Transcript Comprehensive Employee Edu.english

Employee Comprehensive
Education
Dr. Ihab Nada,DOE.MSKMC
Table of Contents
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Section 1: Employee Code of Conduct
Section 2: Fire Safety (Code Red)
Section 3: Utilities Management
Section 4: Hazardous Materials
Section 5: Radiation Safety
Section 6: MRI Safety
Section 7: Public Safety
Section 8: Disaster/Emergency Preparedness
Section 9: International Patient Safety Goals
Table of Contents (cont.)
• Section 10: Patient/Visitor Incident Reporting
• Section 11: Employee Work-Related Accident, Injury, or Illness
Reporting
• Section 12: Patient Care Equipment
• Section 13: Infection Control
• Section 14: BloodbornePathogens
• Section 15: Tuberculosis
• Section 16: Age-Specific Care
• Section 17: Confidentiality and Personal Information
Table of Contents (cont.)
• Section 18: Receiving Gifts
• Section 19: Policies, Procedures, Guidelines and Directives
• Section 20: Employee Training Next Steps
Section 1:
Employee Code of
Conduct
Our Commitment
• MSKMC is committed to helping all our
employees, physicians, volunteers, and
contractors act in a way that preserves the
trust and respect of those whom we serve and
with whom we deal.
• Our goal is to do the right thing
Code of Conduct
• Is a guide to MSKMC staff in making decisions
and choosing actions
No Patient or Employee Abuse, Neglect, or
Harassment is allowed at MSKMC
• MSKMC protects patients from abuse, neglect and
harassment of all forms whether from staff, other patients or
visitors. In the event that an individual alleges abuse, neglect
or harassment by other patient, Medical center employee or
member of the medical staff the hospital will ensure a prompt
and complete investigation of all serious complaints
• The Medical Center has a ZERO tolerance for violence, also
committed to maintaining a Drug and Alcohol Free work place
Fraud, Waste and Abuse - Definitions
• Fraud – e.g.: spouse medical insurance
• Waste – e.g.: spilling , improper size , paper
abuse ……….etc
• Abuse – Improper behaviors or practices that
are inconsistent with policies/laws and create
unnecessary costs.
Fraud, Waste and Abuse - Examples
• Pharmacy and Prescriptions:
– Billing for brand when generic was dispensed
– Billing Multiple Payers for the Same Prescription
• Identity Theft
Integrity
We live our mission, keep our promises, follow
applicable laws.
Respect
We treat everyone with dignity, kindness, and
significance.
Compassion
We listen attentively, help solve problems,
apologize when necessary.
Excellence
• We commit to high standards, take
accountability, and strive to grow.
Stewardship
We live within our means so that we can be
better tomorrow.
Community
We practice cultural competency by honoring
patients’ and each other’s cultural orientation.
Service to the Community
“Service to the community is at the core …and
an important part of our mission. We have a
covenant to care for the underserved
Section 2:
Fire Safety (Code Red)
The Medical Center uses the phrase
CODE RED for all fire emergencies
• We have an acronym all employees should
remember. This acronym helps you
remember what you need to do in the event
of a code red
R.A.C.E.
R.A.C.E.
Rstands for Rescue
• Remove anyone from harms way who is not
capable of self rescue
• Do not put yourself in danger while rescuing
R.A.C.E.
A stands for Alarm
• Sound the Alarm by activating a pull station and
• Always call the emergency line #___________ from a safe
distance to notify responders of the precise location of
smoke/fire.
• When contacting the emergency number, employees must be
prepared to give the following information: Type of Code
emergency (Code Red); Location of emergency (building, floor,
room number); caller’s name and call back number.
R.A.C.E.
C stands for Contain
• Contain the fire by closing all doors, windows
and other openings.
• By closing doors you trap smoke and heat
allowing time for evacuation
• By trapping heat you activate the sprinkler
system quickly
R.A.C.E.
E stands for Extinguish / Evacuate
• Use portable fire extinguishers to put out
small fires, if trained and can be done safely.
• Execute your specific department evacuation
plan including taking direction from the Floor
Marshal, Fire Department and /or Safety
Officer. evacuation of the whole area either
horizontally or vertically.
Know the Following Department
Specific Fire Safety Information
• Fire alarm pull stations, extinguishers, and
emergency exit locations
• Identification of your Floor Marshal
• Location of your department’s evacuation plan
• Doors that need to be shut
• Location of oxygen shut-off (if applicable)
• Location of designated meeting spot
• Recognition of the all-clear notification
Prevention Strategies
• Smoking is NOT permitted inside the hospital or
outside on hospital property-Refer to the hospital No
Smoking Policy
• Keep and store flammable or combustible materials
away from heat sources.
• Keep all exits, stairwells and corridors free of
obstructions.
• Doors are not to be propped open or blocked from
closing freely.
Operating Fire Extinguishers
Pull the pin.
Aim low, at the base of the fire.
Squeeze the handle.
Sweep from side to side.
• Use your judgment. Never jeopardize personal
safety!
• Initially stand 6-8 feet away from the fire and aim
at the burning material
• Position yourself so you can exit the area easily.
• Fire extinguishers should only be deployed by
those trained in their use.
• You are not required to use an extinguisher
• Only use a fire extinguisher if the fire is small
Section 3: Utilities Management
Utility Examples
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Steam
Plumbing System
Heating, Ventilation, and Air Conditioning
Medical Gas System
Natural Gas System
Electrical
Elevators
What should you do in the event of
failure or problems with these
utilities?
Utility Failure
• Call Maintenance
• Be careful around leaking steam; .
• If you suspect a natural gas leak, do not turn on lights, electrical
appliances, or other sources of ignition; open all windows.
• Be aware of electrical hazards:
• Do not use frayed/broken power cords.
• The use of extension cords is prohibited.
• All equipment should have hospital grade, grounded 3-prong
plugs.
Section 4: Hazardous Materials
Chemicals and Hazardous Materials in
Your Department
• All departments must maintain an accurate
inventory of hazardous materials in use.
• You must be familiar with the
contents and location of the Inventory.
• Each hazardous material must have a
Material Safety Data Sheet (MSDS).
What Information is on the MSDS?
The MSDS includes information about:
• Chemical components
• Safe use & Protective equipment
• Storage &Disposal
• Routes of exposure
• Symptoms of acute and chronic exposures
• Emergency response guidelines (spills or
exposures)
Master Files of All MSDS
• Electronic database
• For 24-hour MSDS access
All Containers Must Be Appropriately
Labeled
• Original containers from suppliers must be pre-labeled
with
– Product name
– Hazardous ingredients
– Hazard warnings
– Name of the manufacturer
• All secondary containers should be labeled with contents.
• All labels should be printed in English; additional
language translations may be added if necessary.
Hazardous Material Spills – Chemical,
Biological, or Radiological
• Small, incidental spills can be cleaned up by users, if trained
and personal protective equipment & spill kit available.
• For large or acutely hazardous spills: CODE ORANGE
– Address any medical emergencies first
– Evacuate spill area
– Call #____________ - Identify location, material &quantity
spilled, name & contact information
– Remain in safe location to provide incident specifics to
response team
Section 5:Radiation Safety
Identifying Radiation Areas
This symbol may be found on:
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Hallway doors
Work areas within restricted areas
Waste cans
Packages
Fume hoods, sinks, and refrigerators
What Should You Do If You See A
Radiation Symbol?
• Do NOT enter the area unless:
– You have received specialized
education.
OR
– There is a trained radiation
worker present to supervise
your work.
Will I Be Exposed to Radiation in
X-Ray Rooms?
• There is no residual radiation present
immediately after the machine is turned off.
• The operator or technician is ALWAYS present
when radiation is being produced.
• Door interlocks cut off radiation immediately
when the door to an X-Ray room opens during
radiation use.
5 Basic Methods to Keep Radiation
Exposure to a Minimum
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Time
Distance
Shielding
Contamination Control
Training
Time
• Spend as little time as possible near a
radiation source.
Distance
• Work as far away from the radiation source as
possible.
Shielding
• Inside a radiation use area,
lead containers, Plexiglass
shields, and lead aprons
are used to minimize the
exposure to radiation.
Section 6: MRI SAFETY
When can you safely enter
the MRI Scan Rooms?
• Before you go into the scan
rooms you MUST be screened
by the MRI Technical staff.
• This screening will identify
whether you have anything in
your body that can harm you in
the presence of the magnetic
field.
• DO NOT ENTER THE SCAN
ROOM UNTIL THE
TECHNOLOGIST SAYS YOUCAN!
All MRI Sites Have Restricted Access
because the MRI Magnets are Always On!
Other Objects that Should NOT Enter
the Magnetic Field
• Metallic objects can become projectiles and can
cause severe injury or death. The following list
identifies some of the many objects that may NOT
be brought into the MRI scan rooms:
– Pens, scalpels, screwdrivers, hammers, or other
common metal tools
– Stretchers, wheelchairs, IV poles, oxygen tanks,
code carts, monitoring devices
– Cleaning or custodial supplies such as mops,
buckets, ladders
– Credit cards and ATM cards, pagers, cell phones,
and watches
• Any person entering the room should be reminded
to check and empty their pockets.
Section 7:Security
Name
What Can You Do to Help Maintain a
Secure Environment?
• Wear your ID badge at all times and in a
visible manner.
• Secure your work area—even if away for 5
minutes.
– Sign out of the computer
– Lock you door/desk
• Report all missing items promptly.
• Report all unusual activity
Other Measures to Maintain a
Secure Environment
• Call Security to report someone “out of
place.”e.g. me in bank
• Do not share access cards or combinations,
and do not hide keys.
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• Protect patient valuables
Section 8: Disaster and
Emergency Preparedness
What Is Emergency Management?
• Emergency Management refers to the Medical
Center’s program which develops plans to
prepare, mitigate, respond and recover from
emergency events that might occur either
within the Medical Center – or in the local
community, city, or region.
How Are Emergencies Announced?
Through the over head announcement system
• ____“CODE RED”
• ____“CODE ORANGE”
• ____“CODE PURPLE”
• ____“CODE TRIAGE”
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CODE TRIAGE
• CODE TRIAGE is the code phrase used to
announce the activation of our Emergency
Operations Plan in response to an emergency
event or disaster.
• CODE TRIAGE notifications are communicated by
pager to key positions on the Incident Command
Team, may be blast e-mailed to all employees, or
heard over the overhead paging system.
• Onlythe Administrator on Call (AOC) can activate
the Code Triage alarm.
There Are Two Types of Code Triage
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External “Influx”Emergencies
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Internal “Non-influx”Emergencies
External “Influx” Emergencies
• Multi-casualty incidents which take place in
the surrounding city and region, and which
may require the mobilization of resources to
treat potentially large numbers of people.
• Examples include: plane crash, train crash,
hurricane, earthquake, civil unrest, or other
large-scale disaster.
Internal “Non-Influx” Emergencies
• Failures or accidents within the Medical Center
that may require alteration in our normal
operations or services.
• Examples include: using power-fail phones during
a Telecomm failure, plugging critical equipment
into red outlets during a power failure or
evacuating areas due to a fire.
– All Ventilators attached to patients and equipment
during surgery should be plugged into the Red Outlets
at all times
Key Resources During a Disaster
• Your manager
• Color coded “Flipcharts” are in all departments which
outline emergency response actions
• Your department’s own specific “Plan of Action”:
– This may include a fan-out call list for your department.
• The hospital organizes its response utilizing the
Hospital Incident Command System (HICS).
• The Incident Command group is responsible for
directing and coordinating care to patients and
managing hospital operations during a disaster.
Plan of Action
• Be sure to know where your department’s
“Flipchart” and disaster plan is kept.
Other Important Reminders
• Always try to remain calm during a disaster
• Follow the directives of the Floor Marshal or
your manager/supervisor
Check With Your Manager
• Be sure to check with your manager to
determine if you are needed to provide
assistance prior to leaving work.
• From home or work you can obtain recorded
updates on Code Triage events and other
emergencies by calling the Command Center
Event Update Line.
Emergency Call Numbers
• Add Numbers here
Section 9:
International Patient Safety Goals
Joint Commission
International:
International
Patient Safety Goals
• MSKMC is a hospital that is/will be accredited by Joint Commission
International (JCI). MSKMC uses JCI Standards to guide us on how
we administer care and continuously improve performance.
• The International Patient Safety Goals are those goals Joint
Commission International considers of highest priority to patient
safety and quality care in a healthcare organization. The
International Patient Safety Goals are specific measures that can be
used for comparison across healthcare settings and offer all who
participate the opportunity to learn evidence- based “best
practice”.
International Patient Safety Goals
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IPSG.1 Identify Patients Correctly
IPSG.2 Improve Effective Communication
IPSG.3 Improve the Safety of High-Alert Medications
IPSG.4 Ensure Correct-Site, Correct-Procedure, CorrectPatient Surgery
• IPSG.5 Reduce the Risk of Health Care–Associated
Infections
• IPSG.6 Reduce the Risk of Patient Harm Resulting from
Falls
Reliable Identification
• Reliable identification of patients can be achieved by:
• Using two fail-safe patient identifiers before
procedures, blood draws, transfusions, and/or
administering medications. Some examples:
•Use name and date of birth, or name
and medical record number
Ask the patient to state his /
her identifying information
whenever possible
Label specimens in the
presence of the patient
Communicate More Effectively
• “Write it down and read it back” for verbal
orders and critical test results.
• Perform “Time-Out” before Surgery or
Procedure
• Do not use prohibited abbreviations!
• Provide pertinent information at hand off and
leave opportunity for clarification/ questions.
Improve the Safety of High-Alert
Medications
• High-alert medications are those medications
involved in a high percentage of errors and/or
sentinel events, medications that carry a higher
risk for adverse outcomes, as well as lookalike/sound-alike medications.
• Lists of high-alert medications are available from
organizations such as the World Health
Organization or the Institute for Safe Medication
Practices.
Label all medications, medication containers
and other solutions on and off the sterile field
Ensure Correct-Site, CorrectProcedure, Correct-Patient Surgery
• Wrong-site, wrong-procedure, wrong-patient surgery is an
alarmingly common occurrence in health care
organizations.
• These errors are the result of ineffective or inadequate
communication between members of the surgical team,
lack of patient involvement in site marking, and lack of
procedures for verifying the operative site.
• In addition, inadequate patient assessment, inadequate
medical record review, , problems related to illegible
handwriting, and the use of abbreviations are frequent
contributing factors.
Reduce the Risk of Health Care–
Associated Infections
• Infections common to all health care settings
include catheter-associated urinary tract
infections, blood stream infections, and
pneumonia (often associated with mechanical
ventilation).
• Central to the elimination of these and other
infections is proper hand hygiene.
Reduce Hospital Acquired Infections due to
multidrug – resistant organisms
• MSKMC conducts periodic risk assessments
for multi-drug resistant organisms. This is
done by the infection control department
• Data is shared with key leaders
• MSKMC has a lab based alert system that
identifies new patients with multidrug
resistant organisms.
Reduce Central Line Associated
Bloodstream Infections
• Use the MSKMCcentral line insertion checklist
when inserting central lines
• Use the standardized kit for central line
insertion
• MSKMC educates staff about protocol for
maintaining central lines
Reduce Surgical Site Infections
• MSKMC educates staff and physicians about the
prevention of surgical site infections
• MSKMC conducts surveillance of surgical site
infections and measures infection rates and
reports this to key leaders
• MSKMC has a surgical site infection prevention
bundle that includes proper antibiotic
administration, control of blood sugar and
temperature and hair removal
Reduce the Risk of Patient Harm
Resulting from Falls
• Patients are assessed for their risk to fall on
admission in the Emergency Department
• IF a patient is at risk to fall, the “fall prevention
bundle” of interventions is implemented by the
care team
• Any patient fall should be immediately reported
in the MSKMC patient safety reporting system
Triggers: Rapid Response Team
• MSKMC has a ”Triggers” program to enable
staff to directly request additional assistance
from specially trained individuals when the
patients condition appears to be worsening.
• There are specific criteria that nurses and
physicians can use to activate a “trigger”
• Patients and families can activate a similar
response by speaking with their nurse
Medication Reconciliation
• MSKMC has a process for
– Comparing the patients home medication list with
those ordered in the hospital
– For communicating the medication list to the next
level of care when patients are transferred
– For providing a complete list of medications to the
patient or family when the patient is discharged
from the hospital
Section 10:
Patient/Visitor Incident Reporting
What Is a Reportable Incident?
• An occurrence which is not consistent with
the routine care of the patient, or the routine
operation of the Medical Center.
Examples of Events to Be Reported
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Slips, falls, or burns
Medical errors
Equipment malfunction
Misidentified patients
Wrong side surgery
Who Is Responsible for
Incident Reporting?
• Any employee or practitioner of the facility
who is involved in, witnesses, or discovers the
incident.
Why Is It Important to
Report an Incident?
• To provide information, and provide
opportunities, for quality improvement
• To track and trend events
• To identify system breakdowns
• To identify the need for continuing education
• To alert the hospital to possible liability
• To comply with the law
How Are Incidents Reported?
• The MSKMC computer based Patient Safety
Reporting System is the mechanism for reporting
incidents.
• If you are unable to use this system, please
contact your manager for instructions on how to
report incidents or unexpected occurrences in
the Patient Safety Reporting System.
• Temporarily , written or verbal notification to
department director
Section 11: Employee Work-Related
Accident, Injury, or Illness Reporting
What Should I Do If I Am Injured At
Work?
• Immediately:
• Notify your manager
• Complete the “Report of Employee Work
Related Injury, Accident, Illness Form”.
What Should I Do If I Am Exposed to
Blood or Body Fluids at Work?
• Immediately – Wash wound with soap and water or rinse eyes
with eye wash or tap water.
– Report injury to manager.
– Go immediately for evaluation and medical
assessment .
Section 12:
Patient Care Equipment
How do I know this piece of
equipment is okay to use?
• Where applicable, the equipment is affixed
with a green Preventive Maintenance (PM)
sticker, which indicates that the equipment:
– Has been inspected by Clinical Engineering
– Is enrolled in the Preventive Maintenance
Program
– Indicates how long the inspection is good for (Has
an expiration date, same as on food products)
Section 13:
Infection Control
What Is Infection Control at MSKMC?
• A program designed to prevent and control
infections
• Whose mission is to reduce the risk of
transmission of infection to patients,
employees, and visitors
• Every employee is responsible for compliance
with infection control procedures:
Infection Control Resources
• Infection Control Practitioners on page
• Online infection control manual (Insert Link)
What Is the Single Most
Effective Measure to
Prevent the Spread of
Infection??
Hand Hygiene
• You should clean your hands:
– After using the bathroom
– After blowing your nose
– After covering a sneeze
– Before eating and drinking
– Before handling food
• In addition if you have patient contact:
– Before and after patient contact
– After contact with patient’s environment
– After handling items contaminated with blood or body fluids
– Before donning gloves
– After removing gloves
What Else Is Important In
Hand Hygiene?
The Nail Is an Area of Special Concern
in Hand Hygiene
Research has shown:
• The area under the nail contains
the highest microbial count on
the hand.
• Both long natural nails and
artificial nails may serve as
reservoirs for bacteria.
• Persons with artificial nails are
more likely to harbor pathogens
on their hands than those
without artificial nails.
How Do You Know Whether Patients
are on Special Isolation/Precautions?
Infection Control Signage
• Signage is the best way to
identify if a patient is on special
isolation/precautions.
• Signs identify appropriate
precautions to take when
entering a patient room.
• If you don’t know or
understand the sign found
outside a patient’s room, ask
the nurse before entering.
Other Measures to Help Reducethe
Spread of Infection
• Immunizations
– Be sure your immunizations are
up to date.
Section 14:
BloodbornePathogens
What Are BloodbornePathogen
Exposures?
• Blood borne pathogens are
transmitted through infected blood
or body fluid.
• Exposures can occur when the
following happen:
– Injury with contaminated
needles/sharps
– Splashes to eyes/nose/mouth
with contaminated blood or
body fluid
Some Duties Which May Cause
Exposure
• Handling needles or sharps
contaminated with blood or body
fluids
• Handling laundry or other items
contaminated with blood or body
fluids
• Performing phlebotomy or other
invasive procedures
• Cleaning up a blood or a body
fluid spill
• Handling biohazard waste
Reducing Exposure to Bloodborne
Pathogens
• Follow Standard Precautions
– Remember, the best way to reduce the risk of
exposure is to handle ALL patients’ blood and
body fluid as potentially infectious.
Engineering Controls
• Needle and sharp
safety devices
• Needle and sharp
collection containers
• Biohazard waste
disposal containers
Personal Protective Equipment
• Is available in all patient care areas
• Is used to protect you from contact with blood and
body fluids
– Gloves, to be used when touching blood, body
fluids, mucous membranes, or non-intact skin of
patients; when touching surfaces or equipment
soiled with blood or body fluids; when
performing phlebotomy
– Gowns or aprons, when splashes to skin or
clothing are likely
– Masks and goggles or face shields, when
splashes to the mouth, nose, or eyes are likely
– Surgical caps/hoods, shoe covers/boots for
situations where gross contamination is likely
What to Do If Exposed
• Wash the affected area; flush the skin, eyes,
nose, or mouth.
• Report exposure immediately to Employee
Occupational Health Services (EOHS) or the
Emergency Department during off-shifts.
• Antiviral therapy may be needed and should
be started as soon as possible after an
exposure.
Section 15:
Tuberculosis
The MSKMC Occupational TB Program
Includes
• Education
• TB skin test screening
• Respiratory protection program
How Is TB Spread?
• Tuberculosis (TB) is a
communicable disease.
• TB causes an infection of
the lungs.
• TB is transmitted through
the air when a person with
active TB disease coughs,
sneezes, laughs, and
sometimes, speaks.
Measures to Reduce
the Exposure to TB
• Early detection and treatment of patients with
TB
• Engineering controls
• Personal protective equipment
• Occupational screening for TB
Engineering Controls
• Isolation of
patients with
active TB disease
• Negative pressure
room with posted
signs on patient’s
door
Personal Protective Equipment
• N95 respirators are required when
caring for a patient with pulmonary
TB.
Occupational TB Screening Routine
and Post-exposure Screening
• TB test screening of employees takes place by
EOHS
– Annually
– After a TB exposure
Section 16:
Age-Specific Care
Neonate or Infant
• Explain the medical condition
and any procedures to the
parents
.
• Ensure that medical equipment is
appropriate for the infant’s size.
.
Toddler, Pre-School, and School-Aged
• Engage the child in conversation about the
hospitalization and procedures using age
appropriate terminology.
• Recognize that some fears may come from
the concrete thinking of a child when
confronted with unfamiliar sights and words.
• Allow younger children the opportunity to
play
• Involve the child in the age appropriate
treatment
Adolescence
• Adolescence is a transitional stage of physical
and mental development, beginning with the
onset of puberty.
– Allow for increased independence during this
transition
– When appropriate, give the patient a choice about
having a parent present.
Young and Middle Adulthood
• Accept the adult’s chosen lifestyle, and assist
with necessary adjustments related to health
.
• Involve the patient in all planning.
Late Adulthood
•
The health care worker must respect the older patient's
wisdom
• To better provide age-specific care to the older adult, the
health care worker should:
– Provide mobility aids/assistive devices, such as walkers
and canes, if needed
– Assist the patient if visual or auditory impairments are
present.
– Not speak loudly, unless you are certain that the patient
is hard of hearing.
Section 17:
Confidentiality and Personal
Information
What Information Is
Confidential or Personal ?
• Patient health information: names, phone
numbers, insurance, and clinical information
• Personal information: names and address,
combined with complete social security number,
driver’s license or other state-issued numbers,
complete credit card or bank account numbers
• Employee information and personnel records
• Research information
• Information about business affairs
How Is Confidential and Personal
Information Transmitted?
• Spoken: conversations, both formal
and informal, over the phone or in
person
• Written: memos, reports, and
medical and personnel records
• Electronic: computers, emails,
PDAs and faxed documents
How Can You Keep Electronic
Information Confidential?
DO:
• Log off your PC when you leave the area.
• Lock diskettes with confidential and personal information.
• Password protect laptops, PDA’s, phones, etc.
.
• Choose passwords with a mix of alphanumeric characters.
– Change your password regularly.
• Keep papers and reports secured.
• Shred documents when no longer needed.
What Is the Protocol for Faxing Confidential
and Personal Patient Information?
• First, verify the identity of the requesting party
and confirm that the fax number is correct.
• Fax under the following conditions only:
– When necessary for emergency care of the patient
– Following the transfer of a patient to another facility
or physician, when the information cannot be sent
with the patient
– When required for continued stay approvals from
third-party payers
Section 18:
Receiving Gifts
Gifts
• Gift giving is a common practice for everyone.
Gifts are often exchanged in business to
promote good will or to say thank you to a
care provider.
• Gifts can cause problems when they
compromise or even appear to compromise,
our ability to make objective decisions on
behalf of our patients or the Medical Center.
How Do I Know If What I Am Doing Is
A Problem?
Ask yourself:
• Is it against the law?
• Does it violate a hospital policy?
• Does it make you feel uneasy, nervous, or
frightened?
Section 19:
Policies, Procedures, Guidelines and
Directives
Know how to access Policies,
Procedures, Guidelines and Directives
(PPGDs)
• PPGDs are located at theMSKMC Website
under Organization Policies, Procedures,
Guidelines or Directives. Some departmental
PPGDs are also located on this site but could
also be in paper copy within your dept.
How do I keep updated regarding
changes to PPGDs?
• Relevant PPGDs will be reviewed at Departmental/
Division Meetings and/ore-mailed and
documented that they have been shared with all
staff
• VPs, Directors and Managers should let you know
about PPGD changes that impact your work
• As PPGDs are updated there is a website link on
the General Portal that will have the monthly
updates