Mandatory Compliance Education Packet Core Content: Rochester Regional Health

Mandatory Compliance Education Packet
Core Content
Rochester Regional Health

Core content for all employees
Rochester Regional Health

Learning & Development
© 2021, Rochester Regional Health
20210101
Mandatory Compliance Education: CORE ǀ January 2021 Contents
Contents
Overview.................................................................................................................1
Purpose................................................................................................................................................... 1
Instructions ............................................................................................................................................. 1
Additional Mandatory Training .............................................................................................................. 1
Organizational Governance & Compliance..............................................................2
Rochester Regional Health Mission, Vision and Values ......................................................................... 2
Charity Care/Financial Assistance Program............................................................................................ 2
Cultural/Age Diversity and Assistance Programs ................................................................................... 3
The Rochester Deaf Community ............................................................................................................ 5
Americans with Disabilities Act .............................................................................................................. 7
Information Privacy and Confidentiality ................................................................................................ 8
Code of Conduct ................................................................................................................................... 11
Professional Misconduct and Reporting Concerns .............................................................................. 12
Quality Assurance, Patient Safety and Performance Improvement .................................................... 13
Health, Safety & Awareness ..................................................................................16
Patient Bill of Rights ............................................................................................................................. 16
Advance Directives ............................................................................................................................... 16
Patient Safety ....................................................................................................................................... 16
Patient Complaints ............................................................................................................................... 17
Abuse, Neglect, and Domestic Violence ............................................................................................... 20
Smoke-Free Environment ..................................................................................................................... 22
Stroke Alert/Signs of a Stroke .............................................................................................................. 22
Ventricular Assist Device (VAD) ............................................................................................................ 24
Infection Prevention ............................................................................................................................. 24
Injury Prevention .................................................................................................................................. 28
Reporting Incidents and Good Catches ................................................................................................ 30
Security & Emergency Essentials...........................................................................33
Emergency Codes/Phone Numbers by Location .................................................................................. 33
Emergency Management & Disaster Planning ..................................................................................... 37
Safe Medical Devices ............................................................................................................................ 37
Fire Safety Procedures and Prevention ................................................................................................ 38
Electrical Safety .................................................................................................................................... 43
© 2021, Rochester Regional Health i

Mandatory Compliance Education: CORE ǀ January 2021 Contents
Hazard Communication Regulations .................................................................................................... 44

Security Management .......................................................................................................................... 46
Workplace Violence.............................................................................................................................. 48
Active Shooter ...................................................................................................................................... 49
Bomb Threats ....................................................................................................................................... 50
Naming Conventions and Use of Icons

For the purposes of this packet, “Rochester Regional Health” or "RRH" will mean all “Rochester
General Health System and Affiliates,” “Unity Health System and Affiliates,” “Clifton Springs
Hospital & Clinic Affiliates,” “Newark-Wayne Community Hospital and Affiliates,” “United Memorial
Medical Center and Affiliates,” “Genesee Region Home Care Association Inc. and Affiliates (‘Lifetime
Care’),” and “Genesee Region Home Care Ontario County and Affiliates (‘Home Care Plus’).”
The word “patient(s)” also may refer to client(s), resident(s), participant(s), etc.
Icons are used to call appropriate attention to specific content such as:
Indicates information that is a note or reminder.
Indicates a stop or warning; something that must be done or a policy that must be
followed in order to proceed.
© 2021, Rochester Regional Health ii

Mandatory Compliance Education: CORE ǀ January 221 Overview
Overview
Purpose
The Joint Commission and DNV (Det Norske Veritas) Healthcare Inc. require documented in-service
training on many topics for new employees. In addition, federal and state regulating agencies such as
Occupational Safety and Health Administration (OSHA) and the Department of Health (DOH) also direct
Rochester Regional Health in training our employees. To help you understand our regulatory obligations
and your role in ensuring Rochester Regional Health remains in compliance, the Rochester Regional
Health Clinical Education Department has compiled these topics into a single “packet in-service.”
Instructions
1. Read each topic. This will give you the key points of the policy. If you need more information,
ask your leader for clarification.
2. Continue to the assessment and answer the questions to show that you have read and
understand the information.
If you have questions about this packet, call Rochester Regional Health Clinical
Education at
585-922-1424.
Additional Mandatory Training

Not Covered In This Packet
If applicable to your job, some mandatory requirements are not fulfilled by reading this packet. Please
contact your leader to determine when and how to complete any additional mandatory training.
Skill Competency Requirements

If applicable to your job, skill competency may need to be demonstrated. Please contact your leader to
determine when and how to complete your specific skill competency requirements.
© 2021, Rochester Regional Health 1

Mandatory Compliance Education: CORE ǀ January 2021 Organizational Governance & Compliance
Organizational Governance & Compliance

Rochester Regional Health Mission, Vision and Values
 Mission: To enhance lives and preserve health by enabling access to a comprehensive, fully
integrated network of the highest quality and most affordable care, delivered with kindness,
integrity and respect.
 Vision: Lead the evolution of healthcare to enable every member of the communities we serve
to enjoy a better, healthier life.
 Values:
 Quality: By setting and surpassing higher standards, we will continue to build a smarter,
faster, more efficient organization that delivers excellent, appropriate care in the right place
at the right time.
 Compassion: Our culture of caring will be unmistakable in every personal interaction as we
treat individuals, families and colleagues with empathy, honesty and openness.
 Respect: We will treat each individual with caring consideration and value the diverse
perspectives each one of them can bring.
 Collaboration: By working together across disciplines and locations to share knowledge and
skills, and through constant communication with those we serve and their families, we will
create a unified, integrated approach to care.
 Foresight: We will anticipate the challenges tomorrow may bring and develop new and
innovative ways to inspire healthier communities.
Charity Care/Financial Assistance Program

Rochester Regional Health is committed to caring for patients 24 hours a day, seven days a week, 365
days a year, regardless of their ability to pay. The Charity Care/Financial Assistance Program was
developed to help Rochester Regional Health meet the needs of our patients who are either uninsured
or underinsured. The following principles and guidelines explain how Rochester Regional Health assists
patients who cannot afford to pay for part or all of their essential healthcare service and how to access
the Charity Care/Financial Assistance Program. Rochester Regional Health:
 Believes fear of a hospital bill should never get in the way of seeking and providing essential
health services.
 Is committed to creating and abiding by financial aid and debt collection policies consistent with
its mission and core values.
 Communicates its Charity Care/Financial Assistance policy in clear, understandable terms and
sensitive to each individual's dignity.
 Is committed to working with government, employers, consumer groups, payers, etc. to find
solutions to expand healthcare coverage to all individuals seeking care.
 Expects eligible patients to access public and private insurance options and to maintain personal
responsibility for their care.

 Protects patient confidentiality in all aspects of its operations including the Charity Care
Program.
 Has trained and designated staff to interview patients without full insurance coverage to
determine insurance and/or Charity Care eligibility and to provide assistance to patients with
the application process. In addition, any patient may contact Patient Financial Services to learn
more about the Charity Care Program.
For more details, refer to http://www.rochesterregionalhealth.org/billing-insurance or call Patient
Financial Services at 585-922-1900.
Lifetime Care employees should contact their manager for Charity Care details.
Cultural/Age Diversity and Assistance Programs

Diversity & Inclusion and Cultural Competence
Rochester Regional Health’s mission is to enhance lives and preserve health through a diverse and
inclusive environment that mobilizes all employees to provide culturally competent care.
As such, Rochester Regional Health promotes an inclusive environment that welcomes the full
engagement of all employees embracing the strength of their differences and fosters a sense of
belonging that cultivates high performance.
Healthcare accreditation organizations such as The Joint Commission and DNV as well as other
regulatory agencies require healthcare workers to be competent in meeting the needs of all
populations. This means that employees must be culturally competent so they can determine and/or
adjust care plans based on age, language, learning barriers, or etc.
Every patient comes to Rochester Regional Health with their unique experiences and needs.
Understanding and valuing the diversity of these unique experiences and needs will help guide efforts
for the individual patient.
What is diversity? Diversity represents the dimensions that can be used to differentiate groups (e.g.,
race, gender, ethnicity, age, national origin, disability, sexual orientation, education, religion,
perspectives, work experiences, lifestyles and cultures). Diversity is often defined in two ways—
representational and cognitive:
 Representational diversity: Identity differences (e.g., gender, race, nationality, physical or
mental abilities, sexual orientation, and so on).
 Cognitive diversity: Differences in how one thinks and acts; in the context of the workplace,
cognitive diversity is expressed in the different ways one sees problems and searches for
solutions.
What is cultural competence? Cultural competence functions at two levels – the individual employee as
well as the organization overall. For an individual, it is his or her ability to function compassionately and
effectively in the presence of difference. An individual’s cultural competence includes three areas:
 Awareness: Starts with self-reflection of one’s own assumptions and values, understanding
that “my way may not be the only or best way”
 Knowledge: Basic information about groups served

 Skill: Being effective in accommodating the differences in others, in determining their needs
as well as how they can be best served
The cultural competence of the organization is reflected through the set of congruent behaviors,
attitudes, policies, and structures that come together, which enables effective work in cross cultural
situations.
Age-Related Considerations
 Each stage of life (such as infant, child, adolescent, adult, etc.) shares certain qualities such as
cognitive abilities and world view, but these may change over the lifespan.
 Every individual has his or her own likes and dislikes, spiritual beliefs, and emotional dimensions.
 Considerations should be taken to adapt approaches and care plans for patients, depending on
the individual’s stage of growth and development.
Cultural Considerations
 What are common health practices of this person’s culture? Think about complementary and
alternative health services.
 What specific family/gender issues exist?
 What is the role of women, head of household, parents, and children?
 How are major health decisions made?
 How do members of the individual’s culture communicate?
 What is the significance of body language, gestures, tone of voice, eye contact, and touch?
 Which family members take the lead in communicating with people outside of their culture?
Roadblocks to Effective Care
 Language barriers
 Learning difficulties
 Physical impairments
 Emotional stress
Language Assistance and Interpreter Services
Effective communication between patients, their authorized representatives, and their healthcare
providers is vital to achieving access to quality care and ensuring good health outcomes. To ensure that
persons with Limited English Proficiency (LEP), those who are deaf or hard-of-hearing, those who are
blind or visually impaired, and those with physical , intellectual, and/or developmental disabilities have
meaningful access and equal opportunity to the services, programs, and information that Rochester
Regional Health provides, a comprehensive language assistance program has been developed.
Interpreter services and language assistance needs are coordinated for the RRH system through the
Interpreter Services department located at the Rochester General Hospital (RGH). All personnel should
be aware of potential language barriers when dealing with patients and their family members.

The Language Assistance Program includes the following:

 The identification of the patient preference and language needs wherever they access their
healthcare services. (Note: In some locations, language interpretation cards are available in
clinical areas to assist treatment team members with the determination of the language that the
patient identifies as the language he or she uses to communicate effectively.)
 The provision of language interpreting and translation services within a reasonable period of
time and at no cost to the individual or to their authorized representatives through a number of
resources, including but not limited to medical interpreting through contracted vendors and use
of dual handset interpretation phones located in all clinical areas.
 Policies and procedures, compliant with federal and state laws, that address the access of
services for people requiring help with communication.
 Policies and procedures describing patient and staff education on Language Assistance and
Interpreter Services.
 Commonly used forms available in languages most representative of patient needs and
identified through an annual language assessment.
Interpreting services may include qualified in-person, on-site interpreters, both for American Sign
Language (ASL) and foreign languages, video remote interpreters, or over-the-phone interpreters.
Generally speaking, interpreting requests are handled by Interpreter Services located at RGH. The
person or office handling your requests may vary at your affiliate.
Interpreter Services at RGH or the assigned delegate at other affiliates should be notified immediately
when appointments are made for patients who need interpreting services. Call 585-922-4673 during
business hours, email Interpreter Services, or schedule through Care Connect. To manage language
assistance needs off-hours, during the weekends, holidays, or those that are emergent in nature (such
as Emergency Department visits), call the switchboard operator for available options and technologies
or the appropriate contracted agency for ASL needs.
To meet the patient language needs on your campus or specific location, please check with your leader
for the proper procedure to use to make request for interpreting services. For more information, refer
to the Interpreter Services policies located on the RRH Home Page under “Policies” for Clifton Springs
Hospital & Clinic (CSHC), RGH and Unity Hospital, as well as other procedures that may exist within your
department.
At UMMC, refer to the “Interpreter Services Non-English Speaking, Hearing , Visual Impaired, Reading
Disability, Language Line & Sign Language Interpreter” policy listed on the UMMC Intranet.
The Rochester Deaf Community

A CRITICAL MASS: As a Rochester Regional Health employee working in Rochester and the surrounding
area, it is highly likely that you will encounter Deaf and Hard-of-Hearing (D/HH) people for whom
American Sign Language (ASL) is a primary language and bond. Rochester has the highest per-capita
population of D/HH adults of any U.S. city. It is known as a Deaf Community hub.

Rochester Regional Health seeks to reduce the healthcare inequities historically experienced by D/HH
persons by raising awareness and providing its staff with education to ensure that D/HH patients and kin
receive the appropriate language accessibility and accommodations necessary to manage a safe
healthcare encounter and good patient experience.
PEOPLE OF THE EYE: The Deaf community may best be characterized as “People of the Eye.” They
depend on their eyes in everyday life (not their ears, hearing aids, amplification, radio, or public-address
systems, etc.). Visually alert, their strongest senses are visual and tactile. They require immediate and
accessible visual communication, captions, and ASL interpreters in both emergent and non-emergent
situations. Without accessible communication in the health care setting, D/HH people risk poor patient-
provider communication, misdiagnosis, improper or delayed medical treatment, poor patient
satisfaction, and poor treatment outcomes, which no healthcare facility can afford.
(UN)ACCEPTABLE TERMINOLOGY: Most members of the Deaf community see themselves as a linguistic
minority, as other ethnic groups, and not handicapped or “impaired.” Therefore, avoid using
euphemisms such as hearing-impaired, hearing-challenged, and hearing-loss, which incorporate
negative framing. The acceptable terms are Deaf and Hard-of-Hearing.
MYTHS; READING LIPS AND WRITING NOTES: These forms of communication can be exhausting and
unreliable. While D/HH people instinctively watch the face, only a small percentage are skilled speech
readers. Many hearing people have poor enunciation and don’t maintain steady eye contact. Thus,
speechreading is not a dependable means of communication.
Writing notes too often fails. For many native ASL speakers, English is a second language. They often
write it as “ASL English,” conforming to the grammar of ASL—and this is easily misinterpreted.
PROFESSIONAL SIGN LANGUAGE INTERPRETERS must be provided not only for signing D/HH patients
but also to Deaf parents, children, and siblings of hearing patients (with patient approval). Utilizing a
qualified, certified, in-person, on-site interpreter is the best practice for this population. Family and
friends of Deaf patients should not be asked to interpret unless the Deaf patient specifically requests
this.
VIDEO REMOTE INTERPRETING (VRI), which uses an offsite interpreter by way of an iPad tablet
(fastened to an armature) through a cellular connection, may be useful when in-person, on-site
interpreting services are not immediately available. Most D/HH patients view the VRI as sub-optimal and
a temporary expedient only to meet their communication/language needs until the in-person
interpreter arrives on-site.
TELECOMMUNICATIONS RELAY SERVICE (TRS) allows D/HH persons to place and receive telephone
calls. There are several forms of TRS, depending on the user’s particular needs and the equipment
available. One can dial 7-1-1 to be automatically connected to a TRS relay operator. 711 dialing access
does not work for Video Relay Service, Internet Protocol (IP) Relay or IP Captioned Telephone Service
Relay calls, because such calls are initiated through the Internet.
VIDEO RELAY SERVICE (VRS) enables D/HH signers to communicate with voice-telephone users through
video equipment instead of typed text. Because the conversation between the VRS user and the Video
Interpreter (VI) flows much more quickly than with a text-based TRS call, VRS has become an
enormously popular form of TRS.
CALLING YOUR D/HH Patient: To know which service your patient uses, simply ask. As there are so
many choices; this is the only way to confirm. In this way, patients will identify which service they use,
which number to call, and how messages will be received. Increasingly, many people prefer direct
texting when available.

Americans with Disabilities Act

In accordance with the provisions of the Americans with Disabilities Act and the New York State
Executive Law, Rochester Regional Health and its affiliates provide equal opportunity for individuals with
disabilities with respect to employment, public accommodations, transportation, telecommunications,
and participation in government-funded services and programs.
This commitment includes following the mandates of the Americans with Disabilities Act of 1990 (ADA),
a federal law that makes it unlawful to discriminate against a qualified person with a disability in all
aspects of the employment process and in the provision of services and benefits. Rochester Regional
Health also follows all New York State laws and regulations that apply to individuals with disabilities.
Service Animals
Service animals are defined as dogs that are individually trained to do work or perform tasks for people
with disabilities.
 Service animals are working animals, not pets.
 Under the ADA, state and local governments, businesses, and nonprofit organizations that serve
the public generally must allow service animals to accompany people with disabilities in all areas
of the facility where the public normally is allowed to go.
o Staff are allowed to ask the owner two questions:
1. Is the dog a service animal required because of a disability?
2. What work or task has the dog been trained to perform?
 Under the ADA, service animals must be harnessed, leashed, or tethered, unless these devices
interfere with the service animal’s work or the individual’s disability prevents using these
devices. In that case, the individual must maintain control of the animal through voice, signal, or
other effective controls.
 A person with a disability cannot be asked to remove his or her service animal from the
premises unless:
o The dog is out of control and the handler does not take effective action to control it
o The dog is not housebroken
 Staff is not required to provide care or food for a service animal.
 Dogs whose sole function is to provide comfort or emotional support do not qualify as service
animals under the ADA.
For policy reference: See facility-specific policy.

Information Privacy and Confidentiality

Protecting Patient Information is Required
Rochester Regional Health is required to comply with a comprehensive set of regulations described in:
 The Health Insurance Portability and Accountability Act (HIPAA)
 The Health Information Technology for Economic and Clinical Health (HITECH) Act
 Omnibus Rule
In this document, we refer to them collectively as HIPAA regulations.
HIPAA regulations are designed to protect patients’ health information and the systems that store,
transmit, and process it. The purpose of the regulations is to prevent inappropriate use or disclosure of
individuals’ medical, demographic, and financial health information. The goal is to have a common-sense
balance between providing patients with personal privacy protections and access to high-quality
healthcare.
Non-Compliance Can Be Costly

Any employee who fails to comply with the HIPAA regulations may face disciplinary action, including the
possibility of termination. In addition, in some cases, civil and/or criminal penalties may be brought
against individuals or institutions violating HIPAA regulations. Based on the severity of the crime,
employees can face imprisonment up to 10 years for a HIPAA violation.
Protected Health Information

The patient has the right to confidentiality of protected health information (PHI). PHI includes any type
of information—verbal, written, or electronic—pertaining to the treatment or care of an individual.
Examples include names, medical record numbers, Social Security numbers, telephone numbers,
account numbers, etc. Confidentiality extends to all forms and formats in which the information is
maintained and stored, including, but not limited to, voice and voice recordings, paper copy,
photographic materials, microfilm and microfiche, electronic mail, or other electronic forms. All
Rochester Regional Health employees are responsible for respecting each patient’s right to privacy.
Policies and Procedures

The HIPAA Privacy & Security policies are available on the Health System’s Policy and Procedure manual
housed in the Unity Health System’s Intranet under Policies; HIPAA or on the Rochester Regional Health
System Portal under All Policies. Department-specific policies and procedures may be found in
Department Policy Manuals and on the intranet.
Education
All new employees receive initial HIPAA training during New Employee Orientation. In addition, leaders
are responsible to provide department-specific HIPAA training to their employees. All employees are
required to complete annual mandatory education on confidentiality and security of PHI.
Patient Rights
Rochester Regional Health is responsible to uphold a patient’s right to confidentiality of his or her PHI.
All Rochester Regional Health affiliates ensure every patient receives a Notice of Privacy Practices

explaining patient rights. We ask patients to sign an Acknowledgment Form verifying they were offered
the Notice and we keep the signed form in each patient’s medical record.
If you know or suspect a breach of patient PHI has occurred, contact your leader or enter the event into
the Safe Connect portal. Consistent with the HITECH Act and Omnibus Rule, Rochester Regional Health is
required to notify the patient when it is believed a breach of PHI that meets privacy breach notification
rules has occurred. In addition, the Secretary of Health and Human Services must be notified.
Identity Theft
Identity theft is one of the top consumer complaints in New York State. Although credit card fraud is the
most common form of reported identity theft, medical identity theft is on the rise. To protect our
patients, Rochester Regional Health makes reasonable attempts to verify patient identity by asking for
photo identification at the time of registration/check-in/admission. No patient will be refused treatment
because he or she cannot present valid identification. If you see suspicious activity that could be related
to identity theft, immediately advise your leader and enter the event into the Safe Connect portal or
contact Data Integrity at 585-922-1889. If the patient is actively being treated, an urgent Help Desk
ticket should be entered.
Business Associates
A “business associate” is a person or entity that performs certain functions or activities that involve the
use or disclosure of protected health information on behalf of, or provides services to, Rochester
Regional Health. Business Associates must have a Business Associate Agreement (BAA) with Rochester
Regional Health. Rochester Regional Health must make reasonable efforts to use, disclose, and request
only the minimum amount of protected health information needed to accomplish the intended purpose
of the use, disclosure, or request. BAA’s are maintained by the Rochester Regional Health Privacy Office.
Questions should be directed to (585) 922-9453.
Special Notes on HIV Confidentiality

New York State Public Health Law 2782 requires informed consent for any HIV-related test and strictly
limits disclosure of confidential HIV-related information. The law applies to persons and facilities
providing health and social services and to anyone who receives confidential HIV-related information
released under this law.
Confidential HIV-related information includes information indicating a person has had an HIV-related
test (even with negative results), HIV infection, HIV-related illness, or AIDS. Information indicating a
person potentially has been exposed to HIV also is covered under this law. The law also prohibits
employees/agents/contractors from discriminating against persons having or suspected of having HIV
infection.
Before HIV-related information can be disclosed, an executed New York State Department of Health
“HIPAA Compliant Authorization for Release of Medical Information and Confidential HIV Related
Information” form is required (form DOH 2557 or DOH 5032). A general authorization for Release of
Information is not sufficient. Disclosure without a release form may be made to certain authorized
persons described in the law and noted on the HIV antibody test consent form. Any unauthorized
disclosure of HIV-related information can result in a fine, jail sentence, or both.

Only employees, contractors, medical, nursing, or health-related students who have

reviewed this educational material on confidentiality and security of information,
including HIV confidentiality, and have such documented, are allowed access to
confidential HIV-related information while performing authorized functions at a
hospital/facility.
Employee Responsibilities for PHI Security

Every employee is expected to follow “reasonable safeguards” when dealing with patient PHI. The
safeguards employees are required to follow are listed below. If you know or suspect a breach of patient
PHI has occurred, immediately contact your leader so this information can be reported (using
SafeConnect portal) for investigation and follow-up. Contact your Privacy Liaison or Privacy Manager at
585-922-9453 for assistance. (For a more complete explanation of HIPAA safeguards, see the HIPAA
Privacy and Security Policies and Procedures.)
Do
1. Read, understand, and sign the Confidentiality Statement and ask questions or seek clarification
on policies and procedures when necessary.
2. Follow the “minimum necessary” rule; that is, you must make reasonable efforts to use and
request only the minimum amount of patient information needed to do your job.
3. Keep private all patient information you see or hear.
4. Use patient information only as required to do your job.
5. Give patient information only to people, companies, agencies, or organizations you know are
authorized to have the specific information.
6. All paper or plastic with patient information on it must be disposed of appropriately in secured
recycle bins.
7. Talk with patients or about patient information in a private area or in a manner (such as
speaking quietly) that is difficult to be overheard by others (including other employees) who are
not part of the conversation.
8. When not in use, lock all rooms, desks, file cabinets, computer equipment, and media containing
or allowing access to PHI.
9. Access only the equipment, systems, and software applications you are authorized to use.
10. Report to your leader any breaches of privacy or security you know about or suspect.
11. Check every page of a document prior to handing it to an authorized person to assure they all
belong to same patient.
Do Not
1. Do not leave patient information unattended or in view of people who should not see it; this
includes papers, charts, computer screens, and fax machines.
2. Do not share any patient information you hear, even if you are at Rochester Regional Health as a
visitor or even if it is about other employees.
3. Do not read any patient information unless it is necessary to do your job. This includes not
looking at your own, a family member’s, a friend’s, or a fellow employee’s information.

4. Do not share your passwords with anyone or allow someone to use your passwords.
5. Do not use someone else’s user ID or passwords to access computer systems or applications.
6. Do not connect personally owned hardware/software to Rochester Regional Health equipment.
7. Do not open email attachments from someone you do not know or insert discs in your computer
without running virus protection on them first.
8. Do not give any information to the media, including radio stations, newspapers, or television
stations.
9. Do not let anyone into areas of Rochester Regional Health unless you know they are authorized
to be there.
10. Do not text protected health information. Rochester Regional Health prohibits text messaging
(via cell phones or other electronic devices with exception of secure paging) to send or
knowingly receive PHI.
Note: IT resources, such as computer equipment, software/applications, storage media, email,
Internet/intranet services, and data, are the property of Rochester Regional Health. For security and
compliance purposes, your access and usage of these items may be monitored.
These employee responsibilities can be printed and posted.
Questions?
 If you have questions or concerns about PHI security, contact your leader.
 If you need additional assistance, call your affiliate privacy liaison OR Rochester Regional Health
Privacy Office at (585) 922-9453.
Code of Conduct
In carrying out its mission and core values, Rochester Regional Health expects that all Staff will conduct
Rochester Regional Health business and operations in accordance with both the law and the highest
standards of business ethics. Because Rochester Regional Health operates or manages a number of legal
entities providing medical services along the continuum of care, the Code of Conduct should not be
interpreted as an exhaustive list of standards expected of Rochester Regional Health Staff. The Code of
Conduct should be considered in conjunction with entity specific policies and procedures, as well as the
Medical and Dental Staff Codes of Conduct developed by the Medical and Dental Staffs of Rochester
Regional Health’s respective entities.
Employees may find this information on the Corporate Compliance Portal Page.
Locate and click the Code of Conduct section.
The Rochester Regional Health Code of Conduct applies to everyone.

Professional Misconduct and Reporting Concerns

It is the responsibility of each professional to be aware of and carry out the laws and regulations
pertaining to professional practice. Professional misconduct is the failure of a licensed professional to
meet expected standards of practice. In New York State, professional misconduct includes the following:
 Engaging in acts of gross incompetence or gross negligence on a single occasion, or negligence
or incompetence on more than one occasion
 Permitting or aiding an unlicensed person to perform activities requiring a license
 Refusing a client or patient service because of race, creed, color, or national origin
 Practicing beyond the scope of the profession
 Releasing confidential information without authorization
 Being convicted of a crime
 Failing to return or provide copies of records on request
 Being sexually or physically abusive
 Abandoning or neglecting a patient in need of immediate care
 Performing unnecessary work or unauthorized services
 Practicing under the influence of alcohol or other drugs
Professional misconduct involves investigation and, depending upon the case, may result in suspension
or revocation of one’s license. It is possible for a professional to be found guilty of professional
misconduct even when the issue of negligence has not been proven. Practicing a profession without a
license and current registration is a felony in New York State.
Additional information on requirements and expectations is available in the Rochester Regional Health
Medical/Dental Staff Code of Conduct.
Reporting Your Concerns

New York State Law requires all actual or suspected cases of professional misconduct be reported to the
Department of Health Office of Professional Medical Conduct (OPMC) for medical personnel or the
Department of Education Office of Professional Discipline for nurses and other licensed professionals.
This law applies to licensed professionals who are employed by or in any way associated with Rochester
Regional Health.
If you suspect someone of professional misconduct, discuss the circumstances with

your leader or anyone who is in a position to resolve the situation.
To ensure additional notification and satisfactory follow-up, create a safety event.
If a concern cannot be resolved through internal reporting channels, you may call:
 New York State Department of Health at 800-804-5447 or
 The Joint Commission at 800-994-6610 or
 DNV Healthcare Inc. at 866-523-6842

Quality Assurance, Patient Safety and Performance Improvement

Overview
The vision of quality and safety at Rochester Regional Health is to be system experts in transformation,
early identification and elimination of risk, harms and defects in the delivery of quality care to our
patients while being a partner in innovative problem solving with our operational colleagues.
Guiding Principles
Clinical excellence and patient safety principles provide structure and direction for improving
organizational performance. The guiding principles provide a framework for improvement activities
within the health system and are based on the Institute of Medicine’s six aims for health care quality. .
 Safe: Avoiding harm to patients from the care that is intended to help them.
 Effective: Providing services based on scientific knowledge to all who could benefit and
refraining from providing services to those not likely to benefit (avoiding underuse and misuse,
respectively).
 Patient-centered: Providing care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide all clinical decisions.
 Timely: Reducing waits and sometimes harmful delays for both those who receive and those
who give care.
 Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
 Equitable: Providing care that does not vary in quality because of personal characteristics such as
gender, ethnicity, geographic location, and socioeconomic status.

Process Improvement Methodology

Rochester Regional Health measures and monitors quality outcomes and assists with the
implementation of appropriate changes using the following guidelines:
 Use data to identify and quantify areas of improvement opportunities (Process Improvement-
PI) and areas for maintain or improving standard of care (Quality Assurance-QA)
 RRH uses an approach to clinical and service quality improvement that is consistent with the
scientific principles of Plan-Do-Check-Act (PDCA).
 Criteria for selection of priorities are determined by facilities and respective departments and
are aligned with the Mission, Vision and Values of RRH.
 RRH has also integrated the principles, methods and tools such as Lean & Six Sigma.
o Lean is a process improvement methodology used to focus on creating value to internal
and external customers of a system or process by eliminating non-value added activities
and/or wastes.
o Six Sigma is a process improvement methodology focusing on data and statistical
analysis to identify and eliminate defects and variability.
 RRH utilizes the Failure-Modes-Effects-Analysis (FMEA) as a pro-active method for evaluating a
process to identify failure points, assess their relative impact and prioritize improvements
towards those failure points with greatest impact to outcomes.
Patient Safety Program

Patient Safety Specialists
The patient safety specialist assists in the development and implementation of patient safety programs
with a focus on high reliability principles. They give presentations and training programs meant to
increase awareness of patient safety initiatives and lead the Safety Champion program which engages
front line team members in safety activities. Creation of learning modules for clinical leaders in safety
culture, that spread patient-safety knowledge of employees. Working collaboratively with local quality
teams to ensure proactive risk mitigation across the system to prevent harm.
Daily Safety Check

A key element in improving patient safety in any organization is fostering a culture of safety: an
environment with high awareness of safety issues at all levels and with leadership that encourages and
rewards reporting of safety problems and concerns. Each affiliate holds Daily Safety Check seven days a
week. Modeled after other high reliability organizations, front-line team members share information
about potential safety problems and concerns with leadership. The Daily Safety Check helps increase
staff’s awareness of patient safety issues; create an environment in which staff is able to share without a
fear of reprisal and to integrate the reporting of safety issues into their daily work. The Daily Safety
Check serves to align and focus leadership on recognition and resolution of issues to prevent and reduce
adverse outcomes.
The Daily Safety Check is a brief 15 minute roll-call meeting. Attendees use a three-point agenda:
1. Look Back: significant safety or quality issues from the last 24 hours
2. Look Ahead: anticipated safety or quality issues in the next 24 hours
3. Follow-up: status reports on issues identified today or days before
Safe Connect Event Reporting System

A comprehensive, electronic, event reporting system implemented across the entire RRH system to be
able to capture good catch events that allow risk mitigation prior to harm reaching the patient as well as

incidents that potentially caused harm. The comprehensive system allows for tracking and trending of
events across all facilities to identify areas that need improvement projects or interventions.
A robust process for reviewing all events that is facilitated by the local quality teams in collaboration
with service line leadership to ensure that events are responded to in a timely manner. The system also
incorporates compliments, complaints, employee events, patient events, and visitor events.

Mandatory Compliance Education: CORE ǀ January 2021 Health, Safety & Awareness
Health, Safety & Awareness

Patient Bill of Rights
All inpatient, outpatient, and emergency service patients receive a copy of the New York State Patient
Bill of Rights. Copies are available in English, Russian, Chinese, Spanish, Italian, Creole, Korean, and
Braille and are located in the Admitting Office, Emergency Department, Nursing Office, and outpatient
areas. A one-on-one interview is available for the visually impaired (patient who is either blind or with
low vision). A copy of the Patient’s Rights is posted in the hospital and off sites at points of service.
Admitting, Emergency, or Outpatient Staff provide initial information about Patient Rights to the
patient. Nursing staff assess whether additional information is needed and follow through. Staff is
responsible for upholding patients’ rights in their daily work. We encourage patients to be an active
participant in their care and to “Speak Up” when they have a question about their care and/or a
procedure.
Advance Directives
The federal Patient Self-Determination Act requires institutions that receive Medicare or Medicaid
reimbursement to screen patients for advance directives. In addition, institutions must provide written
information to all individuals receiving healthcare regarding their right to make decisions in advance
about their medical treatment.
Patients are given information about their rights to formulate advance directives such as a healthcare
proxy or living will, in addition to the right to consent to a Do Not Resuscitate order.
Copies of any pre-existing advance directives should be provided by the patient or designated agent for
placement in the hospital medical record. Pre-existing documents must be reviewed with the patient or
designated agent for accuracy during each encounter. They also may be found in Care Connect in Chart
Review Navigator on the Advance Directive “Filter” or on the “Storyboard.” If not available at time of
admission, a plan must be made and documented as to how the document(s) will be obtained for
placement in the record or the patient is offered an opportunity to complete a new advance directive.
Patient Safety
Patient safety is one of the most important activities in which Rochester Regional Health employees
participate. Patients together with all levels of staff are the best team to prevent errors and maintain a
safe environment.
At Rochester Regional Health we believe error-likely situations are predictable and manageable and
subsequently promote a patient safety-oriented culture in the following ways:
 Analysis is done before new processes, techniques, etc., are implemented to determine how the
new approach might affect patient safety. Adjustments to ensure patient safety are made to

new processes and techniques prior to their implementation. This is called proactive risk
assessment.
 Analysis is done before initiating new construction or renovation projects. Multidisciplinary
teams review plans and ensure patient/staff safety during all construction projects.
 A high-risk process is identified at least once every 18 months and evaluated for possible failures
that could result in patient harm. The process is then re-designed to eliminate the potential for
failure and ensure patient safety.
 Medical staff communicates unanticipated outcomes to patients and families.
For more information on this topic, refer to the Disclosure of Unanticipated

Outcomes Policy and Procedure on the Rochester Regional Health portal.
 Patients and employees are asked about their perception of the level of patient safety in the
organization and are asked to make recommendations to improve safety.
 New employees are oriented to patient safety standards, practices, expectations, and
improvements at Rochester Regional Health.
 In-services and learning packages on patient safety and improvements are provided to all
employees on an annual basis and as new standards are developed.
 Employees are comfortable reporting good catches as well as actual events using our event
reporting system, SafeConnect. Rochester Regional Health uses submissions into our system to
identify how to improve safety and does not retaliate against employees who were involved in
or reported an error or if the good catch was caused by themselves or others. A “just culture”
that promotes reporting errors and hazards and recognizes people should not be held
accountable for system issues over which they have no control. Staff members are held
accountable in situations of confirmed disregard of established policies and standards of
practice.
 Variation in processes is minimized and standardization is maximized whenever possible.
 RRH Sentinel event alerts and recommendations are compared against external organization
recommendations such as the National Patient Safety foundation and the New York State
Department of health. Organizational policies and procedures are revised as necessary to ensure
maximum patient safety.
 Patient safety is integrated into the quality improvement process within the organization.
 Patient safety goals are communicated and monitored to ensure compliance. Oversight by the
Board of Directors providers strong administrative and clinical leadership.
Whenever appropriate, patients and their families are involved to help prevent medical mistakes.
Patient Complaints
At Rochester Regional Health, patients and families have the right to express complaints and
compliments about the care and services provided. Our policy is designed to review and resolve patient
complaints in order to improve quality of care.

For each encounter or care timeframe, employees are encouraged to assess how patients are perceiving
their care and address any concerns in a timely fashion. If needed engage your leader to assist in
addressing the problems or concerns, if needed.
We value feedback about the delivery of care and services. Patients and visitors are encouraged to share
feedback in the following ways:
 Directly with a member of the care team
 Contact the Speak Up line at 585-922-LINK (5465)
 Q-Reviews
 RRH website
 Contact a Patient Relations Coordinator at 585-922-NEED (6333)
 Patient satisfaction surveys
Remember that patient safety as well as patient satisfaction is the responsibility of all employees.
Key Steps When You Receive a Complaint

 Acknowledge the person’s concerns/inconvenience
 Apologize that they are unhappy with situation
 Listen carefully to their concern
 Ask what you can do for them:
o “How can I help you?”
o “How can I make this better for you?”
 Act in a professional manner to rectify the problem as quickly as possible
 Thank the person for sharing the information with you so it can be reviewed and addressed
 Follow through with what you told them you would do
 Do not make promises you cannot keep
 Check back in a timely manner to be sure the issue was resolved and ensure the customer is
satisfied with your response
 Report the issue to appropriate staff so action can be taken to identify improvements
 For guidance on recovery actions, refer to the Rochester Regional Health Service Recovery
handbook or contact Risk Management at 585-922-RISK (7475)
Each employee is responsible for the outcome of their efforts. Recognize that the
work of each individual is a reflection of our organization. Our manner and
expression will convey our concern for and willingness to serve our customers.
Complaint Procedures
A patient complaint is a verbal concern that in most circumstances can be resolved at the time of the
complaint by staff present, or, if communicated post -hospitalization, would routinely have been
handled by staff present. Any employee who directly receives a complaint is expected to facilitate the

management of the complaint in the scope of his/her role and responsibility. Every effort should be
made to resolve the complaint immediately.
A patient grievance is a concern that cannot be remedied promptly by staff present without significant
delay or extensive review. Complaints that are received in writing must receive a written response per
CMS guidelines.
Staff should follow the steps below to appropriately document a patient grievance or a complaint that
cannot be remedied promptly by staff present.
1. Log into Safe Connect and complete as Patient Feedback event.
2. Follow the prompts to enter a description of the event, date of complaint, patient’s name, MRN,
date of birth, date of event, and service area.
3. If you have received a letter from a patient or family member, scan the letter and attach it to
the safety event report in Safe Connect in the Attachment section.
Additional Information:
RGH/NWCH/CSHC/Unity  Forward complaint letters, time sensitive and/or complex
complaints/grievances or for guidance, contact the Patient Relations
Department either by phone 585-922-NEED (6333) or email
patientrelations@rochesterregional.org
UMMC  Forward complaint letters, time sensitive and/or complex
complaints/grievances or for guidance contact the Quality
Department and Quality Improvement Line by phone 585-344-8161.
Resident  All complaints by residents, their families, or their representatives will
Complaints/Grievances be fully investigated and responded to.
(Hill Haven, DeMay  All responses to residents contain a statement that, if the resident or
Living Center, Unity LTC resident’s representative is not satisfied with the investigation, they
Facilities, ElderONE) may contact a higher authority. A telephone number will be provided
upon request.
If the resident or their designee is not satisfied with the facility’s oral
or written response, they may complain to the New York State
Department of Health’s Office of Health Systems Management. The
facility will provide the telephone number of the local office of the
Department of Health upon request. It is posted at the front door and
throughout the facility.

Lifetime Care Complaint Process (Refer to Administrative Policy#9004)

The steps in the complaint process:
 At Lifetime Care, the complaint policy ensures the right and freedom
of patients or principal caregivers to express complaints regarding
policies, care and services or to recommend changes
 The purposes of the Complaint Policy and its procedure are to
investigate and to resolve client complaints, as reasonably as is
possible, in order to improve quality of care
The steps in the complaint process:
 On admission, the client/caregiver is provided with oral and written
notification of the complaint-resolution process and given appropriate
information about other resources for registering complaints
 All PHV should promptly report patient complaints to their manager
for resolution
 Complaints must be followed up within 15 days as mandated by
regulation
Refer to the SafeConnect Event Reporting & Management Policy for further definition.
Complaints immediately resolved to the patient's complete satisfaction do not

require a formal investigation.
Abuse, Neglect, and Domestic Violence

Domestic violence is the physical or psychological abuse of one family member by another,
encompassing spousal and partner abuse, child abuse, and the abuse of elder family members. The
abuse can be:
 Physical – like beating or burning
 Sexual
 Mental
Domestic violence is a crime.
 All suspected or known cases of child abuse or neglect must be reported to Child Protective
Services.
 Employees are not required to report cases of adult domestic violence to the police or the
County Department of Social Services, even though it is a crime, unless the patient wants us to.
 What the healthcare professional can do, whenever they suspect cases of adult domestic
violence, is to provide information to the abused or for those at risk, regarding available
services. Suspected cases of elder abuse or at-risk patient abuse must be referred to the unit
social worker for further assessment and follow-up.

Remember, the healthcare worker may be the only person outside the family who knows about the
violence. Some signs of possible violence may be when a patient:
 Talks about it
 Cannot explain bruises and other injuries
 Explains injuries but it doesn’t make sense
 Delays coming to the hospital after injury
 Does not want to talk about injuries
 Has repeated emergency room visits for injuries
If you suspect a patient is the victim of domestic violence, tell the patient’s nurse or the social worker on
the unit. You can also call the Social Work Department.
All patients are assessed for risk of abuse on admission. Those who appear to be at risk or have signs of
actual abuse are offered referral to community services.
Community Services Available for Abuse Prevention or Intervention

 Police departments
 Shelter or safe houses (such as Willow Domestic Violence Center, formerly known as
Alternatives for Battered Women, Inc.)
 Domestic Violence Hotlines (Lifeline)
 District Attorney
 Legal Aid
 Counseling (for victims and the abuser)
 Adult Protective Services
 Child Protective Services
 Hospital Emergency Departments
 Statewide Child Abuse Hotline
Child Abuse
An “abused child” is a child less than 18 years old whose parent or caregiver causes or allows:
 Physical harm
 Risk of harm
 Sexual harm
Other forms of child abuse include:
 Not feeding, clothing, or giving shelter
 Not sending to school
 Not getting medical care
 Harsh punishment
 Overuse of drugs or alcohol

Note: Engaging a child in sex trafficking or labor trafficking is a form of Child Abuse. Any child under the
age of 18 who is induced to engage in commercial sex is a victim of sex trafficking. Examples of sex
trafficking of children include prostitution, pornography, and sex tourism
(https://www.childwelfare.gov). Child Labor Trafficking is the use of force, fraud, or coercion for the
purpose of subjection in involuntary servitude, peonage, debt bondage, or slavery. Examples of labor
trafficking include agricultural or domestic service workers who are underpaid or not paid at all,
physically abusive traveling sales crews that force children to sell legal items (e.g., magazines) or illegal
items (e.g., drugs) or to beg, and workers in restaurants and hair/nail salons who are abused, confined,
and/or not paid (https://www.childwelfare.gov).
For more information about violence and abuse, refer to the Violence Resource Manual available in your
department or in the Social Work Department.
Lifetime Care: Refer to Policy # 5009
Smoke-Free Environment
Policy
Rochester Regional Health is committed to providing a safe and healthy environment for all staff,
visitors, and patients. Therefore, in compliance with New York Public Health Law Article 13-E § 1399-N –
X and RRH Policy R30, smoking or the usage of any tobacco products (such as cigarettes, e-cigarettes,
cigars, pipes, chewing tobacco, or snuff) is strictly prohibited on all hospital campuses, including off-site
locations, buildings, parking areas, parking garages, or within 15 feet of the property line of any grounds
surrounding facilities owned or leased by Rochester Regional Health or affiliates. Employees are not
permitted to smoke in privately owned vehicles while on Rochester Regional Health or affiliate property.
Compliance
Compliance with maintaining a smoke-free environment is the responsibility of everyone at Rochester
Regional Health affiliates. Report smoking offenders to your facility’s Safety and Security staff or to your
building’s property management company. Employees who do not comply with the smoke-free
environment policy will be addressed under the Rochester Regional Health Notice and Action Policy.
Stroke Alert/Signs of a Stroke

Overview
Every Rochester Regional Health employee plays a role in helping to quickly treat patients, visitors, or
community members who might be experiencing a stroke.
Stroke Warning Signs and Symptoms

Be concerned if there has been an acute change: Think FAST

Signs of a Stroke
 Sudden numbness or weakness of the face, arm, or legs, especially on one side of the body
 Sudden trouble seeing in one or both eyes
 Sudden confusion, trouble speaking, or understanding
 Sudden trouble with walking, dizziness, or loss of balance
 Sudden, severe headache with no known cause
What to do?
If you are at work and you think someone may be experiencing a stroke:
 In patient areas: Get a nurse right away.
 In the cafeteria, hallway, lobby, etc.: Stay with the person and call for someone to help you.
o At Newark Wayne Hospital: Dial 42-711 to reach the operator so an overhead page can
be called for the Stroke to respond to the designated area. Please ask the operator to
page the Stroke Team overhead to the unit and room where their response is needed.
o At RGH: Call the Operator by dialing 2-4444 to activate the Emergency Response team
o At UMMC: Dial 333 to activate the Emergency Response Team
o At Unity: Dial extension 6666 to activate the Emergency Response Team
 In the community: Call 911 and tell them you think a person may be having a stroke.

Ventricular Assist Device (VAD)

Overview
Rochester General Hospital surgically implanted its first Ventricular Assist Device (VAD) in November
2018. VADs are advanced therapy for patients with end-stage heart failure that allow for improved
quality of life by assisting the heart with blood flow. Important things to know about VAD patients:
 Patients have a driveline that exits their abdomen and connects to a controller and
batteries/power source. Patients carry extra batteries and the controller with them at all times.
 Patients will likely not have a palpable pulse and will only have blood pressure that is assessable
by Doppler with a manual cuff.
 The patient’s driveline must not get tugged or pulled, and the driveline dressing must remain
intact to maintain driveline site integrity.
 When admitted, patients have a nurse assigned who has been trained in VAD care.
 Patients with VADs will be at RGH in CTICU, MICU or 4400.
 For any concerns, contact VAD coordinators at 585-442-5320 or 585-922-4000 and ask for the
VAD Provider on call.
Infection Prevention
Overview
Healthcare acquired infections (HAI’s) are infections that develop in the healthcare setting. Although
significant progress has been made in preventing some HAI types, there is much more work to be done.

On any given day, about 1 in 31 hospital patients has at least one healthcare-associated infection.
Rochester Regional Health’s Infection Prevention Program is designed to decrease the risk of infection
transmission between employees, patients, visitors, and families.
The goals of the RRH Infection Prevention Program are to:
 Reduce the risk of HAI transmission between employees, patients, visitors, and families
 Make recommendations and institute practices that reduce the risk of infection transmission
and prevent further infections
 Incorporate findings, recommendations, and actions into the overall performance improvement
program
 Assure that appropriate standards of practice, standards of care, and protocols are developed,
maintained, and adhered to in order to ensure that all staff are knowledgeable to perform their
functions
 Ensure that all personnel, students, and medical staff are competent to fulfill their infection
prevention duties and to provide on-the-job training, orientation, resources, consultation, and
continuing education to facilitate this process
Infection Prevention polices and guidelines can be found on the RRH portal under Departments:
Infection Prevention. These documents incorporate evidence-based national guidelines as well as
federal, state, and local regulations. Infection Prevention policies should be followed by all employees.
Hand Hygiene
Hand hygiene is still the single most important and effective way to prevent the spread of infection.
Articles in medical and nursing journals cite studies where healthcare workers wash their hands less than
50% of the times they should. Studies have shown that many outbreaks are linked to the breakdown of
this basic practice.
Hand hygiene is important because we can carry thousands of bacteria on one square inch of skin. Hand
hygiene is aimed at either removing them with soap and water or killing them with alcohol-based hand
sanitizer. Not performing good hand hygiene is risky for you, your patients, and your co-workers.

How to Wash
There are two ways to complete hand hygiene (both are effective)
1. Washing with soap and water
When you wash with plain soap, 1 ml is enough – there is no benefit to using more than that.
Containers automatically dispense the proper amount when you push the lever. Wet hands and
apply soap to all hand surfaces. After lathering your hands, use friction by rubbing hands together
vigorously over all surfaces. Be sure to wash under your fingernails, between fingers, under rings,
and up to the wrist. Rinse hands thoroughly and pat dry. Turn off the faucet with a paper towel.
The process should take at least 20 seconds.
2. Using the approved alcohol-based hand sanitizer
Apply hand sanitizer to cover all surfaces of the hands and fingers. Rub until hands are dry.
What to Use
 Unless hands are visibly soiled, use an alcohol-based hand sanitizer
 Wash your hands with soap and water when hands are visibly soiled, before eating, and after
using the restroom
 If liquid soap or waterless hand sanitizer dispensers are empty, notify Environmental Services
When to Clean Hands
Use EITHER soap and water or alcohol-based hand sanitizer:
 Before and after all patient contacts
 When entering/leaving patient room/environment
 At the beginning and end of your work shift
 After smoking
 After blowing your nose, sneezing, coughing into your hand
 Before applying and after removing gloves

 After any “dirty task” like picking up something off the floor
You MUST wash your hands using soap and water:
 After using the restroom
 Before eating
 If your hands are visibly soiled with blood or body fluids
 Whenever your hands LOOK dirty
GLOVES DO NOT TAKE THE PLACE OF GOOD HAND HYGIENE.

Bacteria can multiply rapidly in the warm, dark, moist environment of gloved hands.
Hands and Nails

 RRH provides hand lotion to protect hands after washing. Lotion not supplied by the
organization is prohibited because it may break down latex gloves.
 Fingernails must be kept clean, neat, well-maintained, and of an appropriate length.
Additionally, in compliance with CDC guidelines, sculptured, acrylic, gel, overlays, or false nails
of any kind may not be worn by any employee who has direct contact with patients, including
any employee who transports patients, enters patient rooms, or handles items that move in and
out of patient care areas or rooms.
Bloodborne Pathogens
Rochester Regional Health is committed to providing a safe and healthy work environment for all
personnel. To achieve this goal, the Bloodborne Pathogens Exposure Control Plan (BBP ECP) is provided
to eliminate or minimize occupational exposure to bloodborne pathogens. This includes Hepatitis B
Virus (HBV), Human Immunodeficiency Virus (HIV) and others that may be encountered by employees in
the workplace, in accordance with OSHA standard 29 CFR 1910.1030, "Occupational Exposure to
Bloodborne Pathogens." The purpose of the BBP ECP is to assist in implementing and ensuring
compliance with the standard, thereby protecting Rochester Regional Health personnel. This plan is
available on the RRH Portal.
At-risk employees are required to complete OSHA Bloodborne Pathogen training.

Reading this document does not fulfill the mandatory requirement.
What Can You Do?

What can you do to reduce the risk of infection transmission to yourself and others?
 Follow Rochester Regional Health’s Infection Prevention policies and guidelines; remind others
to follow them as well.
 Perform hand hygiene.
 Follow instructions posted on isolation precaution signs.
 Use appropriate personal protective equipment such as masks, gown, goggles, gloves, etc.,
according to protocol.
 Follow Employee and Occupational Health standards including:
o Obtain all appropriate immunizations and keep them up-to-date.

o Provide evidence of immunity to vaccine preventable diseases (e.g. measles).

o Complete your annual health survey and TB testing.
o Get an annual flu vaccination to protect yourself, your patients, and your family. The flu
can be spread even if you do not have symptoms. Per NYS Law unvaccinated healthcare
workers must wear a mask once the NYS Commissioner of Health deems that the flu is
prevalent.
o Stay home if you are sick with fever (100⁰ or greater), vomiting or diarrhea.
o Tell your supervisor or contact Employee and Occupational Health if you think you have
an infectious illness.
o Report to Employee and Occupational Health if you have any of the following
symptoms: fever and chills; productive cough; skin rash or vesicles; draining wounds or
sores; diarrhea or vomiting; skin lesions; or sore throat.
 Practice respiratory hygiene/cough etiquette: cover your cough.
 Discard garbage appropriately, in either regular trash (clear bags) or medically regulated trash
(red bags).
Affiliate IP Contact Number

Clifton Springs Hospital and LTC 315-462-0506
Newark Wayne Community Hospital 315-359-2544
United Memorial Medical Center 585-344-7288
Rochester General Hospital 585-922-5683
Unity Hospital 585-723-7188
Unity Living Center 585-642-0929
DeMay Living Center 315-332-2703
Hill Haven 585-922-2283
Park Ridge Living Center/Transitional Care Center 585-723-7206
Edna Tina Wilson 585-368-6181
Lifetime Care Employees 585-474-1951
Lifetime Care Patients 585-214-1022
Injury Prevention
Overview
Prevention is the key to decreased injury. Musculoskeletal dysfunctions are seldom caused by one single
incident or injury. Poor sitting and standing posture, prolonged, awkward or repetitive use, twisting,
bending, lifting, faulty body mechanics, decline in physical fitness, decreased flexibility, and stressful
living can all contribute to an elevated risk for injury.
Most experts agree that direct hands-on patient care workers should not exert more than 35 pounds of
force while assisting a patient due to the challenging body mechanics and unpredictability of patients.

Safe patient handling mechanical aids/equipment should be used to reduce forces to 35 pounds or
below. All other manual tasks and general industries recommend force limits up to 50 pounds.
The most common factor contributing to an injury is the tendency to exceed one’s own safe physical
capacity, putting excess force on the musculoskeletal system. Take the time to promote neutral
postures and obtain the right equipment to improve your safety and comfort during job tasks.
Rules of Good Body Mechanics/Ergonomics
1. Test the load, plan the move and ask for help if needed
2. Use a wide, balanced stance with one foot slightly, keeping heavier loads at waist level
3. Keep the head up and back in its normal arched position while lifting, pushing or pulling
4. Reduce reaching by bringing tasks and loads as close to the body as possible
5. Push rather than pull whenever possible
6. Tighten stomach muscles and use larger muscles in legs and arms with heavier tasks
7. Promote neutral positioning of extremities and avoid twisting the spine
8. Change position or task every 30 to 60 minutes for short 1-to 2-minute microbreaks
Talk to your leader and/or call our Injury Prevention Specialists with questions or
concerns. Resources are also available through the Rochester Regional Health portal.
Safe Patient Handling and Mobility (SPHM)

The NYS Safe Patient Handling Act was passed in 2014 supported by the NYS Department of Labor
(NYSDOL), Occupational Safety and Health Administration (OSHA), American Nurses Association (ANA),
American Physical Therapy Association (APTA), and the National Institute of Safety and Health (NIOSH)
recommends direct patient care providers lift, push and pull no more than 35 pounds of force at any one
given time. This legislation will ultimately keep our patients safe and protect our providers from the
unnecessary physical demands that were previously expected of them.
 Direct patient care providers handle approximately 2 tons of weight on a regular basis.
 Backaches and pain account for a high percentage of all sick days in most health care facilities.
 Healthcare is the most injured industry due to the nature of the work.
 Patients are frequently repositioned, transferred, lifted, and transported from one place to
another.
Safe Patient Handling and Mobility Policy/Equipment

Important points to remember:
1. Limit forces to 35 pounds or less
2. No manual lifting of patients from the floor unless a medical emergency
3. Use equipment (Hoyer or Hoverjack) to lift patients from floor that can’t rise independently
4. Use appropriate safe patient handling equipment to assist with patient transfers
5. 2-person or more assist or requiring more than minimal assistance indicates need for equipment
6. Boosting a patient up in bed requires the assistance of at least two staff at all times

7. Consider use of friction reducing sheets and air mats with supine repositioning needs
Call the Safe Patient Handling and Mobility Specialists with questions or concerns.
Resources are also available through the Rochester Regional Health portal.
Reporting Incidents and Good Catches

Using the Quality Referral Process
Rochester Regional Health uses the event reporting process to identify risks and safety issues within the
organization. The process allows the organization to track actual events and near misses and make
improvements as necessary.
Events can include Incidents, good catches, or sentinel events
1) Incident: Safety event that reaches a patient, whether or not it causes harm
2) Good catch: Potential errors which did not reach the patient and/or where the patient was not
involved in any way
3) Sentinel events: An unexpected occurrence to a patient, employee or visitor involving death or
serious physical or psychological injury or involving a significant risk of serious physical or
psychological injury.
Examples include:
 Accidents occurring on Rochester Regional Health property
 Lost or damaged property
 Breach of patient rights
 Medical equipment malfunction
 Medication variances
 Sexual or assaultive behaviors
A good catch is a potential event prevented by recognizing an error before it reaches

the patient. For example, an ID bracelet is placed on the wrong patient but caught
before any treatment, medications, food orders, etc., are implemented.
Reporting good catches allows us to identify system problems and correct them
before an error occurs.
Any incident or Good Catch (Near Miss) event is reported via the online event reporting system,
SafeConnect. Appropriate follow-up services are provided as necessary.
Depending on the nature of the event, different types degrees of investigation will be conducted. Any
serious sentinel events are thoroughly reviewed via a root cause analysis process, and findings are
reported internally to Quality Committees and Boards, and externally to federal and state regulatory
agencies and standards organizations. The appropriate improvements and corrective actions will be
taken to provide a safe environment for patients, residents, visitors and employees.

Follow up with patient and/or family is done if outcomes of care differ significantly from the anticipated
outcomes. Guidance should be sought from the Risk Management Department prior to
discussion/disclosure of significant sentinel events.
While any employee or provider has the right to report concerns about the safety or quality of care
directly to the Joint Commission (1-800-944-6610) or any other external regulatory agency, reporting
them through the online event reporting system allows the organization to review and respond in a
quicker fashion. In either case, Rochester Regional Health will not take any disciplinary action or
retaliate against an employee or provider who makes such a report either internally or to the Joint
Commission.
Reporting
 All employees/staff are responsible for identification and notification of any incident/ good
catch to their supervisor/manager.
 Incidents/good catches are reported in the online event reporting system.
 Reporter enters event into online system as soon as possible, but no later than 24 hours after
event discovery.
 Event reporting is considered a quality referral and is confidential.
Reporting issues through our organization’s event reporting system, SafeConnect allows our
organization to review and respond in an appropriate manner to the event.
The electronic event becomes part of a confidential database that allows us to capture, track, and
analyze medical errors, adverse events, good catches, and all related types of medical incidents. This
provides us with a comprehensive overview and detailed analysis of the incidents occurring in our
organization.
Event reports are used to record pertinent facts relevant to an unusual or

unanticipated event and are CONFIDENTIAL. The event report is not a part of a
patient’s medical record. It is information used to assist with Rochester Regional
Health’s improvement, complaint, risk management, or regulatory processes. Only
facts surrounding the event should be recorded in the patient’s chart. To maintain
confidentiality, documentation in the medical record should not reference the event -
reporting process.
For affiliates accredited by the Joint Commission:

Any employee/staff member has the right to report concerns about the safety or quality of care
directly to The Joint Commission.
Rochester Regional Health will not retaliate or take disciplinary action against any
employee who creates a report either internally or to The Joint Commission.
Reporting Concerns to The Joint Commission

Mail: Email: complaint@jointcommission.org
Office of Quality Monitoring
The Joint Commission Fax: Office of Quality Monitoring 630-792-5636

One Renaissance Boulevard

Oakbrook Terrace, IL 60181
If you have questions about how to file a concern, contact The Joint Commission
weekdays, 8:30 a.m. to 5:00 p.m. Central Time, at 800-994-6610.
This content is in the Quality Referral Policy (Administrative Policy Number S19).
For Affiliates Accredited by DNV GL Healthcare:

If you have a concern regarding the quality of care provided to you or someone else, please consider
contacting the healthcare organization first and ask to speak with their Patient Advocate. It is the
responsibility of a patient advocate to address grievances against their organizations.
If you are not able to resolve or diffuse the issue with the organization’s patient advocate and want to
take further action, please call 866-496‐9647, or complete the Patient Complaint Report below.
Alternatively, you may also fax the information to us at 513-947-1250.
DNV GL - Healthcare
400 Techne Center Drive
Suite 100
Milford, OH 45150
For Lifetime Care, please follow Lifetime Care Guidelines.

Mandatory Compliance Education: CORE ǀ January 2021 Security & Emergency Essentials
Security & Emergency Essentials

Emergency Codes/Phone Numbers by Location
Every employee is expected to know the emergency code terms and emergency phone numbers of the
location in which they work. Review these with your department leader for your location if there are any
questions. See additionally more specific policies and procedures in regards to these emergency
situations.
Alexander Park Call

Safety & Security 585-922-4300
Fire Alert or Code Situation 911
BHN Security (Mon – Thurs 0800 to 2000; Fri 0800 to 1700) 585-922-6330
Clifton Springs Call

Fire Alert (location) 315-462-7777 or 7777
Code Team (location) 315-462-7777 or 7777
Pediatric Code Team (location) 315-462-7777 or 7777
Rapid Response Team (location) 315-462-7777 or 7777
Amber Alert (missing child under 18 years old) 315-462-7777 or 7777
Announcement will include a description of the child and last location
Assistance Needed STAT (behavioral/uncontrolled person) (followed 315-462-7777 or 7777
by location)
Command Center Activated – OPS Council to report to (location) 315-462-7777 or 7777
Critical Security Incident – Armed Aggressor (location) (shelter in 315-462-7777 or 7777
place until additional information is received – if in the area: run, ONLY if safe to do so
hide, fight)
Decontamination Team Alert 315-462-7777 or 7777
Lockdown (alerts staff that facility lockdown is in effect; be aware of 315-462-7777 or 7777
suspicious persons in the area)
Missing Person (missing person 18 years or older) 315-462-7777 or 7777

Lifetime Care Call

Safety & Security 911 and/or 922-4300 RRH
Security
Hildebrant Hospice only:

911 and/or 723-7745
Unity Security
Fire Alert, Medical Emergency or Safety Situation 911
Newark-Wayne Call
Fire Alert (location) 42711
Code Team (location) 42711
Pediatric Code Team (location) 42711
OB Team STAT (location) 42711
Amber Alert (missing child under 18 years old) 42711
Assistance Needed STAT (behavioral/uncontrolled person) (followed 42711
by location)
Command Center Activated – OPS Council to report to (location) 42711
Critical Security Incident – Armed Aggressor (location) (shelter in 42711
place until additional information is received – if in the area: run, ONLY if safe to do so
hide, fight)
Decontamination Team Alert 42711
Lockdown (alerts staff that facility lockdown is in effect; be aware of 42711
suspicious persons in the area)
Missing Person (missing person 18 years or older) 42711

Rochester General Hospital (RGH) Call

Safety & Security 2-4300 or 585-922-4300
Fire Alert (followed by location) 2-4444 or 585-922-4444
Code Team (followed by location) 2-4444 or 585-922-4444
Pediatric Code Team (followed by location) 2-4444 or 585-922-4444
Amber Alert (missing child under 18 years old) 2-4444 or 585-922-4444
Announcement to include:
 Estimated age
 Gender
 Description
 Clothing
Assistance Needed STAT (Behavioral/Uncontrolled person or 2-4444 or 585-922-4444
incident) (followed by location)
Critical Security Incident (followed by location) 2-4444 or 585-922-4444
Lockdown (Alerts staff that facility lockdown is in effect; be 2-4444 or 585-922-4444
aware of suspicious persons in the area)
Command Center Activated (External and Internal Disasters) 2-4444 or 585-922-4444
Announcement to include: Hospital Command Center Team
report to (designated location)
Missing Person Alert (Any age other than Amber Alert) 2-4444 or 585-922-4444
 Estimated age
 Gender
 Description
 Clothing
St. Mary’s Call

Security 585-368-3411
Fire Alert (followed by location) 585-368-3333
Code Team (followed by location) 585-368-3333
Command Center Activated (External and Internal Disasters) 585-368-3333
Missing Person Alert (Any age other than Amber Alert) 585-368-3333
 Estimated age
 Gender
 Description
 Clothing

United Memorial Medical Center (UMMC) Call

Safety & Security @ Bank Street and other buildings 911, then 333
Fire Alert, North Street and Bank Street Dial 333
Adult/Pediatric Code Team Dial 333
Critical Security Incident or Safety & Security @ North Street 911, then 333
Hazardous Material Response Dial 333
Assistance Needed Stat, North Street and Bank Street Dial 333
Amber Alert, all buildings 911, then 333
Stroke Alert Dial 333
Rapid Response Dial 333
Evacuation Dial 333
Multi Casualty Incident Dial 333
Unity Call
Security 585-723-7745
Fire Alert (followed by location) 6666
Code Team (Adult or Pediatric) (followed by location) 6666
Cardiac/ Respiratory arrest
Amber Alert Newborn (missing infant) 6666
Assistance Needed STAT (Behavioral/Uncontrolled person or 6666
incident) (followed by location)
Command Center Activated (External and Internal Disasters) 6666
Missing Person Alert (Any age other than Amber Alert) 6666
 Estimated age
 Gender
 Description
 Clothing
Note: For sites not listed above, call 911

Emergency Management & Disaster Planning

The Comprehensive Emergency Management Plan for each hospital outlines steps to follow to protect
the lives of patients, employees, and any other persons involved, if a disaster occurs in our facilities or
community. The plans also describe how each hospital will establish and maintain a program to ensure
effective response to disasters or emergencies that affect the environment of care. The plan addresses
four phases of emergency management activities: mitigation, preparedness, response, and recovery.
Examples of a disaster that could activate this plan include a disruptive occurrence outside the hospital
that results in a large number of patients brought to the hospital. These multiple casualty incidents
include fires, transportation accidents (aviation accidents, train derailments), chemical spills, bio-
terrorism incidents, etc.
Be sure to review your specific department’s Emergency Response Plan. Staff can access the Rochester
General Hospital and Unity Hospital Comprehensive Emergency Management Plan on the Rochester
Regional Health intranet.
Newark staff should access this plan on the T-drive; Clifton staff should access this plan on the H-drive.
Safe Medical Devices

A medical device is any machine or equipment used in the diagnosis or treatment of any patient. This
includes items such as x-ray machines, intra-aortic balloon pumps, IV infusion devices, or even IV tubing.
All personnel who use medical devices must receive training prior to use and in-service records must be
maintained. Ongoing competency is assessed periodically.
 All medical equipment, including trial and rental equipment, must be inspected by
Clinical/Biomedical Engineering prior to use.
 Medical equipment used in patient areas is inspected periodically in accordance with
departmental policy.
Incident Reports
Any individual who witnesses, discovers, or otherwise becomes aware of information reasonably
suggesting a medical device may have caused or contributed to the death of, or serious injury to, a
patient or employee of the facility is responsible for immediately reporting the incident to his or her
leader or designee. The individual is obligated to make an immediate verbal report to their supervisor
and must enter the information on the SafeConnect portal. The Quality Coordinator will perform an
investigation. The Quality Team will investigate the incident and determine if the incident needs to be
reported to the manufacturer and/or the FDA. Every incident where a medical device may have caused
serious injury or death of a patient, family member, or employee must be reported.
Procedures
1. Take immediate steps to ensure safety of the patient, staff, and/or environment.
2. Isolate the medical device.
o Do not move the device from the site of the event if moving could disturb or alter conditions
useful in determining cause.

o Do not change the settings on the device.

o Do not unplug the device if this would alter information important to determining the cause.
3. Report all clinical equipment-related problems requiring immediate assistance.
4. If the equipment is sparking, smoking, or on fire, immediately implement your facility's Fire
Reporting Procedure.
5. Contact your leader or designee immediately in case the problem presents a safety concern.
6. Place all single-use items used on a patient and considered contaminated in a red bag. Clean
products do not need to be bagged. Include original packaging with the item whenever possible.
Note: Packaging materials should not be placed in the red bag. Label outside of bag.
7. Follow infection control guidelines to clean soiled clinical equipment and reusable accessories.
Note: If a piece of equipment is malfunctioning in any way and you take it to Clinical/Biomedical
Engineering for repair, PLEASE report what was observed. DO NOT label the equipment as “Broken.” An
explanation is needed to guide the evaluation and ensure it functions properly and safely.
Note: Lifetime Care will follow their incident reporting process until trained on SafeConnect.
Fire Safety Procedures and Prevention

Fire Safety Procedures
As a Rochester Regional Health employee, you need to know both general fire procedures and your
specific duties in case of fire. Basic procedures are below; your leader is responsible for explaining
location-specific fire procedures and your duties.
If you discover a fire, stay calm, call out “Fire Alert,” and follow RACE!
 Remove anyone in immediate danger of the fire or smoke and close the door(s) to the room of
fire origin.
 Activate the nearest fire alarm pull station (if your facility is equipped with such devices) and call
the appropriate in-house emergency phone number or 911 as applicable. Give the operator your
name, exact location, and details of the incident.
o ACM and satellite offices: Dial 911
o Clifton Springs Hospital: Dial 7777
o McCormick Transitional Care Unit: Dial 6666
o Newark-Wayne Hospital: Dial 4-2711
o Rochester General: Dial 2-4444
o St. Mary’s: Dial 3333
o Unity Hospital: Dial 6666
o United Memorial Medical Center: Dial 333
o All other locations: Dial 911
 Confine the fire/smoke area. Close all doors and windows, clear the corridors, and reassure the
patients.
 Evacuate patients and employees as appropriate, in accordance with the facility’s policy, or as
directed by the Charge Person, leader, Security, or the Fire Department. Horizontal evacuation is

the first choice. Only use stairs if horizontal evacuation into another smoke compartment is not
available. Do not use elevators for evacuation. Proceed to the nearest exit or stairwell. Once
outside, stay grouped with your department. Check that everyone working is present in your
group. If someone is missing, immediately tell your supervisor. Follow your department-specific
or facility Fire and Evacuation plan for information on evacuation routing and Safe Staging areas.
 Extinguish a small/contained fire ONLY IF:
o The steps above have been implemented
 For example, the Fire Department has been notified and the building is being
evacuated
o The fire is small enough to handle and can be handled safely
o There is a clear path to an exit (your back is toward the door)
o You are using the right category of extinguisher for the fire you are fighting
o You have received documented training in the proper use of fire extinguishers
IMPORTANT:
 Do not use a portable fire extinguisher unless you have been trained.
 Treat all fire alerts as the “real thing” until the situation is cleared.
Additional information for employees at Unity facilities: At Unity Hospital, Security will page a “Fire
Alert,” followed by the location in the hospital, St. Mary’s or the McCormick Transitional Care Unit.
 If you hear “Fire Alert” called in your area:
o Ensure the alarm has been activated
o Report any additional information you have to 6666/3333/911
o Assist other staff in the RACE process
 If you hear “Fire Alert” called in another area:
o Remain in your department
o Clear hallways
o Prepare to receive evacuated patients
 If you hear a “Fire Alert Confirmed” for any area:
o Check with your leader for instructions
o Remain in your area unless otherwise advised
For more information, contact your building fire safety or life safety office.
Review and practice your department- or facility-specific Fire and Evacuation plans
frequently. Practicing the procedures helps you to react calmly and provides for the
safety of you and our patients.

Fire Prevention
A firefighter’s quote: “There is no honor in fighting a fire that could have been prevented.”
Think of fire as a triangle. The “fire triangle” consists of three parts: heat, fuel, and oxygen. When joined,
a reaction between these three parts results in a fire. Fire prevention may easily be achieved by keeping
the three parts of the “fire triangle” separated.
 Heat is the ignition source for fire. It is readily available in patient care, maintenance, laboratory,
and office settings. Examples of heat or ignition sources include:
o Electrical equipment and appliances ranging from coffee makers to electro-surgical
devices
o Bunsen burners in labs
o Cooking appliances in food service areas and employee break rooms including
microwaves and toasters
o Torches used for cutting or soldering
 Fuel is also plentiful in our work places. Examples of fuel sources include:
o Combustible materials such as paper, wood, fabrics, linens, furniture and bedding
o Flammable materials such as alcohol, gasoline, and xylene
o Gases such as acetylene or propane
 Oxygen is in the air we breathe. It is also abundant in our facilities through:
o Piped systems
o Stored and supplied via portable cylinders
o Brought into our facilities by patients as necessary therapy devices
Some Steps to Fire Prevention

 Observe the “NO SMOKING” policy. Inform patients and visitors of the policy.
 Follow the manufacturer’s instructions for the safe and proper use of electrical appliances and
equipment.
 Use only approved electrical equipment.
 Take damaged or defective electrical appliances and equipment out of service and request the
device be repaired.
 Keep water and other liquids away from electrical devices. If they spill, it may cause short
circuits and fire.
 Use and store flammable or combustible chemicals, gases, cardboard, linens, and other
materials properly and reduce quantities whenever possible.
 Follow good housekeeping practices by keeping trash accumulations to a minimum and by using
appropriate trash receptacles.
Preparing for a fire emergency is as important as fire prevention. Our facilities are
equipped with fire and life safety features such as fire and smoke doors, fire alarm
systems, emergency lighting and exit signage, and special extinguishing systems. If
such features are obstructed, damaged, or misused, they will not be acce ssible or
operational if a fire occurs.

General Fire Safety Practices

 When a fire alert is activated, treat it as the "real thing"—do not try to determine if it is "only a
drill." Do not call Security and ask if it is a drill. They are busy handling the emergency and do
not have time for non-emergency calls.
 Do not obstruct or prop open fire or smoke doors, any doors opening to a corridor, or window
openings protected by roll down fire shutters.
 Do not obstruct access through exit corridors. Storing equipment in exit corridors is prohibited
by fire code and Rochester Regional Health policy.
 Do not block or cover exit signs.
 During any construction project, work with Life Safety/Facilities to implement temporary safety
measures and plans.
 Do not obstruct visibility or access to emergency equipment such as fire alarm pull stations, fire
extinguishers, fire valve locations, manual releases for special fire suppression systems, and
medical gas valves.
 Be observant and report any damaged emergency equipment to the responsible facility
representative or department immediately. This includes doors, shutters, lighted exit signs, etc.
 Maintain at least 18” clearance under sprinkler heads.
 Do not hang any item from or attach any item to sprinkler heads or piping.
 Follow the facility policy for the use of or restrictions on:
o Seasonal or other types of decorations
o Staff and patient-owned electrical devices
o Extension cords are not permitted
 Do not use “cheater plugs” or three to two prong plug adapters.
 Promote fire safety practices to co-workers, patients, and visitors.
The effects of fire, no matter how small, can have a devastating impact on the
occupants of our facilities, as well as the building itself. All employees, physicians,
and volunteers must be well versed and practiced in the facility’s “Fire Reporting and
Response” procedures to protect patients, visitors, and staff and to reduce the
possible impact on equipment and the structure resulting from fire and smoke
damage.

If You Discover a Fire or Hear Someone Calling out "Fire Alert"

 FOLLOW RACE!
o Remove anyone from immediate danger; call out "Fire Alert/FIRE."
o Activate the fire alarm and make the backup phone call.
o Confine the fire by closing all doors to control the spread of fire and smoke.
o Extinguish the fire if appropriate and you are trained to do so; evacuate if instructed.
 Remain calm. This keeps patients and visitors calm.
 If the fire alarm is sounding and you hear “Fire Alert” paged for your area, but it is apparent that
a staff member has not activated an alarm, CHECK all corridors and rooms for a sign of fire,
smoke, or other possible cause of the alarm system being activated. If you find a smoke
condition or fire, make the back-up call.
 Staff who are away from their assigned work area must return immediately for accountability
and to assist as needed, unless they are staying with a patient.
 The “Charge Person” or Supervisor will direct their staff’s actions and maintain accountability for
staff and patients.
 Meet and assist Facility Emergency Response personnel and the fire department.
 As necessary and as applicable, implement the procedures for control of piped medical gas
systems such as oxygen and/or nitrous oxide in accordance with the facility and departmental
policy.
 Shelter in place if site plan allows; otherwise, evacuate beyond the immediate fire area.
 If evacuation is necessary or if an immediate evacuation is required by policy, staff members will
relocate with patients and visitors in accordance with the department/unit/site evacuation plan.
 If extended evacuation is underway, take medical records and necessary medical equipment and
supplies to the Evacuation staging areas as defined in the department, or facility-specific Fire
and Evacuation Plan. The "Charge Person" or Supervisor will identify the mechanism for patient
transfer, whether ambulatory, by wheelchair, stretcher, bed, or other appropriate means. Assist
and/or direct visitors as needed.
If You Are NOT Working in the Fire Area or Area of Alarm Origin
 Prepare to implement your department- or facility-specific Fire and Evacuation Plan.
 Inspect corridors and rooms for signs of fire or smoke.
 Close all doors to restrict unnecessary travel from the area.
 Clear all corridors of equipment and obstructions.
 Stand by for further instructions that may be given in person, by phone, or by the paging
system.

General Rules
 Do not make non-emergency phone calls to the Receptionist, Operator, Safety & Security,
Engineering, or Plant Services departments until “All Clear” is announced.
 Do not use elevators during a “Fire Alert.” Use stairs when necessary.
 Ensure that all temporary obstructions of equipment, wheelchairs, stretchers, etc., are cleared
from all corridors and exit paths.
 All routine activities shall stop until the all clear is given.
 Review and practice your department- or facility-specific Fire and Evacuation Plans frequently.
Medical Gases and the Fire Emergency

The #1 misconception about oxygen is that it burns, but in fact, oxygen and nitrous oxide are non-
flammable gases. However, both will support combustion and, in elevated concentration, materials may
burn more rapidly and intensely. If a fire occurs in a room that has one or both of these gases flowing for
patient care reasons, curtail the flow of gas by disconnecting piped-in oxygen and nitrous oxide at the
wall outlet as the patients are removed from the scene. If the wall outlet is not accessible because of the
fire, it may be necessary to shut off the supply at the zone isolation valve(s). Because this step may
impact other patients in the area who are on piped-in gases, it is imperative that such patients’ needs be
assessed and provided for prior to closing any zone isolation valve(s). Close medical gas valves only
under the direction of the Nursing Supervisor.
If piped medical gases are present in your facility

 Understand your facility’s policy, protocol, and procedures for fire emergencies involving piped
medical gases.
 Locate all zone isolation valves in your area and understand the areas they serve. Valves may
range from one for each room to one or more serving multiple rooms.
 Learn and follow your facility’s policies and procedures for properly and safely handling and
storing oxygen and nitrous oxide gas cylinders.
Electrical Safety
Biomedical and Engineering staff urge all employees to take a proactive role in matters of electrical
safety. The benefits of this approach include an increase in the level of safety for all Rochester Regional
Health affiliates and the patients they serve. In addition, safe, well-maintained equipment is an asset to
the organization, enabling employees to perform their duties in an efficient and professional manner.
Responsibility for electrical safety and proper functioning equipment is divided between the Biomedical
Engineering Department (anything from the patient to the plug) and the Engineering Services
Department (anything from the outlet to the electrical distribution system, and electrical equipment not
in contact with the patient).

Electronic Equipment Inspection

 Engineering Services will check all non-medical equipment upon arrival at Rochester Regional
Health or after repairs or modification. This includes trial and rental equipment.
 Three-to-two wire adapters, “cheater” plugs, and extension plugs are prohibited.
 Do not use equipment if a hazard is obvious or suspected. Remove from service and contact
Biomedical for medical equipment or Engineering Services for all other equipment.
Electrical Safety Reminders
 Become familiar with the electrical equipment in your area.
 When using equipment (medical or non-medical), train yourself to look for inspections past due,
bent/broken line cord plugs, bare wires, loose or broken parts, unusual sounds, excessive heat,
or strange odors.
 If there is an equipment problem or suspected problem, remove the item from service and file a
report before patient use.
 If equipment is sparking, smoking, or on fire, immediately implement your facility's Fire
Reporting Procedure.
 Before connecting any equipment, be on the safe side and call Plant Services for a fast
consultation on appropriate use of wiring devices and power cord capacity.
Per HR Telecommunications Policy # SOP23: Personal pagers, mobile phones, or other

forms of personal communication equipment should not be used while the employee
is working or when it creates a distraction or disturbance in the workplace.
See facility-specific policy.
Hazard Communication Regulations

Rochester Regional Health is obligated to comply with hazard communication regulations from four
government agencies:
 OSHA (Occupational Safety and Health Administration)
 EPA (Environmental Protection Agency)
 DEC (Department of Environmental Conservation)
 DOT (Department of Transportation)
The OSHA Hazard Communication Standard (HCS) identifies requirements necessary to ensure chemical
safety in the workplace. Communication about chemical hazards is accomplished in three ways: safety
data sheets, labels, and training.
Safety Data Sheets

Safety Data Sheets (SDSes), formerly known as Material Safety Data Sheets (MSDSes), are the
cornerstone of chemical hazard communication and central to the safe handling of hazardous
substances. Provided by the chemical manufacturer, they offer detailed information needed to work
with the material safely. The SDSes are located on the Rochester Regional Health Portal:
 Under EXTERNAL LINKS, MSDS Online

Labels
All hazardous chemicals, liquids, gases, and solids must have a label with the following information:
 Name(s) of the hazardous material
 Hazards of the chemical or chemical mixture
 Identification and address of the supplier or manufacturer
The manufacturer’s label must not be removed or defaced. If the product is transferred from the
original container to a secondary container, it must be labeled with the full product name and
appropriate hazard warnings.
Training
Any department that uses hazardous materials and/or produces hazardous waste must adhere to
hazardous communication policies and procedures consistent with the Rochester Regional Health
Administrative Policies. This information must be reviewed with each new employee upon hire, annually
thereafter, and whenever a new chemical is introduced into the workplace. Leaders are responsible for
site-specific training of all hazardous chemicals found in their department.
Awareness Tips for All Employees

 Be informed about hazardous materials.
 Know where the Safety Data Sheets are kept at your affiliate and your specific department.
 Safety Data Sheets are also available electronically on Rochester Regional Health portal (Sites M-
Z, Safety, MSDS Online link).
 Be properly trained in the use of hazardous materials and appropriate Personal Protective
Equipment (PPE).
 Always wear PPE as specified in directions for use.
 Know how to read all labels and pictograms.
 Report all exposures to your leader and be seen by Team Member Health Services or Emergency
Department.
 Fill out a SafeConnect event report for any exposures.
 Review, understand, and follow your facility’s Hazardous Material Spill Reporting and response
procedures.
 Review, understand, and follow your facility’s Hazardous Waste Disposal procedures.
 Locate and understand the operation of emergency equipment in your work area, such as
eyewash stations, emergency showers, fire equipment, emergency alarms, etc.

HCS Pictograms and Hazards

Health Hazard Flame Exclamation Mark
Carcinogen Flammables Irritant (skin and eye)

Mutagenicity Pyrophorics Skin Sensitizer
Reproductive Toxicity Self-Heating Acute Toxicity
Respiratory Sensitizer Emits Flammable Gas Narcotic Effects
Target Organ Toxicity Self-Reactives Respiratory Tract Irritant
Aspiration Toxicity Organic Peroxides Hazardous to Ozone Layer (Non-Mandatory)
Environment Corrosion Exploding Bomb
(Non-Mandatory)
Skin Corrosion/Burns Explosives

Aquatic Toxicity Eye Damage Self-Reactives
Corrosive to Metals Organic Peroxides
Flame Over Circle Gas Cylinder Skull and Crossbones
Oxidizers Gases Under Pressure Acute Toxicity (fatal or toxic)
Security Management
Rochester Regional Health strives to maintain a safe and secure environment through the incorporation
of a proactive security management program.
You can be a responsible member of Rochester Regional Health by:
1. Properly displaying your identification (ID) badge at all times when on campus.
o The ID badge provides for the patient’s right to clearly identify a hospital employee.
o The ID badge should be attached on a lanyard or clip and properly worn above the waist
o The ID badge when utilized in conjunction with access control ensures authorized entry
into security-sensitive areas.
o No foreign objects should be on the ID badge (pins, stickers, etc.).
o Any employee without an ID badge will be considered a visitor.
o The ID badge is required by various regulatory agencies.

o Loss of the ID must be reported immediately to your leader and Safety and Security.
Lost or stolen IDs must be replaced immediately.
2. Locking up:
o Personal items, leaving valuables at home.
o Rochester Regional Health items (supplies, equipment, etc.).
o Patient-related information. Log out of the computer.
o Facility keys (do not leave them unattended).
o All hazardous storage areas and areas where medications are kept.
3. Not propping open doors.
o It is each employee’s responsibility to ensure areas are kept secure. Propping open a
door is not permitted for security and fire reasons.
o A door propped open puts the facility and your property, as well as your co-workers, at
risk.
4. Reporting the following incidents to Safety and Security:
o Property losses & theft
o Accidents or injuries
o Vandalism
o Illegal use, possession, loss or diversion of controlled substances
o Missing patients or persons
o Unsecured areas
o All acts or threats of workplace violence
o Suspicious situations or unidentified persons
What you can do for Rochester Regional Health security:
 Watch for individuals who look out of place
 Ask “Can I help you?” to determine their intent
 Call Security if you have concerns or are suspicious of any persons or situations:
Site Phone
BHN 585-922-6330/585-922-4300
Clifton Springs 7777
Lifetime Care 911 and/or 922-4300 RRH Security
Hildebrant Hospice only:
911 and/or 723-7745 Unity Security
Newark Wayne 315-332-2221
Riedman Campus 585-922-4300
RGH 585-922-4300
RMHC 585-922-2507/922-4300

Site Phone
St. Mary's Campus 585-368-3411
(x3333 for emergencies on campus only)
UMMC 911, then 333
Unity/Park Ridge Campus 585-723-7745
(x6666 for emergencies on campus only)
Wilson 585-922-4300
Offsite location when security is 911
not present
 Give Security your location and describe the incident:

o Describe the person(s) involved
o Remain on the telephone line until officers respond and until advised by dispatcher that
they are all set
Workplace Violence
It is the goal of Rochester Regional Health to provide a work environment free of violence or threat of
violence. Acts or threats of violence that involve or affect Rochester Regional Health or that occurs on
any Rochester Regional Health properties will not be tolerated. This may lead to disciplinary or legal
action, as is deemed appropriate.
Violence Defined
Violence is defined as any physical or verbally assaulting behaviors, including hitting, biting, punching,
choking, pinching, scratching, throwing, pushing, cursing, threatening, striking, or injuring with a weapon
or item (such as knife, chair, club, flowerpot, etc.). Threats of violence include intimidation, harassment,
or coercion. It is the employee’s responsibility to report all acts or implied acts of violence to the
Security Department immediately.
Weapons Policy
Weapons are not permitted on Rochester Regional Health property. This includes hospitals, medical
practices, senior housing, clinics, and so on. Weapons refer to any firearm, knife, or any device that
could cause bodily harm or injury. This applies to employees, patients, visitors, providers, students,
volunteers, and contracted personnel. RGH Department of Safety and Security has implemented an
Armed Security Officer program. Those specially selected, trained, and equipped armed security officers
are exempt from this policy, with the exception of being armed in weapon restricted secure areas, to
include the Crisis Intervention Unit (CIU) and G1. Law enforcement personnel are exempt from this
policy except when they are being treated in the hospital, when in psychiatric units, or in other
situations as determined by the Director of Safety and Security or Nursing Administration.

Workplace Inspection
To provide a safe and secure environment, Rochester Regional Health reserves the right to check
packages, bags, briefcases, purses, etc. Rochester Regional Health provides lockers, storage areas, desks,
files, etc., for employee use while at work. These items are Rochester Regional Health property and are
subject to inspection.
Active Shooter
Active shooter events at a healthcare facility present unique challenges, but a survival mindset can help
increase the odds of surviving. During an active shooter situation, the natural human reaction is to be
startled, feel fear and anxiety, and even experience initial disbelief.
Here’s what you can do if someone enters your work area and starts shooting:
Run!
o Get out of the area at the first sign of danger
o Leave your belongings behind
o Take others with you if possible
o Try to prevent others from entering the danger area
o When it is safe to do so, call 911, give them the address, exact location of the shooter inside the
building, and a description of the shooter if possible
o Follow orders from law enforcement
Hide!
o Find a place to hide where the shooter is less likely to find you
o Stay out of the shooter’s view
o Lock the door; barricade it with heavy furniture if possible
o Hide behind heavy objects such as desks, file cabinets, and so on
o Remain quiet—silence your cell phone
o Dial 911 if possible; if you cannot talk, leave the line open
Fight!
o As a last resort to save your life, you may have to attack the shooter
o Act as aggressively as possible!
o An attack by a group is more effective than by a single person
o Improvise weapons (chairs, laptop, fire extinguisher, sharp objects, etc.)
o Throw things
o Yell and shout; try to disorient the aggressor
o Commit to your actions!
What to do when law enforcement arrives

o Be prepared for them to shout orders and push people to the floor

o Keep your hands empty and in plain sight

o Follow their orders to the letter; save your questions for later
o Understand that rescuing the wounded will not occur until the scene is secure
o Expect to be taken to a safe location and told to remain there until you are identified and
debriefed
Bomb Threats
Bombs can be constructed to look like almost anything and can be placed or delivered in any number of
ways. The only common denominator that exists among bombs is that they are designed or intended to
explode.
The majority of bomb threats are called into a target location.
Two reasons for reporting a bomb threat are:

1. The caller has definite knowledge or believes that an explosive or incendiary device has been or will
be placed and they want to minimize personal injury or property damage.
2. The caller may want to create an atmosphere of anxiety and panic, which will result in a disruption of
the normal activities at the facility.
In most cases, the switchboard operator would receive a bomb threat. However, it is possible that
anyone might receive such a call. If you receive the bomb threat call, do the following:
1. Remain calm.
2. Keep the caller on the phone as long as possible while summoning help from a co-worker.
3. Ask:
 a. When is the bomb going to explode?
 b. Where is the bomb located?
 c. What does it look like?
4. Listen – What does the caller’s voice sound like?
5. Report – To report the bomb threat, call:
 Clifton Springs - 7777
 Newark Wayne – 32444 or 42711
 Off-site Facilities – 911
 RGH campus – 4444
 St Mary’s Campus – 3333
 UMMC - 333
 Unity Campus – 6666
If the warning is received by mail, do the following:
1. Avoid handling and isolate the package.

2. Look for indicators (protruding wires, strange odor, excessive taping etc.)
3. Notify emergency personnel by calling:
 Newark Wayne – 32444 Or 42711
 Off-site Facilities – 911
 RGH campus – 4444
 St Mary’s Campus – 3333
 UMMC - 333
 Unity Campus – 6666
4. Notify an administrator or their alternate.
Immediately after receiving a bomb threat, the switchboard operator will notify key persons and
departments (Security, Police & Fire Departments, individual in charge of the building at the time,
nursing leader, or administrator on call, Engineering, Housekeeping leader).
The notified persons and department representatives will report to the designated site Command
Center.
No announcement will be made on the public address (PA) system unless it is general instructions to
hospital personnel as directed by the administrator in charge. During a search for a bomb, do not use
light switches, radios, and cellular phones.

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Mandatory Compliance Education Packet Core Content: Rochester Regional Health

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Mandatory Compliance Education Packet

Rochester Regional Health

Rochester Regional Health

© 2021, Rochester Regional Health i

Hazard Communication Regulations .................................................................................................... 44

Naming Conventions and Use of Icons

Indicates information that is a note or reminder.

© 2021, Rochester Regional Health ii

Additional Mandatory Training

Skill Competency Requirements

© 2021, Rochester Regional Health 1

Organizational Governance & Compliance

Charity Care/Financial Assistance Program

© 2021, Rochester Regional Health 2

Cultural/Age Diversity and Assistance Programs

© 2021, Rochester Regional Health 3

© 2021, Rochester Regional Health 4

The Language Assistance Program includes the following:

The Rochester Deaf Community

© 2021, Rochester Regional Health 5

© 2021, Rochester Regional Health 6

Americans with Disabilities Act

For policy reference: See facility-specific policy.

© 2021, Rochester Regional Health 7

Information Privacy and Confidentiality

Non-Compliance Can Be Costly

Protected Health Information

Policies and Procedures

© 2021, Rochester Regional Health 8

Special Notes on HIV Confidentiality

© 2021, Rochester Regional Health 9

Only employees, contractors, medical, nursing, or health-related students who have

Employee Responsibilities for PHI Security

© 2021, Rochester Regional Health 10

These employee responsibilities can be printed and posted.

© 2021, Rochester Regional Health 11

Professional Misconduct and Reporting Concerns

Reporting Your Concerns

If you suspect someone of professional misconduct, discuss the circumstances with

© 2021, Rochester Regional Health 12

Quality Assurance, Patient Safety and Performance Improvement

© 2021, Rochester Regional Health 13

Process Improvement Methodology

Patient Safety Program

Daily Safety Check

Safe Connect Event Reporting System

© 2021, Rochester Regional Health 14

© 2021, Rochester Regional Health 15

Health, Safety & Awareness

© 2021, Rochester Regional Health 16

For more information on this topic, refer to the Disclosure of Unanticipated

© 2021, Rochester Regional Health 17

Key Steps When You Receive a Complaint

© 2021, Rochester Regional Health 18

© 2021, Rochester Regional Health 19

Lifetime Care Complaint Process (Refer to Administrative Policy#9004)

Complaints immediately resolved to the patient's complete satisfaction do not

Abuse, Neglect, and Domestic Violence

© 2021, Rochester Regional Health 20

Community Services Available for Abuse Prevention or Intervention

© 2021, Rochester Regional Health 21

Stroke Alert/Signs of a Stroke

Stroke Warning Signs and Symptoms