Revised 12/14/2017

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Organizational Information

Our Mission We carry on the healing mission of Jesus Christ by promoting personal and community health, relieving

pain and suffering, and treating each person in a loving and caring way.

At PeaceHealth, the fulfillment of our Mission is our shared purpose. It drives all that we are and all that we do.

To those who embrace the spirit of these words and our commitment to Exceptional Medicine and

Compassionate Care, we offer the opportunity to learn and grow as a member of the PeaceHealth family.

Our Core Values Respect We respect the dignity and appreciate the worth of each person as demonstrated by our compassion, caring and

acceptance of individual differences.

Stewardship

We choose to serve the community and hold ourselves accountable to exercise ethical and responsible

stewardship in the allocation and utilization of human, financial and environmental resources.

Collaboration

We value the involvement, cooperation and creativity of all who work together to promote the health of the

community.

Social Justice

We build and evaluate the structures of our organization and those of society to promote the just distribution of

health care resources.

Our Vision Every person receives safe, compassionate care; every time, every touch.

Our Promise Our “Spirit of Health” promise is the embodiment of PeaceHealth.

Everything we do is in service to a higher purpose: to work with and help our neighbors live healthier, happier

lives.

We take care of the needs of people, we don’t simply treat patients. We put people at the center, enabling them

to be their best, and providing personalized, compassionate care when they are not. We make them feel

welcome, comfortable and safe. We are neighbors, caring for and loving one another, for the betterment of all.

Caring for those in our community is not new to PeaceHealth; it’s been in practice since the Sisters of St.

Joseph of Peace arrived in Fairhaven, Washington to serve the needs of the loggers, mill workers, fishermen and

their families. They knew strong, healthy communities benefit individuals and society, and that social and

economic factors can make some community members especially vulnerable. The Sisters believed they had a

responsibility to care for them, and that ultimately, healthier communities enable all of us to rise to a better life.

This philosophy inspires us today and guides us toward the future.

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PeaceHealth at a glance PeaceHealth, based in Vancouver, Wash., is a not-for-profit Catholic health system offering care to

communities in Alaska, Washington and Oregon. PeaceHealth has approximately 16,000 caregivers

(employees), a multi-specialty medical group practice with more than 800 providers, and 10 medical centers

serving both urban and rural communities throughout the Northwest. In 1890, the Sisters of St. Joseph of Peace

founded what has become PeaceHealth. Today, PeaceHealth is the legacy of its founding Sisters and continues

to serve communities when invited to do so with a spirit of collaboration and stewardship. This is The Spirit of

Health- the Spirit of PeaceHealth. For more information, visit www.peacehealth.org.

PeaceHealth Facilities

Ketchikan Medical Center

Ketchikan, Alaska

St. Joseph Medical Center

Bellingham, Washington

Peace Island Medical Center

Friday Harbor, Washington

United General Medical Center

Sedro-Woolley, Washington

St. John Medical Center

Longview, Washington

Southwest Medical Center

Vancouver, Washington

Sacred Heart RiverBend

Springfield, Oregon

Sacred Heart University District

Eugene, Oregon

Cottage Grove Medical Center

Cottage Grove, Oregon

Peace Harbor Medical Center

Florence, Oregon

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Important information to help you get started

Notice of Privacy Practices We are required by law to: maintain the privacy and security of patient health information. The Notice

of Privacy Practices (NPP) describes for patients how we use and/or disclose their health information. All

PeaceHealth workforce members (employees, volunteers, students, etc.) with access to patient information

MUST READ this information. It is found at: https://www.peacehealth.org/privacy-rights-and-practices.

To prepare for any clinical experience at PeaceHealth, a signed confidentiality agreement must be obtained and

on file. A computer user set up form is required for all experiences where documentation in the patient record is

required. Following is a sample of the agreement/form and key points to remember:

Confidentiality Agreement

CA.pdf

Computer User Set Up form

User Set up form.pdf

PeaceHealth’s Reporting Process When you have a concern, you have a duty to report or to ask questions. Likewise, the department/unit manager

or hospital supervisor has a duty to follow-up without retaliation. Reporting a compliance concern or problem

should be as natural as picking up the phone to report a leaky pipe or a frayed carpet. When you have a

question, or want to report a concern, we encourage you to refer to the following resources: 1. The facility supervisor and/or department/unit manager/director

2. The facility OI Officer

3. The PeaceHealth Integrity Line: (877) 261-8031 (an independent, confidential service open 24/7 except

holidays)

4. Online PeaceHealth Integrity Line at https://peacehealth.alertline.com.

Name Badge *Job shadows/observers do not require name badges as they must always be escorted by PeaceHealth

caregiver while on site. A written visitor badge may be provided by the unit/department.

If a PeaceHealth badge is needed, it will be obtained through your placement coordinator. Otherwise, you must

always wear your school name badge above your waist while on site. Keep your badge safe when not in use.

At some sites or regions, it is an e-key for entrance or exit to secure areas and MUST be returned to

instructor/supervisor upon leaving the organization.

Dress Policy Please comply with guidelines that encourage professional attire. Modest and neat apparel is the overall guide.

Your assigned placement coordinator or your unit preceptor will provide you with further information.

No Smoking Policy Smoking is not allowed in any PeaceHealth building or on any PeaceHealth property.

Before signing a confidentiality agreement, please remember:

√ Access to patient health information is restricted to those

workforce members who need to know that information.

√ Sharing your log-on and password is NOT ALLOWED

√ Always log-off or lock the device when leaving it or walking

out of view of the workstation

√ You are responsible for information entered or viewed under

your user log-in

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General Safety Information

Electrical Equipment All electrical equipment brought into the facility by staff or patients (radios, hair dryers, fans,

heaters, etc.) must be approved for use by a qualified staff member at each facility and have a

dated and signed label attached. Any electrical equipment purchased for patient care use must be checked out by

your regional Engineering Staff.

Lock-Out Tag If any electrical equipment malfunctions or shocks someone, Engineers will place a

LOCK-OUT label on it. Do not remove a LOCK-OUT label or use any equipment that has

been tagged as a LOCK-OUT.

Hazard Communication A Safety Data Sheet (SDS) reference guide must be made available to employees under the “Right

to Know Act”. Each department maintains a chemical inventory and corresponding SDS’s for

hazardous products in their area. Know where this reference guide is located online and review the

SDS before handling hazardous chemicals.

REMEMBER! In case of a spill:

1. Act quickly.

2. Wear Personal Protective Equipment (PPE).

3. Contain the spill.

4. Notify Switchboard if the spill is considered significant as noted in the Safety Data Sheet

(SDS).

5. Determine appropriateness of safe re-entry into area.

6. Complete an electronic incident report.

7. Report to the Emergency Department if exposed to a hazardous chemical.

8. Dispose of clean up materials following SDS and Departmental Guidelines.

Emergency Management Plan Participant Responsibilities:

1. Remain on duty until excused.

2. Report to person in charge of department for assignment and questions.

3. Department heads and others with specific responsibilities assume Emergency Management Plan roles.

During an emergency, remember to:

1. Use stairways. DO NOT USE ELEVATORS

2. Know where exits are and what the posted evacuation plan is for your area.

3. Limit use of phones as much as possible.

4. Wear ID badge.

If not on site:

1. Report to work at next scheduled time unless otherwise directed.

2. Report to work if specifically instructed by Emergency Broadcast message, pager or phone call.

*All students to report to clinical supervisor/preceptor immediately for directions

Lock Out!

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General Patient Care Information

Patient Identification Standardized Patient Identification Wrist Bands are place on patients for accurate identification prior to

treatment to minimize medical errors and patient harm. These bands include:

• A patient label with bar codes used for patient identification and medication/blood administration

• Standardized color clips used as visual clues

Nursing validates the correct band and clips are placed on the patient:

• On admission

o During the initial assessment, the nurse assesses factors associated with:

▪ Fall risks

▪ Allergies

▪ Latex Allergy

▪ Limb Alert (restricted extremity)

▪ Do Not Resuscitate (DNR)

• At the beginning of the shift and time of transfer

o Any changes in orders and/or status that may impact the band or clip color(s), the nurse will either:

▪ Add a new clip

▪ Remove the old band and replace it with a new one that has the correct clips attached

Another clip needs to be added A clip needs to be removed

• Confirm the change with the patient

(family) and with the medical record

• Retrieve the correct color clip

• Apply the clip to the patient’s wrist

band

• Educate the patient and family to the

new clip

• Include the change in hand-off

communication with other caregivers

• Confirm the change with the patient

(family) and with the medical record

• Retrieve a new wrist band and add ALL

the correct color clips needed

• Remove the old band from the patient’s

wrist

• Apply the new band to the patient

• Educate the patient and family to the

change

• Include the change in hand-off

communication with other caregivers

7 Examples of each clip:

Allergies to:

•Drug(s)

•Food

•Environ

menta

l

Allergy to

latex

Fall alert

Implement fall

bundle

interventions

Restricted

extremity

movement, i.e.

mastectomy,

fistula, or new

pacemaker

placement

Order for Do Not

Resuscitate (DNR)

Continue

reviewing

allergies with

patient

Place sign on

door

Educate

patient/family to

call for help

getting out of bed

Restricted IVs,

BPs or blood

draws, i.e. fistula

Confirm provider’s

orders concerning

code status

Refer to

electronic

medical record

for specifics

Indicate

allergy on

patient’s

white board

Indicate risk on

patient’s white

board

Continue placing

signs at the head

of the patient’s

bed or on their

door

Click on the Pre-

Arrest Treatment

(DNR) tab on the

patient banner in

the electronic

medical record to

review the Pre

Arrest Medical Care

selections if

applicable

Label patient’s

door

Patient and/or student incidents All incidents involving student injuries and/or patient care provided by students MUST be reported to the

immediate supervisor, school supervisor/instructor and PeaceHealth student placement coordinator. Such events

require completion of an online incident report.

Arrangements for follow-up regarding an incident will be managed through the PeaceHealth student placement

coordinator and the school representative.

Daily Management System (DMS) aka Readiness Huddles Using the Daily Management System (DMS), caregivers learn to dedicate a small part of their day to making

improvements within their groups. Over time, the use of DMS enables caregivers to provide consistent excellent

service and care to our patients and families.

8 Who is involved?

• All caregivers in the areas participating in daily

huddles

What does it involve?

• Readiness huddles

o Routine, 5-10 minute daily huddles

o Sharing information

▪ What happened the day before

▪ Critical unit issues

▪ What the plan is for the day

o Focuses the team on performance measures

o Addresses key elements such as safety, workload, staffing, methods, equipment and supplies

o Reports issues and the fix, in addition to escalation of BIG issues

o Generates a sense of ownership among the team about its work and environment

• Performance Board

o Includes metrics used to measure the work unit’s progress in critical areas:

▪ Fall prevention

▪ Pressure ulcer prevention

▪ Hospital acquired infection rates

o Updated routinely

o Clearly states goals, metrics and objectives that

all team members are accountable for obtaining

Where does it occur?

• In front of the Readiness Board located in a

designated space in each department

When does it occur?

• Each department has a routine huddle schedule- during orientation ask when the huddle is scheduled for

the specific department

• It is required that all department/unit caregivers attend these huddles when patient care allows for the

opportunity

Why do we do this?

• Improves communication between teams, locations and supporting departments

• Tells a story at a glance on how well the department is doing (visible management system)

• Improves collaboration and reduce communication frustrations (i.e. “I didn’t know anything about that!)

• Improves patient and caregiver satisfaction

Students are invited and encouraged to attend unit/department huddles

9 Purposeful Rounding Reactive vs Proactive Care

Why is rounding important?

Evidence shows that when purposeful rounding is done, there is a:

▪ 50% decrease in falls

▪ 14% decrease in skin breakdown

▪ 35% decrease in calls for pain medication

▪ Overall decrease in anxiety, worry, and waiting

What are the benefits of rounding?

▪ Improves our patient’s perception of care

▪ Provides pro-active care instead of reactive care

▪ Decreases call light use to better control workflow with less interruptions

▪ Reduces patient falls and skin breakdown

▪ Increases workflow efficiency

▪ Increases patient and caregiver satisfaction

How is rounding done?

5P’s of Purposeful Rounding include:

10 Emergency Codes Please learn the following codes that are initiated by dialing the emergency number posted by your region.

*Be sure to check with your unit supervisor for directions regarding code initiation specific to your assigned unit/department.

Code Announcement: Code (+ other) & Location

Repeat 3x

Description

CODE ORANGE Code Orange,

Pharmacy

Hazardous material spill or release, radiation exposure

CODE GRAY Code Gray, Medical

Unit

Combative person; patient or visitor

CODE BLACK

Code Black, 1st Floor Bomb threat

CODE RED Code Red, 1st Floor Fire: If you see smoke or fire: RACE

Rescue those in immediate danger if safe to do so

Alarm, pull the nearest one to the fire, call out “Code Red”

and phone in the alert following facility policy

Contain/Confine the fire (close doors and windows)

Extinguish (if safe to do so)

Pull, Aim, Squeeze, Sweep fire extinguisher, and

Evacuate if directed to do so

CODE AMBER Code Amber 3,

Pediatrics

Infant/child abduction

CODE SILVER Code Silver,1st Floor Weapon or hostage situation

CODE BLUE

CODE BLUE

Pediatric

Code Blue, ICU

Code Blue Pediatric (or

age), Emergency

Department

Advanced Cardiac Life Support Team requested

Pediatric Advanced Life Support Team requested for

infant/child

Trauma Alert Trauma Alert; trauma

team report to the

Emergency

Department

Trauma Team activation for possible groups of patients

coming to the hospital

Disaster Plan

SWW only:

Triage Plan

Implement the

external/internal

disaster plan

External Disaster; occurs outside of the medical facility

(earthquake, shooting, etc.)

Internal Disaster; occurs inside the medical facility (loss of

power, shooting, etc.)

Rapid Response

Team

Access the RRT by

following your unit’s

procedure

Call the Rapid Response Team if the patient has a: ➢ Change in heart rate with rate less than 40 or greater than 120 ➢ Change in systolic blood pressure less than 90mm/Hg

➢ Change in respiratory rate to less than 8 or greater than 24

➢ Threatened airway or change in oxygen saturation level (< 90% despite being on oxygen)

➢ Change in level of consciousness or mental status

➢ Failure to respond to a treatment

➢ Complaint of chest pain unrelieved by treatment ➢ Urine output of less than 50ml in 4 hours

Call the Rapid Response Team if:

➢ Staff member is concerned or worried about a patient

➢ Patient or family is concerned about patient status/condition

11 Infection Prevention Hand hygiene is a key expectation in patient safety for preventing the spread of infections. It is the

responsibility of every caregiver to utilize appropriate hand hygiene practices- every time, every touch. At

PeaceHealth we “wash-in” or gel when entering a patient room and “wash-out” with either gel or soap and

water when leaving. The following information provides other expectations of hand hygiene required of our

caregivers.

Glove Use Reminders:

Wearing gloves does not replace the need for hand

hygiene. Gloves can protect both patients and

caregivers from exposure to infectious agents.

Gloves should be worn as a single use item for:

• Each invasive procedure

• Contact with sterile sites and non-intact skin or mucous membranes

• Any activity that has been assessed as carrying a risk of exposure to blood, body substances, secretions

and excretions

Gloves should be changed:

• Between patients

• During the care of a patient, to prevent cross-contamination from dirty to clean body sites, e.g., enteral

to central line site

• If the patient interaction includes touching equipment that is transported room to room, e.g., glucose

meter

Hand hygiene is required with glove use at these times:

• Before putting on gloves

• Immediately after removing gloves

• In between the “5 Moments” while caring for a patient

• Do not apply hand hygiene products to gloves

Help each other to be successful:

• Assume positive intent

• Have each other’s backs. It’s ok to ask or speak up:

o “Can I help you with that while you wash your hands?”

o “I’d like you to remind me to do hand hygiene; may I remind you too?”

• Focus on safety

1. Before touching a patient (Wash-in) When? Clean your hands before touching a patient when approaching

him/her.

Why? To protect the patient against harmful germs carried on your

hands.

2. Before Clean/Aseptic Procedure When? Clean your hands immediately before performing a

clean/aseptic procedure.

Why? To protect the patient against harmful germs, including the

patient’s own, from entering his/her body.

3. After Body Fluid Exposure Risk When? Clean your hands immediately after an exposure risk to body

fluids (and after glove removal).

Why? To protect yourself and the health-care environment from

harmful patient germs.

4. After touching a patient When? Clean your hands after touching a patient and her/his

immediate surrounds, when leaving the patient’s side.

Why? To protect yourself and the health-care environment from

harmful patient germs.

5. After touching patient surroundings (Wash-out) When? Clean your hands after touching any object or furniture in the

patient’s immediate surroundings, when leaving- even if the patient

has not been touched.

Why? To protect yourself and the health-care environment from

harmful patient germs. World Health Organization, Patient Safety, Save Lives- Clean Your Hands

12 Infection Prevention continued Multidrug Resistant Organisms (MDROs) key points:

• These organisms are resistant to 1 or more classes of antibiotics

• Patients’ infected with MDROs are at an increased risk of prolonged illness and mortality

• Cost of caring for patients’ infected with MDROs is more than double than caring for those without

• Caregivers exposed can become infectious and then become carriers

• Most common MDROs:

o Methicillin Resistant Staphylococcus aureus (MRSA) commonly found on skin

o Vancomycin-resistant Enterococcus (VRE) found in the GI and Urinary Tracts

Active Infection vs colonization

• Active infection is defined as presence of the organism with infection present

• Colonization is defined as presence of the organism without infection present

o Colonized patients are 2.5 times more likely to get a new infection

o 4% of healthcare workers are colonized with MRSA

o Both active and colonized carriers spread the infection

o Patients, families and/or caregivers can transmit the infection

o Transmission occurs when hands come in contact with the infectious organism either from

another person or an object

Prevent transmission by:

• Adhering to standard precautions

o Hand hygiene

o Personal Protective Equipment (PPE)

• Cleaning rooms and equipment thoroughly

• Placing patients’ in private rooms with signage posted

Clostridium difficile (C. diff) is not a MDRO but it is considered an organism of concern.

C. diff:

• Has surpassed MRSA as the #1 hospital-acquired infection in the United States

• Is transmitted through the GI tract

• Is prevented by washing hands with soap and water after contact with a patient and/or equipment in a

patient’s room who has been identified as a carrier of C. diff

o Hand gel does NOT protect against this organism

C-Diff Soap Water

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Incident Reporting All safety-related incidents are to be promptly reported using the electronic incident reporting system,

which is found on Crossroads, PeaceHealth’s internal electronic system.

✓ The person most directly involved in an incident, or the person who first discovers the incident, is

responsible for completing the incident report form using the instructions below.

✓ Incident reports are highly confidential and are not to be copied for any reason.

✓ The information contained in the incident report may be used only for risk management purposes and

may not be used for any other purpose including peer review or employee corrective action.

✓ Incident reports are not a part of the patient medical record and no mention of an incident report should

be documented in the medical record. Only the facts of an incident involving a patient are to be recorded

in the medical record.

Incident Reporting

Select the “Crossroads” icon on the lower left tool bar

Select “Report Incident” (use Caregiver Injury for injuries that occur to students)

Scroll down the menu and select “Caregiver Injury” or “Patient/Visitor Incident" and follow the instructions

Policies

From “Crossroads” click on “My Tools” on the upper tool bar and then scroll down the menu to “Policies”

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Thank you for taking the time to read the orientation material.

While in a PeaceHealth facility, you will be responsible for this information. If you have any questions, please

ask your supervisor, manager, preceptor or educator. We hope you enjoy your experience at PeaceHealth.

Welcome!

REQUIRED POLICY REVIEW for all experiences except job shadowing

Immediately upon beginning an on-site experience at PeaceHealth, please use the instructions above to

review the following policies (you will be accountable for the information while at a PeaceHealth facility):

• Serious Safety Event #101.387.9

• Workplace Violence Prevention #101.356.42

• Infection Prevention:

o Infection Prevention and Control #SYS.82.17

o Standard Precautions #101.82.1

Additional Helpful Resources

From the Crossroads Home Page, go to “My Tools” and scroll down the menu to “Library”

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Facility Specific Additional Information

Alaska Washington Oregon Ketchikan Medical Center-

Ketchikan, Alaska

St. Joseph Medical Center-

Bellingham, Washington

Sacred Heart RiverBend-

Springfield, Oregon

SHMCs.docx

Peace Island Medical Center-

Friday Harbor, Washington

Sacred Heart University

District- Eugene, Oregon

SHMCs.docx

United General Medical Center-

Sedro-Woolley, Washington

Cottage Grove Medical Center-

Cottage Grove, Oregon

CGCH.docx

St. John Medical Center-

Longview, Washington

Peace Harbor Medical Center-

Florence, Oregon

Florence.docx

Southwest Medical Center-

Vancouver, Washington