Dear Colleague:

Welcome to Mountain States Health Alliance, and congratulations! You are joining a team of exceptional professionals who value, above all else, the selfless act of caring for others. You were chosen because we believe you, too, are exceptional, and have much to add to our organization. We want your journey with Mountain States Health Alliance to be rewarding personally and professionally. We know it’s important for you to get off to a great start, so your colleagues have worked hard to prepare this orientation process. We hope you take full advantage of the opportunity to learn everything you can. This process is about ensuring – no matter what your role – that you are fully prepared to do your part to create an environment where our patients and their families receive the most loving care available. So please…ask questions!

The orientation manual is designed to assist you in your initial introduction to Mountain States Health Alliance, and certainly may be a reference guide for you in the future. We plan to discuss the information in the manual with you over the next few days, both in group meetings, as well as through informal discussions with your supervisor or department manager. Again, make sure you ask your supervisor to clarify anything you don’t understand, as we want you to be comfortable with the information.

We firmly believe the process of orientation never ends, as we are always learning. To that end, many education opportunities are provided to our team members even after your formal orientation period ends, and you are encouraged to take full advantage of these opportunities!

We strive to deliver the best in Patient-Centered Care, and we all have a role to play. All team members are identified as Caregivers, and Caregivers have the opportunity every day to create an environment focused on building relationships with fellow team members, patients and their families - relationships that lend themselves to healing through caring. No matter who you are, you have something to offer that can have an incredible impact on the lives of the people around you. This is a gift that, when given, reaps great rewards. Trust me…give this gift each day to our patients and their families, and to your fellow team members, and you’ll see what I mean!

I’m excited to have you as a part of our team, and I look forward to working with you.
Let’s make it happen!

With my warmest personal regards,

Alan Levine

President and CEO

General Orientation Program Guide

7:30-7:45 / Registration
8:00-8:10 / Welcome and Announcements
8:10-9:10 / What We Are All About
9:10-9:30 / Infection Prevention
9:30-9:45 / Break
9:45 – 10:05 / Safety and Security
10:05 – 10:25 / Patient Perspective
10:25-10:45 / Corporate Compliance
10:45-11:00 / Break
11:00-11:50 / Patient Experience
11:50-12:00 / Lincoln Financial
12:00-1:00 Lunch is served

See your schedule for your next destination.

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Table of Contents

Topic / Page #
Alan Levine, President and CEO / Inside front cover
Announcements / 3
Commitment to Quality / 4
Tradition and Culture / 6
Dress Code and Personal Appearance / 8
Organizational Development / 9
Corporate Compliance / 11
Abuse, Neglect and Exploitation / 14
Patient Safety Reporting / 16
Infection Prevention / 17
Team Member Health / 20
Ergonomics and Back Care / 25
Patient Experience and Service Excellence / 26
Service Excellence and First Impressions / 27
Value Optimization System and Performance Improvement / 29
Continuous Service Readiness and CMS / 32
National Patient Safety Goals / 33
Environment of Care – Safety and Security / 34
MRI Safety / 37
Law Enforcement Inquiries and Care of Forensic Patient / 38
Workplace Violence: Protecting Team Members, Patients and Families / 39
Suicide Precautions / Indicators / 40
Restraints / 43
Fall Risk Assessment / 46
Pain Management / 47
(IHI) (IHI) Institute for Healthcare Improvement / 48
Patient Rights and Responsibilities / 49
Cultural Diversity and Pastoral Care / 50
Obesity Sensitivity / 52
MD Link / 53
Communication / Patient Handoff / 54
Organ and Tissue Donation / 56
Medication and Blood Policies / 61
Team Member Calendar / 64
Worked Time Correction Form / 65
Pre/Post Test and Answer Sheet / 67
Map to Market Street Buildings / Inside back cover

Please note that all material provided in this packet may or may not be covered by a presenterduring the orientation process. Please review all material as appropriate to your position.

2 RevisedJanuary 2016

Announcements

►Orientation Schedule: You should have received an orientation schedule prior to your arrival. If you have any questions about your orientation schedule please see the educator at orientation to clarify. Some schedules (depending on your position) will say “report to work unit as assigned by your manager.” This means there is nothing scheduled for orientation during this timeframe and you need to check with your manager to see if they need you on the unit.

►All electronic devices should be on vibrate. If you need to take a call, please do so in the hallway. No texting during class please.

►Restrooms: go left out of the auditorium and the restrooms are on the left just before you reach the elevators (beside of the time clock).

►CPR Classes: MSHA requires American Heart Association (AHA) Healthcare Provider CPR certification for team members with direct patient care. We offer CPR classes as a part of your orientation process. The class takes place at the American Heart Training Center on Market Street. Please refer to your job description to determine if this is a requirement for you. If required for your job, you will be asked to fill out a payroll deduction form, which will be for $26.00 and covers the cost of the book and card. Note: You will be charged a $25 no show fee if you do not come to class and do not notify the training center 24 hours prior to class. Please adhere to MSHA dress code when attending CPR class. Appropriate dress is business casual or scrub attire.For more information or to cancel or change a date for class, please contact Linda Rogersat 423-431-7159 or by email at .

►Clocking in: All hourly team members paid by MSHA must file a “Worked Time Corrections Form” with their manager for time in orientation this week (blank form located in booklet). You will begin clocking in after being trained how to properly use the time clock.

►Evaluations: Within 7 days, please complete an evaluation for Day 1 Orientation by clicking on the link sent to you via email this week. If you rate below a 4 on any category, please explain in the comments section. We value your feedback and do use comments to help us improve future programs!

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Mountain States Health Alliance:

Our Commitment to Quality and Excellence in Everything We Do

Quality and Excellence: Our Foundation

Our Mission

MSHA is committed to Bringing Loving Care to Health Care. We exist to identify and respond to the healthcare needs of individuals and communities in our region and to assist them in attaining their highest possible level of health.

Our Vision

We passionately pursue healing of the mind, body and spirit as we create a world-class healthcare system.

Our Values

  • Integrity…honesty in everything we do
  • Service…with caring and compassion
  • Leadership…with creativity and innovation
  • Excellence…always pursuing a higher standard

Quality and Excellence: The Environment We Create

Our Patient-Centered Care Philosophy

MSHA team members as Caregivers create relationships, environments, and service delivery centered on the patient through a holistic approach to healing that ministers to the mind, body, and spirit. MSHA Caregivers believe that healing can exist without curing, but healing cannot exist without caring.

Our Patient-Centered Care Guiding Principles

  • Care is based on continuous healing relationships.
  • The patient is the source of control for their care.
  • Care is customized and reflects patient needs, values, and choices.
  • Families and friends of the patient are considered an essential part of the care team.
  • All team members are considered Caregivers.
  • Care is provided in a healing environment of comfort, peace, and support.
  • Knowledge and information are freely shared between and among patients, care partners, physicians, and other Caregivers.
  • Transparency is the rule in the care of the patient.
  • Patient safety is a visible priority.
  • All Caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient.

4

Quality and Excellence: How We Achieve It

5

Mountain States Health Alliance:

Tradition and Culture

Our Roots:

Root date to 1911

MSHA was created September 1, 1998 with JCMC acquisition of six Columbia/HCA Hospitals

MSHA 1998 – present and future

  • 1,717 licensed beds
  • 15 owned hospitals
  • 53 affiliated hospitals and nursing homes
  • Approximately 9,000 Team Members
  • Teaching relationships with East Tennessee State University’s Quillen College of Medicine and Health Sciences Division, Milligan College, and approximately 95 other colleges and universities
  • Facilities fully accredited by The Joint Commission, Healthcare Facilities Accreditation Program, and Commission on the Accreditation of Rehabilitation Facilities

Our Culture:

Quality and excellence in a Patient-Centered Care environment!

Our Facilities / Entities:

  • Franklin Woods Community Hospital
  • Indian Path Medical Center
  • Johnson City Medical Center
  • Johnson County Community Hospital
  • Niswonger Children’s Hospital
  • Sycamore Shoals Hospital
  • Woodridge Psychiatric Hospital
  • Dickenson Community Hospital
  • Johnston Memorial Hospital
  • Norton Community Hospital
  • Russell County Medical Center
  • Smyth County Community Hospital
  • Francis Marion Manor
  • Unicoi County Memorial Hospital
  • Unicoi County Long Term Care
  • Blue Ridge Medical Management Corporation
  • Home Health / Hospice / Durable Medical Equipment
  • Integrated Solutions Health Network
  • Mountain States Medical Group

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Make your First Impression Lasting!

Tips to Help You, in your New Position,

Make a Great First Impression!

  • Have a Positive Attitude:

“Attitude is a little thing that makes a big difference.” ~Winston Churchill

  • Dress Professionally: Do not think that your attire will go unnoticed! Our professional attire, whether a suit or scrubs, can lend credibility in your new position.
  • Listen: Actively listen to who is speaking, repeat back to them what you think you have heard. This lets the speaker know you understood what they were trying to say.
  • Learn Co-Workers’ Names Quickly

1. When you hear someone's name repeat it out loud as soon as possible in conversation.

2. Append it to the beginning or ending of your greeting to that person: "It's a pleasure to meet you, Amber" or "Tyrone, how nice to meet you."

  • Ask Questions/Ask for Help: You aren’t expected to know everything or solve organizational problems on your first day so relax. Always ask questions or for help when needed. It’s better to ask questions then complete a task wrong.
  • Give Help Without Being Asked
  • Take Notes: Take notes of the various systems and how processes work. Attend classes that will help you to better understand any information you feel you don’t understand correctly.
  • Show Appreciation: For those who help and guide you.
  • Be Punctual: Make sure to always arrive on time. We often don’t allot enough time for ourselves to: get up, get ready, eat and travel to work. Expect the unexpected; give yourself an extra 10-15 min.
  • Be a Self Starter; Take Initiative
  • Take Advantage of Clubs and After Hours Activities: Here at MSHA we offer Team Members many after hour activities and non-work related clubs.
  • Get and Stay Organized- Set Personal Goals

“Goals are the fuel in the furnace of achievement.” ~ Brain Tracy

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Dress Code – Personal Appearance

The dress code policy can be found on the MSHA Intranet. Dress code guidelines must be observed at all times when on duty. A name badge is required for all team members.

Uniforms will be approved at the departmental level and be worn in accordance with departmental policies.

Uniforms should be clean, in good repair, and appropriately sized to the wearer. Please refer to the policy for description of ‘business casual’ for areas that do not wear uniforms.

The following are examples of attire which DO NOT support MSHA business and professional image

  • Western style jeans of any color
  • Blue denim pants, any style
  • Tank tops, low cut tops
  • Any revealing fabrics or styles
  • Bib Overalls
  • Shorts, skorts, leggings, parachute pants
  • Exposure of skin at the waist and upper leg
  • Skirts shorter than 2” above the knee
  • Skirts with slits open more than 2” above the knee
  • Visible tattoos
  • Nose, tongue, eyebrow, lip or cheek jewelry
  • Artificial hair colors (purple, green)

Guidelines for appropriate appearance

  • Clean, neat, and pressed
  • Nails trimmed, clean, and conservatively polished
  • Hair clean and well groomed
  • Beards and moustache neatly trimmed
  • Shoes clean, polished and in good repair
  • Cosmetics worn sparingly
  • Jewelry should be conservative
  • MSHA name badge should be worn above the waste
  • Out of consideration of guests and team members, please do not wear heavily scented colognes or perfumes.

Reminder!! This is not an all-inclusive list. Please read carefully and abide by guidelines for dress and appearance of MSHA team members; the complete detailed policy is located on the MSHA Intranet.

8

Organizational Development

Providing a Network for Learning and Development

WHAT SERVICES ARE AVAILABLE THROUGH ORGANIZATIONAL DEVELOPMENT

New Team Member Onboarding
  • General Orientation
  • Clinical Orientation
  • Computer Orientation
  • New Leader Orientation
Leadership Development
  • Aspiring Leader
  • Talent Development
  • Crucial Conversations
  • Leadership Development Series
American Heart Training Center
  • Certification and Renewal
  • ACLS
  • PALS
  • BLS (CPR)
/ Team Member Development
  • Career Planning
  • Effective Meetings
  • Career Resource Center
  • Effective Communication
Clinical Education
  • CNA Course
  • PCP Course
  • IV Therapy Courses
  • Nurse Intern Program
  • SOAR Program (Supporting Onboarding and Retention for new nurse graduates)
  • Critical Care Education
  • Dysrhythmia
  • 12-Lead EKG
  • Cardiovascular Medications
  • Basic & Advance Critical Care Classes
  • Certification Exam Review Courses
  • Emergency Certification Review (CEN)
  • Critical Care Certification Review (CCRN)
  • Medical/Surgical Certification Review (MSN)

9

Learning Resources Center (LRC)

Location

The medical library is called the Learning Resources Center and is located on the first level of the Johnson City Medical Center near the ED Entrance.

Hours

The library is open and staffed from 7:15 a.m. until 4:30 p.m., Monday through Friday.

Users

The primary users of the library are health care professionals and support staff at Johnson City Medical Center. Other users are students in medicine, nursing and allied health specialties. Employees at all MSHA facilities are also encouraged to use its services. Members of the community who visit are provided guided assistance.

Collections

The library collections include medical and nursing books and journals, patient care information, and audiovisual materials. The MSHA University Self-Study collection is also located here. Books and audiovisual materials circulate for two weeks and may be renewed once. Journals do not circulate.

Computers

Computers for library users provide access to the Internet, email, Microsoft Word, Excel, and PowerPoint, as well as full text medical journals. There is additional information, including consumer and pediatric health links on the LRC Home Page. For physicians and allied health professionals, the library provides access to UpToDate, PubMed and Thomson Gale. For Nursing, the LRC provides links to EBSCO (including CINAHL) and Mosby’s Nursing Consult. Of interest to pharmacists, are Johns Hopkins ABX Guide.

Resources for Certification

Books and/or CDs needed for the following courses: CPR, ACLS, PALS, Neonatal Resuscitation, Understanding EKGs, and CNA are available.

Library Services

The library staff will assist you with your information needs. This includes selecting materials to answer reference questions, giving instruction for computer searches, as well as processing interlibrary loans.

Please contact the Learning Resources Center for further information at (423) 431-1691

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Corporate Compliance – What it means to you

MSHA’s commitment to operating in accordance with federal, state and local laws, regulations and internal policies and procedures.

Every Board Member, Executive, & Team Member is involved in this process.

How does MSHA promote compliance?

  • We don’t knowingly participate in any business practice or activity that is illegal or improper.
  • We always strive to be aware of our legal and ethical responsibilities and carry out our business practices accordingly.

Corporate Compliance Concerns:

Fraud and Abuse

  • Healthcare fraud requires “showing of intent.” It is something an individual knows is wrong, yet does it anyway to gain personal or organizational benefit. For example, when bills are being generated, an individual might put a higher billing code on than necessary, getting more money than is deserved from Medicare in payment.
  • Healthcare abuse does not require showing intent. For instance, an honest mistake could be made in coding that gains more money in payment than allowed; it is still wrong.

Health Insurance Portability and Accountability Act (HIPAA)

  • HIPAA regulations are designed to improve efficiency through standardization of information and to ensure confidentiality and security of Protected Health Information.

Anti-Kickback/Self-Referral Laws

  • Make it illegal to offer discounts, rebates, profit-sharing arrangements, free or below market value rent, free equipment, free services, etc. to induce others to do business with the organization.

How does the US Government enforce compliance with laws and regulations?

Civil Fines and Penalties

  • Under the Federal False Claims Act and similar state false claims acts specific to Tennessee and Virginia, each incorrectly submitted claim can result in a potential fine of up to $11,000 plus three times the government’s loss. Each false claims act provides protection against retaliation for any team member filing an action under the act and contains a provision whereby the individual can share in government recoveries resulting from successful (qui tam/whistleblower) lawsuits.
  • Under the HIPAA and HITECH regulations, a maximum penalty of $1.5 million can be assessed for each type of provisional violation

Criminal Prosecution