HIRE - Markham Stouffville Hospital

RESPECT TRUST COMPASSION COMMITMENT COURAGE 1 | P a g e

NEW HIRE HANDBOOK

Updated: May 2019


Table of Contents Overview and Floor Plan .................................................................................................. 3

Markham Stouffville Hospital: Vision, Mission & Core Values .......................................... 6

Section 1: ESSENTIAL INFORMATION .............................................................................. 9

Occupational Health & Safety ............................................................................... 10

Emergency Codes.................................................................................................. 14

Workplace Hazardous Materials Information System (WHMIS) ............................. 20

Radiation Safety .................................................................................................... 24

Quality, Patient Safety, Patient Relations & Experience and IPAC .......................... 26

Infection Prevention and Control (IPAC) Program ................................................. 29

“Expect Respect” – Violence and Harassment Prevention Education Program ....... 32

Privacy, Confidentiality and Personal Health Information ...................................... 37

Ethics ..................................................................................................................... 40

Accessibility for Ontarians with Disabilities ............................................................ 42

Conflict of Interest Policy ...................................................................................... 43

Whistleblower Policy ............................................................................................. 44

LiME eLearning Mandatory Courses ...................................................................... 46

Section 2: OTHER INFORMATION .................................................................................. 51

Employment Standards in Ontario ........................................................................ 52

Parking and Security ............................................................................................. 54

Education Funding ................................................................................................ 57

Employee Referral Program ................................................................................... 57

Part-time Employee Benefits ................................................................................. 58

Places to Eat .......................................................................................................... 58

Gift Shop ............................................................................................................... 59

Dale’s Pharmacy .................................................................................................... 59


Overview and Floor Plan

Building B

Building A

Building C Medical Offices Building (MOB) Dales’ Pharmacy Waiting Room Café

Building D Health Services Building (HSB) MSH Auditorium

Building E Cornell Community Centre

Building A • Original building; 3 levels • In-patient Medicine services • Out-Patient Surgery, Out-Patient Rehab,

Admission Assessment Unit • Ambulatory clinics • Food Services, Facilities, Patient

Transport • Laboratory • Cafeteria and Gift Shop • Administration Offices • Main Lobby Entrance

Building B • Four levels • Roof- top helipad, mechanical rooms • Additional 100 beds • ED, OR, Critical Care, In-patient Surgery,

NICU, Birthing Unit, Mental Health, Out-patient Mental Health and Diagnostic Imaging

• HR, OHS, In-patient Pharmacy • Link Lobby Entrance

Emergency

Main Lobby


Markham Stouffville Hospital: Vision, Mission & Core Values


Being Green Being green comes naturally to Markham Stouffville Hospital! The Markham Stouffville Greening Committee aims to inspire and encourage each member of the Markham Stouffville Hospital community to make environmentally sound choices in each aspect of their professional lives. Ultimately, the Committee’s goal is to create a ‘greener’ Hospital by implementing measures that help develop eco-friendly purchasing policies, use energy more efficiently, reduce resource consumption and promote ‘green’ commuting practices amongst the staff. You can make a difference! The MSH Greening Committee wants to hear from you. Email [email protected] to share your thoughts and ideas on how to create a greener Markham Stouffville Hospital.


Section 1: ESSENTIAL INFORMATION

ESSENTIAL INFORMATION Section 1:


Occupational Health & Safety The Occupational Health and Safety (OHS) department at Markham Stouffville Hospital is committed to preventing occupational illness and injury in the workplace and establishing a safe and healthy workplace environment for all employees, as per the Occupational Health and Safety Act (OH&SA). The OH&SA is a provincial legislation that outlines specific conditions for constructing a safe and healthy environment in the workplace. A copy of the OH&SA is available in every department, in addition health and safety policies are available on the Hospital’s intranet. MSH is committed to support each individual’s right to work in an atmosphere that is safe, healthy, supportive, secure and respectful. The Hospital has a zero tolerance for behavior that is disrespectful or threatening. All staff is required to sign a Statement of Commitment form at General Hospital Orientation. This commitment is valid and on-going. The OHS department maintains a safe and healthy work environment by providing employees with necessary resources. Services it provides include:

o Medical assessments, including hand hygiene assessments o Immunizations and vaccinations o Mask fit testing o Health, Safety, and Wellness o Employment assistance program (EAP), including lunch-n-learns and critical

incident debriefing o Return to work following medical absence o Confidential counseling and referrals o Workplace health and safety assessments and recommendations o Emergency disaster procedures o Injuries, illnesses, accidents, and hazardous conditions

General Hospital Policies That Affect Your Health and Safety

Smoke Environment Markham Stouffville Hospital’s property is 100 per cent smoke-free.

Fragrance-Reduced Area For the health and comfort of everyone, please refrain from using fragrances or heavily scented products when working or visiting the Hospital.


Latex-Safe Environment Latex can cause a severe allergic reaction. In an effort to reduce the risk of exposure to natural rubber latex, latex balloons are not allowed in the Hospital. Mylar balloons, however, are acceptable.

For more information, contact the Occupational Health and Safety department:

o Markham Site ext.6280 / Uxbridge Site ext. 5233, or o visit the Hospitals intranet page and click on Occupational Health

Your Role in Safety- Know your role Staffs’ roles and responsibilities under the OH&SA, includes:

o Work in compliance with the OH&SA o Use/wear required protective equipment o Avoid removing protective devices o Identify and report hazards/defects in equipment o Report any contraventions of the OH&SA

Procedures for Reporting Health and Safety Concerns The OHS department must be notified for any injury or illness occurred in the Hospital. Business Hours MUST be assessed in OHS following the incident. After hours, staff must be in contact with OHS by 1200 hours on the next business day:

o Inform the Manager/Director o Complete Employee Incident Report (in intranet IReport) within 24 hours o Notify OHS immediately if 1) seek healthcare and/or 2) miss time from work o Participate in the investigation

STAFF (WORKER) ROLES: • Right to know—know the

hazardous materials in their workplace

• Right to participate—by joining the Joint Occupational Health and Safety Committee

• Right to refuse unsafe work—this process is outlined in the OH&SA

SUPERVISOR ROLES: • Ensure equipment, materials,

supplies are provided, maintained, and used in compliance

• Ensure policies and procedures are developed, implemented, maintained, and reviewed

• Inform, instruct, and supervise workers

• Take every reasonable precaution for protection of workers

MANAGEMENT ROLES: • Ensure workers comply with

the OH&SA • Ensure workers use/wear

required protective equipment

• Advise workers of potential and actual hazards

• Provide written instructions • Take every reasonable

precaution for the protection of workers


o Participate in the early and safe return to work program, designed to support staff returning to pre-injury/illness duties in an early and safe manner

When staff has a health and safety concern:

o Staff reports concern to director or manager o Director or manager investigates concern and provides feedback to staff o Concern is addressed

When staff feels his/her concern was not addressed:

o Staff contacts a member of the JOHSC o JOHSC member reviews concern with staff and director or manager o JOHSC and director or manager work together to solve concern o Concern is addressed

When staff feels his/her concern was not addressed:

o Ministry of Labour (MOL) is contacted o MOL investigates concern with the workplace parties and makes

recommendations o Recommendations are implemented o Concern is addressed

IReport IReport is a system for staff to report actual or potential incidents and adverse events that compromise patient care or staff safety. Employees must report all occupational accidents, illnesses, incidents, hazardous conditions, near misses and non-injury property damage immediately to the appropriate director, manager or delegate and the OHS department. Employees must complete the online Employee Incident Report in the IReport System within 24 hours of the incident occurring. Refer to Hospital’s intranet for the process and procedures related to medical treatment, investigation, documentation and follow-up of employee incidents. Joint Occupational Health and Safety Committees The Joint Occupational Health and Safety Committee is an advisory group that is required to be in place under the Occupational Health and Safety Act. The Hospital has two committees, one at each of Markham Stouffville Hospital’s sites. The Committees are made up of members who equally represent management and employees. The members work together to stimulate awareness of health and safety issues, and recognize and deal with any workplace risks. The members are committed to improving and promoting health and safety at the Hospital.


The Committees’ responsibilities and Terms of Reference, the membership list, minutes of the Committee and other information are available on the Hospital’s health and safety boards or on the Hospital’s intranet. Work Refusal Process Staff can refuse work where safety is in jeopardy, with the exceptions: o When a circumstance is a normal condition of employment; or o When the work refusal or stoppage would directly endanger the life, health, or safety

of another person When You are Too Sick to Work Employees should seek medical assistance if their symptoms are contagious. Contact OHS if they are not certain. The following conditions are symptoms to keep in mind: Reporting Absences Due to Non-Occupational Illness/Injury Employees unable to report for work as scheduled must notify their department head or unit/department as early as possible prior to the start of the first shift for which they will be absent. Where departments have established their own procedure for absence notification or such notification is specified in a collective agreement, the employee must follow this procedure. When reporting their absence, employees are required to provide the following information: o How long he/she anticipates remaining medically unfit for work; o The date (if known) on which he/she expects to report back to work; o Contact details during normal business hours; and o If illness/injury is work-related, employee is also responsible for contacting the

Occupational Health and Safety Department and is to follow the procedures set out in the Reporting and Investigation of Employee Accident and Incidents Policy; Administrative Manual – Health and Safety.

• Fever: temperature over 38 degrees or 100.4 Fahrenheit

• Vomiting or diarrhea • Rashes with or without fever • Uncontrollable coughing • Any type of draining lesion or

weeping dermatitis • Untreated conjunctivitis or pink eye

• Any conditions that affects your ability to wash your hands

• Upper respiratory infection with fever present

• Persistent sore throat lasting longer than 3 days and/or accompanied by fever

• Known infectious diseases such as Chicken Pox, Influenza, Tuberculosis


Illness on the Job If an employee becomes ill while at work, he/she should first report the illness to his/her department head and obtain permission to leave the work area. During regular business hours, the employee must report to the Occupational Health and Safety Department. After hours, the employee is to advise his/her department head if he/she is leaving work to home. Evidence of Medically Justified Absence When an employee is absent for three or more consecutively scheduled shifts (or less if identified by Occupational Health and Safety and/or the director/manager) the employee must produce a completed and signed Application for Disability Benefits/Leave. The employee is required to seek medical attention within 48 hours following the third consecutively missed shift and submit the completed Application for Disability Benefits/Leave within the pay period that the sick absence occurred. The Hospital’s Application for Disability Benefits/Leave is available on the Hospital’s intranet, staff portal (accessible from home), outside of the occupational health and safety department, inside Human Resources as well as at departments and units throughout the Hospital. Communication: Keep your department head informed during the absence to discuss issues such as extended leave and return to work. Emergency Codes Emergency Codes are in place to protect personnel, patients, visitors and property of the Hospital during an emergency situation. Codes are initiated by: Markham site: Dialing 555 and informing Telecommunications, Uxbridge site: Dialing 58 and announcing code over PA system. All codes are announced over the Public Address System 3 times, naming the specific area where help is needed and are in effect until an “All Clear”, “End” or “Cancel” announcement is made. Complete an iReport once the situation is over. For More Information on Any of the Codes: o Go to the Hospital’s intranet, click on Policies, click Corporate Policies and

Procedures and select Emergency and Disaster Manual o Access your Emergency and Disaster Manual, available on each unit

STEP 1: Call a Code Markham site Dial 555 Uxbridge site Dial 58

STEP 2: Inform & Assist

Give report to the Incident Manager, Stay in the area,

Assist team leader

STEP 3: Report Complete an iReport once the situation is

over


Know your codes: Below are the emergency codes and their corresponding definition. This information is also listed on the back of the staff photo ID badge.

CODE EMERGENCY TYPE

Code Blue Cardiac Arrest or Medical Assistance Code Pink Infant Cardiac Arrest Code Yellow Missing Patient Code Yellow Amber Missing Child Code White Violent Person Code Green Evacuation Code Brown Chemical Spill Code Orange External Disaster Code Orange- CBRN Chemical Biological Radiological Nuclear Disaster Code Black Bomb Threat Code Grey Air Exclusion or Infrastructure Failure Code Purple Hostage Taking Code 111 Short Term Assistance

Code Red Fire

Code Silver Active Attacker

Code Blue should be called when any adult, age 18 and older, is under cardiac arrest or respiratory arrest requires or any Medical Assistance. A Code Blue can be initiated by pressing the Code Blue button in the patient’s room, if available or call 555 (Markham site); 58 (Uxbridge site). When a Code Blue is initiated, a team arrives to take over using advanced life support techniques. Until they arrive, if you have the skill to initiate CPR, it is imperative and expected that you do so. Every second counts for the victim of an airborne or cardiac arrest. The sooner resuscitation is started, the better the outcome.

Code Pink is intended to inform staff and physicians that a child between 0 months to 18 years of age is having a cardiac or respiratory arrest. A cardiac arrest team including a pediatrician (Markham site) will be responding to the code. A Broselow/Neonatal crash cart is also brought to the location.

is activated when a patient is deemed as missing; the Code Yellow search procedure will be initiated. A patient’s level of risk will be assessed to assist in determining the appropriate stage of the Code Yellow search plan to be implemented. The Clinical Manager, Facilitating Nurse or delegate is responsible to initiate the Code if


a patient is discovered missing. This person assumes the role and responsibilities of the Search Coordinator. All staff, physicians, students and volunteers are expected to participate and follow the policy.

S Secure designated exits for Code Yellow Amber. Search own department/unit using your search maps. Advise Security immediately if you are unable to secure an exit.

E Engage Evacucheck markers and close all doors after each room is searched.

A Be on Alert for missing patient. For a Code Yellow Amber, be alert for suspicious persons (e.g. Persons wearing bulky clothing, carrying bags, appearing pregnant). In Code Yellow Amber, all bags are searched at the secured exits.

R Record on Search Map. For Code Yellow amber, remain at exits until clearance. C Call Search Coordinator with results. H Hand over Search Map to Search Coordinator at end of Code.

Code Yellow Amber is a Hospital wide search for an infant or child (patient or visitor) who is missing. The Incident Manager for Code Yellow Amber is the Patient Care Coordinator or the Facilitating Nurse in the Care Area from which the child has gone missing. In non-patient situations, the Incident Manager may be Security if this is most appropriate. Code Yellow Amber search defines a method of securing the exits and conducting a hospital-wide search to a) prevent the abduction of an infant or small child; and/or b) a child is missing from an area where he/she is expected to be. This procedure is used when there is reason to believe that the infant/child could be hidden from view and carried out of the Hospital or the child has left without authorization. Code Yellow Amber uses the same search procedures as a Code Yellow As per the Newborn Security program, all newborn infants are restricted to the 4th floor, Markham site (4Wh, 4Wf) except for diagnostic tests or at time of discharge. At time of discharge, the parent(s) and significant other will be given a green envelope labelled “Infant Discharge”. As a member of the Hospital you should approach the new mother described above, and explain the Newborn Infant Security policy. You should then verify that she and the infant are wearing corresponding ID bands. If they match, redirect the mother back to Building B, 4th floor and observe to see that she does return to the area. If the mother does not cooperate or you feel the infant is in danger at any time, contact Security immediately.

Code White is intended to provide a timely, efficient and effective response when a patient is behaving aggressively and poses a threat to self, others or the Hospital. The Code White Team serves as a resource to departments to assist in de-escalation and, where necessary, control of violent, disruptive behaviour. The Team uses Crisis Prevention Intervention Techniques, a safe, non-harmful behaviour management system designed to help healthcare workers provide the best possible care of disruptive or out-of-control persons even during their most aggressive moments.


Code Green is intended to facilitate the evacuation when a crisis poses a threat to safety. It refers to the evacuation of a specific area or of the entire building.

Code Green: Classifications Code Green: Hospital wide evacuation Code Green (Area Specific): Area evacuation

Code Brown is the procedure that allows staff to respond to an uncontrolled or unplanned release of a potential hazardous material in any quantity, reducing any potential for adverse effects on human health and the environment. Chemical specific spill kits are found in specific departments (e.g. formalin, chemotherapy drugs). A general spill kit is found outside Receiving (Building A), or behind MDRD (Building B). Ensure staffs are aware of where the department spill kits are located. The Hospital has specific staff trained in spill response procedures. If you are person detecting the spill (beyond department capabilities): S Safely evacuate area and SECURE the scene. P Prevent spread of vapours/gases/fumes – close doors.

I Inform Telecommunications (Markham - Dial 555; Uxbridge - Dial 58 and announce, Uxbridge) – provide details (location, size, source, chemicals involved and code level).

L Leave all electrical equipment alone. L Locate Material Safety Data Sheets (MSDS) and available spill kit.

Code Orange is a plan to help mobilize the Hospital's resources in the event of an external disaster. The size of the disaster will determine the response at that point in time due to the number and severity of casualties and based on the resources currently available in the Hospital. Staffs are notified of a Code Orange via the following methods:

On-Call Staff: Paged On-Site Staff: Overhead page Off-duty Staff: Called back through the use of the "Call and Go, Fan Out Procedure"

Code Orange, CBRN is intended to mobilize Hospital resources in the event of a major external Chemical Biological Radiological and Nuclear (CBRN) disaster that exceeds the Hospital’s ability to provide services due to the number and severity of the casualties requiring mass decontamination. It is an expectation that all staff and physicians will respond to both a real and/or a Mock Code Orange – CBRN according to the plan. A Code Orange – CBRN has 4 Stages, each of which can be activated independently or progressively depending on the needs of the situation. Stage 1: Pre-Alert & Preparation

Hospital is informed of an external disaster and alerted of potential involvement.

Stage 2: Hospital is involved and resources and abilities may be


Decontamination exceeded. Preparation for decontamination of patients will take place at this time. Call back of off-duty staff may be limited to Nursing, Medical and those required to meet the current needs.

Stage 3: Disaster

Hospital is involved and resources and abilities are exceeded. (The whole organization will be mobilized). During day shift Monday to Friday, sufficient resources may exist within the Hospital and may only require activation of Code 111.

Stage 4: Debriefing, Evaluation & Recovery

At this stage, the emergency is ending and key staff is debriefed to identify the effectiveness of the response and where improvements can be made.

Code Black is a coordinated Hospital-wide search for a bomb with provisions to ensure staff, patient and public safety. Threats MUST be taken seriously. Code Black is in place to provide information and an organized plan of action to ensure the safety of staff, physicians, patients, the public and the Hospital in the event of a bomb threat. All bomb threats will be considered genuine until proven otherwise. Any staff and physicians can initiate a Code Black. A bomb threat can come in the form of a telephone call, written note, e-mail or suspicious package. Staff will conduct a search of their departments. All staff should remain in the Hospital until the “All Clear” is announced. Code Grey is to alert the Hospital of an unplanned interruption/loss of essential service/infrastructure failure and external air contamination. Its purpose is to provide an immediate plan of action to ensure the safety of everyone within the building and allow the Hospital to continue its operations. Some examples of interruption/loss of essential services may include but not limited to, electricity/power, medical gas, water, telecommunications, fire panel, air handling units, mag-locks in Mental Health and elevator system. Code Purple is when there is an incident of hostage-taking. A hostage-taking incident can occur when: any person(s) is confined, imprisoned, forcibly seized or detained against their will by a person without the authority to do so; the hostage taker(s) causes any person(s) to receive a threat of death or bodily harm or induce any person or organization to commit an act or mission for releasing the hostage(s); or any person(s) have confined or barricaded themselves in a room and threaten violence and/or have weapons. Code 111 is announced when there is a request for immediate short-term assistance for a critical situation anywhere in the Hospital and additional staff is required for a short period of time. Code 111 can be activated independently or in conjunction with other


Emergency Codes (for example, a Code 111 may be needed to assist in a Code Green). Code Red policy contains procedures used to respond to a fire emergency, while ensuring everyone’s safety and minimizing the potential for injury or damage. What to do when there is fire in the area:

R Remove anyone in the room. Call out “Code Red, location” and close the door. E Ensure All doors are closed, activate Evacucheck markers. A Activate the fire alarm (pull station).

C Call (Markham – dial 555; Uxbridge – dial 58 & announce). Give exact location and nature of fire.

T Try to extinguish the fire if safe to do so and you are trained. Refer to the fire safety plan for information specific to your department Code Silver, Active Attacker is to be called if there is one or more individuals brandishing or claiming to possess a firearm with the intention of bodily harm or injury, and/or there is an active attacker in the building. Staff who encounter an active attacker, should call 911 immediately, then follow instructions of the 911 operator. Code Silver will not result in other hospital staff coming to assist, but is designed to keep people from harm. All staff are to make every reasonable effort to protect themselves, patients, visitors and others in their immediate area. By following these three steps:

• Run – remain calm and evacuate safely • Hide – if unable to evacuate safely • Defend – as last resort defend yourself, if your life is in immediate danger


Workplace Hazardous Materials Information System (WHMIS) In the early 1980s, there were approximately 500,000 work related injuries in Canada per year. The numbers of injuries were on the rise as more and more injuries and deaths were occurring every year. As a result, WHMIS was legislated by the federal and provincial governments in October 1988 to help reduce the number of incidents throughout Canada. As a health care worker, staff may be exposed to potentially hazardous agents. As such, you need to:

• Understand what WHMIS is and how it affects you • Able identify hazardous products at the Hospital • Understand the information found on WHMIS labels • Understand where to find a Material Safety Data Sheets (MSDS) and Safety Data

Sheets (SDS) and how to read them WHMIS 1988 to WHMIS 2015 WHMIS has aligned with the worldwide hazard communication system known as the Globally Harmonized System (GHS). Updates to implement GHS will be referred to as WHMIS 2015.

Pictograms are graphic images that immediately show a hazardous product and what type of hazard is present. Most pictograms have a distinctive red diamond border, instead of the black bordered circle. Pictograms will be on the product supplier labels of the hazardous products. They will also be on the safety data sheets (SDS), symbols or words that describe the symbol. The components consist of: Labels—identifies the type of hazard, alerts the dangers, and provides safety precautions


Safety Data Sheets—provides detailed information on hazardous products Worker Education—an education program that keeps employees informed on how to work safely with hazardous products The responsibilities vary depending on the relevant party: For Suppliers—they must classify products, provide labels, and SDS For Employers—they must have a WHMIS program, Chemical inventory, SDS availability, labels, and training For Staff—they must participate in training, apply the knowledge, and report deficiencies Labels Each hazard class and category is assigned a “hazard statement”. It is brief and standardized sentences that describe the exact hazard of the product.

Hazard statements, refer to note 4 in the above label, are brief, standardized sentences that describes the exact hazard of the product. Each hazard class and category has an

Supplier Label – WHMIS 2015 1) Product identification 2) Pictogram 3) Signal word – “Danger” or Warning” 4) Hazard statements 5) Precautionary statements

− General − Prevention − Response (e.g. first aid) − Storage − Disposal

6) Supplier identification


assigned “hazard statement”. It also helps describe the degree of the hazard. For example, “May cause cancer” is more hazardous than “Suspected of causing cancer”. Product label and Section 2 of Hazards Identification of the SDS still require the signal word, hazard statement(s), and other required label elements

Safety Data Sheets Safety Data Sheets (SDS) is required for every hazardous product and is required to be updated within 90 days of the supplier being aware of any new information. SDS informs users of: Hazards of the product, How to use the product safely, What to expect if the recommendations are not followed, How to recognize symptoms of exposure, What to do if emergencies occur Sections detailed in Safety Data Sheets: Pictograms

1. Identification 2. Hazard Identification 3. Composition/Information on

Ingredients 4. First aid measures 5. Firefighting measures 6. Accidental release measures 7. Handling and storage 8. Exposure controls/Personal

protection 9. Physical and chemical properties

10. Stability and reactivity 11. Toxicological information 12. Ecological information* 13. Disposal considerations* 14. Transportation information* 15. Regulatory information* 16. Other information

*Sections 12- 15 are optional information. However, headings must be present

Workplace Labels Required when: o A hazardous product is produced at the workplace and

used in that workplace, o A hazardous product is decanted (e.g. transferred) into

another container, or o A supplier label becomes lost or illegible (unreadable).


Hazard Classes Each hazard class contains at least one category or “type”, e.g. 1, 2, etc. and sometimes with a subcategory, e.g. 1A, 1B, etc. Category informs how hazardous the product is, i.e. severity. For example: Category 1 is greatest level of hazard (within class), Category 1A (within class) is greater hazard than 1B. Exceptions: Compressed gas goes by physical state (e.g. liquefied gas, refrigerated liquefied gas, dissolved gas). Reproductive Toxicity has a separate category (e.g. “Effects on or via lactation”) in addition to Categories 1 and 2 relating to effects on fertility and/or unborn child. Training

Pictograms depict a hazardous symbol and are surrounded with a red border. Not all hazardous products are under a hazardous class or category requiring a pictogram.

Same pictogram can represent more than one hazard class. For example: Health Hazard • Carcinogenicity • Germ cell mutagenicity • Respiratory sensitizer • Reproductive toxicity • Specific target organ toxicity • Specific target organ toxicity • Aspiration hazard

One hazard class can have more than one pictogram. For example: Acute Toxicity • Skull and Crossbones—acute toxicity or

fatal if exposed • Exclamation mark—less serious

consequences (i.e. respiratory sensitizer)


Under legislation, employer’s responsibility is to provide information and training that is general and “site specific”; all staff must be trained, and have the responsibility to participate in ongoing education. Annual WHMIS training is available on LiME. Site Specific Training consists of storage and disposal procedures (e.g. where to keep them, whether to store with other chemicals, how to dispose etc.) and accidental release into environment (e.g. what to do if spilled in sink). Lastly, training must include controlled products covered by other regulations (e.g. TDG), if applicable to your job. Summary GHS does not replace WHMIS, rather it incorporates new elements. It was designed to enhance worker safety. All staff is required to continue: 1. Reading labels and pay attention to precautionary phrases and symbols 2. Following safe handling procedures 3. Be comfortable with accessing and interpreting information from MSD/SDS 4. Do annual refresher training

Radiation Safety Recognition of Radiation Warning Symbols


Pregnant Workers Education and Information about Radiation There are several modules on LiME, the Hospital e-learning system, that provide critical information for

those wanting to learn more about radiation and MRI safety, as well as for those who work with or around X-ray equipment (including mobile X-ray). All staff who will be working with or around radiation sources, MRI or X-ray equipment must be qualified and trained. The radiation safety officer (RSO) should be contacted for any concerns or questions about appropriate levels of training and awareness for a worker’s role or their duties. Contact for Information on Radiation If you have any concerns or further questions about radiation within the Hospital, email to [email protected] and the radiation safety officer will contact you.

The “Pink Dot” can also be interpreted as a flag for pregnant workers to be aware when a patient is radioactive. A patient is radioactive due to a recent nuclear medicine examination. Having this knowledge gives pregnant workers an opportunity to employ radiation safety measures which use the ALARA (As Low As Reasonably Achievable) principles to reduce radiation.


Quality, Patient Safety, Patient Relations & Experience and IPAC

Introduction

MSH is committed to providing safe, high-quality patient-centred care. Our unwavering focus on improved quality and safety has been driven by a variety of reasons. These include and are not limited to our desire to be known as the hospital of choice; a hospital that provides patients with an extraordinary experience. Earlier this year, we launched a strategic planning process which will define our future direction, including our quality and safety agenda. In the interim, our 2018/19 Strategy Map aligns seamlessly with our commitment to providing the higest quality care for our patients. Our refreshed quality improvement agenda is intended to reflect the idea that every person in the organization has the responsibility for – and contributes to – the quality of care and services. In developing this plan we reflected on input from stakeholders, observations of our processes, performance data and informed evidence. At the centre of our plan are our patients – listening to them, involving them and responding to their needs. As such, putting patients at the “heart of everything we do” continues to be a priority for MSH. We aspire to embed quality and safety throughout the orgazination, in all we do. This plan includes the quality priorities we have committed to in our 2018/19 Quality Improvement Plan (QIP) and provides an opportunity for us to clearly set our priorites for quality improvement over the next two years. This plan is a “living” document that will continue to evolve as we remain focused on the more challenging goals to ensure we deliver the best, highest quality and safest care possible.

Our foundation

The foundation reflects a clear understanding of how quality of care will be defined, measured, and continously improved in pursuit of our goal to be trusted providers of care and be the hospital of choice for extraordinary quality care and experiences. Quality definition:

MSH has adopted Health Quality Ontario’s definition of quality care. As such, quality care is care that is safe, effective, patient-

centred, timely, efficient and equitable. This definition reflects the shift from viewing quality of care as the responsibility of individual providers and institutions to a system responsibility.


Quality and safety framework

Our quality and safety framework considers MSH’s organizational strategic directions along with its core values. The model is shaped by Jurant’s Trilogy, an improvement cycle that reduces poor quality by planning quality into the process. The quality and safety framework focuses our quality and safety efforts at all levels and promotes monitoring and improvement of our services over time. As a continuous improvement model the quality framework, and quality and safety plan will assist us to measure, monitor and refine our efforts as we pursue the highest levels of quality care and patient safety.


Strategic goals

Our goals for quality and safety reflect our quality improvement plan initiatives, Accreditation Canada’s required organizational practices, the key elements of safety as defined by the Canadian Patient Safety Institute and the Excellent Care for All Act (ECFAA).

Patient & Family Experience 1. Extraordinary experience

Goal: Become a patient-led organization

By doing so, we will provide the best patient care experiences while treating our patients with compassion and respect each and every day

Safety 2. Safety first

Goal: Zero serious safety events

By doing so, we will establish practices and processes to embed safety in everything we do and every decision we make

Quality 3. Continuous improvement

Goal: Foster an environment of continuous learning

By doing so, we will build on existing strengths, reduce inefficiencies and improve quality of services


Infection Prevention and Control (IPAC) Program Infection Prevention and Control (IPAC) refers to evidence based practices and procedures that when applied consistently and efficiently can prevent or reduce the risk of transmission of microorganisms to health care providers, patients, and visitors (PIDAC 2012). The mission of IPAC at Markham Stouffville Hospital (MSH) is to reduce the risk of healthcare associated infections (HAIs) amongst its patient population. Amongst a number of different strategies applied to attain this mission there are some key practices to preventing and reducing the spread of infections. One key practice is the use of routine practices (RP) for every patient every time. Routine practices include: Hand hygiene (HH) must be done using facility provided and approved alcohol

based hand rub (ABHR) or soap and warm running water. HH is done to remove visible soil and transient microorganisms and includes surgical hand antisepsis. Gloves are not a substitute for hand hygiene. HH is an essential practice at MSH and it is imperative that it is done efficiently all the time. You will find information on HH program as you proceed further in your reading.

Personal Protective Equipment (PPE) must be worn when the risk assessment

deems necessary. Based on your encounter with the patient, you may be required to don on a mask and eye protection or face shield, gown, gloves and/or a combination of the different PPE depending on the type of encounter you anticipate. Examples (not limited to): Mask and Eye Protection or Face shield must be used during

procedures/encounters where there is anticipated risk to your mucous membranes (eyes, nose and mouth) either through splashing or spraying of blood, body fluids, secretions and excretions.

Gowns (long sleeved) should be worn where contamination of the skin or clothing is anticipated

Gloves must be worn when there is risk of contact with blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated surfaces and objects.

Environment and Equipment that is being used by more than one patient must

be cleaned between patients using the site approved cleaning agents/products. MSH has approved cleaners and disinfecting agents. List of cleaners and disinfecting agents is available through housekeeping. Depending on your area of work remember if you have shared equipment between patients it will need to be cleaned between each patient before use and when soiled.


Linen and waste should be handled carefully. Soiled articles should be handled such that personal and patient contamination is avoided.

Sharps Injury Prevention is critical to staff and patient safety and as an

employee of MSH you must ensure that you are aware of the Sharps use and disposal procedure/protocol.

Patient Placement must be considered when accommodating patients who may

be at risk of contaminating the environment or requiring precautions in addition to RP.

Hand Hygiene HH is the single most effective measure to reduce HAIs. MSH annually sets a compliance target and our current target for 2018 is 80%. Each area/unit is assessed for HH compliance and results are captured through an auditing tool. The auditing tool captures information based on the practices as per the four moments of HH.

The process is as follows: Auditors Our in house trained HH champions are the observers They observe interactions between staff and patients and moments of HH Based on what they observe they electronically document the moments Provide on the spot feedback, they may provide information on areas where you

have missed and opportunity and improvements

RP must be done for every patient every time

https://www.bing.com/images/search?view=detailV2&ccid=JffKbhdA&id=E7D7BD22FB26D226C09AB6E872D5B0E2F31774A7&thid=OIP.wMieptU4Y1Hnls4h5fgbvQHaFS&mediaurl=http://www.clipartkid.com/images/387/remember-sticky-note-clip-art-at-clker-com-vector-clip-art-online-niGLs7-clipart.png&exph=428&expw=600&q=remember&simid=608042753198130023&selectedIndex=0


IPAC Our onsite Infection Control Practitioners (ICPs) review the data monthly and

provide updates to unit managers and staff Areas of improvements and further developments are discussed within the team

References Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Best Practices for Hand Hygiene in All Health Care Settings. 4th ed. Toronto, ON: Queen’s Printer for Ontario; January 2014.

DON’T MISS AN OPPORTUNTITY to DO HAND HYGIENE

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“Expect Respect” – Violence and Harassment Prevention Education Program Markham Stouffville Hospital is committed to promoting, providing, and maintaining a work environment where respect and dignity are demonstrated at all times. We foster behaviours that contribute to minimizing the risk of violence and harassment in the workplace. The Hospital has a zero tolerance policy of violence and harassment in the workplace environment. The Hospital’s Violence and Harassment Prevention Education program, entitled “Expect Respect”, applies to all Markham Stouffville and Uxbridge employees, medical/dental/midwifery staff, volunteers, students, patients and their family members, visitors, suppliers, vendors, contractors, consultants and any person working on behalf of the Hospital. New employees will receive introductory “Expect Respect” classroom or e-learning education. Annually, all staff is also required to take “Expect Respect” e-learning refresher education available on LiME. All workplace parties have roles and responsibilities in the Hospital’s Violence and Harassment Prevention Education program. Workplace parties include: o Employer and Employee o Director and Manager o Medical, Dental, and Midwifery Staff o Volunteers and Students o Human Resources o Joint Occupational Health & Safety Committee o Occupational Health and Safety Department The major roles and responsibilities for all staff are to: o Uphold the Expect Respect program o Participate in recognizing, assessing and controlling workplace hazards o Comply with the Hospital’s Violence and Harassment Prevention policy and

procedures o Report all incidents or injuries of violence/harassment or threats to your

manager/director o Sign a Statement of Commitment to the Prevention of Violence and Harassment in

the workplace For Director/Managers, their roles and responsibilities are to: o Ensure employees complete the initial and annual refresher education


o Enforce policy and procedures and monitor compliance o Complete a Workplace Violence Risk Assessment form and action plan o Identify/alert employees of violent individuals or hazardous situations and take

preventative measures o Investigate all violence/harassment reports

There are resources available to you as an employee of Markham Stouffville Hospital. o Speak confidentially with your Manager or Director about the situation o Contact Occupational Health and Safety, Human Resources or Spiritual and Religious

Care departments o Access the MSH Employee Assistance Program by phone (866-641-3847) or online

(www.guidanceresources.com, password is EAP4MSH) o Register for our internal Crisis Prevention and Intervention Training (CPIT)

http://www.guidanceresources.com/


Other Definitions of Violence includes: o Bullying – repeated, persistent, continuous negative behaviour against a worker

where there is an imbalance of power o Assault – the use or threatened use of force where the victim believes the abuser

could carry out the threat. Assault is a criminal offence o Harassment – engaging in a course of vexatious comments or conduct against a

worker that is known or ought reasonably known to be unwelcome o Sexual Harassment – engaging in a course of vexatious comment or conduct against

a worker in a workplace because of sex, sexual orientation, gender identity or gender expression, where the course of comment or conduct is known or ought reasonably to be known to be unwelcome

o Domestic Violence – any use of physical or sexual force, actual or threatened in an intimate partner relationship. It may include a single act or pattern of violent acts forming a pattern of abuse


Below is a list of policies and procedures relating violence prevention and emergency response measures. They can be accessed on the Hospital’s intranet. To report an issue, staff is required to log onto IReport link on the Hospital’s intranet.

Violence and Harassment Related Policies and Procedures 030.901.080

Terms of Reference – Violence Prevention Committee

160.901.040 Professional Staff Conduct Complaints

080.901.130 Workplace Violence and Harassment

Prevention

530.914.914.005 Abuse of Patients by Staff or Volunteers

030.911.240 Code of Behaviour – Respect in the

Workplace

530.914.101.005 Domestic Violence Screening Guideline

XXX.XXX.XXX Alert for Behavioral Care

If there is immediate danger: Use personal alarm system if provided; call for help; call Code White; call the police


Privacy, Confidentiality and Personal Health Information Personal Health Information Protection Act The Ontario government enacted the Personal Health Information Protection Act (PHIPA) (Ontario) to establish the rules for the collection, use and disclosure of personal health information. PHIPA is designed to give individuals greater control over how their personal health information is collected, used or disclosed. At the same time, the PHIPA provides health-care professionals with a flexible framework to access and use health information as necessary for the provision of care. Personal Health Information (PHI) is practically any information related to the health or health care of an identifiable person. It can be as simple as a phone number or a postal code, when collected in a health care context. It is everywhere around us—in papers, conversations, computers, etc.—so that no matter what our job is, we all need to help protect it. As an employee working at Markham Stouffville Hospital, you are considered an ‘agent’ under PHIPA. As an agent of the hospital, you are expected to adhere to the hospital’s privacy and security policies to protect the privacy of our patients. Protecting privacy is an integral part of high-quality care, honouring the trust patients put in us, and treating patients with dignity and compassion. It promotes patient and staff satisfaction and ensures complete and accurate clinical information. In addition, it is required and expected by law, professional standards, hospital policies, emerging technologies, and increasingly, the public. Keep in mind that the consequences of not protecting patients’ privacy can be detrimental as you and the hospital are exposed to the penalties at law. Individuals failing to adhere to PHIPA can be fined up to $100,000. The institution can be fined up to $500,000 for failing to comply with the legal obligations under the Act. Patient’s Rights Patients can expect to be informed about how their personal health information will be collected, used and disclosed by MSH. Patients can also expect administrative, technical and physical safeguards relating to their PHI to be in place. PHIPA gives individuals the right to: • Understand the purposes for the collection, use and disclosure of PHI


• Refuse to give consent to the collection, use or disclosure of PHI, except in circumstances specified in PHIPA

• Withdraw consent to the collection, use or disclosure of PHI by providing notice to the hospital

• Request access to one’s own personal health information • Request corrections to be made to one’s own patient record • Complain to the Information and Privacy Commissioner (IPC) of Ontario How can you protect patient privacy?

• Never access records for individuals to whom you have no duty to care. Do not access your own records or those of your family. Before looking at patient information, ask yourself: “Do I need to know this to do my job?” and if not, don’t access the record.

• Do not disclose, release, copy or print PHI without the proper authorization. Patients requesting access to their personal health information should be directed to Health Records.

• Only access and use the minimum necessary amount of PHI in order to perform your job or duties.

• Do not leave records of PHI unattended or unsecure. • Always remember to log-off your workstation. Sign off the application after you

are finished or whenever you walk away from the work station. • Passwords selected must be strong passwords that are difficult to guess. Keep

your passwords confidential. • Keep digital PHI only in the secure hospital data centre, or on an encrypted

device approved by IT. • Unless an email is from a trusted source, never click on an attachment or link in

the email, and never respond with confidential information such as your password.

• Confidential health information about patients should NEVER be posted on social media or networking sites such as Facebook, Instagram, Twitter (etc.) for personal purposes.

• Use of cell phone cameras or other personal recording devices by staff to record patients or their family members is not permitted. Patient consent must be obtained prior to recording patients for marketing, education and/or research purposes.

• If you observe or suspect that the privacy and confidentiality of patient information has been violated or compromised, you must immediately report it to your supervisor and the Manager of Access, Privacy and Release of information by phone at (905) 472-7373 ext. 6004 or by email at [email protected]

mailto:[email protected]


• Remember it is everyone’s responsibility to protect the privacy and confidentiality of patient information.

Additional Resources This summary provides a basic overview of your privacy obligations under the Personal Health Information Protection Act (PHIPA). Information handling policies and guidelines are available on the Access and Privacy page on the hospital’s intranet. Educational resources and tips are also available on the Information and Privacy Commissioner’s (Ontario) website at www.ipc.on.ca Should you have further questions or concerns, please contact: Manager of Access, Privacy and Release of Information

Office of Access and Privacy Telephone: ext. 6004 Email: [email protected]



Ethics At Markham Stouffville Hospital everyone, from those who give care to those who support those in giving care have a role to play in the ethical provision of healthcare. Need support? Contact the ethicist: [email protected] , or see the Ethics Department page on the intranet for more information on the Integrated Ethics Framework! Ethics is about:

• Deciding what we should do – what decisions are morally right or acceptable • Explaining why we should do it – justifying our decision using language of values and

principles • Describing how we should do it – outlining an appropriate process for enacting the

decision • Having a plan to assess and evaluate how the decision is impacting the situation • Providing opportunities to re-visit decisions when new information becomes available

MSH is a member of the Health Ethics Alliance whose strategic goals are to enhance patient centred care, build ethics capacity, facilitate preventative ethics, innovate delivery of ethics services and influence the changing healthcare environment.

Organizational Ethical Issues: The Accountability for Reasonableness (A4R)

Organizational ethical decisions are generally those that involve and impact groups of patients/clients/residents or staff members, units, systems, or the organization as a whole and centre on the values of the organization (e.g., which program should receive the gifted funds?). Some ethical decisions may be predominantly clinical in nature;



Clinical Ethical Issues: The IDEA Ethics Framework Tool Clinical ethical issues are typically those that involve and impact specific individuals or staff members and focus on individual values (e.g., Should Mr. B have a feeding tube inserted?). The IDEA framework tool is designed to assist in the resolution of clinical ethical issues, and is comprised of four steps for ethical decision making. The first letter of each step in this framework forms the acronym ‘IDEA.’ MSH Mission, Vison and Values guide and influence how the framework is used.

MISSION: Excellence...Your Expectation, Our Inspiration VISION: Progressive Care for the Community

OUR VALUES Respect: Be Respectful – Holds the individuality of others in high regard, embracing diversity and maintains the dignity of others, especially when no one is looking. Compassion: Be Kind – Empowers others through explicit expressions of empathy, sensitivity and understanding. Trust: Be truthful – Unshakable dependability, reliability, honest and truthfulness. Courage: Be Strong – Displays commitment and leads others in overcoming obstacles and barriers, takes unpopular stance when necessary and faces unexpected hardships head on. Commitment: Be accountable – Engage with devotion and resilience

I D E A IDENTIFY the facts 1. Describe the situation 2. What are the

Clinical/Medical/Organizational facts?

3. What do people prefer? 4. What evidence is there? 5. What other influences are

there? Ask: What are the ethical issues?

DETERMINE- the relevant ethical principles 1. Who are all the Stakeholders? 2. What ethical

principles should be considered?

E.g. Respect for Persons, Do the most good, Do the least harm, Justice. Ask: Have other viewpoints been

EXPLORE - the options 1. What are the options? 2. Consider the strength

and weakness of each.

3. Consider laws and policies that might apply.

4. Does the chosen option support our Mission, Vision and Values?

Ask: What option can

ACT 1. Decide, develop and

carry out plan. 2. Evaluate your

decision Remember to document your plan and the outcome. Ask: Are we (am I) comfortable with this

http://sunnynet.ca/Default.aspx?cid=100495&lang=1


Accessibility for Ontarians with Disabilities Markham Stouffville Hospital supports the rights of all persons with disabilities to safe and equal access to the facilities, services and programs that the Hospital has to offer. This is in accordance with the Ontarians with Disabilities Act, 2001 and the Accessibility for Ontarians with Disabilities Act (AODA), 2005. AODA was passed by the government in 2005 to make Ontario accessible for people with disabilities by 2025. Under the AODA, accessibility standards have been created for organizations to identify, remove and prevent barriers to enable people with disabilities

1. Accessibility Standard for Customer Service- This standard became law in 2008. It is about ways to deliver accessible customer service to persons with disabilities.

2. Integrated Accessibility Standards Regulation (IASR)- This standard became law in 2011 and includes four standards in the areas of Information and Communications, Employment, Transportation, and the Built Environment.

3. Ontario Human Rights Code- This standard explains how the Human Rights Code supports persons with disabilities.

New staff members are required to successfully complete and pass each of the three (3) e-modules within three (3) months of hire. In addition, all staff must complete the Customer Service e-module annually as a refresher. The e-modules can be found in LiME. Persons with disabilities, who visit, work in or use the Hospital facilities, services and properties will have access to safe and barrier-free environments, programs and services. For more information about this policy, click on Policy tab on the Hospital’s intranet and refer to the policy entitled Accessibility.

considered? Have any been missed?

be best defended ethically?

decision?


Conflict of Interest Policy A conflict of interest (COI) in the workplace is defined as a situation in which an individual has the opportunity or ability to use their position at the Hospital or on the Board Committee to influence, directly or indirectly, a decision or action which could result in a personal gain or an advantage, gain, or benefit for any business or corporation, controlled in whole or in part by the individual or their immediate family.

In the Hospital’s Conflict of Interest Policy, the term MSH Agents refers to: o Staffs, medical/dentistry/midwifery staff o Students, researchers, residents o Volunteers, Board Committee members o Vendors and contractors

Examples of conflict of interest are as follows: o Involvement directly/indirectly in a business transaction or private arrangement that

results in personal/immediate family/close friend gain because of one’s position with MSH

o Accepting outside employment or other unauthorized activities which deprive MSH of services expected from the individual, or will involve unauthorized use of MSH Hospital time, equipment, staff, facilities and/or resources

o Using Hospital property without approval o Disclosing Hospital property information to unauthorized persons o Using information related to MSH for personal gain or to the advantage of any

business entity with which the individual holds a position or has a vested interest (personal or financial)

o Accepting gifts greater than nominal value of $50.00 from a patient, client, family member or supplier with whom the corporation may transact business. If the patient,


client, family member, supplier insists on presenting the gift, the matter should be disclosed to the agent’s supervisor

o Soliciting gifts and sponsorships unless they are in support of learning events, fundraising activities, or to support events that would benefit Hospital staff as a whole.

As MSH Agents, we have a duty and responsibility to act for or on behalf of the hospital’s best interests. This means that we will not engage in any other work, activity, relationship and/or business transaction which could be perceived to be in conflict with the best interest of the Hospital without prior consultation with your manager/director/associate vice president/vice president/chief. This also means that we will: o Identify and seek to avoid actual, potential or perceived conflicts of interest o Fully and accurately disclose, in writing, any relationships, affiliations, financial or

personal interests that may create a conflict of interest (actual or perceived) o If a conflict of interest is unavoidable:

- identify the problem - discuss it with your immediate supervisor, and - manage it in a transparent manner

If conflict of interest arises, Human Resources and Manager will refer issue(s) to a member of Senior Leadership Team. The manager/director must also ensure that annual training is completed by staff. Human Resources will collaborate with Manager and/or one level above to determine action plan if COI exists and to create written decision with steps to mitigate (when necessary) for staff member. MSH Agents shall read the Conflict of Interest Policy and participate in the annual training on LiME. For more information about this policy, click on Policy tab on the Hospital’s intranet and refer to the policy entitled Conflict of Interest. Whistleblower Policy Markham Stouffville Hospital has a Whistleblower policy intended to encourage staffs and others to make good faith reports of suspected fraud, corruption or other improper activity within the Hospital to appropriate Hospital officials, and to support the process that will be followed in evaluating and investigating such reports. For more information about this policy, click on the Policy tab on the Hospital intranet and refer to the policy entitled Whistleblower policy.


LiME eLearning Mandatory Courses Instructions: Register for the course on LiMe and review the content online. Complete the quiz at the end of the course and print the certificate for your records. Please visit learn.msh.ca and sign in with your MediTech username and password. For assistance with your Username and Password please contact IT.

Course Name/Description Who needs to complete

Complete

upon hire

Complete annually

Occupational Health & Safety

2019 Occ. Health and Safety Handbook – (type ‘handbook’ in search bar) An overview of MSH's Occupational Health and Safety Policies.

All Staff and Physicians


2019 Corporate Health and Safety Policies – (type ‘policies’ in search bar)



2019 WHMIS -(type ‘whmis’ in search bar) A review of WHMIS and applications to the workplace. Department specific WHMIS provided by your unit during orientation.



2019 MSD Prevention Safe Patient Handling – (type ‘msd’ in search bar) Any staff required to perform patient transfers as part of their responsibility

Any staff required to perform patient transfers


2019 MSD Prevention Manual Material Handling - All other staff

Staff not required to perform patient transfers


2019 Safety Engineered Medical Sharps (SEMS) – (type ‘sems’ in search bar) Reviews the type of SEMS used at MSH, safe use and reporting a sharps incident.


Infection Prevention &

Control

2019 Infection Prevention & Control Hand Hygiene 4 Moments– (type ‘hygiene’ in search bar) The 4 Moments of Hand Hygiene necessary to meet the requirement of hospital best practices.



Control

2019 Infection Prevention & Control Chain of Transmission– (type ‘IPAC’ in search bar)

All Staff excluding administration


Control

2019 Infection Prevention & Control Health Care Provider Controls– (type ‘IPAC’ in search bar)

Managers and Clinical Leads


Control

2019 Infection Prevention & Control Administrative Controls– (type ‘IPAC’ in search bar)

Managers and Clinical Leads


Control

2019 Infection Prevention & Control Additional Precautions– (type ‘IPAC’ in search bar) Clinical Staff


Risk 2019 Emergency Codes – (type ‘Emergency’) Review of the Emergency Codes used at MSH


Risk 2019 Code Brown – (type ‘brown’ in search bar)Roles and responsibilities, levels of Code Brown and how to respond to a departmental spill.


Risk

Code Spill Response Team – (type ‘brown’ in search bar) Procedures for the Spill Response Team to follow as a guide when responding to a Code Brown.

Required by Spill Response Team, including; Support Services, Plant Maint., Laboratory, Security; and Nursing at the Uxbridge site only.

Human Resources

2019 Expect Respect Refresher – (type ‘expect’ in search bar) The hospital's program to address workplace violence prevention.


Human Resources

2019 AODA Accessibility Standard for Customer Service – (type ‘AODA’ in search bar) Review of accessible customer service for persons with a variety of disabilities.


Note: if you have completed

this course in 2017, you will not have to re-

complete.

Human Resources

2019 AODA Integrated Accessibility Standards Regulation – (type ‘AODA’ in search bar) Standards for information and Communication, Employment and Design of Public Spaces.




complete.

Human Resources

2019 AODA Ontario Human Rights Code – (type ‘rights’ in search bar) This module explains how the Human Rights Code supports persons with disabilities.




complete.

Human Resources

2019 Conflict of Interest – (type ‘conflict’ in search bar) A review of the hospital's Conflict of Interest Policy.


Privacy

2019 Annual Privacy and Security Training– (type ‘privacy’ in search bar) Key privacy and security topics, covering all the bases required by the Privacy Commissioner’s Office

All Staff

Privacy

2019 Annual Privacy and Security Training– (type ‘privacy’ in search bar) Key privacy and security topics, covering all the bases required by the Privacy Commissioner’s Office

Physicians

Information Technology

2019 Information Security- (type 'infosec' in search bar) An overview of IT security standards at MSH



LiME Access On Site- intranet.msh.ca

Employee Orientation Handbook Employee Orientation Handbook Section 1: Training Materials

STEP 1: Find LIME From MSH intranet, find “Education and Training“ Click on LiME hyperlink

Step 2: Login Use your MSH network username and password, click OK.

Step 3: Review your LIME homepage All courses you are registered to take/ have taken or need to take are listed on the tabs. To register for a new course, click on Course Registration (2)


Search for a Course 1. Type a course word e.g. privacy. 2. Click on Search. Refer to the Staff Development Calendar for a list of open courses, contact your PPL or manager for a list of department specific courses to complete. Review the mandatory course list as stated above.

Register for an E-Module or Classroom Course 1. Find the course that you are

searching for. 2. Click on Register (on the far right

in the e-module course listing). For classroom course, follow the prompts to complete the registration and note the date of the course.

Take the Course 1. Click on Learning Home. The

course will show up. 2. Click on a hyperlinked course

and the course will automatically begin.


LiME Access Off Site- www.msh.on.ca

Step 1: Find LIME 1. Visit www.msh.on.ca. 2. Click tab—“Staff and

Physician” portal.

Step 2: Route into the intranet 1. Click Learn.MSH.ca. 2. Follow instructions to access

the intranet and follow the intranet path as previously outlined.

Step 3: Login 1. Type in your MSH network

username and password. 2. Click OK.

http://www.msh.on.ca/


Section 2: OTHER INFORMATION

OTHER INFORMATION Section 2:


Employment Standards in Ontario The ministry of Labour enforces and promotes awareness of employment standards, such as minimum wage, work hours, public holidays and other standards. The


Employment Standards Act is a law in Ontario. Visit www.labour.gov.on.ca for more information.

http://www.labour.gov.on.ca/


Parking and Security On the first day of Hospital Orientation, parking is free in the North Visitors Lot # 1 directly in front of the Hospital main entrance (facing Church Street). Parking on day 1 is free; take a parking ticket upon entering the lot. When leaving for the day, contact the parking office through the communication button at the parking exit and inform them that you are a new employee. They will open the parking bar for you to leave. If you choose to park at the Hospital, this information will be added to your ID badge. (see below for sign-up). At the end of the day, Security will bring new staff ID badges to the orientation room and distribute them. You will then be able to access the parking lot automatically with your ID badge when returning to the Hospital.


Signing-up for Parking New employees Markham & Uxbridge Site: Complete an Authorization for Payroll Deduction of Parking Fees form provided to you during the orientation. Submit the completed form to the Facilitator. Orientation @ Markham site for Uxbridge Primary Employees: For your first day please park in Visitor Lot 1 as indicated above, for any orientation dates after that at Markham, please park in Staff Lot 4, take a ticket at entrance and when you leave, buzz parking office by saying your name and that you are an Uxbridge Employee. ID Badges ID badges are individually programmed for authorized access to work areas, assigned parking lot, and Hospital staff entrances. They are programmed to your discipline or as instructed by your manager. Misplaced ID badges must be reported immediately to Security so access can be reviewed. Replacement badges are subject to a $20 fee. If you require keys for your office, request them through your manager. Safety Devices 1. Personal Safety device (PSD) for Code White

Specific areas may have this availability - see your manager for instructions 2. Parking Emergency Call Stations at the Pillars

Press the button to connect directly to security’s two-way radio 3. Lockers in the building

If required, combination locks will be provided by the Hospital. Management of lockers within units/departments will be completed by the department. Lockers on the first floor of Building A will be assigned by Facilities and Support Services.

I-Pass Parking (For Part-Time and Casual staff who elect not to enroll in MSH parking $19.50 per paycheck)

For I-pass your staff ID card must be used to enter and exit and the system will charge a set rate for each entry/exit. Billing will be through Precise Parklink I-Pass system and registration is on line. The Rates (Tariff)

Casual Staff Regular parking cost at $3.00 per in/out o Access to Lot 2 and 4

Casual Staff Premium parking cost at $5.00 per in/out.


o Access to Lot 2, 4, 5 and 7


Registration: Staff will need to go on line https://ipass.preciserd.com/clientlogin and register their ID, vehicle information and payment process.

Staff will receive a notice that registration has been completed. In addition Staff will have a user name and password to review their access and

billing. For Assistance please call 416-243-6990

Education Funding As the needs of the health care system change, our full-time & part-time staff must have opportunities to enhance their knowledge and skills. Markham Stouffville Hospital is committed to encouraging and supporting the learning needs of our staff by providing financial support for continuing education in a fiscally responsible manner. All staff will have equitable access to financial support, to take courses/programs or attend external conferences/seminars/workshops aligned with our strategic priorities; that are relevant to the employee’s current role; and/or help to prepare them for a different role at the Hospital. MSH supports professional development through in-house programming by Professional Practice and Organizational Development; lectures from internal/external subject matter experts, Grand Rounds, Case Presentations, and other methods. Education is also supported by providing financial support to attend external education opportunities such as certification for work-related competencies, college/university courses, seminars, conferences and workshops. Please see our Education Funding program information on the intranet for policy and process. Employee Referral Program People are the Hospital’s most valuable asset. As a result, there’s no better way to recruit talented professionals to work at the Hospital than within our own network of people. The Hospital offers a referral bonus to current staff referring external applicants who are successfully hired into designated hard-to-fill permanent positions. Current hard-to-fill positions, eligible for referral bonus include:

• Pharmacy Technicians • Experienced RNs with all required credentials for: Emergency, Operating

Room, Post Anesthetic Care Unit, Critical Care, and Childbirth Centre • Maintenance Mechanics

https://ipass.preciserd.com/clientlogin


The referral bonus amounts for hard-to-fill positions are set as follows:

• Part-time regular positions = $250 • Full-time regular positions = $500

For more information, refer to the Hospital’s intranet, under Departments, Human Resources, Employee Referral section. Part-time Employee Benefits Part time and casual staff who are not covered under MSH’s health care plan have the option to enroll privately through an independent insurance company. Please note the benefit coverage offered through the Health Care Providers Group Insurance Plan is purchased directly by the individual and is not part of the Hospital's benefit program. This Plan is not part of your contract of employment with Markham Stouffville Hospital, the Hospital is not responsible for this plan in any way. The Health Care Providers Group Insurance Plan provides private insurance coverage for Extended Health, Dental, Life Insurance, Long-term Disability, and Accidental Death and Dismemberment benefits to part-time staff who qualify under their plan. This plan provides each qualifying part-time with a thirty-one (31) day initial introduction window to purchase coverage without any medical questions asked of themselves or their families. A thirty-one (31) day window is also available to new part-timers and to persons who transfer to regular part-time status and are no longer entitled to coverage under the plans offered by the Hospital to full-time employees. For more information or to enroll, visit their website at www.healthcareproviders.ca. Places to Eat Tim Hortons Building A, next to the Main Lobby Entrance

Druxy’s / Cafeteria Building A, level 1

Tim Hortons After Hours Building B, level 1, next to Emergency

Presse Café Cornell Community Centre and Library

Waiting Froom Café Medical Office Building, next to Dale’s Pharmacy

http://www.healthcareproviders.ca/


Gift Shop The Cornflower Gift Shop offers a variety of snacks and gifts for purchase. Staff receives a 10% discount on gift items.

Dale’s Pharmacy Located in the Medical Office Building (MOB) connected to the Hospital, Dale’s can meet your medication and health-care product needs. Upon showing your staffs ID badge, you can receive 10 per cent off everything, excluding prescriptions and sale items. Full-time staff with benefits may have prescriptions filled with Dale’s and have payment directly made to the insurance provider.


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HIRE - Markham Stouffville Hospital

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Transcript of HIRE - Markham Stouffville Hospital