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RESPECT TRUST COMPASSION COMMITMENT COURAGE 1 | P a g e

NEW HIRE HANDBOOK

Updated: August 2018


Table of Contents

Overview and Floor Plan .................................................................................................. 3

Markham Stouffville Hospital: Vision, Mission & Core Values .......................................... 6

Section 1: ESSENTIAL INFORMATION .............................................................................. 8

Occupational Health & Safety ................................................................................. 9

Emergency Codes.................................................................................................. 13

Workplace Hazardous Materials Information System (WHMIS) ............................. 18

Radiation Safety .................................................................................................... 23

Quality, Patient Safety, Patient Relations & Experience and IPAC .......................... 24

Infection Prevention and Control (IPAC) Program ................................................. 27

“Expect Respect” – Violence and Harassment Prevention Education Program ....... 30

Privacy, Confidentiality and Personal Health Information ...................................... 35

Ethics ..................................................................................................................... 38

Accessibility for Ontarians with Disabilities ............................................................ 40

Conflict of Interest Policy ...................................................................................... 40

Whistleblower Policy ............................................................................................. 42

LiME eLearning Mandatory Courses ...................................................................... 43

Section 2: OTHER INFORMATION .................................................................................. 47

Employment Standards in Ontario ........................................................................ 48

Parking and Security ............................................................................................. 49

Education Funding ................................................................................................ 50

Employee Referral Program ................................................................................... 51

Part-time Employee Benefits ................................................................................. 51

Places to Eat .......................................................................................................... 52

Gift Shop ............................................................................................................... 52

Dale’s Pharmacy .................................................................................................... 52


Overview and Floor Plan

Building B

Building A

Building C

Medical Offices Building (MOB)

Dales’ Pharmacy

Waiting Room Café

Building D

Health Services

Building (HSB)

MSH Auditorium

Building E Cornell Community Centre

Building A

• Original building; 3 levels

• In-patient Medicine services

• Out-Patient Surgery, Out-Patient Rehab,

Admission Assessment Unit

• Ambulatory clinics

• Food Services, Facilities, Patient

Transport

• Laboratory

• Cafeteria and Gift Shop

• Administration Offices

• Main Lobby Entrance

Building B

• Four levels

• Roof- top helipad, mechanical rooms

• Additional 100 beds

• ED, OR, Critical Care, In-patient Surgery,

NICU, Birthing Unit, Mental Health, Out-

patient Mental Health and Diagnostic

Imaging

• HR, OHS, In-patient Pharmacy

• Link Lobby Entrance

Emergency

Main Lobby


Markham Stouffville Hospital: Vision, Mission & Core Values


Being Green

Being green comes naturally to Markham Stouffville Hospital!

The Markham Stouffville Greening Committee aims to inspire and encourage each member of

the Markham Stouffville Hospital community to make environmentally sound choices in each

aspect of their professional lives. Ultimately, the Committee’s goal is to create a ‘greener’

Hospital by implementing measures that help develop eco-friendly purchasing policies, use

energy more efficiently, reduce resource consumption and promote ‘green’ commuting

practices amongst the staff.

You can make a difference!

The MSH Greening Committee wants to hear from you.

Email [email protected] to share your thoughts and ideas on how to create a greener

Markham Stouffville Hospital.


ESSENTIAL INFORMATION

Section 1:

Section 1: ESSENTIAL INFORMATION


Occupational Health & Safety The Occupational Health and Safety (OHS) department at Markham Stouffville Hospital

is committed to preventing occupational illness and injury in the workplace and

establishing a safe and healthy workplace environment for all employees, as per the

Occupational Health and Safety Act (OH&SA). The OH&SA is a provincial legislation that

outlines specific conditions for constructing a safe and healthy environment in the

workplace. A copy of the OH&SA is available in every department, in addition health

and safety policies are available on the Hospital’s intranet.

MSH is committed to support each individual’s right to work in an atmosphere that is

safe, healthy, supportive, secure and respectful. The Hospital has a zero tolerance for

behavior that is disrespectful or threatening. All staff is required to sign a Statement of

Commitment form at General Hospital Orientation. This commitment is valid and on-

going.

The OHS department maintains a safe and healthy work environment by providing

employees with necessary resources. Services it provides include:

o Medical assessments, including hand hygiene assessments

o Immunizations and vaccinations

o Mask fit testing

o Health, Safety, and Wellness

o Employment assistance program (EAP), including lunch-n-learns and critical

incident debriefing

o Return to work following medical absence

o Confidential counseling and referrals

o Workplace health and safety assessments and recommendations

o Emergency disaster procedures

o Injuries, illnesses, accidents, and hazardous conditions

General Hospital Policies That Affect Your Health and Safety

Smoke Environment

Markham Stouffville Hospital’s property is 100 per cent smoke-free.

Fragrance-Reduced Area

For the health and comfort of everyone, please refrain from using

fragrances or heavily scented products when working or visiting the

Hospital.


Latex-Safe Environment

Latex can cause a severe allergic reaction. In an effort to reduce the risk of

exposure to natural rubber latex, latex balloons are not allowed in the

Hospital. Mylar balloons, however, are acceptable.

For more information, contact the Occupational Health and Safety department:

o Markham Site ext.6280 / Uxbridge Site ext. 5233, or

o visit the Hospitals intranet page and click on Occupational Health

Your Role in Safety- Know your role

Staffs’ roles and responsibilities under the OH&SA, includes:

o Work in compliance with the OH&SA

o Use/wear required protective equipment

o Avoid removing protective devices

o Identify and report hazards/defects in equipment

o Report any contraventions of the OH&SA

Procedures for Reporting Health and Safety Concerns

The OHS department must be notified for any injury or illness occurred in the Hospital.

Business Hours MUST be assessed in OHS following the incident. After hours, staff must

be in contact with OHS by 1200 hours on the next business day:

o Inform the Manager/Director

o Complete Employee Incident Report (in intranet IReport) within 24 hours

o Notify OHS immediately if 1) seek healthcare and/or 2) miss time from work

o Participate in the investigation

STAFF (WORKER) ROLES:

Right to know—know the

hazardous materials in their

workplace

Right to participate—by

joining the Joint

Occupational Health and

Safety Committee

Right to refuse unsafe

work—this process is

outlined in the OH&SA

SUPERVISOR ROLES:

Ensure equipment, materials,

supplies are provided,

maintained, and used in

compliance

Ensure policies and

procedures are developed,

implemented, maintained,

and reviewed

Inform, instruct, and

supervise workers

Take every reasonable

precaution for protection of

workers

MANAGEMENT ROLES:

Ensure workers comply with

the OH&SA

Ensure workers use/wear

required protective

equipment

Advise workers of potential

and actual hazards

Provide written instructions

Take every reasonable

precaution for the

protection of workers


o Participate in the early and safe return to work program, designed to support

staff returning to pre-injury/illness duties in an early and safe manner

When staff has a health and safety concern:

o Staff reports concern to director or manager

o Director or manager investigates concern and provides feedback to staff

o Concern is addressed

When staff feels his/her concern was not addressed:

o Staff contacts a member of the JOHSC

o JOHSC member reviews concern with staff and director or manager

o JOHSC and director or manager work together to solve concern


When staff feels his/her concern was not addressed:

o Ministry of Labour (MOL) is contacted

o MOL investigates concern with the workplace parties and makes

recommendations

o Recommendations are implemented


IReport

IReport is a system for staff to report actual or potential incidents and adverse events

that compromise patient care or staff safety. Employees must report all occupational

accidents, illnesses, incidents, hazardous conditions, near misses and non-injury

property damage immediately to the appropriate director, manager or delegate and the

OHS department. Employees must complete the online Employee Incident Report in the

IReport System within 24 hours of the incident occurring.

Refer to Hospital’s intranet for the process and procedures related to medical treatment,

investigation, documentation and follow-up of employee incidents.

Joint Occupational Health and Safety Committees

The Joint Occupational Health and Safety Committee is an advisory group that is

required to be in place under the Occupational Health and Safety Act. The Hospital has

two committees, one at each of Markham Stouffville Hospital’s sites. The Committees

are made up of members who equally represent management and employees. The

members work together to stimulate awareness of health and safety issues, and

recognize and deal with any workplace risks. The members are committed to improving

and promoting health and safety at the Hospital.


The Committees’ responsibilities and Terms of Reference, the membership list, minutes

of the Committee and other information are available on the Hospital’s health and

safety boards or on the Hospital’s intranet.

Work Refusal Process

Staff can refuse work where safety is in jeopardy, with the exceptions:

o When a circumstance is a normal condition of employment; or

o When the work refusal or stoppage would directly endanger the life, health, or safety

of another person

When You are Too Sick to Work

Employees should seek medical assistance if their symptoms are contagious. Contact

OHS if they are not certain. The following conditions are symptoms to keep in mind:

Reporting Absences Due to Non-Occupational Illness/Injury

Employees unable to report for work as scheduled must notify their department head or

unit/department as early as possible prior to the start of the first shift for which they will

be absent. Where departments have established their own procedure for absence

notification or such notification is specified in a collective agreement, the employee

must follow this procedure.

When reporting their absence, employees are required to provide the following

information:

o How long he/she anticipates remaining medically unfit for work;

o The date (if known) on which he/she expects to report back to work;

o Contact details during normal business hours; and

o If illness/injury is work-related, employee is also responsible for contacting the

Occupational Health and Safety Department and is to follow the procedures set out

in the Reporting and Investigation of Employee Accident and Incidents Policy;

Administrative Manual – Health and Safety.

Fever: temperature over 38 degrees

or 100.4 Fahrenheit

Vomiting or diarrhea

Rashes with or without fever

Uncontrollable coughing

Any type of draining lesion or

weeping dermatitis

Untreated conjunctivitis or pink eye

Any conditions that affects your

ability to wash your hands

Upper respiratory infection with

fever present

Persistent sore throat lasting longer

than 3 days and/or accompanied by

fever

Known infectious diseases such as

Chicken Pox, Influenza, Tuberculosis


Illness on the Job

If an employee becomes ill while at work, he/she should first report the illness to his/her

department head and obtain permission to leave the work area. During regular business

hours, the employee must report to the Occupational Health and Safety Department.

After hours, the employee is to advise his/her department head if he/she is leaving work

to home.

Evidence of Medically Justified Absence

When an employee is absent for three or more consecutively scheduled shifts (or less if

identified by Occupational Health and Safety and/or the director/manager) the

employee must produce a completed and signed Medical Absentee

Certificate/Supporting Physician Statement. The employee is required to seek medical

attention within 48 hours following the third consecutively missed shift and submit the

completed Medical Absentee Certificate within the pay period that the sick absence

occurred. The Hospital’s Medical Absentee Certificate/Supporting Physician Statement is

available on the Hospital’s intranet, outside of the occupational health and safety

department as well as at departments and units throughout the Hospital.

Communication: Keep your department head informed during the absence to discuss

issues such as extended leave and return to work.

Emergency Codes Emergency Codes are in place to protect personnel, patients, visitors and property of the

Hospital during an emergency situation. Codes are initiated by: Markham site: Dialing

555 and informing Telecommunications, Uxbridge site: Dialing 58 and announcing

code over PA system. All codes are announced over the Public Address System 3 times,

naming the specific area where help is needed and are in effect until an “All Clear”, “End”

or “Cancel” announcement is made. Complete an iReport once the situation is over.

For More Information on Any of the Codes:

o Go to the Hospital’s intranet, click on Policies, click Corporate Policies and

Procedures and select Emergency and Disaster Manual

o Access your Emergency and Disaster Manual, available on each unit

STEP 1: Call a Code

Markham site Dial 555

Uxbridge site Dial 58

STEP 2: Inform &

Assist Give report to the Incident

Manager, Stay in the area,

Assist team leader

STEP 3: Report

Complete an iReport

once the situation is

over


Know your codes: Below are the emergency codes and their corresponding definition.

This information is also listed on the back of the staff photo ID badge.

CODE EMERGENCY TYPE

Code Blue Cardiac Arrest

Code Pink Infant Cardiac Arrest

Code Yellow Missing Patient

Code Yellow Amber Missing Child

Code White Violent Person

Code Green Evacuation

Code Brown Chemical Spill

Code Orange External Disaster

Code Orange- CBRN Chemical Biological Radiological Nuclear Disaster

Code Black Bomb Threat

Code Grey Air Exclusion/Infrastructure Failure

Code Purple Hostage Taking

Code 111 Short Term Assistance

Code Red Fire

Code Blue should be called when any adult, age 18 and older, is under cardiac arrest or

respiratory arrest requires or any Medical Assistance. A Code Blue can be initiated by

pressing the Code Blue button in the patient’s room, if available or call 555 (Markham

site); 58 (Uxbridge site). When a Code Blue is initiated, a team arrives to take over using

advanced life support techniques. Until they arrive, if you have the skill to initiate CPR, it

is imperative and expected that you do so. Every second counts for the victim of an

airborne or cardiac arrest. The sooner resuscitation is started, the better the outcome.

Code Pink is intended to inform staff and physicians that a child between 0 months to

18 years of age is having a cardiac or respiratory arrest. A cardiac arrest team including a

pediatrician (Markham site) will be responding to the code. A Broselow/Neonatal crash

cart is also brought to the location.

is activated when a patient is deemed as missing; the Code Yellow search

procedure will be initiated. A patient’s level of risk will be assessed to assist in

determining the appropriate stage of the Code Yellow search plan to be implemented.

The Clinical Manager, Facilitating Nurse or delegate is responsible to initiate the Code if

a patient is discovered missing. This person assumes the role and responsibilities of the

Search Coordinator. All staff, physicians, students and volunteers are expected to


participate and follow the policy.

S Secure designated exits for Code Yellow Amber. Search own department/unit using

your search maps. Advise Security immediately if you are unable to secure an exit.

E Engage Evacucheck markers and close all doors after each room is searched.

A

Be on Alert for missing patient. For a Code Yellow Amber, be alert for suspicious

persons (e.g. Persons wearing bulky clothing, carrying bags, appearing pregnant).

In Code Yellow Amber, all bags are searched at the secured exits.

R Record on Search Map. For Code Yellow amber, remain at exits until clearance.

C Call Search Coordinator with results.

H Hand over Search Map to Search Coordinator at end of Code.

Code Yellow Amber is a Hospital wide search for an infant or child (patient or visitor)

who is missing. The Incident Manager for Code Yellow Amber is the Patient Care

Coordinator or the Facilitating Nurse in the Care Area from which the child has gone

missing. In non-patient situations, the Incident Manager may be Security if this is most

appropriate. Code Yellow Amber search defines a method of securing the exits and

conducting a hospital-wide search to a) prevent the abduction of an infant or small

child; and/or b) a child is missing from an area where he/she is expected to be. This

procedure is used when there is reason to believe that the infant/child could be hidden

from view and carried out of the Hospital or the child has left without authorization.

Code Yellow Amber uses the same search procedures as a Code Yellow

As per the Newborn Security program, all newborn infants are restricted to the 4th floor,

Markham site (4Wh, 4Wf) except for diagnostic tests or at time of discharge. At time of

discharge, the parent(s) and significant other will be given a green envelope labelled

“Infant Discharge”. As a member of the Hospital you should approach the new mother

described above, and explain the Newborn Infant Security policy. You should then verify

that she and the infant are wearing corresponding ID bands. If they match, redirect the

mother back to Building B, 4th floor and observe to see that she does return to the area.

If the mother does not cooperate or you feel the infant is in danger at any time, contact

Security immediately.

Code White is intended to provide a timely, efficient and effective response when a

patient is behaving aggressively and poses a threat to self, others or the Hospital. The

Code White Team serves as a resource to departments to assist in de-escalation and,

where necessary, control of violent, disruptive behaviour. The Team uses Crisis

Prevention Intervention Techniques, a safe, non-harmful behaviour management system

designed to help healthcare workers provide the best possible care of disruptive or out-

of-control persons even during their most aggressive moments.

Code Green is intended to facilitate the evacuation when a crisis poses a threat to

safety. It refers to the evacuation of a specific area or of the entire building.


Code Green: Classifications

Code Green: Hospital wide evacuation

Code Green (Area Specific): Area evacuation

Code Brown is the procedure that allows staff to respond to an uncontrolled or

unplanned release of a potential hazardous material in any quantity, reducing any

potential for adverse effects on human health and the environment. Chemical specific

spill kits are found in specific departments (e.g. formalin, chemotherapy drugs). A

general spill kit is found outside Receiving (Building A), or behind MDRD (Building B).

Ensure staffs are aware of where the department spill kits are located. The Hospital has

specific staff trained in spill response procedures.

If you are person detecting the spill (beyond department capabilities):

S Safely evacuate area and SECURE the scene.

P Prevent spread of vapours/gases/fumes – close doors.

I

Inform Telecommunications (Markham - Dial 555; Uxbridge - Dial 58 and

announce, Uxbridge) – provide details (location, size, source, chemicals involved

and code level).

L Leave all electrical equipment alone.

L Locate Material Safety Data Sheets (MSDS) and available spill kit.

Code Orange is a plan to help mobilize the Hospital's resources in the event of an

external disaster. The size of the disaster will determine the response at that point in

time due to the number and severity of casualties and based on the resources currently

available in the Hospital. Staffs are notified of a Code Orange via the following methods:

On-Call Staff: Paged

On-Site Staff: Overhead page

Off-duty Staff: Called back through the use of the "Call and Go, Fan Out

Procedure"

Code Orange, CBRN is intended to mobilize Hospital resources in the event of a major

external Chemical Biological Radiological and Nuclear (CBRN) disaster that exceeds the

Hospital’s ability to provide services due to the number and severity of the casualties

requiring mass decontamination. It is an expectation that all staff and physicians will

respond to both a real and/or a Mock Code Orange – CBRN according to the plan. A

Code Orange – CBRN has 4 Stages, each of which can be activated independently or

progressively depending on the needs of the situation.

Stage 1:

Pre-Alert & Preparation

Hospital is informed of an external disaster and alerted of

potential involvement.

Stage 2:

Decontamination

Hospital is involved and resources and abilities may be

exceeded. Preparation for decontamination of patients will

take place at this time. Call back of off-duty staff may be


limited to Nursing, Medical and those required to meet the

current needs.

Stage 3:

Disaster

Hospital is involved and resources and abilities are

exceeded. (The whole organization will be mobilized).

During day shift Monday to Friday, sufficient resources may

exist within the Hospital and may only require activation of

Code 111.

Stage 4:

Debriefing, Evaluation &

Recovery

At this stage, the emergency is ending and key staff is

debriefed to identify the effectiveness of the response and

where improvements can be made.

Code Black is a coordinated Hospital-wide search for a bomb with provisions to ensure

staff, patient and public safety. Threats MUST be taken seriously. Code Black is in place

to provide information and an organized plan of action to ensure the safety of staff,

physicians, patients, the public and the Hospital in the event of a bomb threat. All bomb

threats will be considered genuine until proven otherwise. Any staff and physicians can

initiate a Code Black. A bomb threat can come in the form of a telephone call, written

note, e-mail or suspicious package. Staff will conduct a search of their departments. All

staff should remain in the Hospital until the “All Clear” is announced.

Code Grey is to alert the Hospital of an unplanned interruption/loss of essential

service/infrastructure failure and external air contamination. Its purpose is to provide an

immediate plan of action to ensure the safety of everyone within the building and allow

the Hospital to continue its operations. Some examples of interruption/loss of essential

services may include but not limited to, electricity/power, medical gas, water,

telecommunications, fire panel, air handling units, mag-locks in Mental Health and

elevator system.

Code Purple is when there is an incident of hostage-taking. A hostage-taking incident

can occur when: any person(s) is confined, imprisoned, forcibly seized or detained

against their will by a person without the authority to do so; the hostage taker(s) causes

any person(s) to receive a threat of death or bodily harm or induce any person or

organization to commit an act or mission for releasing the hostage(s); or any person(s)

have confined or barricaded themselves in a room and threaten violence and/or have

weapons.

Code 111 is announced when there is a request for immediate short-term assistance for

a critical situation anywhere in the Hospital and additional staff is required for a short

period of time. Code 111 can be activated independently or in conjunction with other

Emergency Codes (for example, a Code 111 may be needed to assist in a Code Green).


Code Red policy contains procedures used to respond to a fire emergency, while

ensuring everyone’s safety and minimizing the potential for injury or damage.

What to do when there is fire in the area:

R Remove anyone in the room. Call out “Code Red, location” and close the door.

E Ensure All doors are closed, activate Evacucheck markers.

A Activate the fire alarm (pull station).

C Call (Markham – dial 555; Uxbridge – dial 58 & announce). Give exact location and

nature of fire.

T Try to extinguish the fire if safe to do so and you are trained.

Refer to the fire safety plan for information specific to your department

Workplace Hazardous Materials Information System (WHMIS) In the early 1980s, there were approximately 500,000 work related injuries in Canada per

year. The numbers of injuries were on the rise as more and more injuries and deaths

were occurring every year. As a result, WHMIS was legislated by the federal and

provincial governments in October 1988 to help reduce the number of incidents

throughout Canada.

As a health care worker, staff may be exposed to potentially hazardous agents. As such,

you need to:

Understand what WHMIS is and how it affects you

Able identify hazardous products at the Hospital

Understand the information found on WHMIS labels

Understand where to find a Material Safety Data Sheets (MSDS) and Safety Data

Sheets (SDS) and how to read them

WHMIS 1988 to WHMIS 2015

WHMIS has aligned with the worldwide hazard communication system known as the

Globally Harmonized System (GHS). Updates to implement GHS will be referred to as

WHMIS 2015.


Pictograms are graphic images that immediately show a hazardous product and what

type of hazard is present. Most pictograms have a distinctive red diamond border,

instead of the black bordered circle. Pictograms will be on the product supplier labels of

the hazardous products. They will also be on the safety data sheets (SDS), symbols or

words that describe the symbol.

The components consist of:

Labels—identifies the type of hazard, alerts the dangers, and provides safety

precautions

Safety Data Sheets—provides detailed information on hazardous products

Worker Education—an education program that keeps employees informed on how to

work safely with hazardous products

The responsibilities vary depending on the relevant party:

For Suppliers—they must classify products, provide labels, and SDS

For Employers—they must have a WHMIS program, Chemical inventory, SDS

availability, labels, and training

For Staff—they must participate in training, apply the knowledge, and report

deficiencies


Supplier Label – WHMIS 2015

1) Product identification

2) Pictogram

3) Signal word – “Danger” or Warning”

4) Hazard statements

5) Precautionary statements

General

Prevention

Response (e.g. first aid)

Storage

Disposal

6) Supplier identification

Labels

Each hazard class and category is assigned a “hazard statement”. It is brief and

standardized sentences that describe the exact hazard of the product.

Hazard statements, refer to note 4 in the above label, are brief, standardized sentences

that describes the exact hazard of the product. Each hazard class and category has an

assigned “hazard statement”. It also helps describe the degree of the hazard. For

example, “May cause cancer” is more hazardous than “Suspected of causing cancer”.

Product label and Section 2 of Hazards Identification of the SDS still require the signal

word, hazard statement(s), and other required label elements

Safety Data Sheets

Safety Data Sheets (SDS) is required for every hazardous product and is required to be

updated within 90 days of the supplier being aware of any new information. SDS

informs users of: Hazards of the product, How to use the product safely, What to

Workplace Labels

Required when:

o A hazardous product is produced at the workplace and

used in that workplace,

o A hazardous product is decanted (e.g. transferred) into

another container, or

o A supplier label becomes lost or illegible (unreadable).


expect if the recommendations are not followed, How to recognize symptoms of

exposure, What to do if emergencies occur

Sections detailed in Safety Data Sheets:

Pictograms

1. Identification

2. Hazard Identification

3. Composition/Information on

Ingredients

4. First aid measures

5. Firefighting measures

6. Accidental release measures

7. Handling and storage

8. Exposure controls/Personal

protection

9. Physical and chemical properties

10. Stability and reactivity

11. Toxicological information

12. Ecological information*

13. Disposal considerations*

14. Transportation information*

15. Regulatory information*

16. Other information

*Sections 12- 15 are optional

information. However, headings

must be present

Pictograms depict a hazardous symbol and are surrounded with a red border. Not all hazardous products are under a hazardous class or category requiring a pictogram.

Same pictogram can represent more than one hazard class. For example: Health Hazard

Carcinogenicity

Germ cell mutagenicity

Respiratory sensitizer

Reproductive toxicity

Specific target organ toxicity

Specific target organ toxicity

Aspiration hazard


Hazard Classes

Each hazard class contains at least one category or “type”, e.g. 1, 2, etc. and sometimes

with a subcategory, e.g. 1A, 1B, etc. Category informs how hazardous the product is, i.e.

severity.

For example: Category 1 is greatest level of hazard (within class), Category 1A (within

class) is greater hazard than 1B.

Exceptions: Compressed gas goes by physical state (e.g. liquefied gas, refrigerated

liquefied gas, dissolved gas). Reproductive Toxicity has a separate category (e.g. “Effects

on or via lactation”) in addition to Categories 1 and 2 relating to effects on fertility

and/or unborn child.

Training

Under legislation, employer’s responsibility is to provide information and training that is

general and “site specific”; all staff must be trained, and have the responsibility to

participate in ongoing education. Annual WHMIS training is available on LiME.

Site Specific Training consists of storage and disposal procedures (e.g. where to keep

them, whether to store with other chemicals, how to dispose etc.) and accidental release

into environment (e.g. what to do if spilled in sink).

Lastly, training must include controlled products covered by other regulations (e.g. TDG),

if applicable to your job.

Summary

GHS does not replace WHMIS, rather it incorporates new elements. It was designed to

enhance worker safety.

All staff is required to continue:

1. Reading labels and pay attention to precautionary phrases and symbols

2. Following safe handling procedures

3. Be comfortable with accessing and interpreting information from MSD/SDS

4. Do annual refresher training

One hazard class can have more than one pictogram. For example: Acute Toxicity

Skull and Crossbones—acute toxicity or fatal if exposed

Exclamation mark—less serious consequences (i.e. respiratory sensitizer)


Radiation Safety

Recognition of Radiation Warning Symbols

Pregnant Workers

Education and Information about Radiation

There are several modules on LiME, the Hospital e-

learning system, that provide critical information for

those wanting to learn more about radiation and MRI safety, as well as for those who

work with or around X-ray equipment (including mobile X-ray). All staff who will be

working with or around radiation sources, MRI or X-ray equipment must be qualified

and trained. The radiation safety officer (RSO) should be contacted for any concerns or

questions about appropriate levels of training and awareness for a worker’s role or their

duties.

Contact for Information on Radiation

If you have any concerns or further questions about radiation within the Hospital, email

to [email protected] and the radiation safety officer will contact you.

The “Pink Dot” can also be interpreted as a flag for

pregnant workers to be aware when a patient is radioactive.

A patient is radioactive due to a recent nuclear medicine

examination. Having this knowledge gives pregnant

workers an opportunity to employ radiation safety measures

which use the ALARA (As Low As Reasonably Achievable)

principles to reduce radiation.


Quality, Patient Safety, Patient Relations & Experience and IPAC

Introduction

MSH is committed to providing safe, high-quality patient-centred care. Our unwavering focus on improved quality and safety has been driven by a variety of reasons. These include and are not limited to our desire to be known as the hospital of choice; a hospital that provides patients with an extraordinary experience. Earlier this year, we launched a strategic planning process which will define our future direction, including our quality and safety agenda. In the interim, our 2018/19 Strategy Map aligns seamlessly with our commitment to providing the higest quality care for our patients. Our refreshed quality improvement agenda is intended to reflect the idea that every person in the organization has the responsibility for – and contributes to – the quality of care and services. In developing this plan we reflected on input from stakeholders, observations of our processes, performance data and informed evidence. At the centre of our plan are our patients – listening to them, involving them and responding to their needs. As such, putting patients at the “heart of everything we do” continues to be a priority for MSH. We aspire to embed quality and safety throughout the orgazination, in all we do. This

plan includes the quality priorities we have committed to in our 2018/19 Quality

Improvement Plan (QIP) and provides an opportunity for us to clearly set our priorites

for quality improvement over the next two years. This plan is a “living” document that will

continue to evolve as we remain focused on the more challenging goals to ensure we

deliver the best, highest quality and safest care possible.

Our foundation

The foundation reflects a clear understanding of how quality of care will be defined,

measured, and continously improved in pursuit of our goal to be trusted providers of

care and be the hospital of choice for extraordinary quality care and experiences.

Quality definition:

MSH has adopted Health Quality Ontario’s definition of quality

care. As such, quality care is care that is safe, effective, patient-

centred, timely, efficient and equitable.

This definition reflects the shift from viewing quality of care as the responsibility of

individual providers and institutions to a system responsibility.


Quality and safety framework

Our quality and safety framework considers MSH’s organizational strategic directions

along with its core values. The model is shaped by Jurant’s Trilogy, an improvement

cycle that reduces poor quality by planning quality into the process. The quality and

safety framework focuses our quality and safety efforts at all levels and promotes

monitoring and improvement of our services over time. As a continuous improvement

model the quality framework, and quality and safety plan will assist us to measure,

monitor and refine our efforts as we pursue the highest levels of quality care and patient

safety.


Strategic goals

Our goals for quality and safety reflect our quality improvement plan initiatives,

Accreditation Canada’s required organizational practices, the key elements of safety as

defined by the Canadian Patient Safety Institute and the Excellent Care for All Act

(ECFAA).

Patient & Family Experience

1. Extraordinary experience

Goal: Become a patient-led organization

By doing so, we will provide the best patient care experiences while

treating our patients with compassion and respect each and every day

Safety

2. Safety first

Goal: Zero serious safety events

By doing so, we will establish practices and processes to embed safety in everything we do and every decision we make

Quality

3. Continuous improvement

Goal: Foster an environment of continuous learning

By doing so, we will build on existing strengths, reduce inefficiencies and improve quality of services


Infection Prevention and Control (IPAC) Program

Infection Prevention and Control (IPAC) refers to evidence based practices and

procedures that when applied consistently and efficiently can prevent or reduce the risk

of transmission of microorganisms to health care providers, patients, and visitors

(PIDAC 2012). The mission of IPAC at Markham Stouffville Hospital (MSH) is to reduce

the risk of healthcare associated infections (HAIs) amongst its patient population.

Amongst a number of different strategies applied to attain this mission there are some

key practices to preventing and reducing the spread of infections. One key practice is

the use of routine practices (RP) for every patient every time. Routine practices

include:

Hand hygiene (HH) must be done using facility provided and approved alcohol based hand rub (ABHR) or soap and warm running water. HH is done to remove visible soil and transient microorganisms and includes surgical hand antisepsis. Gloves are not a substitute for hand hygiene. HH is an essential practice at MSH and it is imperative that it is done efficiently all the time. You will find information on HH program as you proceed further in your reading.

Personal Protective Equipment (PPE) must be worn when the risk assessment

deems necessary. Based on your encounter with the patient, you may be required to don on a mask and eye protection or face shield, gown, gloves and/or a combination of the different PPE depending on the type of encounter you anticipate. Examples (not limited to): Mask and Eye Protection or Face shield must be used during

procedures/encounters where there is anticipated risk to your mucous membranes (eyes, nose and mouth) either through splashing or spraying of blood, body fluids, secretions and excretions.

Gowns (long sleeved) should be worn where contamination of the skin or clothing is anticipated

Gloves must be worn when there is risk of contact with blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated surfaces and objects.

Environment and Equipment that is being used by more than one patient must

be cleaned between patients using the site approved cleaning agents/products. MSH has approved cleaners and disinfecting agents. List of cleaners and disinfecting agents is available through housekeeping. Depending on your area of work remember if you have shared equipment between patients it will need to be cleaned between each patient before use and when soiled.


Linen and waste should be handled carefully. Soiled articles should be handled such that personal and patient contamination is avoided.

Sharps Injury Prevention is critical to staff and patient safety and as an

employee of MSH you must ensure that you are aware of the Sharps use and disposal procedure/protocol.

Patient Placement must be considered when accommodating patients who may

be at risk of contaminating the environment or requiring precautions in addition to RP.

Hand Hygiene

HH is the single most effective measure to reduce HAIs. MSH annually sets a

compliance target and our current target for 2018 is 80%. Each area/unit is assessed for

HH compliance and results are captured through an auditing tool. The auditing tool

captures information based on the practices as per the four moments of HH.

The process is as follows:

Auditors Our in house trained HH champions are the observers They observe interactions between staff and patients and moments of HH Based on what they observe they electronically document the moments Provide on the spot feedback, they may provide information on areas where you

have missed and opportunity and improvements

RP must be done for every patient every time

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IPAC Our onsite Infection Control Practitioners (ICPs) review the data monthly and

provide updates to unit managers and staff Areas of improvements and further developments are discussed within the team

References Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Best Practices for Hand Hygiene in All Health Care Settings. 4th ed. Toronto, ON: Queen’s Printer for Ontario; January 2014.

DON’T MISS AN OPPORTUNTITY to DO HAND HYGIENE

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“Expect Respect” – Violence and Harassment Prevention Education

Program Markham Stouffville Hospital is committed to promoting, providing, and maintaining a

work environment where respect and dignity are demonstrated at all times.

We foster behaviours that contribute to minimizing the risk of violence and harassment

in the workplace. The Hospital has a zero tolerance policy of violence and harassment in

the workplace environment.

The Hospital’s Violence and Harassment Prevention Education program, entitled “Expect

Respect”, applies to all Markham Stouffville and Uxbridge employees,

medical/dental/midwifery staff, volunteers, students, patients and their family members,

visitors, suppliers, vendors, contractors, consultants and any person working on behalf

of the Hospital.

New employees will receive introductory “Expect Respect” classroom or e-learning

education. Annually, all staff is also required to take “Expect Respect” e-learning

refresher education available on LiME.

All workplace parties have roles and responsibilities in the Hospital’s Violence and

Harassment Prevention Education program. Workplace parties include:

o Employer and Employee

o Director and Manager

o Medical, Dental, and Midwifery Staff

o Volunteers and Students

o Human Resources

o Joint Occupational Health & Safety Committee

o Occupational Health and Safety Department

The major roles and responsibilities for all staff are to:

o Uphold the Expect Respect program

o Participate in recognizing, assessing and controlling workplace hazards

o Comply with the Hospital’s Violence and Harassment Prevention policy and

procedures

o Report all incidents or injuries of violence/harassment or threats to your

manager/director

o Sign a Statement of Commitment to the Prevention of Violence and Harassment in

the workplace

For Director/Managers, their roles and responsibilities are to:

o Ensure employees complete the initial and annual refresher education


o Enforce policy and procedures and monitor compliance

o Complete a Workplace Violence Risk Assessment form and action plan

o Identify/alert employees of violent individuals or hazardous situations and take

preventative measures

o Investigate all violence/harassment reports

There are resources available to you as an employee of Markham Stouffville Hospital.

o Speak confidentially with your Manager or Director about the situation

o Contact Occupational Health and Safety, Human Resources or Spiritual and Religious

Care departments

o Access the MSH Employee Assistance Program by phone (866-641-3847) or online

(www.guidanceresources.com, password is EAP4MSH)

o Register for our internal Crisis Prevention and Intervention Training (CPIT)

http://www.guidanceresources.com/


Other Definitions of Violence includes:

o Bullying – repeated, persistent, continuous negative behaviour against a worker

where there is an imbalance of power

o Assault – the use or threatened use of force where the victim believes the abuser

could carry out the threat. Assault is a criminal offence

o Harassment – engaging in a course of vexatious comments or conduct against a

worker that is known or ought reasonably known to be unwelcome

o Sexual Harassment – engaging in a course of vexatious comment or conduct against

a worker in a workplace because of sex, sexual orientation, gender identity or gender

expression, where the course of comment or conduct is known or ought reasonably

to be known to be unwelcome

o Domestic Violence – any use of physical or sexual force, actual or threatened in an

intimate partner relationship. It may include a single act or pattern of violent acts

forming a pattern of abuse


If there is immediate danger:

Use personal alarm system if provided; call for help; call Code White; call the police

Below is a list of policies and procedures relating violence prevention and emergency

response measures. They can be accessed on the Hospital’s intranet.

To report an issue, staff is required to log onto IReport link on the Hospital’s intranet.

Violence and Harassment Related Policies and Procedures

030.901.080

Terms of Reference – Violence Prevention

Committee

160.901.040

Professional Staff Conduct Complaints

080.901.130

Workplace Violence and Harassment

Prevention

530.914.914.005

Abuse of Patients by Staff or Volunteers

030.911.240

Code of Beahviour – Respect in the

Workplace

530.914.101.005

Domestic Violence Screening Guideline

XXX.XXX.XXX

Alert for Behavoural Care


Privacy, Confidentiality and Personal Health Information Personal Health Information Protection Act

The Ontario government enacted the Personal Health Information Protection Act (PHIPA)

(Ontario) to establish the rules for the collection, use and disclosure of personal health

information. PHIPA is designed to give individuals greater control over how their

personal health information is collected, used or disclosed. At the same time, the PHIPA

provides health-care professionals with a flexible framework to access and use health

information as necessary for the provision of care.

Personal Health Information (PHI) is practically any information related to the health

or health care of an identifiable person. It can be as simple as a phone number or a

postal code, when collected in a health care context. It is everywhere around us—in

papers, conversations, computers, etc.—so that no matter what our job is, we all need to

help protect it. As an employee working at Markham Stouffville Hospital, you are considered an ‘agent’

under PHIPA. As an agent of the hospital, you are expected to adhere to the hospital’s

privacy and security policies to protect the privacy of our patients.

Protecting privacy is an integral part of high-quality care, honouring the trust patients

put in us, and treating patients with dignity and compassion. It promotes patient and

staff satisfaction and ensures complete and accurate clinical information. In addition, it is

required and expected by law, professional standards, hospital policies, emerging

technologies, and increasingly, the public.

Keep in mind that the consequences of not protecting patients’ privacy can be

detrimental as you and the hospital are exposed to the penalties at law. Individuals

failing to adhere to PHIPA can be fined up to $100,000. The institution can be fined up

to $500,000 for failing to comply with the legal obligations under the Act.

Patient’s Rights

Patients can expect to be informed about how their personal health information will be

collected, used and disclosed by MSH. Patients can also expect administrative, technical

and physical safeguards relating to their PHI to be in place.

PHIPA gives individuals the right to:

Understand the purposes for the collection, use and disclosure of PHI

Refuse to give consent to the collection, use or disclosure of PHI, except in

circumstances specified in PHIPA

Withdraw consent to the collection, use or disclosure of PHI by providing notice to

the hospital


Request access to one’s own personal health information

Request corrections to be made to one’s own patient record

Complain to the Information and Privacy Commissioner (IPC) of Ontario

How can you protect patient privacy?

Never access records for individuals to whom you have no duty to care. Do not

access your own records or those of your family. Before looking at patient

information, ask yourself: “Do I need to know this to do my job?” and if not,

don’t access the record.

Do not disclose, release, copy or print PHI without the proper authorization.

Patients requesting access to their personal health information should be

directed to Health Records.

Only access and use the minimum necessary amount of PHI in order to perform

your job or duties.

Do not leave records of PHI unattended or unsecure.

Always remember to log-off your workstation. Sign off the application after you

are finished or whenever you walk away from the work station.

Passwords selected must be strong passwords that are difficult to guess. Keep

your passwords confidential.

Keep digital PHI only in the secure hospital data centre, or on an encrypted

device approved by IT.

Unless an email is from a trusted source, never click on an attachment or link in

the email, and never respond with confidential information such as your

password.

Confidential health information about patients should NEVER be posted on

social media or networking sites such as Facebook, Instagram, Twitter (etc.) for

personal purposes.

Use of cell phone cameras or other personal recording devices by staff to record

patients or their family members is not permitted. Patient consent must be

obtained prior to recording patients for marketing, education and/or research

purposes.

If you observe or suspect that the privacy and confidentiality of patient

information has been violated or compromised, you must immediately report it

to your supervisor and the Manager of Access, Privacy and Release of

information by phone at (905) 472-7373 ext. 6004 or by email at

[email protected]

Remember it is everyone’s responsibility to protect the privacy and

confidentiality of patient information.

mailto:[email protected]


Additional Resources

This summary provides a basic overview of your privacy obligations under the Personal

Health Information Protection Act (PHIPA). Information handling policies and guidelines

are available on the Access and Privacy page on the hospital’s intranet. Educational

resources and tips are also available on the Information and Privacy Commissioner’s

(Ontario) website at www.ipc.on.ca

Should you have further questions or concerns, please contact:

Manager of Access, Privacy and Release of Information

Office of Access and Privacy

Telephone: ext. 6004

Email: [email protected]



Ethics

At Markham Stouffville Hospital everyone, from those who give care to those who

support those in giving care have a role to play in the ethical provision of healthcare.

Need support? Contact the ethicist: [email protected] , or see the Ethics Department

page on the intranet for more information on the Integrated Ethics Framework!

Ethics is about:

Deciding what we should do – what decisions are morally right or acceptable

Explaining why we should do it – justifying our decision using language of values and

principles

Describing how we should do it – outlining an appropriate process for enacting the

decision

Having a plan to assess and evaluate how the decision is impacting the situation

Providing opportunities to re-visit decisions when new information becomes available

MSH is a member of the

Health Ethics Alliance whose

strategic goals are to enhance

patient centred care, build

ethics capacity, facilitate

preventative ethics, innovate

delivery of ethics services and

influence the changing

healthcare environment.

Organizational Ethical Issues:

The Accountability for Reasonableness (A4R)

Framework Tool Organizational ethical decisions

are generally those that involve and

impact groups of

patients/clients/residents or staff

members, units, systems, or the

organization as a whole and centre

on the values of the organization

(e.g., which program should receive

the gifted funds?). Some ethical

decisions may be

predominantly clinical in nature;

others will be largely organizationally

focused.



Clinical Ethical Issues: The IDEA Ethics Framework Tool

Clinical ethical issues are typically those that involve and impact specific individuals or

staff members and focus on individual values (e.g., Should Mr. B have a feeding tube

inserted?).

The IDEA framework tool is designed to assist in the resolution of clinical ethical issues,

and is comprised of four steps for ethical decision making. The first letter of each step in

this framework forms the acronym ‘IDEA.’ MSH Mission, Vison and Values guide and

influence how the framework is used.

MISSION: Excellence...Your Expectation, Our Inspiration

VISION: Progressive Care for the Community

OUR VALUES

Respect: Be Respectful – Holds the individuality of others in high regard, embracing diversity

and maintains the dignity of others, especially when no one is looking.

Compassion: Be Kind – Empowers others through explicit expressions of empathy, sensitivity

and understanding.

Trust: Be truthful – Unshakable dependability, reliability, honest and truthfulness.

Courage: Be Strong – Displays commitment and leads others in overcoming obstacles and

barriers, takes unpopular stance when necessary and faces unexpected hardships head on.

Commitment: Be accountable – Engage with devotion and resilience

I D E A IDENTIFY the facts

1. Describe the situation

2. What are the Clinical/Medical/Organizational facts?

3. What do people prefer?

4. What evidence is there?

5. What other influences are there?

Ask: What are the ethical issues?

DETERMINE- the

relevant ethical

principles

1. Who are all the

Stakeholders?

2. What ethical principles should be considered?

E.g. Respect for Persons,

Do the most good, Do the

least harm, Justice.

Ask: Have other

viewpoints been

considered? Have any

been missed?

EXPLORE - the options

1. What are the options?

2. Consider the strength

and weakness of

each.

3. Consider laws and

policies that might

apply.

4. Does the chosen

option support our

Mission, Vision and

Values?

Ask: What option can be

best defended ethically?

ACT

1. Decide, develop and

carry out plan.

2. Evaluate your decision

Remember to document

your plan and the

outcome.

Ask: Are we (am I)

comfortable with this

decision?

http://sunnynet.ca/Default.aspx?cid=100495&lang=1


Accessibility for Ontarians with Disabilities

Markham Stouffville Hospital supports the rights of all persons with disabilities to safe

and equal access to the facilities, services and programs that the Hospital has to offer.

This is in accordance with the Ontarians with Disabilities Act, 2001 and the Accessibility

for Ontarians with Disabilities Act (AODA), 2005.

AODA was passed by the government in 2005 to make Ontario accessible for people

with disabilities by 2025.

Under the AODA, accessibility standards have been created for organizations to identify,

remove and prevent barriers to enable people with disabilities

1. Accessibility Standard for Customer Service- This standard became law in 2008. It is about ways to deliver accessible customer service to persons with disabilities.

2. Integrated Accessibility Standards Regulation (IASR)- This standard became

law in 2011 and includes four standards in the areas of Information and

Communications, Employment, Transportation, and the Built Environment.

3. Ontario Human Rights Code- This standard explains how the Human Rights

Code supports persons with disabilities.

New staff members are required to successfully complete and pass each of the three (3)

e-modules within three (3) months of hire. In addition, all staff must complete the

Customer Service e-module annually as a refresher. The e-modules can be found in

LiME.

Persons with disabilities, who visit, work in or use the Hospital facilities, services and

properties will have access to safe and barrier-free environments, programs and

services. For more information about this policy, click on Policy tab on the Hospital’s

intranet and refer to the policy entitled Accessibility.

Conflict of Interest Policy

A conflict of interest (COI) in the workplace is defined as a situation in which an

individual has the opportunity or ability to use their position at the Hospital or on the

Board Committee to influence, directly or indirectly, a decision or action which could

result in a personal gain or an advantage, gain, or benefit for any business or

corporation, controlled in whole or in part by the individual or their immediate family.

In the Hospital’s Conflict of Interest Policy, the term MSH Agents refers to:

o Staffs, medical/dentistry/midwifery staff

o Students, researchers, residents

o Volunteers, Board Committee members

o Vendors and contractors


Examples of conflict of interest are as follows:

o Involvement directly/indirectly in a business transaction or private arrangement that

results in personal/immediate family/close friend gain because of one’s position with

MSH

o Accepting outside employment or other unauthorized activities which deprive MSH

of services expected from the individual, or will involve unauthorized use of MSH

Hospital time, equipment, staff, facilities and/or resources

o Using Hospital property without approval

o Disclosing Hospital property information to unauthorized persons

o Using information related to MSH for personal gain or to the advantage of any

business entity with which the individual holds a position or has a vested interest

(personal or financial)

o Accepting gifts greater than nominal value of $50.00 from a patient, client, family

member or supplier with whom the corporation may transact business. If the patient,

client, family member, supplier insists on presenting the gift, the matter should be

disclosed to the agent’s supervisor

o Soliciting gifts and sponsorships unless they are in support of learning events,

fundraising activities, or to support events that would benefit Hospital staff as a

whole.

As MSH Agents, we have a duty and responsibility to act for or on behalf of the

hospital’s best interests. This means that we will not engage in any other work, activity,

relationship and/or business transaction which could be perceived to be in conflict with

the best interest of the Hospital without prior consultation with your

manager/director/associate vice president/vice president/chief.


This also means that we will:

o Identify and seek to avoid actual, potential or perceived conflicts of interest

o Fully and accurately disclose, in writing, any relationships, affiliations, financial or

personal interests that may create a conflict of interest (actual or perceived)

o If a conflict of interest is unavoidable:

- identify the problem

- discuss it with your immediate supervisor, and

- manage it in a transparent manner

If conflict of interest arises, Human Resources and Manager will refer issue(s) to a

member of Senior Leadership Team. The manager/director must also ensure that annual

training is completed by staff.

Human Resources will collaborate with Manager and/or one level above to determine

action plan if COI exists and to create written decision with steps to mitigate (when

necessary) for staff member.

MSH Agents shall read the Conflict of Interest Policy and participate in the annual

training on LiME.

For more information about this policy, click on Policy tab on the Hospital’s intranet and

refer to the policy entitled Conflict of Interest.

Whistleblower Policy Markham Stouffville Hospital has a Whistleblower policy intended to encourage staffs

and others to make good faith reports of suspected fraud, corruption or other improper

activity within the Hospital to appropriate Hospital officials, and to support the process

that will be followed in evaluating and investigating such reports.

For more information about this policy, click on the Policy tab on the Hospital intranet

and refer to the policy entitled Whistleblower policy.


LiME eLearning Mandatory Courses All staff, students and physicians are to complete the following e-learning modules

annually. Please note some courses are for Clinical (bedside); Non-clinical

(administrative); or All

Occupational Health

and Safety Handbook

An annual review of Markham Stouffville Hospital’s

Occupational Health and Safety Policies.

All

Workplace Hazardous

Materials Information

System (WHMIS)

An annual review of WHMIS and applications to the

workplace. Department specific WHMIS will be

provided by your unit during orientation.

All

Expect Respect A review of core concepts relating to the Hospital’s

workplace violence prevention.

All

Musculoskeletal

Disorder (MSD)

Prevention:

Safe Patient Handling

For CLINICAL Staff: An annual review of prevention

in musculoskeletal disorder (MSD) for patient care

staff and any staff required to perform patient

transfers.

For NON-CLINICAL Staff: An annual review of

prevention in musculoskeletal disorder ((MSD) for all

other staff (i.e. non-patient care).

Clinical

Non-

Clinical

Safety Engineered

Medical Sharps (SEMS)

An annual review of the type of SEMS used, how to

use SEMS safely and report a sharps incident.

Clinical

Information Security

An annual review of standard security practices and

responsibilities as it relates to protecting information

technology systems and hospital data.

All

Privacy and Security

Education

An annual review of the privacy and security policies

by all staff, physicians, and students.

For new hires, the review must be completed within

two (2) weeks of hire.

All

Conflict of Interest Annual refresher of the organization’s conflict of

interest policy, and your responsibilities under it

All

AODA Annual refresher All

Hand Hygiene Annual refresher All


LiME Access On Site- intranet.msh.ca

Employee Orientation Handbook

Employee Orientation Handbook

Section 1: Training Materials

STEP 1: Find LIME From MSH intranet, find

“Education and Training“

Click on LiME hyperlink

Step 2: Login Use your MSH network

username and password,

click OK.

Course Access

1. You are on the home

page for LiME.

2. Click on

Course Registration.

Step 3: Review your LIME homepage All courses you are registered to take/ have taken or need to take are listed on the tabs. To register for a new course, click on Course Registration (2)


Search for a Course 1. Type a course word e.g. privacy. 2. Click on Search. Refer to the Staff Development Calendar for a list of open courses, contact your PPL or manager for a list of department specific courses to complete. Review the mandatory course list as stated above.

Register for an E-Module or Classroom Course 1. Find the course that you are

searching for. 2. Click on Register (on the far right

in the e-module course listing). For classroom course, follow the prompts to complete the registration and note the date of the course.

Take the Course 1. Click on Learning Home. The

course will show up.

2. Click on a hyperlinked course

and the course will

automatically begin.


LiME Access Off Site- www.msh.on.ca

Step 1: Find LIME 1. Visit www.msh.on.ca. 2. Click tab—“Staff and

Physician” portal.

Step 2: Route into the intranet 1. Click Learn.MSH.ca.

2. Follow instructions to access

the intranet and follow the

intranet path as previously

outlined.

Step 3: Login 1. Type in your MSH network

username and password.

2. Click OK.

http://www.msh.on.ca/


OTHER INFORMATION

Section 2:

Section 2: OTHER INFORMATION


Employment Standards in Ontario The ministry of Labour enforces and promotes awareness of employment standards,

such as minimum wage, work hours, public holidays and other standards. The

Employment Standards Act is a law in Ontario. Visit www.labour.gov.on.ca for more

information.

http://www.labour.gov.on.ca/


Parking and Security On the first day of Hospital Orientation, parking is free in the North Visitors Lot # 1

directly in front of the Hospital main entrance (facing Church Street). Parking on day 1 is

free; take a parking ticket upon entering the lot. When leaving for the day, contact the

parking office through the communication button at the parking exit and inform them

that you are a new employee. They will open the parking bar for you to leave.

During the orientation day, your photo will be taken for ID badge production. If you

choose to park at the Hospital, this information will be added to your ID badge. (see

below for sign-up). At the end of the day, Security will bring new staff ID badges to the

orientation room and distribute them. You will then be able to access the parking lot

automatically with your ID badge when returning to the Hospital.


Signing-up for Parking

New employees Markham Site: Complete an Authorization for Payroll Deduction of

Parking Fees form provided to you during the orientation. Submit the completed form

to the Facilitator.

New employees Uxbridge Site: Contact Val Stockhaus-Shank inside the Administration

office, extension 5281 and she will assist you with obtaining a parking tag for your car.

ID Badges

ID badges are individually programmed for authorized access to work areas, assigned

parking lot, and Hospital staff entrances. They are programmed to your discipline or as

instructed by your manager.

Misplaced ID badges must be reported immediately to Security so access can be

reviewed. Replacement badges are subject to a $20 fee. If you require keys for your

office, request them through your manager.

Safety Devices

1. Personal Safety device (PSD) for Code White

Specific areas may have this availability - see your manager for instructions

2. Parking Emergency Call Stations at the Pillars

Press the button to connect directly to security’s two-way radio

3. Lockers in the building

If required, combination locks will be provided by the Hospital. Management of

lockers within units/departments will be completed by the department. Lockers on

the first floor of Building A will be assigned by Facilities and Support Services.

Education Funding

As the needs of the health care system change, our full-time & part-time staff must have

opportunities to enhance their knowledge and skills. Markham Stouffville Hospital is

committed to encouraging and supporting the learning needs of our staff by providing

financial support for continuing education in a fiscally responsible manner. All staff will

have equitable access to financial support, to take courses/programs or attend external

conferences/seminars/workshops aligned with our strategic priorities; that are relevant

to the employee’s current role; and/or help to prepare them for a different role at the

Hospital.

MSH supports professional development through in-house programming by

Professional Practice and Organizational Development; lectures from internal/external

subject matter experts, Grand Rounds, Case Presentations, and other methods.


Education is also supported by providing financial support to attend external education

opportunities such as certification for work-related competencies, college/university

courses, seminars, conferences and workshops. Please see our Education Funding

program information on the intranet for policy and process.

Employee Referral Program People are the Hospital’s most valuable asset. As a result, there’s no better way to

recruit talented professionals to work at the Hospital than within our own network of

people. The Hospital offers a referral bonus to current staff referring external applicants

who are successfully hired into designated hard-to-fill permanent positions.

Current hard-to-fill positions, eligible for referral bonus include:

Pharmacy Technicians

Experienced RNs with all required credentials for: Emergency, Operating

Room, Post Anesthetic Care Unit, Critical Care, and Childbirth Centre

Maintenance Mechanics

The referral bonus amounts for hard-to-fill positions are set as follows:

Part-time regular positions = $250

Full-time regular positions = $500

For more information, refer to the Hospital’s intranet, under Departments, Human

Resources, Employee Referral section.

Part-time Employee Benefits Part time and casual staff who are not covered under MSH’s health care plan have the

option to enroll privately through an independent insurance company. Please note the

benefit coverage offered through the Health Care Providers Group Insurance Plan is

purchased directly by the individual and is not part of the Hospital's benefit

program. This Plan is not part of your contract of employment with Markham Stouffville

Hospital, the Hospital is not responsible for this plan in any way.

The Health Care Providers Group Insurance Plan provides private insurance coverage for

Extended Health, Dental, Life Insurance, Long-term Disability, and Accidental Death and

Dismemberment benefits to part-time staff who qualify under their plan.

This plan provides each qualifying part-time with a thirty-one (31) day initial

introduction window to purchase coverage without any medical questions asked of

themselves or their families. A thirty-one (31) day window is also available to new part-


timers and to persons who transfer to regular part-time status and are no longer

entitled to coverage under the plans offered by the Hospital to full-time employees.

For more information or to enroll, visit their website at www.healthcareproviders.ca.

Places to Eat

Tim Hortons Building A, next to the Main Lobby Entrance

Druxy’s / Cafeteria Building A, level 1

Tim Hortons After Hours Building B, level 1, next to Emergency

Presse Café Cornell Community Centre and Library

Waiting Froom Café Medical Office Building, next to Dale’s Pharmacy

Gift Shop

The Cornflower Gift Shop offers a variety of snacks and gifts for purchase. Staff receives

a 10% discount on gift items.

Dale’s Pharmacy Located in the Medical Office Building (MOB) connected to the Hospital, Dale’s can

meet your medication and health-care product needs. Upon showing your staffs ID

badge, you can receive 10 per cent off everything, excluding prescriptions and sale

items. Full-time staff with benefits may have prescriptions filled with Dale’s and have

payment directly made to the insurance provider.

http://www.healthcareproviders.ca/


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