New Hire Orientation 2021

New Associate Orientation Guide

In This Guide Welcome from the CEO .................................................................................................................... 1 Mission, Vision, & Values .................................................................................................................... 2 Holiday Schedule, Pay Periods ......................................................................................................... 4 Dress Code, Attendance Policy, Company Property .................................................................... 6 Kern Medical Maps ...........................................................................................................................11 Safe Surrender Law............................................................................................................................ 15 Doing What Matters! ......................................................................................................................... 17 Customer Service Standards ............................................................................................................19 The Joint Commission ....................................................................................................................... 28 HIPAA ................................................................................................................................................. 41 Environment of Care ........................................................................................................................ 51 Emergency Preparedness, Badges, Security ................................................................................ 58 Infection Prevention ......................................................................................................................... 65 MDRO’s and HAI’s ............................................................................................................................ 77 Employee Health .............................................................................................................................. 80 Kern Medical Drug and Alcohol Policy........................................................................................... 83 Workplace Violence ........................................................................................................................ 85 KernLink .............................................................................................................................................. 87

Welcome to Kern Medical from the CEO Welcome to Kern Medical and thank you for choosing to be part of our organization. You are joining a team with more than 1,400 people united together in our commitment to incredible patient care, education, and service to our community. This is a significant mission and I am glad you are choosing to help us carry it forward. In 2017, Kern Medical celebrated its 150th anniversary as the oldest hospital in Kern County. Our medical center’s services range from

the area’s only Trauma Center, to physicians caring for patients in very busy outpatient offices with clinics specializing in everything from primary care, to specialty services for high-risk pregnancy, Valley Fever, cancer, or HIV. As part of our mission, Kern Medical serves as one of 21 public hospitals in California that operate as safety net health systems caring for everyone regardless of their ability to pay. It’s inspiring to see our staff not just provide amazing care, but do it with a warm smile while comforting families and supporting their coworkers. I hope you will join us in making Kern Medical a better place for everyone who comes through our doors. Another part of our unique mission is serving as the area’s only teaching hospital, with over 200 students, residents, and fellows undergoing medical training. Our resident and fellowship programs are affiliated with the David Geffen School of Medicine at UCLA. To enhance our education and patient care, we are investing in new technology, recruiting doctors, and expanding our services. On July 1, 2016, Kern Medical transitioned from being owned and operated by the County of Kern to become a freestanding Hospital Authority. We are now able to be more agile, flexible, and responsive to serving our community’s needs, which in turn empowers us to deliver care more efficiently, to expand our services, and to ensure a strong, vibrant future for Kern Medical, our patients, and their families. It truly is an exciting time to be at Kern Medical. On behalf of everyone at Kern Medical, welcome to our team. With warmest regards, Russell V. Judd Chief Executive Officer

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Mission, Vision, & Values

Who we are Kern Medical is proud to be a Highly Specialized Tertiary Referral Center, Academic Teaching Institution, and Safety Net Hospital. Mission Guided by the needs of our patients and their families, Kern Medical delivers safe, compassionate, high quality care, and improves the health and well-being of our community.

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Vision Kern Medical will: • Place the patient at the center of the healthcare experience • Lead academic and professional excellence in the community • Advance healthcare delivery through a fully integrated system across the spectrum of care • Realize the triple aim of providing the best patient experience, highest quality of care, and most appropriate use of healthcare resources • Hire and develop the best team that is both inspired and committed to healing • Commit to financial stability through efficient management of resources

Values Kern Medical is guided by the principles of: • Compassionate Healing: We ensure a culture of caring that nurtures the well- being of the whole person • Respect: Be kind and listen to understand, while embracing the skills and knowledge of others • Integrity: We earn your trust by delivering the best in healthcare • Innovation: We are committed to new ideas, creativity, and academic achievements • Collaboration: We value our partnerships to advance the health of our community • Fiscal responsibility: We are committed to effectively utilizing and maximizing our resources

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Holiday Schedule 2021 Friday

January 1st January 18th

New Year’s Day

Monday Monday Monday Thursday

Martin Luther King’s Birthday

May 31st July 5th

Memorial Day

Independence Day Thanksgiving Day Day after Thanksgiving Christmas Eve (Observed)

November 25th November 26th December 23rd December 24th

Friday

Thursday

Friday

Christmas Day

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Payroll Periods and Paydays 2021

Kern County Payroll Periods 2021

Pay Period Start Sat

End Fri Pay Tue

2021-01 2021-02 2021-03 2021-04 2021-05 2021-06 2021-07 2021-08 2021-09 2021-10 2021-11 2021-12 2021-13 2021-14 2021-15 2021-16 2021-17 2021-18 2021-19 2021-20 2021-21 2021-22 2021-23 2021-24 2021-25 2021-26

1/2/2021 1/15/2021 1/26/2021 1/16/2021 1/29/2021 2/9/2021 1/30/2021 2/12/2021 2/23/2021 2/13/2021 2/26/2021 3/9/2021 2/27/2021 3/12/2021 3/23/2021 3/13/2021 3/26/2021 4/6/2021 3/27/2021 4/9/2021 4/20/2021 4/10/2021 4/23/2021 5/4/2021 4/24/2021 5/7/2021 5/18/2021 5/8/2021 5/21/2021 6/1/2021 5/22/2021 6/4/2021 6/15/2021 6/5/2021 6/18/2021 6/29/2021 6/19/2021 7/2/2021 7/13/2021 7/3/2021 7/16/2021 7/27/2021 7/17/2021 7/30/2021 8/10/2021 7/31/2021 8/13/2021 8/24/2021 8/14/2021 8/27/2021 9/7/2021 8/28/2021 9/10/2021 9/21/2021 9/11/2021 9/24/2021 10/5/2021 9/25/2021 10/8/2021 10/19/2021 10/9/2021 10/22/2021 11/2/2021 10/23/2021 11/5/2021 11/16/2021 11/6/2021 11/19/2021 11/30/2021 11/20/2021 12/3/2021 12/14/2021 12/4/2021 12/17/2021 12/28/2021 12/18/2021 12/31/2021 1/11/2022

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Kern Medical Policy Overview

Dress and Grooming Standards Policy DEFINITIONS:

1. Professional Uniform – An identical or consistent style/color without variation, designated in areas such as housekeeping, engineering, dietary, etc., and provided by Kern Medical to non-clinical personnel. 2. Clinical Attire – Industry standard attire worn by staff designated by color or scheme as determined by assignment. Clinical attire includes but is not limited to attire commonly known as “scrubs.” POLICY: It is the policy of Kern Medical that all Kern Medical staff will dress according to the standards set forth in this policy. It is the intention and spirit of Kern Medical Center and this policy to provide a workplace which is neutral, conducive to medical care and healing, free from distractions, exposure to political messages and clothing, and potential conflicts PROCEDURE • General Grooming Standards – All Associates 1. Hair – Must be clean and well groomed. Long hair must be kept in a neat hairstyle and contained in such a manner that it does not come in contact with the patient or visitors. Extremes in hair styles, color, hair adornments will be avoided and must be suitable for hospital or healthcare environment. Facial hair must be neatly trimmed and may not interfere with, or compromise, the proper fit of hospital provided respirator devices for those required to wear personal safety masks. 2. Personal Hygiene – Employees are expected to maintain a high standard of cleanliness, i.e., regular bathing, oral hygiene, use of deodorant and clean clothing. 3. Makeup - Must be simple and professional. Extremes in style and colors will be avoided at work. 4. Gum – Associates will not chew gum while on duty. 5. Jewelry – Acceptable if it is simple, suitable for individual work area and must not interfere with safe working conditions or patient care. A small lapel pin related to a health campaign (i.e. breast cancer awareness) is acceptable. • Body Piercings – Visible, faddish body jewelry, including those in the nose, tongue, eyebrow, neck, etc. are prohibited while on duty. • Dark glasses (sunglasses) may only be worn inside if they are prescribed.

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6. Perfume, Cologne and Fragrances – Will not be worn due to the potential sensitivity and allergies of fellow associates, visitors and patients. 7. Tattoos – Visible tattoos (including temporary and henna type) are prohibited and must be covered while on duty (i.e. long sleeves, gloves, make-up, bandages, etc.). 8. Fingernails • Must be neatly manicured and of reasonable length (1/8” {3.1 mm} beyond fingertip). • Artificial nail enhancements are not to be worn. Nail polish is permitted, but anything applied to natural nails other than polish is considered an enhancement. This includes, but is not limited to, artificial nails, tips, wraps, appliqués, acrylics, gels, and any additional items applied to the nail surface. • Unchipped nail polish is permissible. • Individual departments may institute measures, in addition to those above, to comply with established standards of care in specialty areas. 9. Badge – Kern Medical identification badges are to be worn in clear sight above the waist with name, title and picture in a clearly visible location (e.g., shoulder, chest, outer layer of clothing, facing forward.) Please see Identification/Access Badge Policy. You can reference the Dress and Grooming Standards Policy through the Kern Advance Intranet for more in depth information. 1. Acceptable Behavior – Behavior that is in accordance with, consistent with and/or supports the mission, vision, business and ethics practices, and governing policies and procedures of Kern Medical and other regulatory agencies and which comports with the written behavioral guidelines published in Kern Medical policies and the Employee Handbook. 2. Conflict of Interest – A situation in which a person, such as a public official, an employee, or a professional has a private or personal interest sufficient to appear to influence the objective exercise of his or her official duties. 3. Disruptive Behavior – Any behavior manifested through personal interaction (e.g., electronic, e-mail, telephonic, recorded, etc.), with physicians, hospital personnel, health care professionals, patients, family members, or others, which interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care. 4. Inappropriate – Behavior that is not in accordance, inconsistent or does not support the Code of Conduct and Business Ethics DEFINITIONS:

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Mission, Vision, Business and Ethics Practices, and governing policies and procedures of Kern Medical and other regulatory agencies and which does NOT comport with the written behavioral guidelines published in Kern Medical policies and the Employee Handbook. POLICY STATEMENT: It is the policy of Kern Medical to recognize that our employees are the key to providing a quality experience for both clinical and non-clinical business activities. In addition, it is Kern Medical’s expectation that all Kern Medical employees, to include, but not limited to, clinical, medical, management and administrative staff, will follow this Code of Conduct and Business Ethics and will operate in an ethical manner consistent with the mission, vision, values, strategic plan and policies of Kern Medical employees will also follow the Code of Conduct, as outlined in the County of Kern Policies & Procedures and Employee Handbook. Failure to do so can result in disciplinary action for individual employees and medical staff members up to and including termination of employment or contractual agreement.

Attendance Policy DEFINITIONS: For the purposes of this policy, the following definitions apply:

• Absence – The inability of an employee to meet a scheduled work commitment. This includes any scheduled overtime or leaving before the scheduled quitting time. Please be advised that if the employee is going to be absent to their scheduled shift, they must verbally speak to a manager/supervisor or approved designee two (2) hours prior to the start of their shift. • Approved absence – Prearranged time away from work upon notification of and an authorization from the supervisor. Examples include:

1. Vacation 2. Jury Duty 3. Bereavement Leave 4. Disciplinary Suspensions 5. Workers’ Compensation Leave 6. Medical Leave of Absence

7. Family Medical Leave 8. Discretionary Leave 9. Military Leave 10. Flexed off

• There is no occurrence imposed for an approved absence. • Unscheduled Absence – Sick days, emergencies, and failure to report to work. You can reference the entire Attendance Policy through the Kern Advance Intranet for more in depth information.

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Issuance of Company Property

Identification/Badge Access Upon the start of employment every member will be provided with identification badge. All members of hospital staff and volunteer services are required to wear their identification badge at all times while on duty. Badges must be visibly worn above the waist and include the employee’s photograph, name, classification, and/or home department. If lost, replacement badges will be provided at the cost of $10.00 per badge. You can reference the Identification/Access Badges Policy through the Kern Advance Intranet for more in depth information. Pager and Cellular Phone Usage Access is assigned based on an employee’s need for two-way communication deemed necessary by a department head. Pager and cellular phone usage master list is maintained by the Information Systems/ Communications Department. Lost or damaged pagers will be replaced the first occurrence at the Department’s cost. Subsequent loss or damaged pagers will result in a replacement charge to the employee of $50.00 per pager. Usage of Cellular phones must be certified each month by the employee to identify any personal call usage. If the cellular phone becomes lost or damaged due to the employee’s own negligence, it is the employee’s responsibility to replace or repair the item at his/her own expense. More in depth information can be referenced through the Pager and Cellular Telephone Usage Policy located on the Kern Advance Intranet page. Key and Lock Control Policy Key requests are submitted to the Engineering Department via Department Manager. Lost, damaged, or stolen keys are to be reported to the Engineering Department immediately. To view more information about Kern Medical’s Lock and Control program you can view the entire policy on the Kern Advance Intranet page.

All Kern Medical Property will need to be turned in at the end of the last day of employment to avoid charges for lost property/equipment.

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Patients are Part of the Healthcare Team The Kern Medical healthcare team is not complete without our patients and their loved ones. It is imperative that everyone is on the same page about the patient’s healthcare needs, priorities and any barriers the patients may have to achieving the best health possible. In order for Kern Medical’s health care providers and the patients to work together, we encourage patients and their families to participate in care the following ways: • Encouraging patients to “Speak Up”: • if they don’t fully understand something • if they have not seen their care provider wash their hands • if their pain is not well controlled • if they have a concern about something • if they don’t think they are receiving the right treatments and medicines • if the patient’s condition deteriorates rapidly • Encouraging patients to follow advice to prevent falls • Encourage patient’s loved ones to visit only if they are feeling well • Encouraging patients and their loved ones ensure their vaccinations are current (including an annual flu vaccination) • Encouraging patients to designate a Partner in Care to speak on the patient’s behalf if the patient is unable to do so • Encouraging patients to know the details of their discharge plan, communicate any foreseeable barriers, and how to best recover at home

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Kern Medical Maps

FIRST FLOOR

Department

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In KEY

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1058 . . . . . . . . . . . . . . . A . . . . . . . . 1 Administration . . . . . . . . . C . . . . . . . . 1 Admitting . . . . . . . . . . . . . A . . . . . . . . 1 Ante-Natal Testing . . . . . . . C . . . . . . . . 4 Case Management . . . . . . G . . . . . . . . 3 Central Supply . . . . . . . . . B . . . . . . . . 2 CDX . . . . . . . . . . . . . . . B . . . . . . . . 1 Diagnostic Treatment Center . B . . . . . . . . 2 Definitive Observation Unit . . D . . . . . . . . 2 Emergency . . . . . . . . . . . . E . . . . . . . . 1 Gift Shop . . . . . . . . . . . . D . . . . . . . . 1 Grill/Cafeteria . . . . . . . . . C . . . . . . . . 1 Inpatient Behavioral Health Unit B . . . . . . . . 3 Inpatient Therapy Services . . C . . . . . . . . 2 Intensive Care Unit (ICU) . . . D . . . . . . . . 2 Lab . . . . . . . . . . . . . . . D . . . . . . . . 1 Labor & Delivery . . . . . . . . B . . . . . . . . 4 Labor & Delivery Registration B . . . . . . . . 4 Medical Records . . . . . . . C . . . . . . . . 1 Medical Surgical Unit C . . . . C . . . . . . . . 2 Medical Surgical Unit C . . . . C . . . . . . . 3 Medical Surgical Telemetry Unit DD . . . . . . . . 3 Mother Baby . . . . . . . . . . C . . . . . . . . 4 Nursery . . . . . . . . . . . . . B . . . . . . . . 4 OR . . . . . . . . . . . . . . . . . E . . . . . . . . 2 OR Waiting . . . . . . . . . . . . E . . . . . . . . 2 Outpatient Clinics . . . . . . . . A . . . . . . . . 1 Pre & Post Surgical Care (Clinic) A . . . . . . . . 1 Pediatrics/Mother Baby . . . D . . . . . . . . 4 Radiology . . . . . . . . . . . . D . . . . . . . 1 Registration . . . . . . . . . . . A . . . . . . . . 1 Security . . . . . . . . . . . . . D . . . . . . . . 1 Serenity Room . . . . . . . . . C . . . . . . . . 1

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•Registration •Admitting

•Outpatient Clinics •Pre & Post Surgical Care Clinic

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B Elevators

B WING

Medical Records

Grill/Cafeteria

G WING

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Serenity Room

Dining Area

C WING

Administration

Courtyard

D WING

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Laboratory

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Gift Shop

Security

YOU ARE HERE

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EMERGENCY ENTRANCE

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1058 . . . . . . . . . . . . . . . A . . . . . . . . 1 Administración . . . . . . . . . C . . . . . . . . 1 Admitir . . . . . . . . . . . . . . A . . . . . . . . 1 Pruebas Ante-Natal . . . . . . . C . . . . . . . . 4 Manejo de casos . . . . . . . . G . . . . . . . . 3 Suministro Central . . . . . . . B . . . . . . . . 2 CDX . . . . . . . . . . . . . . . . B . . . . . . . . 1 Centro de tratamiento de diagnóstico . . . . . . . . . . B . . . . . . . . 2 Unidad de Observación DefinitivaD . . . . . . . . 2

ENTRADA ALA A

•Registro •Admitir

•Clínicas Ambulatorias •Cuidados pre y post Quirúrgicos

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Kern Medical Maps

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A WING

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B WING

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Diagnostic Treatment Center

G WING

Central Supply

Simulation Center

C WING

Employee Health

G WING ENTRANCE

Inpatient Therapy Services

Medical Surgical Unit C

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Intensive Care Unit (ICU)

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Kern Medical Maps

THIRD FLOOR

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1058 . . . . . Administration Admitting . . . Ante-Natal Tes Case Managem Central Supply CDX . . . . . . Diagnostic Trea Definitive Obse Emergency . . Gift Shop . . . Grill/Cafeteria Inpatient Beha Inpatient Thera Intensive Care Lab . . . . . . Labor & Delive Labor & Delive Medical Recor Medical Surgic Medical Surgic Medical Surgica Mother Baby . Nursery . . . . OR . . . . . . . OR Waiting . . Outpatient Clin Pre & Post Surg Pediatrics/Mo Radiology . . . Registration . Serenity Room Simulation Cen

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Inpatient Behavioral Health Unit

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Kern Medical Maps

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Department 1058 . . . . . Administration Admitting . . . Ante-Natal Test Case Managem Central Supply CDX . . . . . . Diagnostic Trea Definitive Obser Emergency . . Gift Shop . . . Grill/Cafeteria Inpatient Behav Inpatient Therap Intensive Care U Lab . . . . . . Labor & Deliver Labor & Deliver Medical Record Medical Surgica Medical Surgica Medical Surgical Mother Baby . Nursery . . . . OR . . . . . . . OR Waiting . . Outpatient Clini Pre & Post Surgi Pediatrics/Mot Radiology . . . Registration . Serenity Room Simulation Cen

A WING

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Labor & Delivery

Labor & Delivery Registration

Nursery

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Mother Baby

Ante-Natal Testing

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Pediatrics/ Mother Baby

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Neonatal Intensive Care Unit (NICU)

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CUARTO PISO

Departamento 1058 . . . . . Administración

California’s Safe Surrender Baby Law

The Safe Surrender Baby Law (also known as the Safe Haven Law or Newborn Abandonment Law) was signed into law by Governor Davis in September 2000 and went into effect on January 1, 2001 . The purpose of the law is to protect babies from being hurt or killed because they were abandoned. The law allows a parent or legal guardian to confidentially surrender an infant, three days old or younger, to any hospital emergency room or other designated site. As long as the baby has not been abused or neglected, the person may surrender the baby without fear of arrest or prosecution for child abandonment. No names are required and the parent(s) will not be subject to prosecution for child abandonment. The baby will receive needed medical treatment and be placed in an adoptive home. You can help spread the word about this law. The following are answers to some frequently asked questions: What is the Safe Surrender Baby Law? The Safe Surrender Baby Law allows a parent or person with lawful custody to surrender a baby confidentially, without fear of arrest or prosecution for child abandonment. This law allows for at least a 14-day cooling off period, which begins the day the child is voluntarily surrendered. During this period, the person who surrendered the child can return to the hospital to reclaim the child. How does it work? A distressed parent who is unable or unwilling to care for an infant can legally, confidentially and safely surrender their baby within three days of birth. All that is required is that the baby be brought to a hospital emergency room and physically surrender the infant to any staff member. As long as the child shows no signs of abuse or neglect, no name or other information is required. A bracelet will be placed on the baby for identification. A matching bracelet will be given to the parent. The bracelet will help connect the parent to the baby if the parent wants the baby back. Are hospital emergency rooms the only location I can surrender the baby? No. In Kern County, the designated sites a baby can be safely surrendered is at any Hospital Emergency Room and any Fire Department.

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Does a parent have to give any information to the people taking the baby? No. Nothing is required. Hospital personnel will give the parent a medical information questionnaire designed to gather family medical history, which would be useful in caring for the child. It is up to the parent if they wish to give any additional information concerning the baby. What happens to the baby? The baby will be examined and given medical treatment, if needed. Child Protective Services will place the baby in a foster or pre-adoptive home. What happens to the parent? Parents who safely surrender their baby may leave the hospital emergency room or other designated site without fear of arrest or prosecution for child abandonment. Their identity will remain confidential and they will have the comfort of knowing their baby will remain in safe hands. If during the 14-day cooling off period the parents decide that they want to reclaim the baby, they can take the identifying bracelet back to the hospital, where staff will provide information about the baby. Why is California doing this? The purpose of the Safely Surrendered Baby Law is to protect babies from being hurt or killed because they were abandoned. You may have heard tragic stories of babies left in dumpsters or public toilets. The persons who committed these acts may have been under severe emotional distress. The mothers may have hidden their pregnancies for fear of what would happen if their families found out. Because they were afraid and had nowhere to turn for help, they abandoned their infants. Abandoning a baby puts the child in extreme danger and it is illegal. Too often this results in the baby’s death. Because of the Safe Surrender Baby Law, this tragedy doesn’t ever have to happen in California again. Safe surrender logo The Safe Surrender Logo was adopted by the State for use in its Safe Surrender Baby Law campaign, “No Shame, No Blame, No Names.” The logo also serves as uniform site marker, and will be displayed prominently at all designated Safe Surrender sites. A new California law requires all designated safe surrender sites in California to post this logo.

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Doing What Matters!

Kern Medical will not be the same tomorrow as it is today. Strategic Plan • Clear vision and mission – Service line planning • Set goals for improvement • Provide direction for resources Why Customer Satisfaction? • We are in a “service industry” – the satisfaction of our customers is our business “ Spread love wherever you go. Let no one ever come to youwithout leaving happier.”

Providing employee’s with tools – to be adopted for the purpose of uncovering the most important opportunities to improve care experience – Get back to the basics Strategic plan is working on #1 This is your tool designed to address #2 • Focus on “end users” – patients, families and care givers • Learn to “create experiences” by viewing your role through the eyes of patients and families

─ Mother Theresa

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Patient Satisfaction Survey Patients have a voice. Consumer Assessment of Healthcare Providers Survey (CAHPS) is used to measure specific outcomes related to Medicare programs. We measure how a patient’s experience was during their stay/visit. Patients desire to be treated with respect and to be included in decisions related to care. Providing not just the patient, but their families, with superior customer service is how we demonstrate that we value our patients. Through our patient satisfaction surveys, Press Ganey, we have insight into what our patients say about us:

Communication is the key • Response to calls lights • Keeping patient informed • Including patient in decisions regarding their care • Providing information about home care • Providing information regarding treatments • Time spent with the patient • Timely response to questions • Explanations in terms the patient can understand • Anticipate their needs

By managing patient satisfaction, this allows us to create lasting change to improve and exceed our patients’ expectations. Every employee contributes to this process in different ways. It is important that each of us understands the importance and value of our patient’s voice.

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Customer Service Standards

Customers are 1. The most important people at Kern Medical

2. People who have needs, it’s our job to fill those needs. 3. Not dependent on us, we are dependent on them. 4. Not interruptions to our work, they are the purpose of it. 5. Deserving of the most courteous and attentive treatment we can give them.

BLAAST of PPWR with Guests Be Committed • Smile & make eye contact within 3 seconds of encounter • Stop what you are doing so that your customer knows that they are the most important person at that time • Acknowledge people by name, if you know it • Acknowledge visitors in the hallways or reception areas Listen to Request • Let the other person talk – avoid interrupting • Listen attentively – hear what they are saying so you understand what their needs are

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Acknowledge and Clarify Request • Repeat back their request in summary • Ask questions for clarification Action Taken • Help the person as best you can • Lend a hand – help out another associate when you can. • Be a patient’s escort – walk the patient to their destination, avoid pointing and giving verbal directions. • Manage up – introduce coworkers and speak positively about them • Estimate how long before the visit, procedure or process will start and how long it will take

• Estimate what will happen next, when results will be available • Report progress periodically, especially if there are delays Satisfaction Confirmed, Thank you • Ask them to share their great experience using the Shout Out card • Ask if they had a great experience during the care provided • “Thank you for allowing us to provide for your healthcare needs” • “Is there anything else that I can do for you” • “Thank you for choosing Kern Medical”

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BLAAST of PPWR on the Phone

Be Committed • Answer inbound calls as quickly possible; by the third (3rd) ring; including Spectralinks • All staff in the department, unit or clinic should assist with answering the phones

Listen to Request • Ask the caller how you may be of assistance • Speak in a low tone; moderate volume and speed. “Good morning, this is Kern Medical Department…., my name is…. How may I help you?” Acknowledge and Clarify Take Action • Ask questions to clarify anything not understood. • If it is necessary to place a caller on hold, ask permission and wait for an answer • Estimate the timeframe. “Mrs./Mr. …, I will need to look up that information for you. May I place you on hold for about 2-3 minutes? (WAIT FOR ANSWER) Thank you, please hold” • Listen attentively • Make sure you understand what is being asked • Repeat key points to clarify the callers needs or requests. If necessary, take notes. “Mrs./Mr. …, I understand that you are calling to check on the date and time of your next appointment. Is that correct?” Confirm Satisfaction, Thank you • Close the call in a friendly, professional manner. “Thank you Mrs./Mr. …. Is there anything else that I can help you with? (WAIT FOR ANSWER) You are welcome. Thank you for calling and have a nice day” • Greet callers in a friendly, professional manner • Smile during the call. Smiling naturally improves the voice making it more energetic and friendly “Good morning” • State your name and location

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AIDET The cornerstone to our success

A Acknowledge I Introduce D Duration E Explanation T Thank You

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AIDET

Acknowledge • Knock on the patient’s door

Duration • Ask if now is a good time to talk

• Ask permission to enter the patient’s room • Acknowledge the patient by name and verify patient identifiers Introduce

• Let them know how long your visit will take • Be sure both of you agree to the time • If the patient is requesting a later visit, honor their request Explanation • During the visit, explain processes, care, or procedures in terms that the patient can understand (“living room” language”) • Be sure to speak with them in their preferred language • Explain all individuals and roles they play in the patient’s care • Answer any questions or concerns the patient may have prior to beginning their care Thank You • “Thank you for allowing us to provide for your healthcare needs” • “Is there anything else that I can get for you” • “Thank you for choosing Kern Medical”

• State your name and department • Explain the purpose of your visit

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Kern Medical Behaviors That Matter

Some behaviors cause a negative impression and fail to convery empathy: • Personal conversations, phone calls and/ or text messaging • Personal tasks such as reading or playing games on phone or computer • Complaining or expressing anger or frustrations in front of patients and families • Trying to explain why something happened, or blaming another department/person • A cluttered or unclean environment • Using headphones in patient care or public access areas • Dismissing patient concerns or complaints without further questioning Strive to exhibit positive behaviors at all times • Clean and professional appearance

• Smile and make eye contact • Interrupt non-essential tasks to serve; customers first…tasks second • Courteous and prompt responses to questions or needs • Low noise levels • Clean and uncluttered environment

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No Pass Zone

What is a No Pass Zone? • Any employee at Kern Medical, clinical and non-clinical, can be responsible for answering patient call lights, bed alarms and attending to patient needs. • “No Pass” is also extended to lost visitors and environmental hazards throughout the campus. Benefits of No Pass Zone • Impacts patient safety and helps establish a patient centered culture. • Creates a shared understanding that the care of the patient is everyone’s responsibility.

• Communicates to the patient and family we are here as a team to be responsive to their needs . What do employees have to do? • Check in on the patient if their call light is on. • Provide patient assistance within your training capabilities.

• Report facility issues to Engineering, Support Services or the Unit Manager. • Guide guests directly to their destination, exceed their expectations! • BE AWARE of environmental hazards, call lights, bed alarms, fall risk patients and visitors who look lost or who are looking for directions.

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All Non-Nursing Staff May • Move the following for the patient: • Call bell bedside device • Telephone • Bedside table or chairs • Trash can • Tissues • Change TV channels or turn TV on/off • Turn bed lights on/off • Obtain blanket, pillow, towel, washcloth, slippers, personal items and toiletries from storage area • Open or close privacy curtains All Non-Nursing Staff May NOT • Physically assist a patient • Turn off alarms • Enter an isolated room (unless otherwise trained) • Offer pain relief

• Explain clinical matters • Explain tests and treatments • Discuss patient scheduling • Handle an IV

• Move meal trays or water pitchers • Assist patients with eating or drinking

• Raise or lower a patient bed • Assist a patient in/out of bed

How to Introduce Yourself to a Patient 1.

Hello Mr./Mrs. (state patient’s last name).

2. My name is (state your first name) from the (state your department). 3. I noticed that your call light is on. 4. Is there something that I can do for you? 5. Sure, I can help you with; or I’m sorry, I am not trained for that, let me get someone who can help you (request) 6. Did I get you everything you need for now? 7. Thank you for letting us know you needed help.

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Management Role

Leadership • Link the strategic plan and operations to the people • Support and facilitate learning and reflection • Identify resources • Address roadblocks and barriers • Set goals and expectations on a unit/ department level • Include data during regular staff meetings • Provide individual feedback and encouragement • Model AIDET and Expected Kern Medical Behaviors • Increase in Management Rounding and provide positive reinforcement when staff are exhibiting Kern Medical Behaviors

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The Joint Commission On accreditation of healthcare organizations

What is the Joint Commission? • The Joint Commission is an independent organization that certifies more than 20,000 health care organizations in the United States • Their mission is to improve health care for the public • Their certification is a symbol of quality that reflects a commitment to meeting performance standards • Kern Medical is Joint Commission certified • If at any time you have questions or concerns about the patient care that is being provided we encourage you first contact your Supervisor/Director or the Quality Department to addresses resolve the issue. However, you have the right to file your concern with one or more of the following:

Office of Quality Monitoring The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 800-994-6610 patientsafetyreport@jointcommission.org

The California Department of Public Health Licensing and Certification Program Bakersfield District Office 4540 California Avenue, Suite 200 Bakersfield, CA, US 93309 661-336-0543

Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, MD 21244-1850

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Hospital National Patient Safety Goals

• The purpose of the National Patient Safety Goals is to improve patient safety • The goals focus on problems in health care safety and how to solve them • They are reviewed each year and updated as necessary • There is a policy and/or process in place for each goal • There is at least one goal that applies to most associates

Kern Medical 2019 Goals • Identify patients correctly • Improve staff communication • Use medicines safely • Use alarms safely • Prevent infection • Identify patient safety risks (suicide prevention) • Prevent mistakes in surgery

What All Employees Need to Do Identify Patients Correctly • The patient’s name • The patient’s date of birth Prevent Infection with Hand Hygiene • One of the most important ways that we can fight Hospital Acquired Infections is to wash your hands for 15 seconds when soiled or use hand sanitizer (like Purell).

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2020 Hospital National Patient Safety Goals

Identify Patients Correctly Use at least two ways to identify patients to make sure that each patient gets the correct medicine and treatment. Make sure that the correct patient gets the correct blood when they get a blood transfusion. At Kern Medical two licensed staff members will check blood at the bedside and ask your name and birth date.

Use Alarms Safely Make improvements to ensure that alarms on medical equipment are heard and responded to on time. At Kern Medical we set your alarms to an audible setting and within specific parameters to ensure that we can hear and respondappropriatelytoyourmedicalneeds.

Improving Staff Communication

Get important test results to the right staff person on time. At Kern Medical staff work together to get your critical test results to your caregiver.

Before a procedure, label unlabled medicines in the area where medicines and supplies are set up. For example, medications in syringes, cups and basins. At Kern Medical all medications and solutions are labeled for a procedure. Takeextracarewith patients who takemedicine to thin their blood. At Kern Medical we have an established program for admitted patients who are taking blood thinners with a follow-up clinic on discharge. Record and pass along correct information about a patient’s past and new medications. Make sure they know which medication to take when they are at home and how important it is to bring their up-to date list of medications every time they visit a doctor. At Kern Medical we find out your medication when you are seen in our emergency room or clinics and then evaluate your medicine throughout your admission or at time of every visit.

Use Medicines Safely

Prevent Infections Use the hand cleaning guidelines from the Centers for DiseaseControl and Prevention or the World Health Organization. Set and meet goals for improving hand cleaning. At Kern Medical we place your safety first and clean our hands before and after giving you care. Use proven guidelines to prevent infections that are difficult to treat. At Kern Medical we have an active infection prevention program which uses proven guidelines to treat difficult infections. These proven guidelines reduce blood infections from central lines and urinary tract infections caused by catheters.

Identify Patient Safety Risks Find out which patients aremost likely to try to commit suicide. At Kern Medical patients are screened for early detection and treatment.

Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. At Kern Medical we will ask you your name and birth date and compare to your paper work to make sure we provided the correct care, surgery, and procedures. Mark the correct place on the patient’s body where the surgery is to be done. At Kern Medical our physicians will ask to mark your body prior to surgery/procedure. Pause before the surgery to make sure that a mistake is not being done. At Kern Medical we perform a pause before surgery/procedures to ensure that it is the right patient , right surgery/procedure and right place on the body.

Prevent Mistakes in Surgery

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Standard – Abuse, Neglect & Exploitation • PC.01.02.09 – The hospital must: • Assess the patient who may be a victim of possible abuse and neglect • Educate staff about how to recognize signs of possible abuse, neglect and/or exploitation and your roles in follow-up (reporting) • The hospital has a policy guiding associates on identifying and reporting suspected abuse and neglect (ADM-RI-601) • Abuse, neglect and exploitation can occur in any age group and crosses all socioeconomic and cultural lines • Abuse can be physical, psychological and/or sexual • Neglect is the intentional or unintentional failure to provide needed care and support. Includes physical protection, nutrition or health care, but can also include human contact and love • Exploitation is the unauthorized use of money or goods for personal gain • Mandated reporters are people who have regular contact with vulnerable people and are legally required to report suspicions directly to the appropriate agency • Many hospital associates are mandated reporters, such as physicians, nurses and social workers • For those of you who are not mandated reporters: • Report any suspicion to your direct supervisor • That supervisor will follow the chain of command for reporting purposes

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Population Served

• Kern County is culturally diverse; our workforce and our patient population is culturally diverse • Kern Medical remains a safety net hospital; we provide care to low-income, uninsured and vulnerable populations • Kern Medical offers specialty services; such as trauma, psychiatric and neonatal care

“We care for those who others won’t, or can’t care for………” Mr. Judd

When providing care, treatment and services in a health care setting to this diverse and often vulnerable population you should be sensitive to the following in your interactions: Language Barriers Kern County has a large Latino base. In addition to Spanish, they may speak a dialect. Kern Medical has an extensive interpreter language line to assist you. Insurance Status Access to medical care and medication may be a challenge (uninsured). Our patient’s may need help in navigating our systems. Case Management and Pharmacy are a good resource. Cultural Differences Many cultures have beliefs in traditional healers such as Curanderos (Mexico and much of Latin America), Santeria (Brazil and Cuba) and Espiritismo (Puerto Rico). These beliefs need to be considered when obtain medical information to ensure for an accurate medical history.

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Language Access Services

• RI.01.01.01 – The hospital must: • Effectively communicate with patients when providing care, treatment and services • Respect the patient’s right to receive information in a manner he or she understands • Provides the following language interpreting and translation services: • Basic Interpreter – directions, appointments, financial services • Clinical Healthcare Interpreter – used for significant healthcare services • Staff Health Care Interpreter • On-line test; available in multiple languages, assigned an interpreter ID • Clinical Healthcare Interpreter • Healthcare Interpreter Network • The following Significant Healthcare Services require a Clinical Healthcare Interpreter • Obtaining informed consent • Taking medical histories • Providing medication instructions (including high alert medications) • Explaining discharge plans (including high alert medications)

• Discussing Advance Directives • Discussing end of life decisions

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Staff Development



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Elsevier

• Elsevier is Kern Medical’s online education software • It is intended to supplement your orientation and educate you on new processes or changes to current processes • In some circumstances, it is possible to pass the post-test without viewing the educational material. This is not recommended. You will be held accountable for the information in the learning module, not the post test • Your supervisor will provide you with a username to log into Elsevier as well as a list of mandatory trainings to be completed during your orientation The proceeding instructions will provide the following: • Find Elsevier • Log in • Change password • Find a course • Enroll in a course • Take the test • Submit the test • Log out

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HIPAA, Security, & Compliance Siri-Ved Khalsa, MSA, CHC Compliance Manager What is HIPAA? • Health Insurance Portability and Accountability Act • Federal Law with 3 rules: 1. The Privacy Rule: • Protects patients’ medical records and personal health information (PHI) • Sets limits and conditions on use and disclosure of PHI 2. The Security Rule: • Requires administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic PHI 3. The Breach Notification Rule: • Requires notifications to affected persons and regulatory agencies

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