1. Welcome to Volunteer Retraining

2. In this course you will learn about:
Customer Service
Integrity Program
Confidentiality and Privacy
Standards of Conduct
Tuberculosis
Precautions
Hand washing
Boundaries
Standard Precautions
Safety and Security
Fire Safety
Hazardous Chemicals
Disaster Codes
Abandoned Newborns

3. Directions Please read everything carefully
Some sections have a quiz (included in your retraining packet). You will need to switch between screens to complete the packet on your computer.
Sign forms when indicated.
When you have completed all sections of retraining and completed your packet, please return packet to Family and Volunteer Services by , mail, or hand delivery.
Adobe is required to complete the packet. Save your packet on your desktop and double-check that the answers are visible.
CHROME USERS: Save the blank packet to your computer’s desktop before  filling out the packet. You will need to open the saved packet in the Adobe Reader program in order to fill it out and re-save it effectively.

4. Nationwide Children’s Mission Our Reason For Being
C - Highest Quality Health Care regardless of families ability to pay
A - Advocacy for children and families
R - Pediatric Research to ensure our children’s future health
E - Education for patients, families, future providers and community
S - Outstanding Service to patients, families and all customers

5. Customer Service Principles
Treat each family as my top priority
Treat each other as valued customers
Take the responsibility to resolve customer concerns
Assure that the customers’ expectations drive what I do
Continuously improve the quality of services I offer
These are the Customer Service Principles which are

6. The Corporate Integrity Program
Standards of Conduct
The Corporate Integrity Program
Volunteers are members of the NCH Team
NCH believes in and encourages an open communication policy
NCH maintains a culture that promotes integrity and ethical behavior

7. Standards of Conduct The Corporate Integrity Program
Employees and volunteers are required to review the hospital Standards of Conduct booklet. Please click on the link to open the hospital website.
The Office for Research Compliance and Integrity--Standards of Conduct
When open, find ‘Standards of Conduct’ on the bottom right and click.

8. Standards of Conduct Non-Retaliation Policy Conflicts of Interest
The Corporate Integrity Program
Non-Retaliation Policy
No disciplinary action or other form of retaliation shall be taken against any volunteer who, in good faith, reports an issue, problem, concern or violation to management, human resources, the Compliance Officer or the Hotline.
Conflicts of Interest
Volunteers will not pursue activities which represent a conflict of interest of the organization or the volunteer program.

9. The Corporate Integrity Program
Standards of Conduct
The Corporate Integrity Program
Your Responsibility
First, contact your direct supervisor/manager.
Second, if you have raised an issue and it’s not getting proper attention or unable to resolve, relay your concerns to the next level of management.
Third, seek guidance from Human Resources, the appropriate Executive Staff member, or the Corporate Compliance Officer.
If assistance is still needed, or if you are uncomfortable taking the above steps, call or the Hotline.

10. Corporate Compliance Officer
Standards of Conduct
The Corporate Integrity Program
Corporate Compliance Officer
Kathleen M. Dunn
Hotline
Call or the hotline if your concerns are not addressed through the standard resolution process or if you wish to remain anonymous.

11. Go to the Retraining Packet:
1. Read and sign the Standards of Conduct form
2. Take the Customer Service/ Corporate Integrity quiz

12. HIPAA: PRIVACY AND CONFIDENTIALITY

13. What is HIPAA? The Health Insurance
Portability and Accountability Act of 1996
HIPAA provides federal government standards and requirements for maintaining and transmitting health information. It defines and protects information that identifies a patient.

14. Patient’s Rights
Patients have a right to know how their information is used, who their information has been shared with and have a right to privacy.
Patients can restrict use and disclosure of health information.

15. Reasonable Safeguards
Minimum Necessary
Volunteers and staff have access to the minimum necessary information to do their job
Reasonable Safeguards
Take the necessary precautions to keep protected health information from unwanted disclosure

16. What is Protected Health Information?
Patient Name
Address
Phone Number
Birth Date
Social Security Number
Name of Relatives
Medical Record Number
address
Name of employer
Fax number
Fingerprint
Full-face photo

17. Where can breaches in confidentiality occur?
At the Hospital
Elevators
Break rooms
Shuttle bus
Smoking hut
Hallways
Cafeteria
Nurses’ stations
In the Community
Neighborhoods
Churches
Ball games
Service organizations
Parties
Stores
Clubs

18. What happens if there is a breach in confidentiality?
The most common breach of confidentiality comes from loose talk, speaking openly in public spaces or in the community.
Volunteers who breach confidentiality are subject to disciplinary action, up to and including termination.
There may be heavy civil and criminal fines for violation of the law for the hospital.

19. Your Role: paper, faxes, phones, computers
Never leave paper information unattended
Paper information includes admitting gift list, or any paper that has patient information
When making copies, do not leave originals in the copy machine
Carefully dispose of confidential information
Grey shredding bins are located throughout the hospital
Use fax and phone wisely
Reasonably verify fax numbers, location of receiving fax machine, identify of person receiving fax. Do not leave originals in fax machine
Reasonably verify phone number, identity of person(s) receiving voice mails
Be careful with computers
Never share or write down your password; log off if you leave.
Do not send patient information (even names) on unsecured
Make sure screens are not visible to those who should not have
access

20. Your Role: Sharing Information
Be careful with all oral communications—who can hear your conversation? This includes other volunteers.
Before sharing information, verify person’s identity or check with the nurses station.
Don’t pass along information from patient to patient— maintain their confidentiality
Don’t share information with patients’ extended family or friends
Do not include PHI (such as patient name) in unsecured communications

21. Go to the Retraining Packet and take the Confidentiality/Privacy quiz
Also, sign Confidentiality and Security Agreement

22. What are Boundaries? Boundaries help set limits.
Boundaries let you know what is ok and what is not ok.
Boundaries protect YOU and patients and families.
Boundaries let you know how involved you can get.
Boundaries helps you evaluate each situation and decide what to do.
Boundaries helps you decide how to respond.

23. Know Your Boundaries Is this part of my assigned volunteer role?
ASK YOURSELF…
Is this part of my assigned volunteer role?
Was I trained in this activity?
Am I maintaining patient confidentiality?
Could this activity present a safety risk for myself or the patients?
How does your activity appear to other patients and families? Could someone feel offended or upset?
Is this how I would want the situation handled if I were in the hospital? Who would I want to know about my personal situation?
Unsure? ASK YOUR COORDINATOR OR FVS STAFF!

24. Know Your Boundaries Boundary Ground Rules
Function within your assignment description and tasks you have been trained.
Do not bring food or gifts to patients or families. Do not accept gifts from families.
Do not offer to babysit in family homes.
Volunteers are discouraged from socializing with patients or families outside the hospital setting.
Do not personally provide transportation to patients and families.
Do not provide your personal contact information to patients or families or accept contact information from them.
Refrain from seeking medical information about patients. Maintain confidentiality—in hospital and in community.

25. Boundaries and Social Media
Volunteers are welcome to have social networking sites in their personal lives.
Your experiences here at the hospital are covered under privacy and confidentiality laws and cannot be shared in a public forum, such as Facebook or Instagram.
A volunteer cannot ‘friend’ a patient or a family member, even after they are discharged.
A volunteer cannot accept a ‘friend’ request from a patient or a family member, even after they are discharged.
The exception is if the patient or family member is a previous acquaintance.

26. Boundaries and Social Media
You may not post photos of patients on any social media site, such as Facebook or Instagram. Always remember patient privacy is of top priority.
There are many different scenarios and social media changes constantly. Just because we haven’t listed a particular website or situation doesn’t mean you shouldn’t consider it.
Think about the intent of the policy. We cannot have a rule for every situation. If a parent says it’s okay, is it? Who might be at risk? Are you really ‘friends’ with everyone in groups you belong to on Social Media? If you have a question, ask your coordinator.

27. Go to the Retraining Packet.
Read and sign
the Boundaries/Therapeutic Relationships form AND
the Social Medial Policy

28. What do volunteers need to know to prevent the spread of infection?
Infection Control
What do volunteers need to know to prevent the spread of infection?
Keep yourself healthy
The healthier you are, the less chance you have of catching or spreading infection
Be up to date on your immunizations
This is not required to volunteer, with the exception of volunteers who have not had the chicken pox.
Have an annual physical
This is not required to volunteer
Get a flu shot! Save your documentation.

29. Tuberculosis TB is spread when people cough, sneeze, speak, sing
Franklin County has the highest TB rate in state
The CDC determines need for TB testing based on an organizations size and risk
Not everyone with TB has symptoms
Tuberculosis is caused by the bacterium M. tuberculosis and is spread through the droplets of moisture that come from your nose or mouth.

30. Signs and Symptoms Fever and chills Chest Pain Swollen Glands
If you have experienced more than one of these symptoms in the last 12 months without explanation, see a doctor.
Cough: > 2 weeks
Coughing blood
Weight loss
Fatigue
Night sweats
Loss of appetite
Nausea
Fever and chills
Chest Pain
Swollen Glands

31. Volunteer Responsibilities
Beginning in 2014: TB testing required of all volunteers
Adults/College Students: What test are you required to have?
I have been an active volunteer at NCH within the past 12 months—see info TB slide 1—you will need a TB skin test.
I have not been an active NCH volunteer for over 12 months—see info on TB slide 2—you will receive a Quantiferon Gold blood test.
See next slides for further information

32. Volunteer Responsibilities See next slide for further information
-TB Slide 1-
Adults/College Students who have been an active volunteer within the past 12 months:
Go to Employee Health to have a PPD skin test placed AND report 2 days later to have it read. There is no charge. Must be completed within 30 days of retraining due date.
--OR--
Go your primary care provider or another provider in the community to have a TB test and provide the results to Employee Health at There will be a charge. Results must be received in Employee Health within 30 days.
See next slide for further information

33. Volunteer Responsibilities See next slide for further information
-TB Slide 2-
Adults/College Students who have not been actively volunteering within the past 12 months:
Go to Employee Health to receive a lab slip for a Quantiferon Gold blood test. Lab work is completed at the Outpatient Care Center lab. There is no charge. Must be completed within 30 days of retraining due date.
--OR--
Submit documentation of Quantiferon Gold blood test completed within the past 9 months to Employee Health at Results must be received in Employee Health within 30 days.
See next slide for further information

34. Volunteer Responsibilities
Beginning in 2014: TB testing required of all volunteers
Adults/College Students Resources:
Employee Health Location and Hours—Use this link to view: -
TB Skin Test information—Use this link to view:
Other locations in the community where you can receive a TB skin test—Use this link to view:
All updated ongoing information is available on the website at under ‘Current Volunteers.’

35. Go to Retraining Packet: Take Tuberculosis quiz
Complete and sign TB Testing Requirements

36. Chicken Pox/Shingles
Chicken pox is highly contagious and to some children can be deadly.
Preventative vaccine is currently available.
If you have not had the chicken pox we require that you receive the vaccination before volunteering
If unsure about personal history of disease and are exposed, DO NOT COME IN TO THE HOSPITAL TO VOLUNTEER.
Shingles is a very painful rash that affects the nerves. If you suspect you have shingles, DO NOT COME IN TO THE HOSPITAL TO VOLUNTEER. A person with shingles can pass on the illness as chickenpox.

37. Standard Precautions
Method of infection control - precautions for all patients
Manage all contact with human blood and body fluids as if it may contain transmissible infectious agent.
Standard Precautions include: hand hygiene and use of PPE as appropriate.

38. Standard Precautions What are PPE?
Wear gloves…if possibility of contact with body fluids
Wear a gown…to protect skin or your clothing
Wear a mask…to protect nose and mouth from body fluids

39. Take Additional Precautions…
To stop transmission of infectious diseases from one patient to another
When patients who are diagnosed with a contagious illness or who have been exposed to an unidentified illness
Color-coded signs on door

40. Contact Precautions Gloves, Gown and Hand hygiene
RSV
Rotavirus
Viral Conjunctivitis
MRSA, VRE
Family and visitors may only be wearing gloves and gown when providing care.
Policy revision: Gloves and gown MUST be worn, even if not touching surfaces or patient.

41. Droplet Precautions Mask and Hand hygiene
Bacterial meningitis
Strep
Family and visitors may only be wearing a mask if having close patient contact.

42. Patients with respiratory infections (Pertussis or Flu) may initially have both signs posted OR the Orange Precautions sign below.
Follow both by wearing:
Gloves
Gown
Mask

43. Airborne Precautions Mask and Hand Hygiene
Chickenpox
Measles
Will be in Airborne infection isolation room
Gloves and gown should be worn if contact with infectious materials is expected.

44. VOLUNTEERS MAY NOT ENTER
Airborne Precautions
VOLUNTEERS MAY NOT ENTER
Requires fitted N-95 mask
Tuberculosis
Smallpox

45. NPO Other Signs You May See… Nothing by mouth—no food or liquid
Toys in this room need to be cleaned with bleach wipes
NPO
Nothing by mouth—no food or liquid
May be some language barriers
Do not enter without talking with nurse

46. Eliminating Patient Falls
We are all expected to do what we can do reduce the risk of falls. This icon on a patient room means that a patient has been assessed as being at HIGH RISK for falls.
Precautions include:
Side rails left up
Bed in lowest position
Help with walking
Place call light and personal items within reach
Patient wearing non-skid foot wear

47. Other signs you don’t recognize?
Check with the nurse’s station
Do not open the patient room door
Take deliveries to nurse’s station

48. Health Care-Associated Infections
Infections patients get while in the hospital
Frequently transmitted by germs on hands
Prevented by handwashing
Wash hands for at least 15 seconds!

49. Handwashing Rubbing Alcohol Gel Versus Soap and Water
You must use soap and water:
After using the restroom
Before and after using gloves
When exposed to blood or body fluids
After blowing nose, sneezing, or coughing
You can choose gel or soap:
When entering and exiting every patient room or curtained area
When dropping items off for patients
Routinely during volunteering to help prevent the spread of germs
When having direct patient care

50. Latex Allergy Redness, skin rash, hives Swelling around the eyes
Children’s Hospital strives to be 100% latex free. It is possible to get a latex exposure in the community from products such as balloons, toys and gloves. If you have any of these symptoms following the use of a latex product, see a doctor.
Redness, skin rash, hives
Swelling around the eyes
Runny nose, sneezing
Shortness of breath
Shock

51. Exposures Wash the area Notify RN in charge Notify FVS
What to do when exposed to blood or body fluids, including urine, feces, vomit, or spit-up:
Wash the area
Notify RN in charge
Notify FVS
In FVS, we will:
Complete incident report
Contact Employee Health, if needed
Follow up with Employee Health
Incident reports are not optional.

52. OSHA Rules While in patient areas, do not:
eat
drink
apply cosmetics or lip balm
handle contact lenses
Do not wear home clothing contaminated with blood/body fluids
get scrubs from SPD and leave clothes—FVS will assist
file incident report
clothes will be washed and returned
Artificial nails are not permitted

53. Go to Retraining Packet and take Standard Precautions/Transmission-Based Precautions quiz

54. Safety and Security Departmental Overview
The Safety and Security Departments:
exist to protect the safety and well being of the hospital family, both environmentally and physically
are staffed twenty-four hours a day seven days a week
patrol the main campus in various ways - bike, on foot, and in vehicles
Safety is concerned with mainly environmental and compliance issues

55. Services Security provides the following services
Escorts for staff, volunteers and visitors
Vehicle assists
Conflict resolutions
Instruction in Self-Defense
And with your help, investigations of suspicious persons and incidents (S.A.F.E.)

56. S. A. F. E.
Become familiar with the hospital’s Security Policy (S. A. F. E.)
S - secure, secure offices when not in use, as well as lockers and desk drawers
A - alert, be alert to your environment Watch for suspicious people and activities
F - foil, call attention to suspicious persons
E - Educate, educate parents on the importance of following these security measures

57. Weapons Policy
Nationwide Children’s Hospital is a weapons free zone. Staff and Volunteers are prohibited from possessing/carrying weapons at any hospital facility, parking area or other property.

58. Fire Safety (Code Red) Education
Help us keep the “Smoke Free” environment at Nationwide Children’s Hospital. Smoking is prohibited in all areas.
Fire Prevention Tips
Please report damaged or defective electrical equipment or any safety issue to ( )
Store combustible/flammable material away from a heat source
Practice good housekeeping

59. Fire Plan R.A.C.E.
R-Rescue, Remove anyone from the area of immediate danger
A- Alarm, Activate the manual pull box and call to report the exact location of the fire
C-Contain, Close doors
E- Evacuate/Extinguish, If possible attempt to quell the fire by using an extinguisher
Evacuate, if ordered to do so by Columbus Fire or the onsite fire director or fire warden, or if you are in immediate danger

60. Fire Extinguisher Use [P.A.S.S.]
P-Pull the pin
A-Aim at the base of the fire
S-Squeeze the handles together
S-Sweep the base of the fire until extinguished

61. Evacuation There are four types of evacuations
Rescue-involves removing people from a room or some other contained area
Horizontal-involves moving people from one unit to another making sure that there is a fire barrier door between you and the fire (Refer to illustration above)
Vertical-involves removing people from a fully involved floor to the floor below by means of the stairwells
Total-involves evacuation of a building or the entire campus. This type of evacuation can only occur once a “Code Yellow” has been initiated and Administration, in conjunction with Columbus Fire, authorizes it.

62. HazMat-The Employees right to know
Hazardous Materials
HazMat-The Employees right to know
According to OSHA law the hospital has an obligation to inform its employees or volunteers of any hazardous, toxic or potentially life threatening chemicals that they might, in the course of their employment, come into contact with.

63. Elements of a HazMat Plan
The Hospital’s hazardous materials plan must contain:
A written policy [located in the policies and procedures manual or on the Intranet.]
MSDS sheets [located in the poison control center] provide information on handling hazardous materials, first aid and proper personal protective equipment (PPE)
Proper Container labeling [primary and secondary]
Personal Protective Equipment supplied, free of charge, for any chemical that you will handle in the course of your duties.
Proper clean-up and disposal of hazardous waste.

64. Disaster Procedures Disaster Codes Fire Code Red Abduction Code Adam
Bomb Threat
Severe Weather
HazMat
Medical Emergency
Disaster
Violent/Combative Person
Person with weapon and/or hostage
Code Red
Code Adam
Code Black
Code Gray
Code Orange
Code Blue
Code Yellow
Code Violet
Code Silver

65. Workplace Violence Disaster Codes
Disaster Procedures
Workplace Violence Disaster Codes
Code Violet--Violent/Combative Person
Activated when a person’s behavior is observed to be increasingly out of control
Behavior threatens the safety of that person or others
Request assistance from staff immediately
Code Silver--Person with weapon and/or hostage
Activated when a person is seen with a weapon, distinctive popping noises or gunshots are heard, or in a hostage situation
Off-duty police or detectives are allowed to carry weapons
is emergency security number

66. Volunteer Activities During a HEICS (Disaster) Activation
FVS will be responsible for
Maintaining the Family Information Center which:
Provides family members with information regarding the patient
Provides a calm and nurturing atmosphere for parents and siblings of patients
Acting as runners between the various disaster centers
Assisting the Section Chiefs by recording ongoing events

67. NCH Flight Risk Gowns
Any child in hospital pajamas without a staff member, parent or other designated adult is someone to stop and question.

68. NCH Flight Risk Gowns
Seeing a patient in a purple gown, without their constant attendant, is a cause for high alert and staff or volunteer should notify security.
Check with nurses station before entering room when patient is wearing purple gown

69. Safe Havens for Newborn Children
Abandoned Newborns
Safe Havens for Newborn Children

70. Ohio Revised Code HB660
Nationwide Children’s is a willing partner in the Abandoned Newborn’s Law.
It states, among many other things, that:
Infants, under 30 days old (with no signs of physical abuse) maybe dropped off at a safe haven.
Persons are allowed to anonymously surrender an infant without fear of questioning or arrest.
If a parent brings a newborn either to the main campus or an off-site location, the volunteer shall;
Contact the staff person in charge and they will make all necessary notifications.

71. Go to Retraining Packet and take Safety/Security quiz

72. Evaluation Form
Please take a few moments to fill out the self- evaluation form. This helps us know how you are doing as a volunteer and if you desire additional training.
The method of reporting is “Self Report”
You choose if you feel you N (Need Review), are M (Meeting Expectations), or E (Exceeding Expectations).

73. Quick Reminders
Volunteers must wear the Nationwide Children’s volunteer uniform polo or vest.
Your photo id must be worn at all times.
Closed-toe shoes are required.
Please, no blue jeans, shorts, capris, sagging, or shirts which expose your mid-section.
Super Volunteer

74. Updates…
You can now check and print your hours and update your contact information at:
Your address is the log-in and your pin # is the password.
Be sure to check your regularly for updates regarding any changes happening at the hospital.
Flu vaccines are mandatory for all volunteers. Send verification to:

75. Flu vaccines are mandatory for all volunteers.
Updates…
Flu vaccines are mandatory for all volunteers.
Flu season is typically September through March and vaccines will be available at this time.
Flu vaccines will be available from Employee Health at no charge
If you get a flu vaccine from another source, send verification to:
Make sure it has your name and ‘Volunteer’ indicated on paperwork.

76. Updates… Volunteer sign in and out Where are the staff?
Volunteer Program Office, located just past the Chapel off of the Tower lobby.
Can use either the Timken office or the new office.
Where are the staff?
Secretaries are in the New Volunteer Program office
Volunteer Coordinators (Brittany and Laura) are in the Timken office
Child Life Specialists may have offices on their unit or may be in Timken—check with them on how to find them.

77. Updates… Parking at the Main hospital
Volunteers using a card key to park at the main hospital now have access to the Underground Visitor Garage.
The address of the Underground garage is 635 Children’s Drive
Do not take a ticket—hold cardkey in front of reader to enter.
When exiting, use right lane, and hold card key in front of reader.
Your badge no longer works at the Mooberry garage.

78. Congratulations! You have finished your annual retraining!
Please remember to complete all quizzes and sign all forms.
Return completed packet to Family and Volunteer Services.
If you have any questions or concerns, don’t hesitate to contact us.