Risk Management Plan 2011 RISK MANAGEMENT PLAN

Transcription

1 RISK MANAGEMENT PLAN September 1,

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3 RISK MANAGEMENT PLAN TABLE OF CONTENTS Please note! This Manual does not represent an all-inclusive list of procedures, but serves as a reference for those procedures that are considered high volume and high risk potential at the University Health Services. Page Section Topic 5 1. Health and Safety Purpose Duties of Health Services Director and Management Duties of Safety Committee Responsibilities of all Employees Injury Reporting Injury/Illness Investigation Training 7 2. Automated External Defibrillator Department AED Coordinator Equipment Medical Response Documentation Post-Event Review Forms 9 3. Bloodborne Pathogens Exposure Control Plan Scope Details of Plan 9 4. Personal Protective Equipment Purpose Health Services Responsibilities Employee Responsibilities Guidelines for the Collection, Handling, and Disposal of Infectious Waste Guidelines Responsibility of Infectious Waste Generators Smoking University Smoking Policy Vehicle Safety Training Patient Management and Care Disruptive or Violent Patient 3

4 Dismissal from Care Adverse Events Adverse Event Procedure Patient Complaints Impaired or incapacitated employee Guidelines for an impaired employee Services outside of normal working hours Authorized Personnel in Patient Care and Secure Areas Patient Care Areas 18 13,2 Designated Secure Areas Confidentiality Review of Clinical Records and Policies Education in the use of the Risk Management Manual The Risk Management and Safety Manual includes Covered in other Sections of this Manual are: UHS Infection Control Plan UHS Fire Safety Plan UHS Severe Weath/ND Alert Plan UHS Emergency Plan (for shooters or hostage situations) UHS Emergency Evacuation Plan Printed reference copies of the online Notre Dame Office of Risk Management policies and guidelines that are referenced in this manual are available in the UHS Risk Management and Safety Reference Manual. 4

5 1. Health and Safety The University of Notre Dame Health Services is committed to a strong program of health and safety principles, injury prevention and complying with all relevant environmental, health and safety laws and regulations. To accomplish this we are following the directions of and utilizing the services of the Notre Dame Office of Risk Management and Safety. This manual and all its contents will be reviewed annually by the University Health Services governing body. 1.1 Purpose The University Health Services makes all reasonable efforts to: a. Protect the health and safety of employees, students, and visitors. b. Provide safe workplace for employees. c. Provide information on health and safety hazards to employees, students, and visitors. d. Identify and correct health and safety hazards and encourage employees and students to report hazards. 1.2 Duties of Health Services Director and Management a. Communicate and implement the Health and Safety Policy and its requirements to the staff. b. Ensure that areas under their management are in compliance with the University s health and safety policies, practices and programs. c. Ensure that individuals under their management have the authority to implement appropriate health and safety policies, practices and programs. d. Direct regular and temporary employees to obtain any required safety training before they work with hazardous chemicals, biohazardous agents, radiation, or other physical/mechanical hazards in their working environments. e. Determine that safety and health program needs (e.g. training, protective equipment and corrective measures including noncompliance items identified in safety audits) have adequate funding. f. Incorporate workplace safety requirements and responsibilities into each appropriate job description and ensure that workplace safety requirement expectations are communicated to each employee. g. Assign responsible individuals to serve on Department or Building Safety Committees and provide them with appropriate resources to administer their responsibilities.

6 1.3 Duties of Safety Committee a. Promote safety at the department level and provide a forum for departmental participation in the overall University health and safety program. b. Ensure that all work related injuries and illnesses and unsafe acts and conditions are properly and timely reported and investigated, c. Coordinate fire drills, first aid and CPR training, emergency action training and other general safety training for the Department. 1.4 Responsibilities of all Employees a. Comply with this policy and all other University health and safety practices and programs. b. Maintain work areas safe and free from hazards. It is the responsibility of each employee to stop an activity and contact their immediate supervisor (or RMS) if they do not feel safe. c. Attend any health and safety training mandated by management. d. Notify a supervisor of any safety hazards in the workplace. e. Keep informed of conditions affecting their health and safety. f. Report all accidents and injuries immediately to their supervisor. 1.5 Injury Reporting a. Every University employee has the responsibility to immediately report injuries or illnesses to their supervisors. In an emergency situation, Notre Dame Security/Police should be contacted immediately by dialing 911 on a campus phone or if using a cell phone call (574) Notre Dame Security/Police will determine the appropriate method of transportation to the proper medical facility. b. In non-emergency incidents supervisors have the responsibility to provide all workrelated injured or ill employees with a Supervisor s Report of an Injury to the Health Center form. This form authorized University Health Services to provide medical treatment under the University s Worker s Compensation Program. Supervisors must then complete the Indiana Worker s Compensation First Report of Employee Injury/Illness form and submit it to the Risk Management and Safety Department within 48 hours of the injury or illness. A copy of the First Report of an Injury form will be forwarded to the Department/Building Safety Committee Chair for investigation if appropriate. (See Appendix for copy of reports) c. Any employee witnessing an incident or coming upon an injured or ill student or visitor is responsible for reporting the injury or illness to Notre Dame Security/Police Notre and their supervisor.dame Security/Police can be reached by dialing 911 on a campus phone or if using a cell phone call (574) Notre Dame Security/Police will complete a Report of the incident with a copy forwarded to the Risk Management and Safety Department. 6

7 d. If the student or visitor does not want medical attention, employees should obtain as much information as they can from the injured or ill individual and complete the form Student or Visitor Report of an Injury available from the UND Office of Risk Management. Completed forms should be forwarded to the Risk Management and Safety Department. A copy of the form will be distributed to the Department/Building Safety Committee Chair. 1.6 Injury/Illness Investigation An investigation shall be completed for all reported injuries and illnesses to employees, students or visitors. Employee Supervisors or Department Safety Committee representatives should investigate each reported incident using the form Injury/Illness Investigation Report available from the UND Office of Risk Management. 1.7 Training University Health Services staff is required to have current certification in CPR/AED with an annual review. Universal Precautions/Bloodborne Pathogens Prevention training is to be reviewed annually. Bloodborne Pathogens Refresher training can be viewed on the Risk Management website at: Online BBP Refresher PowerPoint. Note that the last slide has a link to a form to report your completion. The University Health Services offers the following training both to its staff and other members of the Notre Dame community: a. CPR/AED training b. First Aid training c. Bloodborne Pathogens Prevention training For more information go to the Health and Safety Policy on the Risk Management website. 2. Automated External Defibrillator An AED will be used in conjunction with Cardio-Pulmonary Resuscitation (CPR) in cases of sudden cardiac arrest on campus, in accordance with accepted protocols, including those developed by the American Red Cross and American Heart Association. Use of the AED and CPR will continue as appropriate during the course of emergency care, until the patient resumes pulse and respiration, and/or local Emergency Medical Services (EMS) arrive at the scene, and assume responsibility for emergency care of the patient. 2.1 Department AED Coordinator: a. Daily (internally by machine) and monthly equipment maintenance per manufacturer s recommendations; 7

8 b. Sending all maintenance and training records to University s Risk Management AED Program Coordinator for review. 2.2 Equipment Each AED will have: One set of defibrillation electrodes with the device; One spare set of electrodes; One resuscitation kit containing two pairs of gloves, one razor, one pair of trauma shears, one towel, and one facemask barrier device. Procedures for purchasing equipment: a. Notify Risk Management and Safety of need; b. Risk Management and Safety will evaluate the request from an individual Department / Owner; c. Individual departments order AED units. All AED equipment and accessories shall be maintained in a state of readiness and per manufacturer guidelines. 2.3 Medical Response Documentation a. Post-Incident Internal Documentation: 1. When an AED is used by Notre Dame Security Police (NDSP), the event report should be filed with the NDSP as per current protocol, with the UHS Medical Director, and the office of Risk Management and Safety. 2. If an AED is used by University Health Services, a copy of the event report should be placed in the patient s chart and a copy sent to the UHS Medical Director and the office of Risk Management and Safety. 3. If an AED is used by a University Responder, the event report should be filed with Risk Management and Safety and with the UHS Medical Director. b. Post-Incident External Documentation: 1. AED Incident Report Form (Appendix I): Completed by a Trained Responder for each event using the AED. Form shall be forwarded to the UHS Medical Director and the office of Risk Management and Safety within 24 hours of a medical event. 2. Any and all patient information generated during AED use must be collected and placed in the patient s confidential medical file in the University Health Services Medical Records Department and stored for seven years. 2.4 Post-Event Review a. A review of each medical event using an AED shall be conducted by the Risk Management and Safety AED Program Coordinator. 8

9 b. All key participants in the medical event shall participate in a review that includes: 1. Actions that went well during the medical event; 2. Opportunities for improvement; 3. Critical incident stress debriefing. c. A summary of the post-event review shall be sent to Risk Management and Safety for maintenance according to the record retention policy. 2.5 Forms (available from Risk Management or on their website in the AED Policy) AED Incident Report AED Operator s Checklist For more information, go to the Automated External Defibrillator Policy which is on the ND Risk Management website 3. Bloodborne Pathogens Exposure Control Plan To ensure adequate protection for University employees, faculty and staff against exposure to potentially infectious bloodborne materials. The requirements of this plan are designed to meet or exceed the Federal requirements defined in 29 CFR Scope This plan applies to all applicable activities that involve the potential exposure to blood or potentially infectious materials. Potentially infectious materials include all bodily fluids or non-intact tissue of the body. There are a number of occupational positions and laboratory personnel that are covered by this plan. They include University Health Services employees, including Physicians, Nurses, Nursing Assistants, Housekeeping Staff who are assigned to University Health Services and other medical assistants. 3.2 Details of Plan Refer to: Infection Control Plan which is part of this Manual ND Bloodborne Pathogens Control Plan which is on the Risk Management website. 4. Personal Protective Equipment 4.1 Purpose The purpose of the Notre Dame Personal Protective Equipment Policy (PPE) is to minimize injury to employees through the proper use and care of personal protective equipment. The 9

10 Program is most effective if administered and enforced by supervision at each facility or department where employee protection is required. It is designed to insure that employees receive the correct PPE that they need, in the right size or style, understand its care, use and disposal and that it is readily available to them. a. All areas and tasks for which PPE is needed under expected routine or non-routine operating conditions are defined in the Health Services Infection Control Plan. The type of PPE required shall also be documented for each area and task associated with PPE use. 1. PPE must be inspected prior to and as appropriate during each use for defects such as holes, tears, scratches, signs of material deterioration, cracks, poor closure or any other sign of degradation which may affect the PPE performance. PPE with defects shall be immediately removed from service and replaced or repaired. 2. Potentially contaminated PPE shall not be worn in designated clean areas (for example offices, control rooms, lunch rooms and clean change rooms). Potentially contaminated PPE shall be cleaned, laundered, or disposed of as deemed appropriate by each department. 3. A schedule for replacement of PPE shall be established if applicable. When limitations or precautions are indicated by the manufacturer, they shall be communicated to the user. 4.2 Health Services Responsibilities a. The Assistant Director, Clinical or a designate shall consult with Risk Management and Safety for the selection of personal protective equipment. b. The Supervisor or designated individual meet with each employee and have them demonstrate that they know and understand how to don, doff, adjust, care for, maintain and store the PPE that they are required to wear on the job. The method of demonstrating may be performance oriented, but should be through one on one interaction.. c. UHS must keep adequately documented records of these certification tests. (Forms available from Risk Management in the Policy on Personal Protective Equipment. Assure that each employee s PPE fits properly. If it does not, the supervisor is responsible for replacing it. Contact Risk Management and Safety for assistance. d. Assure that each employee routinely check their PPE for visible damage. e. Notify Risk Management and Safety when changes have occurred in the process, chemicals or equipment used which may change the departmental personal protective equipment needs. With the assistance of the department, Risk Management and Safety will then evaluate the PPE needs for the department. f. Schedule annual training by contacting Risk Management and Safety. 10

11 4.3 Employee Responsibilities: a. Attend annual training. b. Comply with policy requirements. c. Inspect his/her PPE daily. d. Understand the following about his/her PPE: 1. When it is necessary to wear PPE. 2. What PPE is necessary. 3. How to properly don, doff, adjust, and wear the PPE. 4. The PPE s limitations. 5. Proper care, maintenance, useful life and the disposal of the contaminated PPE. e. Contact his/her supervisor when questions arise. Refer to 5.2 below and to the UND Personal Protective Equipment Policy in the Risk Management and Safety Reference Manual for further Details. 5. Guidelines for the Collection, Handling, and Disposal of Infectious Waste The University of Notre Dame, in its continual efforts to protect the health and safety of its employees, students, and guests, has instituted an infectious waste disposal program. The program is required under Indiana State Board of Health regulations, Title 410. The University recognizes that the various researchers and departments involved with infectious material and waste go to great extremes to insure that the material is handled as safety as possible and protection is afforded at all times. The University also recognizes that the disposal of infectious waste has become a national problem and it is with this understanding adopts these following guidelines. 5.1 Guidelines The following guidelines are instituted in order to additionally safeguard the employees and students who handle infectious waste products, and includes the responsibilities of individuals, researchers, and departments in the safe handling of disposal of infectious waste. Infectious waste, while a very broad term, is generally accepted and includes waste that epidemiological evidence indicates is capable of transmitting dangerous communicable diseases. This definition includes but is not limited to: a. Cultures and stocks of infectious agents and associated biologicals. Including cultures from medical and pathological laboratories; cultures and stocks of infectious agents from research and industrial laboratories, waste from the production of biologicals; discarded live and attenuated vaccines and culture dishes and devices used to transfer, inoculate, and mix cultures. 11

12 b. Pathological wastes. c. Body tissues and their containers. d. Human or animal blood and blood products. e. Liquid waste, human and animal blood, products of blood, items saturated or dripping with human or animal blood; items that were saturated and dripping that are now caked with dried human or animal blood; including serum, plasma, and other blood components and their containers which were used or intended for use either in patient care, testing, laboratory analysis, research, or the development of pharmaceuticals. Intravenous bags are also included in this category. f. Used and unused sharps Sharps that have been used in animal or human patient care, treatment or medical research, or industrial laboratories; including hypodermic needles, syringes (with or without the attached needle), Pasteur pipettes, scalpel blades, blood vials, needles with attached tubing, and culture dishes (regardless of presence of infectious agents). Also included are other types of broken or unbroken glassware that were in contact with infectious agents such as used slides and cover slips. g. All Animal Carcasses h. Other waste that has been intermingled with infectious waste. Any material (i.e. : paper products, plastic products, disposables), that has at any time been in contact with or believed to have been in contact with any infectious agent. 5.2 Responsibility of Infectious Waste Generators a. It shall be the responsibility of the infectious waste generator (i.e.: individual, researcher, department) to adhere to the following guidelines and procedures as listed: b. The individual generator (researcher, department) shall be required to render innocuous all infectious waste (except sharps and sharps containers, animal carcasses and contaminated bedding) through autoclaving prior to discard as solid waste. c. The individual generator (researcher, department) upon autoclaving shall be required to separate the infectious waste as follows: 1. Used and unused sharps should be placed in the container identified as SHARPS. 2. Infectious cultures and stocks, pathological waste, and human blood products should be placed in the container labeled as CULTURES, PATHOLOGICALS, BLOOD, (after autoclaving). 3. Contaminated animal bedding be placed in the container labeled ANIMAL BEDDING. 4. Contaminated animal carcasses should be properly protected and frozen. 5. It shall be the individual department s responsibility to provide protective garments as necessary to persons involved in infectious agent research or infectious waste handling. 6. The individual generator (researcher, department) has the responsibility to ensure that the infectious wastes are located in the appropriate container, that the container lids are kept on, and that the general area is maintained in a clean and sanitary condition. 12

13 7. Keep infectious waste storage area secured or otherwise protected from unauthorized entry. For more details, refer to Guidelines for the Collection, Handling, and Disposal of Infectious Waste on the Risk Management website. 6. Smoking The University of Notre Dame Smoking Policy has been revised to be in accordance with St. Joseph County Ordinance #04-06), which restricted smoking in our community beginning Monday, April 10, Our policy is now being revised to conform to LEED certification and to reflect the University s commitment to sustainable campus design and improved personal health initiatives by limiting smoking around the outside of buildings. 6.1 University Smoking Policy In accordance with St. Joseph County Ordinance #04-06 and LEED certification requirements, the University of Notre Dame prohibits smoking within 25 feet of all buildings and stadiums, as well as in all vehicles owned, leased or operated by the University. Under these guidelines, smoking is prohibited in all buildings. a. The University, through the Office of Human Resources, will provide access to smoking cessation programs for faculty and staff upon request. The Office of Drug & Alcohol Education will provide access to smoking cessation programs for students upon request. b. The sale, distribution and advertisement of tobacco products are prohibited on campus. c. The University policy on smoking will be posted online and available to all students, faculty, and employees. d. The success of this policy depends upon the thoughtfulness, consideration, good will and cooperation of both smokers and non-smokers. All members of the Notre Dame Community, as well as visitors, share in the responsibility of adhering to and enforcing this policy. Violators who refuse to conform to this policy at University events (i.e., athletic events, concerts, etc.) will be escorted out of the event. e. Smoking is prohibited within 25 feet of the outside of any building to prevent tobacco smoke from entering through the entrances, windows, ventilation systems or other means. f. Complaints about violators of the smoking policy or air quality resulting from the above should be brought to the attention of the building representative or person responsible for the area in which the violation occurred. The responsible person, if unable to remedy the situation, will contact Risk Management and Safety for assistance. (Note: If the complaining party cannot identify the appropriate building representative, he/she should contact Risk Management and Safety directly.) Risk Management and Safety will review the infraction and refer to the appropriate authority for corrective action or further restriction to the smoking policy. 13

14 For more details, refer to Smoking Policy on the Risk Management website 7. Vehicle Safety Training Golf Cart Training In order to drive the golf carts on campus the following is necessary ( links are to the Risk Management website): a. View the Moving Off-Road Vehicle Training Powerpoint b. Please fill out and submit the Motorized Off-Road Vehicle Training Quiz online or to Risk and Management Safety or drop in campus mail to 636 Grace Hall. Driver Training a. Students driving University vehicles are first required to attend a safe driving class sponsored by the Transportation Services Department. Students need only attend this session once during their time at Notre Dame. b. Staff who spend the majority of their professional time driving a University vehicle must attend a safe driving class sponsored by Transportation Services within a reasonable period: c. of time after being hired. All staff who drive University vehicles are encouraged to attend a safe driving class every three years. 8. Patient Management and Care 8.1 Disruptive or Violent Patient POLICY: In the event that a patient becomes disruptive or violent while in the student health center, Notre Dame Security and Police (NDSP), University Counseling Center (UCC) and the Office of Student Affairs will be notified for assistance and support pending removal from the health center and/or transfer to an emergency department or inpatient psychiatric facility. To provide support to the disruptive and/or violent patient and to protect the safety and security of other students and staff member: a. Staff will be advised of the incident. b. NDSP will be notified immediately to provide assistance by dialing 911 on a campus phone or if using a cell phone call (574) c. Contact University Counseling Center, as appropriate, to request assistance from any available counselor. d. While waiting for NDSP and/or UCC response, the UHS staff will intervene as follows: 1. Remove other patients from area and/or take patient to private area. 2. Administrator, MD or Registered Nurse on duty will assign roles for each staff member involved. 14

15 3. The patient will sit in a designated area with a staff member continuing to verbally deescalate. Another staff member should be in the immediate vicinity. 4. The patient will be informed of the procedure. 5. If the patient escalates while waiting for UCC and NDSP response, the secondary staff member will call for immediate staff assistance or call 911 if using a campus phone and (574) if using a cell phone, as appropriate. 6. The patient will be transported by University police to an appropriate location, with or without a UCC staff member, accompanying the patient. 7. Student Affairs will be notified of the incident by the Director, supervisor on call or designate. 8. Student Affairs will take appropriate action and notify the Director of any action that would affect the patient and student health center relationship. See policy Disruptive or Violent Patient 8.2 Dismissal from Care A patient may be dismissed from care for the following reasons: a. Refuses to follow Health Services policies b. Leaves against medical advice (AMA) 1. Use the form: Refusal of Care a copy of which is on the UHS website on the FORMS page c. The relationship is terminated by mutual consent of the patient and doctor d. The doctor is dismissed by the patient. e. The clinical services of the doctor are no longer needed by the patient. f. The doctor properly withdraws from the doctor/patient relationship. Refer to: American Medical Association Council on Ethical and Judicial affairs Opinion which states that a physician has an obligation to support continuity of care for their patient. Refer to article on American Medical Association website: Right to Choose Patients and Duty Not to Neglect 9. Adverse Events An unexpected or undesirable event during a healthcare encounter that may cause death or serious physical harm not related to natural course of patient s illness or underlying condition. (Loss of limb or function) 15

16 A variation in a procedure or process that carries a potential or significant chance of a serious outcome. A breach in medical care, administrative breaches, or other breaches resulting in or causing a potential for a negative impact or outcome for a patient. This includes breaches of confidentiality. An event that is unexpected or undesirable that potentially could cause harm. (ex. patient or visitor fall, medication error, or infection post treatment) 9.1 Adverse Event Procedure a. If the adverse event requires immediate or emergency medical attention, the patient will be provided appropriate medical care and/or be transported to a local hospital. A physician on duty or on-call will be notified, as well as a supervisor on duty or on-call. b. An Adverse Event Report form will be completed, signed appropriately and provided to the supervisor over the service area(s) of involvement. The supervisor will notify the Director and will provide the copy after investigation and follow-up, as appropriate. c. General Counsel and University Risk Management will be notified by the Director or supervisor in her/his absence, if event warrants the contacts. d. State, government, and other external departments or agencies are notified in accordance with law or regulation. Call will be directed by Risk Management or General Counsel. e. The completed Adverse Event Report will be presented and reviewed by the Governance Committee and analyzed to assure action or improvements to a process have occurred to prevent or minimize the likelihood of a repeat event. Strategies to prevent or reduce risk may include, but not limited to: a. Education b. Skill validation c. Quality Improvement study with measureable outcomes and implementation of new process or procedure, as appropriate. d. The Governance Committee will identify which supervisor is responsible for implementation and oversight of any action plan or QI study and to monitor outcomes. Updates and reports will be provided at governance meetings, as appropriate. e. At least annually, the Governance Committee will review all adverse events for the previous year. 16

17 In event of an adverse event the Adverse Event Report shall be used. A copy is found in Nursing Forms Folder. 10. Patient Complaints All significant patient, visitor, family and guest complaints/concerns are documented and reported to the Director of Health Services to support a coordinated and comprehensive program for promptly receiving and responding to patient/family conflicts, concerns, questions and/or problems. Refer to Administrative Policy Complaint Management 11. Impaired or incapacitated employee University Health Services (UHS) adheres to the University Impaired Employee and For-Cause Drug Testing Policy The After Hours Drug Screen and Alcohol Testing Procedure will also be followed Guidelines for an impaired employee a. During business hours, if an employee is suspect of being under the influence, the supervisor on duty will be notified immediately. If on a shift when a supervisor is not present, the on-call supervisor will be notified immediately. b. If an employee is suspect of being under the influence of alcohol, drug, or other substance, the employee will be asked to leave a patient care area. c. The supervisor or RN in charge will then call the Notre Dame Security/ Police(NDSP) to assist, if necessary, and to administer the breath alcohol testing. If there is still suspicion, the supervisor will contact UHS Business Partner in Human Resources during business hours, or NDSP will contact the Human Resource Business Partner on-call if it is after hours. d. If the confirmatory test is needed, NDSP will contact Wipperman s Occupational Health. e. During business hours, NDSP will escort the employee to Wipperman s Occupational Health Center for the test. f. After business hours, NDSP will call the on-call staff member from Wipperman s Occupational Health Center who will come to UHS to administer the test. 12. Services outside of normal physician/business hours 17

18 a. Students: All dimensions of University Health Services and those services provided in Saint Liam Hall respect the dignity of each individual. i. Hours of operation, physician availability, and seasonal schedules are published on the UHS website: uhs.nd.edu ii. Emergent and life threatening illness/injury are transported to a local emergency room by community ambulance. Dial 911 iii. Charges for services and questions concerning charges should be directed to the student insurance office. If after normal business hours, medical care/ treatment should not be withheld due to an inability to pay. In that case, the supervisor on duty shall be notified or a note left for the student insurance office personnel. b. Worker Compensation Care: Any Notre Dame employee who is injured on the job and does not require emergency intervention will be evaluated at UHS. If a physician is on duty, they will evaluate and treat, or refer to a specialist in the community. If a registered nurse is on duty, and the patient requires medical services beyond his/her scope of practice, the employee will be sent to Wipperman s Occupational Health Center or to St. Joseph Regional Medical Center Emergency Room. 13. Authorized Personnel in Patient Care and Secure Areas To protect the privacy of the patients, staff members, prospective staff members and others, any medical/private/personal information shall be given only to authorized persons for medical care, insurance, legal matters, and other legitimate purposes according to standards and law Patient Care Areas a. Only professionals, who are appropriately licensed, certified and/or trained are allowed in patient care areas. b. During patient care/treatment, visitors or observers must have prior approval of the healthcare professional. Due to patient privacy, the patient must also give consent. The consent for any such visitor/observer must be documented in the patient s chart Designated Secure areas 18

19 a. Only Health Services Staff or personnel authorized/approved by the governing body of Health Services are allowed in areas where patient information is located, stored, or can be viewed. b. Computer screens must be positioned so that patient information is kept private and out of view Confidentiality To preserve the confidentiality of patient, staff member, proprietary, and other information regarding activities of and medical treatment provided in or supported by University Health Services, all employees of University Health Services will be required to read, accept, and sign a Confidentiality Statement of Understanding document. 14. Review of Clinical Records and Policies Clinical policies and procedures are reviewed by the Assistant Director, Clinical Services, on an annual basis. Revisions and updates are made as necessary and communicated to appropriate staff. Medical records are reviewed annually for compliance with standards of nursing documentation. 15. Education in the use of the Risk Management Manual Education in the contents of the UHS Risk Management Manual shall be given within 30 days of hire and annually thereafter The Risk Management and Safety Manual includes the UHS: a. Infection Control Plan d. Severe Weather/ND Alert Plan b. Risk Management Plan e. Emergency Plan (Shooters/hostage) c. Fire Safety Plan f. Emergency Evacuation Plan Printed reference copies of the online Notre Dame Office of Risk Management policies and guidelines that are referenced in this manual are available in the UHS Risk Management and Safey Reference Manual. 19