Monroe County Hospital

1. Monroe County Hospital New Employee Orientation

2. MCH Personnel Policies Managed by: Debra K. Flowers, PHR Director, Human Resources Extension 209

3. Annual Policy Review • Each employee should be familiar with all policies and procedures. • Policies and any related forms are posted on the web site for your convenience: • Employee Documents • Type in monroe as password • Click on document you would like to review/print • This is short review; please go to the web site to review the complete policy.

4. Annual Updates • Annual recertification/updates are mandatory for all employees. Requirements include: • PPD Skin Test (or Chest X-Ray if history of positive skin test) • Passing score on annual update chapters (via the web) (90% or higher) • Any required license renewal to include CPR and ACLS

5. Attendance • It is essential that all employees work the hours they are scheduled to work. • MCH requires employees to provide adequate notice, as well as justifiable reason, for absenteeism and tardiness. • Excessive absenteeism and/or tardiness can result in disciplinary action, up to and including, termination.

6. Confidentiality • It is the responsibility of all employees to safeguard MCH information. • Never share patient information with strangers or anyone without prior consent from the patient. • Never discuss confidential patient information where others can overhear your conversation. • Never reveal any information to the media or other public source; refer questions to your supervisor. • Safeguarding patient information is every employee’s obligation.

7. Direct Deposit • All employees are required to sign up for direct deposit for all payroll checks.

8. Donation of Paid Days Off (PDO) • An employee may donate his/her accrued PDO hours to another employee. • Transfer of PDO is on an hour-for-hour basis. • Recipient’s PDO balance must be below 24 hours. • Donating employee must have at least 48 hours accrued in his/her PDO account. • PDO hours are not recoverable. • All PDO donation hours are approved by Administration prior to transfer.

9. Dress Code • Administrative Staff: • Business casual is required. • No jeans. • A neat, well-groomed appearance is required. • Socks or hose will be worn. • Hair must be neat and clean. • Fridays are “casual” days; denim jeans and shorts are not allowed. • ID badge will be worn at all times.

10. Dress Code • Clinical Staff: • Scrubs will be worn. • White nursing shoes (including clogs w/o holes) or tennis shoes may be worn. No open toe shoes are allowed. • Socks or hose will be worn. • Hair should be neat and clean. • Excessive jewelry is not allowed. • No artificial nails are allowed. • ID badge will be worn at all times.

11. Educational Assistance Program • MCH will provide financial assistance to current employees wishing to enter a program of study in a field which the Hospital Authority identifies as beneficial to the hospital. All such requests/ applications for financial assistance will require approval by the Hospital Authority.

12. Employee Benefits • Once a full-time employee has successfully completed their introductory period (90 days), they are eligible for the following benefits: • Group Health Insurance (eligible after 30 days) • Dental Insurance • Long Term Disability • Life Insurance • Supplemental Insurance through AFLAC • ING Retirement Plan • Vision Insurance

13. Employee Classifications • Full Time: • An individual that is scheduled to work a minimum of 36 hours or more per week. • Part Time: • An individual that is scheduled to work less than 36 hours per week. • PRN (As needed): • An individual that is scheduled to work based on prevailing workload.

14. Employee Wellness Physical • As an added benefit to MCH employees, all employees are eligible to receive a wellness physical free of charge. The physical may include the following: • Comprehensive Metabolic Panel • Complete Blood Count • Prostrate Specific Antigen • Chest X-Ray • Mammogram

15. Employee Wellness Physical • The following govern the program: • Employees must complete the Employee Wellness Physical form and take it to radiology or lab. • Employees are responsible for their own appointments. Coordinate appointments with supervisor. • All lab work ups will be completed at MCH lab. • All chest x-rays and mammograms will be completed at MCH radiology department.

16. Employee Wellness Physical • Only one wellness check per year per employee. • Only one chest x-ray and mammogram per year per employee. • All results are sent directly to primary care physician. • Employee Wellness Physical form must be returned to Human Resources when completed.

17. Equal Employment Opportunity • MCH will provide equal opportunity regardless of race, color, sex, religion, national origin, age, or disability. • MCH will provide promotion and advancement in a non-discriminatory fashion. • MCH will not permit employees to engage in discriminatory practices.

18. Extended Illness Bank • All full-time employees are eligible. • Accrual rate is 2.154 hours per pay period. • Maximum accrual is 960 hours (120 days). • EIB starts on the 4th day of illness unless admitted to the hospital. • Outpatient surgery will qualify for EIB use; diagnostic procedures do not. • MCH reserves the right to verify illness at any time during benefit period. • EIB is forfeited upon resignation, termination, or retirement.

19. Family Medical Leave Act (FLMA) • MCH provides 12 weeks of unpaid leave to eligible employees each calendar year. • Applies to employees who have worked one year and for at least 1250 hours over the previous 12 months. • Leave is granted for birth of child, serious health condition of employee or family member. • Employee is required to complete FMLA documentation and provide certification from attending physician. • Return to work authorization is required prior to employee’s return to duties.

20. Grievance Procedure • MCH wishes to cultivate clear and open communications between employees and supervisors. • If an employee cannot resolve a specific concern with his or her supervisor, the employee should follow these procedures: • Initiate grievance to next higher level of supervision • If not resolved in 5 days, put grievance in writing and forward to department director

21. Grievance Procedures cont… • If grievance is still not resolved, it will be forwarded to HR director who will act as mediator between employee and supervisor. • If appropriate action has note been taken with 5 days, the problem should be presented to CEO. • Upon review of information, CEO will determine course of action to be taken.

22. Jury Duty • Employees will be compensated for lost time from work. • Any payment received from courts will be turned in to the Business Office. • Employee must report to work when it does not conflict with jury obligations. • Employees are responsible for keeping their supervisor informed about amount of time required for jury duty. • Time spent on jury duty does not count as overtime.

23. New Employee Orientation • All employees are required to complete the New Employee Orientation. • This orientation is done on your first day of work. • Department Managers are responsible for introducing new employees to co-workers and department managers.

24. Paid Days Off (PDO) • All full-time employees are eligible for PDO. • PDO days are days off which include vacation, holidays, bereavement leave, and short term illness. • Holidays are: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Day • Employees start to accrue PDO on date of hire, but cannot use it until they have satisfactorily completed the 90-day introductory period. • Employees are paid PDO upon proper resignation; if terminated PDO will be forfeit.

25. Performance Evaluations • MCH has a merit-based evaluation system. • Evaluations are done at the 90-day point and annually on anniversary date of hire. • Salary increases are neither automatic nor periodic. Salary is reviewed and increases are based on performance and overall fiscal goals of MCH. • Performance evaluations are a permanent part of an employee’s personnel file.

26. Progressive Discipline • All employees are expected to abide by the general rules of good conduct. Should it become necessary for disciplinary action the following is usually taken: • Oral Warning • Written Warning • Suspension • Termination • If the severity of the infraction is sufficiently serious, one or more of these steps may be bypassed.

27. Rehire of Former Employees • An employee involuntarily terminated by MCH, regardless of reason, is ineligible for reemployment. • HR Director will review former employee’s personnel records prior to re-hire. • Former employees who quit without notice are ineligible for re-hire.

28. Safety • All employees are required to report any incident or accident or any unsafe practice. • Follow these guidelines: • Notify your supervisor • Complete the Accident Report Form and Lab Request Form • Escort employee to ER to be examined by ER doctor • Escort employee to lab for drug screen • Return to work, if released by ER physician • Forward Accident Report Form to HR

29. Sexual Harassment • Defined as: • Unwelcome sexual advances, request for sexual favors, and other verbal or physical contact of a sexual nature constitutes sexual harassment. • This is strictly prohibited. • Appropriate action will be taken against any employee who violates this policy, up to and including termination. • Retaliation against employees who complain about sexual harassment is strictly prohibited.

30. Smoke Free Facility • No smoking or other tobacco products is permitted inside the hospital or patients rooms. • Employees may only smoke in designated area: • Area outside of South Wing entrance, first floor, known as the “loading dock.” • Failure to comply with this regulation may result in disciplinary action, up to and including termination.

31. Substance Abuse • It is a a violation of MCH policy to use, possess, sell, trade, offer for sell, or offer to buy illegal drugs or otherwise engage in the illegal use of drugs on or off the job. • It is a violation for employees to report to work under the influence of illegal drugs or impaired by alcohol. • It is a violation for employees to use prescription drugs illegally.

32. Termination/Resignation • An employee desiring to terminate employment with MCH is asked to give a minimum 2 weeks notice; managers are asked to give 30 days notice. • If employee provides proper notice, any accrued PDO will be paid. • All terminations will be treated in a confidential and professional manner. • Employees terminated by MCH will receive all earned pay and any expenses due at the time of the next regular paycheck. • If an employee is terminated, all PDO is forfeit.

33. Test 1. Are you required to wear your MCH ID badge at all times? a. Yes b. No 2.When do you receive your first evaluation? a. 90 days after employment. b. 1 year after employment. c. Whenever your supervisor thinks it is necessary. 3.What are the guidelines for an accident/incident?

34. The Core ValuesManaged by:Presented by:Kay FloydChief Executive OfficerExtension 211

35. Guiding Statements • Mission Statement: • We will be the hospital of choice in our service area and will be guided by our core values of caring, quality, integrity, and respect to those we serve and to our employees, medical staff, volunteers, and partners. • Vision Statement: • To be an independent community hospital that is an asset to its community

36. Core Values • The Value of Caring – the common thread that runs through our hearts. • The Value of the Person – we are all equal in God’s sight. • The Value of Quality – we always do the very best we can. • The Value of Integrity – we will always do what we said we would do.

37. Core Value Test 1.What core value is the first and most important? a. Person b. Caring c. Integrity d. Quality 2. Why are Core Values so important? a. Because my grandmother has these values. b. Because we act the way we think and believe. c. I’ll get 10% off at the grocery store if I rattle them off to the cashier. d. Because I’ll look foolish if I don’t know them.

38. Quality Management ProgramPresented by:Kathy LouthDirector, Quality ManagementExtension 215

39. Why is Quality Improvement (QI) done? The goal of QI is to continuously improve patient health outcomes. A hospital’s performance affects its patients outcomes, the cost to achieve these outcomes, and the perception of its patients and their families about the quality and value of its services.

40. How is QI done? Our hospital’s approach to QI consists of process design, performance measurement, performance assessment, and performance improvement. The methodology used is the PDCA method PLAN DO CHECK ACT

41. PDCA

42. Cycle at MCH Each department is responsible to monitor any critical processes within that department. This includes any monitors set forth by regulatory agencies such a Joint Commission.

43. Cycle at MCH (con’t) Each department collects the data needed to report on these critical processes. The data is graphed on a statistical control chart –run chart- and turned in monthly to the Director of Quality.

44. Cycle at MCH (con’t)

45. Cycle at MCH (con’t) The Director of Quality Management, Kathy Louth, analyzes the graphs and determines the trend, range, and cause on each critical process graphed. Trend is the direction the graph is going. This can be negative, positive, stable, or unstable. The range is the difference from one point to another point. This can be increasing, decreasing, stable, or unstable. Cause is what actually made the graph the way it is. This can be normal or special.

46. Cycle at MCH (con’t) All graphs with special causes or increasing ranges for consecutive quarters are reported at the Quality Council (QC) meeting held quarterly. The QC has members from the Hospital Authority, Administration, QI, Nursing Administration, and Medical Staff. These members channel the information to the rest of the Medical Staff, Hospital Authority, Department Managers, and Staff.

47. Cycle at MCH (con’t) A performance improvement (PI) team is set up for any problems that need attention based on this data. Teams are prioritized based on a criteria set forth by the organization. The team uses the Cause and Effect Diagram (a.k.a. the Fishbone Diagram) to help solve the problem.

48. Cause & Effect (Fishbone Diagram) PLANT PEOPLE PROBLEM POLICY PROCEDURE

49. External Quality Programs Healthcare Research & Medical Evaluation System (HERMES) Collaborative Approach to Research Effectiveness (CARE) Program Hospital Quality Alliance (HQA) Georgia Medical Care Foundation (GMCF)

50. Healthcare Research & Medical Evaluation System (HERMES) CARE 2 Patient care outcomes and QI Med Eval Physician costs and performance High Risk High risk patient safety and reportable events CARE Core Clinical processes and The Joint Commission Submission