2016 - Los Angeles County, California


2016Orientation/Reorientation HandbookDaniel CastilloChief Executive OfficerLos Angeles County – Department of Health Services

This handbook was prepared as collaborative effort of many individuals.We appreciate their contributions.ContributorsRoberto Avitia, RNJackie Carter, RNMonique OrtegaWalter CastilloSharon RobinsonLa Tonya CallowayChi FongPat Hokama, PT, MBAFernando BravoVictoria E. Walsh, RNMarie PecsonAnnie Marquez, RNPaul Holtom, MDEric Wei, MDGregory Van DamKimberly KilpatrickJennifer PappLaura Rinard, CPANina Vasillian, MPH, MCHESMaria Elena GaitanRisk ManagementPain ManagementHuman ResourcesHuman ResourcesDHS Human ResourcesDHS Human ResourcesDHS Risk ManagementRehabilitation ServicesCultural and Linguistic CenterAccreditation and Policy ManagementSurgical ServicesPsychiatric ServicesInfection Prevention and ControlPatient SafetyFacilities ManagementNutrition and Food ServicesDHS Audit & ComplianceDHS Human ResourcesDHS Office of Diversity and Cultural CompetencyDHS Human ResourcesProduced by DHS Human ResourcesOffice of Regulatory CompliancePublication SupportIrma OrtegaRevisedDecember 2015

QUICK REFERENCELAC USC Medical Center1200 North State StreetLos Angeles, CA 90033Department(323) 226-2622(323) 409-1000Contact PersonPhone NumberChief Executive OfficerDaniel Castillo, MHA, FACHE, FACMPE(323) 409-2800Chief Operating OfficerHenry Ornelas(323) 409-3162Chief Medical OfficerBrad Spellberg, MD(323) 409-6734Chief Nursing OfficerIsabel Milan, RN(323) 409-6747Interim Chief Financial OfficerMark Corbet(323) 409-6871Chief Information OfficerOscar Autelli(323) 409-6866Chief Clinical Operations OfficerBonnie Bilitch, RN(323) 409-2808Augustus HawkinsNursing Office(310) 668-8151Admission/Bed ControlAl Castillo(323) 409-5327Appointment Center (make/cancel)Shawn McGowan, RN(323) 226-5111Chaplains: Spiritual CareFather Chris Ponnet(323) 409-4715Clinical Social WorkLawrence Schneider, LCSW(323) 409-5253College of Nursing & Allied HealthBarbara Collier, RN, MEd(323) 226-6511Command CenterChristopher Celentano, MD(323) 409-1443Compliance OfficerCecil Clark(323) 409-4242County Sheriff DepartmentSergeant Martha Kennison(323) 226-4126Cultural and Linguistic CenterFernando Bravo(323) 226-5537Customer Service CenterShawn McGowan, RN(800) 341-9211DHS Risk ManagementEdgar Soto(323) 869-7124Health, Safety & EnvironmentalGeneral Line(323) 890-7514Return to WorkLeticia Gordo(323) 869-7111Claims & OperationsGeneral Line(323) 890-8482Diagnostic ServicesDaniel Amaya(323) 409-7291DietaryKimberly Kilpatrick(323) 409-6901Drug Information CenterKevin Wiseman, MD(323) 226-7741Employee Health ServicesShawn McGowan, RN(323) 226-5236Epidemiology/Infection ControlPaul Holtom, MD(323) 409-6705Expenditure ManagementRusty Thomsen(323) 226-2400Facility Accreditation/Policy ManagementVictoria Walsh, RN(323) 226-6370Facilities ManagementGus Pizarro(323) 226-6873Graduate Medical EducationLawrence Opas, MD(323) 409-6931LAC USC Medical Center Administration

DepartmentContact PersonPhone NumberHealth Information Management (HIM)Shirley Lewis(323) 226-6911HIPAA Compliance CoordinatorLubna Ahmed(323) 226-6100HIPAA Security CoordinatorSedik Shamoradian(323) 226-6265Monique Ortega(323) 226-8207Human ResourcesHR Satellite Office, Personnel OfficerDHS Employee Relations(323) 869-7132DHS HR Operations(323) 890-8315DHS Payroll(323) 890-8383DHS Performance ManagementJoi Williams(323) 890-7928DHS Recruitment & ExaminationMarilyn Hawkins(323) 890-7937DHS Regulatory ComplianceSharon Robinson(323) 869-8001DHS Time CollectionHelp Desk(626) 293-1415DHS Training & DevelopmentLewis Lewis(323) 890-7753Infection Prevention & ControlPaul Holtom, MD(323) 409-6645Information SystemsOscar Autelli, CIO(323) 409-6866Directory AssistanceOscar Autelli, CIO(323) 409-1000General Public InformationRosa Saca, RN(323) 226-2622IT Help DeskEdward Tamer(323) 409-2100IT InformationEdward Tamer(323) 409-6866Pager OperatorKinly Kao(323) 409-4906Patient InformationFernando Bravo(323) 409-5800LAC USC Medical Center ReferralBehnaz Hekmatnia(800) 341-9211Labs and PathologyIra Shulman, MD(323) 409-7148Blood BankIra Shulman, MD(323) 409-7134Core LabMichael Chan, PhD(323) 409-7033CytologyJuan Felix, Chief(323) 409-3001Frozen SectionChandra Soma, Chief(323) 409-4606MicrobiologyIra Shulman, MD(323) 409-7012Medical AdministrationBrad Spellberg, MD(323) 409-6734Medical Library ResourcesBella Kwong(323) 409-7006Medicine/Women & Children ServicesSandy Correa(323) 409-2809Nursing AdministrationIsabel Milan, RN(323) 409-6747Nurse EpidemiologistsPaul Holtom, MD(323) 409-6645Nurse Recruitment & RetentionEsperanza Perez(323) 409-4664Palliative CareEve Cruz, RN(323) 409-8532Patient and Guest RelationsFernando Bravo(323) 409-6959

DepartmentContact PersonPatient Resource CenterPhone Number(323) 226-5402Patient Safety OfficerEric Wei, MD(323) 409-6535PharmacyAmy Gutierrez, Pharm.D(323) 409-6763Psychiatric ServicesChristopher Arevalo(323) 409-6861Public InformationRosa Saca, RN(323) 409-6899Quality ImprovementLaura Sarff, RN(323) 409-6738Radiology, General ReceptionDaniel Amaya(323) 409-7292AngioEfrain Carranza(323) 409-7266CTHector Huerta(323) 409-7202MammographyIsabel Ramos(323) 409-2531MRIWendy O’Connor(323) 409-1290Nuclear MedicineLynn Jacobs(323) 409-7855UltrasoundSong Seung or Gilbert Montejo(323) 409-1571Referral OfficeBehnaz Hekmatnia(800) 341-9211Regulatory AffairsRamon Sanchez(323) 226-3679Rehabilitation ServicesPat Hokama, PT(323) 409-5096Revenue Management(323) 226-7773Risk ManagementRoberto Avitia, RN(323) 226-2586Safety OfficerGregory Van Dam(323) 409-7485Supply Chain OperationsDolores Gonzalez(323) 226-5305Support ServicesCecil Clark(323) 409-4242TB ControlYesenia Eras(323) 226-7962STD ControlTerry Miller, RN(323) 226-5252Volunteer ServicesCoco Ceja(323) 409-6945Surgical ServicesMarie Pecson(323) 409-3501HotlinesAdverse Drug Reaction (ADR)(323) 226-2246Child Abuse(800) 540-4000DHS Compliance/HIPAA(800) 711-5366DHS Patient Safety(213) 989-7233DHS Quality Improvement Program(800) 611-4365Domestic Violence/Intimate Partner(800) 978-3600Elder Abuse/Adult Abuse(877) 477-3646Fraud (LA County)(800) 544-6861

HotlinesThe Joint Commission(800) 994-6610L.A. County Sheriff Department(323) 226-3333Patient Safety(323) 226-SAFE (7233)Poison Center(800) 411-8080Safely Surrendered Baby(877) 222-9723Suicide Prevention(877) 727-4747

TABLE OF CONTENTSLAC USC MEDICAL CENTER1Introduction . 1History Highlights . 1Mission, Vision and Values . 2Los Angeles County Strategic Plan . 3CUSTOMER SERVICE4Customer Service Philosophy. 4AIDET . 5Teamwork. 6Effective Workplace Communication . 6Principles of Interdisciplinary Collaboration . 7Coordination of Care . 7Conflict Resolution through Team Building . 8THE JOINT COMMISSION9The Joint Commission’s Focus on Patient Safety and Quality Care . 9Survey Process . 9The Joint Commission Accreditation Participation Requirements (APR09.02.01). 10PATIENT SAFETY PROGRAM11LAC USC Medical Center Patient Safety Plan. 11Safe and Just Culture . 11Deteriorating Patient Condition. 12Fall Prevention and Response . 13National Patient Safety Goals . 15STAFF RIGHTS AND RESPONSIBILITIES20DHS Workforce Member Emergency Protocol . 20Staff Rights . 21DHS Compliance Program and Code of Conduct . 21False Claims Act . 22Procurement Process . 25Training and Competency . 26Professional Credentials (License/Certification/Registration/Permit) . 26Criminal Background Checks. 27Professional Appearance . 28Attendance/Tardiness . 28LAC USC Medical Center

Health Screening . 29Smoke-Free Environment . 29Employee Assistance Program (County Employees Only) . 29County Policy of Equity . 29Cultural and Linguistic Competence . 32Threat Management “Zero Tolerance” . 37Workforce Behavioral Expectations. 38Abuse Prevention, Sexual Abuse, Sexual Coercion (Inappropriate BehaviorTowards a Patient) . 39Reporting of Abuse/Neglect Incidents . 40Reporting Suspicious Injuries . 41Americans with Disabilities Act (ADA) . 41Safe Haven/Safely Surrendered Baby (SSB) Law . 42PATIENTS’ RIGHTS AND SERVICES43Patients’ Rights . 43Augustus F. Hawkins Family Mental Health Center – Patients’ Rights . 45Patients’ Responsibilites . 47Patient Relations Representatives . 47Interpreter Services . 47Spiritual Needs of Patients . 48Advance Health Care Directives . 49Americans with Disabilities Act (ADA) . 49Service Animals . 49Organ/Tissue Donation . 50Emergency Medical Treatment and Active Labor Act (EMTALA) . 51PERFORMANCE IMPROVEMENT52Performance Improvement Activities . 53ORYX Initiative/Core Measures . 53RISK MANAGEMENT55Reporting Near Miss, Adverse and Sentinel Events . 55Reportable Unusual Occurrences . 57Timely Reporting . 57Documentation – A Key Defense . 58Subpoenas and Summons . 59ENVIRONMENT OF CARE60Workforce Safety Program . 60Emergency Codes . 60LAC USC Medical Center

Security . 62Safety Awareness . 63Infant/Child Abduction (Code Pink/Purple) . 63Bomb Threats (Code Yellow). 63Weapons . 64Workplace Violence . 64Hazardous Materials/Hazard Communication . 64Radiation Exposure . 66Emergency Preparedness and Management . 66Emergency Transport (Carries) . 67Fire/Life Safety . 68Medical Equipment and Utilities . 69Reporting Work-Related Injuries/Illnesses. 70Injury and Illness Prevention Program (IIPP) . 71Body Mechanics . 71Guidelines for Decreasing Musculoskeletal Injury . 71Ergonomics . 73INFECTION PREVENTION & CONTROL75Standard Precautions . 75Hand Hygiene . 75Respiratory Hygiene/Cough Etiquette . 77Isolation Precautions . 78Meticulous Cleaning . 79Waste Disposal Guidelines . 80Communication . 80Education . 81Evaluation . 81Hospital Acquired Infection Surveillance . 81Multi Drug Resistant Organisms (MDROs) . 83Methicillin-Resistant Staphylococcus Aureus (MRSA) . 83Vancomycin-Resistant Enterococci (VRE) . 84Blood-Borne Pathogen Control Plan . 84Preventing Sharps Injuries. 85Safe Injection Practices . 85Injection Safety Tips for Providers . 86Vaccinations . 86Seasonal Influenza. 87Tuberculosis (TB) Control Plan . 87Airborne Transmissible Disease Plan . 88Pandemic Influenza Plan . 89LAC USC Medical Center

MANAGEMENT OF INFORMATION91Confidentiality of Patient Information (HIPAA) .

LAC USC Medical Center 1200 North State Street Los Angeles, CA 90033 (323) 226-2622 (323) 409-1000 Department Contact Person Phone Number LAC USC Medical Center Administration Chief Executive Officer Daniel Castillo, MHA, FACHE, FACMPE (323) 409-