Student Orientation, Attestation, and Release TSSH Mission Statement: Excellence in: Surgical Services, Diagnostic & Interventional Radiology, Pain Management, and Customer Service Policy and Procedure Manuals – Located in each department and under policy shortcut on computers. Please discuss policy and procedures with your Tulsa Spine & Specialty Hospital department contact. Patient Rights – All Tulsa Spine & Specialty Hospital patients have the following rights: Access to considerate and respectful care; To be informed about and participate in care decisions; To participate in ethical questions regarding care; To have security, confidentiality and privacy maintained; To designate a decision maker; The right to all PHI. If an ethical issue is identified, an ethics consultation will be initiated. The Joint Commission – Tulsa Spine & Specialty Hospital is accredited with the Joint Commission Association of Healthcare Organizations. We adhere to all Joint Commission standards and Patient Safety Goals. Refer to your assigned department for how these affect your department. Confidentiality – Tulsa Spine & Specialty Hospital employees and representatives, including students, shall strive to maintain the confidentiality of the patient, as well as any other confidential or proprietary information in accordance with applicable legal and ethical standards. The inappropriate release of confidential information will result in removal of privileges to work or clinical learning at Tulsa Spine & Specialty Hospital. Every student and staff member has an obligation to actively protect and safeguard confidential, sensitive and proprietary information and to prevent the unauthorized disclosure of said information. ID Badges – All Students are to wear their designated identification badges provided by their representative institution. ID badges are to be worn in plain sight at all times while in the hospital. Dress Code – All students must be well groomed and tastefully attired while at Tulsa Spine & Specialty Hospital. Employees are expected to adhere to dress code per their department regulations. Therefore, employees are required to be well groomed and tastefully attired while on duty. (Visible facial piercings, visible tattoos and offensive clothing are strictly prohibited).

After Hours Access – Can be obtained by ringing the bell outside the East entrance door. This button will alert staff that you are requesting entry into the building. Be prepared to identify yourself and state your business. Reporting Structure – Chain of Command – Conflicts with any other Tulsa Spine & Specialty Hospital employee should be addressed by discussing the issue directly with that employee. If the issue is not satisfactorily resolved with this discussion, the matter should be addressed with the employee’s immediate supervisor, your instructor and Department Leader. If the issue remains unresolved, Human Resources should then be contacted for assistance. Infection Control/Hand Washing – Hand washing is the single most effective method in preventing the spread of infection. Care providers must wash their hands before and after patient contact, when hands are obviously soiled, and after contact with bodily fluids. Patient Safety Goal # 7 is concerned with the prevention of Hospital Acquired Infections. This goal focuses on hand washing as a method to reduce the risk of such infections. The CDC guidelines require a minimum 15 seconds of hand washing using soap, water and friction. Singing the song, "Happy Birthday" takes approximately 15 seconds. Singing it to yourself while washing your hands will satisfy the minimum requirement. Reducing the spread of infection requires good personal hygiene habits, and healthy Care Providers. Come to work only if you are well and free of infection. See “Infection Control Review” and “Tuberculosis” handouts. Code Designations – Codes are called by using the overhead paging system. This can be accessed through the telephone system by dialing #9, or by pushing the “Code Blue” button on the phone. Each code should be called overhead three times. For example, “Code Red PACU, Code Red PACU, Code Red PACU”. Code Designations are as follows:

Code Blue – Person in severe crisis Code Red – Fire Code Black – Severe Weather Code Grey – Security Requested Code Adam – Infant/Child Abduction Code Green – Bomb Threat Code Orange – Hazardous Material Release Code Yellow – Disaster Plan Activation Code Active Intruder Lockdown – Armed intruder entering building

Cultural Awareness –Tulsa Spine & Specialty Hospital care for persons from different ethnic and cultural backgrounds is based on respect for human dignity, with sensitivity and appreciation for values, beliefs and practices of others. We foster diversity by valuing individuals, encouraging employees to discuss and resolve conflict, and by acting on input received from employees in regards to job structure, work processes, conditions and benefits. At Tulsa Spine & Specialty Hospital, we believe a diverse workplace benefits employees because people are happier and more productive when they can be themselves. Fire Safety – The first 3 – 5 minutes after fire discovery are critical – “Indecision or inadequate measures during the early crucial moments can cause tragic loss. If a fire occurs, the immediate concerns are: 1. Alert others to the fire 2. Transfer patients to safety 3. Contain the fire 4. Respond to a Fire emergency

a. RACE protocol – Rescue Alarm Confine Extinguish

5. RESCUE: It is every employee's responsibility to take the necessary steps to rescue ANY person from immediate danger.

a. Rescue should be performed immediately upon discovery of the fire, while simultaneously alerting others to the fire.

b. Patients in the room of fire origin should be evacuated immediately c. Turn off any Oxygen being used in the room of fire origin. d. Place a wet towel at the bottom of the door at the room of fire origin. e. All other patients located between the smoke doors where the fire is located should

also be evacuated. f. Check doors with the forearm or back of the hand to see if the door is hot. g. DO NOT open a hot door! h. Take evacuated patients to the Pain Management lobby once an occupied patient

room has been evacuated, mark vacant rooms by placing a pillow on the floor outside the empty room.

6. Alarm: If you see signs of a fire and the fire alarms have not sounded go to nearest manual fire alarm pull and activate it.

7. Notification: When calling 911 caller should give the following information. a. Their name b. Phone number you are calling from c. The exact location d. A description of what is seen and smelled

8. Confine: Controls the spread of the fire.

a. Fire and toxic combustibles must be confined b. Close all doors

i. Prevents smoke from spreading ii. Cut off the supply of oxygen to the fire iii. Saves lives

9. Extinguish: If no immediate danger and confining the fire will not help, extinguishing fire

may be the first priority. Fire extinguishers are located every 100 feet in hallways and near all exits. Most fire extinguishers are located in white metal boxes and some are hanging from the wall.

a. When should you use a fire extinguisher? i. If the fire department has been called. ii. If fire is small and contained. iii. If the fire isn’t higher that your head. iv. If you know your escape route and its clear of smoke. v. If you can fight the fire with your back to the exit and your able to back your

way out of the area.

10. Fire Extinguisher use. a. P – Pull the pin ( you may have to twist to break plastic pin lock) b. A – Aim at the base of the fire. c. S – Squeeze the trigger d. S – Sweep side to side of base

11. Exit signs designate the path to the outside

a. Visualize you exits b. Do not block Auto shutting fire doors. c. Keep exits clear

Receipt

This is to certify that I have reviewed and signed a copy of Agency Orientation and Attestation and have reviewed the orientation components listed below regarding practicing within my scope of practice at Tulsa Spine & Specialty Hospital. All Students must review, print, sign, and deliver to TSSH prior scheduling a rotation or shift the following documents.

1. Student Emergency Contact Information 2. Student Orientation & Attestation 3. Infection Control 4. Tuberculosis 5. Student Orientation Acknowledgement 6. Employee/ Student / Volunteer Confidentiality Statement 7. Code of Conduct 8. Behavior Expectations 9. Receipt and Acknowledgment of Tulsa Spine & Specialty Hospital Joint

Commission Notice 10. Tulsa Spine & Specialty Hospital Employee Disclosure Statement

As students you must sign that you reviewed these clinical presentations on http://www.tulsaspinehospital.com prior to scheduling a shift. Links to these presentations can be found under Education then Students on our website.

1. Scope and Standard of Practice 2. Current National Patient Safety Goals 3. Spine Anatomy and Procedures 4. HIPAA Confidentiality

I agree to comply with said Rules and Regulations here at Tulsa Spine & Specialty Hospital. Date Signature School Printed Name Printed Name

Attestation As a student I believe that I am qualified to perform all patient care procedures for which I have training in and have been verified by my instructor to be competent in. Furthermore, I realize that training of specialty does not necessarily qualify me to perform certain procedures here at TSSH as a student role. By signing this Attestation, I hereby:

Acknowledge that I have received, or been given access to, and read the policy and procedures and any other manuals and policies relevant to a student scope of practice, generally to clinical practice at the hospital facilities, and agree to be bound by the terms thereof in all matters relating to HIPAA, and OSHA. Pledge to maintain an ethical practice, to provide for continuous care for my patients, and to refrain from excepting or delegating the responsibility for any aspect of the care of my patients to an unauthorized provider; Agree to keep Tulsa Spine and Specialty Hospital representatives up to date on any change made or proposed in my eligibility to my practice as a student, and on the status of current or initiation of new negligence or malpractice claims against my license or person. Acknowledge that I, as a student, I have the burden of production of adequate information for a proper evaluation of my academic competence, professional competence, character, ethics and other qualifications for clinical skill between my scope of practice and for resolving any doubts about such qualifications; and Acknowledge that any misstatements in or omissions of my record constitute cause for denial of access to TSSH as a clinical learning site.

All information submitted by me in this, is true and complete to my best knowledge and belief. A copy of this original attestation and authorization constitutes my written authorization and request to release any and all supportive documentation regarding this application. Said copy shall have the same force and effect as the signed original. Date Signature Agency Printed Name Printed Name

Authorization for Release of Information

By agreeing to Tulsa Spine & Specialty Hospital, I hereby:

Authorize TSSH and their representative to consult with instructors and schools associates and others who may have information bearing on my professional competence, character, health status, ethical qualifications, ability to work cooperatively with others, and my qualifications.

Consent to the inspection by TSSH or their representatives of all documents that may be material to an evaluation of my qualifications and competence;

Consent to the release of such information and documents;

Release from liability all representatives of TSSH and its staff for their acts performed and statements made, in substantial good faith and without malice, concerning my professional competence, ethics, character and other qualifications.

A copy of this original authorization constitutes my written authorization and request to release any and all supportive documentation regarding my licensure, certification(s), and competencies and shall have the same force and effect as the signed original.

I hereby confirm that all information submitted by me to my respective agency/employer is true and complete to the best of my knowledge and belief.

Date Signature Agency Printed Name Printed Name

Student Emergency Contact Information

Please read the following statements and enter the information below.

Full Printed Name ______________________________

Date of Birth ______________________________

Drug Allergies ______________________________

Emergency Contact #1 ______________________________

Name and Number ______________________________

Emergency Contact #2 ______________________________

Name and Number ______________________________

____________________________ _________________________

Student Signature Student Printed Name

____________________________ _______________________

Date School Name

Page 1 of 3

Fire Safety Orientation The first 3 – 5 minutes after fire discovery are critical – “Indecision or inadequate measures during the early crucial moments can cause tragic loss.”

If a fire occurs, the immediate concerns are: • Alert others to the fire • Transfer patients to safety • Contain the fire

Respond to a Fire emergency using the RACE protocol – Rescue Alarm Confine Extinguish

RESCUE: It is every employee's responsibility to take the necessary steps to rescue ANY person from immediate danger. Rescue should be performed immediately upon discovery of the fire, while simultaneously alerting others to the fire. Patients in the room of fire origin should be evacuated immediately. Turn off any Oxygen being used in the room of fire origin. Place a wet towel at the bottom of the door at the room of fire origin. All other patients located between the smoke doors where the fire is located

should also be evacuated. Check doors with the forearm or back of the hand to see if the door is hot. DO NOT open a hot door! Take evacuated patients to the Pain Management lobby Once an occupied patient room has been evacuated, mark vacant rooms by

placing a pillow on the floor outside the empty room. ALARM: If you see signs of a fire and the fire alarm has NOT sounded – go to the nearest EXIT and pull the manual Fire Alarm. When calling 9-1-1, callers should give:

• Their name. • The phone number they are calling from. • Their exact location. • A description of what they see and smell.

CONFINE: Fire, smoke, and toxic combustion must be confined. In the event of fire, close all doors. Closing a door can: • Prevent smoke from spreading.

Page 2 of 3 • Cut off the supply of Oxygen to the fire. • Slow the spread of the fire. • Save lives. EXTINGUISH: If no one is in immediate danger, and confining the fire will not help, extinguishing the fire may be the first priority. Fire extinguishers are located every 100 feet in the hallways, and are near every EXIT around the hospital. Most extinguishers are located in white metal boxes mounted on the wall. A few just hang on the wall (kitchen, power plant, main electrical room, pharmacy). To open – pull the cover and lift the extinguisher out of the box.

When should you use a Fire Extinguisher? • If the Fire Department has been called. • If the Fire is small and contained. • If the Fire is not higher than your head. • If you know your escape route and it is clear of smoke. • If you can fight the fire with your back to the EXIT and back your way out

of the area. • Do not enter a room if the fire is too large.

How do you use a Fire Extinguisher? P A S S PULL the pin – (you may have to twist it to break the tie) AIM low – (at the base of the fire) SQUEEZE the lever SWEEP from side to side

EXIT signs designate the path to the outside – Fire Exit paths must be kept clear. Call the On-Duty Engineer Immediately @: 1405, 1410, or 672-9732

Remember: RRAACCEE,, PASS, 99--11--11

________________________________ Employee Signature Name / Date

________________________________ Student Name Printed

________________________________ School Name

Page 3 of 3

This verifies that above signed has successfully reviewed this material and agrees to the standards of Tulsa Spine and Specialty Hospital.

CDC 57.203

Influenza Vaccine Attestation

Yes No I have written proof that I have received the influenza vaccination. Please attach copy of written proof

Y N I have a medical contraindication to the influenza vaccine

Y N I do NOT have a medical contraindication to the vaccine, but have declined to receive it

Y N

You should answer “yes” to one of these questions

__________________________________________ Name - PLEASE PRINT

__________________________________________ Name - Signature

__________________________ Date

CDC 57.203 Denominator Notes 1. The denominator includes HCP who have worked at the facility for at least 1 working day between October 1 and March 31 during the reporting period, regardless of clinical responsibility or patient contact. This includes HCP who joined after October 1 or left before March 31, or who were on extended leave during part of the reporting period. Working for any number of hours a day counts as one working day. 2. Both full-time and part-time personnel should be included. HCP should be counted as individuals rather than full-time equivalents. If a healthcare worker (HCW) works in two or more facilities, each facility should include the HCW in their denominator. 3. Licensed practitioners who receive a direct paycheck from the reporting facility, or who are owners of the reporting facility, should be counted as employees. 4. The denominator categories are mutually exclusive. The numerator data are to be reported separately for each of the denominator categories.

As an employee of Tulsa Spine & Specialty Hospital, the following behaviors are expected of all employees.

Failure to conform to the following behavior guidelines could lead to disciplinary action, up to and including

termination.

Behavior Expectation 1. Practices Professionalism Maintains positive, calm demeanor in all situations.

Takes responsibility for own actions.

Demonstrates personal self-control.

Solves problems independently.

Smiles / projects a positive attitude.

Offers and accepts constructive criticism.

Works effectively under stressful situations.

Speaks positively about the hospital community and staff.

Portrays friendly, caring, competent, confident attitude.

Addresses concerns / complaints immediately, if able, then

per appropriate chain of command.

Utilizes therapeutic touch appropriately.

Adheres to Tulsa Spine & Specialty Hospital dress code.

2. Satisfies Patients / Customers Sits with patient for at least 5 minutes during shift to assess

patient’s satisfaction needs.

Speaks courteously and respectfully to all customers.

Answers phone promptly, identifies self and department.

Offers assistance without being prompted.

Assesses for patient’s expectations.

Utilizes methods / interventions designed to exceed patient

expectations.

Actively contributes to clean and quiet environment.

Demonstrates positive tone of voice and body language.

Participates in maintaining appearance of facility.

Responds to customer requests / call lights and follows up

in a timely manner.

Assesses patient for pain and responds appropriately to

patient’s report of pain (reports findings and/or manages

pain per physician orders).

3. Demonstrates Teamwork

Behaviors

Offers to assist others (when work is complete) without

being prompted.

Is supportive of team goals and efforts.

Respects the policies of other departments.

Takes action to clarify information received from others.

Avoids negative statements.

Encourages and supports others.

Communicates effectively with patients, families, and co-

workers.

Reports potential problems and/or offers possible solutions.

Demonstrates behaviors that support a “teamwork”

approach rather than seeking individual recognition.

Recognizes the contributions of other departments.

Works with other departments to solve common problems.

Supports hospital mission/values at work and in the

community.

Demonstrates respect when requesting assistance /

resources.

Projects a friendly, caring, competent and confident

attitude.

4. Demonstrates Ethics,

Honesty, and Integrity

Reflects TSSH values and sensitivity to ethical and

compliance principles in performing daily activities.

Does not contribute to negative situations.

Communicates information timely, truthfully, and tactfully.

Respects personal / hospital property.

Does not discuss hospital issues to public or in patient care

areas.

5. Protects Patient Rights Protects confidentiality and privacy in all areas (verbal,

written, and computer-generated information).

Communicates at appropriate patient levels.

Uses appropriate salutation / greeting based on patient

preference (does not use “sweetie, honey, etc. in place of

Mr., Mrs., or Ms., etc.).

Knocks on door before entering room.

Introduces self when entering room.

Informs / educates prior to procedure / task, discusses

outcome options.

Respects patient’s personal privacy and dignity.

Respects patient’s autonomy by allowing him/her to make

informed decisions about care and then respecting the

decision.

6. Manages Information

Appropriately

Collects data in an accurate and timely manner according

to departmental policy.

Interprets data appropriately.

Makes decisions based upon accurate and complete data

collection.

Utilizes appropriate procedures during computer downtime.

Communicates information as needed.

Makes decisions consistent with patient condition.

Maintains / retains records according to TSSH policy.

7. Participates in Performance

Improvement Initiatives

Participates in assigned team projects.

Recommends performance improvement activities.

Uses outcomes measurements to assess and improve

department and / or organizational systems and processes.

Assists with implementation of solutions.

Identifies internal and external customers.

Reports problems and follows up as necessary.

8. Controls Costs Does not waste supplies.

Understands cost containment and impact to TSSH.

Follows hospital procedures for charging / replacing

supplies and / or equipment.

Uses time appropriately.

Completes work timely and avoids unapproved overtime.

9. Practices Safety / Infection

Control

Uses personal protection equipment (PPE) appropriately.

Practices proper handwashing.

Prevents and reports safety and environmental hazards.

Responds to all emergency codes / alarms as per policy.

Practices appropriate isolation techniques.

Ensures that work area is uncluttered and free of safety

hazards.

Reports all patient / Visitor / Employee occurrences as per

policy.

Utilizes equipment in an appropriate and safe manner.

Knows location of fire extinguishers and oxygen cut-off

valves.

Disposes of biohazardous materials per policy.

Enforces hospital wife smoking policy.

As a student attending clinical at Tulsa Spine & Specialty Hospital, I agree to abide by the behavior expectations as listed above.

______________________________________________ __________________ Employee Signature Date

______________________________________________ __________________ Witness signature Date

Code of Conduct:

We are here to serve our customers. Our customers are our patients, our physicians, and each other.

Arrive at work a few minutes early to login, get dressed, greet each other and be ready to start the day on time.

Expect to remain at work for your entire shift.

Check with your supervisor before leaving for the day to see if he/she needs you to do anything else.

You must request time off well in advance. We must respect each other by recognizing the effect on staffing when people “call out” at the last minute.

Project a positive, professional attitude while at TSSH. We all have

problems, but while at work it’s not about us; it’s solely about those we serve.

Be polite and courteous to everyone. Your temperament influences the entire atmosphere and directly impacts customer satisfaction. Avoid gossip; nothing productive is achieved by gossiping.

Keep your cell phone in your locker and check messages on your

break or on your lunch time. Limit personal phone calls.

Respect differences and strive to collaborate daily to meet TSSH goals.

To err is human. So admit your mistake and work together to continuously improve your/our/TSSH performance by learning from them.

Together let’s create a positive work environment where we have

fun and seek ways to help and encourage each other throughout the day!

EMPLOYEE SIGNATURE DATE

MANAGER SIGNATURE DATE

Receipt and Acknowledgement of Tulsa Spine & Specialty Hospital

Joint Commission Notice Please read the following statements and sign below.

1. Any TSSH employee who has concerns about the safety or quality of care provided in the hospital may report these concerns to the Joint Commission:

Office of Quality Monitoring Joint Commission on Accreditation of Healthcare Organizations One Renaissance Blvd Oakbrook Terrace, IL 60181 Telephone 800.994.6610 or fax 630.792.5636 Email: complaint@jcaho.org

2. TSSH will take no disciplinary action because an employee reports safety or

quality of care concerns to the Joint Commission.

3. TSSH demonstrates this commitment by taking no retaliation or disciplinary action against employees when they do report safety or quality of care concerns to the Joint Commission.

Who is our Compliance Officer? Terry Woodbeck, CEO By signing below, I acknowledge I have received and understand my responsibility in reporting quality of care issues. ____________________________________________ Employee/Student/Volunteer/Agency Signature

___________________ Date

HOSPITAL EMPLOYEE DISCLOSURE STATEMENT

Name: ______________________________________________________________________ Address: ____________________________________________________________________ Job Title/Department: __________________________________________________________ Supervisor: __________________________________________________________________ 1. I confirm that I have received information and will comply with both the spirit and the letter of the Tulsa Spine & Specialty Hospital Conflict of Interest Policy, Code of Conduct Policy, and False Claim Prevention Compliance Policy for Employees. 2. I confirm that as of today’s date, there are no disclosures required to be made by me in accordance with the procedures set forth in the Policy, except _____________________ ______________________ (provide details in an attached statement or indicate “none”). 3. I confirm that I will avoid participating in any hospital decisions in which, by any reasonable standard, it could be said that I have any personal financial or other stake in the decision or where other outside influences of any type could influence my independent judgment. 4. Where there is a question regarding any action involving me that could reasonably be construed as a conflict of interest under the policy, I will raise the question in advance with my supervisor. 5. I will abide by the Code of Conduct and do agree that I have a duty to report any suspected violations of this Code by any option available to me. I also agree to conduct myself as an employee / student / volunteer of this hospital in accordance with this Code of Conduct. __________________________________ ______________________________________ Signature Date PRINT NAME________________________________________________________________

Student Orientation Acknowledgement

Please read the following statements and sign below.

I acknowledge that I have received training in Infection Control

practices.

I acknowledge that I have received training in Fire Safety and

procedures.

I acknowledge that I have received training for Emergency Code

responses and procedures.

I acknowledge that I have received training in Code of Conduct.

I acknowledge that I have reviewed the “Scope Standards of

Practice”, “Current National Patient Safety Goals”, Spine Anatomy

and Procedures”, and” HIPAA Confidentiality”

I agree to remain with a preceptor for the duration of my time here at

Tulsa Spine & Specialty Hospital.

I acknowledge that I have received training on Health Insurance

Portability and Accountability Act and have signed a confidentiality

statement.

____________________________ _________________________

Student Signature Student Printed Name

____________________________

Date