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University of Maryland Medical
Center Mini New Employee
General Orientation
Mission
We heal, we teach, we discover, we care . . . we touch
Maryland’s life every day.
The University of Maryland Medical Center exists to serve
the state and the region as a tertiary/quaternary care
center, to serve the local community with a full range of
care options, to educate and train the next generation
of health care providers, and to be a site for world
class clinical research.
Vision
The University of Maryland Medical Center will serve as
health care resource for Maryland and the region,
earning a national profile in patient care, education and
research, strengthened by our partnership with the
School of Medicine and the School of Nursing.
Overview
•
The University of Maryland Medical Center is a major,
innovative teaching hospital in downtown Baltimore
that provides a full range of health care to more than
300,000 patients each year from Maryland and the MidAtlantic region. It serves as a regional referral center
for the most serious and complicated health problems
in adults and children, including cancer, trauma, heart
disease, neurological disorders and organ transplants.
•
As one of the nation's first teaching hospitals, the
Medical Center has its roots in the Baltimore Infirmary,
a hospital built in 1823 at Lombard and Greene streets
by doctors from the University of Maryland School of
Medicine.
Highlights
•
The Medical Center is the academic centerpiece of the
University of Maryland Medical System, a regional, not-forprofit network that also includes four community hospitals
and three specialty hospitals, as well as outpatient sites for
primary and specialty care throughout Maryland.
•
The Medical Center is composed of University Hospital, the
Marlene and Stewart Greenebaum Cancer Center, the R
Adams Cowley Shock Trauma Center and the University of
Maryland Hospital for Children.
•
All of its physicians are on the faculty of the University of
Maryland School of Medicine.
Over half of Maryland's physicians and other health care
professionals received training at the Medical Center.
Commitment to Excellence
At the University of Maryland Medical Center, we are
embarking on a journey to transform the patient
experience – by providing the safest care anywhere,
exceeding patient expectations
and becoming an even greater place to work. We need
your commitment to excellence in everything you do.
Pillars of Excellence
Core strategies at the University of Maryland Medical
Center are built around pillars and teams
UMMC Pillar Measurements
People
Be an “employer of choice” and a health care industry leader in
staff recruitment, satisfaction, retention and ongoing leadership
development.
Service
Provide compassionate care and accessible service in a culturally
sensitive manner to all patients and families at a level that exceeds
expectations.
Safety & Quality
Provide the safest care anywhere, maintain positive healthcare
environments and employment conditions, and become a
recognized leader in achieving optimal patient care outcomes.
Stewardship
Achieve volume growth and manage operating expenses in order
to attain financial results that allow for investment in our strategic
priorities, while meeting our mission to provide services to all.
Innovation
Develop innovative programs and services to improve the health
status and quality of life for residents of communities served while
fulfilling our academic mission.
C2X Teams
• Employee Loyalty
– Expands reward and recognition opportunities
– Recognizes employee achievements through organization-wide celebrations
– Identifies “storytelling” opportunities
• Patient Experience
– Develops and implements tools and practices to support positive patient
encounters
– Implements “WOW” service behaviors
– Develops and implements a robust service recovery initiative
• Communication
– Provides consistent communication of service excellence initiatives
– Develops new communication venues as needed
– Supports effective communication for all service teams
C2X Teams
• Behavioral Standards
– Develops and implements standards of performance
– Incorporates standards into the organizational culture
– Conducts monthly celebration of standards
• Measurement
– Analyzes patient and physician satisfaction results
– Develops formats to communicate results to the organization
– Identifies best practices and shares them organization-wide
• Physician Partnership
– Identifies and removes physician irritants
– Coaches physicians on service excellence
Behavioral Standards
• Accountability
• Appearance
• Communication
• Respect
• Service
Accountability
We commit to take ownership of all that we do and
responsibility for the outcomes of all our actions.
•Take pride in the hospital as if you own it
•Accept the responsibilities of your job
•Take responsibility to create a safe and incident-free environment
•Use protective clothing and equipment per standard
•Comply with HIPAA privacy and security regulations
•Use resources responsibly to reduce waste in all forms
Appearance
We commit to respect our personal appearance, work
environment and all areas visible to patients and customers.
•Follow dress code policies
•Wear your ID badge correctly at all times
•Take pride in facility appearance: pick up litter and dispose of
properly, clean up spills and return equipment to its proper place
•Take pride in personal appearance: grooming and dress reflect
respect for our customers
•Do not use personal technology in the work environment
•Maintain a clean and orderly work area
Communication
We commit to clear, open, honest and timely communication.
•Listen actively to our customers and coworkers in order to fully
understand their needs
•Answer telephone calls within 3 rings: identify name, department
and ask “How may I help you?”
•Respond to pager, voicemail and email in a timely manner
•Communicate plans, time frames and unexpected delays in all
settings
•Pay close attention to both verbal and non-verbal messages
Respect
We commit to treat others as they would want to be treated.
•Offer help when possible and cooperate in the workplace
•Respect privacy and dignity; use a quiet and respectful tone of
voice at all times
•Be sensitive to cultural differences
•Treat coworkers and customers with courtesy, honesty and respect
•Provide praise and recognition for a job well done
•Assume that your coworker wants to do a good job
Service
We commit to provide our patients, families, visitors and
coworkers with courteous, prompt and safe service.
•Smile, make eye contact and introduce yourself
•Greet and acknowledge patients, families, visitors and coworkers
•All employees are responsible for answering call lights
•Follow proper elevator etiquette
•Anticipate customer needs: follow through that expectations were
met
WE CARE standards
W – Welcome customers by identifying yourself.
E – Engage with customers by asking how you can help
C – Communicate with patients, families, physicians and co-workers
A – Address customers’ needs
R – Respect individual values and cultural differences
E – Educate customers
Cultural Competence
Cultural competency is the capacity to function
effectively with groups and individuals from similar
and different cultural systems.
Rosalyn Taylor O’Neal
Cultural Competence Values
• Cultural competence is for everyone
• Cultural competence is integral to best practice
• Cultural competence is an ongoing process
• Cultural competence is part of the overall organizational
goal of excellence
• Culturally competent organizations must be customerdriven
• Cultural competence is a key factor to continued financial
survival
• Culturally competent organizations should foster
leadership throughout the organization
• Adapted from Child Welfare League of America
University of Maryland Medical Center 2008 – 2013 Strategic Plan
Our Vision: UMMC will serve as a resource for Maryland and the region, earning a national
profile in patient care, education and research, strengthened by our partnership with the
Schools of Medicine and Nursing
Create a high-performing culture across all
aspects of operations to provide
compassionate care and accessible service in
a culturally sensitive manner to all patients
and families at a level that exceeds
expectations.
Become an “employer of choice” and a
health care industry leader in staff
recruitment, satisfaction, retention and
ongoing leadership development.
•Workforce
•Medical Education/Training
•Operational Excellence
•Service Excellence
Advance our growth and market share
of patient volumes across the state of
Maryland by increasing our geographic
reach, strengthening physician ties,
ensuring ease of access, and elevating
our reputation.
•Clinical Program Growth
•Referral Relationships
•Capacity & Infrastructure
Safety & Quality
Provide the safest care anywhere, and
become a recognized leader in the
development of innovative patient care
delivery models for both inpatient and
ambulatory care
•Clinical Outcomes & Safety
•Multidisciplinary Care Models
Build and sustain a
financial position allowing
investment in people,
clinical programs,
technology, facilities and
our community.
Strengthen relationships
with UMMS’ hospitals and
the UM Schools of
Medicine and Nursing.
•Relationships with UMB
Schools
•Financial Performance
•Corporate Citizenship
Corporate Compliance
Do the right thing
Corporate Compliance
What is It?
• Commitment to ethical business practices.
• Commitment to quality patient care and service.
• Compliance with laws, rules, regulations and policies.
• Commitment to our patient’s right to privacy.
• Do the right thing
• Everyone is involved
Compliance With What?
• Medicare regulations
• Medicaid regulations
• Medicare/Medicaid Fraud and
Abuse Anti-Kickback Statute
• Stark Act
• False Claims Act
• Occupational Safety and Health
Administration (OSHA)/ Maryland
Occupational Safety and Health
(MOSH)
• Conflicts of interest
• Equal Employment Opportunity
(EEO)
• Clinical Laboratory Improvement
Amendments (CLIA)
• U. S. Environmental Protection Agency
(EPA)
• Blood borne pathogens
• Americans With Disabilities Act (ADA)
• State licensure and certification
• Emergency Medical Treatment and
Active Labor Act (EMTALA)
• Family Medical Leave Act (FMLA)
• Antitrust
• Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
• The Joint Commission
• Drug Enforcement Administration (DEA)
HIPAA
Health Insurance Portability and
Accountability Act of 1996
• Privacy Rule (effective April 14, 2003)
– Limits the use and disclosure (leaking) of confidential patient
information to prevent improper use.
– Establishes patient rights relating to their health information.
• Security Rule (effective April 21, 2005)
– Protect confidentiality of electronic patient information when stored,
maintained or transmitted.
• Patients have the right to have their health information kept
private.
• Do not discuss patient information in public areas, e.g.
elevators, cafeteria lines, hospital lobby and hallways.
Patient Privacy
• Keep patient information on a “need to know” basis. Share information with
staff who need to know for treatment, payment or Medical Center operations.
• Locate fax machines used to send or receive patient information in places not
easily accessible to patients, family members or visitors.
• Keep patient information out of public view.
• Transport patient information face down, covered, or preferably in envelopes.
• Remove paper records with patient information from meeting rooms or public
areas after use
• Keep computer screens out of public view and log off of the computer when
done.
• Make sure patients are properly covered when they are transported.
• Close doors and draw the curtains around patients when they are receiving
care.
The Joint Commission
• Provides an accreditation process that challenges organizations to
improve their performance on an ongoing basis
• For us it means patient safety and quality patient care
What to do about patient safety concerns:
• Talk to your immediate supervisor or charge nurse for immediate
resolution of your concern
• Talk to your nurse manager or director about problems that recur
and/or show a pattern
• If your concerns are not resolved or addressed, call the patient
safety hotline – 410-328-SAFE or 8-SAFE (7233)
• You may also call your concerns to
– The Maryland Office of Healthcare Quality – 410-902-8016
– The Joint Commission – 1-800-994-6610
Impaired Staff or Licensed
Independent Practitioners (LIPs)
• The Medical Center strives to maintain a drug free
workplace
• Report LIPs or co-workers who are suspected of
suffering from abuse of these substances or who may
be suffering from psychiatric illness, emotional
distress or physical disability immediately to your
manager
What do you do if you suspect a
business practice is unethical?
• Check policies/procedures, the Code of Conduct on the
Medical Center Intranet
• Talk with your manager or supervisor
• Call UMMC Hotline at 1-877-300-DUTY (3889)
• Report via internet at www.reportit.net (user name- UMMC,
password- UMMC)
A question asked prevents a broken rule.
There is no retaliation for reporting.
Security Awareness
Prevention is the key!
Security
• Security strategic posts
Main lobby
Shock Trauma Center
Gudelsky entrance
Emergency Department entrance
• 24/7 Patrols throughout the hospital
• Security telephone number 8-8711
UMB Campus Police
• The campus is patrolled by
the University of Maryland at
Baltimore Campus Police
(C.O.P.S.), 6-1408
• Or may be reached by
emergency call boxes or call
410-706-6882
Workplace Safety
• Don’t walk alone to isolated areas.
• If you are working in isolated areas or after hours, call
Security- ext. 8-8711- and give your name and
location.
• Always lock your door when leaving
• If you witness workplace violence, acts of vandalism,
or disruptive behavior, contact Security immediately
at ext. 8-8711 – The Medical Center has zero tolerance for
workplace violence
UMMC ID Badges
• It is a state law that you wear your badge at all times, prominently
displayed above the waist.
• Report lost or stolen badges to ext. 8-1329.
– The replacement cost for a badge is $10.
• Treat unbadged persons as guests.
• Advise them to get a guest pass
• Report description and location of suspicious persons to Security-ext. 8-8711
• Never allow an unbadged person to follow you into a locked area
• Do not give up control of your Security ID
Important Information
• Safe Haven Law –The Medical Center is a Safe Haven. A
distressed parent who is unable or unwilling to care for an infant
can give up custody of a baby who is less than 72 hours old,
safely, legally, and confidentially. If someone hands you a
newborn baby, don’t ask any questions. Take the baby to the
Pediatrics Emergency Room.
The Medical Center is a TOBACCO FREE facility
• In order to provide the healthiest possible environment for its
patients, visitors, employees and volunteers, the University of
Maryland Medical Center launched “UMMC Completely
Tobacco-Free” policy on February 14, 2008. The new policy
expands the existing hospital ban on all tobacco products inside
the hospital’s facilities to the outside sidewalks and walkways
that are part of the Medical Center’s property.
• The new policy applies to all patients, visitors and employees
Guest Services
• Call
– For answers to
questions
– To voice concerns
– To get directions
• Dial 8-1500 on any
house phone.
Environment of Care
Any safety concern, risks or observations of close calls or
near misses should be reported to the Safety Officer.
Safety Officer – Jim Chang (Phone 8-6001/Pager 1336)
Employee Rights
Employees have the basic right to
• Make a complaint regarding unsafe or unhealthy workplace
conditions
• Address complaint in-house by notifying supervisor and/or
the Safety Officer at 8-6001 or 8-2337 ID#1336
• Report patient safety issues to Customer (8-SAFE)
• Report patient safety issues to The Joint Commission
• Call Connect (SOSC) (8-5174/8-8711/8-7072)
• Not face retaliation for making a complaint
• Request confidentiality
Space Management
• Hallways are for people, not
stuff. If you have items in the
hallways, they need to be kept
on one side.
• Remember – when the fire
alarm sounds, everything
needs to be moved out of the
hallway(s).
Hazardous Materials and Waste Management
• Hazardous materials (hazmats) are any substance that when
used or stored improperly poses a risk to people, property or the
environment.
• Each department should have a chemical inventory and access
to Material Safety Data Sheets (MSDS for all inventory items.
MSDS are fact sheets that describe the possible health effects,
first aid information and the clean up procedures for spills of all
hazardous materials used at the Medical Center.
• An MSDS should be posted in every area where hazardous
materials are stored.
• If a hazardous materials is spilled in your area:
– Contain and clean up the spill if it is safe to do so, and you are
appropriately trained
– If you need help, call the SOSC at 8-5174
– Report all spills to your Department Safety Office and the Hospital
Safety Officer
Fire Safety
Code Red is the disaster code for fire.
Your role if the fire alarm sounds:
• If the fire alarm is in the same building and same floor (or
floor directly above or directly below)
– Clear the corridors – move carts and equipment out of the corridor
into rooms or alcoves;
– Close all door and windows; and
– Be prepared to move if necessary or directed to do so.
• If the alarm is in another building, stay alert
• If the alarm is in the same building, but on a different floor,
stay alert and be prepared to help if needed
Fire Safety
If you discover a fire or smoke, RACE:
R – Remove/Rescue anyone in immediate area of fire.
A – Activate the alarm and call 8-2911.
C – Confine the fire by closing doors and/or windows
E – Extinguish the fire only if safe to do so or evacuate.
• Do not store equipment in the hallways, in front of fire exits
or in the stairwells.
• Never prop open fire doors
• Know the location of the fire exits and fire extinguishers in
your area
Fire Extinguisher
When using a fire extinguisher
remember PASS
Pull the pin
Aim the nozzle at the base of the
fire.
Squeeze the handle.
Sweep from side to side at the
base of the fire.
Medical Equipment
• All pieces of patient-related equipment (including loaners,
demos, patient-owned equipment) are inspected and tested
prior to use by staff in Clinical Engineering.
• If electrical or biomedical equipment is malfunctioning:
– Remove the equipment from service and notify your
manager/supervisor
– Place “Out of Order” labels on the equipment, if necessary, to
distinguish it from other equipment
– Contact BioMed at 8-5343 (pager 6000) for patient related
equipment and Facilities at 8-5174 for non-patient equipment.
• Clinical equipment that requires scheduled inspections
carry a safety inspection tag with date inspected and date
due. Equipment that does not require periodic inspection is
labeled “No Inspection”.
Utility Outage
• At the Medical Center, we have six emergency generators that
provide backup power for critical functions in the event we lose
commercial power. This power is provided through red outlets.
• In general, any critical piece of equipment (e.g., life support and
patient monitoring equipment) should be plugged into red outlets
if available. Conversely, non-critical equipment, e.g. copy
machines, and coffee pots) should not be plugged into red outlets.
Contact Facilities at 8-5174 if uncertain.
• For a utility malfunction such as a water leak or an electrical
outage:
– Know the location of your medical gas shutoff valves and who is authorized
to use them (usually the charge nurse or chief technologist).
– Keep the area in front of medical gas shutoff valves, and electrical panels,
clear of all obstructions (i.e., no cabinets, no carts, etc.)
– Call the SOSC at 8-5174.
MRI Safety - Protecting yourself
and the patient
• If you are a nurse or this is your responsibility, complete
the MRI checklist accurately
• Remember the MAGNET IS ALWAYS ON
• Heed posted warning signs
• Stay away from the MRI suite unless it is necessary for you
to be there
• Be mindful of metal on your body or equipment that you
use
Emergency Management
The hospital disaster plan can be found on the Intranet. Your role in a
disaster:
• Report to work when scheduled (or when called in).
• Follow the direction of your supervisor.
• Note: If the hospital activates the Hospital Incident Command System
(HICS), you may be assigned an additional role(s) and responsibilities.
How do I report an emergency at the Medical Center?
• For life-threatening emergencies such as a Code Blue or fire, call the
Stat Operator at 8-2911 and notify your manager/supervisor
• For all other emergencies (security issues, utility failures, etc.) contact
the SOSC at 8-5174 and notify your supervisor
Patient Safety
Patient Safety at UMMC
• Patient safety is everybody’s work
• Leaders ensure that our culture supports safety and blame free
reporting
• Staff follow policies, talk to each other, report safety risks
including near misses, and exercise care and caution
• Patients/families inform their caregivers of their full history,
report risks they observe, accept responsibility for
consequences of decisions they make
National Patient Safety Goals
• Improve the accuracy of patient identification by accurately
identifying the individual for whom the service and
treatment is intended.
• Improve the effectiveness of communication among
caregivers.
• Improve the safety of using medications.
• Reduce the risk of healthcare associated infections.
• Accurately and completely reconcile medications across
the continuum of care.
National Patient Safety Goals
• Reduce the risk of patient harm resulting from falls.
• Encourage patients’ active involvement in their own care as
a patient safety strategy.
• Improve recognition and response to changes in a patient’s
condition.
• Universal Protocol: Prevent wrong site, wrong procedure,
wrong person surgery and procedures
Infection Control
Hand hygiene is the single most important procedure for the
prevention of health care associated infections.
• Alcohol based hand rubs can be used if hands are not
visibly soiled.
• Use antimicrobial (CHG) soap and water and wash for 15
seconds if hands are visibly soiled.
• Do not use alcohol based hand rubs for patients that have
Clostridium difficule (C-diff).
• Include the patient and family in our Hand Hygiene
Campaign.
• Be familiar with your unit’s hand hygiene performance:
GOAL-100% compliance. Be a role model for others.
Code Pink
If a child or infant is determined missing, a
CODE PINK will be overhead paged.
• Be alert to unusual behavior and report to security
• Be aware that a disturbance may occur in another area
creating a diversion that facilitates an abduction
• Be aware of anyone looking suspicious, carrying an infant
instead of pushing a bassinet, carrying a tote or duffel bag
• If you see a suspicious person, get a good description and
call security STAT
• If possible, detain suspected person through conversation
Employee Injury/Exposure
What do I do after a needle stick/body fluid exposure?
• Wash the area with soap and water. For mucous membrane
exposures, irrigate the affected area with saline.
• Call the Exposure Hotline immediately at 8-BEEP ID# STIK
(7845).
• Contact your supervisor.
• Contact Environmental Services through SOSC for
replacement of needle boxes.
Management of Patients on
Isolation Precautions
• If the nursing assessment reveals that the patient may have
a communicable disease (e.g. diarrhea of unknown etiology,
signs and symptoms of a viral respiratory illness), the nurse
can initiate presumptive isolation precautions and then
follow-up with the physician for an order.
• Isolation attire is not to be worn outside the patient room
unless the staff is transporting a patient on precautions.
• An isolation cart is acceptable in the hallway only if the
patient has a visible isolation sign.
• Isolation signage must be in accordance with the hospital
policy; handwritten signs are unacceptable.
TB Exposure Prevention
• Tuberculin skin testing is required annually; if you are
known to be positive, an annual screening questionnaire
must be completed.
• If you are exposed to a patient with tuberculosis, a followup skin test 10-12 weeks after exposure is required.
Performance Improvement
Methodology at the Medical Center
• Plan
What do you hope to accomplish with the change?
Plan for the collection of data.
• Do
Carry out the change or test.
Collect data.
• Study
Complete analysis of data
Summarize what was learned
• Act
Adapt of abandon change based upon knowledge gained.
Are we ready to implement?
Plan for next cycle.
Performance Improvement
Staff Responsibilities
• Identify hospital PI initiatives
• Tie unit-based activities into hospital priorities
• Describe unit based work around PI
• Use chart and posters to help describe
• Describe the process and outcome succinctly