Hospital of the University of Pennsylvania

Transcription

1 Effective March 2016 Revised 3/9/16 Hospital of the University of Pennsylvania Radiologic Technologist Education Program Handbook 1

2 Effective March 2016 Revised 3/9/16 Table of Contents I. RADIOGRAPHY PROGRAM MISSION, GOALS AND OBJECTIVES... 6 Program Mission Statement... 6 Goals of the Radiography Program... 6 Program Effectiveness Goals... 6 Programmatic Assessment... 6 Goal 1 (Clinical Competency): Graduates will be clinically competent Goal 2 (Communication): Graduates will demonstrate effective communication skills Goal 3 (Critical Thinking): Graduates will effectively apply critical thinking skills Goal 4 (Professionalism): Graduates will display professionalism Programmatic Effectiveness Goal 1: The program will graduate entry-level technologists General Program Competencies Specific Academic and Clinical Competencies Learning and Counseling Resources Students with Disabilities II. GENERAL INFORMATION Overview Programmatic Accreditation III. ADMISSIONS INFORMATION Admission Procedure Background Investigation and Drug Screening Policy for All Accepted Students Notice of Non-Discrimination Program Transfer Policy Program Withdrawal Policies Readmission to the Program Widener University Affiliation Bloomsburg University and Gwynedd Mercy College Agreements Health Records Documentation Tuberculosis IV. FINANCIAL INFORMATION Tuition Payment Plan Options for Academic Year: Tuition Payment Plan Options for Academic Year: Tuition Refund Policy No refund will be granted if the student has been in the program for more than two weeks V. ACADEMIC INFORMATION

3 Effective March 2016 Revised 3/9/16 Program Course Descriptions (in alphabetical order) Advanced Radiographic Procedures Anatomy & Physiology I/Lab Anatomy & Physiology II/Lab Career Planning & Exploration Cross-Sectional Anatomy Computers & Digital Imaging in Radiology Fundamentals of Radiologic Science & Healthcare Medical Terminology Patient Care, Ethics and Law in Radiologic Sciences Pharmacology and Drug Administration Production and Characteristics of Radiation Radiation Protection & Biology Radiographic Imaging, Equipment, and Processing Radiographic Pathology Radiographic Procedures and Image Analysis I Radiographic Procedures and Image Analysis II Radiography Seminar Radiologic Modalities General Attendance Policy Means of Communication Advisement Procedures Eligibility to Remain in the Program Course Grading Scale Year I Comprehensive Exam Graduation Requirements Graduation Activities Academic Calendar Academic Calendar VI. CLINICAL INFORMATION Overview of Clinical Education Clinical Education Course Descriptions Clinical Education I Clinical Education II Clinical Education III Clinical Education IV Clinical Education V Clinical Education VI

4 Effective March 2016 Revised 3/9/16 Clinical Education Objectives Clinical Education Assignment The Hospital of the University of Pennsylvania The Children s Hospital of Philadelphia Pennsylvania Hospital Tuttleman Center at Penn Medicine Rittenhouse Penn Medicine Bucks County Penn Medicine Radnor Penn Medicine Valley Forge Clinical Rotations Additional Elective Rotations Clinical Education Assignment Hours Student Employment in a Clinical Education Setting Reporting of Absence or Lateness Eligibility for Continued Clinical Placement Patient-Student Technologist Relationship Patient Injuries Lunch VII. PROGRAM POLICIES AND PROCEDURES (in alphabetical order) Alcohol and/or Drugs Bereavement Time Dress Code Dismissal from the Program Emergency Situations Exposure to Infectious Diseases FERPA Family Educational Rights and Privacy Act of Grievance Policy HIPAA - Health Insurance Portability and Accountability Act Hospital Visiting Privileges Inclement Weather Infectious Diseases Jury Duty Leave of Absence Policy Lockers Malpractice Insurance Military Leave Photography, Video Recording, and Audio Recording Pregnancy Policy

5 Effective March 2016 Revised 3/9/16 Professional Conduct Program Resources Usage Policy Racial Harassment Radiation Protection Practices Radiology Department Policies Protection Practices Patient Protection Supervision of Students - Direct/Indirect Radiation Monitor Exposure Reports Sexual Harassment Smoking Student Injuries Telephone Use VIII. APPENDIX (To view details, click on the appropriate link)

6 Effective March 2016 Revised 3/9/16 I. RADIOGRAPHY PROGRAM MISSION, GOALS AND OBJECTIVES Program Mission Statement The mission of the RT Education Program sponsored by Penn Medicine is to prepare students for entry-level employment in radiologic technology. The program will accomplish this by educating them in the fundamental concepts related to the profession through didactic and clinical instruction. The RT Education Program Mission supports the Penn Medicine Mission of creating the future of medicine through: Patient Care and Service Excellence: The RT Education program will cultivate professional competence in its graduates while reinforcing the concepts of excellent patient care and radiation protection. Educational Pre-eminence: The RT Education program uses web-enhanced courses and diverse clinical experiences to provide students with a well-rounded education. New Knowledge and Innovation: The clinical affiliates of the program are at the forefront of imaging technology, and RT Education students will have an opportunity to utilize this technology firsthand. National and International Leadership: UPHS is a national and international leader in healthcare, and the program is designed to position its graduates for success. See APPENDIX A: Penn Medicine Mission and Vision Goals of the Radiography Program 1. Graduates will be clinically competent. 2. Graduates will demonstrate effective communication skills. 3. Graduates will effectively apply critical thinking skills. 4. Graduate will display professionalism. Program Effectiveness Goals 1. The program will graduate entry-level technologists. 2. The program will regularly evaluate the assessment plan to achieve continuous quality improvement. Programmatic Assessment The RT Education Program in support of its mission and goals incorporates a systematic approach to evaluating student learning outcomes and programmatic effectiveness and uses the results for continual program planning and development. The comprehensive plan outlined on the following pages details the program goals, student learning outcomes, tools for evaluating outcomes, and benchmarks for performance. Results are documented and the data are analyzed for each class cohort followed by the development of action plans for improvement. The assessment plan and learning resources are reviewed and evaluated on an annual basis. 6

7 Effective March 2016 Revised 3/9/16 Goal 1 (Clinical Competency): Graduates will be clinically competent. Outcome Tools Benchmark/ Timeframe 1.1 Graduates will position patients and set technical factors for radiographic exams. 1.2 Graduates will adapt positioning for non-routine examinations Including technical factor adaptations. 1.3 Graduates will provide appropriate radiation protection. 1.1a Radiographic Procedures II Final Exam Lab Competency Form ques b Clinical Proficiency Evaluation Form (questions 1-10) 1.2a Clinical Education Competency Exam Forms (Mobile or Trauma Exams) * 1.2b Graduate Follow-up Employer Questionnaire (question 14) 1.3a Radiographic Procedures II Final Exam Lab Comp Form - ques. 8,11, &13 1.3b Clinical Proficiency Evaluation Form - ques Avg. score of 80%. Spring Year 1 Avg. score of 85% Avg. Score of 90% or better (sampling of 3 per student) Spring Year II Session Avg. of 3.5 or better on 5 point scale 6 months post graduation Average score of 80% or better; Spring Year I Average score of 85% Summer Year II Outcome Data/ Benchmark Status Analysis of Data/ Responsible Person Instructor Clinical Coordinator/ Instructor Clinical Coordinator/ Instructor Program Director Clinical Coordinator/ Instructor Clinical Coordinator/ Instructor Action Plan 7

8 Effective March 2016 Revised 3/9/16 Goal 2 (Communication): Graduates will demonstrate effective communication skills. Outcome Tools Benchmark/ Timeframe Action Plan 2.1 Graduates will effectively orally communicate. 2.2 Graduates will effectively communicate in writing. 2.1a Clinical Ed. I Communication Competency Forms (before, during, and after exam) * 2.1b Anatomy & Physiology II Oral Presentation Rubric * 2.2a Advanced Procedures Course - Article Critique Rubric * 2.2b Radiographic Pathology Reflection Paper Rubric * Avg. score of 93% or better Fall - Year 1 Average score of 88 points or better on 100 point scale Spring Year 1 Average score of 90 points or better on 100 point scale Fall Year II Average score of 90 points or better on 100 point scale Spring Year II Outcome Data/ Benchmark Status Analysis of Data/ Responsible Person Clinical Coordinator/ Instructor Instructor Instructor Instructor 8

9 Effective March 2016 Revised 3/9/16 Goal 3 (Critical Thinking): Graduates will effectively apply critical thinking skills. Outcome Tools Benchmark/ Timeframe 3.1 Graduates will demonstrate skills required for a decision making process and the ability to analyze consequences 3.2 Graduates will demonstrate ability to critique radiographs / images for image quality. 3.1a Rad. Procedures & Image Analysis I: Case Study Evaluation Form * 3.1b Clinical Dilemma Assignment Form * 3.2a Clinical Education III Image Evaluation Form * 3.2b Image Critique Session Form * Average score of 4 on an 8 point scale Fall Year 1 Avg. score of 6 or better on 8 point scale Summer II Session Average score of 84% or better (sampling of 3 per student). Summer Session 1 Average score of 93% or better Spring Year II Outcome Data/ Benchmark Status Analysis of Data/ Responsible Person Clinical Coordinator/ Instructor Clinical Coordinator/ Instructor Instructor Clinical Coordinator /Instructor Action Plan 9

10 Effective March 2016 Revised 3/9/16 Goal 4 (Professionalism): Graduates will display professionalism. Outcome Tools Benchmark/ Timeframe 4.1 Graduates will examine an area (modality) of personal interest. 4.2 Graduates will employ professional practices by their actions. 4.1a Career Planning Exploration Course Reflection Paper Rubric * 4.1b Research Experience Presentation Evaluation Form * 4.2a Clinical Education III Professional Characteristics Evaluation Form * 4.2b Excerpt from RE-III Rotational Evaluation Form (items 1-8 professionalism section) Avg. of 3.5 or better on 5 point scale Summer Session 1 Avg. of 3.5 or better on 5 point scale Spring Year II Avg. of 93% or better Summer Session 1 Avg. of 93% or better Summer Session II Outcome Data/ Benchmark Status Analysis of Data/ Responsible Person Instructor Program Director Clinical Coordinator/ Instructor Clinical Coordinator/ Instructor Action Plan 10

11 Effective March 2016 Revised 3/9/16 Programmatic Effectiveness Goal 1: The program will graduate entry-level technologists. Outcome Tools Benchmark/ Timeframe Action Plan 1. Graduates will be successful on the ARRT exam on the 1 st attempt. 2. Graduates seeking employment will be employed within 1 year of completion. 3. Graduates will complete program within 24 months. 4. Graduates will report satisfaction with their educational experience. 5. Employers will report satisfaction with graduate performance. ARRT 1 st time pass rate Graduate Survey Question 2 Job Placement Rate Program Completion Rate Calculation Graduate Survey - Question 22 Graduate follow-up Employer questionnaire- Question 15 Five-year average pass rate of not less than 75% on 1 st attempt Five-year average job placement rate of not less than 75% within 1 year of graduation 75% program completion rate annually Average score of 3.5 on 5pt. scale Average score of 3.5 on 5pt. scale Outcome Data/ Benchmark Status Analysis of Data/ Responsible Person Program Director Program Director Program Director Program Director Program Director 11

12 Effective March 2016 Revised 3/9/16 General Program Competencies Upon completion of the program the student will: 1. Use professional terminology when interacting with health care professionals. 2. Be able to properly interpret radiographic procedures requisitions. See APPENDIX TT: Requisitions for Radiologic Examinations 3. Demonstrate knowledge of human structure and function including general anatomy and anatomical relationships, organ and system functions and relationships and sectional anatomy. 4. Demonstrate knowledge and use of positioning terminology. 5. Demonstrate the ability to properly use immobilization devices. 6. Demonstrate knowledge and use of proper breathing instructions. 7. Demonstrate ability to make positioning modifications for patients unwilling or unable to cooperate. 8. Be able to identify and evaluate technique and positioning variations for trauma, pediatric, geriatric and atypical patients. 9. Demonstrate knowledge of adequate patient preparation for procedures. 10. Demonstrate knowledge of patient instructions regarding diet restrictions. 11. Demonstrate knowledge of injectable and non-injectable contrast media types, uses and precautions. See APPENDIX UU: Safety Precautions in Administration of Diagnostic Agents See APPENDIX VV: Contrast Media Storage 12. Identify pharmaceuticals commonly used for radiography procedures. 13. Demonstrate knowledge of pathology and the ability to recognize common disease processes on images. 14. Demonstrate knowledge of methods of verification of patient identification and requested procedures. 15. Properly use methods of patient transfer and good body mechanics. 16. Demonstrate knowledge of methods of disinfecting and sterilization. 17. Demonstrate knowledge of the various types of isolation techniques. 18. Be able to monitor vital signs. 19. Be able to recognize emergency patient conditions and initiate first aid and basic life-support procedures. 20. Demonstrate knowledge of monitoring medical equipment used in Medical Imaging. See APPENDIX SS: Safe Medical Devices Act 21. Be able to anticipate and provide basic patient care and comfort. 22. Be able to operate radiographic imaging equipment and accessory devices. 23. Demonstrate knowledge of x-ray tube operating characteristics. 24. Be able to manipulate a fluoroscopic unit. 25. Be able to evaluate performance of radiographic systems including recognition of safe limits of equipment operation, and methods for reporting deficiencies to the proper authority. 26. Be able to identify the basic components and control panel of radiographic equipment. 27. Demonstrate an understanding of the electronics of x-ray generation to include circuitry and equipment variables. 28. Be able to perform basic mathematical functions necessary for determining technical factors. 29. Be able to evaluate and adapt exposure factors for various patient conditions, equipment, accessories and contrast media to maintain radiographic quality. 30. Understand concepts of intensifying screens appropriate to specific procedures. 31. Be able to evaluate the need for and proper use of grids and other image enhancing devices. 32. Demonstrate knowledge of film processing methods and skills relating to quality assurance. 33. Be able to evaluate radiographic/image quality. 34. Demonstrate understanding of digital imaging concepts and information processing techniques (CR, DR, PACS). 35. Properly use methods of patient protection for all patients including male patients, women of child bearing age and pediatric patients. 36. Be able to modify exposure factors to increase protection for the patient. 37. Demonstrate understanding of proper use of filtration, accessory equipment and methods, beam restriction devices, patient positioning aids, and shielding devices to protect the patient from unnecessary ionizing radiation. 38. Demonstrate understanding of dose effect to include genetic dose indicators, somatic dose indicators and adverse biological effects. 12

13 Effective March 2016 Revised 3/9/ Demonstrates understanding of personnel protection concepts including time, distance and shielding during radiography and fluoroscopy. 40. Demonstrate knowledge of the basic properties of radiation. 41. Demonstrate awareness of the ethical responsibilities of radiation protection. 42. Demonstrate knowledge of the criteria for radiation monitoring methods. 43. Demonstrate knowledge of established standards and recommendations from NCRP. 44. Be able to exercise independent judgment in the technical performance of medical imaging procedures. 45. Demonstrate understanding of venipuncture theory and techniques. 46. Demonstrate understanding of oxygen administration techniques. 47. Demonstrate the ability to think critically. 48. Be able to perform web-based assignments by accessing web sites, downloading appropriate materials and completing independent learning activities. 49. Be able to develop PowerPoint and poster presentations at an elementary level. Specific Academic and Clinical Competencies Each student must demonstrate competence in patient care and radiographic performance skills as outlined by the American Registry of Radiologic Technologists (ARRT). See APPENDIX B: ARRT Content Specifications for the Examination in Radiography See APPENDIX C: ARRT Radiography Didactic and Clinical Competency Requirements See APPENDIX D: Program Semester Clinical Competency Guideline Learning and Counseling Resources To assure achievement of student learning outcomes and program goals, substantial learning resources are provided. Learning resources include access to the university and medical school libraries with accessible computer-learning labs and study rooms, a radiography printed materials classroom library, program specific computer software programs, a whole body manikin, anatomical models and charts. From time to time, students may experience problems affecting their personal and/or professional lives. If you are in need of counseling services, please contact Nicole Nardone, LSW, MLSP (Triage Clinician / Referral Coordinator at the University of Pennsylvania) at (215) or nnardone@exchange.upenn.edu for assistance in finding a counselor in the area that you can speak to. Students with Disabilities The program follows the University of Pennsylvania Medical Center s policy for employees with disabilities. See APPENDIX W: Employees with Disabilities As an educational program, the RT Education program also recognizes that the individual learning needs of each student need to be considered. This includes students who may have a documented learning disability. In these cases, the RT Education program may provide accommodations including, but not limited to, extended test time or a quiet testing environment, to students with a documented learning disability. Students who wish to register a learning disability must submit a psycho-educational or neuropsychological evaluation directly to the RT Education Program Director. The evaluation must meet the following requirements in order to be considered valid: 1. A qualified evaluator must perform the testing: Clinical psychologists, neuropsychologists, psychiatrists, and medical doctors trained in evaluating psycho-educational and/or neuropsychological evaluations are considered qualified evaluators. Information about their professional credentials, including licensing, certification, and their areas of specialization, must be clearly indicated on the report. Testing may not be completed by anyone who is in any way related to the student requesting the evaluation. 13

14 Effective March 2016 Revised 3/9/16 2. Testing must be current and valid: Testing must be administered within the past three years for students aged 18 and older. Dates of testing must be included on the report. 3. Testing must include pertinent educational, developmental, and medical history: The evaluator must investigate and discuss educational, developmental, and medical history relevant to the learning disability. 4. Testing must describe co-existing conditions: The evaluator must investigate and discuss dual diagnoses, as well as the possibility of diagnostic alternatives such as co-existing mood, behavioral, neurological, and/or personality disorders which may confound a diagnosis of a specific learning disability. 5. Testing must show evidence of a substantial limitation to academic functioning, e.g., how the disability is likely to affect performance in a rigorous academic setting: Testing must demonstrate that a learning disability substantially limits the student s ability to participate in their academic setting. 6. Testing must include all scores/data and provide clear and specific diagnosis of a learning disability. Confidentiality Notice: Neither the RT Education program nor UPHS will release any information at any point in the disability accommodation process without his or her informed written consent, or under compulsion of legal process. Information will be released only on a need to know basis, except where otherwise required by law. Information will be stored on the RT Education shared drive. The program director, clinical coordinator, program faculty, and program coordinator are the only individuals with the ability to access this location. II. GENERAL INFORMATION Overview The radiologic technologist is a healthcare practitioner who plays an important role on the medical team. Technologists are usually employed in a department of radiology or medical imaging center performing a variety of radiographic procedures including basic x-ray procedures or advanced procedures such as computed tomography or magnetic resonance imaging. Typical responsibilities of the radiologic technologist include interacting regularly with ill, injured, or suffering individuals, producing and processing quality diagnostic images, and communicating effectively with fellow technologists, physicians, and other healthcare team members. The RT Education Program, sponsored by Penn Medicine Hospital of the University of Pennsylvania, is an entry-level, full-time program offering students a challenging and rewarding curriculum taught by seasoned radiologic technology faculty with diverse professional backgrounds. The program for radiologic technologists sponsored by Penn Medicine Hospital of the University of Pennsylvania is a full-time program with not more than 40 hours per week. The curriculum is balanced between academic and clinical coursework. Didactic coursework and clinical education activities are scheduled from 8:00 am and 4:00 pm, weekdays. Programmatic Accreditation Students are provided with information regarding programmatic accreditation by the Joint Review Committee on Education in Radiologic Technology at the program orientation. Students should be cognizant of the JRCERT Standards for an Accredited Program in Radiologic Sciences provided in this handbook. See APPENDIX H: JRCERT Standards for an Accredited Educational Program in Radiologic Sciences 14

15 Effective March 2016 Revised 3/9/16 The Penn Medicine HUP RT Education Program seeks to provide a radiography program in compliance with the JRCERT standards. Students seeking more information may contact the RT Education Program Director for assistance or: Joint Review Committee on Education in Radiologic Technology 20 North Wacker Drive, Suite 2850 Chicago, IL (312) / mail@jrcert.org III. ADMISSIONS INFORMATION Admission Procedure Admission to the radiography program is selective and interested individuals must follow the application procedure as follows: Individuals interested in the radiography program must apply online by visiting Sign up for an account or login via Facebook to begin the application process. Individuals interested in the radiography program must complete and submit the following no later than April 1 st for admission consideration into the program the following September: Application form with fee ($75.00); Official transcripts (in a sealed envelope received directly from the institution); - High school or GED documentation - College, if applicable - Technical school, if applicable Two recommendation forms (completed online) Completed HealthcareSource Applicant Survey (a link for the survey will be ed to applicants upon submission of completed application) All prerequisite coursework must have been completed within the last 10 years. For interested international applicants, the official high school transcript and a detailed U.S. equivalency course evaluation must be submitted detailing the completion of the minimum program prerequisites. Educational Credential Evaluators, Inc. (414) Global Education Group, Inc. (305) World Education Services (212) The application is reviewed by the Program Director or designated person for completeness. The applicant will be able to check the status of their application at any time by visiting and signing into their account. Applicants with completed applications by April 1 st will be instructed, in writing, how to arrange to schedule and take the required computerized entrance test at an approved testing site by the required date. The fee, paid directly to the testing site at the time of registration, is currently $ This fee is subject to change. Applicants who successfully complete the entrance test with an overall average of 75% or better (for grammar, reading comprehension, writing and math) will be eligible to continue in the admissions process and will be contacted, in writing, concerning the scheduling of the admissions interview. 15

16 Effective March 2016 Revised 3/9/16 Upon completion of the admissions interview, the Admissions Committee will review and score all applications. The Radiography Program Admissions Committee consists of the following members: 1. Radiology Administrator or designee/s 2. Radiography Program Director 3. Designated Faculty 4. Designated Clinical Instructors The Radiography Program Admissions Committee reviews candidate s application with particular attention to: Strength of secondary/post-secondary academic curriculum Secondary/post-secondary grades and cumulative grade point average Entrance examination score Secondary/post-secondary community service, work experience, and extracurricular activities Interviewing skills/hsi behavioral assessment The applicant is notified in writing concerning the decision of the Admissions Committee. All offers of acceptance, both verbal and written, include a statement confirming that the offer is being made conditional/contingent on successful completion of the background investigation and drug screen. Applicants who submit a fully completed application by November 1 st will be notified of the decision of the Admissions Committee by January 15 th. Applicants who submit a fully completed application between November 1 st and April 1 st will be notified of the decision of the Admissions Committee by May 22 nd. Background Investigation and Drug Screening Policy for All Accepted Students It is the policy of the Health System to provide a safe environment for patients, visitors and employees. The Health System conducts pre-employment/acceptance background investigations and drug screening, on all new hires, re-hires, and accepted students, as a condition of employment, enrollment, and/or as required by law or business reason. Full details may be found in appendices S (Pre-Employment Drug Screening Policy) and T (Pre-Employment Background Investigation Policy)( whereas it refers to employee, this implies the student). See Appendix S: Pre-Employment Drug Screening Policy See Appendix T: Pre-Employment Background Investigation Procedures The background investigations and drug screening are conducted in collaboration with an outside vendor that specializes in providing these services to healthcare organizations. 1. Pre-enrollment background investigations and drug screens are completed on every student accepted into the RT Education Program. 2. Each student will be required to take the test in the allotted time as specified in the paperwork/documentation. 3. All offers of acceptance, both verbal and written, include a statement confirming that the offer is being made conditional/contingent on successful completion of the background investigation and drug screen. Failure to comply with the required procedures will result in the rescinding of the offer for acceptance into the program. 4. The results of the drug test need to be received by RT Education office before the program begins. 16

17 Effective March 2016 Revised 3/9/16 5. A positive or questionable screening outcome will result in an escalated review and further action up to and including retesting or termination from the program 6. All information gathered during this process will be maintained in strict confidence. The designated program representative will be notified as to whether the accepted individual passed or failed any part of the background investigation or drug screening. Notice of Non-Discrimination Admissions into the Radiologic Technologist Educational Program sponsored by Penn Medicine - HUP is non-discriminatory with respect to race, color, religion, gender, age, disability, and national origin. Program pre-requisites and technical standards are provided in the program brochure. See APPENDIX HH: Policy Statement on Equal Opportunity/Affirmative Action See APPENDIX NN: Non-Discrimination Program Transfer Policy A student requesting to transfer into the program from another radiography program: Must submit an application and all transcripts two months prior to the requested entering semester. Will be exempt only from courses determined to be equivalent in content to courses in the HUP Program and only after successful completion of the required HUP readmission/transfer exam. Must have earned a grade of C (75%) or better in academic radiography courses previously taken to be granted exemption. Must complete a minimum of 51% of the radiography courses while enrolled in the Penn Medicine - Hospital of the University of Pennsylvania RT Education Program. See APPENDIX V: Readmission/Transfer Policy Program Withdrawal Policies The Program Director must be informed, in writing, of intent to withdraw from the radiography program or a course in the program. A formal withdrawal from the program or course must be completed to avoid failing grades. This involves completing the necessary paperwork. For program withdrawal, an exit interview is scheduled with the Program Director. All medical center property must be returned to the program office including but not limited to the student identification badge, radiation monitor, and lead markers. Readmission to the Program Students may apply for readmission to the program after voluntarily and temporarily withdrawing from the program if prerequisite courses have been successfully completed. Prior to re-entering the radiography program, readmission testing must be completed. The student s potential for success will be evaluated by the faculty before readmission is permitted. The student may be required to repeat one or more courses previously completed. A course may only be repeated once and must be successfully completed to continue in the program. See APPENDIX V: Readmission/Transfer Policy Widener University Affiliation The program is affiliated with Widener University to provide students an opportunity to acquire college credits, and pursue an associate of science degree while enrolled in the program. Entering students who have earned college credits prior to beginning the program may receive transfer credit for their coursework according the College Credit Transfer Guidelines. See APPENDIX R: College Credit Transfer Guidelines Bloomsburg University and Gwynedd Mercy College Agreements Applicants accepted into the RT Educational Program who are currently enrolled in Bloomsburg University or Gwynedd Mercy College are eligible to complete the Penn Medicine (HUP) program and earn a bachelor s degree from the aforementioned educational institutions upon graduation. 17

18 Effective March 2016 Revised 3/9/16 Health Records Documentation 1. Entering students are required to submit a detailed health form provided by the medical center. All information is confidential. 2. Students must provide documentation of up to date immunization prior to clinical assignment. Additional immunizations may be necessary when required by circumstances. See APPENDIX DD: Influenza Immunization 3. Students must provide documentation of current health insurance coverage. Coverage must be maintained throughout the program. Any changes in coverage must be reported immediately to the program office. Documentation must be provided to the program office again during the first week of each summer clinical course. 4. Students have a responsibility to maintain high standards of health practice, since they have direct contact with individuals who suffer a variety of illnesses. Tuberculosis It is the student's responsibility to have two PPD screenings completed and documented by his/her family physician prior to entering the first fall clinical semester. Additional PPD screening required during the summer or fall semester prior to year two will be administered by the medical center. Failure to abide by hospital policy for PPD screening will result in dismissal from the program IV. FINANCIAL INFORMATION Tuition Payment Plan Options for Academic Year: Plan A: Tuition payment of $5,600.00/year plus $50 technology fee is paid in full by September 1 st of first year. Deposit (nonrefundable): $ upon acceptance Payment One: $1, by July 1, 2015 Payment Two: $4, by September 1, 2015 Technology/Activities Fee: $50.00 by September 1, 2015 Plan B: Tuition payment of $5,600.00/year plus $50 technology fee is paid in full by December 1 st of first year. Deposit (nonrefundable): $ upon acceptance Payment One: $1, by July 1, 2015 Payment Two: $2, by September 1, 2015 Technology/Activities Fee: $50.00 by September 1, 2015 Payment Three: $2, by December 1, 2015 Tuition Payment Plan Options for Academic Year: Plan A: Tuition payment of $5,600.00/year plus $50 technology fee is paid in full by September 1 st of second year. Payment One: $1, by July 1, 2016 Payment Two: $4, by September 1, 2016 Technology/Activities Fee: $50.00 by September 1, 2016 Plan B: Tuition payment of $5,600.00/year is paid in full by December 1 st of second year. Payment One: $1, by July 1, 2016 Payment Two: $2, by September 1, 2016 Technology/Activities Fee: $50.00 by September 1,

19 Effective March 2016 Revised 3/9/16 Payment Three: $2, by December 1, 2016 Tuition is subject to change each year. Failure to meet financial obligations by the required date will result in dismissal from the program after past due notification. Tuition must be paid within two weeks of past due notification. Tuition Refund Policy If written notification of cancellation is submitted to the RT Education Program Director two or more weeks prior to the program start date, a full refund will be granted minus a $50.00 processing fee. If written notification of cancellation is submitted to the RT Education Program Director within two weeks before or two weeks after the start date of the course, a refund of 80% will be granted minus a $50.00 processing fee. No refund will be granted if the student has been in the program for more than two weeks. V. ACADEMIC INFORMATION Program Course Descriptions (in alphabetical order) Advanced Radiographic Procedures This course is a sequel to Radiographic Procedures and Image Analysis I and II and is designed to provide a knowledge base necessary to assist in the performance of advanced radiographic imaging procedures. A discussion of fluoroscopy and considerations related to pediatric, geriatric, mobile, and trauma radiography are discussed. A research component is included. Students will spend a half day learning about research related to radiology and attend lectures. The day concludes with each student being assigned a study to investigate. The student will be expected to develop a presentation and present it to the radiology staff as part of the Radiographic Pathology Course in the fall semester. Anatomy & Physiology I/Lab Content is designed to establish a knowledge base in anatomy and physiology with emphasis on medical imaging. Components of the cell, tissues, organs and systems will be described and discussed. Within this course an introduction to the chest (including the respiratory system), abdomen (including the gastrointestinal and genitourinary systems), appendicular skeleton and muscular system will also be discussed. Lab sessions are incorporated with lecture sessions. Anatomy & Physiology II/Lab This course is a continuation of Anatomy & Physiology I and is designed to establish a knowledge base in anatomy and physiology with emphasis on medical imaging. Components of the axial skeleton, cardiovascular, respiratory, endocrine, lymphatic, nervous, and reproductive systems will be described and discussed. Lab sessions are incorporated with lecture sessions. Career Planning & Exploration This course is designed to provide students with exposure and advisement concerning career options in Medical Imaging. Students will examine a modality or area of interest and write a reflection paper on their professional growth and development acquired from their exploration. Career planning, resume writing, interviewing strategies, and an introduction to portfolio development are also integral aspects of the course. Students will be exposed to program and external lecturers to enrich their experience. Cross-Sectional Anatomy This course is designed to prepare the student to recognize and identify normal and abnormal gross anatomy as demonstrated by computed tomography and magnetic resonance imaging. 19

20 Effective March 2016 Revised 3/9/16 Computers & Digital Imaging in Radiology This course is designed to introduce the student to the basics of computer information processing and electronic imaging in a radiology department. The basic concepts of electronic image production will be discussed including image capture, display, storage and distribution. Computed radiography and direct radiography will be explored in relation to the effects on image quality as compared to radiographic film and screens both in radiography and fluoroscopy. Artifacts and imaging problems specific to electronic imaging will be identified. Fundamentals of Radiologic Science & Healthcare The course will provide the student with an overview of the foundations in radiography and the practitioner s role in the health care delivery system. Principles, practices, and policies of the health care organization(s) will be examined and discussed in addition to the professional responsibilities of the radiographer. Content also includes the promotion of a better understanding of patients, patient families, and professional peers through the comparison of diverse populations based on influences, health risks, and life stages. Factors that influence relationships with patients and professional peers in a radiology setting will be studied. Medical Terminology This course will provide the student with an introduction to the origins of medical terminology. A word building system will be introduced, and abbreviations and symbols will be discussed. Also introduced in this course will be an orientation to the understanding of radiographic orders and interpretation of diagnostic reports. Related terminology is addressed. Patient Care, Ethics and Law in Radiologic Sciences This course will provide the student with the basic concepts of patient care, including consideration for the physical and psychological needs of the patient and family. Routine and emergency patient care procedures will be described, as well as infection control procedures utilizing standard precautions. The role of the radiographer in patient education will be identified. Content will also provide a fundamental background in ethics. The historical and philosophical basis of ethics, as well as the elements of ethical behavior will be discussed. The student will examine a variety of ethical issues and dilemmas they may face in clinical practice. An introduction to legal terminology, concepts and principles will also be presented in this unit. Topics include misconduct, malpractice, legal and professional standards and the ASRT scope of practice. The importance of proper documentation and informed consent is emphasized in this unit. Pharmacology and Drug Administration This course will provide the student with the basic concepts of pharmacology. The theory and practice of basic techniques of venipuncture and the administration of diagnostic contrast agents and/or intravenous medications is included. The appropriate delivery of patient care during these procedures is emphasized. Production and Characteristics of Radiation Content is designed to establish a basic knowledge of atomic structure and terminology. Also presented are the nature and characteristics of radiation, x-ray production and the fundamentals of photon interactions with matter. Radiation Protection & Biology Initial content is designed to present an overview of the principles of radiation protection including the responsibilities of the radiographer for patients, personnel and the public. Radiation health and safety requirements of federal and state regulatory agencies, accreditation agencies and health care organizations are incorporated. Content will be expanded to provide an overview of the principles of the interaction of radiation with living systems. Radiation effects on molecules, cells, tissues and the body as a whole will be presented. Factors affecting biological response are presented, including acute and chronic effects of radiation. 20

21 Effective March 2016 Revised 3/9/16 Radiographic Imaging, Equipment, and Processing Courses are designed to establish a knowledge base in factors that govern and influence the production and recording of radiographic images, and in equipment requirements and design for radiographic, fluoroscopic, mobile, and tomographic equipment. Film and electronic imaging with related accessories will be emphasized. Class demonstrations and labs are used to demonstrate application of theory. The content will also provide a basic knowledge of quality control. Radiographic Pathology Contents are designed to introduce theories of disease causation and the pathophysiologic disorders that compromise healthy systems. Eti0ology, pathophysiologic responses, clinical manifestations, radiographic appearance and management of alterations in body systems will be presented. A research component is included. Students will investigate an assigned study and prepare a presentation to the radiology staff outlining the following topics: protocol number and current status, protocol summary, study background & significance, anatomy & pathology relative to the study, technology involved in protocol, primary & secondary endpoints of study, unusual anticipated events, statistical considerations and participant inclusion/exclusion criteria will draw a conclusion based on results of trial. Students will also provide a 3-4 page reflection paper regarding their experience during the research component. Radiographic Procedures and Image Analysis I Content is designed to provide a knowledge base necessary to perform standard radiographic procedures of the chest, abdomen, extremities, shoulder and pelvic girdles, gastrointestinal system, and genitourinary system. Trauma and mobile radiographic procedures of the above areas are covered in this course. Pediatric radiography is also included in this course. Consideration will be given to the production of radiographs of optimal diagnostic quality. Course content also provides a basis for analyzing radiographic images. The course includes the importance of minimum imaging standards, discussion of a problem solving technique for image evaluation, and the factors that can affect image quality. Actual images will be included for analysis. Laboratory experience is used to complement the didactic portion of the course. Radiographic Procedures and Image Analysis II This course is a continuation of Radiographic Procedures and Image Analysis I and is designed to provide a knowledge base necessary to perform standard radiographic procedures of the bony thorax, vertebral column, skull, facial bones, and paranasal sinuses. Trauma and mobile radiographic procedures of the above areas are covered in this course. Pediatric radiography is also included in this course. Consideration will be given to the production of radiographs of optimal diagnostic quality. Course content also provides a basis for analyzing radiographic images. The course includes the basic equipment requirements and design for radiographic, fluoroscopic, mobile, and tomographic equipment. The basics of radiation protection safe practices in the clinical setting are also emphasized. The course includes the importance of minimum imaging standards, discussion of a problem solving technique for image evaluation, and the factors that can affect image quality. Actual images will be included for analysis. Laboratory experience is used to complement the didactic portion of the course. Radiography Seminar This course is designed to provide the student with test-taking strategies, an understanding of the American Registry of Radiologic Technologists (ARRT) certification exam application process and a comprehensive review of RT Education curricular components Radiologic Modalities This course includes the importance of minimum imaging standards and the factors that can affect image quality in various imaging modalities. Actual images will be included for discussion. Advanced Skeletal Imaging, Breast Imaging, Central Nervous System Imaging, Computed Tomography, Gastrointestinal Imaging, Genitourinary Imaging, Interventional Radiology, Magnetic Resonance Imaging, Nuclear Medicine, Positron Emission Tomography, Radiation Therapy, and Ultrasound will be discussed. Specific course sequencing for each semester can be found in: 21

22 APPENDIX DDD: Course Sequence Sheet Effective March 2016 Revised 3/9/16 Course numbers, prerequisites, and contact hours can be found in: APPENDIX EEE: Course Numbers General Attendance Policy The RT Education program utilizes the UPHS Performance Improvement and Progressive Steps policy as the basis of its policy. The following guidelines apply to students enrolled in the RT Education program. For attendance infractions or violations, the UPHS Performance Improvement and Progressive Steps policy is applied to the student. A total of three (3) personal days (six half days) will be allotted per academic year (September August). Absences exceeding this amount are occurrences of attendance and are subject to the Performance Improvement and Progressive Steps policy detailed in Appendix E. The Radiologic Technologist Education program at Penn Medicine is a competency-based program. Making up hours is not permitted. Students are expected to attend all academic classes and clinical assignments on-time. Clinical days are scheduled until 4:00 pm, clocking out early is not permitted. Occurrences extend for a maximum of two days. On the third day, a doctor s note is required to return. On the fourth day, leave-of-absence paperwork needs to be completed. There is a limit of four occurrences for absence, lateness, or missed clock-in/clock-out on Evalue. Failure to clock in or out is an occurrence. Clocking in one minute late is still a lateness; three latenesses equates to one occurrence. One hour late or greater automatically counts as an occurrence. Absence from class prohibits participation in class discussion and activities. This will consequently affect the participation grade component of the final course grade. Failure to attend class/clinical regularly may contribute to a lack of mastery of course material and/or clinical skill. This could result in course failure and prevent the student from continuing on in the program. Students are expected to be present for all examinations. A 15% penalty will apply for any exam/quiz taken late due to absence. Students must report any absence or lateness to class or clinical in accordance with the Reporting of Absence or Lateness policy outlined on p. 31. The following infractions automatically escalate to Coaching, regardless of the number of occurrences accrued: o o o Switching clinical rotations without permission Cell phone usage on the clinical floor Not wearing appropriate RT Education program uniform The following infractions automatically escalate to First Written Warning, regardless of the number of occurrences accrued: o o Failure to properly notify faculty and clinical managers of absence Unreported absence The following infractions automatically escalate to Second Written Warning, regardless of the number of occurrences accrued: o Unreported absence for two consecutive days 22

23 Effective March 2016 Revised 3/9/16 o Failure to carry out an appropriate directive from RT Education faculty The following infractions automatically escalate to Dismissal, (dismissal from the program), regardless of the number of occurrences accrued: o o Unreported absence for three consecutive days Falsification of clock-in/clock-out hours on Evalue. For infractions of attendance, the Performance Improvement and Progressive Steps policy is applied. All occurrences after the assignment of a progressive step become cumulative and allinclusive. Coaching First Written Warning Second Written Warning Final Written Warning Dismissal from program 5 th occurrence 6 th occurrence 7 th occurrence 8 th occurrence 9 th occurrence For more information, see APPENDIX E: Performance Improvement and Progressive Steps Means of Communication Students are required to have a working address for communication purposes and are required to check it at least every 24 hours. Advisement Procedures Students will meet with the program director and clinical coordinator once per semester in order to ensure their continued success within the program. Academic and clinical performance, and attendance will be reviewed. In addition, the student will have the opportunity to address any questions and concerns at this time. Of course, meetings can be scheduled with program faculty by the student at other times as well. Eligibility to Remain in the Program A student must maintain an average of C or better in all academic and clinical courses to remain in the program. Course Grading Scale Scale Quality Points A A B B C C Passing 2.0 D D F 65 and below 0 Year I Comprehensive Exam Students are required to take and successfully complete (score of 75% or better) a comprehensive curricular exam at the conclusion of the spring semester of year one. The exam consists of 100 questions covering radiography content taught in the following courses: Patient Care, Ethics, & Law Fundamentals of Radiologic Science & Healthcare Anatomy & Physiology I and II Radiographic Procedures & Image Analysis I and II 23

24 Effective March 2016 Revised 3/9/16 Production & Characteristics of Radiation Medical Terminology See APPENDIX U: Year I Comprehensive Exam Graduation Requirements Upon completion of the RT Education Program, the graduate will receive a certificate of completion. To be eligible to receive a graduation certificate from the RT Program, the student must complete: All academic courses with a grade of C (75%)or better Clinical Education courses I - VI with a grade of C (75%) or better Successful completion of the Year I Comprehensive Exam with a grade of 75% or better All required basic and terminal competencies Ten hours of community service Research Project The program does not offer an early release option. Graduation Activities Upon completion of the program, the student and guests will be provided with a special ceremony to receive the RT Professional pin and graduation certificate. Academic Calendar Fall 2015 Semester 9/8/15: Fall 2015 semester begins 24

25 9/25/15 9/28/15: Papal visit, no classes or clinical 10/13/15: Last date for withdrawal Effective March 2016 Revised 3/9/16 11/26/15: Thanksgiving Holiday, no classes or clinical 12/16/15: Reading day 12/17/15 12/23/15: Fall 2015 Final Exams 12/24/15 1/3/16: Christmas / New Year s Holiday, no classes or clinical Spring 2016 Semester 1/4/16: Spring 2016 semester begins 2/16/16: Last date for withdrawal 4/18/16 4/22/16: Spring 2016 Final Exams week Summer 2016 Semester 4/25/16: Summer 2016 semester begins 4/25/16: First year comprehensive examination 5/24/16: Last date for withdrawal 5/30/16: Memorial Day Holiday, no classes or clinical 7/4/16: Independence Day Holiday, no classes or clinical 8/8/16 8/12/16: Summer 2015 Final exams week 8/11/16: Class of 2016 Graduation and Pinning Ceremony Academic Calendar Fall 2016 Semester 9/6/16: Fall 2016 semester begins 10/11/16: Last date for withdrawal 11/24/16: Thanksgiving Holiday, no classes or clinical 25

26 12/19/16 12/23/16: Fall 2016 Final Exams week Effective March 2016 Revised 3/9/16 12/24/16 1/3/17: Christmas / New Year s Holiday, no classes or clinical Spring 2017 Semester 1/2/17: Spring 2017 semester begins 2/14/17: Last date for withdrawal 4/17/17 4/21/17: Spring 2017 Final Exams week Summer 2017 Semester 4/24/17: Summer 2017 semester begins 5/23/17: Last date for withdrawal 5/29/17: Memorial Day Holiday, no classes or clinical 7/4/17: Independence Day Holiday, no classes or clinical 8/7/17 8/10/17: Summer 2017 Final exams week 8/10/17: Class of 2017 graduation and pinning ceremony *Calendar subject to change VI. CLINICAL INFORMATION Overview of Clinical Education Penn Medicine is committed to providing a comprehensive clinical education experience essential to prepare a student for entry into the radiologic technology profession. The clinical curriculum is composed of six sequentially linked competency-based clinical education courses that increase in complexity and requirements. Compliance with all handbook policies is required. Grades in clinical courses will be lowered to reflect lack of adherence to clinically related policies. Specific details of the clinical curriculum are in the clinical syllabi and in the Master Plan of Education in the Program Director s office. Clinical syllabi are provided to the student at the commencement of each clinical course. 26

27 Effective March 2016 Revised 3/9/16 Clinical Education Course Descriptions Clinical practice consists of six sequentially linked courses. Content and clinical practice experiences shall be designed for sequential development, application, critical analysis, integration, synthesis and evaluation of concepts and theories in the performance of radiologic procedures. Through structured sequential competency-based assignments in clinical setting, concepts of team practice, patient-centered clinical practice and professional development shall be discussed, examined and evaluated. Clinical practice experiences shall be designed to provide patient care and assessment, competent performance of radiographic imaging and total quality management. Levels of competency and outcomes measurement shall assure the well-being of the patient preparatory to, during and following the radiologic procedure. Clinical Education I course consists of 20 hours or more per week (not to exceed 40 hours). The student begins this course by orienting to the hospital and radiology department environment. The student will begin by observing department routines and procedures and move into a more active role of performance (under the direct supervision of a staff technologist). The student will also practice patient care skills, learned in prerequisite courses, in the hospital and radiology department with staff technologists and a rotation with a radiology nurse. Students will begin working on radiographic competency requirements, with a minimum of 7 required this semester. Patient care competencies will also be performed this semester. This clinical course is designed to introduce the student to performance of basic radiographic procedures and application of health care principles. Clinical Education II course is sequentially linked to F1-CE, Clinical Education I and will consist of 20 or more hours per week (not to exceed 40 hours) of clinical observation, participation and performance. The student will have received classroom and laboratory instruction in non-contrast procedures of the spine, cranium, facial bones, and breast as well as basic contrast procedures. The student will continue working on required radiographic competencies (minimum of 12) and is expected to demonstrate a more confident persona when performing basic procedures learned in the previous semester. The student will also continue to refine patient care skills. Clinical Education III course is sequentially linked to S1-CE, Clinical Education II and will consist of 28 or more hours per week (not to exceed 40 hours) of clinical observation, participation and performance. The student will have received classroom and laboratory instruction in all general diagnostic radiographic procedures. The student is fairly confident by this semester and usually requires minimal supervision from the staff radiographers when performing general diagnostic procedures. The student will continue working on required radiographic competencies (minimum of 12). All mandatory competencies except for Portable Orthopedic study and C-Arm study are to be completed by the end of this semester The student will continue to refine skills in procedures for which they have previously demonstrated competency. The student will also continue to refine patient care skills. The student will begin rotating through advanced modalities during this clinical course. Rotations through these areas will consist of observation and assisting the staff technologists under direct supervision. The student will also meet with RT Faculty and classmates once each week to engage in case study analyses of procedures the student has performed. Students will critique their own, and each other s, images according to criteria learned in previous classes. This activity is performed with improving image quality in mind. Clinical Education IV course is sequentially linked to SS1-CE, Clinical Education III and will consist of 24 or more hours per week (not to exceed 40 hours) of clinical observation, participation and performance. The student will have received classroom and laboratory instruction in all general diagnostic radiographic procedures. The student is confident by this semester and usually requires minimal supervision from the staff radiographers when performing general diagnostic procedures. The student has gained confidence in his/her ability to critique radiographic images. The student will continue working on required radiographic competencies (Minimum of 10). The remaining two mandatory competencies must be completed by the end of this quarter. The student will continue to refine skills in procedures for which they have previously demonstrated competency. The student will also continue to refine patient care skills. The student will continue rotating through advanced modalities during this clinical course. Rotations through these areas will consist of observation and assisting the staff technologists under direct 27

28 Effective March 2016 Revised 3/9/16 supervision. The student may request to rotate through elective rotation areas as outlined in the Program Handbook. The student will continue E-portfolio compilation from during this clinical course. Clinical Education V course is sequentially linked to F2-CE, Clinical Education IV and will consist of 24 or more hours per week (not to exceed 40 hours) of clinical observation, participation and performance. The student will have received classroom and laboratory instruction in all general diagnostic radiographic procedures and most advanced radiology procedures. The student is confident by this semester and shall require minimal supervision from the staff radiographers (provided the student has demonstrated competency on the procedure) when performing general diagnostic procedures. The student should require minimal assistance with non-advanced modality procedures, but remain under direct supervision when rotating through advanced modality clinical areas. The student has gained confidence in his/her ability to critique radiographic images and to identify obvious pathology. The student will continue working on required radiographic competencies (minimum of 8). The student will continue to refine skills in procedures for which they have previously demonstrated competency. The student will also continue to refine patient care skills. The student will continue rotating through advanced modalities during this clinical course. Rotations through these areas will consist of observation and assisting the staff technologists under direct supervision. The student may request to rotate through elective rotation areas as outlined in the Program Handbook. The student will continue E- portfolio compilation during this clinical course. All elective competency requirements should be fulfilled by the end of this quarter. Clinical Education VI course is sequentially linked to S2-CE, Clinical Education V and will consist of 32 or more hours per week (not to exceed 40 hours) of clinical observation, participation and performance. The student will have received instruction in all general and advanced radiographic procedures. The student is confident by this semester and shall require minimal supervision from the staff radiographers when performing procedures for which he/she has demonstrated competency. The student has gained confidence in his/her ability to critique radiographic images including identifying common pathology. The student will continue working on required radiographic competencies to meet graduation requirements. The student will demonstrate continued competency and increased proficiency in procedures for which they have previously demonstrated competency. The student and the Clinical Coordinator will meet to determine the procedures for which the student will perform a repeat competency. The student will demonstrate excellent patient care and guest relation skills. The student will continue rotating through advanced modalities during this clinical course. Rotations through these areas will consist of observation and assisting the staff technologists under direct supervision. The student may request to rotate through elective rotation areas as outlined in the Program Handbook. The student will complete E-portfolio compilation during this clinical course. Clinical Education Objectives The student will observe, practice and demonstrate the professional skills of a radiographer by: 1. successfully completing the required number of competency examinations during each clinical course. 2. evaluating the request and following patient identification policy of radiology department. See APPENDIX OO: Patient Identification 3. preparing the radiographic room. 4. using proper body mechanics in clinical practice in order to avoid injury. 5. supporting, assisting, evaluating, questioning, observing, and informing the patient. 6. positioning the patient for the procedure. 7. practicing good radiation protection according to institutional practices and program guidelines. 8. using equipment and technical factors correctly. 9. processing and evaluating images as applicable. 10. demonstrating a professional level of record-keeping procedures. The student will observe, practice and demonstrate learning and growth in professional behaviors by: 1. demonstrating an ability to work with others. 2. demonstrating effective and caring communication skills with all patients and members of the health care team. 28

29 Effective March 2016 Revised 3/9/16 3. accepting constructive criticism willingly as a helpful contribution toward his/her improvement. 4. demonstrating an effective use of time by working systematically and efficiently. 5. adhering to clinical education setting and program policies and requirements. 6. demonstrating ethical conduct and respecting the patients' values and rights, particularly confidentiality in accordance with HIPAA (Health Insurance Portability and Accountability Act) policies. 7. demonstrating initiative in clinical responsibilities. 8. demonstrating dependability and responsibility in clinical assignments including punctuality. 9. presenting an appearance and demeanor that communicates professionalism and competence. 10. demonstrating interest in the profession of radiography by joining a professional organization such as Philadelphia Society of Radiologic Technologists (PhilaSRT), and/or American Society of Radiologic Technologists (ASRT). 11. performing a minimum of ten hours of community service, such as participating in charitable events and promoting the profession (attending health fairs, visiting local schools, and participating in open house events for the RT Education Program); Four of the ten hours may be used for advanced educational activities such as professional lectures related to the field, or other continuing education seminars or presentations. Clinical Education Assignment The program Clinical Coordinator or designee assigns students to specific clinical areas. These assignments provide students with the volume and variety of clinical experiences to progress successfully through the program. The clinical education assignments are equally distributed among enrolled students. The clinical education settings of the program include: The Hospital of the University of Pennsylvania (public transportation available) 3400 Spruce Street Philadelphia, PA The Children s Hospital of Philadelphia (public transportation available) 34 th Street and Civic Center Boulevard Philadelphia, PA Pennsylvania Hospital (public transportation available) 800 Spruce Street Philadelphia, PA Tuttleman Center at Penn Medicine Rittenhouse (public transportation available) 1840 South Street Philadelphia, PA Penn Medicine Bucks County (no public transportation available) 777 Township Line Road Suite 150 Yardley, PA Penn Medicine Radnor (public transportation available) 250 King of Prussia Road Radnor, PA Penn Medicine Valley Forge (no public transportation available) 1001 Chesterbrook Boulevard 29

30 Effective March 2016 Revised 3/9/16 Berwyn, PA Clinical Rotations Include: o Inpatient Radiology o Outpatient Radiology o Mobile Radiography o Surgical Radiography o Emergency/Trauma Radiography o Gastrointestinal/Genitourinary Radiology o Computed Tomography o DEXA Scanning o Interventional Radiology o Neurovascular Radiology o Mammography o Magnetic Resonance Imaging o Pediatric Radiography Additional Elective Rotations Include: o 3-D Imaging Lab o Cardiac Catheterization o Nuclear Medicine o PET-CT o Radiation Therapy o Radiology Assistant/Radiology Practitioner Assistant o Ultrasound o Veterinary Medicine Clinical Education Assignment Hours The usual clinical education assignment hours are 8:00 a.m. to 4:00 p.m. Adequate supervision will be provided for all clinical assignments. Total clinical and classroom hours do not exceed 40 hours per week. Assignments on any one-day are not scheduled to exceed 8 hours, but no student will be permitted to leave a patient during the course of an examination. The student is required to complete any examination s/he begins, which includes getting images checked for necessary repeats or additional images and seeing that the patient is dismissed from the department. Clinical assignments follow a consistent schedule coherent with classroom scheduling, as outlined in the summary chart below: Semester Number of Clinical Days Per Week Length of Semester Fall Year I (CE I) 3 15 Weeks Spring Year I (CE II) 3 15 Weeks Summer Year I (CE III) Weeks Fall Year II (CE IV) 3 15 Weeks Spring Year II (CE V) 3 15 Weeks Summer Year II (CE VI) 4 15 Weeks Note: Paid employment or other activity of a student has no bearing on the structured clinical experience and is not accepted as a rationale for any change in clinical education assignments or requirements Student Employment in a Clinical Education Setting A student will not be employed as a radiographer since a student does not possess the skills of a graduate radiographer. If employed in some other capacity (i.e. technologist assistants), student clinical education in radiography MUST be kept separate at all times from the duties of employment. Failure to abide by this policy may result in dismissal from the program. 30

31 Effective March 2016 Revised 3/9/16 Reporting of Absence or Lateness All absences or anticipated lateness to clinical will be reported as follows: If a student must be absent from the clinical assignment, he/she must personally notify the Clinical Coordinator and the designated person in the clinical education area prior to his/her assigned clinical start time. Notification must be done via , or phone call. See APPENDIX J: Program Personnel Contact Information Failure to notify the appropriate person prior to scheduled start time will result in disciplinary action as stated in the Performance Improvement and Progressive Steps Policy. Lateness is unprofessional and irresponsible. In the event of an anticipated lateness (i.e. doctor appointment or personal day), the student is expected to notify the Program Director, Clinical Coordinator, and the designated person in the clinical education area one day prior to the anticipated lateness or prior to his/her assigned clinical start time. Eligibility for Continued Clinical Placement Eligibility for continued clinical placement requires that a student meet the following criteria: A grade of "C" or better in previous academic and clinical courses Placement in Clinical Education IV requires successful completion of the Year I Comprehensive Exam with a grade of 75% or better In any medical service assignment, it is imperative that providers at all levels be proficient in basic life-saving techniques, therefore, radiography students are required to be certified in adult, child, and infant cardiopulmonary resuscitation (CPR). Adherence to medical center and program policies including but not limited to the completion of specified Knowledge Link courses prior to the commencement of the program. See APPENDIX FF: Responsibility to Meet Regulatory Education Requirements Patient-Student Technologist Relationship Some basic rules when working with patients: 1. Address all patients by title and last name (Mr. Smith). 2. Verifies patient identification by using two identifiers (name, DOB, wristband, etc.) 3. Rough or improper treatment of a patient is not acceptable or appropriate. 4. Chewing gum, whistling, and horseplay are inappropriate clinical behaviors. 5. Patients must be properly draped at all times. 6. Students will not administer medication, water, contrast media, or treatment of any kind to a patient while in the department without the direction of a staff technologist. 7. Students are not permitted to complete procedures in Centricity RIS-IC without direct supervision. A certified staff technologist s name must appear as the performing provider. 8. Patients must be attended to at all times. See APPENDIX I: Patients Rights and Responsibilities See APPENDIX LL: Missing Patient See APPENDIX MM: Newborn Safe Haven (Newborn Abandonment) Patient Injuries If a patient under a student s care is injured in any way, the following steps must be followed: 1. Report occurrence immediately to the Clinical Instructor or supervisor in the clinical area 2. Assist in proper documentation to describe the accident or injury 3. Notify the RT Education Program office as soon as possible. Lunch A forty-five minute lunch period will be assigned by the designated person in the clinical area. 31

32 Effective March 2016 Revised 3/9/16 VII. PROGRAM POLICIES AND PROCEDURES (in alphabetical order) Alcohol and/or Drugs Use of alcohol and/or non-prescription or illegal drugs while at all clinical education settings is prohibited. See APPENDIX CC: Impaired Employees/Use of Alcohol and/or Drugs Bereavement Time The program follows the University of Pennsylvania Medical Center Policy for Bereavement. See APPENDIX M: Bereavement RT Education students are considered to be full-time students. As such, for the purposes of this policy, students are considered as equivalent to an employee with an FTE of 1.0: Upon the death of a father, mother, spouse, domestic partner, son, daughter, sister, brother, legal guardian, or step patent, 40 hours of bereavement leave is allotted. Upon the death of an uncle, aunt, grandparent, grandchild, niece, nephew, or in-law, 8 hours of bereavement leave is allotted. The student may elect to utilize personal time if additional time off is desired, or for bereavement of those not covered by this policy. The RT Education Program Director may require documentation of the death (for example, death certificate, obituary, documentation from funeral home, etc.). Dress Code While students are in classroom/clinical areas, they are required to present a professional appearance at all times. It is the patient's right to be treated with dignity and care by clean individuals. It is, therefore, required that each student practice good personal hygiene. The dress code for all students while in classroom/clinical assignments is: Cleanliness and neatness without odor of any kind is required. Specified chocolate brown scrub uniform only with program embroidery, clean, neat, and unstained. White uniform shoes (polished), or clean entirely white, brown, or black sneakers/shoes. used only for clinical education purposes. No high-heeled shoes are permitted while in a clinical area. White, beige, or brown sweaters or lab jackets if clinical assignment area necessitates additional clothing for warmth. A plain white, beige, or black turtleneck or shirt under the uniform shirt is permitted. No sweatshirts or sweat jackets are permitted with the exception of radiology approved apparel. The HUP identification badge must be visible and worn at all times in the classroom and clinical areas. See APPENDIX AA: Photo Identification Badges CHOP student badges will be required when students are rotating through the emergency department, inpatient, portables, and the operating room. The cost for replacement is $ University of Pennsylvania Medical Center Radiation Monitor (currently dated) at collar. One pair of Post non-dangling earrings (in the ear only), wedding rings and a watch may be worn. (No hoop earrings) Hair must be neat in appearance and of a natural color. Long hair (touching shoulder or longer) must be worn up and secured off the face. Facial hair, if any, must be trimmed and neatly kept. 32

33 Effective March 2016 Revised 3/9/16 "R" and "L" lead markers will be assigned to each student at the commencement of the program. These markers must be carried with the student at all times. The cost for replacement is $10.00 per marker or $20.00 per set. Fingernails must be short and neatly trimmed (no artificial nails are permitted). See APPENDIX AAA: Artificial Nail Policy Nail polish, if worn, should be clear or of skin tone. Where applicable, medical center scrubs are to be worn in the operating room (OR). When assigned in the OR, the student is expected to wear regular uniform to assigned area, change into scrubs when going to the OR, and change back into uniform when OR cases are completed. At no time is it acceptable for operating room hospital scrubs to be in the student s possession outside of the medical center. See APPENDIX K: Hospital Provided Scrub Attire Any student not in uniform as described above may be sent home and the day will be considered an absence from the classroom/clinical assignment. This lies under the discretion of the Clinical Coordinator or Program Director. In the event of unexpected soiling during the day, the Clinical Coordinator will provide guidance. See APPENDIX X: Radiology Professional Image Policy for accepted attire during presentations and other academic involvement. Dismissal from the Program Dismissal from the program may occur due to 1. Failure to meet financial obligations. Students who fail to submit tuition payments by the required dates will be dismissed from the program after past due notification has been issued. 2. Students who do not maintain a C or better in academic courses will be dismissed from the program. 3. Students who do not maintain a C or better in clinical courses will be dismissed from the program. 4. Students found guilty of clinical misconduct may face immediate dismissal from the program. The Program follows the Performance Improvement and Progressive Steps Policy and students must adhere to this policy. See APPENDIX E: Performance Improvement and Progressive Steps A student dismissed from the program may elect to grieve the dismissal by following the grievance procedure. Emergency Situations In case of an emergency situation involving a student, the student should contact the Program Director or Clinical Coordinator immediately by calling the program office or appropriate faculty members. See APPENDIX J: Program Personnel Contact Information The RT Education Program follows the Radiology department s policies for emergency/disaster situations. See APPENDIX WW: Radiology Emergency Response Policies and Procedures Exposure to Infectious Diseases During clinical education, students may be exposed to infectious diseases, prior to the awareness that such an infectious disease situation exists in a patient, employee or visitor. Students may also be exposed to blood or body fluids. The student will be treated according to the infection control policy at the medical center. Treatment may be billed to the student s health insurance carrier or to the student. The student s family physician and/or the medical center must clear (in writing) any student who subsequently contracts an infectious disease in order to return to school. See APPENDIX FFF: Treatment after Exposure to Blood or Body Fluids See APPENDIX GGG: Transmission of Infections 33

34 Effective March 2016 Revised 3/9/16 FERPA Family Educational Rights and Privacy Act of 1974 The Family Educational Rights and Privacy Act (FERPA) afford students certain rights with respect to their educational records. They are: The right to inspect and review the student s educational records within 45 days of the day the hospital receives a request for access. Students should submit to the Program Director a written request that identifies the record(s) they wish to inspect. The Program Director will make arrangements for access and notify the student of the time and place where the records may be inspected. The right to challenge the content of the student s educational records and to ask the hospital to amend a record the student believes is inaccurate or misleading. Students should notify the program official responsible for the record, clearly identify the part of the record they want changed, and specify why it is inaccurate or misleading. If the hospital decides not to amend the record as requested by the student, the Program Director will notify the student of the decision and advise the student of his or her right to a hearing on the matter. The hearing will be provided in accordance with the Program Grievance Procedure. The right to consent to disclosures of personally identifiable information contained in the student s educational records, except to the extent that FERPA authorizes disclosure without consent. One exception that permits disclosure without consent is disclosure to school officials with legitimate educational interests. A school official is a person employed by the hospital in an administrative, supervisory, academic, research, or support staff position; a representative of an approval or accrediting agency, a person employed by or under contract to the hospital to perform a special task, such as the attorney or auditor. A record of disclosures will be maintained by the Program Director and may be reviewed by the student. o The hospital may disclose certain personally identifiable information, designated as directory information, concerning students in attendance. The following categories of information have been designated as directory information: the student s name, address, internet address, telephone number, date and place of birth, program of study, participation in officially recognized activities, dates of attendance, awards received, and the most recent previous educational institution attended. Any student who does not wish directory information released must so inform the Program Director in writing within thirty days after commencement of the fall semester. In any event, the hospital may disclose directory information from the record of an individual who is no longer in attendance at the hospital without public notice or prior permission. The right to file with the U.S. Department of Education a complaint concerning alleged failures by the Program to comply with the requirements of the Family Educational Rights and Privacy Act. The name and address of the office that administers FERPA is: Family Policy Compliance Office U.S. Department of Education 400 Maryland Avenue, SW Washington, D.C Any disclosures requested by the student will require prior written notification to the Program Director. See APPENDIX G: Family Educational Rights & Privacy Act (FERPA) for more details. 34

35 Effective March 2016 Revised 3/9/16 Grievance Policy The policies and regulations set forth in this handbook have been established as a guide for students and are designed to ensure a proper atmosphere for academic, personal, and professional growth as well as for student health and safety. It is hoped that students will respond with maturity and a strong sense of individual responsibility. In accordance with our program mission and goals we hope to: Demonstrate openness and fairness with respect to our students; Value continuous learning; Ensure accountability for behavioral choices; and Be unequivocally committed to quality care, patient safety and academic excellence. PURPOSE The purpose of this policy is to set forth fair, reasonable and equitable processes to review Program Faculty decisions and actions regarding individual student performance, violations of UPHS/RT Education rules, academic and clinical policies, and safety practices, standards of professional conduct, and student attendance and timeliness. All policies are in line with the Joint Review Committee on Education in Radiologic Technology policies. It is incumbent upon all involved parties to handle all communications pertaining to this process with strictest confidence. OBJECTIVES Foster a climate of open communication between students and their respective Program Faculty by supporting prompt resolution of issues and concerns. Establish processes for further review of a Program Faculty decision to apply a Progressive Step for Performance Improvement, above a Coaching Step, in relation to a student s performance or a determination of a violation of a UPHS/RT Education policy, safety practice, standard of professional conduct, or attendance or timeliness requirement. Ensure the application of a review process that is reasonable, fair and applies equally. Reinforce standards for students behavior that support the UPHS/RT Education program mission, goals, vision, values and strategies. SCOPE This policy applies to all full time UPHS/RT Education students, MRI Interns and CT Interns enrolled in the Penn Medicine HUP Radiologic Technologist Education Program. PROCEDURES FOR REVIEW OF PROGRESSIVE STEPS There may be occasions when consultation between the student and the Program Director/Clinical Coordinator does not produce a resolution that is acceptable to one or more of the parties involved. In particular, if the student disagrees with a Program Director/Clinical Coordinator s decision to apply a Progressive Step, the student has two avenues, depending on the basis for the Program Director/Clinical Coordinator s action. If the problem remains unresolved, the student may request in writing that the Program Director/Radiology Administrator form a non-partial dispute resolution committee; known from here on as the Grievance Review Committee. Step 1 If the student has a concern of any kind, that is an academic or non-academic problem, and it occurs during the clinical semester, the student should first contact the RT Instructor/Clinical Coordinator to discuss the problem. If the student is not satisfied with the resolution rendered by the RT Instructor/Clinical Coordinator or does not feel comfortable approaching the RT Instructor/Clinical Coordinator then the student should move to the next level and contact the Program Director in writing. 35

36 Effective March 2016 Revised 3/9/16 If the student has a concern of any kind, academic or non-academic, that occurs during an academic semester then the student should first contact the instructor of the course, to discuss the problem. If the student is not satisfied with the resolution rendered by the Instructor or does not feel comfortable approaching the instructor, then the student should move to the next level and contact the Program Director in writing. Step 2 The student must contact the Program Director within 3 working days concerning the incident or offence. The Program Director will review all material involved in the issue. The Program Director will then render a decision to the student in writing within 10 business days from the date of the incident/concern. If the resolution is reached regarding the current issue and the student does not agree with the Program Director s decision, then the student would move to the next and final level in the grievance process. Step 3 In the event that a student is not satisfied with the resolution of the matter through the Program Director in connection with a determination of a violation of a UPHS/RT Education rule, academic or clinical policy, safety practice, standard of professional conduct, or attendance or timeliness requirement, the student may request a Decision Review Hearing. The student shall contact the Program Director to file an official written grievance by completing the Grievance Committee Review Hearing Request Form 3 business days from the date of the incident/concern. The Grievance Committee Reviewing hearing will be held within two weeks of receiving the Grievance Committee Review Hearing Request Form. See Appendix HHH: Grievance Committee Review Hearing Request Form The Grievance Committee will notify the student in writing of their findings upon completion of their review. The Grievance Committee Review Hearing members will conduct a hearing where the student and the Program Director may be asked to present their perspectives of the matter. The student must grant permission in writing if grades will be reviewed and/or discussed. Participants in the hearing may have no direct relationship to the Penn Medicine - HUP Radiologic Technologist Education Program. This committee is composed of at least three, but no more than five members, of the following areas: 1. a Human Resources Representative 2. a Registered Nurse 3. an ancillary person 4. an Administrator/Department Head 5. a staff Physician Under no circumstance may any person from outside of UPHS participate in the hearing. Due to the diversity of the grievance committee 10 business days will be allowed for the committee to hold the Grievance Review Hearing. Following the hearing, the Grievance Committee will reach a majority decision on and recommend whether the Program Director s decision should be confirmed, modified or rejected. The recommendations from the Grievance Review Committee are final. HIPAA - Health Insurance Portability and Accountability Act OVERVIEW The main objective of HIPAA is to protect the privacy of patient information. HIPAA does this by requiring the Department of Health and Human Services to define rules for the protection of patient information. All RT Education Program students will receive training in accordance with hospital policies prior to the first clinical course. Additional information and training will be provided as appropriate. PROGRAM SPECIFIC PROCEDURES 1. Students will temporarily record patient information (protected health information) only for the following purposes: a. Record on competency forms in order to review images with the RT faculty. 36

37 Effective March 2016 Revised 3/9/16 b. Record information for image evaluation purposes during the Clinical Education III Course. c. Completed forms are kept secured in the Clinical Coordinator s office. No other patient information shall be maintained by a student or RT faculty member besides that which is necessary for image review. 2. Students will have PACS Web access while working with technologists in the clinical setting. In accordance with hospital policy, it is considered misuse to use or acquire a technologist s code to access patient information. A student may only view information while working with the technologist who has logged onto the system. 3. Any student found in violation of HIPAA policies or found misusing protected health information (PHI) will be subject to possible disciplinary action and/or dismissal from the RT Education Program. The student may also be liable for civil or criminal proceedings as described in the HIPAA guidelines. See Appendix XX: HIPAA Disclosure of Information from the Patient Information System See APPENDIX YY: HIPAA Need to Know Determination See APPENDIX ZZ: HIPAA Workforce Training for HIPAA Hospital Visiting Privileges Students are to follow all existing medical center policies when personally visiting any patient. See APPENDIX RR: Visiting Policy Inclement Weather In the event of inclement weather, classes/clinical assignments may be cancelled. To find out the operating status for the program in the event of severe weather: Contact the program office at (215) A recording indicating the operating status will be available by 6:30a.m. Infectious Diseases Students receive extensive instruction in the mechanisms of disease transmission and infection control. All policies regarding isolation and materials disposal must be followed according to UPHS policies. Students are discouraged from engaging in patient care activities when they themselves have an active potentially contagious illness/disease. The student has the responsibility to protect patients or any other vulnerable individual including staff members in such a situation. See APPENDIX BB: Employees with Communicable Diseases A student may not refuse to participate in the care or treatment of a patient based solely on the patient s diagnosis (e.g., HIV/AIDS or other sexually transmitted diseases, tuberculosis, or other contagious diseases) or behavior. Under limited circumstances, the student may elect not to participate in aspects of patient care or treatment for cultural, religious, or ethical reasons. Students who have questions regarding potentially contagious conditions are advised to contact the Program Director or Clinical Coordinator. The program follows the University of Pennsylvania Medical Center Policy on Staff Rights and students must adhere to this policy. See APPENDIX L: Staff Rights Jury Duty The program follows the University of Pennsylvania Medical Center Policy for Jury Duty. See APPENDIX EE: Jury Duty Leave of Absence Policy The Penn Medicine HUP Radiologic Technologist Education Program may authorize and grant Leaves of Absence for specified reasons as outlined below. PURPOSE The purpose of this policy is to define the process and procedure to be followed when applying for leaves of absence. 37

38 SCOPE This policy applies to all RT Education students. Effective March 2016 Revised 3/9/16 DURATION All students may request a one-time leave of absence for a maximum of 3 weeks. Absence on the 16th day will result in the necessity to restart the program. A spot will be held for this individual, but they must test back into the program. An approved LOA does not excuse the student from completing course requirements for the current academic and clinical courses enrolled. It is the student s responsibility to make sure all course requirements are completed. All available allotted days for the current academic year (September August) will be exhausted with an approved LOA. PROCEDURES The need for LOA must be documented. When requesting a leave of absence, the student must: 1) Inform the RT Education faculty 2) Schedule a meeting with the RT Education program director to facilitate completion of the necessary paperwork. SEE APPENDIX III: Leave of Absence Lockers Each student will be assigned a locker by a program official. Coats and personal belongings are not to be taken into the clinical areas. The medical center is not responsible for loss of personal property. Students are not permitted to remove the locks from assigned lockers as they are property of the RT Education Program. Malpractice Insurance Liability insurance is provided by University of Pennsylvania Medical Center. Military Leave The program follows the health system policy. Upon returning to the program, the student may be required to sit for readmission examinations to assess retention of material learned and the appropriate placement in the curriculum. Students requiring leave for military reasons. See APPENDIX N: Military Leave Photography, Video Recording, and Audio Recording Students should be aware of limitations with the use of cameras, video recorders, and audio recorders. See APPENDIX BBB: Photographs, Video Recording and Audio Recording Pregnancy Policy If pregnancy occurs while enrolled in the radiography program, disclosure to program officials is entirely voluntary. However, in an effort to minimize dose to the unborn child, the student is encouraged to notify the Program Director in writing once the pregnancy has been confirmed. The student will be given the best available information on potential risks and consequences of radiation exposure during pregnancy by the Department Physics Section as outlined in the U. S. Nuclear Regulatory Commission Guide concerning prenatal radiation exposure. See APPENDIX O: NRC Guide Pregnancy The student may then elect to: 1. withdraw her declaration of pregnancy in writing to the Program Director. 2. continue in the program without modification, after signing a release. 3. withdraw immediately in good standing from the program, with readmission according to the readmission policy after the pregnancy. 38

39 Effective March 2016 Revised 3/9/16 Professional Conduct The RT Education Program expects every student to observe basic rules of conduct. Matters defined in the employee handbook as grounds for immediate dismissal for the employee apply to students in the radiography program. See APPENDIX Y: UPHS Professionalism and Standards of Conduct The Program follows the Performance Improvement and Progressive Steps Policy of the University of Pennsylvania Medical Center and students must adhere to this policy. See APPENDIX E: Performance Improvement and Progressive Steps The behaviors below and behaviors listed in the aforementioned policies will be subject to disciplinary action, up to and including dismissal from the program: 1. Deliberate inattention to patient care. 2. Divulging any confidential information. 3. Refusal to carry out assignments or reasonable instructions. 4. Failure to fulfill responsibilities to an extent that might or does cause injury to a patient, visitor, employee, or another student. 5. Chronic or habitual absenteeism and lateness. 6. Deliberate violation of a posted health, safety, fire prevention, or security rule. 7. Willful or negligent acts which cause damage to, waste of, or loss of material, supplies, equipment, facilities or other property of the medical center. See APPENDIX PP: Property Removal 8. Falsification of medical center records or requested documents. 9. Theft, removal of, unauthorized possession of, unauthorized use of property belonging to any other student, employee, visitor, patient or the medical center. This includes the intent to remove or the actual removal of property from medical center grounds. 10. Threatened or actual physical violence or verbal abuse of a patient, visitor, staff or fellow student. See APPENDIX QQ: Violence in the Workplace 11. Illegal use of or possession of drugs or the dispensing of drugs without a prescription. 12. Possession or use of an intoxicant or narcotic on medical center premises, or reporting to school under the influence of an intoxicant or narcotic. 13. Disorderly or immoral conduct on Hospital premises. 14. Soliciting tips, loans or gifts from patients or other persons. See APPENDIX KK: Solicitation 15. Rude or discourteous behavior. 16. Unauthorized possession, use, copying, or revealing information about medical center business and activities or about patient health information. 17. Unauthorized posting of information about medical center business and activities or about patient health information on the Internet and / or social media. 18. Gambling on medical center premises. 19. Unauthorized absence from assigned area. 20. Failure to report an injury, accident, incident, or unsafe condition occurring or existing on medical center premises. 21. Possession of a lethal weapon on medical center property. 22. Unauthorized use of nourishments or food for patients or belonging to patients. 23. Any conduct seriously detrimental to patient care, fellow students, employees or medical center operation. 24. Cheating or questionable conduct during written examinations. 25. Plagiarism on written assignments. 26. Performance of any radiographic examination without a physician's written request. The RT Education Program ensures non-retaliation for individuals who report ethical concerns or noncompliance to hospital and program policies. See APPENDIX GG: Non-Retaliation and Fair Treatment in Addressing Reports of Compliance or Ethics Concerns 39

40 Effective March 2016 Revised 3/9/16 Program Resources Usage Policy 1. Computers in the Internship and RT Education classrooms are to be used for educational purposes only including but not limited to accessing accounts and checking education related s only. 2. Students are not permitted to alter computer screen displays from original configurations (e.g. changing screensavers or wallpaper). 3. Any student failing to comply with this policy will be disciplined according to Performance Improvement and Progressive Steps Policy. 4. All copying needs should be done either at the library or at home for assignments and lectures. 5. Students are responsible for all program resources in care. 6. Students utilizing laptop computers or models must sign a logbook at the time of initial use and time of return. Program resources are to remain in the RT Education section at all times. See APPENDIX F: Acceptable Use of Information Technology Racial Harassment The RT Education Program seeks to maintain an environment free from racial harassment and the program follows the University of Pennsylvania Medical Center policy. See APPENDIX JJ: Racial Harassment Radiation Protection Practices Radiology Department Policies o Student orientation includes a review of department radiation safety policies. It is the responsibility of the student to read, understand, and adhere to these policies as outlined in section B of the Radiology Department Policy Manual on the department website. o Section B - Radiation Safety: B-1 Monitor Performance of Equipment B-2 Fluoro Badging and Apron Requirements B-3 Pregnant Personnel Policy B-4 Pregnant Patient B-5 Fluoroscopy Time Recording B-6 Monitoring Patient Dose B-7 RT and Nurses Radiation In-Services B-8 Quality Assurance and Radiation Safety Program B-9 Radiation Safety (Penn Website): Handling Tissue Samples Containing Radioactive Material Personnel Monitoring Lead Garment Testing Pregnant Radiation Worker Information B-10 Dose Optimization and Patient Shielding Protection Practices o A student is required to exercise sound radiation protection practices at all times. At no time may a student participate in a procedure utilizing unsafe protection practices. This includes holding patients and/or image receptors while an exposure is occurring. A student will always wear a lead apron when doing portable radiography or fluoroscopy. Patient Protection o Radiation protection of the patient is the student's responsibility when s/he is performing the study. Students must be aware of and practice procedures of patient shielding. Supervision of Students - Direct/Indirect o IN ACCORDANCE WITH THE JOINT REVIEW COMMITTEE STANDARDS, THE POLICY FOR DIRECT AND INDIRECT SUPERVISION IS AS FOLLOWS AND IS TO BE FOLLOWED WITHOUT EXCEPTION. 40

41 Effective March 2016 Revised 3/9/16 o o o o o o o Direct Supervision is defined as student supervision by a qualified practitioner, who reviews the procedure in relation to the student s achievement, evaluates the condition of the patient in relation to the student s knowledge, is present during the procedure, and reviews and approves the procedure. Direct supervision exists when the student has a technologist present in the room or control area when the patient is exposed to ionizing radiation. At a minimum, direct supervision is used: when the student has not yet successfully completed a competency test on the particular exam being performed, whenever a repeat radiograph is being performed, when a student is in the first year of the program before and after the successful completion of a competency test. Indirect Supervision is defined as student supervision provided by a qualified practitioner immediately available to assist the student regardless of the level of student achievement. Immediately available is interpreted as the physical presence of a qualified practitioner adjacent to the room or location where a radiographic procedure is being performed. This availability applies to all areas where ionizing radiation equipment is in use. Indirect supervision may be used: only after the student has successfully completed a competency test on the particular examination, only during the second year of the program. Repeat Radiographs constitute a situation in which a particular responsibility for patient welfare exists. It is program policy that if a student at any time, for any reason repeats a radiograph, DIRECT SUPERVISION IS REQUIRED. THERE IS NO EXCEPTION TO THIS POLICY. FAILURE TO COMPLY WITH THIS POLICY WILL RESULT IN DISCIPLINARY ACTION. Policy for Performance of Mobile Radiography This policy is designed to ensure student and patient safety during the performance of any mobile radiographic procedure (i.e., emergency room, operating room, patient room, etc.). The policy is as follows: The student may begin to observe, assist, and perform mobile radiography, excluding operating room procedures, during Fall Semester of Year One after classroom instruction. The student may begin to observe, assist, and perform operating room radiography in the spring semester of Year One. DIRECT SUPERVISION IS REQUIRED DURING THE PERFORMANCE OF ANY MOBILE OR OPERATING ROOM RADIOGRAPHIC PROCEDURE REGARDLESS OF THE STUDENT S COMPETENCY LEVEL. FAILURE TO COMPLY WITH THIS POLICY WILL RESULT IN DISCIPLINARY ACTION. Radiation Monitor o Each student is responsible for and expected to wear the provided radiation monitor (personal radiation monitor) in the clinical area and in laboratory classes. Students not wearing a radiation monitor will not be permitted to participate in any clinical or lab activities including scheduled classes. o The radiation monitor issued by the medical center is worn at the collar and outside the lead apron. o The radiation monitor must be placed on the monitor board in the Program Office at the end of the day. No student is permitted to take the monitor home, but an exception is made if the student is assigned outside of the Hospital of the University of Pennsylvania. o Each student is responsible for exchanging radiation monitors on time each quarter. o The radiation monitor must be removed while the student is a patient having diagnostic or therapeutic medical or dental procedures. 41

42 Effective March 2016 Revised 3/9/16 o o An accident with or loss of monitor must be reported, in writing, immediately to the Program Office. The program administrative assistant or designee will initiate the process of getting a replacement monitor. The student may not attend clinical or radiographic room lab activities without a current radiation monitor. Clinical reassignment may be necessary while awaiting a replacement monitor. Exposure Reports o The Program Office receives reports on all student radiation monitors. Students are required to review the report within 30 school days and sign acknowledgement of this review. The radiation exposure for any 12-month period must not exceed the occupational effective dose limit of 50.0 msv (5.0 rem) outlined in NCRP 116 publication. This limit is regulated by state and federal agencies for radiological health workers. Any student who exceeds 1.25 msv (125 mrem) for a quarter will be counseled by a Radiation Safety Office representative or a physicist from the Radiology department. Carelessness in radiation practices will result in disciplinary action according to the Performance Improvement and Progressive Steps Policy. Sexual Harassment The RT Education Program seeks to maintain an environment free from sexual harassment and the program follows the University of Pennsylvania Medical Center policy. See APPENDIX II: Sexual Harassment Smoking Smoking is not permitted on the premises of all clinical education settings except in designated areas during the lunch break. See APPENDIX Z: Smoke Free Environment Student Injuries When a student is injured while in the clinical education or classroom setting, s/he must: 1. Report immediately to the Program Director, Clinical Coordinator, faculty, or designated person in the clinical area for advisement. 2. The student must present a note to the RT Education Program Office from Occupational Medicine, the emergency room physician, or family physician stating when the student may resume normal duties For more information on this procedure See APPENDIX P: Volunteer, Student and Rotating House Staff Injury Telephone Use See APPENDIX CCC: Telephone Use Weapons Policy See APPENDIX JJJ: Weapons Policy 42

43 Effective March 2016 Revised 3/9/16 VIII. APPENDIX (To view details, click on the appropriate link). A. Penn Medicine Mission and Vision B. ARRT Content Specifications for the Examination in Radiography C. ARRT Appendix C: Radiography Didactic and Clinical Competency Requirements D. Program Semester Clinical Competency Guideline E. Performance Improvement and Progressive Steps F. Acceptable Use of Information Technology G. Family Educational Rights and Privacy Act (FERPA) H. JRCERT Standards for an Accredited Educational Program in Radiological Sciences I. Patients Rights and Responsibilities J. Program Personnel Contact Information K. Hospital Provided Scrub Attire L. Staff Rights M. Bereavement N. Military Leave Policy O. NRC Guide Pregnancy P. Volunteer, Student and Rotating House Staff Injury R. College Credit Transfer Guidelines S. Pre-Employment Drug Screening Policy T. Pre-Employment Background Investigation Policy U. Year I Comprehensive Exam V. Readmission/Transfer Policy W. Employees with Disabilities X. Radiology Professional Image Policy Y. UPHS Professionalism and Standards of Conduct Z. Smoke Free Environment AA. BB. CC. Photo Identification Badges Employees with Communicable Diseases Impaired Employees/Use of Alcohol and/or Drugs 43

44 Effective March 2016 Revised 3/9/16 DD. EE. FF. GG. HH. II. JJ. KK. LL. MM. NN. OO. PP. QQ. RR. SS. TT. UU. VV. WW. XX. YY. ZZ. AAA. BBB. CCC. DDD. EEE. FFF. GGG. HHH. III. JJJ. Influenza Immunization Jury Duty Mandatory Education: Responsibility to Meet Regulatory Education Requirements Non-Retaliation and Fair Treatment in Addressing Reports of Compliance or Ethics Concerns Policy Statement on Equal Opportunity/Affirmative Action Sexual Harassment Racial Harassment Solicitation Missing Patient Newborn Safe Haven (Newborn Abandonment) Non-Discrimination Patient Identification Property Removal Violence in the Workplace Visiting Policy Safe Medical Devices Act Requisitions for Radiologic Examinations Safety Precautions in Administration of Diagnostic Agents Contrast Media Storage Radiology Emergency Response Policies and Procedures HIPAA Disclosure of Information from the Patient Information System HIPAA Need to Know Determination (Minimum Necessary Requirements) HIPAA Workforce Training for HIPAA Artificial Nail Policy Photographs, Video Recording and Audio Recording Telephone Use Course Sequence Sheet Course Numbers Treatment after Exposure to Blood or Body Fluids Transmission of Infections Grievance Committee Review Hearing Request Form Leave of Absence Weapons Policy 44

45 Mission & Vision Organization About Us University of Pennsylvania Health System... Page 1 of 1 6/19/2012 University of Pennsylvania Health System Mission and Vision of Penn Medicine Mission Statement Creating the future of medicine through: P = Patient Care and Service Excellence E = Educational Pre-eminence N = New Knowledge and Innovation N = National and International Leadership Vision Statement Penn Medicine is committed to remain a world-leading institution in three equally valued and inter-related missions of patient care, education, and research. The success of these missions requires the integration of the School of Medicine and Health Services and a shared destiny with the University of Pennsylvania. By recruiting and retaining a worldclass faculty and staff who strive for excellence, innovation, quality, and professionalism, we will accomplish our missions. Our goal is to be recognized nationally as the most accomplished and respected School of Medicine and Health System. Patient Care Education Research Penn Medicine, Philadelphia, PA PENN 2012, The Trustees of the University of Pennsylvania APPENDIX A

46 CONTENT SPECIFICATIONS FOR THE EXAMINATION IN RADIOGRAPHY Publication Date: August 2010 Implementation Date: January 2012 The purpose of the ARRT Examination in Radiography is to assess the knowledge and cognitive skills underlying the intelligent performance of the tasks typically required of the staff technologist at entry into the profession. To identify the knowledge and skills covered by the examination, the ARRT periodically conducts practice analysis studies involving a nationwide sample of staff technologists 1. The results of the most recent practice analysis are reflected in this document. The complete task inventory, which serves as the basis for these content specifications, is available from our website The table below presents the five major content categories, along with the number and percentage of test questions appearing in each category. The remaining pages provide a detailed listing of topics addressed within each major content category. This document is not intended to serve as a curriculum guide. Although certification programs and educational programs may have related purposes, their functions are clearly different. Educational programs are generally broader in scope and address subject matter not included in these content specifications. CONTENT CATEGORY PERCENT OF TEST NUMBER OF QUESTIONS 2 A. Radiation Protection 22.5% 45 B. Equipment Operation and Quality Control 11.0% 22 C. Image Acquisition and Evaluation 22.5% 45 D. Imaging Procedures 29.0% 58 E. Patient Care and Education 15.0% % A special debt of gratitude is due to the hundreds of professionals participating in this project as committee members, survey respondents, and reviewers. 2. Each exam includes up to an additional 20 unscored (pilot) questions. On the pages that follow, the approximate number of test questions allocated to each content category appears in parentheses. Copyright 2010 by The American Registry of Radiologic Technologists. All rights reserved. Reproduction in whole or part is not permitted without the written consent of the ARRT. APPENDIX B

47 A. RADIATION PROTECTION (45) 1. Biological Aspects of Radiation (10) A. Radiosensitivity 1. dose-response relationships 2. relative tissue radio sensitivities (e.g., LET, RBE) 3. cell survival and recovery (LD 50 ) 4. oxygen effect B. Somatic Effects 1. short-term versus long-term effects 2. acute versus chronic effects 3. carcinogenesis 4. organ and tissue response (e.g., eye, thyroid, breast, bone marrow, skin, gonadal) C. Acute Radiation Syndromes 1. CNS 2. hemopoietic 3. GI D. Embryonic and Fetal Risks E. Genetic Impact 1. genetic significant dose 2. goals of gonadal shielding F. Photon Interactions with Matter 1. Compton effect 2. photoelectric absorption 3. coherent (classical) scatter 4. attenuation by various tissues a. thickness of body part (density) b. type of tissue (atomic number) 2. Minimizing Patient Exposure (15) A. Exposure Factors 1. kvp 2. mas B. Shielding 1. rationale for use 2. types 3. placement C. Beam Restriction 1. purpose of primary beam restriction 2. types (e.g., collimators) D. Filtration 1. effect on skin and organ exposure 2. effect on average beam energy 3. NCRP recommendations (NCRP #102, minimum filtration in useful beam) E. Exposure Reduction 1. patient positioning 2. automatic exposure control (AEC) 3. patient communication 4. digital imaging 5. pediatric dose reduction 6. ALARA F. Image Receptors (e.g., types, relative speed, digital versus film) G. Grids H. Fluoroscopy 1. pulsed 2. exposure factors 3. grids 4. positioning 5. fluoroscopy time (Section A continues on the following page) APPENDIX B

48 A. RADIATION PROTECTION (cont.) 3. Personnel Protection (11) A. Sources of Radiation Exposure 1. primary x-ray beam 2. secondary radiation a. scatter b. leakage 3. patient as source B. Basic Methods of Protection 1. time 2. distance 3. shielding C. Protective Devices 1. types 2. attenuation properties 3. minimum lead equivalent (NCRP #102) D. Special Considerations 1. portable (mobile) units 2. fluoroscopy a. protective drapes b. protective Bucky slot cover c. cumulative timer 3. guidelines for fluoroscopy and portable units (NCRP #102, CFR-21) a. fluoroscopy exposure rates b. exposure switch guidelines 4. Radiation Exposure and Monitoring (9) A. Units of Measurement* 1. absorbed dose 2. dose equivalent 3. exposure B. Dosimeters 1. types 2. proper use C. NCRP Recommendations for Personnel Monitoring (NCRP #116) 1. occupational exposure 2. public exposure 3. embryo/fetus exposure 4. ALARA and dose equivalent limits 5. evaluation and maintenance of personnel dosimetry records D. Medical Exposure of Patients (NCRP #160) 1. typical effective dose per exam 2. comparison of typical doses by modality * Conventional units are generally used. However, questions referenced to specific reports (e.g., NCRP) will use SI units to be consistent with such reports. APPENDIX B

49 B. EQUIPMENT OPERATION AND QUALITY CONTROL (22) 1. Principles of Radiation Physics (9) A. X-Ray Production 1. source of free electrons (e.g., thermionic emission) 2. acceleration of electrons 3. focusing of electrons 4. deceleration of electrons B. Target Interactions 1. bremsstrahlung 2. characteristic C. X-Ray Beam 1. frequency and wavelength 2. beam characteristics a. quality b. quantity c. primary versus remnant (exit) 3. inverse square law 4. fundamental properties (e.g., travel in straight lines, ionize matter) 2. Imaging Equipment (9) A. Components of Radiographic Unit (fixed or mobile) 1. operating console 2. x-ray tube construction a. electron sources b. target materials c. induction motor 3. automatic exposure control (AEC) a. radiation detectors b. back-up timer c. density adjustment (e.g., +1 or 1) 4. manual exposure controls 5. beam restriction devices D. Components of Digital Imaging (CR and DR) 1. PSP - photo-stimulable phosphor 2. flat panel detectors - direct and indirect 3. start up and shut down 4. CR plate erasure 5. equipment cleanliness (imaging plates, CR plates) E. Types of Units 1. dedicated chest unit 2. tomography unit F. Accessories 1. stationary grids 2. Bucky assembly 3. image receptors 3. Quality Control of Imaging Equipment and Accessories (4) A. Beam Restriction 1. light field to radiation field alignment 2. central ray alignment B. Recognition and Reporting of Malfunctions C. Digital Imaging Receptor Systems 1. artifacts (e.g., non-uniformity, erasure) 2. maintenance (e.g., detector fog) 3. display monitor quality assurance D. Shielding Accessories (e.g., lead apron and glove testing) B. X-Ray Generator, Transformers, and Rectification System 1. basic principles 2. phase, pulse, and frequency C. Components of Fluoroscopic Unit (fixed or mobile) 1. image intensifier 2. viewing systems 3. recording systems 4. automatic brightness control (ABC) APPENDIX B

50 C. IMAGE ACQUISITION AND EVALUATION (45) 1. Selection of Technical Factors (20) A. Factors Affecting Radiographic Quality. Refer to Attachment C to clarify terms that may occur on the exam. (X indicates topics covered on the examination) 1. Density/Brightness 2. Contrast/Gray Scale 3. Recorded Detail/Spatial Resolution 4. Distortion a. mas X b. kvp X X c. OID X (air gap) X X d. SID X X X e. focal spot size X f. grids* X X g. filtration X X h. film-screen X X i. beam restriction X X j. motion X k. anode heel effect X l. patient factors (size, pathology) X X X X m. angle (tube, part, or receptor) X X * Includes conversion factors for grids B. Technique Charts 1. pre-programmed techniques anatomically programmed radiography (APR) 2. caliper measurement 3. fixed versus variable kvp 4. special considerations a. casts b. anatomic and pathologic factors c. pediatrics d. contrast media D. Digital Imaging Characteristics 1. spatial resolution a. sampling frequency b. DEL (detector element size) c. receptor size and matrix size 2. image signal (exposure related) a. quantum mottle (noise) b. SNR (signal to noise ratio) or CNR (contrast to noise ratio) C. Automatic Exposure Control (AEC) 1. effects of changing exposure factors on radiographic quality 2. detector selection 3. anatomic alignment 4. density control (+1 or 1) (Section C continues on the following page) APPENDIX B

51 C. IMAGE ACQUISITION AND EVALUATION (cont.) 2. Image Processing and Quality Assurance (12) A. Image Identification 1. methods (e.g., photographic, radiographic, electronic) 2. legal considerations (e.g., patient data, examination data) B. Film Screen Processing 1. film storage 2. components* a. developer b. fixer 3. maintenance/malfunction a. start up and shut down procedure b. possible causes of malfunction (e.g., improper temperature, contamination, replenishment, water flow) C. Digital Imaging Processing 1. electronic collimation (masking) 2. grayscale rendition (look-up table (LUT), histogram) 3. edge enhancement/noise suppression 4. contrast enhancement 5. system malfunctions (e.g., ghost image, banding, erasure, dead pixels, readout problems) 6. CR reader components 3. Criteria for Image Evaluation (13) A. Brightness/Density (e.g., mas, distance) B. Contrast/Gray Scale (e.g., kvp, filtration, grids) C. Recorded Detail (e.g., motion, poor filmscreen contact) D. Distortion (e.g., magnification, OID, SID) E. Demonstration of Anatomical Structures (e.g., positioning, tube-part-image receptor alignment) F. Identification Markers (e.g., anatomical, patient, date) G. Patient Considerations (e.g., pathologic conditions) H. Image artifacts (e.g., film handling, static, pressure, grid lines, Moiré effect or aliasing) I. Fog (e.g., age, chemical, radiation, temperature, safelight) J. Noise K. Acceptable Range of Exposure L. Exposure Indicator Determination M. Gross Exposure Error (e.g., mottle, light or dark, low contrast) D. Image Display 1. viewing conditions (i.e., luminance, ambient lighting 2. spatial resolution 3. contrast resolution/dynamic range 4. DICOM gray scale function 5. window level and width function E. Digital Image Display Informatics 1. PACS 2. HIS 3. RIS (modality work list) 4. Networking (e.g., HL7, DICOM) 5. Workflow (inappropriate documentation, lost images, mismatched images, corrupt data) * Specific chemicals in the processing solutions will not be covered (e.g., glutaraldehyde). APPENDIX B

52 D. IMAGING PROCEDURES (58) This section addresses imaging procedures for the anatomic regions listed below (1 through 7). Questions will cover the following topics: 1. Positioning (e.g., topographic landmarks, body positions, path of central ray, immobilization devices). 2. Anatomy (e.g., including physiology, basic pathology, and related medical terminology). 3. Technical factors (e.g., including adjustments for circumstances such as body habitus, trauma, pathology, breathing techniques). The specific radiographic positions and projections within each anatomic region that may be covered on the examination are listed in Attachment A. A guide to positioning terminology appears in Attachment B. 1. Thorax (10) A. Chest B. Ribs C. Sternum D. Soft Tissue Neck 2. Abdomen and GI Studies (8) A. Abdomen B. Esophagus C. Swallowing Dysfunction Study D. Upper GI Series, Single or Double Contrast E. Small Bowel Series F. Barium Enema, Single or Double Contrast G. Surgical Cholangiography H. ERCP 3. Urological Studies (3) A. Cystography B. Cystourethrography C. Intravenous Urography D. Retrograde Pyelography 4. Spine and Pelvis (10) A. Cervical Spine B. Thoracic Spine C. Scoliosis Series D. Lumbar Spine E. Sacrum and Coccyx F. Sacroiliac Joints G. Pelvis and Hip 5. Head (5) A. Skull B. Facial Bones C. Mandible D. Zygomatic Arch E. Temporomandibular Joints F. Nasal Bones G. Orbits H. Paranasal Sinuses 6. Extremities (20) A. Toes B. Foot C. Calcaneus (Os Calcis) D. Ankle E. Tibia, Fibula F. Knee G. Patella H. Femur I. Fingers J. Hand K. Wrist L. Forearm M. Elbow N. Humerus O. Shoulder P. Scapula Q. Clavicle R. Acromioclavicular Joints 6. Extremities (cont.) S. Bone Survey T. Long Bone Measurement U. Bone Age V. Soft Tissue/Foreign Bodies 7. Other (2) A. Arthrography B. Myelography APPENDIX B

53 E. PATIENT CARE AND EDUCATION (30) 1. Ethical and Legal Aspects (4) A. Patient s Rights 1. informed consent (e.g., written, oral, implied) 2. confidentiality (HIPAA) 3. additional rights (e.g., Patient s Bill of Rights) a. privacy B. Legal Issues b. extent of care (e.g., DNR) c. access to information d. living will; health care proxy e. research participation 1. examination documentation (e.g., patient history, clinical diagnosis) 2. common terminology (e.g., battery, negligence, malpractice) 3. legal doctrines (e.g., respondeat superior, res ipsa loquitur) 4. restraints versus immobilization C. ARRT Standards of Ethics 2. Interpersonal Communication (5) A. Modes of Communication 1. verbal/written 2. nonverbal (e.g., eye contact, touching) B. Challenges in Communication 1. patient characteristics 2. explanation of medical terms 3. strategies to improve understanding 4. cultural diversity C. Patient Education 1. explanation of current procedure 2. respond to inquiries about other imaging modalities (e.g., CT, MRI, mammography, sonography, nuclear medicine, bone densitometry regarding dose differences, types of radiation, and patient preps) 3. Infection Control (5) A. Terminology and Basic Concepts 1. asepsis a. medical b. surgical c. sterile technique 2. pathogens a. fomites, vehicles, vectors b. nosocomial infections B. Cycle of Infection 1. pathogen 2. source or reservoir of infection 3. susceptible host 4. method of transmission a. contact (direct, indirect) b. droplet c. airborne/suspended d. common vehicle e. vector borne C. Standard Precautions 1. handwashing 2. gloves, gowns 3. masks 4. medical asepsis (e.g., equipment disinfection) D. Additional or Transmission-Based Precautions 1. airborne (e.g., respiratory protection, negative ventilation) 2. droplet (e.g., particulate mask, restricted patient placement) 3. contact (e.g., gloves, gown, restricted patient placement) E. Disposal of Contaminated Materials 1. linens 2. needles 3. patient supplies (e.g., tubes, emesis basin) (Section E continues on the following page) APPENDIX B

54 E. PATIENT CARE AND EDUCATION (cont.) 4. Physical Assistance and Transfer (4) A. Patient Transfer and Movement 1. body mechanics (balance, alignment, movement) 2. patient transfer B. Assisting Patients with Medical Equipment 1. infusion catheters and pumps 2. oxygen delivery systems 3. other (e.g., nasogastric tubes, urinary catheters, tracheostomy tubes) C. Routine Monitoring 1. equipment (e.g., stethoscope, sphygmomanometer) 2. vital signs (e.g., blood pressure, pulse, respiration) 3. physical signs and symptoms (e.g., motor control, severity of injury) 4. documentation 5. Medical Emergencies (5) A. Allergic Reactions (e.g., contrast media, latex) B. Cardiac or Respiratory Arrest (e.g., CPR) C. Physical Injury or Trauma D. Other Medical Disorders (e.g., seizures, diabetic reactions) 6. Pharmacology (3) A. Patient History 1. medication reconciliation (current medications) 2. premedications 3. contraindications 4. scheduling and sequencing examinations B. Complications/Reactions 1. local effects (e.g., extravasation/ infiltration, phlebitis) 2. systemic effects a. mild b. moderate c. severe 3. emergency medications 4. radiographer s response and documentation 7. Contrast Media (4) A. Types and Properties (e.g., iodinated, water soluble, barium, ionic versus non-ionic) B. Appropriateness of Contrast Media to Exam 1. patient condition (e.g., perforated bowel) 2. patient age and weight 3. laboratory values (e.g., BUN creatinine, GFR) C. Patient Education 1. verify informed consent 2. instructions regarding preparation, diet, and medications 3. pre- and post-examination instructions (e.g., discharge instructions) D. Venipuncture 1. venous anatomy 2. supplies 3. procedural technique E. Administration 1. routes (e.g., IV, oral) 2. supplies (e.g., enema kits, needles) APPENDIX B

55 Attachment A Radiographic Positions and Projections 1. Thorax A. Chest 1. PA upright 2. lateral upright 3. AP Lordotic 4. AP supine 5. lateral decubitus 6. anterior and posterior obliques B. Ribs 1. AP and PA, above and below diaphragm 2. anterior and posterior oblique C. Sternum 1. lateral 2. RAO breathing technique 3. RAO expiration 4. LAO 5. PA sternoclavicular joints 6. anterior oblique sternoclavicular joints D. Soft Tissue Neck 1. AP upper airway 2. lateral upper airway 2. Abdomen and GI studies A. Abdomen 1. AP supine 2. AP upright 3. lateral decubitus 4. dorsal decubitus B. Esophagus 1. RAO 2. left lateral 3. AP 4. PA 5. LAO C. Swallowing Dysfunction Study D. Upper GI series* 1. AP scout 2. RAO 3. PA 4. right lateral 5. LPO 6. AP E. Small Bowel Series 1. PA scout 2. PA (follow through) 3. ileocecal spots 4. enteroclysis procedure F. Barium Enema* 1. left lateral rectum 2. left lateral decubitus 3. right lateral decubitus 4. LPO and RPO 5. PA 6. RAO and LAO 7. AP axial (butterfly) 8. PA axial (butterfly) 9. PA post-evacuation G. Surgical Cholangiography 1. AP H. ERCP 1. AP * single or double contrast 3. Urological Studies A. Cystography 1. AP 2. LPO and RPO 60º 3. lateral 4. AP 10-15º caudad B. Cystourethrography 1. AP voiding cystourethrogram female 2. RPO 30º, voiding cystogram male C. Intravenous Urography 1. AP, scout, and series 2. RPO and LPO 30º 3. PA post-void 4. AP post-void, upright 5. nephrotomography 6. AP ureteric compression D. Retrograde Pyelography 1. AP scout 2. AP pyelogram 3. AP ureterogram 4. Spine and Pelvis A. Cervical Spine 1. AP angle cephalad 2. AP open mouth 3. lateral 4. cross table lateral 5. anterior oblique 6. posterior oblique 7. lateral swimmers 8. lateral flexion and extension 9. AP dens (Fuchs) 10. PA dens (Judd) B. Thoracic Spine 1. AP 2. lateral, breathing 3. lateral, expiration C. Scoliosis Series 1. AP/PA scoliosis series (Ferguson) D. Lumbar Spine 1. AP 2. PA 3. lateral 4. L5-S1 lateral spot 5. posterior oblique 45º 6. anterior oblique 45º 7. AP L5-S1, 30-35º cephalad 8. AP right and left bending 9. lateral flexion and extension E. Sacrum and Coccyx 1. AP sacrum, 15-25º cephalad 2. AP coccyx, 10-20º caudad 3. lateral sacrum and coccyx, combined 4. lateral sacrum or coccyx, separate F. Sacroiliac Joints 1. AP 2. posterior oblique 3. anterior oblique G. Pelvis and Hip 1. AP hip only 2. cross-table lateral hip 3. unilateral frog-leg, non-trauma 4. axiolateral inferosuperior, trauma (Clements-Nakayama) 5. AP pelvis 6. AP pelvis, bilateral frog-leg 7. AP pelvis, axial anterior pelvic bones (inlet, outlet) 8. anterior oblique pelvis, acetabulum (Judet) 5. Head A. Skull 1. AP axial (Towne) 2. lateral 3. PA (Caldwell) 4. PA no angle 5. submentovertical (full basal) 6. PA 25-30º angle (Haas) 7. trauma cross table lateral 8. trauma AP, 15º cephalad 9. trauma AP, no angle 10. trauma AP, axial (Towne) B. Facial Bones 1. lateral 2. parietoacanthial (Waters) 3. PA (Caldwell) 4. PA (modified Waters) C. Mandible 1. axiolateral oblique 2. PA no angle 3. AP axial (Towne) 4. PA semi-axial, 20-25º cephalad 5. PA (modified Waters) 6. submentovertical (full basal) D. Zygomatic Arch 1. submentovertical (full basal) 2. parietoacanthial (Waters) 3. AP axial (Towne) 4. axial oblique 5. lateral E. Temporomandibular Joints 1. lateral (Law) 2. lateral (Schuller) 3. AP axial (Towne) F. Nasal Bones 1. parietoacanthial (Waters) 2. lateral 3. PA (Caldwell) G. Orbits 1. parietoacanthial (Waters) 2. lateral 3. PA (Caldwell) H. Paranasal Sinuses 1. lateral 2. PA (Caldwell) 3. parietoacanthial (Waters) 4. submentovertical (full basal) 5. open mouth parietoacanthial (Waters) APPENDIX B

56 6. Extremities A. Toes 1. AP, entire foot 2. oblique toe 3. lateral toe B. Foot 1. AP angle toward heel 2. medial oblique 3. lateral oblique 4. mediolateral 5. lateromedial 6. sesamoids, tangential 7. AP weight bearing 8. lateral weight bearing C. Calcaneus (Os Calcis) 1. lateral 2. plantodorsal, axial 3. dorsoplantar, axial D. Ankle 1. AP 2. AP mortise 3. mediolateral 4. oblique, 45º internal 5. lateromedial 6. AP stress views E. Tibia, Fibula 1. AP 2. lateral 3. oblique F. Knee 1. AP 2. lateral 3. AP weight bearing 4. lateral oblique 45º 5. medial oblique 45º 6. PA 7. PA axial intercondylar fossa (tunnel) G. Patella 1. lateral 2. supine flexion 45º (Merchant) 3. PA 4. prone flexion 90º (Settegast) 5. prone flexion 55º (Hughston) H. Femur 1. AP 2. mediolateral I. Fingers 1. PA entire hand 2. PA finger only 3. lateral 4. oblique 5. AP thumb 6. oblique thumb 7. lateral thumb J. Hand 1. PA 2. lateral 3. oblique K. Wrist 1. PA 2. oblique 45º 3. lateral 4. PA for scaphoid 5. scaphoid (Stecher) 6. carpal canal L. Forearm 1. AP 2. lateral M. Elbow 1. AP 2. lateral 3. external oblique 4. internal oblique 5. AP partial flexion 6. axial trauma (Coyle) N. Humerus 1. AP non-trauma 2. lateral non-trauma 3. AP neutral trauma 4. scapular Y trauma 5. transthoracic lateral trauma 6. lateral, mid and distal, trauma O. Shoulder 1. AP internal and external rotation 2. inferosuperior axial, nontrauma 3. posterior oblique (Grashey) 4. tangential non-trauma 5. AP neutral trauma 6. transthoracic lateral trauma 7. scapular Y trauma P. Scapula 1. AP 2. lateral, anterior oblique 3. lateral, posterior oblique Q. Clavicle 1. AP 2. AP angle, 15-30º cephalad 3. PA angle, 15-30º caudad R. Acromioclavicular Joints AP Bilateral With and Without Weights S. Bone Survey T. Long Bone Measurement U. Bone Age V. Soft Tissue/Foreign Body 7. Other Procedures A. Arthrography B. Myelography APPENDIX B

57 Attachment B Standard Terminology for Positioning and Projection Radiographic View: Describes the body part as seen by the image receptor or other recording medium, such as a fluoroscopic screen. Restricted to the discussion of a radiograph or image. Radiographic Position: Refers to a specific body position, such as supine, prone, recumbent, erect, or Trendelenburg. Restricted to the discussion of the patient s physical position. Radiographic Projection: Restricted to the discussion of the path of the central ray. POSITIONING TERMINOLOGY A. Lying Down 1. supine lying on the back 2. prone lying face downward 3. decubitus lying down with a horizontal x-ray beam 4. recumbent lying down in any position B. Erect or Upright 1. anterior position facing the image receptor 2. posterior position facing the radiographic tube 3. oblique position erect or lying down a. anterior (facing the image receptor) i. left anterior oblique body rotated with the left anterior portion closest to the image receptor ii. right anterior oblique body rotated with the right anterior portion closest to the image receptor b. posterior (facing the radiographic tube) i. left posterior oblique body rotated with the left posterior portion closest to the image receptor ii. right posterior oblique body rotated with the right posterior portion closest to the image receptor APPENDIX B

58 Anteroposterior Projection Posteroanterior Projection Right Lateral Position Left Lateral Position Left Posterior Oblique Position Right Posterior Oblique Position Left Anterior Oblique Position Right Anterior Oblique Position APPENDIX B

59 Attachment C ARRT Standard Definitions Term Film-Screen Radiography Term Digital Radiography Recorded Detail The sharpness of the structural lines as recorded in the radiographic image. Spatial Resolution The sharpness of the structural edges recorded in the image. Density Radiographic density is the degree of blackening or opacity of an area in a radiograph due to the accumulation of black metallic silver following exposure and processing of a film. Density = Log incident light intensity transmitted light intensity Brightness Brightness is the measurement of the luminance of a monitor calibrated in units of candela (cd) per square meter on a monitor or soft copy. Density on a hard copy is the same as film. Contrast Radiographic contrast is defined as the visible differences between any two selected areas of density levels within the radiographic image. Scale of Contrast refers to the number of densities visible (or the number of shades of gray). Long Scale is the term used when slight differences between densities are present (low contrast) but the total number of densities is increased. Contrast Image contrast of display contrast is determined primarily by the processing algorithm (mathematical codes used by the software to provide the desired image appearance). The default algorithm determines the initial processing codes applied to the image data. Scale of Contrast is synonymous to gray scale and is linked to the bit depth of the system. Gray scale is used instead of scale of contrast when referring to digital images. Short Scale is the term used when considerable or major differences between densities are present (high contrast) but the total number of densities is reduced. Film Latitude The inherent ability of the film to record a long range of density levels on the radiograph. Dynamic Range The range of exposures that may be captured by a detector. The dynamic range for digital imaging is much larger than film. Film latitude and film contrast depend upon the sensitometric properties of the film and the processing conditions, and are determined directly from the characteristic H and D curve. Film Contrast The inherent ability of the film emulsion to react to radiation and record a range of densities. Receptor Contrast The fixed characteristic of the receptor. Most digital receptors have an essentially linear response to exposure. This is impacted by contrast resolution (the smallest exposure change or signal difference that can be detected). Ultimately, contrast resolution is limited by the dynamic range and the quantization (number of bits per pixel) of the detector. Exposure Latitude The range of exposure factors which will produce a diagnostic radiograph. Exposure Latitude The range of exposures which produces quality images at appropriate patient dose. Subject Contrast The difference in the quantity of radiation transmitted by a particular part as a result of the different absorption characteristics of the tissues and structures making up that part. Subject Contrast The magnitude of the signal difference in the remnant beam. APPENDIX B

60 RADIOGRAPHY DIDACTIC AND CLINICAL COMPETENCY REQUIREMENTS Eligibility Requirements Effective January 2012* Candidates for certification are required to meet the Professional Requirements specified in Article II of the ARRT Rules and Regulations. This document identifies the minimum didactic and clinical competency requirements for certification referenced in the Rules and Regulations. Candidates who complete a formal educational program accredited by a mechanism acceptable to the ARRT will have obtained education and experience beyond the requirements specified here. Didactic Requirements Candidates must successfully complete coursework addressing the topics listed in the ARRT Content Specifications for the Examination in Radiography. These topics are presented in a format suitable for instructional planning in the ASRT Radiography Curriculum (2007). Clinical Requirements As part of their educational program, candidates must demonstrate competence in the clinical activities identified in this document. Demonstration of clinical competence means that the program director or designee has observed the candidate performing the procedure, and that the candidate performed the procedure independently, consistently, and effectively. Candidates must demonstrate competence in the areas listed below. Six mandatory general patient care activities. Thirty-one mandatory imaging procedures. Fifteen elective imaging procedures to be selected from a list of 35 procedures. One elective imaging procedure from the head section. Two elective imaging procedures from the fluoroscopy studies section, one of which must be either an Upper GI or a Barium Enema. Documentation The following pages identify specific clinical competency requirements. Candidates may wish to use these pages, or their equivalent, to record completion of the requirements. The pages do NOT need to be sent to the ARRT. To document that the didactic and clinical requirements have been satisfied, candidates must have the program director (and authorized faculty member if required) sign the ENDORSEMENT SECTION of the Application for Certification included in the Certification Handbook. * Note: Candidates who complete their educational program during 2012 or 2013 may use either the previous requirements (effective 2005) or the current requirements (effective 2012). Candidates who graduate after December 31, 2013 may no longer use the previous competency requirements. Copyright 2010 by The American Registry of Radiologic Technologists. All rights reserved. APPENDIX C

61 Radiography Clinical Competency Requirements The clinical competency requirements include the six general patient care activities listed below and a subset of the 66 imaging procedures identified on subsequent pages. Demonstration of competence should include variations in patient characteristics (e.g., age, gender, medical condition). 1. General Patient Care Requirement: Candidates must demonstrate competence in all six patient care activities listed below. The activities should be performed on patients; however, simulation is acceptable (see footnote) if state or institutional regulations prohibit candidates from performing the procedures on patients. 1. CPR General Patient Care 2. Vital signs (blood pressure, pulse, respiration) 3. Sterile and aseptic technique 4. Venipuncture 5. Transfer of patient 6. Care of patient medical equipment (e.g., oxygen tank, IV tubing) Date Completed Competence Verified By Note: The ARRT requirements specify that certain clinical procedures may be simulated. Simulations must meet the following criteria: (a) the student is required to competently demonstrate skills as similar as circumstances permit to the cognitive, psychomotor, and affective skills required in the clinical setting; (b) the program director is confident that the skills required to competently perform the simulated task will generalize or transfer to the clinical setting, and, if applicable, the student will evaluate related images. Examples of acceptable simulation include: demonstrating CPR on a mannequin, positioning a fellow student for a projection without actually activating the x-ray beam, and performing venipuncture by demonstrating aseptic technique on another person, but then inserting the needle into an artificial forearm or grapefruit. APPENDIX C

62 Radiography Clinical Competency Requirements (cont.) 2. Imaging Procedures Requirement: Candidates must demonstrate competence in all 31 procedures identified as mandatory (M). Procedures should be performed on patients; however, up to eight mandatory procedures may be simulated (see previous page) if demonstration on patients is not feasible. Candidates must demonstrate competence in 15 of the 35 elective (E) procedures. Candidates must select one elective procedure from the head section. Candidates must select either Upper GI or Barium Enema plus one other elective from the fluoroscopy section. Elective procedures should be performed on patients; however, electives may be simulated (see previous page) if demonstration on patients is not feasible. Institutional protocol will determine the positions or projections used for each procedure. Demonstration of competence includes requisition evaluation, patient assessment, room preparation, patient management, equipment operation, technique selection, positioning skills, radiation safety, image processing, and image evaluation. Imaging Procedure Mandatory or Elective Date Completed Patient or Simulated Competence Verified By Chest and Thorax 1. Chest Routine M 2. Chest AP (Wheelchair or Stretcher) M 3. Ribs M 4. Chest Lateral Decubitus E 5. Sternum E 6. Upper Airway (Soft-Tissue Neck) E Upper Extremity 7. Thumb or Finger M 8. Hand M 9. Wrist M 10. Forearm M 11. Elbow M 12. Humerus M 13. Shoulder M 14. Trauma: Shoulder (Scapular Y, Transthoracic or Axillary)* M 15. Clavicle E 16. Scapula E 17. AC Joints E 18. Trauma: Upper Extremity (Nonshoulder)* M * Trauma is considered a serious injury or shock to the body. Modifications may include variations in positioning, minimal movement of the body part, etc. APPENDIX C

63 Imaging Procedure Lower Extremity Radiography Clinical Competency Requirements (cont.) Mandatory or Elective 19. Toes E 20. Foot M 21. Ankle M 22. Knee M 23. Tibia-Fibula M 24. Femur M 25. Trauma: Lower Extremity* M 26. Patella E 27. Calcaneus (Os Calcis) E Head Candidates must select at least one elective procedure from this section. 28. Skull E 29. Paranasal Sinuses E 30. Facial Bones E 31. Orbits E 32. Zygomatic Arches E 33. Nasal Bones E 34. Mandible E Spine and Pelvis 35. Cervical Spine M 36. Trauma: Cervical Spine (Cross Table Lateral)* 37. Thoracic Spine M 38. Lumbar Spine M 39. Pelvis M 40. Hip M 41. Cross Table Lateral Hip M 42. Sacrum and/or Coccyx E 43. Scoliosis Series E 44. Sacroiliac Joints E Abdomen 45. Abdomen Supine (KUB) M 46. Abdomen Upright M 47. Abdomen Decubitus E 48. Intravenous Urography E E Date Completed Patient or Simulated Competence Verified By * Trauma is considered a serious injury or shock to the body. Modifications may include variations in positioning, minimal movement of the body part, etc. APPENDIX C

64 Radiography Clinical Competency Requirements (cont.) Imaging Procedure Mandatory or Elective Date Completed Patient or Simulated Competence Verified By Fluoroscopy Studies Candidates must select either Upper GI or Barium Enema plus one other elective procedure from this section. 49. Upper GI Series (Single or Double Contrast) E 50. Barium Enema (Single or Double Contrast) E 51. Small Bowel Series E 52. Esophagus E 53. Cystography/Cystourethrography E 54. ERCP E 55. Myelography E 56. Arthrography E Surgical Studies 57. C-Arm Procedure (Orthopedic) M 58. C-Arm Procedure (Non- Orthopedic) Mobile Studies 59. Chest M 60. Abdomen M 61. Orthopedic M Pediatrics (age 6 or younger) 62. Chest Routine M 63. Upper Extremity E 64. Lower Extremity E 65. Abdomen E 66. Mobile Study E E APPENDIX C

65 REVISED 1/8/15 Semester Clinical Competency Guideline General Patient Care Requirement Candidates must demonstrate competence in the first five patient care activities listed below by the end of the first Fall semester. These activities will take place in the Patient Care course. The student will demonstrate competency in venipuncture during the Pharmacology course (SY2). The activities should be performed on patients; however, simulation is acceptable (see endnote) if state or institutional regulations prohibit candidates from performing the procedures on patients. 1. CPR General Patient Care 2. Vital signs (blood pressure, pulse, & respiration) 3. Sterile and aseptic technique Date Completed Fall Year I (Prior to CE I) Fall Year I Fall Year I 4. Transfer of patient Fall Year I 5. Care of patient medical equipment (e.g., oxygen tank, IV tubing) 6. Venipuncture Fall Year I Spring Year II Competence Verified By Radiologic Procedures Requirement Candidates must demonstrate competence in all mandatory procedures designated in each semester as listed below. Failure to complete any of the assigned semester competencies will result in the following: 1 competency incomplete = drops 1 letter grade from final clinical average (see note) 2 competencies incomplete = drops 2 letter grades from final clinical average (see note) 3 competencies incomplete = automatic failure of clinical course and program dismissal NOTE 1: If the competencies are still incomplete at the end of the following semester, the student will be dismissed from the program. All mandatory competencies must be completed by the end of Clinical Education VI, or the student will not be eligible to graduate. NOTE 2: In order to fulfill graduation requirements, 31 Mandatory (M) and 15 Elective (E) procedures must be completed prior to graduation

66 REVISED 1/8/15 LIST OF MANDATORY COMPETENCIES 1.Chest Routine 2. Chest AP (Wheelchair or Stretcher) 3. Abdomen Supine (KUB) 4. Abdomen Upright 5. Hand 6. Wrist 7. Elbow 8. Forearm 9. Shoulder 10. Trauma Shoulder (Scapular Y, Transthoracic, or Axillary)* 11. Foot 12. Ankle 13 Tibia / Fibula 14. Knee 15. Pelvis 16. Hip COMPETENCY COMPLETION GUIDELINES: Radiologic Procedure 17. Portable Chest 18. Portable Abdomen 19. Ribs 20. Thumb or Finger 21. Humerus 22. Trauma Upper Extremity (non-shoulder)* 23. Femur 24. Trauma Lower Extremity 25. Cross-Table Lateral Hip 26. Cervical Spine 27. Thoracic Spine 28. Lumbosacral Spine 29. Pediatric Chest 30. Portable Orthopedic study 31. C-Arm Procedure (orthopedic) Clinical Education I Clinical Education II Clinical Education III Clinical Education IV Clinical Education V Clinical Education VI A minimum of 7 mandatory competencies must be completed prior to the end of the semester. A minimum of 12 mandatory competencies must be completed prior to the end of the semester. A minimum of 12 mandatory competencies must be completed prior to the end of the semester. Students will be working on finishing elective competencies when available. Minimum of 10 competencies FIVE repeat mandatory (M) competencies ONE terminal competency will be completed in this semester. Students will be working on finishing elective competencies when available. Minimum of 8 competencies FIVE repeat mandatory (M) competencies ONE terminal competency will be completed in this semester. Students will be working on finishing elective competencies when available. Minimum of 6 competencies. FIVE Repeat mandatory (M) competencies ONE terminal competency will be completed in this semester.

67 REVISED 1/8/15 Terminal competencies are performed in the second year under the supervision of the Program Director, Clinical Coordinator, or designee. A different scoring form will be utilized for terminal competency evaluations. * NOTE- REGARDING TRAUMA COMPETENCIES: Trauma is considered a serious injury or shock to the body. Modifications may include variations in positioning, minimal movement of the body part, etc. Policy on Simulations The ARRT requirements specify that certain clinical procedures may be simulated. Simulations must meet the following criteria: (a) the student is required to competently demonstrate skills as similar as circumstances permit to the cognitive, psychomotor, and affective skills required in the clinical setting; (b) the program director is confident that the skills required to competently perform the simulated task will generalize or transfer to the clinical setting. Examples of acceptable simulation include: demonstrating CPR on a mannequin; positioning a fellow student for a projection without actually activating the x-ray beam, and evaluating an image from a teaching file; performing venipuncture by demonstrating aseptic technique on another person, but then inserting the needle into an artificial forearm or grapefruit. During Clinical Education VI, a MAXIMUM of 5 non-contrast, non- portable, non pediatric competencies may be simulated. These competencies eligible for simulation do not include any of those listed above. Electives may be simulated, but they will be randomly selected by the Clinical Coordinator or designee. Competencies eligible for simulation include: ALL competencies in the Head category, Abdomen Decubitus, Lateral Decubitus Chest, Soft Tissue Neck, Scapula, Clavicle, AC Joints, Toes, Os Calcis, Patella, Sacrum, Coccyx, SI Joints.

68 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Number: Page 1 of 10 Effective: 1/01/08 POLICY STATEMENT The University of Pennsylvania Health System (UPHS) is committed to being the healthcare Employer of Choice in the Philadelphia region, by fostering an environment in which each employee can perform to the best of his or her ability. In support of this strategic goal, UPHS has established a comprehensive employee relations program to promote an organizational culture that: Demonstrates openness and fairness with respect to its employees; Values continuous learning; Ensures accountability for behavioral choices; and Is unequivocally committed to quality care, patient safety and academic excellence. UPHS believes in a voluntary commitment to a pro-active employee relations program that encourages application of human resources policies and procedures through measured and thoughtful management practices. The organization s human resources policies and procedures provide a framework, which coupled with the exercise of thoughtful and fair managerial judgment, establishes an environment of positive, consistent and constructive relations with employees. PURPOSE The purpose of this policy is to set forth fair, reasonable and equitable processes to address concerns relating to individual employee performance, violations of UPHS rules, policies, safety practices, and standards of professional conduct, and employee attendance and timeliness. OBJECTIVES Maintain a set of standards for performance and behavior that are reasonable, fair and apply equally. Communicate standards for employee behavior that support the UPHS mission, vision, values and strategies. Prescribe corrective action when employee performance or behavior is not in keeping with organizational expectations. Provides affirmative feedback when performance or behavior changes to meet expectations. SCOPE This policy applies to all budgeted full time and part time UPHS employees who have completed their initial or extended introductory period of employment, inclusive of staff of Clinical Care Associates, UPHS Corporate departments, Clinical Practices of the University of Pennsylvania, Home Care and Hospice Services, The Hospital of the University of Pennsylvania, Pennsylvania Hospital, and Penn Presbyterian Medical Center. Employees covered by a collective bargaining agreement follow the provisions of this policy unless otherwise stated. This policy does not apply to physicians and House Staff, the oversight of whom is the responsibility of departments and/or entity medical staffs. The provisions of this policy do not apply in taking corrective action or terminating a per diem/prn employee, or an employee in their initial or extended introductory period. APPENDIX E

69 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Number: Page 2 of 10 Effective: 1/01/08 PROCEDURES 1. Job Performance Deficiencies A Job Performance Deficiency is the failure of the employee to carry out the role or responsibility of the position, typically as a result of a skill or competency deficit. In the event that the manager determines that an employee s job performance is deficient, i.e., that it does not meet expectations for the position, the manager must first identify and consider all relevant facts pertaining to the potential performance problem. This fact-finding process should include the opportunity for the affected employee to present his or her perspective on the matter. During this process, the manager should consider whether (a) clear expectations have been communicated to the employee; (b) the necessary processes, procedures, training systems, and work environment that effect employee performance are in place and accessible to the employee; and (c) performance monitoring and feedback has been provided. If under these circumstances, the potential exists to correct the performance problem by providing such resources or interventions, the manager should make every effort to address the matter in that manner before proceeding to the Progressive Steps for Performance Improvement set forth below. In such instances the manager should also document the employee s progress in response to the application of available resources and interventions. If upon completion of the fact-finding process the manager determines that (a) a job performance deficiency exists that cannot be corrected through the provision of such resources or interventions as set forth above, or (b) such efforts have already been made and have been unsuccessful, then the Progressive Steps for Performance Improvement set forth below, will be followed. 2. Violations of Rules, Policies and Professional Standards In the event that the manager determines that an employee may have violated an organizational rule or policy, safety practice, or a standard of professional conduct, then the manager ought to investigate the facts pertaining to the alleged violation. This fact-finding process should include the opportunity for the affected employee to present his or her perspective on the matter. If after review the manager determines that a violation has occurred, then depending on the nature of the violation, the manager will proceed to the appropriate level of the Progressive Steps for Performance Improvement. For entities of UPHS that utilize an automated time recording system, it is the responsibility of the employee to record his or her time of arrival at work ( swipe in ) and departure from work ( swipe out ). Employees must swipe in and out in order to ensure the accurate calculation of payroll, effective management of staff, and for a variety of other purposes. Accordingly, failure to swipe in and out constitutes a work rule violation that will result in the application of the Progressive Steps as set forth in the schedule below. A manager may invoke a Progressive Step if an employee demonstrates a pattern or practice of failing to swipe in or out that may not precisely satisfy the criteria set forth in the schedule below but, nevertheless, in the manager s judgment, constitutes a swiping in/swiping out violation. A manager, in his or her discretion, may determine that a violation of an organizational rule or policy, safety practice, or a standard of professional conduct should be disregarded if in the manager s judgment, extraordinary circumstances provide the appropriate justification. 3. Attendance (Absence and Lateness) Infractions In the event that the manager determines that the employee has been excessively absent or late, the employee will be subject to the Progressive Steps for Performance Improvement in accordance with the schedule set forth below. An absence or lateness will be deemed to be an attendance violation if it is not scheduled and approved by the employee s manager in advance of the occurrence. An occurrence of an absence is defined as time off from work separated by time worked. APPENDIX E

70 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Number: Page 3 of 10 Effective: 1/01/08 A manager, in his or her discretion, may determine that an absence or lateness violation should be disregarded if in the manager s judgment, extraordinary circumstances provide the appropriate justification. Similarly, a manager may invoke a Progressive Step if an employee demonstrates a pattern or practice of absenteeism or lateness that may not precisely satisfy the criteria set forth in the schedule below but, nevertheless, in the manager s judgment, constitutes an attendance infraction. Upon issuance of the progressive step, the manager will notify the employee that any additional occurrence of absence/lateness in the next 365 days will advance him/her in the process. ATTENDANCE AND SWIPING IN/OUT VIOLATIONS AND OCCURRENCE MANAGEMENT Prompt to Initiate Corrective Action Number of unscheduled occurrences of absences in rolling 12 month period Number of unscheduled occurrences of lateness in rolling 12 month period Number of failures to swipe in or out in rolling 12 month period* Coaching 5 First Written Warning Second Written Warning Final Warning Termination *Applies to UPHS entities that utilize an automated time recording system. 4. Combined Performance and Violation Occurrences. In some cases, the occurrence may have some characteristics of a Job Performance Deficiency (Section 1 above), and some characteristics of a Violation (Section 2 above). In those instances, the manager will consult with Human Resources to determine the most appropriate classification. In determining this classification, the manager will consider whether the occurrence is primarily a result of the employee s lack of skills or competencies to perform the job duty, or primarily because of the employee s unwillingness to do so. Once the appropriate determination is made, the manager will follow the Progressive Steps in accordance with that classification. 5. Documentation. It is the responsibility of the manager to fully document the procedures followed in connection with the alleged performance deficiency or violation, including the fact-finding, analysis, discussions with the employee and other necessary parties, and any follow-up action. Attachment A provides a suggested format for documentation of Coaching, and Attachment B provides a suggested format for documentation of all other Progressive Steps. APPENDIX E

71 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Number: Page 4 of 10 Effective: 1/01/08 PROGRESSIVE STEPS FOR PERFORMANCE IMPROVEMENT The progressive steps are intended to provide the employee with notification of a deficiency in performance or violation of a rule, policy or professional standard of conduct, and to convey expectations for improvement, and are invoked by the manager upon the occurrence of such an event. The Progressive Steps for Performance Improvement are as follows: 1. Coaching Coaching is an ongoing, informal process through which the manager articulates, models and reinforces expected performance, and addresses (a) performance deficiencies, (b) violations of rules, policies, safety practices and standards of professional conduct, and (c) attendance and lateness infractions. The coaching process is intended to focus on the employee s development through an informal process that reflects a mutual commitment to the success of the employee, and should occur sufficiently close in time to the relevant events so as to provide the appropriate and effective guidance to the employee. Documentation of the coaching process is the responsibility of the manager, and will be maintained in the manager s department file. Coaching documentation will be forwarded to the employee s Human Resources file in the event that the employee is subject to a subsequent Progressive Step (typically, but not necessarily, a First Written Warning) within a twelve month period immediately following Coaching. Examples of violations whose single occurrence would typically result in Coaching may include the following: Presence in unauthorized areas Unauthorized use of UPHS mail, phones, equipment, computers or supplies for personal business Personal use of cell phones or other personal communications devices while on duty Failure to wear proper UPHS ID badge Disregard of UPHS standards regarding one s appearance, uniform, dress or personal hygiene Selling or advertising sale of merchandise, tickets or services without authorization Unauthorized solicitation for a charity or cause This list of examples is intended only for illustrative purposes and is not exhaustive; in addition, serious or inexcusable occurrences may warrant more stringent discipline. 2. First Written Warning This step is initiated by the manager in the event of ongoing performance problems, more serious violations, recurrence of prior violations, or persistence of attendance or lateness infractions. A First Written Warning also is appropriate for an occurrence that would ordinarily result in Coaching, if it occurs within twelve months of a prior Coaching. At the First Written Warning phase, the employee is advised, with a heightened sense of urgency, of the seriousness of the matter. Absent extenuating circumstances, communication of the step should be delivered to the employee in writing within five business days of the subject event, except that the manager should notify the employee of a First Written Warning due to an attendance or swiping in/out violation no later than the day on which the employee is paid for the pay period during which the absence or lateness occurred. APPENDIX E

72 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Number: Page 5 of 10 Effective: 1/01/08 The First Written Warning also communicates the corrective action required and the applicable time frame. It is the responsibility of the manager to fully document this step in the performance improvement process, which should then be reviewed by Human Resources prior to presentation to and discussion with the employee. This documentation becomes a part of the employee file. Examples of violations that would typically result in a First Written Warning in the event of a single occurrence include the following: Failure to report to work after request for time off has been denied Failure to submit completed leave of absence paperwork within required time frame Unauthorized absence from workplace during work hours Failure to properly notify manager of absence Failure to follow safety procedures Offensive language or behavior Acceptance of a gratuity Failure to report an on-the-job injury This list of examples is intended only for illustrative purposes and is not exhaustive; in addition, serious or inexcusable occurrences may warrant more stringent discipline. 3. Second Written Warning This step is invoked by the manager in the event of persistent performance problems following a First Written Warning during the preceding twelve month period, even if under other circumstances the occurrence would only typically result in a Coaching or First Written Warning. At the Second Written Warning phase, the employee is notified that the next progressive step will be nothing less than a Final Warning that any further performance deficiency or violation of any kind or magnitude will result in termination of employment. Absent extenuating circumstances, the Second Written Warning should be delivered to the employee in writing within five business days of the subject event, except that the manager should notify the employee of a Second Written Warning due to an attendance or swiping in/out violation no later than the day on which the employee is paid for the pay period during which the absence or lateness occurred. This Second Written Warning also communicates the corrective action required, and the applicable time frame. It is the responsibility of the manager to fully document this step in the performance improvement process, which should then be reviewed by Human Resources prior to presentation to and discussion with the employee. This documentation becomes a part of the employee file. 4. Final Warning This step is taken in the event that, after thorough investigation, the manager determines that performance deficiencies, violations of rules, policies, safety practices or standards of professional conduct, or attendance or lateness infractions, have not been rectified, or that the employee has committed a very serious violation. At the Final Warning stage, the employee is advised that his or her employment is in jeopardy and that immediate and sustained improvement of performance or elimination of all violations or infractions is required. The employee is further advised that any further performance deficiency or violation, of any kind or magnitude, during the next twelve month period will result in immediate termination of employment. Absent extenuating circumstances, the Final Warning should be delivered to the employee in writing within five business days of the subject event, APPENDIX E

73 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Number: Page 6 of 10 Effective: 1/01/08 except that the manager should notify the employee of a Final Warning due to an attendance or swiping in/out violation no later than the day on which the employee is paid for the pay period during which the absence or lateness occurred. An employee in the Final Warning stage is not eligible to receive any pay increase until after the deactivation of the Final Warning in accordance with the Documentation Deactivation Schedule., and any such adjustment will only apply to the time period after the deactivation occurs and will not be retroactive. The Final Warning must include the time frame for any applicable corrective action. It is the responsibility of the manager to fully document this step in the performance improvement process, which should then be reviewed by Human Resources prior to presentation to and discussion with the employee. This documentation becomes a part of the employee file. Examples of violations that would typically result in a final warning in the event of a single occurrence include the following: Unreported absence for two consecutive work shifts Smoking in unauthorized areas on hospital grounds or patient care facilities Failure to carry out an appropriate directive from an authorized manager Intentionally accessing confidential information Inappropriate disclosure or usage of confidential information This list of examples is intended only for illustrative purposes and is not exhaustive. 5. Termination of Employment In the event that (a) an employee engages in an egregious violation or reckless behavior with respect to a work rule, policy or professional standard of conduct, or (b) notwithstanding improvement efforts, (i) the employee s performance remains deficient, (ii) serious violations or infractions by the employee continue to occur or (iii) absence or lateness infractions persist, then termination of employment is the appropriate step in this process. The decision to terminate the employee must be based on a thorough review of the facts and circumstances and must be consistent with all applicable UPHS policies and procedures. It is the responsibility of the manager to fully document this decision, which should then be reviewed by Human Resources. In consultation with Human Resources, the manager will provide the employee with written confirmation of the termination decision. Examples of violations that would typically result in termination of employment in the event of a single occurrence include the following: Unreported absence from work for three consecutive work shifts (job abandonment) Failure to report to work after expiration of authorized leave of absence Smoking inside hospital buildings Intentional misrepresentation or falsification of clinical or other information or UPHS record Fighting or disorderly conduct Possession of a weapon, firearm or explosive on UPHS property, including parking lot or other exterior UPHS property Unauthorized possession of property belonging to UPHS, or another employee, patient or visitor APPENDIX E

74 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Number: Page 7 of 10 Effective: 1/01/08 Sleeping on the job Harassment, discrimination or unlawful retaliation of any kind Any act intended to deceive an employee, patient or visitor Gross misconduct Unauthorized use or possession of a drug or alcohol on UPHS property Refusal to submit to reasonable medical examination prescribed by a medical provider Failure to be fit for duty due to drug or alcohol consumption Intentional disclosure of confidential information to unauthorized individuals Action or inaction that may create a life-threatening situation or that threatens the safety or wellbeing of a patient, employee or visitor This list of examples is intended for illustrative purposes only and is not exhaustive. 6. Administrative Leave In the event that an investigation is warranted in connection with an allegation of a performance deficiency, a violation of a UPHS rule, policy, safety practice or standard of professional conduct, or attendance or lateness infraction, the employee may be suspended or put on Administrative Leave, with or without pay, pending that investigation. As a part of the investigation, the manager should consider whether (a) clear expectations have been communicated to the employee; (b) necessary processes, procedures, training systems, and work environment that effect employee performance or behavior are in place and accessible to the employee; (c) performance monitoring and feedback has been provided; and (d) whether the allegation could result in termination. Managers considering suspension or Administrative Leave pending investigation should consult with Human Resources. If a performance deficiency, violation or infraction is determined to have occurred, the employee will not receive back pay for the suspension or leave. Conversely, if none has occurred, then the employee will receive pay for the time off pending investigation. Administrative Leave may occur at any time during the Progressive Steps for Performance Improvement. DOCUMENTATION DEACTIVATION SCHEDULE 1. If an employee is subject to only one Progressive Step during a 365 day period, documentation of that Progressive step is deactivated, i.e. no longer eligible for consideration, 365 days after that Progressive Step has been issued. 2. If an employee received a subsequent Progressive Step within 365 days of a prior Progressive Step, the period required for deactivation of the second Progressive Step will also apply to the first Progressive Step. Both the prior and subsequent Progressive Step will be deactivated only when the employee completes a 365 day period without an additional Progressive Step. 3. Documentation of a Progressive Steps becomes part of the employee s Human Resources file and is available for consideration in connection with subsequent Progressive Steps until deactivated. Upon deactivation, the document is retained as part of the employee s Human Resources file. In the event of extraordinary circumstances, although deactivated, the Progressive Steps action can be considered for a subsequent step. Such extraordinary circumstances may include for example, concerns regarding the safety of a patient or employee. APPENDIX E

75 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Number: Page 8 of 10 Effective: 1/01/08 IMPLEMENTATION Implementation of this policy is the responsibility of UPHS Senior Leadership and the manager of the subject employee. RETALIATION UPHS does not permit nor will it condone intimidating or retaliatory acts against employees who report perceived or actual work rule or other regulatory violations. Corrective action up to and including termination may be warranted based on the outcome of a UPHS investigation. AT WILL EMPLOYMENT NOT AFFECTED Notwithstanding anything to the contrary stated in this policy, nothing herein is intended to alter the at-will status of any employee. UPHS at all times retains the right to terminate any employee or impose progressive discipline at any step at any time for any lawful reason, or for no reason at all. SUPERSEDES: Absence Control Policy Constructive Discipline Policy Lateness Control Policy Managing Unacceptable Performance Policy ISSUED BY: Patricia J. Wren Interim Vice President, Human Resources APPENDIX E

76 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Number: Page 9 of 10 Effective: 1/01/08 Attachment A COACHING RECORD Documentation of the coaching process is the responsibility of the manager, and will be maintained in the manager s department file. A copy will be provided to the employee upon request. Coaching documentation will be forwarded to the employee s Human Resources file in the event that the employee is subject to a subsequent Progressive Step within a three hundred sixty five (365) day period immediately following Coaching, or will be deactivated in accordance with the UPHS Progressive Steps for Performance Improvement Documentation Deactivation. Employee Name Title UPHS Entity Department Immediate Manager Manager s Title Subject of Coaching: Performance Improvement/Corrective Action Plan: Follow Up Date: By Whom: Follow Up Date: By Whom: Employee s Signature Date Manager s Signature Date APPENDIX E

77 Subject: University of Pennsylvania Health System Policy Manual Performance Improvement and Progressive Steps Attachment B DOCUMENTATION OF PROGRESSIVE STEP FOR PERFORMANCE IMPROVEMENT Number: Page 10 of 10 Effective: 1/01/08 Employee Name Title UPHS Entity Department Immediate Manager Manager s Title Progressive Step: First Written Warning Second Written Warning Final Warning Basis for Progressive Step: (specify performance deficiency or violation, dates, times, other individuals involved, etc., and attach relevant documentation): Corrective Action Required, including applicable time frame(s): I acknowledge that this Progressive Step has been discussed with me by my manager. I further acknowledge that if I fail to demonstrate immediate and sustained improvement I may be subject to additional disciplinary action up to and including termination of employment. I further acknowledge that nothing in this Documentation of Progressive Step for Performance Improvement alters the at-will employment relationship between UPHS and me, and that either UPHS or I may terminate the employment relationship at any time without cause and without notice. Employee s Signature Date I have attached additional comments I wish to make regarding this action. Manager s Signature Date Next Level Manager s Signature Date APPENDIX E

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86 Family Educational Rights and Privacy Act (FERPA) Page 1 of 2 6/19/2012 U.S. Department of Education Advanced Search Funding Policy Research News About ED Policy General Legislation Regulations Policy Guidance Adult Education Civil Rights Elementary & Secondary Education Grants & Contracts Higher Education Research & Statistics Special Education & Rehabilitative Services Vocational Education About ED Budget & Performance News Publications Teaching Resources FAQs Contact Help Jobs at ED Online Services Recursos en español Web Survey GENERAL Family Educational Rights and Privacy Act (FERPA) The Education Department is releasing a Notice of Proposed Rule Making (NPRM) under the Family Educational Rights and Privacy Act (FERPA). The proposed regulations would give states the flexibility to share data to ensure that taxpayer funds are invested wisely in effective programs. Parents and students put their trust in the stewards of education data to ensure students personal information is properly safeguarded and is used only for legitimate purposes and only when absolutely necessary. The Department deeply values this trust and strives to ensure it is doing all it can do to protect the privacy of our students as the uses of their data to improve education increase. We welcome your feedback on our proposed amendments in the NPRM and encourage the public to comment at: by the May 23rd deadline. FERPA NPRM PDF (201K) Press Release Family Policy Compliance Office (FPCO) Home Safeguarding Student Privacy PDF (250K) The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. Student loans, forgiveness Pell grants College accreditation Grants No Child Left Behind More Contact Race to the Top Upward Bound TRIO Programs FERPA FERPA gives parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. Students to whom the rights have transferred are "eligible students." Parents or eligible students have the right to inspect and review the student's education records maintained by the school. Schools are not required to provide copies of records unless, for reasons such as great distance, it is impossible for parents or eligible students to review the records. Schools may charge a fee for copies. More... Facebook Twitter YouTube Updates Parents or eligible students have the right to request that a school correct records which they believe to be inaccurate or misleading. If the school decides not to amend the record, the parent or eligible student then has the right to a formal hearing. After the hearing, if the school still decides not to amend the record, the parent or eligible student has the right to place a statement with the record setting forth his or her view about the contested information. Key Policy Letters Generally, schools must have written permission from the parent or eligible student in order to release any information from a student's education record. However, FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions (34 CFR 99.31): School officials with legitimate educational interest; Other schools to which a student is transferring; Specified officials for audit or evaluation purposes; Appropriate parties in connection with financial aid to a student; Organizations conducting certain studies for or on behalf of the school; Accrediting organizations; To comply with a judicial order or lawfully issued subpoena; Appropriate officials in cases of health and safety emergencies; and State and local authorities, within a juvenile justice system, pursuant to specific State law. Schools may disclose, without consent, "directory" information such as a student's name, address, telephone number, date and place of birth, honors and awards, and dates of attendance However schools must tell parents and eligible students APPENDIX G

87 Family Educational Rights and Privacy Act (FERPA) Page 2 of 2 6/19/2012 and dates of attendance. However, schools must tell parents and eligible students about directory information and allow parents and eligible students a reasonable amount of time to request that the school not disclose directory information about them. Schools must notify parents and eligible students annually of their rights under FERPA. The actual means of notification (special letter, inclusion in a PTA bulletin, student handbook, or newspaper article) is left to the discretion of each school. For additional information, you may call USA-LEARN ( ) (voice). Individuals who use TDD may call Or you may contact us at the following address: Family Policy Compliance Office U.S. Department of Education 400 Maryland Avenue, SW Washington, D.C Printable view Last Modified: 04/08/2011 News Press releases Speeches Media advisories Secretary's schedule Video Newsletters Blog How do I find... Student loans, forgiveness Pell grants College accreditation Grants No Child Left Behind More Funding Federal student aid Apply for grants Contract opportunities Forecast of funding opportunities Research & Statistics Institute of Ed Sciences Education statistics Evaluation reports Nation's Report Card Doing What Works State information State ed data State ed performance Policy Recovery Act (ED) Obama ed plan Recent guidance Guidance documents Policy by program NCLB policy letters No Child Left Behind Programs By subject By title By CFDA# Search About ED Initiatives ED offices Senior staff Political appointees Contact Boards, committees Budget, performance Annual reports Jobs at ED Inspector General FAQs Online services Open Government White House Initiatives Recursos en español Site Policies and Notices FOIA Privacy Security Information quality Non-Discrimination, No FEAR Act Improper payments Help Other Sites Whitehouse.gov Recovery.gov USA.gov Benefits.gov APPENDIX G

88 Standards for an Accredited Educational Program in Radiography EFFECTIVE JANUARY 1, 2014 Adopted by: The Joint Review Committee on Education in Radiologic Technology - October 2013 Joint Review Committee on Education in Radiologic Technology 20 N. Wacker Drive, Suite 2850 Chicago, IL (Fax) The Joint Review Committee on Education in Radiologic Technology (JRCERT) is dedicated to excellence in education and to the quality and safety of patient care through the accreditation of educational programs in the radiologic sciences. The JRCERT is the only agency recognized by the United States Department of Education (USDE) and the Council on Higher Education Accreditation (CHEA) for the accreditation of traditional and distance delivery educational programs in radiography, radiation therapy, magnetic resonance, and medical dosimetry. The JRCERT awards accreditation to programs demonstrating substantial compliance with these STANDARDS. Copyright 2014 by the JRCERT

89 Introductory Statement The Joint Review Committee on Education in Radiologic Technology (JRCERT) Standards for an Accredited Educational Program in Radiography are designed to promote academic excellence, patient safety, and quality healthcare. The STANDARDS require a program to articulate its purposes; to demonstrate that it has adequate human, physical, and financial resources effectively organized for the accomplishment of its purposes; to document its effectiveness in accomplishing these purposes; and to provide assurance that it can continue to meet accreditation standards. The JRCERT accreditation process offers a means of providing assurance to the public that a program meets specific quality standards. The process helps to maintain program quality and stimulates program improvement through program assessment. There are six (6) standards. Each standard is titled and includes a narrative statement supported by specific objectives. Each objective, in turn, includes the following clarifying elements: Explanation - provides clarification on the intent and key details of the objective. Required Program Response - requires the program to provide a brief narrative and/or documentation that demonstrates compliance with the objective. Possible Site Visitor Evaluation Methods - identifies additional materials that may be examined and personnel who may be interviewed by the site visitors at the time of the on-site evaluation to help determine if the program has met the particular objective. Review of additional materials and/or interviews with listed personnel is at the discretion of the site visit team. Following each standard, the program must provide a Summary that includes the following: Major strengths related to the standard Major concerns related to the standard The program s plan for addressing each concern identified Describe any progress already achieved in addressing each concern Describe any constraints in implementing improvements The submitted narrative response and/or documentation, together with the results of the on-site evaluation conducted by the site visit team, will be used by the JRCERT Board of Directors in determining the program s compliance with the STANDARDS.

90 Standards for an Accredited Educational Program in Radiography Table of Contents Standard One: Integrity...4 The program demonstrates integrity in the following: representations to communities of interest and the public, pursuit of fair and equitable academic practices, and treatment of, and respect for, students, faculty, and staff. Standard Two: Resources...23 The program has sufficient resources to support the quality and effectiveness of the educational process. Standard Three: Curriculum and Academic Practices...35 The program s curriculum and academic practices prepare students for professional practice. Standard Four: Health and Safety...47 The program s policies and procedures promote the health, safety, and optimal use of radiation for students, patients, and the general public. Standard Five: Assessment...57 The program develops and implements a system of planning and evaluation of student learning and program effectiveness outcomes in support of its mission. Standard Six: Institutional/Programmatic Data...64 The program complies with JRCERT policies, procedures, and STANDARDS to achieve and maintain specialized accreditation. Awarding, Maintaining, and Administering Accreditation Radiography

91 Standard One Integrity Standard One: The program demonstrates integrity in the following: Representations to communities of interest and the public, Pursuit of fair and equitable academic practices, and Treatment of, and respect for, students, faculty, and staff. Objectives: In support of Standard One, the program: 1.1 Adheres to high ethical standards in relation to students, faculty, and staff. 1.2 Provides equitable learning opportunities for all students. 1.3 Provides timely, appropriate, and educationally valid clinical experiences for each admitted student. 1.4 Limits required clinical assignments for students to not more than 10 hours per day and the total didactic and clinical involvement to not more than 40 hours per week. 1.5 Assures the security and confidentiality of student records, instructional materials, and other appropriate program materials. 1.6 Has a grievance procedure that is readily accessible, fair, and equitably applied. 1.7 Assures that students are made aware of the JRCERT Standards for an Accredited Educational Program in Radiography and the avenue to pursue allegations of non-compliance with the STANDARDS. 1.8 Has publications that accurately reflect the program s policies, procedures, and offerings. 1.9 Makes available to students, faculty, and the general public accurate information about admission policies, tuition and fees, refund policies, academic calendars, clinical obligations, grading system, graduation requirements, and the criteria for transfer credit Makes the program s mission statement, goals, and student learning outcomes readily available to students, faculty, administrators, and the general public Documents that the program engages the communities of interest for the purpose of continuous program improvement Has student recruitment and admission practices that are non-discriminatory with respect to any legally protected status such as race, color, religion, gender, age, disability, national origin, and any other protected class Has student recruitment and admission practices that are consistent with published policies of the sponsoring institution and the program. 4 Radiography

92 1.14 Has program faculty recruitment and employment practices that are non-discriminatory with respect to any legally protected status such as race, color, religion, gender, age, disability, national origin, and any other protected class Has procedures for maintaining the integrity of distance education courses.

93 1.1 Adheres to high ethical standards in relation to students, faculty, and staff. Explanation: High ethical standards help assure that the rights of students, faculty, and staff are protected. Policies and procedures must be fair, equitably applied, and promote professionalism. Required Program Response: Describe the procedure for making related policies and procedures known. Provide copies of policies and procedures that assure equitable treatment of students, faculty, and staff. Possible Site Visitor Evaluation Methods: Review of student handbook Review of employee/faculty handbook Review of course catalog Review of student records Interviews with faculty Interviews with students Interviews with staff 6 Radiography

94 1.2 Provides equitable learning opportunities for all students. Explanation: The provision of equitable learning activities promotes a fair and impartial education and reduces institutional and/or program liability. The program must provide equitable learning opportunities for all students regarding learning activities and clinical assignments. For example, if an opportunity exists for students to observe or perform breast imaging, then all students must be provided the same opportunity. If evening and/or weekend rotations are utilized, this opportunity must be equitably provided for all students. Required Program Response: Describe how the program assures equitable learning opportunities for all students. Possible Site Visitor Evaluation Methods: Review of published program materials Review of master plan of education Review of course objectives Review of student clinical assignment schedules Interviews with faculty Interviews with clinical instructors Interviews with clinical staff Interviews with students 7 Radiography

95 1.3 Provides timely, appropriate, and educationally valid clinical experiences for each admitted student. Explanation: Programs must have a process in place to provide timely, appropriate, and educationally valid clinical experiences to all students admitted to the program. Students must have sufficient access to clinical settings that provide a wide range of procedures for competency achievement including mobile, surgical, and trauma examinations. Clinical settings may include hospitals, clinics, specialty/imaging centers, orthopedic centers, and other facilities. With the exception of observation site assignments, students must be provided the opportunity to complete required program competencies during clinical assignments. Clinical placement must be non-discriminatory in nature and solely determined by the program. A meaningful clinical education plan assures that activities are educationally valid and prevents the use of students as replacements for employees. The maximum number of students assigned to a clinical setting must be supported by sufficient human and physical resources. The number of students assigned to the clinical setting must not exceed the number of clinical staff assigned to the radiography department. The student to radiography clinical staff ratio must be 1:1. However, it is acceptable that more than one student may be temporarily assigned to one technologist during uncommonly performed procedures. Students assigned to advanced imaging modalities, such as computed tomography, magnetic resonance, angiography, and sonography, are not included in the calculation of the authorized clinical capacity (unless the clinical setting is recognized exclusively for advanced imaging modality rotations). Once the students have completed the advanced imaging assignments, the program must assure that there are sufficient clinical staff to support the students upon reassignment to the radiography department. The utilization of clinical assignments such as file room, reception area, and patient transportation should be limited. Additionally, traditional programs that require students to participate in clinical education during evenings and/or weekends must assure that: students clinical clock hours spent in evening and/or weekend assignments must not exceed 25% of the total clinical clock hours. program total capacity is not increased through the use of evening and/or weekend assignments. The JRCERT defines the operational hours of traditional programs as Monday - Friday, 5:00 a.m. - 7:00 p.m. Programs may permit students to make up clinical time during term or scheduled breaks; however, they may not be assigned to clinical settings on holidays that are observed by the sponsoring institution. Program faculty need not be physically present; however, students must be able to contact program faculty during makeup assignments. Also, the program must assure that its liability insurance covers students during these makeup assignments. Required Program Response: Describe the process for student clinical placement. Provide current student assignment schedules in relation to student enrollment. Describe how the program assures a 1:1 student to radiography clinical staff ratio at all clinical settings. Describe how the program assures that all students have access to a sufficient variety and volume of procedures to achieve program competencies. Submit evening and/or weekend rotation(s) calculations, if applicable. 8 Radiography

96 Possible Site Visitor Evaluation Methods: Review of published program materials Review listing of enrolled students in relation to clinical assignments, including evening and/or weekend, if applicable Review of clinical placement process Review of student clinical records Interviews with faculty Interviews with clinical instructors Interviews with students 9 Radiography

97 1.4 Limits required clinical assignments for students to not more than 10 hours per day and the total didactic and clinical involvement to not more than 40 hours per week. Explanation: This limitation helps assure that students are treated ethically. For the safety of students and patients, not more than ten (10) clinical hours shall be scheduled in any one day. Scheduled didactic and clinical hours combined cannot exceed forty (40) hours per week. Hours exceeding these limitations must be voluntary on the student s part. Required Program Response: Describe the process for assuring that time limitations are not exceeded. Provide documentation that required student clinical assignments do not exceed ten (10) hours in any one day and the total didactic and clinical involvement does not exceed forty (40) hours per week. Possible Site Visitor Evaluation Methods: Review of master plan of education Review of published program materials Review of student schedules Interviews with faculty Interviews with clinical instructor(s) Interviews with clinical staff Interviews with students 10 Radiography

98 1.5 Assures the security and confidentiality of student records, instructional materials, and other appropriate program materials. Explanation: Appropriately maintaining the security and confidentiality of student records and other program materials protects the student s right to privacy. Student records must be maintained in accordance with the Family Education Rights and Privacy Act (Buckley Amendment). If radiation monitoring reports contain students dates of birth and/or social security numbers, this information must be maintained in a secure and confidential manner. Required Program Response: Describe how the program maintains the security and confidentiality of student records and other program materials. Possible Site Visitor Evaluation Methods: Review of institution s/program s published policies/procedures Review of student academic and clinical records Tour of program offices Tour of clinical setting(s) Interviews with administrative personnel Interviews with faculty Interviews with clinical instructor(s) Interviews with clinical staff Interviews with students

99 1.6 Has a grievance procedure that is readily accessible, fair, and equitably applied. Explanation: A grievance is defined as a claim by a student that there has been a violation, misinterpretation, or inequitable application of any existing policy, procedure, or regulation. The program must have procedures to provide students an avenue to pursue grievances. The procedure must outline the steps for formal resolution of any grievance. The final step in the process must not include any individual(s) directly associated with the program (e.g., program director, clinical coordinator, clinical instructors, diagnostic imaging department director). The procedure must assure timely resolution. The program must maintain a record of all formal grievances and their resolution. Records must be retained in accordance with the institution s/program s retention policies/procedures. The records must include information on how the grievance was resolved and assurance that there are no trends that could negatively affect the quality of the educational program. Additionally, the program must have a procedure to address any complaints apart from those that require invoking the grievance procedure. The program must determine if a pattern of complaint exists that could negatively affect the quality of the educational program (e.g., cleanliness of the classroom). Required Program Response: Describe the nature of any formal grievance(s) that would jeopardize the program s ability to meet its mission. Describe the nature of any complaint(s) that would jeopardize the program s ability to meet its mission. Provide a copy of the grievance procedure. Provide a copy of any formal grievance(s) resolution. Possible Site Visitor Evaluation Methods: Review of institutional catalog Review of student handbook Review of formal grievance(s) record(s), if applicable Review of complaint(s) record(s), if applicable Interviews with faculty Interviews with students 12 Radiography

100 1.7 Assures that students are made aware of the JRCERT Standards for an Accredited Educational Program in Radiography and the avenue to pursue allegations of non-compliance with the STANDARDS. Explanation: The program must assure students are cognizant of the STANDARDS and must provide contact information for the JRCERT. Students have the right to submit allegations against a JRCERT-accredited program if there is reason to believe that the program has acted contrary to JRCERT accreditation standards or that conditions at the program appear to jeopardize the quality of instruction or the general welfare of its students. Contact of the JRCERT should not be a step in the formal institutional/program grievance procedure. The individual must first attempt to resolve the complaint directly with institution/program officials by following the grievance procedures provided by the institution/program. If the individual is unable to resolve the complaint with institution/program officials or believes that the concerns have not been properly addressed, he or she may submit allegations of non-compliance directly to the JRCERT. Required Program Response: Describe the procedure for making students aware of the STANDARDS. Describe how students are provided contact information for the JRCERT. Possible Site Visitor Evaluation Methods: Review of program publications Interviews with faculty Interviews with students 13 Radiography

101 1.8 Has publications that accurately reflect the program s policies, procedures, and offerings. Explanation: Maintaining published information regarding the program s current policies, procedures, and offerings provides interested parties with an accurate overview of program requirements and expectations. Required Program Response: Provide program publications that reflect program policies, procedures and offerings. Possible Site Visitor Evaluation Methods: Review of published program materials Review of student handbook Interviews with faculty Interviews with students 14 Radiography

102 1.9 Makes available to students, faculty, and the general public accurate information about admission policies, tuition and fees, refund policies, academic calendars, clinical obligations, grading system, graduation requirements, and the criteria for transfer credit. Explanation: The institutional and/or program policies must be published and made readily available to students, faculty, and the general public on the institution s/program s Web site to assure transparency and accountability of the educational program. For example, requiring the general public to contact the institution/program to request program information is not adequate. Policy changes must be made known to students, faculty, and the general public in timely fashion. It is recommended that revision dates be identified on program publications. The institution and/or program must establish and publicly disclose the criteria used when determining the transfer of credit earned from other institutions and/or programs. Also, programs must publicly disclose a list of institutions with which the program has established an articulation agreement. The program s academic calendar must be published and, at a minimum, identify specific start and end dates for each term, holidays recognized by the sponsoring institution, and breaks. Student clinical obligations (e.g., drug screening, background checks, and associated fees) must be clearly identified in appropriate program publications. Additionally, if evening and/or weekend clinical assignments are required or if students must travel to geographically-dispersed clinical settings, this information must also be included. Required Program Response: Describe how institutional and/or program policies are made known to students, faculty, and the general public. Provide publications that include these policies. Possible Site Visitor Evaluation Methods: Review of institutional materials Review of published program materials Review of institutional and/or program Web site Interviews with faculty Interviews with Admissions personnel Interviews with Registrar Interviews with students 15 Radiography

103 1.10 Makes the program s mission statement, goals, and student learning outcomes readily available to students, faculty, administrators, and the general public. Explanation: Program accountability is enhanced by making its mission statement, goals, and student learning outcomes available to the program s communities of interest on the institution s/program s Web site to assure transparency and of the educational program. Requiring the general public to contact the institution/program to request program information is not adequate. Example: Mission: The mission of the radiography program is to prepare competent, entry-level radiographers able to function within the healthcare community. Goal: Students will be clinically competent. Student Learning Outcomes: Students will apply positioning skills. Students will select technical factors. Students will utilize radiation protection. Goal: Students will demonstrate communication skills. Student Learning Outcomes: Students will demonstrate written communication skills. Students will demonstrate oral communication skills. Goal: Students will develop critical thinking skills. Student Learning Outcomes: Students will adapt standard procedures for non-routine patients. Students will critique images to determine diagnostic quality. Goal: Students will model professionalism. Student Learning Outcomes: Students will demonstrate work ethics. Students will summarize the value of life-long learning. Required Program Response: Describe how the program makes its mission statement, goals, and student learning outcomes available to students, faculty, administrators, and the general public. Provide copies of publications that contain the program s mission statement, goals, and student learning outcomes. Possible Site Visitor Evaluation Methods: Review of published program materials Review of institutional and/or program Web site Interviews with administrative personnel Interviews with faculty Interviews with students 16 Radiography

104 1.11 Documents that the program engages the communities of interest for the purpose of continuous program improvement. Explanation: Communities of interest are defined as institutions, organizations, groups, and/or individuals interested in educational activities in radiography. Obtaining formal feedback on program operations, student progress, employer needs, etc. from communities of interest allows the program to determine if it is meeting expectations and assures continuous program improvement. The program can use a variety of tools to obtain this feedback. Required Program Response: Describe the process of obtaining feedback. Provide representative samples of appropriate meeting minutes, evaluations (e.g., course and faculty), and surveys (e.g., graduate and employer). Possible Site Visitor Evaluation Methods: Review of meeting minutes Review of evaluations Review of surveys Interviews with members of various communities of interest 17 Radiography

105 1.12 Has student recruitment and admission practices that are non-discriminatory with respect to any legally protected status such as race, color, religion, gender, age, disability, national origin, and any other protected class. Explanation: Non-discriminatory practices assure applicants have equal opportunity for admission. Statistical information such as race, color, religion, gender, age, disability, national origin, and any other protected class may be collected; however, this information must be voluntarily provided by the student. Use of this information in the student selection process is discriminatory. Required Program Response: Describe how admission practices are non-discriminatory. Provide institutional and/or program admission policies. Possible Site Visitor Evaluation Methods: Review of published program materials Review of student records Interviews with faculty Interviews with Admissions personnel Interviews with students 18 Radiography

106 1.13 Has student recruitment and admission practices that are consistent with published policies of the sponsoring institution and the program. Explanation: Defined admission practices facilitate objective student selection. In considering applicants for admission, the program must follow published policies and procedures. Required Program Response: Describe the implementation of institutional and program admission policies. Provide institutional and program admission policies. Possible Site Visitor Evaluation Methods: Review of published program materials Interviews with faculty Interviews with Admissions personnel Interviews with students 19 Radiography

107 1.14 Has program faculty recruitment and employment practices that are non-discriminatory with respect to any legally protected status such as race, color, religion, gender, age, disability, national origin, and any other protected class. Explanation: Recruitment and employment practices that are non-discriminatory assure fairness and integrity. Equal opportunity for employment must be offered to each applicant. Employment practices must be applied equitably to all faculty. Required Program Response: Describe how non-discriminatory employment practices are assured. Provide copies of employment policies and procedures that assure non-discriminatory practices. Possible Site Visitor Evaluation Methods: Review of employee/faculty handbook Review of employee/faculty application form Review of institutional catalog Interviews with faculty 20 Radiography

108 1.15 Has procedures for maintaining the integrity of distance education courses. Explanation: Programs that offer distance education must have processes in place that assure that the students who register in the distance education courses are the same students that participate in, complete, and receive the credit. Programs must verify the identity of students by using methods such as, but not limited to: secure log-ins, pass codes, and/or proctored exams. These processes must protect the student s privacy. Student costs associated with distance education must be disclosed. Required Program Response: Describe the process for assuring the integrity of distance education courses. Provide published program materials that outline procedures for maintaining integrity of distance education courses. Provide published program materials that identify associated fees for students enrolled in distance education courses. Possible Site Visitor Evaluation Methods: Review of published program materials Review the process of student identification Review of student records Interviews with faculty Interviews with students 21 Radiography

109 Summary for Standard One 1. List the major strengths of Standard One, in order of importance. 2. List the major concerns of Standard One, in order of importance. 3. Provide the program s plan for addressing each concern identified. 4. Describe any progress already achieved in addressing each concern. 5. Describe any constraints in implementing improvements. 22 Radiography

110 Standard Two: Resources Standard Two: The program has sufficient resources to support the quality and effectiveness of the educational process. Objectives: In support of Standard Two, the program: Administrative Structure 2.1 Has an appropriate organizational structure and sufficient administrative support to achieve the program s mission. 2.2 Provides an adequate number of faculty to meet all educational, program, administrative, and accreditation requirements. 2.3 Provides faculty with opportunities for continued professional development. 2.4 Provides clerical support services, as needed, to meet all educational, program, and administrative requirements. Learning Resources/Services 2.5 Assures JRCERT recognition of all clinical settings. 2.6 Provides classrooms, laboratories, and administrative and faculty offices to facilitate the achievement of the program s mission. 2.7 Reviews and maintains program learning resources to assure the achievement of student learning. 2.8 Provides access to student services in support of student learning. Fiscal Support 2.9 Has sufficient ongoing financial resources to support the program s mission For those institutions and programs for which the JRCERT serves as a gatekeeper for Title IV financial aid, maintains compliance with United States Department of Education (USDE) policies and procedures. 23 Radiography

111 2.1 Has an appropriate organizational structure and sufficient administrative support to achieve the program s mission. Explanation: The program s relative position in the organizational structure helps facilitate appropriate resources and assures focus on the program. To operate effectively, the program must have sufficient institutional administrative support. Both organizational structure and administrative support enable the program to meet its mission and promote student learning. Required Program Response: Describe the program s relationship to the organizational and administrative structures of the sponsoring institution and how this supports the program s mission. Provide institutional and program organizational charts. Possible Site Visitor Evaluation Methods: Review of organizational charts of institution and program Review of meeting minutes Review of published program materials Review of master plan of education Interviews with faculty and institutional officials Interviews with clinical instructor(s) 24 Radiography

112 2.2 Provides an adequate number of faculty to meet all educational, program, administrative, and accreditation requirements. Explanation: An adequate number of faculty promotes sound educational practices. A full-time program director is required. Faculty teaching loads and release time must be consistent with those of comparable faculty in other health science (allied health) programs in the same institution. Additionally, a full-time equivalent clinical coordinator is required if the program has more than five (5) active clinical settings or more than thirty (30) students enrolled in the clinical component. The clinical coordinator position may be shared by no more than four (4) appointees. If a clinical coordinator is required, the program director may not be identified as the clinical coordinator. The clinical coordinator may not be identified as the program director. The program director and clinical coordinator may perform clinical instruction; however, they may not be identified as clinical instructors. A minimum of one clinical instructor must be designated at each recognized clinical setting. The same clinical instructor may be identified at more than one site as long as a ratio of one full-time equivalent clinical instructor for every ten (10) students is maintained. Required Program Response: Provide, if available, institutional policies in relation to teaching loads and release time. Describe faculty teaching loads and release time in relation to a comparable health science (allied health) program within the institution. Describe the adequacy of the number of faculty and clinical staff to meet identified accreditation requirements and program needs. Possible Site Visitor Evaluation Methods: Review institutional policies in relation to teaching loads and release time Review of master plan of education Review of position descriptions Review of clinical settings Interviews with faculty Interviews with clinical instructor(s) Interviews with students 25 Radiography

113 2.3 Provides faculty with opportunities for continued professional development. Explanation: Continued professional development results in more knowledgeable, competent, and proficient faculty. Opportunities that enhance and advance educational, technical, and professional knowledge must be available to program faculty. Required Program Response: Describe how continued professional development opportunities are made available to faculty. Possible Site Visitor Evaluation Methods: Review of institutional and program policies Review of program budget or other fiscal appropriations Review of evidence of faculty participation in professional development activities Interviews with administrative personnel Interviews with faculty 26 Radiography

114 2.4 Provides clerical support services, as needed, to meet all educational, program, and administrative requirements. Explanation: Clerical support services necessary to assist in meeting educational, program, and administrative requirements of the program must be provided as appropriate. Required Program Response: Describe the availability and use of clerical support services. Possible Site Visitor Evaluation Methods: Review of program s staffing plan Interviews with administrative personnel Interviews with faculty Interviews with students 27 Radiography

115 2.5 Assures JRCERT recognition of all clinical settings. Explanation: JRCERT recognition helps assure an appropriate learning environment for student clinical education. All clinical settings must be recognized by the JRCERT. Recognition of a clinical setting must be obtained prior to student placement. A minimum of one (1) clinical instructor must be identified for each recognized clinical setting. An observation site is used for student observation of the operation of equipment and/or procedures. If the program uses observation sites, these sites do not require recognition by the JRCERT. These sites provide opportunities for observation of clinical procedures that may not be available at recognized clinical settings. Students may not assist in, or perform, any aspects of patient care during observational assignments. Facilities where students are participating in service learning projects or community-based learning opportunities do not require recognition. Required Program Response: Assure all clinical settings are recognized by the JRCERT. Describe how observation sites, if used, enhance student clinical education. Possible Site Visitor Evaluation Methods: Review of JRCERT database Review of clinical records Interviews with faculty Interviews with clinical instructors Interviews with clinical staff Interviews with students 28 Radiography

116 2.6 Provides classrooms, laboratories, and administrative and faculty offices to facilitate the achievement of the program s mission. Explanation: Learning environments are defined as places, surroundings, or circumstances where knowledge, understanding, or skills are studied or observed such as classrooms and laboratories. Learning environments must be consistent with those of comparable health science programs in the same institution. Provision of appropriate learning environments facilitates achievement of the program s mission. Although a dedicated classroom and/or laboratory are not required, scheduled accessibility to facilities conducive to student learning must be assured. Faculty office space should be conducive to planning and scholarly activities. Space should be made available for private student advisement. Required Program Response: Describe how classrooms, laboratories, and administrative and faculty offices facilitate the achievement of the program s mission. Possible Site Visitor Evaluation Methods: Tour of the classroom, laboratories, and administrative and faculty offices Interviews with faculty Interviews with students 29 Radiography

117 2.7 Reviews and maintains program learning resources to assure the achievement of student learning. Explanation: The review and maintenance of learning resources promotes student knowledge of current and developing imaging technologies. The program must provide learning resources to support and enhance the educational program. These resources must include: a print or electronic library with a variety of materials published within the last five years, computer access, and additional learning aids (e.g., educational software, classroom/laboratory accessory devices, etc.). The JRCERT does not endorse any specific learning resources. Required Program Response: Describe the available learning resources. Describe the procedure for review and maintenance of learning resources. Possible Site Visitor Evaluation Methods: Tour of learning facilities Review of learning resources Review of surveys Review of meeting minutes Interviews with faculty Interviews with students 30 Radiography

118 2.8 Provides access to student services in support of student learning. Explanation: The provision of appropriate student services promotes student achievement. At a minimum, the program must provide access to information for: personal counseling, requesting accommodations for disabilities as defined by applicable federal (Americans with Disabilities Act) and state laws, and financial aid. Additional student services may be provided at the discretion of the program. These services should be sufficient to assure student learning. All services provided must be made known to students and the general public. Required Program Response: Describe the students access to student services. Provide published program materials that outline accessibility to student services. Possible Site Visitor Evaluation Methods: Review of published program materials Interviews with faculty Interviews with students 31 Radiography

119 2.9 Has sufficient ongoing financial resources to support the program s mission. Explanation: Adequate, ongoing funding is necessary to accomplish the program s mission and to support student learning. The sponsoring institution must demonstrate ongoing financial commitment to the program and its students by providing adequate human and physical resources. Required Program Response: Describe the adequacy of financial resources. Provide copies of the program s budget and/or expenditure records. Possible Site Visitor Evaluation Methods: Review of program budget and/or other fiscal appropriations Interviews with administrative personnel Interviews with faculty 32 Radiography

120 2.10 For those institutions and programs for which the JRCERT serves as gatekeeper for Title IV financial aid, maintains compliance with United States Department of Education (USDE) policies and procedures. Explanation: A gatekeeper is defined as an agency holding responsibility for oversight of the distribution, record keeping, and repayment of Title IV financial aid. The program must comply with USDE requirements to participate in Title IV financial aid. If the program has elected to participate in Title IV financial aid and the JRCERT is identified as the gatekeeper, the program must: maintain financial documents including audit and budget processes confirming appropriate allocation and use of financial resources, have a monitoring process for student loan default rates, have an appropriate accounting system providing documentation for management of Title IV financial aid and expenditures, and inform students of responsibility for timely repayment of Title IV financial aid. Required Program Response: Provide evidence that Title IV financial aid is managed and distributed according to the USDE regulations to include: o recent student loan default data and o results of financial or compliance audits. Describe how the program informs students of their responsibility for timely repayment of financial aid. Possible Site Visitor Evaluation Methods: Review of records Interviews with administrative personnel Interviews with faculty Interviews with students 33 Radiography

121 Summary for Standard Two 1. List the major strengths of Standard Two, in order of importance. 2. List the major concerns of Standard Two, in order of importance. 3. Provide the program s plan for addressing each concern identified. 4. Describe any progress already achieved in addressing each concern. 5. Describe any constraints in implementing improvements. 34 Radiography

122 Standard Three Curriculum and Academic Practices Standard Three: The program s curriculum and academic practices prepare students for professional practice. Objectives: In support of Standard Three, the program: 3.1 Has a program mission statement that defines its purpose and scope and is periodically reevaluated. 3.2 Provides a well-structured, competency-based curriculum that prepares students to practice in the professional discipline. 3.3 Provides learning opportunities in current and developing imaging and/or therapeutic technologies. 3.4 Assures an appropriate relationship between program length and the subject matter taught for the terminal award offered. 3.5 Measures the length of all didactic and clinical courses in clock hours or credit hours. 3.6 Maintains a master plan of education. 3.7 Provides timely and supportive academic, behavioral, and clinical advisement to students enrolled in the program. 3.8 Documents that the responsibilities of faculty and clinical staff are delineated and performed. 3.9 Evaluates program faculty and clinical instructor performance and shares evaluation results regularly to assure instructional responsibilities are performed. 35 Radiography

123 3.1 Has a program mission statement that defines its purpose and scope and is periodically reevaluated. Explanation: The program s mission statement should be consistent with that of its sponsoring institution. The program s mission statement should clearly define the purpose or intent toward which the program s efforts are directed. Periodic evaluation assures that the program s mission statement is effective. Required Program Response: Provide a copy of the program s mission statement. Provide meeting minutes that document periodic reevaluation of the mission statement. Possible Site Visitor Evaluation Methods: Review of published program materials Review of meeting minutes Review of master plan of education Interviews with faculty 36 Radiography

124 3.2 Provides a well-structured, competency-based curriculum that prepares students to practice in the professional discipline. Explanation: The well-structured curriculum must be comprehensive, appropriately sequenced, include current information, and provide for evaluation of student achievement. A competency-based curriculum allows for effective student learning by providing a knowledge foundation prior to performance of procedures. Continual refinement of the competencies achieved is necessary so that students can demonstrate enhanced performance in a variety of situations and patient conditions. In essence, competency-based education is an ongoing process, not an end product. Programs must follow a JRCERT-adopted curriculum. An adopted curriculum is defined as: the latest American Society of Radiologic Technologists professional curriculum and/or another professional curriculum adopted by the JRCERT Board of Directors following review and recommendation by the JRCERT Standards Committee. Use of a standard curriculum promotes consistency in radiography education and prepares the student to practice in the professional discipline. At a minimum, the curriculum should promote qualities that are necessary for students/graduates to practice competently, make good decisions, assess situations, provide appropriate patient care, communicate effectively, and keep abreast of current advancements within the profession. Expansion of the curricular content beyond the minimum is at the discretion of the program. The program must submit the latest curriculum analysis grid (available at Required Program Response: Describe how the program s curriculum is structured. Describe the program s competency-based system. Submit current curriculum analysis grid. Describe how the program's curriculum is delivered, including the method of delivery for distance education courses. Identify which courses, if any, are offered via distance education. Describe alternative learning options, if applicable (e.g., part-time, evening and/or weekend curricular track). Possible Site Visitor Evaluation Methods: Review of master plan of education Review of didactic and clinical curriculum sequence Review of analysis of graduate and employer surveys Interviews with faculty Interviews with students Observation of a portion of any course offered via distance delivery Review of part-time, evening and/or weekend curricular track, if applicable 37 Radiography

125 3.3 Provides learning opportunities in current and developing imaging and/or therapeutic technologies. Explanation: The program must provide learning opportunities in current and developing imaging and/or therapeutic technologies. It is the program s prerogative to decide which technologies should be included in the didactic and/or clinical curriculum. Programs are not required to offer clinical rotations in developing imaging and/or therapeutic technologies; however, these clinical rotations are strongly encouraged to enhance student learning. Required Program Response: Describe how the program provides opportunities in developing technologies in the didactic and/or clinical curriculum. Possible Site Visitor Evaluation Methods: Review of master plan of education Interviews with faculty Interviews with students 38 Radiography

126 3.4 Assures an appropriate relationship between program length and the subject matter taught for the terminal award offered. Explanation: Program length must be consistent with the terminal award. The JRCERT defines program length as the duration of the program, which may be stated as total academic or calendar year(s), total semesters, trimesters, or quarters. Required Program Response: Describe the relationship between the program length and the terminal award offered. Possible Site Visitor Evaluation Methods: Review of course catalog Review of published program materials Review of class schedules Interviews with faculty Interviews with students 39 Radiography

127 3.5 Measures the length of all didactic and clinical courses in clock hours or credit hours. Explanation: Defining the length of didactic and clinical courses facilitates student transfer of credit and the awarding of financial aid. The formula for calculating assigned clock/credit hours must be consistently applied for all didactic and all clinical courses, respectively. Required Program Response: Describe the method used to award credit hours for lecture, laboratory and clinical courses. Provide a copy of the program s policies and procedures for determining credit hours and an example of how such policy has been applied to the program s coursework. Provide a list of all didactic and clinical courses with corresponding clock or credit hours. Possible Site Visitor Evaluation Methods: Review of published program materials Review of class schedules Interviews with faculty Interviews with students 40 Radiography

128 3.6 Maintains a master plan of education. Explanation: A master plan provides an overview of the program and allows for continuity among, and documentation of, all aspects of the program. In the event of new faculty and/or leadership to the program, the master plan provides the information needed to understand the program and its operations. The plan should be evaluated annually, updated, and must include the following: course syllabi (didactic and clinical courses) and program policies and procedures. While there is no prescribed format for the master plan, the component parts should be identified and readily available. If the components are not housed together, the program must list the location of each component. If the program chooses to use an electronic format, the components must be accessible by all program faculty. Required Program Response: Identify the location of the component parts of the master plan of education. Provide a Table of Contents for the program s master plan. Possible Site Visitor Evaluation Methods: Review of master plan of education Interview with program director Interviews with faculty 41 Radiography

129 3.7 Provides timely and supportive academic, behavioral, and clinical advisement to students enrolled in the program. Explanation: Appropriate advisement promotes student achievement. Student advisement should be formative, summative, and must be shared with students in a timely manner. Programs are encouraged to develop written advisement procedures. Required Program Response: Describe procedures for advisement. Provide sample records of student advisement. Possible Site Visitor Evaluation Methods: Review of students records Interviews with faculty Interviews with clinical instructor(s) Interviews with students 42 Radiography

130 3.8 Documents that the responsibilities of faculty and clinical staff are delineated and performed. Full-time Program Director: Assures effective program operations, Oversees ongoing program assessment, Participates in budget planning, Maintains current knowledge of the professional discipline and educational methodologies through continuing professional development, and Assumes the leadership role in the continued development of the program. Full-time Clinical Coordinator: Correlates clinical education with didactic education, Evaluates students, Participates in didactic and/or clinical instruction, Supports the program director to help assure effective program operation, Coordinates clinical education and evaluates its effectiveness, Participates in the assessment process, Cooperates with the program director in periodic review and revision of clinical course materials, Maintains current knowledge of the discipline and educational methodologies through continuing professional development, and Maintains current knowledge of program policies, procedures, and student progress. Full-time Didactic Program Faculty: Prepares and maintains course outlines and objectives, instructs and evaluates students, and reports progress, Participates in the assessment process, Supports the program director to help assure effective program operation, Cooperates with the program director in periodic review and revision of course materials, and Maintains appropriate expertise and competence through continuing professional development. Part-time Didactic Program Faculty: 43 Radiography

131 Prepares and maintains course outlines and objectives, instructs and evaluates students, and reports progress, Participates in the assessment process, when appropriate, Cooperates with the program director in periodic review and revision of course materials, and Maintains appropriate expertise and competence through continuing professional development. Clinical Instructor(s): Is knowledgeable of program goals, Understands the clinical objectives and clinical evaluation system, Understands the sequencing of didactic instruction and clinical education, Provides students with clinical instruction and supervision, Evaluates students clinical competence, Maintains competency in the professional discipline and instructional and evaluative techniques through continuing professional development, and Maintains current knowledge of program policies, procedures, and student progress. Clinical Staff: Understand the clinical competency system, Understand requirements for student supervision, Support the educational process, and Maintain current knowledge of program policies, procedures, and student progress. Explanation: The clear delineation of responsibilities facilitates accountability. Faculty and clinical staff responsibilities must be clearly delineated and must support the program s mission. Full- and part-time status is determined by, and consistent with, the sponsoring institution s definition. At all times when students are enrolled in didactic and/or clinical components, the program director and/or clinical coordinator must assure that their program responsibilities are fulfilled. Required Program Response: Provide documentation that faculty and clinical staff positions are clearly delineated. Possible Site Visitor Evaluation Methods: Review of position descriptions Review of handbooks Interviews with faculty and clinical staff to assure responsibilities are being performed Interviews with students 44 Radiography

132 3.9 Evaluates program faculty and clinical instructor performance and shares evaluation results regularly to assure instructional responsibilities are performed. Explanation: The performance of program faculty and clinical instructor(s) must be evaluated minimally once per year. Evaluation assures that instructional responsibilities are performed and provides administration and faculty with information to evaluate performance. Evaluation promotes proper educational methodology and increases program effectiveness. Evaluation results must be shared minimally once per year with the respective program faculty and clinical instructor(s) being evaluated to assure continued professional development. Any evaluation results that identify concerns must be discussed with the respective individual(s) as soon as possible. Required Program Response: Describe the evaluation process. Describe how evaluation results are shared with program faculty and clinical instructor(s). Provide samples of evaluations of program faculty. Provide samples of evaluations of clinical instructor(s). Possible Site Visitor Evaluation Methods: Review of program evaluation materials Review of clinical instructor evaluation Interviews with administrative personnel Interviews with program faculty Interviews with clinical instructor(s) Interviews with students 45 Radiography

133 Summary for Standard Three 1. List the major strengths of Standard Three, in order of importance. 2. List the major concerns of Standard Three, in order of importance. 3. Provide the program s plan for addressing each concern identified. 4. Describe any progress already achieved in addressing each concern. 5. Describe any constraints in implementing improvements. 46 Radiography

134 Standard Four Health and Safety Standard Four: The program s policies and procedures promote the health, safety, and optimal use of radiation for students, patients, and the general public. Objectives: In support of Standard Four, the program: 4.1 Assures the radiation safety of students through the implementation of published policies and procedures that are in compliance with Nuclear Regulatory Commission regulations and state laws as applicable. 4.2 Has a published pregnancy policy that is consistent with applicable federal regulations and state laws, made known to accepted and enrolled female students, and contains the following elements: Written notice of voluntary declaration, Option for student continuance in the program without modification, and Option for written withdrawal of declaration. 4.3 Assures that students employ proper radiation safety practices. 4.4 Assures that medical imaging procedures are performed under the direct supervision of a qualified radiographer until a student achieves competency. 4.5 Assures that medical imaging procedures are performed under the indirect supervision of a qualified radiographer after a student achieves competency. 4.6 Assures that students are directly supervised by a qualified radiographer when repeating unsatisfactory images. 4.7 Assures sponsoring institution s policies safeguard the health and safety of students. 4.8 Assures that students are oriented to clinical setting policies and procedures in regard to health and safety. 47 Radiography

135 4.1 Assures the radiation safety of students through the implementation of published policies and procedures that are in compliance with Nuclear Regulatory Commission regulations and state laws as applicable. Explanation: Appropriate policies and procedures help assure that student radiation exposure is kept as low as reasonably achievable (ALARA). The program must maintain and monitor student radiation exposure data. This information must be made available to students within thirty (30) school days following receipt of data. The program must have a published protocol that identifies a threshold dose for incidents in which dose limits are exceeded. Programs are encouraged to identify a threshold dose below those identified in NRC regulations. Required Program Response: Describe how the policies are made known to enrolled students. Describe how radiation exposure data is made available to students. Provide copies of appropriate policies. Possible Site Visitor Evaluation Methods: Review of published program materials Review of student records Review of student dosimetry reports Interviews with faculty Interviews with students 48 Radiography

136 4.2 Has a published pregnancy policy that is consistent with applicable federal regulations and state laws, made known to accepted and enrolled female students, and contains the following elements: Written notice of voluntary declaration, Option for student continuance in the program without modification, and Option for written withdrawal of declaration. Explanation: Appropriate radiation safety practices help assure that radiation exposure to the student and fetus are kept as low as reasonably achievable (ALARA). The policy must include appropriate information regarding radiation safety for the student and fetus. The program must allow for student continuance in the clinical component of the program without modification. The program may offer clinical component options such as: (1) clinical reassignments and/or (2) leave of absence. Required Program Response: Describe how the pregnancy policy is made known to accepted and enrolled female students. Provide a copy of the program s pregnancy policy. Possible Site Visitor Evaluation Methods: Review of published program materials Review of student records Interviews with faculty Interviews with clinical instructor(s) Interviews with students 49 Radiography

137 4.3 Assures that students employ proper radiation safety practices. Explanation: The program must assure that students are instructed in the utilization of imaging equipment, accessories, optimal exposure factors, and proper patient positioning to minimize radiation exposure to patients, selves, and others. These practices assure radiation exposures are kept as low as reasonably achievable (ALARA). Students must understand basic radiation safety practices prior to assignment to clinical settings. Students must not hold image receptors during any radiographic procedure. Students should not hold patients during any radiographic procedure when an immobilization method is the appropriate standard of care. As students progress in the program, they must become increasingly proficient in the application of radiation safety practices. The program must also assure radiation safety in energized laboratories. Students utilization of energized laboratories must be under the supervision of a qualified radiographer who is readily available. If a qualified radiographer is not readily available to provide supervision, the radiation exposure mechanism must be disabled. Programs are encouraged to develop policies regarding safe and appropriate use of energized laboratories by students. Required Program Response: Describe how the curriculum sequence and content prepares students for safe radiation practices. Provide the curriculum sequence. Provide policies/procedures regarding radiation safety. Possible Site Visitor Evaluation Methods: Review of program curriculum Review of radiation safety policies/procedures Review of student handbook Review of student records Review of student dosimetry reports Interviews with faculty Interviews with clinical instructor(s) Interviews with clinical staff Interviews with students 50 Radiography

138 4.4 Assures that medical imaging procedures are performed under the direct supervision of a qualified radiographer until a student achieves competency. Explanation: Direct supervision assures patient safety and proper educational practices. The JRCERT defines direct supervision as student supervision by a qualified radiographer who: reviews the procedure in relation to the student s achievement, evaluates the condition of the patient in relation to the student s knowledge, is physically present during the conduct of the procedure, and reviews and approves the procedure and/or image. Students must be directly supervised until competency is achieved. Required Program Response: Describe how the direct supervision requirement is enforced and monitored in the clinical setting. Provide documentation that the program s direct supervision requirement is made known to students, clinical instructors, and clinical staff. Possible Site Visitor Evaluation Methods: Review of published program materials Review of student records Review of meeting minutes Interviews with faculty Interviews with clinical instructor(s) Interviews with clinical staff Interviews with students 51 Radiography

139 4.5 Assures that medical imaging procedures are performed under the indirect supervision of a qualified radiographer after a student achieves competency. Explanation: Indirect supervision promotes patient safety and proper educational practices. The JRCERT defines indirect supervision as that supervision provided by a qualified radiographer immediately available to assist students regardless of the level of student achievement. Immediately available is interpreted as the physical presence of a qualified radiographer adjacent to the room or location where a radiographic procedure is being performed. This availability applies to all areas where ionizing radiation equipment is in use on patients. Required Program Response: Describe how the indirect supervision requirement is enforced and monitored in the clinical setting. Provide documentation that the program s indirect supervision requirement is made known to students, clinical instructors, and clinical staff. Possible Site Visitor Evaluation Methods: Review of published program materials Review of student records Review of meeting minutes Interviews with faculty Interviews with clinical instructor(s) Interviews with clinical staff Interviews with students 52 Radiography

140 4.6 Assures that students are directly supervised by a qualified radiographer when repeating unsatisfactory images. Explanation: The presence of a qualified radiographer during the repeat of an unsatisfactory image assures patient safety and proper educational practices. A qualified radiographer must be physically present during the conduct of a repeat image and must approve the student s procedure prior to re-exposure. Required Program Response: Describe how the direct supervision requirement for repeat images is enforced and monitored in the clinical setting. Provide documentation that the program s direct supervision requirement for repeat images is made known to students, clinical instructors, and clinical staff. Possible Site Visitor Evaluation Methods: Review of published program materials Review of student records Review of meeting minutes Interviews with faculty Interviews with clinical instructor(s) Interviews with clinical staff Interviews with students 53 Radiography

141 4.7 Assures sponsoring institution s policies safeguard the health and safety of students. Explanation: Appropriate sponsoring institutional policies and procedures assure that students are protected. These policies must, at a minimum, address emergency preparedness, harassment, communicable diseases, and substance abuse. Policies and procedures must meet federal and/or state requirements as applicable. Enrolled students must be informed of policies and procedures. Required Program Response: Provide program policies that safeguard the health and safety of students. Possible Site Visitor Evaluation Methods: Review of published program materials Review of student records Interviews with faculty Interviews with students 54 Radiography

142 4.8 Assures that students are oriented to clinical setting policies and procedures in regard to health and safety. Explanation: Appropriate orientation assures that students are cognizant of clinical policies and procedures. The policies and procedures must, at a minimum, address the following: hazards (fire, electrical, chemical), emergency preparedness, medical emergencies, HIPAA, and Standard Precautions. Required Program Response: Describe the process for orienting students to clinical settings. Provide documentation that students are apprised of policies and procedures specific to each clinical setting. Possible Site Visitor Evaluation Methods: Review of orientation process Review of student records Interviews with faculty Interviews with clinical instructor(s) Interviews with students 55 Radiography

143 Summary for Standard Four 1. List the major strengths of Standard Four, in order of importance. 2. List the major concerns of Standard Four, in order of importance. 3. Provide the program s plan for addressing each concern identified. 4. Describe any progress already achieved in addressing each concern. 5. Describe any constraints in implementing improvements. 56 Radiography

144 Standard Five Assessment Standard Five: The program develops and implements a system of planning and evaluation of student learning and program effectiveness outcomes in support of its mission. Objectives: In support of Standard Five, the program: Student Learning 5.1 Develops an assessment plan that, at a minimum, measures the program s student learning outcomes in relation to the following goals: clinical competence, critical thinking, professionalism, and communication skills. Program Effectiveness 5.2 Documents the following program effectiveness data: Five-year average credentialing examination pass rate of not less than 75 percent at first attempt within six months of graduation, Five-year average job placement rate of not less than 75 percent within twelve months of graduation, Program completion rate, Graduate satisfaction, and Employer satisfaction. 5.3 Makes available to the general public program effectiveness data (credentialing examination pass rate, job placement rate, and program completion rate) on an annual basis. Analysis and Actions 5.4 Analyzes and shares student learning outcome data and program effectiveness data to foster continuous program improvement. 5.5 Periodically evaluates its assessment plan to assure continuous program improvement. 57 Radiography

145 5.1 Develops an assessment plan that, at a minimum, measures the program s student learning outcomes in relation to the following goals: clinical competence, critical thinking, professionalism, and communication skills. Explanation: Assessment is the systematic collection, review, and use of information to improve student learning and educational quality. An assessment plan helps assure continuous improvement and accountability. Minimally, the plan must include a separate goal in relation to each of the following: clinical competence, critical thinking, professionalism, and communication skills. The plan must include student learning outcomes, measurement tools, benchmarks, and identify timeframes and parties responsible for data collection. For additional information regarding assessment, please refer to Required Program Response: Provide a copy of the program s current assessment plan. Possible Site Visitor Evaluation Methods: Review of assessment plan Review of assessment tools Interviews with faculty 58 Radiography

146 5.2 Documents the following program effectiveness data: Five-year average credentialing examination pass rate of not less than 75 percent at first attempt within six months of graduation, Five-year average job placement rate of not less than 75 percent within twelve months of graduation, Program completion rate, Graduate satisfaction, and Employer satisfaction. Explanation: Credentialing examination, job placement, and program completion data must be reported annually to the JRCERT. Graduate and employer satisfaction data must be collected as part of the program s assessment process. Credentialing examination pass rate is defined as the number of student graduates who pass, on first attempt, the American Registry of Radiologic Technologists (ARRT) certification examination or an unrestricted state licensing examination compared with the number of graduates who take the examination within six months of graduation. Job placement rate is defined as the number of graduates employed in the radiologic sciences compared to the number of graduates actively seeking employment in the radiologic sciences. The JRCERT has defined not actively seeking employment as: 1) graduate fails to communicate with program officials regarding employment status after multiple attempts, 2) graduate is unwilling to seek employment that requires relocation, 3) graduate is unwilling to accept employment due to salary or hours, 4) graduate is on active military duty, and/or 5) graduate is continuing education. Program completion rate is defined as the number of students who complete the program within 150% of the stated program length. The program must establish a benchmark for its program completion rate. The program specifies the entry point (e.g., required orientation date, final drop/add date, final date to drop with 100% tuition refund, official class roster date, etc.) used in calculating program s completion rate. Graduate and employer satisfaction may be measured through a variety of methods. The methods and timeframes for collection of the graduate and employer satisfaction data are the prerogative of the program. Required Program Response: Provide actual outcome data in relation to program effectiveness. Possible Site Visitor Evaluation Methods: Review of program effectiveness data Interviews with faculty 59 Radiography

147 5.3 Makes available to the general public program effectiveness data (credentialing examination pass rate, job placement rate, and program completion rate) on an annual basis. Explanation: Program accountability is enhanced by making its effectiveness data available to the program s communities of interest and the general public. In efforts to increase accountability and transparency, the program must publish, at a minimum, its five -year average credentialing examination pass rate, five-year average job placement rate, and program completion rate data on its Web site to allow the public access to this data. The program effectiveness data should clearly identify the sample size associated with each associated measure (i.e., number of first time test takers, number of graduates actively seeking employment, number of graduates). Additionally, the JRCERT will post five-year average credentialing examination pass rate, five-year average job placement rate, and program completion rate data at The program must publish the JRCERT URL ( to allow the public access to this data. Required Program Response: Provide copies of publications that contain the program s program effectiveness data (credentialing examination pass rate, job placement rate, and program completion rate). Provide samples of publications that document the availability of program effectiveness data via the JRCERT URL address from the institution s/program s Web site. Possible Site Visitor Evaluation Methods: Review of program publications Review of institutional and/or program Web site Interviews with faculty Interviews with students 60 Radiography

148 5.4 Analyzes and shares student learning outcome data and program effectiveness data to foster continuous program improvement. Explanation: Analysis of student learning outcome data and program effectiveness data allows the program to identify strengths and areas for improvement to bring about systematic program improvement. This analysis also provides a means of accountability to communities of interest. It is the program s prerogative to determine its communities of interest. The analysis must be reviewed with the program s communities of interest. One method to accomplish this would be the development of an assessment committee. The composition of the assessment committee may be the program s advisory committee or a separate committee that focuses on the assessment process. The committee should be used to provide feedback on student achievement and assist the program with strategies for improving its effectiveness. This review should occur at least annually and must be formally documented. For additional information regarding assessment, please refer to Required Program Response: Describe how the program analyzes student learning outcome data and program effectiveness data to identify areas for program improvement. Describe how the program shares its student learning outcome data and program effectiveness data with its communities of interest. Describe examples of changes that have resulted from the analysis of student learning outcome data and program effectiveness data and discuss how these changes have led to program improvement. Provide a copy of the program s actual student learning outcome data since the last accreditation award. This data may be documented on previous assessment plans or on a separate document. Provide documentation that student learning outcome data and program effectiveness data has been shared with communities of interest. Possible Site Visitor Evaluation Methods: Review of student learning outcome data and program effectiveness data to support the assessment plan Review of representative samples of measurement tools used for data collection Review of aggregate data Review of meeting minutes related to the assessment process Interviews with faculty 61 Radiography

149 5.5 Periodically evaluates its assessment plan to assure continuous program improvement. Explanation: Identifying and implementing needed improvements in the assessment plan leads to programmatic improvement and renewal. As part of the assessment cycle, the program should review its assessment plan to assure that assessment measures are adequate and that the assessment process is effective in measuring student learning outcomes. At a minimum, this evaluation must occur at least every two years and be documented in meeting minutes. For additional information regarding assessment, please refer to Required Program Response: Describe how this evaluation has occurred. Provide documentation that the plan is evaluated at least once every two years. Possible Site Visitor Evaluation Methods: Review of meeting minutes related to the assessment process Review of assessment committee meeting minutes, if applicable Interviews with faculty 62 Radiography

150 Summary for Standard Five 1. List the major strengths of Standard Five, in order of importance. 2. List the major concerns of Standard Five, in order of importance. 3. Provide the program s plan for addressing each concern identified. 4. Describe any progress already achieved in addressing each concern. 5. Describe any constraints in implementing improvements. 63 Radiography

151 Standard Six Institutional/Programmatic Data Standard Six: The program complies with JRCERT policies, procedures, and STANDARDS to achieve and maintain specialized accreditation. Objectives: In support of Standard Six, the program: Sponsoring Institution 6.1 Documents the continuing institutional accreditation of the sponsoring institution. 6.2 Documents that the program s energized laboratories are in compliance with applicable state and/or federal radiation safety laws. Personnel 6.3 Documents that all faculty and staff possess academic and professional qualifications appropriate for their assignments. Clinical Settings 6.4 Establishes and maintains affiliation agreements with clinical settings. 6.5 Documents that clinical settings are in compliance with applicable state and/or federal radiation safety laws. Program Sponsorship, Substantive Changes, and Notification of Program Officials 6.6 Complies with requirements to achieve and maintain JRCERT accreditation. 64 Radiography

152 6.1 Documents the continuing institutional accreditation of the sponsoring institution. Explanation: The goal of accreditation is to ensure that the education provided by institutions meets acceptable levels of quality. The sponsoring institution must be accredited by: an agency recognized by the United States Department of Education (USDE) and/or Council for Higher Education Accreditation (CHEA), The Joint Commission (TJC), or equivalent standards. Required Program Response: Provide documentation of current institutional accreditation for the sponsoring institution. This may be a copy of the award letter, certificate, or printout of the institutional accreditor s Web page. 65 Radiography

153 6.2 Documents that the program s energized laboratories are in compliance with applicable state and/or federal radiation safety laws. Explanation: Compliance with applicable laws promotes a safe environment for students and others. Records of compliance must be maintained for the program s energized laboratories. Required Program Response: Provide certificates and/or letters for each energized laboratory documenting compliance with state and/or federal radiation safety laws. 66 Radiography

154 6.3 Documents that all faculty and staff possess academic and professional qualifications appropriate for their assignments. Full-time Program Director: Holds, at a minimum, a master s degree, Is proficient in curriculum design, program administration, evaluation, instruction, and academic advising, Documents three years clinical experience in the professional discipline, Documents two years of experience as an instructor in a JRCERT-accredited program, and Holds American Registry of Radiologic Technologists current registration in radiography or equivalent (i.e., unrestricted state license for the state in which the program is located). Full-time Clinical Coordinator: Holds, at a minimum, a baccalaureate degree, Is proficient in curriculum development, supervision, instruction, evaluation, and academic advising, Documents two years clinical experience in the professional discipline, Documents a minimum of one year of experience as an instructor in a JRCERT-accredited program, and Holds American Registry of Radiologic Technologists current registration in radiography or equivalent (i.e., unrestricted state license for the state in which the program is located). Full-time Didactic Program Faculty: Holds, at a minimum, a baccalaureate degree, Is qualified to teach the subject, Is knowledgeable of course development, instruction, evaluation, and academic advising, Documents two years clinical experience in the professional discipline, and Holds American Registry of Radiologic Technologists current registration in radiography or equivalent (i.e., unrestricted state license for the state in which the program is located). 67 Radiography

155 Part-time Didactic Program Faculty Holds academic and/or professional credentials appropriate to the subject content area taught and Is knowledgeable of course development, instruction, evaluation, and academic advising. Clinical Instructor(s): Is proficient in supervision, instruction, and evaluation, Documents two years clinical experience in the professional discipline, and Holds American Registry of Radiologic Technologists current registration in radiography or equivalent (i.e., unrestricted state license for the state in which the clinical setting is located). Clinical Staff: Holds American Registry of Radiologic Technologists current registration in radiography or equivalent (i.e., unrestricted state license for the state in which the clinical setting is located). Explanation: Appropriate knowledge, proficiency, and certification (if appropriate) provide a foundation that promotes a sound educational environment. Faculty and staff must possess academic and professional qualification(s) appropriate for their assignment. Clinical instructors and clinical staff supervising students performance in the clinical component of the program must document ARRT registration (or equivalent) or other appropriate credentials. Appropriate credentials, other than ARRT registration (or equivalent), may be used for qualified health care practitioners supervising students in specialty areas (e.g., registered nurse supervising students performing patient care skills, phlebotomist supervising students performing venipuncture, etc.). Required Program Response: For all program officials not previously identified on the program s database, submit a request for recognition of program officials including a current curriculum vitae and documentation of current registration by the American Registry of Radiologic Technologists* or equivalent. For all currently recognized program officials [program director, educational coordinator (if applicable), full-time didactic faculty, and all clinical preceptors], submit a current registration by the American Registry of Radiologic Technologists* or equivalent. *These may be copies of current registration cards or ARRT Identification page available at 68 Radiography

156 6.4 Establishes and maintains affiliation agreements with clinical settings. Explanation: Formalizing relations between the program and the clinical setting helps assure the quality of clinical education by delineating appropriate responsibilities of the program and the clinical setting. An appropriate termination clause assures that students will have an opportunity to complete the clinical education component. The JRCERT defines an affiliation agreement as a formal written understanding between an institution sponsoring the program and an independent clinical setting. An affiliation agreement must identify the responsibilities of all parties and, specifically, must address student supervision, student liability, and provide adequate notice of termination of the agreement. An affiliation agreement is not needed for clinical settings owned by the sponsoring institution; however, a memorandum of understanding between the clinical setting and the sponsoring institution is recommended. At a minimum, the memorandum should address responsibilities of both parties and student supervision. Required Program Response: Provide copies of current, signed affiliation agreements with each clinical setting. 69 Radiography

157 6.5 Documents that clinical settings are in compliance with applicable state and/or federal radiation safety laws. Explanation: Compliance with applicable laws promotes a safe environment for students and others. Records of compliance must be maintained for each clinical setting. Clinical settings may be recognized by The Joint Commission (TJC), DNV Healthcare, Inc., Healthcare Facilities Accreditation Program (HFAP), or an equivalent agency, or may hold a state-issued license. Required Program Response: Provide letters, certificates, or printouts of Web pages demonstrating the current recognition status of each clinical setting. 70 Radiography

158 6.6 Complies with requirements to achieve and maintain JRCERT accreditation. Explanation: Programs must comply with JRCERT policies and procedures to maintain accreditation. JRCERT accreditation requires that the sponsoring institution has primary responsibility for the educational program and grants the terminal award. Sponsoring institutions may include educational programs established in vocational/technical schools, colleges, universities, hospitals, or military facilities. The JRCERT also recognizes a consortium as an appropriate sponsor of an educational program. A consortium is two or more academic or clinical institutions that have formally agreed to sponsor the development and continuation of an educational program. The consortium must be structured to recognize and perform the responsibilities and functions of a sponsoring institution. The JRCERT does not recognize branch campuses. The JRCERT requires that each program location have a separate accreditation award. Additionally, the JRCERT will not recognize a healthcare system as the program sponsor. A healthcare system consists of multiple institutions operating under a common governing body or parent corporation. A specific facility within the healthcare system must be identified as the sponsor. The JRCERT requires programs to maintain a current and accurate database. Updates should be reflected within thirty (30) days of effective change date. Additionally, the JRCERT requires notification of substantive changes within thirty (30) days of implementation. Required Program Response: Report any database changes. Report any substantive change not previously submitted. 71 Radiography

159 Summary for Standard Six 1. List the major strengths of Standard Six, in order of importance. 2. List the major concerns of Standard Six, in order of importance. 3. Provide the program s plan for addressing each concern identified. 4. Describe any progress already achieved in addressing each concern. 5. Describe any constraints in implementing improvements. 72 Radiography

160 Awarding, Maintaining, and Administering Accreditation A. Program/Sponsoring Institution Responsibilities 1. Applying for Accreditation The accreditation review process conducted by the Joint Review Committee on Education in Radiologic Technology (JRCERT) can be initiated only at the written request of the chief executive officer or an officially designated representative of the sponsoring institution. This process is initiated by submitting an application and self-study report, prepared according to JRCERT guidelines, to: Joint Review Committee on Education in Radiologic Technology 20 North Wacker Drive, Suite 2850 Chicago, IL Administrative Requirements for Maintaining Accreditation a. Submitting the self-study report or a required progress report within a reasonable period of time, as determined by the JRCERT. b. Agreeing to a reasonable site visit date before the end of the period for which accreditation was awarded. c. Informing the JRCERT, within a reasonable period of time, of changes in the institutional or program officials, program director, clinical coordinator, full-time didactic faculty, and clinical instructor(s). d. Paying JRCERT fees within a reasonable period of time. e. Returning, by the established deadline, a completed Annual Report. f. Returning, by the established deadline, any other information requested by the JRCERT. Programs are required to comply with these and other administrative requirements for maintaining accreditation. Additional information on policies and procedures is available at Program failure to meet administrative requirements for maintaining accreditation will lead to being placed on Administrative Probationary Accreditation and result in Withdrawal of Accreditation. 73 Radiography

161 B. JRCERT Responsibilities 1. Administering the Accreditation Review Process The JRCERT reviews educational programs to assess compliance with the Standards for an Accredited Educational Program in Radiography. The accreditation process includes a site visit. Before the JRCERT takes accreditation action, the program being reviewed must respond to the report of findings. The JRCERT is responsible for recognition of clinical settings. 2. Accreditation Actions JRCERT accreditation actions for Probation may be reconsidered following the established procedure. JRCERT accreditation actions for Accreditation Withheld or Accreditation Withdrawn may be appealed following the established procedure. Procedures for appeal are available at All other JRCERT accreditation actions are final. A program or sponsoring institution may, at any time prior to the final accreditation action, withdraw its request for initial or continuing accreditation. Educators may wish to contact the following organizations for additional information and materials: accreditation: curriculum: certification: Joint Review Committee on Education in Radiologic Technology 20 North Wacker Drive, Suite 2850 Chicago, IL (312) American Society of Radiologic Technologists Central Avenue, S.E. Albuquerque, NM (505) American Registry of Radiologic Technologists 1255 Northland Drive St. Paul, MN (651) Copyright 2014 by the JRCERT 74 Radiography

162 Subject to the condition that proper attribution is given and this copyright notice is included on such copies, JRCERT authorizes individuals to make up to one hundred (100) copies of this work for non-commercial, educational purposes. For permission to reproduce additional copies of this work, please write to: JRCERT 20 North Wacker Drive Suite 2850 Chicago, IL (312) (312) (fax) ( ) 75 Radiography

163 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL SUBJECT: PATIENTS RIGHTS AND RESPONSIBILITIES Number: Page 1 of 5 Effective: 8/1/2011 KEY WORDS: Rights Responsibilities SEE ALSO: # Organizational Ethics Section 504 Grievance Procedures Response to a Patient or Family Member s POLICY: The Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) recognize the individual's rights to freedom of expression, independent decision, and action, and has concern for his/her personal dignity and human relationships. HUP/CPUP endeavors to create an environment supporting patients' rights pursuant to federal and state regulation, A patient has the right to: Respectful care given by competent personnel which reflects consideration of his/her personal values and belief systems and which optimizes his/her comfort and dignity. Upon request, be given the name of his/her attending physician, the names of all other physicians or practitioners directly participating in his/her care, and the names and professional status of other health care personnel, including medical students, residents or other trainees, having direct contact with him/her. Every consideration of privacy concerning his/her medical care program. Case discussion, consultation, examination, and treatment are considered confidential and should be conducted discreetly, giving reasonable visual and auditory privacy when possible. This includes the right, if requested, to have someone present while physical examinations, treatments, or procedures are being performed, as long as they do not interfere with diagnostic procedures or treatments. This also includes the right to request a room transfer if another patient or a visitor in the room is unreasonably disturbing him/her and if another room equally suitable for his/her care needs is available. Have all information, including records, pertaining to his/her medical care treated as confidential except as otherwise provided by law or third-party contractual arrangements. Know what hospital policies, rules, and regulations apply to his/her conduct as a patient. To expect emergency procedures to be implemented without unnecessary delay. To good quality care and high professional standards that are continually maintained and reviewed. To full information in layperson s terms, concerning diagnosis, treatment, and prognosis, including information about alternative treatments and possible complications. When it is not medically advisable that such information be given to a patient, the information shall be given on his/her behalf to his/her designated/legally authorized representative. Except for emergencies, the physician must obtain the necessary informed consent prior to the start of any procedure or treatment, or both. Not be involved in any experimental, research, donor program, or educational activities unless he/she has, or his/her designated/legally authorized representative has, given informed consent prior to the actual participation in such a program. A patient or his/her designated/legally authorized representative may, at any time, refuse to continue in any such program to which informed consent has previously been given. Accept medical care or to refuse any drugs, treatment, or procedure offered by the institution, to the extent permitted by law, and a physician shall inform a patient of the medical consequences of such refusal. Assistance in obtaining consultation with another physician at his/her request and expense. Expect good management techniques to be implemented within this health care facility considering APPENDIX I

164 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL SUBJECT: PATIENTS RIGHTS AND RESPONSIBILITIES Number: Page 2 of 5 Effective: 8/1/2011 effective use of his/her time and to avoid his/her personal discomfort. Examine and receive a detailed explanation of his/her bill. Full information and counseling on the availability of known financial resources for his/her health care. Expect that the health care facility will provide a mechanism whereby a patient is informed upon discharge of continuing health care requirements following discharge and the means for meeting them. Seek review of quality of care concerns, coverage decisions, and concerns about his/her discharge. A patient cannot be denied the right of access to an individual or agency who is authorized to act on his/her behalf to assert or protect the rights set out in this section. Have a family member or representative of his/her choice and his/her physician notified promptly of his/her admission to the hospital. Medical and nursing services without discrimination based upon age, sex, race, color, ethnicity, religion, gender, disability, ancestry, national origin, marital status, familial status, genetic information, gender identity or expression, sexual orientation, culture, language, socioeconomic status, domestic or sexual violence victim status, source of income, or source of payment. Appropriate assessment and management of pain. In collaboration with his/her physician, make decisions involving his/her health care. This right applies to the family and/or guardian of neonates, children, and adolescents. While this health care facility recognizes his/her right to participate in his/her care and treatment to the fullest extent possible, there are circumstances under which a patient may be unable to do so. In these situations (for example, if he/she has been adjudicated incompetent in accordance with law, are found by his/her physician to be medically incapable of understanding the proposed treatment or procedure, are unable to communicate his/her wishes regarding treatment, or are an unemancipated minor) his/her rights are to be exercised to the extent permitted by law, by his/her designated representative or other legally authorized person. Make decisions regarding the withholding of resuscitative services or the foregoing of or the withdrawal of life-sustaining treatment within the limits of the law and the policies of this institution. Receive care in a safe setting, and be free from all forms of abuse and harassment. Be free from restraint and seclusion not medically necessary or used as a means of coercion, discipline, convenience or retaliation by staff. Have his/her medical record read only by individuals directly involved in his/her care, by individuals monitoring the quality of his/her care, or by individuals authorized by law or regulation. He/she has the right to receive written notice that explains how his/her personal health information will be used and shared with other health care professionals included in his/her care. A patient or his/her designated/legally authorized representative, upon request, will have access to all information contained in his/her medical records, unless access is specifically restricted by the attending physician for medical reasons. Be communicated with in a manner that is clear, concise and understandable. If he/she does not speak English, a patient should have access, where possible, free of charge, to an interpreter. This also includes providing a patient with help if the patient has vision, speech, hearing or cognitive impairments. Access protective services and to be free from neglect, exploitation, and verbal, mental, physical and sexual abuse. Participate in the consideration of ethical issues surrounding his/her care, within the framework established by this organization to consider such issues. APPENDIX I

165 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL SUBJECT: PATIENTS RIGHTS AND RESPONSIBILITIES Number: Page 3 of 5 Effective: 8/1/2011 Formulate an advance directive, including the right to appoint a health care agent to make health care decisions on his/her behalf. These decisions will be honored by this facility and its health care professionals within the limits of the law and this organization s mission, values and philosophy. If applicable, a patient is responsible for providing a copy of his/her advance directive to the facility or caregiver. A patient is not required to have or complete an advance directive in order to receive care and treatment in this facility. When this facility cannot meet the request or need for care because of a conflict with our mission or philosophy or incapacity to meet his/her needs or request, a patient may be transferred to another facility when medically permissible. Such a transfer should be made only after a patient or his/her designated/legally authorized representative has received complete information and explanation concerning the need for, and alternatives to, such a transfer. The transfer must be acceptable to the other institution. Decide whether he/she wants visitors or not during his/her stay here. A patient may designate those persons who can visit him/her during his/her stay. These individuals do not need to be legally related to him/her. They may include, for example, a spouse, domestic partner, including a same sex partner, another family member, or a friend. The hospital will not restrict, limit, or deny any approved visitor on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability. The hospital may need to limit or restrict visitors to better care for him/her or other patients. He/she has the right to be made aware of any such clinical restrictions or limitations. Designate a family member, friend, or other individual as a support person during the course of his/her stay or during a visit to a physician or other ambulatory care treatment. Give or withhold informed consent to produce or use recordings, films or other images of a patient for purposes other than his/her care. Without recrimination, voice complaints regarding his/her care, to have those complaints reviewed, and, when possible, resolved. A patient should act in accordance with UPHS policies, rules, and regulations and assume responsibility for the following: This health care facility expects that a patient or his/her designated/legally authorized representative will provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, advance directives, and other matters relating to his/her health history or care in order for him/her to receive effective medical treatment. In addition, a patient is responsible for reporting whether he/she clearly understands the planned course of action and what is expected of him/her. It is expected that a patient will cooperate with all hospital personnel and ask questions if directions and/or procedures are not clearly understood. A patient is expected to be considerate of other patients and health care personnel, to assist in the control of noise and visitors in his/her room, and to observe the non-smoking policy of this institution. A patient is also expected to be respectful of the property of other persons and the property of the Health System. Threats, violence, disruption of patient care or harassment of other patients, visitors or staff will not be tolerated. A patient is also expected to refrain from conducting any illegal activity on UPHS property. If such activity occurs, UPHS will report it to law enforcement. APPENDIX I

166 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL SUBJECT: PATIENTS RIGHTS AND RESPONSIBILITIES Number: Page 4 of 5 Effective: 8/1/2011 In order to facilitate his/her care and the efforts of the health care personnel, a patient is expected to help the physicians, nurses, and allied medical personnel in their efforts to care for him/her by following their instructions and medical orders. Duly authorized members of a patient s family or designated/legally authorized representative are expected to be available to UPHS personnel for review of his/her treatment in the event a patient is unable to properly communicate with his/her health caregivers. It is understood that a patient assumes the financial responsibility of paying for all services rendered either through third-party payers (his/her insurance company) or being personally responsible for payment for any services which are not covered by his/her insurance policies. It is expected that a patient will not take drugs which have not been prescribed by his/her attending physician and administered by appropriate staff and that he/she will not complicate or endanger the healing process by consuming alcoholic beverages or toxic substances during his/her hospital stay and or visit. PURPOSE: It is the purpose of this policy to identify patient rights and responsibilities, and to clarify mechanisms by which patients are advised of those rights and responsibilities. SCOPE: This policy applies to all patients, employees and staff of the Hospital of the University of Pennsylvania (HUP) and those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which practice at or in conjunction with HUP, operating under the HUP license. This policy also applies to: (i) those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g. HUP s inpatient rehabilitation facility; (ii) private entities that lease space in property owned or leased by HUP only if they provide contracted clinical services to HUP; and (iii) personnel that provide contracted clinical services to HUP patients. IMPLEMENTATION: All employees and staff of HUP/CPUP are responsible for fulfilling their duties in a respectful, competent manner. All employees and staff are expected to respect the patient's right to participate in his own care, his right to privacy, and the confidentiality of information regarding his contacts with HUP/CPUP. PROCEDURE: 1. At the time of admission, The Admission Center staff gives those patients who are seen in The Admission Center a copy of the statement of patient s rights and responsibilities. 2. Each patient receives a statement of the patients rights and responsibilities at the time of admission and/or upon arrival at the patient s room. 3. The Patient Bill of Rights and Responsibilities are available in physician offices, at reception desks in the Hospital of the University of Pennsylvania, the Clinical Practices of the University of Pennsylvania and public areas. 4. Posters outlining patients rights and responsibilities are displayed in public areas such as The Admission Center, the Emergency Department, Hospital lobbies and waiting areas, and physician office waiting areas. 5. If the patient or a family member thinks that a complaint or grievance remains unresolved through the APPENDIX I

167 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL SUBJECT: PATIENTS RIGHTS AND RESPONSIBILITIES Number: Page 5 of 5 Effective: 8/1/2011 Hospital process, he/she has the right to contact the Division of Acute and Ambulatory Care, PA Department of Health. P.O. Box 90, Health and Welfare Building, Harrisburg, PA , (800) Patients with concerns related to quality and / or safety of care issues (including premature discharge) or safety of environment issues may contact The Division on Accreditation Operations, Office of Quality Monitoring, TJC, One Renaissance Boulevard, Oakbrook Terrace, IL 60181, Fax (630) SUPERSEDES: 11/1/09 PTS RIGHTS RESP Aug 2011 ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth B. Johnston Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX I

168 Program Personnel Contact Information HUP Outpatient Diagnostic (Silverstein, Sports Medicine, PCAM Chest, and PCAM Bone) Supervisor: Donna Rucci Office: (215) HUP General Inpatient (Chest/Bone, ED, Portables, OR) Supervisor: Val Ciminera Office: (215) HUP GI/GU Radiology Supervisor: Val Ciminera Office: (215) or (215) HUP 3-D Imaging Lab Supervisor: Cheryl Carroll or Megan Kull Office: HUP CT Supervisor: Office: (215) Laura Posey (215) HUP DEXA Supervisor: Donna Rucci Office: (215) HUP Interventional Cardiology (Cath Lab/EP Lab) Supervisor: Tanya Smith Office: (215) HUP Interventional Radiology Supervisor: David Waters Office: (215) (call department) Hospital of the University of Pennsylvania Revised March2015 1

169 Program Personnel Contact Information HUP Mammography Supervisor: Sue Penta Office: (215) HUP MRI Supervisor: Office: Andrea Pogozelski (215) HUP Neurovascular Radiology Supervisor: Loretta Clements Office: (215) (call department) HUP Nuclear Medicine Supervisor: Ellie Mantel Office: (215) HUP PET/CT Supervisor: Ellie Mantel Office: (215) HUP Radiation Oncology Supervisor: Pat Miller-Wilson Office: (215) HUP Radiology Nurse Supervisor: Sue Sweeney Office: (215) HUP Ultrasound Supervisor: Chris Iyoob Office: (215) (call department) Revised March2015 2

170 Program Personnel Contact Information The Children s Hospital of Philadelphia CHOP General Diagnostic (Inpatient, Outpatient, MSSK, ED, Portables, OR) Supervisor: Anthony Nicholson Office: (267) NicholsonA@ .chop.edu CHOP CT Supervisor: Office: Chris Harris (267) (scanner) HarrisC@ .chop.edu CHOP Fluoroscopy Supervisor: Joanne Kerwood Office: (267) Kerwood@ .chop.edu CHOP Interventional Radiology Supervisor: Jeanine Graff Office: (267) Graff@ .chop.edu CHOP MRI Supervisor: Office: Chris Harris (215) (scanner) HarrisC@ .chop.edu CHOP Nuclear Medicine Supervisor: Kevin Edwards Office: (267) EdwardsK@ .chop.edu CHOP Ultrasound Supervisor: Laura Poznick Office: (267) PoznickL@ .chop.edu Pennsylvania Hospital PAH General Diagnostic (Inpatient, Outpatient, Fluoroscopy, Portables, OR) Supervisor: Alan Muchler Office: (215) MuchlerA@pahosp.com Revised March2015 3

171 Program Personnel Contact Information Outpatient Radiology at Tuttleman Center General Diagnostic Supervisor: Debbie Miller-Smith Office: (215) / Penn Radiology at Penn Medicine Radnor Radnor General Diagnostic Practice Manager: Tiffany Ali Technologist Liaisons: Christie Jordan, Kelly Larson, & Jeanne Porter Department: (610) Penn Radiology at Penn Medicine Valley Forge Valley Forge General Diagnostic Practice Manager: David DiMarcantonio Technologist Liaisons: Joelle Nosia & Linda Stover Department: (610) Penn Radiology at Penn Medicine Bucks County Bucks County General Diagnostic Practice Manager: Faith Kenny Technologist Liaisons: Lynn Joynt, Loretta Lukasko, & Patricia Schuster Department: (215) Penn Veterinary Hospital Penn Vet General Diagnostic Supervisor: Barbara Kaminsky Office: (215) Revised March2015 4

172 Program Personnel Contact Information HUP RT Education Department Contacts Full-Time Faculty: Michael Pallanti- Interim Program Director Office: (215) Christina McCormack - CT Internship Director and Clinical Coordinator Office: (215) Christina.Mccormack@uphs.upenn.edu Anthony Festa - MRI Internship Director Office: (215) Anthony.Festa@uphs.upenn.edu Adjunct Faculty: Scott Cupp - Diagnostic Imaging Physicist Office: (215) Scott.Cupp@uphs.upenn.edu Joyce Dees - ACR/QC Coordinator Office: (215) Joyce.Dees@uphs.upenn.edu Main Department: Victoria Seidner - RT Education Coordinator Office: (215) Fax: (215) Victoria.Seidner@uphs.upenn.edu Revised March2015 5

173 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania Perelman Center for Advanced Medicine PENN Medicine at Rittenhouse MATERIALS MANAGEMENT POLICY MANUAL SUBJECT: HOSPITAL PROVIDED SCRUBS Number: MM_Policy-02-02_Hospitalscrubs Page 1 of 2 Effective:12/21/04 Revised: 12/07 Reviewed without edits: 6/08 KEY WORDS: SEE ALSO: Policy Hospital of the University of Pennsylvania will provide and launder scrub attire for the following areas: Operating Room Anesthesia PACU Labor & Delivery Cardiac Cath Lab Electro physiology Lab Surgical Pathology Urology Radiology (Neuroradiology, Angiography) Residents Central Processing Intensive Care Units Purpose The use of hospital provided and laundered scrub uniforms is based on the following rationale supported by the Center for Disease Control to: Reduce the bioburden in clean or restricted areas of the hospital. Provide changes of hospital laundered clothing to those employees at greater risk of blood or body fluid contamination in their daily work, while preventing the transport of contaminated items into the community. Procedure Areas authorized for hospital issued scrubs will be par stocked with daily predetermined amounts of scrub tops and bottoms. Scrub attire is to be removed prior to exiting the hospital and placed in appropriate soiled laundry hamper. No scrub wear is to be worn outside of hospital, nor in transit to or from work. Scrub attire, which is visibly soiled or wet, must be changed. Clean scrub attire will be issued as needed to replace soiled scrubs. Removal of soiled garment should be done in a way to avoid exposure to skin. APPENDIX K

174 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania Perelman Center for Advanced Medicine PENN Medicine at Rittenhouse MATERIALS MANAGEMENT POLICY MANUAL SUBJECT: HOSPITAL PROVIDED SCRUBS Number: MM_Policy-02-02_Hospitalscrubs Page 2 of 2 Effective:12/21/04 Revised: 12/07 Reviewed without edits: 6/08 SUPERSEDES: New /s/ Robert Fisher Director, Materials Management, Hospital of the University of Pennsylvania /s/ Mia Gonzales Dean, MBA, MS PT Assistant Hospital Director, Support Services, Hospital of the University of Pennsylvania APPENDIX K

175 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 1 of 3 SUBJECT: STAFF RIGHTS Effective: 03/01/06 POLICY HUP/CPUP/Shared Services is committed to providing medically appropriate, quality care to all its patients without regard to disability, race, creed, color, gender, national original or sexual orientation. This policy describes how requests will be reviewed from staff members who decline to participate in certain aspects of patient care or treatment when such care or treatment conflicts with the employee's cultural values, ethics, or religious beliefs. PURPOSE The purpose of this policy is to ensure patient care is not compromised if an employee chooses to exercise his/her right not to participate in certain aspects of patient care or treatment. SCOPE This policy applies to all staff members of HUP/CPUP/Shared Services. IMPLEMENTATION Implementation of this policy is the responsibility of Entity Senior Leadership, Department Directors/Business Administrators, and other management staff. PROCEDURE A staff member must submit a request in writing to be excluded from specific aspects of patient care or treatment for cultural, religious, or ethical reasons. This request must be submitted to: His/her line supervisor or Department Manager/Business Administrator AND The entity Executive Director B. Examples of patient care or treatment that staff members may request not to participate in may include: 1. Abortion; 2. Sterilization procedures; 3. Withholding or withdrawing of life-sustaining treatment, including nutrition and hydration; 4. Following a physician's orders or plan of care when the employee believes that the best interests of the patient are at risk. APPENDIX L

176 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 2 of 3 SUBJECT: STAFF RIGHTS Effective: 03/01/06 C. The staff member must provide a written request not to participate in the care or treatment of a patient to His/Her line supervisor or Department Director/Business Administrator AND The entity Executive Director. 1. The written request must be dated and must include what aspect of the care or treatment the staff member declines to participate in and the reason for the decision. 2. The request must be signed by the staff member. 3. The Executive Director will decide on the justification of the request. In cases where justification is questionable, Human Resources with appropriate clinical and administrative leadership, and/or a member of the Ethics Committee may be asked to participate in the review. 4. The requesting staff member is responsible for continuing to provide appropriate patient care until alternate arrangements can be made. Refusal to provide care will result in disciplinary action up to and including termination. In no circumstances will a request be granted if doing so would negatively affect the care of the patient. 5. Copies of granted requests will be maintained in departmental employee file. When it is not possible to grant requests because of staffing limitations, staff members may request transfer to a position in which conflict of care issues are less likely to occur. No staff member will be subject to any adverse action or evaluation for exercising his/her rights under this policy. However, the individual's ongoing performance assessment and appraisal process may include whether requests not to participate in patient care continue to be justifiable AND can continue to be accommodated. D. A staff member may not refuse to participate in the care or treatment of a patient based solely on the patient's diagnosis (e.g., HIV/AIDS or other sexually transmitted diseases, tuberculosis or other contagious diseases) or behavior. Such refusal is considered an action which could cause a life-threatening situation and will be subject to corrective disciplinary action/performance management.. APPENDIX L

177 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 3 of 3 SUBJECT: STAFF RIGHTS Effective: 03/01/06 1. Exception will be made for a staff member who has been directed in writing by a personal physician to avoid patients with certain diagnoses because of danger to an existing health condition of the staff member. 2. The staff member will provide the written directive to -- His/her immediate supervisor or Department Director/Business Administrator AND -- The entity Executive Director 3. The Executive Director in conjunction with Human Resources and the appropriate clinical and administrative leadership, will review the physician s directive, and discuss whether the accommodation can be made. 4. The notice will be maintained in the departmental employee file. E. When a staff member has exercised his/her right under this policy, the care or treatment of the patient shall not be compromised. 1. The manager will make the coverage arrangements with another member of the staff who is qualified to care for the patient. 2. The physician who is attending or ordering the care or treatment may personally deliver it. 3. In the event that all qualified staff members request not to participate in the care or treatment of a patient and a physician is not able to provide it, reasonable efforts will be made to secure the desired care and treatment at another facility. Patient care will not be compromised while these efforts are being made. F. Requests granted under this policy will be forwarded to the Ethics Committee for overall review from an organizational standpoint and for reporting purposes on an annual basis. SUPERSEDES: 04/15/97, 01/01/01 ISSUED BY: Christine M. Lynch Vice President, Human Resources APPENDIX L

178 University of Pennsylvania Health System POLICY MANUAL Number: Page: 1 of 2 SUBJECT: BEREAVEMENT Effective: 06/01/2013 A. POLICY SUMMARY The University of Pennsylvania may provide eligible employees with time off with pay for bereavement. B. PURPOSE The purpose of this policy is to ensure that eligible employees are provided with paid time off for making arrangements, bereavement and/or attending the funeral or memorial service of a member of the employee s immediate family. C. SCOPE This policy applies to regularly budgeted employees who work 20 hours or more per week*, and are in active pay status. There is no waiting period for this benefit. This policy applies to all employees of the Hospital of the University of Pennsylvania (HUP), those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which practice at or in conjunction with HUP operating under its license, and UPHS Corporate departments. This policy also applies to those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g. HUP s inpatient rehabilitation facility. For purposes of this policy, the above facilities, practices and sites are collectively referred to as entity. D. RESPONSIBILITY FOR IMPLEMENTATION Implementation and compliance of this policy are the responsibility of the entity senior leadership, department directors/business administrators, managers, and supervisors. E. POLICY 1. Paid bereavement leave is not earned time and will be granted only if needed. Managers and supervisors may require documentation of the death (e.g., death certificate, obituary, documentation from funeral home, etc.). 2. An employee should provide as much advance notice as possible to his/her supervisor. 3. If a death occurs while an employee is on a scheduled vacation or personal holiday, the appropriate days for bereavement leave will be granted and vacation or personal time may be rescheduled. 4. The amount of paid bereavement leave granted is calculated based on employees Full Time Equivalent (FTE).

179 University of Pennsylvania Health System POLICY MANUAL Number: Page: 2 of 2 SUBJECT: BEREAVEMENT Effective: 06/01/2013 Upon the death of a father, mother, spouse, domestic partner, son, daughter, sister, brother, legal guardian, or step-parent, bereavement leave can be calculated using the following formula: (40 x FTE = Hours of bereavement leave) Upon the death of an uncle, aunt, grandparent, grandchild, niece, nephew, father-in-law, mother in-law, brother-in-law, sister-in-law, son-in-law, and daughter-in-law, bereavement leave can be calculated using the following formula: (8 x FTE = Hours of bereavement leave) Employees may request to use vacation, personal or legal holiday time if additional time off is desired, or for bereavement of those not covered by this policy. Approval of requests for vacation, personal or legal holiday time is up to the discretion of the manager. F. EXAMPLE OF BEREAVEMENT LEAVE CALCULATION Upon the death of a father, mother, spouse, domestic partner, son, daughter, sister, brother, legal guardian, or step-parent: If employee FTE is 1.0, then (40 x 1.0 = 40 hours of Bereavement leave) If employee FTE is.90, then (40 x.90 = 36 hours of Bereavement leave) If employee FTE is.60, then (40 x.60 = 24 hours of Bereavement leave) Upon the death of an uncle, aunt, grandparent, grandchild, niece, nephew, father-in-law, mother in-law, brother-in-law, sister-in-law, son-in-law, and daughter-in-law: If employee FTE is 1.0, then (8 x 1.0 = 8 hours of Bereavement leave) If employee FTE is.90, then (8 x.90 = 7.2 hours of Bereavement leave) If employee FTE is.60, then (8 x.60 = 4.8 hours of Bereavement leave) Any questions regarding this policy may be referred to Human Resources. SUPERSEDES: Policy No Effective date 07/01/02, 09/24/06 ISSUED BY: Judy Schueler, Vice President, Organization Develop and Chief Human Resources Officer ISSUED BY: Garry Scheib, Executive Director Hospital of the University of Pennsylvania

180 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 1 of 5 SUBJECT: MILITARY LEAVE Effective: 10/01/01 POLICY The HUP/CPUP/Shared Services will grant leaves of absence of up to five (5) years (unless an additional period of service is required by the Federal or State government) to individuals who are called for Reserve or National Guard duty, who enlist in the armed forces, or who are drafted. PURPOSE The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) protects job rights and benefits for veterans and members of the reserves. USERRA, and various state laws, apply to all employers doing business in this country regardless of size. The law protects all persons serving in the Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service Commissioned Corps, and the reserve components of these services and the National Guard. SCOPE This policy applies to all Employees of the HUP/CPUP/Shared Services who hold positions which are not brief and nonrecurrent in nature and in which the Employee has a reasonable expectation that such employment will continue indefinitely or for a significant period. IMPLEMENTATION Implementation of this policy is the responsibility of the Entity Senior Leadership and Department Directors/Business Administrators. DEFINITIONS: Activation: When military personnel are ordered to active duty. AD/Active Duty: Full-time military service. ADT/Active Duty, Training: Full-time military service or entering active duty for basic training and/or training in the MOS (Military Occupational Specialty) or other required military training of six months or less. ETS: End of Time in Service/Military Separation Date. Armed Forces: Army, Air Force, Marines, Navy, Coast Guard, Public Health Service Commissioned Corps and the reserve components of these services and the National Guard. AT: Annual Training/Summer Training. Base Rate of Pay: The military daily rate of pay exclusive of any other pays or allowances. Hospital Usual Rate of Pay: Hourly rate inclusive of shift differential, exclusive of overtime. APPENDIX N

181 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 2 of 5 SUBJECT: MILITARY LEAVE Effective: 10/01/01 PROCEDURE A. ANNUAL TRAINING (AT): A maximum of two weeks (10 working days) each year will be allowed for Reservists or National Guards to attend annual military training. This time is in addition to usual vacation allowances. Routine weekend training is not included. The Employee will be paid the difference between a Reservists or National Guard s military base rate of pay and the usual HUP/CPUP/Shared Services rate of pay, not to exceed 80 hours of usual HUP/CPUP/Shared Services pay. This provision applies when the military base rate of pay is less than the Employee s usual HUP/CPUP/Shared Services daily pay (up to the number of scheduled pay period hours exclusive of overtime). The HUP/CPUP/Shared Services is not responsible to reimburse the Employee when the military base rate/per diem exceeds the usual HUP/CPUP/Shared Services pay rate. This reimbursement formula applies to all military statuses. Upon completion of AT, the Employee must take the military pay voucher to the Payroll Department. The Payroll Department will determine the amount due (if any) and assume payment responsibilities. B. ACTIVE DUTY FOR TRAINING (ADT): When an Employee requests leave time for ADT, the provisions for AD apply and will be followed. C. MILITARY PHYSICAL: One day, per year, with usual pay will be granted if an employee is required to take a physical examination for any of the Armed Forces, and the employee presents documentation of the duty to the supervisor or department director at least five (5) calendar days in advance of the required duty. D. ACTIVE DUTY: When an Employee of HUP/CPUP/Shared Services enters active duty with the Armed Forces for any period of time up to five (5) years that Employee will be placed on leave of absence. If an Employee so chooses, all accrued vacation and holiday hours will be paid at the commencement of active duty. 1. NOTICE: Unless precluded by military necessity or circumstances under which the giving of notice is otherwise impracticable or unreasonable, the Employee (or an appropriate officer of the uniformed service in which the Employee is to serve) must give as much advance written or oral notice as possible of the need for military leave. 2. REINSTATEMENT PROVISIONS: HUP/CPUP/Shared Services generally will reinstate returning Employees if they meet the following criteria: a. The Employee had been employed in a position which was not brief and nonrecurrent in nature and in which the Employee had a reasonable expectation that such employment would continue indefinitely or for a significant period; APPENDIX N

182 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 3 of 5 SUBJECT: MILITARY LEAVE Effective: 10/01/01 b. The Employee gave notice to HUP/CPUP/Shared Services prior to leaving, unless precluded by military necessity or to do so would have been impracticable or impossible; c. The cumulative period of active service did not exceed five (5) years, excluding certain services required by, among other things, a declared war or national emergency; d. The Employee was not discharged from the military under other than honorable terms; e. The Employee reported back to the civilian job in a timely manner. An Employee generally must apply for reemployment within 90 days of discharge from active duty, or within two (2) years if disabled or convalescing due to an injury incurred or aggravated as a result of military duty; and f. Circumstances have not so changed as to make such reemployment impossible or unreasonable and does not impose an undue hardship on HUP/CPUP/Shared Services. HUP/CPUP/Shared Services may request that the Employee present a certificate of discharge or release from active duty under honorable conditions. 3. BENEFITS: This section is intended to explain how your Employee Benefits are impacted in the event that you are placed on a Leave of Absence for active military reasons. Generally, as long as you are being paid (even if you are using accrued Vacation and/or Holiday time) your Employee Benefits will continue. Otherwise, unless you take certain critical actions as described below, your benefits may stop after the first thirty (30) days of your military duty. Please read the following explanations as they apply to specific Employee Benefits. Please Note: The treatment of employee benefits of those employees called to active duty is complicated under the law. HUP/CPUP/Shared Services intends to treat all benefit entitlement in accordance with controlling law. a. HUP/CPUP/Shared Services Flex Benefits HUP/CPUP/Shared Services provides you with limited health coverage during your military leave. Medical, Dental and Vision Insurance and Employee Assistance Program ( EAP ) shall continue in effect, consistent with other leaves of absence for not less than twelve (12) weeks on the same basis as if you had not taken leave. Those on duty in excess of twelve (12) weeks may elect to continue employer- APPENDIX N

183 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 4 of 5 SUBJECT: MILITARY LEAVE Effective: 10/01/01 sponsored health care for up to eighteen (18) months, or longer under certain circumstances, in accordance with controlling law. HUP/CPUP/Shared Services may require Employees electing coverage to pay 102% of the full premium under the plan. However, you should check with the appropriate military personnel to determine what medical and other benefits, if any, are available to you and your dependents while you are on active duty. Group Life Insurance, Accidental Death & Dismemberment (AD&D) and Dependent Life Insurance shall continue in effect for not less than twelve (12) weeks on the same basis as if you had not taken the leave. You will be given an opportunity to purchase coverage directly through the carrier. You must contact the carrier directly in order to activate this conversion right. The carrier, in turn, will provide you with the individual insurance rates and other pertinent information that should be helpful to you in deciding whether or not to purchase the coverage. Some insurance policies do not cover death or injuries incurred in the course of combat. Accordingly, it is important for you to understand which acts or reasons for death or dismemberment may be excluded. Employees participating in the Flexible Savings Accounts (Health or Dependent Care) may continue to submit claims against balances accumulated in their accounts through the duration of the calendar year and relevant filing period. b. Retirement and/or Pension Plans Qualified pension plans administered in full compliance with all controlling federal and state regulations with respect to benefits during military leave. This means that you may continue to be eligible for purposes of vesting and pension accrual purposes while you are on a leave of absence. However, no distributions (other than Hardship distributions if available) from any pension plan of which you are or were a participant will be made while you are on a leave of absence. c. Tax Deferred Annuity (TDA) Plans All contributions to the TDA plan will stop with your last paycheck. You have the option at all times to change the underlying investment of your TDA plan. You must contact your TDA vendor to do this. Generally, no distributions (other than Hardship distributions if available) from any TDA plan of which you are or were a participant will be made while you are on a leave of absence. You may, however, make retroactive contributions upon return to work. The requirements for making retroactive contributions are complex under the controlling law, and we will advise you of your rights and obligations upon your reemployment. APPENDIX N

184 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 5 of 5 SUBJECT: MILITARY LEAVE Effective: 10/01/01 d. Tuition Benefits All eligibility for you or any dependents is suspended while you are on a leave of absence (see Policy ). If you or a dependent is approved for tuition at the time you are called to active duty, your military leave of absence will be credited toward the one (1) year of service required to discharge any repayment obligation for tuition assistance. e. Short- and Long-Term Disability This coverage will remain in effect through the last day that you are actively at work. Myriad issues may arise concerning your rights during military leave. This policy does not, and cannot, address all such issues. Insofar as issues arise that are not addressed in this policy, HUP/CPUP/Shared Services will abide by USERRA and any controlling state laws. Should you have any questions or require further information, please see your Human Resources Department for further information regarding military leave. SUPERSEDES: 01/01/88; 01/01/01 ISSUED BY: Christine M. Lynch Associate Vice President, Human Resources APPENDIX N

185 Revision 3 JUNE 1999 REGULATORY GUIDE 8.13 (Draft was issued as DG-8014) INSTRUCTION CONCERNING PRENATAL RADIATION EXPOSURE A. INTRODUCTION The Code of Federal Regulations in 10 CFR Part 19, Notices, Instructions and Reports to Workers: Inspection and Investigations, in Section 19.12, Instructions to Workers, requires instruction in the health protection problems associated with exposure to radiation and/or radioactive material, in precautions or procedures to minimize exposure, and in the purposes and functions of protective devices employed. The instructions must be commensurate with potential radiological health protection problems present in the work place. The Nuclear Regulatory Commission's (NRC's) regulations on radiation protection are specified in 10 CFR Part 20, Standards for Protection Against Radiation ; and 10 CFR , Dose to an Embryo/Fetus, requires licensees to ensure that the dose to an embryo/fetus during the entire pregnancy, due to occupational exposure of a declared pregnant woman, does not exceed 0.5 rem (5 msv). Section also requires licensees to make efforts to avoid substantial variation above a uniform monthly exposure rate to a declared pregnant woman. A declared pregnant woman is defined in 10 CFR as a woman who has voluntarily informed her employer, in writing, of her pregnancy and the estimated date of conception. This regulatory guide is intended to provide information to pregnant women, and other personnel, to help them make decisions regarding radiation exposure during pregnancy. This Regulatory Guide 8.13 supplements Regulatory Guide 8.29, Instruction Concerning Risks from Occupational Radiation Exposure (Ref. 1), which contains a broad discussion of the risks from exposure to ionizing radiation. Other sections of the NRC's regulations also specify requirements for monitoring external and internal occupational dose to a declared pregnant woman. In 10 CFR , Conditions Requiring Individual Monitoring of External and Internal Occupational Dose, licensees are required to monitor the occupational dose to a declared pregnant woman, using an individual monitoring device, if it is likely that the declared pregnant woman will receive, from external sources, a deep dose equivalent in excess of 0.1 rem (1 msv). According to Paragraph (e) of 10 CFR , Records of Individual Monitoring Results, the licensee must maintain APPENDIX O

186 records of dose to an embryo/fetus if monitoring was required, and the records of dose to the embryo/fetus must be kept with the records of dose to the declared pregnant woman. The declaration of pregnancy must be kept on file, but may be maintained separately from the dose records. The licensee must retain the required form or record until the Commission terminates each pertinent license requiring the record. The information collections in this regulatory guide are covered by the requirements of 10 CFR Parts 19 or 20, which were approved by the Office of Management and Budget, approval numbers and , respectively. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. B. DISCUSSION As discussed in Regulatory Guide 8.29 (Ref. 1), exposure to any level of radiation is assumed to carry with it a certain amount of risk. In the absence of scientific certainty regarding the relationship between low dose exposure and health effects, and as a conservative assumption for radiation protection purposes, the scientific community generally assumes that any exposure to ionizing radiation may cause undesirable biological effects and that the likelihood of these effects increases as the dose increases. At the occupational dose limit for the whole body of 5 rem (50 msv) per year, the risk is believed to be very low. The magnitude of risk of childhood cancer following in utero exposure is uncertain in that both negative and positive studies have been reported. The data from these studies are consistent with a lifetime cancer risk resulting from exposure during gestation which is two to three times that for the adult (NCRP Report No. 116, Ref. 2). The NRC has reviewed the available scientific literature and has concluded that the 0.5 rem (5 msv) limit specified in 10 CFR provides an adequate margin of protection for the embryo/fetus. This dose limit reflects the desire to limit the total lifetime risk of leukemia and other cancers associated with radiation exposure during pregnancy. In order for a pregnant worker to take advantage of the lower exposure limit and dose monitoring provisions specified in 10 CFR Part 20, the woman must declare her pregnancy in writing to the licensee. A form letter for declaring pregnancy is provided in this guide or the licensee may use its own form letter for declaring pregnancy. A separate written declaration should be submitted for each pregnancy. 1. Who Should Receive Instruction C. REGULATORY POSITION Female workers who require training under 10 CFR should be provided with the information contained in this guide. In addition to the information contained in Regulatory Guide 8.29 (Ref. 1), this information may be included as part of the training required under 10 CFR Providing Instruction The occupational worker may be given a copy of this guide with its Appendix, an explanation of the APPENDIX O

187 contents of the guide, and an opportunity to ask questions and request additional information. The information in this guide and Appendix should also be provided to any worker or supervisor who may be affected by a declaration of pregnancy or who may have to take some action in response to such a declaration. Classroom instruction may supplement the written information. If the licensee provides classroom instruction, the instructor should have some knowledge of the biological effects of radiation to be able to answer questions that may go beyond the information provided in this guide. Videotaped presentations may be used for classroom instruction. Regardless of whether the licensee provides classroom training, the licensee should give workers the opportunity to ask questions about information contained in this Regulatory Guide The licensee may take credit for instruction that the worker has received within the past year at other licensed facilities or in other courses or training. 3. Licensee's Policy on Declared Pregnant Women The instruction provided should describe the licensee's specific policy on declared pregnant women, including how those policies may affect a woman's work situation. In particular, the instruction should include a description of the licensee's policies, if any, that may affect the declared pregnant woman's work situation after she has filed a written declaration of pregnancy consistent with 10 CFR The instruction should also identify who to contact for additional information as well as identify who should receive the written declaration of pregnancy. The recipient of the woman's declaration may be identified by name (e.g., John Smith), position (e.g., immediate supervisor, the radiation safety officer), or department (e.g., the personnel department). 4. Duration of Lower Dose Limits for the Embryo/Fetus The lower dose limit for the embryo/fetus should remain in effect until the woman withdraws the declaration in writing or the woman is no longer pregnant. If a declaration of pregnancy is withdrawn, the dose limit for the embryo/fetus would apply only to the time from the estimated date of conception until the time the declaration is withdrawn. If the declaration is not withdrawn, the written declaration may be considered expired one year after submission. 5. Substantial Variations Above a Uniform Monthly Dose Rate According to 10 CFR (b), The licensee shall make efforts to avoid substantial variation above a uniform monthly exposure rate to a declared pregnant woman so as to satisfy the limit in paragraph (a) of this section, that is, 0.5 rem (5 msv) to the embryo/fetus. The National Council on Radiation Protection and Measurements (NCRP) recommends a monthly equivalent dose limit of 0.05 rem (0.5 msv) to the embryo/fetus once the pregnancy is known (Ref. 2). In view of the NCRP recommendation, any monthly dose of less than 0.1 rem (1 msv) may be considered as not a substantial variation above a uniform monthly dose rate and as such will not require licensee justification. However, a monthly dose greater than 0.1 rem (1 msv) should be justified by the licensee APPENDIX O

188 D. IMPLEMENTATION The purpose of this section is to provide information to licensees and applicants regarding the NRC staff's plans for using this regulatory guide. Unless a licensee or an applicant proposes an acceptable alternative method for complying with the specified portions of the NRC's regulations, the methods described in this guide will be used by the NRC staff in the evaluation of instructions to workers on the radiation exposure of pregnant women. REFERENCES 1. USNRC, Instruction Concerning Risks from Occupational Radiation Exposure, Regulatory Guide 8.29, Revision 1, February National Council on Radiation Protection and Measurements, Limitation of Exposure to Ionizing Radiation, NCRP Report No. 116, Bethesda, MD, APPENDIX O

189 APPENDIX QUESTIONS AND ANSWERS CONCERNING PRENATAL RADIATION EXPOSURE 1. Why am I receiving this information? The NRC's regulations (in 10 CFR 19.12, Instructions to Workers ) require that licensees instruct individuals working with licensed radioactive materials in radiation protection as appropriate for the situation. The instruction below describes information that occupational workers and their supervisors should know about the radiation exposure of the embryo/fetus of pregnant women. The regulations allow a pregnant woman to decide whether she wants to formally declare her pregnancy to take advantage of lower dose limits for the embryo/fetus. This instruction provides information to help women make an informed decision whether to declare a pregnancy. 2. If I become pregnant, am I required to declare my pregnancy? No. The choice whether to declare your pregnancy is completely voluntary. If you choose to declare your pregnancy, you must do so in writing and a lower radiation dose limit will apply to your embryo/fetus. If you choose not to declare your pregnancy, you and your embryo/fetus will continue to be subject to the same radiation dose limits that apply to other occupational workers. 3. If I declare my pregnancy in writing, what happens? If you choose to declare your pregnancy in writing, the licensee must take measures to limit the dose to your embryo/fetus to 0.5 rem (5 millisievert) during the entire pregnancy. This is one-tenth of the dose that an occupational worker may receive in a year. If you have already received a dose exceeding 0.5 rem (5 msv) in the period between conception and the declaration of your pregnancy, an additional dose of 0.05 rem (0.5 msv) is allowed during the remainder of the pregnancy. In addition, 10 CFR , Dose to an Embryo/Fetus, requires licensees to make efforts to avoid substantial variation above a uniform monthly dose rate so that all the 0.5 rem (5 msv) allowed dose does not occur in a short period during the pregnancy. This may mean that, if you declare your pregnancy, the licensee may not permit you to do some of your normal job functions if those functions would have allowed you to receive more than 0.5 rem, and you may not be able to have some emergency response responsibilities. 4. Why do the regulations have a lower dose limit for the embryo/fetus of a declared pregnant woman than for a pregnant worker who has not declared? A lower dose limit for the embryo/fetus of a declared pregnant woman is based on a consideration of greater sensitivity to radiation of the embryo/fetus and the involuntary nature of the exposure. Several scientific advisory groups have recommended (References 1 and 2) that the dose to the embryo/fetus be limited to a fraction of the occupational dose limit APPENDIX O

190 5. What are the potentially harmful effects of radiation exposure to my embryo/fetus? The occurrence and severity of health effects caused by ionizing radiation are dependent upon the type and total dose of radiation received, as well as the time period over which the exposure was received. See Regulatory Guide 8.29, Instruction Concerning Risks from Occupational Exposure (Ref. 3), for more information. The main concern is embryo/fetal susceptibility to the harmful effects of radiation such as cancer. 6. Are there any risks of genetic defects? Although radiation injury has been induced experimentally in rodents and insects, and in the experiments was transmitted and became manifest as hereditary disorders in their offspring, radiation has not been identified as a cause of such effect in humans. Therefore, the risk of genetic effects attributable to radiation exposure is speculative. For example, no genetic effects have been documented in any of the Japanese atomic bomb survivors, their children, or their grandchildren. 7. What if I decide that I do not want any radiation exposure at all during my pregnancy? You may ask your employer for a job that does not involve any exposure at all to occupational radiation dose, but your employer is not obligated to provide you with a job involving no radiation exposure. Even if you receive no occupational exposure at all, your embryo/fetus will receive some radiation dose (on average 75 mrem (0.75 msv)) during your pregnancy from natural background radiation. The NRC has reviewed the available scientific literature and concluded that the 0.5 rem (5 msv) limit provides an adequate margin of protection for the embryo/fetus. This dose limit reflects the desire to limit the total lifetime risk of leukemia and other cancers. If this dose limit is exceeded, the total lifetime risk of cancer to the embryo/fetus may increase incrementally. However, the decision on what level of risk to accept is yours. More detailed information on potential risk to the embryo/fetus from radiation exposure can be found in References What effect will formally declaring my pregnancy have on my job status? Only the licensee can tell you what effect a written declaration of pregnancy will have on your job status. As part of your radiation safety training, the licensee should tell you the company's policies with respect to the job status of declared pregnant women. In addition, before you declare your pregnancy, you may want to talk to your supervisor or your radiation safety officer and ask what a declaration of pregnancy would mean specifically for you and your job status. In many cases you can continue in your present job with no change and still meet the dose limit for the embryo/fetus. For example, most commercial power reactor workers (approximately 93%) receive, in 12 months, occupational radiation doses that are less than 0.5 rem (5 msv) (Ref. 11). The licensee may also consider the likelihood of increased radiation exposures from accidents and abnormal events before making a decision to allow you to continue in your present job APPENDIX O

191 If your current work might cause the dose to your embryo/fetus to exceed 0.5 rem (5 msv), the licensee has various options. It is possible that the licensee can and will make a reasonable accommodation that will allow you to continue performing your current job, for example, by having another qualified employee do a small part of the job that accounts for some of your radiation exposure. 9. What information must I provide in my written declaration of pregnancy? You should provide, in writing, your name, a declaration that you are pregnant, the estimated date of conception (only the month and year need be given), and the date that you give the letter to the licensee. A form letter that you can use is included at the end of these questions and answers. You may use that letter, use a form letter the licensee has provided to you, or write your own letter. 10. To declare my pregnancy, do I have to have documented medical proof that I am pregnant? NRC regulations do not require that you provide medical proof of your pregnancy. However, NRC regulations do not preclude the licensee from requesting medical documentation of your pregnancy, especially if a change in your duties is necessary in order to comply with the 0.5 rem (5 msv) dose limit. 11. Can I tell the licensee orally rather than in writing that I am pregnant? No. The regulations require that the declaration must be in writing. 12. If I have not declared my pregnancy in writing, but the licensee suspects that I am pregnant, do the lower dose limits apply? No. The lower dose limits for pregnant women apply only if you have declared your pregnancy in writing. The United States Supreme Court has ruled (in United Automobile Workers International Union v. Johnson Controls, Inc., 1991) that Decisions about the welfare of future children must be left to the parents who conceive, bear, support, and raise them rather than to the employers who hire those parents (Reference 7). The Supreme Court also ruled that your employer may not restrict you from a specific job because of concerns about the next generation. Thus, the lower limits apply only if you choose to declare your pregnancy in writing. 13. If I am planning to become pregnant but am not yet pregnant and I inform the licensee of that in writing, do the lower dose limits apply? pregnant. No. The requirement for lower limits applies only if you declare in writing that you are already 14. What if I have a miscarriage or find out that I am not pregnant? If you have declared your pregnancy in writing, you should promptly inform the licensee in writing that you are no longer pregnant. However, if you have not formally declared your pregnancy in writing, you need not inform the licensee of your nonpregnant status. 15. How long is the lower dose limit in effect? The dose to the embryo/fetus must be limited until you withdraw your declaration in writing or you APPENDIX O

192 inform the licensee in writing that you are no longer pregnant. If the declaration is not withdrawn, the written declaration may be considered expired one year after submission. 16. If I have declared my pregnancy in writing, can I revoke my declaration of pregnancy even if I am still pregnant? Yes, you may. The choice is entirely yours. If you revoke your declaration of pregnancy, the lower dose limit for the embryo/fetus no longer applies. 17. What if I work under contract at a licensed facility? The regulations state that you should formally declare your pregnancy to the licensee in writing. The licensee has the responsibility to limit the dose to the embryo/fetus. 18. Where can I get additional information? The references to this Appendix contain helpful information, especially Reference 3, NRC's Regulatory Guide 8.29, Instruction Concerning Risks from Occupational Radiation Exposure, for general information on radiation risks. The licensee should be able to give this document to you. For information on legal aspects, see Reference 7, The Rock and the Hard Place: Employer Liability to Fertile or Pregnant Employees and Their Unborn Children What Can the Employer Do? which is an article in the journal Radiation Protection Management. You may telephone the NRC Headquarters at (301) Legal questions should be directed to the Office of the General Counsel, and technical questions should be directed to the Division of Industrial and Medical Nuclear Safety. You may also telephone the NRC Regional Offices at the following numbers: Region I, (610) ; Region II, (404) ; Region III, (630) ; and Region IV, (817) Legal questions should be directed to the Regional Counsel, and technical questions should be directed to the Division of Nuclear Materials Safety APPENDIX O

193 REFERENCES FOR APPENDIX 1. National Council on Radiation Protection and Measurements, Limitation of Exposure to Ionizing Radiation, NCRP Report No. 116, Bethesda, MD, International Commission on Radiological Protection, 1990 Recommendations of the International Commission on Radiological Protection, ICRP Publication 60, Ann. ICRP 21: No. 1-3, Pergamon Press, Oxford, UK, USNRC, Instruction Concerning Risks from Occupational Radiation Exposure, Regulatory Guide 8.29, Revision 1, February (Electronically available at 4. Committee on the Biological Effects of Ionizing Radiations, National Research Council, Health Effects of Exposure to Low Levels of Ionizing Radiation (BEIR V), National Academy Press, Washington, DC, United Nations Scientific Committee on the Effects of Atomic Radiation, Sources and Effects of Ionizing Radiation, United Nations, New York, R. Doll and R. Wakeford, Risk of Childhood Cancer from Fetal Irradiation, The British Journal of Radiology, 70, , David Wiedis, Donald E. Jose, and Timm O. Phoebe, The Rock and the Hard Place: Employer Liability to Fertile or Pregnant Employees and Their Unborn Children What Can the Employer Do? Radiation Protection Management, 11, 41-49, January/February National Council on Radiation Protection and Measurements, Considerations Regarding the Unintended Radiation Exposure of the Embryo, Fetus, or Nursing Child, NCRP Commentary No. 9, Bethesda, MD, National Council on Radiation Protection and Measurements, Risk Estimates for Radiation Protection, NCRP Report No. 115, Bethesda, MD, Single copies of regulatory guides, both active and draft, and draft NUREG documents may be obtained free of charge by writing the Reproduction and Distribution Services Section, OCIO, USNRC, Washington, DC , or by fax to (301) , or by to <DISTRIBUTION@NRC.GOV>. Active guides may also be purchased from the National Technical Information Service on a standing order basis. Details on this service may be obtained by writing NTIS, 5285 Port Royal Road, Springfield, VA Copies of active and draft guides are available for inspection or copying for a fee from the NRC Public Document Room at 2120 L Street NW., Washington, DC; the PDR's mailing address is Mail Stop LL-6, Washington, DC 20555; telephone (202) ; fax (202) APPENDIX O

194 10. National Radiological Protection Board, Advice on Exposure to Ionising Radiation During Pregnancy, National Radiological Protection Board, Chilton, Didcot, UK, M.L. Thomas and D. Hagemeyer, Occupational Radiation Exposure at Commercial Nuclear Power Reactors and Other Facilities, 1996, Twenty-Ninth Annual Report, NUREG-0713, Vol. 18, USNRC, Copies are available at current rates from the U.S. Government Printing Office, P.O. Box 37082, Washington, DC (telephone (202) ); or from the National Technical Information Service by writing NTIS at 5285 Port Royal Road, Springfield, VA Copies are available for inspection or copying for a fee from the NRC Public Document Room at 2120 L Street NW., Washington, DC; the PDR's mailing address is Mail Stop LL-6, Washington, DC 20555; telephone (202) ; fax (202) APPENDIX O

195 FORM LETTER FOR DECLARING PREGNANCY This form letter is provided for your convenience. To make your written declaration of pregnancy, you may fill in the blanks in this form letter, you may use a form letter the licensee has provided to you, or you may write your own letter. To: DECLARATION OF PREGNANCY In accordance with the NRC's regulations at 10 CFR , Dose to an Embryo/Fetus, I am declaring that I am pregnant. I believe I became pregnant in (only the month and year need be provided). I understand the radiation dose to my embryo/fetus during my entire pregnancy will not be allowed to exceed 0.5 rem (5 millisievert) (unless that dose has already been exceeded between the time of conception and submitting this letter). I also understand that meeting the lower dose limit may require a change in job or job responsibilities during my pregnancy. (Your signature) (Your name printed) (Date) APPENDIX O

196 REGULATORY ANALYSIS A separate regulatory analysis was not prepared for this regulatory guide. A regulatory analysis prepared for 10 CFR Part 20, Standards for Protection Against Radiation (56 FR 23360), provides the regulatory basis for this guide and examines the costs and benefits of the rule as implemented by the guide. A copy of the Regulatory Analysis for the Revision of 10 CFR Part 20 (PNL-6712, November 1988) is available for inspection and copying for a fee at the NRC Public Document Room, 2120 L Street NW, Washington, DC, as an enclosure to Part 20 (56 FR 23360) APPENDIX O

197 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: VOLUNTEER, STUDENT AND ROTATING HOUSE STAFF INJURY Number: Page: 1 of 2 Effective: 01/01/01 POLICY HUP/CPUP/Shared Services herein establishes guidelines for the documentation and treatment of volunteers, students and house staff from other institutions who are injured while on HUP/CPUP/Shared Services property. PURPOSE The purpose of this policy is to clarify and standardize the procedure for HUP/CPUP/Shared Services volunteers, students and rotating house staff from other institutions, and others donating their services to HUP/CPUP/Shared Services, who are not paid employees and who are injured while performing their services for the HUP/CPUP/Shared Services. SCOPE This policy applies to all volunteers, students and rotating house staff. IMPLEMENTATION Implementation of this policy is the responsibility of the respective Entity Senior Leadership, Department Directors/Business Administrators and the Director of Occupational Medicine. PROCEDURE Any volunteer, student or house staff member who is at HUP/CPUP/Shared Services in a status not paid by the Hospital but performing duties for HUP/CPUP/Shared Services, who is hurt in the course of performing those duties on the premises will report that injury promptly to his or her immediate supervisor in the area to which he or she is assigned. Note: University of Pennsylvania students, including medical students, will report to the University Student Health Service. The immediate supervisor will complete the "Referral to Occupational Medicine" form and send the individual to the Occupational Medicine immediately after learning of the injury. If Occupational Medicine is closed, the individual will report to the Emergency Department. Initial care will be provided to the injured person according to established APPENDIX P

198 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: VOLUNTEER, STUDENT AND ROTATING HOUSE STAFF INJURY Number: Page: 2 of 2 Effective: 01/01/01 practice and policy. Follow-up care will be arranged with Occupational Medicine (HUP), with the individual s home institution, or with the individual s primary care provider as appropriate to the situation. The supervisor will notify the Safety Office immediately of the incident (x3642). The supervisor will complete the Safety Department "Accident/Loss Investigation Report" and send to the Safety Office within twenty-four hours. If the individual is covered by insurance, OM or the Emergency Department will use that insurance to defray the cost of treatment. Charges beyond the insurance coverage (or all charges for which the individual is not covered) will be considered on a case-by-case basis by the Business Office. Any questions concerning this policy should be referred to Workers Compensation Office, Human Resources. SUPERSEDES: 01/01/98 ISSUED BY: Christine M. Lynch Associate Vice President, Human Resources APPENDIX P

199 Penn Medicine - HUP Penn Medicine (HUP) Radiologic Technologist Educational Program College Credit Transfer Guidelines Upon acceptance into the program, an evaluation of your transcripts will be conducted to determine if the you have met the requirement of an associate degree to be eligible to apply to the American Registry of Radiologic Technologists (ARRT) for the Certification Examination in Radiography. Associate Degree prior to admission Completion of an associate degree from an accredited college or university prior to admission to the Penn Medicine -HUP (Hospital of the University of Pennsylvania) Radiologic Technologist Educational Program will be accepted to meet the eligibility requirement for applying to the American Registry of Radiologic Technologists (ARRT) for the Certification Examination in Radiography. Associate Degree while enrolled The Program is affiliated with Widener s University College to provide students an opportunity to pursue an associate degree while enrolled in the program if not earned prior to beginning the program. Entering students with earned college credits prior to admission but who have not earned an associate degree are required to have their transcripts evaluated for transfer of credit by Widener s University College. Transfer from another radiography program An applicant wishing to transfer from another radiography program must submit an application and all transcripts three months prior to the requested entering semester and will be considered if space is available. The applicant will: be required to successfully complete the Penn Medicine HUP Readmission/Transfer Exam to be granted transfer of radiography academic and clinical courses completed. The purpose of the 2008; revised 5/2010; 5/2012; 6/2012 APPENDIX R

200 exam is to ensure placement in the program is at an academic/clinical level that will allow for the greatest opportunity for success. be eligible to test on radiography courses completed with an earned grade of C (75%) or better. receive transfer posting (designated by TR ) on transcript only for radiography courses deemed equivalent in content to the courses in the Penn Medicine HUP RT Education Program. complete radiography competency simulations as part of the Penn Medicine HUP Readmission/Transfer Exam be required to complete a minimum of two semesters in the Penn Medicine HUP RT Education Program to graduate and complete all graduation requirements. To be eligible to receive a graduation certificate from the RT Program, the student must complete: All academic courses with a grade of C (75%)or better (from point of entry) Clinical Education with a grade of C (75%) or better (from point of entry) Successful completion of the Year I Comprehensive Exam with a grade of 75% or better All required basic and terminal competencies. Ten hours of community service ACR Research Internship The program does not offer an early release option. be required to have their transcripts evaluated by Widener s University College for transfer of college credits if applicable. 2008; revised 5/2010; 5/2012; 6/2012 APPENDIX R

201 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 1 of 13 Revised: 4/11/10 POLICY It is the policy of the University of Pennsylvania Health System (UPHS) to provide a safe environment for patients, visitors and employees. UPHS, in accordance with this policy will test all new hires and re-hires, students, and volunteers for prohibited drug use through pre-employment drug screening regardless of status as a condition of employment and as required by law or a business reason. PURPOSE The purpose of this policy is to ensure the safe and competent job performance provided by UPHS employees. The information received through the pre-employment drug screening will assist in making sound hiring decisions, protecting the well being of patients, visitors and employees, as well as potentially reducing liability for UPHS. SCOPE The requirements and procedures outlined in this policy statement apply to all University of Pennsylvania Health System (UPHS) entities. The term UPHS entity is defined as the Hospital of the University of Pennsylvania (HUP), The Clinical Practices of the University of Pennsylvania (CPUP), UPHS Corporate, Penn Presbyterian Medical Center (PPMC), Pennsylvania Hospital (PAH), Penn Home Health Care and Hospice Services (HCHS), and Clinical Care Associates (CCA). CONTRACTORS AND VENDORS Contractors and vendor employees working on UPHS property or on assignment on behalf of UPHS will be required to comply with this policy. PROCEDURE PRE-EMPLOYMENT DRUG SCREENING Pre-Employment drug screening is to be completed on every external applicant being considered for employment within UPHS. All applicants being considered for employment within UPHS are required to complete the pre employment drug screen within 2 business days from receipt of chain of custody. (Any individual who has left UPHS and is rehired within 90 days of termination DOES NOT need to complete the pre employment drug screening.) All offers of employment, including verbal and subsequent written confirmation, should include a statement indicating that the offer is being made conditional on successful completion of the preemployment drug screen. This procedure must be completed prior to processing the applicant onto payroll. Information should be secured through the chosen 3 rd party vendor and the documentation will be maintained in the employee file kept in the Records department of the respective Entity. APPENDIX S

202 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 2 of 13 Revised: 4/11/10 An applicant who has received a confirmed positive test for substance use as part of the preemployment drug screening must wait a minimum of twelve (12) months before being eligible for reconsideration for any type of employment. Positive results from the drug screen will result in an investigation by the independent Medical Officer. If the results indicate drug use, the offer of employment will be rescinded. A representative from Staffing or Nurse Recruitment will notify the candidate and the hiring manager. A. GENERAL PROVISIONS 1. UPHS new hires and re-hires will be tested for the following substances: a. Marijuana b. Cocaine c. Opiates d. Phencyclidine e. Amphetamines f. Barbiturates g. Benzodiazepines h. Methadone i. Propoxyphene 2. It will be mandatory for all applicants to sign a Consent Acknowledgement Form (Appendix AA), or consent electronically, for any and all urine specimens, under the provisions of this plan, for UPHS Entities to consider the applicant for employment. 3. A negative test result or a verified negative test result is required prior to the new hire/re-hire performing any and all functions for UPHS Entities. B. URINE SPECIMEN COLLECTION REQUIREMENTS 1. The drug testing chain-of-custody (COC) form is to be used as a permanent record on which identifying data on the applicant and on the specimen collection and transfer process are retained. The drug-testing plan requires testing for marijuana, cocaine, opiates, phencyclidine, amphetamines, barbiturates, benzodiazepines, methadone, and propoxyphene. The collection procedures under this plan are derived from the federal rules and regulations, as published in 49 Code of Federal Register (CFR), Part 40, the Urine Specimen Collection Procedures Guidelines for Transportation Workplace Drug Testing Programs. 2. Urine specimens collected under this policy may be used only to test for the prohibited drugs designated or approved for testing as described in this section and shall not be used to conduct any other analysis or tests. This policy does not prohibit procedures reasonably incident to analysis of the specimen for controlled substances (e.g., determination of PH or tests for specific gravity, creatinine, concentration, presence of adulterants or interfering substances). APPENDIX S

203 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 3 of 13 Revised: 4/11/10 3. At all times, donors will be treated with respect, ensuring the modesty and privacy, as much as practicable, of the donor. Collectors must avoid conduct and/or remarks that might be construed as accusatorial, offensive or inappropriate. 4. The collector shall not leave the collection site during the collection procedure. If it becomes necessary for the collector to leave the site, the collection shall be null and void. 5. If an applicant refuses to cooperate with the collection process, the collector shall inform the chosen 3rd party vendor and document on the chain-of-custody form. 6. The collection site shall have all necessary personnel, materials, equipment, facilities, and supervision to provide for the collection, security, temporary storage, and shipping or transportation of urine specimens to a certified drug-testing laboratory designated by the chosen 3rd party vendor. An independent medical facility may also be utilized as a collection site provided the other applicable requirements are met. 7. A designated collection site shall be any suitable location where a specimen can be collected under conditions set forth in the following procedures, including a properly equipped mobile facility. a. a designated collection site shall provide an enclosure within which private urination can occur. b. a toilet for completion of urination and a suitable clean surface for writing. c. a source of water for washing hands, which if practicable, should be external to the enclosure where urination occurs. C. SECURITY The purpose of this section is to prevent unauthorized access, which could compromise the integrity of the specimen during the collection process. 1. The designated collection site is to be secure at all times. If a facility cannot be dedicated solely to drug testing, the portion of the facility used for testing shall be secure during drug testing. 2. A facility normally used for other purposes, such as a public restroom or hospital examining room, may be secured by visual inspection to ensure other persons are not present and undetected access (e.g., through a rear door not in the view of the collection site person) is not possible. Security during collection may be maintained by effective restriction of access to collection materials and specimens. In the case of public restroom, the facility must be posted against access during the entire collection procedure to avoid embarrassment to the applicant or APPENDIX S

204 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 4 of 13 Revised: 4/11/10 distraction of the collection site person. 3. If it is impractical to maintain continuous physical security of a collection site from the time the specimen is presented until the sealed mailer is transferred for shipment, the following minimum procedures shall apply: a. The specimen shall remain under the direct control of the collection site person from delivery to its being sealed in the mailer. b. The mailer shall be immediately mailed, maintained in secure storage, or remain under the personal control of the collection site person until mailed. D. CUSTODY CONTROL 1. The chain-of-custody block of the drug testing custody and control form shall be properly executed by authorized collection site personnel upon receipt of specimens. A chain-of-custody form shall be used for maintaining control and accountability of each specimen from the point of collection to the final disposition of the specimen. 2. Since specimens are sealed in packages that would indicate any tampering during transit to the laboratory and couriers, express carriers and postal service personnel do not have access to the chain-of-custody forms, there is no requirement that such personnel document chain-of-custody for the package during transit. E. ACCESS TO AUTHORIZED PERSONNEL ONLY 1. No unauthorized personnel shall be permitted in any part of the designated collection site when urine specimens are collected and stored. Only the collection site person may handle specimens prior to their security in the mailing container or monitor a specimen collection. 2. To promote security of specimens, avoid distraction of the collection site person, and ensure against any confusion in the identification of specimens, the collection site person shall have only one donor under supervision at any given time. 3. For this purpose, a collection procedure is complete when the urine bottle has been sealed and initialed, the drug testing custody and control form has been executed, and the applicant has departed the site; or, in the case of an applicant who was unable to provide a complete specimen, has entered a waiting area. F. DONOR PRIVACY APPENDIX S

205 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 5 of 13 Revised: 4/11/10 1. Procedures for collecting urine specimens shall allow individual privacy unless there is a reason to believe that a particular individual may alter or substitute the specimen to be provided. 2. The following circumstances are the exclusive grounds constituting a reason to believe that the individual may alter or substitute the specimen: a. The applicant has presented a urine specimen that registers outside the normal temperature range of 32 to 38 degrees Centigrade or 90 to100 degrees Fahrenheit, and the applicant declines to provide a measurement of oral body temperature; or, the oral body temperature varies by more than 1 degree Centigrade or 1.8 degrees Fahrenheit from the temperature of the specimen. b. The last urine specimen provided by the applicant was determined by the laboratory to have a specific gravity of less than and a creatinine concentration below 0.2g/L. c. The collection site person observes conduct clearly and unequivocally indicating an attempt to substitute or adulterate the specimen. d. The applicant has previously been determined to have used a controlled substance without medical authorization. 3. A higher-level supervisor of the collection site person shall review and concur in advance with any decision by a collection site person to obtain a specimen under the direct observation of a same gender collection site person. G. INTEGRITY AND IDENTIFICATION The collection site person shall take precautions to ensure that a urine specimen is not adulterated or diluted during the collection procedure and that information on the urine bottle and on the urine custody and control form can identify the individual from whom the specimen was collected. The following minimum precautions shall be taken to ensure the unadulterated specimens are obtained and correctly identified: 1. To deter dilution of specimens at the collection site, toilet-bluing agents shall be placed in toilet tanks, wherever possible, so that reservoir of water in the toilet bowl always remains blue. If no bluing agent is available to deter specimen dilution, the collector shall instruct the donor not to flush until the specimen is delivered to the collector. After the collector has possession of the specimen, the individual will be instructed to flush the toilet or urinal to participate in the completion of the chain-ofcustody. Where practicable, there shall be no other source of water in the enclosure when urination occurs. If there is another source of water in the enclosure, it shall be effectively secured or monitored to ensure it is not used as a source of diluting the specimen. APPENDIX S

206 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 6 of 13 Revised: 4/11/10 2. When an individual arrives at the collection site, the collection site person shall ensure that the individual is positively identified as the applicant selected for testing, using a picture ID (e.g., through presentation of photo identification or identification of the employer s representative). If the applicant requests, the collection site person shall show proper identification to the applicant. The collector will begin to complete the first section of the chain-of-custody form. 3. If the individual fails to arrive at the assigned time, the collection site person shall contact the collection administrator to obtain guidance on the action to be taken. 4. The collection site person shall ask the individual to remove any unnecessary outer garments, such as a coat or jacket that might conceal items or substances that could be used to tamper with or adulterate the individual s urine specimen. The collection site person shall ensure that all personal belongings, such as a purse or briefcase, will remain with the outer garments. The individual may retain his/her wallet. If the applicant requests it, the collection site person shall provide the applicant with a receipt for any personal belongings. 5. The donor shall be instructed to wash and dry his/her hands, without soap, prior to voiding. 6. After washing hands, the individual shall remain in the presence of the collector and shall not have access to any water fountain, soap dispenser, cleaning agent or any other materials, which could be used to adulterate the specimen. 7. The individual may provide their specimen in the privacy of a stall or otherwise partitioned area that allows for individual privacy. The collection site person shall instruct the donor to choose a collection kit. The collection site person shall note any unusual behavior or appearance on the chain-of-custody form under the Collector s Notes Section. The collector can complete the first section of the chainof-custody form. 8. UPHS is using the single collection method. The donor may void either directly into a specimen bottle or into a separate collection container. If a separate collection container is used, the collector will instruct the donor to pour at least thirty (30) ml of urine from the collection container to the specimen bottle. This must be done in the presence of the collector. 9. Upon receiving the specimen from the donor, the collector shall determine if it has at least thirty (30) ml of urine. If the individual is unable to provide the minimum quantity of urine, the collector shall instruct the donor to drink not more than forty (40) ounces of fluids and, after a period of up to three (3) hours, again attempt to provide a complete specimen, using a fresh collection kit. 10. After the specimen has been provided and submitted to the collector, the donor shall be allowed to wash his/her hands. 11. Within four (4) minutes of collection, the collector must read the temperature of the specimen. The temperature-measuring device used must accurately reflect the APPENDIX S

207 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 7 of 13 Revised: 4/11/10 temperature without contaminating the specimen. All collection kits provided by a SAMHSA laboratory have a temperature measuring device on the outside of the collection container or specimen bottle. 12. An out of range specimen temperature constitutes a reason to believe that the donor has altered or substituted the specimen. The donor supplying the specimen may volunteer to have their temperature taken to provide evidence to counter the reason to believe the individual may have altered or substituted the specimen. 13. Immediately following the collection, the collector shall inspect the specimen to determine its color and look for signs of contaminants. Any unusual findings must be noted on the chain-of-custody form in the Collector s Notes Section. All specimens suspected of being adulterated shall be forwarded to the laboratory. Whenever there is a reason to believe that a particular donor has altered or substituted the specimen, a second specimen shall be obtained, as soon as possible, under the direct observation of a same gender collector. 14. Both the donor and the collector shall keep the specimen in view, at all times, prior to its being sealed and labeled. The specimen must be sealed with a temperresistant integrity seal, over the bottle cap and down the sides of the bottle, and labeled. The collector and the donor must be present, at all times, during the following procedures: a. If the specimen is transferred from a collection container to a specimen bottle, the collector should instruct the donor to pour the urine and place the cap on the specimen bottle tightly. The donor will then give the specimen to the collector. b. The collector will apply the temper-resistant integrity seal with the specimen identification number, as outlined above, and enter the date. The collector will instruct the donor to initial the seal to certify that the specimen was collected from that donor. The collector will then seal the specimen in the plastic specimen bag. c. The collector shall instruct the donor to complete the appropriate donor certification step and the collector will the complete the actual chain. d. The collector shall place the appropriate copy of the chain-of-custody form in the plastic specimen bag or the shipping box with the specimen. The sealed specimen bag will be placed in the shipping bag or box and sealed. After the donor is given the donor copy, the specimen is ready for shipment, and the donor is free to leave. H. TRANSPORATION TO THE LABORATORY APPENDIX S

208 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 8 of 13 Revised: 4/11/10 The collector shall arrange to ship the specimen to the laboratory. The specimens shall be placed in the shipping containers that are designed to minimize the possibility of damage during shipment. I. DRUG TESTING LABORATORY 1. General a. UPHS shall use a drug-testing laboratory certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), under the Department of Health and Human Services (DHHS). b. The laboratory is required, by contract, to maintain test records in confidence and to disclose information relating to the test only to the Medical Review Officer c. Each specimen kit received by the laboratory will be inspected for tampering and/or damage, and the chain-of-custody form will be reviewed for any discrepancies. If the specimen and the chain-ofcustody form are intact, the specimen will be analyzed to determine if the specified drugs are present. d. The laboratory will transmit results to the chosen 3rd party vendor. by various electronic means; e.g., FTP, facsimile or computer, in a manner designed to ensure confidentiality of the information. e. The applicant will be responsible for any and all additional analyses that may be requested. If the additional laboratory analysis proves negative, the applicant will NOT be reimbursed. 2. Laboratory Procedures a. Initial Test (Emit Screen) All specimens will be initially screened for the use of prohibited substances by using an enzyme immunoassay technique (EMIT), which will eliminate negative urine specimens from confirmation testing. Any specimen, which resulted in a positive after the initial screening, will be subject to confirmation testing using a more stringent and precise testing method. The cut-off levels listed below will be used in the initial screening of specimens: 1. Marijuana metabolites 50 ng/ml 2. Cocaine metabolites 300 ng/ml 3. Opiate metabolites ng/ml 4. Phencyclidine (PCP) 25 ng/ml APPENDIX S

209 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 9 of 13 Revised: 4/11/10 5. Amphetamine metabolites 1000 ng/ml 6. Barbiturates 300 ng/ml 7. Benzodiazepines 300 ng/ml 8. Methadone 300 ng/ml 9. Propoxyphene 300 ng/ml b. Confirmation Test (GC/MS) All specimens which are identified as positive on the initial test will be confirmed by a second analysis (independent from the initial screen) which uses gas chromatography/mass spectrometry (GC.MS) to confirm the initial positive test result. The cut off levels listed below will be used to determine a confirmed positive test result: 1. Marijuana metabolites 15 ng/ml (Delta-9-tetrahydrocannabionol-9- carboxylic acid) 2. Cocaine metabolites 150 ng/ml 3. Opiate metabolites ng/ml each (1) Morphine (2) Codeine 4. Phencyclidine (PCP) 25 ng/ml 5. Amphetamine metabolites 500 ng/ml (1) Amphetamine (2) Methamphetamine 6. Barbiturates 200 ng/ml 7. Benzodiazepines 200 ng/ml 8. Methadone 200 ng/ml 9. Propoxyphene 300 ng/ml c. After receipt of the specimen by the laboratory, all results will be reported to the chosen 3 rd party vendor after being reviewed and certified as accurate by the certifying scientist. d. The laboratory shall report as negative all specimens, which are negative on the initial test or negative on the confirmation test. A specific drug(s) will be indicated on the confirmed positive only. APPENDIX S

210 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 10 of 13 Revised: 4/11/10 J. MEDICAL REVIEW e. The laboratory may provide the quantitative level(s) of the positive test results. The chosen 3rd party vendor shall report the test as negative or positive and the drug metabolite(s) for which it was positive, and shall disclose the quantitative level(s) to UPHS upon request. f. Reanalysis When a reanalysis is conducted, it is possible that some analytes may deteriorate during storage; therefore, the results of a retest are to be reported as a confirmation of the original test results if the detected level of the drug(s) are below the established limits and equal to or greater than the sensitivity of the test. 1. General a. The MRO shall review confirmed positive drug results and interview the individuals to verify the laboratory results before UPHS is notified. b. The MRO has contracted with the chosen 3rd party vendor. to provide UPHS with the medical review services for this drug-testing plan. 2. Reporting and Review of Results a. The MRO shall review confirmed positive drug results to verify consistencies in prescriptions and medications as noted on the chain-ofcustody form. A confirmed positive test result does not automatically identify an applicant as having used drugs. The MRO shall review the chain-of-custody to ensure that it is complete and sufficient on its face. 3. Qualifications and Responsibilities a. The MRO shall be a licensed physician with knowledge of substance abuse disorders and retained for this purpose. The MRO shall not be an employee of the laboratory conducting the drug test unless the laboratory establishes a clear separation of functions to prevent any appearance of a conflict of interest including assuring that the MRO has no responsibility for, and is not supervised by or the supervisor of, any person who have responsibility for the drug testing or quality control operations of the laboratory. b. The role of the MRO is to review and interpret confirmed positive test results obtained through the UPHS testing program. In carrying out this responsibility, the MRO shall examine alternate medical explanations for any positive test result. This action could include conducting a telephone medical interview with the applicant and telephone review of the applicant s medical history or a telephone review of any other relevant biomedical factors. The MRO may review all medical records made available by the tested applicant when a confirmed positive preemployment test could have resulted from legally prescribed medication. APPENDIX S

211 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 11 of 13 Revised: 4/11/10 4. Positive Test Results a. Prior to making a final decision on verification of a positive test result, the MRO shall give the applicant an opportunity to discuss the test result. b. The MRO shall contact the applicant directly, on a confidential basis, to determine whether the applicant wishes to discuss the test result. A staff person under the MRO s supervision may make the initial contact, and a medically licensed or certified staff person may gather information from the applicant. If the MRO determines there is a legitimate medical explanation for the positive test result, the MRO shall report the test result to the chosen 3rd party vendor. as negative. c. If, after making reasonable attempts and documenting them, the MRO is unable to reach the applicant directly, the MRO shall contact the UPHS or designee to direct the applicant to contact the MRO as soon as possible. If it becomes necessary to reach the applicant through the UPHS designee, such official shall employ procedures that ensure, to the maximum extent practicable, that the requirement of the applicant to contact the MRO is held in the strictest confidence. d. The MRO may verify a test as positive without having communicated directly with the applicant about the test in two (2) circumstances: 1. The applicant expressly declines the opportunity to discuss the test. 2. The UPHS designee has successfully made a contact with the applicant and instructed him/her to contact the MRO, and more than five (5) days have passed since the date the applicant was successfully contacted by the UPHS or designee. e. Following verification of a positive test result, the MRO shall refer verification to the chosen 3rd party vendor for UPHS. DEFINITIONS 1. Chain-of-Custody procedures to account for the integrity of each urine specimen by tracking its handling and storage from point of specimen APPENDIX S

212 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 12 of 13 Revised: 4/11/10 collection to final disposition of the specimen. These procedures shall require that an appropriate drug testing custody form from a Substance Abuse and Mental Health Services Administration (SAMHSA) certified laboratory be used from the time of collection to receipt by the laboratory. 2. Collection Site a designated clinic/facility where applicants may present themselves for the purpose of providing a specimen of their urine to be analyzed for the presence of drugs. 3. Collector a person who instructs and assists applicants through the specimen collection process 4. Confirmation Drug Test a second analytical procedure to identify the presence of a specific drug or metabolite which is independent of the initial test and which uses a different technique and chemical principle from that of the initial test in order to ensure reliability and accuracy. Gas chromatography/mass spectrometry (GC/MS) is the authorized confirmation method for marijuana, cocaine, opiates, phencyclidine, amphetamines, barbiturates, benzodiazepines, methadone and propoxyphene. 5. Fail a Drug Test or Test Positive the confirmation test result shows positive evidence of the presence of a prohibited drug in the applicant s system 6. Initial Drug Test an immunoassay screen to eliminate negative urine specimens from further analysis. The Emit Screen is the authorized screening method for marijuana, cocaine, opiates, phencyclidine and amphetamines. 7. Negative Drug Test a drug test in which a prohibited drug(s) was not detected in the initial drug test (Emit Screen); or, if the specimen screened positive during the Emit Screen, no prohibited drug(s) were detected during the confirmation drug test (GC/MS). 8. Passes Drug Test or Test Negative the initial testing or confirmation testing does not show evidence of the presence of a prohibited drug in the employee s or applicant s system. 9. Positive Drug Test the confirmation drug test (GC/MS) identified the presence of a prohibited drug(s). 10. Prohibited Drug - marijuana, cocaine, opiates, phencyclidine, amphetamines, barbiturates, benzodiazepines, methadone and propoxyphene. 11. Refusal to Submit to a Test When an applicant fails to provide an APPENDIX S

213 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE-EMPLOYMENT DRUG SCREENING Number: Page: Page 13 of 13 Revised: 4/11/10 adequate urine specimen, without a valid medical explanation, after receiving notice of a drug test requirement, in accordance with the provisions of this policy and engages in conduct that clearly obstructs the testing or collection process. 12. SAMHSA - Substance Abuse and Mental Health Services Administration, a division of the Department of Health and Human Services, established to regulate and certify laboratories that perform analytical drug test on human body fluids (formerly NIDA, National Institute on Drug Abuse) 13. Verified Negative Drug Test Result a positive test result in which the Medical Review Officer was provided with a legitimate medical explanation. 14. Verified Positive Drug Test Result a positive test result in which the Medical Review Officer was not provided with a legitimate medical explanation. SUPERSEDES: 03/01/99 ISSUED BY: Judy Schueler, Vice President Organization Development & Chief Human Resources Officer APPENDIX S

214 University of Pennsylvania Health System POLICY MANUAL Number: Page: 1 of 5 SUBJECT: PRE EMPLOYMENT BACKGROUND INVESTIGATION Revised: 9/1/2011 POLICY It is the policy of the University of Pennsylvania Health System (UPHS) to provide a safe environment for patients, visitors and employees. UPHS, in accordance with this policy will conduct background investigations, including criminal history record checks for all new hires and re-hires, students, and volunteers regardless of status as a condition of employment and as required by law or a business reason. Background investigations will only include an Act 73 check on employees entering positions identified as having significant likelihood of regular contact with children (under age 18) in the form of care, guidance, supervision, or training. PURPOSE The purpose of this policy is to ensure the safe and competent job performance provided by UPHS employees. The information received through pre-employment background investigations will assist in making sound hiring decisions, protecting the well being of patients, visitors and employees, as well as potentially reducing liability for UPHS. SCOPE This policy may apply, as specified, to all personnel (including employees, auxiliary healthcare providers, contracted personnel, other personnel who provide contracted clinical services to patients) of Hospital of the University of Pennsylvania (HUP), those parts of Clinical Practices of the University of Pennsylvania (CPUP) which practice at or in conjunction with HUP operating under its license, and UPHS Corporate departments. This policy also applies to those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g. HUP s inpatient rehabilitation facility. CONTRACTORS AND VENDORS Contractors and vendor employees working on UPHS property or on assignment on behalf of UPHS will be required to comply with this policy. PROCEDURE Pre-Employment background investigations are to be completed on every external applicant (defined as a new hire or a re-hire) being considered for employment within UPHS. Background investigations will only include an Act 73 check on employees entering positions identified as having significant likelihood of regular contact with children (under age 18) in the form of care, guidance, supervision, or training. See Appendix F. Any individual who has left UPHS and is rehired within 90 days of termination DOES NOT need to complete the standard pre employment background investigation. However, position specific background checks and clearances will be completed on rehires.) APPENDIX T

215 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE EMPLOYMENT BACKGROUND INVESTIGATION Number: Page: 2 of 5 Revised: 9/1/2011 In the case where a criminal history check is required by law or for a business reason (see E below), internal applicants will also be required to complete appropriate paperwork and undergo that portion of the investigation. All offers of employment, including verbal and subsequent written confirmation, should include a statement indicating that the offer is being made conditional upon successful completion of the background investigation. The procedure must be completed prior to processing the applicant onto payroll. Information should be secured through a third party vendor, and the documentation should be maintained in the employee file kept in the Records department of the respective Entity. A. Authorization to Obtain Information - Before initiating the background investigation, the applicant will complete the UPHS Employment Application and sign the Release Authorization and Fair Credit Reporting Act Disclosure (Appendix A). This form is to be maintained in the employee file kept in the Records department of the respective Entity. B. Summary of Rights document - At the time of authorization the applicant will receive a Summary of Rights document, outlining their rights under the Fair Credit Reporting Act (FCRA) (Appendix B). C. Content of Background Investigation Report The following information will be verified on all external applicants, consultants and vendor employees: 1. Education (highest level completed): The Candidate will show proof the school meets the accreditation requirements outlined by the Department of Education ( Attendance of school outside the US will be validated to meet the minimum education requirements as stated in the Job Description. 2. Employment History (seven (7) years or four (4) employers) 3. Social Security Number Verification & Validation 4. Address Verification 5. Professional Licensure - if deemed applicable to the job 6. Criminal History Record Information (refer to D. and E. below) 7. State/Federal Program Exclusions (OIG) 8. Driving Records and/or Credit Reports - if deemed applicable to the job 9. Protective Services Act if deemed applicable to the job 10. Act 73 - if deemed applicable to the job 11. PA Access to Criminal History (PATCH) check if deemed applicable to the job Internal applicants who transfer or are promoted will be subject to any and all background checks and clearances required based on their new position. See Employee Transfer and Promotion Policy. APPENDIX T

216 University of Pennsylvania Health System POLICY MANUAL Number: Page: 3 of 5 SUBJECT: PRE EMPLOYMENT BACKGROUND INVESTIGATION Revised: 9/1/2011 D. Criminal History Record Information With respect to each position in UPHS, a criminal history check will be required, either by applicable law (see Section E) or for business reasons. If a criminal history check is required, any applicant for the position, whether internal or external, will be required to complete the appropriate criminal history record paperwork. Failure to fully complete any required paperwork may result in denial or loss of employment. If any consent form is required by a law enforcement agency to release the information, the applicant will be required to provide such a consent form. The falsification of information on the application may result in the rescinding of the offer. If the criminal history provided by the applicant is not congruent with the information obtained by UPHS in the criminal history record check, the applicant will be given an opportunity to explain any inaccuracies. If a satisfactory explanation is not given, the applicant will not be considered further for the position. 1. If after commencing employment any employee is discovered to have lied or made material omissions regarding his or her criminal history, that individual may immediately be terminated. 2. Unless required by applicable law, UPHS will not inquire about arrest records. 3. UPHS may inquire about probation, including deferred adjudication in accordance with applicable law. 4. UPHS equal employment opportunity policy will be followed with respect to any criminal history information. Accordingly, the following factors will be considered when an individual has a criminal history in determining whether to hire the individual. (see Appendix C) The nature of the criminal act The frequency of criminal acts The period of time elapsed since the last conviction The time between convictions The nature of the job Evidence the individual has successfully rehabilitated himself/herself Seriousness of offence or offences: Consideration of the property, safety and welfare of employees and general public E. Adverse Action Notification Procedures as Required under the Fair Credit Reporting Act (FCRA) in order to comply with the federal statutory requirements under FCRA, the following two (2) letters will be sent out to applicants when any information contained in the background investigation report could result in the withdrawal of the conditional offer of employment: APPENDIX T

217 University of Pennsylvania Health System POLICY MANUAL SUBJECT: PRE EMPLOYMENT BACKGROUND INVESTIGATION Number: Page: 4 of 5 Revised: 9/1/ st Adverse Action Notice Letter (Appendix D) This letter will be sent out immediately along with two attachments: (1) a copy of the Background report from third party vendor, and (2) a copy of the Summary of Rights (Appendix B ). 2. 2nd Adverse Action Notice Letter (Appendix E) - On the fifth business day from the date of mailing of the 1st Adverse Action Notice Letter, a review should be done of supplementary information submitted by the applicant (if any), and a decision made regarding employment. If a decision is made to withdraw the conditional offer of employment based in whole or in part on the adverse information, the 2nd Adverse Action Notice letter will be sent, along with two attachments: (1) the Summary of Rights (Appendix B), and (2) a signed copy of the Release Authorization and Fair Credit Reporting Act Disclosure (Appendix A) originally signed by the applicant. The letters should be sent by both regular mail and registered mail (no signature required), or Federal Express (no signature required), to the address given by the applicant on the authorization form. Information obtained from pre-employment background investigations will be treated as confidential material. Any Questions concerning the application of and/or compliance with this policy should be directed to the Entity Chief Human Resource Officer or designee. F. Protective Services Act Healthcare organizations that have Skilled Care units are required to conduct criminal history checks of job applicants before hiring and employing those applicants. The applicants may be hired only if they are free from certain criminal convictions under amendments to Pennsylvania s Older Adults Protective Services Act (see details under Appendix C). This law, effective July 1, 1998, applies to facilities which include long-term nursing facilities, home health care agencies (including any private or public organization which provides care to a care-dependent individual in the individual s residence), domiciliary care homes, older adult daily living centers, and personal care homes. Mandatory Pennsylvania state police criminal history records are required. Criminal background checks other than those performed by the state police are not acceptable. The law requires applicants to submit a criminal history report from the Pennsylvania state police with their employment application. If the applicant does not reside in Pennsylvania, or has not resided there for the two years immediately preceding the application, then a federal criminal history record and fingerprint report must be obtained from the Federal Bureau of Investigation in addition to the state police report. APPENDIX T

218 University of Pennsylvania Health System POLICY MANUAL Number: Page: 5 of 5 SUBJECT: PRE EMPLOYMENT BACKGROUND INVESTIGATION Revised: 9/1/2011 G. ACT 73 Effective July 1, 2008, any employee hired on or after that date in a position or department/practice that has significant likelihood of regular contact with children (under 18 years of age) in the form of care, guidance, supervision or training must obtain the following background checks as a condition of employment: 1. Pennsylvania State Police Criminal History clearance (PATCH Report) 2. Pennsylvania Child Abuse Clearance (DPW Childline Clearance) 3. Federal (FBI) Criminal Background Check (using electronic fingerprinting through Cogent systems to DPW.) If the applicant can provide any of the above clearances that are less then 1 year old, the applicant would not be required to have that clearance reprocessed. The background checks would be facilitated through entity or corporate staffing departments. An employee going through the above process can be employed on a provisional status at the discretion of the recruiter and manager for that area until all background information can be received and reviewed. The provisional period is for 30 days for Pennsylvania residents and 90 days for out of state residents. During this period, individuals may be employed on provisional status, if certain conditions are met. These include: 1. A requirement that the provisional employee has applied for the mandatory background checks, provides evidence of completion of the request form, and swears or affirms in writing that he or she is not disqualified from employment. 2. The hospital must not be aware of any information that would disqualify the provisional employee from employment. 3. The provisional employee must work in the immediate presence of a regular employee and not work alone with children. 4. If the information that is obtained from any of the above background checks reveals that the provisional employee is disqualified from employment based on a conviction or report of child abuse, the individual must be immediately dismissed. SUPERSEDES: 01/01/88, 4/1/2010 ISSUED BY: Judy Schueler, Vice President Organization Development & Chief Human Resources Officer ISSUED BY: Garry Scheib, Executive Director Hospital of the University of Pennsylvania APPENDIX T

219 APPENDIX A Release Authorization and Fair Credit Reporting Act Disclosure UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM This is to notify you that in connection with your application for employment, we may procure a consumer report on you as part of the process of considering your application. Should we decide to procure this report, the following information would be obtained: 1. Education 5. Professional Licensure Verification 2. Employment History 6. Criminal History Record 3. Social Security Number Verification 7. State/Federal Program Exclusion (OIG) 4. Address Verification 8. Driving Records and/or Credit Reports, if deemed applicable In the event that information from the report is utilized in whole or in part in making an adverse decision, before making the adverse decision, we will provide you with a copy of the consumer report and a description in writing of your rights under the Fair Credit Reporting Act. Please be advised that we may also obtain an investigative consumer report including information as to your character, general reputation, personal characteristics, and mode of living. This information may be obtained by contacting your present and previous employers or references. Please be advised that you have the right to request, in writing, within a reasonable time, that we make a complete and accurate disclosure of the nature and scope of the information requested. By signing below, I hereby authorize all entities having information about me, including present and former employers, criminal justice agencies, and departments of motor vehicles, schools, and credit reporting agencies, to release such information to chosen 3 rd party vendor. This release and authorization shall remain valid and in effect during the term of your employment. We reserve the right to run subsequent consumer reports and/or investigative consumer reports on an as needed basis. Date Authorized Signature Full Name: (PRINT LEGIBLY) * Please list other names or aliases including maiden names: * Date of Birth * Social Security #: Current Residence: Street Address City State Zip * List previous residence history for the past 7 years: Street Address City State Zip Street Address City State Zip Street Address City State Zip * Required for background investigation purposes only, and will be used for no other purposes APPENDIX T

220 Appendix B Para informacion en espanol, visite o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C A Summary of Your Rights Under the Fair Credit Reporting Act This Summary was prepared by the FTC and can be obtained at its website ( The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every consumer reporting agency (CRA). Most CRAs are credit bureaus that gather and sell information about you such as if you pay your bills on time or have filed bankruptcy to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C u, at the Federal Trade Commission s web site ( The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights. You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you such as denying an application for credit, insurance or employment must tell you and give you the name, address, and phone number of the CRA that provided the consumer report. You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars. You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise national CRAs to which it has provided the data of any error.) The CRA must give you a written report of the investigation, and a copy of your report if the investigation results in any change. If the CRA s investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change. Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source. APPENDIX T

221 You can dispute inaccurate items with the source of the information. If you tell anyone such as a creditor who reports to a CRA that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you ve notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error. Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies. Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA usually to consider an application with a creditor, insurer, employer, landlord, or other business. Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission. You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely. You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court. APPENDIX T

222 The FCRA gives several different federal agencies authority to enforce the FCRA: For questions or concerns Regarding: CRAs, creditors and others not listed below National banks, federal branches/agencies of foreign banks (word National or initials N.A. appear in or after bank s name Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Savings associations and federally chartered savings banks (word Federal or initials F.S.B. appear in federal institution s name) Federal Credit Unions (words Federal Credit Union appear in institution s name) State-chartered banks that are not members of the Federal Reserve System Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Activities subject to the Packers and Stockyards Act, 1921 Please contact: Federal Trade Commission Consumer Response Center FCRA Washington, DC Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC Federal Reserve Board Division of Consumer & Community Affairs Washington, DC Office of Thrift Supervision Consumer Programs Washington, DC National Credit Union Administration 1775 Duke Street Alexandria, VA Federal Deposit Insurance Corporation Division of Compliance & Consumer Affairs Washington, DC FDIC Department of Transportation Office of Financial Management Washington, DC Department of Agriculture Office of Deputy Administrator GIPSA Washington, DC APPENDIX T

223 APPENDIX C Assessment of Job-Relatedness of Prior Criminal Convictions General Factors to consider: NOTE: CONVICTION OF A CRIME DOES NOT AUTOMATICALLY DISQUALIFY SOMEONE FROM WORKING AT UPHS. HIRING OFFICERS SHOULD CONSIDER ALL THE RELEVANT FACTS AND CIRCUMSTANCES IN DECIDING WHETHER OR NOT A PRIOR CONVICTION IS RELEVANT TO THE JOB. IN MOST CASES, HIRING OFFICERS SHOULD GIVE A CANDIDATE AN OPPORTUNITY TO TELL THEIR SIDE OF THE STORY BEFORE A DECISION IS MADE. HOWEVER, IN CERTAIN CASES, THE NATURE AND/OR TIMING OF THE UNDERLYING OFFENSE AND/OR CONVICTION ITSELF MAY MAKE FURTHER INQUIRIES UNNECCESSARY. FACTORS TO CONSIDER INCLUDE: Are you certain that a mistake has not been made and that the candidate is in fact the person about whom you have received a criminal conviction report? Are there any inaccuracies in the report? What were the specific acts committed that lead to the conviction? Is there more than one conviction? Is there evidence of recidivism (i.e., repeated offenses)? What were the surrounding circumstances? Was the candidate forthcoming about the prior conviction, or did he/she try to hide it? Did the candidate voluntarily and accurately reveal the presence of a conviction on his/her job application? Did the candidate s acts involve dishonesty or violence against persons or property? How old is the conviction? How old was the candidate at the time the offense was committed? What duties are involved in the current position? Is the conviction job-related? Does the position involve the use or possession of master keys? Does the position involve an element of trust? Is the position a high-visibility position? Does the position involve the handling of money or the handling or supervision of valuable assets? Does the position confer access to residence halls, dining halls, or other areas frequented by employees? Does the position confer access to offices and other work areas? Does the position involve contact with students? Does the position involve contact with the public? Is the position safety-sensitive in nature? Does the position involve the operation of a motor vehicle or heavy machinery? Does the position involve the care, use, or handling of dangerous substances, items, or instrumentality s? Does the position involve access to controlled substances? Was the person pardoned by the president or the governor? Has the person been rehabilitated? What is the person s prior and subsequent work history? Consider the overall societal interest in encouraging the employment of persons previously convicted of one or more criminal offenses but who have paid their debt to society. APPENDIX T

224 Specific Job Duties and Disqualifying Convictions (includes attempt, solicitation or conspiracy to commit any of the following offenses): Child-Care Services (automatic disqualification) Drug crimes (in last 5 years) Child abuse 18 Pa. C.S. Chapter 25 (relating to criminal homicide). 18 Pa.C.S (relating to aggravated assault). 18 Pa.C.S (relating to harassment and stalking). 18 Pa.C.S (relating to kidnapping). 18 Pa.C.S (relating to unlawful restraint). 18 Pa.C.S (relating to rape). 18 Pa.C.S (relating to statutory sexual assault). 18 Pa.C.S (relating to involuntary deviate sexual intercourse). 18 Pa.C.S (relating to sexual assault). 18 Pa.C.S (relating to aggravated indecent assault). 18 Pa.C.S (relating to indecent assault). 18 Pa.C.S (relating to indecent exposure). 18 Pa.C.S (relating to incest). 18 Pa.C.S (relating to concealing death of child). 18 Pa.C.S (relating to endangering welfare of children). 18 Pa.C.S (relating to dealing in infant children). A felony offense under 18 Pa.C.S. 5902(b) (relating to prostitution and related offenses). 18 Pa.C.S. 5903(c) or (d) (relating to obscene and other sexual materials and performances). 18 Pa.C.S (relating to corruption of minors). 18 Pa.C.S (relating to sexual abuse of children). Care of older adults (need to consider timing/job-relatedness * ) 18 Pa.C.S., Chapter 25 (relating to criminal homicide). 18 Pa.C.S (relating to aggravated assault). 18 Pa.C.S (relating to kidnapping). 18 Pa.C.S (relating to unlawful restraint). 18 Pa.C.S (relating to rape). 18 Pa.C.S (relating to statutory sexual assault). 18 Pa.C.S (relating to involuntary deviate sexual intercourse). 18 Pa.C.S (relating to sexual assault). 18 Pa.C.S (relating to aggravated indecent assault). 18 Pa.C.S (relating to indecent assault). * As of December 11, 2001, the constitutionality of the provisions of the Older Adults Protective Services Act whereby persons are automatically disqualified from working in an Older Adult Care Facility is in question. Care should be taken to consider all relevant facts and circumstances and the degree of job-relatedness before making a decision as to any individual employee or applicant for employment. APPENDIX T

225 18 Pa.C.S (relating to indecent exposure). 18 Pa.C.S (relating to arson and related offenses). 18 Pa.C.S (relating to burglary). 18 Pa.C.S (relating to robbery). A felony offense under 18 Pa.C.S. Chapter 39 (relating to theft and related offenses) or two or more misdemeanors under 18 Pa.C.S. Chapter Pa.C.S (relating to forgery). 18 Pa.C.S (relating to securing execution of documents by deception). 18 Pa.C.S (relating to incest). 18 Pa.C.S (relating to concealing death of child). 18 Pa.C.S (relating to endangering welfare of children). 18 Pa.C.S (relating to dealing in infant children). 18 Pa.C.S (relating to intimidation of witnesses or victims). 18 Pa.C.S (relating to retaliation against witness or victim). A felony offense under 18 Pa.C.S. 5902(b) (relating to prostitution and related offenses). 18 Pa.C.S. 5903(c) or (d) (relating to obscene and other sexual materials and performances). 18 Pa.C.S (relating to corruption of minors). 18 Pa.C.S (relating to sexual abuse of children). APPENDIX T

226 APPENDIX D st 1 Adverse Action Notice Letter (To be sent immediately to applicant or employee upon receipt of the third party report) [DATE] Dear [Name of Applicant]: As you authorized during the application process, the University of Pennsylvania Health System (UPHS) has recently obtained a pre-employment background check as part of your application review process. We are providing you with a copy of the report we have received and wish to inform you that there is information in the report, which would lead us to withdraw our conditional offer of employment. A copy of the report is enclosed. A summary of your rights under the law is enclosed. If you want to know what information in the report falls outside of UPHS hiring guidelines or if you want to provide us with any explanation or additional information, please contact [INSERT NAME, TITLE & TEL. # OF CONTACT] directly within four (4) business days from the date of this letter. If we do not hear from you within that time, we will assume that you no longer wish to pursue employment with UPHS. In addition to contacting us above, if you wish to dispute the accuracy or completeness of any of the information in the enclosed report, or if you wish to receive an additional free copy of the report, you have the right under the law to do so by contacting directly within 60 days the organization that provided the report to us. Contact information is provided in the report. Please note that chosen 3 rd party vendor did not and will not make any adverse decision and is not able to explain why any decision was or was not made by UPMC. Please be advised that the University of Pennsylvania Medical Center may make a final decision with respect to your application for employment at any time, so it is imperative that you contact us within four (4) business days of the date of this letter. Sincerely yours, Encls. Summary of Rights under the FCRA Form APPENDIX T

227 APPENDIX E nd 2 Adverse Action Notice (This form must promptly be filled out and sent to any applicant or employee as to whom any information from a CRA was used adversely to the applicant or employee.) [DATE] Dear [Name of Applicant]: The University of Pennsylvania Health System (UPHS) has decided to withdraw its conditional offer of employment previously extended to you. This decision was based in whole or in part on your consumer report, obtained by us with your written authorization. A copy of that report, a summary of your rights under the Fair Credit Reporting Act, and a form for contacting the company that provided the report to us were included in our letter to you on [insert date you provided the consumer report and summary of rights; attach a copy of signed authorization and summary of rights.] Your consumer report was provided to us by UPHS s chosen 3rd party vendor. Contact information is provided on the report. The above-listed consumer reporting agency did not make the decision not to hire you, and is unable to provide you the specific reasons why you were not hired. The law gives you the right to dispute the accuracy or completeness of any information provided by the consumer reporting agency and have the right to obtain a free consumer report from consumer reporting agency upon your request, within 60 days. Sincerely, Encls. Signed Authorization Summary of Rights under the FCRA APPENDIX T

228 APPENDIX F HUP/CPUP POSITIONS REQUIRING ACT 73 All Medical Residents The following positions in below listed departments: Nurse Practitioner, Physician Assistant, Registered Nurse*, Certified Registered Nurse Anesthetist, Lactation Consultant, Infant Delivery & Resuscitation Coordinator, Licensed Practical Nurse, Certified Nursing Assistant, Medical Assistant, Patient Care Tech, ED Tech, OR Tech, Unit Secretary, and Allied Health Therapists. HUP - Women s Health Division including PEEC - Perioperative Nursing - Staffing for All Seasons - Emergency Department - Penn Star - Radiation Oncology - Respiratory Therapy/Pulmonary Therapy - Radiology Ultrasound - Diagnostic Radiology - Interventional Radiology CPUP - Community Radiology - Dermatology - Family Practice - Neonatology - OB/GYN - Radiation Oncology - Medical Assistant Flex Pool - Medicine Cardiology - Medicine GI - Medicine Medical Genetics *Exception: Director level and above positions requiring an RN. APPENDIX T

229 APPENDIX F PAH POSITIONS REQUIRING ACT 73 All Medical Residents The following positions in below listed departments: Nurse Practitioner, Physician Assistant, Registered Nurse*, Certified Registered Nurse Anesthetist, Lactation Consultant, Licensed Practical Nurse, Certified Nursing Assistant, Medical Assistant, Patient Care Tech, ED Tech, OR Tech, Unit Secretary, and Allied Health Therapists, Cardiology EEG Techs, Anesthesia Techs PAH - Women s Health Division - Perioperative Nursing - Emergency Department - Respiratory Therapy/Pulmonary Therapy - Radiology Ultrasound - Diagnostic Radiology - Interventional Radiology - Orthopedics Department - Behavioral Health (Hall Mercer) - Behavioral Health (Millcreek) - Cardiology (EEG Techs only) *Exception: Director level and above positions requiring an RN. APPENDIX T

230 APPENDIX F PPMC POSITIONS REQUIRING ACT 73 All Medical Residents The following positions in below listed departments: Nurse Practitioner, Physician Assistant, Registered Nurse*, Certified Registered Nurse Anesthetist, Licensed Practical Nurse, Certified Nursing Assistant, Medical Assistant, Patient Care Tech, ED Tech, OR Tech, Unit Secretary, and Allied Health Therapists. PPMC - Perioperative Nursing - Emergency Department - Respiratory Therapy/Pulmonary Therapy - Radiology Ultrasound - Diagnostic Radiology - Interventional Radiology - Family Practice - RN Flex Pool *Exception: Director level and above positions requiring an RN. APPENDIX T

231 APPENDIX F HCHS POSITIONS REQUIRING ACT 73 The following positions in below listed departments: Lead Bereavement Coordinator, Bereavement Coordinator, Children s Bereavement Coordinator, Bereavement Assistant Coordinator, Hospice Volunteer HCHS - Children s Bereavement Department APPENDIX T

232 APPENDIX F CCA POSITIONS REQUIRING ACT 73 The following positions in below listed departments: CCA DEPARTMENTS C1255 WCHS Medical Director C2000 South Jersey Family Med PA C2125 Chestnut Hill Family Practice C2150 Concordville Medical Assoc C2300 Kennett Family Practice C2350 Newtown Square Family Practice C2425 Royersford Medical Associates C2450 University City Family Med C2500 West Chester Family Medicine C2575 Penn Med Assoc Cherry Hill PA C2600 Family Med PennMed atrittenhs C2625 Main Street Family Care PA C3275 Inpatient Physician Services C3300 Mayfair Family Practice C3800 Penn Speciality Care Main Str C4050 ElmwoodOB-GYN Associates C4100 Penn Care OB-GYN PA C4150 Penncare OB-GYN Midwifery C4200 Pinelands OB-GYN PA C4350 PennCare PAH Laborists Assoc C4425 PennCare for Women PA C5125 Penncare for Kids Phx C5130 Penncare for Kids Limerick C5225 Adolescent-Young Adult Assoc C9000 Emergency Room C9325 PennCare - Bucks County C9400 Transitional Unit at HUP N2000 South Jersey Family Med N2300 Penn Med Assoc Cherry Hill NJ N4000 Elmwood OB-GYN Associates N4200 Pinelands OB-GYN Associates N4425 PennCare for Women NJ POSITIONS CCA LPN Lead LPN LPN Peds RN Care Manager Lead RN PRN RN Birthing Suite PRN RN CRNP PT Nurse Practitioner PRN Nurse Practitioner RN Specialty Nurse Midwife Director Nurse Midwifery RN Birthing Suite PRN Nurse Midwife Nursing Supervisor Director Quality Improv CCA Cast Technician GI Tech RN Diabetes Nurse Educator RN Peds Perinatal Coordinator RN Nursing Coordinator Registered Dietitian Social Worker BSW X-Ray Technician Radiology Tech Echo Vascular Technologist Echo Cardiographer Sr Echo Cardiographer Phlebotomist Lead Phlebotomist PRN Phlebotomist Medical Technologist Lab Technologist Lead Medical Assistant Clinical Coordinator Medical Assistant I Medical Assistant II Medical Assistant III APPENDIX T

233 POSITIONS CCA (cont d) Patient Services Rep II PRN Medical Assistant Physician Assistant PRN Physician Internist Cardiologist Pediatrician Endocrinologist Oncologist Rheumatologist Other IM Specialist Family Practice Physician OBGYN Orthopaedic Surgeon Radiation Oncologist Medical Director Spec Proj Chief Medical Officer PMC Chief Medical Officer CCA Urologist Cardivascular Tech Med Asst Clinical Coordinator Medical Esthetician PRN Medical Esthetician Ped Research - Outpatient Co Nurse Midwife PT Mammography Tech Lab Technician Nursing Assistant Medical Assist Peds Physician Assistant PT Medical Coordinator APPENDIX T

234 Year I Comprehensive Exam As stated in the RT Education Program Handbook, students are required to take and successfully complete (score of 75% or better) a comprehensive curricular exam at the conclusion of the spring semester of year one. The exam consists of 100 questions covering radiography content taught in the following courses: Patient Care, Ethics, & Law Fundamentals of Radiologic Science & Healthcare Anatomy & Physiology I and II Radiographic Procedures & Image Analysis I and II Production & Characteristics of Radiation Medical Terminology The Year I Comprehensive Examination takes place in April of the first year. This is a computer based test, and all students will have two hours to complete the exam. The format will be similar to the ARRT examination in Radiography. See APPENDIX B - ARRT Content Specifications for the Examination in Radiography This examination will consist of 97 multiple choice questions and 3 multiple response questions (one per category). The content of this examination is as follows: I. Equipment Operation and Quality Control (15%) a. Principles of Radiation Physics (8 questions) b. Radiographic Equipment (7 questions) II. Radiographic Procedures (60%) a. Thorax (6 questions) b. Abdomen and GI Studies (9 questions) c. Urological Studies (4 questions) d. Spine and Pelvis (10 questions) e. Cranium (7 questions) f. Extremities (24 questions) III. Patient Care and Education (25%) a. Ethical and Legal Aspects (5 questions) b. Interpersonal Communication (3 questions) c. Infection Control (7 questions) d. Physical Assistance and Transfer (2 questions) e. Medical Emergencies (2 questions) f. Contrast Media (6 questions) Revised 6/19/12 1 APPENDIX U

235 Exam Purpose The purpose of this exam is to see where the student stands with their level of knowledge during the first year of the program. Any student who does not successfully pass this examination with a 75% or greater will be placed in an eight week remediation program and will receive guidance and tutoring from the instructor(s). The remediation program will be tailored to the student s particular area(s) of weakness. The student will meet on a weekly basis with the faculty member who taught the class in which the weakness was shown. The faculty member will create assignments and/or tests weekly to evaluate the student s progress. Student Responsibilities 1. Meet with the faculty member(s) as scheduled. 2. Complete all required assignments/tasks. 3. Prepare questions for any concepts not clearly understood prior to reexamination. At the conclusion of the remediation program, the student will be required to take a comparable exam to the initial examination and pass with a grade of 75% or greater in order to continue on in the program. Revised 6/19/12 2 APPENDIX U

236 Penn Medicine (HUP) Radiologic Technologist Educational Program READMISSION/TRANSFER POLICY Transfer from another radiography program: An applicant wishing to transfer from another radiography program must submit an application and all transcripts three months prior to the requested entering semester and will be considered if space is available. The transfer applicant will: be required to successfully complete the Penn Medicine HUP Transfer/Readmission Exam to be granted transfer of radiography academic and clinical courses completed. The purpose of the exam is to ensure placement in the program is at an academic/clinical level that will allow for the greatest opportunity for success. be eligible to test on radiography courses completed with an earned grade of C (75%) or better. receive transfer posting (designated by TR ) on transcript only for radiography courses deemed equivalent in content to the courses in the Penn Medicine HUP RT Education Program. complete radiography competency simulations as part of the Penn Medicine HUP Transfer/Readmission Exam be required to complete a minimum of 51% of the radiography courses while enrolled in the Penn Medicine HUP RT Education Program (Year 1 Summer Session, Year 2 Fall, Spring, and Summer Sessions) be required to have their transcripts evaluated by Widener s University College for transfer of college credits if applicable. complete all graduation requirements as follows: To be eligible to receive a graduation certificate from the RT Program, the student must complete: o All academic courses with a grade of C (75%) or better (from point of entry) o Clinical Education with a grade of C (75%) or better (from point of entry) o Successful completion of the Year I comprehensive exam with a grade of 75% or better o All required basic and terminal competencies. o Ten hours of community service o ACR Research Internship The program does not offer an early release option. Revised 8/10/15

237 ELIGIBILITY TO TAKE TRANSFER/READMISSION EXAMINATION TO ENTER/ RE- ENTER RT EDUCATION PROGRAM The purpose of the Transfer/Readmission Examination is two fold: First, to provide the program director and technologist faculty with the foundation upon which to base a decision concerning a student's application for readmission or transfer into the program. Second, it is designed to assure that a student's readmission or transfer into the program is at an academic/clinical level that will allow for the greatest opportunity for academic success. The Transfer/Readmission examination is administered to any internal readmission applicant or external transfer applicant who has interrupted progression through the radiography curriculum. Transfer Applicants Only: Applicants transferring from another program may only be eligible to take sections 1 2 determined by evaluation of coursework completed at former institution. The examination includes up to two written sections and two competency positioning sections covering Penn Medicine RT Education Program coursework for the Fall and Spring Semesters of the first year. Competency sections are only to be administered after successful completion of the corresponding written section. The sections must be completed in sequence (Section 1 and 1A must be taken before Section 2 and 2A). Readmission Applicants Only: Readmission applicants seeking to re enter the program may be eligible to take sections 1 5 determined by semester level completed at time of program interruption. Competency sections are only be administered after successful completion of the corresponding written section. The sections must be completed in sequence (Section 1 and 1A must be taken before Section 2 and 2A). WRITTEN EXAM SECTIONS: The individual written sections contain blocks of questions representing the specific course content of a particular semester. Exam Section 1 Fall Courses Year 1 Patient Care, Ethics & Law (50 questions) Fundamentals of Radiologic Science & Healthcare (25 questions) Anatomy & Physiology I (50 questions) Radiographic Procedures & Image Analysis I (75 questions) Medical Terminology (25 questions) Exam Section 2 Spring Courses Year 1 Anatomy & Physiology II (50 questions) Radiographic Procedures & Image Analysis II (75 questions) Production & Characteristics of Radiation (50 questions) Exam Section 3 Summer Courses Year 1* Radiographic Imaging, Equipment & Processing (75 questions) Exam Section 4 Fall Courses Year 2* Computed Tomography & Cross Sectional Anatomy (50 questions) Radiation Protection & Biology (50 questions) Advanced Radiographic Procedures (50 questions) Revised 8/10/15

238 Exam Section 5 Spring Courses Year 2* Radiographic Pathology (50 questions) Pharmacology & Drug Administration (25 questions) Computers & Digital Imaging in Radiology (50 questions) *Written Exam Sections 3-5 for readmission applicants only COMPETENCY EXAM SECTIONS: The individual competency positioning sections will require the student to demonstrate (in the lab setting) positioning for all competency examinations successfully completed during the corresponding clinical education courses or equivalent external courses, prior to exiting the program. Section 1A (Year 1 Fall Semester) Clinical Education I Section 2A (Year 1 Spring Semester) Clinical Education II Section 3A* (Year 1 Summer Semester) Clinical Education III Section 4A* (Year 2 Fall Semester) Clinical Education IV Section 5A* (Year 2 Spring Semester) Clinical Education V *Competency Exam Sections 3A-5A for readmission applicants only SCORING OF TRANSFER/READMISSION EXAM The individual sections of the Transfer/Readmission will be scored as a whole. Successful completion of an individual section will be recognized by achieving a minimum score of 75 percent. This applies to both the written and competency portions. If Section 1 is not successfully completed, the applicant will be considered as an entry level applicant according to the Program Admission Procedure outlined on the Program Website. Successful completion of Section 1 and 1A of the Transfer/Readmission Exam will allow the applicant to be admitted/readmitted into the Spring Semester of year 1. Successful completion of Sections 1, 1A, and 2, 2A of the Transfer/Readmission Exam will allow the applicant to be admitted/readmitted into the Summer Session between year 1 and 2. Readmission Applicants Only: Readmission applicants seeking to re enter the program in the second year may take sections 3 5 of the Transfer/Readmission Exam. Successful completion of Sections 1, 1A, 2, 2A, 3, 3A of the Transfer/Readmission Exam will allow the applicant to be readmitted into the Fall Semester of year 2. Successful completion of Sections 1, 1A, 2, 2A, 3, 3A, 4, 4A of the Transfer/Readmission Exam will allow the student to be readmitted into the Spring Semester of year 2. Successful completion of Sections 1, 1A, 2, 2A, 3, 3A, 4, 4A, 5, 5A of the Transfer/Readmission Exam will allow the student to be readmitted into the Summer Session of year 2. Revised 8/10/15

239 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 1 of 3 SUBJECT: EMPLOYEES WITH DISABILITIES Effective: POLICY It is the policy of the University of Pennsylvania Health System (UPHS) that no qualified individual with a disability shall, on the basis of the disability, be excluded from participation in UPHS programs and activities, and affirmative action shall be taken with regard to employment of qualified individuals with disabilities. PURPOSE The Americans with Disabilities Act (ADA) requires employers to reasonably accommodate qualified individuals with disabilities. UPHS will reasonably accommodate qualified individuals with a disability so that they can perform the essential functions of a job. UPHS complies with all federal and state laws concerning the employment of persons with disabilities. For purposes of this policy, the following definitions apply: A disability is defined as: - Any physical or mental impairment that substantially limits one or more major life activities; or - Having a record of such an impairment; or - Being regarded as having such an impairment A qualified individual with a disability means an individual as defined above, who is capable of performing the essential functions of a particular job with or without reasonable accommodations for his/her disability. Reasonable accommodations are determined on a case by case basis and may include, for example: - Making facilities used by staff readily accessible to and useable by individuals with disabilities. - The acquisition or modification of equipment or devices - The provision of qualified readers and interpreters - Modified work schedule - Restructured job responsibilities or reallocation of non-essential (marginal) job functions - The appropriate adjustment or modification of training materials or policies. Undue hardship means an action requiring significant difficulty or expense by UPHS. Essential functions of the job refers to those job activities that are determined by UPHS to be essential or core to performing the job; these functions cannot be modified. SCOPE This policy may apply, as specified, to all personnel (including employees, medical staff, and auxiliary healthcare providers) of the Hospital of the University of Pennsylvania (HUP), those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which practice at or in conjunction with HUP operating under its license, and UPHS Corporate departments. This policy also applies to those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g. HUP s inpatient rehabilitation facility. APPENDIX W

240 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 2 of 3 SUBJECT: EMPLOYEES WITH DISABILITIES Effective: IMPLEMENTATION Implementation of this policy is the responsibility of entity Senior Leadership, Department Directors/Business Administrators, Managers and Supervisors PROCEDURE A. Requesting Accommodations UPHS will reasonably accommodate a qualified individual with a disability, provided that the accommodation does not impose an undue hardship on UPHS. UPHS is not required to provide an accommodation that will have the effect of eliminating an essential function of the job. Reasonable accommodations will be provided only when an individual properly identifies him/herself as a qualified individual with a covered disability and provides the below documentation: - Employee Request for Reasonable Accommodation Form: The employee completes this form and submits this document immediately upon knowledge of need for accommodation to the Disability Management Department. - Medical Inquiry Form: This documentation is completed by the treating physician and should be returned to the Disability Management Department. Receipt of this form is critical to the timing of the review and response to employee s request for accommodation. An accommodation or service which is personal in nature, such as a hearing aid, a wheelchair, or a personal care attendant will not be provided by UPHS. B. Approving Accommodation Request The entity Chief Human Resources Officer or designee will review the Employee Request for Reasonable Accommodation with the department manager and other necessary management staff and engage in an informal, consultative process with the employee as necessary. The decision will be communicated in writing to the requesting employee. C. Funding for Accommodations If an accommodation is deemed appropriate and reasonable for an employee, then the department bears the initial responsibility for funding the accommodation. If the cost is beyond the means of the department, then higher levels in the department s reporting line should share the cost. D. Resolving Disagreements The entity Executive Director in conjunction with the Chief Human Resources Officer is responsible for ensuring that UPHS is compliant with its equal opportunity and non-discrimination obligations arising under federal, state, and local laws. In the event that an employee disagrees with the determination and/or proposed accommodation, he/she may contact the UPHS Director of Human Resources Risk Management. APPENDIX W

241 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 3 of 3 SUBJECT: EMPLOYEES WITH DISABILITIES Effective: E. Confidentiality All medical records that are related to requests for accommodations will remain confidential except that administrators, managers, and supervisors may be informed as part of the approval process and may be notified of any work restrictions or reasonable accommodations; clinical and safety personnel may be informed to the extent necessary to administer any emergency treatment; and government officials may be informed as they investigate/audit UPHS s compliance with the law. SUPERSEDES: ISSUED BY: Judy Schueler, Vice President, Organization Development and Chief Human Resources Officer ISSUED BY: Garry Scheib, Executive Director, Hospital of the University of Pennsylvania APPENDIX W

242 University of Pennsylvania Health System Employee Request for Reasonable Accommodation Form Employee Full Name: Position Title: Department: Employee Phone Number Cell Home: 1. What is your disability? 2. Is this a permanent condition? Yes No If No, provide expected duration From: to 3. Please describe the accommodations you are requesting. Please be as specific as possible. 4. What are the essential functions of your job and how will the requested accommodation(s) assist you in performing them? 5. Your Manager s Name 6. Name of Treating Physician (Physician Inquiry Form is required to support a request for reasonable accommodation.) Full Name: (print) Signature: Date: Your signature affirms that this information is true to the best of your knowledge. Please submit to Disability Management: UPHS Disability Management 3001 Market Street, Suite 320 Philadelphia, PA (215) Phone (215) Fax APPENDIX W

243 University of Pennsylvania Health System Physician Inquiry Form I. TO BE COMPLETED BY EMPLOYEE So that we may properly evaluate your request for reasonable accommodations for your disability, please have your treating physician complete this form and return it directly to the UPHS Disability Management Office. This form, and the information contained on it, will be kept separate from your personnel file and will remain confidential. I,, authorize my physician, or any other professional clinician who may share in my care, to release to the designated representative of the University of Pennsylvania Health System (UPHS) any and all information which shall be required with respect to my disability and the accommodations being requested. I understand that: 1) this authorization will expire on the day my employment at UPHS expires; 2) that I may revoke this authorization at any time, in writing, except to the extent that action has been taken in reliance on this authorization; 3) that my provider may not refuse to treat me if I refuse to sign this authorization; and 4) that once this information is disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient(s), and may no longer be protected by federal privacy regulations. I give this authorization voluntarily and with full understanding of its nature. Employee Full Name: (print) Entity: Department: Employee Signature: Date: II. To Be Completed By Treating Physician/Healthcare Provider 1. What is the covered disability for which accommodations are being requested? 2. What major life activity is significantly limited by the disability? Please describe the limitations. 3. Please explain how the employee s disability impacts his/her ability to perform the essential functions of his/her job at the University of Pennsylvania Health System. Page 1 of 2 APPENDIX W

244 Physician Inquiry Form Page 2 4. If the employee s disability prevents him/her from performing any of the essential functions of his/her position, please identify any accommodations that could be made to assist the employee in performing these functions. 5. Is there any additional information that you think is relevant to our evaluation of this employee s request for reasonable accommodations at UPHS? Physician Name( print): Physician Signature: License Number: State: Address: City: State: Zip Code: Phone Number: Please return this form directly to the UPHS Department of Disability Management: UPHS Disability Management 3001 Market Street, Suite 320 Philadelphia, PA (215) Phone (215) Fax Page 2 of 2 APPENDIX W

245 HUP Hospital of University of Pennsylvania RADIOLOGY Professional Image Page 1 of 3 POLICY April 2008 Update 12/17/2012 All members of the Radiology Department at the Hospital of the University of Pennsylvania shall carry out the University of Pennsylvania Health System mission: high-quality patient care and service, advancing medical science through research, and educating the next generation of leaders in medicine. In doing so, they shall present a professional image, including professional behavior and professional appearance to patients, their families and visitors as well as to colleagues. In interacting with patients, family members, visitors and colleagues, radiology staff will demonstrate the HUP Model of Excellence in Professional Practice to provide world-class patient care. PROCEDURE Professional Behavior Professional behavior shall portray radiology s commitment to provide competent and professional care as reflected in actions and attitudes to patients, families, and colleagues. In conjunction with the HUP Philosophy and the HUP Professional Service Standards, patients and their families will: Be able to identify their radiology staff who participates in patient care delivery, Receive care that is competent, courteous and compassionate, Be satisfied with the care they receive. Have the full attention of the staff. Radiology staff may not have/use cell phones or headphones in any patient care or public area. UPHS cell phones may be used for official business. In relationships with colleagues, radiology staff will: a. Accept responsibility for establishing and maintaining effective interpersonal relationships with co-workers and other members of the staff, b. Accept responsibility for enhancing their ability to deliver quality care and service to patients and their families, c. Accept responsibility for assuring patient and family satisfaction, d. Actively participate in the development of a healthy work environment, e. Provide positive feedback for a job well-done and constructive feedback in a non-threatening manner, f. Communicate ideas and concerns to the appropriate people, g. Communicate in a professional/respectable manner at all times in the patient care area.

246 HUP Hospital of University of Pennsylvania RADIOLOGY Professional Image Page 2 of 3 Professional Appearance Professional appearance shall project competency, inspire confidence, and communicate respect to patients and their families/visitors as well as to colleagues. Guidelines include: Wearing a clean, appropriately fitting standard uniform, Reception and technical aide wine color, Technical staff pewter color, Solid colored long or short sleeve t-shirts may be worn under scrub top, Solid colored acceptable/designated matching jacket may be worn over scrub top; Jackets are not to be tied around the waist. Two sets of scrub attire will be provided by the Hospital upon hire for technical staff, and Five sets of scrub attire will be provided by the Hospital upon hire for technical aide and reception staff. To be refreshed annually, Additional scrub uniforms will be available from uniform vendor via on-line ordering at the employee s expense, Scrub attire is to be neat, clean and worn daily, Shirts must have sleeves and be tucked in the waist, Hats or head coverings are not permitted unless they are work related, related to a medical condition or related to a religious belief, Sunglasses may not be worn inside the building unless medically necessary, Tattoos must not be visible. Foot Wear Shoes/low top sneakers are to be clean, low heeled with enclosed toes. Hair, Nails, Perfume Hair shall be clean and neatly kept. Long hair must be tied back, Men will shave daily or have neatly trimmed facial hair. Good grooming includes trimming hair in the nose, ears and eyebrows. Men will not have hair protruding from the shirt, Fingernails shall be kept clean and at a length that will ensure safe delivery of care. There shall be no artificial nails or nail enhancement as outlined in the hand hygiene policy in the Infection Control Manual, Strong perfumes/scents are not to be worn. Jewelry Jewelry shall be conservative, Jewelry is to be removed if it interferes with safe delivery of patient care.

247 HUP Hospital of University of Pennsylvania RADIOLOGY Professional Image Page 3 of 3 Identification/Name Tags Hospital identification is to be visible to patients, families, and colleagues and shall be worn at chest level at all times. Non-uniform professional attire, which is clean, neat and conservative, can be worn with a long white lab coat by designated radiology management staff in accordance with departmental guidelines Maternity Attire Maternity clothing should reflect the same style and level of professionalism your uniform exhibits at work. Please refrain from tight fitting garments. Unacceptable and / or inappropriate items include: Artificial Nails if providing patient care Visible tattoos Visible body piercing in the tongue, eyebrow, lips, etc. One set of post earrings may be worn in the earlobe. Extreme hairstyles or hair color. Fleece garments present a potential infection control issue and may not be worn. No items of clothing that display any logo or sports teams Large button pins are not allowed except for UPHS sponsored campaigns This list is not all-inclusive. The Administrative Director of Radiology or designee will reserve the right to determine appropriate dress.

248 University of Pennsylvania Health System POLICY MANUAL Number: Page 1 of 5 SUBJECT: UPHS Professionalism and Standards of Conduct Effective: 02/01/11 POLICY The University of Pennsylvania Health System ( UPHS or Health System ) is committed to treating all individuals, including patients, students, employees and staff with courtesy, respect and dignity. Consistent with that commitment, all UPHS employees, medical staff, and auxiliary health care providers must conduct themselves in a professional and collegial manner at all times. This policy defines inappropriate behavior and establishes a standard of conduct expected from all employees. PURPOSE The purpose of this policy is to promote a safe, collegial, and respectful environment, which is critical to optimal patient care. This policy also is intended to prevent and resolve conduct that may affect patient care by disrupting operations, by affecting the ability of health care providers and employees to do their jobs effectively, by creating a hostile or intimidating environment, or by adversely affecting the confidence in the organization s ability to provide optimal patient care. SCOPE This policy applies to all UPHS employees and is consistent among the UPHS entities. School of Medicine faculty members and non-employed auxiliary health care providers granted privileges or scope of practice at UPHS hospitals and/or in Clinical Practices of the University of Pennsylvania ( CPUP ) practices (hereinafter, Medical Staff ) are covered by the Disruptive Medical Staff policies of the various hospitals as discussed below. IMPLEMENTATION This policy shall be implemented by UPHS senior leadership, entity senior leadership and department management. PRINCIPLES OF RESPONSIBLE CONDUCT All UPHS personnel, including, e.g. UPHS employees, medical staff members, are expected to adhere to the following Principles of Responsible Conduct: Ethical and Responsible Conduct Personnel should conduct themselves ethically, with the highest integrity, in compliance with all applicable laws, regulations, and UPHS and University of Pennsylvania ( Penn or University ) policies, in all aspects of their work. They should be fair and principled in University and Health System business transactions and other related professional activities, acting in good faith when dealing with both internal constituents and external entities. Their conduct should always reflect their position of trust and loyalty with respect to University, the Health System, and members of these communities. APPENDIX Y

249 University of Pennsylvania Health System POLICY MANUAL Number: Page 2 of 5 SUBJECT: UPHS Professionalism and Standards of Conduct Effective: 02/01/11 Respect for Others in the Workplace Penn and UPHS recognize that people are the most important resource for achieving eminence in the areas of teaching, research, community service and patient care. Penn and UPHS value academic freedom, diversity and respect for one another. Penn and UPHS are committed to the principle of non-discrimination and do not tolerate conduct that constitutes unlawful harassment, including sexual, racial, ethnic, religious, or gender harassment. Avoidance of Conflict of Interest As more fully stated in Penn and UPHS conflict of interest policies. Penn and UPHS personnel should avoid conflicts of interest in their work. As a non-profit institution, it is imperative, for both legal and ethical reasons that University and Health System personnel do not improperly benefit from their positions of trust at Penn and UPHS. Financial conflicts must be appropriately disclosed in accordance with conflict of interest and conflict of commitment policies, so they can be reviewed, and as appropriate, managed or eliminated. UPHS personnel are responsible for identifying potential conflicts and seeking appropriate guidance. Responsible Conduct in Research As members of a complex research university, Penn and UPHS personnel have significant responsibility to ensure research is conducted with the highest integrity, and in compliance with federal, state, and local laws and regulations, as well as University and Health System policy. Responsible Stewardship and Use of Penn Property, Funds, and Technology Penn faculty, administration and staff are expected to ensure that Penn property, funds, and technology are used appropriately to benefit the institution, consistent with all legal requirements as well as University and Health System policies. Environment Health and Safety Penn and UPHS are committed to protecting the health and safety of the University and Health System communities and creating a safe working environment. To accomplish this end, Penn and UPHS provide training in health and safety regulation and policy. Penn and UPHS personnel are expected to comply with sound practices and legal requirements. Respect for Privacy and Confidentiality In their various roles and positions at Penn and UPHS, personnel may become aware of confidential information of many different types. Such information may relate to students, faculty, administration, staff, employees, alumni, donors, research sponsors, licensing partners, patients, and others. Penn and UPHS personnel are expected to inform themselves about applicable legal, contractual, and policy obligations to maintain the confidentiality of such information, to protect it from improper disclosure and to protect the privacy interests of our community. Appropriate Conduct with Respect to Gifts, Travel, and Entertainment Penn faculty, administration and staff are expected to conduct themselves so as to ensure that their positions are not misused for private gain, with respect to acceptance of gifts and the undertaking of university-related travel and entertainment. APPENDIX Y

250 University of Pennsylvania Health System POLICY MANUAL Number: Page 3 of 5 SUBJECT: UPHS Professionalism and Standards of Conduct Effective: 02/01/11 Appropriate Use of University Name and Logos Penn and UPHS regulate the use of their names, shield, and related trademarks and logos in order to protect the University s and Health System s reputation, and to ensure that their use is related to the University s and Health System s educational, research, community service, and patient care missions. Penn and UPHS personnel are expected to protect the University s and Health System s name and logos from improper use. Responsible Reporting of Suspected Violations and Institutional Response Penn and UPHS personnel are expected to report suspected material violations of University and Health System policies, as well as violations of application laws and regulation, to appropriate offices, as set forth in various policies. Penn and UPHS personnel may be subject to discipline in accordance with the various policies. INAPPROPRIATE AND DISRUPTIVE BEHAVIOR IN THE WORKPLACE UPHS does not tolerate behavior that leads to the disruption of patient care and/or creates a hostile work environment. In accordance with the UPHS Performance Improvement and Progressive Steps Policy, any violators of this policy may be subject to corrective action up to and including termination of employment. PROCESS Any employee may bring a complaint alleging inappropriate behavior against another employee, faculty, house officer or medical staff member. Inappropriate behavior may include: Physical violence, or actual threat thereof; Behavior that violates pertinent policies pertaining to prohibited discrimination and harassment; Unprofessional verbal or physical language or conduct that may or may not potentially jeopardize patient safety or disrupt patient care; Verbal abuse or physical harassment of non-constructive criticism is intended to intimidate, undermine confidence, belittle, or imply stupidity or incompetence; and Refusal to perform duties or assignments reasonably expected. An individual may bring a complaint in any of the following ways: Complaints may be brought to the individual s supervisor or manager. Complaints may also be brought to the individual s entity Human Resources Department. Complaints involving a house officer may be brought to the program director or the Office of Graduate Medical Education. If brought to Human Resources, they will be referred to the program director. APPENDIX Y

251 University of Pennsylvania Health System POLICY MANUAL Number: Page 4 of 5 SUBJECT: UPHS Professionalism and Standards of Conduct Effective: 02/01/11 Complaints involving a medical staff member (faculty or non-employed auxiliary health care provider) should be brought to the department chair, medical director, or the hospital s Professionalism Committee for handling in accordance with the hospital s Disruptive Medical Staff Policy. If brought to Human Resources, such complaints will be referred to the department chair, medical director, or the hospital s Professionalism Committee for handling in accordance with the Disruptive Medical Staff Policy. The Penn Occurrence and Reporting and Tracking System ( PORTS ), UPHS s web-based incident reporting system, also is available online and complaints can be entered into PORTS. However, not all PORTS complaints can or will be investigated, unless sufficient detail is evident or provided in the complaint itself. Employees are strongly encouraged to use one of the alternative reporting opportunities listed above when raising an alleged violation of this policy. CONDITIONS FOR IMMEDIATE TERMINATION OF EMPLOYMENT Employees violating standards and/or work rules that jeopardize the safety of patients or staff; create a hostile or intimidating work environment; and/or adversely affect confidence in the organization s ability to provide optimal care may be subject to immediate termination. As per the UPHS Performance Improvement and Progressive Step policy, examples of violations that would result in immediate termination in the event of a single occurrence include: Unreported absence from work for three consecutive work shifts (job abandonment); Failure to report to work after expiration of authorized leave of absence; Smoking inside hospital buildings; Intentional misrepresentation or falsification of clinical or other information or UPHS record; Fighting or disorderly conduct; Possession of a weapon, firearm or explosive on UPHS property (including parking lot or other exterior UPHS property); Unauthorized possession of property belonging to Penn Medicine, or another employee, patient or visitor; Sleeping on the job; Unprofessional verbal or physical conduct potentially jeopardizing patient safety or disrupting patient care; Verbal and/or physical abusive behavior that violates pertinent policies pertaining to prohibited acts of discrimination, harassment and/or retaliation; Any act intended to deceive an employee, patient or visitor; Inappropriate access, release and/or disclosure of personal health information (PHI). This includes but is not limited to lost or stolen PHI information from laptop or PDA; faxing personal health information without first confirming security of receive site; sharing of PHI with coworkers, friends who are not authorized to receive the information. Unauthorized use or possession of a drug or alcohol on UPHS property; Failure to perform job duties as a result of drug or alcohol consumption*; Action or inaction that may create a life-threatening situation or that threatens the safety or well being of a patient, employee or visitor. APPENDIX Y

252 University of Pennsylvania Health System POLICY MANUAL Number: Page 5 of 5 SUBJECT: UPHS Professionalism and Standards of Conduct Effective: 02/01/11 *The Chief Human Resource Officer at the entity level may attempt to resolve the fit for duty violation by way of accommodation (if appropriate, in the case of disability) or refer case for independent review as per the guidelines of this policy. The above list of examples is intended for illustrative purposes only and is not exhaustive. INVESTIGATION OF COMPLAINT Investigation of a complaint concerning employees not covered by the hospitals Disruptive Medical Staff Policy will be conducted by the Office of Human Resources at the entity level. Any corrective action will be administered under the UPHS Progressive Action Policy. CONDITIONS FOR INDEPENDENT REVIEW The Executive Director at the entity level may seek an independent review of an investigation when the situation potentially jeopardizes the safety of patients/employees and/or adversely affects public confidence in the organization s ability to provide optimal care. An independent review is required if a terminable action has occurred and mitigating circumstances exist that support a disciplinary sanction other than termination. The independent review is coordinated through the Office of the Vice President, Human Resources at the corporate level in collaboration with other resources including Corporate Compliance and the Office of General Counsel. ACTION STEPS REQUIRED IN SITUATIONS THAT WARRANT IMMEDIATE TERMINATION In the event of an employee termination, HR in collaboration with Security, will ensure the following actions are taken to further safeguard the organization and the patients and staff it serves. Terminated employees immediately surrender keys and identification badge; Security immediately disables identification badge; IT Security stops terminated employee s access to all information system applications and VPN access; HR processes involuntary termination with a Do Not Rehire designation; and Notification and/or cooperation with law enforcement agencies when a violation also includes an unlawful act. ISSUED BY: SUPERSEDES: Judy Schueler, Vice President Organizational Development and Chief Human Resources Officer APPENDIX Y

253 Hospital of the University of Pennsylvania POLICY MANUAL Number: Page: Page 1 of 2 SUBJECT: SMOKE FREE ENVIRONMENT Effective: 12/1/05 POLICY The Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) seek to provide a safe environment for patients, staff, and visitors through the establishment of a smoke free environment. No smoking is allowed in any of HUP s buildings including areas in the Penn Tower Hotel occupied by HUP/CPUP or in any other HUP/CPUP clinical space (for example, those at 3710, 3634, or 3535 Market Street) by UPHS employees or visitors. Smoking is not permitted in exterior areas which are within 50 feet of an entrance to a building and 50 feet from the entrance to the ambulance bay. Employees who work in leased space can only smoke in areas designated by the landlord as a smoking area. PURPOSE The purpose of this policy is to protect against the known hazards of smoking and to promote the concept of health by creating a smoke-free environment for patients, visitors, employees, physicians, and all other persons who come to HUP and the CPUP/HUP facilities of Penn Tower. SCOPE This policy applies to all employees of HUP/CPUP/Shared Services. IMPLEMENTATION Implementation for HUP/CPUP/Shared Services employees is the responsibility of HUP/CPUP/Shared Services Management. In addition, each Department Director and Chairman is responsible for compliance in his/ her areas of responsibility. Security Department personnel have primary responsibility to promote compliance in common areas of HUP and Penn Tower, but it is ultimately up to each employee to promote a smoke-free environment. PROCEDURE 1. Smoking is permitted in the following areas: Outside provided it is at least 50 feet from an entrance including ambulance bay. In designated area of the Rhoades Courtyard. (Smoking is not permitted in Miller Plaza) In exterior areas of the University of Pennsylvania campus and along the exterior perimeter of the Hospital as long as it occurs at least 50 feet from an entrance and access to the Hospital s premises and facilities is not inhibited by smokers, and there are no posted NO SMOKING signs. APPENDIX Z

254 Hospital of the University of Pennsylvania POLICY MANUAL Number: Page: Page 2 of 2 SUBJECT: SMOKE FREE ENVIRONMENT Effective: 12/1/05 2. Smokers are expected to dispose of cigarette butts in appropriate containers and not litter the streets and sidewalks. 3. Employees who fail to comply with this policy will be subject to disciplinary action as outlined below: a) Smoking inside any of the HUP buildings/rooftops, Penn Tower Hotel, or in any other HUP/CPUP clinical space (for example, those at 3710, 3624, or 3535 Market Street) will result in disciplinary action up to and including discharge. b) Smoking outside of the hospital and within 50 feet of an entrance will result in staff receiving a Smoking Violation Warning from a Security Officer. Employees should consider this a Coaching and immediately follow the guidelines found in this policy. c) An employee receiving two Smoking Violation Warning forms will be subject to a Department Written Warning. Managers will receive a copy of the second Warning notice from Security and be expected to issue a Department Written Warning. d) An employee receiving a third Smoking Violation Warning form will be subject to an Official Written Warning. The employee s manager and administrator will receive a copy of the third Warning notice. The manager will be expected to issue an Official Written Warning. e) An employee receiving a fourth Smoking Violation Warning form will be subject to a Suspension. The manager and administrator will receive a copy of the fourth Warning notice. The manager will issue the Suspension to the employee. f) An employee receiving an additional Smoking Violation Warning will be subject to termination of employment. The manager and administrator will receive a copy of this final warning notice. The manager will issue the termination of employment notice. 4. Employees should refer to Admin istrative Policy Policy for a Smoke Free Environment for procedures regarding patients, visitors, vendors, physicians, or others who come to the HUP/CPUP facilities. The sale of all tobacco products, matches, disposable lighters, and lighter fluid is prohibited. SUPERSEDES: ISSUED BY: Christine M. Lynch Vice President, Human Resources APPENDIX Z

255 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 1 of 3 SUBJECT: PHOTO IDENTIFICATION BADGES Effective: 09/24/06 A. POLICY SUMMARY All employees, faculty, students, and other individuals regularly conducting business in HUP/CPUP/Shared Services will wear a clearly visible HUP/CPUP/Shared Services photo identification at all times when on HUP/CPUP/Shared Services property. B. PURPOSE The purpose of this policy is to ensure the clear identification of HUP/CPUP/Shared Services personnel to patients and others, including security personnel. C. SCOPE This policy applies to all employees of HUP/CPUP/Shared Services, all employees of other University of Pennsylvania Health System (UPHS) entities, all employees of the University of Pennsylvania, contracted employees working on HUP/CPUP/Shared Services properties, and students. D. RESPONSIBILITY FOR IMPLEMENTATION Implementation and compliance of this policy are the responsibility of the entity senior leadership, department directors/business administrators, managers, and supervisors. E. POLICY All employees, faculty, students, and other individuals regularly conducting business in HUP/CPUP/Shared Services will wear a clearly visible HUP/CPUP/Shared Services photo identification at all times when on HUP/CPUP/Shared Services property. Anyone refusing to wear their photo identification badge may be subject to disciplinary action and removal from the premises. The photo identification badge may not be defaced, pierced, or visually obstructed in any manner. Unauthorized stickers, pins or other items may not be affixed to the photo identification badge. The photo identification badge must be used solely by the individual to whom it was issued. Under no circumstances may it be transferred to, or used by, another individual. E1. Buddy Punching Buddy punching is defined as an employee card punching or identification swiping in and/or out for another employee. Card punching or identification swiping in and/or out for another person constitutes falsification of records and is subject to disciplinary action, up to and including, termination of employment. APPENDIX AA

256 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 2 of 3 SUBJECT: PHOTO IDENTIFICATION BADGES Effective: 09/24/06 F. PROCEDURE F1. Photo Identification Badge Appearance The photo identification badge is to be worn above the waist and be visible to onlookers. In addition to the employee's name and department, photo identification badges will include the employee s position and academic, licensure, or certification information as defined by the Department Director/Business Administrator. F2. Photo Identification Badge Issuance Permanent photo identification badges will be issued by the Security Office after new employees have been cleared through Occupational Health to begin work. Photo identification badges will be reissued to employees who have changed departments, have official name changes, or have worn/tattered badges. F3. Lost or Stolen Photo Identification Badges Lost or stolen identification badges are to be immediately reported to the department manager/supervisor or business administrator, and the Security Office. If the identification badge remains missing for 48 hours, a new badge must be purchased from the Security Office. Employees who lose their photo identification badges must purchase new ones from Security at a cost of $5.00. F4. Found Photo Identification Badges In the event that an identification badge is found, it is to be immediately reported to the Security Office. F5. Types of Identification Required of Other Persons Working in HUP/CPUP/Shared Services F5a. Physicians, Employees of Other UPHS entities, Employees of the University of Pennsylvania, Medical, Nursing and Other Students Physicians, employees of the University of Pennsylvania who regularly work in HUP/CPUP/Shared Services, medical, nursing and other students, must all wear photo identification badges to be supplied by HUP and issued by Security. F5b. House Staff House Officers must wear photo identification badges supplied by HUP/CPUP/Shared Services and issued by Security. F5c. Volunteers Volunteers must wear photo identification badges supplied by HUP/CPUP/Shared Services and issued by Security. APPENDIX AA

257 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 3 of 3 SUBJECT: PHOTO IDENTIFICATION BADGES Effective: 09/24/06 F5d. Private Duty Nurse Private duty nurses who frequently work at HUP/CPUP/Shared Services must wear photo identification badges supplied by HUP/CPUP/Shared Services and issued by Security. F5e. Salespeople Salespeople must secure temporary identification badges from the Security Office. Please see Policy No , Vendor Visitation/Management. F5f. Contractors and Service Personnel Contractors and service personnel must wear clearly visible temporary identification badges issued by Security. F5g. Temporary Workers from Agencies, Work-Study Students, and Other Special Temporary Workers Temporary workers from agencies, work-study students and other special temporary workers must wear clearly visible temporary identification badges issued by Security, or photo identification provided by the agency. Cross reference policy: Vendor Visitation/Management # Any questions regarding this policy may be referred to the Human Resources Department or the Director of Security. SUPERSEDES: Policy No Effective date 01/01/01 ISSUED BY: Christine M. Lynch Vice President, Human Resources APPENDIX AA

258 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: EMPLOYEES WITH COMMUNICABLE DISEASES Number: Page: 1 of 2 Effective: 01/01/01 POLICY If an employee believes or suspects that he or she has a communicable disease which can be transmitted to patients or coworkers during the routine performance of his or her duties, the employee should report to Occupational Medicine (OM) so that fitness for duty can be determined and the condition cared for in an appropriate manner. Or, if the supervisor of the employee believes an employee has a communicable disease which can be transmitted to patients or coworkers during the routine performance of his or her duties, he or she should initiate the process by referring the employee to OM. PURPOSE The purpose of this policy is to provide an environment that protects the health and safety of patients and staff as far as possible. SCOPE This policy applies to all employees of HUP/CPUP/Shared Services and to all other individuals who provide services within the HUP/CPUP/Shared Services premises. IMPLEMENTATION Implementation of this policy is the responsibility of all employees of HUP/CPUP/Shared Services and all other individuals who provide services on the HUP/CPUP/Shared Services premises. PROCEDURE 1. If an employee believes or suspects he or she has a communicable disease which can be transmitted to patients or coworkers during the routine performance of his or her duties, the employee shall report to OM in accordance with Policy #2-3-03, Occupational Medicine - Employee Access. If the supervisor believes an employee has a communicable disease which can be transmitted to patients or coworkers during the routine performance of his or her duties, a referral to OM shall be made, in accordance with Policy #2-3-03, Occupational Medicine - Employee Access. Referral to OM shall also occur whenever an employee may be mentally or physically incapable of performing his or her duties as the result of a communicable disease. 2. OM will evaluate the employee to determine a) his or her physical and mental ability to perform essential job functions; b) the risk(s) potentially posed to patients and coworkers; c) the risk(s) potentially posed to the employee him or herself. In making these determinations, OM will seek consultation from the Infection Control Section and/or other sources, as appropriate. 3. OM and the appropriate responsible administrators will determine the employee s fitness for duty. 4. If OM determines that an infected employee may represent a potential risk to patients and/or coworkers, this information will be communicated to the Hospital Epidemiologist for appropriate action. APPENDIX BB

259 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: EMPLOYEES WITH COMMUNICABLE DISEASES Number: Page: 2 of 2 Effective: 01/01/01 5. OM will determine whether medical follow-up is necessary, and, if so, with what frequency it shall occur. 6. Absences from work will be handled in accordance with HUP/CPUP/Shared Services policies. Please see Policy #2-2-10, Sick Time Policy, #2-3-03, Employee Access, #2-5-08, Absence Control, and #2-6-07, Leaves of Absence for further information. 7. As appropriate, employees can take advantage of counseling offered by OM, Human Resources, and/or other sources regarding health and disability benefits, financial planning, reasonable work accommodations, and other issues which arise from an illness. 8. Information regarding the employee's evaluation at OM shall be kept confidential, except to the extent that such confidentiality conflicts with this policy or prevents appropriate treatment of the employee or is needed to protect other employees, patients and visitors, or as required by law. Any questions regarding this policy should be referred to Human Resources. SUPERSEDES: 01/01/98 ISSUED BY: Christine M. Lynch Associate Vice President, Human Resources APPENDIX BB

260 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 1 of 16 Effective: 07/01/04 POLICY Employees of HUP/CPUP/Shared Services are a very valuable resource and their health and safety is of utmost concern. HUP/CPUP/Shared Services is committed to establishing and maintaining a safe and healthy environment for employees, patients and visitors. HUP/CPUP/Shared Services, in accordance with this policy, will encourage employees to selfidentify their current chemical dependency or inappropriate use of alcohol, assist them in seeking appropriate treatment, and facilitate reentry into the workplace when appropriate. HUP/CPUP/Shared Services will also impose appropriate discipline, up to and including termination of employment, in cases involving theft, diversion, or abuse of prescription drugs or other violations of this policy. PURPOSE The purpose of this policy is to ensure safe and competent job performance provided by HUP/CPUP/Shared Services employees through the identification of chemical dependency or inappropriate use of alcohol or drugs. In addition, a process is outlined for entering and completing treatment, as well as monitoring a return to work program. This policy applies to all employees who have completed three months of service of HUP/CPUP/Shared Services. The return to work/after care section of this policy does not apply to employees with less than three months of service (See section E and F). University payroll employees are governed by the University's Employee Assistance Program Services and Referrals. House Staff employees are governed by the Substance Abuse Policy for House Staff. PROCEDURE A. ON THE JOB USE, POSSESSION, THEFT, PURCHASE OR SALE OF DRUGS OR ALCOHOL 1. Alcohol Being under the influence of alcohol or in possession of alcohol while performing UPMC business or while on the campus of any Health System facility is prohibited. Under no circumstances may any employee consume alcoholic beverages during working hours or be under the influence before starting work. 2. Illegal Drugs Consistent with existing state and federal laws, the use, sale, purchase, transfer or possession of an illegal drug by any employee is prohibited. The presence in any detectable amount of any illegal drug or possession of any illegal drug by an employee while in the course of employment, while on leave of absence, or while in any Health System facility is prohibited. APPENDIX CC

261 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 2 of 16 Effective: 07/01/04 3. Prescription/Over the Counter Medications An employee is required to notify immediately the appropriate supervisor/manager when reporting for duty or in the course of his or her shift if the use of any medications is having an adverse affect or may have an adverse affect on his or her ability to perform job functions (e.g., drowsiness, memory alterations) or if the use of any medications is compromising or may compromise the safety of the employee or others. The supervisor/manager may then notify Occupational Medicine or, if the presentation is after hours, the Emergency Department if he or she reasonably believes that medical intervention is warranted. A supervisor must fill out the appropriate referral form (see Appendix C) Alternatively, the employee may notify Occupational Medicine or the Emergency Department directly. Occupational Medicine or the Emergency Department will then determine if the use of any medications is having, or is likely to have, an adverse affect on the employee s ability to perform safely his or her job functions, or if the use of medications is compromising, or is likely to compromise, the safety of the employee or others. In the event of a determination of adverse affect on job performance or compromised safety, Occupational Medicine or the Emergency Department will, if appropriate, work with the employee and/or the employee s healthcare provider to reduce or eliminate any adverse effect on job performance or threat to safety by making recommendations or proposing work-related restrictions that would allow the employee to perform his or her essential job duties safely and effectively. During this process, Occupational Medicine and/or the Emergency Department may consult with the employee s supervisor or a Human Resources Generalist, as appropriate. Before any employee who has previously been determined to be experiencing an adverse effect on job performance, or compromised work safety due to the use of medications, returns to work, Occupational Medicine or the Emergency Department must first grant the employee written clearance to return to work, with or without duty restrictions or other job-related recommendations. 4. Drug Diversion Consistent with existing state and federal laws and this policy, diversion of drugs, which may include record falsifications, theft of controlled substances, and/or drug substitution, is prohibited and may result in disciplinary action up to and including immediate termination and reporting to licensing and credentialing agencies when appropriate. APPENDIX CC

262 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 3 of 16 Effective: 07/01/04 5. Self Identification a. Self identification is defined as the voluntary disclosure by an employee of his or her current drug or alcohol abuse under circumstances where the employee is not currently under suspicion of or under investigation for possible violation of this or any other policy or of any law, rule or regulation (either internally or externally) b. Employees who disclose a drug or alcohol problem after coming under suspicion or investigation for possible violation of this or any other policy or of any rule, rule or regulation (either internally or externally), will not be considered to have properly self-identified and may be subjected to disciplinary action up to and including termination. c. Employees who self identify to their supervisors or other UPMC management for current use of alcohol/drugs or chemical dependency will be escorted with a supervisor to Occupational Medicine for toxicology testing. A supervisor should contact a Human Resources Generalist. The employee will also be referred to the Employee Assistance Program (EAP) by the Human Resources Generalist as a mandatory referral. EAP will be responsible for notifying an Human Resources Generalist within two business days if the employee complied by making an appointment. With a sign of release (see appendix F) an Human Resources Generalist will be notified by the EAP if the employee attends or does not attend the appointment. The employee will be eligible for leave under the terms of the applicable leave of absence policy, and will be subject to a Return to Work Agreement (see Appendix A and B). d. Self-identification will not shield an employee from possible disciplinary action for otherwise violating this or any other UPMC Policy, but will be taken into account in determining the appropriate level of discipline. B. INVOLVEMENT OF LAW ENFORCEMENT AGENCIES/LICENSING AGENCIES The use, sale, purchase, transfer, theft, or possession of an illegal drug is a violation of the law. Upon legal advice, Security will refer such illegal drug activities to law enforcement. Licensing and credentialing agencies will be notified when appropriate. C. REQUESTING A TOXICOLOGY SCREEN AND MEDICAL ASSESSMENT 1. Procedure to be followed by a supervisor, in house, who suspects an employee is currently using or under the influence of alcohol and/or drugs: APPENDIX CC

263 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 4 of 16 Effective: 07/01/04 a. If a supervisor reasonably suspects based on physical symptoms, reported or observed behaviors, or other available evidence or information, that an employee is currently using or under the influence of illegal drugs, is abusing prescription or over-the-counter medications, is currently under the influence of alcohol, or is otherwise impaired to an extent that reasonably calls into question the employee s ability to safely or competently perform the duties of his or her job, then a supervisor should immediately contact a Human Resources Generalist and inform the employee that a toxicology screen and medical assessment is being requested. A supervisor should immediately escort the employee to Occupational Medicine (or, if closed, the Emergency Department). A toxicology screen will be requested and conducted at that time (see paragraph 3, below). If needed, a supervisor should call another supervisor or manager to assist in escorting the employee to the Occupational Medicine Department or the Emergency Department and to stay with the employee. Under no circumstances is the employee to be left alone, either pending an evaluation or awaiting testing or transportation. A supervisor must stay with employee until specimens are obtained, medical assessment is completed, and the employee is discharged from Occupational Medicine or the Emergency Department b. A supervisor is to complete a "Referral for Medical Evaluation" Form (Appendix C) and document observations that lead the supervisor to believe the employee is currently using or under the influence of drugs or alcohol on Fitness for Duty Observation Form (Appendix E). A supervisor is to bring both Forms with them to Occupational Medicine or the Emergency Department. c. Managers, supervisors and the Occupational Medicine or Emergency Department staff should not use force in seeking compliance with requests for a toxicology screen. The signing of any forms is strictly voluntary on the part of the employee. 2. Procedures to be followed by Occupational Medicine or the Emergency Department when suspecting that an employee is currently using and/or chemically dependent: a. Without a referral by a supervisor for evaluation of current use and/or chemical dependency, a medical provider in Occupational Medicine or the Emergency Department may refer an employee to be evaluated for chemical dependency and/or current use of drug/alcohol by requesting a toxicology screen under the following conditions: 1. If an employee is working and is being evaluated for an injury/illness. 2. If an employee is not working but is being evaluated to return to work. APPENDIX CC

264 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 5 of 16 Effective: 07/01/04 If there is a positive toxicology screen, Occupational Medicine is to notify the employee's supervisor and a Human Resources Generalist so that their responsibilities can be carried out as defined in this policy. b. If an employee is not working and is attending a follow-up appointment in Occupational Medicine, the medical provider in Occupational Medicine may refer the employee to the EAP for evaluation of current use and/or chemical dependency. 3. Toxicology Screening a. Upon arrival to Occupational Medicine or the Emergency Department, a medical assessment, blood tests, urinalysis, and alcohol/drug screening, consistent with the then current protocol maintained by Occupational Medicine, will be required of those employees suspected of using or being under the influence of alcohol and/or drugs. All toxicology tests will be processed under a confidential code to protect the identity of the employee. b. The employee must promptly sign an Agreement to Submit to Toxicology Screen by Blood or Urine Tests if they agree to be assessed (see Appendix D). If the employee refuses to be tested, it will be assumed that he or she is impaired and the employee will not be permitted to return to work. The supervisor will make arrangements for transportation. In addition the employee will be told by a supervisor that appropriate disciplinary action may be taken, up to and including termination. c. Any attempt by the employee to delay, hinder, or tamper with any tests, or to alter the results of any toxicology screen, or the failure to cooperate fully with any medical assessment under this policy, will be considered a refusal to be tested. It will be assumed the he or she is impaired and the employee will not be permitted to return to work. Arrangements will be made for transportation by a supervisor. In addition the employee will be told by a supervisor that appropriate disciplinary action may be taken, up to and including termination. d. The employee and a supervisor will remain in Occupational Medicine or, if closed, the Emergency Department until specimens are obtained and provider evaluation is complete. Based on OM evaluation, if immediate detoxification or psychiatric admission is needed, either the employee will be sent to Psychiatric Emergency Evaluation Center (PEEC) or an immediate referral to EAP will be made. If findings do not warrant immediate intervention a supervisor will arrange for transportation home. The results of the toxicology screen will be reported to the employee s manager or supervisor the day after testing. In some cases this may be delayed until 48 hours after testing. The employee will be given written discharge instructions to contact OM the next morning to confirm the date and time of their follow-up appointment. The employee will remain out of work pending test results. APPENDIX CC

265 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 6 of 16 Effective: 07/01/04 e. In cases where the employee has properly self-identified (as defined in this policy) and there is a positive screen (defined as the presence of an illicit drug, alcohol, or a prescribed or over the counter medication that adversely affects the employee s ability to perform job functions), Occupational Medicine or the Emergency Department should call the EAP or PEEC. If the examining physician determines the employee requires inpatient detoxification or psychiatric admission, the EAP will assist in arranging admission through the employee's health plan. In addition, a supervisor should contact Human Resources and appropriate disciplinary action should be considered. f. In cases where the employee did not self-identify (as defined by this policy) and there is a positive screen for illegal drugs or alcohol (defined as the presence of an illicit drug or alcohol in any detectable amount), a supervisor should consult with an Human Resources Generalist regarding appropriate disciplinary action, up to and including termination of employment. g. For cases not requiring inpatient admission, an Human Resources Generalist should contact the EAP immediately so that an appointment can be scheduled within two business days. h. In cases where there is a positive screen for a prescribed or over-the-counter medication in an amount that exceeds prescribed or recommended dosages or that interacts adversely with other medications or substances in a manner that adversely affects the employee s ability to perform job functions, the Occupational Medicine or Emergency Department physician should consult with a Human Resources Generalist and, where appropriate, with a supervisor or manager, to determine if there is some reasonable accommodation that would allow the employee to return to work without posing a substantial risk of harm to him/herself, patients, co-workers, or others in the workplace. In no case should an employee be allowed to return to work if that employee poses a substantial risk of harm to him/herself, patients, co-workers, or others in the workplace. D. INTERVENTION AND TREATMENT Assessment a. In the event of a positive test result, the Department Head, Human Resource Generalist and a Supervisor will meet to discuss the incident and develop a plan. b. Employees whose toxicology screens are positive must become involved in a treatment and rehabilitation program or will be disciplined up to and including termination. APPENDIX CC

266 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 7 of 16 Effective: 07/01/04 c. In accordance with the rules and regulations of the Commonwealth of Pennsylvania Bureau of Professional and Occupational Affairs, all licensed employees who are impaired will be reported to the appropriate Case Manger at the Pennsylvania Voluntary Recovery Program by a supervisor in coordination with Human Resources Generalist. Employees in the Voluntary Recovery Program must be approved by the state for return to work before consideration of reentry into the workplace. [In addition, certain additional conditions and restrictions may be imposed on employees re-entering the workplace in order to ensure safety and to prevent or minimize the risk of relapse]. d. In the interest of maximizing confidentiality, including positive diagnosis of addictive illness, managers and supervisors are to restrict conversations concerning possible violation of this policy to only those persons participating in any questioning, evaluation, investigation or disciplinary action or who have a need to know about the details of the alcohol/drug investigation and/or details of treatment for addictive illness. If a manager or supervisor is unsure whether to divulge information to a particular individual, he or she should consult a Human Resource Generalist or Legal Affairs. 2. Employee Benefits During Treatment a. Accrued sick time, vacation hours, or short-term disability, if applicable, may be utilized during the employee's treatment as defined under the terms of the applicable Leave of Absence policy and the Family & Medical Leave Act. b. Verification of health insurance coverage, or questions regarding coverage should be directed to the EAP Counselor. E. RETURN TO WORK/AFTERCARE 1. Employees who actively participate in and successfully complete a Recovery Program, as specified/recommended by the EAP, will be eligible for reentry into the workplace. Employees who self disclose that they have self-referred to inpatient or outpatient treatment and are seeking to return to work must be evaluated through a formal referral to the EAP before they are eligible for reentry into the workplace. 2. A reintegration meeting involving the employee, the immediate supervisor, EAP, Department Head, Human Resources Generalist will occur before the employee returns to work. The goal of the meeting is to review the objectives of the Return to Work Agreement and to ensure understanding by all parties of those objectives. The manager will be responsible for ensuring that the Return to Work Agreement is being adhered to by the employee. 3. These employees will be required to sign and adhere to the provisions set forth in a Return to Work Agreement (See Examples in Appendix A and B). APPENDIX CC

267 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 8 of 16 Effective: 07/01/04 4. Employees returning to work must sign release of information forms available from Occupational Medicine (which provide authorization for the employee s treating health care professionals to disclose information to Occupational Medicine about the employee s care and recovery) and must be cleared for duty by Occupational Medicine, prior to return to work. F. RELAPSE MANAGEMENT 1. A positive toxicology screen after an employee has returned to work under the terms and conditions of a Return to Work Agreement may result in termination of employment. 2. When the employee is terminated, the EAP will be contacted by the immediate supervisor to facilitate any follow-up activities. 3. If the employee is participating in the Voluntary Recovery Program, the state will be notified of the employee's termination by the employee s supervisor. G. DISCIPLINARY ACTION 1. Violation of any section of this policy may result in disciplinary action up to and including termination, even for the first offense, in accordance with the Constructive Discipline policy. 2. If a licensed employee is already being investigated by the Professional Health Monitoring Program, prior to UPMC s notification, the employee may be suspended without pay pending a decision from the Professional Health Monitoring Program. SUPERSEDES: 03/01/99; 01/01/01 ISSUED BY: Christine M. Lynch Associate Vice President, Human Resources APPENDIX CC

268 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 9 of 16 Effective: 07/01/04 Appendix A UNIVERSITY OF PENNSYLVANIA MEDICAL CENTER LICENSED PERSONNEL DENTAL HYGIENIST, PHARMACISTS, PHYSICIAN ASSISTANTS, PHYSICAL THERAPISTS, SOCIAL WORKERS, LICENSED PRACTICAL NURSES, PSYCHOLOGIST, OCCUPATIONAL THERAPISTS AND REGISTERED NURSES CHEMICAL DEPENDENCY TREATMENT AND RECOVERY PROGRAM RETURN TO WORK AGREEMENT I,, recognize that I suffer from a chronic disease, alcoholism and/or chemical dependency, and desire to commit to a treatment and recovery program during employment with UPHS, and therefore I agree to the following requirements: 1. I agree to enter and comply with the requirements of the Voluntary Recovery Program of the Bureau of Professional and Occupational Affairs. 2. I agree to completely abstain from alcohol, marijuana, cocaine, any non-prescribed stimulants, narcotics, sedatives, antianxiety drugs (tranquilizers) and all other mind altering or potentially addicting drugs or medications, as identified in the Federal and State Controlled Substances Act. In the event that such medications may be medically required as part of treatment, I agree to immediately notify Occupational Medicine (OM) within 24 hours of initiating the medications. 3. I agree to inform my personal health care provider(s) of the requirements of this Agreement and request that he or she not prescribe any of the above medications, or any medication that may affect my ability to perform my job functions, or may compromise the safety of myself or others unless there is no reasonable alternative available (if you don't have a health care provider, a referral can be obtained). I agree to inform any physician, nurse practitioner or midwife, whom I might see on a consult basis for my own health, of my history of alcohol or chemical dependency and of the conditions of this Agreement. 4. I agree to a physical examination by OM before returning to work and to obtain similar examinations as requested as long as I am a participant in the Voluntary Recovery Program. 5. I agree to an evaluation by the EAP (or a designated representative of the EAP) before returning to work and to obtain similar evaluations as requested as long as I am a participant in the Voluntary Recovery Program. 6. I agree to self disclose my alcohol or chemical abuse to a person who can be contacted in an emergency situation related to this problem. Name: Home Phone: Work Phone: APPENDIX CC

269 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 10 of 16 Effective: 07/01/04 7. For Nurses, I agree to not administer narcotics or other mind-altering drugs or potentially addicting drugs for a period of at least 6 months, then to administer these drugs for a minimum of three months under direct observation, from preparation to actual delivery, by a designated peer support person or designated RN on the nursing unit where I am working. I cannot work as a supervisor, work in an Intensive Care Unit, Coronary Care Unit or Emergency Department unless approved by the primary treatment provider and verified by the Voluntary Recovery Program Case Manager. In addition, I understand that due to program restrictions I may not be able to practice in certain areas. 8. For Nurses. I agree to attend the weekly nursing peer support group Pennsylvania Recovery Nurses' Association (PRNA) in Philadelphia for the duration of the Professional Health Monitoring Program (PHMP). PRNA will inform the EAP if there is a breach of attendance, not attending the entire meeting or being under the influence at a meeting. If the PRNA group is not logistically possible, attendance at another peer support group can be negotiated with the designated liaison. 9. l agree to be actively engaged in treatment and/or recovery group(s) weekly for at least one year as negotiated with the treating therapist and EAP. I agree to authorize the EAP (through a signed release of information form - See Appendix F) to contact my therapist for updates on treatment compliance. I also agree to authorize the EAP to speak with Human Resources (through a signed release of information form See Appendix F) regarding updates on treatment compliance. 10. All other licensees, except nurses, if currently licensed to administer, dispense or prescribe medication will not do so until such practice is approved by the treatment provided and verified by the Voluntary Recovery Program Case Manager. 11. I agree to maintain my attendance and supply documentation from Alcoholics Anonymous, Cocaine Anonymous and/or Narcotics Anonymous meetings or any other prescribed self-help group meeting, as negotiated with the treating therapist and EAP. 12. I understand that chemical monitoring is an integral part of this program and my recovery. I, therefore, agree to submit, voluntarily and without question, to urine and/or blood examinations as requested. 13. I agree to abide by the terms of this contract for a period of 3 years of active employment at any UPHS facility. The program may be extended depending on my recovery process. Licensed employees who are participating in the Voluntary Recovery Program must successfully complete the requirements of that program to maintain their employment. 14. I agree that adjustments in my work schedule, unit assignment and limitation of responsibilities may occur. 15. I understand that if I am not in compliance with this treatment and recovery program, I may be reported to the Voluntary Recovery Program and terminated. Employee Signature Date Witness APPENDIX Date CC

270 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 11 of 16 Effective: 07/01/04 Appendix B UNIVERSITY OF PENNSYLVANIA MEDICAL CENTER NON-LICENSED PERSONNEL CHEMICAL DEPENDENCY MONITORING, TREATMENT AND RECOVERY PROGRAM RETURN TO WORK AGREEMENT I,, recognize that I suffer from a chronic disease, alcoholism and/or chemical dependency, and desire to commit to treatment and a recovery program through my recovery process (during employment with UPMC) and therefore I agree to the following requirements: 1. I agree to completely abstain from alcohol, marijuana, cocaine, stimulants, narcotics, sedatives, anti-anxiety drugs (tranquilizers) and all other mind altering or potentially addicting drugs or medications, as identified in the Federal and State Controlled Substances Act. In the event that such medications may be medically required as a part of treatment, I agree to immediately notify Occupational Medicine (OM). 2. I agree to inform my personal health care provider(s) of the requirements of this Agreement and request that he or she not prescribe any of the above medications for me unless there is no reasonable alternative available (if you don't have a health care provider, a referral can be obtained). I agree to inform any physician, nurse practitioner or midwife, whom I might see on a consulting basis for my own health, of my history of alcoholism and/or chemical dependency and of the conditions of this Agreement. 3. I agree to a physical examination by Occupational Medicine before returning to work and to obtain similar examinations as requested. 4. I agree to an evaluation by the EAP (or a designated representative of the EAP) before returning to work and to obtain similar evaluations as requested. 5. I agree to self disclose my alcohol and/or chemical dependency to a person who can be contacted in an emergency situation related to this problem. Name: Home Phone: Work Phone: 6. I agree to be actively engaged in treatment and/or recovery group(s) for at least one year, as negotiated with the treating therapist and EAP. I agree to authorize EAP (through a signed release of information form See Appendix F) to contact my therapist for updates on treatment compliance. I also agree to authorize the EAP to speak with Human Resources (through a signed release of information form See Appendix F) regarding updates on treatment compliance. APPENDIX CC

271 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 12 of 16 Effective: 07/01/04 7. I understand that chemical monitoring is an integral part of this program and my recovery. I, therefore, agree to submit, voluntarily and without question, to urine and/or blood examinations as requested. 8. I agree to abide by the terms of this contract for a period of 3 years. The program may be extended depending on my recovery process. 9. I agree that adjustments in my work schedule, unit assignment and limitation of responsibilities may occur. 10. I understand that if I am not in compliance with this treatment and recovery program, I may be terminated immediately. Employee Signature Date Witness Date APPENDIX CC

272 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 13 of 16 Effective: 07/01/04 UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM PATIENT EVALUATION FORM Appendix C TO BE COMPLETED BY SUPERVISOR - PART I ENTITY: ( ) HUP ( ) CPUP ( ) UPHS ( ) PRESBY ( ) CCA ( ) OTHER REFERRED BY: Employee s Name: Date of Injury/Illness Time of Injury/Illness Employee s Occupation/Department: Employee s Work Site Phone No: ( ) Supervisor s Name: Supervisor s Phone and Fax #: (Office) (Fax) Place of Accident: Description: ( ) Leave Of Absence ( ) Initial Visit ( ) Follow up Visit # ( ) Fitness for Duty ( ) Illness/Injury on the Job ( ) Other TO BE COMPLETED BY CLINICIAN - PART II Work Status/Limitations: ( ) Recommend return to work with no limitations on. ( ) May return to work on with the limitations below. ( ) Is unable to work at this time. ( ) Employee will be re-evaluated on. CLINICIAN: CHECK ONLY AS RELATED TO THE ABOVE CONDITIONS: ( ) Sedentary Work: Lifting 5 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers, and small tools. In a work day, employee may: Stand/Walk ( )None ( )1-4 hours ( )4-6 hours ( ) > 6 hrs Sit ( )None ( )1-4 hours ( )4-6 hours ( ) > 6 hrs ( ) Light Work: Lifting 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Drive ( )None ( )1-4 hours ( )4-6 hours ( ) > 6 hrs ( ) Light Medium Work: Lifting 30 pounds maximum with frequent lifting and/or carrying of objects weighing up to 20 pounds. ( ) Medium Work: Lifting 50 pounds maximum with frequent lifting and/or carrying of objects weighing up to 25 pounds. ( ) Light Heavy Work: Lifting 75 pounds maximum with frequent lifting and/or carrying of objects weighing up to 40 pounds. ( ) Unrestricted Other instructions and/or limitations: Employee may not use hands for repetitive: ( )Single Grasping ( )Pushing & Pulling ( )Fine Manipulation Employee may not use foot/feet for repetitive movement as in operating foot controls ( ) Employee may: Each Day Each Day Not (0-33%) (34-66%) No at all Occasionally Frequently Restrictions Bend ( ) ( ) ( ) ( ) Twist ( ) ( ) ( ) ( ) Squat ( ) ( ) ( ) ( ) Climb ( ) ( ) ( ) ( ) Reaching overhead ( ) ( ) ( ) ( ) Physical Therapy ( ) Occupational Therapy ( ) # times per week Provider s Signature Provider s Name Printed Date Phone Number DISTRIBUTION White: Departmental Copy Yellow: Occupational Medicine Pink: Workers Comp./Insurance Carrier APPENDIX CC

273 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 14 of 16 Effective: 07/01/04 UNIVERSITY OF PENNSYLVANIA MEDICAL CENTER Appendix D AUTHORIZATION TO CONDUCT TOXICOLOGY SCREEN BY BLOOD AND URINE TESTS BY THE HOSPITAL OCCUPATIONAL MEDICINE SERVICE OR EMERGENCY DEPARTMENT AND TO RELEASE RESULTS I have been informed that the University of Pennsylvania Health System is concerned, based on observations of my behavior, appearance, etc. that I may be under the influence of illegal drugs and/or alcohol, may be abusing prescribed or over-the-counter medications, or currently using illegal drugs/alcohol, or may otherwise be unable to perform my job safely. I have therefore been requested to submit to a drug/alcohol screen by blood and/or urine tests and medical assessment, which is to be administered by Occupational Medicine or the Emergency Department. I have been informed and I understand that my agreement to submit to the requested alcohol and/or drug screens by blood and/or urine tests is completely voluntary on my part, and I have the right to refuse to submit to the test. I understand that my refusal to submit to the drug and/or alcohol screen by blood and/or urine tests and/or medical assessments may be grounds for disciplinary action, up to and including immediate termination. I hereby authorize that the results of this drug and/or alcohol screen by blood and/or urine tests and/or medical assessment may be released to my immediate Supervisor, Department Head and Human Resources Generalist and such other hospital officials and employees as the Chief Human Resources Officer or designee as may be determined necessary. I understand the information released to UPHS will be used to determine whether I am fit to perform my job duties and/or whether I violated UPHS work rules or policies concerning drug and alcohol use and that the results of such tests(s) may form the basis for disciplinary action, up to and including immediate termination. This authorization expires one year from the date indicated next to my signature below and shall remain effective authorization for the taking of all samples and the testing of any samples during that time. I understand that I can revoke this Authorization at any time, except to the extent it has already been relied upon or specimens have already been taken. In the event I revoke my authorization, the release of all claims, below, shall remain in full force and effect. I hereby release my employer and each of its employees, agents, and contractors, and the laboratory from any and all liability arising from this request to provide sample(s), the taking or testing of the sample(s), the reporting of the results, and any decisions made concerning my employment based upon the results of the analysis of any samples I provide. Having read and understood this agreement and with full knowledge of the above information, I agree to submit to the requested drug and/or alcohol screen by blood and/or urine tests and/or medical assessment by Occupational Medicine or Emergency Department and voluntarily sign my name below. (Note: A witness other than the Supervisor who has requested that the employee submit to a drug and/or alcohol screen by blood and/or urine tests and/or medical assessment should also sign the consent form.) Employee Signature Name (Please print legibly) Date of Birth Witness Date Date APPENDIX CC

274 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 15 of 16 SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Effective: 07/01/04 Employee s name: FITNESS FOR DUTY OBSERVATION FORM Appendix E Date of observation: / / Month Day Year Time of observation: From: a.m. p.m. To: a.m. p.m. Location: CAUSE FOR SUSPICION CHECK ALL APPROPRIATE ITEMS 1. Presence of Drugs and/or Drug Paraphernalia (specify): 2. Appearance: Normal Flushed Disheveled Bloodshot Eyes Puncture Marks Dilated/Constricted pupils Profuse Sweating Inappropriate wearing of sunglasses Dry-mouth Symptoms Runny Nose/Sores Tremors Smell of Alcohol Other 3. Behavior Speech: Normal Incoherent Slurred Silent Confused Slowed Whispering Other Awareness: Normal Confused Mood Swing Euphoria Lethargic Lack of Coordination Paranoid Disoriented Other 4. Motor Skill: Balance: Walking & Turning Normal Swaying Falling Staggering Other Normal Swaying Arms Raised for Balance 5. Other Observed Actions or Behavior (specify): Stumbling Falling Reaching for Support Other Witnessed By/Reported To: am/pm (Signature) (Title) (Date) (Time) am/pm (Signature) (Title) (Date) (Time) APPENDIX CC

275 University of Pennsylvania Medical Center POLICY MANUAL SUBJECT: IMPAIRED EMPLOYEE / USE OF ALCOHOL AND/OR DRUGS Number: Page: 16 of 16 Effective: 07/01/04 AUTHORIZATION FOR LIMITED RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION On this day of, I (Day) (Month) (Name) Appendix F (Address) authorize: Inpatient Facility/Outpatient Treatment /EAP or a Clinical Representative of the EAP ( ) (Name of Facility, Treatment Provider, and/or EAP) (Address) to release limited confidential information to: Human Resources (General Compliance) /EAP or a Clinical Representative of the EAP (Specific Clinical Information) (Work Site Address) The specific information to be released to Human Resources is limited to the following: A. WAS THE EMPLOYEE COMPLAINT WITH ASSESSMENT AND/OR TREATMENT? B. WERE FURTHER RECOMMENDATIONS MADE? C. DID EMPLOYEE MAKE CONTACT WITH FURTHER RECOMMENDATIONS? and pertains to services received during the 90 day period after the signing of this release This information is needed for the following purposes: Compliance and Follow-up Signature of Site Representative (Dept.) Signature of Client Date The confidentiality of any information received or disclosed by the use of this authorization is protected by Federal Law Federal Regulation (42 CFR Part 2, Section 2.32) prohibits any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. This authorization is void after 90 days from the date of employee / site representative signature. APPENDIX CC

276 Subject: POLICY University of Pennsylvania Health System Policy Manual PENN MEDICINE INFLUENZA IMMUNIZATION POLICY Number: Page 1 of 3 Effective: 9/7/10 Requires influenza immunization on an annual basis for all personnel working/volunteering within a Penn Medicine facility. PURPOSE The purpose of this policy is to protect patients, employees, family members and the community from influenza infection through annual immunization of all Penn Medicine faculty, staff, students/trainees in clinical setting, clinical research personnel, contracted personnel who work in patient care areas,, volunteers and persons with professional staff privileges or credentials. SCOPE This policy applies to all Penn Medicine faculty, staff, students/trainees in clinical setting, clinical research personnel, contracted personnel who work in patient care areas, volunteers and persons with professional staff privileges or credentials. IMPLEMENTATION HRIS assumes responsibility for distributing periodic compliance reports to update managers on the immunization rates and exemptions for staff who work in their respective areas. Penn Medicine managers and supervisors are responsible for the enforcement of this policy requiring influenza immunization on an annual basis unless exemption has been granted as described below: PROCEDURES A. Annual Influenza Immunization: 1. All faculty and staff working in a Penn Medicine facility must be immunized against influenza each year. This includes all personnel as defined under the scope of the policy. 2. Influenza vaccine is available free of charge to all Penn Medicine employees. The vaccination program is coordinated through Occupational Medicine. Dates of the influenza vaccination program will be determined by Occupational Medicine and Healthcare Epidemiology, Infection Prevention and Control on an annual basis. 3. If faculty and staff and personnel covered by this policy are vaccinated through services other than Penn Medicine and Occupational Medicine (i.e. private physician office, public clinics) they must provide proof of immunization to Occupational Medicine. Proof of immunization may include a physician s note, a receipt, or copy of consent. B. Infection Control Procedures: 1. All personnel will be required to strictly adhere to respiratory hygiene and hand hygiene practices, as well as isolation precautions. 2. Influenza season typically occurs sometime between November and March. Individuals granted an exemption cannot work in high risk areas and will be reassigned to alternate sites. High risk areas include the neonatal intensive care unit, all areas where bone marrow, stem cell and solid organ transplant recipients are located, and other areas as determined by the Director of Healthcare Epidemiology, Infection Prevention and Control. Exact dates for reassignment will be determined annually when influenza is APPENDIX DD

277 Subject: University of Pennsylvania Health System Policy Manual PENN MEDICINE INFLUENZA IMMUNIZATION POLICY Number: Page 2 of 3 Effective: 9/7/10 identified in the community where the hospital or organization is located. This will be determined by the Director if the Department of Healthcare Epidemiology, Infection Prevention and Control. C. Occupational Medicine will maintain a record of influenza immunizations and exemptions via Lawson (HRIS).. D. All faculty and staff and personnel covered by this policy must adhere to the Penn Medicine Influenza Immunization Policy as a condition of employment or access to Penn Medicine facilities. They must be vaccinated or granted an exemption within two months of the start of the influenza vaccination program each year. E. All faculty and staff and personnel covered by this policy who have not been vaccinated or granted an exemption will not be permitted to work if urgent situation is declared. An urgent situation may be declared by the Chief Medical Officer in consultation with Occupational Medicine, Healthcare Epidemiology, Infection Prevention and Control and Human Resources. Determination of an urgent situation may be based upon one or more of the following conditions: 1. Influx in patient admissions attributable to influenza; 2. Advisories by local or state Department of Health officials or the Centers for Disease Control and Prevention; 3. Marked increase in employee absenteeism. F. Failure to comply with the immunization policy will result in a written warning. If an individual is not vaccinated or granted an exemption within 2 weeks of the warning, they will be subject to further disciplinary action up to termination of employment. G. If an unvaccinated individual fails to comply with reassignment following a written warning, they are subject to further disciplinary action up to termination of employment. H. In the event of an influenza vaccine shortage, the situation will be evaluated by the Chief Medical Officer at the corporate level in collaboration with Occupational Medicine, Infection Control, Human Resources, Pharmacy and Administration. Influenza vaccine will be offered to faculty and staff and personnel covered by this policy based on job function and risk of exposure to influenza. Priority will be given to those who provide direct hands-on patient care with prolonged face-to-face contact with patients, care for patients at high risk for complications from influenza and/or have highest risk of exposure to patients with influenza, as well as to personnel who are at high risk for complications from influenza. I. Exemptions 1. Exemption to immunization may be granted for medical contraindications or religious beliefs. 2. Individuals requesting exemption due to medical contraindications must have their physician complete the Request for Medical Exemption from Influenza Vaccination form and submit the form to Occupational Medicine. Medical contraindications include: i. Severe allergic reaction to eggs ii. History of previous severe allergic reaction to influenza vaccine or a component of the vaccine APPENDIX DD

278 Subject: University of Pennsylvania Health System Policy Manual PENN MEDICINE INFLUENZA IMMUNIZATION POLICY Number: Page 3 of 3 Effective: 9/7/10 iii. History of Guillain-Barre syndrome within 6 weeks of receiving a previous dose of influenza vaccine 3. Individuals requesting a religious accommodation must have their clergy complete a Request for Religious Exemption from Influenza Vaccination form and submit the form to Human Resources. The request must be consistent with prior vaccination history. 4. Standard criteria for medical exemption will be established based upon recommendations from the Centers for Disease Control and Prevention. The standard criteria will be utilized at each hospital and service organization. 5. Each request for medical exemption, regardless of the reason, will be evaluated individually by occupational medicine at the hospital or service organization level, with consultation with Healthcare Epidemiology, Infection Prevention and Control. 6. If medical exemption is granted, the individual will be notified in writing within five (5) business days after presenting a request for exemption in person to occupational medicine. 7. If exemption is granted for a temporary condition, the individual must resubmit a request for exemption each year. If exemption is granted for a permanent condition (e.g. allergy or history of Guillain-Barre after a previous influenza vaccine) the exemption does not need to be requested each year unless vaccine technology would change to eliminate issues regarding allergies. SUPERSEDES: 09/17/09 ISSUED BY: Judy Schueler, Vice President Organization Development and Human Resources Garry Scheib, Executive Director Hospital of the University of Pennsylvania APPENDIX DD

279 University of Pennsylvania Health System POLICY MANUAL Number: Page: 1 of 2 SUBJECT: JURY DUTY Effective: 06/01/2013 A. POLICY SUMMARY Employees are encouraged to serve jury duty and fulfill their court-related, civic obligations. The University of Pennsylvania Health System (UPHS) provides employees paid time off to meet their civic duty without change in status or loss of pay. There is no waiting period for this benefit. B. PURPOSE The purpose of this policy is to encourage employees to meet their civic duties and to ensure that time spent on jury duty will not affect continuous service, accrual of benefits or payment of his/her regular salary. C. SCOPE This policy applies to all regularly budgeted HUP/CPUP/Corporate employees who work 20 or more hours per week and are in an active pay status. This policy applies to employees of the Hospital of the University of Pennsylvania (HUP), those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which practice at or in conjunction with HUP operating under its license, and UPHS Corporate departments. This policy also applies to those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g. HUP s inpatient rehabilitation facility. For purposes of this policy, the above facilities, practices and sites are collectively referred to as entity. D. RESPONSIBILITY FOR IMPLEMENTATION Implementation and compliance of this policy are the responsibility of the entity senior leadership, department directors/business administrators, managers, and supervisors. Exceptions to the policy must be approved by senior leadership. F. PROCEDURE F1. Notification Upon receipt of a summons, the employee should promptly notify his/her supervisor who shall take the necessary action to accommodate for the absence of the employee. The supervisor shall also document the absence due to Jury Duty on the employee s time record.

280 University of Pennsylvania Health System POLICY MANUAL Number: Page: 2 of 2 SUBJECT: JURY DUTY Effective: 06/01/2013 F2. Pay While serving on the Jury, the employee will be paid his/her regular base rate based on scheduled hours for the affected day(s). When returning from Jury Duty, the employee must present his/her supervisor with a copy of the check or check stub received for jury service. This shall serve as verification of the employee s attendance at jury service. Employees cannot substitute jury duty pay if jury duty service occurs during a day or time period that the employee is not working because of a scheduled day off, is on vacation, or is using-preapproved holiday or personal time. F3. Work Schedule Employees who work Evening or Night shifts may request an adjustment of their Evening/Night schedule if they wish to work a modified schedule while serving jury duty. Approval of a request to work Evening/Night hours while serving on a jury during the day is at the discretion of their manager/supervisor. Employees who work Evening or Night schedules while serving jury duty during their off hours will not be paid for both time served on jury duty plus time worked, but will be paid for time worked only. Any questions regarding this policy may be referred to Human Resources. SUPERSEDES: 07/01/02, 09/24/06 ISSUED BY: Judy Schueler, Vice President, Organization Development and Chief Human Resources Officer ISSUED BY: Garry Scheib, Executive Director Hospital of the University of Pennsylvania

281 UNIVERSITY OF PENNSYLVANIA MEDICAL CENTER POLICY MANUAL SUBJECT: MANDATORY EDUCATION: RESPONSIBILITY TO MEET REGULATORY EDUCATION REQUIREMENTS Number: Page: 1 of 3 Effective: 01/03/07 POLICY HUP/CPUP/Shared Services employees are required to complete regulatory requirements, as appropriate, which are designed to reinforce the competencies and safeguards that are necessary to effectively fulfill the organizational mission, vision and goals related to hospital operations and employee and patient safety. PURPOSE To define Department Director, Manager, and Supervisor accountability, policy, and procedure for ensuring that staff meet all regulatory requirements necessary to provide their chartered scope of service within the University of Pennsylvania Medical Center (HUP, CPUP, Shared Services) in compliance with the Department of Health (DOH), Center for Medicare/Medicaid Services (CMS), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Occupational Safety and Health Administration (OSHA), and all other appropriate regulatory agencies. SCOPE This policy applies to HUP/CPUP/Shared Services employees as appropriate. Entity Leadership and Department Directors, Managers, and Supervisors are responsible for defining and monitoring the mandatory education requirements for HUP/CPUP/Shared Services employees. Entity Leadership may mandate education and other requirements for all employees, large job functions or employees in a particular position or location based on the institution s interpretation of regulatory requirements. To support Department Directors, Managers, and Supervisors in ensuring their staff meet regulatory requirements, UPHS and Entity Process Owners (individuals who have authority for a process) with the support of Entity Leadership will assign required education based on their knowledge of the work an employee is doing and the location where the work is occurring a majority of the time. IMPLEMENTATION Process Owners: UPHS and Entity Process Owners will annually review regulatory requirements, update employee education content, update UPHS Mandatory Education Guidelines, and ensure all requirements are assigned to the appropriate employees based on their knowledge of the work an employee is doing and the location where the work is occurring a majority of the time. Process Owners, who want to introduce a new education requirement, must submit a recommendation to Compliance Central at ComplianceCentral@uphs.upenn.edu. Compliance Central with the Process Owner will identify the necessary stakeholders to facilitate the approval process. Department Directors, Managers, and Supervisors: Department Directors, Managers, and Supervisors are responsible for: 1. Being aware of all external regulatory and internal educational and other requirements for their respective accounting units. Guidelines for Mandatory Education and Health Screening Requirements can be found on the UPHS intranet at ( 2. Overseeing and ensuring employee compliance with requirements which include: APPENDIX FF

282 UNIVERSITY OF PENNSYLVANIA MEDICAL CENTER POLICY MANUAL SUBJECT: MANDATORY EDUCATION: RESPONSIBILITY TO MEET REGULATORY EDUCATION REQUIREMENTS Number: Page: 2 of 3 Effective: 01/03/07 a. Providing information about the designated mandatory education and occupational health requirements for their respective accounting unit/staff members. b. Monitoring staff compliance on a regular basis. c. Taking appropriate action to quickly remedy and address any non-compliance issue. d. Modeling the desired behavior by ensuring that they, too, are compliant with the appropriate requirements. 3. Requesting exemptions as appropriate and maintaining related documentation. (See Procedure.) The Chief Learning Officer will ensure that requirements are updated and available for employees as requested by UPHS and Entity Process Owners and Leaders. PROCEDURE 1. Department Directors, Managers, and Supervisors will provide opportunities for employees to complete designated mandatory programs that are relevant to their respective job duties and responsibility. Typical requirements (but not all requirements) are identified on UPHS Mandatory Education Guidelines. This tool provides Department Directors, Managers, and Supervisors with information on the requirement, job categories that are impacted, agency who is requiring, frequency of requirement, evaluation methods, etc., at All employees providing patient care services and nursing department orientees are expected to complete UPHS Orientation, on-line Mandatory Education and receive Occupational Health clearance before having patient contact. Role specific education and validation of competency can occur in the clinical area under the supervision of an assigned preceptor and should be completed by the end of the formal orientation period. Nursing department orientees must also complete Nursing orientation. 2. Department Directors, Managers, and Supervisors will provide information about requirements to their employees and will monitor and ensure the compliance of staff within their accounting unit(s). 3. Through Knowledge Link (UPHS Learning Management System), employees will access mandatory training online, take specified courses, and complete and pass required assessments (if applicable). Updated employee records of mandatory training will be tracked electronically wherever possible. Said records will be available for Department Directors, Managers and Supervisors on a quarterly basis. Employees have immediate access to their Educational Record via Knowledge Link. 4. Exemptions may be granted for mandatory courses based on specific job duties and the location of an employee s work. These exemptions will be documented by Compliance Central in consultation with the respective Process Owner and Subject Matter Expert and can be reviewed by visiting a. Department Directors will provide a written exemption request to Compliance Central at 3930 Chestnut Street, 2 nd Floor. The exemption request should include the following information: i. Accounting unit, job duties/responsibility, specific location APPENDIX FF

283 UNIVERSITY OF PENNSYLVANIA MEDICAL CENTER POLICY MANUAL SUBJECT: MANDATORY EDUCATION: RESPONSIBILITY TO MEET REGULATORY EDUCATION REQUIREMENTS Number: Page: 3 of 3 Effective: 01/03/07 ii. Specific education requirement targeted for exemption iii. Reason/justification for the exemption request b. The exemption request will be reviewed by the appropriate Process Owner/Subject Matter Expert(s) for validity and adequacy of the request and for the interpretation and application of regulatory standards (federal, state, or local regulations, rules, standards, ordinances, or laws). Process Owners/Subject Matter Experts may include designated individuals in the following departments: CEQI/Patient Safety, HIPAA/Privacy & Information Office, Infection Control, Occupational Medicine, Office of the General Counsel, Organization Design & Competency Systems, Regulatory Affairs, and/or Safety Management. c. Based on the information submitted and reviewed, and other relevant factors, a determination will be made whether to approve or deny the request for exemption. The requestor will be notified, in writing, of the final determination by the Process Owner/Subject Matter Expert. The Process Owner will also inform Compliance Central to assure that Knowledge Link and the compliance database reflects any changes in required mandatory requirement for an accounting unit s employees. d. Documentation of approved or denied exemptions should be maintained in departmental files. e. Each Department Director will be responsible for tracking his/her requested exemptions and for requesting reviews when necessary. Approved exemptions can be reviewed by visiting Questions regarding this policy should be referred to Compliance Central at (215) Supersedes: Issued By: Christine M. Lynch Vice President, Human Resources APPENDIX FF

284 Subject: University of Pennsylvania Health System Policy Manual Non-Retaliation and Fair Treatment in Addressing Reports of Compliance or Ethics Concerns Number: Page 1 of 3 Effective: 7/1/08 POLICY University of Pennsylvania Health System is committed to maintaining a culture that promotes the detection, prevention and resolution of instances of conduct that do not conform to law or policies. UPHS aims to create an environment where employees can report their concerns without fear of retaliation or unfair treatment. PURPOSE The purpose of this policy is to protect individuals exercising their right to report non-compliance or violations of rules, laws or policies without fear of retaliation or intimidation. SCOPE This policy applies to all employees, medical staff, house staff, students, and others working for the University of Pennsylvania Health System. IMPLEMENTATION Implementation of this policy is the responsibility of Department Directors/Business Administrators and Entity/Health System Senior Leadership. PROCEDURES Individuals at UPHS, the University, and those not affiliated with either, may raise concerns with a number of offices at UPHS. The concerns may be about non-compliance with a federal, state or local law, requirements by contract or UPHS or entity policies. The concerns may be about basic misconduct or unethical behavior by any staff member. Regardless of the nature of the concern, the following procedures and protections apply. 1. Referral to Appropriate Offices Reports of non-compliance or ethics concerns should be referred to individuals or offices with authority and expertise to evaluate, investigate and otherwise address such reports. These individuals or offices are as follows: Entity management or leadership Human Resources Department Entity or Health System Privacy Officer U of P Office of Audit, Compliance and Privacy Office of General Counsel Office of Billing Compliance Penn Occurrence Reporting and Tracking System (PORTS) APPENDIX GG

285 Subject: University of Pennsylvania Health System Policy Manual Non-Retaliation and Fair Treatment in Addressing Reports of Compliance or Ethics Concerns Number: Page 2 of 3 Effective: 7/1/08 2. Non-retaliation UPHS staff may not intimidate, threaten, coerce, discriminate against, or take any retaliatory action against any employee, volunteer, student, legally authorized representative, association, organization or group that in good faith and with honest and non-malicious intent: a. Discloses or threatens to disclose information about a situation they feel is inappropriate, or is illegal; b. Provides information to or testifies against the alleged offending individual or the Health System or University; c. Is involved in any compliance review or peer review process; or d. Files a valid or legitimate report or a complaint, or an incident report. UPHS leadership is concerned about the quality of care provided and the safety of every patient. Staff members are encouraged to discuss concerns about quality of care and patient safety with their supervisors. Retaliation will not occur against an employee who reports a quality of care or safety concern to The Joint Commission (TJC) or the Pennsylvania Department of Health Individuals who violate this policy will be subject to the appropriate and applicable disciplinary process up to and including termination. Individuals handling reports shall inform the person making the report, and others as may be necessary, about UPHS s prohibition against retaliation. Note that an adverse personnel, academic, or other disciplinary action against an employee or student whose conduct or performance warrants such action for reasons unrelated to the reporting a concern will not be deemed a violation of this policy. Further, an individual who knowingly and intentionally makes a false allegation of non-compliance to a public body or UPHS official shall be subject to disciplinary measures up to and including discharge, in accordance with UPHS s policies and procedures. 3. Confidentiality Individuals are permitted to make reports anonymously. They may also identify themselves, but request confidentiality about their identity as the inquiry goes forward. If the person making the report requests such treatment, his or her identity will be protected within legal limits, to the extent practicable, and to the extent that continued protection does not interfere with the entity or health system s ability to investigate allegations of misconduct and to take corrective action. Depending upon the nature of the allegations raised (e.g., unlawful discrimination), in order to conduct a fair and complete investigation, the full details of the allegations, including the complainant s identity, may be shared. The individual should be told about UPHS s commitment to protect confidentiality when possible, as well as the fact that there may be circumstances under which the entity or the health system will not be able to maintain confidentiality, for example in the case of court orders or to properly conduct the investigation described above. APPENDIX GG

286 Subject: University of Pennsylvania Health System Policy Manual Non-Retaliation and Fair Treatment in Addressing Reports of Compliance or Ethics Concerns Number: Page 3 of 3 Effective: 7/1/08 4. Protection for Subjects of a Report Individuals who are subjects of a report shall be treated fairly and respectfully. To assure fair treatment, those accused of misconduct should ordinarily be notified about the nature of the allegations as soon as the administrator responsible for investigating concludes it will not risk the integrity of the investigation. 5. Investigations of Retaliation All suspected or alleged cases of retaliation must be reported to the Human Resources Department. After a complete investigation of the circumstances, the Human Resources Department shall determine whether a violation of this policy has occurred. If a violation has occurred, the Human Resources Department will determine the appropriate discipline of the individual who committed the violation in accordance with UPHS policies and procedures. Any exceptions to the procedures delineated in this policy must be approved by Human Resources. Any questions regarding this policy may be referred to Human Resources. ISSUED BY: Patricia J. Wren Interim Vice President, Human Resources APPENDIX GG

287 University of Pennsylvania Health System POLICY MANUAL POLICY STATEMENT ON EQUAL OPPORTUNITY / AFFIRMATIVE ACTION The University of Pennsylvania Health System (UPHS) does not discriminate on the basis of race, color, age, sex, sexual orientation, religion, national or ethnic origin, citizenship status, disability or status as a disabled or Vietnam Era veteran. This UPHS policy statement applies to all employees, applicants and suppliers of goods and services. UPHS recognizes its responsibilities for, and commitment to Affirmative Action and Equal Opportunity as required by law and the policies of the Health System. UPHS will not discriminate regarding the appointment, promotion, organizational affiliations, transfer, compensation, benefits, training, tuition assistance, job elimination, terminations, recreation and vendor programs is fundamental to the effective operation of the organization. However, simple absence of discrimination is not sufficient. The challenge is to act positively toward the elimination of any vestiges of unequal and disparate treatment. Within UPHS the Affirmative Action Policies/Plan are dedicated to the full realization of equal employment opportunity for all. Note: All employees are required to speak and understand the English language when speaking with customers, patients and other staff for the following business reasons when it is imperative that all staff speak a common language: Patient and visitor safety Emergency situations such as internal or external disasters As required by law and its own policies, UPHS maintains a written affirmative action plan identifying opportunities to improve the utilization of women, minorities and persons with disabilities throughout the organization. Representation includes, but is not limited to employment but to vendors and providers of goods and services. The Affirmative Action Plan of UPHS is available from the entity CHRO. UPHS also recognizes an individual's right to raise and pursue, in an appropriate manner, honest concerns of alleged discrimination by reporting such concerns to a supervisor or Human Resources professional, without adverse action or retaliation for doing so. UPHS maintains policies against unlawful discrimination, harassment and retaliation, with specific reporting mechanisms available to individuals who believe they have been discriminated against on the basis of their protected class status or because they have engaged in activity protected by law. Any concerns related to these policies should be directed to Human Resources. SUPERSEDES: 2004 ISSUED BY: Judy Schueler, Vice President Organization Development & Chief Human Resources Officer APPENDIX HH

288 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 1 of 2 SUBJECT: SEXUAL HARASSMENT Effective: 01/01/01 POLICY HUP/CPUP/Shared Services seeks to preserve a work environment free from sexual harassment. PURPOSE It is the purpose of this policy to reaffirm HUP/CPUP/Shared Services' position prohibiting sexual harassment and to identify the resources available to concerned individuals. SCOPE This policy applies to all employees regardless of status. IMPLEMENTATION Implementation of this policy is the responsibility of all employees. DEFINITION Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a suggestive nature constitute harassment when: PROCEDURE (1) submission to such conduct is made, either explicitly or implicitly, a term or condition of an individual's employment; or (2) submission to or rejection of such conduct is used, or threatened to be used, as a factor in employment decisions; or (3) such conduct has the actual or potential effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile, or offensive work environment. All employees are expected to conduct themselves so that the work atmosphere at HUP/CPUP/Shared Services are free from sexual harassment. Sexual harassment is a violation of the institution's standards of conduct, and those inflicting such behavior on others are subject to the full range of internal disciplinary action, including termination. An employee who has a sexual harassment concern has three options available: (1) confronting the harasser and making it known that the behavior is unwelcome and should stop; (2) notifying his/her supervisor of the harassment; and/or (3) directly contacting Human Resources. Supervisors at all levels bear a responsibility to explain this policy to employees and to enforce its provisions. In the interest of administrative consistency, a supervisor who receives a complaint of sexual harassment or who otherwise learns that such harassment may be taking place is required to consult with Human Resources to discuss appropriate investigation and resolution. APPENDIX II

289 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 2 of 2 SUBJECT: SEXUAL HARASSMENT Effective: 01/01/01 Information about sexual harassment can be sensitive or embarrassing. Furthermore, if the harassing behavior involves events in the complainant's work area, there may be a reluctance to bring the concern to someone in the chain of command. Therefore, the employee has the option at all times to contact Human Resources, who will discuss the matter with the employee and investigate. Of course the employee should always consider alerting the supervisor to the problem. Complaints or allegations of sexual harassment will be treated in confidence. Disclosure will be made at the appropriate management level and to the extent necessary for competent investigation and fair resolution. Every complaint will be investigated. If sexual harassment has occurred, the perpetrator will be disciplined to the degree warranted by the circumstances. Complainants and subjects of complaints have the right to disputed the resolution of the complaint through the Open Door Policy, as appropriate. Persons coming forward with information concerning possible sexual harassment shall not be subject to retaliation. Any instances or threats of retaliation should be reported to Human Resources. Questions about this policy may also be directed to Human Resources. SUPERSEDES: 01/01/88 ISSUED BY: Christine M. Lynch Associate Vice President, Human Resources APPENDIX II

290 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 1 of 2 SUBJECT: RACIAL HARASSMENT Effective: 01/01/01 POLICY HUP/CPUP/Shared Services seeks to maintain a work environment free from racial harassment. PURPOSE It is the purpose of this policy to reaffirm HUP/CPUP/Shared Services' position that racial harassment will not be tolerated and to identify the resources available to concerned individuals. SCOPE This policy applies to all employees of HUP/CPUP/Shared Services regardless of status and to those working on the HUP/CPUP/Shared Services' behalf. IMPLEMENTATION Implementation of this policy is the responsibility of the Entity Senior Leadership and Department Directors/Business Administrators, Managers and immediate supervisors, monitored by the Human Resources. DEFINITION Racial harassment refers to any verbal, symbolic, or physical behavior that stigmatizes, victimizes, or persecutes an individual or individuals through use of threats or unrealistic demands based on race, ethnic or national origin. Racial harassment is defined as behavior that: 1) is directed to an identifiable person or persons; and 2) insults, or demeans, or abuses a power relationship with the person or persons to whom the behavior is directed, on the basis of his or her race, color, ethnicity, or national origin, such as (but not limited to) the use of slurs, epithets, hate words, demeaning jokes, or derogatory statements; and 3) is intended by the speaker to inflict direct injury on the person or persons to whom the behavior is directed; or is sufficiently abusive or demeaning that a reasonable, disinterested observer would conclude that the behavior is so intended; or occurs in the context such that an intent to inflict direct injury may reasonably be inferred. Such actions may include: Violence against persons or property, breach of peace, threat of immediate violence, or incitement to immediate violence or to breach of the peace. Discrimination in the administration of HUP/CPUP/Shared Services policies or conduct of HUP/CPUP/Shared Services programs. Discriminatory deprivation of access to clinical, research, service, or employment resources of the HUP/CPUP/Shared Services. APPENDIX JJ

291 Discriminatory threat to employment status. University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 2 of 2 SUBJECT: RACIAL HARRASSMENT Effective: 01/01/01 All employees are expected to conduct themselves so that the work atmosphere at HUP/CPUP/Shared Services is free from racial harassment. Racial harassment is a violation of the institution's standards of conduct, and those inflicting such behavior on others are subject to the full range of internal disciplinary action, including termination. An employee who has a racial harassment concern has three options available: 1. Confront the harasser and make it known that the behavior is unwelcome and should stop; 2. notify his/her supervisor of the harassment; and/or 3. directly contact Human Resources Supervisors at all levels bear a responsibility to explain this policy to employees and to enforce its provisions. In the interest of administrative consistency, a supervisor who receives a complaint of racial harassment or who otherwise learns that such harassment may be taking place, is required to consult Human Resources to discuss appropriate investigation and resolution. Information about racial harassment can be sensitive or embarrassing. Furthermore, if the harassing behavior involves events in the complainant's work area, there may be a reluctance to bring the concern to someone in the chain of command. Therefore, the employee has the option at all times to contact Human Resources, who will discuss the matter with the employee and investigate. Of course, the employee should always consider alerting the supervisor to the problem. Complaints or allegations of racial harassment will be treated in confidence. Disclosure will be made at the appropriate management level and to the extent necessary for competent investigation and fair resolution. Every complaint will be investigated. If racial harassment has occurred, the perpetrator will be disciplined to the degree warranted by the circumstances up to and including termination. Complainants and subjects of complaints have the right to grieve the resolution of the complaint through the Open Door Procedure (Policy #2-5-14). Persons coming forward with information concerning possible racial harassment shall not be subject to retaliation. Any instances or threats of retaliation should be reported to Human Resources. Any questions about this policy may also be directed to Human Resources. SUPERSEDES: 10/01/91 ISSUED BY: Christine M. Lynch Associate Vice President, Human Resources APPENDIX JJ

292 University of Pennsylvania Medical Center POLICY MANUAL Number: Page: 1 of 1 SUBJECT: SOLICITATION Effective: 01/01/01 POLICY Solicitation of people or distribution of materials to people on HUP/CPUP/Shared Services property will be limited. PURPOSE The purpose of this policy is to provide maximum opportunity for the professional and efficient delivery of patient services. SCOPE The following procedure applies to all people on the HUP/CPUP/Shared Services property, including employees, visitors, patients, students and volunteers. IMPLEMENTATION Implementation of this policy is the responsibility of the Entity Senior Leadership and Department Directors/Business Administrators, and the Security Department, if necessary. PROCEDURE Organizations and persons, other than employees of the HUP/CPUP/Shared Services of the University of Pennsylvania may not engage in solicitations, distributions or posting of written or printed materials of any nature at any time in or on the premises of HUP/CPUP/Shared Services unless prior written approval of the HUP/CPUP/Shared Services Entity Senior Leadership and Department Directors/Business Administrators has been given. HUP/CPUP/Shared Services intends to give such prior approval rarely, when in its judgment, a particular solicitation, as limited by such approval, is essential or appropriate to HUP/CPUP/Shared Services' operation. These particular solicitations will be limited to those providing a direct benefit to HUP/CPUP/Shared Services and to those which are required to fulfill our role as a responsible corporate citizen in the community. Employees may not solicit patients or visitors for any purpose, nor may employees distribute any material to patients or visitors that is not a necessary part of the employee's job requirements. Solicitation or distribution of literature by HUP/CPUP/Shared Services employees is prohibited during working time or in immediate patient care areas. Working time includes all time when employees have work tasks to perform, but does not include an employee s own time, meal time, or other periods when employees are not performing work tasks. Any questions regarding this policy may be referred to Human Resources. SUPERSEDES: 01/01/88 ISSUED BY: Christine M. Lynch Associate Vice President, Human Resources APPENDIX KK

293 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 2 SUBJECT: MISSING PATIENT Effective: 4/22/11 KEY WORDS: Missing patient Elopement AWOL AMA Code Silver SEE ALSO: # "Evening Weekend Emergency Oncall Notification System POLICY The Hospital of the University of Pennsylvania (HUP or the Hospital) and the Clinical Practices of the University of Pennsylvania (CPUP) will exert reasonable efforts to locate a patient who leaves without proper authority, explain to the patient the risks of having left the Hospital, and return him/her as appropriate. PURPOSE The purpose of this policy is to mobilize forces appropriately when a patient is missing from the Hospital and to notify the family and other appropriate persons of the absence. SCOPE This policy applies to the Hospital of the University of Pennsylvania (HUP), and # Discharge those parts of the Clinical Practices of the University of Pennsylvania (CPUP) Against Medical Advice that practice at or in conjunction with HUP, including all off campus facilities and departments. This policy also applies to: (i) those practices and sites that are # Occurrence off campus facilities or departments of HUP and operating under its license, Reporting including e.g. HUP s inpatient rehabilitation facility; (ii) private entities that lease space in property owned or leased by HUP only if they provide contracted clinical services to HUP; and (iii) personnel that provide contracted clinical services to HUP patients. IMPLEMENTATION Implementation of this policy is the responsibility of all persons involved in direct patient care, Security, and other individuals as described below. PROCEDURE I. The nurse or other clinical provider will take the following steps. The order in which these steps are followed depends on the individual patient's clinical condition, decision-making capacity, and the level of concern raised by his/her having absented him/herself from treatment. A. Determine that the patient has left the premises without authority. 1. Check to see if the patient is still on the patient care unit. 2. Have the patient paged overhead to determine if he/she is still in the Hospital. B. If missing, verify the time the patient was last seen, where, and by whom. C. Notify Security and give all pertinent information including a description of the patient. D. Notify the Nurse Manager, senior supervisory staff, Nursing Coordinator, or Director of Nursing. E. Notify the patient s resident and attending physician as appropriate. F. Record on patient s record all known information concerning the absence. G. Complete a report in the Penn Occurrence Reporting System (PORTS) if the patient is not found in the Hospital or clinical area. (See Policy # , Occurrence Reporting ) APPENDIX LL

294 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 2 SUBJECT: MISSING PATIENT Effective: 4/22/11 II. Clinical Nurse or Physician A. Call the patient's home to see if he/she is there. B. Contact the patient's family, the legally authorized representative or designated support person listed in the medical record. III. In areas covered by HUP Security, the security staff will: A. Make a search of the Hospital and the area around the Hospital. B. Report to the appropriate associate administrator or to the administrator on call (See Policy # , "Evening Weekend Emergency On-call Notification System ). C. After consultation with the associate administrator, the administrator on call and the clinical staff caring for the patient, contact the police department if determined to be appropriate. D. When Security is advised by clinical staff that a missing patient (inpatient or outpatient) has been diagnosed to have impaired decision making ability, after consultation with the Nurse Administrator, an Internal Emergency Code Silver shall be declared (specify location of elopement), and the Security Department procedure for Missing Patients with Impaired Decision Making Ability (Code Silver) shall be followed. IV. In areas not covered by the HUP Security Department, the building security staff will be notified and will follow their own procedure. V. Reports of elopement to the Department of Health should be made, when appropriate, by the Department of Risk Management in conjunction with Hospital Administration. VI. See Policy # , Discharge Against Medical Advice for situations in which the patient expresses his/her desire to leave. SUPERSEDES: 9/15/10 MISSING PATIENTapril 2011 ISSUED BY: Garry L. Scheib Elizabeth B. Johnston Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX LL

295 Hospital of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 3 SUBJECT:NEWBORN SAFE HAVEN (ABANDONMENT OF NEWBORNS) Effective: 5/13/08 KEYWORDS: Safe Haven Newborn abandonment Newborn surrender Newborn Protection Act (Act 201) SEE ALSO: # Assessment of Victims of Possible Abuse. Policy: It is the policy of the Hospital of the University of Pennsylvania (HUP) to offer a safe haven to Newborn infants whose parent is considering abandonment. The policy protects the anonymity of the parent to the extent permitted by law and offers a safe place for the newborn. The parent of a Newborn may leave the Newborn in the care of the hospital without being criminally liable, providing that the following criteria are met: The parent expresses orally, or through conduct, that they intend for the hospital to accept the Newborn and; The Newborn is not a victim of child abuse or criminal conduct. Purpose: The purpose of this policy is to define the process and procedure for reception of Newborns in accordance with the Newborn Protection Act (Act 201 of 2002; 23 Pa. C.S et seq.). Scope: It is the responsibility of all HUP employees, health care providers and staff to comply with this policy, [including administrative, managerial and security personnel employed by the hospital]. For purposes of this policy, all references to HUP/CPUP employee, personnel or staff member refers to Good Shepherd Penn Partners employee, personnel or staff member when within the setting of HUP s inpatient rehabilitation facility, the Penn Institute for Rehabilitation Medicine Implementation: The departments identified in the procedure have specific responsibility for implementing the policy. Definition: Newborn: A child less than 28 days of age as reasonably determined by a physician. Procedure: 1. When a parent presents to any department of the Hospital and requests to relinquish the Newborn, greet him/her calmly. 2. Physically take the Newborn if the parent offers it. 3. Take the parent to a safe quiet place if he/she has not offered you the Newborn. Every effort should be made not to frighten the parent and to secure the Newborn as rapidly as possible. The parent is an individual in crisis and needs calm reassurance that you will protect his/her anonymity. 4. Do not ask the parent s name. Ask if you can call her Jane or him John. APPENDIX MM

296 Hospital of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 3 SUBJECT:NEWBORN SAFE HAVEN (ABANDONMENT OF NEWBORNS) Effective: 5/13/08 5. Reassure the parent that he/she is doing the right thing. Reassure him/her that the Newborn will receive the best of care. 6. Ask if he/she would be willing to share with you any information about the Newborn. For example: When was the baby born? Did she have any problems while she was pregnant? Did she take any medicine or smoke or use any alcohol or drugs while she was pregnant? Did she have any problems with the delivery? Was the baby born earlier than expected? Does the baby s father have any medical condition that she knows of? 7. Keep the conversation casual and non-threatening. Tell the parent you are asking for the information for the well being of the Newborn. 8. Ask the mother if she would like to see a physician. If she does and needs to be admitted, she may be admitted under an alias name. 9. The parent may leave before the screening of the Newborn is completed. Do not attempt to physically detain the parent. 10. The Department of Clinical Resource Management and Social Work should be notified as soon as possible and, depending on the presenting situation may be of assistance in the initial discussion with the parent. 11. Once a parent relinquishes a Newborn, the Newborn cannot be returned to the parent by the hospital. The relinquishing parent(s) should be referred to the County Office of Children, Youth and Families (CYF) at (215) No information should be given to television or newspaper reporters or anyone else. Principles of confidentiality should be observed. 13. The Newborn shall be taken to the Emergency Department, and registered as a critical care patient. For the Penn Institute of Rehabilitation Medicine, the following shall apply: a. The Social Worker on call shall be notified as soon as the Newborn is brought to the facility. b. The Social Worker shall then arrange for the transfer of the Newborn to the HUP Emergency Department, where the infant will be registered as a critical care patient. 14. The Neonatolgist on call shall examine the Newborn and make a determination about the infants care needs and the most appropriate place for that care to be given. 15. If the Department of Clinical Resource Management is not already involved, the on-call social worker should be notified as soon as the Newborn is brought to the Emergency Department. 16. If necessary, the infant will be transferred to the Children s Hospital of Philadelphia (CHOP). The transfer will be discussed with CYF. As part of a transfer report, CHOP will be notified of any contacts with outside agencies. APPENDIX MM

297 Hospital of the University of Pennsylvania POLICY MANUAL Number: Page 3 of 3 SUBJECT:NEWBORN SAFE HAVEN (ABANDONMENT OF NEWBORNS) Effective: 5/13/ If the Newborn is found to have evidence of child abuse or intentional injury on exam, the appropriate hospital personnel will notify the County CYF as outlined in policy # Assessment of Victims of Possible Abuse. 18. In the absence of child abuse, the Department of Clinical Resource Management and Social Work should notify the County CYF to report that a Newborn has been left at the hospital under the Newborn Protection Act and the parent s anonymity should be maintained. A similar report will be made to the local police department. 19. The Emergency Department shall notify the Chief Operating Officer and the Director of Public Affairs that the hospital has activated the Newborn Safe Haven Policy. 20. If the event should occur during nights, weekend, or holidays, the Nursing Coordinator should be notified. He/she will notify the Administrator on call and will be responsible for coordinating the response to the event with the Emergency Department staff, Neonatolgist, Security, and Social Worker on call as appropriate. 21. No hospital or health care provider at HUP shall be subject to civil liability or criminal penalty solely by reason of complying with the Newborn Protection Act except for failure to report acceptance. 22. A written report shall be sent to CYF and the local police department by the Executive Director or his/her designee within 48 hours of the verbal report being made. 23. Information regarding the Newborn Protection Act and this policy shall be made part of the orientation of new employees, 24. Material regarding the Pennsylvania Newborn Protection Program (Safe Haven) that may be distributed to the public is available through the Patient Family Education Center. Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. SUPERSEDES: 6/15/04 ISSUED BY: /s/ Garry L. Scheib APPENDIX MM

298 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 2 SUBJECT: NON-DISCRIMINATION Effective: 11/15/04 KEY WORDS: Non- Discrimination Equal Access to Care SEE ALSO: # Patients Rights and Responsibilities POLICY The Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) will provide inpatient and outpatient care (including admission, treatment, and discharge) in a manner that does not discriminate against patients, healthcare providers or HUP/CPUP staff on the basis of race, color, national origin, religious creed, sex, age, marital status, ancestry, sexual preference or gender identity. HUP/CPUP will not unlawfully discriminate against patients on the basis of physical or mental disability. PURPOSE The purpose of this policy is to prevent discrimination in the admission, treatment and discharge of HUP/CPUP patients. SCOPE The policy applies to all patients receiving inpatient or outpatient care at, and staff, medical staff, healthcare providers of the HUP and those parts of CPUP, which practice at or in conjunction with HUP as well as persons who and organizations which refer patients to HUP/CPUP for treatment or admission. PROCEDURE 1. Inpatient and outpatient care will be provided in a manner that does not discriminate against patients on the basis of race, color, national origin, age, sex, religious creed, marital status, ancestry, sexual preference or gender identity. Care will be provided in a manner which does not unlawfully discriminate against patients on the basis of physical or mental disability. In the event a healthcare provider or HUP/CPUP staff member receive a discriminatory request arising from a patient, co-worker or healthcare provider in connection with the provision of patient care, such requests shall be reported promptly to the appropriate manager/director, who shall then report such request to the Executive Director of HUP or the Executive Director of CPUP or his/her designee. 2. Patients are to be assigned to rooms, floors, sections, buildings, and other areas without regard to race, color, national origin, religious creed, marital status, ancestry, sexual preference or gender identity. SUPERSEDES: 2/28/98 H:\policies chapt 12\Non discrimination 2004.doc ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth Johnston APPENDIX NN

299 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 2 SUBJECT: NON-DISCRIMINATION Effective: 11/15/04 3. Patients and visitors have access to public areas without regard to race, color, national origin, religious creed, age, sex, marital status, ancestry, sexual preference, gender identity, or physical or mental disability. 4. Patients are not to be asked whether or not they are willing to share accommodations with persons of a different race, color, national origin, religious creed, age, marital status, ancestry, sexual preference, gender identity, or physical or mental disability, and requests for transfer on this basis shall not be honored. 5. All procedures regarding financial arrangements will be implemented without regard to race, color, national origin, religious creed, age, sex, marital status, ancestry, sexual preference, gender identity, or physical or mental disability. 6. Information about price and availability of accommodation will be provided without regard to race, color, national origin, religious creed, age, sex, marital status, ancestry, sexual preference, gender identity, or physical or mental disability. SUPERSEDES: 2/28/98 H:\policies chapt 12\Non discrimination 2004.doc ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth Johnston APPENDIX NN

300 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 5 SUBJECT: PATIENT IDENTIFICATION Effective: 9/15/05 KEY WORDS: Patient Identification Identification verification ID Bands SEE ALSO: # Occurrence Reporting # Patient Registration # Correct Patient, Procedure and Site Confirmation # Requisition and Transfusion of Blood and Blood Products # Patient Search, Selection and Assignment of a Medical Record Number POLICY It is the policy of the Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) that all patients be identified using two identifiers, the patient s full name or name by which he/she is known in medical documents and date of birth, prior to any treatment, administration of medications, procedure, or transport. If there are two patients with the same name and date of birth, the HUP/CPUP staff member will compare the Medical Record Number in the record with the Medical Record number on the patient s documentation as the third identifier. that the identification process is active, that is the patient is asked for the information, rather than being asked to confirm information given by the provider to verify that the treatment, procedure, etc., is being performed on the correct patient prior to its initiation. PURPOSE It is the purpose of this policy to define the mechanism by which patients are identified and the service or treatment is matched to the correct individual. SCOPE This policy applies to all staff of HUP or CPUP who have interaction with any patient of HUP or CPUP, including but not limited to procedure, administration of medication, treatment, registration, transport, and so forth. IMPLEMENTATION It is the responsibility of all staff to identify patients as outlined in this policy. Individual compliance with this policy shall be assessed as part of the annual performance appraisal process. Organizational compliance will be monitored by CEQI through review of occurrence reports. PROCEDURE A. Prior to any patient encounter, all patients must be registered. SUPERSEDES: 3/17/03 patient id 2005 ISSUED BY: /s/ C. William Hanson, III, M.D. /s/ David W. Kennedy, M.D. APPENDIX OO

301 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 5 SUBJECT: PATIENT IDENTIFICATION Effective: 9/15/05 B. Upon presentation to the Clinical Practices for an initial encounter or to the Hospital for admission, the patient will be asked to show picture identification. If the patient presents without picture identification, registration information must be verified at the point of service or at the nearest central registration point. C. Once correct registration is confirmed, all caregivers must confirm the correct patient identification and correct treatment of the patient using two unique identifiers. These identifiers are the patient s full name or name by which he/she is known in medical documents and date of birth. If there are two patients with the same name and date of birth, the HUP/CPUP staff member will compare the Medical Record Number in the record with the Medical Record number on the patient s documentation as the third identifier. Patient room number is not a unique identifier D. Every patient admitted to a Hospital bed or Hospital service or treated in the Emergency Department or Labor and Delivery shall have a patient identification band placed on his/her wrist (and/or ankle) before treatment is administered. No patient shall be accepted into a treatment or procedural area (PACU, angiography suite, outpatient chemotherapy, Cardiac Catheterization laboratory, any procedure areas involving sedation etc.) without a personal patient identification band. Newborns are identified and banded according to departmental procedures. E. When staff verbally communicates about a patient, whether over the telephone or in person, the patient s name and date of birth must be used. If there are two patients with the same name and date of birth, the HUP/CPUP staff member will compare the Medical Record Number in the record with the Medical Record number on the patient s documentation as the third identifier. The patient s room number cannot be used as a source of identification. F. Patients who require emergency life saving therapy may be treated prior to placing a band, however, the patient identification band must be placed on the patient immediately following the emergency treatment. G. When staff must choose a patient encounter/account from a list (for example on registration, or locating lab test results, etc.) the patient name, date of birth and event date should be used to assist in identifying the right patient. If there are two patients with the same name and date of birth, the HUP/CPUP staff member will compare the Medical Record Number in the record with the Medical Record number on the patient s documentation as the third identifier. H. PATIENTS WHO HAVE A PATIENT IDENTIFICATION BAND 1. The patient identification band of the patient who has been admitted to a Hospital bed or Hospital service will include the patient s name, medical record number, and date of birth, and sex. Patient identification bands for other patients in ambulatory care settings will include two unique identifiers. 2. When a patient identification band is placed, bands from all external facilities (including other UPHS entities) and jewelry that might be confused with a color coded identification band must be removed. SUPERSEDES: 3/17/03 patient id 2005 ISSUED BY: /s/ C. William Hanson, III, M.D. /s/ David W. Kennedy, M.D. APPENDIX OO

302 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 3 of 5 SUBJECT: PATIENT IDENTIFICATION Effective: 9/15/05 3. Where appropriate, additional color coded wrist/ankle band(s) will be placed in order to alert staff to allergies, similar names, and so forth. 4. Any caregiver or staff placing an identification band on a patient must first confirm the patient s identity by asking the patient to state his/her full name and date of birth to ensure accuracy. The identification bands must be worn at all times by patients and must be validated by the caregiver prior to any administration of medication, procedure or treatment. 5. Errors involving information on the identification band must be immediately communicated to the persons involved in the patient s care and the Department that originally issued the band for review and correction. 6. All HUP or CPUP personnel involved in the administration of any medication, treatment, diagnostic procedure, or transport of a patient must first confirm the patient information on the patient s band (name and birth date) with the patient and compare it to the information on the request form. In any situation of continuing one to-one care in which the caregiver knows the individual, one of the identifiers can be direct facial recognition. However, the presence of a correct identification band must be verified each time the caregiver administers medication, treatment or performs a diagnostic study. 7. If an identification band is removed from a patient for any reason, the person removing the band is responsible for immediately replacing the band with a new one. If a band falls off a patient, any staff member who becomes aware that the band is not in place should notify nursing personnel. It is the responsibility of nursing personnel to prepare a replacement band as soon as possible. The patient s identifying information shall be re-confirmed by asking the patient to state his full name and date of birth prior to replacing an identification band. 8. Every patient entering an operating room must have a patient identification band on his/her wrist (and/or ankle if appropriate) and verified before any treatment is begun. I. PATIENTS WITHOUT A PATIENT IDENTIFICATION BAND 1. For clinical areas where an identification band is not used, identification of patients must include date of birth in addition to the patient s full name or name by which he/she is known in medical documents. If there are two patients with the same name and date of birth, the HUP/CPUP staff member will compare the Medical Record Number in the record with the Medical Record number on the patient s documentation as the third identifier. 2. The patient shall take an active part in his/her identification by being asked to give his full name and other identifying information required. SUPERSEDES: 3/17/03 patient id 2005 ISSUED BY: /s/ C. William Hanson, III, M.D. /s/ David W. Kennedy, M.D. APPENDIX OO

303 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 4 of 5 SUBJECT: PATIENT IDENTIFICATION Effective: 9/15/05 3. The identifying information given by the patient must match the information on the request sheet, order sheet, or patient chart. 4. In an ambulatory care setting, the patient shall be asked to repeat his/her full name and other identifying information prior to being taken to a consultation/treatment room. 1. TELEPHONE CONTACTS: If the discussion is not occurring face to face, but by telephone, it is still necessary to identify the patient correctly using two identifiers. 1. These identifiers are the patient s full name or name by which he/she is known in medical documents and date of birth. 2. If there are two patients with the same name and date of birth, and the patient does not know his/her Medical Record Number, the last four digits of the Social Security number can be used as a third identifier. 3. If the patient does not have a social security number, identifiers such as the mother s or father s first name may be used. J. PATIENTS UNABLE TO RESPOND/IDENTIFY SELF (i.e., non- English speaking, cognitive impairment, unconscious) 1. If a person who is unable to respondis wearing a patient identification band, the information on the band must be compared to the information on the order or request sheet. 2. If a person who is unable to respond is not wearing a patient identification band, then identification must be confirmed by asking individuals who have accompanied or know the patient. This information should be confirmed by the patient as soon as he is able to respond. If the patient is not able to be identified, the patient will be assigned a name with sequential number and a new medical record number by designated personnel (e.g. TRAUMA, PATIENT or CRITICAL CARE, PATIENT and a sequential number) and a patient identification band with this information will be placed on the patient. K. VERIFICATION OF TREATMENT, PROCEDURES, ETC. Once proper identification of the patient is established, the intended clinical care should be confirmed with the patient or surrogate representative. 1. For tests, physician visits, treatment, the patient s active confirmation of the intended care should be used in the confirmation process. SUPERSEDES: 3/17/03 patient id 2005 ISSUED BY: /s/ C. William Hanson, III, M.D. /s/ David W. Kennedy, M.D. APPENDIX OO

304 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 5 of 5 SUBJECT: PATIENT IDENTIFICATION Effective: 9/15/05 2. For administration of medication, administration of blood or blood products, the product being administered should be checked against the order given. (See policy # ) 3. If there is any discrepancy in the confirmation of the patient's identification or proposed encounter, the treatments/medication/services/etc MUST NOT BE PROVIDED until the discrepancy can be resolved with the source requesting the service and in conjunction with the patient or surrogate decision-makers. L. OCCURRENCE REPORTING If any treatment, medication administration, procedure, etc., occurs in error, this should be reported through the occurrence reporting mechanism. Near misses should be reported also. See policy # , Occurrence Reporting. SUPERSEDES: 3/17/03 patient id 2005 ISSUED BY: /s/ C. William Hanson, III, M.D. /s/ David W. Kennedy, M.D. APPENDIX OO

305 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 3 SUBJECT: PROPERTY REMOVAL POLICY Effective: 9/01/08 KEY WORDS: Property Pass Personal Property UPHS (HUP/CPUP) Property SEE ALSO: # Security POLICY Property belonging to the Hospital of the University of Pennsylvania (HUP), Clinical Practices of the University of Pennsylvania (CPUP), and other entities of the University of Pennsylvania Health System (UPHS), may not be removed from the premises by anyone without a written authorization This includes property that is being moved from one UPHS site to another, other than delivery of routine equipment/supplies. In addition, persons removing personal property from the premises must be able to show written documentation that it is personal property.. PURPOSE The purpose of this policy is to establish a means to prevent unauthorized removal of UPHS property, to monitor off-site use of such property, and to maintain an on-going record of property that must be returned to UPHS. SCOPE This policy applies to all HUP, CPUP, Shared Services, and University staff, faculty or personnel, contractors, and others who may be required to remove UPHS, private or personal property from the Hospital of the University of Pennsylvania, Penn Tower, the Perelman Center for Advanced Medicine, the Penn Institute of Rehabilitation Medicine or from HUP/CPUP space in buildings in which HUP or CPUP is a tenant. IMPLEMENTATION This policy will be implemented by all department heads or designees, with the HUP Security Department having special responsibility as described below. PROCEDURE 1. Property removal can be authorized on a property pass form or on official letterhead. 2. Property Pass Form Departments may obtain a property pass from the Security Department. The department head or designee must complete the pass and sign it in order for an individual to remove UPHS or the personal property of HUP, CPUP, Shared Services, and University staff, faculty or personnel, and contractors from the premises. The department head or designee must identify legibly and precisely the property to be removed and the name of the person who will be removing the property. This information, along with the authorized signature, must appear on all three parts of the pass. The department head will keep their respective copy on file. 3. Official Letterhead The department can also create a property removal pass on Official Letterhead. The department head or designee must identify legibly and precisely the property to be removed and the name of the person who will be removing the property. This information, along with the authorized signature, must appear on this letter. The department must then or fax this letter to Security Department for proper documentation. APPENDIX PP

306 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 3 SUBJECT: PROPERTY REMOVAL POLICY Effective: 9/01/08 4. If a Property Pass is used, the three copies of the passed will be distributed as follows: First Copy (White) Handed to Security Department at time of removal from premises. Second Copy (Pink) Furnished to the individual who will be removing the property from premises. Third Copy (Green) Maintained by the issuing department director/designee for control purposes. 5. If authorization is written on letterhead the individual removing the property will have one copy, a second copy will be faxed or ed to HUP Security Department, and a third copy will be kept by the department for control purposes. 6. Property Removal When property is actually ready for removal from the facility, the individual transporting the property must present the completed form / letter and photo identification to the security officer at the point of exit. Following inspection of the property and review of the authorizing property pass, the individual will be permitted to remove the property from the facility. The inspecting Security officer will then initial the white copy of the property pass / letter and submit to the Security office. Note: Security s initialing of the Property Pass confirms the following: - Property Pass matches property to be removed from premises. - Photo Identification matches name on the Property Pass. 7. The issuing department will then be responsible for monitoring/controlling any expected date of return of the UPHS property removed from the premises. 8. Where there is no direct presence of HUP Security, the procedure outlined above will be followed however, the site manager or designated person is responsible for reviewing and initialing the white copy of the property pass / letter and faxing or ing this information to Security Department. 9. ADMINISTRATIVE PROPERTY PASS a. If an employee has a frequent occasion to remove UPHS property for off-site work-related purposes, the employee should ask his or her department head to request that the Security Department issue an administrative property pass. The Security Department will notify the appropriate authority of the request. Upon approval from the appropriate authority (Associate Director, Associate Executive Director, or Executive Director), the Department of Security will complete, initial, and issue the administrative property pass to the person removing the property. The person named on the pass shall present it to the Security Officer when the property is removed from the HUP/Penn Tower. b. Administrative property passes may also be issued to individuals who routinely take personal property (such as lap top computers) in and out of HUP, Penn Tower, the Perelman Center for Advanced Medicine, the Penn Institute of Rehabilitation Medicine, or buildings in which HUP or CPUP is a tenant. APPENDIX PP

307 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 3 of 3 SUBJECT: PROPERTY REMOVAL POLICY Effective: 9/01/08 c. An administrative property pass may be issued for up to a 12 month time period. A property pass is only valid for the time period noted on the pass. Property passes may then be renewed using the same procedure. d. The Director of Security, department heads, and authorized parties named in paragraph 9.a above, shall keep a list of administrative property passes requested and issued by their office. SUPERSEDES: 1/17/05 ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth Johnston Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX PP

308 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 2 SUBJECT: VIOLENCE IN THE WORKPLACE Effective: 9/01/08 KEY WORDS: Violence Security Incident Reporting Occurrence Reporting SEE ALSO: POLICY The Hospital of the University of Pennsylvania (HUP or Hospital) and the Clinical Practices of the University of Pennsylvania (CPUP) is committed to providing a safe workplace for all employees. In keeping with this commitment, HUP/CPUP has developed this policy enunciating a zero-level tolerance for all forms of violence in the workplace. # Weapons in the Hospital # Security # Occurrence Reporting PURPOSE for violence in the workplace to all employees. SCOPE The purposes of this policy are to protect the safety and welfare of our employees to the greatest extent possible; to provide a mechanism for reporting and tracking incidents of violence in the workplace; and to establish a system for training employees and communicating HUP/CPUP's zero-level tolerance This policy is intended to protect all employees of HUP/CPUP from incidents of violence involving co-workers, visitors, and patients. DEFINITION Violence in the workplace is defined as any incident of a threat or actual commission of an intentional harmful action against an employee by a co-worker, patient or visitor on HUP/CPUP premises. Violence in the workplace also includes any such threat or actual commission of a harmful action if the threat or action is precipitated by something which occurred while the employee was working. IMPLEMENTATION Implementation of this policy is the responsibility of all employees of HUP/CPUP. PROCESS 1. Handling of incidents of violence in the workplace: Incidents of violence in the workplace involving visitors to HUP/CPUP should be referred immediately to Security at x2677 from a HUP/CPUP phone at 3400 Spruce Street, the Perelman Center for Advanced Medicine, and Penn Tower. At the Penn Institute of Rehabilitation Medicine, assistance is available by dialing Security personnel are best equipped to evaluate the potential for violence and to diffuse a situation involving a visitor. During the period while Security personnel are in route to the scene of the incident, employees should not unnecessarily engage the aggressor but should take all steps necessary to safeguard themselves and their patients. Incidents of violence in the workplace involving patients are most often handled effectively by direct patient care providers without the intervention of Security personnel. Patient care providers should understand, however, that Security personnel are available at all time to assist in these matters. APPENDIX QQ

309 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 2 SUBJECT: VIOLENCE IN THE WORKPLACE Effective: 9/01/08 Incidents arising between co-workers should be mediated by their direct supervisors, with the assistance of the Human Resources generalist(s). All employees should understand that engaging in violence in the workplace (which, as defined in this policy, includes threats of violence) is grounds for discipline, including immediate discharge. Once again, Security personnel are available to intervene in these incidents when necessary or appropriate. 2. Reporting of incidents of violence in the workplace: Any employee who is a victim of an incident of violence in the workplace is required to report the incident immediately to his/her supervisor. No employee will be retaliated against for making a good faith report of an incident of violence in the workplace. Supervisors are required to ensure that the incident is immediately documented in the PENN Occurrence Reporting and Tracking System (PORTS), as well as any other required reporting mechanism, e.g., OSHA's Occupational Illness and Injury Log. Supervisors are also required to refer the affected employee to Occupational Medicine and/or the Employee Assistance Program ( ) for appropriate followup. Finally, supervisors are required to report the incident to their managers. HUP/CPUP will monitor incidents of violence in the workplace, as reported through PORTS and elsewhere, in order to ensure that all reasonable steps are being taken to minimize the potential for future incidents. 3. Training and communication with employees: All new employees will receive a copy of this policy during New Employee Orientation. All supervisors are required to provide a copy to each of their current employees. It is suggested that supervisors remind their employees of the contents of this policy, and offer a new copy, annually at the time of performance evaluations. Areas in HUP/CPUP which are at significant risk for incidents of violence in the workplace will receive specialized periodic in-service training from the Employee Assistance Program and Security Department regarding methods to prevent incidents and to minimize the potential for injury if an incident does occur. Any other area in HUP/CPUP which requests training will receive it. Requests for specialized training should be directed to your Human Resources Generalist. SUPERSEDES: 2/28/98 Workplace VIOLENCE ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth Johnston Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX QQ

310 SUBJECT: Hospital of the University of Pennsylvania POLICY MANUAL VISITATION RIGHTS FAMILY PRESENCE AND PARTICIPATION Number: Page 1 of 6 Effective: 4/22/11 KEY WORDS: Visitors Support Persons Family Visiting children Patient Rights SEE ALSO # Violence in the Workplace # Non Discrimination # Consent to Health Care Services # Patients Rights and Responsibilities # Advance Directive HIPAA Policies HUP Patient-and Family- Centered Care Initiative POLICY It is the policy of the Hospital of the University of Pennsylvania (HUP) to promote patient and family-centered care within the framework of providing a therapeutic environment for patients and a safe environment for patients, family, visitors, and staff. PURPOSE The purpose of this policy is to provide guidance regarding the presence and participation of families and to ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences and to promote a safe and therapeutic environment. SCOPE This policy applies to all persons admitted to a bed at HUP or a service at HUP (such as the Day Surgery Unit), their families, support persons, and visitors. It applies to all staff and employees of HUP. IMPLEMENTATION All staff and employees of HUP are responsible for implementing this policy. Departments listed below have specific responsibilities in implementation. The Patient and Family-Centered Care Steering Committee is responsible to monitor and evaluate this policy. KEY DEFINITIONS Patient- and family-centered care An innovative approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families. Patient- and familycentered care applies to patients of all ages, and it may be practiced in any health care setting. Family The Hospital of the University of Pennsylvania uses a broad definition of family as defined by each patient. This concept is recognized by the American Academy of Family Physicians, which defines family as a group of individuals with a continuing legal, genetic and/or emotional relationship (American Academy of Family Physicians, 2009). Patients and their families are respected as an essential part of the patient s network of caregivers working in concert with the health care team, helping to ensure quality and safety. Patients define their family and how they will be involved in care, care planning, and decision-making. Family members, as identified by the patient, provide support, comfort, and important information during ambulatory care experiences, a hospital stay in critical care, medical/surgical, and specialty units, in a an emergency room visit, and in the transition to home and community care. APPENDIX RR

311 SUBJECT: Hospital of the University of Pennsylvania POLICY MANUAL VISITATION RIGHTS FAMILY PRESENCE AND PARTICIPATION Number: Page 2 of 6 Effective: 4/22/11 Legally Authorized Representative A person authorized by law to consent to care for the patient. Examples include court appointed guardians, health care agents designated by patients in an advance directive or health care power of attorney, and health care representatives as specified by Pennsylvania Law (Act 169). The legally authorized representative gives consent for treatment when the patient is unable to do so. A support person (designated when the patient was competent) may or may not be the patient s legally authorized representative. Visitors Visitors include family members, friends, and guests of the patient who come to see the patient during the hospitalization. Visitors may include, but not be limited to a spouse, a domestic partner, including samesex domestic partner, another family member, a friend, etc. Visiting hospitalized loved ones is a traditional way of showing support and offering encouragement. Patients (or their support person) may designate anyone as an approved visitor. Support Person This may be a family member, friend, or other individual of the patient s choice whose presence with the patient provides emotional support, comfort, and alleviates fear during the course of the hospital stay. This individual may or may not be the patient s legally authorized representative. The patient designates their support person. The clinical staff will work with the patient and their designated support person to achieve goals of care and plan for care after the hospitalization. PROCEDURE The following procedure is intended to be flexible in order to respond to the diverse and individual needs and preferences of each patient and unanticipated or unique circumstances, as well as to assure the safety of patients, families and staff. The Hospital may restrict visitation when there is a clinical or safety reason to do so. Circumstances under which visitation may be limited or restricted are described in paragraphs 9 through 11 below. The patient and/or his/her family and/or support person will be informed of visitation rights and limitations. 1. Identification of the Support Person a. The admitting nurse will ask the patient to identify their support person and indicate how they would like them to be involved in their care and decision-making. Ask if there is a legally authorized representative established in an Advance Directive or Health Care Power of Attorney. Clarify patient preferences regarding who may be present during rounds, change of shift report, exams, and procedures. b. Document this information in the medical record and discuss with the care team. c. Patients may modify their preferences during their hospital stay. 2. The Hospital will not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability. All visitors APPENDIX RR

312 SUBJECT: Hospital of the University of Pennsylvania POLICY MANUAL VISITATION RIGHTS FAMILY PRESENCE AND PARTICIPATION Number: Page 3 of 6 Effective: 4/22/11 enjoy full and equal visitation privileges consistent with patient privileges and the limitations set forth in this policy. 3. Identification Bands for Support Persons (Blue Bands) a. The nurse will place a BLUE identification bracelet marked with the patient s name and inpatient location on the individual designated by the patient as their support person. b. The patient will be given a document to sign indicating whether they have identified a support person. The nurse will place the document in the patient s chart. c. The nurse will explain the reason for the identification band and provide an information sheet outlining the role and resources for the inpatient s support person(s). d. The nurse will instruct the support person to display their identification band to Information Desk Staff and Security Officers when entering the hospital and whenever requested by hospital staff. When the main entrance information desk is closed for the evening, security officers may verify the individual and the inpatient unit location. If verified, the security officer will not be required to call the inpatient-nursing unit to determine if the support person may come to the unit. This verification process may be adjusted based on the discretion of the security supervisor. 4. Nurses, social workers and others on the health care team provide guidance to patients and their families/support person in a variety of ways over time about: a. How to work with staff to ensure patient safety and quality of care; b. How to be involved in care, care planning, and decision-making, and how to support the patient during the hospital stay and during the transition to home and community care; and c. How to honor privacy and be respectful of other patients and families in close proximity or who share the same patient room. 5. Accommodations for overnight stay a. Families are welcome 24 hours a day according to patient preference. b. All hospital staff and clinicians encourage support persons and families to be involved in care according to patient preference. c. When the patient s support person or a family member plans to remain in the hospital overnight, the nursing staff will identify resources and locations taking into consideration the needs of other patients and families in the area. In situations where there are shared rooms, this may include discussion with the other patient, his or her family and/or support person at the discretion of the nurse on duty. 6. Patients, families, nurses, and other members of the health care team can ask to reevaluate or modify the presence and participation of families and support persons. All such collaborative decisions should be documented in the patient record. a. The number of people welcomed at the bedside at any one time will be determined in collaboration with the patient and family. Assess the patient s preferences regarding the number of visitors desired at one time. Be aware that cultural values may affect the size and involvement of family. If the patient wants fewer people in the room, or if you are examining the patient or sharing confidential information, consider asking the family to step out of the room. b. The number of persons in the room with a patient may be limited due to concerns about infection control/or safety. (See paragraph 10) APPENDIX RR

313 SUBJECT: Hospital of the University of Pennsylvania POLICY MANUAL VISITATION RIGHTS FAMILY PRESENCE AND PARTICIPATION Number: Page 4 of 6 Effective: 4/22/11 7. Supporting Children s Presence a. Patients may want or need to see children during their inpatient stay. b. Children supervised by an adult are welcome to visit and are not restricted by age. c. Visiting by young children should be planned in collaboration with the patient, family, and nursing staff. Children are prepared for the hospital environment and the family member s illness as appropriate. d. Children are expected to remain with the adult who is supervising them at all times. e. Children s behavior is monitored by the responsible adult and the nurse to ensure a safe and restful environment for the patient(s) and a positive and developmentally appropriate experience for children. 8. If a patient cannot identify a support person: a. Hospital staff make decisions based on the immediate circumstances and information available at the time b. Staff welcomes whoever arrives with the patient using a broad definition of family. c. Decisions about the presence of family and other support persons made under emergency situations may need to be revised. Consult the Department of Clinical Resource Management and Social Work or Office of General Counsel for assistance in identifying and/or determining the legal authorized representative. (See Policy # Consent to Health Care Services and Tools for Consent ) d. Various forms of proof may help establish a support person s status as such. These include, e.g.,: 1. Advance directive 2. Written documentation of the patient s chosen individual even if not an advance directive 3. Shared residence 4. Shared ownership of property or business 5. Financial interdependence 6. Marital relationship status 7. Existence of a legal relationship recognized in another jurisdiction, e.g., parent, child, civil union, marriage, domestic partnership 8. Acknowledgment of a committed relationship, such as through an affidavit 9. Disruptive and Unsafe Practice: Disruptive behavior and unsafe practices are not acceptable; these situations, while usually rare, will be addressed directly and promptly. Behavior that creates a risk of threat to patient, families or staff may lead to the disruptive person having to leave the hospital. a. If threatening or risky behavior is observed, staff members will work with their manager/nursing coordinator and Security to assess the actual risk. b. If necessary, staff/manager/coordinator/security should develop and implement a plan to ask the individual to leave. c. Complete a safety report regarding the unsafe situation. d. Interactions with unsafe individuals will be handled respectfully. e. Security, in collaboration with Nursing and other administrative staff, will determine if and when a disruptive family member, support person, or visitor may return to the hospital premises. APPENDIX RR

314 SUBJECT: Hospital of the University of Pennsylvania POLICY MANUAL VISITATION RIGHTS FAMILY PRESENCE AND PARTICIPATION Number: Page 5 of 6 Effective: 4/22/ Infection Control Considerations a. All families, support individuals, and visitors must be free of communicable disease and must follow the Hospital s/health System s infection control policies. Isolation precautions must be followed. b. Individuals with acute respiratory illness, colds, flu, fever, diarrhea, active tuberculosis, chickenpox, shingles, measles, mumps, or certain skin infections should not be present in the inpatient setting. c. Individuals who have been exposed to chickenpox, measles, mumps, or pertussis (whooping cough) should not enter the hospital until they have consulted with their primary care provider to determine whether they are susceptible to the infection. If they are susceptible, they should not enter the hospital for three weeks following their last exposure. If there are questions or concerns, consult Infection Control. d. In the event of an end-of- life or emergent situation, where the question arises of possible exception(s) to these restrictions, Infection Control consultation should be obtained and Patient and Guest Relations notified. 1) If an outbreak or infection requires restrictions for public health, the staff must collaborate with the patient and family to ensure that selected family members are still welcomed and able to offer emotional support to the patient to the extent feasible while assuring safety and infection control. 11. Considerations for Restrictions or Limitations of Visitors a. Individuals will be denied access to the patient if there is a court order or other legal documentation in the chart prohibiting or limiting their contact or access to the patient (e.g., custody issues, applicable restraining orders etc.). Contact a social worker, manager, or Patient and Guest Relations to facilitate appropriate restrictions, and the Office of General Counsel to advise regarding the meaning and applicability of such legal documentation. b. Behavior presenting a direct risk or threat to the patient, hospital staff, or others in the immediate environment. c. Behavior disruptive of the functioning of the patient care unit. d. Reasonable limitations on the number of visitors at any one time. e. Patient s risk of infection by the visitor, f. Visitor s risk of infection by the patient. g. Extraordinary protections because of a pandemic or infectious disease outbreak. h. Substance abuse treatment protocols requiring restricted visitation. i. Need for privacy or rest by another individual in the patient s shared room. The information or justification for visitation restrictions and limitations should be documented in the medical record. It is not possible to delineate or anticipate every clinical or safety reason that could warrant restrictions or limitations on patient visitations. The Hospital reserves the right to determine any other situation where it deems it necessary to limit visitation. When such situations occur, this should be explained to the patient. 12. When potential problems with support persons or family members are identified, staff should use a multidisciplinary approach to problem solving and are encouraged to seek consultation early. Consultation is available from any of the following: APPENDIX RR

315 SUBJECT: Hospital of the University of Pennsylvania POLICY MANUAL VISITATION RIGHTS FAMILY PRESENCE AND PARTICIPATION Number: Page 6 of 6 Effective: 4/22/11 Any member of Nursing Leadership group. Social Work Physicians Ethics consultation service Pastoral Care Patient and Guest Relations Key References Department of Health and Human Services, Centers for Medicare and Medicaid Services, 42 CFR Parts 482, 485. Changes to the Hospital and Critical Access Hospital Conditions of Participation to Ensure Visitation Rights for All Patients. Federal Register, Vol. 75 (223): Friday November 19, Institute for Patient- and Family-Centered Care. Changing hospital visiting policies and practices: supporting family presence and participation. August Neal A, Twibell R, Osborne KE, Harris D. Providing family-friendly care-even when stress is high and time is short. American Nurse Today. November The Joint Commission Standard RI The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and Family- Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL: The Joint Commission, The White House Office of the Press Secretary Presidential Memorandum for the Secretary of Health and Human Services - Hospital Visitation. Released April 15, SUPERSEDES: Visiting Policy (5/13/2008), # Family Member. Remaining Overnight (8/15/1996) Visitation Rights draft final ISSUED BY: /s/ Garry L. Scheib Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX RR

316 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 4 SUBJECT: SAFE MEDICAL DEVICES ACT Effective: 5/25/07 KEY WORDS:.POLICY Safe Medical Devices Act SMDA Device tracking Device failure SEE ALSO: # Medical Devices Implant Tracking UPHS Safety Policy on Product Recall To comply with the provisions of the Safe Medical Devices Act of 1990 (SMDA) (Pub. L. No ), the Medical Center has established a procedure for identification and reporting of adverse incidents involving a medical device. Any physician or other Medical Center health care worker or employee who becomes aware of information that reasonably suggests that a device was involved in (caused or contributed to) an incident resulting in an illness or injury or death of a patient or an employee or person affiliated with the Medical Center who suffered death or serious injury from a device used at the Medical Center (or that immediate medical or surgical intervention was required to prevent such illness, injury or death), will report this information in accordance with the procedures set forth in this policy. The device(s) involved shall be handled as set forth in this policy. For the purposes of this policy, a device should be understood to mean anything used in the diagnosis or treatment of a patient that is not a drug. PURPOSE The purpose of this policy is to set forth the procedures for compliance with the provisions of the SMDA. SCOPE This policy applies to all health care workers and employees of the Hospital and Medical Center including all outpatient diagnostic and outpatient treatment facilities and ambulatory care facilities. DEFINITIONS 1. Safe Medical Devices Act - The Safe Medical Devices Act (SMDA) of 1990 and accompanying regulations require certain health care facilities, including parts of the Medical Center and ambulatory care facilities, outpatient diagnostic and outpatient treatment facilities to report certain device related incidents to the manufacturer of the device and, if a death is involved, to the FDA. Such reports must be made within ten (10) working days after the facility becomes aware of the incident. The health care facility is held to have knowledge of an incident under the SMDA if any health care facility health care worker has such knowledge. 2. Device - An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part or accessory, which is: (1) recognized in the official National Formulary, or the United States Pharmacopeia, or any supplement to them, SUPERSEDES: 22/28/98 J:\bauers documents\policies\policies chapt 5\ smda 2007.doc ISSUED BY: /s/ Garry l. Scheib /s/ Elizabeth Johnston APPENDIX SS

317 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 4 SUBJECT: SAFE MEDICAL DEVICES ACT Effective: 5/25/07 (2) intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, or (3) intended to affect the structure or any function of the body, and which does not achieve any of its principal intended purposes through chemical action within or on the body and which is not dependent upon being metabolized for the achievement of any of its principal intended purposes. This definition is a matter of federal law. In essence, anything that is not a drug can be a device. Examples include, but are not limited to: anesthesia machine, pacemaker, heart valve, suture, surgical sponge, wheelchair, hospital bed or gurney, catheter, infusion pump, dialysis machine, artificial joint. 3. Health care worker - Employees, physicians, nurses, other allied health professionals, students, volunteers, and all other persons involved in providing health care to Medical Center, outpatient diagnostic and outpatient treatment facilities and ambulatory care facility patients. 4. Patient of the facility - means: (1) any individual who is being diagnosed or treated and/or receiving medical care at or under the control or authority of the facility. (2) an employee of the facility or individual affiliated with the facility who in the course of their duties suffers a device related death or serious injury that has or may have been contributed to by a device used by the facility. IMPLEMENTATION 1. Identifying and Reporting Incidents a. Primary responsibility for identifying and reporting adverse patient incidents involving devices rests with the health care workers directly involved with patient care. b. Secondary responsibility for reporting rests with other health care workers and Medical Center and ambulatory care facility, or outpatient diagnostic/ treatment facility, employees who are device users, who repair devices or provide preventive maintenance, or who review patient care. 2. Device Handling This will be performed by the department (Operations and Maintenance, Clinical Engineering, or Materials Management) most appropriate for handling the device. 3. Compliance Compliance will be monitored by Risk Management. SUPERSEDES: 22/28/98 J:\bauers documents\policies\policies chapt 5\ smda 2007.doc ISSUED BY: /s/ Garry l. Scheib /s/ Elizabeth Johnston APPENDIX SS

318 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 3 of 4 SUBJECT: SAFE MEDICAL DEVICES ACT Effective: 5/25/07 PROCEDURE I. Reporting within the Facility When any physician or other Medical Center health care worker or employee becomes aware of information that reasonably suggests that a device was involved in an incident that has or may have caused or contributed to an illness or injury or death of a patient (or that medical or surgical intervention was required to prevent such illness, injury or death), he/she will report this information using the standard form and procedure (See HUP Policy # , Incident Reporting.) Such events may have occurred as a result of (1) failure; (2) malfunction; (3) improper or inadequate design; (4) manufacture; (5) labeling; or (6) user error. Risk Management must be notified immediately by telephoning ( ). The Incident Report must be entered into the PORTS: Penn Occurrence Reporting and Tracking System (electronic Incident Reporting System) immediately. To the extent that the following information is known, it should be included in the report along with the usual incident information: names of persons likely to have knowledge of the event device information (type, manufacturer, model number, lot number, serial number or any other identifying information) current location of device Multiple reports of the same incident Under this policy, several persons may have an obligation to report the same incident. All such persons have the obligation to report unless they are informed by Risk Management that a PORTS report already has been received. II. Disposition of the device A device involved in an incident that has or may have caused or contributed to a serious injury or death must be sequestered, impounded and evaluated. Secure the device, including packaging. Place it where it cannot be used or accessed and tag it "DEFECTIVE." Handling of such a device shall follow the guidelines set forth in the Incident Reporting Policy. A device that is contaminated shall be handled following the guidelines set forth in the Infection Control Manual. A. The user/reporter shall notify the department that supplies or maintains the device so that the department can take appropriate action. B. Clinical Engineering must be notified immediately by telephone ( ) if the incident involves any medical equipment. C. If the device is available at the time the incident is discovered, the reporter of the incident is responsible for the following: SUPERSEDES: 22/28/98 J:\bauers documents\policies\policies chapt 5\ smda 2007.doc ISSUED BY: /s/ Garry l. Scheib /s/ Elizabeth Johnston APPENDIX SS

319 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 4 of 4 SUBJECT: SAFE MEDICAL DEVICES ACT Effective: 5/25/07 1. A non-disposable device must be labeled and identified on the PORTS Report. The department that services the device shall be notified so that it can evaluate and repair/replace the device as appropriate. 2. A disposable device shall be bagged, labeled, and identified on the PORTS Report. Such a device shall be delivered to the Risk Management Office, if appropriate. 3. A device that is removed from the patient by surgical procedure shall be bagged and labeled and delivered to Pathology for examination. D. Under no circumstance is any device, whether electrical or otherwise, to be returned to the vendor or manufacturer without approval by Clinical Engineering and Risk Management. III. Reporting outside the Medical Center of device-related incidents A. Risk Management will determine whether a particular incident must be reported under the SMDA, and will file the required reports within 10 (ten work days (Monday-Friday, excluding Federal Holidays)) of the facility becoming aware of the event. Risk Management will maintain the required system of records. B. Other departments, including but not limited to Clinical Engineering, Operations and Maintenance, Materials Management, Nursing, Medical Records, Clinical Resource Management, and all clinical departments shall cooperate with and assist Risk Management in obtaining the information and doing the work necessary to comply with the reporting requirements. IV. Requests from persons, agencies or entities outside the Medical Center for information concerning device-related incidents All information related in any way to a device-related incident shall be treated as confidential patientrelated information and, as appropriate, as confidential peer review/quality assurance information and/or as confidential attorney-client communications. All requests for such information from government agencies, device manufacturers or distributors shall be referred to, and reported to, Risk Management at (215) SUPERSEDES: 22/28/98 J:\bauers documents\policies\policies chapt 5\ smda 2007.doc ISSUED BY: /s/ Garry l. Scheib /s/ Elizabeth Johnston APPENDIX SS

320 UPDATED 5/9/2011 HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA DEPARTMENT OF RADIOLOGY REQUISITIONS FOR RADIOLOGIC EXAMINATIONS 3/30/90 Policy There shall be a specific written order for any examination performed in the Department of Radiology. Purpose The purpose of this policy is to ensure that the appropriate examination is requested and performed on all radiology patients. Scope This policy applies to all clinical sections in the Department of Radiology. Implementation The implementation of this policy is the responsibility of Radiology Section Supervisors and employees. Procedure Every examination performed in the department of Radiology will be done at the request of a referring MD. The request for the examination must be in writing and available when the patient presents in Radiology. The request must include at least two patient identifiers, pertinent clinical history and examination requested. If the patient presents without a written request form, the patient MD will be notified and examination order acquired at that time. Inpatient, Emergency Room and some Outpatient exam orders are processed through the on line examination ordering system. The examination requisition will print in the radiology department once an MD places the order in the ordering system. Once a patient arrives in Radiology, the Radiology exam order is reviewed by the radiographer performing the examination. This is done in advance of the examination to ensure orders requested, clinical history, etc. APPENDIX TT

321 UPDATED 5/9/2011 HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA DEPARTMENT OF RADIOLOGY SAFETY PRECAUTIONS IN THE PARENTERAL ADMINISTRATION OF DIAGNOSTIC AGENTS 7/94 Policy The Department of Radiology shall have a policy to monitor safety precautions in the parenteral administration of diagnostic agents. Purpose To be prepared to treat any reaction to contrast media while patients are having diagnostic studies, since potential reactions cannot be predicted. Procedure 1. Code cart and O2 tank are available in all areas that use contrast media. These areas include: Angiography, Neuroradiology, GI/GU, MRI, Perelman Center and CT. 2. All new radiographers and staff are oriented to their location. 3. No intravascular contrast medium examination is started unless the Radiologist, Nurse or Radiographer has interviewed the patient to identify the risk factor and/or presence of allergy. 4. If a major reaction appears to be developing, the radiologist should quickly diagnose the type and immediately begin to treat it, at the same time sending for skilled help by calling a Rapid Response ( ) or by placing a CODE CALL if necessary. (Dial CODE: State section and location to operator). 5. All radiographers are oriented by nurse to location of CODE CALL equipment. This is done as part of the orientation of all new employees and reviewed with all employees annually. 6. IR, Neuroradiology, CT, Perelman, Nuclear Medicine and GI/GU have available cardiac monitors, defibrillators, and suction apparatus. 7. All radiographers and technical aides are BLS certified. Radiology nurses are ACLS certified. In-service records for non-physicians are maintained in the Radiology Administrator's office. APPENDIX UU

322 8. Equipment needed to start an intravenous is available in all above areas. APPENDIX UU

323 Hospital of the University of Pennsylvania Department of Radiology POLICY MANUAL Number: Page 1 of 1 SUBJECT: Contrast Media Storage Effective: 4/10/2006 UPDATED 5/9/2011 POLICY All radiology contrast media will be stored according to manufacturer s specifications. PURPOSE It is the purpose of this policy to establish practices for the safe storage of contrast media. SCOPE This policy applies to all radiology sections in which contrast media is required and stored. IMPLEMENTATION It is the responsibility of each section chief/manager to educate section staff on appropriate procedures and monitor that those procedures are followed. It is the responsibility of every employee to follow established practices. PROCEDURE 1. Storage temperature ranges for each specific contrast product is established by the manufacturer of that product. 2. A first-in-first-out log which tracks contrast medium by lot number is kept with each contrast warmer. 3. Notation of contrast media stored and used is made on the log. 4. A traceable thermometer is kept on each warmer. 5. Temperature of the warmer is check at the beginning of each shift and noted on the log. SUPERSEDES: NEW ISSUED BY: APPENDIX VV

324 Updated May 26, 2011 Department of Radiology Emergency Response Policies and Procedures September 2003 The policies within this packet have been developed for the Department of Radiology in conjunction with, and as a supplement to, Hospital-wide policies and procedures. It is the responsibility of all Department members to be familiar with the content of this procedure and to proceed accordingly when an emergency response condition occurs. The hospital Emergency Notification System (ENS) will notify the Chairman of the Department of Radiology and the Radiology Director and of an emergency and the department phone tree and/or department ENS can be started as detailed below. Additional personnel that may need to be contacted in an emergency are: Radiology Director: Ann Costello Radiology Chair: Nick Bryan, MD, PhD Office: Office: Cell: Cell: Home: Home: Department Fire/Safety Officer: John Detruf Radiology Vice-Chair: Michael Bleshman, MD Office: Office: Cell: Cell: Home: Home: Personal Cell: Department Nurse Manager: Sue Sweeney Vice-Chair Informatics: Curtis Langlotz, MD Office: Office: Pager: Cell: HUP Cell: Personal Cell: Home: Associate Chair, Inpatient Operations: Bill Stavropoulos, MD Office: Cell: Home: Department of Radiology Emergency Response Policy: It is the policy of the Department of Radiology to establish and follow the specified procedures described below and to initiate and proceed accordingly during conditions of an emergency disaster. During any emergency event, all Radiology personnel must wear their HUP identification badges. Purpose: To clearly delineate personnel responsibilities during an emergency disaster. Scope: All department members must observe the procedures identified in this policy. Procedure: Implementation of the Emergency Plan APPENDIX WW

325 The UPHS operator/administration will make contact with the Chairman of the Department of Radiology (Nick Bryan) and back-up (Michael Bleshman) and the Radiology Director (Ann Costello) and back-up (John Detruf) for the emergency through the Emergency Notification System (ENS). 1. The first act will be for the Radiology Director or back-up to contact the highest ranking radiology physician in the hospital (Chair, On-call Attending or On-call Resident) to assess the situation and the resources that may be needed. Once the situation has been assessed the Radiology Director will go to the HUP Command Center which is at 106 Dulles (backup Command Center is the ED Conference room) for additional information and to obtain hand-held radio. 2. In case of large-scale emergency: Radiology Director or back-up will begin phone chain activating the Radiology group on the UPHS ENS which consists of Radiology Modality Supervisors including the Nursing Supervisor. The IT Single Point of Contact will also be contacted. 3. Supervisors will contact attending physicians on-call for given section. 4. Supervisors will then contact appropriate technologists and/or nurses in their modality. 5. Attending physicians who are on-call will contact Section Chiefs in their section. If Radiology services will not be immediately affected: 1. In the event that radiology services will not be affected by the emergency event, supervisors should remain available and prepared if the status changes. 2. Primary communication to the section supervisors will be the responsibility of one of the following individuals: Department Director, Department Fire/Safety Officer, and Department Nurse Manager. If Radiology Services will be affected: 1. Depending on the disaster, a meeting may be arranged with the section supervisors to describe the disaster and to specify the plan of action, including instructions regarding the need to discontinue normal patient exams, and to remove patients from the designated areas. 2. If/when the decision to evacuate inpatients is made; radiology clinical staff are required to transport patients to their inpatient rooms. At least one employee must be specifically designated to stay with and monitor patients still in the Department. The department nurses are responsible for monitoring and verifying that each patient is stable, and can be moved safely. If a patient needs special attention, a physician and/or nurse must accompany the patient to the floor. APPENDIX WW

326 3. Each radiology nurse will report to area assigned by Director, Safety Officer, or nurse manager. Nurse will provide appropriate treatment as needed with the assistance of a department physician. 4. Outpatients will be apprised of the circumstances, and informed of their ability to leave building. These patients will also be given instructions about rescheduling their exams if necessary. 5. Employees who are working in nonclinical areas should report to clinical areas as instructed by their supervisor. 6. Clinical Radiology Information Systems downtime procedures will be implemented as needed. Emergency Classification: Emergency events at HUP are classified as either External, Internal or Access emergencies. An External emergency is an incident outside of the hospital that causes a large influx of patients into the Emergency Room such as a mass casualty incident. An Internal emergency is an incident that occurs within the hospital, such as a water pipe break and flood, and may impact the ability to complete procedures. An Access emergency is an event that makes it difficult for staff to gain access to the hospital such as a large snowstorm. External Emergency Response: With a large influx of casualties, a primary consideration will be the volume of patients requiring radiology services and the demand that may be placed on the Radiology Department. The following guidelines will be followed. 1. Notification of an External emergency will be announced via the overhead paging system. There may be a follow-up phone call from the hospital telephone operator or from the HUP Command Center ( ) to the Radiology Director. The Radiology director and Radiology Chairman are also on the Emergency Notification System list for the hospital and will receive any alerts sent via that system. The Radiology Director will notify the Department Chairman or highest-ranking Radiology physician in the Department at the time of the Emergency. The Radiology Director will begin phone chain which involves activating the Radiology group on the UPHS ENS (consisting of Radiology Modality Supervisors including the Nursing Supervisor) and will be in charge of the ALERT in the Radiology Department. The IT Single Point of Contact will also be contacted. On nights, weekends, and holidays, the highest ranking MD or resident on duty will implement and be in charge of the ALERT until the arrival of the Radiology Director. 2. The director/radiologist in charge will go to the HUP Emergency Department to assess the extent of the disaster; type of x-ray examinations to be expected and the volume of patients. The decision will be made by the director/radiologist, according to volume of patients expected in APPENDIX WW

327 Radiology, how many people will be needed to put this Emergency Plan into action. 3. The director/radiologist will notify the receptionist and the technologists on duty to notify their supervisors. Supervisors will be contacted at home based on the volume of patients expected. They will be instructed to call in their staff and the attending physicians on-call for their modality based on need. Phone numbers for staff are in the Chest/Bone Control Room, they are updated quarterly by the Radiology Director. 4. The Supervisor of the shift will: 1. Review patients presented in the Department and examinations in progress, assess the need to cancel, reschedule or postpone regularly scheduled appointments 2. Stop the scheduling of inpatients and outpatients 3. Assign available staff (and additional staff as they arrive) to sections where needed to handle demand 4. Have one additional portable unit brought to the Emergency Department. Internal or Access Emergency Response: It will be necessary to determine if the event is impacting the operations of Radiology or may impact appointments, schedules or the ability of staff to complete their work schedules or get into work. 1. The Director or designee will stay in contact with the HUP Command Center ( ) or Administration to determine the impact of the internal or access event on the Radiology department. 2. Follow guidelines as noted above under Implementation of the Emergency Plan. Additional guidelines for: Coordinating Patient Evacuation Information: Radiology Safety officer and Nurse Manager will circulate through the Department to provide instructions to section supervisors as needed, and to feed back information to the Chairman/Director acting as the principal department coordinator. Evacuation of Disabled Employees: If the Internal Emergency is determined to require evacuation of employees, employees with known handicaps will be assisted to a designated safe location by a staff member in his/her section immediately after the evacuation alert has been sounded. Radiation Exposure: If the disaster involves concerns involving radioactive exposure, this will be handled by the radiation safety department of the University of Pennsylvania. The contact with this office will be handled by the department director or designee. Release of Radiology Personnel: During or after a declared Emergency, it may be necessary to dismiss personnel for the following reasons: APPENDIX WW

328 1. An employee may be concerned about his/her family and/or possessions, in the event that someone was involved with the ALERT, and desires to go home. 2. An employee may have difficulty with child/elderly care due to events related to the ALERT in his/her environment. This may have necessitated bringing the dependents to work. 3. An employee may be emotionally upset by the event and desire to go home. The decision regarding the above circumstances will be handled by the employee's immediate supervisor. If this individual is not available, the Radiology Director will make the decision. No employee should leave the Hospital without approval. Radiology Procedures for Unexpected Downtime of Radiology Information Systems: If the RIS is unavailable: 1) Immediately call the single point of contact (SPOC) support line ( ). 2) Any orders that were completed before the system went down are likely available in Talk, and can be reported there. 3) If SPOC is unable to bring the system back up within 30 minutes, call SPOC again to confirm that you should begin using paper/phone downtime procedures, as follows: a) Inform callers that anyone wishing to schedule an exam must call radiology scheduling ( ). b) Call in backup resident to answer ED reading room phone ( ) and provide preliminary readings to referring providers who call. c) Use paper forms as a substitute work list, writing preliminary readings on the forms. d) Use Talk to dictate the report. At the beginning of each report, dictate the control number from the paper form along with the patient name, MRN, DOB, date of service, exam time, exam code, and radiologist(s) names. The report will be held in Talk and will be sent to the RIS when it becomes available. e) Any verbal communication of results must be documented on the paper form or in the dictated report. f) File paper forms in an accordion folder in ED reading room, where they can be used to provide preliminary readings to referring providers who call. If the GE PACS is unavailable: 1) Immediately call the single point of contact (SPOC) support line ( ). 2) If SPOC is unable to bring the system back up within 30 minutes (15 minutes for chest/bone), call SPOC again to confirm that you should begin using Terarecon. 3) If necessary, remind technologists to send images to downtime destination. APPENDIX WW

329 4) Start Terarecon, which is installed on all PACS workstations in the department. In the event of a problem using Terarecon, contact the SPOC support line ( ). 5) Use the RIS work list to select cases. Launch the cases manually on Terarecon for interpretation. 6) Referring providers will need to visit the reading room if they wish to view images. If Talk is unavailable: 1) Use GE speech recognition If there is a data center outage or a loss of connectivity to the data center: It is likely that both RIS and PACS will be unavailable. 1) Immediately call the single point of contact (SPOC) support line ( ). 2) If SPOC is unable to bring the system back up within 30 minutes (15 minutes for chest/bone), call SPOC again to confirm that you should begin using PACS-IW. 3) If necessary, remind technologists to send images to downtime destinations. 4) Images sent to downtime destinations can be viewed on PACS-IW, which is installed on all PACS workstations in the department. In the event of a problem using PACS-IW, contact the SPOC support line ( ). 5) For orders and reports, use the RIS downtime procedures described above. 6) Referring providers will need to visit the reading room if they wish to view images. If there is an internal network outage: The network may be completely unavailable or partially unavailable, and can exhibit many different failure modes, so some flexibility is required in response to network downtimes: 1) If SPOC believes that a network outage is causing the problem you are experiencing, they may ask you to describe the issue to UPHS desktop support ( ), which is responsible for maintaining the network. 2) If the RIS loses connectivity, Talk may be usable as a backup reporting system. Otherwise, institute RIS downtime plan as above. 3) If the PACS loses connectivity but Terarecon does not, institute PACS downtime plan as above. 4) If the modalities cannot send images, or if no image viewing software is functional, images must be reviewed on the modality consoles. If there is a Complete Power Failure If there is a hospital-wide power failure, the CT scanner in the ED is connected to the emergency power. Portable plain x-ray units can be used with the red emergency outlets. These can be brought to the ED if needed and/or can be used to take ICU images. The CT images will be read off the CT scanner by the body imaging radiologist or in-house on call radiologist if power failure occurs after hours. An Emergency Downtime report APPENDIX WW

330 book will be kept in the ED CT control room and paper reports will be written in this report book until power and RIS dictation system is restored. Update Record Date Revision Team V1.0 Stavropoulos, Langlotz, Costello, Bryan, Bleshman V1.0 Langlotz, Stavropoulos, Costello V1.1 Stavropoulos, Costello APPENDIX WW

331 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL SUBJECT:DISCLOSURE OF INFORMATION FROM THE PATIENT INFORMATION SYSTEM Number: 1-12-H6 Page 1 of 3 Effective: 3/1/12 KEY WORDS: HIPAA PHI Confidentiality Patient Information Systems SEE ALSO: HIPAA Policies #1-12-H1 through #1-12-H20 POLICY It is the policy of the Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) that the information in the patient information system used or disclosed for directory purposes will be released in a manner that respects a patient s right to privacy, and in accordance with HIPAA privacy regulations and applicable law. PURPOSE It is the purpose of this policy to outline procedures for the appropriate handling of information in the patient information system used or disclosed for directory purposes. SCOPE This policy applies to all patient information of HUP/CPUP used or disclosed for directory purposes. IMPLEMENTATION Members of our workforce who respond to requests by persons from outside UPHS for patient information for directory purposes are responsible for implementing this policy. DEFINITIONS Protected health information (PHI) is information that is created or received by UPHS and the School of Medicine; and relates to the past, present, or future physical or mental health or condition of a patient; the provision of health care to a patient; or the past, present, or future payment for the provision of health care to a patient; and that identifies the patient or for which there is a reasonable basis to believe the information can be used to identify the patient. PHI includes information of persons living or deceased. The following components of a patient's information also are considered PHI: a) names; b) street address, city, county, precinct, zip code; c) dates directly related to a patient, including birth date, admission date, discharge date, and date of death; d) telephone numbers, fax numbers, and electronic mail addresses; e) Social Security numbers; f) medical record numbers; g) health plan beneficiary numbers; h) account numbers; i) certificate/license numbers; j) vehicle identifiers and serial numbers, including license plate numbers; k) device identifiers and serial numbers; l) Web Universal Resource Locators (URLs); m) biometric identifiers, including finger and voice prints; n) full face photographic images and any comparable images; and o) any other unique identifying number, characteristic, or code. Use means, with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within UPHS and the School of Medicine. Disclosure means the release, transfer, provisions of access to, divulging in any other manner of information outside UPHS and the School of Medicine. PROCEDURE APPENDIX XX

332 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL SUBJECT:DISCLOSURE OF INFORMATION FROM THE PATIENT INFORMATION SYSTEM Number: 1-12-H6 Page 2 of 3 Effective: 3/1/12 1. General Rule: Providing an Opportunity to Object a) The Notice of Privacy Practices will inform HUP/CPUP s patients of the potential uses and disclosures of their PHI for directory purposes from the patient information system, and will provide patients with an opportunity to object or restrict such uses or disclosures by instructing them to do so at the time of admission or presentation for appointment. Patients objecting to the disclosure of some or all of the following information should be directed to speak with the Director or designee of The Admissions Center or the Director of Patient Registration, and their objections recorded in the patient information system. 2. Patients admitted to a behavioral health unit PHI of a person admitted to a behavioral health unit will not be disclosed from the patient information system. However, such patients or their authorized representatives may choose to have their information disclosed, if they so designate. 3. Using and Disclosing PHI from the Patient Information System for Directory Purposes a) Unless a patient has objected as specified in the Notice of Privacy Practices and as recorded in the Patient Information System, or is a patient admitted to a behavioral health unit, HUP/CPUP may use and disclose the following PHI from the patient information system for directory purposes: i) patient s name; ii) patient s location in the facility (for example, room number); iii) a general description of the patient's condition that does not communicate specific medical information about the patient (for example, good, fair, poor, critical ); iv) the patient's religious affiliation to members of the clergy. b) Information may be used or disclosed for directory purposes to: i) members of the clergy, or ii) except for religious affiliation, other persons who ask for the patient by name. 4. Opportunity to Object Impractical a) If the opportunity to object to permitted uses and disclosures is impractical due to the patient's incapacity or an emergency treatment situation, and if the person has been admitted to a unit other than a behavioral health unit, HUP/CPUP may use and disclose some or all of the above information for directory purposes, if such use or disclosure is: i) consistent with a prior preference expressed by the patient, if any, that is known to HUP/CPUP, and APPENDIX XX

333 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL SUBJECT:DISCLOSURE OF INFORMATION FROM THE PATIENT INFORMATION SYSTEM Number: 1-12-H6 Page 3 of 3 Effective: 3/1/12 ii) in the patient's best interest as determined by HUP/CPUP, in the exercise of professional judgment. b) HUP/CPUP must inform patients of uses and disclosures for directory purposes, and provide them with an opportunity to object to further such uses and disclosures when it becomes practicable to do so. SUPERSEDES: 6/5/06 Facility Directories March 2012 ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth B. Johnston Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX XX

334 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: 1-12-H10 Page 1 of 4 SUBJECT: NEED TO KNOW DETERMINATION (MINIMUMNECESSARY REQUIREMENTS) Effective: 3/1/12 POLICY It is the policy of the Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) that each cost center owner: Identify the positions and/or job families that require access to protected health information (PHI) to carry out their duties; For each position and/or job family, identify the category of PHI to which access is needed and the appropriate conditions to access such information; and Inform each employee of their designated category and ensure they understand their responsibilities upon employment; Limit the amount of PHI disclosed to the amount reasonably necessary to accomplish the purpose of the disclosure; Limit the amount of PHI that HUP/CPUP requests from other covered entities to the amount reasonably necessary to accomplish the purpose of the request. PURPOSE The purpose of this policy is to outline the responsibility of cost center owners in determining the minimum necessary PHI required to complete the duties of a particular job, and their obligation to ensure each employee understands their responsibilities; and to establish procedures to limit the amount of information disclosed and requested, as required under the HIPAA minimum necessary rules. SCOPE This policy applies to all members of the workforce. For purposes of this policy, workforce includes employees, volunteers, trainees, physicians, our own students, and other persons whose work performance is under the direct control of HUP/CPUP, whether or not they are paid by HUP/CPUP. IMPLEMENTATION It is the responsibility of the cost center owner to implement this policy with the support of the Human Resources/Nurse Recruitment staff. DEFINITIONS Protected health information (PHI) is information that is created or received by UPHS and the School of Medicine; and relates to the past, present, or future physical or mental health or condition of a patient; the provision of health care to a patient; or the past, present, or future payment for the provision of health care to a patient; and that identifies the patient or for which there is a reasonable basis to believe the information can be used to identify the patient. PHI includes information of persons living or deceased. The following components of a patient's information also are considered PHI: a) names; b) street address, city, county, precinct, zip code; c) dates directly related to a patient, including birth date, admission date, discharge date, and date of death; d) telephone numbers, fax numbers, and electronic mail addresses; e) Social Security numbers; f) medical record numbers; g) health plan beneficiary numbers; h) account numbers; i) certificate/license numbers; j) vehicle identifiers and serial numbers, including license plate numbers; k) device identifiers and serial numbers; l) Web Universal Resource Locators (URLs); m) biometric identifiers, including finger and voice prints; n) full face photographic images and any comparable images; and o) any other unique identifying number, characteristic, or code. Use means, with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within UPHS and the School of Medicine. APPENDIX YY

335 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: 1-12-H10 Page 2 of 4 SUBJECT: NEED TO KNOW DETERMINATION (MINIMUMNECESSARY REQUIREMENTS) Effective: 3/1/12 Disclosure means the release, transfer, provisions of access to, divulging in any other manner of information outside UPHS and the School of Medicine. Categories of Access/ PHI Designation: Category Color Types of Protected Health Information Required Types of positions which would require this level of access 0 Blue Position does not require access to patient information 1 Green Pure Demographic and Insurance Information Patient demographic data and insurance information only 2 Orange Scheduling Information Patient scheduling information, plus category 1 information 3 Pink Diagnosis/Billing and Payment Information Patient diagnosis (including diagnostic coding), billing and payment information, plus categories 1 & 2 4 Yellow Clinical Information Clinical information, plus categories 1, 2 & 3 5 Purple Highly-Sensitive Clinical Information Highly sensitive clinical information such as psychiatric diagnosis, HIV infection, STD history, substance abuse treatment, etc., or information on public figures, health system employees, etc., plus all other categories. PROCEDURE USES OF PROTECTED HEALTH INFORMATION Current staff: On an annual basis the cost center owner should: 1. Identify the positions and/or job families which require access to PHI to carry out their duties; 2. For each position and/or job family, identify the category of PHI to which access is needed, and the appropriate conditions to access such information; and 3. Each employee in a cost center should be oriented to which PHI is necessary to the performance of the function. Furthermore, the Department Director/Business Administrator should identify whether access, disclosure, or use of the information is a requirement of the job. The employee should also be informed if, in the course of their assigned duties, they need access to PHI to which they do not normally have access, they should consult with their supervisor; and 4. Once the employee is informed, have each employee sign the Acknowledgement of HIPAA Minimum Necessary Criteria & Responsibility Form and place it in the employee s department file; and 5. Have each employee sign the Privacy Officer s audit form to confirm that they have been informed of their designation, their responsibilities and have signed the Acknowledgement of HIPAA Minimum Necessary Criteria & Responsibility Form. Send the completed audit form to the Entity Privacy Officer; and 6. Report access level of each position to the Entity Privacy Officer using the Staffing Plan (see attached template). APPENDIX YY

336 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: 1-12-H10 Page 3 of 4 SUBJECT: NEED TO KNOW DETERMINATION (MINIMUMNECESSARY REQUIREMENTS) Effective: 3/1/12 New Hires: 1. Whenever a new position is created or new job description is written, the cost center owner must identify which PHI is necessary to the performance of the function on the Staffing Requisition (PA42.1). Furthermore, the cost center owner should identify whether access, disclosure, or use of the information is a requirement of the job. 2. Upon employment, a new hire in a department/section will be informed by the Staffing Specialist/Nurse Recruiter on behalf of the Cost Center which PHI is necessary to the performance of their function. Furthermore, they will be informed whether access, disclosure, or use of the information is a requirement of the job. The Staffing Specialist/Nurse Recruiter will have the employee sign the Acknowledgement of HIPAA Minimum Necessary Criteria & Responsibility Form to indicate that they have been informed of their designation and responsibilities. They will then identify the employee s designation on the Personnel Action Form (PAF) (PA52.1), and forward the PAF and the Acknowledgement of HIPAA Minimum Necessary Criteria & Responsibility Form to the Records Department, where it will be placed in the employee s file. 3. During each employee s Department Orientation, each employee should again be oriented in greater depth to which PHI is necessary to the routine performance of the function. Furthermore, the Department Director/Business Administrator should identify whether access, disclosure, or use of the information is a requirement of the job. The employee should also be informed if, in the course of their assigned duties, they need access to PHI to which they do not normally have access, they should consult with their supervisor. The employee signature on the Department Orientation Checklist identifies completion of this orientation. 4. During System Orientation, each employee should receive information on the HIPAA guidelines and their responsibility to support them. Employee Job Change: Whenever an employee s position accountabilities change or the employee transfers to a new position, the cost center owner is accountable for ensuring that the employee PHI designation is appropriate. If a change is required, the cost center owner should inform the employee, and have them sign the Acknowledgement of HIPAA Minimum Necessary Criteria & Responsibility Form. The form and a completed Personnel Action Form (PAF) (PA 52.1) should be forwarded to employee records. Employee Records will change the employee s designation in Lawson and place the Acknowledgement of HIPAA Minimum Necessary Criteria & Responsibility Form in the employee s file. PROCEDURE DISCLOSURE OF PROTECTED HEALTH INFORMATION 1. Routine and recurring disclosures. HUP/CPUP routinely discloses PHI in a number of circumstances. In these cases HUP/CPUP will limit the information it discloses to the amount reasonably necessary to fulfill the purpose of the disclosure. In determining the amount reasonably necessary, HUP/CPUP may rely, if reasonable under the circumstances, on a requested disclosure as the minimum necessary for the stated purpose when: a. Making disclosures to public officials permitted under HUP/CPUP policies, if the public official represents that the information requested is the minimum necessary for the stated purpose; b. The information is requested by another covered entity; c. The information is requested by a professional who is a member of its workforce or is a business associate of HUP/CPUP for the purpose of providing professional services to HUP/CPUP, if the professional represents that the information requested is the minimum necessary for the stated purpose; d. Approval by a UPHS Institutional Review Board (IRB) is presented when PHI is being requested for research purposes. 2. Non-Routine disclosures. For non-routine disclosures, HUP/CPUP should consider the following criteria in determining the amount reasonably necessary to accomplish the purpose for which the disclosure is sought: a. Need for the information; b. Whether the information may feasibly be obtained from the subject of the information; APPENDIX YY

337 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: 1-12-H10 Page 4 of 4 SUBJECT: NEED TO KNOW DETERMINATION (MINIMUMNECESSARY REQUIREMENTS) Effective: 3/1/12 c. Whether the situation requires imminent action; d. The sensitivity of the information being sought; e. Considerations otherwise important to HUP/CPUP s mission. PROCEDURE MAKING REQUESTS FOR PROTECTED HEALTH INFORMATION 1. Routine and recurring requests. HUP/CPUP routinely requests protected health information from HIPAAcovered entities, including most major providers, all health plans, and health care clearinghouses, in a number of circumstances. In these cases, HUP/CPUP will limit the information it requests to the amount reasonably necessary to fulfill the purpose of the request. 2. Non-routine requests. For non-routine requests, HUP/CPUP should review such requests on an individual basis and consider the following criteria in determining the amount reasonably necessary to accomplish the purpose for which the request is made: a. Need for the information; b. Whether the information may feasibly be obtained by the subject of the data; c. Whether the situation requires imminent action; d. The sensitivity of the information being sought; e. Considerations otherwise important to HUP/CPUP s mission. SUPERSEDES: 4/13/03 Minimum Neccesary March 2012 ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth B. Johnston Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX YY

338 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: 1-12-H15 Page 1 of 2 SUBJECT: WORKFORCE TRAINING FOR HIPAA Effective: 3/1/12 POLICY It is the policy of the Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) to train all members of its workforce on the policies and procedures that it has in place with respect to the privacy of patient health and medical information as necessary and appropriate for workforce members to carry out their functions within HUP/CPUP. Education should include: a. The responsibilities of all members of the workforce with respect to patients' health and medical information; b. The privacy policies and procedures of HUP/CPUP applicable to all members of the workforce; c. The personal and ethical obligations of each member of the workforce with respect to patients' health and medical information; and d. The disciplinary actions and legal sanctions applicable to members of the workforce who violate the privacy policies and procedures. SCOPE HIPAA privacy training is mandatory for all members of the workforce. For purposes of this policy, workforce includes employees, physicians, house staff, volunteers, trainees, and other persons whose work performance is under the direct control of HUP/CPUP, whether or not they are paid by HUP/CPUP. IMPLEMENTATION Workforce Educational Needs: The UPHS Chief Privacy Officer is responsible for identifying and developing the content and educational programs that are common for all UPHS workforce members and large cross entity job families in order for UPHS to be compliant with UPHS HIPAA policies, as well as department/job specific training needs. The UPHS Chief Privacy Officer is charged with developing system-wide training programs that reflect the requisite content.. The UPHS Chief Privacy Officer is responsible for facilitating train-the-trainer sessions for each HUP/CPUP s training staff/management. HUP/CPUP s EntityPrivacy Officer is responsible for ensuring that their respective workforce members receive the training necessary and appropriate to permit the workforce members to carry out their functions within HUP/CPUP. HUP/CPUP s Entity Privacy Officer is responsible for tracking completion of required workforce education utilizing the Learning Management System ( LMS ) currently utilized by UPHS. The Department/Accounting Unit/Cost Center Manager is responsible for ensuring that all workforce members under their supervision enroll in and complete the training within the appointed time frames, appropriate for them to carry out their functions within HUP/CPUP. The Department/Accounting Unit/Cost Center Manager is responsible for tracking such completion in the LMS currently utilized by UPHS. PROCEDURE 1. Mandatory Training and Education. 2. Timing. All members of the workforce are required to complete HIPAA education and training at the time of: Rollout of the policies and procedures; Material changes to the policies and procedures; Upon employment or placement / assignment; and As designated by UPHS Senior Leadership Completion is mandatory and will be documented in the LMS currently utilized by UPHS.. Training must be provided for the existing workforce no later than April 14, New members of the APPENDIX ZZ

339 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: 1-12-H15 Page 2 of 2 SUBJECT: WORKFORCE TRAINING FOR HIPAA Effective: 3/1/12 workforce must receive the appropriate privacy training within a reasonable period of time of joining HUP/CPUP, generally no later than thirty days after their hire date / assignment. 3. Roll-out of the Policies and Procedures. Workforce members may be divided for purposes of training based upon their access to PHI. Workforce members may be divided between those who are reasonably likely to encounter privacy-related issues as a part of their job performance and those who are not. a. Workforce Members Who Do Not Have Access to PHI: Workforce members in this category should have received HIPAA general education prior to the effective date of the Privacy Rule of April 14, b. Workforce Members Who Have Access to PHI: As necessary, workforce members requiring more specific training and education should be divided into groups according to their duties under the HIPAA regulations; e.g., those who are responsible for patient registration and scheduling, patient care, patient billing, etc. These workforce members shall be required to attend all training and education sessions addressing privacy-related issues specific to their jobfunction.. The topics to be covered by this training and education session should include function/process specific details of the policy and procedures regarding the use and disclosure of and access to patients' health information including non-routine access issues. 4. Subsequent Training. Subsequent training will be provided for workers whose job functions are affected by a material change in the policies and procedures required by the HIPAA privacy regulations within a reasonable period of time after the change becomes effective. General training and education "refresher" sessions may be required of all workforce members as deemed necessary by the UPHS Chief Privacy Officer. 5. Records and Documentation. The Department/Accounting Unit/Cost Center manager shall assure that workforce members under their supervision complete their mandatory training within a reasonable period of time, generally, no later than thirty days. All training records are being kept and maintained in the LMS currently utilized by UPHS. These records will include, but not be limited to: Date, time, and duration of the session; Subject matter of presentation; and Assessment date/score (if applicable) SUPERSEDES 4/13/03 Training March 2012 ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth B. Johnston Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX ZZ

340 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 1 SUBJECT: Artificial Nail Policy Effective: 3/20/02 Policy Artificial fingernails may not be worn by any healthcare personnel who provide direct patient care. Purpose The purpose of this policy is to decrease the potential transmission of pathogens from healthcare workers to patients. Scope This policy applies to all healthcare personnel who provide direct patient care. Implementation Implementation of this policy is the responsibility of department managers and supervisors. Procedure 1. Healthcare personnel who provide direct patient care may not wear artificial fingernails of any length. 2. Healthcare personnel who provide direct patient care may wear fingernail polish as long as it is not chipped. 3. Healthcare personnel who provide direct patient care are to keep short length fingernails. References Foca, M et. al (2000) Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. NEJM 343: Hedderwick, S. et. al (2000) Pathogenic organsims associated with artificial fingernails worn by healthcare workers. ICHE, 21: Edel, E (1998) Impact of a 5 minute scrub on the microbial flora found on artificial, polished or natural fingernails of operating room personnel. Nursing Research 47: McNeil, S et. al (2001) Effect of Hand Cleansing with Antimicrobial Soap or Alcohol-Based Gel on Microbial Colonization of Artificial Fingernails Worn by Healthcare Workers. CID 32: SUPERSEDES: NEW artificial fingernails.doc ISSUED BY: /s/ Michael A. Grippi, M.D. /s/ David E. Longnecker, M.D. APPENDIX AAA

341 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 5 SUBJECT: PHOTOGRAPHS, VIDEO RECORDING, AND AUDIO RECORDING Effective: 1/1/10 KEY WORDS: Photography Videotaping Digital audio/visual recording Confidentiality Release of Information SEE ALSO: 1-12-H20 Disclosure of PHI with Patient Authorization POLICY: It is the policy of the Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) to ensure the appropriateness of photography, videotaping and digital audio/visual recording of patients, and workforce. PURPOSE: The purpose of this policy is to define the limitations upon the use of cameras (including cell phone and personal data assistant device (PDA) cameras), video recorders, audio recorders, or any other type of equipment or devices regardless of the technology used to capture or record visual and/or audio media and digital images and to ensure that the use of such devices does not compromise the integrity of Protected Health Information (PHI), proprietary information, individual rights to privacy, quality of patient care and the efficient operations of HUP and CPUP. SCOPE: This policy applies to all patients and visitors. This policy also applies to all personnel including medical staff, auxiliary healthcare providers, students, volunteers, contracted personnel, and employees of HUP and CPUP ( workforce ) and to vendors, television crews, production companies, newspapers, magazines or other media related entities. This policy applies to the interiors and exteriors of the HUP and the CPUP practices that operate at or in conjunction with HUP (referred to as campus ). This policy does not include photography, videotaping, digital audio/visual recording for security or emergency management or other routine operational purposes (except for performance improvement activities as specified below in Section II). IMPLEMENTATION: HUP/CPUP employees and staff have a responsibility to see that this policy is followed by patients, family members, visitors and other workforce. Penn Medicine s Department of Communications has a responsibility to see that this policy is followed by television crews, production companies, newspapers, magazines or other media related entities coming on HUP/CPUP s campus to film. Supervisors and managers have a responsibility to see that this policy is followed by workforce and vendors. PROCEDURE: I. Photography. Videotaping and Digital Audio/Visual Recording Initiated by Patients, Family Members and Visitors A. Still photographs and video of a patient taken by a member of the patient s family or by visitors of the patient may be permitted if the patient does not object and it is not disruptive to HUP/CPUP workforce or other patients. B. Photography, videotaping and digital audio/visual recording by a family member of the birth of a baby on the Labor and Delivery Unit of HUP will be permitted only with the authorization of the mother and the physicians, auxiliary healthcare providers and nurses involved in the delivery. APPENDIX BBB

342 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 5 SUBJECT: PHOTOGRAPHS, VIDEO RECORDING, AND AUDIO RECORDING Effective: 1/1/10 C. Still photographs or video of HUP and CPUP workforce are not permitted without their express written authorization. D. The physicians, auxiliary healthcare providers, nurses or Communications Officers may require that photographing, filming or recording be stopped immediately at any time that may be considered by them to be disruptive or to interfere with the healthcare operations or the care of the patient. E. Requests for photographing, videotaping and digital audio/visual recording for legal purposes should be referred by the Department of Communications to the UPHS Office of General Counsel for permission before any such photography, videotaping or digital audio/visual recording may occur. F. Photographing and/or videotaping or recording daily operations of the healthcare environment by patients and visitors is prohibited. G. If it is observed or suspected that a patient, family member, visitor or vendor has taken recordings or photographs of other patients, staff or of the White Board or Navicare Screen without permission, HUP Security should be contacted. HUP Security reserves the right to confiscate the recording device and erase any unauthorized film, photographs and other images. II. Photography, Videotaping, and Digital Audio/Visual Recording Initiated by HUP and/or CPUP Employees and Staff A. Workforce of HUP and/or CPUP may make and use recordings, films, or other images of a patient for the identification, diagnosis, or treatment of the patient. The individual is responsible for explaining to the patient why the recording or image is necessary and shall make sure such recordings/photographs are added to the patient s medical record. B. Workforce of HUP and/or CPUP may make and use recordings, films, or other images of patients for internal or external use other than the identification, diagnosis, or treatment of the patient (for example, education purposes). In order to do so, the individual must generally secure the patient s or the patient s legally authorized representative s authorization prior to the production of any recordings, films, or other images and prior to the use/disclosure of the patient s protected health information. (See the attached Consent/Authorization form that has been approved for use throughout the University of Pennsylvania Health System.) Once signed, this consent/authorization should become a part of the patient s medical record. C. In the event a workforce member is unable to secure a patient s authorization prior to HUP/CPUP approved filming or videotaping for internal purposes other than for the identification, diagnosis, or treatment of the patient, the photograph or tape must remain in the hospital s possession without being viewed or used for any purpose until and unless patient informed consent is obtained. D. When a patient is unable to give consent or authorization prior to the production of recordings, films, or other images and consent or authorization for use cannot subsequently be obtained, HUP and/or CPUP will destroy the images or video tape without viewing or using it for any purpose. E. HUP and CPUP will inform patients of their right to request cessation of the production of any recordings, films, or other images. HUP and CPUP will accommodate a patient's right to rescind consent or authorization before the recording, film, or image is used. APPENDIX BBB

343 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 3 of 5 SUBJECT: PHOTOGRAPHS, VIDEO RECORDING, AND AUDIO RECORDING Effective: 1/1/10 F. Where HUP or CPUP engage in routine filming for internal use (for example, performance improvement) other than the identification, diagnosis, or treatment of the patient, it will post signage informing patients of the same. Before engaging in such recording or filming of patients, anyone who is not already bound by UPHS confidentiality policies must sign a confidentiality statement to protect the patient s identity and confidential information. G. Filming, photographing or recording for the purposes of research must be approved by the University of Pennsylvania Institutional Review Board (IRB). A separate consent form for filming or recording is not required if it is specifically included in the IRB approved research consent form. III. Photography, Videotaping and Digital Audio/Visual Recording Requests by Media A. Requests by television crews, production companies, newspapers, magazines or other media related entities to film, photograph or videotape on HUP/CPUP s campus, including inpatient, outpatient and other ambulatory areas, must be approved by Penn Medicine s Department of Communications. Requests to interview and/or photograph patients must be made directly to Penn Medicine s Department of Communications before any contact can be made with HUP/CPUP workforce or patients for photographing. B. Penn Medicine s Department of Communications will coordinate the preparation of Location Agreements and other documents (e.g. HIPAA authorization forms, appearance releases, etc.) that may be necessary to use HUP/CPUP s campus for these filming purposes. C. A representative of Penn Medicine s Department of Communications must be present while any photography, filming, audio recording or interviews are conducted on HUP/CPUP s campus. D. Safeguarding the life, health and legal rights of patients and HUP/CPUP workforce is to be considered at all times when conducting media business on HUP/CPUP s campus. Penn Medicine s Department of Communications reserves the right to stop any photographing or videotaping deemed to be disruptive to the operations of HUP and/or CPUP. Violations of these procedures will result in immediate removal by HUP/CPUP Security. SUPERSEDES: NEW Photographing 2010 ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth Johnston Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX BBB

344 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 4 of 5 SUBJECT: PHOTOGRAPHS, VIDEO RECORDING, AND AUDIO RECORDING Effective: 1/1/10 CONSENT TO RECORD AND RELEASE Patient Name: Address: Phone Number: Date of birth: Last 4 digits of SSN: I give permission to my physicians, the hospitals of the University of Pennsylvania Health System ( UPHS ), its agents, employees, and students, or other health care providers providing healthcare services to me or my child to photograph, videotape, audiotape or otherwise make recordings of my image and/or voice or that of my child in any medium (collectively referred to as Recordings ) for the following purposes: Check all that apply and describe in detail the specific purpose(s): Educational purposes: Marketing and publicity: Public affairs: Development and fundraising: Research activities: Other: I understand that I may revoke this consent at any time, in writing, and that no further Recordings will be taken. However, such revocation will have no effect on Recordings already taken, which may still be used for the purposes described above. I agree that the Recordings will remain the property of UPHS. I also agree that the personal satisfaction derived from my cooperation in furthering the health, education, and research objectives of UPHS and the individuals identified above is sufficient consideration for the activities authorized hereunder, and waive any payments, royalties or other compensation. I release the Trustees of the University of Pennsylvania, its hospitals, agents, employees and assigns, my physician(s) and any other persons providing health care services to me at UPHS, from any claims and any liability arising in connection with the taking, use, or distribution of any Recordings taken of me or my child pursuant to this consent. I understand that the publication and/or distribution of these Recordings may require me to complete an Authorization for Use and/or Disclosure of Protected Health Information including Recordings. I give this consent voluntarily and with full understanding of its nature. Signature of Patient or Patient s Personal Representative (as applicable) Name of Patient's Personal Representative (as applicable) Date Relationship to Patient or Statement of Authority to act on Patient s Behalf (e.g. spouse, parent, legal guardian, in loco parentis, etc.) APPENDIX BBB

345 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 5 of 5 SUBJECT: PHOTOGRAPHS, VIDEO RECORDING, AND AUDIO RECORDING Effective: 1/1/10 AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION INCLUDING RECORDINGS Patient Name: Address: Phone Number: Date of birth: Last 4 digits of SSN: I authorize my physicians, the hospitals of the University of Pennsylvania Health System ( UPHS ), its agents, employees, and students, or other health care providers providing healthcare services to me or my child to use and/or disclose my or my child s protected health information for the following purposes: Check all that apply and specifically describe the persons or class of persons to whom the disclosure will be made (e.g. attendees at CME conference, name of publication or brochure, etc.) External educational purposes: Marketing and publicity: Public affairs: Development and fundraising: * Use/disclosure for research activities requires the completion of the Research Subject Authorization Confidentiality & Privacy Rights Form The information that may be used and/or disclosed includes demographic information, progress notes, discharge summaries, operative reports, results of lab tests, radiology reports and consultations and other information related to my or my child s inpatient and outpatient care. In addition, it may include any photographs, videotapes, audiotapes or other recordings (collectively, Recordings ) made of me or my child s image or voice. I understand that these Recordings may include identifiable images of the face. I understand that this authorization will expire in fifty (50) years from the date of execution. I further understand that I may revoke this authorization at any time in writing except to the extent that action has been taken in reliance on this authorization. I understand that my provider may not refuse to treat me or my child if I refuse to sign this authorization. I understand that once this information is disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient(s), and may no longer be protected by federal privacy regulations. I give this authorization voluntarily and with full understanding of its nature. Signature of Patient or Patient's Personal Representative (as applicable) Name of Patient's Personal Representative (as applicable) Date Relationship to Patient or Statement of Authority to act on Patient s Behalf (e.g. spouse, parent, legal guardian, in loco parentis, etc.) APPENDIX BBB

346 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 2 SUBJECT: TELEPHONE USE Effective: 10/31/05 KEY WORDS: Telephones Cell phones SEE ALSO: # Transmitting Communication Device Use # Allocation, Acquisition, and Use of Cellular Phones # Pagers POLICY: The Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) have established guidelines on the use of telephones both landline and mobile: to enhance patient safety and patient/customer satisfaction to enhance workforce productivity to help mitigate the incidence of misuse and abuse of telephone services provided by HUP and CPUP by unauthorized individuals and to better allow for the prompt detection of external piracy of services. PURPOSE: The purpose of this policy is to provide HUP and CPUP departments with guidelines for the use of local and long distance calling services offered by Telecommunications and personally owned mobile phones. The ultimate goals are to encourage the proper use of telephones, the protection from toll fraud and to control and reduce unauthorized telecommunications expense for departments and thereby for HUP and CPUP. SCOPE: This policy applies to all users of any phone line that is part of HUP s and CPUP s telecommunications system including fax lines and to all staff, employees, students or volunteers who utilize personally owned mobile phones. IMPLEMENTATION: It is the responsibility of department directors, managers and supervisors to implement this policy. PROCEDURE: Usage Guidelines for HUP/CPUP phone lines: 1. Local and long-distance calling that is offered and administered by Telecommunications is made available for the purpose of conducting HUP and CPUP business only. Incidental and occasional personal use of electronic communications may occur when such use is not excessive in time or cost to the hospital or the practices. Any such incidental and occasional use of hospital or CPUP electronic communications resources for personal purposes is subject to the provisions of this policy. 2. Standard local and long distance service, which is offered on all HUP and CPUP telephone sets, consists of nonrestricted calling access to area codes 215, 610, 484, 267, 856, 609, 302. Calls within these area codes do not require an authorization code. 3. Calls outside of the area codes listed above are considered long distance calls and require use of an Authorization Code. There are two (2) classifications of long distance. They are described below. 4. Domestic long distance is classified as calls placed outside the area codes listed above, but within the United SUPERSEDES: 11/15/02 H:\policies chapt 12\Telephone Use 2005.doc ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth B. Johnston APPENDIX CCC

347 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 2 SUBJECT: TELEPHONE USE Effective: 10/31/05 States and require the use of an Authorization Code. 5. To place Domestic long distance calls, employees must submit a request for an Authorization Code and have it approved by a Department Director or Chairperson. 6. International long distance calls require the use of an Authorization Code. This is an additional level of restriction, which is typically limited to department directors, chairpersons, and senior management. Employees requiring international long distance calling capabilities must submit a request for an Authorization Code and have it approved by a Departmental Director or Chairperson and a Vice President or Executive Director. 7. The duration of domestic and international long distance calls should be minimized. Usage Monitoring and Guideline Enforcement 1. It is every department s responsibility to identify phone usage that is not in alignment with HUP or CPUP, or that constitutes abuse. 2. Overall usage will be reported by Telecommunications. Usage that exceeds reasonable thresholds will be identified and reported to a department s administration. The department may be asked to investigate, explain, and correct. 3. A monthly report is distributed to each department. This report should be checked by each department s manager to verify the accuracy of the telephone extensions represented, as well as to identify calls outside of the normal call profile of the department. 4. It is the department management s responsibility to notify Telecommunications to terminate an authorization code once the employee leaves or changes his/her role where access to long distance calling is no longer needed. Personal Mobile Phone Usage: 1. Incidental and occasional personal use of mobile phones may occur when such use is not excessive in time to HUP or CPUP. 2. When possible, calls should be made or received during break times and away from the immediate work environment. 3. Personal calls must not be made or received when a staff member, employee, student or volunteer is engaged in an activity that brings him/her into contact with a patient, family member or visitor. A staff member, employee, student or volunteer should be aware of his or her surroundings when discussing patient specific or easily misinterpreted information on the telephone. In addition, out of respect for colleagues, phones should be place in a vibrate mode when the user attends a meeting, in a patient care area, and so forth. SUPERSEDES: 11/15/02 H:\policies chapt 12\Telephone Use 2005.doc ISSUED BY: /s/ Garry L. Scheib /s/ Elizabeth B. Johnston APPENDIX CCC

348 Penn Medicine - HUP RT Education Program COURSE SEQUENCE SHEET Effective September 2015 Courses provided by Penn Medicine are represented by PM designator; Courses provided by Widener University are represented by WU designator. Initial Summer Session Year 1 Credits WU UCS 102 Intro to University College Civic Engagement 1 WU English 101 Composition and Critical Thought 3 WU Math 115 Conceptual Mathematics 3 Total 7 Fall Year 1 PM Patient Care, Ethics & Law 3 PM Fundamentals of Radiologic Science & Healthcare 1 PM Anatomy & Physiology I/Lab 3 PM Radiographic Procedures & Image Analysis I 5 PM Medical Terminology 1 PM Clinical Education I 3 Total 16 Spring Year 1 PM Anatomy & Physiology II/Lab 3 PM Radiographic Procedures & Image Analysis II 5 PM Production & Characteristics of Radiation 3 PM Clinical Education II 3 WU SOC 105 Introduction to Sociology 3 Total 17 Summer Year 1 PM Clinical Education III (with case study analyses) 5 PM Career Planning & Exploration 1 PM Radiographic Imaging, Equipment & Processing 5 WU Humanities Option 3 Total 14 Humanities Options: HIST 215 Social History of American Medicine HIST 301 Historical Perspectives on Technology HUM 352 Science and Religion APPENDIX DDD

349 Fall Year 2 PM Radiographic Pathology 3 PM Advanced Radiographic Procedures 3 PM Pharmacology & Drug Administration 1 PM Radiation Protection & Biology 3 PM Clinical Education IV 4 WU UCS 201 Capstone course 3 Total 17 Spring Year 2 PM Cross-Sectional Anatomy 2 PM Radiologic Modalities 1 PM Computers & Digital Imaging in Radiology 3 PM Clinical Education V 4 Total 11 Summer Year 2 PM Clinical Education VI 5 PM Radiography Seminar 3 Total 8 Scheduling for PM courses is in nonblock format: Academic Courses Year 1 Fall and Spring Semesters - 15 week blocks Year 2 Fall and Spring Semesters - 15 week blocks Clinical Courses Year 1 Fall and Spring Semesters - 15 week blocks Year 2 Fall and Spring Semesters - 15 week blocks Summer Sessions Courses - 15 week blocks All PM courses include an additional 16 th week for final examinations Scheduling for Widener University courses: Fall/Spring Semester 15 week sessions Summer Session I and II 6 week sessions Online Courses 15 week sessions Associate of Science is earned through Widener University College Program Credits: 73 PM, 16 WU = 88 total Sequence of courses subject to change APPENDIX DDD

350 COURSE NUMBER/TITLE/CREDITS PREREQUISITES CONTACT HOURS FALL YEAR ONE F 1-PC Patient Care, Ethics & Law (3) None 45 F 1-FUN Fundamentals of Radiologic Science & Healthcare (1) None 15 F 1-AP Anatomy & Physiology I & Lab (3) None 45 F 1-PRO Radiographic Procedures & Image Analysis I (5) None 75 F 1-MT Medical Terminology (1) None 15 F 1-CE Clinical Education I (3) F 1-PC, F 1-FUN, F 1-AP, F 1-PRO, F 1-MT 256 SPRING YEAR ONE S 1-PHY Production & Characteristics of Radiation (3) F 1-FUN 45 S 1-PRO Radiographic Procedures and Image Analysis II (5) F 1-PRO 75 S 1-AP Anatomy & Physiology II & Lab (3) F 1-AP 45 S 1-CE Clinical Education II (3) F 1-PRO, F 1-CE, F 1-AP, S 1-AP, S 1-PRO 256 SUMMER YEAR ONE SS 1-CE Clinical Education III (with case study analyses) (4) F 1-PRO, S 1-PRO, S 1-CE, F 1-AP, S 1-AP 448 SS 1-CP Career Planning & Exploration (1) F 1-FUN 15 SS 1-RT Radiographic Imaging, Equipment, and Processing (5) F 1-PRO 75 FALL YEAR TWO F 2-PTH Radiographic Pathology (3) F 1-PRO, S 1-PRO, F 2-RAD, SS 1-CE 45 F 2-ADV Advanced Radiographic Procedures (3) F 1-AP, F 1-PRO, S 1-AP, S 1-PRO 45 F 2-RAD Radiation Protection & Biology (3) S 1-PHY 45 F 2-CE Clinical Education IV (4) F 1-PRO, S 1-PRO, SS 1-CE, S 1-AP 384 SPRING YEAR TWO S 2-CT Computed Tomography & Cross-Sectional Anatomy (4) F 1-AP, S 1-AP 60 S 2-PHR Pharmacology & Drug Administration (1) F 1-PC, F 1-PRO, S 1-PRO, F 2-ADV 15 S 2-DIG Computers & Digital Imaging in Radiology (3) S 1-PHY 45 S 2-CE Clinical Education V (4) F 1-PRO, S 1-PRO, SS 1-CE, F 2-CE, S 1-AP 384 SUMMER YEAR TWO SS 2-CE Clinical Education VI (5) F 1-PRO, S 1-PRO, S 2-CE, S 1-AP, F 1-AP 512 SS 2-RS Radiography Seminar (3) All Prior Coursework 45 TOTAL CREDITS: 73 (50 academic credits, 23 clinical credits) TOTAL CONTACT HOURS: 2990 CLINICAL: 2240 ACADEMIC: 750 Scheduling for Widener University courses: Fall/Spring Semester 15 week sessions Summer Session I and II 6 week sessions Online Courses 15 week sessions Associate of Science is earned through Widener University College COURSE NUMBERS Effective September 2014 PROGRAM CREDITS: 73 HUP, 16 WU = 89 TOTAL Sequence of courses subject to change Revised DAG

351 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 1 of 3 SUBJECT: TREATMENT AFTER EXPOSURE TO BLOOD OR BODY FLUIDS Effective: 3/4/2011 KEY WORDS: Blood Borne Pathogens Post-Exposure Treatment HIV Consent SEE ALSO: # Consent to Health Care Services # Human Immunodeficiency (HIV) Counseling, Testing and Consent All Hospital volunteers POLICY: It is the policy of the Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) to provide postexposure assessment and prophylaxis, when clinically appropriate, to HUP/CPUP personnel following a significant exposure to blood or body fluids. SCOPE: This policy applies to all HUP/CPUP personnel (known collectively as the workforce ) including: All staff, employees, medical staff, students and post doctoral fellows of the University of Pennsylvania functioning within HUP/CPUP All staff, medical staff, students, and employees of the Hospital of the University of Pennsylvania and its component clinical areas All visiting medical staff, staff, employees, and students working or training at HUP/CPUP All contract or agency personnel functioning within HUP/CPUP IMPLEMENTATION The implementation of this policy is the responsibility of Occupational Medicine (OM), the Student Health Service (SHS), the Emergency Department (ED), and all HUP/CPUP personnel, trainees, students and volunteers. PROCEDURE 1. Reporting a. A potentially exposed individual must report any exposure immediately. Such an exposure should be reported to the individual s immediate supervisor. b. The exposed individual should be evaluated as soon as possible with the goal evaluation within 2 hours of exposure in accordance with CDC guidelines and OM procedures. c. Following the report of an exposure incident, a confidential medical evaluation and follow-up will be made available to the individual in accordance with Occupational Medicine s Blood and Body Fluids Exposure Protocol. 2. Counseling and Risk Assessment a. The counseling process will be initiated in OM, SHS, or the ED as soon as an individual reports potential exposure. For individuals seen initially in the ED during the evening or weekend hours, counseling and management will be continued by OM or SHS. Counseling will be provided by trained and approved staff in OM or SHS, including physicians, auxiliary healthcare providers, and/or nurses. OM and Infectious Disease specialists are on call for consultation 24 hours/day. b. Risk assessment for exposure to the bloodborne pathogens including HIV, Hepatitis B and Hepatitis C, is performed by trained clinicians as described above. c. Risk categories and indications for post-exposure prophylaxis may be modified as new information is received regarding the status of the donor or health care worker. There are exposures after which postexposure prophylaxis is either recommended, or offered. d. The assessment is based on two major risk criteria: (1) the nature of the injury; and (2) the likelihood of the presence of an infectious agent in the donor, if identifiable. e. Rapid decision making on whether or not to begin post exposure prophylaxis with anti-hiv drugs takes precedence over all other aspects of the evaluation. This decision is based on donor risk factors for HIV, employee preferences and clinical judgment on the part of the OM or the SHS provider. f. HIV antibody testing: Knowledge of the source patient s HIV antibody status assists in assessment. This APPENDIX FFF should be determined if possible, within the constraints of policy # , and all legal requirements. In

352 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 2 of 3 SUBJECT: TREATMENT AFTER EXPOSURE TO BLOOD OR BODY FLUIDS Effective: 3/4/2011 general, written consent of the patient is required. If the attending physician requires assistance, a physician from Occupational Medicine or Infection Control will be available for consultation. If the patient refuses to consent, the test will not be performed without the patient's consent unless the patient is incompetent and the patient's legally authorized representative consents. Where it is refused and there is available blood, testing may take place under specified circumstances. If informed consent cannot be obtained when testing is deemed necessary and appropriate, Infection Control and the Office of the General Counsel should be notified immediately for the purpose of determining further appropriate procedures. An exposed health care worker should not request consent for testing from the patient. In accordance with CDC guidelines, HIV antibody testing of an exposed individual at the time of exposure to HIV-contaminated fluids is recommended, provided the individual consents to such testing. Any individual found to be positive is not a candidate for post-exposure prophylaxis, but will be offered counseling and care through existing channels. If prescribed, post-exposure prophylaxis may be initiated before results of antibody testing become available for donor or exposed individual. 3. Prophylaxis a. Prophylaxis will be provided according to OM protocols and the most recent recommendations on postexposure prophylaxis provide by the Centers for Disease Control and Prevention (CDC). Such information is available at b. Informed consent: Individuals who choose to receive post-exposure prophylaxis must give informed consent. The exposed individual must sign the post-exposure testing and prophylaxis consent form whether or not he/she elects to prophylactic treatment. 4. Pregnancy: Knowledge of an exposed woman s pregnancy status will enable the patient and counselor to balance potential risks and benefits of post-exposure treatment. It is strongly recommended that an exposed woman have a pregnancy test before post exposure prophylaxis. Whenever possible, a pregnant employee s obstetrician should be involved in the decision of when to start or continue treatment. 5. Payment: Cost of work related post-exposure prophylaxis for HUP employees (including Housestaff) is covered by the HUP Worker s Compensation Policy, University of Pennsylvania Workers Compensation which covers faculty/medical staff, and other University employees and other Workers Compensation programs as appropriate (for example for contract employees). The Medical School of the University of Pennsylvania will assume financial responsibility for post exposure prophylaxis prescribed to medical student following a training exposure. Payment for care and treatment of HUP volunteers, students and housestaff from other institutions is in accordance with HUP Policy # SUPERSEDES: 3/11/98 BBP post exposure 2011 ISSUED BY: /s/ Deborah A. Driscoll, MD /s/ Peter D. Quinn, MD Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX FFF

353 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: Page 3 of 3 SUBJECT: TREATMENT AFTER EXPOSURE TO BLOOD OR BODY FLUIDS Effective: 3/4/2011 ACCESS TO CARE APPENDIX A The usual source of medical care following a potential exposure is outlined below, however if a member of the HUP/CPUP workforce is at a geographically distant location at the time of exposure he/she should seek care at the closest OM or ED facility available : Normal Holidays, Population Hours 1 After Hours, Weekends HUP Employees 2 OM ED Faculty/Medical Staff 3 OM ED Univ. of Penna. Employees 4 OM ED HUP Contract Employees OM ED Visiting House Officers 5 OM ED HUP Volunteers 5 OM ED Visiting Students 5 OM ED Penn Medical Students 6 OM ED Other Penn Students 6 SHS ED 1 Student Health Service (SHS) is open 24 hours a day except when the school is not in session. A SHS physician is on call every day, even if the University is not in session, and that physician must be contacted when the potentially exposed individual student is a University of Pennsylvania student other than a Medical Student. 2 All exposed individuals should notify their supervisors of a potential exposure to human blood or body fluids as soon as possible. The Workers Compensation Officer should be notified about the exposure as usual for any work-related injury. See HUP Policy Penn faculty/medical staff/house staff performing services at a non-hup location should seek immediate care for any potential exposure at that location, but should seek follow-up care at OM. 4 University of Pennsylvania employees are covered by University of Pennsylvania Workers Compensation. 5 HUP Policy # provides that visiting house officers, volunteers, or visiting students may seek medical care in OM, but that they may be charged for services. This charge is evaluated on a case by case basis. 6 Penn students on rotation at other medical centers, hospitals, or schools, should seek immediate care for any potential exposure at that location, but should notify OM or SHS of the potential exposure and should return to OM or SHS for followup care. FOLLOW-UP CARE Follow-up care should be obtained within 1-7 days of the exposure as defined by OM protocol. a. It is available at OM Monday through Friday, preferably by appointment. b. All individuals must be referred through OM (unless they are visiting staff, students or house officers, etc. who wish to return to their own institution for care. If visiting staff or students wish to return to their own institution for care, they may request copies of any OM records. Students should be aware that OM records are separate from SHS records and that copy requests must therefore be made separately. c. Penn Students, other than Medical Students, must be referred to Student Health Service. APPENDIX FFF

354 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: I-A Page 1 of 3 SUBJECT: TRANSMISSION OF INFECTIONS Effective: 8/14/11 KEY WORDS: Mechanisms of transmission: Direct Indirect Droplet Vehicle route Vector Purpose: It is the policy of the Hospital of the University of Pennsylvania and the Clinical Practices to protect the health of both employees, patients, visitors, students and contract employees from exposure to infectious diseases. Definition of Terms A nosocomial or health care associated infection is one that occurs as a result of contact with the healthcare environment and is not present or incubating at the time the contact is initiated. It may occur in a hospital, doctor's office, clinic, or long term care facility. To prevent the spread of communicable diseases within the health care system, special procedures must be followed for patients with such diseases. Decisions regarding which infectious cases to isolate and which isolation procedures to utilize require an understanding of the epidemiology of infectious disease in the hospital setting. Three elements must be present for a nosocomial infection to occur: a source of the infecting organism, a means of transmitting that organism, and a susceptible host. Source of Infection Human sources of infectious agents include patients, visitors and healthcare workers. These individuals may have a clinically apparent infectious disease, be in the incubation period of the disease, or be colonized by the infectious agent with no apparent disease (carriers). A second major source of infection is inanimate objects in the environment, including shared patient care equipment, respiratory therapy equipment, catheters, etc. Means of Transmission There are five main routes for the transmission of microorganisms: contact, droplet, airborne, vehicle and vector-borne. Some organisms can be spread by more than one route. The differences in infectivity and in the mode of transmission of the various agents form the basis for the categories of isolation and precautions that are explained later in this manual. A. The CONTACT ROUTE can be divided further into two subgroups: 1. DIRECT CONTACT is the physical transfer of the organism directly from an infected/colonized person to a susceptible host, such as may occur between patient and healthcare personnel during the changing of dressings or the performing of other practices that require direct physical contact. Direct contact can also take place between two patients, one the source of infection and the other the susceptible host. An important direct source of infection can be the patient s endogenous flora (autoinfection). 2. INDIRECT CONTACT occurs when a person (patient, visitor, or healthcare worker) comes into contact with contaminated inanimate articles referred to as fomites. APPENDIX GGG

355 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: I-A Page 2 of 3 SUBJECT: TRANSMISSION OF INFECTIONS Effective: 8/14/11 B. DROPLET SPREAD is the transmission of infectious agents in large droplets via coughing, sneezing, or talking when a person is either incubating or has clinical disease of the respiratory tract or is in the carrier state. These droplets may then come in contact with the conjunctiva, nose or mouth of a susceptible individual. This method of spread is considered a contact infection because close physical proximity is necessary -- droplets usually travel no more than three feet and are too heavy to remain suspended in the air. C. AIRBORNE transmission occurs through the dissemination of either droplet nuclei (the residue of evaporated droplets that may remain suspended in the air for a long period of time) or dust particles containing the infectious agent. Organisms carried in this manner may be inhaled by the susceptible host. An example of airborne transmission is pulmonary tuberculosis, which is spread from untreated, infected patients to susceptible individuals by this route. D. The VEHICLE ROUTE applies to diseases transmitted through a medium (vehicle),such as: 1. Contaminated FOOD or WATER, e.g., salmonellosis and shigellosis. 2. Contaminated DRUGS; e.g., bacteremia resulting from the use of contaminated intravenous solutions. 3. Contaminated BLOOD; e.g., Hepatitis B or Hepatitis C. E. VECTOR-BORNE transmission is of considerably less significance in the United States than in other countries; examples of this mode are malaria and West Nile Virus transmitted by mosquitoes, rickettsial diseases transmitted by ticks, mites, or lice and borrelial diseases transmitted by ticks. Host Factors The third element necessary for the establishment of an infection is the susceptible host. Individual resistance to pathogenic microorganisms varies markedly. Persons particularly prone to infection are immunocompromised hosts including those with HIV infection, diabetes mellitus, lymphoma, leukemia, agranulocytosis, uremia, and those being treated with certain antibiotics, corticosteroids, irradiation, or immunosuppressive agents. Age, chronic debilitating disease, shock, coma, and trauma (accidental or surgical) also affect susceptibility. Some individuals may be immune or able to resist colonization by a certain infectious agent; others exposed to the same agent may establish a commensal relationship with the infecting organism and become healthy carriers, and still others may develop the clinical disease. NOTE: Healthcare personnel and visitors may also acquire nosocomial infections, e.g. influenza, pertussis, and tuberculosis. Because the infectious agent and host factors are the more difficult to control, efforts to interrupt the chain of infection are directed primarily at transmission. Isolation presents certain disadvantages both to the hospital and to the patient. The procedures may be time-consuming and add to the cost of hospitalization. They may render visits by physicians, nurses, and aides inconvenient and may make it difficult for the hospital staff to give the isolated patient the best possible APPENDIX GGG

356 Hospital of the University of Pennsylvania Clinical Practices of the University of Pennsylvania POLICY MANUAL Number: I-A Page 3 of 3 SUBJECT: TRANSMISSION OF INFECTIONS Effective: 8/14/11 care. Solitude deprives the patient of normal social relationships and may be psychologically injurious. The procedures set forth in this manual represent an attempt to balance the disadvantages of isolation against the hazards posed by the various kinds of communicable diseases and to prevent the spread of infections among patients, visitors, and healthcare personnel. Healthcare workers should also refer to the Hospital's Bloodborne Pathogens Exposure Control Plan, which is available in the Departments of Infection Control, Safety, Occupational Medicine, Administration and Nursing. SUPERSEDES: ISSUED BY: Neil O. Fishman, MD Reviewed July 2011 Approved August 17, 2011 Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission. APPENDIX GGG

357 Grievance Committee Review Hearing Request Form Student Name: Program: RT, CT, or MRI Name of Director: Progressive Step under review: First Written Warning Second Written Warning Final Warning Termination Issue: Rule or Policy Violation Safety Practice Professional Conduct Attendance & Timeliness Job Performance Names and titles of faculty completing prior Department review: 1 st Level Review: Name Title 2 nd Level Review: Name Title Student should attach all relevant documentation, including information provided to student by the director/faculty relating to the Progressive Step and the determination of a violation. Student s Request and Reason for Request: Student s Signature: Date Director Review 1 st Level Faculty/Director 2 nd Level Faculty/Director Response to student request and reason: Reviewer s Signature: Date Grievance Committee Review Hearing Requested [ ] yes [ ] no DATE:

358 PENNSYLVANIA HOSPITAL & SURGERY CENTER OF PENNSYLVANIA HOSPITAL ADMINISTRATIVE POLICY MANUAL Page 1 of 14 EFFECTIVE: 12/01/2012 SUBJECT: LEAVE OF ABSENCE POLICY NUMBER: HR27 Issued: July 1985 Committee Approval: Administrative Policy Review Committee: November 1999 October 2001 December 2004 December 2005 December 2006 December 2007 April 2009 February 2011 Attachment(s): Addendum A New Jersey Family Leave Act Related Policies: HR26 upenn.edu/pahhrpl/p dfs/hr26.pdfmilitary Leave HR47 - Workers Compensationhttp://u phsxnet.uphs.upenn. edu/pahhrpl/pdfs/hr 47.pdf POLICY For purposes of this policy, Pennsylvania Hospital includes all off campus licensed facilities, including but not limited to the Surgery Center of Pennsylvania Hospital. Pennsylvania Hospital (PAH) may authorize and grant Leaves of Absence for specified reasons as outlined below. Including reasonable accommodations under the Americans with Disabilities Act (see Policy #HR-83). PURPOSE The purpose of this policy is to define the process and procedure to be followed when applying for leaves of absence for Family Leave (for the birth, adoption of a child, placement of a foster child, care of a family member such as spouse, child or parent who has a serious health condition), Medical Leave (for your own serious health condition), Personal and Educational Leaves (see also, HR26 - Military Leave Policy). SCOPE This policy applies to all regular employees (excluding House Staff) who meet the specified eligibility requirements for the various types of leave. House Staff employees should see their Program Director or the Graduate Medical Education Office. Where any part of this policy is inconsistent with the provisions of an applicable collective bargaining agreement, the latter shall prevail. IMPLEMENTATION Implementation and control of this policy are the responsibilities of the Department Directors/ Business Administrators and Entity Senior Leadership. SERVICE REQUIREMENTS FAMILY/MEDICAL LEAVE (FMLA) An employee is eligible for Family/Medical leave who has worked 1250 hours in the 12 month period immediately preceding the date the requested leave of absence is to begin and who has completed a combined total of at least one year (365-days) of prior service at any time in the past (including temporary assignments at Pennsylvania Hospital). Any periods of approved Military Leave should be counted when calculating these hours of service requirements for FMLA leave. FAMILY LEAVE (FLA New Jersey) See attached Addendum A New Jersey Family Leave Act. APPENDIX III