Attachments & Reference Documents

Attachments
& Reference
Documents

Organizational Overview (OO)

OO1 01 Hospital Plan for Patient Services

OO2 02 VP/CNO curriculum vitae
OO3 O1 BHSF 2011-2012 Annual Report
OO3 02 Homestead Hospital 2013 Annual Report
OO3 03 System Nursing 2012-2013 Report
OO3 04 Homestead Hospital 2013 Annual Nursing Report
OO3 05 HH 400-5200-105 Performance Improvement Initiative
OO3 06 HH-400-5200-102 Performance Improvement Steering Council
OO3 07 HH-400-2000-200-04 Nursing Performance and Quality Improvement
OO3 08 BHSF-1406 Patient Safety Plan
OO3 09 Homestead Hospital FY 2013 and 2014 Strategic Goals
OO3 10 Homestead Hospital Nursing FY 2013 and 2014 Strategic Goals
OO4 01 Homestead Hospital Organizational Chart
OO4 02 Homestead Hospital Plan for Patient Services
OO4 03 Homestead Hospital Nursing Organizational Chart
OO4 04 Shared Governance Model
OO4 05 CNO 1 to 1 meetings

OO5 01 BHSF-4100 Tuition Reimbursement Program
OO5 02 BHSF-4200 Nurse Scholars Program
OO5 03 Nurse Scholars brochure
OO5 04 BHSF-7001.00 Continuing Education Contact Hour Approval for Nursing and Allied Health Professionals
OO5 05 BHSF-HR 4300 Mandatory and Professional Development Employee Education
OO5 06 Baptist Health University (BHU) Student Quick Reference
OO5 07 BHSF-4100 Tuition Reimbursement Program (highlighted)
OO5 08 BHSF-1300.04 Access to Library Services
OO5 09 Medical-Surgical Certification Flyer
OO5 10 Travel and Education Request Process
OO5 11 HH 400-2010-200-09 Center for Excellence in Nursing Council (CEN) (highlighted)
OO6 01 Survey Instrument
OO6 02 Learner Needs Assessment Hospital-wide Results
OO6 03 2014 ANCC-Approved Classes

OO11 01 HH-400-6030-840 Allied Health Professionals Policy
OO12 01 BHSF-100 Patient Privacy Rights
OO12 02 BHSF 101.10 Provision of the BHSF Notice of Privacy Practices
OO12 03 Notice of Privacy Practices Brochure [English]
OO12 04 Notice of Privacy Practices Brochure [Spanish]
OO12 05 Patient Acknowledgement of Notice of Privacy Practices [English]
OO12 06 Patient Acknowledgement of Notice of Privacy Practices [Spanish])
OO12 07 HH-400-5610-1148 Security Management Plan
OO12 08 BHSF-1406 Patient Safety Plan
OO12 09 HH-1195 Security Lockdown of the Hospital

OO12 10 HH-400-5610-1030 Code Green – Disruptive patient, visitor or employee
OO12 11 HH-400-5610-1080 Code 9 – Medical Emergencies of Visitors/Non-Patient Employee Inside the Hospital Building
OO12 12 BHSF-301 Using, Disclosing and Requesting Patient Information for Baptist Health Treatment Purposes
OO12 13 BHSF-400 Use or Disclosure of Medical Record Information
OO12 14 BHSF 352.02 HIPAA Privacy Procedures - Patient’s Request for Restriction on Uses and Disclosures of Health Information
OO12 15 HH-100-7940-1320 Ethical Issues and Ethics Consultation Requests
OO12 16 Homestead Hospital Clinical Ethics Committee Charter

OO12 17 HH-400-7983-798 Levels of End-of-Life Care
OO12 18 HH-400-5830-798-1 Neonatal - Levels of End-of-Life Care
OO12 19 HH-400-7983-796 Comfort Measures Only [CMO] Standard of Care
OO12 20 HH-400-5830-800 Brain Death Determination in Adults
OO12 21 HH-400-5830-810 Standard of Care of the Potential Organ Donor Determined to be Brain Dead by Neurological Criteria to Maintain Organ Vitality
OO12 22 HH-400-5830-799 Donation After Cardiac Death
OO12 23 BHSF-819 Code of Ethics policy
OO12 24 Code of Ethics brochure
OO12 25 Medical Staff Quality Committee charter, highlighted

OO12 26 HH-100-12 Nursing Peer Review
OO12 27 HH-400-5830-700 Patient Rights and Responsibilities
OO12 28 Patient Rights and Responsibilities brochure [English]
OO12 29 Patient rights and Responsibilities brochure [Spanish]
OO12 30 HH-400-6050-703 Complaint and Grievance Management
OO12 31 HH-400-5660-715 Patients and Visitors with Communication and Special Needs policy
OO12 32 HH-400-2000-706 Patient Visitation
OO12 33 HH-400-5660-791 Interpreter Services for Patients and Families
OO12 34 HH-400-6050-001 Patient and Guest Services Department – Scope of Service
OO13 01 Comfort Room Quick Survey
OO13 02 BHSF-HR 5700 Employee Assistance Program
OO13 03 Critical Stress Incident Management WINK
OO13 04 BHSF-656.07 Services Offered at Employee Fitness Centers
OO13 05 Wellness Advantage Brochure
OO13 06 BHSF-3400 Family and Medical Leave of Absence
OO13 07 BHSF-HR 3410 Medical Leave of Absence Non-FMLA
OO13 08 BHSF-3425 Personal Leave of Absence
OO13 09 BHSF-HR 3550 Paid Bereavement Benefit
OO13 10 BHSF-503 Sunshine Fund Policy
OO13 11 BHSF-2295 Uninterrupted Meal Breaks
OO13 12 BHSF-3360 Ergonomics Program Guidelines
OO13 13 HH-100-7940-1305 Scope of Service for Pastoral Care
OO13 14 Diversity brochure
OO13 15 Culture tool
OO13 16 Visual Impairment tool
OO13 17 Diversity Dining Day Poster
OO13 18 BHSF-HR 1020 Equal Employment Opportunity
OO13 19 BHSF-HR 5075 Policy Prohibiting Harassment and Discrimination

OO13 20 BHSF-HR 1500 Accommodations for Applicants and Employees with Disabilities

OO13 21 BHSF-6250 Business-related Verbal and Written Communications
OO13 22 BHSF-1400 New Employee Orientation, highlighted
OO13 23 BHSF-HR 5220 Ethical Objections to Participation in Patient Care
OO13 24 BHSF 5360 Flexible Work Arrangements
OO13 25 BHSF-HR 5500 Performance Evaluations
OO13 26 BHSF-HR 5200 Resolution of Grievances
OO13 27 Grievance form
OO13 28 BHSF-250 Patient Safety, highlighted
OO13 29 BHSF-1250 Transfers and Promotions
OO13 30 Employee Handbook
OO13 31 BHSF-HR 5225 Unauthorized Release of Confidential Information
OO13 32 BHSF-HR 2600 Employment Records
OO14 01 BHSF-823 Compliance Hotline
OO14 02 BHSF-819 Code of Ethics policy

OO14 03 Code of Ethics brochure
OO14 04 BHSF-822 Non-Retaliation for Reporting of Potential or Actual Violations of the Code of Ethics
OO14 05 BHSF-HR 4300 Mandatory and Professional Development Employee Education
OO14 06 Audit and Compliance Intranet Site Screenshot
OO15 01 Employee Handbook
OO15 02 BHSF-819 Code of Ethics Policy and brochure
OO15 03 BHSF-822 Non-Retaliation for Reporting of Potential or Actual Violations of the Code of Ethics
OO15 04 BHSF-823 Compliance Hotline
OO15 05 BHSF-HR-5100 Preventing Workplace Violence
OO15 06 BHSF-825 Compliance Training
OO15 07 BHSF- 838 Compliance Liaison
OO15 08 BHSF 826 Communicating Corporate Compliance Program Standards
OO15 09 BHSF-1402 Incident Reporting
OO15 10 BHSF-6150 Drug-Free Workplace Program
OO15 11 HH-100-12 Nursing Peer Review
OO15 12 Medical Staff Quality Committee charter, highlighted
OO15 13 HH-1030.05 Employee Violence Communication Plan
OO15 14 BHSF-HR 5250 Employee Conduct
OO15 15 BHSF 5300 Corrective Action
OO15 16 BHSF-HR 5075 Policy Prohibiting Harassment and Discrimination
OO15 17 BHSF 806 Distribution of Audit Reports
OO15 18 BHSF 807 Compliance Audits and Investigations
OO15 19 BHSF 811 Management's Response to Audit Findings
OO15 20 BHSF 820 Appropriate Discipline for Compliance Program Violations

OO15 21 BHSF 839 Compliance Advisory Committee

OO16 01 BHSF-HR 5075 Policy Prohibiting Harassment and Discrimination
OO16 02 BHSF-HR 5250 Employee Conduct
OO16 03 HH-400-6030-825 Medical Staff Conduct
OO16 04 Homestead Hospital Medical Staff Performance Expectations
OO16 05 BHSF 5300 Corrective Action
OO16 06 BHSF-5200 Resolution of Grievances
OO16 07 BHSF-5200 Grievances Form
OO16 08 BHSF-5075 Policy Prohibiting Harassment and Discrimination
OO16 09 BHSF- 5100 Preventing Workplace Violence
OO16 10 BHSF-5700 Lifeworks Employee Assistance Program
OO17 01 Press Ganey Letter
OO17 02 Consumer Report Hospital Safety Rating 2012
OO17 03 Safest Hospital in America
OO18 01 Shared Governance Bylaws (highlighted)
OO18 02 BHSF-830.03 IRB Meetings
OO18 03 BHSF-200-5810-833.03 Vulnerable Subjects
OO18 04 BHSF-833.01 General Requirement of Informed Consent
OO18 05 BHSF-1340.01 IRB Approval
OO18 06 BHSF-1340.02 Informed Consent Procedure for Clinical Investigations
OO18 07 BHSF-1340.02 Informed Consent Process Documentation
OO18 08 BHSF-1340.02 Documentation of Enrollment/Consent Process
OO18 09 BHSF-1340.05 Research Staff Training
OO18 10 BHSF-1340.14 Medicare Coverage Analysis
OO18 11 BHSF-100-8085-401.00 Research Uses and Disclosures
OO18 12 BHSF-830.00 The Role and Authority of BHSF IRB
OO18 13 BHSF IRB Registration
OO18 14 BHSF-200-5810-831.00 IRB Initial Review of Protocols
OO18 15 BHSF-834.01 IRB Audit Program
OO18 16 BHSF-1340.06 Quality Assurance and Monitoring
OO19 01 Shared Governance Council Bylaws: EBPRC highlighted
OO19 02 BHSF-830.02 IRB Membership policy
OO19 O3 List of RN IRB Members, highlighted at the bottom of the document
OO19 04 BHSF-831.04 Exemptions from IRB Reviews
OO19 05 BHSF-831.03 Expedited Review Procedures
OO19 06 BHSF-831.00 IRB Initial Review of Protocols Policy
OO20 01 Research Table

Transformational Leadership (TL)

TL2 01 Homestead Hospital FY 2013 Strategic Goal
TL2 02 Departmental Responsibility Report [DRR] FTE Approval
TL2 03 ED Triage Adult/Pediatric Class Roster
TL2 04 Staffing Sheet Reflecting New Guidelines
TL2 05 BFHI Pathway Model Action Plan
TL2 06 BFHI Online Training and Badge Buddy Purchase Orders
TL2 07 BFHI Completion Report
TL2 08 Baby Friendly Train Completion Report
TL2 09 HH-400-2640-708 Infant Feeding
TL3EO 01 Homestead Hospital FY 13 Strategic Goals, highlighted
TL3EO 02 HH-400-2000-1000 OB/GYN Hospitalist/OB/GYN Emergency Department [Laborist Program]: Scope of Services
TL3EO 03 Laborist coverage schedule
TL3EO 04 Laborist Program Process Flow
TL4 01 Board of Directors Agenda
TL4 02 Strategic Planning Retreat Agenda
TL4 03 LDI Newsletter May 2013
TL4 04 Strategic Plan FY 2014-2016
TL4 05 Studer Steering Council Meeting Minutes
TL4 06 PCLC Strategic Plan 2014-2016
TL4 07 PCLC Meeting Minutes 9/27/12
TL4 08 PCLC Minutes 5/16/13 & 9/19/13, highlighted
TL4 09 Homestead Hospital Senior Leadership Meeting Minutes 4/8/14
TL4 10 Operations Minutes 4/11/14
TL5 01 Message from the President, 7/2/12
TL5 02 Nursing Operations meeting minutes 9/7/12
TL5 03 BHSF-2240 Revised RN Supplemental Weekend Plan Policy
TL5 04 Nursing Operations Meeting Minutes 1/4/13
TL5 05 Self-scheduling Paper Worksheet
TL5 06 Web Scheduler Training BHU Completion Report
TL5 07 ICU/CU Staff Meeting Minutes and Sign-in Sheet 8/26/13
TL5 08 E-mail from Clinical Nurses and Web Scheduler Screenshot
TL6 01 Nurse Leadership Meeting Minutes 4/18/14
TL6 02 Versant Orientation Agenda
TL6 03 Travel/Education Grant Requests
TL6 04 Gordon’s Email to Nurses with Mentor workshop attendance
TL6 05 Clinical Nurse Mentee Letter
TL6 06 BHSF’s 10 Core Leadership Competencies Rating Tool
TL6 07 Talent Management Process
TL6 08 Participants’ Leaders Orientation & Thank You Email
TL6 09 Aleman’s Education Transcript Showing Attendance in BHLE
TL6 10 Aleman’s Promotion Email
TL6 11 Talent Evaluation
TL6 12 Calibration Discussion
TL6 13 NEA Competency Assessment Completed by CNO
TL6 14 Department of Nursing Services Organizational Chart 2009, 2012 and 2014
TL6 15 BHSF Follow up Care Clinic Project Update
TL6 16 AVP Core Competency Model
TL6 17 AVP Talent Management Career Discussion Form
TL6 18 Leadership Meeting Minutes 9/19/14
TL6 19 Monthly Report Card Meeting Agenda and IDP Discussion
TL6 20 Nursing Organizational Charts 2009 & 2014

TL7 01 Palliative Care Steering Council Strategic Planning Meeting Minutes and Sign-in Sheet 9/13/13
TL7 02 Critical Care Staff Meeting Minutes and Sign in Sheet 1/27/14
TL7 03 Homestead Hospital FY 15 Final FTE BudgetTL8 01 90-Day Meeting Log
TL8 01 90-Day Meeting Log
TL8 02 Rounding Schedule
TL8 03 South Meeting Minutes and Sign-in Sheet 4/22/13
TL8 04 PCLC minutes 5/16/13
TL8 05 Rounding Log and Staff Meeting Sign-in Sheets
TL8 06 Thank You Email from Weatherspoon
TL8 07 Meeting Minutes 6/13/13
TL8 08 NLC Meeting Minutes 10/18/13

Structural Empowerment (SE)

SE5 01 Consortium Newsletter
SE5 02 Student Field Trip Request
SE5 03 Email to Nurses
SE5 04 DITLOAN Toolkit
SE5 05 2014 Pre- and Post-Event Participant Survey
SE6 01 BHU Screenshot
SE6 02 HH-400-2000-711 Patient and Family Education Policy
SE6 03 Roll-out Subcommittee Meeting Minutes 3/3/13
SE6 04 BHU Course Completion Report
SE7 01 Versant Program Curriculum
SE7 02 Transition RN Residency Curriculum
SE7 03 ACC Transition Residency Focus Group Validation Results
SE7 04 Versant® Transition Residency End-of-Cohort Focus Group Report – March 2013 Cohort
SE7 05 VEOR Metric and Evaluation Measurement Guidelines – Transition Residency
SE7 06 Multispecialties Competency Voyager Screen Shot
SE8 01 Preceptor Class Flyer and Attendance Roster
SE8 02 Preceptor Effectiveness Evaluation: HH RN Versant Residency Program August 2013, highlighted
SE8 03 Attendance Roster
SE8 04 CNE Meeting Minutes 9/25/13 and Charter
SE8 05 PDC Minutes 2/1/13
SE9 01Time Off Request
SE9 02 BHSF 502 Community Outreach Program Pro-Active Charity
SE9 03 StepOne Screenshot and Sample Report
SE9 04 Travel Information Memo
SE9 05 Chavez’ Time Card Screenshot and BHSF-HR 6800 Policy
SE9 06 CNO Email to Nurse Leaders
SE9 07 HH-400-6600-011 Volunteer and Community Service Recognition Program Policy & VIP Form
SE9 08 Sample LEM Annual Evaluation with Community Involvement highlighted
SE9 09 Email from AMSN Chapter President
SE9 10 Fair Log
SE10EO 01 Community Health Needs Assessment
SE11 01 Homestead Hospital 2013 Strategic Goals
SE11 02 DAISY Award Nominations
SE11 03 Ozete’s DAISY Award webpage
SE11 04 Nursing Grand Rounds FYI Article and Roster 3/26/13
SE11 05 2013 Nursing Strategic Goal
SE11 06 CCI Champion Letter
SE11 07 CNOR Strong Facility Certificate
SE11 08 CNOR Strong Facility Map Screenshot
SE11 09 FYI January 2013 Issue and 2014 Annual Nursing Report, page 27, highlighted

Exemplary Professional Practice (EP)

EP1 01 MSC meeting minutes April-July 2010 and Sign-in Sheet
EP1 02 PPM Versions
EP1 03 PPM Discussion Group Completion Report

EP1 04 PPM Survey
EP1 05 Nursing Strategic Retreat Minutes and Sign-in Sheet
EP4 01 Homestead Hospital Intercultural Palliative Training Program completion report
EP4 02 Long’s DAISY Award Nomination
EP4 03 Palliative Care Notes
EP4 04 Bioethics Family Meeting Progress Note
EP4 05 Conversations in Ethics November 2013 Flyer and Roster
EP4 06 PFCC Charter
EP4 07 PFCC Meeting Minutes 1/18/12
EP4 08 PFCC Meeting Minutes 7/18/12
EP4 09 HH-400-2630-400-15 Visitation Policy for Perinatal Unit
EP4 10 PFCC Meeting Minutes 9/11/13
EP5 01 Email from Wound Care Resource Nurse
EP5 02 September 2013 Stand-Up Meeting Agenda
EP5 03 Internal Medicine, Dietary and Physical Therapy Notes
EP5 04 Case Management and Nursing Notes
EP5 05 HH-400-5180-740 Compassionate Care Medications Policy
EP5 06 Gossman Medical Staff Leadership Program Curriculum
EP5 07 FTE justification
EP5 08 Stakeholder Meeting Sign-in Sheets
EP5 09 Community Resource Guide
EP6 01 Falls NRP Instructor Card
EP6 02 FY 2014 Equipment Budget Justification and Quote
EP6 03 Perinatal Roundtable Presentation and Sign-in Sheet
EP6 04 Oxygen Blender Purchase Order
EP6 05 Perinatal Services Employee Engagement Result
EP7EO 01 Couplet Care Competency Validation Checklist
EP7EO 02 Revised Perinatal Care Delivery System
EP8EO 01 Value Stream Map
EP9 01 ICU/ PCU Staffing Guidelines & Unit Overview
EP9 02 Email from Andrea Tilleman RN
EP9 03 November 2013 Staff Meeting Minutes
EP9 04 September ICU/ PCU Nursing Leadership Minutes 9/26/12
EP9 05 TH Course Completion Report
EP9 06 Medical/Surgical/Telemetry Staffing Guidelines
EP9 07 MS3 Staff Meeting Minutes 6/26/14
EP9 08 Rounding Log
EP9 09 Medical-Surgical RN Satisfaction Meeting E-mail 3/27/13
EP9 10 FY14 MS3 Staffing Budget and DRR

EP10 01 Surgical Services Retreat Agenda and Notes March 13-14, 2013
EP10 02 Surgical Services Labor Worksheet
EP10 03 DRR Budgeted FTE’s
EP10 04 HH-400-3600-600-006 Scheduling Operating Room
EP10 05 Throughput Committee Minutes 4/2/14
EP10 06 ED Throughput TRIM
EP10 07 Approved FTE Request
EP10 08 Staffing Sheet
EP12 01 ABCDE Bundle Task Force Meting Minutes and Sign-in Sheet 9/12/12
EP12 02 HH-400-2510-33 Spontaneous Awakening Trials [SAT] & Spontaneous Breathing Trials [SBT]
EP12 03 ABCDE Bundle Task Force Meting Minutes and Sign-in Sheet 11/1412 and 12/12/12
EP12 04 In-Service Sign-in Sheet and Respiratory Competency Assessment
EP14 01 Medical Library E-Resources website screenshot
EP14 02 “The Deep Dive: Searching the Databases” flyer and attendance roster
EP14 03 BSHF-1300.04 Access to Library Services policy
EP14 04 Medical Library budget for E-Resources
EP14 05 Medical Library Plan
EP14 06 Medical Library furniture purchase order
EP14 07 Thank You Email from a Nurse Library Client
EP14 08 Online Journal Club SharePoint site
EP15 01 Performance Evaluation
EP15 02 RN Population-Specific Ongoing Competency Validation
EP15 03 Professional Development Form
EP15 04 RN Self-Assessment
EP15 05 RN Peer Performance Assessment
EP15 06 Director LEM Annual Evaluation
EP15 07 Director Job Description Self-Evaluation
EP15 08 RN Leader-Director Self-Assessment
EP15 09 RN Leader-Director Peer Performance Assessment
EP15 10 Director Individual Development Plan
EP16 01 Sitter Task Force Meeting Minutes 7/6/12, 7/10/12, 7/17/12
EP16 02 Sitter Policy
EP16 03 Sitter Algorithm
EP16 04 Sitter Request Form
EP16 05 Resource UPC Meeting Minutes and Sign-In Sheet 6/18/12
EP16 06 Medical-Surgical/Telemetry Collaborative Meeting Minutes and Sign-in Sheet 9/25/12
EP16 07 Medical-Surgical/Telemetry Collaborative Meeting Minutes and Sign-in Sheet 10/29/12
EP16 08 Omnicell Project Power Point Presentation
EP17 01 HH-100-7940-1320 Ethical Issues and Ethics Consultation Requests Policy
EP17 02 Homestead Hospital Clinical Ethics Committee Meeting Minutes
EP17 03 Ethics Consultant Note
EP17 04 HH-400-5830-800 Brain Death Determination in Adults Policy
EP17 05 ICU/PCU Staff Meeting Minutes and Roster

New Knowledge, Innovations and Improvement (NK)

NK1EO 01 Cue Turn Poster
NK2 01 EBPRC Meeting Minutes 3/5/1
NK2 02 EBPRC 2013 Goals
NK2 03 BPF Planning Committee Meeting Minutes
NK2 04 Completed Project Evaluation Scorecard
NK2 05 2013 BPF Sign-in Sheet and Flyer
NK2 06 BHSF Poster Acceptance Letter to BHSF 8th Research Conference
NK2 07 Poster Acceptance Letter to AMSN Conference
NK2 08 Poster Printing Purchase Order
NK2 09 Homestead Hospital Research Dissemination Plan
NK2 10 SCALE Poster
NK3 01 CETEP Model and Elaboration
NK3 02 PI Steering Council Meeting Minutes 12/6/13
NK3 03 Enteral Feeding PI Team Meeting Minutes 02/19/14
NK3 04 Enteral Feeding Protocol and Order Set
NK3 05 CETEP Check-Off List
NK3 06 Product In-service Rosters and Product Evaluation by Surgical Staff
NK3 07 Paid Product Invoice
NK3 08 HH-400-3600-600-011 Electrosurgical Equipment
NK4EO 01 Redesigned Workflow Flowchart 66