STUDENT ORIENTATION PACKET

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1 STUDENT ORIENTATION PACKET Instructions: 1. Review and complete the entire Student Orientation Packet. 2. Complete the Infection Prevention Quiz. 3. Receive Tuberculosis Skin test and attach proof of clearance. 4. Login to our website select school to begin your background check and drug screen. 5. Once all of the above is completed please turn in the completed packet, (pages 16-24), to Human Resources 520 W Mineral King Ave, Visalia, CA (First Floor) 6. Complete the 48 hour checklist on your first day and return it to Human Resources. Please note: This can take up to 10 business days to process. All backgrounds & drug screen clearances need to be within 30 days of your start date. Updated Thank you and Welcome

2 WHO WE ARE OUR VISION Delivering excellence. Together, Kaweah Delta and the Medical Staff will be recognized for consistently delivering a broad range of exceptional health care services, superior clinical quality and exemplary customer service LIVING OUR MISSION STATEMENT To provide safe, high quality, customeroriented and financially strong healthcare services that meet the needs of those we serve. As the title of this section suggests, living out the mission by our actions is far more important than just words. This means that we exist for one reason only: our patients and their families. Through our conduct and our care we must constantly strive to help the patient achieve the best possible outcome, whether it is an in-patient setting or outpatient facility in any of the many District venues. Being courteous and professional at all times must be the hallmark of all District staff. Every person we meet should be treated with special consideration. We must all be good stewards of the resources we have, using our supplies and equipment properly, performing jobs with skill and expertise, maintaining a clean and safe environment, and remaining progressive by constantly improving in all that we do. Living out the mission statement is part of everyone s job description. As the mission statement is incorporated into our everyday life, we can be assured that Kaweah Delta Health Care District will continue to provide the best in healthcare services to our patients and community. OUR VALUES In 1992, we took the values that had always existed at Kaweah Delta Health Care District and put them in writing. Kaweah Delta Values are as follows: Vision - We plan for and act to produce an ever-improving future. Integrity - We are completely honest, candid, and transparent in our dealings. Care- The patient must be at the center of all we do. Accountability - We are completely responsible for our results - no excuses. Respect - We collaborate effectively with others and are socially and interpersonally competent. Excellence - We accept nothing less than our very best efforts and expect the same of others. SERVICES The Kaweah Delta Health Care District (KDHCD) serves Visalia and surrounding communities. The District is defined as including all campus locations of KDHCD. KDHCD provides a full spectrum of healthcare services utilizing an array of cutting-edge medical technologies. The District consists of nine (9) campuses from Visalia to Porterville. Kaweah Delta Medical Center, located in downtown Visalia, is only part of the extensive district, which has been recognized for its dedication to the health, and well-being of the South Valley. From open-heart surgery to physical therapy, from cancer care to neurosurgery, Kaweah Delta makes world-class care available right at home. Kaweah Delta Health Care District includes the largest acute care hospital in Tulare County with 581 beds and is designated as a Level III Trauma Center. Visalia Family Medicine Center located in the 202 W. Willow building is where its Family Medicine Residents practice. South Campus includes Kaweah Delta Urgent Care, a walk-in medical clinic, Kaweah Delta Skilled Nursing and Transitional Care Unit, Kaweah Delta Admissions and Testing services, and the Employee Assistance Program. Kaweah Delta has four (4) rural health Clinics. They include Kaweah Delta Exeter Health Clinic, Kaweah Delta Woodlake Health Clinic, Kaweah Delta Lindsay Health Clinic, and Kaweah Delta Dinuba Health Clinic. These clinics serve the rural areas of Tulare County with Family Medicine, Adult Medicine, Women s Health and Behavioral Health Services. Kaweah Delta has two (2) dialysis centers. One (1) center is in Porterville and the second is in Visalia. Located on our West Campus, are Kaweah Update

3 Delta s Rehabilitation Hospital, Kaweah Delta Mental Health Hospital, Kaweah Delta Imaging Center, Sequoia Regional Cancer Center, Visalia Dialysis, The Lifestyle Center, Therapy Specialists and Sequoia Prompt Care. In addition, Kaweah Delta maintains partnerships with Sequoia Surgery Center, Sequoia Regional Cancer Center in Visalia and Hanford, Quail Park Retirement Village and Quail Park Memory Care Residences. Kaweah Delta continues to invest in the newest technology to service the community and to attract the finest physicians to the area. Kaweah Delta s six-floor Acequia Wing tower opened its doors in The expansion included increasing the size of the Emergency Department, which handles more than 90,000 visits a year. Its helipad, completed in 2014, services incoming and outgoing medical emergencies. It provides support to the Trauma Center. The Acequia Wing includes post- delivery rooms for mothers and their babies. Cardiovascular care is a large part of what is provided inside the Acequia Wing. The Telemetry Department, Cardiac Surgery and Catheterization Labs, three (3) new surgery suites and the new Cardiac Intensive Care Unit complete the cardiovascular care offered inside the Acequia Wing. Kaweah Delta attracts patients from a broad area of the Central Valley because of the array of services and the technology offered. Examples of those include the hybrid endovascular surgical suite, EP cardiology, cancer care, Neonatal Intensive Care Unit, Pediatrics, sleep disorders center, Exeter Pediatric Specialty Clinic, specialized orthopedics, comprehensive inpatient and outpatient rehabilitation services, and mental health services. Patients who at one time would have had to travel out of the area for specialized care are now able to stay close to home, near friends and family, to receive high-quality care. Kaweah Delta is committed to delivering services in a personal, professional and compassionate manner to members of our community, one patient at a time. OUR HISTORY Kaweah Delta Health Care District is one of the area s most progressive healthcare providers in Tulare County. Since its beginnings in 1961, Kaweah Delta employees have worked tirelessly to provide the community it serves with a broad spectrum of high-quality healthcare services. In March of 1961, voters approved the establishment of a hospital district and on July 1, 1963, the new hospital opened as Kaweah Delta District Hospital with 224 beds and approximately 900 full- and part- time employees, a voluntary Medical staff and contract physicians in the Emergency Department. Kaweah Delta has always been at home in downtown Visalia. It has been there, in one form or another, since 1921, when doctors began converting homes in the area to offices. More than 5,000 people work downtown and a good portion of them work at the hospital. Today, the District employs more than 3,800 employees. Kaweah Delta Health Care District is a political subdivision of the State of California and is governed by an elected board of directors. The District derives less than one- half percent of total budgeted operating revenues from local taxes. The remainder includes net patient services revenue, management services revenue, and other operating revenues. Kaweah Delta has continued to expand its campus to grow with the community and the ever-changing world of technology. Our Kaweah Care Culture Kaweah Care is our shared vision for achieving outstanding levels of patient, staff and physician satisfaction. By providing personal, professional and compassionate experiences for every person, every time, we co-create an environment where we are known for being the best place to work, the best place to practice medicine and, above all else, the best place to receive care in the Central Valley. Update

4 Kaweah Care taps into the creativity and experience of employees at all levels throughout the organization to challenge status quo and seek excellence in all that we do. You can expect Kaweah Care to be modeled by your supervisor and your coworkers; Kaweah Care is much more than what we do, it is who we are! Kaweah Care Service Teams Kaweah Care Service Teams are comprised of staff and leaders selected for their outstanding performance and commitment to service excellence. The primary purpose of service teams is to support the goals of the organization by creating energy, tools, and resources to improve and support Kaweah Care experiences. Kaweah Care Action Tools All employees are empowered and accountable to model Kaweah Care, and are provided with tools to support our goals. These tools include: RELATE Words that Work Patient Rounding PROACT Service Recovery Behavioral Standards of Performance Leadership Competencies Communication Boards Employee Rounding District Daily PSAT Patient Satisfaction Action Tool Physician Action Line Speak with your supervisor for more information regarding Kaweah Care. OUR LOCATIONS Main Campus, Kaweah Delta Medical Center, 400 W. Mineral King, West Campus: o Kaweah Delta Rehabilitation Hospital, 840 S. Akers, o Kaweah Delta Mental Health Hospital, 1100 S. Akers, o The Lifestyle Center, 5105 W. Cypress, o Kaweah Delta Imaging Center, 4949 W. Cypress, o Kaweah Delta Visalia Dialysis o 5040 W. Tulare Avenue, o Sequoia Prompt Care, 820 W. Akers, o Therapy Specialists, 820 W. Akers, o Sequoia Regional Cancer Center (Visalia and Hanford locations), South Campus, 1633 S. Court St. includes o Kaweah Delta Urgent Care, Kaweah Delta Skilled Nursing & Transitional Care Unit, o Kaweah Delta Admissions & Testing services, and o Employee Assistance Program, Rural Health Clinics: o Kaweah Delta Exeter Health Clinic, 1014 o San Juan Ave, Exeter, o Kaweah Delta Lindsay Health Clinic 839 o North Sequoia Ave., Lindsay, CA o o Kaweah Delta Woodlake Clinic, 180 E. Antelope Ave., Woodlake, o Kaweah Delta Dinuba Clinic, 855 Monte Vista Drive, Dinuba Other Services o Sequoia Prompt Care, 1110 S. Ben Maddox Way, Visalia, o Sequoia Prompt Care, 820 W. Akers St., Suite 100, inside Sequoia Medical Plaza, o Kaweah Delta Porterville Dialysis o Center, 385 N. Pearson, Kaweah Delta Hospice, 900 W. Oak, Sequoia Regional Cancer Center Hanford,1443 W. 7 th Street, Hanford, Parking - Refer to parking maps, pages & park in public lots Parking permits are issued to all District staff members (red permit), doctors (green permit), and clergy (blue permit). The permit should be hung from the vehicle s rear view mirror. Cars parked in staff member lots without a permit will be cited with a parking ticket that is reported to the Department of Motor Vehicles. Vehicles parked in District lots without the appropriate permit may be towed away at the District s discretion. Parking violations are subject to discipline. No staff Update

5 members (except for night shift) may park in visitor lots. If you are a staff member not on duty and visiting or using hospital facilities not as a staff member, you may park in visitor lots. A map of our parking lots is available in Human Resources. If you received a citation and believe it was issued in error, please contest the citation by going online to: or you can submit your response by mail to the address listed on the back of the parking citation. If you feel that you have been unfairly treated or have a complaint against the issuing officer, please contact the Security Services Manager at Social Networking Policy Kaweah Delta Health Care District (District) believes that participation in online communities can promote better communication with District s colleagues and customers, the general public, traditional and non-traditional media, and other community stakeholders. Such participation may include, but is not limited to, postings in online forums, web logs (blogs), microblogs, wikis or vlogs (e.g., Facebook, LinkedIn, MySpace, YouTube, Twitter, health pages and blogs, media sites or other similar types of online forums). Communications produced by the District s employees and workforce, which includes Medical Staff members, volunteers, trainees and other persons whose conduct, in the performance of work for the District or on behalf of the District in the online community, must be consistent with the District s Code of Conduct and Employee Handbook policies. The purpose of this policy is to assure i) communications in online communities made on behalf of the District are consistent with the organizations Employee Handbook and Code of Conduct, policies, and applicable laws, including laws concerning privacy, confidentiality, copyright, and trademarks; ii) that employees, physicians and contractors personal opinions in online communities express the fact that they are not posting comments as representatives of the District; and iii) Use of District- sponsored communities are appropriate The District urges employees to report any violations or possible or perceived violations to supervisors, managers or the HR Department or Compliance Department. Violations include discussions of the District s activities, its employees, patients, patient care clients, proprietary information, and any unlawful activity related to blogging or social networking. See policy HR.236 Professional Image and Staff Member Appearance Kaweah Delta Health Care District is committed to maintaining a professional workplace environment. Many factors contribute to a professional image, one of which is professionally dressed staff. Personal neatness and appropriate attire enhance your professional appearance and inspire confidence in your abilities. All employees are expected to meet good standards of grooming and attire. Managers will counsel any staff member whose appearance is not considered acceptable and in accordance with District policy. See policy HR.197 Solicitation and Distribution Refer to Code of Conduct section, and refer to HR Policy, 196 Personal Calls, Visits, Mail, Electronic Media and Social Networking Except in emergency cases, staff members are discouraged from making and receiving personal visits and telephone calls during working hours. Visits from friends and family are to be kept to a minimum, in order to preserve an appropriate work environment. It is extremely important that the impression left with District visitors is that of a professional organization with the highest standards of conduct. All communication systems, including but not limited to electronic mail, Intranet, Internet access, telephones, and voic are the property of the District and are to be used primarily for+ business purposes in accordance with electronic communications policies and standards. The District maintains the right and the ability to access such messages. Employees may not use internal communication channels or access to the Internet at work to post, store, transmit, download or distribute any threatening or false materials, sexually offensive or pornographic material, chain letters, personal broadcast messages or copyrighted documents that are not authorized for reproduction. The District uses social media in limited circumstances for defined business purposes. Social media is a set of Internet tools that aid in the facilitation of interaction between people online. Use of Internet-based social media programs such as Face- book, LinkedIn, and Twitter (this is not meant to be an exhaustive list - if you have specific questions about which programs the District deems to be social media, Update

6 please consult with your supervisor or Human Resources) may be used in furtherance of District goals. If it is necessary for you to use a social networking tool to perform your job duties your supervisor and Human Resources will provide you with written authorization to do so. The authorization is limited to business purposes. Personal use of these social media program during work hours is prohibited and can result in discipline up to and including termination. See policy HR.195 Harassment It is the policy of Kaweah Delta Health Care District to provide a work environment free from unlawful harassment. District policy prohibits sexual harassment and harassment based on: District policy prohibits unlawful discrimination based on: Race Marital Status Color Ancestry National Origin Sex Physical Disability Mental Disability Age (over 40) Gender Identity Gender Expression Gender Sexual Orientation Medical Condition Pregnancy Pregnancy Disability Leave Registered domestic partner status Request for or utilization of f medical and family care leave Request for or utilization of pregnancy disability leave District policy prohibits retaliation for protesting discrimination related to one of the above referenced categories District policy prohibits retaliation for reporting patient abuse in tax supported institutions or any other consideration made unlawful by federal, state or local laws. District Policy prohibits unlawful discrimination based on the perception that anyone has any of the above referenced characteristics or is associated with a person who has or is perceived as having any of those characteristics. All such discrimination is unlawful. It is the policy of the District to comply with the Americans with Disabilities Act (ADA), the Americans with Disabilities Act Amendments Act of 2008 (ADAAA) the California Fair Employment & Housing Act (FEHA), and the comprehensive civil rights laws that prohibit discrimination against a qualified applicant or employee because of his/her disability. Under the ADA, ADAAA and FEHA, qualified individuals with disabilities must have equal access to all aspects of employment that are available to employees without disabilities. Pursuant to the ADA, ADAAA and the FEHA, the District will provide reasonable accommodation to a qualified applicant and/or employee with a disability to allow him/her to perform the essential functions of his/her job, unless the accommodation would create an undue hardship for the District. Unlawful discrimination or harassment in any form, including verbal, physical, and visual conduct, threats, demands or harassing conduct that affects tangible job benefits, that interferes unreasonably with an individual's work performance or that creates an intimidating, hostile or offensive working environment is strictly prohibited. Retaliation is also prohibited. Refer to Code of Conduct page 12 for additional information. Drugs, Alcohol and Smoke Free Workplace Refer to Code of Conduct document, and refer to HR.200 January 1, 2011, the District became a tobaccofree workplace. The District s policy includes the prohibition of electronic cigarettes. Effective January 5, 2015, the District began enforcing a no smoking policy for its patients, visitors and employees so as to comply with a local municipal ordinance. There is No Smoking Zone signage throughout the District s properties. Any staff member violating this policy could be subject to disciplinary action. Any visitors observed violating this policy will be asked to follow the policy or asked to leave the premises. See policy HR.193 Workplace Violence Kaweah Delta Health Care District maintains a ZERO TOLERANCE standard of violence in the workplace. The purpose of this policy is to provide District employees guidance for maintaining an environment throughout the District and at District events that are free of violence and the threat of violence. Violent behavior of any kind or threats of violence either implied or direct, are prohibited at the District, at Update

7 District- sponsored events, or where an employee performs any work-related duty, including travel to and from work assignments. Such conduct by a District employee will not be tolerated. An employee who exhibits violent behavior may be subject to criminal prosecution and subject to disciplinary action up to and including termination. See policy HR.202 and Code of Conduct, page 12. Workplace Bullying It is the policy of the District to provide a work environment free from behaviors that undermine a culture of safety. A culture of safety includes both employee and patient safety. It is the District s policy that all employees should be able to work in an environment free of bullying. Therefore, the District has adopted a ZERO TOLERANCE policy for workplace bullying which may adversely affect an employee s work or work environment. Workplace bullying refers to repeated, unreasonable intimidating and/or disruptive behavior of individuals (or a group) directed toward an employee (or a group of employees), which is intended to intimidate, degrade, humiliate, or undermine; or which creates a risk to the health or safety of any patient or employee(s). An employee who exhibits bullying behavior may be subject to disciplinary action up to and including termination. See policy HR.214 and Code of Conduct, page 13. Purpose of the Code of Conduct Our Code of Conduct provides guidance to all Kaweah Delta Health Care District (Kaweah Delta) employees and our care partners. The Code assists us in carrying out our daily activities and working within appropriate ethical and legal standards. These obligations apply to our relationships with patients, affiliated physicians, third-party payers, subcontractors, independent contractors, vendors, volunteers, consultants and one another. The Code is a critical component of our overall Compliance Program. We have developed the Code to ensure we all understand our ethical obligations and standards, and comply with all applicable laws and regulations. The Code is intended to be comprehensive and easily understood. However, in many cases, the subject matter discussed may have complexities that require additional guidance and direction. To provide additional guidance, we have developed comprehensive policies and procedures which may be accessed on Kaweah Delta s Intranet. Those policies expand upon many of the principles communicated in this Code of Conduct. The standards set forth in the Code are mandatory and must be followed. The District Kaweah Delta Health Care District is a community venture, operating under the authority granted through the California Health and Safety Code as a health care district. The purpose of the District is to provide quality health care within defined areas of expertise. It is the intent of District that no person shall be denied emergency admission or emergency treatment based on ability to pay. It is further the intent of the District that no person shall be denied admission or treatment based upon race, color, national origin, ethnic, economic, religious or age status or on the basis of sexual preference. The medical welfare of the community and its particular health needs will be fulfilled to the capacity of the District s financial limitations. Kaweah Delta Health Care District operates under the authority of California Code for a health care district. As such, Kaweah Delta Health Care District is publicly owned and operates as a nonprofit entity. SAFETY AND HEALTH Environment of Care (Safety) Every District staff member is responsible for safety and the safety of others in the workplace. To achieve our goal of maintaining a safe workplace, everyone must be safety conscious at all times. In compliance with state and federal laws and to promote a safe workplace, the District maintains an Environment of Care program and a disaster plan. You must comply with safety policies and procedures at all times. You must know and understand the disaster plan for your job and department. Fire Prevention and Fire Safety (Life Safety) It is mandatory that every new staff member read and understand the Environment of Care manual, which includes fire safety (Life Safety) information. Update

8 Every precaution is taken to prevent fire. You are asked to do your part daily by being constantly alert (this includes keeping fire doors shut.) Fire instructions are contained In your Environment of Care manual. If you observe a fire or smoke, remember R.A.C.E. R A C E Rescue anyone who is in immediate danger (patients, visitors, etc.) Alarm. Sound the fire alarm know where the fire alarms are in your work area and pull the alarm. If you are located within Kaweah Delta Hospital, dial 44. If you are located at Kaweah Delta Rehabilitation Hospital, dial 44. If you are located at Kaweah Delta Subacute, Urgent Care, Kaweah Delta Mental Health hospital, dial to report the emergency and your street location. Then, dial 44 to notify the hospital operator. If you are in an outside building (Support Services, General Accounting, Kaweah Kids, Dialysis, Warehouse, Multi-Service Center, etc.), dial to report the emergency and your street location. Then, call 44 and notify the hospital operator. Contain the fire by closing the door. Extinguish the fire if possible. Know where the fire extinguishers are located in your work area. You are required to attend the annual training on fire extinguishers. The code name for a fire is Code Red. You are required to read the Environment of Care manual carefully and review it frequently for procedures during fires and disasters. Disaster Plan There are two types of disasters: internal and external. An internal disaster means there is a disaster within one or more of the District s facilities. An external disaster is usually located outside the District area. Our response to a community disaster will always vary depending upon the time of day, number of patients, type of disaster, and other hospital factors. The hospital utilizes HICS (Hospital Incident Command System) for its response to internal and external disasters. The Environment of Care manual explains your role and the use of the HICS program in an internal or external disaster. Emergency Codes and Notification In addition to Code Red for fire, the District has a number of emergency codes used to alert you of various situations occurring in the District s facilities.. These codes are listed on your badge attachment. All staff members are expected to know their duties during an emergency. Please refer to the Environment of Care manual for your response in these situations. If your department is not in the hospital building, you must dial for emergency services. After calling through or to your operator (depending upon location) call and report to the District operator by dialing 44. Reporting Accidents Injury to Patients: If a patient is injured or involved in an accident, you must provide all assistance possible and then report the incident to a representative of the Nursing Department as well as to your supervisor. If the patient is seriously injured, do not attempt to move the patient until you have approval from the attending physician or an authorized representative of the Nursing Department. A Notification of Event form must be completed for all such accidents by the department concerned and submitted to the Performance Improvement Department. In the event of serious injury, the District s Director of Risk Management must be informed immediately by calling or through the hospital operator. Injuries to Visitors: Essentially the same procedures for injury to patients apply to injuries to visitors. If a visitor is injured they may be evaluated in the Emergency Department. They may, however, wish to proceed directly to their own physician. In either event, the Unit Manager or Nursing Supervisor will be responsible for documenting the incident and the arrangements made for care on the Notification of Event form. A Notification of Event form must be completed for any injury to a visitor and submitted to the Performance Improvement Department. In the event of serious injury the District s Director of Risk Management must be informed immediately by calling or through the hospital operator. DO NOT indicate to the visitor that medical care will be provided free of charge. This determination can only be made by the Director of Risk Management or their designee after investigation of the incident. Update

9 Injuries on the Job: WORK INJURIES, NO MATTER HOW MINOR, MUST BE REPORTED IMMEDIATELY (OR AS SOON AS THE STAFF MEMBER IS AWARE OF THE INJURY) TO THE SUPERVISOR ON DUTY. A Staff Member must complete a Report of Accident/Injury form. A California State DWC form must be completed if treatment is needed. This form is obtained in Employee Health Services. Upon notification of the injury/illness to the supervisor, you must call or come to the Employee Health Services department to report your injury. These steps are necessary in order for you to be covered under the District s workers compensation program. Failure to report a work injury may result in corrective disciplinary action. Workers Compensation is intended to provide medical care and temporary disability pay for lost time resulting from a job related injury or illness. There is a waiting period of three days before any benefits are paid for non-hospitalized injuries and illnesses. Accrued EIB will be used if available. Upon the exhaustion of sick time any available PTO time will be used. Benefits for hospitalization are effective without a waiting period. The District integrates benefits with any sick time payable. Time utilized during the waiting period will be PTO if the staff member is off work more than 14 days by order of a healthcare provider. If eligible, FMLA (Family Medical Leave Act) will run concurrently with the period of time during which the staff member is not actively working while recovering from a work related injury. STAFF MEMBER IS AWARE OF THE INJURY) TO THE SUPERVISOR ON DUTY. When a staff member of the District is exposed to a highly contagious disease or industrial hazard requiring immediate therapy, prophylactic or otherwise, the following procedure will be implemented: Report to Employee Health Services or to the Nursing Supervisor if EHS is not open. Complete the work-related injury report form. Employee Health Services or the Nursing Supervisor will instruct you in the next step to take. If treatment is required, report to Employee Health Services. If immediate treatment is needed after hours report to the Emergency Department or Urgent Care. For any work-related exposure, the District will control and direct the treatment of a staff member for thirty (30) days following date of reporting unless prior to exposure the staff member s choice of reporting physician is indicated on their Employee Health Services record. Staff members attending athletic or social events sponsored by the District are not covered by workers compensation during such events. See policy HR.115. Exposure of Employees to Highly Contagious Diseases and/or Hazards THESE INCIDENTS, NO MATTER HOW MINOR, MUST BE REPORTED IMMEDIATELY (OR AS SOON AS THE Update

10 EXAMPLES OF BREACHES OF CONFIDENTIALITY Accessing confidential information that is not within the scope of your duties: Unauthorized reading of patient account information; Unauthorized reading of a patient s chart; Unauthorized access of personnel file information; Accessing information that you do not need-toknow for the proper execution of your duties; Accessing your personal health information; Accessing protected health information of your family or friends Disclosing to another person your sign-on code and /or password for accessing electronic confidential information or for physical access to restricted areas: Telling a co-worker your password so that he or she can log in to the computer system or access your work area; Telling an unauthorized person the access codes for personnel files, patient accounts, or restricted areas. Intentional or negligent mishandling or destruction of confidential information: Leaving confidential information in areas outside of your work area, such as the cafeteria or your home; Disposing of confidential information in a nonapproved container, such as a trash can. Attempting to access a secured application or restricted area without proper authorization or for purposes other than official KDHCD business: Trying passwords and login codes to gain access to an unauthorized area of the computer system or restricted area; Using a co-worker s application for which you do not have access after he or she is logged in. Misusing, disclosing without proper authorization, or altering confidential information: Making unauthorized marks on a patient s chart; Making unauthorized changes to a personnel file; Sharing or reproducing information in a patient chart or a personnel file with unauthorized personnel; Discussing confidential information in a public area such as a waiting room or elevator. Using another person s sign-on code and/or password for accessing electronic confidential information or for physical access to restricted areas: Using a co-worker s password to log in to the KHDCD computer system or access their work area; Unauthorized use of a login code for access to personnel files, patient accounts, or restricted areas. Leaving a secured application unattended while signed on: Being away from your desk while you are logged into an application; Allowing a co-worker to use your secured application for which he or she does not have access after you have logged in. The examples above are only a few types of mishandling of confidential information. If you have any questions about the handling, use or disclosures of confidential information please contact your supervisor, manager, director, or District Compliance and Privacy Officer at (559) Update

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16 ORIENTATION INFORMATION PACKET OF IMPORTANT DOCUMENTS FOR: Students This packet provides a brief overview of our District s vision, mission, expectations, our internal safety and environment of care polices and is your orientation to the District. Please carefully review the information listed above as this orients you to the District. I have read and reviewed the orientation packet. This material contained the following information: Vision- Mission- Goals- Values Compliance- Standards of Conduct Declaration of Confidentiality Safety and Security Electrical Safety Hazardous Materials Infection Control Patients Rights and Responsibilities Recognition and Reporting of Abuse HIPAA Procedures for Following Up On An Incident Appropriate Dress Parking Kaweah Delta s Service Excellence Standards Cultural Diversity Attached TB clearance Began the process for my background and drug screen ( I agree that I have read all guidelines, procedures and conditions presented in the orientation materials. Print Name Signature Date Preceptor s Name Department Instructors Name Phone number Start Date: End Date: Update

17 CONFIDENTIAL INFORMATION FORM Last Name First Name MI Address City State Zip Code Birth Date Main Phone Number Message Number Social Security Number Address School Name I verify that the above information is correct: Signature Date Update

18 KDHCD Clinical Student Guidelines Agreement As a clinical student, for I,, agree that: (Name of School & Program attending) (Student s Name Please Print) 1. My time and services are given for educational purposes without contemplation of compensation or future employment. 2. I shall not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions or religious material on District premises, unless I receive the express authorization of the District Executive Director, to engage in these activities. 3. I shall, if requested, submit to examinations, which may include chest X-rays, skin tests, appropriate laboratory tests and/or immunizations that may be necessary as a part of my Temporary Employee service. If requested, I hereby authorize my doctor(s) to furnish the hospital information concerning my health. I also authorize the person(s) making X-ray films to report the results to District. 4. I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my work professional in quality. 5. I shall attempt to resolve any problems related to my student internship activities with my on-site clinical coordinator, and if unsuccessful attempt to resolve any such problems in the manner put forth by the school I am placed through. 6. I shall make my best effort to fulfill my commitment to the District by completing all assignments that I accept. 7. I shall at all times uphold the philosophy and standards of District. 8. I understand that if injured at the work site, KDHCD agrees to provide first aid treatment if I require such care, but is not obligated to provide any other professional service to me. 9. I understand that the District Human Resources reserves the right to terminate my student internship status as a result of (a) failure to comply with District policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work or appearance; or (d) any other circumstances which, in the judgment of the Human Resource Department, my on-site clinical coordinator and/or the school I am placed through, would make my continued service or time as a student intern contrary to the best interest of the District. 10. I release Kaweah Delta Health Care District from any liability related to my student internship at the District. I have read each of the above conditions and I agree to be bound by them. Print Name Signature Date I agree that I have explained each of the conditions of service to the individual who has signed this form and that I have witnessed their signature. Print Instructor s Name or Preceptor Signature Date Update

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21 Confidentiality Agreement Confidentiality: As a user of information of Kaweah Delta Health Care District ( KDHCD ) electronic/computer systems, you may develop, use, or maintain (1) patient information (for health care, quality improvement, peer review, education, billing, reimbursement, administration, research, or for other purposes), (2) personnel information (for employment, payroll, or other business purposes), or (3) confidential business information of KDHCD and/or third parties, including third-party software and other licensed products or processes. This information from any source and in any form, including, but not limited to, paper record, oral communication, audio recording, and electronic display, is strictly confidential. Access to confidential information is permitted only on a need-to-know basis and limited to the minimum amount of confidential information necessary to accomplish the intended purpose of the use, disclosure, or request. It is the policy of KDHCD that users (i.e., employees, medical staff, students, volunteers, and outside affiliates) shall respect and preserve the privacy, confidentiality and security of confidential information. Violations of this statement include, but are not limited to: Accessing information that is not within the scope of your duties; Accessing your own health information, or the health information of your family and/or friends; Misusing, disclosing without proper authorization, or altering confidential information; Disclosing to another person your sign-on code and/or password for accessing electronic or confidential information or for physical access to restricted areas; Using another person s sign-on code and/or password for accessing electronic confidential information or for physical access to restricted areas; Intentional or negligent mishandling or destruction of confidential information; Leaving a secured application unattended while signed on; or Attempting to access a secured application or restricted area without proper authorization or for purposes other then official KDHCD business. Violation of this statement will constitute grounds for corrective action up to and including termination of employment, indefinite loss of information system security access, and/or loss of KDHCD privileges or contractual or affiliation rights in accordance with applicable KDHCD procedures. Unauthorized use or release of confidential information may also subject the violator to personal, civil, and/or criminal liability and legal penalties. I have read and agree to comply with the terms of the Confidentiality Statement and will comply with KDHCD Privacy Confidentiality of Protected Health Information (PHI) and Information Security Policies, as applicable, copies of which will be provided upon request. Name: (please print) Office/Company Name: Username: Last four digits of Social Security Number (SSN): Signature/Date: / (please sign) Date Affiliation: [ ] Employee [ ] Contract Employee [ ] Medical Staff [ ] Physician Office Staff [ ] Student [ ] Other Providers [ ] Volunteer [ ] Vendor [ ] Other Update

22 HEPATITIS B VACCINE DECLINATION I understand that due to my occupational exposure to blood or other potentially infectious material I may be at risk of acquiring Hepatitis B virus infection. I have been informed that I could be vaccinated with Hepatitis B Vaccine (HBV). However, I decline Hepatitis B Vaccine at this time. I understand that by declining to obtain this vaccination series I continue to be at possible risk of acquiring Hepatitis B and assume full responsibility for my decision to decline the vaccination. Print Name Signature Date I have already completed the Hepatitis B Vaccine series. Print Name Signature Date Update

23 HAND HYGIENE QUIZ Please self correct this quiz and return it to HR or fax it to Answers are at the end of the quiz. 1. Alcohol hand gel can be used if hands are visibly soiled. True False 2. Glove use for ALL patient care contacts is the best way of reducing the transmission of organisms. True False 3. How often should you clean your hands after touching a patient or a contaminated surface in the hospital? a. Always b. Often c. Sometimes d. Never 4. Bacteria can be transmitted from both colonized and infected patients. True False 5. How often should you clean your hands after touching a patient s intact skin (for example, when measuring a pulse or blood pressure). a. Always b. Often c. Sometimes d. Never 6. Use of artificial nails by healthcare workers poses a risk of infection to patients. True False 7. When a healthcare worker touches a patient who is colonized, but not infected, with resistant organisms (EG: MRSA or VRE) the Health Care Worker s hands can be a source for spreading resistant organisms to other patients. True False Answers: 1- false; 2- false; 3- a; 4- true; 5- a; 6- true; 7- true NAME DATE Update

24 KDHCD DEPARTMENT ORIENTATION CHECKLIST Staff Member Name: Employee # Department: Position: New Employee Employee Transfer Temp Employee Traveler Contractor (Independent Contractor) Student/ Clinical Instructors Volunteer This form should be completed on the first working day in the assigned department with manager. Each subject must be initialed, form must be signed, and faxed to Human Resources Department within 48 hours. As the following subjects are explained to you, INITIAL the column. If the topic does not apply to your department / position, please mark N/A. **Fax copy to HR at ** Subject Initial Subject Initial Initial Competencies checklist is reviewed. Staff member realizes that patient care procedures cannot be performed until competency to perform that procedure is confirmed. Received copy of Job Description with review of responsibilities: attendance and punctuality standards, disciplinary policies complaint and grievance procedure Performance Review procedures including evaluation dates and pay for performance Location and review of policy/procedure manuals (District-wide and Department-specific) Current District Performance Improvement Model and current department projects/goals including measures used to evaluate performance Staff should be scheduled for orientation based on job duties. Staff who transfers to a new role should work with their manager to determine orientation needs. Tour of Department Hours of work, shifts, overtime policy Lunch/rest periods, and restroom location Time Clocks Department work schedule and how to make requests for time off. Procedure for reporting ill. Intradepartmental communication including department meetings, communication logs, interoffice mail system Usage of telephone system Introduction to co-workers and review of their responsibilities Review Confidentiality and HIPAA Rules If applicable, received Management/Leadership Orientation Checklist Review of Service Plan or Plan of Care Review of Patient Abuse Reporting Body Mechanics Process/Forms for Reporting a work injury Notification of Utility Problem/Location of Important Shut Off Valves Procedure for Electrical Safety Inspection New Equipment Location of information regarding: Fire Response, Hazardous Materials, Disaster Evacuation, Code Blue, and Code Pink. To include staff members responsibilities. "R.A.C.E." Procedure Location of fire extinguisher and fire alarms. Nearest Fire Alarm Pull Stations Department Specific Response/Roles to Different Triages, Codes and HICS Departmental Evacuation Plan. Wall Mounted Evacuation Routes MSDS sheets (Review and sign) Procedure of: entry, storage, use, disposal of hazardous substances. Proper response to chemical spills Review of department infection control guidelines (Blood borne & airborne pathogen packet) Infection Control Manual Hand Washing Procedures Disposal and Definition of Sharps Protective Equipment and Barriers Role of Clinical Engineering- Filling out red repair tags Roles of security officers in the provision of staff safety. Reporting of a security incident Review Code Gray and areas of high risk for violence Correct use of department machinery/equipment, and protective measures Process/Form for Statement of Concern/ Occurrence Report Review of dress code HR Policy 197 Professional Appearance Guidelines Registered for RELATE training- Employees only PROACT Service Recovery Program Patient/Personal Electrical Safety Inspection Procedure National Patient safety goals discussed Staff Member Signature Department Manager Signature Location of PROACT Service Recovery Binder Date Competed Date Completed Update

25 Update

26 Dear Kaweah Delta Team Member: We are proud to introduce our revised Code of Conduct for Kaweah Delta Health Care District (Kaweah Delta). Our Code of Conduct reflects Kaweah Delta s commitment to providing high quality services to patients, and our commitment to ethical and legal business practices. These goals are vital to the ongoing success of Kaweah Delta. This information booklet is a very real expression of our commitment to integrity, accountability, and excellence three of Kaweah Delta s fundamental values. It has been designed to show each of us how our core values and standards go hand in hand. Every person at Kaweah Delta plays a role, directly or indirectly, in the patient experience and our reputation is based on how we conduct ourselves on a daily basis. Our reputation brings hope to patients who trust us to deliver high quality care and attracts people with the highest integrity to seek employment or an affiliation with us. The information in our Code of Conduct will assist you in understanding the variety of legal, professional and ethical standards that regulate our work. Please make it a priority to become familiar with it. Much of what you see in the Code of Conduct will not be new to you, but it will provide an accessible source of information when you have a question about a particular situation. There may be times when you face a situation that is not specifically covered by the Code of Conduct. The complex challenges we face in the health care arena are not always easily categorized, and you may find that you need assistance in addressing a specific issue related to compliance. We encourage you to discuss the situation and initially seek guidance from your supervisor. If you are ever uncomfortable discussing the situation with your supervisor and/or would rather speak to Compliance and Privacy Officer directly, you may do so by contacting the Compliance and Privacy Officer at If you prefer to report an issue or concern anonymously, you may call our Confidential Reporting Line at We will work diligently to ensure that questions and issues brought to our attention are addressed and resolved. A commitment to ethical and legal business practices in caring for our patients and in our business dealings is crucial. Compliance means doing the right thing. I thank you for your personal commitment to compliance, this Code of Conduct and the part you play in making Kaweah Delta a organization that we can all be proud of. Sincerely, Lindsay K. Mann Chief Executive Officer 400 West Mineral King Avenue Visalia, CA Fax Update

27 Table of Contents Purpose of the Code of Conduct 1 The District 1 Mission, Values and Vision. 1 Kaweah Delta Compliance Program Program Structure and Standards.. 2 Training and Education.. 2 Resources for Reporting a Concern... Personal Obligation to Report Internal Investigations... 3 Corrective Action... 3 Discipline... 3 Measuring Program Effectiveness Leadership Responsibilities... 3 Our Fundamental Commitment.. 4 Our Commitment to our Patients 4 Patient Care and Rights. 4 Interpretive Services 5 Patient Information 5 Abuse and/or Neglect Reporting... 6 Legal and Regulatory Compliance. 6 Witnessing Legal Documents 6 Coding and Billing for Services 6 Cost Reports.. 7 Financial Reporting and Records 7 Emergency Treatment- EMTALA. 7 Response to Government Inquiries 8 Accreditation and Federal/State Agencies 8 Risk Management 8 Update

28 Internal Audit. 8 Performance Improvement and Patient Safety 9 Business Records and Information Systems 9 Accuracy, Retention, and Disposal of Documents and Records 9 Electronic Media 9 Information Security and Confidentiality of Information 9 Workplace Conduct and Employment Practices 10 Diversity and Equal Employment Opportunity 10 Conflicts of Interest. Interactions with Physicians Relationships with Subcontractors and Suppliers 11 Research, Investigations and Clinical Trials 11 Sanctioned/Excluded Individuals and Entities 11 Identification Badge Policy 12 Kaweah Delta Property and Assets. 12 Controlled Substances.. 12 Harassment and Workplace Violence.. 12 Health and Safety. 12 Behaviors That Undermine a Culture of Safety 13 License and Certification Renewals.. 13 Substance Abuse and Mental Acuity.. 13 Marketing, Advertising and Fundraising Practices Marketing and Advertising Antitrust- Compete Fairly.. 14 Kaweah Delta Foundation.. 14 Government Relations and Political Activities.. 14 Solicitation, Fundraising and Distribution of Material Acknowledgement Process Update

29 Purpose of the Code of Conduct Our Code of Conduct provides guidance to all Kaweah Delta Health Care District (Kaweah Delta) employees and our care partners. The Code assists us in carrying out our daily activities and working within appropriate ethical and legal standards. These obligations apply to our relationships with patients, affiliated physicians, third-party payers, subcontractors, independent contractors, vendors, volunteers, consultants and one another. The Code is a critical component of our overall Compliance Program. We have developed the Code to ensure we all understand our ethical obligations and standards, and comply with all applicable laws and regulations. The Code is intended to be comprehensive and easily understood. However, in many cases, the subject matter discussed may have complexities that require additional guidance and direction. To provide additional guidance, we have developed comprehensive policies and procedures which may be accessed on Kaweah Delta s Intranet. Those policies expand upon many of the principles communicated in this Code of Conduct. The standards set forth in the Code are mandatory and must be followed. The District Kaweah Delta Health Care District is a community venture, operating under the authority granted through the California Health and Safety Code as a health care district. The purpose of the District is to provide quality health care within defined areas of expertise. It is the intent of District that no person shall be denied emergency admission or emergency treatment based on ability to pay. It is further the intent of the District that no person shall be denied admission or treatment based upon race, color, national origin, ethnic, economic, religious or age status or on the basis of sexual preference. The medical welfare of the community and its particular health needs will be fulfilled to the capacity of the District s financial limitations. Kaweah Delta Health Care District operates under the authority of California Code for a health care district. As such, Kaweah Delta Health Care District is publicly owned and operates as a nonprofit entity. Mission, Values and Vision Kaweah Delta Mission To provide high quality, customer oriented and financially strong health care services to meet the needs of those we serve. Kaweah Delta Values Vision we are able to anticipate and plan for positive action. Integrity we are committed to uncompromised honesty. Caring we are genuinely concerned for the well being of our patients and others. Accountability we are responsible to our community, patients, and colleagues for our actions and performance as representatives of Kaweah Delta Health Care District. Respect we honor diversity and believe each individual is unique and important, deserving our best effort. Excellence through continual learning we are committed to achieve superior performance. Kaweah Delta Vision Delivering Excellence. Together, Kaweah Delta and the Medical Staff will be recognized for consistently delivering a broad range of exceptional health care services, superior clinical quality and exemplary customer service. Update

30 Kaweah Delta Compliance Program Program Structure and Standards The Compliance Program is intended to demonstrate in the clearest possible terms the absolute commitment of the organization to the highest standards of ethics and compliance. The elements of the program include setting standards (the Code and Policies and Procedures), communicating the standards, providing a mechanism for reporting potential exceptions, monitoring and auditing, and maintaining an organizational structure that supports the continued growth of the program. Each of these elements is detailed below. These elements are supported at all levels of the organization. Providing direction, guidance and oversight are the Compliance Committee of the Board of Directors and the Executive Team consisting of senior management. The Compliance and Privacy Officer is responsible for the day-to-day direction and implementation of the Compliance Program. This includes developing resources (including policies and procedures, training programs, and communication tools) and providing support to others. The Compliance Team plays a key role in ensuring the successful implementation of our Compliance Program. They are responsible for distributing standards, ensuring training is conducted, conducting monitoring and responding to audits, investigating and resolving Confidential Reporting Line issues and otherwise administering the Compliance Program. Another important resource to address issues related to this Code of Conduct is the Human Resources Department. Human Resources staff is highly knowledgeable about many of the compliance risk areas described in this Code of Conduct, particularly those that pertain to employment and the workplace. The Human Resources staff is responsible for ensuring compliance with various employment laws. If a concern relates to specific details of an individual s work situation, rather than larger issues of organizational ethics and compliance, the Human Resources Department is the most appropriate area to contact. In that we promote the concept of management autonomy, every effort should be made to resolve workplace conduct and employment practice issues through the individual s supervisor. However, the Human Resources Department is also available to provide support to employees and management. Training and Education Training and education has been developed to ensure that employees throughout the organization are aware of the standards that apply to them. Code of Conduct training is conducted at the time an individual joins the organization and communicated regularly to all employees. Compliance training in areas of specific compliance risk (e.g., billing, coding, cost reports) is required of certain individuals. Kaweah Delta policies outline the training requirements. Many resources regarding our program are available to all Kaweah Delta employees on our Intranet and to the general public on the Internet. Resources for Reporting a Concern To obtain guidance on an ethical or compliance issue or to report a concern, individuals may choose from several options. We encourage the resolution of issues, including human resources-related issues (e.g., payroll, fair treatment and disciplinary issues). It is an expected good practice, when one is comfortable with it and thinks it appropriate under the circumstances, to raise concerns first with one s supervisor. If it is uncomfortable or inappropriate, the individual may discuss the situation with the Compliance and Privacy Officer or the Human Resources Department. Individuals are always free to contact the Confidential Reporting Line at If the issue is employee relations in nature, employees should contact the Human Resources Department for assistance and further guidance. Kaweah Delta makes every effort to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports concerns or possible misconduct. There is no retribution or discipline for anyone who reports a concern in good faith. Any employee who deliberately makes a false accusation with the purpose of harming or retaliating against another employee is subject to discipline. To report a concern to ask questions contact: Kaweah Delta Compliance and Privacy Officer (559) Update

31 Kaweah Delta Compliance Advocate Kaweah Delta Legal Counsel (559) or Confidential Reporting Line 1 (800) Kaweah Delta has a legal and ethical obligation to act in compliance with applicable laws and to ensure that its resources are used in a manner that furthers the public good.. Personal Obligation to Report We are committed to ethical and legal conduct that is compliant with all relevant laws and regulations and to correct any wrongdoing whenever it may occur in the organization. Each employee has an individual responsibility for reporting any activity by any employee, physician, subcontractor, or vendor that appears to violate applicable laws, rules, regulations, accreditation standards, medical practice standards, Federal healthcare Conditions of Participation or this Code. If a matter poses serious compliance risk to the organization or that involves a serious issue of medical necessity, clinical outcomes or patient safety is reported, and if the reporting individual doubts that the issue has been given sufficient or appropriate attention, the individual should report the matter to higher levels of management, the Director of Risk Management, the Compliance and Privacy Officer or the Confidential Reporting Line until satisfied that the full importance of the matter has been recognized. Internal Investigations We are committed to investigating all reported concerns promptly and confidentially to the extent possible. The Compliance and Privacy Officer coordinates findings from investigations and immediately recommends corrective action or changes that need to be made. We expect all employees to cooperate with investigation efforts. Corrective Action Where an internal investigation substantiates a reported violation, it is the policy of the organization to initiate corrective action, including, as appropriate, making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting disciplinary action as necessary and implementing systemic changes to prevent a similar violation from recurring in the future. Discipline All violators of the Code will be subject to disciplinary action. The precise discipline utilized and frequency of the violation may result in any or all of the following disciplinary actions: Written Warning Written Reprimand Suspension Termination and/or Restitution Measuring Program Effectiveness We are committed to assessing the effectiveness of our Compliance Program through various efforts. Much of this effort is provided by the Internal Audit Department, which routinely conducts internal audits of issues that have regulatory or compliance implications. Responsible Executives and management routinely undertake monitoring efforts in support of policies and compliance in general. Departments conduct self-monitoring, and the Compliance Department conducts reviews designed to assess facility implementation of the Code, policies and procedures, Confidential Reporting Line and related investigations, and monitoring efforts. Most of these methods of assessment result in reports of findings by the reviewers and corrective action plans by the departments that are reviewed. Through these reviews, we are continuously assessing the effectiveness of the Program and finding ways to improve it. Leadership Responsibilities While all Kaweah Delta employees are obligated to follow our Code, we expect our leaders to set the example, to be in every respect a model for others. We expect everyone at Kaweah Delta with supervisory responsibilities to be kind, sensitive, honest, thoughtful and respectful. We expect all leaders to create an Update

32 environment where each team member feels free to raise concerns and propose new ideas. We also expect that leadership will provide their team members with sufficient information to comply with laws, regulations, policies and procedures, as well as the resources to address and resolve ethical dilemmas. They must help to create and maintain a culture that promotes the highest standards of ethics and compliance. This culture must encourage everyone in the organization to share concerns when they arise. We must never sacrifice ethical and compliant behavior in the pursuit of business objectives. Kaweah Delta Leaders at all levels should use all available education and guidance to most effectively incorporate ethics and compliance into all aspects of Kaweah Delta. Our Fundamental Commitment We are committed to providing Personal, Professional, Compassionate Experiences, Every Person Every Time and specifically: To our patients: We are committed to providing high quality care that is sensitive, compassionate, promptly delivered, and cost effective. To our employees: We are committed to a working environment which treats all employees with fairness, dignity and respect, and affords them an opportunity to grow and develop professionally, and to work in a team environment in which all ideas are considered. To our affiliated physicians: We are committed to providing a work environment which has excellent facilities, equipment and outstanding professional support. To our third-party payers: We are committed to dealing with our third-party payers in a manner that demonstrates our commitment to contractual obligations and reflects our shared concern for quality healthcare and bringing efficiency and cost effectiveness to healthcare. We encourage our payers to adopt their own set of ethical practices to recognize their obligations to patients and the need for fairness and responsiveness. To our regulators: We are committed to maintaining an environment of compliance with rules, regulations, policies and sound business practices. We accept the responsibility to selfgovern and monitor adherence to the requirements of the law and to our Code of Conduct. To our joint venture partners: We are committed to fully performing our responsibilities to manage our jointly owned facilities in a manner that reflects the mission and values of each of our organizations. To the communities we serve: We are committed to understanding the needs of the communities we serve and to providing high quality, cost-effective healthcare. We realize that we have a responsibility to those in need. We proudly support charitable contributions and community events in an effort to promote goodwill, health and other good causes. To our suppliers: We are committed to fair competition among prospective suppliers and the sense of responsibility required of a good customer. We encourage our suppliers to adopt their own set of ethical principles. To our volunteers: We are committed to ensuring that our volunteers feel a sense of meaning from their work and receive recognition for their volunteer efforts. Volunteers assisting our patients and their families are an integral part of the fabric of healthcare. Our volunteers are an important part of the Kaweah Delta team. To our Foundation donors: We are committed to ensuring that donations made to Kaweah Delta are managed respectfully and responsibly to serve the needs of Kaweah Delta and the patients and communities we serve. Our Commitment to our Patients Patient Care and Rights In the availability of services; the admission, transfer or discharge of patients; or in the care we provide, we make no inappropriate distinctions based on age, gender, disability, race, color, religion, sexual orientation, gender identity or national origin. Upon admission, we provide each patient with a written statement of patient rights and a notice of privacy practices. These statements include the rights of the patient to make decisions regarding medical care and regarding his or her 4 Update

33 health information maintained by Kaweah Delta. Such statements conform to all applicable state and federal laws, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (hereinafter referred to as HIPAA). We seek to involve patients in all aspects of their care, including giving consent for treatment and making healthcare decisions, which may include managing pain effectively, foregoing or withdrawing treatments, and, as appropriate, end of life care. In the promotion and protection of patients rights, each patient and his or her representatives are afforded appropriate confidentiality, privacy, security and protective services, opportunity for resolution of complaints, and pastoral or spiritual care. Patients are treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care. Kaweah Delta facilities maintain processes to support patient rights in a collaborative manner which involves Kaweah Delta leaders and others. These processes are based on policies and procedures, which address both patient care and organizational ethics. These processes include informing each patient or, when appropriate, the patient s representative of the patient s rights in advance of furnishing or discontinuing care. Patients and, when appropriate, their families or caregivers are informed about the outcomes of care, including unanticipated outcomes. Additionally, patients are involved as clinically appropriate in resolving dilemmas about care decisions. Kaweah Delta has a comprehensive program to promote the quality of patient care and measure its effectiveness. The commitment to quality care and patient safety is everyone s responsibility. Kaweah Delta maintains processes for prompt resolution of patient grievances which include informing patients of the grievance process which includes notification of the resolution. Patients and/or their families have a right to file a complaint or grievance regarding their care and may do so by contacting Kaweah Delta s Risk Management Department, the Joint Commission or California Department of Public Health. Kaweah Delta maintains an ongoing, proactive patient safety effort for the identification of risk to patient safety and the prevention, reporting and reduction of healthcare errors. Kaweah Delta has established patient safety and quality of care policies. It is the responsibility of each staff member to follow our standards and policies. It is important to report non-compliance, safety or quality concerns to management so the issues can be addressed. Kaweah Delta is committed to investigate and respond to all reported concerns. An employee may also report safety or quality of care concerns to the Joint Commission (TJC) by accessing their website at Additionally TJC can be contacted by at complaint@jcaho.org or by fax at (630) Kaweah Delta will take no disciplinary action against any employee because they report a safety or quality of care concern. Interpretive Services Fluency in English is required for all employees having patient contact. To facilitate communication with non-english speaking or hearing impaired individuals, Kaweah Delta has alternatives in place including a 24-hour Language Line of more than 100 languages. Employees may access the line directly. A procedure is in place explaining how to use the Language Line. Employees may also contact management or the Interpreter Services department for assistance. Interpreting services are available for both foreign and sign languages. Contact the nursing staffing office for details or to obtain an interpreter. Kaweah Delta employees who are able to communicate in a second language are encouraged to contact the Interpreter Services Department for information on the voluntary interpreter program. Patient Information We collect information about the patient s medical condition, history, medication, and family illnesses. We realize the sensitive nature of this information and are committed to maintaining its confidentiality. Kaweah Delta employees must never access, use or disclose confidential information in a manner that violates the privacy rights of our Update

34 patients. In accordance with our appropriate access and privacy policies and procedures, which are consistent with state and federal privacy requirements, no Kaweah Delta employee, affiliated physician or other healthcare partner has a right to any patient information other than what is necessary to perform his or her job duties. Subject only to emergency exceptions, patients can expect their privacy will be protected. Patient-specific information will be released only to persons authorized by the patient to receive the information or those authorized by law to receive the information. Abuse and/or Neglect Reporting Kaweah Delta is committed to promoting a health care environment free from threats, harassment, abuse (verbal, physical, mental, or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Following State and Federal laws and Kaweah Delta policy, all employees are mandated reporters of suspected child or elder/dependent adult abuse and domestic violence injuries. Patient and Family Services staff is available to help assess patients and make appropriate telephone and written reports. Legal and Regulatory Compliance Kaweah Delta provides a variety of healthcare services in the local area. These services are provided pursuant to appropriate federal, state, local laws and regulations and the Conditions of Participation for Federal healthcare programs. We have developed policies and procedures to address many legal and regulatory requirements. However, it is impractical to develop policies and procedures that encompass the full body of applicable law and regulation. Obviously, those laws and regulations not covered in organization policies and procedures must be followed. There are sources of expertise within the organization concerning these matters and these resources should be utilized for advice concerning human resources, legal, regulatory, and the Conditions of Participation requirements. Witnessing Legal Documents Employees must not act as a witness to a last will and testament, a promissory note, or other legal document not prepared by Kaweah Delta, for a patient, a patient s family member, or another staff member. Coding and Billing for Services We have implemented policies, procedures and systems to facilitate accurate billing to government payers, commercial insurance payers and patients. These policies, procedures, and systems conform to pertinent federal and state laws and regulations. Kaweah Delta prohibits its employees and agents from knowingly presenting or causing to be presented claims for payment or approval which are false or otherwise fraudulent. In support of accurate billing, medical records must provide reliable documentation of the services rendered. It is important that all individuals who contribute to medical records provide complete and accurate information and do not destroy any information considered part of the official medical record. Accurate and timely documentation also depends on the diligence and attention of physicians who treat patients in our facilities. We expect those physicians to provide us with complete and accurate documentation in a timely manner. Any subcontractors engaged to perform billing, coding services or collection services are expected to have the necessary skills, systems and appropriate quality control procedures to ensure all billings are accurate and complete. Kaweah Delta requires the business associate to have their own ethics and compliance programs and a code of conduct or to adopt Kaweah Delta s code as their own. Both the Federal and California State False Claims Acts cover fraud involving any state or federally funded contract or program, including the Medicare and Medicaid (Medi-Cal) programs. Both acts establish liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the State or Federal government for payment. To encourage individuals to come forward and report misconduct involving false claims, both the federal False Claims Act and the California False Claims Act include qui tam or whistleblower provisions. The qui tam or whistleblower provision allows a person who is the original source of knowledge of a past or present fraud to file a qui tam action. The party bringing the action is known as the relator. Original source is defined as direct and Update

35 independent knowledge of the information on which the allegations are based and has voluntarily provided the information to the Government before filing a lawsuit on behalf of the U.S. Government or State of California. In addition to a possible financial award, the False Claims Act entitles whistleblowers to additional relief, including employment reinstatement, back pay, and any other compensation arising from retaliatory conduct against a whistleblower for filing an action under the False Claims Act or committing other lawful acts, such as investigating a false claim or providing testimony for, or assistance in, a False Claims Act action. For coding questions, you can contact Health Information Management Services at For billing questions, contact Patient Accounting Services at To report any suspected billing or coding misconduct, contact the Compliance and Privacy Officer at or the Confidential Reporting Line at We take great care to assure that all billings to the government, third party payers and patients are accurate and conform to all applicable federal and state laws and regulations Cost Reports We are required by federal and state laws and regulations to submit certain reports of our operating costs and statistics. We comply with federal and state laws, regulations, and guidelines relating to all cost reports. These laws, regulations, and guidelines define what costs are allowed and outline the appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries. Kaweah Delta policies address cost report compliance and articulate our commitment to ensuring accurate development and submission. Finance Department personnel are educated regarding federal and state laws, regulations and guidelines, and corporate policies; maintain a standardized work paper package to provide consistency in the preparation, organization, presentation, and review of cost reports; apply a uniform cost report review process; identify and exclude non-allowable costs; adhere to documentation standards; and use transmittal letters to report protested items and report other appropriate disclosures. All issues related to the preparation, submission and settlement of cost reports must be performed by or coordinated with our Finance Department. Financial Reporting and Records We have established and maintain a high standard of complete accuracy in documenting, maintaining, and reporting financial information. This information serves as a basis for managing our business and is important in meeting our obligations to patients, employees, suppliers, and others. The financial records are also necessary for compliance with tax and financial reporting requirements. All financial information must reflect actual transactions and conform to generallyaccepted accounting principles. All funds or assets must be properly recorded in the books and records of the organization. Kaweah Delta maintains a system of internal controls to provide reasonable assurances that all transactions are executed in accordance with management s authorization and are recorded in a proper manner so as to maintain accountability of the organization s assets. We diligently seek to comply with all applicable auditing, accounting and financial disclosure laws. Finance management receives training and guidance regarding auditing, accounting and financial disclosures relevant to their job responsibilities. They are also provided the opportunity to discuss issues of concern with the Board of Directors Audit Committee. Anyone having concerns regarding accounting or auditing matters should report such matters to the Director of Internal Audit, the Compliance and Privacy Officer or the Confidential Reporting Line. Emergency Treatment-EMTALA We follow the Emergency Medical Treatment and Active Labor Act ( EMTALA ) and Kaweah Delta policy in providing an emergency medical screening examination and necessary stabilization to all patients, regardless of ability to pay. Provided we have the capacity and capability, anyone who presents in the Emergency Room with an emergency medical condition or 7 Update

36 who is in labor is treated. In an emergency situation or if the patient is in labor, we will not delay the medical screening and necessary stabilizing treatment in order to seek financial and demographic information. We do not admit, discharge, or transfer patients with emergency medical conditions simply based on their ability or inability to pay or any other discriminatory factor. Patients with emergency medical conditions are only transferred to another facility at the patient s request or if the patient s medical needs cannot be met at Kaweah Delta Medical Center (e.g., we do not have the capacity or capability) once the patient has been stabilized, appropriate care is knowingly available at another facility and the receiving hospital has accepted the transfer. Patients are only transferred in strict compliance with state and federal EMTALA regulatory and statutory requirements. Response to Government Inquiries Various agencies may contact individuals associated with Kaweah Delta to initiate a compliance-related inquiry. We will comply with lawful and reasonable requests or demands and we will provide truthful responses to government inquiries. At the same time, it is imperative that we protect the rights of Kaweah Delta and its employees. Both Kaweah Delta and its employees have the right to be represented by legal counsel during any compliance-related governmental inquiry. Kaweah Delta employees have the right to have an attorney present during questioning by outside government agencies, whether that questioning occurs at work or away from work. Any individual who receives an inquiry, visit, subpoena or other legal document from a government agency, at work or at home regarding Kaweah Delta business shall immediately notify his or her supervisor, the Compliance and Privacy Officer or the Director of Risk Management. Your supervisor, Director of Risk Management and/or the Compliance and Privacy Officer will assist in verifying the credentials of the investigator and determining the legitimacy of the inquiry, and will follow proper procedures for cooperating with the request. In some cases government investigators, or persons presenting themselves as such, may contact employees outside of the workplace, during non-work hours, or at the employee s home. Do not feel pressured to talk with the person under such circumstances without first contacting the Compliance and Privacy Officer, the Director of Risk Management or the Compliance Advocate. Accreditation and Federal/State Agencies In preparation for, during and after surveys, Kaweah Delta employees respond to all consultants and representatives of accrediting bodies in a direct, open and honest manner. No action should ever be taken when interacting with representatives of accrediting bodies that would mislead any member of a survey team. Risk Management The Risk Management Department oversees the risk prevention and claims process. Each employee is considered an important component of Kaweah Delta s risk prevention program. Every employee plays a key role in risk prevention by functioning within the scope of their job description and following Kaweah Delta s policies, procedures and guidelines. Staff must alert their supervisors to unsafe situations. If something does not feel right or you suspect an undesired patient outcome, notify your immediate supervisor and complete an occurrence report. Any employee who has a concern about the safety or quality of care provided in Kaweah Delta may report their concerns to Risk Management, Compliance or the Confidential Reporting Line. Internal Audit The Internal Audit Department serves as an independent and objective auditing and consulting service for Kaweah Delta, reporting to the Board of Directors and the Chief Operating Officer. The Internal Audit Department seeks to gain an indepth understanding of the business culture, systems, and processes in place at the organization and to provide assurance to the Board and Management that internal controls are in place, that they adequately mitigate risks and that they help Kaweah Delta meet its organizational goals and objectives. While the Department assesses the internal controls throughout the organization, each Kaweah Delta employee is a part of and is responsible for maintaining a proper control structure. This Update

37 involves performing their roles as outlined in their job description, following all laws and regulations and adhering to District policies. Any employee that has a concern related to internal controls at Kaweah Delta, adherence to Kaweah Delta policies and procedures, or adherence to laws and regulations should notify their supervisor immediately. Concerns may also be reported to Internal Audit, Compliance, Risk Management or the Confidential Reporting Line Performance Improvement and Patient Safety Kaweah Delta works to continuously improve its clinical and organizational functions. Each performance improvement activity is carried out in various formal and informal settings. Continuous performance improvement is achieved through the effective implementation and coordination of three distinct but overlapping processes: The systematic measurement and evaluation of outcomes, processes and services, especially as they relate to Kaweah Delta s strategic plan defined annually The analysis of these observations and measures The design and implementation of performance improvement projects when desired or necessary. All individuals must maintain integrity in business conduct and avoid any activities that could reflect adversely on Kaweah Delta s reputation. Business Records and Information Systems Accuracy, Retention, and Disposal of Documents and Records Each Kaweah Delta employee is responsible for the integrity and accuracy of our organization s documents and records, not only to comply with regulatory and legal requirements but also to ensure records are available to support our business practices and actions. No one may alter or falsify information on any record or document. Records must never be destroyed in an effort to deny governmental authorities that which may be relevant to a government investigation. Medical and business documents and records are retained in accordance with the law and our record retention policy. It is important to retain and destroy records only according to our policy. Kaweah Delta employees must not tamper with records. Electronic Media All communications systems, including but not limited to electronic mail, Intranet, Internet access, telephones, and voice mail, are the property of Kaweah Delta and are to be used primarily for business purposes in accordance with electronic communications policies and standards. Users of computer and telephonic systems should presume no expectation of privacy in anything they create, store, send, or receive on the computer and telephonic systems. Kaweah Delta reserves the right to monitor and/or access electronic media usage and content consistent with policies and procedures. Employees may not use internal communication channels or access the Internet at work to post, store, transmit, download, or distribute any threatening materials; knowingly, recklessly, or maliciously false materials; obscene materials; or anything constituting or encouraging a criminal offense, giving rise to civil liability, or otherwise violating any laws. Information Security and Confidentiality of Information Confidential information about our organization s strategies and operations is a valuable asset. Although Kaweah Delta employees may use confidential information to perform their jobs, it must not be shared with others unless the individual(s) and/or entities have a legitimate need to know the information in order to perform their specific job duties or carry out a contractual business relationship. In addition, these individuals and/or entities must have agreed to maintain the confidentiality of the information. We exercise due care and diligence in maintaining the confidentiality, availability and integrity of information. Because so much of our clinical and business information is generated and contained within our computer systems, it is essential that each Kaweah Delta employee protect our computer systems and the information contained in them by not sharing passwords and by Update

38 reviewing and adhering to our information security policies and guidance. It is Kaweah Delta s policy to observe copyrights, trademarks, and/or licenses and safeguard the intellectual property of Kaweah Delta and those with whom we do business. Because much of our clinical and business information is increasingly generated and maintained within our computer systems, all users must exercise diligence to protect our computer systems and the information stored therein Workplace Conduct and Employment Practices Diversity and Equal Employment Opportunity It is the responsibility of Kaweah Delta to create and maintain an equal opportunity work environment in which employees are treated with respect, diversity is valued, and opportunities are provided for development. Harassment or abuse is prohibited in the workplace. Kaweah Delta also prohibits discrimination in any work-related decision on the basis of race, creed, sexual orientation, gender identity, age, disability status, national origin, or any other illegal basis. We make reasonable accommodations to the known physical and mental limitations of otherwise qualified individuals with disabilities. We comply with all laws, regulations, and policies related to non-discrimination in all of our personnel actions. Such actions include hiring, staff reductions, transfers, terminations, evaluations, recruiting, compensation, corrective action, discipline, and promotions. If a Kaweah Delta employee perceives that inequitable or unfair conduct is occurring in the workplace, the employee should contact the Human Resources Department. If the employee feels the matter was not resolved to his/her satisfaction, the employee may contact the Compliance and Privacy Officer or the Compliance Advocate or call the Confidential Reporting Line. Conflicts of Interest A conflict of interest may occur if a Kaweah Delta employee s outside activities, personal financial interests, or other personal interests influence or appear to influence his or her ability to make objective decisions in the course of the employee s job responsibilities. A conflict of interest may also exist if the demands of any outside activities hinder or distract an employee from the performance of his or her job or cause the individual to use Kaweah Delta resources for other than Kaweah Delta purposes. A good rule of thumb is that a conflict of interest may exist any time an objective observer of your actions might wonder if your actions are motivated solely by your personal financial activities or interests. Kaweah Delta employees are obligated to ensure they remain free of conflicts of interest in the performance of their responsibilities. If employees have any question about whether an outside activity or personal interest might constitute a conflict of interest, they must obtain the approval of their supervisor before pursuing the activity, obtaining or retaining the interest. Kaweah Delta employees are prohibited from soliciting or receiving gifts, loans, entertainment or any other consideration of value from any individual or organization that does business or may wish to do business with Kaweah Delta. If an employee receives any gift or favor, it must be returned, and the employee s supervisor must be notified. A Kaweah Delta employee must not accept a personal gift of any consideration of value or any cash payment from a patient. In accordance with Kaweah Delta policy, patients wishing to express appreciation to employees may do so in the form of flowers or candy addressed to and for the enjoyment of the entire department or by donating to the Foundation Guardian Angel recognition program in the employee s honor. Even the appearance of a conflict may be as serious and potentially damaging as an actual conflict. For that reason, employees should avoid even the appearance of a conflict of interest. Update

39 Interactions with Physicians Federal and state laws and regulations govern the relationship between hospitals and physicians who may refer patients to the facilities. The applicable federal laws include the Anti- Kickback Law and the Stark Law. It is important that those employees who interact with physicians, particularly regarding making payments to physicians for services rendered, leasing space, recruiting physicians to the community, and arranging for physicians to serve in leadership positions in facilities, are aware of the requirements of the laws, regulations, and policies that address relationships between facilities and physicians. If relationships with physicians are properly structured, but not diligently administered, failure to administer the arrangements as agreed may result in violations of the law. Any business arrangement with a physician must be structured to ensure compliance with legal requirements, our policies and procedures and with any operational guidance that has been issued. Keeping in mind that it is essential to be familiar with the laws, regulations, and policies, there are two overarching principles that govern our interactions with physicians: We do not pay for referrals. We accept patient referrals and admissions based solely on the patient s medical needs and our ability to render the needed services. We do not pay or offer to pay anyone - employees, physicians, or other persons or entities - for referral of patients. We do not accept payments for referrals we make. No Kaweah Delta employee or any other person acting on behalf of the organization is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of patients. Similarly, when making patient referrals to another healthcare provider, we do not take into account the volume or value of referrals that the provider has made (or may make) to us. Relationships with Subcontractors and Suppliers We must manage our subcontractor and supplier relationships in a fair and reasonable manner, free from conflicts of interest and consistent with all applicable laws and good business practices. We promote competitive purchasing to the maximum extent practicable. Our selection of subcontractors, suppliers, and vendors will be made on the basis of objective criteria including quality, technical excellence, price, and delivery, adherence to schedules, service, and maintenance of adequate sources of supplies. Our purchasing decisions will be made on the supplier s ability to meet our needs, and not on personal relationships and friendships. We employ the highest ethical standards in business practices in source selection, negotiation, determination of contract awards, and the administration of all purchasing activities. Research, Investigations and Clinical Trials We follow high ethical standards and comply with federal and state laws and regulations in any research, investigations and clinical trials conducted by our physicians and staff. All patients asked to participate in a clinical investigation or research project are given a full explanation of alternative services. They are also fully informed of potential discomfort and are given full disclosure of the risks, expected benefits and alternatives. Patient informed consent to participate is documented and retained according to policy. Formal approval for any research, investigation and/or clinical trial must be obtained by the Kaweah Delta Research Council (HSPC). Sanctioned/Excluded Individuals and Entities We do not contract with, employ, or bill for services rendered by an individual or entity that is excluded or ineligible to participate in Federal healthcare programs; suspended or debarred from Federal government contracts; or has been convicted of a criminal offense related to the provision of healthcare items or services and has not been reinstated in a Federal healthcare program after a period of exclusion, suspension, debarment, or ineligibility, provided that we are aware of such criminal offense. Pursuant to Kaweah Delta s policy, we routinely search the Department of Health and Human Services Office of Inspector General and General Services Administration s lists of such excluded and ineligible persons. Kaweah Delta s policy addresses the procedures for timely and thorough review of such lists and appropriate enforcement actions. Update

40 Employees, vendors, and privileged practitioners at Kaweah Delta facilities are required to report to us if they become excluded, debarred or ineligible to participate in Federal healthcare programs; or have been convicted of a criminal offense related to the provision of healthcare items or services. Identification Badge Policy All Kaweah Delta employees, contracted non-employees, physicians, care providers, vendors and volunteers are required to wear an identification badge at all times while performing their work on Kaweah Delta premises. Additionally, all employees should wear a badge attachment, which contains important safety information. Badges must be worn above waist level. If an employee damages or loses their badge, a replacement must be purchased through the Human Resources Department. Kaweah Delta Property and Assets Kaweah Delta property is made available to Kaweah Delta employees only for authorized business purposes and shall not be used for personal reasons. This applies to physical assets such as office equipment, computers, software, medical supplies, as well as other types of property such as company records, patient information and customer lists. Kaweah Delta property must not be removed from the premises unless it is necessary to do so to perform your job. If property is removed from the premises, you must maintain them in your possession at all times and return the property as soon as it is no longer needed. All Kaweah Delta employees are expected to maintain and properly care for Kaweah Delta property. We all have an obligation to treat Kaweah Delta property and equipment with care and respect. This includes reporting any damage or malfunction of Kaweah Delta property to appropriate personnel. If you are aware of anyone intentionally or negligently damaging Kaweah Delta property or equipment, report your observations to your supervisor or other manager who will investigate the matter and take appropriate action. Client lists are a valuable asset and should never be disclosed to anyone outside Kaweah Delta without specific management approval. Ask your supervisor about any request you receive for such a client listing. Controlled Substances Some of our employees routinely have access to prescription drugs, controlled substances, and other medical supplies. Many of these substances are governed and monitored by specific regulatory organizations and must be administered by physician order only. Prescription and controlled medications and supplies must be handled properly and only by authorized individuals. If you become aware of inadequate security of drugs or controlled substances or the diversion of drugs from the organization, the incident must be reported immediately. Harassment and Workplace Violence Each Kaweah Delta employee has the right to work in an environment free of harassment, abusive, threatening, intimidating and disruptive behavior. We do not tolerate harassment by anyone based on the diverse characteristics or cultural backgrounds of those who work with us. Degrading or humiliating jokes, slurs, intimidation, or other harassing conduct is not acceptable in our workplace. Sexual harassment is prohibited. This prohibition includes unwelcome sexual advances or requests for sexual favors in conjunction with employment decisions. Moreover, verbal or physical conduct of a sexual nature that interferes with an individual s work performance or creates an intimidating, hostile, or offensive work environment will not be tolerated at Kaweah Delta. Harassment also includes incidents of workplace violence. Workplace violence includes robbery and other commercial crimes, stalking, violence directed at the employer, terrorism, and hate crimes committed by current or former employees. Employees who observe or experience any form of harassment or violence should report the incident to their supervisor, the Human Resources Department, a member of management, the Compliance and Privacy Officer or the Confidential Reporting Line. Health and Safety Kaweah Delta shall comply with all applicable workplace health, safety, and environmental laws and regulations. Kaweah Delta employees handle hazardous chemicals, Update

41 infectious agents, medical waste, and low-level radioactive material at various locations. All employees are expected to handle materials according to established control, storage and disposal procedures. If you do not know the correct procedure for handling or disposing of any material, promptly ask your supervisor or another Kaweah Delta resource such as the Safety Officer or Director of Risk Management for assistance. Most chemicals used in our facilities are not classified as hazardous waste. Information regarding the hazards, proper handling, and disposal of chemicals is contained within the Material Safety Data Sheets (MSDS) supplied to us by the manufacturer. The MSDS can be found on Kaweah Delta s Intranet and in a binder available to departments where hazardous materials are used. If you are not sure, ask your supervisor or the Safety Officer before disposing of any chemical waste. Kaweah Delta safety plans and manuals provide additional guidance. Kaweah Delta contracts with licensed disposal companies to remove and treat biohazardous waste to render it non-infectious. Biohazardous waste is placed in designated containers, either all red in color or having a fluorescent orange and black biohazard symbol. It is important that we all comply with all applicable workplace health, safety, and environmental laws and regulations and that we know where to find available guidance. Behaviors that undermine a culture of safety Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction, contribute to adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators, and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, we endeavor to address behaviors that threaten the performance of the health care team. Intimidating and disruptive behaviors include overt actions such as verbal outbursts, and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated. License and Certification Renewals Employees, individuals retained as independent contractors, and privileged practitioners in positions which require professional licenses, certifications, or other credentials are responsible for maintaining the current status of their credentials and shall comply at all times with federal and state requirements applicable to their respective disciplines. To assure compliance, Kaweah Delta may require evidence of the individual having a current license or credential status. Kaweah Delta does not allow any employee, independent contractor or privileged practitioner to work in a position that requires a license or certification without valid, current licenses or credentials. Substance Abuse and Mental Acuity To protect the interests of our employees and patients, we are committed to an alcohol and drug-free work environment. All employees must report for work free of the influence of alcohol and illegal drugs. Reporting to work under the influence of any illegal drug or alcohol; having an illegal drug in an employee s system; or using, possessing, or selling illegal drugs while on Kaweah Delta work time or property may result in immediate termination. We may use drug testing as a means of enforcing this policy. It is also recognized that individuals may be taking prescription or over-the-counter drugs, which could impair judgment or other skills required in job performance. Employees with questions about the effect of such medication on their performance or who observe an individual who appears to be impaired in the performance of his or her job must immediately follow the reporting chain of command. 13 Update

42 Marketing, Advertising and Fundraising Practices Marketing and Advertising Kaweah Delta will advertise to inform the community of the availability and value of our services, to provide educational information about personal health, and to inform the public of Kaweah Delta s views on public policy issues related to health care. Kaweah Delta is perceived as a reliable, authoritative source of information about medical care within the heath care system. We shall remain mindful of the trust the public places in us to provide accurate, balanced information. Advertising will be honest and accurate and, when presenting views on issues, clearly distinguish opinion from factual data. Advertising shall not disparage or demean competitors, customers, or patients. Antitrust - Compete Fairly Antitrust laws are designed to create a level playing field in the marketplace and to promote fair competition. These laws could be violated by discussing Kaweah Delta business with a competitor, such as how our prices are set, disclosing the terms of supplier relationships, allocating markets among competitors, or agreeing with a competitor to refuse to deal with a supplier. Our competitors are other health systems and facilities in markets where we operate. At trade association meetings, employees must be alert to potential situations where it may not be appropriate to participate in discussions regarding prohibited subjects with competitors. Prohibited subjects include any aspect of pricing, our services in the market, key costs such as labor costs, and marketing plans. If a competitor raised a prohibited subject, employees must end the conversation immediately. In general, employees should avoid discussing sensitive topics with competitors or suppliers. Employees also must not provide any information in response to an oral or written inquiry concerning an antitrust matter without first consulting their manager, responsible Executive Team member or the Compliance and Privacy Officer. Kaweah Delta Foundation Kaweah Delta Foundation is one of our oldest and strongest traditions. The members of the Foundation board of directors are volunteers from the community including Kaweah Delta employees and doctors who believe in advancing local health care by being donors, fundraisers, and ambassadors for Kaweah Delta. Since being established in 1980, the Foundation has raised monies to build new facilities, purchase medical technology, and advance patient care. The Foundation conducts fundraising activities throughout the year; it receives gifts from individuals, businesses, Kaweah Delta employees and other foundations in the form of cash, securities and bequests. Government Relations and Political Activities Kaweah Delta complies with all federal, state, and local laws governing participation in government relations and political activities. Additionally, Kaweah Delta funds or resources may not be contributed directly to individual political campaigns, political parties, or other organizations which intend to use the funds primarily for political objectives. Organization resources include financial and non-financial donations such as using work time and telephones to solicit for a political cause or candidate or the loaning of Kaweah Delta property for use in the political campaign. Kaweah Delta engages in public policy debate only in a limited number of instances where it has special expertise that can inform the public about the public policy formulation process. When the organization is directly impacted by public policy decisions, it may provide relevant, factual information about the impact of such decisions on the private sector. In articulating positions, the organization only takes positions that it believes can be shown to be in the larger public interest. The organization encourages trade associations with which it is associated to do the same. It is important to separate personal and corporate political activities in order to comply with the appropriate rules and regulations relating to lobbying or attempting to influence government officials. Update

43 No use of Kaweah Delta resources, including , is appropriate for personally engaging in political activity. An employee may, of course, participate in the political process on his or her own time and at his or her own expense. While doing so, it is important that Kaweah Delta employees not give the impression they are speaking on behalf of or representing Kaweah Delta in these activities. Employees cannot seek to be reimbursed by Kaweah Delta for any personal contributions for such purposes. At times, Kaweah Delta may ask employees to make personal contact with government officials or to write letters to present its position on specific issues. In addition, some members of Kaweah Delta s Management Team may be required to interface on a regular basis with government officials. Solicitation, Fundraising and Distribution of Material In order to avoid disruption of healthcare operations or disturbance of patients, and to maintain appropriate order and discipline, solicitation and distribution of literature on Kaweah Delta premises and among Kaweah Delta staff and patients is prohibited. Kaweah Delta supports community organizations who engage in health-related charitable and fundraising activities/events that are consistent with or advance Kaweah Delta s mission. Furthermore, Kaweah Delta will consider support of those health-related charitable activities/events that are held in the local communities. Formal approval is required by Kaweah Delta policy for these types of charitable and fundraising activities. Acknowledgment Process Kaweah Delta requires all employees to attest in acknowledgment confirming they have received the Code, understand it represents mandatory policies of Kaweah Delta and agree to abide by it. New employees are required to sign in acknowledgment as a condition of employment. Adherence to and support of Kaweah Delta s Code of Conduct and participation in related activities training is considered in decisions regarding hiring and promotion. 15 Update

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