HUNTINGTON MEMORIAL HOSPITAL CLINICAL POLICY & PROCEDURE

HUNTINGTON MEMORIAL HOSPITAL CLINICAL POLICY & PROCEDURE SUBJECT: SCHOOLS OF NURSING AUTHORIZED APPROVAL: PURPOSE: POLICY NO.: 8740.144 EFFECTIVE DATE: 6/16 Page 1 of 9 SUPERCEDES/ REPLACES: 5/13 This policy outlines the requirements and procedures that must be followed in order to facilitate positive student nurse/allied health experiences. POLICY STATEMENTS: Huntington Hospital values the opportunity to participate in the education of nursing/allied health students. The hospital is committed to ensuring the safe care of our patients, a great patient experience and providing opportunities to foster student growth. Therefore, the Affiliating Schools as well as the hospital personnel must comply with the following procedures. Clinical Instructors must be familiar with patient care routines, hospital policies and procedures, and must become acquainted with the staff of the patient care unit to which they are assigned. PROCEDURES: I. SCHEDULING PROCEDURE NURSING A. Huntington Hospital utilizes the Computerized Clinical Placement System (CCPS) developed by the Los Angeles Nursing Resource Center (LANRC) for Nursing School Placements. Schools can propose schedules in the system on a semi-annual basis; usually March for the Fall-Winter and October for the Spring-Summer. Nursing schools not submitting traditional rotation requests via the computerized system will not be considered for placements of traditional clinical rotations. Preceptorship and Leadership requests are exempt. See I.D for specific requirements. B. After receipt of all requests, a tentative schedule will be prepared by the hospital and submitted to each school for their review. Any amendments/changes to the finalized schedule must be made in the CCPS or via the approved form. C. Clinical rotation schedule, including preceptorship requests will be assigned based on historical requests submitted prior to the deadline and considering unit availability and Manager or Director s approval. Any request received after the deadline date will be considered on a space available basis in chronological receipt. If there are any questions or

POLICY NO.: 8740.144 Page 2 of 9 concerns, they should be brought to the attention of the Academic Coordinator (within 1 week of mailing). All questions or requests for change must be submitted in writing to the Affiliating Schools of Nursing Liaison. Western Governor s University is exempt from this process D. Placement requests for Preceptor ships and Leadership Rotations must be submitted to HH Academic Coordinator and must be submitted within 30 days prior to rotation. Western Governor s University is exempt from this process. E. Annual communication meetings are held to discuss mutual concerns between the hospital and the Schools of Nursing, evaluate processes/outcomes and finalize scheduling agreements. It is imperative that faculty overseeing clinical rotations at Huntington and program chairs attend this meeting. II. SCHEDULING PROCESS ALLIED HEALTH A. A pre-schedule request is required from all schools. Submission dates are set by individual allied health departments. B. Allied health student schedules are prepared and finalized with the individual Huntington Hospital departments, schools and are dependent on space, availability and patient care needs. C. Annual communication occurs to discuss mutual concerns between Huntington Hospital and Allied Health, evaluate processes/outcomes and finalize scheduling agreements. III. ORIENTATION FOR INSTRUCTORS ALL SCHOOLS A. All new and returning clinical faculty assigned to patient care unit/areas must be oriented to the hospital expectations by the HH Academic Coordinator. Faculty will make an appointment with the Department Manager(s) of their assigned units to coordinate department specific orientation and will be designed to meet individual needs. Documentation of instructor orientation must be received by the HH Academic Coordinator prior to bringing students onto the Patient Care Units. Orientation must occur on all units where the students are placed. B. The faculty member is responsible for making arrangements for his/her or personal orientation two weeks prior to the student experience. Failure to do so may result in a delay of the student assignments. C. The HH Academic Coordinator maintains a system for documenting and monitoring instructor unit orientation. Orientation packets may be obtained from the Clinical Education Department for Schools of Nursing and Individual Departments for Allied Health. The packets include the

POLICY NO.: 8740.144 Page 3 of 9 required orientation checklists and information specific to the hospital such as methods of documentation and clinical policies. D. It is the responsibility of the clinical faculty to communicate the information in the orientation packet to their students prior to patient care activities. Documentation of student orientation must be given to the HH Academic Coordinator by the end of the first clinical week. Access to mynetlearning is available to the instructor and modules can be assigned that will assist the instructor in fulfilling these student orientation objectives. IV. REGULATORY STANDARDS A. While working at the hospital, academic staff and students must comply with all applicable State and federal laws, regulations, The Joint Commission (TJC) and CMS Standards and with all hospital policies and procedures. B. All academic staff and students supplied by the agency/schools shall be appropriately screened by the agency or school in accordance with the terms of this agreement and policies and procedures consistent with the then current published standards of The Joint Commission. 1. Criminal Background Checks: Prior to a Student or Faculty Member participating in the Program, Institution shall conduct a criminal background check to include at a minimum, a state and county criminal history investigation and state sex offender search where the Student or Faculty Member resides and where HMH is located. Any criminal history identified shall be reported to HMH by Institution prior to the Student s or Faculty Member s participation in the Program. Institution shall immediately provide HMH an executed original of the criminal background verification upon request. C. All faculty and students must demonstrate proof of attendance and/or knowledge of the following: 1. Basic Life Support (BLS Provider consistent with AHA standards) 2. ACLS, PALS and/or NRP is required for faculty supervising students in clinical areas serving critical care, pediatric and/or neonatal patients. 3. General Safety 4. Infection Control 5. Life Safety 6. Body Mechanics 7. Hazardous Materials (SDS) 8. Age specific/population specific care 9. Emergency Preparedness 10. Restraints 11. HIPAA/Compliance

POLICY NO.: 8740.144 Page 4 of 9 12. National Patient Safety Goals D. Academic Institution must review and orient their staff to the policies and procedures for Corporate Compliance Standards of Business Conduct which includes compliance with the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) and state requirements relating to protected health information (as defined by federal regulations implementing HIPAA). Staff assigned to the hospital must comply with the policies adopted by the hospital relating to the access, use and disclosure of protected health information. V. HEALTH STANDARDS FOR ALL STUDENTS AFFILIATING WITH HUNTINGTON HOSPITAL A. The school must ensure that students and faculty have: 1. Documentation of complete physical examination within 12 months of beginning of the professional program. 2. Documentation of a two-step negative tuberculin text (Mantoux), or chest x-ray as appropriate, within 12 months of clinical experience at the hospital. i. Annual review of possible TB exposures & symptoms is also required by Huntington Hospital. Form is provided. 3. Documentation of immune status or immunization for measles, rubella, mumps, poliomyelitis and a tetanus immunization within 10 years of clinical experience at hospital. 4. Education and immunization for Hepatitis B, due to the potential exposure to patients with hepatitis. If a student member declines vaccination after education regarding the risk of contracting Hepatitis B, he/she must sign a declaration stating that he/she has been advised of the risks of Hepatitis B and has made an informed decision to decline immunization. 5. School identification with photograph and hanging student badge identification card is to be worn at all times during clinical rotation. B. The school must send health standard confirmation documentation to the hospital upon request. Periodic audits will be performed to confirm the availability of the necessary information. C. The school should recommend that students and faculty: 1. Receive an annual immunization for flu VI. STUDENT ASSIGNMENTS (Patient Assignments) A. Once clinical assignments are determined, the clinical faculty is expected to consult with the Department Manager of the Unit(s) (or their designee) regarding appropriate assignment of role models and preceptors for the students.

POLICY NO.: 8740.144 Page 5 of 9 B. Affiliating student nurses may perform all clinical functions performed by RNs if they meet the following criteria: 1. They have received didactic instruction and/or lab experience in the specific skill. 2. They are supervised by a competent clinical faculty and/or competent RN employed by the hospital. 3. The students must carry their own malpractice insurance. 4. The student s malpractice insurance has been checked for any excluded skills. C. Affiliating Allied Health students may perform all clinical functions performed by HH Allied Health Professionals if they meet the following criteria. 1. They have received didactic instruction and/or lab experience in the specific skill. 2. They are supervised by a competent clinical faculty or allied health professionals employed by the hospital. 3. The students must carry their own malpractice insurance. 4. The student s malpractice insurance has been checked for any excluded skills. D. Faculty must give a copy of the course objectives to the Department Manager prior to the student experience, as well as posting a copy on the unit. Students must communicate their objectives to the preceptor prior to commencing clinical experiences. 1. Students will utilize the Nursing Student Daily Communication Tool With Preceptor form to ensure adequate communication of daily goals and objectives including student level of training with the assigned preceptor. E. Final decisions regarding patient assignments are made by the Department Managers or their designee after negotiation among involved parties. A copy of the day s student assignment and instructor s cell phone number must be posted at the main desk where it can be readily access for the manager and preceptors. 1. In the case of a placement conflict, the faculty will immediately notify the HH Academic Coordinator. F. Faculty for preceptorships, nursing leadership courses and CNS or NP students must coordinate assignments with the Affiliating Schools Liaison before the student sessions begin. All requested assignments will be approved by the Manager or Director, as in the case of Leadership, CNS and NP students. Course objectives must be provided to the preceptor as well as the HH Academic Coordinator. VII. STUDENT ROSTER A student roster will be submitted to the Affiliated Schools Liaison prior to the first on-site clinical session. This roster will include the title of the clinical rotation,

POLICY NO.: 8740.144 Page 6 of 9 dates and times of the assignment, instructor name and contact information, total number of clinical hours per rotation, student names & email addresses, phone number, and car license plate number. VIII. COMPUTER, POC GLUCOSE TESTING AND PYXIS ACCESS A. Faculty and students will be given computer access as appropriate for their clinical need and hospital policy. It will be the responsibility of each affiliating school to designate a faculty member to function as a Super User. These Super Users will be responsible for the computer training of the faculty from their respective schools. They will be allowed access to our computer training facilities. Faculty will be responsible for training their students on the HH patient care systems as designated. B. On-site Instructors will review all instances of student documentation for accuracy and completeness. The instructor is required to either file a note in the electronic health record indicating this or in the case of paper charting, will co-sign the documentation. C. Faculty and students will be given Pyxis Medstation Access as appropriate for their clinical need and per hospital policy. It will be the responsibility of the instructor and the student all the information on the request form is completed thoroughly and accurately. The access will be issued to only the assigned areas. D. Faculty and students will be given access to our POCT system as appropriate for their clinical need and per hospital policy. It will be the responsibility of the instructor and the student to ensure all documentation needed is completed thoroughly and accurately. 1. This is a two step process: a. Policy review and post-test which requires a passing grade of 90% or higher. b. Competency Validation on the POCT device IX. PARKING A. Parking is provided for students and instructors on the top deck (roof) of the South parking structure. Alternative parking locations may be designated by the director of parking services at his/her discretion to meet the needs of the hospital. B. Parking cards are provided for lot access for the duration of the affiliation. Privileges may be rescinded if the Instructor or student does not abide by the parking assignments. Student car pooling is highly recommended. C. Parking cards must be returned at the end of each clinical rotation to the HH Academic Coordinator. Failure to return parking cards will result in a

POLICY NO.: 8740.144 Page 7 of 9 replacement fee per card at the current rate at the time of loss, and may result in revocation of the parking privileges. X. CONFERENCE ROOMS A. Meeting rooms are designated for pre and post conference sessions. Instructors will request conference rooms through the HH Academic Coordinator. Room confirmations will be forwarded to the Instructor. B. Conference time will not be held in any publicly accessed location. This includes, but is not limited to, the Cafeteria (old or new location), courtyard or lobby areas. Conference rooms located in the department where clinical time is spent cannot be utilized without the written permission of the Manager or Director. XI. MESSAGES Email is the preferred method of contacting the HH Academic Coordinator. Voicemail is an alternate method of communication. Appointments are recommended to ensure efficiency and to deliver required information to the satisfaction of both parties. XII. SUBSTITUTE INSTRUCTORS It is the responsibility of the affiliating schools to inform the HH Academic Coordinator when a substitute will be assuming supervisory responsibilities. All substitute faculty must comply with the orientation guidelines prior to acting in the capacity of Instructor (See Section III). XIII. DEFINITION OF RESPONSIBILITIES A. The curriculum and the instruction and supervision of its students are the responsibility of each of the Schools. B. The Hospital has sole responsibility for the well-being of its patients and for the operation of the Hospital. C. Academic Affiliation Agreements between the hospital and the various institutions are on file in the Risk Management Department and are reviewed at least triennially. Failure to comply with this policy may result in cancellation of the agreement for future placements/rotations. D. It is the responsibility of the schools and instructor to maintain a current copy of his/her California RN license or appropriate Allied Health licenses (i.e., RT, LCSW, RCP), current BLS Provider card (ACLS, PALS and/or NRP documentation if required by clinical area), and documentation of competencies. He/she will be asked for original proof of such documentation prior to the student s experience as well as a picture ID (School picture ID card or CDL is acceptable).

POLICY NO.: 8740.144 Page 8 of 9 E. Copies of current California RN/Allied Health licensure and all registered competencies are kept on file in the Clinical Education Department for each clinical instructor. Failure of faculty to maintain current documentation on file jeopardizes their participation in the clinical practice experiences at Huntington Hospital. XIV. FACULTY AND STUDENT I.D. A. Students must wear a uniform or patch that readily identifies them as student nurses or student in their designated allied health field. Students will wear a school ID badge with their name, title and picture clearly visible at all times in addition to the STUDENT hanging badge issued by Huntington Hospital while on Hospital premises. B. Faculty will obtain a picture ID badge from Huntington Hospital Security Services. This badge will have access limited to those areas in the Hospital in which their students are assigned. Faculty must also have name badge, pin or patch that clearly identifies their status. XV. CAFETERIA Students and faculty may eat in the hospital cafeteria. Trays may not be taken to classrooms or conference rooms. The cafeteria will not be used for conferences. No discussion of patient care related topics should ever take place in a public setting such as the cafeteria. XVI. FACULTY MEMBER OR STUDENT NURSE INJURIES Faculty members or students who are injured while on duty at HH will receive emergency treatment as directed by their school, and follow-up care will be referred to the schools Health Services. A Supervisor s Accident Investigation Report must be A BeeSafe report is completed at the time of injury by either the Department Manager where the injury occurred or the House Supervisor. XVII. HUNTINGTON EMPLOYEES ACTING AS ADJUNCT FACULTY A. Huntington employees employed by an affiliate school as an adjunct clinical instructor- Faculty member will not: a. Utilize Huntington employee privileges such as PYXIS, POCT glucose testing or parking access, but will utilize instructor specific access only. b. Perform any tasks other than responsibilities as clinical instructor. c. Discuss placement requests directly from Department manager without consulting with the HH Academic Coordinator.

POLICY NO.: 8740.144 Page 9 of 9 d. Use any additional computer access not issued as an instructor while in the role of instructor. e. Park in the employee section but will park in the designated Instructor location when on campus in the capacity of Instructor. B. Huntington employees serving as adjunct faculty will wear their school ID badge and Huntington Instructor badge while on hospital premises. Huntington employee badge will not be utilized to gain access to areas not included in the student s approved rotation. Reviewed by: Director, Clinical Education and Academic Partnerships and Clinical Affiliations Coordinator APPROVALS: Clinical P&P 2/16 MEC 6/16 REFERENCES: CAMH Title XXII, Title XVI California BRN