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Mandatory Education
This booklet has been prepared to educate and
familiarize non-employees with the mandatory
requirements for Atlantic Health System.
Please review and complete the test, return to
The Department Manager
Atlantic Health System Mandatory Education for Non-Employees 2014
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Atlantic Health System
VISION:
Atlantic Health System will be recognized as one of the nation’s best health care
systems.
MISSION:
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

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Deliver high-quality, safe, affordable patient care within a healing culture
Educate, in an exemplary manner, present and future health care
professionals
Innovate through leadership
Improve the health status of the communities we serve
Patient Rights:
Patient Rights are posted in every patient room, waiting areas and other
departments where care is provided. Patient rights include, but are not limited
to the following: Privacy, Confidentiality, Right to Information, Informed Consent,
Pain Management, Participation in Care Decisions, Advance Directives,
Restraints and Seclusion, Abuse and Neglect, Patient Complaints.
Cultural Awareness:
Cultural awareness refers to the understanding that our patients, employees,
physicians, and visitors may have different cultural, spiritual, or religious beliefs
than our own. Direct patient care providers are expected to identify and
support the cultural or spiritual needs of every patient, respecting the customs
and traditions of other people.
Risk Management:
Atlantic Health provides risk management services 24 hours/7 days a week.
Check the Risk Manager Web oncall director for the covering individual on
evenings, nights, weekends and holidays. An electronic Quantros Report
(occurrence report) is completed for any unusual occurrence involving patients,
visitors, damage to equipment or property.
Occupational Safety and Health Administration (OSHA) Training
Bloodborne Pathogens and TB
The Occupational Safety and Health Administration (OSHA) “Bloodborne
Pathogens Standard” was issued in 1991 and was designed to protect
healthcare personnel (HCP) at risk for occupational exposure to the
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hepatitis B (HBV) and C (HCV) and the Human Immune Deficiency (HIV)
viruses.
The Atlantic Health Exposure Control Plan is available to all hospital
personnel on the hospital Infection Control intranet site or in hard copy in
the libraries of the hospitals, Infection Prevention Offices, and
Occupational Medicine Service (OMS).
HBV is a disease of the liver with an incubation time of 6 weeks to 6
months. Symptoms may be so mild that a person does not know that they
have been infected, moderate in intensity, or so severe that
hospitalization is required. HBV may become a chronic illness leading to
cirrhosis, liver cancer and at times death. The good new is that it can be
prevented with a vaccine that has been available since the early 1980’s.
HCV is also a disease of the liver and also has an incubation time of 2
weeks to 6 months. Symptoms of HCV are similar to those of HBV but often
milder. It has risks and complications similar to HBV. Unfortunately there is
no vaccine available for HCV.
HIV is the virus that causes the Acquired Immune Deficiency Syndrome
(AIDS). It attaches the body’s immune system and has an incubation
period of weeks to months. There is also no vaccine available for HIV.
Potentially Infected Body Fluids and Routes of Transmission
Bloodborne pathogens (BBP) are found in the following body fluids of an
infected individual; blood; cerebrospinal, amniotic, synovial, pleural, and
peritoneal fluid; semen and vaginal secretions; and any body fluid visibly
contaminated with blood. Exposure to a BBP occurs through:
 Sharps injury from needles, scalpel, or anything than can pierce,
puncture, or cut your skin.
 Exposure to non-intact skin (open cuts, sores or nicks in skin).
 Exposure to mucous membranes (splashes or sprays of blood to your
eyes, nose or mouth).
Methods to Prevent Exposure Include:
Following standard precautions
Following work practices: These are procedures that you must follow to
reduce your and your co-workers risk of exposure. For example: Promptly
dispose of needles and sharps in appropriate containers, do not recap
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needles or eat or drink in patient care areas. Always wash your hands
before and after patient contact and when they are visibly soiled.
Wearing appropriate personal protective equipment (PPE) will reduce
exposure risks. Wear the following PPE when you may have contact with
body fluids:
 Gloves to protect your skin.
 Fluid resistant gowns to protect skin and clothing.
 Masks to protect your nose and mouth from splashes and sprays of
body fluids.
 Protective eyewear to protect your eyes from splashes and sprays
of body fluids.
Put on and remove PPE correctly in order to prevent infections.
The Care Environment
To keep your environment free of hazards:
 Clean all equipment and work surfaces as soon as possible after
contact with body fluids.
 Clean up contaminated broken glass using a dust pan and brush,
not your hands.
 Handle linens as little as possible. Confine and contain trash in
plastic bags by keeping them closed.
 Dispose of body fluids that may be contaminated with potentially
infectious materials into a liquid regulated medical waste (RMW)
located in soiled utility rooms. Non liquid items soiled with bodily
fluids go into red bag containers. A biohazard symbol indicates a
potentially infectious material.
Procedures to Follow with Exposure to a Potentially Infectious Body Fluid
1. Wash the affected area immediately with soap and water. If
exposure is to your eyes, nose, or mouth; flush with large amounts of
water or saline.
2. Immediately report the exposure to whoever is in charge of the
department. Contact the “Off Shift Supervisor” as there may be a
need to complete an incident report.
3. Proceed to the Emergency Department (ED) for an evaluation.
Take the name of the source patient with you to the ED, if possible.
4. A report of the incident may be required. For guidance on
procedures to follow you may contact the hotline numbers at each
facility:
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Chilton Medical Center: 973-831-5116
Morristown Medical Center: 973-971-5819
Newton Medical Center: 973-579-8577
Overlook Medical Center: 908-522-5304
If you have questions regarding bloodborne pathogens contact one of
the following resources for assistance:
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Infection Control Department, CMC phone: 973-831-5150
Infection Control Department, MMC on call cell phone: 973-294-0512
Infection Control Department NMC on-call cell phone: 973-222-4933
Infection Control Department OMC on-call cell phone: 973-294-0645
Occupational Medicine Service pager: 877-595-7143
Tuberculosis: Control Measure for TB Patients
Follow airborne precautions when a patient is or may be infected with TB
disease.
This includes:
 Placing the patient in a negative air pressure isolation room (NPIR).
Contact unit resources for proper procedures.
 Particulate respirators (N95) must be worn when entering patient
rooms. Anyone caring for TB patients must be fit-tested annually in
order to use these respirators.
 When caring for patients with or who may have TB disease –
o Minimize the transportation of patients; when they must leave
their isolation room, when possible, have them wear a
surgical mask.
o Keep patients on airborne precautions until three (3) negative
sputum tests are confirmed.
o Discontinue airborne precautions only when an infectious
disease specialist, pulmonologist, or the Infection Prevention
Department approves it.
All Caregivers are required to have an annual tuberculin skin test (TST)
except those with proof of the following:
 A documented positive TST
 Adequate treatment for TB disease or preventive therapy for TB
infection
 A medical contraindication
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Infection Prevention
What is Infection Prevention?
Infection Prevention addresses factors related to the spread of infections
with the healthcare setting. This practice improves patient safety by
reducing risk of infection. It requires the commitment of every healthcare
worker to achieve this goal.
Hand Hygiene (washing or using alcohol rubs) is the number one way to
prevent the spread of infections.
Information Resource: Infection Prevention website contains all pertinent
policies, procedures, guidelines, forms and links for information.
Contact Information:
Office
Morristown
973-971-4003
Overlook
908-522-2912
Newton
973-579-8372
Chilton
973-831-0515
Off Shift Cell
973-294-0512
973-294-0645
973-222-4933
973-831-5000 (Nursing Supervisor)
Hand Hygiene: The practice of hand hygiene measures is required before
and after handling patients. Using medical equipment on patients,
before giving medications, contact with patient skin, contact with body
fluids or excretions, wound dressing, removing gloves, or in the patient’s
environment are all examples of when hand hygiene is a requirement to
ensure patient safety, and to protect against cross-contamination.
The process of hand washing requires – wetting the hands first with water,
applying soap and rubbing hands together for at least 15 seconds,
covering all surfaces of the hands and fingers, rinsing with water and
drying thoroughly. Use a paper towel to turn off the faucet upon
completion.
Alcohol-based rubs can be used when your hands are not visibly soiled or
contaminated with fluids. Do not use alcohol-based rubs with caring for
patients with C. difficile. When applying this product ensure that all
surfaces of hands and fingers, including under fingernails have been
covered. Continue rubbing until product dries – at least 15 seconds.
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Fingernails and Lotions: Natural nails kept to one-fourth inch long. No
artificial nails are permitted for healthcare workers who: provide direct
patient care, supervise direct patient care, or have contact with patient
care supplies, equipment or food. Only hospital-approved, non-glycerin
based lotion is permitted and available for use at Atlantic Health.
Healthcare Acquired Infections (HAI) are infections a patient acquires
while receiving treatment for a condition. It is one of the top 10 leading
causes of death in the United States. These infections: Urinary Tract,
Bloodstream, Ventilator Associated Pneumonia, Surgical Site, and
Multidrug Resistant Organisms can be acquired through patient medical
equipment, tubes used to administer IV fluids, machines that help a
patient breathe, body parts where surgery took place, and from
medications, the environment, and your hands. National Patient Safety
Goal #7 refers to improving patient safety by reducing the risk of
healthcare acquired infections. Complying with hand hygiene, following
hospital protocols, as well as personal protective equipment (i.e. gloves)
complies with this safety goal and reduces this risk.
Isolation Precautions: Regardless of a patient diagnosis, there are
standard as well as different types of precautions designed to protect you
from getting specific types of diseases. Make sure you follow all
instructions on posted signs and wear appropriate personal protective
equipment (gowns, gloves, or masks).
Please remember that many of the patients in our hospitals are recovering
from severe illnesses and/or have poor immune systems. Infections with
organisms like influenza can lead to very serious illness and even death.
To ensure safe patient care, do not come to hospital if you have an upper
respiratory tract infection with a fever, or diarrhea or vomiting.
When handling patient equipment, follow responsible care and cleaning
between patients. Supplies or equipment labeled as single use must be
disposed of after use on a patient. Contact Sterile Processing or Infection
Prevention for any cleaning questions.
Influenza (“Flu”)
Seasonal flu usually occurs in the Fall through early Spring. It most severely
affects the very young, the elderly and those with chronic illnesses.
Symptoms include: fever, headache, fatigue, dry cough, sore throat,
runny or congested nose, muscle aches, and can include diarrhea,
vomiting and nausea.
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On average 5% to 20% of the U.S. population contracts the flu. More than
114,000 are hospitalized and approximately 36,000 people die from this
virus. The annual shot is the most effective method to prevent infection
with this virus.
The CDC recommends the following precautions for healthcare workers:
practice hand hygiene before and after patient contact; follow standard
precautions; wear a surgical mask when working within 3 feet of the
patient; and get the flu vaccine.
A “pandemic” is an epidemic that occurs in many parts of the world at
the same time. For an influenza pandemic to occur, a new strain of the
virus must emerge and spread easily from person to person. The 2009
H1N1 was classified as a pandemic with increased risk for serious flurelated complications. The precautions recommended by the CDC have
been standard, respiratory, airborne, as well as wearing respiratory
protection such as the N95 respirator which requires fit-testing.
In the event of a pandemic, visitors may be restricted. In a serious
pandemic, it may be necessary to close most facility entrances and to
post security at the open entrances. Staff and visitors may need to be
screened for flu-like symptoms.
Occupational Medicine Services asks that all staff, volunteers, visitors, and
physician are aware of the symptoms. They ask that individuals
experiencing symptoms go home, and if needed, follow up with your
physician.
Hazardous Materials and Waste
Hazardous materials and waste in use at Atlantic Health include: several
EPA listed chemotherapy drugs, xylene; mercury, solvents, various
chemicals, reagents, and spill clean-up materials.
Regulated Medical Waste (RMW) classes of materials or products at
Atlantic Health include needles, syringes, and sharps, human blood, blood
products and pathological waste, isolation waste, cultures and stocks of
infectious agents and associated biological.
Sharps including needles, pipettes, test tubes, vacutainers, cultures/stocks
and glass sides are to disposed of in the approved rigid containers. Nonsharps including bloody gauze pads, empty feeding bags and tubing,
and empty suction canisters are disposed of in “Red Bag Receptacles.”
Liquid RMW are disposed of in “red and biohazardous liquid receptacles.”
All articles and containers with free-flowing RMW must be placed into
liquid receptacles to comply with the US Department of Transportation.
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Unless IV Bags or tubing has been contaminated with blood or regulated
body fluids, they are not considered RMW and can be disposed of in
regular waste.
All batteries, lamps, mercury containing devices and consumer
electronics must be collected and handled separately.
Emergency Management
The Atlantic Health System Emergency Operations Plan is available on the
Atlantic Health intranet under Forms and Policies then Safety Manual and
Emergency Management. Each department has a role in emergency
management and department specific plans/policies are defined.
The Atlantic Health System Emergency Operations Plan addresses the four
phases of Emergency Management: Mitigation, Preparedness, Response
and Recovery. Refer to manuals for further guidance. A Hazard
Vulnerability Analysis is done as a risk assessment. Emergency
Management exercises are conducted a minimum of twice a year for
Internal and External Disasters, ensuring preparedness, response and
protocols to follow. Further reference includes the EM Quick Reference
Guide posted throughout the facilities, as well as Communications
Matrices available in the Biological, Chemical and Radiological Response
Plans.
The Incident Command Center (ICS) is a standardized all-hazard incident
management system that enables hospitals and others to organize
resources, staff, and facilities in order to remain operational during an
emergency and promote the restoration of day-to-day operations.
Communications are maintained through a variety of methods including
email, internet/intranet, dedicated call-in lines, department snowball lists,
faxes, emergency telephones, handheld radios and information sharing
with the state.
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Atlantic Health has standardized Emergency Codes:
Homeland Security Advisory System (HSAS) disseminates information
regarding the risk of terrorist acts, and provides warnings in the form of a
set of graduated “Threat Conditions” that increase as the risk of the threat
increases. To access Atlantic Health HSAS interventions online on the
intranet – select Departments, then Protection and Security Services, then
the HSAS picture in left sidebar.
Medical Equipment Management
The Clinical Engineering/BioMed Department at Morristown Medical
Center:
MMC: call 973-971-5634
Located on the C level of the Meade building.
Hours are 7:00am to 4:00pm Mon-Fri.
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The Clinical Engineering/BioMed Department at Overlook Medical Center:
OMC: call 908-522-2903
Located on the 3rd Floor.
Hours are 8:00am to 4:30pm Mon-Fri.
The Clinical Engineering/BioMed Department at Newton Medical Center:
NMC: call 973-579-8573
Located Ground Level, Administration Building.
Hours are 8:00am to 4:30pm Mon-Fri.
The Clinical Engineering/BioMed Department at Chilton Medical Center:
OMC:
CMC:call
call908-522-2903
973-845-7589
Located
on
the
3rd Level
Floor.
Located Ground
Hours are 7:00am to 4:00pm
Inspects and repairs all medical equipment throughout hospital. All
medical equipment must be inspected prior to use; and all medical
equipment requiring repair should be taken out of service and reported to
the Clinical Engineering/Biomed department. In addition, all medical
equipment must have an inspection sticker. If the “Inspection Due” date
has expired, do not use the device, return it to the Clinical
Engineering/BioMed department at the facility.
Utility Management
Plant Engineering/Maintenance is responsible for the maintenance and
operation of all electrical, water, heating, ventilation, and AC systems.
Red power outlets are used for emergency backup power systems. Only
critical emergency medical equipment should be plugged into the red
emergency power outlets serviced by the hospital’s emergency backup
power system.
Safety Management
In addition to Atlantic Health System’s concern for the health and safety
of our staff, many of our programs are driven by the requirements of Joint
Commission, the Occupational Health and Safety Administration (OSHA)
and the NJ Department of Environmental Protection (NJDEP). Our
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hospitals have a multidisciplinary group serving as the Occupational
Health and Safety Committee which represents the interests of all
departments and services the hospital. They are responsible to do
environmental tours periodically to inspect both patient and non-patient
areas. There are two Safety Officers at each hospital, one is the
Occupational Safety Officer and the other is the Public Safety Officer. To
contact the OSO or the PSO at MMC, call extension X5779 for OSO or
beeper #866-586-4189, or X5697 for the PSO. To contact the OSO or the
PSO at OMC, call extension X5318 for the OSO or X5308 for the PSO. To
contact to OSO at NMC, call extension 773-971-5250 or the PSO at 973660-3122. The Occupational Health and Safety (O&ES) Inquiry Form is
used to formally report and get answers about potentially unsafe
conditions.
Right to Know About Chemical Hazards in Your Work Environment or the
HazCom Standard communicates information about hazardous
chemicals used in our work environment by ensuring container labeling,
the written program is available online on the O&ES web page.
Material Safety Data Sheets (MSDS) are information sheets available in
the Safety Management Program located in online through the O&ES
webpage, or in the library at both hospitals.
Chemical Spills require notification to Environmental Services Department
at X5030 at MMC and X2169 at OMC and X8304 at NMC so that they may
ensure proper clean-up. Be sure to call and give information on what,
where, and how much was spilled.
Certain clinical activities involve potential exposure to ionizing radiation.
These include X-ray imaging, radioactive materials to diagnose and treat,
and certain radioactive materials to irradiate blood samples. People
working in these areas are required to participate in radiation monitoring
and will be provided a radiation badge they are required to wear. Only
people approved for this area may work there.
If you are injured while working at one of the facilities, you need to report
your injury using an incident report and seek medical attention. If you are
not an employee of Atlantic Health, being treated at an Atlantic Health
facility may be subject to your own medical insurance.
Life Safety
Although rare, fires do happen in healthcare facilities. Life and Fire Safety
Guidelines require everyone to know that oxygen enriched environments
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enhance the spread of fire, can generate large volumes of toxic gas, and
intense heat. In the event of a fire be sure to follow the steps in the
R.A.C.E. acronym when responding:
 Rescue those in immediate danger and conduct a systematic
search for others in the area.
 Alarm the nearest fire alarm pull station and then dial extension
8888 at MMC, X777 at OMC and X8888 at NMC to report the
location of the fire.
 Contain the fire by closing ALL doors and windows.
 Extinguish the flames using a fire extinguisher if it’s a small fire just
getting started, or evacuate to behind the nearest fire doors.
When using the fire extinguisher, use the P.A.S.S. acronym to remember
how to use the extinguisher:
 Pull the pin from the handle of the fire extinguisher.
 Aim at the base of the fire.
 Squeeze the handle of the fire extinguisher to activate and
discharge the extinguisher on the fire.
 Sweep the base of the fire until it’s out or the extinguisher is empty.
There are three different classes of fire we deal with and fire extinguishers
are divided into various categories based on the different type of fire:
 Class A: Ordinary combustible or fibrous materials. Examples: wood,
paper, cloth, rubber, and some plastics.
 Class B: Flammable or combustible liquids. Examples: alcohols,
xylene, gasoline, kerosene, paint and paint thinner, and propane.
 Class C: Energized electrical equipment. Examples: appliances,
switches, panel boxes and power tools.
The label on a fire extinguisher will tell you what class of fire it covers.
Approximately 90% of the fire extinguishers used at Atlantic Health are
ABC (universal/dry chemical) extinguishers.
Be sure to follow the proper steps in evacuating from a fire area. Step 1 –
move horizontally to next smoke zone; Step 2 – move vertically – down
two flights. Compartmentalization allows us to isolate the smoke and fire
to the unit where the fire occurs minimizing the amount of evacuation
necessary.
Things to Remember: Do not use the elevators. Follow exit signs. In
patient care areas, place diagonal piece of tape on room doors that
have already been swept/clear to eliminate duplicating efforts.
Security
The Protection and Security Services departments at the hospitals are a
24/7 department. The department is located on Simon B level in MMC,
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with a telephone number of 973-971-5555. At OMC, the Security
Command Center is located on the 5th Floor with a phone number of 908522-5529, at NMC on 973-383-2121. This department is responsible for the
physical safety of the hospitals and its sites, as well as issuing ID badges
and parking decals. Other services include monitoring security sensitive
areas, investigating, responding to various codes, providing support for
employee escorting, and maintaining a constant security presence
throughout the hospital. All staff, volunteers, students, physicians and
vendors must wear ID badges when present in the facility.
If you observe unusual or suspicious activity, please report it to the Security
Command Center at X5555 (MMC) or X5529 (OMC), at X8888 (NMC).
Code Pink/Code Adam: When these codes are announced all
departments adjacent to entryways, exits, stairwells and elevators are
required to “Adopt an Exit.” Monitoring these accesses is important to
ensure all suspicious activity is reported immediately.
Code Lockdown: This code is enacted when there is a “potential or
active shooter.” If involved in a code lockdown at the point of origin, Dial
“9-then 9-1-1, and the internal emergency number X8888 (MMC) or X7777
(OMC), X8888 (NMC) as soon as possible, advise telecommunications
from the nearest safe area. Stay on line if possible to provide further
information. Seeking safe shelter within the building, assisting patients and
visitors, as necessary, are what all employees are instructed on. An “All
Clear” will only be called by the Security Department.
Workplace Violence
There are three regulatory agencies that require Atlantic Health to work to
prevent workplace violence: OSHA, Joint Commission, and NJDHSS.
Workplace Violence is defined as any physical assault, threatening
behavior, or verbal abuse occurring in the work setting.
Atlantic Health has a policy on Workplace Violence that prohibits
conduct that includes threats, threatening language, or other any
aggressive behavior including verbal or physical harassment. Disciplinary
actions up to and including termination may be initiated after
investigation of a claim of workplace violence. Also, any employee who
makes false accusations will be subject to similar disciplinary actions.
Atlantic Health completes an annual risk assessment, analyzes reportable
incidents, and does workplace violence training.
All incidents of workplace violence should be reported to security.
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With regard to patients and patient families, a Code White should be
called when the caregiver feels a patient’s behavior presents an
imminent danger to self, others and/or property. Call X8888 (MMC) or
X7777 (OMC), X8888 (NMC) to issue a Code White.
Mandatory Education Review
1.
The Atlantic Health Exposure Control Plan is available to all hospital
personnel on the hospital Infection Control intranet site or in hard copy in the
libraries of the hospitals.
TRUE__________
FALSE__________
2.
Bloodborne Pathogens (BBP) exposure can occur through sharps injury,
scalpel, or anything that can pierce the skin.
TRUE__________
FALSE__________
3.
Following standard precautions includes washing your hands and
personnel protective equipment (PPE) to reduce exposure risks.
TRUE_________
FALSE__________
4.
Contaminated body fluids may be disposed of in regular medical waste
containers.
TRUE__________
FALSE__________
5.
Particulate respirators must be worn when entering patient rooms on
airborne precautions.
TRUE__________
6.
FALSE__________
Caregivers are not required to have an annual tuberculin test.
TRUE__________
FALSE__________
7.
Hand washing or using alcohol rubs is the number one way to prevent the
spread of infection.
TRUE__________
FALSE__________
Atlantic Health System Mandatory Education for Non-Employees 2014
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8.
Isolation precautions are only required to be followed by employees.
TRUE__________
FALSE__________
9.
Only Security has a role in the Atlantic Health’s Emergency Management
Plan.
TRUE___________
10.
FALSE__________
Match the following codes:
Fire Emergency
Bomb Threat
Cardiac Arrest
Unruly Patient/Visitor
Emergency Mgmt Plan
Medical Emergency
Missing Child
Infant Abduction
Green
Blue
Red
Black
Purple
White
Pink
Adam
11.
Clinical Engineering maintains and inspects all electrical, water, heating,
ventilation and AC systems.
TRUE__________
FALSE__________
12.
The MSDS information sheet is available in the Safety Management
Program located on the intranet, or in the library at MMH.
TRUE__________
FALSE__________
13.
Environmental Services Department (X5030) should be notified in the
event of a chemical spill.
TRUE__________
14.
R.A.C.E. stands for Rescue, Alarms, Contain and Extinguish.
TRUE__________
15.
FALSE__________
FALSE__________
P.A.S.S. stands for:
a.
Pass, Aim, Switch, and Spread
b.
Pull, Aim, Squeeze, Sweep
Atlantic Health System Mandatory Education for Non-Employees 2014
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NAME:__________________________________ DATE:________________________
(To review the answers to this quiz, please see the following page)
Atlantic Health System Mandatory Education for Non-Employees 2014
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Answers to Quiz
Mandatory Education Review
1.
The Atlantic Health Exposure Control Plan is available to all hospital personnel on
the hospital Infection Control intranet site or in hard copy in the libraries of the hospitals.
TRUE____X______
FALSE__________
2.
Bloodborne Pathogens (BBP) exposure can occur through sharps injury, scalpel, or
anything that can pierce the skin.
TRUE_____X_____
FALSE__________
3.
Following standard precautions includes washing your hands and personnel
protective equipment (PPE) to reduce exposure risks.
TRUE_____X____
FALSE__________
4.
Contaminated body fluids may be disposed of in regular medical waste
containers.
TRUE__________
FALSE____X______
5.
Particulate respirators must be worn when entering patient rooms on airborne
precautions.
TRUE____X______
6.
FALSE__________
Caregivers are not required to have an annual tuberculin test.
TRUE__________
FALSE____X______
7.
Hand washing or using alcohol rubs is the number one way to prevent the spread
of infection.
TRUE_____X_____
8.
Isolation precautions are only required to be followed by employees.
TRUE__________
9.
FALSE__________
FALSE____X______
Only Security has a role in the Atlantic Health’s Emergency Management Plan.
TRUE___________
FALSE_____X_____
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10.
Match the following codes:
Fire Emergency
Bomb Threat
Cardiac Arrest
Unruly Patient/Visitor
Emergency Mgmt Plan
Medical Emergency
Missing Child
Infant Abduction
ANSWERS
RED
BLACK
BLUE
WHITE
GREEN
PURPLE
ADAM
PINK
11.
Clinical Engineering maintains and inspects all electrical, water, heating,
ventilation and AC systems.
TRUE__________
FALSE____X______
12.
The MSDS information sheet is available in the Safety Management Program
located on the intranet, or in the library at MMH.
TRUE____X______
FALSE__________
13.
Environmental Services Department (X5030) should be notified in the event of a
chemical spill.
TRUE_____X_____
14.
R.A.C.E. stands for Rescue, Alarms, Contain and Extinguish.
TRUE_____X_____
15.
FALSE__________
FALSE__________
P.A.S.S. stands for:
a.
Pass, Aim, Switch, and Spread
b.
Pull, Aim, Squeeze, Sweep
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19
ATLANTIC HEALTH SYSTEM
INFORMATION SECURITY AWARENESS
Introduction –
Welcome to the Atlantic Health System, Information Security
Awareness training module. This mandatory training course has
been designed primarily for non Full time, Part time or Per Diem
workforce members. Examples of who are required to complete this
training include (but are not limited to); business partners, nursing
students, volunteers and contractors or consultants. This would
include anyone with electronic access to Atlantic Health Systems
either on the property of one of our facilities or someone requiring
remote access to Information Resources. At the end of the course
you will be required to agree to a “Statement of Understanding”
assuring that you have viewed the course and understand your
responsibilities in assuring we maintain a secure environment.
Technology Device Usage –
 If you will be using a non Atlantic Health System (AHS) issued device
such as a laptop computer you will only have access to the AHS
“Guest” wireless network
 At no time will you be permitted to plug a non-AHS
issued/managed laptop into our “wired” network or connect to the
AHS wireless business network.
 If necessary you will be provided an AHS loaner laptop if deemed a
requirement during your engagement. This should be discussed with
the Manager you will be reporting to prior to beginning your
assignment.
 If a non-AHS issued laptop is used to store any type of proprietary
AHS data it must have full disk encryption installed. In addition all
security updates must be current and Anti-Virus software must be
installed with the most recent virus definitions.
 Removable media such as CD’s, DVD’s, flash drives or portable
hard drives are utilized to store any AHS proprietary data they must
be encrypted.
Laptops –
Laptops and other mobile devices are expensive and small making
them good targets for theft. Some surveys indicate over 10,000 laptops
are lost every week in US airports alone.
A missing laptop with unencrypted sensitive information is a data
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breach with the potential for grave reputational, financial, and often
legal consequences. Laptops with sensitive information or the ability
to access secure systems must be encrypted and securely managed
to ensure loss or theft does not result in a data breach. Any missing
laptop, including those with secure encryption and management,
must be reported immediately.
Studies indicate the cost associated with a lost or stolen laptop
containing sensitive information can cost an organization in excess of
eight million dollars not to mention reputational damage that is hard
to quantify.
Appropriate Use –
Limited incidental personal use of Atlantic Health System information
systems, including the telephone is permissible provided that the
usage is
 De minimis – so little that there is no impact on AHS systems
 Does not interfere with job performance,
 Does not impact or affect other Users’ access to the system assets,
 Does not incur significant costs and
 Cannot be reasonably carried out during non-working hours with
non-Atlantic Health System Information Assets.
You should have no expectation of privacy when using the Atlantic
Health System network. All Activity is monitored and logged.
Network activity is automatically monitored and audited for security
purposes. Audit trails include websites visited, time spent on websites,
email monitoring and application access. Inappropriate or excessive
Internet use is reported to Human Resources and/or Protection and
Security Services.
Some examples of appropriate use include limited access to view
news articles, weather forecasts and personal banking.
Examples of inappropriate use include:
 Conducting a personal business or performing work for another client
while being paid by AHS
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 Interfering with Atlantic Health System business
 Illegal activities
 Visiting websites that are sexually oriented, allow gambling, or
promote negative beliefs such as hate language, harassment, or
threats.
 Using Atlantic Health System computing devices to complete paid
surveys.
Any inappropriate use of computing equipment is a reportable
incident.
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All activity performed while utilizing the AHS wired or Guest network
is monitored and logged.
There should be no expectation of privacy when using the AHS
network. All activity is monitored and logged by Information Security
personnel.
Remote Access 
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Atlantic Health System maintains multiple technologies to provide
remote access
Services such as LogMeIn, GoToMyPC and Webex are not allowed
for remote access into AHS systems
Work with your AHS manager to have proper remote access setup
File Transfer FTP/SFTP –
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FTP should never be used to transmit any AHS proprietary data as it
is sent un-encrypted
SFTP is an acceptable solution for configuring automated transfers
Atlantic Health System employs ShareFile for sending or receiving
files securely. If you need access to ShareFile please contact the
Customer Support Center at 973-971-7272
E-Mail Security 

If you are issued an AHS email account all outbound messages to
recipients who are not part of the AHS domain will be automatically
encrypted if they contain PHI or PII.
Personal email accounts must never be used to conduct AHS
business. Only secure email platforms shall be used for email
communications. Any email containing PHI/PII/PCI information must
be encrypted.
User Accounts and Password Security –
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Any form of a generic account is prohibited for accessing AHS
systems. All accounts must be a unique naming convention that
links a specific individual to their activity
All passwords must be complex to include the use of upper and
lower case letters, numbers and at least one special character.
At no time should your credentials be shared with anyone.
Your computer must be configured to automatically lock the
system after fifteen minutes of inactivity. When you step away from
your computer the screen shall be manually locked to prevent
unauthorized access.
Internet Security –
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AHS employs content filtering so not all websites will be accessible.
All internet activity is monitored and logged
Protecting Information –
With proper authentication and a mobile device, access to
sensitive information is available almost anywhere. Personnel with
remote access have a responsibility to support our Information
Security policies by protecting access to information from outside
threats.
Follow these rules to protect sensitive information:
 Encrypt any sensitive information while in transit. This includes
transit on physical devices, which are easily lost or stolen such as
CDs, thumb drives, and backup disks.
 Email containing sensitive or protected information must use
authorized encryption. Contact the ISS Customer Support Center
at 973-971-7272 if you need assistance.
 Never use a personal email account to send or receive any
Atlantic Health System business. Policies are clear that you may
only use your Atlantic Health System email for conducting Atlantic
Health System business.
 Authenticate requestors of sensitive information, or refer them to
designated employees.
 Do not retain sensitive information longer than needed and
dispose of hardcopies using authorized means such as a ShredEx
bin.
 Report any suspicious attempt to obtain patient, Atlantic Health
System, or employee information.
 AHS automatically encrypts anything copied to removable media
such as a flash drive, CD or DVD from an Atlantic Health System
owned and managed Information Asset.
Depending on your role, you may have specific procedures for
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handling Atlantic Health System and patient information, and you
may be required to take additional training.
Incident Reporting –

Incident Reporting is a critical element of an effective Information
Security program. Reporting what you believe is a small incident
may prevent a loss of Atlantic Health System or patient information
that can prove costly and cause reputational damage.

Workforce Members who receive a report of identity theft from a
customer must immediately notify Corporate Compliance in writing
or e-mail about the report and provide details and any background
documentation in support of same.

Be vigilant, and report any suspicious incident immediately such as
missing, lost, or stolen equipment, suspicious visitors, inappropriate
requests for information, inappropriate access to sensitive
information, or misuse of computing equipment.
You Make a Difference
Everyone with access to Atlantic Health System information systems has a
responsibility to follow and enforce Information Security policies and act in
a manner that protects information assets.
To protect sensitive information, your responsibilities include:
 Log off or Lock your computer when it is unattended.
 Report suspicious events and security incidents quickly.
 Never share passwords with anyone.
 Use your Atlantic Health System computer and IT assets appropriately.
 Use best practices to protect Atlantic Health System and patient
information.
 Comply with all Atlantic Health System Information Security, Corporate
Compliance, Protection and Security Services, HR and ISS policies, which
can be found on the intranet.
Information Security is a responsibility we all must share. Please sign the
attestation on the next page and submit it to the AHS manager you will
be reporting to.
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Atlantic Health System Information Security Awareness Training
Please complete the following and submit to manager:
DATE____________________
NAME:__________________________________________________
(Print clearly)
DEPARTMENT/LOCATION:________________________________
EMPLOYEE ID #:_________________________________________
As a user with access to Atlantic Health System computer systems or data, I
understand that I am required to comply with all AHS policies (including
Information Security policies)s as well as the information I have reviewed above
and report the misuse, loss, abuse, or unauthorized access of Atlantic Health
Information Systems. Information Security policies are available via our intranet.
Please ask the person you are reporting to for the specific location.
SIGNATURE:_______________________________________ DATE:____________________
Manager/Supervisor you report to: ___________________________________________
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