PERSONNEL MANUAL TABLE OF CONTENTS 1. Selecting the Right Staff 2. Employee Policies 3. Telephone Policy 4. New Employee Orientation 5. Personnel Responsibilities 6. Resignation/Termination Policy 7. American Disability Act (ADA) 8. Job Description - Associate Medical Director 9. Job Description - Medical Director 10. Job Description - Administrative RN Clinical Director 11. Job Description - Clinical Director 12. Job Responsibilities of Clinical Director 13. Job Description - Endoscopy Center Endoscopy Nurse 14. Job Description - Endoscopy Nurse 15. Job Description - Licensed Practice Nurse 16. Job Responsibilities - Licensed Practical Nurse 17. Job Description - Nurse Specialist - PAR 18. Job Description - Medical Records Clerk 19. Job Description - Billing and Collections Coordinator 20. Job Description - Medical Transcriptionist 21. Unit Clerk 22. Job Description/Performance Evaluation Unit Clerk Coordinator 23. Job Description - GI Unit Clerk 24. Job Description - Medical Records Manager 25. Medical Records Clerk 26. Orientation Objectives for Gastroenterology Nurses 27. Orientation Procedure for Endoscopy Nurses (form) 28. Employee Performance Evaluation (form) 29. Employee Progress Report (form) 30. Progress Report (form) EMPLOYEE POLICIES HOURS OF WORK: The working hours of the FACILITY will be Monday through Friday. The FACILITY will not be open on the weekends or any holiday. Your shift will be determined by the Clinical Director of the FACILITY according to the average patient census per day. It will be required that each employee be flexible in their work shift to accommodate patient census and patient care. Every effort will be make to make your shift regular, but there may be some rotating of shifts. A normal work shift for full-time employees consists of seven and one-half (7.5) hours, including a thirty (30) minute duty free lunch period. There is an employee lounge for your use at lunch and on breaks. You may leave the office building for lunch only with the permission of the Clinical Director or whomever he/she leaves in charge. TIME CARDS: You are responsible for keeping your time accurately each day, utilizing the time clock. Your supervisor shall instruct you on the use of the time clock and you may refer to the Policy and Procedure Manual. You are responsible for any time that needs to be added to your time care (i.e., sick time, vacation time, etc.) This is to be added to the back of your card with an explanation and initialed by the Clinical Director. Deliberately falsifying your time record is cause of immediate dismissal. You may take a fifteen (15) minute rest period during your first four (4) hours of work and another fifteen (15) minute rest period during your second three and one-half (3.5) hours of work. Rest periods are counted as time worked and are scheduled by your supervisor based on departmental needs. ATTENDANCE: Regular attendance by all employees is very important. If you are unable to work as assigned, you must notify the Clinical Director immediately. You will be required to notify your supervisor, at least two (2) hours before your scheduled time to work. If you need to be excused from work for part of the day for personal business, doctor's appointments, etc., you must notify your supervisor, at least twenty-four (24) hours in advance. If you are absent for more than one (1) day, you must check in daily with your supervisor unless other arrangements have been made. Frequent absence or tardiness will subject you to disciplinary action. Three (3) consecutive absences from work without notification to your supervisor will effectively terminate your employment. PAY DAY: You will be paid by check once every two (2) weeks. If you have a problem with your check, please see your supervisor. Your check will be given to you by your supervisor. DEDUCTIONS: In accordance with the law, deductions are made from each paycheck for federal tax and for social security taxes (FICA). Another deduction that you may want to authorize is hospitalization insurance for your family. OVERTIME: Occasionally, you may be asked to work overtime in order to maintain the Services. We do not intend that this will be a common occurrence, but the flexibility of the employees is required on this matter. You will be able to take back any time that was worked overtime as soon as it is feasible with the work load and at the discretion of the Clinical Director. LOCKERS: Lockers are provided for your use and you will be assigned a locker and key shortly after employment. The FACILITY is not responsible for money or other valuables in lockers. Employees are responsible for their locker keys and lockers may be inspected at any time without prior notice. It is very likely that you will share a locker with another employee. Lockers will be available for patient use during their stay in the FACILITY. They will also be locked and the key will be the responsibility of the Recovery Room personnel. At any time that you notice anything suspicious you should notify your supervisor. GRIEVANCE POLICY AND PROCEDURE METHODS OF CORRECTIVE ACTION: Rules and regulations are necessary in every society. The best working conditions prevail when employees conduct themselves with respect and consideration for themselves, their fellow employees and their employer. Rules and regulations to provide for the safety, happiness, and productivity of employees must be enforced to be effective. Violations bring discipline. In the more serious areas of misconduct, the necessary result may even be discharge. Each case will be carefully evaluated by the supervisor concerned before appropriate action is taken. Verbal Warning: An employee whose on the job behavior and/or job performance is not satisfactory, is warned verbally concerning the specific nature of the problem(s) and the consequences of not correcting the unsatisfactory behavior and/or job performance. Written Warning: An employee who fails to respond to verbal warnings, is warned in writing concerning the specific nature of the problem(s) and the consequences of not correcting the unsatisfactory behavior and/or job performance. Demotion: Incompletely resolved on the job behavior or performance problems may cause an employee to be demoted into a position at a lower salary grade. If problems are effectively resolved in this grade, such an employee may again be eligible for promotion to positions for which he/she qualifies. Suspension: An employee with serious on the job behavior or performance problems may be suspended from duty by the supervisor for one(1) to five (5) days. All such actions are reported in writing to the Medical Director of the FACILITY and become part of the employees permanent record. Discharge: Employees may be discharged. If, after attempts by the supervisor to apply both goal oriented employee development techniques and employee discipline techniques, the employee fails to correct and/or improve unsatisfactory on the job performance, employment will be terminated. Termination is imposed only as a last resort when all other techniques have failed to bring about desired change. Reasons for discharge may include, but are not limited to, the following: Abuse or mistreatment of patients Excessive absence Possession of weapons Possession, consumption or under the influence of intoxicating beverages, narcotics or other behavior-affecting drugs. Gambling Swearing and foul language Improper behavior toward patients, visitors, or other employees Insubordination in carrying out reasonable directions of supervisor Unauthorized possession of FACILITY property Fighting. Sleeping on the job Falsification of records Vandalism or willful destruction of FACILITY property. IMMEDIATE TERMINATION: Theft The specific facts surrounding any person being recommended for discharge will be reviewed to determine if continued employment is in order. We understand that questions or misunderstandings may arise in any employee group. Every effort will be made to assist you in settling these differences with the following procedure. Clinical Director with Employee: Employee should present his/her concern orally to the Department Head. The Department Head will thoroughly review the complaint with the employee and render an oral decision to the employee. Medical Director of the FACILITY with Employee: If the employee is dissatisfied with the decision reached at Step 1, he/she may appeal the concern to the Medical Director of the FACILITY. The Medical Director will arrange a meeting with the employee, review the facts surrounding the case and render a decision. Appointed Executive of the Board of Directors with Employee: If a satisfactory decision is not made at Step 2, the employee may appeal his/her concern to this Executive. This appeal must be made in writing. The executive will arrange a meeting with the employee, review the facts surrounding the case and render a decision. Board of Directors with Employee: If Step 3 does not provide a satisfactory settlement, the employee may appeal his/her concern to the Board of Directors of the FACILITY. This appeal must be made in writing. The Board of Directors will arrange a meeting with the employee, review the proceedings of the case and render a final decision to the employee. Each step in the grievance procedure should be accomplished as quickly as possible. The response to each step of the grievance procedure will be documented in the employee's file with steps 2, 3, and 4, becoming a permanent part of the employee's record. GENERAL POLICIES OF THE FACILITY Your conduct and courtesy at the SADDEC should be one that represents the SADDEC in a very positive and pleasant manner at all times. This institution is one that helps people and your conduct should compliment this. Every effort should be made to make patients and their families at ease and welcome to the SADDEC. Being friendly and courteous, supplying and helpful information, giving directions or simply being kind to others will be expected of every employee. Your personal attitude and appearance should reflect your professionalism at all times. Most of what goes on in the FACILITY is confidential. Any information regarding a patient's illness or personal affairs is not to be discussed with other patients, employees or those outside the SADDEC. To violate this rule may result in disciplinary action and possible discharge. All employee records will remain strictly confidential. No information will be provided to any individual or company outside the SADDEC without specific permission of the employee. This permission will be granted by the employee on an individual basis in writing. The employee must provide such permission before the information will be provided. The only exception to this policy will be information regarding the employment dates of the employee. All employee information will be maintained under lock for security. TELEPHONE POLICY EXPLANATION: The telephone is an important public contact tool. Certain techniques should consistently be used when answering and talking on the telephone. FORM: Telephone log PROCEDURE: The telephone should always be answered in the following manner: "Good morning (afternoon, etc.), (name of facility), " in a pleasant cheerful tone of voice. Many calls will be prospective patients inquiring about access, hours of operation, etc. Give all information simply and courteously. If appropriate, ask the caller's name and addressed, and send them a brochure. If prices are requested, give the patient the basic visit charge and state that this is the charge for the BASIC visit, and if other procedures are done, the price may change. If the caller asks for a list of prices, state that it is our policy not to give out our fee schedule on the telephone, but if they would care to come in, the facility manager would be happy to give them the information they desire. If another call comes in while you are on the telephone, inform the caller you will have to put them on hold. Never put someone on hold without first informing them. Alternatively, when you are not speaking with a caller, always put them on hold. Never leave a receiver hanging without being on hold. All medical questions should be referred to the nurse for screening. NO MEDICAL ADVICE SHOULD BE GIVEN ON THE TELEPHONE. Refer the caller to the physician in emergency situations. Remember that as an employee, all actions you take are considered part of the physician's own actions. This means that anything you say or do in the performance of your job is legally interpreted as something said or done by the physician. It is essential for your to be aware of and cautious about what you say and to whom you say it. Remember, this is an area where it is possible for you to do something that can make the facility liable. If you get inquiries for medical information about a patient: Any inquires about patients should be treated cautiously. All such information directly relates to what goes on between the patient and the physician. It is therefore "privileged communication" and may not be given out without the patient's express consent. If you are skeptical about a caller (i.e., someone representing themselves as an insurance agent) return the telephone call. This will screen out callers who are not honest about who they represent. Tell the caller you have to check the records before answering any questions and will call back. The way the telephone is answered when you return the call let's you know the caller's identify and who the patient claims to represent. If doubt remains, tell the caller you must have a written request accompanied by the patient's signed authorization. About "HOLD": Few things are more annoying to a caller then to be kept on hold. If you can neither answer a questions nor transfer the call to the appropriate person, obtain the caller's name and number and explain that you (or the appropriate person) will return the call as soon as soon as possible. ALL STAFF MEMBERS SHOULD BE CONSCIENTIOUS ABOUT TAKING MESSAGES AND RETURNING CALLS. If you remember different reactions you have had to various calls you have made (e.g., to the telephone company, etc.) it is easy to keep in mind the public relations impact of the telephone. Remember: Answer the phone correctly. Don't give medical information over the telephone. Don't keep caller on hold. Return all calls promptly. Take complete messages. NEW EMPLOYEE ORIENTATION PURPOSE: To acquaint and orient the new employee to all aspects of the endoscopy center, as well as the general office locations and functions. (135.6.b.6) POLICY: Orientation will be carried out in such a manner as to provide the employee with successful acquaintance to all aspect of the endoscopy center and general offices. RESPONSIBLE PARTY: Personnel INTRADEPARTMENTAL PROCEDURE: Time management: To discuss work hours, breaks, lunch and general principles of time management. Location of generator and emergency power: To help familiarize employee with location and usage of generator and location of emergency power outlets. New employee handbook: To provide adequate opportunity to read and discuss the new employee handbook of SADDEC. Employee job description: Assist employee in the reading and discussion of the job description pertinent to their particular position. Orientation to endoscopy suite To provide adequate orientation to the procedure rooms and their equipment, etc. Routine of FACILITY: To provide a thorough discussion regarding basic routine procedures of the FACILITY. Policy and Procedures: To provide adequate time for review and discussion of policy and procedures manual pertaining to the FACILITY. Orientation with preceptor: To ensure new employee has adequate time for orientation with assigned preceptor. Success of orientation with preceptor to be evaluated by an ongoing process. PERSONNEL RESPONSIBILITIES Personnel are required to maintain any licensure required for the position held at the SADDEC All personnel will be required to perform their duties in a legal, professional and ethical manner. (135.7.b) Personnel are required to maintain the GI unit, endoscopic equipment, accessories, and supplies as directed. Insure proper use, function and infection control. Have knowledge of infection control measures within the FACILITY. This includes equipment, personal protection, the unit itself, waste disposal and patient protection. CPR certification is required for all nursing staff and medical assistants. (135.7.h) Schedule patients for procedures providing explanation of the procedure and written instructions for preparation. Completes the required documentation for patients undergoing endoscopic procedures. Prevents, corrects and reduces health risks through patient education. Supports the endoscopy policies consistently. RESIGNATION / TERMINATION POLICY JUSTIFICATION FOR DISCIPLINARY ACTIONS: Rules and regulations are necessary in every society. The best working conditions prevail when employees conduct themselves with respect and consideration for themselves, their fellow employees and their desired change. Reasons for discharge may include, but are not limited to, the following: Abuse or mistreatment of patients. Excessive absence. Possession of weapons. Possession, consumption or under the influence of intoxicating beverages, narcotics or other behavior affecting drugs. Gambling. Swearing and foul language. Improper behavior towards patients, visitors or other employees. Insubordination in carrying out reasonable directions of supervisor. Unauthorized possession of FACILITY property. Fighting. Sleeping on the job. Falsification of records. Vandalism or willful destruction of SADDEC property.