(CORPORATE) ESSENTIALS OF ORIENTATION 2022

Name:(Print) Signature:
SALVADOR GONZALEZ, Payroll Coordinator
Date: Vendor/Agency/Academic Affiliation:
05/21/2022 PHMI
Score: Reviewer:

Welcome to Prime Healthcare and we’re glad you’re here! The Essentials of Orientation Module is intended to
give you an overview of important guidelines and general safety information while being on a Prime Healthcare
campus.
All employees, contracted employees, vendors, and academic affiliates of Prime Healthcare are required to
complete the Essentials of Orientation module. An employee who completes the hospital-based annual
mandatories and competencies will only need to complete this module upon hire. Contracted employees,
vendors and academic affiliates must complete this module upon hire and annually. The information in this
module is designed to support the information given in the General Orientation Program and does not serve as a
replacement for a full orientation or a competency validation for clinical skills. Arrangements can be made for
accommodations for special needs or instruction.

Upon Hire or
Entry into
System

Essentials
Packet
Annually

Do you have
HealthStream?

YES NO

Follow Use the Essentials

Rapid Regs & Annually
Corporate Plan

DIRECTIONS
1. Read the self-learning “Essentials” thoroughly.
2. Complete the Post Test (circle the correct answer) and complete the evaluation form.
3. Submit the Post Test and evaluation form to your HR Department.

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THIS IS PRIME HEALTHCARE
Promise: To provide compassionate care and clinical excellence to all patients and create hospitals that
improve healthcare in every community we serve.
Mission: To save and improve hospitals so that they can deliver compassionate quality care to patients and
better healthcare for our communities.
Values: Our values are
▪ Quality: We are committed to always providing exceptional care and performance.
▪ Compassion: We deliver patient centered healthcare with compassion, dignity and respect for
every patient and their family.
▪ Community: We are honored to be trusted partners who serve, give back and grow with our
communities.
▪ Physician Led: We are a uniquely physician founded, and physician led organization that
allows doctors and clinicians to direct healthcare at every level.

AIDET+
AIDET+ is a communication framework used in healthcare to communicate with other healthcare professionals
and patients. It can be used by every department and discipline. It can improve the patient experience by helping
to form a trusting relationship.
A = Acknowledge Greet everyone by name; make eye
contact.
I = Introduce Introduce yourself and others. Manage
up whenever possible.
D = Dialogue Dialogue about expectations including
duration, preferences, and concerns.
Use reflective listening.
E = Education/Empathy Explain what to expect next, answer
questions and elicit potential barriers
the patient may face that need follow-
though. Use empathy when emotions
arise.
N= Name the emotion
V= Validate the emotion
A= Acknowledge/use blameless
apology
R= Reassure
T = Thank You Express gratitude for their time and for
choosing Prime Healthcare.
+ = Go above and beyond Connect with patients and loved ones.
Whenever possible go above and
beyond in creating a positive and
memorable moment.
Good Morning Mr. Jones
My name is Sheila Carter, and I am a
Registered Dietician. I will be helping
you learn more about diet modifications
that will help you with your high blood
pressure.
I will be meeting with you each day you
are in the hospital for about 10 minutes.
First, I will be asking you some questions
about your current dietary habits and
then we will work together to find a plan
that works for you.
If emotions arise:
It sounds like you’re scared. Most people
in your position would feel the way you
do. I’m here for you.
It has been a pleasure spending time
with you this morning. Thank you for
choosing Prime Healthcare.
Say a brief person-centered comment
early on whenever possible.
I see that you’re reading about airplanes
Mr. Jones. My uncle is a pilot and I find
aviation fascinating!

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CORPORATE COMPLIANCE
Corporate Compliance ensures that we have adequate internal controls to prevent and detect violations of the
law. You can discuss any concerns with your supervisor/manager or call your Corporate Compliance Officer, HR
Manager, Chief Medical Officer, Administration/Chief Nursing Officer, or the Compliance Line at (877) 350-5827
without fear of retaliation.

PATIENT EXPERIENCE
At Prime Healthcare, our primary duty is to care for patients who need hope and healing. We proactively work to
improve the patient experience by engaging and educating our staff on these service fundamentals:

Elevating our Service Delivery:

10’ – 5’ Rule
• At 10 feet make eye contact and smile
• At 5 feet say "Hello" to everyone - patient, visitors, and staff - every time
Caring Communication
• Point your heart toward the person you’re communicating with
• Have a seat – helps you have more of a personal connection
• Conveys “I care about you. I want to help.”
• Tell me one thing about you
Purposeful Rounding
• Recognizes the great work people are doing everyday
• Celebrate the wins and recognize opportunities for improvement
• Allows us to get first-hand information in real time from those we serve

HCAHPS - A Better Outcome is Associated with a Better Experience

• The acronym stands for Hospital Consumer Assessment of Healthcare Providers and Systems.
• The HCAHPS is a survey required by CMS (Center for Medicare and Medicaid Services – The Federal
Government) for all hospitals. The survey impacts financial reimbursements through Value Based
Purchasing (VBP).
• The HCAHPS survey asks many questions related to How Can we Always Help Patients (and Providers)
succeed?
• Patients who rate us highly have the following positive correlations:
o Reduced rate of readmissions
o Improved patient safety and quality
o Better clinical outcomes
o Fewer malpractice claims
o Less healthcare resource use
o Improved adherence to recommended treatment
o Better adherence to preventative care

Service Recovery 4A Model

Anticipate:
Anticipate or recognize a potential concern and act to prevent or reduce the impact
• Put yourself in the patient’s place
• Read their body language
• Be sensitive

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Acknowledge:
The prompt, sincere acknowledgement of a concern.
Acknowledge their concerns - sit down, maintain eye contact, listen carefully to the whole story
Remember- separate yourself from your emotions
• Summarize what you hear to confirm understanding
• Empathize
• Take ownership
• Resolve the complaint
• Remember – perception is reality

Apologize:
Apologize for their experience.
• Express concern and provide a genuine apology
• Thank the patient or family member for bringing the issue to your attention
o “I am so sorry that happened. We don’t want that to happen here at ____. Thank you for
letting us know so we can improve.”
o “I am so glad you told me about this.”

Act:
Act by taking responsibility for solving a concern. Own it and do your best to fix it.”
• Offer solutions, ask the patient if they agree with the suggested resolution
• Keep the patient informed
• Communicate the concern to other team members
• Resolve the problem – take the necessary action and involve others as needed
• Ask if there is anything else that we can do
• Write a personal note if appropriate.
o “Thank you for telling me about this problem. Please accept my sincere apologies.”
o “I am so sorry that you were inconvenienced. Please accept my personal apology.”

We Each Have A Role to Play in Improving the Patient, Family and Staff Experience.
Whether we are caring for a patient face-to-face in a small or large facility, we want every person we encounter to
feel supported and well cared for. Moment by moment, each decision or interaction builds a relationship of trust
and caring. As we work toward our goal of being the best, we must sharpen our focus on delivering consistent,
compassionate, and exceptional experiences for patients and their families. Thank you for making a positive
difference for our patients and team.

“Patient Experience is everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA):

EMTALA is a federal law that mandates medical screening and stabilization requirements before a patient can be
transferred to another facility. The purpose is to require proper screening and care of a person regardless of
their ability to pay for the services. Any potential violations should be reported to the supervisor immediately.
EMTALA violations may be subject to hospital fines, physician fines or termination of a hospital’s Medicare
Provider Agreement.

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HIPAA & CONFIDENTIALITY (Health Insurance Portability and Accountability Act of 1996):
All hospital personnel are obligated to protect patient privacy rights, securing Protected Health
Information (PHI) in any form: electronic, paper, oral, CD, flash drive or by any other means. We value the
confidentiality of our patients and information systems. PHI is given only to those who have an
appropriate and authorized need for the information. Patients have a right to privacy. If you see a breach
in patient confidentiality, please report it to your immediate supervisor/manager. Breaches in patient
confidentiality can lead to employee discipline including termination and legal actions.

PATIENT GRIEVANCES
If a patient has a concern, everything should be done to address and resolve the concern while the patient is
still in our hospital. If you are not a Prime Healthcare employee, please report the issue or potential issue to
the appropriate staff member. Please use the chain of command so that the management team may assist
you with the concern as well. Be aware that patients can also file a complaint with the state Department of
Health or The Joint Commission. Work to make things right and follow up to ensure we have corrected the
problem. Always follow the complaint and grievance policy.

TEAM BUILDING
Prime Healthcare prides itself on collaborative multi-disciplinary care provided by highly effective teams. Team
building is an important piece of this process. Effective teams set clear goals, evaluate progress, plan ahead, take
advantage of individual talents, clarify roles, and share leadership. This requires advocacy, effective
communication, active listening, and constructive feedback.

EMPLOYEE HEALTH
BODY MECHANICS/ERGONOMICS
It is always important to use proper body mechanics in order to prevent injury. The back muscles are weaker
than the leg muscles. When picking up objects, assess the load. If it is too heavy, get help. Bend knees, hold
object(s) close to the body, keep the back straight, tighten abdominal muscles, lift with the legs, and avoid
twisting motions of the trunk. It is safer to push rather than pull. Utilize safe patient handling devices when
appropriate. Do not jeopardize safety to save time.

BLOOD BORNE PATHOGENS

OSHA
OSHA Blood borne Pathogens Rule:
To prevent transmission of serious infections, such as human immunodeficiency virus (HIV), Hepatitis B and
Hepatitis C, the hospital has a Blood borne Pathogens Exposure Plan. You can access this plan in the Infection
Control Policy Manual, from the hospital’s intranet home page. Standard Precautions are the cornerstone of this
plan. This includes hand hygiene and respiratory etiquette, plus Hepatitis B vaccination, safe handling of sharps,
use of personal protective equipment (PPE) to prevent exposure to blood or body fluids, and emergency care in
the event of accidental exposure.
Blood & Body Fluid Exposure:
Exposure to blood or body fluids through a sharp’s injury, mucous membranes (eyes, nose or mouth) or through
non- intact skin is a medical emergency. If this occurs, the employee should notify the supervisor/manager to
obtain relief from an assignment, conduct appropriate hand off, and proceed to the Emergency Department. This
needs to be done quickly because medications might be recommended to prevent HIV infection. These work best
if given within 1 (one) to 2 (two) hours after the incident. Healthcare workers must understand that exposure to

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blood and body fluids either through a break in the skin or a splash or spray to the eyes, nose, or mouth, is a
medical emergency. All employees should review the policy related to blood & body fluid exposure.
Sharps Safety
Focus on the task at hand whenever using a needle or other sharp instrument. Identify where the sharps
container is in the room prior to using a sharp instrument. When using a sharp, deploy the safety mechanism
correctly and drop the instrument into a sharp’s container, keeping hands away from the opening. Replace the
sharps container as soon as the contents reach the fill line.
Personal Protective Equipment (PPE)
The hospital supplies PPE, such as gloves, gowns, masks, visors, respirators, face shields and goggles. Before
performing patient care, think about whether the task will pose a risk of exposure to blood or body fluids and put
on whatever is needed to prevent exposure. Do not make this decision based on whether you think the patient
may have a disease. Act on the assumption that every patient you encounter could have a blood borne pathogen.
Remove PPE with care to prevent contaminating yourself; then perform hand hygiene.

EMPLOYEE VACCINATION/TESTING
Immunizations, as specifically recommended for health care workers by the CDC, are provided to employees by
the hospital. This includes the annual seasonal Influenza vaccination and the Hepatitis B vaccination. Hepatitis
B, which can be debilitating or even fatal, is vaccine preventable so every employee is encouraged to complete
the vaccination series with Employee Health. There is no vaccine for HIV or Hepatitis C. Employees who have an
allergy or another personal reason they are not able to comply with a required vaccine should consult with the
Employee Health Department. Employees who receive the influenza vaccination from another healthcare
source must provide Employee Health with evidence of vaccination (see the local policy). Any employee who
has not received the influenza vaccine will be required to wear a mask during the designated influenza season.

COVID-19
COVID-19 is a disease caused by a virus called SARS-CoV-2. Most people with COVID-19 have mild symptoms,
but some people can become severely ill or even die. Although most people with COVID-19 get better within
weeks of illness, some people experience post-COVID conditions. Post-COVID conditions are a wide range of
new, returning, or ongoing health problems people can experience more than four weeks after first being
infected with the virus that causes COVID-19. Older people and those who have certain underlying medical
conditions are more likely to get severely ill from COVID-19.
Prime Healthcare has a comprehensive COVID-19 Safety Plan, which aligns with OSHA’s COVID-19 Emergency
Temporary Standards. At least one COVID-19 Safety Coordinator has been designated for the hospital, who can
assist you in accessing and reviewing the Plan document. Know who your COVID-19 Safety Coordinator is.
The most important thing you can do to prevent contracting or transmitting COVID-19 in the workplace and in
the community is to get fully vaccinated and, if eligible, to receive recommended booster shots. Vaccines
against COVID-19 are safe and effective. The COVID-19 vaccine is free and readily available through Employee
Health.
Do not come to work if you have signs and symptoms of COVID-19 such as loss of sense of taste or smell, or a
fever of 100.4 or higher with a cough or shortness of breath. All employees are required to do a self-
assessment for signs and symptoms of COVID-19 prior to entering our buildings. If you have symptoms, you are
to stay home and contact your direct supervisor and employee health. If you are not an employee, please reach
out to your point of contact at Prime Healthcare to let them know you will not be reporting to campus as
scheduled. You must also report if you have had a significant unprotected exposure to someone who has or is
suspected of having COVID-19. “Exposure” means that you have been within 6 feet of the person for a total of

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15 minutes or more in a 24-hour period. Employees who have not experienced symptoms or been exposed
must complete an attestation of this prior to the start of each shift.
Prime Healthcare continuously monitors infection control guidance from the Centers for Disease Control
related to COVID-19. Policies and procedures are revised frequently. Current policies are housed in SharePoint
Type text here
in the COVID-19 folder.
COVID-19 can be transmitted by droplets and microdroplets. People who are infected may or may not show
signs of illness. To prevent transmission between employees or between employees and patients, all employees
must wear a face cover/facemask while on the premises, unless they are working alone in an office with the
door closed. Except when unavoidable, due to the need for teamwork in providing patient care, employees are
expected to maintain a distance of 6 feet between themselves and others. While fully vaccinated employees
may remove their masks in designated spaces such as break rooms, and may be in close proximity with other
fully vaccinated employees, those who are unvaccinated must wear a mask except to eat or drink, while
maintaining a distance of 6 feet from others. Staggering breaks is a good strategy to facilitate physical
distancing.
Patients are screened for COVID-19 symptoms upon entry and throughout their hospital stay. Unless there is a
medical contraindication, patients are expected to wear a facemask when receiving care or when in the
presence of others. Remind patients to put on their mask when you enter their room. Visitors are screened and
are expected to wear a suitable face cover at all times.
Universal PPE: In communities with substantial to high transmission of COVID-19, a face mask, plus eye
protection (goggles or a face shield) is required to provide care to any patient, regardless of diagnosis. When
present for procedures which could cause respiratory secretions to become aerosolized, wear a NIOSH
approved respirator (N95, PAPR, CAPR or elastomeric respirator), rather than a facemask.
Enhanced Precautions: Patients who have confirmed or suspected COVID-19 are placed on a combination of
Droplet/Airborne and Contact Precautions, plus eye protection. When caring for a patient with suspected or
confirmed COVID-19, the minimum PPE includes a NIOSH approved respirator, goggles or a face shield, a gown
and gloves. Aerosol-generating procedures should be performed in a negative pressure room if one is available.
Following the procedure, surfaces in the room must be disinfected and PPE, including the respirator should be
changed. Disposable PPE should be discarded upon removal. Cloth isolation gowns must be laundered
between use. Face shields should be disinfected upon removal.

ENVIRONMENT OF CARE/SAFETY
GENERAL
• Report all unsafe conditions to your supervisor.
• Electrical system failure: Red plugs are to be used only for emergency power – i.e., all lifesaving
equipment must use red plugs.
• Disruption of overhead paging or telephone service: Use available cell phones.
• Sewer-water system failure: Do not use toilets or water. Conserve available water.
• Safety Data Sheets (SDS) are available 24 hours a day on our portal or by calling 1-800-451-8346. The
SDS have first aid and clean-up procedures for those items used in your department.
• Utility system failure: Notify engineering or after hours call the nursing supervisor.

EMERGENCY MANAGEMENT/DISASTER
All Prime Healthcare facilities utilize the nationally recognized Hospital Incident Command System (HICS) All
Hazards Approach to disaster preparedness. Policies and procedures related to Emergency Management are

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compiled into an Emergency Operations Plan (EOP) manual. The hospital’s EOP is designed to coordinate its
communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and
support activities during an emergency. These policies and procedures are made available 24/7 online and in
printed form. Contact your supervisor or facility Safety Officer for the location of the Incident Command Center
and printed copy of your facility EOP. Participation in coordinated drills is required and helps provide for readiness
and confidence in calmly supporting our patients and staff during an actual event.

DISASTER
During a natural disaster it is important to stay calm – don’t panic. Listen for disaster codes being called and
follow any instructions given by the command center. Protect yourself and move patients away from windows
and areas that may have falling objects. Evacuation must take place horizontally first and then vertical.

FIRE SAFETY
In case of a fire, use the acronym R.A.C.E.
R = Rescue: Assist anyone in immediate danger and help get them to a safe area as quickly as possible,
A = Alarm: Alert others by activating the alarm system,
C = Contain: Contain the fire as much as possible by closing windows and doors behind you as you
evacuate,
E = Extinguish: Only attempt to put out a fire if it is small, and you have the proper equipment to do so.
The acronym P.A.S.S. outlines the proper procedure for using a fire extinguisher.
P = PULL the pin from the fire extinguisher
A = AIM the nozzle toward the base of the fire.
S = SQUEEZE the handle of the fire extinguisher.
S = SWEEP the hose from side to side at the base of the fire.

SECURITY
Report all suspicious activity and thefts to the Security Department immediately.

SMOKING POLICY
Prime Healthcare facilities are smoke-free campuses. This includes entryways to our facilities. If you choose to
smoke, check with Security for an appropriate space off campus grounds where smoking may be permitted.

VIOLENCE PREVENTION
We support a violence-free workplace. Prime Healthcare has a Workplace Violence Prevention Plan that is
accessible to all employees. All incidents of aggressive behavior must be reported whether it involves an injury or
not. Give the person/patient calm, clear and quiet directions. Allow the person to verbalize concerns. Potential
signs of violent behavior are loud, angry speech, pacing that escalates beyond baseline behavior, inappropriate
hand gestures or the presence of a weapon. Special training courses, Behavioral Violence Prevention (BVP
Courses), are held at every Prime facility.

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ETHICS/RIGHTS & RESPONSIBILITIES
CODE OF CONDUCT/ANTI-BULLYING
Studies have indicated that “disruptive and inappropriate behaviors” from staff, physicians, administrators,
as well as other members of the healthcare team can result in medical errors, poor patient satisfaction,
preventable adverse outcomes, increased costs, and higher turnover of staff. Inappropriate behaviors can
be defined as verbal outbursts, physical threats, reluctance, or refusal to answer questions, condescending
language or tone, and impatience with questions. If you are subject to or witness this type of behavior,
please report the behavior immediately to your supervisor, human resources, or to administration. There
are non-retaliation protections for the person reporting the improper behavior. An incident report should be
completed for any incident of bullying or misconduct.

COMMITMENT TO DIVERSITY We value the importance of creating an environment in which all of our
employees, with their diverse backgrounds and identities, can feel valued, included, and empowered. We
recognize that each employee’s uniqueness provides a diverse perspective, and we invite all employees to be
their best self, engaging and collaborating with each other to achieve excellence for those we serve. Therefore,
our goal is to foster an environment that is an incubator for great service, is attractive to the best talent, and that
creates a profound sense of belonging and pride.

CULTURAL DIVERSITY & SENSITIVITY

We work in a culturally diverse setting. Prime Healthcare believes that all staff, physicians, patients, and visitors
have the right to work or heal in a safe, supportive environment that is free from all forms of prejudice,
discrimination, harassment, and abuse. Culturally competent care begins with knowing what your own beliefs
and values are and being comfortable with working or caring for those who have different beliefs and values.
Everyone is entitled to respect and dignity. Resources are available on all clinical units. Please be sensitive to
those around you by communicating with other staff members in English in all work areas.

IMPLICIT BIAS
Implicit Bias refers to a subconscious attitude and/or stereotype that may affect a healthcare worker’s ability to
involuntarily communicate, interact and respond to our patients in a favorable or unfavorable way. It occurs
without the awareness or intention of the individual. Implicit bias is not limited to race. It may also be noted with
gender, religion, socioeconomic class, obesity, age, and many other characteristics where bias can be seen. In
healthcare, implicit bias may lead to disparities. Prime Healthcare has developed policies, education and training
for staff that aide in preventing bias related negative impacts on patient care.

DIVERSITY
Diversity refers to the unique traits that individuals possess. These traits can be understood in two general
ways: Inherent diversity, traits that are central to identity (e.g. race, gender, sexual orientation, disability); and
Acquired diversity, traits that are acquired through experience (e.g. diversity of thought, language, social skills).
Diversity is ways in which organizational culture supports, celebrates, and encourages a variety of experiences,
values, worldviews, and approaches. It is understanding, accepting, and valuing differences between people.

INCLUSION
Inclusion is a state in which all employees feel a sense of belonging, valued for their differences, and empowered
to participate and contribute freely. “Diversity is Being Invited to the Party; Inclusion Is Being Asked to Dance.”

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EQUITY
Equity is an approach that ensures everyone access to the same opportunities. Equality refers to treating all
individuals the same and does not consider individual differences. Equality and Equity are not the same thing.
Equity recognizes that advantages and barriers exist, and that, as a result, we don’t all start from the same place.
Equity focuses on the outcome of “fair treatment.” While equality focuses on equal opportunity, equity takes it a
step further and addresses the accommodations required to achieve a fair outcome. It considers individual
differences.

ALLYSHIP
An ally is any person or group of people that actively promotes and aspires to advance the culture of inclusion
through intentional, positive, and conscious efforts that benefit people as a whole.

PROHIBITING DISCRIMINATION, HARASSMENT, AND RETALIATION

Prime Healthcare prohibits any unwelcome conduct that is based on an individual’s race, religion, color, age, sex
(including pregnancy, childbirth, and medical conditions related to pregnancy, childbirth, or breastfeeding), sex
stereotyping, sexual orientation, gender, gender identity, gender expression, national origin, ancestry, citizenship
status, marital status, physical or mental disability, medical condition, genetic characteristic or information,
military or veteran status, protected activity under the Affordable Care Act, or any other status, conduct, or
classification of an individual or the individual’s associates or relatives that is protected by applicable federal,
state, or local law. Prime Healthcare interprets these statuses broadly to include both the actual status and also
any assumptions and perceptions made regarding these statuses. Therefore, Prime Healthcare prohibits any
employee, manager, supervisor, officer, director, client, vendor, or any other third party that an employee
encounters in connection with business, to harass, discriminate, or retaliate against any employee on the basis of
any legally protected status or activity. Prime Healthcare’s prohibition on employment discrimination and
harassment is extensive, and we invite you to re-review the applicable sections of the Employee Handbook
discussing Prime Healthcare’s prohibition on employment discrimination, harassment and retaliation,
commitment to equal employment opportunities, and policies regarding reasonable accommodations.

PROHIBITED CONDUCT
The conduct prohibited by Prime Healthcare, whether verbal, physical, or visual, includes any discriminatory
employment action and any unwelcome or retaliatory conduct that is inflicted on someone because of that
individual’s protected status. Among the types of unwelcome conduct prohibited by Prime Healthcare are
epithets, slurs, negative stereotyping, intimidating acts, and the circulation or posting of written or graphic
materials that show hostility toward individuals because of their protected status. Prime Healthcare prohibits
such conduct in the workplace, even if the conduct is not sufficiently severe or pervasive to constitute unlawful
harassment.

SEXUAL HARASSMENT
Harassing conduct based on sex or gender can be sexual in nature or not. Prime Healthcare forbids harassment
based on sex or gender regardless of whether the offensive conduct is sexual in nature. Any unwelcome conduct
based on sex or gender is forbidden regardless of whether the individual who engaged in harassment and the
individual who is being harassed are of the same or are of different genders.
Unwelcome sexual advances, requests for sexual favors, and other verbal, physical or visual conduct based on sex
constitute unlawful sexual harassment when (1) submission to such conduct becomes an implicit or explicit term
or condition of employment, (2) submission to or rejection of the conduct is used as the basis for any employment
decision, or (3) the conduct has the purpose or effect of unreasonably interfering with an individual’s work
performance or creating an intimidating, hostile or offensive working environment. Prime Healthcare forbids

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harassment based on sex or gender regardless of whether it rises to the level of a legal violation. Accordingly,
Prime Healthcare prohibits the following conduct in the workplace:
▪ Unwelcome or unwanted sexual advances, flirtations, advances, leering, whistling, touching, pinching,
assault, blocking normal movement;
▪ Requests for sexual favors or demands for sexual favors, such as unwanted sexual advances, which
condition an employment benefit upon an exchange of sexual favors;
▪ Obscene or vulgar gestures, posters, or comments;
▪ Sex-oriented kidding, teasing, or jokes;
▪ Comments about a person’s body, sexual prowess, or sexual deficiencies;
▪ Propositions, or suggestive or insulting comments of a sexual nature;
▪ Graphic or degrading comments about an individual’s appearance or sexual activity;
▪ Offensive visual conduct, including leering, making sexual gestures, and the display of derogatory and/or
sexually suggestive objects, pictures, cartoons, posters, and/or drawings;
▪ Sexually-explicit letters, e-mails voicemails, or other communications;
▪ Offensive physical contact, such as patting, grabbing, pinching, or brushing against another’s body;
▪ Unwelcome sexually-related comments;
▪ Conversations about one’s own or someone else’s sex life;
▪ Conduct or comments consistently targeted at only one gender, even if the content is not sexual;
▪ Sexual favoritism; and
▪ Teasing or other conduct directed toward a person because of the person’s sex or gender.
The above list is not exhaustive of the types of conduct that is unacceptable in the workplace and in any work-
related settings such as business trips and business-related social functions, regardless of whether the conduct is
engaged in by a supervisor, director, manager, department head, co-worker, client, customer, vendor, or other
third party. We invite you to contact Human Resources should you have any questions or concerns that involve
Prime Healthcare’s prohibition on discrimination, harassment, and retaliation.

EMPLOYEE RESPONSIBILITY
Everyone at Prime Healthcare can help assure that our workplace is free from prohibited harassment,
discrimination, and retaliation. Everyone is expected to avoid any behavior or conduct that reasonably could be
interpreted as prohibited harassment, discrimination, and/or retaliation. No employees, not even the highest-
ranking individuals at Prime Healthcare, are exempt from the requirements of Prime Healthcare’s prohibition on
such conduct. Every employee is expected to inform any person in the workplace whose conduct the employee
finds unwelcome.

REPORTING AND INVESTIGATION

All incidents of alleged harassment, discrimination, retaliation, or other conduct inconsistent with this policy must
be reported immediately to your manager or supervisor, Human Resources, Facility CEO, or the confidential
compliance hotline at 877-350-5827. These are the individuals authorized to receive and act upon complaints of
discrimination, harassment, and retaliation on behalf of Prime Healthcare. This policy does not require reporting
discrimination, harassment, or retaliation directly to an employee’s immediate supervisor or to any individual who
is creating the harassment, discrimination, or retaliation. Any department head/director/manager/supervisor who
is aware of conduct inconsistent with Prime Healthcare’s prohibition on discrimination, harassment, and
retaliation or who receive a report of prohibited conduct must report it immediately to Human Resources.

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Upon receipt of any claim of harassment, discrimination or retaliation, Prime Healthcare will immediately conduct
a fair, timely, and thorough investigation. To the extent possible, Prime Healthcare will endeavor to keep the
reporting employee’s concerns confidential. Prime Healthcare will take further appropriate action once the claim
has been reported, including, but not limited to, separating complainants from alleged harassers while the
investigation is ongoing. Upon completion of the investigation, Prime Healthcare will decide whether a violation
has occurred, did not occur, or that Prime Healthcare cannot conclude whether or not a violation occurred.
If an investigation reveals a violation of this policy or other inappropriate conduct has occurred, then Prime
Healthcare will take corrective action, including discipline up to and including dismissal, reassignment, changes in
reporting relationships, training, or other measures Prime Healthcare deems appropriate under the
circumstances, regardless of the job positions of the parties involved. Prime Healthcare may take corrective action
for any inappropriate conduct discovered in its investigation, regardless of whether the conduct amounts to a
violation of law or even a violation of Prime Healthcare’s policies.

NO RETALIATION
No employee will be subject to, and Prime Healthcare prohibits, any form of discipline or retaliation for reporting
perceived violations of Prime Healthcare’s prohibition on discrimination, harassment and retaliation for assisting
another employee or applicant in making such a report, for participating and cooperating in an investigation into
alleged conduct inconsistent with this policy, or for filing and pursuing an administrative claim with the EEOC or a
state governmental agency. All employees who believe they have experienced or witnessed any conduct that they
believe to be retaliatory are to immediately follow the reporting procedures outlined above.

IMPAIRED/DISRUPTIVE STAFF/PHYSICIAN
Prime Healthcare has a policy to identify and manage disruptive physicians and/or staff which may include
suspicion of practicing under the influence of a substance. Please report symptoms of impairment or
disruptive behavior to your immediate supervisor. Signs of impairment that may be observed include physical
state and behavior in the hospital. Examples are as follows:
• Deterioration in personal hygiene
• Deterioration in clothing and dressing habits
• Unusual patterns of prescribing and/or taking prescription dugs
• Frequent visits to physicians and dentists
• Accidents
• Emotional crises
• Making rounds late, or displaying inappropriate, abnormal behavior during rounds
• Decreasing quality of performance, e.g., in staff presentations, writing in charts
• Inappropriate orders or over‐prescription of medications
• Reports of behavioral changes from other personnel
• Involvement in malpractice suits and legal sanctions against hospital
• Unavailability or inappropriate responses to telephone calls
• Hostile, withdrawn, unreasonable behavior to staff and patients
• Complaints by patients to staff about doctor’s or practitioner’s behavior

PATIENT RIGHTS
All patients have the right to high quality care, a clean and safe environment, involvement in their care,
protection of privacy, help with health-related bills and filing of insurance claims. Patients also have the right to

Updated 1/2022 Page 12 of 25

refuse care. We can respect patient rights through patient education, keeping patients informed, encouraging
questions, and providing resources, following HIPAA guidelines, asking for advanced directives and many other
ways. Patients are given a copy of their rights by Admitting and must sign a written acknowledgement of receipt.

STAFF IDENTIFICATION
All employees, affiliates, or contract personnel MUST wear appropriate picture identification (ID badge) at all
times while on the hospital premises. ID badges must be worn above the waist.

STAFF RIGHTS
If a staff member feels that they are having difficulty caring for a patient due to religious or ethical reasons,
the staff member should notify a direct Supervisor/Charge Nurse/Manager to see if reassignment can be
made or further investigation of the issue should occur. Employees may report any concerns about the safety
or quality of care provided in the hospital to the Compliance Officer/hotline (877) 350- 5827 or directly to the
state Workforce Commission.
Employees reporting concerns related to safety or quality issues will not be subject to any disciplinary action
for sharing their concerns. Any attempts at retaliation are prohibited and should be reported to the
Compliance Officer.

PERFORMANCE IMPROVEMENT
We use the FOCUS-PDCA model (Find, Organize, Clarify, Understand, Select, Plan, Do, Check, Act and a
multidisciplinary approach. “Do the right thing. Do the right thing well.” Performance improvement is
everyone’s responsibility. If you notice a process in place that you feel is impeding our ability to provide
high quality care, please provide that information to your immediate supervisor/manager.

CORE MEASURES
Prime Healthcare participates in the following nationally recognized quality core measures that have been created
by the Core Quality Measure Collaborative from the CMS, NQF and the America’s Health Insurance Plans (AHIP).
Following the standard of care for each core measure will provide evidence-based care that leads to high quality
outcomes. It also provides data for value-based payment and purchasing.
1. Sepsis Bundle Project (SEP)
2. Emergency Department (ED)
3. Outpatient (OP)
4. Immunization (IMM)
5. Stroke (STK)
6. Venous Thromboembolism (VTE)
7. Perinatal Care (PC) as applicable
8. Hospital Based Inpatient Psychiatric Services (HBIPS) as applicable
9. Tobacco Treatment (TOB) as applicable
10. Substance Use (SUB) as applicable

Updated 1/2022 Page 13 of 25

PROVISION OF CARE/TREATMENT & SERVICES
2022 NATIONAL PATIENT SAFETY GOALS (NPSG)
Prime Healthcare is committed to providing a safe environment for patients and staff. To achieve this, all staff
must be observant for processes that need to be revised to improve safety.
Goal 1: Improve the accuracy of patient identification
NPSG.01.01.01
Use at least two patient identifiers (Name and Date of Birth) when providing care, treatment, and services.
• Use at least two patient identifiers when administering medications, blood, or blood components,
when collecting blood samples and other specimens for clinical testing and when providing treatments
or procedures.
• Label containers used for blood and other specimens in the presence of the patient.
• Use distinct methods to identify newborn patients.
Goal 2: Improve the effectiveness of communication among caregivers.
NPSG.02.03.01
Report critical results of tests and diagnostic procedures on a timely basis.
Goal 3: Improve the safety of using medications.
NPSG.03.04.01
Label all medications, medication containers and other solutions on and off the sterile field in the peri-
operative and other procedural settings. This applies even if there is only one medication being used.
NPSG.03.05.01
Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
NPSG.03.06.01
Maintain and communicate accurate patient medication information.
Goal 6: Reduce patient harm associated with clinical alarm systems.
NPSG.06.01.01
Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Goal 7: Reduce the risk of health care-associated infections.
NPSG.07.01.01
Comply with either the current Center for Disease Control and Prevention (CDC) hand hygiene guidelines
and/or the current World Health Organization (WHO) hand hygiene guidelines.
Goal 15: The hospital identifies safety risks inherent in its patient population.
NPSG.15.01.01
Reduce the risk for suicide.
Universal Protocol: Prevent mistakes in surgery.
UP.01.01.01
Conduct a pre-procedure verification process.
UP.01.02.01

Updated 1/2022 Page 14 of 25

 Mark the procedure site.
UP 01.03.01
A time-out is performed before procedures.

ABUSE RECOGNITION & REPORTING

Healthcare workers are mandated reporters of suspected abuse.
• Abuse can be physical, emotional, fiduciary (money), neglect or sexual.
• If abuse is suspected the employee should make an immediate telephone report to the police agency
for the jurisdiction in which the incident occurred. Do not call 911 unless an urgent situation exists. A
written report must be sent within 36 hours of discovery for suspected child abuse and within 2
working days for adult/elder abuse and firearm/assaultive/abusive conduct. Social Services needs to
be informed via email or telephone for documentation and follow up. Remember- appropriate
agencies must be contacted immediately when abuse is suspected.

HUMAN TRAFFICKING
Human trafficking is the trade of humans for the purpose of forced labor, sexual slavery, or commercial sexual
exploitation for the trafficker or others. This may encompass providing a spouse in the context of forced marriage,
or the extraction of organs or tissues, including for surrogacy and ova removal. Human trafficking can occur within
a country or trans-nationally. Human trafficking is a crime against the person because of the violation of the
victim's rights of movement through coercion and because of their commercial exploitation. Human trafficking is
the trade in people, especially women and children, and does not necessarily involve the movement of the person
from one place to another.
As a healthcare provider, your role is to identify and respond to individuals who are at risk of trafficking, currently
experiencing trafficking, or who have experienced trafficking using a trauma-informed, person-centered
approach. This includes addressing the individual’s immediate needs, referring them to appropriate services, and
reporting when mandated by state. In every interaction, regardless of your specific role, it is important to follow
the guiding principles of trauma-informed care.
A person who has experienced trafficking will likely need a variety of health-related services. To ensure their
needs are met, collaborate with specialists, and expand your referral network as needed.

FALLS
It is the responsibility of all employees to help to minimize environmental hazards that could lead to falls
throughout our campuses. This can be accomplished by simple acts such as keeping our hallways and rooms
free of clutter and notifying environmental services if necessary, for spills and slippery surfaces. Notify
head/director/manager/supervisor discuss any fall risks that are noted that you feel need attention.

INFECTION PREVENTION
Type text here
An infection is a condition produced by invasion of body tissues by microorganisms. Infection control efforts are
aimed at breaking one or more links in the “chain of infection”. These include:
▪ An adequate number of pathogens, or disease-causing organisms, to cause disease.
▪ A reservoir or source that allows the pathogen to survive and multiply (e.g., blood).
▪ A mode of transmission from the source to the host.
▪ An entrance through which the pathogen may enter the host.
▪ A susceptible host (e.g., one who is not immune).

Updated 1/2022 Page 15 of 25

Infection prevention and control is everyone’s responsibility. It is not limited to clinical staff. Many diseases
and conditions can be prevented or controlled through appropriate personal hygiene, including proper
handwashing, body washing, facial cleanliness and oral care. Employees are expected to maintain their
personal hygiene, and patient care providers are responsible for assisting patients as needed to meet their
hygiene needs.
Employees who have a disease or condition that may be transmissible at work must report this to Employee
Health. Employee Health will follow Center for Disease Control & Prevention (CDC) guidelines and hospital policy
to determine if the employee can work and what precautions the employee must take to protect others.
Common conditions which can result in temporary exclusion from work include influenza, diarrheal illness, pink
eye, skin abscesses, non-intact skin in any exposed area, especially the hands (e.g., herpetic lesions) and fever. In
addition, employees must report if they have been exposed to an infectious disease since some diseases are
transmissible before symptoms appear.
Hand Hygiene
All medical staff, hospital employees, vendors, contracted agency and academic affiliates are expected to be
meticulous about hand hygiene. We must also teach our patients and visitors, so they can do their part. Hand
hygiene is the single most important thing we can do to prevent the spread of infection. In general, all medical
and hospital staff are expected to perform hand hygiene before entering and upon exiting patient rooms. Also,
employees perform hand hygiene in accordance with the World Health Organization’s “5 moments” for hand
hygiene.
1. Before ANY patient contact
2. Before performing a clean or aseptic procedure
3. After risk for blood or body fluid exposure
4. After patient contact—when leaving
5. After contact with the patient’s immediate environment—when leaving
Alcohol based hand sanitizer is preferred over soap and water in most situations. The sanitizer dispenser is
designed to supply the correct amount. Follow the instructions posted throughout the facility to ensure
complete coverage of all surfaces of the hands, including under the nails. Be sure to allow the sanitizer to dry
completely.
Handwashing- Hands must be washed with soap and water whenever they are visibly soiled, after actual
contact with blood or body fluids and, of course, after use of the restroom. Begin by turning on the tap and
adjusting the water temperature. Wet your hands and apply the soap. Wash following the same sequence of
maneuvers as with hand sanitizer. Rinse your hands. Dry with paper towels. Use paper towels to turn off the
tap, and then discard. Soap and water are more effective than hand sanitizer for removing Cryptosporidium,
Norovirus, and Clostridioides difficile.
Respiratory Etiquette
▪ Face coverings are required in the facility at this time, with limited exceptions, as outlined in the COVID-
19 policies and Safety Plan.
▪ Do not remove your mask to cough or sneeze. Cough into fabric (your sleeve or shoulder).
▪ Step away from others and use tissue for a productive cough or to blow your nose. Discard; then perform
hand hygiene.
▪ Do not come to work if you have a respiratory infection. Contact Employee Health who will do
an assessment and determine when it is safe for you to return to work and what precautions
you need to take upon return.

Updated 1/2022 Page 16 of 25

 ▪ Teach respiratory etiquette to patients and visitors and ensure that they have access to the
supplies that they need to comply.

RISK MANAGEMENT
SENTINEL EVENT
A sentinel event is an unexpected occurrence involving the death or serious injury to a patient, or a risk that a
reoccurrence could cause a bad outcome. These events must be immediately reported to the
supervisor/manager, and include such things as, but are not limited to, infant abduction or discharge of an
infant to a wrong family, suicide of an admitted patient, hemolytic transfusion reactions, or wrong site
surgery. Once reported, an analysis of the root cause must be done within 45 days of the event.

SERIOUS REPORTABLE EVENTS

(See Policy, Adverse Event Reporting)
Since January 1, 2015 it is mandatory to report all Serious Reportable Events (SREs) that occur at hospitals and
ambulatory surgery centers. This mandate was following amendments to the state Health and Safety Code during
the 81st Legislative Session that require both reporting by healthcare facilities to the Department of State Health
Services and that the Department shall post SRE data on its public website.
Staff will report all events to the Quality Director for further reporting to the designated entity.
The National Quality Forum (NQF) has developed a set of SRE that help to guide the decision-making process
for a healthcare facility to determine if an event would be considered an SRE.

Serious Adverse Events that are required to be reported are:

• Healthcare-associated adverse conditions or events for which the Medicare program will not
provide additional payment to Prime Healthcare under a policy adopted by the federal Centers
for Medicare and Medicaid Services; and
• Events included in the list of adverse events are identified by the NQF.
This is the official SRE list compiled by the NQF
Applicable areas may vary in: hospitals, outpatient/office-based surgery centers, ambulatory practice
settings/office-based practices, long-term care/skilled nursing facilities. For a list of SREs associated with
the applicable site please visit http://www.qualityforum.org/topics/sres/serious_reportable_events.aspx
1. SURGICAL OR INVASIVE PROCEDURE EVENTS
1A. Surgery or other invasive procedure performed on the wrong site.
1B. Surgery or other invasive procedure performed on the wrong patient.
1C. Wrong surgery or other invasive procedure performed on a patient.
1D. Unintended retention of a foreign object in a patient after surgery or other invasive
procedure.
1E. Intraoperative or immediately postoperative/post procedure death in an ASA Class 1 patient.
2. PRODUCT OR DEVICE EVENTS
2A. Patient death or serious injury associated with the use of contaminated drugs, devices, or
biologics provided by the healthcare setting.

Updated 1/2022 Page 17 of 25

 2B. Patient death or serious injury associated with the use or function of a device in patient care,
in which the device is used or functions other than as intended.
2C. Patient death or serious injury associated with intravascular air embolism that occurs while
being cared for in a healthcare setting.
3. PATIENT PROTECTION EVENTS
3A. Discharge or release of a patient/resident of any age, who is unable to make decisions, to
other than an authorized person.
3B. Patient death or serious injury associated with patient elopement (disappearance).
3C. Patient suicide, attempted suicide, or self-harm that results in serious injury, while being
cared for in a healthcare setting.
4. CARE MANAGEMENT EVENTS
4A. Patient death or serious injury associated with a medication error (e.g., errors involving the
wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or
wrong route of administration)
4B. Patient death or serious injury associated with unsafe administration of blood products.
4C. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy
while being cared for in a healthcare setting (updated).
4D. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy.
4E. Patient death or serious injury associated with a fall while being cared for in a healthcare
setting.
4F. Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation
to a healthcare setting.
4G. Artificial insemination with the wrong donor sperm or wrong egg.
4H. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable
biological specimen.
4I. Patient death or serious injury resulting from failure to follow up or communicate laboratory,
pathology, or radiology test results.
5. ENVIRONMENTAL EVENTS
5A. Patient or staff death or serious injury associated with an electric shock in the course of a
patient care process in a healthcare setting.
5B. Any incident in which systems designated for oxygen or other gas to be delivered to a patient
contains no gas, the wrong gas, or are contaminated by toxic substances.
5C. Patient or staff death or serious injury associated with a burn incurred from any source in the
course of a patient care process in a healthcare setting.
5D. Patient death or serious injury associated with the use of physical restraints or bedrails while
being cared for in a healthcare setting.
6. RADIOLOGIC EVENTS
6A. Death or serious injury of a patient or staff associated with the introduction of a metallic
object into the MRI area.
7. POTENTIAL CRIMINAL EVENTS
7A. Any instance of care ordered by or provided by someone impersonating a physician, nurse,
pharmacist, or other licensed healthcare provider.
7B. Abduction of a patient/resident of any age.

Updated 1/2022 Page 18 of 25

 7C. Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare
setting.
7D. Death or serious injury of a patient or staff member resulting from a physical assault (e.g.,
battery) that occurs within or on the grounds of a healthcare setting.
The Center for Medicare and Medicaid Services (CMS) has developed a list of Hospital-Acquired Conditions
(HACs) that are considered reportable and may negatively impact reimbursement payments.
HACs are defined as:
• Foreign object retained after surgery
• Air embolism
• Blood incompatibility
• Stage III or IV pressure ulcers
• Falls and trauma resulting in fractures, dislocations, intracranial injuries, crushing injuries, burns and
electric shock
• Manifestations of poor glycemic control
o Diabetic ketoacidosis
o Nonketotic hyperosmolar coma
o Hypoglycemic coma
o Secondary diabetes with ketoacidosis
o Secondary diabetes with hyperosmolarity
• Catheter-associated Urinary Tract Infection (CAUTI)
• Vascular catheter-associated infection (CLABSI)
• Deep vein thrombosis (DVT)/Pulmonary embolism (PE) with total knee or hip replacement
• Surgical site infections related to Bariatric Surgery
• Surgical site infections related to certain orthopedic procedures of spine, shoulder and elbow
• Surgical site infections following cardiac implantable electronic device (CIED) procedures
• Iatrogenic pneumothorax with venous catheterization
For a more detailed list developed by the CMS with specific instructions on reporting please visit.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index

Updated 1/2022 Page 19 of 25

Salvador Gonzalez 05/21/2022
Payroll Coordinator

Essentials of Orientation Post Test

After reading the Essentials of Orientation packet, please complete the following Post Test. Read each answer
carefully and circle the best answer for each below. A passing score of 80% is required.

MISSION
1. The mission of Prime Healthcare is to save and improve hospitals so that they can deliver compassionate
quality care to patients and better healthcare for communities.
a. True b. False

AIDET+
2. Which of the following statements is NOT true about AIDET?
a. It can only be used by clinical staff
b. It stands for Acknowledge, Introduce, Duration, Explanation, Thank You
c. It improves the patient experience
d. It builds patient relationships

CORPORATE COMPLIANCE
3. The process to ensure that a facility has adequate internal controls to prevent and detect violations of the
law is called:
a. Code of Conduct
b. Corporate Compliance
c. Risk Management
d. Human Resources

PATIENT EXPERIENCE
4. What are the three fundamentals in Elevating our Service Delivery?
a. Saying hello to all, sitting at bedside, always smile
b. 10’ - 5’ rule, Caring Communication, Purposeful Rounding
c. Having conversations with co-workers, sharing patient concerns, staff recognition

5. What are the components of the Service Recovery 4A model?

a. Acknowledge, Appreciate, Apologize, Address
b. Address, Accept, Anticipate, Apologize
c. Anticipate, Acknowledge, Apologize, Act
EMTALA
6. EMTALA is a federal law that requires hospitals to medically screen patients and stabilize patients prior to
discharge or transfer, regardless of the ability to pay for services.
a. True b. False

HIPAA AND CONFIDENTIALITY

7. The following is true about HIPAA and Patient Confidentiality.

Updated 1/2022 Page 20 of 25

 a. Patient information can be given to anyone who requests it.
b. If you see a breach in patient confidentiality you should report it to your immediate
supervisor/manager.
c. HIPAA is only applicable to nurses and physicians.
d. It is OK to print out patient information and bring it home.

PATIENT GRIEVANCES
8. If the patient has a concern, you should do everything in your power to address it. If necessary, have your
supervisor get involved. Patients may also contact the Department of Health Services for your state or
deeming status accreditation agency (Joint Commission/ HFAP / DNV) to complain if they feel their
concerns are not being addressed.
a. True b. False

TEAM BUILDING
9. Multi-disciplinary teams that work collaboratively are NOT effective in providing high quality patient care.
a. True b. False

BODY MECHANICS/ ERGONOMICS

10. Concepts to remember when lifting an object are:
a. Assess the load (should a safe patient handling device be used, or do you need assistance?)
b. Keep the back straight and do not twist
c. Bend the knees and lift with the legs straight
d. Push rather than pull
e. All of the above

BLOOD BORNE PATHOGENS

11. Exposure to blood or body fluids through a sharp’s injury, mucous membrane or through non-intact skin is
a medical emergency.
a. True b. False

EMPLOYEE VACCINATION/TESTING
12. Which of the following statements is true about Employee Vaccines?
a. There is no vaccine for Hepatitis B.
b. If you do not receive the influenza vaccine, you will be required to wear a mask during the
designated influenza season.
c. If an employee has an allergy to a vaccine, they will be expected to receive it regardless.
d. If you receive your Influenza vaccine elsewhere, you will still need to get it again at your facility.

COVID-19
13. Prime Healthcare updates our policies and procedures related to COVID-19 with the latest federal, state,
and local guidelines in order to maintain a safe environment for staff, patients and visitors.
a. True b. False

SAFETY – ENVIRONMENT OF CARE, GENERAL/UTILITIES

Updated 1/2022 Page 21 of 25

 14. The mnemonic R.A.C.E. is used for:
a. Fire: Rescue; Alarm; Contain; Evaluate
b. Fire: Rescue; Alarm; Call for Help; Extinguish
c. Fire: Rescue; Alarm; Contain; Extinguish
d. Extinguishers: Rip off clip; Aim; Contain; Evaluate
15. Copies of Safety Data Sheets are available 24 hours a day on the portal by calling 1-800-451-8346. SDS
have first aid and clean up procedures for items used in each department.
a. True b. False

NATURAL DISASTER
16. The most important thing to do in a natural disaster is:
a. Stay calm and don’t panic
b. Run out of the building
c. Evacuate all patients immediately
d. Go home

SECURITY
17. You should report all suspicious activity and/or thefts to the Security Department immediately.
a. True b. False

SMOKING POLICY
18. Staff is permitted to smoke in designated areas within the building.
a. True b. False

VIOLENCE PREVENTION
19. You must report all incidents of aggressive behavior whether it involves an injury or not.
a. True b. False
20. Prime Healthcare provides staff with behavioral violence prevention training.
a. True b. False

CODE OF CONDUCT
21. Non-retaliation protection is in place for those who report bullying and disruptive behavior.
a. True b. False

CULTURAL DIVERSITY/SENSITIVITY
22. The best way to work with different cultures is to:
a. Know your own beliefs but be respectful of others’ beliefs.
b. Let others know that your cultural beliefs are always right.
c. Indicate what works best in your culture and follow those guidelines with your patients.
d. None of the above

HARASSMENT POLICY Type text here

Updated 1/2022 Page 22 of 25

 23. Harassment is any unwelcome verbal, visual or physical conduct creating an intimidating, abusive,
offensive, or hostile work environment that interferes with work performance.
a. True b. False

IMPAIRED/DISRUPTIVE STAFF/PHYSICIANS
24. It is Prime’s policy that any disruptive behavior by staff or physicians should be reported to the
management team.
a. True b. False

PATIENT RIGHTS
25. Which of the following are part of Patient Rights? The right…
a. to a clean and safe environment
b. to refuse care
c. to receive help with health-related bills and filing of claims
d. All of the above

STAFF IDENTIFICATION
26. All employees, affiliates, or contract personnel MUST always wear appropriate picture identification (ID
badge) while on hospital premises.
a. True b. False

STAFF RIGHTS
27. Employees may report any concerns about the safety or quality of care provided to:
a. The manager/supervisor
b. Compliance Officer
c. The state department of health
d. The Joint Commission
e. All of the above

PERFORMANCE IMPROVEMENT
28. Performance improvement is the responsibility of:
a. Your manager
b. Yourself
c. Administration
d. Everyone

CORE MEASURES
29. When caring for a patient with a core measure diagnosis be sure to follow the standard of care.
a. True b. False

NATIONAL PATIENT SAFETY GOALS

30. All hospital employees are responsible for patient safety.
a. True b. False

Updated 1/2022 Page 23 of 25

 31. The National Patient Safety Goals from the Joint Commission focuses on implementing safety initiatives
throughout the hospital. Which of the following are NOT included?
a. Identify patient correctly
b. Uses medicine safely
c. Promotes measures to increase infection
d. Uses alarms safely

ABUSE RECOGNITION AND REPORTING

32. Healthcare practitioners are mandated reporters of suspected abuse.
a. True b. False

DISCHARGE PLANNING

FALLS
33. It is the responsibility of all employees to help to minimize environmental hazards that could lead to falls,
a. True b. False

INFECTION PREVENTION
34. The single most important thing we can do to prevent the spread of infection is:
a. Close the patient’s door
b. Hand hygiene
c. Take antibiotics
d. Wear a mask

35. Washing with soap and water is required, instead of alcohol-based hand sanitizer, whenever hands are visibly
soiled.
a. True b. False
36. Respiratory etiquette consists of:
a. Cough into fabric (your sleeve or shoulder)
b. Use tissues for productive cough or nose blowing, dispose of the tissue and perform hand hygiene
c. Follow Covid-19 protocols for face coverings/masking
d. All of the above

SBAR

SERIOUS REPORTABLE EVENTS

37. Serious Reportable Events occurring at health care facilities should never happen to patients, personnel or
visitors. If they do, the event must be reported to the Department of Health Services for your state.
a. True b. False
Quality Director

Updated 1/2022 Page 24 of 25

SENTINEL EVENT
38. A sentinel event is an unexpected occurrence involving the death or serious injury of a patient while in the
hospital setting. Examples are an infant abduction, suicide while in the hospital, and discharging a baby to
the wrong family. If something like this happens, staff should notify Administration immediately.
a. True b. False ^manager/supervisor

Completed by
Salvador Gonzalez
Dated: 05/21/2022 --09:44

Updated 1/2022 Page 25 of 25