APPLICATION FOR SHADOW/OBSERVER

APPLICATION FOR SHADOW/OBSERVER

Date(s) of Observation: __________________________________________________ ______________________________________________________________________________________ Name (First, Middle, Last): ______________________________________________________________________________________ Street Address ___________________________________ ___________________ ____________________________ City State Zip ___________________________________ ___________________________________ Telephone (Daytime) Telephone (Evening) Have you ever worked for SJHS? Yes ______ No ______ If yes, when and in what position/Department: Have you ever performed volunteer service for SJHS? Yes ______ No ______ If yes, when: List the physician(s) you would like to shadow/observe, and briefly explain why you want to work in the career you are exploring:

APPROVED: ______________________________________ Hospital President (or designee)

Packet needs to be returned to the Medical Staff Office PRIOR to Observation Date(s)

Return entire packet to: South Jersey Healthcare

Medical Staff Office 1505 West Sherman Avenue

Vineland, NJ 08360 F:\VOL1\MSO-WP\Policy & Procedure & privileges\MSO72 Shadow-Observer\MSO 72 SHADOWER-OBSERVER Application.doc

72.1

ACKNOWLEDGEMENT FOR SHADOW/OBSERVER SJH has prepared the following information to keep you, our patients and staff safe during your shadow/observation experience. This information was written to serve as a guide during your experience. Please read, sign and return the statement below. Feel free to contact the Medical Staff Services Department at 856-641-7513 with any questions or concerns. Completion and receipt of this form is necessary for your request for a shadow/observer experience to be processed. The hospital mission is to “Support the provision of quality, accessible, cost-effective health services that contribute to the improved health and well being of all in the communities we serve.” The requirements for all individuals entering the hospital for employment or educational purposes, is to ensure the quality of care as well as meeting regulatory requirements.

1. Hazard Communication (HAZCOM): These are chemicals used by the hospital that are considered hazardous. Your mentor is responsible for ensuring your safety while at the hospital. For this reason, you must not handle any chemicals.

2. Infection Control: There are procedures at the hospital that involve exposure to infectious or potentially infectious diseases and/or materials. Your mentor is responsible for ensuring that you are not exposed to these risks. Therefore, you will not be permitted to participate in activities or procedures that would increase your potential for exposure to these infectious diseases and/or materials. Do not enter isolation rooms or handle infectious materials.

3. Appearance Standards: SJH requires that all persons participating in this program be dressed in a professional manner (casual business attire). The hospital reserves the right to cancel your shadow/observer experience should your attire be considered inappropriate.

4. Emergency Pages: There are certain situations, such as internal or external disasters, that require immediate response by the entire hospital staff. Should you hear one of the following overhead pages, it is imperative that you observe the instructions of your mentor. Code RED (Fire) Code SILVER (Hostage Situation) Code BLUE (Adult Medical Emergency) Code ORANGE (Hazardous Material Incident) Code WHITE (Pediatric Medical Emergency) Code TRIAGE (Disaster) Code AMBER (Infant/Child Abduction) Code CVA (Stroke) Code YELLOW (Bomb Threat) Code CLEAR (Situation Cleared) Code GRAY (Security Emergency-Patient Elopement)

5. Incident Reporting: Should an incident occur while you are at the hospital, it is extremely important that it be reported. An incident is defined as any occurrence that is other than anticipated or outside of the normal scope of business. Examples of incidents include injury to yourself or others, loss of or damage to property, any real or perceived situation, which may result in injury, or damage. Your mentor is responsible for assisting you in completing the necessary forms to document these incidents (located on the Intranet).

6. Confidentiality: Shadows/Observers can only be provided the minimal necessary information regarding patients.

7. Medical History: To avoid exposure or risk to any of our customers, the hospital requires you to be free from communicable diseases. Your signature on this form indicates that you:

� Could provide evidence of current MMR vaccination status and PPD within the past year. � You are free from communicable disease, which includes absence of:

o Cough, fever, night sweats o Draining wounds or sores o Active diarrhea

I have read and understand the above material as presented to me. I understand that I am responsible for following all directives as given to me by my assigned hospital mentor. Printed Name of Shadow/Observer Applicant:

Date:

Signature of Shadow/Observer Applicant:

Academic Institution (if applicable):

F:\VOL1\MSO-WP\Policy & Procedure & privileges\MSO72 Shadow-Observer\MSO 72 SHADOW-OBSERVATION acknowledgement form for shadower-observer.doc 72.2

Information for Mentors of Shadow/Observer Program

Shadow/Observer Name: _________________________________ Date(s): ______________________ SJH has prepared the following information to inform mentors who provide non-employees with experience at SJH of their responsibilities. Please review the following information and sign below to document your understanding and role in this program. For questions, please feel free to contact the Medical Staff Services Department at 856-641-7513.

1. Medical Conditions: All shadows/observers are required to declare they are free of communicable disease to ensure that they pose no risk to patients, visitors, or staff. If you suspect that a shadow/observer has a medical condition that may present a risk, please ask the individual to leave. If the medical condition resulted in potential exposure to any individual in the hospital, an incident report must be completed (located on the Intranet).

2. Hazard Communication (HAZCOM): Shadows/Observers are not to handle hazardous chemicals, or participate in processes or procedures during which they may be exposed to hazardous chemicals.

3. Infection Control: You are responsible for ensuring that your shadow/observer is not placed at risk for exposure to infectious diseases and/or materials. For this reason, shadows are not allowed to enter isolation rooms, or to participate in any procedures which involve direct contact with blood, bogy fluids, non-intact skin, mucous membranes, contaminated equipment, or infectious waste. If the shadow/observer does suffer a significant exposure, follow the policy outlined in the Infection Control Manual (located on the Intranet).

4. Emergency Pages: Should an emergency page be given, it is imperative that you respond immediately to ensure the safety of your shadow. Do not involve your shadow/observer in any response that may put the shadow/observer in additional danger. Pages to consider include: Code RED (Fire) Code SILVER (Hostage Situation) Code BLUE (Adult Medical Emergency) Code ORANGE (Hazardous Material Incident) Code WHITE (Pediatric Medical Emergency) Code TRIAGE (Disaster) Code AMBER (Infant/Child Abduction) Code CVA (Stroke) Code YELLOW (Bomb Threat) Code CLEAR (Situation Cleared) Code GRAY (Security Emergency-Patient Elopement)

5. Incident Reporting: Should an incident occur while you are mentoring a shadow/observer, it is necessary to report it. You are responsible for completing the necessary forms to document any such incident at the time of the occurrence, while the shadow/observer is still present (located on the Intranet).

6. Confidentiality: You can only be provided the minimal necessary information regarding patients.

7. Patient Consent: It is the obligation of the mentor to obtain the consent (which may be oral) of every patient having a shadow/observer be present during encounters with that patient.

8. Responsibility of Mentor: The mentor will be held responsible to the Hospital and the Medical Staff for any violations by the shadow/observer of any of the obligations (including confidentiality) of the shadow/observer under this program.

I have read and understand the above material as presented to me. I understand that as a mentor, my primary responsibility is to ensure the safety of the shadow/observer assigned to me. Printed Name of Mentor:

Date:

Signature of Mentor:

Department:

F:\VOL1\MSO-WP\Policy & Procedure & privileges\MSO72 Shadow-Observer\MSO 72 SHADOW-OBSERVATION information acknowledgement for physician.doc 72.4

A federal law named “HIPAA” (Health Insurance Portability and Accountability Act) de�nes “protected health information” and sets standards for health care providers to protect that information. The law also defines stiff penalties (fines and even imprisonment) for violating those privacy provisions. Various New Jersey state laws also protect the privacy of patient information. Protected information is any information regarding a patient’s stay at our facility. That information includes, but is not limited to; name, address, phone number, date of birth, financial information, diagnosis, and treatment information. In addition to defining protected health information, the law requires that we must define the minimum necessary information which employees, volunteers, contracted agencies, and site visitors can have access to. You will have access to protected health information (e.g.: name, location in the facility, reason for the visit or hospitalization, financial information). It is important that you recognize that any protected health information cannot be removed from this facility or shared: *at home or school, *with friends or family, *outside the hospital, *by written, verbal, or e-mail communication The easiest way to remember how to implement this law is the saying, “What you see here or hear here, must remain here.” I have reviewed the information above, understand it, and agree to abide by it. ______________________________________________________ ___________________________ Signature Date _______________________________________________________ Name (Please print) _______________________________________________________ Clinical Instructor Overseeing Site Visit F:\VOL1\MSO-WP\Policy & Procedure & privileges\MSO23 Student Rotation\MSO 23.3 Student Rotation Confidentiality Statement.doc 23.3

Confidentiality Statement

POLICY & PROCEDURE

Subject: Observers/Shadows

Department: Medical Staff Office

CDC Task Category: I II III N/A

Page: 1 of 1 Policy #: MSO 72 Effective Date: 3/08 Replaces Policy #: _______ Dated: ____________ Supersedes Page: of Dated:

Distribution: All Corporations X Regional Medical Center X Elmer

72.

This Policy and Procedure #72 applies to situations in which a member of the Medical Staff seeks permission to be accompanied in the Hospital by an individual who is not enrolled in an accredited graduate school program that is affiliated with the Hospital., That is, this Policy and Procedure applies to persons who have traditionally been referred to as shadowers or observers. Persons who are in a graduate training program may accompany Medical Staff members in accordance with Policy and Procedure #23. This Policy and Procedure does not pertain to situations involving the presence in the Hospital of medical school graduates who are participating in a Residency program that has a formal relationship with the Hospital. The presence of such Residents in the Hospital is controlled by Policy and Procedure #67. Any uncertainties or disagreements regarding which of these Policies and Procedures applies in any particular situation will be referred to the Hospital’s Chief Medical Officer for a final determination. I. A member of the Medical Staff (“Mentor”) may request permission for a person who is not a student in an approved educational program that has an educational affiliation agreement with the Hospital to accompany the Mentor within the clinical, non-public areas of the Hospital for the purpose of observing the activities that take place in a hospital setting. Such persons are referred to herein as “Observers/Shadows”. A person who accompanies a Medical Staff member only into areas that are accessible to visi tors (e.g., lobby, waiting rooms, nurses’ stations) will not be considered Observers/Shadows and will not be subject to this Policy and Procedure. An example of such a person is a child of a Medical Staff member who accompanies his or her parent to the Hospital, but who does not enter a patient room or other private area. II. No person may be an Observer/Shadow and no Mentor may bring an Observer/Shadow into the Hospital unless permission is properly granted in accordance with this Policy and Procedure. III. A Mentor may bring an Observer/Shadow into the Hospital under the following conditions: A. A written request (“Application for Observer/Shadow”, Attachment 72.1) to have the Observer/Shadow at the Hospital must be received from the Mentor and forwarded for approval through the Medical Staff Office for approval by the Chief Medical Officer, or his or her designee. B. Permission to be an Observer/Shadow is a privilege that may be withheld or subsequently withdrawn at any time by the Hospital. C. If permission is received, the Observer/Shadow must complete and sign the “Acknowledgement for Shadow/Observer” form (Attachment 72.2) and the Confidentiality Statement (Attachment 72.3). D. The Mentor must complete and sign the Information for Mentors form (Attachment 72.4). E. Patients may not be interviewed, examined or treated in the presence of an Observer/Shadow without the permission of the patient or person responsible for making decisions on behalf of the patient. F. An Observer/Shadow must wear a nametag that identifies him or her as such. G. If the Mentor intends to bring the Observer/Shadow into the OR/Endoscopy Suite, the attending surgeon, the Chief of Surgery and the Director of Surgical Service must be notified in advance. The Mentor and the Observer/Shadow must abide by whatever conditions and procedures may be imposed. The Observer/Shadow may be required to leave the operating suite at any time by the attending surgeon, anesthesiologist, nurse anesthetist or a circulating RN. IV. The role of the Observer/Shadow is strictly limited to observation only. It is the responsibility of the Mentor to make the Observer/Shadow aware of this Policy. The Mentor will be subject to discipline by the Medical Staff should he or she not properly supervise and control the behavior of the Observer/Shadow. Approved: Credentials: MEC: Board: F:\VOL1\MSO-WP\Policy & Procedure & privileges\MSO72 Shadow-Observer\MSO 72 Shadow-Observation Policy.doc MEC approved 6/12/08