient s room or visiting areas Listen for additional announcements ALL CLEAR: Tells you fire alarm is over Resume normal activity Section K: Hazardous Materials & Waste Hazardous Materials Spills - Services to be contacted in case of a spill: Blood Downtown Campus: Call Environmental Services at x Community Campus: Call Environmental Services at Chemicals Downtown Campus: Call Environmental Health and Safety at x Nights and weekends: Call University Police Department at x Community Campus: Call Environmental Services at Radioactive Materials Downtown Campus: Call Radiation Safety at x Community Campus: Call Radiology at or

33 Persons exposed to hazardous spills are to be directed to the Emergency Department with the applicable Material Safety Data Sheet (MSDS)/ Safety Data sheet (SDS) Hazardous Material (HAZMAT) spills that cannot be contained require: Remove persons from the spill danger and notify others in the area to leave. Notify- Downtown Campus: Call Environmental Health and Safety at x4-5782; Nights and weekends: Call University Police Department at x Community Campus: Call Public Safety of the incident at Environmental Services at any time Give your name, exact location of the spill, and the type of spill, if known. Regulated Medication Waste Disposal: Regulated Medications are drugs that are toxic to the environment if they are not handled and disposed of properly. When used as prescribed, these drugs do not pose a risk for the nurse or patient. When they go un-used, or partially used, they must be handled differently than non-regulated medications. If you have any questions regarding regulated medication collection and disposal, please contact Environmental Health and Safety at or Community Campus, contact Pharmacy at or Environmental Services at Section L: Incident Command The hospital manages all emergency/disaster events through the Hospital Incident Command System (HICS). An emergency is an INTERNAL or EXTERNAL event that may disrupt the resources, personnel, and patient care services provided by University Hospital. The emergency may be a natural event, such as an ice storm, or pandemic/epidemic. A disaster may be human related, such as a train accident, or riot. A third category can be a hazardous material event that involves a radiological or chemical contamination of individuals. Lastly, it may be a technological issue such as water failure or information systems failure. HICS provides: Organized system to manage events Individuals assigned to specific areas Identified by different colored vest Each job has a job description called Job Action Sheet which lists the tasks to perform, who to report to, and how to contact this person 33

34 When INCIDENT COMMAND is activated: Operator will page THREE times Attention all Hospital Personnel. Incident Command has been activated. Please return to your assigned work area. Incident Command Emergency Number is (at UUH x at Community Campus ) (DO NOT CALL OPERATOR) EMERGENCY COMMUNICATIONS Regular Phones Red Phones (Numbers are listed on the backside of the Incident Command Organizational Chart and policy No. DIS J-06) Vocera FAX Messages may be sent to (at UUH ; at Community Campus ) (policy DIS J-08) Unit Specific Worksheet F80201 should be completed immediately (DIS R-01) GroupWise, FAX messages, and individuals wearing vests will update staff with NEW INFORMATION Operator will page THREE times CODE CLEAR once the situation has been resolved. Section M: Infection Control Hand Hygiene Upstate University Hospital follows the Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health-Care Settings You Should Wash Your Hands Before and after giving care to a patient (touching patient or environment) Before and after eating After removing gloves After sneezing, coughing, or using the bathroom Hand Washing Skill Wet hands with warm water Apply soap Wash hands using friction Wash for at least 15 seconds Dry thoroughly Washing your hands properly takes as long as singing the Happy Birthday song twice. Alcohol-Based Waterless Hand Sanitizers Use only if hands are not visibly soiled Push one time to get gel/foam into palm of hand Rub both hands together using friction till dry 34

35 Employees Who Are Required To Wear Gloves Artificial nails are not acceptable anything that is not your natural nail Nail polish must be in good repair Natural nails should be short Refer to Hand Hygiene Policy/Procedure (Policy IC D-01/Infection Control Manual) Exposure to Blood/Body Fluids Intact skin (no breaks in skin) Wash area with soap and water This is not a blood/body fluid exposure Non-intact skin (breaks in skin) Wash area with soap and water and report injury Needle Sticks and other sharps injuries Wash area with soap and water and report injury Splashes to mucus membranes of eyes, nose, or mouth Flush/rinse area with water and report injury Large volume splash report to Emergency Department for eye irrigation Reporting Blood/Body Fluid Exposures Monday through Friday, 7:30AM to 4PM contact your Employee/Student Health Office - Downtown: ; Community Campus: All other times, weekends and holidays - report to your Emergency Department for evaluation and care. Refer to Management of Employee Exposure to Communicable Diseases -Policy IC E-01 Reporting Communicable Disease Exposures Report the exposure (e.g. chickenpox, measles, scabies, tuberculosis, influenza, pertussis, gastrointestinal illness) to: Monday through Friday, 7:30AM to 4PM contact your Employee Health Office Downtown: ; Community Campus: All other times, weekends and holidays contact the Administrative Supervisor Downtown: call hospital operator/by ; Community Campus: call hospital operator at Refer to Management of Employee Exposure to Communicable Diseases- Policy IC E-01 35

36 Biohazard Symbols This symbol tells staff that something has blood/body fluid on it that could be harmful to them contaminated The color RED is another signal for contamination with blood/body fluids (e.g. instrument bin.) Standard Precautions Infection prevention practices are used to protect both the healthcare worker and the patient Applies to all patients for handling blood & body fluids, excretions and secretions Include the use of hand hygiene and personal protective equipment (PPE) Basic Barrier Precautions includes: Gloves Masks/attached visor Gowns Protective eyewhere Use a resuscitation mask/ambu bag if your patient can t breath Sharps and needles are placed in special containers; staff using sharps should: Avoid using needles or sharps whenever possible Use safety devices whenever possible (safety butterflies, safety IV catheters, safety lancets, etc.) Use transfer devices for filling blood tubes directly Plan for sharps disposal before starting a procedure NEVER recap used needles Soiled or dirty linen is placed in a plastic bag for transport to laundry Discard body waste into hopper or toilet: if chance of splashing, wear eye protection/masks. If soiled with blood/body fluids, reusable equipment is surface wiped down with hospital-approved germicide wipes and then placed in dirty utility/soiled staging area for pick-up. Spills: wipe up gross material with paper towels, and then clean area with a hospital-approved germicide. Clean spills immediately. Wear gloves Watch for sharps Large spill clean-up: Flood large spills with germicide before wiping up Downtown- Vocera housekeeping Community Campus- call Environmental Services at Empty trash carefully, holding it away from your body, never push trash down with your hand or foot 36

37 Section N: Missing of an Infant/Child or Patient Site of Missing or Abducted Child (under 19 years of age) If an infant or child is discovered to be missing or abducted from a patient care unit, treatment, or visitor area, staff will perform the following actions: Report CODE AMBER call Downtown University Police (x4-4000) or Community Campus (x5511) Report last known location of child A description of child (age, sex and race) Person last seen with child Direction of travel Any order of protection Any important medical information Staff then call the Operator Press 0 then press 0 again for Downtown Campus or x2211 for Community Campus Give operator location from which abduction occurred Give operator age, sex and race of child Operator will overhead page CODE AMBER and include descriptive information Remain at incident scene until released by responding Police or Administrative Supervisor Ensure that scene of incident remains untouched Make sure a staff member stays with the family of the abducted/missing person Close all doors Check all patients ID bracelets and visitor badges All Hospital Staff Upon hearing Code Amber Overhead Page Monitor hallways and stairway exits in the immediate area of your location Standby exit doors leading out of the facility, or any public area such as the hospital lobby or cafeteria Look for anything suspicious or out of the ordinary such as an individual carrying a large parcel or forcibly struggling with a child Intervene if it safe to do so while having a co-worker or other individual call UPD If unable to intervene, monitor the direction of the individual and contact UPD Provide a description of the suspicious individual to include race, approximate age, clothing description, vehicle description if applicable. 37

38 When the situation is resolved a CODE AMBER ALL CLEAR will be announced. Site of Missing Adult Patient (over 18 years of age) Ref. Policy M-03 If a patient is assessed to be High Risk and is missing: Search surrounding area Report CODE GREY call Downtown University Police (x4-4000) or Community Campus (x5511) Report last known location of patient A description of patient (age, sex and race) Direction of travel Any order of protection Any important medical information Staff then call Operator Press 0 then press 0 again for Downtown Campus or x2211 for Community Campus Give operator location from which incident occurred Give operator age, sex and race of patient Operator will overhead page CODE GREY and include descriptive information Remain at incident scene until released by responding Police or Administrative Supervisor Ensure that scene of incident remains untouched Make sure a staff member stays with the family of the missing person All Hospital Staff Upon Hearing Code Grey Overhead Page Remain alert in your area of concern to missing patient event and description If patient is seen, attempt to intervene and return patient to unit and/or contact UPD to provide location/direction of travel. 38

39 Section O: Patients And Families Rights The Patient Bill of Rights and other rights are in the patient handbook that we offer to our patients. Patients, staff, and visitors can view the UH Patient Handbook- A Guide to Patients Rights on our Admitting Information website: It is important to know and respect the rights of our patients and families. THE NYS PATIENTS BILL OF RIGHTS: As a patient in a hospital in New York State, you have the right, consistent with law, to: 1. Understand and use these rights. If for any reason you do not understand or you need help, the hospital MUST provide assistance, including an interpreter. 2. Receive treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation, source of payment, or age. 3. Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints. 4. Receive emergency care if you need it. 5. Be informed of the name and position of the doctor who will be in charge of your care in the hospital. 6. Know the names, positions, and functions of any hospital staff involved in your care and refuse their treatment, examination, or observation. 7. A no smoking room. 8. Receive complete information about your diagnosis, treatment, and prognosis. 9. Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment. 10. Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet Deciding About Health Care A Guide for Patients and Families. 11. Refuse treatment and be told what effect this may have on your health. 12. Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation. 13. Privacy while in the hospital and confidentiality of all information and records regarding your care. 14. Participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge. 39

40 15. Review your medical record without charge. Obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay. 16. Receive an itemized bill and explanation of all charges. 17. Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response. If you are not satisfied with the hospital s response, you can complain to the New York State Health Department. The hospital must provide you with the State Health Department telephone number. 18. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors. 19. Make known your wishes in regard to anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the hospital. 20. Complain without fear of reprisals about care and services you are receiving and to have the hospital respond to you and if you request it, a written response. If you are not satisfied with the hosopital s response, you can complain to the New York State Health Department. The hospital must provide you with the State Health Department telephone number. 21. Make known your wishes in regard to anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the hospital. Public Health Law(PHL)2803 (1)(g)Patient s Rights, 10NYCRR, 405.7,405.7(a)(1),405.7(c) IN NYS WE HAVE A PARENTS BILL OF RIGHTS: Each hospital is required to post in a conspicuous place and provide a pediatric patient s parent or other medical decision maker with a copy of a Parents Bill of Rights advising that, at a minimum and subject to laws and regulations governing confidentiality, in connection with every hospital admission or emergency room visit: 1) The hospital must ask each patient or the patient s representative for the name of his or her primary care provider, if known, and shall document such information in the patient s medical record; 2) The hospital may admit pediatric patients only to the extent consistent with their ability to provide qualified staff, space and size appropriate equipment necessary for the unique needs of pediatric patients; 3) To the extent possible given the patient s health and safety, the hospital shall allow at least one parent/guardian to remain with the patient at all times. RIGHTS FOR FAMILY AT UPSTATE UNIVERSITY HOSPITAL: At Upstate University Hospital, you have the right to: 1. Respect and personal dignity We will treat you and your child with courtesy and respect. You know your child best. We can learn from you what is best for your child and family. 40

41 As much privacy as can be provided to allow you and your family time alone. 2. Care that supports you and your family We will provide a place for one family member to spend the night or stay as close to your child as possible at all times. 3. Information that you can understand You have a right to any information you may need to make decisions about your child s care in a language you can understand. 4. Quality health care Family is important for your child s health. You know your child the best. The information you have about your child is important. As members of your child s health care team, we will rely on you to speak up about information that can help in planning what is best for your child. Before your child leaves the hospital, we will provide you with information about caring for your child. We will share community resources that can assist you once your child is home. 5. Emotional support When your child is in the hospital, you and your family may feel sad, angry, guilty, or lonely. Please say what you feel. We can help you work through these feelings. We can help you meet other families with similar experiences or find you additional help if you ask. Care that respects a child s need to grow, play and learn We will provide your child with people to talk to and play with who understand the needs of children. Let us know what play and learning activities your child likes to do to. This will help your child to keep these activities as normal as possible. 6. Make decisions about your child s care You can ask for a second opinion. You may refuse treatments as permitted by law. You can ask to change to another hospital. You can change your mind about your child s care even after you have given permission for treatment. Patients, staff and visitors can also view the Bill of Rights for Children and Teens in our UH Patient Handbook- A Guide to Patients Rights on our Admitting Information website: BILL OF RIGHTS FOR CHILDREN AND TEENS: We will honor your privacy. We will explain things in a way you can understand. You will be taken care of by doctors, nurses, and people who know about children and teenagers. 41

42 We will provide a place for one family member to spend the night or stay as close to you as possible at all times. Your family can stay together as much as possible. If this is not possible, the people caring for you will explain why. You can talk or play with people who know how to help when you have questions or problems. You can make choices whenever possible. You may tell us how we can help you to feel more comfortable. Let us know what play and learning activities you like to do to help you grow and learn while in the hospital. NYS BILL OF RIGHTS FOR BREASTFEEDING MOTHERS: 1. Before You Deliver: You have the right to complete information about the benefits of breastfeeding for yourself and your baby. This will help you make an informed choice on how to feed your baby. You have the right to receive information that is free of commercial interests and includes: How breastfeeding benefits you and your baby nutritionally, medically and emotionally; How to prepare yourself for breastfeeding; How to understand some of the problems you may face and how to solve them. 2. In The Maternal Health Care Facility: You have the right to have your baby stay with you right after birth whether you deliver vaginally or by cesarean section. You have the right to begin breastfeeding within one hour after birth. You have the right to have someone trained to help you in breastfeeding give you information and help you when you need it. You have the right to have your baby not receive any bottle-feeding or pacifiers. You have the right to know about and refuse any drugs that may dry up your milk. You have the right to have your baby in your room with you 24 hours a day. You have the right to breastfeed your baby at any time day or night. You have the right to know if your doctor or your baby s pediatrician is advising against breastfeeding before any feeding decisions are made. You have the right to have a sign on your baby s crib clearly stating that your baby is breastfeeding and that no bottle-feeding of any type is to be offered. 42

43 You have the right to receive full information about how you are doing with breastfeeding and get help on how to improve. You have the right to breastfeed your baby in the neonatal intensive care unit. If nursing is not possible, every attempt will be made to have your baby receive your pumped or expressed milk. If you, or your baby, are re-hospitalized in a maternal care facility after the initial delivery stay, the hospital will make every effort to continue to support breastfeeding, to provide hospital grade electric pumps and rooming in facilities. Section P: Sexual Harassment Upstate Medical University is committed to maintaining an environment that is free from unlawful sexual harassment. Inappropriate and disrespectful conduct and communication of a sexual nature will not be tolerated. What is the Law? Sexual harassment is a form of sex discrimination. It is a violation of federal law under Title VII of the 1964 Civil Rights Act, as amended; Title IX of the Education Amendment of 1972; New York State Human Rights Law; and Executive Order In addition, New York State Executive Orders require State agencies to prohibit sexual harassment in the workplace. In 1980, the Federal Equal Employment Opportunity Commission issued guidelines under Title VII, which state that unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitutes sexual harassment when: 1. submission to such conduct is made either explicitly or implicitly as a term or condition of an individual s employment 2. submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual 3. such conduct has the purpose or effect of unreasonably interfering with an individual s work performance or creating an intimidating, hostile or offensive environment What is Sexual Harassment? A PRACTICAL DEFINITION Sexual harassment is defined as unwelcome verbal or physical sexual advances or statements, which: Are offensive or objectionable to the recipient Cause the recipient discomfort or humiliation Interfere with the recipient s performance Adversely affect a term or condition of employment Sexual harassment may involve the behavior of a person of either sex against a person of the opposite sex or the same sex, when that behavior falls within the definition of sexual harassment. 43

44 Retaliation Federal law prohibits adverse actions against any individual who opposes sexual harassment, files a complaint, or assists or participates in any manner in an investigation, proceeding, or hearing. Those in violation of this law are subject to disciplinary action, up to and including dismissal. Confidentiality In accordance with existing policies and laws, every effort will be made to protect the privacy of all individuals throughout all phases of the complaint investigation and resolution process. Information about complaints will be maintained in confidence to the fullest extent possible. Section Q: Workplace Violence Workplace Violence is defined as violent acts, including physical assaults and threats of assaults, directed toward persons at work, on duty, or on Upstate premises and includes, but is not limited to: 1. The use of force with the intent to cause harm, e.g. physical attacks, any unwanted contact such as hitting, fighting, pushing, or throwing objects; 2. Acts or threats which are intended to intimidate, harass, threaten, bully, coerce, or cause fear of harm, whether directly or indirectly; 3. Acts or threats made directly or indirectly by oral or written words, gestures or symbols that communicate a direct or indirect threat of physical or mental harm. Upstate Medical University is committed to maintaining an environment that is free from intimidation, threats, and violent acts against employees, students, patients, volunteers, vendors, and visitors. Any such acts will be thoroughly investigated and appropriate action taken. All persons are responsible for helping to create an environment of mutual respect, following policies and procedures, and for assisting in maintaining a safe and secure environment. Retaliatory action is prohibited against any person acting in good faith who has made a complaint of workplace violence. No person, without legal authority, may carry, possess, or use any weapon on Upstate owned or leased property. Any individual who commits such an act may be subject to removal from Upstate premises and civil/criminal prosecution. Employees may also be subject to disciplinary action. Section R: Sexual Violence I. Define Sexual Violence A. Sexual violence is a form of sexual harrassment. Sexual violence refers to physical sexual acts perpetrated against a person s will or where a person is incapable of giving consent. B. Sexual violence includes rape, sexual assult, sexual battery, sexual abuse, and sexual coercion. 44

45 1. Sexual assult includes any actual or attempted nonconsensual sexual activity 2. Rape - sexual intercourse without consent, committed with coercion, threat, or intimidation (actual or implied), with or without physical force by a person(s) known or unknown to the victim. C. Intoxication of the accused cannot be used as a defense to an alleged incident involving sexual violence. II. Define Consent A. Affirmative Consent: 1. Affirmative consent is knowing, voluntary, and mutual decision among allparticipants to engage in sexual activity. Consent can be given by words or actions, as long as those words or actions create clear permission regarding willingness to engage in the sexual activity. Silence or lack of resistance, in and of itself, does not demonstrate consent. Consent is required regardless of whether the person initiation the act is under the influence of drugs and/or alcohol. Consent may be initially given but withdrawn at any time. Consent cannot be given when a person is incapacitated, which occurs when an individual lacks the ability to knowingly choose to participate in sexual activity. Consent cannot be given when it is the result of any coercion, intimidation, force, or threat of harm. III. Steps To Take in Response To Sexual Violence: A. Get to a safe place as soon as possible B. Try to preserve all physical evidence; do not bathe, douche or change clothes C. Contact SUNY Upstate Medical University Campus Police at , or call 911 (Syracuse Police) or (Abused Person Unit) D. You may also CONTACT State Police on the dedicated 24-hour hotline at Section S: Workplace Diversity & Creating a Culturally Inclusive Environment Workplace diversity and inclusion is about acknowledging the diverse skills and perspectives that people may contribute because of their gender, age, language, ethnicity, cultural background, disability, religious belief, sexual orientation, working style, education level, professional skills, work and life experiences, socialeconomic backgrounf, job function, geographic location, and other dimensions of diversity. A Culturally inclusive environment requires mutual respect, effective relationships, clear communication, explicit understandings about expectations and critical reflection. 45

46 Cultual Humility To practice cultural humility is to maintain a willingness to suspend what you think you know about a person based on generalizations or stereotypes. Inclusive Practice Inclusive environments on campus contribute to making Upstate Medical University a safe, enjoyable and productive place for everyone in the organization and enhance our interactions with the wider community we serve. Respectful Relationships When genuine acknowledgment, appreciation of, and interest in diversity is experienced, respectful relationships develop. Engaging in respectiful relationships means demonstrating a positive appreciation of people and their cultural values. For more information on workplace diversity and creating a culturally inclusive environment contact: Office of Diversity and Inclusion, Jacobson Hall, suite 711, , odaa@ upstate.edu. Section T: Gender Identy Awareness Governor Cuomo issued state-wide regulations prohibiting harassment and discrimination on the basis of gender identity or transgender status. The New York State Division of Human Rights adopted new regulations that ban discrimination and harassment against transgender people. The regulations affirm that transgender individuals are protected under the state s Human Rights Law. All public and private employers should know that discrimination against transgender persons is unlawful and will not be tolerated anywhere in the state of New York. 46

47 BEST PRACTICES When addressing patients, avoid using gender terms like sir or ma am EXAMPLES How may I help you today? When talking about patients, avoid pronouns and other gender terms. Or, use gender neutral words such as they. NEVER refer to someone as it. Politely ask if you are unsure about a patient s preferred name. Ask respectfully about names if they do not match in your records. Did you goof Politely apologize. Only ask information that is required. Your patient is here in the waiting room They are here for the 3 o clock appointment. What name would you like us to use? I would like to be respectiful - how would you like to be addressed? Could your chart be under another name? What is the name on your insurance? I apologize for using the wrong pronoun. I did not mean to disrespect you. Ask yourself: What do I know? What do I need to know? How can I ask in a sensitive way? Clearly, it is not always possible to avoid mistakes, and simple apoligies can go a long way. If you do slip, you can say something like: I apologize for using the wrong pronoun/name. I did not mean to disrespect you. If you have any questions or would like more information please contact: Office of Diversity and Inclusion Jacobson Hall, suite 711, , odaa@ upstate.edu 47

48 Section U: Emergency Medical Response Policy CM E-15 Emergency Medical Response Tracker Code: EMERGENTMEDICAL Downtown Campus How to call for emergency medical assistance at the following locations: The Code Blue/Code White Team will respond to medical emergencies for patients, visitors, and staff located in: Hospital Proper Cancer Center Tunnel connecting University Hospital and Crouse Hospital Immediately outside of University Hospital and Cancer Center, including: Front Traffic Circle ED Parking Lot Golisano Children s Hospital Circle Bridge to Parking Garage East Sidewalks on south side of Adams Street from corner of Almond Street to Irving Avenue Call x Request Code Blue(Adult) or Code White(Pediatric) Give location and call back number University Hospital main buildings NOT located at 750 East Adams Street: Building 49 Jacobsen Hall CAB Clark Tower Parking Garages/Parking lots Campus West Building (CWB) Weiskotten Hall IHP Call 911 from nearest phone Give location State situation Rev. 12/

49 Policy CM E-15 Emergency Medical Response Community Campus How to call for emergency medical assistance at the following locations: The Code Blue/Code White/Code Stork Team will respond to medical emergencies for patients, visitors, and staff located in: Hospital Proper Traffic Circle Call x 2211 Request Code Blue (Adult) or Code White (Pediatric) Give location and call back number. Other University Hospital Community Campus buildings: Parking Garages Parking Lots Hematology Oncology Associates of Onondaga Hill POB (Physician Office Building) - North and South Cord Blood Bank Center Call 911 Give location State situation Revision 10/

50 Policy CM E-15 Emergency Medical Response Off Campus University Departments How to call for emergency medical assistance at all off campus locations: 550 Harrison Center Bone and Joint Center, 6620 Fly Road, East Syracuse Crouse POB Developmental Evaluation Center, 215 Bassett Street Hill Medical Center, 1000 East Genesee Street IHP--505 Irving Ave Joslin Diabetes Off Center, Campus 3229 East Departments Genesee Street Madison Irving, 475 Irving Ave McMahon/Ryan Child Advocacy Center, 601 E. Genesee St. PT/OT 102 West Seneca Turnpike, Suite 200 Sleep Center, Medical Center West Suite 101, 5700 West Genesee Street TU #3-713 Harrison Street UHCC-90 Presidential Plaza Upstate Pediatrics, Belgium Meadows 3448, Rt. 31 Upstate Rehabilitation Center, 4671 Onondaga Blvd Call x 911 Give location State emergency Call x 911 Give location State situation Rev. 12/

51 Section V: Risk Management What you need to know Responsibilities for the department of Risk Management Strategies to reduce risk How to report an Event Risk Management is the preventative process for managing risks. This involves identifying risks, strategizing ways to avoid or mitigate those risks and developing a contingency plan in cases where risks cannot be prevented or avoided. Identification of the risk is very important. Filing an Event Report is one way to identify an issue that requires attention and follow up. I. DEPARTMENT OF RISK MANAGEMENT: a. Hospital wide program responsible for the monitoring, controlling, and prevention of potential liability exposure b. Enhances the safety of patients, visitors, and employees, and, c. Seeks to prevent liability through a process of education, feedback, and early response II. CLAIMS MANAGEMENT a. Claims Handling Medical Malpractice b. Interface with NYS Attorney General c. Receiver of Legal Requests d. Coordinator of Investigations e. Processing Event Reports f. Processing Medication Events III. REGULATORY FUNCTIONS a. Department of Health NYPORTS & DOH Complaint Investigations b. Justice Center/ Office of Mental Health Reporting and Investigations c. Office of Professional Discipline Reporting for Licensed Personnel d. EMTALA/COBRA Case Reviews and Regulatory Reporting IV. EVENT AND INJURY REPORTING (POLICY NUMBER: I-03) a. All University Hospital workforce members are to notify Risk Management upon identification of various events/occurrences including safety hazards, near misses, accidents, adverse events, medical events, or injuries within 24 hours of the event. b. The Upstate University Hospital Intranet Web Event Reporting System is available on the Novell Applications Window at every computer terminal via the Safety Intelligence icon. c. The Patient Safety Hotline is available for reporting by calling 4-SAFE (4-7233) d. If the event involves a visitor, University Police must be contacted e. If the event involves employees or volunteers, Injury Report Form #F83120 must be submitted to Human Resources Benefits Office within 24 hours of the event. 51

52 f. For a significant adverse event or outcome identified following review of the facts, a Root Cause Analysis (RCA) will be initiated to determine what causal factors contributed to the event and what improvements can reduce the likelihood of recurrence. RISK MANAGEMENT OFFICES: Downtown - Jacobsen Hall 914 Phone: Fax: gagnont@upstate.edu ISO Section 9001 W: ISO 9001 Community - Suite 1504 Phone: Fax: georgep@upstate.edu ISO 9001 is a Quality Management System that utilizes best practice for achieving systematic high quality. ISO 9001 has 3 C s as its main principles; they are: Provide Consistent service Improve patient/customer satisfaction Continually improve the organization Upstate University Hospital s quality information is located on the Policy Page under the quality tab in the blue bar near the top of the screen. ISO 9001 are the policies that help us to be consistent in our practices and help with continual improvement Policies should always be accessed on the ipage, NEVER stored in hard- copy format Performance Improvement is the same as quality improvement: As a hospital we are working on improving Patient Satisfaction, Patient Safety, and Staff Satisfaction Decreasing hospital acquired infections Improving turnaround times for patient care Upstate s policies and procedures are in place to ensure compliance with standards and regulatory requirements; therefore you need to adhere to our policies at all times. All policies can be accessed from the ipage, Policies & Forms icon 52

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54 SOUTH AVENUE RTE. 173 COMMUNITY CAMPUS 4900 BROAD RD. SYRACUSE, NY PATIENT PARKING GARAGE PHYSICIAN S OFFICE BUILDING SOUTH PHYSICIAN S OFFICE BUILDING NORTH WALKWAY AFTER HOURS CARE EMERGENCY DEPARTMENT EMERGENCY DEPARTMENT PARKING MAIN ENTRANCE UPSTATE UNIVERSITY HOSPITAL H.O.A.C. MEDICAL PARKWAY PARKING CORD BLOOD BANK BROAD ROAD Patient Parking Physician Offices and Patient Care Areas Under Construction TO DOWNTOWN CAMPUS (750 EAST ADAMS ST., SYRACUSE): 3 MILES NORTHEAST OF COMMUNITY CAMPUS 54

55 HARRISON STREET EAST ADAMS STREET WALKWAY EAST ADAMS STREET HARRISON STREET MADISON STREET HILL MEDICAL CENTER SOUTH CROUSE AVENUE MADISON- IRVING MEDICAL CENTER FAMILY MEDICINE INSTITUTE FOR HUMAN PERFORMANCE DOWNTOWN CAMPUS 750 E. ADAMS ST. SYRACUSE, NY PUBLIC PARKING PHYSICIAN S OFFICE BUILDING IRVING AVENUE UPSTATE JOSLIN DIABETES CENTER 3229 E. GENESEE ST. 2.7 MILES NE OF MAIN CAMPUS RONALD McDONALD HOUSE 1100 E. GENESEE ST..6 MILES NE OF MAIN CAMPUS CLARK TOWER CAMPUS ACTIVITIES BUILDING JACOBSEN HALL ELIZABETH BLACKWELL STREET PARKING GOLISANO CHILDREN S HOSPITAL EMERGENCY DEPARTMENT CROUSE HOSPITAL WEISKOTTEN HALL SETNOR ACADEMIC BUILDING HEALTH SCIENCES LIBRARY SYRACUSE V.A. MEDICAL CENTER UPSTATE CHILD CARE CENTER 650 S. SALINA ST. 1.2 MILES SW OF MAIN CAMPUS UPSTATE COLLEGE OF NURSING 545 CEDAR ST..5 MILES N OF MAIN CAMPUS CENTER FOR FORENSIC SCIENCES SARAH LOGUEN ST. EAST PARKING GARAGE WALKWAY UPSTATE UNIVERSITY HOSPITAL MAIN ENTRANCE SILVERMAN HALL PSYCHIATRY AND BEHAVIORAL SCIENCES WEST PARKING GARAGE UPSTATE CANCER CENTER REGIONAL ONCOLOGY CENTER CAMPUS WEST BUILDING ALMOND STREET INTERSTATE 81 - NORTH EXIT 18 MADISON TOWERS EXIT 18 PARKING UPSTATE HEALTH CARE CENTER INTERSTATE 81 - SOUTH PARKING UPSTATE SPECIALTY SERVICES CENTER GENEVA TOWER 550 HARRISON CENTER Patient Parking Under Construction Physician Offices and Patient Care Areas Golisano Children s Hospital Partner TOWNSEND STREET Academic/ Administrative/ Student Building TO COMMUNITY CAMPUS (4900 BROAD RD., SYRACUSE): 3 MILES SOUTHWEST OF DOWNTOWN CAMPUS?F83098 Rev. 8/2017