2011

VOLUNTEER
HANDBOOK

ST. LUKE’S- ROOSEVELTHOSPITALCENTER

TABLE OF CONTENTSPAGE

Welcome to St. Luke’s-Roosevelt Hospital Center1 - 2

SLRHCMission, Description and History3

Volunteer DepartmentMission and Organization4

SLRHC Core Competencies

Security6

Fire Safety7 - 8

Emergency Management and Codes9 - 10

Infection Control11

Hand Hygiene/Washing12

Patient Rights13

Cultural Competency14

Language Services15

Advance Directives16

Privacy and Confidentiality17

Accident Reporting17

HCAHPS18

AIDET19

Standards of Customer Care20

Volunteer Policies and Procedures

Responsibilities of Volunteers21

Personal Conduct22

Smoking Policy22

Personal Use of Cell Phones & Electronics22

Transport/Escort of Patients23

Non-Discrimination and Anti-Harassment Policy24 -26

Dress Code & Hygiene27

Reporting Illnesses and Absences28

Health Assessment28

Performance Assessment29

Letter of Service29

Termination30

Exit Interview30

H:\Misc\RH1\Volunte\Handbook\2011 VOLUNTEER HANDBOOK.doc

WELCOME TO ST. LUKE’S-rOOSEVELT HOSPITAL CENTER

Welcome to St. Luke’s-Roosevelt Hospital Center. We are delighted to have you apply to the Volunteer Department. Our hard-working and dedicated volunteers play an important role at the HospitalCenter and enrich the lives of our patients. Whether it is helping an office worker or spending time with patients, each volunteer makes a valuable contribution.

Opportunities for volunteers exist throughout St. Luke’s- Roosevelt. Some of the assignments involve patient contact, while others entail office support. We will try to place you in a position that will reflect a combination of your skills and interests with the needs of the HospitalCenter. Remember – whatever service you perform is vital to the total care received by our patients. We hope that you find your volunteer experience personally fulfilling and derive satisfaction from helping the HospitalCenter provide the highest quality care to its patients.

St. Luke’s – RooseveltHospitalCenter is committed to assuring that all staff members and Volunteers are highly competent and consistently provide qualityservices to our patients and our community. This handbook has been designed as aresource to help volunteers develop and maintain their competence. Topics havebeen selected because of their importance to our patients and our institution.It is essential that you carefully review the Handbook atthe time of your application and during each calendar year thereafter. This is aninstitutional requirement that will help us to meet the mandates of regulatoryagencies such as The Joint Commission, the Occupational Safety and HealthAdministration (OSHA) and the New York State Department of Health(NYSDOH).

If you have any questions about the content of the handbook and how it applies to you

and your assignment, be sure to discuss these issues with thevolunteer administrator for him/her to review with you.

After reviewing the handbook, please complete the test related to the content.Ofcourse, you may refer to the handbook to check for the accuracy of your answers.Give your completed test to the volunteer administrator for him/her to review with you. Please remember to continue to incorporate the information that you have reviewedinto your everyday practice.

You are very special to us. Thank you for your time and interest in joining the St. Luke’s-Roosevelt Hospital volunteer team.

Kathleen Dalton, Director of Volunteer Services

ST. LUKE’S-ROOSEVELT HOSPITAL CENTER MISSION

The mission of St. Luke's RooseveltHospitalCenter is threefold

  • Provide outstanding health care
  • Provide the highest quality education to health care professionals
  • Further research medical knowledge and develop excellence in health care delivery

Our vision is to become the provider of choice for Manhattan's West Side communities.

Description and History

St. Luke's-Roosevelt Hospital Center is a 1,076-bed, full-service community and tertiary care hospital. We are centers of clinical excellence for cardiology, neurology, oncology and much more. Plus, we are leaders in caring for the elderly, treating breast cancer, and providing physical rehabilitation.
St. Luke's-Roosevelt Hospital Center consists of two separate locations - St. Luke's Hospital at 1111 Amsterdam Avenue and RooseveltHospital at 1000 Tenth Avenue. The St. Luke's and RooseveltHospitals were established in 1846 and 1871, respectively. St. Luke's-Roosevelt was formed in 1979 by a merger of St. Luke's Hospital, adjacent to the campus of ColumbiaUniversity, and The Roosevelt Hospital, located two blocks west of Columbus Circle.

We are part of Continuum Health Partners, which also includes Beth Israel, Long IslandCollegeHospital, and New York Eye and Ear Infirmary.

We Care about Community

Throughout our history St. Luke's-Roosevelt has placed strong emphasis on responding with compassion and sensitivity to the unique needs of the communities we serve, including areas whose residents have multiple social and economic challenges.

The HospitalCenter's ability to serve these populations is enhanced through relationships with groups including the WilliamF.RyanCommunityHealthCenter and the CouncilHealthCenter, as well as through school-based clinics at area high schools. St. Luke's-Roosevelt initiates and supports a wide range of community health-focused activities and maintains an extensive network of relationships with churches and community groups throughout the West Side and Upper Manhattan.

VOLUNTEER departmentMISSION

It is the mission of the Volunteer Department to provide St. Luke’s Roosevelt Hospital Center (SLRHC) with highly competent volunteers who consistently provide quality services to our patients to enhance the mission of the Hospital.

It is the philosophy of the Department to provide the Hospital with volunteers who are committed to enhance patient care. It is the function of the Department to provide qualified volunteers where needed in both patient and non-patient areas through recruitment, orientation and training. Therefore, we do not have volunteer positions for shadowing or observing physicians.

Volunteer support is available to most departments in the Hospital however, volunteers in no way replace paid employees.

VOLUNTEER Department organization

The Volunteer Services Department has two offices, one at the St. Luke’s site and one at the Roosevelt site.

1

SLRHC CORE COMPETENCIES

1

Security

“SECURITY IS EVERYONE’S BUSINESS”

MINIMIZE SECURITY RISKS:

  • Wear and conspicuously display, your hospital Identification (ID) badge at all times while on premises
  • Secure your personal belongings
  • Safeguard patient, hospital, personal property

EMERGENCY PROCEDURES

For immediate security response due to threatening, aggressive or violentbehavior

For Security Emergencies at St. Luke’s and Roosevelt-Dial 4444

Inform the operator of a security emergency

REPORTING “NON-EMERGENCY” SECURITY INCIDENTS:i.e. suspicious person in the hallways

Security representatives are available 24 hours/day:

St. Luke’s: 212-523-1000

Roosevelt: 212-523-7512

  • Provide your name and location of the incident
  • Describe the nature of the incident
  • Provide information and description

SECURITY TIPS

  • Stay Alert – observe who is in front of you and whois behind you. Don’t be distracted by diversions
  • Remain calm
  • Without being obvious, take notice of details:clothing, behavior, means of escape, uniquefeatures of persons
  • Exhibit confidence
  • When possible, let someone know where you aregoing and when you expect to return
  • Remember anyone can be a victim of crime at anytime
  • TRUST YOUR INSTINCTS – If you feeluncomfortable, walk away, consider your optionsand notify security or seek other help

Fire Safety

7 TIPS FOR FIRE SAFETY

  • “Fire Code Word” - Never yell “fire” - it can cause fear and panic. Usethe phrase “Code Red” at St. Luke’s-Roosevelt Hospital Center when discovering a fire or smoke situation.
  • Fire Alarms -When fire alarms are sounded, remember to check the fire alarm code chart (located at the stairwells) to find the location of the fire.
  • Elevators -Never use elevators during a fire alarm situation. Useelevators only when directed by the Fire Department.
  • Smoke / Fire Barrier Doors - Designated cross-corridor hallway doorsclose automatically when there is a fire alarm activation. All room doorsare closed by staff. Please provide a quick reassuring word ofexplanation to patients when closing their room doors.
  • Horizontal Evacuation or Area of Refuge - The first mode ofevacuation is moving patients horizontally, to the other side of smokebarrierdoors or a designated area of refuge on the same floor.
  • Vertical Evacuation -Moving patients vertically can be dangerous andshould only be considered as a last resort. This type of evacuation will becompleted only when ordered by Fire Department personnel or thehospital administration. Evacuate personnel at least two floors below thefire/smoke affected area.
  • Storage – Do not store anything within 18 inches of the top of a sprinklerhead.

In the Event of a Fire: Ambulatory patients are evacuated first.

Whenever a fire alarm is activated, remember to implement:

R - RESCUE persons in danger

A - ALARM; yell out CODE RED, pull the alarm, dial 4444

C - CONTAIN fire by closing doors

E - EXTINGUISH fire if possible with an extinguisher

Please ask your manager/supervisor to explain or provide information on your department’s specific fire response. When you are located on your unit or department, please walk around and become familiar with the location of important fire prevention items:

  • Stairwells
  • Manual fire alarm pull stations
  • Fire alarm code charts (know your area’s fire alarm code and the general building codes)
  • Portable fire extinguishers (determine the type of extinguisher for your area, and read the directions on the side of the extinguisher)
  • Smoke and fire barrier doors
  • Medical gas shut off valves and note the area or room(s) they control

(remember medical valves can only be shut upon the direction of unit’s

nurse-in-charge)

IT IS EVERYONE’S RESPONSIBILITY TO LISTEN AND RESPOND APPROPRIATELY TO FIRE ALARM ACTIVATION. YOU MUST ALSO PARTICIPATE IN ALL FIRE DRILLS.

To use a fire extinguisher you – PASS

P- Pull the pin. The pin is in place to prevent the accidental discharge ofthe fire extinguisher. Check its location on the extinguisher.

A- Aim the nozzle. The nozzle is usually clipped to the side of theextinguisher. In the event of a fire, aim the nozzle at the base of the fire.

S- Squeeze the handle. Use firm pressure and squeeze the two handleslocated on top of the extinguisher.

S- Sweep the extinguisher nozzle from side to side. Holding thenozzle and pointing at the base of the fire, the person activating the fireextinguisher should try to move nozzle in a sweeping motion.

EMERGENCY MANAGEMENT AND CODES

EMERGENCY PLAN: CODE D

An event is determined a disaster if the event has an effect on St. Luke’s -RooseveltHospitalCenter’s ability to maintain a ‘safe environment of care’ for patients and staff. Any event that threatens that ability can trigger SLRHC to activate our emergency response plans (Code D plan.)

SLRHC categorizes a disaster/emergency in one of two ways: Internal (fire inside the hospital) or external (a blizzard that hampers staff’s ability to report to work; or a pandemic influenza outbreak.)

The Code D is activated by senior administration on duty and the staff and volunteers are notified by:

  • a series of four fire alarm bells followed by,
  • an overhead announcement: ‘Code D is activated’

If VOLUNTEERS are on assignmentwhen a Code D is activated:

  • Report to your supervisor for direction
  • End all telephone calls that are not an emergency

If VOLUNTEERS are home, and hear about the event on the media call the Continuum Prepares Hotline: 1-877-518-1878 and call the Volunteer Office for further instruction.

CODE PINK

In the event that a newborn, infant, or child is discovered missing from thematernal infant care or pediatric unit, a Code Pink will be activated. Thefollowing announcement will be made over the public address system 3 times:

“Code Pink, (state location), all personnel must report to their assigned locations.”

  • When a Code Pink is announced, all staff in the hospital should go “on alert”and notify Security immediately of anyone acting suspiciously. Be especiallyaware of persons carrying large bags or transporting an infant in arms insteadof in a bassinet.
  • Depending on where you work, you may be assigned to check bathrooms orrooms or monitor an egress. Check with your supervisor about what your roleis when a Code Pink alert is announced.
  • It is important to remember that allemployees and volunteers are the eyes and ears for the Security staff. Notify Security if you see anyone or anything suspicious.

CODE GREEN

What is Code Green? Code green is a response to Non–Life Threatening Medical Emergencies. Code Green assures that non life-threatening medical emergencies that occur on and off Hospital campus will be responded to in an appropriate manner, without putting the patient in danger.

What to do in the event of a Non-Life Threatening emergency oncampus:

  • Once you have identified that another person, (a patient, staff member orvisitor) requires emergency medical assistance but is still alert, pick up thenearest phone and dial 4444.
  • Inform the operator that this is a Code Green, indicating that medicalintervention is required but that the person needing assistance appears alert.
  • The operator calls a Code Green on the overhead paging system to theidentified location.
  • Someone should remain with the patient at all times, providing support andcomfort.
  • The respective Emergency Department responds.
  • The Department of Transportation responds to the site with a stretcher.
  • Once the patient is transported, complete an occurrence report and forwardit to Hospital Administration.

Infection control

Using Standard Precautions reduces the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. In hospitals Standard Precautions apply to:

-blood
-all body fluids, secretions and excretions, except sweat, regardless of whether or not they contain visible blood
-non-intact skin
-mucous membranes

You follow Standard Precautions if and when you:

-practice hand hygiene after touching bodily fluids, blood… whether or not gloves are worn

-use protective equipment to reduce the risk of exposure

-report all needle injuries and mucous membrane exposures as an incident

-use approved hospital disinfectants to clean up and decontaminate spills of blood and body fluids

hAND HYGIENE/HAND WASHING

Hand hygiene remains the single most important way to prevent the spread of infection for patients, associates and volunteers.

The Hand Hygiene Guidelines developed by the Centers for Disease Control and Prevention (CDC) recommend that healthcare workers use an alcohol-based hand wash to routinely clean their hands between patient contacts, as long as their hands are not visibly soiled.

You should always wash your hands:

-after touching patient care equipment or environmental surfaces

-when hands are visibly contaminated or soiled with blood or body fluids

-when caring for a patient with C. difficile, wash with soap and water

-after leaving a patient’s room

-after removing gloves

-after blowing your nose

-after handling garbage

-before and after eating

-after using alcohol based hand rubs 6 times in a row

Hand washing with soap and water is most effective if it’s done for at least 10-15 seconds.

Fingernail Length and Artificial Nails

As per SLRHC dress code policy nail length should be short enough to allow for thorough cleaning underneath the nails and not cause gloves to tear.
Volunteers with direct patient contact may not wear artificial fingernails or extenders
since they are proven risk factors for colonization of organisms of the hand.
Personal Protective Equipment
PPE is primarily described as items worn to protect the skin, eyes, nose and through of associates from pathogens, blood and other bodily fluids. This includes: gloves, mask, eyewear and gowns.
Transmission Based Precautions
Transmission Based Precautions are designed for patients documented or suspected to be infected with a highly transmissible pathogen for which additional precautions beyond Standard Precautions are needed to interrupt spread of the infections.
Types of precautions include: Airborne (e.g. TB Measles); Droplet (e.g. influenza) and Contact (e.g. draining wounds, diarrhea.)
When patients are on precaution, the type of isolation/precaution is identified by a sign on the door to alert all associates, volunteers and visitors.

PATIENTS’ BILL OF RIGHTS

As a patient in a hospital in New YorkState, you have the right, consistent with law, to:

  • Understand and use these rights. If for any reason you do not understand or you needhelp, the hospital MUST provide assistance, including an interpreter.
  • Receive treatment without discrimination as to race, color, religion, sex, national origin,disability, sexual orientation or source of payment.
  • Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.
  • Receive emergency care if you need it.
  • Be informed of the name and position of the doctor who will be in charge of your care inthe hospital.
  • Know the names, positions and functions of any hospital staff involved in your care andrefuse their treatment, examination, or observation.
  • A no smoking room.
  • Receive complete information about your diagnosis, treatment and prognosis.
  • Receive all the information that you need to give informed consent for any proposedprocedure or treatment. This information shall include the possible risks and benefits ofthe procedure or treatment.
  • Receive all the information you need to give informed consent for an order not toresuscitate. You also have the right to designate an individual to give this consent foryou if you are too ill to do so. If you would like additional information, please ask for acopy of the pamphlet “Do Not Resuscitate Orders - A Guide for Patients and Families.”
  • Refuse treatment and be told what effect this may have on your health.
  • Refuse to take part in research. In deciding whether or not to participate, you have theright to a full explanation.
  • Privacy while in the hospital and confidentiality of all information and records regardingyour care.
  • Participate in all decisions about your treatment and discharge from the hospital. Thehospital must provide you with a written discharge plan and written description of howyou can appeal your discharge.
  • Review your medical record without charge. Obtain a copy of your medical record forwhich the hospital can charge a reasonable fee. You cannot be denied a copy solelybecause you cannot afford to pay.
  • Receive an itemized bill and explanation of all charges.
  • Complain without fear of reprisals about the care and services you are receiving and tohave the hospital respond to you and if you request it, a written response. If you are notsatisfied with the hospital’s response, you can complain to the New York State HealthDepartment. The hospital must provide you with the Health Department telephonenumber.
  • Authorize those family members and other adults who will be given priority to visitconsistent with your ability to receive visitors.
  • Make known your wishes in regard to anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the hospital.

CULTURAL Competency