UnityPoint Health - Des Moines Volunteer Services - Readiness Guide

Volunteer Readiness Guide 2023

Table of Contents Message from Volunteer Services ...................................... 3 DNV (Det Norske Veritas) Overview................................ 4-5 Potential Questions from DNV Surveyors ....................... 6-8

COVID-19 Specific Guidelines for Volunteers .................... 9 Confidentiality, HIPAA and the HITECH Act ................ 10-11 “No Pub”/”Do Not Announce” Patients & Social Media ..... 12 Confidentiality Guidelines for Volunteers .......................... 13 Expectations for Service Excellence................................. 14 AIDET, No Point Policy, and the 10-5 Rule ...................... 15

Emergency Respond Procedures ................................ 16-17 People to Know and Important Phone Numbers............... 18 Volunteer Services Staff and Contact Information ............ 19

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Message from Volunteer Services Thank you for your ongoing commitment to being the best you can be for our patients, caregivers, team members and community. Reviewing this Volunteer Readiness Guide will help you in maintaining the basic knowledge and skills necessary to perform your important volunteer role.

This information is important for you to know should you be asked questions by any of our regulatory surveyors, including the DNV. They visit our hospitals each year and help us ensure we are doing our best, in every aspect, for our patients. As a volunteer at UnityPoint Health – Des Moines, you play an important role in delivering on our mission, vision and FOCUS values. This guide is just one of many ways that we offer to ensure you have the knowledge you need to do just that.

We remain grateful for your passion and service, Ashley Thompson, MPH Executive Director of Volunteer Services and the Volunteer Services Team Mission: To improve the health of the people and communities we serve.

Vision: Best Outcome, Every Patient, Every Time FOCUS Values: Foster Unity, Own the Moment, Champion Excellence, UnityPoint Health, Seize Opportunities

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DNV (Det Norske Veritas) Overview What is DNV? Det Norske Veritas (“The Norwegian Truth”) or DNV is an accrediting organization for hospitals. DNV helps to ensure the highest levels of excellence in hospital quality and patient safety.

What does DNV do? Through ongoing collaboration and onsite hospital surveys, DNV staff, or “surveyors”, partner with hospitals to observe patient care and interview patients, employees, and volunteers.

Why are DNV surveyors/staff coming to the hospital? Hospitals are not required to seek accreditation; however, UnityPoint Health – Des Moines hospitals voluntarily seek the review. DNV Accreditation assures safe, high quality care is delivered.

How often does DNV visit and survey the hospital? Annually.

The DNV survey team usually comes to UnityPoint Health – Des Moines hospitals for one week, sometime in April or May of each year.

What can I expect as a volunteer? If you are volunteering on the day that the DNV survey team is on site, you may be asked questions about what you do in your volunteer work, what to do if you hear a specific code, confidentiality, and infection control (like hand washing). You already know much of this information simply through your new volunteer training, our Volunteer Services handbook, everyday volunteer activities, our newsletters and annual training.

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DNV (Det Norske Veritas) Overview DNV Surveyors Arrival Procedure Volunteer Expectations: • DNV surveyors will typically arrive at hospital front lobby

entrances at approximately 8:00 a.m. If a surveyor approaches you, please introduce yourself as a volunteer. Each campus has specific instructions when surveyors arrive on campus.

• If you have any conversations with surveyors, please let your

Volunteer Coordinator know.

• Remember: Surveyors are here to validate the great work you

are doing as a volunteer, the exceptional care and services being provided by our team members and medical staff, and the highquality care we provide in our hospitals. They are here to help!

Volunteer Quick Tip If a surveyor asks you a question that you are unsure of how to answer, that is okay!

Please say: “I’m not sure, but I can ask any staff to assist me in any emergency situation and follow his/her/their instructions.” or

“I’m not sure, but I know I can always ask any member of the Volunteer Services team for assistance.”

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Potential Questions from DNV Surveyors Question: What do you do as a volunteer?

Answer: Describe the duties you perform as a volunteer. Examples: Escort patients and family members to different areas of the hospital, deliver flowers to hospital units.

Question: What type of training did you receive?

Answer: I completed the New Volunteer Orientation (Volunteer Handbook and Non-Mandatory Reporter Training) and volunteer role/ department specific training.

Question: Do you receive ongoing training?

Answer: Yes, through new volunteer orientation, annual education, our Volunteer Voice and Weekend Update newsletters, emails, notices, Volgistics touch screen messages.

Question: Do you know where you can get your volunteer position description?

Answer: Yes, a copy is in the Volunteer Services Office.

Question: Are you aware of the importance of confidentiality and privacy?

Answer: Yes, patients have the right to confidentiality and privacy. As a volunteer, I have received training on confidentiality, the Health Insurance Portability and Accountability Act (HIPAA) and Protection Health Information (PHI). “What you see here, what you hear here, must remain here, when you leave here.”

Question: To whom can you give patient information?

Answer: I can only give a room number if the person asks for a patient by name. To find out a room number and if the patient is listed as “Do Not Announce / No Pub” (meaning, I can’t give this information out to anyone), I call the hospital operator/message center.

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Potential Questions from DNV Surveyors Question: Another volunteer wants to know information about a patient. Can you share this information?

Answer: Only if that volunteer needs the information for the role that he/she/they does as a volunteer.

Question: What do you do if a patient or family has a complaint?

Answer: Thank the patient for bringing forward the complaint and connect them with the department supervisor or a member of the Guest Relations team (call x15000) immediately.

Question: What do you do if you notice a spill?

Answer: Notify Environmental Services (call x17000) and stay at the location of the spill until they arrive. If it is water, coffee or a liquid from my own cup or mug, I know that it is safe for me to clean the spill up myself.

Question: If a chemical spill occurs, what do you do?

Answer: Notify the department supervisor for immediate assistance in determining what should be done based on the type of spill. Notify Environmental Services (call x17000) immediately!

Volunteer Quick Tip All of our training information is available in the UnityPoint Health – Des Moines Volunteer Handbook on our website or in any of the Volunteer Services offices.

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Potential Questions from DNV Surveyors Question: Do you practice infection control?

Answer: Yes. The number one way to avoid the spread of infection is hand hygiene (washing our hands). We also follow all hospital policies and procedures related to masking and related infection prevention procedures.

Question: Does everyone get training on infection control?

Answer: Yes, training is provided during New Volunteer Orientation and our annual education. Everyone is responsible for infection control.

Question: What is the best way to prevent the spread of infection?

Answer: Proper hand hygiene (washing our hands). We are trained to wash our hands at the beginning and end of every volunteer shift, before and after eating, using the restroom, blowing our nose, coughing, touching our face, entering and existing patient rooms, after removing gloves, or interactions with others.

Question: What do you do if you encounter a precautionary sign on a patient’s door?

Answer: Precautionary signs can be found on a patient’s door to notify visitors of specific precautionary measures that are being taken with a specific patient, such as a patient with an active COVID-19 infection.

Volunteers do NOT enter rooms with precautionary signs present.

Question: Do you know where the Volunteer Services Emergency Management Plan is located?

Answer: Yes, the plan (red binder) is located in the Volunteer Services office.

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COVID-19 Specific Guidelines for Volunteers • Volunteers must follow all universal masking and social

distancing according to policy, while volunteering. Current guidelines, policies and procedures are shared with volunteers via email and in each Volunteer Services office.

• Volunteers should not provide services to COIVD-positive patients.

• All volunteers should strictly adhere to hand hygiene, respiratory

hygiene and cough etiquette (covering of the nose and mouth when coughing or sneezing) and continuously monitor themselves for signs and symptoms of infection (fever, cough, shortness of breath).

• Volunteers involved in direct patient contact must follow the

hospital’s current policies for Personal Protective Equipment (PPE) during any patient interaction.

• Volunteers should report unprotected (unmasked or no eye

protection) exposures to suspected or confirmed COVID-positive patients or coworkers in accordance with local exposure reporting policies and procedures.

• Volunteers with exposure to COVID-19 should report their exposure

to a member of the Volunteer Services team immediately to determine current policies and procedures.

• Volunteers who are not feeling well, or have symptoms related to

COVID-19 need to alert Volunteer Services and Employee Health.

Volunteers must follow the directions of Employee Health direction for any necessary next steps such as testing and when to return to volunteering.

Volunteer Quick Tip Unsure of current COVID-19 policies and procedures?

Contact any member of the Volunteer Services team for assistance.

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Confidentiality, HIPAA and the HITECH ACT “What you see here, what you hear here, must remain here, when you leave here.”

UnityPoint Health - Des Moines has a strong tradition of protecting the privacy of patient information. Confidentiality has always been part of the hospital culture. However, there is also a federal law that sets the national standard to protect medical records and other personal health information. The law is the Health Insurance Portability and Accountability Act or HIPAA. HIPAA establishes accountability: civil and criminal penalties administered to individuals or institutions that do not follow this regulation. HIPAA regulates Protected Health Information (PHI) in any form: verbal, written, video or electronic. Examples: • A patient’s medical record • A patient’s name, address, and phone number • A patient’s Social Security Number and medical record number • A patient’s vehicle information, such as a license plate number

HIPAA requires volunteers to take reasonable steps to only use or disclose the minimum amount of PHI necessary to do their assigned tasks.

HITECH Act The Health Information Technology for Economic and Clinical Health (HITECH) Act contains a provision that allows the criminal prosecution of any individual who knowingly discloses or obtains PHI without authorization. It is important that volunteers understand the types of breaches of confidentiality which are covered under HIPAA and the HITECH Act. They are as follows:

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HITECH ACT 1. Carelessness or Inadvertent a. Unintentional or careless access, review or disclosures by a volunteer and/or disclosure of PHI without a legitimate “need to know.” Example: Faxing to wrong fax number; leaving computer terminal unattended in accessible area with PHI unsecured 2. Failure to follow policy or access for curiosity or concern a. Examples: A volunteer accesses and reviews a patient’s medical record out of concern or curiosity; a volunteer shares on social media that, while they were volunteering at the hospital, they saw their neighbor in the ED/ER.

3. Personal Gain or Malice: An intentional access or disclosure of PHI for personal gain or with malicious intent a. Example: Volunteer accesses or discloses PHI for use in personal relationship; volunteer gathers PHI to be sold.

Volunteers are bound by hospital policy regarding confidentiality and are not to discuss or disclose information concerning a patient to anyone inside or outside the hospital while volunteering at any UnityPoint Health – Des Moines site. A patient’s privacy must be respected at all times. Any violation of this policy will result in immediate dismissal.

Some examples of breaches of confidentiality include: • Sharing the names of patients or details of their hospitalization • Taking home information about patients in a printed form • Talking with the media or others about patients • Taking photos in the hospital with a personal cell phone

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HIPAA: “No Pub” or “Do Not Announce” Patients and Social Media “No Pub” or “Do Not Announce” Patients When admitted to our hospitals, patients may choose to not to be shown on the public patient roster or computer listing. These are called “No Pub Patients” or “Do Not Announce Patients”. This means that these patients have chosen to have no visitors, mail, phone calls, or flowers.

If a visitor, delivery person, or caller is looking for a “no pub” patient, please state the following: “We are sorry but we don’t have anyone on our list by the name.” You might suggest that the person inquiring checks with a family member. The guest is always welcome to check with a family member.

• If we are unable to verify a room number, the patient is likely

on the “no pub” list. Mail or floral items will be returned.

• Failure to protect these “no-pub” or “do not announce” patients

can result in a fine to you as an individual as well as the hospital.

Social Media • Patient privacy and confidentiality laws extend to social media. It

is a violation of federal law to post or discuss PHI on social media sites like Facebook, Instagram, or TikTok. • Even if you think you have left out details about a patient in the

post, people may be able to figure out who you are talking about.

• Do not take pictures while volunteering (unless authorized) as

patients or patient information may be in the picture.

Volunteer Quick Tip When in doubt, seek it out! Please contact a member of the Volunteer Services team or the department supervisor if you have any questions about information that can or can’t be shared.

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Confidentiality Guidelines for Volunteers • Ask for, look for, and share only that information needed

to do the assigned volunteer role.

• Do not go through the patient census to look for

individuals you know. If you see someone you know, please do not to visit them without expressed permission.

• When a volunteer needs to share confidential information,

do so in a private place and out of hearing of others. Avoid hallways, elevators, lobbies, cafeteria, etc.

• Always use your own username and password. Do not use

another volunteer’s sign in. Never share computer passwords with anyone.

• Keep patient information in a secure and private place that

is not accessible to others who do not need to have access.

• If using a patient list, never leave the list on a desk or

unattended. The volunteer must keep the list private and turn the identifying patient information face downward or use a cover sheet when it is not being used.

• Properly discard all materials containing PHI by using

Shred-All Bins.

• When delivering any item to patients, such as flowers, gifts, or

mail, take reasonable steps to make sure the attached label, addressing information or gift card with the patients’ name is not visible to others.

• Do not share information about other volunteers who are

hospitalized unless the patient/volunteer has given verbal or written permission to Volunteer Services staff.

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Expectations for Service Excellence To realize the mission and vision of UnityPoint Health – Des Moines, it is essential that everyone understand the expected behaviors for daily interaction with patients and families.

• Smile, wear your volunteer uniform, and

name badge where it is highly visible.

• Introduce yourself and explain your role.

• Phone finesse. Answer the telephone with a

“smile.” Identify yourself and ask how you can help the caller.

Transfer the caller only if absolutely necessary.

• Go the extra mile. Anticipate the needs of the people you serve.

Ask, “How can I help?” or “Is there anything else I can do?”

• Present a professional image: clean uniform and appearance.

• Assist patients, visitors, and families in a positive and

professional manner. Provide clear, accurate information that meets or exceeds the needs of patient, customers and visitors.

• Respond with respect to customer requests in a friendly,

positive and prompt manner.

• Keep it quiet/keep it clean. Help keep the noise level down and

all public and patient areas free of clutter.

• Respect the privacy and confidentiality of the people you

serve, our physicians, employees and your fellow volunteers.

• Manage wait times and work to eliminate delays before they

happen.

• If a problem has occurred for patients for family members,

perform “service recovery.” Use the H.E.A.T. Model: Hear, Empathize, Apologize and Take action.

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AIDET, No Point Policy, and the 10-5 Rule AIDET: The Five Fundamentals of Patient Communication • Acknowledge: Smile, greet & be positive.

• Introduce: Tell others who you are &what your role is.

• Duration: Communicate the length of wait or walk times.

• Explanation: Help others understand what you’re doing & why.

• Thank you: Be sincere, be kind, and show appreciation.

Example: “Good morning, Ms. Smith. My name is Jim, I’m a volunteer and am happy to walk you to your appointment. The Radiology department is a three minute walk…[after walk] it was nice to talk with you, Ms. Smith.

You are in great hands with our Radiology team. Is there anything else I can do for you today?...Thank you and have a nice day!”

No Point Policy At UnityPoint Health – Des Moines, we escort all patients and visitors to their desired destination if at all possible. We do not point and verbally provide directions unless this is the only option.

It is okay to hand off the patient or visitor to another volunteer or staff member to ensure they get to their desired destination.

10-5 Rule When you encounter anyone that is 10 feet from you, please smile. When you encounter anyone 5 feet from you, please verbally engage with them by saying, “Good Morning!” or “Hello” or something appropriate for the moment.

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Emergency Response Procedures H.E.A.T. Model for Service Recovery H: Hear their story – listen attentively without interrupting E: Empathize – Put yourself in their shoes, how would you feel?

A: Apologize – “I’m so sorry you had this experience.”

T: Take Action/Thank – Tell the person what your next steps will be, what you will do to help. Elevate this to a manager.

P.A.S.S. Model for Fire Extinguisher Use P: Pull the pin A: Aim at the base of the fire S: Squeeze the handle

S: Sweep across the fire from side to side

R.A.C.E. Model for Fire Procedures R: Rescue – Remove anyone in danger, move patients behind fire doors, closing off door to impacted area.

A: Alarm – Activate the nearest fire alarm and from a hospital phone, dial 777 or 241-777 from a cell phone.

C: Contain – Confine the fire by closing nearby doors and windows.

E: Extinguish or Evacuate – Use a fire extinguisher if the fire is small, evacuate if you cannot safely extinguish the fire.

Hostile Threat or Active Shooter A: Accept that the situation is real A: Assess what is happening

A: Act (avoid area, barricade, fight as last resort) A: Alert (notify Public Safety at 777 or panic button)

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Emergency Response Procedures

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UnityPoint Health – Des Moines People to Know and Phone Numbers David Stark ............................................................. President & CEO Denny Linderbaum ........................................ President, Foundation Denise Cundy .............................................. Chief Nursing Executive Dr. Tracy Ekhardt ............................................. Chief Medical Officer

Erin Feilmeier ...................................................... Compliance Officer Proctor Lureman ..................................... Vice President, Operations Tom Mathews ................................................. Chief Financial Officer Joyce McDanel ........................... Vice President, Human Resources Tom Mulrooney ............................................. Chief Operating Officer Dr. Wendy Woods-Swafford ...... Medical Director, Blank Children’s

Vicki Berberich, Agi Gavin & Danira Halilovic ..... Guest Relations

Emergency (from hospital phones) ........................................... 777 Emergency (from cell phone) .................................. (515) 241-7777 Emergency (off hospital campuses) ......................................... 911 Non Emergency/Public Safety .................. (515) 241-6476 or 16476 Employee & Volunteer Injuries ................. (515) 241-3333 or 13333 Translation Services/Interpreters ............ (515) 241-7000 or 17000 Employee/Volunteer Health .............. ILH: (515) 263-5213 or 35213 ......................................................... IMMC: (515) 241-6425 or 16425 ..........................................................MWH: (515) 343-1087 or 31087 Volunteer Services............................. ILH: (515) 263-5227 or 35227 ......................................................... IMMC: (515) 241-6414 or 16414 ..........................................................MWH: (515) 343-1645 or 31645

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Volunteer Services Department Staff and Contact Information Ashley Thompson, MPH Executive Director Ashley.Thompson@unitypoint.org (515) 263-5226 (ILH) | (515) 241– 8108 (IMMC) | (515) 537-6089 (cell)

Melinda (Mindy) Brightman Office Manager Melinda.Brightman@unitypoint.org (515) 241-5343

Caroline Baker Volunteer Coordinator, Iowa Methodist Medical Center Caroline.Baker@unitypoint.org (515) 241-8140

Sarah Brix Volunteer Coordinator, Iowa Methodist Medical Center Sarah.Brix@unitypoint.org (515) 241-8273

Megan Delanty, CCLS Volunteer Coordinator, Iowa Lutheran Hospital Megan.Delanty@unitypoint.org (515)263-5475

Elizabeth Johnson Manager, Not New Shop – Iowa Lutheran Hospital Elizabeth.Johnson2@unitypoint.org (515) 266-7610

Ginny Kerr Volunteer Coordinator, Iowa Lutheran Hospital Ginny.Kerr@unitypoint.org (515) 263-5227

Riley Maher Volunteer Coordinator, Iowa Lutheran Hospital Riley.Maher@unitypoint.org (515) 263-5231

Sheri Vining Volunteer Coordinator, Methodist West Hospital Sheri.Vining@unitypoint.org (515) 343-1088

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Last Updated: April 2023 Questions or comments may be directed to UnityPoint Health – Des Moines Volunteer Services at (515) 241-5343 or dm_volunteers@unitypoint.org.