1. Orientation Kaiser Permanente Medical Center Santa Rosa Employees, Students, Patient Advisors, Volunteers Revised April 2014

2. Page 2 Table of Contents What is Kaiser Permanente? Patient Rights and Responsibilities Compliance Safety  Injury and Illness Prevention & Reporting  Infection Control  Codes Security  Parking and no-smoking policies  Identification

3. Page 3 What is Kaiser Permanente?

4. Page 4 Kaiser Permanente History In 1934 Dr. Sidney Garfield and Industrial Indemnity team up during a time when everything was fee for service. Executives suggested 5 cents per day per person. Kaiser membership grew to 100,000 during WWII and dropped below 15,000 at the end of the war when peace time jobs became available. Physicians visited the job sites to develop processes to prevent injuries. Kaiser Oakland Hospital opened in the 1940s and it was not segregated unlike most other hospitals at that time.

5. Page 5 7 Principles of Kaiser Permanente 1)Prepayment of Medical Bills 2)Prevention 3)Group Practice 4)Integration of Facilities 5)Voluntary Enrollment 6)Physicians' Responsibility 7)Nonprofit Operation

6. Founded in 1945, Kaiser Permanente is the nation’s largest not-for-profit health plan, serving more than 9 million members, with headquarters in Oakland, California. Kaiser Foundation Hospitals Kaiser Foundation Hospitals is a nonprofit, public benefit corporation that owns and operates community hospitals in California, Oregon, and Hawaii. The corporation owns outpatient facilities in several states; provides or arranges hospital services; and sponsors charitable, educational, and research activities. Kaiser Foundation Health Plans The Kaiser Foundation Health Plans are nonprofit, public benefit corporations that contract with Kaiser Foundation Hospitals and medical groups to provide services. In our regions that are not hospital-based, they may contract with non-Kaiser hospitals. The Health Plans are the health insurance component of the organization. Each region has its own health plan company. Permanente Medical Groups Permanente Medical Groups are partnerships or professional corporations of physicians, represented nationally by The Permanente Federation, which contract exclusively with the Kaiser Foundation Health Plans to provide or arrange medical services for members and patients. The Permanente Federation

7. Page 7 Kaiser Permanente Regions Recognized as one of America’s leading health care providers and not-for-profit health plans, Kaiser Permanente serves members in eight states and the District of Columbia through seven separate regions, each with its own leadership. Northern California One of the largest of the Kaiser Permanente regions, Northern California currently serves members in 20 counties. Southern California The largest of Kaiser Permanente’s regions, Southern California serves the Coachella Valley, also Los Angeles, Orange, Kern, Riverside, San Bernardino, San Diego and western Ventura counties. Hawaii Since 1958, Kaiser Permanente has served the people of Hawaii. The region today serves the islands of Oahu, Hawaii, Maui, Kauai, Lanai and Molokai. Northwest Among Kaiser Permanente’s oldest regions, established in 1951, Northwest serves members in Portland and Salem, Oregon, also southwest Washington. Colorado Established in 1961, Kaiser Permanente’s Colorado region serves members in Denver, Boulder and Southern Colorado. Georgia One of Kaiser Permanente’s regions, Georgia serves members in the metropolitan Atlanta area. Mid-Atlantic States Kaiser Permanente’s only East Coast region, Mid-Atlantic States serves members in Maryland, Virginia, and the District of Columbia.

8. Page 8 Kaiser Permanente National Fast Facts Medical Centers: 38 Medical Offices: 611 Physicians: ~ 16,900 + Nurses: ~ 48,700 + Employees: technical, administrative, clerical employees and caregivers ~ 174,200 +

9. Page 9 Our Brand We stand for Total Health. Kaiser Permanente’s integrated health care delivery system and commitment to preventive care empowers our members to maximize their total health — mind, body, and spirit. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health.

10. Page 10 The Value Compass represents our strategy Kaiser Permanente delivers value to our members, customers, and communities by striving to achieve balance on all four points of the compass.

11. Page 11 Our Service Credo Our Cause is Health. Our Passion is Service. We’re Here to Make Lives Better.

12. Page 12 Kaiser Permanente Santa Rosa Medical Center (SRO) Kaiser Foundation Hospital The Permanente Medical Group Judy Coffey, RN, Senior VP/ Area Manager Vicky Locey, RN, Chief Operating Officer Chief Nursing Officer Kirk Pappas, MD Physician In Chief Guy Chicoine, MBA Medical Group Administrator

13. Page 13 Santa Rosa’s Mission, Vision and Aspiration Mission A Healthy Community Vision Excellence in Quality and Service Partnership with those we serve Aspiration World Class Medical Center

15. Page 15 Members146,413 Physicians and Staff2,640 Licensed Hospital Beds173 Births (2013)1,898 Emergency Dept. Visits (2013)47,288 Hospital Discharges (2013)8,021 Prescriptions Filled (2013)1,226,000 Surgeries (2013)9,816 Fast Facts about Kaiser Permanente Santa Rosa Services Primary care and Specialty care Hospital services including emergency, critical care, medical/surgical, pediatrics, labor and delivery, perioperative services, and interventional radiology Primary Stroke Center Occupational medicine Rehabilitation services including physical, speech, and occupational therapy Laboratory X-ray and imaging Pharmacy Health education KP HealthConnect electronic medical records My Doctor Online tools: e-mail your doctor, schedule routine appointments, refill prescriptions, view many lab test results, healthy living programs, and summaries of recent doctor’s office visits.

16. Page 16 Patient Rights and Responsibilities

17. Page 17 Patient Rights Access to Care Respect and Dignity Privacy and Confidentiality Personal Safety Identity Access to Medical Records Transfer and Continuity of Care Refusal of Treatment Ethical Issues Conflicts/Complaints Pain Assessment & Management Consent Consultation

18. Page 18 Patient Responsibilities Provision of Information Compliance with Instructions Refusal of Treatment Financial Charges Hospital Rules and Regulations Respect and Consideration Pain Assessment and Management

19. Page 19 Honoring Diversity Watch for signs of communication misunderstandings. Identify and record a patient’s primary language and dialect in HealthConnect. Be patient and respectful of culture and language differences. Consider that cultural issues may exist for illness or treatment plans. Know how use Santa Rosa language assistance resources – ask your supervisor or check the intranet page. “Diversity at KP is not an initiative; it is who we are as an organization from the boardroom to the hospital room.” George C. Halvorson, Former Chairman & CEO Kaiser Permanente

20. Page 20 Kaiser Permanente Compliance

21. Page 21 Loss of trust and good reputation Loss of community respect Exclusion from federal programs (Medicare and Medicaid) Fines, penalties, sanctions, and potential prosecution Increased government oversight Possible loss of our accreditations Disciplinary action and/or termination of employees Federal, state, and local laws/regulations Federal health care program requirements Licensing & Accreditation standards IRS requirements (non-profit status) KP Policies & Procedures It is …… Doing the Right Thing! Compliance means to fully adhere to: What does compliance mean?

22. Page 22 Protect the health and safety of patients and employees Continue KP’s mission of providing Quality and Affordable Healthcare Ensure continuity of services without interruption by maintaining accreditation and licensing Importance of Compliance

23. Page 23 The Compliance Community Daniel Garcia Chief Compliance Officer National KP Cris MacKenzie Compliance / Privacy Officer Marin /Sonoma Your immediate supervisor Your HR representative Your compliance office Maura Anderson (707-393-2846) KP Compliance Hotline (1-888-774-9100) Your Union representatives Compliance at Kaiser Permanente

24. Page 24 Communicates KP’s expectations at work so we know how to do the right thing ! Applies to everyone including volunteers and contractors Presents a summary of laws and regulations governing health care organizations Protects against Fraud, Waste & Abuse Reminds employees to avoid conflicts of interest and to protect organizational assets Condition of employment at Kaiser Permanente Kaiser Permanente Principles of Responsibility (Code of Conduct)

25. Page 25 Your Responsibility to Prevent Fraud What does this mean for you? Recognize unusual behaviors or areas that could lead to potential fraud, waste & abuse Report to Compliance & Privacy Officer areas you identified posing a risk for fraud, waste & abuse Follow KP’s Policies, communicate concerns to your supervisor, HR or Compliance & Privacy Officer 3 1 2 You are expected to identify and report potential fraud, waste & abuse

26. Page 26 Six Principles to help insure privacy and security of patient information 1.“Need to know” – only access, use or disclose patient information needed to do your job. You cannot access your own record or those of family members in KP HealthConnect. 2.“Minimum Necessary” – only access, use or disclose minimum information needed to do your job. 3.Safeguard patients’ information as if it were your own. This applies to electronic, written and verbal information. 4.Report to your supervisor or Compliance Officer immediately when you have concerns or observed situations impacting privacy of individual patients or organizational expectations. 5.Never Assume - Confirm that PHI (Protected Health Information) is necessary information. If you don’t know ask your supervisor or Compliance Officer. 6.Golden Rule - Always treat patient information as if it were your own and a patient’s important personal matter.

27. Page 27 Safety

28. Page 28 Safety Motto SAFETY FIRST, Then TEAMWORK!

29. Page 29 Santa Rosa’s Safety Team Environmental Health & Workplace Safety Manager: Judi Goodin, RN Environmental Health & Safety (E H & S) Coordinator: Tammy Marshall E H & S Department Secretary: Laura Settlemyer Emergency Preparedness: Gabe Kearney Work Place Safety (WPS) Specialist: Bill Fitchett WPS Project Manager: Nancy Abela If Needed Dial “3-6000” - Off Sites 8-533-6000

30. Page 30 Orientation: No employee should be expected to work without orientation. Safety: Never undertake a job that is unsafe. Chemicals : Never use chemicals without safety knowledge and skills. Reporting : Report unsafe conditions. Injuries: Report within 24 hours. PPE: Use Personal Protective Equipment Injury and Illness Prevention

31. Page 31 Notify within 24 hours Call Employee Health (EH) for Visit or Phone Consultation. EH makes Medical Referrals Provide Manager with VOT (Verification of Treatment). If Injury NOT FIRST AID receive DWC-1 Form (Workers Compensation Claim Form). Only report to the Emergency Department if the Injury is Emergent such as: Exposure to Eyes, Sharps, Critical Injury. Injury Reporting

32. Page 32 Wash hands or use alcohol de-germer before and after patient contact, and after removal of personal protective equipment (PPE). After every patient with Clostridium difficile (C. diff), you must wash hands with soap and water. Alcohol de-germer does not kill C. diff spores. Wash hands with soap and water for at least 15 seconds. Infection Control: Hand Hygiene

33. Page 33 Protect yourself and our patients No food or drink is permitted in patient care areas, where lab specimens are set, in the presence of patients or visitors, or at clinical computer stations. Clean up small liquid biohazard/blood spills and allow to air dry. Call EVS for large biohazard/blood spills. Contact your Supervisor/Manager or the Safety Department (393-6000) if you are uncertain how to clean-up a chemical spill or dispose of spill clean-up debris. If you have a needle stick or eye injury, immediately contact your Manager for guidance, and report to Employee Health, if open, or Emergency Department, within 1 hour to assess need for prophylactic treatment.

34. Page 34 R Rescue/Remove A Alarm C Confine/Contain E Extinguish Code Red – if there’s a fire…

35. Page 35 Protect-in-Place vs. Evacuate Protect in Place: Hospital and Outpatient Surgical Dept.- MOB-5 Assess Area for Smoke or Fire Pull Alarm & call x3-6000 or 8-533-6000 Evacuate only if ordered - Do not use elevators: * 1st horizontally to closest fire compartment * 2nd down to next floor * 3rd to outside Evacuate: All Medical Office Buildings (except the Outpatient Surgery Department at MOB 5) Support Services Building EVACUATION IS AUTOMATIC Coolly - calmly leave by nearest safe exit. Proceed to evacuation relocation area.

36. Page 36 Code Triage Code Triage Will Be Paged Overhead for: ACCIDENTS EARTHQUAKE EMERGENCY FLOODS Return immediately to your department. Be prepared to be assigned to help.

37. Page 37 A Code Pink / Purple is paged overhead if an infant (Pink) or child (Purple) is missing or is being abducted or there is any unusual activity related to infants or children. Prevention  Green Identification Badges in Maternal Child.  Security Officer on duty 24-7.  Must swipe in or sign out a security card to enter. Actions for suspicious activity  Call 3-6000 report.  Off-sites – call 393-6000; MOB 4/5 & Rohnert Park, use phone intercom to page “Code Pink / Purple” overhead. Actions when Code Pink or Code Purple is announced  Go to pre-assigned area to monitor.  Go to nearest exit or stairwell.  Ask everyone to stay and not leave until the “all clear” is paged. Code Pink / Purple

38. Page 38 A Code Blue is called when a patient is not breathing, has no pulse and/ or needs CPR. Bicentennial Campus: CALL OUT “CODE BLUE” DIAL extension 36000, say “CODE BLUE” All other locations: DIAL 911 for offsite locations Code Blue

39. Page 39 Code Gray A Code Gray is called when you are threatened or are concerned for the safety of yourself or others due to a combative individual. On the main campus, call 3-5888, say “Code Gray.” At MOB 4, 5 and Rohnert Park, call 8-533-5888. For all other locations, or if there are weapons involved, call 9-911. Security will arrive on the scene to evaluate, stabilize or de-escalate the situation. Be prepared to: Give your name, extension and identify exact location of the incident. Describe if the situation is physical or verbal in nature. Identify if there are weapons involved. Give a brief description of the subjects involved.

40. Page 40 Code Silver A Code Silver should be called when confronted with a person with a weapon or in a hostage situation. Call 9-911. Call Security at 3-5888 (or 8-533-5888 if offsite location) and state “Code Silver”. State your location, name, number of individuals and types of weapons involved. All staff near the incident area should not go to the location indicated as this is an extremely dangerous and sensitive situation that should only be handled by trained experts.

41. Page 41 Code Green A Code Green is called when an At Risk Patient* elopes (leaves without permission while undergoing treatment). If you determine or suspect that an at risk patient has eloped  Dial Operator (PBX) x 3-6000 and provide: Department and floor, description of patient (gender, age, clothing). Provide your name and location  Dial Security at 3-5888 and provide: Department and floor, description of patient (gender, age, clothing, include ethnicity, if known), last known location and/or direction of travel. Provide your name, location, and contact number When a Code Green is called overhead:  Conduct an immediate and thorough search of surrounding area, including stairwells and exit locations. Patient may be in dark green disposable scrubs or a dark green gown.  Hospital and clinic staff: Monitor exterior exits as assigned in Code Green policy.  If you see the eloping patient, dial Security at 3-5888 and state the patient’s location * “AT RISK PATIENT” is a patient who cannot be safely released from the ED or Hospital as a result of a mental disorder, presents danger to him/herself or others, or is gravely disabled.

42. Page 42 Abuse Reporting Requirements Child Abuse Reporting Requirements California State Law requires reporting of suspected child abuse. Kaiser Permanente Santa Rosa has a policy, “Abuse Reporting,” that provides resources to learn to recognize potential abuse, how to get help in making the decision to report, and how to report. This policy is located on our intranet (policies tab/ policy and procedure manager). When in doubt, notify your supervisor if you believe that you may need to report suspected child abuse. Dependent And Elder Abuse Reporting Requirements Kaiser Permanente requires that you understand how to report any signs of abusive treatment of patients. If you find yourself in a situation at work where you suspect evidence of abuse, please refer to the local policy, “Abuse Reporting.” It will help you identify definitions, reporting procedures, and who to call to assist you with the process.

43. Page 43 Security

44. Page 44 Security Services: Santa Rosa Parking Policy It’s Simple – For 401 Bicentennial Way: Monday through Friday  Between 6:30 A.M. AND 6:00 P.M.  Park in the Garage; Students park at MOB 5 & use Shuttle  Lower Level is physicians only Weekends/Holidays:  May park anywhere on campus  Excluding designated handicapped spaces Decals are required for all personnel.

45. Page 45 No Smoking Policy  We are a smoke-free campus, including e-cigarettes.  Smoking is not permitted on Kaiser Permanente property.

46. Page 46 Employee Identification Badges  Photo ID badge must be visible and worn above the waist at all times while working at the medical center.  Badges are obtained at the Security Office from 8:00 am to 4:00 pm in the Hospital Lower Level.  Be aware of those around you – question strangers.

47. Page 47 Message from Leadership Message from Leadership: It is expected that all personnel complete annual requirements within the appropriate time frames. Influenza vaccination/mist or declination as well as required trainings including Corporate Compliance, must be completed by the posted deadline date. Annual TB screening must be completed within 10 days of expiration date. There is a 30-day window for satisfying the Annual Safety Training. Failure to complete the requirements within a reasonable period of time will be considered a voluntary termination. We are committed to Safety. Any workplace injury/illness regardless of the apparent severity must be reported immediately to the manager/designee. Any employee who identifies a risk and/or is involved in an incident that could lead to an injury/illness is expected to advise the manager/designee as soon as possible and no more than 24 hours after the event. If you have any questions about the expectations, please speak with your manager or a member of the Leadership Team. Acknowledgment: I have reviewed and understand this document and the related applicable documents/ policies. I understand my responsibilities to comply with these requirements/policies and I agree to abide by these requirements. I further understand that if I have any questions, I will speak with my manager for clarification.

48. Page 48 Resources Emergency Preparedness Procedures – Rainbow Emergency Chart Santa Rosa’s Intranet site http://kpnet.kp.org/ncal/santarosa/ Santa Rosa’s Internet site http://mydoctor.kaiserpermanente.org/ncal/facilities/region/santarosa /area_master/home/ My Doctor online http://mydoctor.kaiserpermanente.org/ncal/mdo/