WEST VIRGINIA UNIVERSITY HOSPITALS. Nuclear Medicine Technology Education Program

Transcription

1 WEST VIRGINIA UNIVERSITY HOSPITALS Nuclear Medicine Technology Education Program Student Handbook Tiffany D. Davis, M.A., R.T.(R)(N), CNMT Original: May 1984 Education Coordinator Revised: June

2 Table of Contents Page # Introduction 4 Preface 5 Section 1: General Program Information 6 Historical Overview & Organization Structure 7 Mission Statement & Goals 8 WVUH Administration Outline 9 WVUH Administration Organization Chart 10 Education Organizational Chart 11 Education Advisory Committee 12 General Information: Certificate 13 Transcript 13 Semester (Mid-Term/End) Dates 13 Housing 13 Placement Service 13 Holidays 13 Class/Clinic Schedule 13 Vacation 14 Radiation Badges 14 Lockers 14 Attendance of Educational Opportunities 14 Libraries 14 Telephone Use & Courtesy 14 Visitors 14 School Calendar (Tentative) 15 Section 2: Didactic Education 16 Instructional Staff & Class List 17 Course Descriptions Textbook List 21 Policies & Procedures: Academic Standards Academic Dishonesty 24 Course Lecture Sessions Make-up 25 Section 3: Clinical Education 26 Clinical Instructors 27 Facilities & Equipment 28 Policies & Procedures: Clinical Standards Clinical Education Direct/Indirect Supervision Clinical Education Make-up 36 2

3 Section 4: NM Program & WVUH Policies & Procedures 37 Nuclear Medicine Program Policies & Procedures: Policy Change 38 Admissions Non-Registered Student Admission Non-Registered Student Admission Agreement 43 Attendance Attendance Documentation Student Fees / Refunds Student Withdrawal 51 Student Resignation Statement 52 Dress Code Due Process 55 Disciplinary/Corrective Action Probationary Period 58 Non-Discrimination 59 Student Health Pregnancy Preganancy / Rad. Saf. Verification Form 64 Radiation Safety & Exposure Monitoring Student Counseling/Advisement 67 Medical Leave of Absence 68 Communicable/Contagious Disease Notification 69 Student Outside Employment 70 Transfer/Advanced Placement/Part-time Student 71 Access or Release of Student Records Programmatic Suspension / Closure 74 Graduation Requirements 75 Inclement Weather 76 WVUH Policies & Procedures: WVUH Peripheral Intravenous Therapy Insertion and Guidelines WVUH Star Behaviors WVUH Standards of Conduct WVUH Smoking WVUH Substance Abuse Policy WVUH Parking & Traffic

4 Nuclear Medicine Technology Education Program Student Handbook Introduction 4

5 Preface Preface West Virginia University Hospitals offers a 12-month Nuclear Medicine Technology Education Program designed to provide students with the basic knowledge of a wide variety of procedures in Nuclear Medicine. The Joint Review Commission on Education accredits our program. The Essentials and Guidelines for Accreditation are available for students to review and may be found in the office of the Program Director. West Virginia University Hospitals. Inc. Nuclear Medicine Technology Education Program awards a certificate to each student who satisfactorily completes the required course of study. Upon graduation, students are eligible to sit for the American Registry of Radiologic Technology Certification Board in Nuclear Medicine and the Nuclear Medicine Technology Certification Board. Students enrolled in the Program are regarded as mature, responsible persons seeking education in Nuclear Medicine. They are not considered employees of West Virginia University Hospitals, Inc. or students of West Virginia University. The following information has been prepared to inform the students of the policies and requirements of this educational endeavor. To Students: You forfeit your chance in life at its fullest when you withhold your best effort in learning. When you give only the minimum to learning, you receive only the minimum in return. Even with your parent s best example and your teacher s best efforts, in the end it is your work that determines how much and how well you learn. When you work to your full capacity, you can hope to attain the knowledge and skills that will enable you to create your future and control your destiny. If you do not, you will have your future thrust upon you by others. Take hold of your life, apply your gifts and talents, work with dedication and self-discipline. Have high expectations for yourself and convert every challenge into opportunity. --The National Commission on Excellence in Education 5

6 Nuclear Medicine Technology Education Program Student Handbook Section 1 General Program Information 6

7 Historical Overview & Organization Structure Historical Overview The Nuclear Medicine Technology Education program graduated the first class in The program has remained a hospital-sponsored program enrolling four to five students. Through the years this program has continually modified its efforts towards programmatic changes in order to update and improve the education process and provide an optimal learning environment. These efforts have at the very least produced entry-level technologists while striving towards expectations of providing our community with highly qualified and competent professionals in our health care systems. Our facility continues to grow with technology advancements as we perform a wide variety of procedures providing students with optimal exposure in the following areas: conventional nuclear medicine procedures and specialty areas such as sentinel node mapping, gated SPECT cardiac studies, Iodine 131 ablations, and pharmaceutical research. The department utilizes five state-of-the-art cameras manufactured by Siemens Medical Systems ( Three E-cam Variable Angle-Dual Head Cameras with Esoft Computer system and 2 Symbia T2 SPECT/ CT cameras to perform and average of 4300 procedures annually. The facility also has an on-site PET/CT facility which houses 2 PET/CT imaging cameras The PET/CT facility performs research studies and approximately 3500 clinical patients and research studies per year. Most recently, WVUH has opened an off-site cardiac clinic which includes a Siemens c.cam heart dedicated camera. In summary, our strong commitment to education and continued efforts to remain technologically advanced, WVUH affords students in the Radiologic Sciences an excellent environment for developing academic, clinical, and professional expertise. Organization Structure The Nuclear Medicine program at West Virginia University Hospitals is a 12-month certificate program designed to provide students with a comprehensive education in Nuclear Medicine Technology through didactic instruction and applied clinical education. The program is accredited to enroll four students per year with classroom and clinical instruction averaging 40 hours per week. Improvements have been made to improve students in both areas while providing a variety of means to connect the knowledge with the clinical skills. 7

8 Mission Statement The Nuclear Medicine Technology Education program at West Virginia University Hospitals is committed to providing students with a solid educational foundation in both the didactic and clinical components in which they will become professionally competent registered nuclear medicine technologists. Through education and development in the utilization of radioactive materials for therapeutic and diagnostic procedures, the students will expand their knowledge of the technical, professional, and philosophical aspects of Nuclear Medicine Technology and the health care environment. Goals 1. Students will demonstrate clinical competence in Nuclear Medicine. 2. Students will practice effective communication skills. 3. Students will employ critical thinking / problem solving skills. 4. Students will exhibit professional behavior. 5. Students will integrate professional growth and development practices. 8

9 WVUH ADMINISTRATIVE OUTLINE Bruce McClymonds President and Chief Executive Officer Stephen Tancin Vice President, Ancillary/Clinical Services Darlene S. Headley Director, Radiology Gary Marano, M.D. Medical Director, Nuclear Medicine Jay S. Morris Education Manager Tiffany D. Davis Education Coordinator, Nuclear Medicine 9

10 West Virginia University Hospitals Administrative Organization West V g a U ve s ty osp ta s d st at ve O ga at o Board of Directors President & CEO WVUHS Tom Jones President Bruce McClymonds Chief Medical Information Officer Kevin Halbritter, MD - Development - Compliance/Audit Vice President Quality & Patient Safety Niti Armistead, MD Vice President Planning and Marketing Gary Murdock Vice President Finance Mary Jo Shahan Vice President & General Counsel Robert Brandfass Vice President Medical Affairs Michelle Nuss, MD Vice President Nursing Dottie Oakes Vice President Information Technology Rich King Vice President Human Resources Charlotte Bennett Vice President Ancillary & Support Services Stephen Tancin Joint Commission Center for Quality Outcomes Risk Management - Patient Advocate - Safety Care Management - Clnical Documentation Mgmt. Program Customer Service Clinical Program Development Marketing Communications Decision Support Community Relations Strategic planning Accounting & Budgeting - Accounts Payable - Payroll Health Information Management Reimbursement Financial Analysis Patient Financial Services Patient Access Legal Services Litigation Management Healthcare Collections Credentialing Peer Review Nursing Care Services - Adult Nursing Services - Stroke Center - Children's Hospital - Dialiysis Unit Infusion Center Perioperative Services - Sterile Processing WVU Eye Insitute Chestnut Ridge Center Nursing Administration - Infection Control - Diabetic Center Jon Michael Moore Trauma Program Nursing Academic Services Pastoral Care Dialysis Services Mary Babb Randolph Cancer Center Cardiac Services Applications -Clinical - Financial -Enterprise -Web-Intranet Development -Integration -Project Management Customer Service/Operations -Computer Operations -Call Center -Role Based Access -End User Support Networks and Telecommunication -Networking -Telecommunications -IT Security -Mid-Range System Administration -Departmental Support Education & Training Human Resources -Employment/Employee & Labor Relations -Benefits/Compensation -Employee Health -Wellness Child Development Center Volunteer Services Family House Pharmacy Radiology/ - Radiation Therapy Rehab Services - Neuro Labs - Sleep Lab Clinical Labs/ Pathology Respiratory Therapy/ Pulmonary Materials Management - Laundry Nutrition Services Environonmental Services Facilities Engineering - Planning, Design & Construction - Security - Parking Patient Satisfaction Cheat Lake Practice Technology Assessment Facility Planning Materials Management - Central Receiving -Central Storeroom Biomedical Engineering 10

11 Educational Organizational Structure Administrative Director Radiology/Radiation Therapy Medical Directors Education Manager/FAA Education Coordinator/Radiography Education Coordinator Nuclear Medicine (0.8 FTE) Education Coordinator Radiation Therapy (0.8 FTE) Education Coordinator Ultrasound (1.0 FTE) Education Coordinator MRI (1.0 FTE) Education Coordinator Radiography (2.6 FTE) Adjunct Clinical Instr(s) Radiography (1.0 FTE) 4 Nuclear Medicine Students 4 Radiation Therapy Students 6 Ultrasound Students 4 MRI Students 30 Radiography Students 11

12 Education Advisory Committee Nuclear Medicine Technology Training Program Mathis Frick, MD Medical Director, Radiology Michael Cunningham, MD Medical Director, Ultrasound Gary Marano, MD Medical Director, Nuclear Medicine Darlene Headley Administrative Director, Radiology Jay Morris Education Manager Joy Mason Clinical Coordinator, Radiology Ed. Ron Linn Education Coordinator, Radiology Ed. Lanny Maxwell Clinical Coordinator, Radiology Ed. Tiffany D. Davis Education Coordinator, Nuclear Medicine Christina Paugh Education Coordinator, Radiation Therapy Candice Norris Education Coordinator, Ultrasound Brad Holben Education Coordinator, MRI Nuclear Medicine Student Representative Ultrasound Student Representative Radiation Therapy Student Representative MRI Student Representative Radiography Senior Class Student Representative Radiography Junior Class Student Representative 12

13 General Information Certificate A certificate of completion of 12 months schooling in Nuclear Radiologic Technology is awarded to each student upon successful completion of the program. The student will also receive a copy of their transcript of grades. Transcript The student will be provided a transcript of grades upon satisfactory completion of the Nuclear Medicine Technology Education Program. A transcript of grades and other information will be forwarded upon written request. Semester (Mid-Term/ End) Dates Semester I: Mid-Term July 1 through September 30 End October 1 through December 31 Semester II: Mid-Term January 2 through March 31 End April 1 through June 30 Housing Students are responsible for making their own living arrangements. University Housing is not available, but the University Housing Office will offer assistance in locating suitable housing. Please contact: WVU Housing Office,. Placement Service The program cannot guarantee employment to the student based upon program completion, but assistance is provided in obtaining employment through posting of current job openings and listings. Holidays The West Virginia University Hospitals, Inc. Nuclear Medicine Technology Education Program will observe all official corporation holidays as follows: New Year s Day Memorial Day Independence Day Labor Day Thanksgiving Day Day After Thanksgiving Christmas Day Class/Clinic Schedule Monday - Friday

14 Vacation Students are granted two vacations. Vacation periods will be determined at the time of the annual revision of the school calendar. Radiation Badges Each student technologist is furnished with a chest radiation badge and ring TLD. These badges must be worn in the clinical areas at all times. Lockers Each student is assigned a locker located in the nuclear medicine or radiology department, as space is available. The department and WVU Hospitals is not responsible for lost or stolen items. Attendance of Educational Opportunities Students may be granted time off to attend educational meetings deemed valuable by Program Officials. Each student is expected to provide written documentation of their attendance. Travel to and from educational meetings is done on your own recognizance. Attendance to a local Nuclear Pharmacy, Society of Nuclear Medicine Workshops (Pittsburg Chapter) is recommended. Each student is responsible for their own transportation and expenses. Travel to and from educational opportunities is done on your own recognizance. Neither WVU Hospitals, the Radiology department, nor the Nuclear Medicine Technology Education Program may be held responsible for your safety and well being. Libraries Two libraries of reference books and periodicals are maintained by, the Radiology departmental library and the Health Science Center Library. You have the privilege of using these materials for your studies. All reference materials must be checked out and returned by the due date. A lost book or reference must be replaced at the student s expense. Upon completion of the Program a Library Release form must be completed by the health Science Center Library and turned into the Education Coordinator. Students will not graduate if all books or reference materials have not been returned. Telephone Use & Courtesy Telephones in the department are intended for hospital business only. Personal calls must be made at a public pay phone located throughout the hospital. Messages will be taken for you during the school day. Messages may be left at ext When using the hospital phone for business, always identify yourself by stating your name and department (i.e., Nuclear Medicine, John Doe speaking, how may I help you). Visitors Students are not permitted to receive visitors in the department at any time. You are to ask your friends and family members to wait for you in the Hospital lobby until you are dismissed for the day. 14

15 Sample Academic Calendar Date: July 1 & 2 July 3 July 6 September 7 September 25 September 28-October 2 Event: New Student Orientation Independence Day Holiday - No Classes Tuition due - Semester I Labor Day Holiday - No Classes Mid-Term Grades due Student Counseling Sessions November November 26 & 27 December 11 December 11 December December 21 - January 4 SNM Annual Fall Winter Symposium (Dates TBD) Thanksgiving Holiday - No Classes Last day of Semester I Semester I Final Grades due Student Counseling Sessions Student Winter Vacation Date: January 4 February 1 March 25 Event: Tuition due - Semester II Application Deadline Mid-Term Grades due March 28-April 1 April 4-8 May 30 June 10 June 10 June 10 June June 17 Student Spring Vacation Student Counseling Sessions Memorial Day Holiday - No Classes Graduation Fee due Graduating students Last day of Semester II Semester II Final Grades due Student Counseling Sessions Graduation Ceremony 15

16 Nuclear Medicine Technology Education Program Student Handbook Section 2 Didactic Education 16

17 Instructional Staff and Course List Tiffany D. Davis, M.A., RT (R)(N), CNMT Introduction to Nuclear Medicine Patient Care Medical Terminology Conversions & Decay Calculations Nuclear Medicine Procedures I & II Nuclear Medicine Instrumentation Radiopharmaceuticals I & II Computer Science & Applications Nuclear Medicine Review Karyn Wallace, MBA, RT(N), CNMT Positron Emission Tomography (PET): 511 kev Coincidence Imaging Health Physicist Radiation Physics I (Radiation Safety / Radiobiology / Atomic / Nuclear / Chemistry) Chris Paugh CPR (fall semester I) Jay Morris Advanced Physics III: CT Lanny Maxwell Image Analysis: Cross-Sectional Anatomy 17

18 Course Descriptions Nuclear Medicine NMT 301 Introduction to Nuclear Medicine This orientation course is designed to introduce the student to the Nuclear Medicine Technology Program at West Virginia University Hospitals. It will familiarize the student with the workings of the Hospital, the Radiology Department, as well as the Nuclear Medicine Department and the Education Program(s) within. During this course, the student and instructor will review the Student Handbook in detail and explain the Clinical Competencies Handbook. This course will also introduce the student to the methods used to maintain patient s nuclear medicine records, patient doses, scheduling of patients, quality control results and other required records. NMT 311 Patient Care This course is designed to introduce nursing procedures & techniques utilized in the care of patients as a function of the Nuclear Medicine Technologist. NMT 312 Medical Terminology This course consists of a series of lectures, which will familiarize the student with the basic terminology used in the field of Nuclear Medicine and the hospital environment. NMT 320 Radiation Physics I: Radiation Safety and Protection and Radiobiology This course details the qualitative and quantitative affects of the human body following exposure to various amounts of ionizing radiation. It includes the potentially harmful effects and the benefits of the medical use of radiation. This course also presents a rationale for working with, and the handling of radioactive material. NMT 321 Nuclear Medicine Instrumentation This course will familiarize the student with the basic radiation detectors, their applications, functions, and limitations. It will also include a study of instruments commonly used in Nuclear Medicine. A basic overview of the electronics of gas filled detectors, scintillation cameras and a review of radioactive decay processes are also covered. Computer science is also covered to provide the student with a basic understanding of the image processing features designed for nuclear medicine procedures. Instruction will be provided in the usage of ROIs, filters, flexible display, and other processing techniques. An overview of the basic operations of computers and their components will be provided 18

19 NMT 323 Radiation Physics II: Atomic Physics and Chemistry This course includes the basic concepts of organic and inorganic chemistry and biochemistry. It also includes a brief review of the concept of conversion from the British system of measurement to the metric. This course also covers the concepts and physical principles that apply to the atom and interactions of the various atomic particles. This includes a historical overview of events and theories that have led to current concepts of atomic structure and presentation of the interrelationships between matter and energy. NMT 324 / 327 Radiopharmaceuticals I & II This course covers radiopharmaceutical preparation, labeling information, methods of localization, record keeping and storage of radioactive materials, and an analysis of quality control of radiopharmaceuticals and federal drug regulations. It also includes an in-depth discussion of generator systems. NMT 326 Nuclear Medicine Board Review This course will review the fundamentals of Nuclear Medicine, and practical and current applications. The student will sit for mock boards and a comprehensive review will take place. The student is given time to prepare for their board exam(s). The student will sit for noon or other conferences pertinent to the field of Nuclear Medicine. A specific section on Federal Regulations and Agencies will also be covered. NMT 334 / 335 Nuclear Medicine Procedures I & II This course consists of a series of lectures and slide presentations/video tapes of various pathological terms, specific examples of general types of disease, brief descriptions of the major classifications of disease and the identification of specific diseases and disorders that can be studied using clinical Nuclear Medicine Procedures. This course will familiarize the student with the RBC Mass Study and Schillings test, as well as other relevant in-vitro procedures performed in Nuclear Medicine. There are labs as needed to acquaint the student to pipetting, the use of the centrifuge, and other pertinent information. NMT 328 Conversions and Decay Calculations This course is designed to instruct the student in the calculation of decay formulas. It will also encompass the conversion of basic units in to the metric system and S.I. Units. The student will be able to calculate activity problems and have the ability to determine the half-life of a radionuclide, given the activity at time zero and at a specific time. They will have the ability to utilize decay factors and be able to calculate decay factors for specific time frames. The student will know the basic activity and volumes to be added to radiopharmaceuticals and be able to calculate specific activity and concentration. 19

20 NMT 339 CPR This course will teach the student how to externally support the circulation and respiration of a victim of cardiac or respiratory arrest through the use of Cardio-pulmonary resuscitation. They will also be instructed on foreign body airway obstruction management on an adult, child and infant with proper external techniques. NMT 420 NMT 420 NMT 420 Applied Radionuclides: PET/CT, I & II Applied Radionuclides: Radiation Safety I Applied Radionuclides: Procedures, I & II Under direct and indirect supervision, the student will develop clinical skills through observation and participation in Nuclear Medicine procedures, in-vivo and in-vitro. The student will rotate through Radiation Safety and PET to familiarize him/herself with these areas and their place in the field of Nuclear Medicine. (During the Radiation Safety and PET rotations the student is to observe and participate as necessary.) NMT 350 PET (Positron Emission Tomography): 511keV Coincidence Imaging This course will briefly describe the major classifications of disease and the identification of specific diseases and disorders that can be studied using PET and / or 511 kev Coincidence Imaging. The course will include a basic overview of PET and 511 kev coincidence instrumentation, quality control and image manipulation, as well as the production of PET tracers. RADT 123 Advanced Radiologic Physics II: CT This course will describe the basic operation of a CT scanner and identify its various development stages. The student will be able to identify the image characteristics specific to CT and their corresponding values. Also included is an overview of the CT # / Houndsfield unit system and its application in determining tissue values. The student will evaluate the basic dose units utilized in CT, their derivation, and equivalents. RADT 133 Imagine Analysis III: Sectional Anatomy This course is designed to introduce cross-sectional planes of the body. The student will be given the opportunity to identify and label different cross-sectional planes of the body including head, thorax, abdomen, and pelvis. Utilization of various CT and MRI images on-line from selected cross sectional anatomy software applications will aid the student in becoming familiar with the aforementioned. The course will also identify imaging modalities which utilize transverse anatomy. 20

21 Nuclear Medicine Technology Training Textbook List The following books are required and must be purchased on or before July 1. You may purchase these texts from any retailer. Text Name Author Edition ISBN # Estimated Price 1. Nuclear Medicine Instrumentation Prekeges 1 st, $ Nuclear Medicine and PET/CT: Christian 7 th, $ Technology and Techniques 3. Radiopharmaceuticals in Nuclear Pharmacy and Nuclear Medicine Kowalsky 3 rd, $ Review of Nuclear Medicine Technology Steves 4 th, $ Medical Dictionary of your choice 21

22 West Virginia University Hospitals Policy No: Nuclear Medicine Education Program Effective: 7/1985 Revised: 7/2007 Academic Standards The sponsored by West Virginia University Hospitals utilize uniform grading scales so that parity is maintained between programs in assigning achievement ratings for individual courses and overall performance. Academic standards are developed in an effort to discourage mediocrity and promote an atmosphere of academic excellence. West Virginia University Hospitals is committed to producing graduates that are highly qualified, competent medical professionals. Support of this commitment can only be validated by mandating minimum academic standards. The following minimum academic standards and grade scales are utilized: Overall Weighted Average / Semester Each student is required to achieve a minimum overall weighted average of 78% at the end of each semester in order to proceed to the subsequent semester. Failure to achieve the minimum overall weighted average of 78% will result in academic dismissal from the program in which the student is enrolled. Didactic Course Minimum Each student is required to complete each didactic course with a minimum percentage grade of 78% (C grade). Failure to achieve the minimum percentage grade of 78% in a particular course will result in the student having to repeat the course during its next scheduled offering. First year radiography students who fail to achieve the required 78% minimum in a particular course may repeat the course during their second year providing the course time frame does not conflict with their second year schedule. Second year radiography and modality students who fail to achieve the required 78% minimum in a particular course will not be eligible for graduation and will have to repeat the course in the corresponding semester the next academic year. In all cases, no student may graduate unless a 78% minimum is achieved in each didactic course. Passing Minimum Successful completion of the core curriculum of each program (core curriculum defined as those didactic courses equaling 24 clock hours or greater) is necessary for the student to advance academically, clinically, and professionally. Although provisions for repeating an academic course are specified, students who achieve less than 78% in multiple core didactic courses have not demonstrated the necessary cognitive skills for advancement into subsequent semesters. Therefore, any student who fails to achieve a minimum percentage grade of 78% in any two (2) major academic courses of equal to or greater than 24 clock hours each at the end of each semester will be dismissed from the program. Grading / Quality Points Scale The following grading/quality points scale will be utilized as an objective evaluation mechanism comprising of percentage values and letter grades which serve to represent the student's didactic course and semester performance. Quality points are utilized in calculating the student's grade point average (GPA). Percentage Grade Letter Grade Quality Points 100% - 93% A % - 86% B % - 78% C % - 70% D 1.0 < 70% F

23 Other Letter Designations (Not counted towards GPA) I Incomplete WP Withdrew Passing WF Withdrew Failing P Passing Work - clockhour credit given + or - Plus or Minus - Instructors discretion Academic Standards cont. Grade Point Average The student's Grade Point Average (GPA) is calculated utilizing the following equations: 1. Multiply the number of quality points assigned to the letter grade by the number of clockhours for each course. Letter grade A = 4.0 Clockhours / Course #1 = 48 Quality points / Course #1 = Add the number of quality points earned from all courses during the semester. Quality points / Course #1 = 192 Quality points / Course #2 = 72 Quality points / Course #3 =108 Quality points / Course #4 = 192 Total Quality Points / Semester = Divide the total quality points / semester by the total number of clock hours for the semester. This is the grade point average. Total Quality Points/Semester = 564 Total Clockhours/Semester = 156 Grade Point Average = 3.62 Clinic Standards / Grade Scales The clinical performance standards and are depicted in the Clinical Standards/Education Policy in the Student Handbook. Education Manager Date 23

24 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 4/1992 Revised: 3/2010 Academic Dishonesty Students enrolled in the Imaging Science programs at West Virginia University Hospitals are expected to demonstrate integrity and ethical behavior in all aspects of their education and professional careers. Dishonesty in the didactic and clinical environment is a direct violation of the professional code of ethics and will result in disciplinary action and possible sanctions by each respective governing body. Students should be aware of the fact that violations relating to ethical and/or dishonest behavior may result in them being disqualified from practicing in their respective field. Academic Dishonesty Academic Dishonesty is defined to include any of the following: 1. Plagiarism: Submitting for credit, without proper acknowledgment, written or oral material that has been knowingly obtained or copied in whole or in part from another individual's academic composition, compilation, or commercially- prepared papers. 2. Fraudulent and dishonest practices in connection with evaluation mechanisms including but not limited to: a. Obtaining unauthorized assistance or knowingly giving unauthorized assistance to another student during didactic examinations, clinical examinations, practicums, or any other applicable cognitive, psychomotor, or affective evaluation process. b. The use of reference materials or any source of information during examinations, unless authorized by the examiner. 3. Forgery, misrepresentation or fraud: a. Forging or altering any official educational record or document. b. Forging or altering any official medical record or document. c. The use of programmatic or institutional documents or data with the intent to defraud. d. Presenting false data or intentionally misrepresenting one's records for admission, registration or withdrawal from the program. Program Officials / Faculty Responsibility: Although the responsibility for ethical behavior lies with the student, program officials should structure their evaluation mechanisms and testing environments so as to avoid the potential for academic or clinical dishonesty. Program officials should provide guidance to all program faculty regarding their responsibility for monitoring evaluation processes and documenting any suspected occurrences of dishonesty. All faculty should use care in observing and verifying the specifics of a potential allegation so as to assure that factual information is documented and a student is not falsely accused. Disciplinary Action / Due Process Students involved in any unethical or dishonest practice are subject to disciplinary action. Please see Policy #1.003 (Disciplinary Action) for specifics. All students are afforded due process when disciplinary action is invoked. Please see Policy #1.002 (Due Process) for specifics. Education Manager Date 24

25 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 3/2008 Policy: Course Lecture Sessions Makeup Policy The program officials and instructors will abide by the following procedure for permitting students to make-up course work missed as a result of being absent from a scheduled lecture session. This policy serves to eliminate, as much as possible, any potential advantage that a student may achieve by being absent from a scheduled lecture session and thereby obtaining a greater amount of study and/or preparation time, for the scheduled activities of the class, than those students in attendance. 1. The student is solely responsible for the lecture material covered and for making up any examinations, quizzes, homework assignments, etc. which occurred during their absence from the lecture session. 2. All examinations and/or quizzes must be made up on the student s first regular scheduled day of attendance (Monday thru Friday) following their absence from the lecture session. The student must follow the following procedure: a. Contact the course instructor by 8am on the day of your return and inform the instructor that you are presenting yourself to make-up the missed examination and/or quiz. b. In the event that the course instructor is not available, contact the program director or program clinical coordinator immediately and inform him/her to this affect. c. Instructors may submit the examination and/or quiz to a program official who will proctor the make-up session for the instructor. Instructors who anticipate that they will not be available for the make-up session must arrange in advance for the program director and/or clinical instructor to proctor the session. 3. Failure of the student to follow the aforementioned make-up guidelines imposes a mandatory requirement upon the instructor to record a percentage grade of zero for the examination and/or quiz. 4. A student who fails to meet an assignment (e.g. term paper) deadline as a result of being absent on the deadline day must submit the assignment on the first regular scheduled day of attendance following the absence. The equivalent of a 10% reduction in grade will be imposed as a penalty for missing the deadline. If the student fails to submit the assignment as described above, the instructor is required to enter a percentage grade of zero for the assignment. This policy and procedure will be followed in all cases except where the Program Director and Instructor have agreed to waive this policy because of special extenuating circumstances. Education Coordinator Date 25

26 Nuclear Medicine Technology Education Program Student Handbook Section 3 Clinical Education 26

27 Clinical Instructors Nuclear Medicine Stephanie Anglin, RT(R)(N) Debra K. Burton, B.A., RT(N), CNMT Julianne Coddington, RT(R)(N) Eric Coffman, CNMT Tiffany Davis, M.A., RT(R)(N), CNMT Susan J. Keener, M.A. RT(R)(N) Megan Stuvek, BS, CNMT Tiffanie Wilkinson, RT(R)(N), CNMT Stephen Zirilli, BA, RT(R)(N), CNMT Gary D. Marano, MD Dan Martin, MD NM Staff Technologist NM Staff Technologist NM Staff Technologist NM Staff Technologist NM Ed. Coordinator NM Lead Technologist NM Staff Technologist, Casual NM Staff Technologist NM Staff Technologist Medical Director, NM & PET/CT Section Chief, NM & PET/CT PET/CT Amber Conway, BSN, RN, RT(R)(N)(M), CNMT Courtney Koren, RT(R)(N), CNMT, PET Ben Parker, RT(R)(N), CNMT Holly Perando, RT(R)(N), CNMT, PET Jennifer Pettry, B.A., RT(R)(N), CNMT, PET Marka Potts, RT(R)(N), CNMT, PET Jamie Walker, RT(R)(N), CNMT, PET Stephen Zirilli, BA, RT(R)(N), CNMT PET/CT Manager PET/CT Staff Technologist PET/CT Staff Technologist PET/CT Staff Technologist PET/CT Staff Technologist PET/CT Staff Technologist PET/CT Staff Technologist PET/CT Staff Technologist 27

28 Facilities & Equipment The WVU Hospital Section of Nuclear Medicine Technology has: o o o o Three (3) Siemens E-Cam dual head SPECT cameras with E-Soft computers Two (2) Siemens Symbia SPECT/CT cameras with E-Soft computers One (1) Captus 3000 Thyroid Uptake Probe Two (2) Capintec dose calibrators The Center for Advanced Imaging PET/CT has: o o o One (1) Siemens mct20 One (1) Siemens Biograph Excel Two (2) Medrad Stellant Syringe (Dual) Power Injectors. 28

29 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 6/2003 Revised: 5/2012 Clinical Standards Policy The Nuclear Medicine Technology Education Program recognizes that the student s clinical performance is a valid indicator of professional progress and achievement. The students are required to achieve and maintain competency status in the Applied Radionuclides Procedures courses (NMT 420 & NMT 430). This policy serves to identify those standards and define the method by which the clinical grade is formulated. This program s clinical education provides the student with the necessary clinical background involving: manipulation of equipment, handling and administrating of all types of radiopharmaceuticals, appropriate patient care skills, computerized processing of data, quality assurance procedures, and office/lab procedures. All areas of these basic skills must be mastered before the student can successfully complete the program and be eligible to be certified by the American Registry of Radiologic Technologists and/or the Nuclear Medicine Technology Certification Board. Overall Weighted Average / Semester Each student is required to achieve a minimum overall weighted clinical average of 85% at the end of each semester in order to successfully complete the clinical education component of the program. Due to the progressive nature of the clinical education component, no provisions are provided for repeating a clinical level. Each clinical education level must be completed before advancing to the subsequent semester; therefore, students who fail to achieve an 85% weighted clinical average at the end of each semester will be dismissed from the program. Students are counseled by the Program Director regarding their clinical progress at mid-term, semester end, and/or as needed; however, it is the student s responsibility to maintain awareness of their clinical progress at all times. Clinical Grade Calculation The student s clinical grade consists of several components that assure a comprehensive evaluation of clinical performance. The following components and weighted averages are utilized: Component Weighted Average Semester I/Semester II Performance Checklist 2% / 2% Quarterly Evaluations 20% / 20% Clinical Education Coordinator Points 8% / 8% Qualifying Exams 15% / 15% Competency Exams 40% / 40% Random Competencies 15% / 15% Each clinical grading component and related forms are included and explained in the student Clinical Handbook for each performance level. 29

30 Clinical Grade Scale The following scale will be utilized as an objective evaluation mechanism for representing the student s clinical grade and performance. Percentage Grade Letter Grade 100% - 93% A 92% - 86% B 85% - 78% C 77% - 70% D < 70% F Education Coordinator Date 30

31 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 6/2003 Revised: 6/2015 Clinical Education Policy The clinical education component of the program requires students to demonstrate a level of competency in clinical activities identified in this document. Demonstration of clinical competence is defined as the program director or clinical instructor observing the student perform all aspects of the procedure in an independent, consistent, and effective manner. All procedures must be performed on patients with the exception of the following being simulated: patients care activities, therapeutic thyroid treatments (option only starting on June 1 st ), and CPR. Students must achieve competency status in: 8 Patient Care Activities o CPR (TBA) * o ECG Placement * o Vital Signs (blood pressure, pulse, respiration, temperature, oxygen administration) * o Venipuncture (intravenous catheter)* 8 Quality Control Procedures o Gamma Camera (daily floods) o Gamma Camera (monthly floods) o Symbia SPECT/CT (daily floods) o PET/CT (daily floods) o Survey Meter (daily check) o Dose Calibrator (constancy) o Dose Calibrator (linearity) o Well Counter / Uptake Probe (energy calibration) 25 Diagnostic and Therapeutic Procedures o Bone Scan (3-Phase with SPECT/CT) o Bone Scan (Whole Body) o Gated Blood Pool Study o Myocardial Perfusion o Thyroid Uptake o Thyroid Scan o o o o o o o Hepatobiliary Choose 2 GI Studies: GE Reflux Gastric Emptying GI Bleeding Meckel s Diverticulum Liver H. Pylori Renal Dynamic Perfusion Lung Perfusion Lung Ventilation Lymphoscintigraphy PET Tumor (Whole Body) 31

32 o o o Choose 3 SPECT Studies: Brain Tumor Liver Cardiac Renal Choose 1 Therapeutic Procedures: Thyroid: ablation Thyroid: hyperthyroidism 7 Electives (if not already used from above) 3 Electives Semester I 4 Electives Semester II The student will achieve 3 elective competencies at the completion of Semester I. The student will achieve an additional 4 elective competencies by the completion of Semester II. The following is a list of potential elective studies. Gallium (abscess and infection) Gallium (tumor) Limited skeletal Cardiac first pass PET (cardiovascular) PET (NaF bone scan) Thyroid metastatic survey (I-131 WB 7 day F/U; I-123 WB) Parathyroid Arthrogram GI Renal: cortical imaging Testicular Cystography Quantitative lung Monoclonal antibodies Therapeutic procedures Central nervous system Brain (planar, dynamic, PET) Cisternography: routine Cisternography: CSF leak 2 Other Categories o 2 Stress Lab Competencies Exercise Stress injection * Pharmacologic Administration Stress injection * o 2 Random Competencies 1 Random Competency Semester I Final ** 1 Random Competency Semester II Final *** 32

33 Once a competency has been achieved, the student must maintain that same level or higher of competency for that procedure. Failure to maintain the initial level of competency will result in the competency being revoked and require the student to re-evaluate the procedure performance and achieve competency again. Patients are to be chosen at random for competencies and the clinical instructors reserve the right to approve/disapprove a given patient for evaluation. When preparing for the competency evaluation, the student needs to be aware that he/she is responsible for both clinical and didactic information pertaining to the procedure. The student will be evaluated on his/her level of competency status at the end of each semester by performing a random competency observed by the program director. All competencies must be achieved by the second Friday in June, with the exception of the Injection Competency (Intravenous), which must be completed by the last Friday in August. Competency Completion Timeline All patient care competencies must be completed by the last Friday in August. It is the student s responsibility to ensure the required competencies have been completed by the end of the each semester. The student will not be able to move forward with second semester competencies until all first semester competencies have been successfully achieved. Note: Second Semester Competencies cannot be attempted until all First Semester Competencies are complete without written permission from the Program Director. Attempting these competencies will result in automatic failure. The student must have successfully completed rotations through the PET Center and Radiation Safety prior to graduation. The above requirements are mandatory graduation requirements. Students not in compliance are subject to dismissal from the program in accordance with the Clinical Standards Policy. Education Coordinator/Date 33

34 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 3/1991 Revised: 3/2006 Policy: Direct / Indirect Student Supervision Policy This policy serves to identify the current guidelines for clinical supervision of a nuclear medicine student in reference to the direct and indirect provisions stated in the Essentials and Guidelines set forth by the Joint Review Committee on Educational Programs in Nuclear Medicine Technology. Direct Supervision A student is required to perform all nuclear medicine imaging procedures and all radiopharmaceutical administrations under direct immediate supervision until they have achieved and documented successful completion of a competency exam for a particular procedure (imaging/radiopharmaceutical administration). Indirect Supervision After achieving and documenting successful completion of a competency under direct supervision, the student may perform that particular procedure (imaging/radiopharmaceutical administration) under indirect supervision*. * Indirect supervision is defined as supervision that is provided by a registered nuclear medicine technologist / clinical instructor immediately available** to assist the student regardless of the level of student achievement. ** Immediately available is interpreted as the presence of a registered nuclear medicine technologist (clinical instructor) adjacent to the room or location where the nuclear medicine procedure is being performed. Supervision Parameters Direct Supervision: 1. A registered nuclear medicine technologist (clinical instructor) reviews the procedure request and condition of the patient in relation to the student s level of clinical competence. 2. The clinical instructor is present during the radiopharmaceutical administration and imaging procedure to offer advice and assist the nuclear medicine student as needed. 3. The clinical instructor reviews and approves all nuclear medicine procedure images including computer-processing techniques prior to radiologist review. 4. The clinical instructor is present during presentation of the case to the radiologist if procedure requires technologist and physician communication. 34

35 Indirect Supervision: 1. A registered nuclear medicine technologist (clinical instructor) verifies the student s ability to perform under indirect supervision. 2. The student evaluates the procedure request, patient condition, and if necessary consults with the clinical instructor. 3. The student performs the nuclear medicine procedure under indirect supervision. 5. The clinical instructor reviews and approves all nuclear medicine procedure images including computer-processing techniques prior to radiologist review. 4. No provisions are made for performing the following nuclear medicine procedures under indirect supervision. Direct supervision guidelines must be followed regardless of the student s level of clinical competence: a. Brain Death Studies b. Sedated Renal Studies (sedation portion of exam) c. RBC Mass Procedures d. Schillings Procedures e. Voiding Cysturethrograms (Direct and Indirect) f. Diamox Brain Studies g. VP Shunt Studies (injection portion of exam) h. Therapies i. I-131 (Ablation) ii. Bone Pain (Palliation) iii. Intracavitary Education Coordinator Date 35

36 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 6/2008 Revised: Clinical Education Make-up Policy Policy: This policy serves to identify the procedure and criteria for making up clinical education when absences in excess of the allotted 6 personal days off (PDO) occur. Absences in excess of the 6 days must be made up by the student in order to complete the clinical education component of their education and receive the recommendation of the Education Coordinator to sit for the ARRT and/or NMTCB examination. The following guidelines will be utilized by the student to re-establish their good standing in the clinical education component of their education. a. The student may convert compensation time to account for excess personal leave, or b. The student's clinical education will be extended beyond graduation to account for the number of days or hours in excess of the allotted 6 personal leave days not to exceed 5 days. c. In all cases, unexcused absences must be made up after graduation. These guidelines will be used by the education program to provide the student with a mechanism to complete their clinical education when the student's attendance has been affected by adverse circumstances (ex: extended illness). Chronic attendance problems will be governed by the Attendance & Disciplinary Action policies. Education Coordinator Date 36

37 Nuclear Medicine Technology Education Program Student Handbook Section 4 Nuclear Medicine Program & WVUH Policies / Procedures 37

38 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 3/1991 Revised: 3/2006 Policy: Policy Change The administration of the West Virginia University Hospital s and the Faculty of the West Virginia University Hospital s Program of Radiologic Technology reserve the right to change any of the stated policies as necessary and/or when advisable for improvement of or to meet new standards within the program. 38

39 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 11/1992 Revised: 4/2007 Admissions Policy Admission to the West Virginia University Hospitals in Nuclear Medicine Technology is governed in accordance with the following minimum admission requirements. Procedure: All of the following criteria are required for admission consideration and must be received on or before February 1 st of the year applying for admission. 1. Completed application and reference forms 2. Completed Performance Standards form 3. United States high school diploma or equivalent 4. Three letters of personal reference 5. Transcripts from all previous academic experiences to include: JRCERT accredited radiography program High School or GED College (if applicable) 6. Official ACT or SAT exam scores: Minimum required composite score: i. ACT = 19 ii. SAT = 900 (math and verbal) Exam scores must be recent (10 years or less) Requirement may be waived for applicants possessing a baccalaureate degree or higher School Codes i. ACT 4549 ii. SAT Applicant must be a graduate (or pending graduate) from a JRCERT accredited program in Radiologic Technology. Application Process & Evaluation: Applicant(s) meeting the above admission requirements will obtain a score in a preliminary screening process. This score is obtained by combining the point value assigned to each of the items below (see Weighted Values for Applicant Selection form). 1. ACT/SAT Scores a. Minimum composite scores are required for admission consideration (ACT 19; SAT 900 (V+M)). Exam scores must be recent ( 10 years). Applicants with a Baccalaureate (or higher) degree may be exempted from this requirement; however, it is highly recommended for the applicant to provide this information for additional points. 2. Radiography Grades a. Cumulative GPA, Physics, Anatomy & Physiology, Radiographic Positioning, and Clinic) 3. College Credits/Degree a. Science versus Non-science oriented degrees. Graduate versus undergraduate. 39

40 4. High School a. Averaged Math, Anatomy, and Science Grades. 5. Medical Experience 6. Reapplication Points Those applicants meeting all admissions criteria will be granted a personal interview. The program reserves the right to limit interviews to the top fifty percent (based upon academic points awarded according to the weighted values for applicant admission points policy) of applicants meeting the minimum requirements. At least three members from the Nuclear Medicine Education Admissions Committee (Program Director, Staff Technologist(s) and/or Nuclear Medicine Manager) will conduct the interview(s). All candidates will be scored based on an academic and interview point system. The total number of points will be totaled and entered on the candidate s Weighted Values for Student Selection Form. The interview portion of the evaluation process will be based on the candidate s: appearance, demeanor, emotional stability, personality, communication skills, learning ability, knowledge about nuclear medicine technology, drive to succeed, and demonstrating initiative to improve chances for program admission. Selection Process: Each candidate will be ranked according to the number of points accumulated from the academic and interview sections. Four candidates with the highest point total will receive the status of Accepted and be offered a position in the program. o Although accredited to enroll 4students per academic year, program officials reserve the right to limit enrollment based upon the quality of the applicant pool and current employment market conditions. Additionally, three to four candidates will receive the status of wait-list according to their point totals. The wait-list candidates with the highest point total will be offered a position should a vacancy occur on the original roster of accepted candidates. The wait-list candidates will receive written notification of their status. o The Program reserves the right to re-evaluate and potentially rescind an offer of admission should adverse conditions involving the student's academic, clinical, and/or professional performance develop between the time of notification and the start of the program. All candidates receiving the status of denied will receive written notification of their status. Those candidates chosen for admission will receive the following: o Acceptance Letter o Copy of the updated Student Handbook o Statement of Intent to Enroll (to be signed and returned) o Non-registered student admission policy and agreement (to be signed and returned) o Invoice for Admission Fee Education Coordinator Date 40

41 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 3/2008 Revised: Non-Registered Student Admission Policy Policy: West Virginia University Hospitals Nuclear Medicine Technology Education Program matriculates students who have provided proof of ARRT registration or have documented in writing that they are ARRT registry eligible for the Radiography examination. This policy is applicable to students that have not passed the American Registry of Radiologic Technologists (ARRT) registry examination in Radiography. Registry eligible students are accepted into the Nuclear Medicine Technology Education Program on the condition that they successfully pass the ARRT exam in Radiography. Procedure: 1. The student must take the ARRT exam in Radiography within 30 days of entering the program (during or before the month of July). 2. The student must provide the Program Director with proof of eligibility, i.e., photocopy of admission ticket. 3. The Program must receive documentation of ARRT Registration within 90 days following matriculation into the Program. 4. In the event that the student does not successfully pass the ARRT Radiography exam taken on or before July, the Education Advisory Committee will review and evaluate the student=s case. The following evaluation criteria will include: Evaluation Criteria: 1. The student must have maintained an overall didactic average of 87% (B) or better while enrolled in the program. 2. The student must not have been counseled regarding poor didactic or clinical performance while in the Program. 3. The student must have demonstrated a high level of proficiency, integrity and clinical ability. 4. The student must have met all financial obligations to the Program. If the education advisory committee decides to allow the student to remain in the Program based on the above criteria, the following action will occur: 1. The student will be placed on academic probation until the results of a repeat attempt on the ARRT Radiography registry are obtained. The repeat attempt must occur within 30 days of the notification by the ARRT that the students failed the registry. 2. The student must provide the Program Director with proof of eligibility, i.e., photocopy of admission ticket. 3. The Program must receive documentation of ARRT Registration within 60 days following the date of the repeat exam. 4. In the event that the student does not successfully pass the repeat ARRT Radiography exam, the student will be dismissed from the Program without further consideration. The student may reapply for admission consideration when they have successfully passed the ARRT exam in Radiography. 41

42 This policy is enacted for the purpose of: 1. Assuring that all students meet the required admissions requirements for the Radiation Therapy Education Program, thereby assuring the Program maintains high admission standards for accepting quality students. 2. Affording students who have made satisfactory academic, clinical and professional progress in the program another attempt to successfully pass their ARRT Exam in Radiography. Education Coordinator Date Medical Director/Advisor Date 42

43 Non-Registered Student Admission Agreement I have received a copy of the non-registered student admissions policy for the West Virginia University Hospitals Radiation Therapy Education Program. I have read and understand these regulations and agree to abide by the same. I agree not to hold West Virginia University Hospitals liable for any losses incurred including financial loss. Student Signature: Date: 43

44 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 7/2007 Revised: 3/2010 Attendance Policy A student's daily attendance is vitally important in order for them to maintain satisfactory didactic and clinical performance. Students that miss exceptional amounts of clinic time will find it difficult to acquire the exams needed to fulfill their clinical education requirements. Students need to realize that poor attendance during their education can have a negative effect on their future. Employers tend to be wary of student applicants that have a record of excessive absenteeism. It is natural to relate absenteeism with a poor work ethic and a lack of commitment to the profession. Personal Days Off: (PDO) Nuclear Medicine students will be allotted six (6) personal days off (PDO) for the twelve-month period. In addition, each school year will include three (3) weeks of leave to include: 2 weeks over the Christmas / New Year holiday, and one week in April (typically coinciding with the Easter holiday). Personal days off (PDO) may be utilized for unscheduled absences (illness, personal emergency, etc.) and scheduled absences (job interviews, doctor appointments, etc.). Students are given one 8 hour PDO extra for an interview day*. The student must return the completed paperwork the next school day to receive an excused absence. *See Attendance Documentation Section. Scheduled & Unscheduled absences 1. It is the student s responsibility to notify both the Program Director and Nuclear Medicine Department when calling to report off for illness or other personal emergencies. Notification must be received by a Program Official fifteen minutes before the beginning of the student s assigned shift. Failure to call a Program Official in a timely manner will result in the student receiving an unexcused absence for that day. Students are required to leave a message on the phone mail system of the Program Director ( ext ) and the Nuclear Medicine Department ( ). 2. In addition to calling off, students must document their absence by completing a PDO / Comp time slip or by ing the clinical education coordinator in charge of attendance. PDO / Comp time slips are located in the clinical education coordinator s office as well as in the student folders in the clinic. Comp time may not be utilized for unscheduled absences. 3. Students that miss consecutive days due to an illness will be charged only one (1) personal day off (PDO) for every three (3) days of absence, providing the student has a valid medical excuse from a physician stating the amount of time that the student is excused. The provision does not apply to time missed due to illnesses or incapacitation related to elective procedures or surgeries. Please refer to the Medical Leave of Absence policy regarding extended illnesses. 4. PDO shall be granted in minimum increments of 0.5 days (4 hours) for both scheduled and unscheduled absences. 5. Students requesting time-off for non-emergent reasons should pre-schedule PDO with program officials at least one (1) day in advance by filling out and submitting a PDO / Comp time Form. 44

45 Excessive Absenteeism This policy serves to identify the procedure and criteria implemented when a student exceeds their allotted six personal days off (PDO) for the twelve-month period. 1. Excessive absenteeism will not be tolerated. If a student exhausts their 6 allotted PDO days, they will be subjected to the following disciplinary action. a. If the 6 allotted PDO days are exhausted, the student will receive an oral warning and counseling regarding their attendance. b. If 2 additional days are missed (total 8), the student will receive a formal written warning regarding their position in the Program. c. If 2 more additional days are missed (total 10), the student will receive a second formal written warning regarding their position in the Program. d. If the total amount of days absent exceeds 10, then the student will be dismissed from the Program if any additional absences occur. Students will be evaluated on an individual basis as to the circumstances causing the absenteeism. 2. In the event that a student exceeds their allotted six (6) PDO days, their clinical education will be extended beyond graduation so that all clinical requirements can be satisfied. However, the clinical education process cannot be extended beyond 5 days after graduation. All absences over the allotted 6 PDO days will be considered as unexcused absences. 3. Students may convert compensatory time to account for excess pre-scheduled personal leave upon pre-approval by the Program Director. 4. In accordance with the Standards of an Accredited Educational Program in Radiologic Sciences, with regard to the maximum hours of clinical and didactic instruction, students will not be permitted to make-up their excessive missed time by extending their hours in clinic on a daily basis. Unexcused absences Unexcused absences are classified as the following: Leaving the facility grounds without a program official s permission. Leaving your assigned clinical area without program officials or a staff technologist s permission. Failure to notify program officials prior to your assigned shift of an unscheduled absence. Absences that occur as a result of disciplinary action (e.g. suspension) or those in excess of the allotted 6 PDO days. In the event that a student incurs an unexcused absence, the Disciplinary Action policy will be implemented. It is mandatory for all students to make-up, after graduation, any time missed as a result of an unexcused absence so that all clinical requirements can be satisfied. As with the excessive absenteeism policy, the clinical education process cannot be extended beyond 6 days after graduation for unexcused absences. Tardiness Students are required to be in their assigned clinical or didactic area prior to or by their designated starting time. Students should be aware that falsifying attendance records is grounds for immediate dismissal. Tardiness is subject to the following guidelines and provisions: 45

46 Tardiness is considered as any arrival time that is past the designated time of arrival. Tardiness beyond 1 hour will be considered an absence and will result in the student being charged 0.5 days (4 hours) of PDO. Students are required to make-up any amount of time missed due to tardiness. Students have one (1) week from the day the tardiness occurred to make-up the time or program official will charge the student 0.5 days of PDO. Make-up time must be pre-approved by a program official. Excessive tardiness will not be tolerated and will result in a reduction in Clinical Points which will negatively affect the student clinical grade. Continued abuse will additionally result in disciplinary action. Exceptions to this policy will be at the program official s discretion and will be limited to unforeseen events such as inclement weather. Funeral Leave Students will be given a maximum of three (3) days excused absence for deaths in their immediate family. Immediate family shall include: husband, wife, mother, father, brother, sister, mother-in-law, father-in-law, and grandparents. Exceptions to this policy may be granted only by the Program Director. Military Leave West Virginia University Hospitals supports the Military Services of the Government of the United States and provides the following provisions for students serving in the Military Reserves during their enrollment in the program. Students serving in any branch of the U.S. Military Reserves are allotted 2 weeks (10 days) of leave per academic year to fulfill their required military commitment. Student that miss additional time (>10 days) due to military service will be required to utilized personal leave or arrange an acceptable time frame in which to make-up the time missed so that the program s clinical requirements can fulfilled. Make-up time is subject to the Education Coordinator s discretion and subsequent approval. Students are responsible for all didactic and clinical course materials presented during their absences related to military service. In the event that a student is called-up to active military duty, the program will reserve a position for that student so that they can be re-enrolled upon the completion of their active duty assignment. Vacation and Holidays Students are granted three (3) weeks of vacation during each year enrolled in the Program. Vacations are scheduled as two (2) week over Christmas/New Year's and one week in April. Program officials reserve the right to alter vacation dates. Students are granted seven (7) holidays per year which include the following: New Year's Day Memorial Day Independence Day (July 4th) Labor Day Thanksgiving Friday following Thanksgiving Christmas 46

47 Attendance Documentation Students are required to document their attendance by using the Kronos System with their student ID badge. The student is also required to complete a Comment documentation form found in the student clinical handbook. In handwriting, the student should comment to describe why the student left early for the day (i.e. CI name let go at 2:30pm). The student will return the completed form at the end of each month in the completed paperwork folder in the clinical area called Completed Paperwork. Using PDO or Compensatory Time: Students desiring to use PDO or Compensatory Time will be required to submit a Leave Request Form to a program official prior to the date or time of their absence. The date and the exact amount of time the student will be absent must be included. Interview Day: Students desiring to use the one allotted Interview day will be required to submit a Leave Request Form prior to the interview date and a completed Interview Day Confirmation form within 2 school days after the interview date to a program official. Both forms must be completed and accurate. Policy Enforcement: Accurate evaluation and interpretation of student attendance can only be accomplished if students are methodical and precise in their documentation. For this reason, the following guidelines have been established and will be strictly enforced. 1. Each student must swipe their student ID in the Kronos System to document daily attendancein/attendance-out times upon their arrival and departure of clinic duties. 2. Students that fail to document accurately and timely will be counted absent until they notify the Education Coordinator or assigned Clinical Liaison. All time not accounted for (missed documentation) will be either deducted from the student s PDO balance or replaced by compensatory time if available. 3. Any student failing to properly utilize the attendance Kronos and/or documentation paper system (failing to swipe student ID badge, failing to comment on early dismals, etc.) will have 1 clinic point deducted for each violation on the Clinical Education Coordinator Points Form used for clinical grade calculations. Once a student s clinic points (5 total) are exhausted, the Disciplinary Action policy will be implemented. 47

48 Education Coordinator Date Time Off Request Form Student: Date: *The student is responsible for assuring that all didactic and clinic responsibilities and/or make-up work are met during the requested leave time. This can be accomplished through arrangements with clinical instructors, classmates, and/or education coordinator. PDO will only be accepted in increments of 1 hour. Anything less will not be accepted. Compensatory time may be used in 30 minute increments only. Anything less will not be accepted. Date(s) of Leave Time Requested Type Requested PDO COMP PDO COMP PDO COMP PDO COMP PDO COMP PDO COMP Brief Description Check this box for Excused Absences (i.e. funeral leave and/or medical leave) along with the coordinating box below. Permission must be granted by the Education Coordinator prior to the student using this type of leave. Medical Leave Funeral Leave Student Signature/Date: Education Coordinator Signature/Date: Approved Denied 48

49 *Scheduled time off must be requested at least 24 hours prior to the anticipated date of absence. It is your responsibility to ensure the Education Coordinator receives this form promptly. Failure to abide by any of the aforementioned could result in a denial of the requested time off. West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 1/1993 Revised: 3/2007 Student Fees / Refunds The sponsored by West Virginia University Hospitals assess students tuition and fees to provide supplementary financial support of educational operations and functions. Students will be invoiced with a formal billing statement at least two weeks in advance of the specific fee deadline. Tuition and fees are subject to change without notice; however, all attempts will be made to publish any changes well in advance of their implementation. Tuition Fee West Virginia University Hospitals assesses student tuition and fees equaling $ per semester. Tuition invoices will be distributed at least two weeks prior to the beginning of the subsequent semester, and payment is due prior to or upon the first day of the semester. Admissions Fee Each new student is assessed a $50.00 admission fee which must be submitted along with the "Intent to Enroll" form upon the acceptance of a student position. The admissions fee will be applied toward the balance of the student s Semester I tuition. Admission invoices are distributed with admission acceptance letters, and payment is due prior to or upon the date specified of the admission acceptance letter. Admission fees are non-refundable. Graduation Fee Each graduating student will be assessed a $25.00 graduation fee. Graduation invoices are distributed at least two week prior to graduation, and payment is due prior to or upon the date of graduation unless otherwise specified. Late Payments Fees / Failure to Remit Payment All payments must be received by the deadline specified on the invoice. Students who fail to remit payment by the specified deadline will be subject to a $25.00 late payment fee. Students who fail to remit payment within two weeks of the specified deadline will be removed from the program roster and their status will be recorded as "withdrew voluntarily". Deferments Students are temporarily exempt from the Late Payment Fees and Failure to Remit Payment requirements if they complete a deferment form prior to or upon the payment deadline. Deferments are only granted to students who have documented that they are waiting for the distribution of an approved form of financial assistance (grants, loans, scholarships, etc.). Deferments can only be granted by the Education Manager. Students who defer tuition payments are subject to the following payment regulations: a. Tuition payments are due within three business days after disbursement of financial aid. b. After the three-business day grace period, the Late Payment Fees and Failure to Remit Payment sections become effective. 49

50 Refunds Students who complete up to 60% of a payment period prior to withdrawing from the Radiologic Technology Education Programs may receive a tuition refund that is prorated upon the percentage of the payment period completed. Student who withdraw after completing 60% of the payment period are not granted refunds. The following procedures will be utilized in determining and issuing a tuition refund if required: 1. The actual clock hours completed by the student are divided by the total clock hours for the payment period (semester) to determine the percentage of the payment period completed. 2. If the percentage of the payment period completed is greater than 60%, no refund is granted. 3. If the percentage of the payment period completed is equal to or less than 60%, the percentage is multiplied by the tuition paid for the payment period to determine the prorated refund amount. Admission fees are non-refundable and are not included as Semester I tuition paid. 4. The refund will be delivered to the student in the form of a check within 30 days of the withdrawal date. The only exception will be for those students who received Title IV funds: a. If according to the Return of Title IV Funds policy, it is determined that a student has not earned 100% of their Title IV funds disbursed for the payment period and a return of funds to the United States Department of Education (U.S.D.E.) is required, the institution will return to the U.S.D.E. the unearned portion of Title IV funds collected for institutional charges (tuition & fees) on behalf of the student. The student will not directly receive a refund from the institution; however, the amount of funds returned by the institution will be subtracted from the total amount of Title IV funds owed the U.S.D.E. by the student. (See Return of Title IV Funds policy). Payment / Collection Procedures All payments are to be remitted to the Education Manager. Received payments will be submitted to the department financial analyst for depositing into the appropriate accounts. Administration of collected tuition and fee funds is relegated to the Financial Services department at West Virginia University Hospitals. All payments must be submitted in the form of a personal/certified check or money order made payable to West Virginia University Hospitals. The student name or Social Security number should be included on the check or money order. Cash or Credit Card payments are not acceptable. Education Coordinator Date 50

51 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 12/1984 Revised: 3/2006 Student Withdrawal Policy This policy governs the procedures relative to a student's withdrawal from an education program sponsored by West Virginia University Hospitals. I. Withdrawal with Notification: A. The student must submit a signed and dated, formal letter of resignation or a Student Resignation Statement to their Education Coordinator. B. The Education Coordinator will notify the Education Manager regarding the student s withdrawal request. C. The Education Manager will notify the appropriate financial aid agency(s) of the student s withdrawal and will perform the necessary calculations to determine potential tuition refunds, the amount of Title IV funds to be returned and/or the amounts the student is required to return to the institution. A copy of these calculations and the necessary actions will be forwarded to the Education Coordinator and the student. D. The Education Coordinator will schedule an exit interview with the student and will document in writing with subsequent student signature, the following items: 1. The student must fulfill all financial obligations to the respective financial aid agencies and the Institution. 2. The student must return all materials, which are the property of the Institution. 3. All courses in progress at the time of withdrawal will be recorded on the student's transcript as "WD" (withdrew). 4. The student is relinquishing their position in the program and readmission can only be obtained by re-entering the application process during the next enrollment period. II. Withdrawal without Notification E. In the event that a student withdraws without notification (as evidenced by violation of the attendance policy), the Education Coordinator will: 1. Document in the student s file the actual date it was determined that the student withdrew without notification. 2. Initiate the steps outlined in sections B&C of this policy. 3. Notify the student via mail, that they have forfeited their position in the program. 4. Included in the notification the specifics outlined in section D of this policy and the financial aid information provide by the Education Manager. 5. Document that in lieu of a WD grade designation, the student s transcript will reflect a failing grade of F for all courses in progress at the time of withdrawal. 51

52 Education Coordinator Date Student Resignation Statement I hereby voluntarily withdraw from West Virginia University Hospitals, Inc. Nuclear Medicine Technology Education Program for the following reason(s): I am not comfortable with the type of clinical experiences involved. I am not comfortable with this profession as a career. I am not satisfied with the quality of classroom instruction. I am not satisfied with the quality of clinical instruction. I am not satisfied with my performance in the program. Personal circumstances beyond my control force my withdrawal. I am not comfortable with the policies and guidelines of the Program and/or Institution. Conflicts involving program/institution personnel force me to withdrawal. I have received a more appealing career/educational opportunity. Other: Please specify. Comments: (Relative to experiences in the program and/or suggestions for improvement in specific areas) I understand that I will receive no credit toward the American Registry of Radiologic Technologist or Nuclear Medicine Technology Certification Board requirements for time spent in this education program and hereby voluntarily resign my student position. Student Signature Date 52

53 Education Coordinator Date West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 7/1986 Revised: 3/2006 Dress Code Policy West Virginia University Hospitals requires all students to adhere to a dress code that is designed to promote a positive professional appearance while providing functionality for patient care and diagnostic imaging activities. Student Uniform Requirements Students enrolled in the will be required to wear the following uniform while participating in clinical activities: Uniform Top (required) Students are required to wear a Caribbean blue scrub top during clinical rotations. Tops must be solid and contain no pattern or trim of a different color. Tops must be modest, be reasonably fitted, and allow comfortable ease of movement. Clothing must be clean, neat, and stain and wrinkle free. Appropriate underclothing is required and must be undetectable through outer clothing. Uniform Pants/Skirts (required) Students are required to wear white or Caribbean pants or skirts during clinical rotations. Skirts must be at least knee length. Pants/Skirts should be made of quality fabric so that undergarments are not clearly visible through the material. Denim material is not permitted. Shoes (required) Students are required to wear white shoes during clinical rotations. Leather athletic shoes (tennis shoes) are permitted and recommended for comfort. Shoes must be 100% leather. Canvas, mesh, or other materials are not permitted. Shoes must cover the heel and the toes. Clog or sandal type shoes are not permitted. Lab Coat (required for all Nuclear Medicine students) Nuclear Medicine students must wear a white or Caribbean lab coat during clinical rotations. It is required to handle all radioisotopes. Other Uniform Guidelines: 1. All students are required to wear the aforementioned uniform while participating in clinical activities. 2. Uniforms must be clean, neatly pressed, and professional looking. 3. Shoes are to be kept clean and polished. Safety, quietness and appearance are the main consideration for footwear. Footwear should cover the toes of the foot, and should either cover the heel or have a back lip or strap to prevent accidental slip offs, should be non-canvas, have a non-skid sole and be of reasonable sole and heel height and appropriate hosiery must be worn. Crocs or croc like shoes are not permitted. 4. Female students are required to wear white hose when wearing a skirt. 5. Students are required to wear their ID badge at all times while on Hospital property and off-site locations. The student s name and picture must be clearly visible. 6. Students are required to wear their dosimeter during all clinical rotations 7. Visible tattoos are not part of WVU Hospital s overall professional appearance. Visible tattoos must be covered during clinical rotations. 53

54 Hospital Issue Scrub Suits 1. Students are not permitted to wear scrub suits unless dictated by their clinical assignment or without first obtaining permission from a program official. 2. Scrub suits are to be worn in accordance with infectious disease control guidelines. (Refer to Radiology Department Policy and Procedure Manuals). 3. Scrub suits are hospital property and are not to leave the building. Jewelry 1. Appropriate jewelry includes wedding bands, engagement rings, wristwatches, and stud type earrings. 2. A maximum of 2 earrings per lobe may be worn. 3. No visible body or tongue piercing is allowed. 4. All other external/visible jewelry is subject to program official approval with regards to professional appearance and appropriateness. Professional Demeanor Rules of medical and professional ethics must always prevail in any activity involving patients and their guests. Friendly, prompt, and careful diagnostic treatment is the primary goal and purpose of this and any Radiology Department. Personal feelings cannot interfere with this purpose. The Program Officials and Faculty may establish their own guidelines for conduct as related to particular courses or instructional labs, etc. Students are required to adhere to the guidelines as established. Guidelines thought to be unfair or not clearly communicated to the student need to be brought to the attention of the Program Director and /or follow the Due Process policy as it applies. Appearance and Personal Hygiene Your appearance is an important part of your professional image. Therefore, the dress code will be adhered to strictly. If you report to clinic unacceptably attired, you will be sent home. The time you are absent will be made up as directed by the program officials. Infractions of this rule will result in disciplinary action and may be cause for eventual dismissal from the program. You are expected to follow these guidelines for good grooming and personal hygiene: 1. Body cleanliness is mandatory, adequate bathing and use of deodorant is essential. 2. Hair must be clean, neatly groomed, and not restrained by excessive ornaments, headbands or scarves. 3. Short, well-trimmed beards and mustaches will be permitted. Daily shaving is required for those not having a beard. 4. Fingernails must be clean and well groomed. Acrylic nails or any type of false nails will not be permitted. The length of nails is to be kept to the ends of the fingers. The department of radiology dress code policy permits only clear fingernail polish. 5. Excessive cosmetics, highly aromatic perfumes or colognes are not to be worn in the clinic area. 6. Oral hygiene is essential for positive patient interaction. Education Coordinator Date 54

55 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 12/1992 Revised: 3/2010 Due Process West Virginia University Hospitals encourage and support a positive appeal process in the event a student feels a disciplinary, academic, or clinical decision was rendered unjustly or under capricious or arbitrary circumstances. Students who wish to appeal such decisions are to adhere to the following policy / guidelines: Appeal Process Students may initiate the appeal process by submitting, in writing, a request for appeal to the appropriate individual(s) listed at each level of appeal beginning at Level I (see below). For all levels of appeal, the student must submit the written request within five days after the decision is rendered and a conference will be arranged within ten days of receipt of said request for Levels I & II and within 20 days for Levels III & IV. Within three days, written documentation of the decision rendered by the appeal committee and/or individual will be delivered to the student. In the event the student is not satisfied with the judgment rendered at a specific level of appeal, the student may continue the appeal process by written request to the next level. In all cases, the decision rendered by the President of West Virginia University Hospitals is final. Levels of Appeal Level I Education Coordinator Level II Level III Level IV Due Process Appeal Committee 1. Program Medical Director (Chairperson) 2. Administrative Director / Radiology & Radiation Therapy 3. Education Manager 4. Student Representative 5. Staff Technologist / Therapist 6. Section Supervisor Vice President - Ancillary Services / WVUH President - CEO / WVUH Non-Compliance Issues The sponsored by West Virginia University Hospitals are recognized by various accrediting agencies and are subject to rules and regulations as a condition of continued accreditation. In the event that a student has questions, concerns, or complaints regarding issues of non-compliance, they are encouraged to contact the appropriate accrediting agencies listed below: Radiography & Radiation Therapy Ultrasound Nuclear Medicine JRCERT CAAHEP JRCNMT 20 North Wacker Drive 35 East Wacker Drive 2000 W. Danforth Rd., Suite 900 Suite 1970 Ste 130 #203 Chicago, IL Chicago, IL Edmond OK (312) (312) Tel: (405)

56 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 12/1992 Revised: 2/2010 Disciplinary / Corrective Action West Virginia University Hospitals matriculates students who have documented in writing that they will agree to abide by the policies, procedures and behavior standards established by the Hospital and the Program. However, in situations in which a student fails to exhibit appropriate behavior and/or fails to follow established policies and procedures, disciplinary action may be taken. Disciplinary measures are applied at the discretion of the Education Coordinator with the approval of the Education Advisory Committee and are dependent upon the nature of the infraction. The following four (4) levels of progressive disciplinary action will be followed unless otherwise noted: A. Progressive Disciplinary Steps I. Documented Counseling Documented counseling can be utilized when the nature of the infraction warrants notification but not a written warning letter. Counseling documents are considered instructional /educational as opposed to disciplinary and do not become a permanent addition to the student s file unless subsequent disciplinary action occurs. Education Advisory Committee (EAC) approval is not required prior to counseling. II. Written Warning Letter(s) Written warning letters (up to a maximum of two) will be utilized to document disciplinary action when the nature of the infraction is sufficient to warrant corrective action and permanent documentation. The issuance of written warning letters requires EAC review and approval. III. Final Warning & Suspension The issuance of a final written warning with suspension is the third and final stage of the progressive disciplinary process and requires EAC review and approval. Suspension is not to exceed three days. Students who missed clinical education assignments due to suspension are required to complete those assignments prior to graduation. IV. Dismissal B. Progressive Disciplinary Exemption At the discretion of the Education Advisory Committee, progressive discipline may not apply in instances involving conduct that constitutes a serious violation of the rights or safety of our patients, families, employees, or students. Examples of such conduct include but are not limited to the following: Mistreatment of patients, guests, employees, or students. Breaches of confidentiality. Disclosure of personal computer security codes to others. Criminal behavior. Being under the influence of alcohol or drugs while on hospital premises Gross violation of safety rules. Fighting or violent behavior. Malicious destruction or theft of patient, visitor, employee, student or institutional property. Falsification of records or documentation. Accessing or discussing protected health information (PHI) for personal gain or with malicious intent. Possession or distribution of illegal drugs or controlled substances. Possession of a firearm while on institutional grounds. Academic or clinical dishonesty. Insubordination. 56

57 It should be noted that immediate dismissal may be invoked upon documenting student participation / involvement in any of the aforementioned behaviors or activities. C. Academic& Clinical Performance As specified in the Academic and Clinical Standards policies, students are required to maintain minimum performance standards in each area of the curriculum. Failure to meet the specified academic or clinical standards by the end of each semester will result in dismissal from the program. (See Academic & Clinical Standards policies) D. Due Process All disciplinary actions are subject to due process. Students should refer to the Due Process policy in the Student Handbook for procedural specifics and time frames for appealing disciplinary decisions. 57

58 Education Manager Date West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 12/1992 Revised: 2/2000 Probationary Period Initial Probation Students are enrolled in the on a probationary status for the initial three-month period of their enrollment. After the initial three months, students are awarded a permanent appointment contingent upon their satisfactory academic, clinical and/or professional progress at that juncture. In the event the student is not making satisfactory progress at the end of the initial three months, the probationary period can be extended for an additional three months at the Education Coordinator s discretion. Students who fail to achieve established academic, clinical or professional standards at the end of the probationary period extension, will be dismissed from the program. It should be noted that students can also be dismissed with one warning letter during the probationary period. Academic & Clinical Probation Students who fail to meet established didactic and clinical performance objectives at the mid-term of each semester will be placed on academic or clinical probation for the remainder of the semester. Mid-term grade reports will reflect a probationary status, and the student will be required to sign the report in acknowledgement of the status. The probationary status will be retracted upon successful academic and/or clinical completion of the semester. Students who fail to achieve established academic or clinical standards at the end of the semester, will be dismissed from the program. 58

59 Education Coordinator Date West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 12/1998 Revised: 1/2007 Non-Discrimination Policy West Virginia University Hospitals, in its sponsorship of the education programs in Radiologic Technology and Nutrition & Dietetics, endeavors to create an educational environment that emphasizes human values and relationships and encourages individual development, attainment of personal & educational goals and selffulfillment. Such an environment will be characterized by open communications, equal opportunities, self-direction, and sensitivity to the student s needs. All interactions and decisions pertaining to students and student candidates will be conducted in such a manner as to not discriminate against individuals on the basis of race, religion, color, national origin, ancestry, age, sex, disability or veteran status. The provisions herein contained are governed by the following: a. Title VI of the Civil Rights Act of 1964 b. Title IX of the Education Amendments of 1972 c. Section 504 of the Rehabilitation Act of 1973 d. The Age Discrimination Act of 1975 Appeals Students or student candidates may refer to Policy (Due Process) for the proper procedures governing the reporting of decisions or actions rendered in which the student alleges capricious or arbitrary circumstances and/or noncompliance with the aforementioned provisions. Education Coordinator Date 59

60 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 7/1984 Revised: 3/2004 Student Health Policy Students enrolled in the WVUH shall have access to WVUH Employee Health services in the event of an education-related illness or injury. In the event that medical attention is required during the second shift (afternoon), students shall report to the Emergency Department for care. This policy governs education related illness or injuries. It is not designed to provide medical coverage for students beyond the educational environment. Students are encouraged to have their own medical insurance. Students will be insured by a designated group accident insurance policy, which will provide coverage during education-related activities. The cost of this insurance will be included in the tuition fee. Services WVUH Employee Health Services available to all students will include: a. PPD (tuberculin test) with follow-up for all new students. b. Health assessments (including pertinent medical history) will be evaluated on all new students. c. Appropriate immunizations to include Hepatitis B vaccine & Varivax. d. Appropriate titers (antibody/antiserum) to verify immunity to chicken-pox for the student who relates a negative history. e. Facilitates medical care of students who become ill or are injured while in school, or who have been exposed to communicable diseases (including TB exposure or follow-up). f. Health counseling and referral of students (not Employee Assistance Program). g. Investigates post exposure follow-up, testing and treatment on all exposure incidents. h. Provides education to all new students during orientation on: hepatitis, blood-borne pathogens, reporting incidents, infection control practices, (i.e., universal precautions, handling infectious medical waste, what illnesses must be reported to Employee Health and a general review on Employee Health Policies. i. Maintenance of all students medical records/information Students may be required to obtain additional vaccinations ( Tetanus / MMR) at their own expense after evaluation by Employee Health. Procedure The following procedure shall be followed in the event that a student sustains an education related injury or illness which requires medical attention: 1. The injured/ill student, with the assistance of their assigned staff clinical instructor or program official, shall complete a WVUH employee incident report form. The incident report is to be submitted to the Education Manager for signature. 2. The completed form shall accompany the student to Employee Health and/or the Emergency Department. 3. The incident report form must be completed regardless of whether medical attention is needed or desired. 4. Employee Health / Emergency Department will evaluate the student s condition, and will provide the necessary treatment and recommended follow-up procedures, if necessary. 60

61 University Health Services Although not students of West Virginia University, WVUH students do have access to the University Health Services located on the Ground floor of the Health Sciences Center for treatment of personal medical conditions. Students can contact one of the program officials for information on these services. 61

62 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 12/1992 Revised: 1/2000 Pregnancy Policy Policy: It is the policy of the West Virginia University Hospitals Radiologic Technology Education Program in Nuclear Medicine to provide reasonable radiation protection to student radiographers occupationally exposed to radiation. Pregnant students are expected to follow the additional protective measures detailed below which have been developed to restrict the fetal radiation dose below the maximum permissible dose (MPD) as recommended by the National Council on Radiation Protection (NCRP) and the Nuclear Regulatory Commission (NRC). Furthermore, it is the policy of this Program to grant a leave of absence, upon verification of pregnancy, to students who do not wish to take the biological risks to the fetus associated with prenatal radiation exposure. 1. Upon initial enrollment to the Program, all female radiography students will receive an orientation / in-service in regard to prenatal radiation exposure as currently recommended by the National Council on Radiation Protection (NCRP) and the Nuclear Regulatory Commission (NRC). This orientation / in-service will be given by a Radiation Safety Officer during student orientation week. 2. Upon medical verification of her pregnant condition, disclosure of the said condition to program officials is the student s responsibility and is to be initiated voluntarily. Students have the right to refuse disclosure of medical information; however, in the event that a student chooses not to disclose information regarding pregnancy, the student is acknowledging that they are assuming all responsibly for their condition and the potential complications that may arise. 3. If the student chooses to voluntarily disclose information regarding her pregnancy, the Education Coordinator will contact the Radiation Safety Officer to arrange for the student to review her previous radiation exposure history and to review protective actions as well as the risks associated with radiation exposure to the fetus. The student shall be issued an additional dosimeter which is to be worn at the level of the pelvis to monitor fetal dose. The student also shall read appendix to NRC (instruction concerning prenatal radiation exposure). The student shall contact the Radiation Safety Officer within five (5) days of notifying the Education Coordinator of her pregnancy. 4. Upon medical verification that a pregnancy exists, students have the following (3) three options: Option #1 Choose Not to Disclose Information Regarding Pregnant Condition By choosing this option, the student implies acknowledgment that she has chosen to disregard the recommendations made by the Radiation Safety Office and the Program and that she is assuming responsibility for all potential risks and related complications. No policy or performance exceptions will be allowed should the student choose this option. Option # 2 Request a Leave of Absence during pregnancy. If the student so decides, she may elect to leave the Program during the pregnancy period. a. If the student decides to accept this option to leave the Program, she must notify the Education Coordinator and the Radiation Safety Officer immediately. 62

63 b. The terms and conditions of the leave of absence are specified in the Medical Leave of Absence policy. Option # 3 - Remain in Program throughout pregnancy. If the student so decides, she may continue in the Program under the following conditions: a. The student shall wear additional exposure monitoring devices as determined by the Radiation Safety Officer's recommendation. b. The student shall wear a wrap-around lead apron during clinical procedures. Lead aprons of 0. 5 mm lead equivalent are considered sufficient to attenuate 88% of the beam at 75 kvp. Above 75 kvp, aprons with 1.0 mm of lead equivalent are recommended. c. The student shall participate in all scheduled clinical rotation areas as assigned. d. The student shall not participate in Iodine 131 / 125 procedures and nuclear generator activities during the Nuclear Medicine clinical rotation (Level III). e. The student shall not participate in source implant procedures during the Radiation Therapy clinical rotation (Level III). f. Absences due to pregnancy are governed by the Attendance and Medical Leave of Absence policy 5. The Education Coordinator shall document the student's decision in regards to Options #2 & #3. 6. For Option #3, the student shall complete and sign the attached form acknowledging receipt of information and associated documentation in regard to the pregnancy. All documentation shall be entered into the student's permanent personal file. Education Coordinator Date 63

64 Pregnancy / Radiation Safety Protection Verification Form I verify by my signature below that : 1. I have notified both the Education Coordinator and the Radiation Safety Officer of my pregnancy. 2. I have been advised by the Radiation Safety Officer in regard to protective actions as well as the risks associated with radiation exposure to the fetus. I have also read the appendix to NRC I have received an additional film badge which I am wearing at the level of the pelvis to monitor radiation dose to the fetus. a. It has been explained to me that by wearing a 0.5 mm lead equivalent protective apron, the dosage to the abdomen/pelvis can be reduced by more than 88% at 75 kvp. It also has been explained to me that a lead apron with 1.0 mm of lead equivalent should be worn when the beam is above 75 kvp. 5. I have had the opportunity to discuss questions concerning radiation safety during my pregnancy with the Radiation Safety Officer. Furthermore, I understand that should additional questions arise, I may again consult with the Radiation Safety Officer. I understand the potential risks involved to myself and my fetus during my pregnancy in. I elect to remain in the Program and adhere to the requirements as stated in Option # 3 of the attached Pregnancy Policy. I do understand the risks involved to myself and the fetus during my pregnancy in regard to pregnancy related radiation safety. I elect not to remain in the Program and that a leave of absence from the Program has been granted to me. I have read, understand, and agree to the conditions specified in the Medical Leave of Absence policy. Student Date Education Coordinator Date 64

65 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 3/1999 Revised: 3/2008 Radiation Safety & Exposure Monitoring Policy Policy: West Virginia University Hospitals, in accordance with the rules and regulations established by the National Council on Radiation Protection and Measurements (NCRP) and in Part 20 the Nuclear Regulatory Commission (NRC), has implemented policies and procedures to assure that health care professional can work safely with or near sources of ionizing radiation. Education Program officials identify that appropriate education is critical to providing the level of understanding necessary for students to practice radiation safety and protection for themselves and their patients. Radiation safety and protection is comprehensively covered through the following mechanisms: 1. Orientation: a. Introductory Radiation Safety In-service conducted by Radiation Safety Officer or other Radiation Safety Department Personnel. b. Related policy review by Program Director. c. Discussion of the radiation safety & protection procedures employed in the clinical environment by Clinical Coordinators. 2. Didactic & Clinical Curriculum a. Program adopts the Society of Nuclear Medicine Technologist Section curriculum, which incorporates radiation safety and protection practices and procedures via various course objectives. b. Formal Radiation Physics Course (Radiation Safety / Radiobiology) conducted in Semester I. c. Annual Radiation Safety in-service (institutional requirement). d. Program clinical experience and evaluation process. The Nuclear Medicine Technology Program conforms to these rules by issuing an OSL Dosimeter film radiation monitor (chest) and TLD ring badge per student, which will be sent to the manufacturer (RS Landauer) to be evaluated for radiation exposure. A report is then sent to each department and is posted in the hot lab area. The student is required to initial the report upon completion of review. Any student receiving an exposure in excess of any applicable limit as set forth in the regulations or in the license, will be investigated as to why the exposure occurred and after the investigation, will be counseled as to the procedure to follow to be more cautious. At the beginning and end of each workday, a room survey is taken to ensure that no spills have occurred. If so, decontamination process will be executed. Guidelines for Dosimeter usage: 1. The OSL dosimeter film radiation monitor (chest) and the TLD (ring badge) should be worn whenever you are in the vicinity of ionizing radiation. If you lose your badge(s) or if it is temporarily not available, you should get a temporary replacement from the Radiation Safety Office. Do not lend your badge(s) to another student. 2. Badges must not be left in the vicinity of sources of radiation when the wearer is not present. The most common reason for exceptionally high dosimeter readings at this institution has been accidental exposure of badges left on lab coats or lead aprons. Do not wear it when you are having medical or dental x-rays of yourself. 65

66 3. Badges should not be subjected to extremes of heat or cold. Do not launder. Do not attempt to open or break the seal around the dosimeter. Please refrain from writing or placing other information on the badge. It is important that we be able to read both your name and all numbers typed on the badge. 4. The OSL dosimeter is exchanged once every 3 months and the TLD ring badge every month. For additional information or questions, please contact Radiation Safety Office, Health Sciences Center North, Room G-139. Phone # or Copies of all NRC licenses held by West Virginia University Hospitals are available in the Radiation Safety Office. Education Coordinator Date 66

67 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 1/1990 Revised: 2/2000 Student Counseling / Advisement Policy West Virginia University Hospitals encourages open communication between students, faculty, and staff. Students are encouraged to seek advisement from faculty and staff when questions or concerns regarding academic, clinical, and/or personal issues arise. The following outlines the required and optional counseling formats that are open to students. Grade Counseling Students will be counseled quarterly with respect to their academic, clinical, and professional performance in the program. Students will be presented with a didactic and clinical grade calculation form, which quantifies their current performance in the program. Academic counseling will be conducted by the Program Director while the Clinical Education Coordinator will conduct clinical counseling. During these sessions, students will be given the opportunity to discuss any academic, clinical, or personal issues they deem important at that time. Students are required to sign their grade calculation form to provide evidence that they have been made aware of their academic progress and to document the counseling session. Performance Counseling When problems or concerns are identified relating to any form of student performance (academic, clinical, professional, or personal), program officials will proactively counsel students in an attempt to gain awareness of the issue and provide corrective measures to facilitate improvement. Counseling will be initiated by the program official and will generally be documented in some form if deemed necessary. Disciplinary Counseling Disciplinary counseling will be conducted when students fail to meet established program requirements or fail to abide by the policies of the program or institution. See Disciplinary Action policy. Open Counseling At any time, students are encouraged to seek advice on any issues or concerns relating to their educational, professional, or personal well-being. Program officials will attempt to provide assistance or will recommend other sources of assistance if deemed necessary. Students are encouraged to seek advice relating to employment, financial aid / sources, educational opportunities, and professional/personal concerns or interests. Education Coordinator Date 67

68 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 12/1992 Revised: 2/2010 Medical Leave of Absence This policy is applicable to students that have incurred an illness, injury, or disability that would temporarily prevent them from performing the essential functions of the clinical and/or didactic education component. In the event of such, all reasonable efforts will be made to meet the students limitations or restrictions. However if the student is unable to participate in clinical / didactic education for a period extending beyond twenty days, a medical leave of absence can be granted providing certain criteria are met. Conditions for Granting a Medical Leave of Absence: 1. Student must provide written documentation from a physician that they are temporarily unable to actively participate in the clinical education component of the program; this does not apply to time missed due to illnesses or incapacitation related to "elective" procedures or surgeries. 2. The student must be making satisfactory academic, clinical, and professional progress at the time of the request. 3. The student must be enrolled beyond the probationary period. If the event occurs prior to completion of the probationary period, the student must reapply for admission consideration. 4. The leave of absence will be granted until the start of the next corresponding semester in which the leave of absence was granted. 5. The student must re-enter the program at the start of the next corresponding semester in which the leave of absence was granted. 6. To assure compliance with regards to the accrediting body imposed student capacity restrictions, program officials will either reserve a position for the student in the next enrollment, or pursue a student capacity waiver from the accrediting body. 7. Should the student be unable to re-enroll after the leave of absence, readmission must be obtained through reapplication and reevaluation. 8. Credit for didactic work will not be given for the semester in which the medical leave of absence is granted. Credit for clinical work will be given on a case by case basis. 9. The student must notify program officials as soon as possible should they decide not to return after their leave of absence so that another applicant can fill the reserved position. This policy is enacted for the purpose of: 5. Assuring that all students meet the required clinical education objectives so that student competency achievement and registry exam eligibility can be documented. 6. Assuring that the student s didactic education is closely coordinated with the clinical component thereby providing the student with the highest quality educational experience and learning environment. 7. Affording students who have made satisfactory academic, clinical and professional progress in the program an option for completing their education after a medical leave of absence. Education Coordinator Date 68

69 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 5/1990 Revised: Communicable / Contagious Disease Notification West Virginia University Hospitals Radiologic Technology Education program officials will notify any student or graduate (all programs) of their subsequent exposure to a communicable / contagious disease during their enrollment period as a student. Program officials will be notified by the West Virginia University Hospitals Employee Health Coordinator in regards to incidents of possible exposure of students. Current students or graduates shall notify program officials if they believe that they may have been exposed to a communicable / contagious disease. Procedure: 1. Current Students- (Radiography, Nuclear Medicine, Radiation Therapy, Diagnostic Medical Sonography) a. Upon notification by the WVUH Employee Health Coordinator, program officials will notify students in the form of a written memorandum. b. Students will follow recommended guidelines for treatment provided by the WVUH Employee Health Coordinator. c. Students shall notify program officials if they believe they may have been exposed to a communicable / contagious disease. 2. Graduates (all programs) a. Upon notification by the WVUH Employee Health Coordinator, program officials will notify graduates by mail and/or telephone. b. In the event that program officials are unable to contact graduates by the aforementioned methods, attempts will be made to contact that individual by contacting spouses, parents and/or relatives or by any information that might be contained in the graduate students permanent file. c. Upon notification, graduates will be referred to WVUH Employee Health for treatment and more information. d. Graduates shall notify program officials if they believe they may have been exposed to a communicable / contagious disease. Education Coordinator Date 69

70 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 7/1986 Revised: 1/1996 Student Outside Employment Policy Student radiographers are not employed to fill job descriptions of Radiologic Technologists. Employment of students for this purpose is in violation of Chapter 30, Article 23, of the West Virginia Code of 1931 as amended, which is commonly referred to as the West Virginia State Licensure Law for Radiologic Technologists. West Virginia University Hospitals does not pay stipends to student radiographers or make any other monetary adjustments to student radiographers for assignments completed in their role as a student radiographer. Students are permitted, but not encouraged, to hold part-time jobs during their radiography education. The Institution and Radiology Department will consider student radiographers for part-time employment to function in the following capacities: 1. Technical Assistant (Radiology) 2. Radiology file room clerk 3. Scheduling and Appointment clerk The Radiologic Technology Education Program requires that part-time employment schedules must not conflict with the student radiographer's daily assignment schedules and that the student radiographer does not function in the aforementioned capacities during clinical education assignment hours. As a result of the continuous monitoring of student progress by Program Officials, should it be documented that the student's performance is below the required academic standards, the Program Director will strongly recommend that the student resign the part-time position immediately. Education Coordinator Date 70

71 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 4/1999 Revised: 6/2008 Transfer / Advanced Placement / Part-Time Student Policy This policy serves to identify the Program s philosophy relative to transfer of credit, advance placement of students and part-time student attendance. With respect to the following considerations: 1. The Nuclear Medicine program length of 12 months; 2. The specificity of the course content; 3. The precise correlation between the didactic curriculum and clinical education; 4. The sequential and progressive nature of the curriculum format; 5. The competitive nature of the enrollment process; and 6. The operational hours of the clinical facility. The Nuclear Medicine program at West Virginia University Hospitals does not make provisions for transfer credit, advance placement status, or part-time enrollment. Education Coordinator Date 71

72 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 4/1999 Revised: Access or Release of Student Records Policy Policy: The Guide to the Organization and Accreditation of Nuclear Medicine Programs as published by the Joint Review Committee on Education in Radiologic Technology requires that records be maintained for all didactic and related coursed attempted and/or completed by all students. The student s permanent record file shall contain the following: 1. Transcripts and associated records 2. Physical examination reports 3. Counseling records 4. Transcripts of didactic, laboratory and clinical achievement 5. Records of attendance, clinical rotation and grades for all courses 6. Documented evidence of student clinical competency Our program is re-evaluated and re-accredited every five years. A site-visit team assigned by the Joint Review Committee will re-evaluate the program at the end of the five year accreditation period. The site visit team will request access to student records to assure that each student s records have been properly maintained. Due to the Family Education Rights and Privacy Act of 1974 also known as the Buckley Amendment it is necessary that we obtain prior authorization from the student to allow access to the student s personal records. Your signature on the attached Authorization for Access or Release to Student Record Information will provide our program with the aforementioned authorization. The following provisions will be followed to assure the students privacy: 1. A record of disclosure will be maintained and kept with the educational records of the student whose personally identifiable information was released. 2. This record must identify the parties who obtained the information and the the reasons why these parties needed the information. 3. In addition, the party to whom the information was disclosed must not disclose the information to any other party without prior written consent of the student or his or her parents. The information taken from the records may be used by the organization only for the purpose for which the disclosure was made. 4. If the organization does release personally identifiable information for other purposes, it must also maintain a complete record of disclosures. Education Coordinator Date 72

73 Authorization For Release Or Access To Student Records Form I authorize West Virginia University Hospitals, Inc. School of Nuclear Medicine Technology to release or allow access to personal student records in accordance with the aforementioned policy and the provisions stated therein.. STUDENT SIGNATURE: DATE: 73

74 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 7/2000 Revised: 12/2005 Programmatic Suspension / Closure Policy It is the intent of West Virginia University Hospitals (WVUH) to maintain operation of the Radiologic Technology Education Programs consistent with the Institution s mission and goals. However, in the event that extenuating circumstances, beyond the control of WVUH, significantly impact the operation of a program causing the clinical and/or didactic education components of that particular program to fall below the requirements of the accrediting body, the program would cease to operate at that point. Extenuating circumstances would include but not be limited to: 1. Insufficient number of clinical staff due to a technologist strike or staffing shortage. 2. Inability to retain or employ professionally and/or academically qualified faculty. 3. Insufficient number of clinical exams necessary to provide adequate educational experience. 4. Temporary closure of the facility or the Radiology Department. 5. Implementation of administrative changes that significantly impact programmatic operations. Unless otherwise dictated, the program would recommence operation when the causative issue(s) have been rectified and program officials can determine that minimum accreditation standards are being met. West Virginia University Hospitals will assume no liability for any financial or personal loss incurred by the student due to circumstances of the aforementioned nature. Education Coordinator Date 74

75 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 3/1985 Revised: 3/1990 Policy: Graduation Requirements Policy To be eligible for graduation and receive a Program certificate, the student must satisfy the following requirements: 1. Demonstrate professional demeanor with the ability to communicate effectively with patients and personnel according to professional and ethical principles. 2. Satisfactorily complete all clinical competency requirements in accordance with published clinical education policy and clinical level requisites. 3. Satisfactorily complete rotations through Radiation Safety, PET/CT, Radiologist Reading Room, and Radiopharmacy. 4. Satisfactorily complete each semester with an overall didactic weighted percent average of 80% and successfully pass each didactic course with a minimum of 78%. The student must also have completed the required number of clock hours in each of these areas. 5. Meet all financial obligations to the Program and the Institution. Education Coordinator Date 75

76 West Virginia University Hospitals Policy No: Nuclear Medicine Technology Education Program Effective: 12/1992 Revised: 2/2010 Inclement Weather The Education Manager, in consultation with the Program Directors of the Radiologic Technology Education Programs, may designate a particular day(s) as a Weather Emergency in response to extreme weather conditions. This decision will be communicated via the phone mail system or through the individual Program Directors. Under a designated Weather Emergency, each student who arrives to school will be granted Compensatory time for the amount of time spent performing procedures and assisting in patient care at the hospital. Those students who are unable to attend school will be excused for that day(s) and not be required to utilize Personal leave. The Education Manager, in consultation with the Program Directors, will determine eligibility for the compensatory time and the Program Directors will be responsible for authorizing such compensatory time to the students of their respective programs. The compensatory time given to students will not be given a usage deadline as in the case of standard compensatory time. With the exception of the usage deadline, utilization of compensatory time will be subject to the procedures outlined in the compensatory time policy. Education Coordinator Date 76

77 WEST VIRGINIA UNIVERSITY HOSPITALS Nursing Service Policy Manual Policy V.01 1st Effective 7/1985 Revised 1/87, 7/88, 10/88, 6/90, 1/94, 10/99, 03/03, 05/04, 06/04, 07/04, 09/05, 08/06, 10/08, 10/09 PERIPHERAL INTRAVENOUS THERAPY INSERTION AND GUIDELINES I. POLICY: Venipuncture for the purpose of intravenous access, continuous or intermittent intravenous infusion of fluid, or infusion of medications may be performed by the RN and LPN after supervised instruction and competency evaluation in venipuncture for peripheral IV therapy. The RN and LPN may initiate intravenous therapy after a physician s order has been obtained, or as necessitated in an emergency situation. (After two unsuccessful attempts at insertion of an IV, the RN and LPN should consult with another competent professional to initiate therapy). The preferred method of access is a needleless system. II. PROCEDURE: A. Initiation of Peripheral IV Therapy 1. Initiation of peripheral IV Therapy shall be to provide intravascular access for definite therapeutic or diagnostic indications. 2. IV access may only be initiated with a physicians order or as necessitated in an emergency situation. B. Choice of Cannula for Peripheral Infusion 1. The cannula shall be of the smallest gauge that will accommodate the prescribed therapy. This will allow for sufficient blood flow around the cannula. 2. Only one device shall be utilized for each attempt. 3. Stylets shall never be reinserted into the cannula when attempting IV access. 4. A nurse should not make more than two (2) attempts to initiate IV access before contacting another competent professional. C. Hand Washing 1. Hospital personnel shall wash their hands before inserting an IV cannula. 2. Soap and water is adequate for hand washing. 3. Clean gloves shall be worn for insertion. D. Site Selection 1. In vein selection, the patient s condition, vein condition, vein size and location, patient age, and the type and duration of therapy shall be assessed to insure ideal and safe IV access. 2. Veins most appropriate for IV therapy are metacarpal, cephalic, basilic, and the median veins. 3. Start peripheral IV therapy in distal areas of the upper extremities. 77

78 4. Avoid lower extremities (legs/feet) unless specifically ordered by the physician or necessitated by the patient s condition (shall be avoided in diabetic patients). 5. Avoid previously used veins and injured or sclerotic veins. 6. Avoid antecubital fossa since this is the preferred site for venipuncture for blood draws and PICC access. 7. Avoid veins in the affected arm of an axillary dissection. There must be a physicians order to use the affected arm. 8. Avoid veins in the arm of a dialysis AV Fistula. 9. If deemed necessary by the physician, he/she may utilize jugular sites for peripheral access. E. Site Preparation 1. Wash skin with soap and water if necessary. 2. When excessive hair exists, hair should be removed (clipping is recommended). 3. Chlorhexidine should be used as antiseptic solution used to scrub site using a back and forth motion, creating friction. Allow to air dry. F. Cannula Placement 1. Prior to use, the nurse shall confirm the integrity of the product (products found defective should be discarded or returned to the manufacturer). 2. A leur lock extension set shall be placed on the catheter hub before securing cannula with high MVP dressing, such as Op-site. 3. The nurse shall ascertain patency and placement of cannula after insertion. 4. There shall be no tape under the high MVP dressing (securing with steri-strips under the Opsite 3000 is acceptable, provided site of insertion is not covered) 5. Tape should be used for further stabilization over the dressing, or around the cannula hub provided the site of insertion is not covered. 6. The personnel placing the cannula should record the date and time of insertion, gauge used, and his/her initials on the dressing. 7. The personnel placing the cannula should document on the bedside chart the number of attempts, cannula size, placement site, and date of insertion. G. Maintenance of IV Site 1. Dressing shall be changed if it becomes damp, visibly soiled, or loosened. 2. Dressing changes should coincide with site change every 96 hours. 3. A high MVP dressing, such as Op-site, is the preferred dressing however, if the skin is moist/diaphoretic, use a tape and gauze dressing. A tape and gauze dressing must be changed every 48 hours. 4. Chlorhexidine shall be used to cleanse site during dressing change. 5. On those patients sensitive to Chlorhexidine, alcohol may be used. 6. Site shall be evaluated at a minimum of every eight (8) hours for evidence of site complications. 7. Site shall be flushed with normal saline after medication administration and/or at a minimum of every eight hours, if IV fluids are not running. 78

79 H. IV Cannula Removal 1. Peripheral IV cannulas should be routinely changed every 96 hours. 2. If another access is not available after attempts per a STAT RN or the Flight Team, a patent peripheral IV cannula without signs/symptoms of phlebitis or infection may dwell longer than 96 hours with a written physicians order. 3. Cannulas inserted in an emergency situation without proper asepsis shall be changed to a new site at earliest opportunity within 24 hours. 4. Cannulas shall be removed if there is pain or tenderness at the insertion site. 5. Cannulas from an outside facility should be replaced on admission, as soon as patient is stable, within 24 hours. 6. Cannulas shall be removed when no longer needed for definite therapeutic diagnostic indications. I. Maintenance of Administration Sets 1. Any tubing contaminated or suspected of being contaminated should be changed immediately. 2. Primary and Secondary continuous IV administration tubing, including extension tubing, should be changed routinely every 96 hours and with each site change. 3. Tubing used for the administration of blood or blood products should be changed after each unit or every four hours, whichever comes sooner. 4. Intermittent or piggyback tubing should be discarded every 24 hours. 5. All tubing should be dated, timed, and initialed; those without dates should be considered outdated and new tubing should be hung. 6. All entries into the tubing, such as administration of medications, should be made through injection ports that are disinfected with alcohol just before entry. 7. Tubing junctions should be leur-lock connections (leur lock or alligator clamps) and used with injection ports. These shall be changed with the administration of each medication. III. SKILL LEVEL: RN and LPN IV. REFERENCE: Infusion Nurses Society Policies & Procedures for Infusion Nursing, 2nd Ed., 2002 Reference text: Best Practices: A Guide to Excellence in Nursing Care, Lippincott Williams & Wilkins, 2003, pp Reference Nursing Service Standards Manual Standard of Practice Infection Prevention: IV Access, Standard IX

80 The Standard: Personal Attention It is the expectation that all communications at the enterprise of University Health Associates, West Virginia University Hospitals and the Health Sciences Center will occur in a professional, caring and courteous manner. Our commitment is to establish standards of communication that will create an environment of caring and compassion for all whom we serve in the highly technological and complex health care arena. 1. Direct Communication a. Direct verbal communication is defined as an interaction between participants that includes verbal and nonverbal exchange with a conscious acknowledgement of the individual through culturally sensitive and appropriate touch and body posturing and respect of individual space. b. The interaction would begin with a greeting, followed by identification of self, a request to help, listening to the request in its entirety without interruption, and a commitment to bring the request to a satisfactory resolution. c. The expectation is that the interaction will be pleasant, courteous, and professional. It is to provide clear, factual and timely information. 2. Indirect Verbal Communication a. An indirect verbal communication is defined as a verbal interaction between individuals using any source of telecommunications. b. The telephone will be answered within 5 rings. c. The interaction would begin with a greeting, followed by identification of self, a request to help, listening to the request in its entirety without interruption, and a commitment to bring the request to a satisfactory resolution. d. The expectation is that the interaction will be pleasant, courteous, and professional. It is to provide clear, factual and timely information. e. When there is a need to place a caller on hold the expectation is that the caller will be asked if they can hold and be provided with the opportunity to respond to the request to hold. No caller is to be automatically placed on hold. f. When there is a need to transfer or forward a call it is expected that the caller will be provided with the number that they are being transferred to as well as the number that they have called or been transferred from in order to assist them. g. It is expected that blind transfers will not occur. Transfers will include the request needed by the individual being transferred so that the individual being transferred does not have to repeat the request and the individual receiving the transfer can greet the individual by name and review of request. 80

81 TheStandard: Behavior ATTITUDE + RESPECT + ACTION = STAR Adopt a Positive Attitude Every Day Do one extra thing each day for someone a patient, a student, a co-worker Choose to be here Avoid the three C s: Don t criticize, condemn or complain Show Respect for Everyone Consider how your actions affect others Demonstrate respect through personal example Expect cooperation and give it Ask for help politely Acknowledge any inconveniences you cause Take Action to Make This a Better Place Smile and mean it Make eye contact and greet people warmly Be enthusiastic Specific Behaviors That Mean a Lot Please and Thank You Always express your appreciation When someone thanks you, acknowledge it my pleasure Always use a pleasant tone of voice Show That You Care Offer to give directions and take lost people to their destination Follow dress code and wear your ID badge with photo/name visible Acknowledge others regardless of position or rank Personal Attention Address people by Mr., Mrs., or Ms. with last name unless asked to use first name Answer phones pleasantly and give accurate information Avoid personal phone calls and conversations in public places Everyone s Time Matters Deal with delays promptly Anticipate customer needs don t wait to be asked Talk with people who have been waiting 20 minutes or longer Elevator Etiquette Wait for others to exit don t rush door Hold door for other passengers Use staff elevators Face customers while riding - back out when moving patients Environment Take pride in our facility Own your area keep it clean If you see trash anywhere, pick it up 81

82 The Standard: Communication of Delays Our patients, families and other customers expect and deserve prompt service. We recognize that their time is very valuable and strive to deliver our services at the times they are scheduled. Our commitment is to avoid delays whenever possible without compromising the quality of care. Throughout the clinical enterprise, including University Health Associates, West Virginia University Hospitals and the Health Sciences Center, we work in a highly complex and technical environment. At times, delays are inevitable. When a delay is experienced, it is imperative to communicate directly with our patients, families and other customers who will be inconvenienced. The success of our enterprise requires that each employee, as a matter of routine, attend to the needs of our patients, families and other customers first. We will establish standards of communication regarding delays that empower patients and families to be a part of the decision making process and to enable them to regain control over this area of their life. It is the expectation that patients, families and other customers whose services are delayed will receive a personal communication from an employee or volunteer within 20 minutes. This communication will include the nature of the delay and an honest estimate of how long it will take until the service can be provided, or the patient can expect a resolution or return call. When the estimated time has elapsed, a follow up communication will be provided promptly, and, if possible, the patient will be offered choices and options for further service or service recovery. Using the standard of personal attention, all communications will occur in a professional, caring and courteous manner. Timeliness - occurring at a suitable/appropriate moment Delay - to postpone, defer or cause to be late Expected - to consider reasonable or due Unexpected -coming without warning or unforeseen Types of Delays Many types of delays can be experienced throughout the enterprise. Delays can involve patients and families. Examples of delays would be waiting for the call light to be answered, waiting for a provider in the clinic, waiting for a consult in the ED, waiting for a bed on the floor or to be discharged to home, waiting for a test in radiology or waiting for a surgery or specialty visit to be scheduled. Delays can also involve other customers and co-workers across departments. Examples of these delays would be waiting for security to arrive and be available to help during a tense time, waiting to have a repaired piece of equipment returned, waiting for medication to arrive to the unit, waiting to find out if a candidate for hire has good references and will be offered a position, waiting for an IT issue to be resolved. Delays can occur throughout the enterprise and involve direct or indirect patient care. All departments must work together to ensure the best patient or customer outcome. Communication is imperative in all situations dealing with delays that involve our patients, families or customers. 82

83 For this standard, we have defined 2 major types of delays personal delays and communication of delays. Personal Delays: These involve a delay that requires an immediate response as a patient, family member or customer is present and asking for resolution. Begin by recognizing the person with eye contact and using his or her name, acknowledge the delay to the individual o Recognize and use the customer is always important standard o Remember to always treat others as you wish to be treated o Staff will need skills in dealing with patients and families that are fearful and angry o Staff will have an awareness of the patient/families and other customer s perspective and concerns Critical communication between appropriate personnel and departments to determine the nature of the delay o Communication skills and knowledge of processes for front line staff is essential The explanation of the delay is to be truthful and non-blaming o o Ownership of the communication of the delay needs to be established Prohibit avoidance behavior (such as not making eye contact and pretending the person is not present) Offer choices, options and time frame for resolution o For example, would you like to go to lunch, would you wish to reschedule your appointment o Service recovery would be initiated at this time Listen with empathy and compassion Apologize for the delay and thank them for being understanding Communication Delays: These involve a telephone call from a patient, family member or other customer when a delay in care or response is experienced. Our goal is to avoid delays but when they occur our expectation is that the person responsible or their designee will provide a return call using the timeframes established below. If a resolution of the issue cannot be obtained then a prompt communication is essential. All departments will establish standards for prioritizing patient or customer requests using the following 4 categories: o Now - within 30 minutes o Immediate - within 4 hours o Urgent - within 24 hours o Routine within 72 hours Begin by acknowledging the person by using his or her name, and verification of the caller s need and his or her perceived delay o Recognize and use the customer is always important standard o Remember to always treat others as you wish to be treated o Staff will need skills in dealing with any individual that is anxious and angry o Staff will have an awareness of the patient/families or other customer s perspective and concerns Critical communication between appropriate personnel and departments to determine the nature of the delay o Communication skills and knowledge of processes for front line staff is essential The explanation of the delay is to be truthful and non-blaming o Ownership of the communication of the delay needs to be established Listen with empathy and compassion Apologize for the delay and thank them for being understanding o Based on departmental prioritization guidelines, establish a time frame for the return call if the patient, family or customer need is not addressed immediately 83

84 Service Recovery: In order to provide a caring, competent service, we need to recognize that some delays will be inevitable. How we care for our patients, families and other customers encountering delays is crucial to a good outcome. Our patients, families or customers are most concerned with an honest explanation of the delay, how long the delay will take and to be offered options. Accommodations should be comfortable with attention to personal care and needs in compliance with the current plan of care and specific department service recovery initiative o Cafeteria and/or coffee passes, etc. would be an example o Assess whether personal needs have been attended to, for example, do they need a pillow, blanket, bottle warmed, etc. 84

85 WEST VIRGINIA UNIVERSITY HOSPITALS POLICY AND PROCEDURE MANUAL Policy V.022 1st Effective Revised ; ; Reviewed PERFORMANCE EXPECTATIONS AND SERIOUS VIOLATIONS OF BEHAVIORAL STANDARDS POLICY West Virginia University Hospitals (WVUH) is committed to fostering an environment that promotes responsibility, teamwork, cooperation, professional behavior, and customer service. This is a shared responsibility where all employees and supervisors play an active role. Employees are responsible for observing WVUH s organizational Performance Expectations, and the specific performance expectations set forth in the employee s job description, and for seeking assistance with understanding and interpreting the meaning of these expectations, and when necessary, correcting and reporting behavior that violates Performance Expectations. Behavior/conduct which deviates from the STAR standards and WVUH Performance expectations and which interferes with respectful, caring relationships Can foster medical errors, contribute to poor patient satisfaction, to preventable adverse outcomes, increase cost of care, and cause staff to seek new positions outside of the hospital. Therefore, disruptive behavior will not be tolerated in our organization, and a corrective action approach will be followed regarding disruptive behavior. This is so, whether or not the particular policy, procedure, or standard specifically states that a violation will or may result in corrective action. WVUH may exercise the discretion to skip any and all steps of the corrective action process. In certain circumstances, some steps may be repeated. Factors that may affect corrective action include, but are not limited to, the nature and severity of the offense, whether patient care is compromised, whether the offense is a violation of the law or subjects the hospital to liability, whether the conduct was intentional or negligent, the number of prior infractions of a similar or dissimilar nature, the lapse of time between infractions, the existence of mitigating circumstances, the employee s ability and willingness to modify his or her behavior or improve his or her performance, and the employee s status with WVUH. The corrective action process may be significantly abbreviated where temporary or provisional employees are concerned. When an employee has performance issues that he or she is unable or unwilling to improve, corrective action/discipline or other appropriate action may be taken including, but not limited to, modification of the assignment, demotion, transfer, or termination. Nothing in this policy is intended to alter the at-will employment status of any employee. NOTE: Reporting, in this hospital, should be done without fear of retribution. Retribution or retaliation will not be tolerated. If it appears that reaction/ action has occurred, please contact your manager. 85

86 Supervisory personnel are responsible for communicating Performance Expectations and assuring awareness of this Policy and other related policies dealing with behavior and disciplinary action. Supervisory personnel are also responsible for investigating suspected, observed or reported violations of Performance Expectations, and taking appropriate action when necessary. PERFORMANCE EXPECTATIONS WVUH has adopted and implemented Performance Expectations and a Culture of Excellence program which help shape the shared values and cultural identity of our organization. These Performance Expectations include the following values and sample behavioral standards: PEOPLE Communication Demonstrates effective communication (open, honest and direct) skills. Listens effectively to demonstrate understanding of the ideas and opinions of others. Provides and receives constructive feedback to peers and supervisors. Shows a sincere interest in others and their concerns; initiates and develops relationships with others (peers and physicians). Teamwork - Demonstrated ability to function as an effective team member. Cooperates with others to achieve department goals. Shares ideas and contributes time to help others (internal & external) of department. Contributes to organizational and department goals. Attends and participates in departmental staff meetings. SERVICE Customer Service - Treats patients, families and others with dignity and respect. Appropriately meets all customer expectations 100% of the time. Facilitates ways to increase customer satisfaction. Follows up on customer requests and issues. Exhibits patience and respect when dealing with difficult customers or their concerns. Meets STAR standards in providing customer service. Resource Management - Utilizes organizational resources effectively. Contributes to and supports the organization s cost reduction goals. Job-Specific Requirements - Meets all job specific standards. Demonstrates appropriate level of knowledge of technical aspects of position. Meets the continuing education requirements (internal & external). Meets 100% agreed upon timelines and deadlines of assigned projects and tasks. PERFORMANCE IMPROVEMENT Cost/Quality - Identifies opportunities to improve performance - quality and cost. Actively participates in the department s and organization s Continuous Improvement Process efforts. Change Capacity - Proactively responds to change. Supports actions that sustain change. Exhibits willingness to offer and try new ideas and supports change. SHARED VALUES/CULTURE Personal Effectiveness - Constantly doing what is expected as an employee of WVUH. (Follows policies, practices, and supports hospital initiatives). Is committed to doing the best work possible at all times. Serves as a role model to peers and patients by promoting WVUH values and modeling pride in the hospital. Ethics and Integrity - Strong personal ethics and demonstrated good personal judgment. Takes responsibility and ownership for decisions and actions taken. Demonstrates an understanding and commitment to compliance standards and conduct. 86

87 Initiative - Takes ownership and initiative for their work. Works with others to help make the hospital better. VIOLATIONS Behavior that deviates from WVUH s Performance Expectations compromises the health, safety and well being of patients, customers, other staff members and our organization at large. Certain actions and behaviors will constitute serious violations of our Performance Expectations and will warrant discharge from employment or a final warning with suspension, dependent upon managerial review of the circumstances and past practice. The following is a representative list only and is not designed to be all-inclusive, self-limiting or to amend other relevant WVUH policies. Actions not specifically addressed or described herein may also be deemed in violation of this Policy: 1. Willful intent to falsify information or to withhold information on an employment application, health assessment/physical, time record, pinc card, or any act of dishonesty regarding hospital business. 2. Unauthorized use or disclosure of the confidential or proprietary information of the hospital or any use or disclosure of patient information which violates hospital policy. 3. Reporting for work in a condition not fit for duty due to the use or abuse of alcohol, drugs, prescription medicines or other controlled substance. 4. Possession of alcohol or illegal drugs or drug paraphernalia while on duty or on Hospital premises. 5. Theft of Hospital property or the property of another employee or patient. 6. Refusal to follow appropriate directives or instructions from supervisory personnel; intentional failure to perform assigned work; sleeping while on duty. 7. Possession of firearms, explosives or concealed weapons on the Hospital s premises. 8. Willfully misusing, destroying, or damaging Hospital property or the property of a patient, visitor or other employee. 9. Fighting, threats of bodily injury, the use of abusive or threatening language (which may include profanity or gestures) or intimidating or unwelcome verbal or physical behavior involving or directed toward a patient, visitor or other employee, including physical or verbal harassment in violation of anti-discrimination laws. 10. Refusal to cooperate with any hospital investigation or audit involving a security, legal, compliance or other business or operational matter affecting the hospital. 11. Intimidating behaviors such as verbal outbursts, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Such behaviors include the reluctance or refusal to answer questions, return phone calls or pages, condescending language or voice intonation, impatience with questions. 12. Any retaliatory action against person reporting behaviors that undermine a culture of safety. 13. Any other willful act or conduct detrimental to patient care or Hospital operation. Bruce McClymonds President & CEO 87

88 WEST VIRGINIA UNIVERSITY HOSPITALS POLICY AND PROCEDURE MANUAL Policy VI.025 1st Effective Revised ; ; ; ; ; ; ; ; ; ; ; ; ; ; Reviewed POLICY: TOBACCO-FREE CAMPUS POLICY Effective November 19, 2009, West Virginia University Hospitals, including satellite locations, will be a tobaccofree campus. This policy applies to all employees, medical staff, residents, patients, customers, visitors, students, volunteers, vendors, and contracted personnel. This policy covers all tobacco products including cigarettes, cigars, pipes, and all forms of smokeless tobacco. The use of tobacco products is prohibited in or on all WVUH owned or leased buildings, grounds, parking lots, ramps, adjacent sidewalks. The policy extends to all vehicles owned, leased, or rented by WVUH. * PURPOSE: Tobacco use is the single most preventable cause of death and disease in West Virginia and the United States. West Virginia University Hospitals is committed to creating a healthy, safe environment for our employees, patients, customers, students, and visitors. As the state s flagship healthcare institution, it is our role to lead by example in modeling good health practices and promoting a tobacco free lifestyle for those we serve. This tobacco-free campus policy, including satellite locations, clearly demonstrates our commitment to health and aligns our practices with our mission. SCOPE: This policy applies to all property, hereinafter called WVUH Campus, owned or leased by WVUH including satellite facilities. This policy applies to all employees, medical staff, residents, patients, customers, visitors, students, volunteers, vendors and contracted personnel. IMPLEMENTATION OF A TOBACCO FREE CAMPUS: Communication of the policy will be by signage at campus entrances, building entrances, parking areas, and will be included on reminder cards to patients. Supervisors will be responsible for notifying their employees of the provisions of this policy and assisting with enforcement. Human Resources will also inform employment candidates of this policy during the application process and in the new hire orientation process. Patients shall be made aware of this policy upon admission to WVUH. When possible, every effort should be made to inform patients and their families of this policy before admission to the hospital, appointments or any outpatient procedures. Other departments who oversee the use of vendors, volunteers, residents, our medical staff, or any other contracted group are also responsible for communicating this policy. 88

89 EXPECTATIONS OF EMPLOYEES: It is expected that all employees adhere to this policy and refrain from the use of tobacco while on the WVUH campus. Although not recommended, employees will be permitted to utilize tobacco in their enclosed vehicles, if parked in the employee approved parking spaces and on an approved meal and rest break. However, employees should refer to Policy V.250 Employee Dress and Appearance, as related to smoking odor if they choose to use tobacco in this manner. Policy compliance is an expectation of employment and will depend on the cooperation of all faculty, staff, students, and visitors. Employees smoking or using tobacco products on the hospital campus are in violation of the stated policy and subject to disciplinary action possibly leading to termination. Violations of the policy should be referred to the employee s supervisor for review and action. Supervisors are responsible for managing this policy within their respective work areas. The medical staff (progressing to Security and the Administrator On-Call) is responsible for upholding this policy in all patient areas. All personnel are encouraged to respectfully communicate this policy. While all employees are responsible for informing others of the policy, Security staff members are responsible for enforcement with those who are in violation. CESSATION RESOURCES FOR EMPLOYEES: The Health Sciences Campus of WVU will assist with compliance by sponsoring tobacco cessation programs and will provide education materials to assist staff in quitting tobacco use. The Wellness Program in collaboration with the Translational Tobacco Reduction Research Program will assistant in identifying cessation resources. EXPECTATIONS OF PATIENTS: It is the expectation that all patients will refrain from using any form of tobacco while on the WVUH campus and their entire visit to the campus. At the patient s request, the appropriate WVUH staff will contact the patient s admitting physician to request cessation resources for the patient. When there is good reason to believe that the patient has used tobacco products while on the WVUH campus, the patient will be advised of this policy and will be asked not to use any tobacco products in the future. In the event of a patient s repeated violation of this policy, the patient will be asked to relinquish all tobacco products in his/her possession to Security. These products will be returned upon discharge from the WVUH Campus. While patient care staff will be primarily responsible for the enforcement of this policy with patients, Security staff may also be utilized to enforce the policy and to report violations. EXPECTATIONS OF MEDICAL STAFF, RESIDENTS, CUSTOMERS, VISITORS, STUDENTS, VOLUNTEERS, VENDORS AND CONTRACTED PERSONNEL: It is the expectation that all medical staff, residents, customers, visitors, students, volunteers, vendors, and contracted personnel refrain from any form of tobacco while on the WVUH campus and their entire visit to the campus. Violations of the policy may result in restrictions or cancelations of their visiting rights or other right to be on the WVUH campus. Medical staff, residents, customers, visitors, students, volunteers, vendors, and contracted personnel may ask their designated WVUH staff personnel for assistance in locating cessation resources while on WVUH campus. While all employees are responsible for informing others of the policy, responsible departments who are utilizing the above are primarily responsible for the enforcement of this policy with medical staff, residents, 89

90 customers, visitors, students, volunteers, vendors or other contracted personnel. Security staff members may also be utilized to enforce the policy and to report violations. OVERSIGHT The Tobacco Free Health Sciences Committee is charged with maintaining the tobacco free policy, monitoring compliance with the policy and developing procedures to increase compliance with the policy. *WVUH does not lease the parking lots between Ruby Memorial Hospital and the football stadium on home football game days. Bruce McClymonds President & CEO 90

91 WEST VIRGINIA UNIVERSITY HOSPITALS POLICY AND PROCEDURE MANUAL POLICIES SUBSTANCE ABUSE Policy V.231 1st Effective Revised ;4-4-03; Reviewed Substance abuse by employees, staff, residents, or students at West Virginia University Hospitals is unacceptable and will not be tolerated. Our patients have a right to care by providers who are not under the influence of drugs or alcohol. Federal law entitles all employees the right to work in a drug free environment. It is everyone's responsibility to report suspected use of alcohol or drugs to the appropriate supervisor. For residents, students, UHA allied health providers, and medical/dental staff, suspected substance abuse should be reported to the Department Service Chief, Chief-of-Staff, or Hospital Administration. For hospital employees, suspected substance abuse should be reported to the Department Manager/Director, Human Resources, or Hospital Administration. Uniform policy statements are provided in order to create uniform responses to questions of practitioner impairment due to alcohol or drug abuse. At the same time, other Health Science entities should implement similar policies. 1. Treatment of physicians and dentists, UHA allied health providers, and all other employees with drug or alcohol abuse will not be punitive, so long as the individual voluntarily complies with treatment, aftercare, and monitoring. 2. Physicians, dentists and UHA allied health providers credentialed by the Medical Staff Office will require consultation with the Physician Health Committee immediately for all suspected cases of drug or alcohol abuse. 3. Any suspected problem shall be immediately reported to the Service Chief, Chief-of-Staff, or Hospital Administration. The individual will be removed from patient care responsibilities pending further investigation. Reports of suspected problems must be reported to the WVUH President. 4. Immediate "on the spot" drug and alcohol testing is expected and appropriate after any incident or report suggesting drug or alcohol abuse. Incidents that justify testing may include the discovery of evidence such as improperly disposed of syringes and missing or improperly accounted for medications. In such cases, the testing must be performed in a nondiscriminatory manner, with all individuals in a particular department, on a particular shift or in a particular job classification, as the Service Chief, Chief-of-Staff, or Hospital Administration determines is appropriate, evaluated on the same basis and in the same manner. STRUCTURE The Practitioner Health Committee will be made a standing committee and will have status in the Medical Staff Bylaws. Its charge includes: a) Education, b) Assessment, c) Intervention, d) Contracts of Treatment, e) Monitoring, and f) Aftercare Supervision. 91

92 TESTING Confidential, independent urine and blood testing will continue to be available 24 hours a day. The Physician Health Committee and Faculty Staff Assistance Program (FSAP) will ensure that testing and reporting methods continue to support this policy. PROGRAMS Educational programs will be broadened and must be repeated on a regular basis in all departments. APPLICATION These standards are to be followed by all Hospital and Medical Staff Departments. 1. At the discretion of the Chief-of-Staff, Department Service Chief, or Hospital Administration, an individual department may establish more stringent standards, including, but not limited to, additional testing and educational programs. 2. Similar programs for WVUH allied health professionals and other hospital employees are to be available, including education, awareness, and appropriate reporting. Bruce McClymonds President & CEO 92

93 WEST VIRGINIA UNIVERSITY HOSPITALS POLICY AND PROCEDURE MANUAL Policy VI.230 1st Effective Revised ; ; ; ; Reviewed Policy PARKING AND TRAFFIC 1. WVUH Provides convenient, free parking facilities for its patients, visitors, physicians, employees, vendors, students, residents, and other customers to the Health Center campus. WVUH s first priority is to provide convenient easily accessible parking spaces for the patient and visitors to our campus. WVUH parking policies are to be written and interpreted with service to patients and their visitors as an overruling priority. Consideration 1. WVUH s first priority is to provide convenient easily accessible parking spaces for the patient and visitors. 2. The primary medical care providers (physicians, nurses, medical technologists, etc.) are to be given next consideration in parking and access policies. 3. Other hospital staff and visitors are also to be given consideration in parking and access policies. Prohibited actions 1. Parking of vehicles on sidewalks, grass areas, or yellow curbs is strictly prohibited. 2. Parking of vehicles in crosswalks, fire and emergency vehicle access lanes is strictly prohibited. Blocking of other vehicles is prohibited. 3. Parking non-conformity within the designated area is prohibited. Failure to park within marked spaces is prohibited. 4. Unlicensed motorized vehicles or motorized equipment are strictly prohibited. This includes motorbikes, go-carts, ATV s, etc. 5. Skateboards, scooters, sleds, skis, roller skates, and bicycles are prohibited when deemed by the WVUH Security Program Administrator to be hazardous to the general public. General 1. Vehicle or pedestrian entrance onto WVUH driveways, parking areas and grounds is for their convenience and solely at their own risk. All vehicles are subject to WVUH parking and traffic policies. WVUH assumes no responsibility for any damage or losses incurred while on WVUH controlled grounds. 2. Bicycles may be parked and/or secured in bicycle parking racks only. Bicycles attached to hospital other than above may be confiscated. 3. Maximum vehicle speed is limited to 15 miles per hour. 93

94 All WVUH Parking Areas / Parking Permits 1. WVUH reserves the right to revoke at any time; any permit, including any obtained under false pretenses. WVUH parking permits are non-transferable. The person to whom a parking permit is issued is responsible for any violations caused by any vehicle displaying such permit. 2. WVUH issued parking permits must be displayed on the rear view mirror with the area, number, and expiration date clearly visible from the outside of the vehicle. 3. WVUH permits expire as indicated by the date on the permit or upon termination of employee status. Upon termination of employment, it is the responsibility of the person to whom the permit is issued to return the permit to the WVUH Security Department Office. 4. The WVUH Security Office upon application and payment of a $5.00 replacement fee may replace lost, misplaced, or stolen staff permits or special permits. Issuance of a replacement permit will void and invalidate the missing permit. The issuance of more than one of the same type of permit to any one individual is strictly prohibited. 5. Parking in violation of WVUH policies without receiving a notice of violation does not constitute waiver of the policy. 6. A summary of warning notices of violations may be issued for the violator s information. Driveway Outside East and West Lobbies of Ruby Memorial 1. Parking of vehicles in the driveway other than as noted below is strictly prohibited 2. Patients and visitors may be picked up or dropped off along the driveway. The maximum stop is limited to 15 minutes in the area between the patient drop-off signs. 3. Vehicles parked unattended under the canopy without authorization are prohibited and will be towed without notice. Driveway Outside Physician Office Center Lobby / Eye Center Lobby 1. Parking and Traffic Policy in this driveway is to be the same as the main lobby driveway of Ruby Memorial Hospital. However, the maximum stop is limited to 10 minutes. 2. Pick-up and drop-off of patients via any ambulance services shall be through the 1 st floor West entry door only. Ambulance parking in the driveway is prohibited. 3. Ambulance parking is located along Stadium Drive in sign posted area or Lot B. H. Special Parking Areas (WHITE Permit) 1. Area C1 and C2 2. A. Parking in Area C1 and C2 is restricted to vehicles with WVUH issued Handicapped permits and vehicles with the state issued handicapped permit or license plate. B. Parking at handicapped signs within Area C1 and C2 is restricted to vehicles with persons who require wheelchair access space. C. Handicapped permits may be issued by the WVUH Security Office to: 1. Handicapped or physically disabled persons admitted, treated, or tested at WVUH. 2. Handicapped or physically disabled visitors of WVUH. D. Determination as to whether a handicapped permit is to be issued will be made by the WVUH Security Office. Requests for handicapped or physical disability status will be reviewed by the WVUH Parking Office in conjunction with medical documentation and may require additional physical examination. The WVUH Security Office may issue permanent or temporary special permits. WVUH employee requests for physical disability special permits may be referred to WVUH Employee Health Department for review and recommendation. 94

95 E. Special parking permits to park in Area C1 and C2 may also be issued to Hospital Volunteers and/or others as approved by Hospital Administration. 3. Emergency Department (RED Permit) A. Parking in the Emergency Department parking area is restricted to the following: 1. Emergency Department Patients and Visitors a. A temporary permit (available from the Security Officer at the Triage Desk) must be displayed within ten (10) minutes of parking in an Emergency Department Patient/Visitor parking garage. 2. Emergency Department Physician Designated spaces a. Emergency Department Physician(s) may park in the designated spaces, but must display their Red ED permit. b. The Medical Director of the Emergency Department will maintain a list of physicians authorized to park in the Physician Designated spaces, which they will receive a permit from the Security Department and must display at all times. 3. Ambulance parking. a. Will park beyond the ED canopy along the curb. The canopy is for loading and unloading only. b. All ambulances will turn their ignitions off while under the ED canopy. 4. Hospital Staff and physicians. a. Hospital staff and physicians called in by the Emergency Department concerning emergency situations may park in the Emergency Department Patient / Visitor parking spaces at the discretion of the Emergency Department physician in charge. If an Emergency Department temporary permit is not displayed and a warning or citation is issued, the warning citation may be voided if the Emergency Department physician in charge documents the situation within five (5) days to the Hospital Security Office. b. Parking in the handicapped designated spaces is restricted to Emergency Department patients and visitors who require a wheelchair access space. Vehicles parked in handicapped designated spaces must display an Emergency Department temporary permit. c. Parking along curbs, in traffic lanes, in driveways, or in other nondesignated areas is not allowed except for emergency vehicles. The curb lane at the Emergency Department entry doors is for pick-up and drop-off of patients only. A maximum of five (5) minutes waiting may be allowed. 95

96 4. Vendor Parking (WHITE Permit) A. Parking in the Vendor Parking Area is restricted to the following: 1. Hospital vendors may park in the Loading Dock area after they have received a temporary vendor permit from the Security Department Office. Temporary vendor parking permits may be issued by the Security Department Office to the above mentioned persons when they require close for frequent access to tools, supplies, etc., in their vehicle and the Hospital. 2. Hospital vehicles will be parking in Area G3A & G3B Loading Dock. 3. Vehicles displaying special permits available from WVUH Security Department and authorized by Hospital Administration will be allowed to park in designated area. 5. Employee Handicap/Volunteer/Years of Service (BLUE Permit) A. Parking in Area C3 is restricted to Handicap or physically disabled employees, volunteers and employees with 35 plus years of service of WVUH. They will need to display a WVUH Handicap or 35 Years of Service parking permit provided by the Security Office on the 4 th floor. 6. Resident Parking (GREEN Permit) 1. Parking in Area K1 and K2 is limited to vehicles displaying Resident parking permits and/or others as approved by Hospital Administration. 7. Faculty Parking On-Call (SILVER Permit) 1. Physicians working on-call who are called into the Hospital for patient related issues on weeknights or weekend are to display a silver Faculty Parking permit for areas C-6 and C-7. This emergency on-call parking shall not be used except when serving on-call. The physician will park in their routine assigned space during all other times. If a permit is not displayed and a citation is issued, the warning citation may be voided if it is proven that the Physician was on-call at the time of the warning, by calling the Security Office at I. Visitor Parking Areas B, C5 and C4 (WHITE Permit) 1. Parking in Areas B, C4, and C5 between 6:30 a.m. and 2:30 p.m. weekdays is restricted to vehicles with a visitor s parking permit displayed from their rearview mirror. 2. Visitor permits are available from the Central Parking Booth, Hospital Security Officers, or from departments authorized to issue visitor permits. 3. Persons eligible to receive a visitor s permit include inpatients, outpatients, patient visitors, and patient s family. Persons not eligible to receive a visitor s permit include employees of WVU, WVUH, WVUMC, CRH, UHA, and WVU students, except when any of the preceding is a patient or a visitor of a patient. Salespersons and department visitors may be granted a visitor s permit if in the opinion of the Hospital Parking/Security Office there are sufficient spaces available. 4. Visitor permits must be dated and initialed by the issuing department/person. Visitor permits are usually for one day s use; however they may be issued and dated for more than one day but not more than five (5) consecutive days per permit. 96

97 5. Visitors and patients displaying a visitor s permit may park in any WVUH parking area B, C4 and C5 6. Disabled visitors/patients may obtain a handicapped-parking permit to park in Special Parking Areas C1 and C2. J. Chestnut Ridge Hospital Parking (WHITE Permit) 1. Parking in Area G2 is restricted to vehicles with a Visitor s permit displayed from the rearview mirror. ALL visitor permits must be stamped C.R.H. and dated. 2. Visitor permits are available from the C.R.H. lobby desk. K. Employee Parking Areas A, A2, C6 C7, D, E, F1, F2, K3, L, and M2(BROWN or GREEN Permit) 1. Parking in all areas A, A2, D, E, F1, F2, K3, L and M2 is 24 hours / 7 day s a week with an issued Employees Parking Permit. Including Holidays. 2. Parking in Area C6 and C7 will not be allowed between the hours of 8:00 am through 9:00 am Monday through Friday with exception of C-6 Parking Permit. Any other hours you must display a proper Parking Permit. If you work midnight and have to stay during the no parking hours until 9:00 am, your tire will be chalked so that you will not receive a ticket. 3. Parking Area F3 is first come- first serve parking with not permit required. L. All WVUH Parking Areas / Stadium Special Events 1. Hospital Parking and Traffic Policies are in effect at all times except when special events at the Stadium are recognized by Hospital Administration and/or supplemental parking and traffic policies are issued. 2. Supplemental parking and traffic policies are to be issued by the WVUH Security Department with sufficient notice to all patients, visitors and staff affected by any changes. 3. Employees scheduled to work on a stadium special event weekend will receive a special parking permit from their department manager. The department manager is responsible to request permits in writing and in advance from the WVUH Security Office for the number of persons scheduled to work during the special event. 4. The department manager is also responsible to submit in advance to the WVUH Security Office, the names of employees scheduled On-call during the special event period. On-call employees must identify themselves to the security personnel as being On-call. 5. During special events, visitors of Hospital patients may obtain a special visitor s permit in advance from the nursing unit. The nursing unit will receive these special visitor permits from the WVUH Security Office. M. Parking Policy Enforcement 1. General A. WVUH Parking / Traffic Policies will be enforced by WVUH Security personnel and by other law enforcement agencies. Refer to the Department Parking Enforcement policy

98 B. Parking / Traffic Policy violators may have their vehicles towed away to an on-site or off-site impoundment. Recovery of the vehicle is the responsibility of the vehicle owner. Violator prior to release of the vehicle must pay towing and impoundment costs, as well as, the assessed fine. Assistance with procedures for recovery of a vehicle may be obtained by contacting any WVUH Security personnel or by calling the WVUH Dispatcher at C. Questions, comments, complaints and requests concerning WVUH Parking may be addressed to the WVUH Security Office, P.O. Box 8029, Morgantown, WV 26505, or by calling , or by contacting the on duty officer at All Areas / Warnings, Citations, Towing, Impoundment A. Violators of Hospital Parking / Traffic Policies may be given a verbal warning, a written warning, and/or may be towed with exception to Chestnut Ridge Hospital.In general, a written warning will be issued to violators. All written warnings are to be reported and recorded in the warning / violation database maintained by the WVUH Security Department Office. B. Upon receiving three (3) written warnings within a three (3) month period, the violator is issued a final warning sticker for the fourth violation in a three (3) month period. C. After a final warning is issued, any further violation within six (6) months will result in the vehicle being towed to the fenced in area behind F-2 without further warning and all attempts will be made to notify the person whom is being towed and that their vehicle has been towed with instructions on how to retrieve their vehicle. The violator will be able to retrieve their vehicle from dispatch 24 hours 7 days a week. The violator needs to either make a check out to WVUH or cash, in the amount of $55.00 and give to the dispatcher. At that time, the dispatcher will write them a receipt with the incident number and license number on the receipt. The Officer will be called to meet the violator to retrieve their vehicle. The violator will first show them a receipt in which they paid for the tow. D. Warnings may be voided by the WVUH Security Department if appropriate and adequate documentation of the situation is presented to the Hospital Security Department Office within five (5) days of the warning or citation. E. Any person may obtain a listing of violations assessed to them or their vehicle by providing their vehicle license number, permit number and name to the WVUH Security Department Office at F. Vehicles may be towed without notice if it creates a hazard to the safety of persons or property. Towing may be utilized for vehicles which repeatedly violate Hospital Parking / Traffic Policies. The loss of WVUH parking privileges may be assessed to repeat violators. G. Before any vehicle is towed, every effort needs to be taken to ensure that the vehicle doesn t belong to a patient/visitor. Each vehicle that is towed needs to have a warning written up. The yellow copy goes onto the vehicle and the white copy goes to the office. A copy goes to dispatch via the officer who towed the vehicle. Dispatch needs the copy immediately after the tow. When a tow is needed on day shift, please notify the Security Department Staff Assistant. On off-shift/weekend, please notify dispatch to make the call. Dispatch will need to be informed of the following information: a) Make of vehicle b) Model of vehicle c) Color of vehicle d) Location of vehicle e) Destination 98

99 H. Vehicles in violation in Chestnut Ridge Hospital Parking Lot. (i.e. G-1; G-2) will be given a final sticker on first offense and the vehicle will be towed on second offense within a (6) month period. Bruce McClymonds President & CEO 99