University of Maryland Medical Center Mini New Employee

University of Maryland Medical Center Mini New Employee General Orientation

Mission We heal, we teach, we discover, we care . . . we touch Maryland’s life every day. The University of Maryland Medical Center exists to serve the state and the region as a tertiary/quaternary care center, to serve the local community with a full range of care options, to educate and train the next generation of health care providers, and to be a site for world class clinical research.

Vision The University of Maryland Medical Center will serve as health care resource for Maryland and the region, earning a national profile in patient care, education and research, strengthened by our partnership with the School of Medicine and the School of Nursing.

Overview The University of Maryland Medical Center is a major, innovative teaching hospital in downtown Baltimore that provides a full range of health care to more than 300,000 patients each year from Maryland and the MidAtlantic region. It serves as a regional referral center for the most serious and complicated health problems in adults and children, including cancer, trauma, heart disease, neurological disorders and organ transplants. As one of the nation's first teaching hospitals, the Medical Center has its roots in the Baltimore Infirmary, a hospital built in 1823 at Lombard and Greene streets by doctors from the University of Maryland School of Medicine.

Highlights The Medical Center is the academic centerpiece of the University of Maryland Medical System, a regional, not-forprofit network that also includes four community hospitals and three specialty hospitals, as well as outpatient sites for primary and specialty care throughout Maryland. The Medical Center is composed of University Hospital, the Marlene and Stewart Greenebaum Cancer Center, the R Adams Cowley Shock Trauma Center and the University of Maryland Hospital for Children. All of its physicians are on the faculty of the University of Maryland School of Medicine. Over half of Maryland's physicians and other health care professionals received training at the Medical Center.

Commitment to Excellence At the University of Maryland Medical Center, we are embarking on a journey to transform the patient experience – by providing the safest care anywhere, exceeding patient expectations and becoming an even greater place to work. We need your commitment to excellence in everything you do.

Pillars of Excellence Core strategies at the University of Maryland Medical Center are built around pillars and teams

UMMC Pillar Measurements People Be an “employer of choice” and a health care industry leader in staff recruitment, satisfaction, retention and ongoing leadership development. Service Provide compassionate care and accessible service in a culturally sensitive manner to all patients and families at a level that exceeds expectations. Safety & Quality Provide the safest care anywhere, maintain positive healthcare environments and employment conditions, and become a recognized leader in achieving optimal patient care outcomes. Stewardship Achieve volume growth and manage operating expenses in order to attain financial results that allow for investment in our strategic priorities, while meeting our mission to provide services to all. Innovation Develop innovative programs and services to improve the health status and quality of life for residents of communities served while fulfilling our academic mission.

C2X Teams Employee Loyalty – Expands reward and recognition opportunities – Recognizes employee achievements through organization-wide celebrations – Identifies “storytelling” opportunities Patient Experience – Develops and implements tools and practices to support positive patient encounters – Implements “WOW” service behaviors – Develops and implements a robust service recovery initiative Communication – Provides consistent communication of service excellence initiatives – Develops new communication venues as needed – Supports effective communication for all service teams

C2X Teams Behavioral Standards – Develops and implements standards of performance – Incorporates standards into the organizational culture – Conducts monthly celebration of standards Measurement – Analyzes patient and physician satisfaction results – Develops formats to communicate results to the organization – Identifies best practices and shares them organization-wide Physician Partnership – Identifies and removes physician irritants – Coaches physicians on service excellence

Behavioral Standards Accountability Appearance Communication Respect Service

Accountability We commit to take ownership of all that we do and responsibility for the outcomes of all our actions. Take pride in the hospital as if you own it Accept the responsibilities of your job Take responsibility to create a safe and incident-free environment Use protective clothing and equipment per standard Comply with HIPAA privacy and security regulations Use resources responsibly to reduce waste in all forms

Appearance We commit to respect our personal appearance, work environment and all areas visible to patients and customers. Follow dress code policies Wear your ID badge correctly at all times Take pride in facility appearance: pick up litter and dispose of properly, clean up spills and return equipment to its proper place Take pride in personal appearance: grooming and dress reflect respect for our customers Do not use personal technology in the work environment Maintain a clean and orderly work area

Communication We commit to clear, open, honest and timely communication. Listen actively to our customers and coworkers in order to fully understand their needs Answer telephone calls within 3 rings: identify name, department and ask “How may I help you?” Respond to pager, voicemail and email in a timely manner Communicate plans, time frames and unexpected delays in all settings Pay close attention to both verbal and non-verbal messages

Respect We commit to treat others as they would want to be treated. Offer help when possible and cooperate in the workplace Respect privacy and dignity; use a quiet and respectful tone of voice at all times Be sensitive to cultural differences Treat coworkers and customers with courtesy, honesty and respect Provide praise and recognition for a job well done Assume that your coworker wants to do a good job

Service We commit to provide our patients, families, visitors and coworkers with courteous, prompt and safe service. Smile, make eye contact and introduce yourself Greet and acknowledge patients, families, visitors and coworkers All employees are responsible for answering call lights Follow proper elevator etiquette Anticipate customer needs: follow through that expectations were met

WE CARE standards W – Welcome customers by identifying yourself. E – Engage with customers by asking how you can help C – Communicate with patients, families, physicians and co-workers A – Address customers’ needs R – Respect individual values and cultural differences E – Educate customers

Cultural Competence Cultural competency is the capacity to function effectively with groups and individuals from similar and different cultural systems. Rosalyn Taylor O’Neal

Cultural Competence Values Cultural competence is for everyone Cultural competence is integral to best practice Cultural competence is an ongoing process Cultural competence is part of the overall organizational goal of excellence Culturally competent organizations must be customer-driven Cultural competence is a key factor to continued financial survival Culturally competent organizations should foster leadership throughout the organization Adapted from Child Welfare League of America

University of Maryland Medical Center 2008 – 2013 Strategic Plan Our Vision: UMMC will serve as a resource for Maryland and the region, earning a national profile in patient care, education and research, strengthened by our partnership with the Schools of Medicine and Nursing e ic v r Se Operational Excellence Service Excellence Clinical Program Growth Referral Relationships Capacity & Infrastructure Pe op le tion ova Inn Advance our growth and market share of patient volumes across the state of Maryland by increasing our geographic reach, strengthening physician ties, ensuring ease of access, and elevating our reputation. Become an “employer of choice” and a health care industry leader in staff recruitment, satisfaction, retention and ongoing leadership development. Safety & Quality Ste wa r ds hi p Create a high-performing culture across all aspects of operations to provide compassionate care and accessible service in a culturally sensitive manner to all patients and families at a level that exceeds expectations. Provide the safest care anywhere, and become a recognized leader in the development of innovative patient care delivery models for both inpatient and ambulatory care Clinical Outcomes & Safety Multidisciplinary Care Models Workforce Medical Education/Training Build and sustain a financial position allowing investment in people, clinical programs, technology, facilities and our community. Strengthen relationships with UMMS’ hospitals and the UM Schools of Medicine and Nursing. Relationships with UMB Schools Financial Performance Corporate Citizenship

Corporate Compliance Do the right thing

Corporate Compliance What is It? Commitment to ethical business practices. Commitment to quality patient care and service. Compliance with laws, rules, regulations and policies. Commitment to our patient’s right to privacy. Do the right thing Everyone is involved

Compliance With What? Medicare regulations Medicaid regulations Medicare/Medicaid Fraud and Abuse Anti-Kickback Statute Stark Act False Claims Act Occupational Safety and Health Administration (OSHA)/ Maryland Occupational Safety and Health (MOSH) Conflicts of interest Equal Employment Opportunity (EEO) Clinical Laboratory Improvement Amendments (CLIA) U. S. Environmental Protection Agency (EPA) Blood borne pathogens Americans With Disabilities Act (ADA) State licensure and certification Emergency Medical Treatment and Active Labor Act (EMTALA) Family Medical Leave Act (FMLA) Antitrust Health Insurance Portability and Accountability Act of 1996 (HIPAA) The Joint Commission Drug Enforcement Administration (DEA)

HIPAA Health Insurance Portability and Accountability Act of 1996 Privacy Rule (effective April 14, 2003) – Limits the use and disclosure (leaking) of confidential patient information to prevent improper use. – Establishes patient rights relating to their health information. Security Rule (effective April 21, 2005) – Protect confidentiality of electronic patient information when stored, maintained or transmitted. Patients have the right to have their health information kept private. Do not discuss patient information in public areas, e.g. elevators, cafeteria lines, hospital lobby and hallways.

Patient Privacy Keep patient information on a “need to know” basis. Share information with staff who need to know for treatment, payment or Medical Center operations. Locate fax machines used to send or receive patient information in places not easily accessible to patients, family members or visitors. Keep patient information out of public view. Transport patient information face down, covered, or preferably in envelopes. Remove paper records with patient information from meeting rooms or public areas after use Keep computer screens out of public view and log off of the computer when done. Make sure patients are properly covered when they are transported. Close doors and draw the curtains around patients when they are receiving care.

The Joint Commission Provides an accreditation process that challenges organizations to improve their performance on an ongoing basis For us it means patient safety and quality patient care What to do about patient safety concerns: Talk to your immediate supervisor or charge nurse for immediate resolution of your concern Talk to your nurse manager or director about problems that recur and/or show a pattern If your concerns are not resolved or addressed, call the patient safety hotline – 410-328-SAFE or 8-SAFE (7233) You may also call your concerns to – The Maryland Office of Healthcare Quality – 410-902-8016 – The Joint Commission – 1-800-994-6610

Impaired Staff or Licensed Independent Practitioners (LIPs) The Medical Center strives to maintain a drug free workplace Report LIPs or co-workers who are suspected of suffering from abuse of these substances or who may be suffering from psychiatric illness, emotional distress or physical disability immediately to your manager

What do you do if you suspect a business practice is unethical? Check policies/procedures, the Code of Conduct on the Medical Center Intranet Talk with your manager or supervisor Call UMMC Hotline at 1-877-300-DUTY (3889) Report via internet at www.reportit.net (user name- UMMC, password- UMMC) A question asked prevents a broken rule. There is no retaliation for reporting.

Security Awareness Prevention is the key!

Security Security strategic posts Main lobby Shock Trauma Center Gudelsky entrance Emergency Department entrance 24/7 Patrols throughout the hospital Security telephone number 8-8711

UMB Campus Police The campus is patrolled by the University of Maryland at Baltimore Campus Police (C.O.P.S.), 6-1408 Or may be reached by emergency call boxes or call 410-706-6882

Workplace Safety Don’t walk alone to isolated areas. If you are working in isolated areas or after hours, call Security- ext. 8-8711- and give your name and location. Always lock your door when leaving If you witness workplace violence, acts of vandalism, or disruptive behavior, contact Security immediately at ext. 8-8711 – The Medical Center has zero tolerance for workplace violence

UMMC ID Badges It is a state law that you wear your badge at all times, prominently displayed above the waist. Report lost or stolen badges to ext. 8-1329. – The replacement cost for a badge is 10. Treat unbadged persons as guests. Advise them to get a guest pass Report description and location of suspicious persons to Security-ext. 8-8711 Never allow an unbadged person to follow you into a locked area Do not give up control of your Security ID

Important Information Safe Haven Law –The Medical Center is a Safe Haven. A distressed parent who is unable or unwilling to care for an infant can give up custody of a baby who is less than 72 hours old, safely, legally, and confidentially. If someone hands you a newborn baby, don’t ask any questions. Take the baby to the Pediatrics Emergency Room. The Medical Center is a TOBACCO FREE facility In order to provide the healthiest possible environment for its patients, visitors, employees and volunteers, the University of Maryland Medical Center launched “UMMC Completely Tobacco-Free” policy on February 14, 2008. The new policy expands the existing hospital ban on all tobacco products inside the hospital’s facilities to the outside sidewalks and walkways that are part of the Medical Center’s property. The new policy applies to all patients, visitors and employees

Guest Services Call – For answers to questions – To voice concerns – To get directions Dial 8-1500 on any house phone.

Environment of Care Any safety concern, risks or observations of close calls or near misses should be reported to the Safety Officer. Safety Officer – Jim Chang (Phone 8-6001/Pager 1336)

Employee Rights Employees have the basic right to Make a complaint regarding unsafe or unhealthy workplace conditions Address complaint in-house by notifying supervisor and/or the Safety Officer at 8-6001 or 8-2337 ID#1336 Report patient safety issues to Customer (8-SAFE) Report patient safety issues to The Joint Commission Call Connect (SOSC) (8-5174/8-8711/8-7072) Not face retaliation for making a complaint Request confidentiality

Space Management Hallways are for people, not stuff. If you have items in the hallways, they need to be kept on one side. Remember – when the fire alarm sounds, everything needs to be moved out of the hallway(s).

Hazardous Materials and Waste Management Hazardous materials (hazmats) are any substance that when used or stored improperly poses a risk to people, property or the environment. Each department should have a chemical inventory and access to Material Safety Data Sheets (MSDS for all inventory items. MSDS are fact sheets that describe the possible health effects, first aid information and the clean up procedures for spills of all hazardous materials used at the Medical Center. An MSDS should be posted in every area where hazardous materials are stored. If a hazardous materials is spilled in your area: – Contain and clean up the spill if it is safe to do so, and you are appropriately trained – If you need help, call the SOSC at 8-5174 – Report all spills to your Department Safety Office and the Hospital Safety Officer

Fire Safety Code Red is the disaster code for fire. Your role if the fire alarm sounds: If the fire alarm is in the same building and same floor (or floor directly above or directly below) – Clear the corridors – move carts and equipment out of the corridor into rooms or alcoves; – Close all door and windows; and – Be prepared to move if necessary or directed to do so. If the alarm is in another building, stay alert If the alarm is in the same building, but on a different floor, stay alert and be prepared to help if needed

Fire Safety If you discover a fire or smoke, RACE: R – Remove/Rescue anyone in immediate area of fire. A – Activate the alarm and call 8-2911. C – Confine the fire by closing doors and/or windows E – Extinguish the fire only if safe to do so or evacuate. Do not store equipment in the hallways, in front of fire exits or in the stairwells. Never prop open fire doors Know the location of the fire exits and fire extinguishers in your area

Fire Extinguisher When using a fire extinguisher remember PASS Pull the pin Aim the nozzle at the base of the fire. Squeeze the handle. Sweep from side to side at the base of the fire.

Medical Equipment All pieces of patient-related equipment (including loaners, demos, patient-owned equipment) are inspected and tested prior to use by staff in Clinical Engineering. If electrical or biomedical equipment is malfunctioning: – Remove the equipment from service and notify your manager/supervisor – Place “Out of Order” labels on the equipment, if necessary, to distinguish it from other equipment – Contact BioMed at 8-5343 (pager 6000) for patient related equipment and Facilities at 8-5174 for non-patient equipment. Clinical equipment that requires scheduled inspections carry a safety inspection tag with date inspected and date due. Equipment that does not require periodic inspection is labeled “No Inspection”.

Utility Outage At the Medical Center, we have six emergency generators that provide backup power for critical functions in the event we lose commercial power. This power is provided through red outlets. In general, any critical piece of equipment (e.g., life support and patient monitoring equipment) should be plugged into red outlets if available. Conversely, non-critical equipment, e.g. copy machines, and coffee pots) should not be plugged into red outlets. Contact Facilities at 8-5174 if uncertain. For a utility malfunction such as a water leak or an electrical outage: – Know the location of your medical gas shutoff valves and who is authorized to use them (usually the charge nurse or chief technologist). – Keep the area in front of medical gas shutoff valves, and electrical panels, clear of all obstructions (i.e., no cabinets, no carts, etc.) – Call the SOSC at 8-5174.

MRI Safety - Protecting yourself and the patient If you are a nurse or this is your responsibility, complete the MRI checklist accurately Remember the MAGNET IS ALWAYS ON Heed posted warning signs Stay away from the MRI suite unless it is necessary for you to be there Be mindful of metal on your body or equipment that you use

Emergency Management The hospital disaster plan can be found on the Intranet. Your role in a disaster: Report to work when scheduled (or when called in). Follow the direction of your supervisor. Note: If the hospital activates the Hospital Incident Command System (HICS), you may be assigned an additional role(s) and responsibilities. How do I report an emergency at the Medical Center? For life-threatening emergencies such as a Code Blue or fire, call the Stat Operator at 8-2911 and notify your manager/supervisor For all other emergencies (security issues, utility failures, etc.) contact the SOSC at 8-5174 and notify your supervisor

Patient Safety

Patient Safety at UMMC Patient safety is everybody’s work Leaders ensure that our culture supports safety and blame free reporting Staff follow policies, talk to each other, report safety risks including near misses, and exercise care and caution Patients/families inform their caregivers of their full history, report risks they observe, accept responsibility for consequences of decisions they make

National Patient Safety Goals Improve the accuracy of patient identification by accurately identifying the individual for whom the service and treatment is intended. Improve the effectiveness of communication among caregivers. Improve the safety of using medications. Reduce the risk of healthcare associated infections. Accurately and completely reconcile medications across the continuum of care.

National Patient Safety Goals Reduce the risk of patient harm resulting from falls. Encourage patients’ active involvement in their own care as a patient safety strategy. Improve recognition and response to changes in a patient’s condition. Universal Protocol: Prevent wrong site, wrong procedure, wrong person surgery and procedures

Infection Control Hand hygiene is the single most important procedure for the prevention of health care associated infections. Alcohol based hand rubs can be used if hands are not visibly soiled. Use antimicrobial (CHG) soap and water and wash for 15 seconds if hands are visibly soiled. Do not use alcohol based hand rubs for patients that have Clostridium difficule (C-diff). Include the patient and family in our Hand Hygiene Campaign. Be familiar with your unit’s hand hygiene performance: GOAL-100% compliance. Be a role model for others.

Code Pink If a child or infant is determined missing, a CODE PINK will be overhead paged. Be alert to unusual behavior and report to security Be aware that a disturbance may occur in another area creating a diversion that facilitates an abduction Be aware of anyone looking suspicious, carrying an infant instead of pushing a bassinet, carrying a tote or duffel bag If you see a suspicious person, get a good description and call security STAT If possible, detain suspected person through conversation

Employee Injury/Exposure What do I do after a needle stick/body fluid exposure? Wash the area with soap and water. For mucous membrane exposures, irrigate the affected area with saline. Call the Exposure Hotline immediately at 8-BEEP ID# STIK (7845). Contact your supervisor. Contact Environmental Services through SOSC for replacement of needle boxes.

Management of Patients on Isolation Precautions If the nursing assessment reveals that the patient may have a communicable disease (e.g. diarrhea of unknown etiology, signs and symptoms of a viral respiratory illness), the nurse can initiate presumptive isolation precautions and then follow-up with the physician for an order. Isolation attire is not to be worn outside the patient room unless the staff is transporting a patient on precautions. An isolation cart is acceptable in the hallway only if the patient has a visible isolation sign. Isolation signage must be in accordance with the hospital policy; handwritten signs are unacceptable.

TB Exposure Prevention Tuberculin skin testing is required annually; if you are known to be positive, an annual screening questionnaire must be completed. If you are exposed to a patient with tuberculosis, a followup skin test 10-12 weeks after exposure is required.

Performance Improvement Methodology at the Medical Center Plan What do you hope to accomplish with the change? Plan for the collection of data. Do Carry out the change or test. Collect data. Study Complete analysis of data Summarize what was learned Act Adapt of abandon change based upon knowledge gained. Are we ready to implement? Plan for next cycle.

Performance Improvement Staff Responsibilities Identify hospital PI initiatives Tie unit-based activities into hospital priorities Describe unit based work around PI Use chart and posters to help describe Describe the process and outcome succinctly