1. Volunteer Services Orientation
2012

2. The University of Kansas Hospital
Facts Regarding
The University of Kansas Hospital

3. Volunteer Orientation Checklist
When each page is discussed, place a “√ ” in front of the page number
to indicate the information was presented.
When finished please sign, date, and return the checklist to your
instructor.
_____ Our Vision
_____ Volunteer Agreement
_____ Confidentiality Policy
_____ H.I.P.A.A.
_____ Material Safety Data Sheet
_____ Infection Control Procedures
_____ Pink Dot Program/Orange Dot Program
_____ Code Red/Other Emergency Codes
_____ Fire Extinguisher Use
_____ Emergency Codes
______ Volunteer Uniform Policy
______ Wheelchairs
______ Important phone numbers
______ Map
By signing this document, I acknowledge that I have read and understand the
above listed materials.   
_______________________________ ____________________
Name Date

4. * Five Star Performance Goals *
Our Vision
To lead the nation in caring, healing, teaching, and learning.
Our Mission
The University of Kansas Hospital will:
Deliver world-class patient care to the people we serve.
Ensure the excellence of future patient care through exceptional learning, teaching, and research.
* Five Star Performance Goals *
SERVICE
PEOPLE
QUALITY
COST
GROWTH

5. Volunteer Agreement
My services are donated to the hospital without contemplation of compensation or future employment.
I will not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on KU Hospital premises.
I will meet the TB skin test requirements as determined by KU Hospital.
I will be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my work professional in quality.
I will make my best effort to fulfill my commitment to KU Hospital by completing all assignments that I accept.
I will at all times while engaged in volunteer activities at KU Hospital uphold the philosophy and ethical principles of KU Hospital.
I understand that the volunteer services department reserves the right to terminate my volunteer status as a result of:
* failure to comply with KU Hospital policies, rules
and regulations.
* absence without prior notification.
* unsatisfactory attitude, work or appearance.
* any other circumstances which, based on the ultimate
decision of the Volunteer Department, would make my
continued services as a volunteer contrary to the best
interest of KU Hospital.

6. Confidentiality Policy
Our patients and employees of the Hospital are entitled to and expect Hospital volunteers to keep medical and personal information confidential. The Hospital also is entitled to and expects its volunteers to closely protect financial and operational information about the Hospital. Supervisors in each department of the Hospital are responsible for ensuring that volunteers understand and follow Hospital policies regarding the release of patient, employee, and Hospital financial and operational material.
1. All patients’ medical and personal information is confidential
information and must be held in strict confidence. This
confidential information must not become casual conversation anywhere in the Hospital. Information can only
be shared with other employees or volunteers if they have a
need to know in order to provide care/services to the patient.
An employee’s/volunteer’s medical or personal information is
confidential. The information must not be disclosed to
managers, supervisors, or other employees/volunteers
unless the information is necessary to ensure the health and
safety or with the employee’s/volunteer’s consent.
Hospital financial and operational information is confidential.
Volunteers who have access to this confidential information
may not disclose it to individuals other than Hospital
employees who have a need to know in order to perform their
job.

7. Confidentiality Policy
The Hospital Information System’s user codes/passwords are
confidential. Only the individual to whom the code/password
is issued should know the code/password. A volunteer must
not attempt to obtain access through the computer information system to which he/she is authorized to view or receive. A new password must be requested if another
knows it.
5. Information will not be given out on “D” (Denial) which means
the patient’s personal information is protected for their safety
and well being. Acknowledging this person is a patient in the
hospital is prohibited. “DP” (Psychiatric Patient Denial)
which means this patient can’t receive flowers, mail, etc. for
their own safety. “O” (Omit) which means the patient’s
personal information is omitted from the Hospital directory, at the patient’s request.
If a volunteer is aware of a violation or suspects a violation of
this policy, it is the volunteer’s responsibility to immediately
report this to his/her supervisor.
Violations of this policy will result in disciplinary action up to
and including termination of volunteer assignment.

8. What is H.I.P.P.A.?
The University of Kansas Hospital Volunteers will strive to maintain the confidentially of patient and other confidential information in accordance with applicable legal and ethical standards.
1. What is HIPAA? Health Insurance Portability and Accountability Act.
a) A set of rules established by the Federal Government that
must be followed by all health care providers.
b) A law that sets national standard to protect medical records
and other personal health information (PHI),
c) A state organization that governs hospital boards.
2. HIPAA regulations apply to all of the following: hospitals, physicians,
insurance companies, labs, home care companies, and surgical
centers.
a) True
b) False
3. Why is HIPAA important?
a) The University of Kansas Hospital promises patients that their
information will stay private unless it is deemed necessary to
disclose it.
b) It is a state law that must be endorsed.
The HIPAA regulations apply to protected health information in:
a) Electronic documents, paper documents, conversations.
b) Paper documents.
c) Electronic and paper documents.
The penalty for an employee or volunteer who knowingly misuses a patient’s
health information under false pretenses is:
a) a fine of up to $1000
b) a fine of up to $50,000 and imprisonment for a term up to five years
c) a fine of up to $250,000 and imprisonment for a term up to ten years

9. What is H.I.P.P.A.?
6. A University of Kansas Hospital employee/volunteer who violates the
confidentiality policy is subject to punishments up to and including termination of employment/volunteer assignment.
a) True
b) False
7. If I leave out a name of a patient in conversation, isn’t that enough?
A) Yes
B) No
8. When a famous person is a patient at the University Of Kansas Hospital, it
is acceptable to
a) Ask them for their autograph and take a picture.
b) Tell your friends that he/she is a patient at the hospital.
c) None of the above
Volunteers shall refrain from revealing any personal or confidential information concerning patients unless
a) Legally required or there is a valid release for patient care
purposes.
b) The nurse manager on duty requests the information.
c) The media requests information regarding the patient.
10. Every patient being treated at The University of Kansas Hospital must be provided with a copy of the Hospital Notice of Privacy Practices when they
first arrive.
11. Hospital volunteers will not reveal any personal or confidential information
regarding
a) Patients, employees, or medical staff members unless
authorized to do so by the University of Kansas Hospital.
b) Patients, employees, or medical staff members, and Pets for Life
animals unless authorized to do so by the University of Kansas .

10. HIPAA Quiz Answers 1. A & B 2. A 3. A 4. A 5. C 6. A 7. B 8. C 9. A
1. A & B A
3. A
4. A
5. C
6. A
7. B
8. C
9. A
10. A A

11. Material Safety Data Sheets
Material Safety Data Sheets are supplied by manufactures and contain the following information for user safety:
Name of chemical Emergency response
Manufacturer Spill and leaks
Associated hazards Handling reactivity
Chemical components Disposal practices
Physical properties Exposure limits
First aid procedures
Recommended personal equipment

12. Infection Control
Hand washing is the most important hygiene measure in preventing the spread of infection.
Wash hands before and after each patient contact, after personal hygiene, eating, drinking, or wearing gloves.
Do not handle anything soiled with blood or body fluid. Call Environmental Services for assistance.
Check with staff before entering a room with isolation card on the door.

13. Wristband DOT Programs
This was created to facilitate the safety of patients with confused, impulsive, and/or wandering behavior. The purpose is to prevent harm to a confused or judgment-impaired patient (especially one with wandering/elopement risk). This is the primary responsibility of the RN assigned to care for the patient. (Elopement means leaving the nursing unit or hospital without the endorsement of the clinicians.)
DO DOT Program
There are patients coming into our hospital for both outpatient and inpatient care who have various barriers to communication (that is, they cannot be understood or they cannot understand others readily). Some examples include patients who:
* Have hearing or speaking difficulties.
* Speak a language other than English.
* Have limited English proficiency.

14. Emergency Codes CODE RED (R.A.C.C.E.E.) Remove- anyone in danger.
   
                                                                
Emergency Codes
CODE RED (R.A.C.C.E.E.)
Remove- anyone in danger.
Activate- Alarm; locate the nearest pull station.
Call 911- provide exact location (room number,
status of situation.
Close- doors, windows, or oxygen zone valves.
eliminate drafts.
Extinguish- small fires if possible.
Evacuate- patients and personnel if needed or
directed.
CODE BLUE– Cardiac/respiratory arrest. Areas to
avoid will be given.
CODE PINK– Infant abduction.
Fire Extinguisher Use
Where are the fire extinguishers located in your work area?
How is it used? (PASS)
P – pull pin
A – aim at the base of fire
S – squeeze trigger
S – sweep from side to side

15. Volunteer Uniform
(*Certain groups may be excluded from this requirement, e.g. Missy’s Boutique volunteers.)
All University of Kansas Hospital volunteers will wear a uniform. Volunteers will purchase a uniform provided from the Volunteer Department for $20.00.
The volunteer uniform consists of a navy blue vest with the hospital logo (purchased from the department), worn with a white shirt and khaki or tan pants. Depending upon the volunteer assignment, volunteers my wear a blue polo shirt with the hospital volunteer logo. Shirts are worn tucked in. Skirts or slacks worn with the uniform must be tan or khaki. NO shorts, jeans, or capri pants are to be worn. No mini-skirts are to be worn.
Nametags provided by the University of Kansas Hospital will be worn at all times when on duty.
Soft soled comfortable and close-toed shoes. Socks or hosiery will be worn at all times. NO sandals or open toed shoes are to be worn.
Jewelry must be simple; no dangling earrings, bracelets or necklaces.
Cologne, perfume and shaving lotion will not be worn.
Volunteer’s appearance will be neat and clean at all times while on duty.

16. Wheelchair Safety Guidelines
In keeping with the University of Kansas Hospital philosophy of patient-centered care, our first consideration in the use of wheelchairs is the patient’s safety and comfort.
Always keep a pleasant, friendly attitude, no matter how unreasonable a patient or family member may seem.
Keep hand brakes locked when the patient is entering/exiting the wheelchair.
Put the footrest up and out of the way when assisting the patient into and out of the wheelchair.
Ask the patient if they are ready before moving the chair and tell them where you are taking them.
See that the patient’s arms are inside the armrests and never hanging over the side of the chair.
See that the patient’s feet are securely placed on the footrests.
Back into the elevator.
Avoid sudden stops. Move slowly. Stop at all hall entrances to be sure traffic is clear for you to enter.
Never lift a patient to put them into or take them out of a chair. Call staff for assistance.
Do not push patients with equipment; this includes oxygen tanks (theirs or ours), and IV poles.
Do not push patients who are obviously very ill. Call staff for assistance.
Stay with the patient when you arrive at their destination until a staff member comes to take over.

17. Important Phone Numbers
Paula Gangel, Director
Volunteer Coordinators Cathy Engmann
Judy Masonbrink
Notes about the Phone System
For dialing inside KU, place an 8 in front of the four-digit extension. If dialing outside of K.U. Med, dial the entire number. To obtain an outside line (to call home, etc.) first dial a “9.”
Information Desk Main Hospital
Information Desk Cancer Center
Information Desk Heart Hospital
Customer Complaints/Patient Relations
Emergency Department
K.U. Police
K.U. Security
Chaplain Protestant
Catholic
Environmental Services
Transportation--Wheelchair Transport
Rapid Response Team