Orientation Kaiser Permanente Medical Center Santa Rosa Employees

Orientation Kaiser Permanente Medical Center Santa Rosa Employees, Students, Patient Advisors, Volunteers Revised April 2014

Table of Contents • What is Kaiser Permanente? • Patient Rights and Responsibilities • Compliance • Safety Ø Injury and Illness Prevention & Reporting Ø Infection Control Ø Codes • Security Ø Parking and no-smoking policies Ø Identification Page 2

What is Kaiser Permanente? Page 3

Kaiser Permanente History • In 1934 Dr. Sidney Garfield and Industrial Indemnity team up during a time when everything was fee for service. Executives suggested 5 cents per day person. • Kaiser membership grew to 100, 000 during WWII and dropped below 15, 000 at the end of the war when peace time jobs became available. • Physicians visited the job sites to develop processes to prevent injuries. • Kaiser Oakland Hospital opened in the 1940 s and it was not segregated unlike most other hospitals at that time. Page 4

7 Principles of Kaiser Permanente 1) 2) 3) 4) 5) 6) 7) Prepayment of Medical Bills Prevention Group Practice Integration of Facilities Voluntary Enrollment Physicians' Responsibility Nonprofit Operation Page 5

Founded in 1945, Kaiser Permanente is the nation’s largest not-for-profit health plan, serving more than 9 million members, with headquarters in Oakland, California. Kaiser Foundation Health Plans The Kaiser Foundation Health Plans are nonprofit, public benefit corporations that contract with Kaiser Foundation Hospitals and medical groups to provide services. In our regions that are not hospital-based, they may contract with non-Kaiser hospitals. The Health Plans are the health insurance component of the organization. Each region has its own health plan company. Permanente Medical Groups are partnerships or professional corporations of physicians, represented nationally by The Permanente Federation, which contract exclusively with the Kaiser Foundation Health Plans to provide or arrange medical services for members and patients. Kaiser Foundation Hospitals is a nonprofit, public benefit corporation that owns and operates community hospitals in California, Oregon, and Hawaii. The corporation owns outpatient facilities in several states; provides or arranges hospital services; and sponsors charitable, educational, and research activities.

Kaiser Permanente Regions Recognized as one of America’s leading health care providers and not-for-profit health plans, Kaiser Permanente serves members in eight states and the District of Columbia through seven separate regions, each with its own leadership. Northern California One of the largest of the Kaiser Permanente regions, Northern California currently serves members in 20 counties. Southern California The largest of Kaiser Permanente’s regions, Southern California serves the Coachella Valley, also Los Angeles, Orange, Kern, Riverside, San Bernardino, San Diego and western Ventura counties. Hawaii Since 1958, Kaiser Permanente has served the people of Hawaii. The region today serves the islands of Oahu, Hawaii, Maui, Kauai, Lanai and Molokai. Northwest Among Kaiser Permanente’s oldest regions, established in 1951, Northwest serves members in Portland Salem, Oregon, also southwest Washington. Colorado Established in 1961, Kaiser Permanente’s Colorado region serves members in Denver, Boulder and Southern Colorado. Georgia One of Kaiser Permanente’s regions, Georgia serves members in the metropolitan Atlanta area. Mid-Atlantic States Kaiser Permanente’s only East Coast region, Mid-Atlantic States serves members in Maryland, Virginia, and the District of Columbia. Page 7

Kaiser Permanente National Fast Facts • • • Medical Centers: 38 Medical Offices: 611 Physicians: ~ 16, 900 + Nurses: ~ 48, 700 + Employees: technical, administrative, clerical employees and caregivers ~ 174, 200 + Page 8

Our Brand We stand for Total Health. Kaiser Permanente’s integrated health care delivery system and commitment to preventive care empowers our members to maximize their total Care for members and patients is focused on their health — mind, body, and spirit. total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community Page 9 health.

The Value Compass represents our strategy Kaiser Permanente delivers value to our members, customers, and communities by striving to achieve balance on all four points of the compass. Page 10

Our Service Credo Our Cause is Health. Our Passion is Service. We’re Here to Make Lives Better. Page 11

Kaiser Permanente Santa Rosa Medical Center (SRO) The Permanente Medical Group Kaiser Foundation Hospital Judy Coffey, RN, Senior VP/ Area Manager Vicky Locey, RN, Chief Operating Officer Chief Nursing Officer Kirk Pappas, MD Physician In Chief Page 12 Guy Chicoine, MBA Medical Group Administrator

Santa Rosa’s Mission, Vision and Aspiration Mission A Healthy Community Vision Excellence in Quality and Service Partnership with those we serve Aspiration World Class Medical Center Page 13

Fast Facts about Kaiser Permanente Santa Rosa Members Physicians and Staff Licensed Hospital Beds Births (2013) Emergency Dept. Visits (2013) Hospital Discharges (2013) Prescriptions Filled (2013) 146, 413 Services • Primary care and Specialty care • Hospital services including emergency, 2, 640 critical care, medical/surgical, pediatrics, labor and delivery, perioperative services, and interventional radiology 173 • Primary Stroke Center • Occupational medicine 1, 898 • Rehabilitation services including physical, speech, and occupational therapy 47, 288 • Laboratory • X-ray and imaging • Pharmacy • Health education 8, 021 • KP Health. Connect electronic medical records • My Doctor Online tools: e-mail your doctor, 1, 226, 00 schedule routine appointments, refill 0 Page 15 prescriptions, view many lab test results, healthy living programs, and summaries of

Patient Rights and Responsibilities Page 16

Patient Rights • Access to Care • Respect and Dignity • Privacy and Confidentiality • Personal Safety • Identity • Access to Medical Records Page 17 • Transfer and Continuity of Care • Refusal of Treatment • Ethical Issues • Conflicts/Complaints • Pain Assessment & Management • Consultation

Patient Responsibilities • • Provision of Information Compliance with Instructions Refusal of Treatment Financial Charges Hospital Rules and Regulations Respect and Consideration Pain Assessment and Management Page 18

Honoring Diversity “Diversity at KP is not an initiative; it is who we are as an organization from the boardroom to the hospital room. ” George C. Halvorson, Former Chairman & CEO Kaiser Permanente • Watch for signs of communication misunderstandings. • Identify and record a patient’s primary language and dialect in Health. Connect. • Be patient and respectful of culture and language differences. • Consider that cultural issues may exist for illness or treatment plans. • Know how use Santa Rosa language assistance Page 19 resources – ask your supervisor or check the intranet

Kaiser Permanente Compliance Page 20

What does compliance mean? Compliance means to fully adhere to: • • • Loss of trust and good reputation • Loss of community respect Federal, state, and local laws/regulations • Exclusion from federal programs (Medicare and Medicaid) Federal health care program requirements • Fines, penalties, sanctions, and potential prosecution Licensing & Accreditation standards • Increased government oversight • Possible loss of our accreditations • Disciplinary action and/or termination of employees IRS requirements (non-profit status) • KP Policies & Procedures It is ……Doing the Right Thing! Page 21

Importance of Compliance • Protect the health and safety of patients and employees • Continue KP’s mission of providing Quality and Affordable Healthcare • Ensure continuity of services without interruption by maintaining accreditation and licensing Page 22

Compliance at Kaiser Permanente The Compliance Community Daniel Garcia Chief Compliance Officer National KP • • Cris Mac. Kenzie Compliance / Privacy Officer Marin /Sonoma Your immediate supervisor Your HR representative Your compliance office Maura Anderson (707 -3932846) • KP Compliance Hotline (1 -888 -774 -9100) • Your Union representatives Page 23

Kaiser Permanente Principles of Responsibility (Code of Conduct) • Communicates KP’s expectations at work so we know how to do the right thing! • Applies to everyone including volunteers and contractors • Presents a summary of laws and regulations governing health care organizations • Protects against Fraud, Waste & Abuse • Reminds employees to avoid conflicts of interest and to protect Page 24 organizational assets

Your Responsibility to Prevent Fraud You are expected to identify and report potential fraud, waste & abuse What does this mean for you? 1 2 3 Page 25 Recognize unusual behaviors or areas that could lead to potential fraud, waste & abuse Report to Compliance & Privacy Officer areas you identified posing a risk for fraud, waste & abuse Follow KP’s Policies, communicate concerns to your supervisor, HR or Compliance & Privacy Officer

Six Principles to help insure privacy and security of patient information 1. 2. 3. 4. 5. 6. “Need to know” – only access, use or disclose patient information needed to do your job. You cannot access your own record or those of family members in KP Health. Connect. “Minimum Necessary” – only access, use or disclose minimum information needed to do your job. Safeguard patients’ information as if it were your own. This applies to electronic, written and verbal information. Report to your supervisor or Compliance Officer immediately when you have concerns or observed situations impacting privacy of individual patients or organizational expectations. Never Assume - Confirm that PHI (Protected Health Information) is necessary information. If you don’t know ask your supervisor or Compliance Officer. Golden Rule - Always treat patient information as if it were your own and a patient’s important personal Page 26 matter.

Safety Page 27

Safety Motto SAFETY FIRST, Then TEAMWORK! Page 28

Santa Rosa’s Safety Team If Needed Dial “ 3 -6000” - Off Sites 8533 -6000 Environmental Health & Workplace Safety Manager: Judi Good Environmental Health & Safety (E H & S) Coordinator: Tammy M E H & S Department Secretary: Laura Settlemyer Emergency Preparedness: Gabe Kearney Work Place Safety (WPS) Specialist: Bill Fitchett WPS Project Manager: Nancy Abela Page 29

Injury and Illness Prevention ü Orientation: No employee should be expected to work without orientation. ü Safety: Never undertake a job that is unsafe. ü Chemicals: Never use chemicals without safety knowledge and skills. ü Reporting: Report unsafe conditions. ü Injuries: Report within 24 hours. ü PPE: Use Personal Protective Equipment Page 30

Injury Reporting ü Notify within 24 hours Call Employee Health (EH) for Visit or Phone Consultation. EH makes Medical Referrals Provide Manager with VOT (Verification of Treatment). If Injury NOT FIRST AID receive DWC-1 Form (Workers Compensation Claim Form). Only report to the Emergency Department if the Injury is Emergent such as: Exposure to Eyes, Sharps, Critical Injury. Page 31

Infection Control: Hand Hygiene • Wash hands or use alcohol de-germer before and after patient contact, and after removal of personal protective equipment (PPE). • After every patient with Clostridium difficile (C. diff), you must wash hands with soap and water. Alcohol de-germer does not kill C. diff spores. • Wash hands with soap and water for at least 15 seconds. Page 32

Protect yourself and our patients • No food or drink is permitted in patient care areas, where lab specimens are set, in the presence of patients or visitors, or at clinical computer stations. • Clean up small liquid biohazard/blood spills and allow to air dry. Call EVS for large biohazard/blood spills. • Contact your Supervisor/Manager or the Safety Department (393 -6000) if you are uncertain how to clean-up a chemical spill or dispose of spill cleanup debris. • If you have a needle stick or eye injury, immediately contact your Manager for guidance, and report to Employee Health, if open, or Emergency Page 33 Department, within 1 hour to assess need for

Code Red – if there’s a fire… R A C E Rescue/Remove Alarm Confine/Contain Extinguish Page 34

Protect-in-Place vs. Evacuate Protect in Place: Hospital and Outpatient Surgical Dept. - MOB-5 ü Assess Area for Smoke or Fire ü Pull Alarm & call x 3 -6000 or 8 -533 -6000 Evacuate only if ordered - Do not use elevators: * 1 st horizontally to closest fire compartment * 2 nd down to next floor * 3 rd to outside Evacuate: All Medical Office Buildings (except the Outpatient Surgery Department at MOB 5) Support Services Building EVACUATION IS AUTOMATIC ü Coolly - calmly leave by nearest safe exit. ü Proceed to evacuation relocation area. Page 35

Code Triage Will Be Paged Overhead for: • • ACCIDENTS EARTHQUAKE EMERGENCY FLOODS Return immediately to your department. Be prepared to be assigned to help. Page 36

Code Pink / Purple A Code Pink / Purple is paged overhead if an infant (Pink) or child (Purple) is missing or is being abducted or there is any unusual activity related to infants or children. Prevention § Green Identification Badges in Maternal Child. § Security Officer on duty 24 -7. § Must swipe in or sign out a security card to enter. Actions for suspicious activity § Call 3 -6000 report. § Off-sites – call 393 -6000; MOB 4/5 & Rohnert Park, use phone intercom to page “Code Pink / Purple” overhead. Actions when Code Pink or Code Purple is announced § Go to pre-assigned area to monitor. § Go to nearest exit or stairwell. § Ask everyone to stay and not leave until the “all clear” is paged. Page 37

Code Blue A Code Blue is called when a patient is not breathing, has no pulse and/ or needs CPR. Bicentennial Campus: ü CALL OUT “CODE BLUE” ü DIAL extension 36000, say “CODE BLUE” All other locations: ü DIAL 911 for offsite locations Page 38

Code Gray A Code Gray is called when you are threatened or are concerned for the safety of yourself or others due to a combative individual. • On the main campus, call 3 -5888, say “Code Gray. ” • At MOB 4, 5 and Rohnert Park, call 8 -533 -5888. • For all other locations, or if there are weapons involved, call 9 -911. • Security will arrive on the scene to evaluate, stabilize or deescalate the situation. Be prepared to: • Give your name, extension and identify exact location of the incident. • Describe if the situation is physical or verbal in nature. Page 39 • Identify if there are weapons involved.

Code Silver A Code Silver should be called when confronted with a person with a weapon or in a hostage situation. • Call 9 -911. • Call Security at 3 -5888 (or 8 -533 -5888 if offsite location) and state “Code Silver”. • State your location, name, number of individuals and types of weapons involved. • All staff near the incident area should not go to the location indicated as this is an extremely dangerous and sensitive situation that should only be handled by trained experts. Page 40

Code Green A Code Green is called when an At Risk Patient* elopes (leaves without permission while undergoing treatment). If you determine or suspect that an at risk patient has eloped § § Dial Operator (PBX) x 3 -6000 and provide: Department and floor, description of patient (gender, age, clothing). Provide your name and location Dial Security at 3 -5888 and provide: Department and floor, description of patient (gender, age, clothing, include ethnicity, if known), last known location and/or direction of travel. Provide your name, location, and contact number When a Code Green is called overhead: § § Conduct an immediate and thorough search of surrounding area, including stairwells and exit locations. Patient may be in dark green disposable scrubs or a dark green gown. Hospital and clinic staff: Monitor exterior exits as assigned in Code Green Page 41 policy.

Abuse Reporting Requirements Child Abuse Reporting Requirements California State Law requires reporting of suspected child abuse. Kaiser Permanente Santa Rosa has a policy, “Abuse Reporting, ” that provides resources to learn to recognize potential abuse, how to get help in making the decision to report, and how to report. This policy is located on our intranet (policies tab/ policy and procedure manager). When in doubt, notify your supervisor if you believe that you may need to report suspected child abuse. Dependent And Elder Abuse Reporting Requirements Kaiser Permanente requires that you understand how to report any signs of abusive treatment of patients. If you find yourself in a situation at work where you suspect evidence of abuse, please refer to the local policy, “Abuse Reporting. ” It will help Page 42 you identify definitions, reporting procedures, and who to call

Security Page 43

Security Services: Santa Rosa Parking Policy It’s Simple – For 401 Bicentennial Way: Monday through Friday § Between 6: 30 A. M. AND 6: 00 P. M. § Park in the Garage; Students park at MOB 5 & use Shuttle § Lower Level is physicians only Weekends/Holidays: § May park anywhere on campus § Excluding designated handicapped spaces Decals are required for all personnel. Page 44

No Smoking Policy § We are a smoke-free campus, including ecigarettes. § Smoking is not permitted on Kaiser Permanente property. Page 45

Employee Identification Badges § Photo ID badge must be visible and worn above the waist at all times while working at the medical center. § Badges are obtained at the Security Office from 8: 00 am to 4: 00 pm in the Hospital Lower Level. § Be aware of those around you – question strangers. Page 46

Message from Leadership: It is expected that all personnel complete annual requirements within the appropriate time frames. Influenza vaccination/mist or declination as well as required trainings including Corporate Compliance, must be completed by the posted deadline date. Annual TB screening must be completed within 10 days of expiration date. There is a 30 -day window for satisfying the Annual Safety Training. Failure to complete the requirements within a reasonable period of time will be considered a voluntary termination. We are committed to Safety. Any workplace injury/illness regardless of the apparent severity must be reported immediately to the manager/designee. Any employee who identifies a risk and/or is involved in an incident that could lead to an injury/illness is expected to advise the manager/designee as soon as possible and no more than 24 hours after the event. Page 47 If you have any questions about the expectations, please speak with your manager or a member of the

Resources Emergency Preparedness Procedures – Rainbow Emergency Chart Santa Rosa’s Intranet site http: //kpnet. kp. org/ncal/santarosa/ Santa Rosa’s Internet site http: //mydoctor. kaiserpermanente. org/ncal/facilities/regi on/santarosa/area_master/home/ My Doctor online http: //mydoctor. kaiserpermanente. org/ncal/mdo/ Page 48