|ORIENTATION REQUIRED FOR ALL TEAM MEMBERS WHO HAVE VCU HEALTH SYSTEM ACCESS|
The VCU Health System (VCUHS) would like to welcome you to our organization. We hope your learning experiences here will be enriching and that you will consider us in your future career decisions. The purpose of the booklet is to introduce you to our organization and provide you with useful information that will make your tour with us enjoyable and safe.
ABOUT THE VCU HEALTH SYSTEM
The VCU Health System comprises nearly 200 specialty areas, many of national and international note. In addition to multidisciplinary centers for cancer, cardiology, neurosurgery, and transplantation, the VCUHS offers virtually every form of contemporary medical service. In particular, the VCUHS has received international recognition for early diagnosis and treatment of chest pain and strokes, organ transplant, head and spinal cord trauma research, burn and wound healing, neonatal intensive care, and genetic research, as well as cancer research, treatment, and rehabilitation.
The VCUHS delivers oncology patient care services for VCU's Massey Cancer Center; a National Cancer Institute designated facility, which offers patients many multidisciplinary treatment options and access to clinical research trials. VCUHS has been recognized in the past by U.S. News & World Report for its leadership in neurology, neurosurgery, orthopedics, respiratory disorders, digestive tract, rehabilitation, and gynecology.
• VCU Medical Center earned special Recognition from The Joint Commission as a 2015 Top Performing Hospital on quality measures
• Children's Hospital of Richmond at VCU was named Virginia's first Level I pediatric trauma center by The American College of Surgeons
• VCU Community Memorial Hospital was awarded the Silver Plus Quality Achievement Award by the American Heart Association/American Stroke Association's Get With The Guidelines-Stroke® program
• Virginia Premier Health Plan's Medicaid plan is accredited by the National Committee of Quality Assurance, a private, non-profit organization dedicated to improving health care quality
• VCU Medical Center received the 2014 AHA-McKesson Quest for Quality Prize, a distinction that goes to one standout U.S. hospital annually for leadership and innovation in quality improvement and safety
At VCUHS, we value each one of our 10,727+ team members. The average age of our team members is 42 years and their average length of tenure is 7.3 years. For the 2,440 new hires in 2015, we received 58,038 applications. We encourage inclusion and diversity and are proud that more than 40 percent of our work force represents minority ethnicities.
The Virginia Commonwealth University Health System is an urban, comprehensive academic medical center in central Virginia established to preserve and restore health for all people, to seek the cause and cure of diseases through innovative research, and to educate those who serve humanity.
The Virginia Commonwealth University Health System is committed to excellence in patient care and education as the preeminent academic medical center in the mid-Atlantic region. Quality and safety drive our vision, which is propelled by the best people dedicated to:
• Demonstrating superior value to patients, employers and payers;
• Securing our position as a national leader in integrated delivery systems;
• Fostering the contributions of all members of the health care team in the care of patients;
• Educating the next generation of health professionals using leading edge techniques and innovation;
• Applying novel research in the clinical and basic sciences, and translating new discoveries to patient care;
• Ensuring sufficient assets to support our mission and vision though disciplined stewardship of financial activities
We provide exceptional service by putting the needs of the patient first.
We earn trust from those we serve and from those with whom we work by our commitment to safety, privacy, and accountability.
We display a positive attitude through kindness, compassion, and empathy to those in our care and with whom we interact.
We respect the dignity of each individual and celebrate the diversity of the communities we serve.
VCU HEALTH SYSTEM LEADERSHIP
Michael Rao, PhD - President VCU & VCU Health System
Arthur Kellermann, MD - CEO VCU Health System & SVP Health Sciences
Peter Buckley, MD - Dean, VCU School of Medicine and Exec VP of Medical Affairs
Ron Clark, MD - Interim Chief Executive Officer VCU Hospitals & Clinics
Elias J. Neujahr, MHA, MBA - Chief Executive Officer Children's Hospital of Richmond
Scott Burnette - Chief Executive Officer VCU Community Memorial Hospital
Melinda Hancock, CPA, FHFMA - Chief Admin & Financial Officer, VCU Health
Tom Yackel, MD, MPH, MS - President, MCV Physicians
Jay Bonfili - Interim VP VCU Finance & Administration
David Lanning, MD - Interim VP Clinical Activities & Chief Medical Officer
Sharon Darby, DNP, RN, NHA, FACHE - Interim Exec Director of Children's Hospital of Richmond at VCU
Deborah Davis, VP for Strategic Initiatives
Ellen Derry, MA, RN-BC, NEA-BC - Chief, Professional Development and Clinical Excellence
Paul Weslowski - Chief Operating Officer MCV hospitals
Sheryl Garland - VP Health Policy and Community Relations
Carl Gattuso - Chief Corporate Officer
Darrell Griffith - Exec Director, MCV Physicians, Senior Assoc Dean of Finance & Admin, VCU School of Med
Karah Gunther - Exec Director Government Relations & Health Policies
Ramana Feeser, MD, MPH - Interim Chief Safety and Quality Officer and Assoc Dean for Patient Safety & Quality Care
Paula Henderson - Chief of Human Resources
Gwynne Jenkins, PhD - Chief of Staff, VCU Health
Marcos Irigaray - VP Strategy, Marketing & Enterprise Analytics
Shirley Gibson - Interim VP Support Services & Planning
Tracy Fry‐Longoria, MBA, BSN - VP, Ambulatory Care, MCV Physicians
Paul Neimeyer - General Counsel & Corporate Secretary, VCU Health
Susan Steagall, PMP, MBA - Chief Information Officer
Dominic Puleo - Executive VP Strategic Financial Planning
Jeniece Roane, MS, RN, NE-BC - Interim Chief Nursing Officer
Susan Torti - VP of Perisurgical Services
B. J. Shelton - Human Resources Employee Relations Director
Penny Trentham - VP Managed Care
Drew Smithson - VP Professional Services
Vacant, MPH - VP of Revenue Cycle
William Zuelzer, MD - Chief of Perisurgical Services Operations
YOUR ROLE AND SUPERVISION
VCU Research staff arrive at VCUHS from a variety of backgrounds and training with an assortment of learning goals. As part of your orientation to VCU Health System, all research staff must participate in new team member orientation and clinical orientation. Your point of contact for orientation will be North 8 - Clinical Research Services Unit nursing team via central email - firstname.lastname@example.org. Each research role varies and requirements for orientation will vary and will be determined by North 8 team.
If you will be providing direct patient care and/or have patient contact, please carefully review the Research Clinical Permissions Table, which outlines direct patient care, clinical function levels of research staff roles while conducting research within the health system. Note this does not effect your research, which does not occur at the health system. As part of our regulatory standards, no person working in a clinical area may be on the unit until they have attended Infection Prevention lecture on Day 1 of Hospital Orientation. BEFORE performing any direct patient care activities, North 8 - Clinical Research Services Unit nursing team or designee must validate your competencies. North 8 will be offering "skills fairs" and training at various points throughout the year to assist you.
Communication is the key to success so when in doubt, ASK!
If you are an employee of VCUHS, who is also functioning in a clinical research role, North 8 - Clinical Research will need a copy of your competencies loaded into OnCore. You may upload these documents yourself to the appropriate folders OR North 8 team will assist you.
All persons who provide care or services to VCUHS patients or assist our customers must display proper identification that includes their name, job title, and the department to which they are assigned. A picture ID MUST be worn at all times, face forward and above the waist, so you can be easily identified. Failure to wear your ID could result in your being denied access to your clinical assignment area.
CELL PHONES AND PAGERS
You may notice signs throughout the facilities that state, "Please Turn off Cell Phones." These signs appear in areas, such as the Emergency Department and Intensive Care Units that have highly sensitive medical instruments that may be affected by the interference of cell phone frequencies. Cell phones are allowed in all other areas of the Medical Center that do not have signage prohibiting cell phone use. Be courteous to others and do not use your cell phone except while on breaks or as required for your role. Keep both pagers and cell phones set to a silent alert. Video/camera phones cannot be used to take pictures or recordings of patients or patient care areas at any time.
VCUHS requires professional, healthcare provider appropriate attire whenever you report to a work unit. Attire must be clean, neat and of appropriate size. Uniforms or business attire representative of your professional career are expected. Manner of dress is often used by patients and families as a cue for recognizing the function of the team members and may shape their perceptions about individuals and the Health System. Patients and family members undergoing the stress of outpatient visits and procedures, as well as hospitalization, need to feel confident in those caring for them. In addition to being in compliance with VCU's dress code policy, the following dress code rules apply at VCUHS.
• Hair shall be clean, well groomed, and worn in such a manner that it will not interfere with patient care or job duties and will present a professional image.
• Facial hair must be trimmed and kept clean. Religious exceptions may apply for styles.
• Make-up may be worn in moderation.
• No excessive perfume, aftershave or scents shall be worn. Use of deodorant and/or personal hygiene sprays/soaps is required unless it is medically contraindicated.
• Do not report to work with the smell of alcohol or other offensive body odors.
• Underwear shall be worn, but not be visible through the uniform fabric.
• Fingernails shall be kept short, clean, neatly manicured and not extend ¼ inch past the fingertips. Artificial nails and nail jewelry are prohibited per Health Department regulations in any patient care role. Artificial nails are defined as any application of a product to the nail to include, but not limited to point, acrylic, overlay, tips, shellac or silk wraps. Nail polish, even clear, is prohibited per infection control guidelines as well.
• Jewelry shall be worn in moderation and not pose a safety hazard or interfere with patient care. Earrings should be worn in a professional manner; earrings are limited to 1-2 per ear.
• There will be no visible body piercing, including but not limited to, the following with the exception of ear piercing: no tongue piercing, no nose piercing, no eyebrow rings / bars. There will be no visible tattoos. Any visible tattoo must be covered with a bandage or clothing. Exceptions may apply to tattoos below the elbows where covering may be contraindicated for infection control practices.
• Non-business use of earphones when providing customer services is prohibited.
• Non-skid shoes of moderate heel are recommended. Shoes should be close toed - no sandals allowed.
STAR SERVICE EXPECTATIONS
Excellent customer service is the kind of service that makes a lasting impression on your customers. It means meeting expectations and satisfying needs in such a way that you are seen as easy to do business with. We expect everyone who represents our organization, including students, to treat all internal (team members and physicians) and external (patients and visitors) customers with respect, courtesy and caring. We share a common purpose, Our Caring Service Begins with Me.
STAR Service Behaviors
SAFETY - I always put safety first and am committed to our vision of being America's safest health system. I am alert, proactive and a clear communicator.
TEAMWORK - I work collaboratively with my fellow team members to provide a safe, caring, respectful, and comfortable experience for all.
ACCOUNTABILITY - I accept responsibility for my actions and behaviors and respectfully hold others accountable to VCU Medical Center standards.
RELATIONSHIPS - I show respect to each individual and celebrate the diversity of our community. I remember that my purpose is to serve each individual in a caring way.
SERVICE THAT SHOWS I CARE - I create an exceptional experience by putting the needs of others first. I interact with all individuals in a warm and caring manner.
If you experience problems related to customer service, please notify the manager of the area to which you are working.
APPRECIATION OF DIFFERENCES
VCUHS strives to provide equal opportunities, services, and access to all persons without regard to race, color, religion, gender, sexual orientation, gender identity, genetics, age, national origin, disability, or veteran's status. One of the great benefits for learning or working at VCUHS is our diverse population. We are internationally recognized in many of our areas of service and therefore, are fortunate to have patients, visitors and team members from around the world. If you have a patient from a culture you are not familiar with, check with the team members on your unit about resources available to help you better meet that patient's needs. VCUHS has a language line (Cyracom) that can be used to access an interpreter to assist with patient teaching, consents, and other needed communication. Many clinical areas also have MARTII (My Accessible Real Time Trusted Interpreter) to support communication - check with your unit leadership to see if one is available.
Any individual who feels that he or she has been the victim of harassment or discrimination is encouraged to report their concerns to either the department manager or the Department of Human Resources.
Access to confidential information is permitted only on a need to know basis. During your rotation, you may have access to proprietary or other confidential business information belonging to the VCU Health System including but not limited to confidential information regarding VCU Health System team members, patients and patient care. Therefore, except as required by your role at VCUHS or by law, you are expected to limit your access to information to that specifically required in your role. Furthermore, it is expected that you will not disclose any information to any other person, or allow any other person access to, any information related to VCUHS which is proprietary or confidential and/or pertains to team members, patients or patient care. "Disclosure of information" includes, but is not limited to, verbal discussions, FAX transmissions, electronic mail messages, voice mail communication, written documentation, "loaning" computer access codes, and/or another electronic transmission or sharing of data.
• All personal patient information should be kept private but generally, confidentiality pertains to information related to the patient's identity, physical or psychological condition (including tests, procedures, and outcomes), emotional status, and financial situation.
• Only discuss your patients with other health care workers who are also providing care to that same patient or who work on that unit.
• Do not share written or verbal information about a patient without first finding out if the individual asking for the information is authorized to have the information due to job duties or written consent from the patient. This includes not giving out information to the patient's family or friends.
• If the patient is a minor, written consent for release of information must be obtained from the parent or guardian.
• Do not discuss patient information or "stories" in the elevator, stairwells, waiting areas, lunchroom, on social media sites, etc. You never know who might be listening or reading!
• If you witness a breach of confidentiality, tell your department leadership.
• You may be granted a computer access code to participate in the retrieval and entry of patient information. If you are, this access code acts as your electronic signature. Never share this code with anyone else.
• Never look up someone in the computer unless it is your own patient. You do not have authorization to "surf" the computer to find interesting cases to review or to check on someone else's patient.
We prefer not to fax information, but occasionally it becomes necessary. All information faxed must have a cover sheet explaining our confidentiality requirements. Before faxing a document, verify the receiving number and that the line is secure. Dial the fax number carefully and verify that you have entered the correct number before hitting send. If you accidentally fax a document to a wrong location, immediately call that location to retrieve and destroy the document. Notify a VCUHS manager or team member so that a record of the event can be recorded. Do not chart the occurrence in the medical record.
QUESTIONS REGARDING CONFIDENTIALITY OR HIPAA
For questions related to confidentiality or the Health Insurance Portability and Accountability Act (HIPAA) contact the Corporate Compliance office at 828-0500. To report a HIPAA violation, call the Compliance Helpline at 1-800-620-1438.
At VCU Health System we use the same two patient identifiers for each and every patient interaction or patient care location: patient name and date of birth. When checking the patient's identification, you must match the patient's name and date of birth to something, such as the patient's verbal communication of name and date of birth or to a document used in that patient's care treatment or service. Two other key points to remember are:
1. A third and, if necessary, fourth identifier should be used whenever the two primary identifiers are insufficient.
2. These identifiers should be matched each and every time any care treatment or services are provided, even when we know the patient.
PATIENT ALLERGY IDENTIFICATION
Patient allergies will be identified in the medical record. The patient will be provided a red band with the word "allergy" written on it to alert team members that the patient's record should be checked for allergy information.
CHANGES IN PATIENT CONDITION
If you observe a change in a patient's condition or if you have any concern about a patient's condition, notify a team member immediately. Remain with the patient until help arrives and then follow the team member's instructions. If the patient has stopped breathing or has no pulse, call *500 and announce Code Blue and the location. In addition, if a patient's condition is rapidly deteriorating, VCUHS has a Rapid Response Team consisting of critical care team members who can be accessed for support by calling *500.
Emergency response in the clinic areas consists of response from the Medical Emergency Response Team (MERT) and Emergency Medical Services (EMS), provided by Richmond Ambulance. The MERT team provides basic support, including an automated external defibrillator if necessary, until the ambulance team arrives. The team has the capability of using more invasive support measures, if a physician is present to order such measures. The MERT team is a core group of healthcare providers who have completed special training in basic life support, airway management, first aid, and use of the Automated External Defibrillator (AED). The MERT team is available Mon through Fri from 8:00 am to 4:30 pm. If a medical emergency arises outside those hours, *500 will activate the operator who will send security as needed and who will call 911 for EMS service dispatch. MERT coverage is available only in the following buildings: Nelson, Ambulatory Care Center, Children's Pavilion, Stony Point, and Hayes E Willis.
If you are in a location away from the Medical Center, including Virginia Treatment Center for Children, Sanger Hall and sidewalks, call 9-911 for assistance.
TOBACCO FREE ENVIRONMENT
VCUHS is a tobacco free environment. Smoking and the use of tobacco products is prohibited in or around any VCUHS facility and all off-campus locations. Use of nicotine replacement patches or lozenges is allowed.
In some areas, respirators (masks) are necessary to protect you from harmful dusts, fibers, fumes, mists, gases, or vapors. Individuals who wear respiratory protection must be fit-tested annually to determine if the respirator is providing an effective barrier. Team members and students who may be exposed to tuberculosis must be fit-tested for a specific (N-95) mask when required to enter an area where possible exposure could occur. If you have not been fit-tested and need to be, talk to your department leadership about the best way to accomplish this prior to an assignment that may expose you to a respiratory risk.
Materials contaminated with blood or body fluids must be discarded properly. Always use standard precautions when handling infectious or medical waste. Use red biohazard bags to dispose of infectious waste materials. Place infectious sharps in a red, biohazard labeled, plastic sharps container that is no more than ¾ full. Do not mix non-infectious sharps with infectious sharps. Sharps contaminated with hazardous medications, including chemotherapeutic agents are not to be placed in containers with infectious sharps. Hazardous medications, including chemotherapeutic agents, must be placed in black labeled disposal containers.
At VCUHS, the main sources of radiation exposure include laboratories, patients, and X-ray producing machines. Some of the areas or departments that use radiation and radioactive material include Nuclear Medicine, Diagnostic Radiology, Radiation Oncology, Clinical Pathology and some patient rooms. Rooms with radiation sources are labeled with a Radiation symbol and say "Caution-Radioactive Materials" or "Radioisotopes Used in this Room." Do not enter these rooms without first talking to VCUHS team members about protective equipment and exposure precautions. If you are in a room when an X-ray is to be performed, either leave the room or put on the personal protective equipment.
Do not use equipment that is not functioning properly. Remove the equipment from service and ask a VCUHS team member to tag it with a DEFECTIVE tag. The team member will report it Clinical Engineering for repair.
If you are injured while on VCUHS premises, please ask a VCUHS team member to assist you in completing an occurrence report. Follow VCU's procedures for reporting injuries and obtaining treatment. If you need emergency care, the VCUHS Emergency Department is located on the ground level of the Critical Care Hospital.
PERSONAL SAFETY PRECAUTIONS
VCUHS is committed to providing a safe environment to work, learn and receive care. The VCU Campus Police patrols all areas of both the Monroe Park and Medical Center Campus. In addition, MCV Hospitals has a Security team that monitors access to the facilities and provides support with building checks and problem resolution. If you have an emergency while on the Medical Campus, call 828-1234 or 8-HELP. This will allow you access to help quicker than 911 since our police officers are already on site. If you would like an escort to your car between the hours of 5 pm and 8 am, an escort service is available by calling 828-WALK. Security phones are located throughout the campus in blue or yellow boxers with a flashing yellow light above them. You need only remove the phone from the cradle or push the button to activate a call to the police department.
DRUG FREE SCHOOL AND WORKPLACE
VCUHS expects all individuals providing care or customer services in our environment, including students, to be able to do so competently and unimpaired by chemical substances. If you suspect an individual of being impaired in the performance of their duties, please report your concern to the department manager of that area. If a researcher is suspected of being impaired, they will be reported to their department and removed from their assignment. Researchers may not return to their assigned area until confirmation is received by VCUHS that the individual is drug/alcohol free.
Patient safety should be taken into consideration in all our interactions with patients, including factoring in the patient's age and medical condition in response to the activity being required. As you begin your research, ask the team members in your assigned area what special safety precautions should be implemented based on equipment used, hazards in the area and measures used specifically to protect the unique patient population on that unit.
UNUSUAL OCCURRENCE REPORTING
As part of our patient safety and performance improvement initiatives, any unusual occurrence that you witness or experience while conducting research should be reported to a VCUHS team member so they may accurately record it in our safety reporting system referred to as Safety Intelligence. This reporting mechanism is used to assess patient and team member risk exposure so appropriate action can be taken to eliminate or reduce risks in the future.
Being a healthcare environment, patients are admitted with a variety of contagious pathogens. To provide the safest environment possible, VCUHS fully supports the standards established by the Occupational Safety and Health Administration (OSHA) and the Center for Disease Control (CDC). Standard Precautions must be practiced by all individuals coming in contact with patients.
PROPER HAND WASHING TECHNIQUE:
If hands are visibly soiled:
1. Moisten hands under running water
2. Apply soap
3. Lather applying friction for 15 seconds
4. Clean between fingers and nails
5. Rinse well
6. Use paper towel to turn off faucets
Use alcohol hand rinse when hands are not visibly soiled:
1. Apply 1-2 pump(s) of product
2. Rub hands with friction until hands are dry
In general, the following principles should be observed in caring for patients:
• Avoid eating and drinking in areas where there is potential exposure to blood and body fluids
• Do not use mouth pipetting
• Do not store food, medications, and specimens in the same place (e.g., refrigerator)
• Do not manipulate, bend, recap, or remove used needles.
• Replace sharps containers when approximately 3/4 full
• Use tongs or dustpan and broom to pick up broken glass
• Place all linen in fluid resistant (impervious) linen bags
• Dispose of infectious waste (any material or item contaminated with blood or body fluids, sharps, pathological and microbiological waste) in red biohazard bags or sharps container
• Place specimen containers into a clear plastic, resealable bag
• Promptly clean up small blood/body fluid spills (per Infection Control manual)
• Contact Environmental Services to handle large blood/body fluid spills
• Clean and disinfect all equipment and surfaces that come in contact with blood and body fluids as specified in Infection Control policy manual (found on intranet)
• Use appropriate hand hygiene to include washing hands
• Before and after patient contact
• After handling potentially contaminated items
• After removal of gloves
• Before eating
• After going to the restroom
• After blowing your nose/coughing/sneezing
• Before inserting or removing contact lenses
• After handling trash
PERSONAL PROTECTIVE EQUIPMENT (PPE)
When caring for patients needing special precautions, wear appropriate devices to protect you and others from exposure including goggles, gowns, gloves, and masks. Before caring for patients with airborne precautions, you need to be fitted for a protective N-95 mask. Registration for N-95 mask testing is completed by calling the fit testing office at 628-5866. The location for testing is the top level of D-deck in the trailer located at the top of the entrance ramp.
CATEGORIES OF PRECAUTIONS
The following categories of precautions are used in addition to Standard Precautions when indicated:
AIRBORNE PRECAUTIONS - used to prevent diseases transmitted by the airborne route (droplet nuclei or contaminated dust particles) by talking, coughing, or laughing. (Example - Flu, TB)
DROPLET PRECAUTIONS - used to prevent diseases transmitted by infectious droplets (large-particle droplets that do not remain suspended in the air). (Example: Pertussis, Rubella)
CONTACT PRECAUTIONS - used to prevent diseases transmitted by direct touch (touching the patient) or indirect (touching surfaces or objects in the patient's environment) contact. (Example: Conjunctivitis, staph infection)
FLU VACCINATION REQUIREMENT
The Centers for Disease Control (CDC) especially recommends the seasonal flu shot for health care workers; adults 65 years and older; persons with underlying chronic medical conditions and/or those with weakened immune systems; pregnant women or those who may become pregnant during flu season. Effective October 1, 2015, all persons, including students & observers, participating in clinical activities at VCU Health are required to receive the flu vaccination for current season unless contraindicated based on a documented medical condition. If you would like to file for a medical or religious exemption, please reach out to email@example.com for the correct forms (typically, the due date for exemptions is late August/early Sept). After that date, confirmation of receipt of the currently recommended flu vaccine is required prior to placement at VCUHS.
Please note that flu vaccination record is not required during non-flu season, which is usually Oct 1st to May 31st, as indicated by the Virginia Department of Health annually.
COVID19 VACCINATION REQUIREMENT
Effective August 6, 2021, all persons, including students & observers, participating in clinical activities at VCU Health are required to receive the flu vaccination for current season unless contraindicated based on a documented medical condition. You must confirm full or partial vaccination by September 15, 2021 and confirm full vaccination by October 18, 2021. If you would like to file for a medical or religious exemption, please reach out to firstname.lastname@example.org for the correct forms. Confirmation of receipt of the currently recommended COVID19 vaccine is required prior to placement at VCUHS.
I acknowledge and understand that I may have access to proprietary and/or other confidential information belonging to or required to keep confidential by the Health System, including without limitation, confidential information regarding affiliates, business operations, financial information, patients, (especially HIV, Drug & Alcohol, and Psychiatric information), patient care, students, team members, and trade secrets (collectively "Confidential Information"). Confidential Information also includes protected health information ("PHI") governed by the Health Insurance Portability and Accountability Act ("HIPAA"). PHI includes any individually identifiable information in possession of or derived from the Health System regarding a patient's medical history, mental, or physical condition or treatment, as well as the patient's and/or their family member's records, test results, conversations, research records and financial information.
I understand, acknowledge, and agree that my obligation of confidentiality extends to any Confidential Information that I may acquire during the course of my employment or affiliation with the Health System, whether in oral, written, or electronic form and regardless of the manner in which it was obtained.
I understand and agree to only retrieve, view, and use Confidential Information on a need to know basis for my position and responsibilities. Therefore, except as required by the Health System or by law, I agree that I will not: (a) disclose to any other person; or (b) access unauthorized or unnecessary information; or (c) allow any other person access to, any information related to the Health System which is proprietary, confidential, private, and/or pertains to patients, patient care, team members except as necessary in the performance of my duties.
Patient, employee or other information must be de-identified (unless it is necessary for patient care) and be limited to the minimal amount necessary. I also understand and agree that unauthorized use or disclosure of Confidential Information may result in corrective action, up to and including termination of my affiliation with the Health System and could result in the imposition of civil and criminal penalties under applicable laws, as well as professional disciplinary action.
With respect to Confidential Information, I must:
1. Use Confidential Information for the sole purpose of performing my duties for the Health System, and where required by or permitted by law, and in a manner which is consistent with officially adopted policies of the Health System. Where no officially adopted policy exists, I will only do so with the express approval of my supervisor or designee;
2. Not disclose any Confidential Information to any person whatsoever (particularly with respect to HIV, Drug & Alcohol, and Psychiatric) except in direct connection with the performance of my job or responsibilities for the Health System;
3. Not copy or reproduce, or permit any person to copy or reproduce, in whole or in part, any Confidential Information other than in the regular course of the services that I am authorized and requested to perform for the Health System;
4. Comply strictly with all applicable laws, standards, regulations, and Health System policies governing confidential information;
5. Report immediately to the Health System any unauthorized use, duplication, disclosure, and/or dissemination of Confidential Information, including protected health information, by any person, including myself;
6. Immediately report any unauthorized uses or disclosures of patient related Confidential Information that I become aware of to my manager/supervisor and Health System Compliance Services; and
7. Speak with my supervisor regarding any questions that I may have regarding compliance with the terms of this agreement.
Disclosure of Confidential Information includes but is not limited to verbal discussion, fax transmissions, electronic transmission (such as email and text), voice communication, written documentation, "loaning" computer access codes, social media discussion/comment, photographing, scanning, and/or other electronic transmission, sharing, copying, or storing of data.
I acknowledge, understand and agree: (a) to protect the confidentiality of all data residing in information systems particularly related to personal health information (PHI) and privacy; (b) my system access is based upon my Health System duties or responsibilities; and (c) if my role or responsibilities change, my system access will change accordingly. I furthermore acknowledge, understand and agree that I must:
• Use Health System information systems and data to conduct Health System business only.
• Not disclose my User ID or confidential code to any individual nor will I use any User ID or code that has been assigned to another user. I understand that I will be held responsible for the consequences of any misuse occurring under my User ID or code due to negligence on my part, including failure to close an application opened using my code.
• Immediately report to my Manager/Supervisor and/or IS Security if there is any reason to believe that my User ID or codes have been compromised.
• Respect and maintain the confidentiality of all patient, student, team member, and private or sensitive information accessed in any Health System information system. I am responsible for the safekeeping and handling of financial, medical, patient and personal information including in part unauthorized disclosure.
• Not access system data to satisfy personal curiosity; this is strictly forbidden.
• Not share data with persons who are not authorized to have access to it or do not have an appropriate 'need to know'.
• Not to alter, add to, delete from, or otherwise change system data, hardware or software without proper authorization and that I will heed warnings not to access or download information unrelated to my job responsibilities.
• Only access Confidential Information to perform tasks for which I have responsibility and proper authorization.
• Follow the Health System information system access policies and procedures. Failure to follow the system access policies and procedures may result in the revocation of my system privileges and/or disciplinary action(s) up to and including termination of employment or services and possible criminal charges.
• Not disclose any Confidential Information after my employment or association with the Health System ends.
I further understand, acknowledge and agree that:
• All Health System information system access and use is subject to security monitoring and auditing and that the Health System will take appropriate action when improper uses are detected up to and possibly including termination of employment, affiliation agreement, or access to premises/systems.
• Equipment/resources provided by the Health System are made available to me for a business purpose(s), and are the property of the Health System. Therefore, the Health System has the right to access/inspect equipment, including but not limited to, personal computers, electronic mail systems, databases, phones, etc. to determine that it is being used as authorized.
• Attaching any personal devices to Health System equipment or systems is prohibited. Non-health system issued devices attached to Health System information systems are subject to inspection for purposes of determining if confidential data has been accessed, removed and/or transferred to the device.
• The Health System will incur irreparable harm by the inappropriate disclosure of such Confidential Information and it retains all of its rights under law and equity including without limitation injunctive relief and damages.
• Violations of this agreement and/or the Health System policies regarding confidentiality and/or privacy may result in corrective action, up to and including termination of employment and/or affiliation agreement and forfeiture of authorization to access systems, property, or resources.
• My obligations under this agreement shall survive my separation or termination of my affiliation, employment, rotation or time at the Health System.