INTERIM LOUISIANA STATE UNIVERSITY (LSU) HOSPITAL
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INTERIM
LOUISIANA STATE UNIVERSITY (LSU)
HOSPITAL
Organizational-wide Policy Signature Sheet
ADMINISTRATION
POLICY NUMBER: 0077
POLICY TITLE: Policy Regarding Job Shadowing and/or Observing
EFFECTIVE DATE: September 30, 2013
INQUIRIES TO: Chief Executive Officer Tel: (504) 903-4900
APPROVED: _______________________________________
Cindy Nuesslein
Chief Executive Officer
REVIEW/REVISION
DATES:
Policy 0077
Page 2 of 6
POLICY REGARDING JOB SHADOWING AND/OR OBSERVING
I. POLICY STATEMENT
It is the policy of the Interim Louisiana State University (LSU) Hospital
(ILH) to allow healthcare professionals who are interested in advancing
their skills or knowledge, or students who are interested in pursuing
careers in healthcare, the opportunity to observe employees and/or
medical staff. This opportunity is only available with a sponsorship by a
credentialed medical staff member or an ILH department director. The
final decision as to whether or not the request for job shadowing and/or
observing may occur is based upon the application of the intended
observer, and the capacity of the facility. The observation experience
cannot impact patient care, department workflow or violate patient
rights.
II. PURPOSE
The purpose of this policy is to establish guidelines that will further ILH’s
educational mission to allow individuals to participate in job shadowing
and/or observing while ensuring that safeguards are in place to protect
ILH patients as well as the observer.
III. SCOPE
This policy applies to:
all medical staff, residents, students, staff, trainees and volunteers;
and
any person who requests to observe or job shadow a medical staff
member or employee.
This policy does not apply to affiliation agreements such as graduate
medical education or allied health care professional training programs.
IV. GENERAL GUIDELINES
A. Registration
1. Persons interested in job shadowing and/or observing must submit
a completed Observer Application Form (See Exhibit I) to the
Director of Hospital Training or designee.
2. If the applicant will be shadowing a member of the medical staff,
the applicant must identify the physician sponsor. The Director of
Hospital Training or designee will contact the Department of
Policy 0077
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Medical Staff Services to inform them of the job shadowing and/or
observation request.
3. The physician sponsor:
will be directly responsible for the observer
must review and approve the completed Observer Application
Form (See Exhibit I)
must ensure that all requirements are met before the observer
is allowed to job shadow and/or observe.
4. If the applicant will be shadowing a non-physician staff member,
the applicant must secure a department director sponsor prior to
the submission of the Observer Application Form (See Exhibit I). If
needed, the Director of Hospital Training or designee can assist in
securing a department director sponsor.
5. The non-physician sponsor:
must review and approve the completed Observer Application
Form (See Exhibit I)
PLEASE NOTE: If the non-physician sponsor is not a department
director, the Statement of Agreement and
Acknowledgment of Rules and Responsibilities
(See Exhibit II) must include approval from the
department director.
if approved by the department director, will forward the
completed application to the appropriate Administrative Council
member for approval
must ensure that all requirements are met before the observer
is allowed to job shadow and/or observe.
B. Requirements
1. The following requirements must be met prior to the applicant
being approved for job shadowing and/or observing:
submission of the following completed documents to the
Director of Hospital Training or designee:
Observer Application Form (See Exhibit I)
Statement of Agreement and Acknowledgment of Roles and
Responsibilities (See Exhibit II)
Observer Confidentiality Agreement (See Exhibit III)
Corporate Compliance Attestation Statement (See Exhibit IV)
the General Orientation Key Elements Checklist for Observers
(See Exhibit V)Policy 0077
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submission of the applicant’s current immunizations -- must
include, at minimum, two (2) MMRs, varicella status (had
chicken pox or the varicella vaccine) and a TB skin test
completed within one year of job shadowing and/or observation
request.
PLEASE NOTE: For applicants who job shadow/observe during flu
season, i.e., December 15 through March 31, a
copy of their flu vaccination valid within one (1)
year of their job shadowing/observer experience
is required if the experience will occur within
patient care areas. If the flu vaccine is declined,
the applicant will be required to wear a surgical
mask throughout the job shadowing/observation
experience.
a sponsor who is willing to be responsible for the applicant
during his/her time at the facility.
2. The applicant must be:
a high school or college student currently enrolled in a formal
educational program related to healthcare that requires
observing the healthcare environment. There must be a letter
from a teacher/professor verifying that job shadowing/observing
is a requirement of the curriculum; or
a post-graduate student or practitioner in the healthcare field
seeking further education/skills related to a specialty or service
provided at the facility.
C. Limitations
1. Applicants approved for a job shadowing and/or observation
experience will not be granted access to the Operating Room, the
Emergency Department or critical care areas without the consent
of the Chief Executive Officer or designee or the Chief Medical
Officer or designee.
2. The observer may not:
partake in any direct clinical action
observe invasive exams or procedures
document in any portion of the patient’s medical record or
official documentation
view patients’ medical records or other depository of patient
information, including CLIQ, the ILH computer system or the
electronic medical record systemPolicy 0077
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bring home any document that contains patients’ protected
health information
take pictures, audio or video record any patient or patient
protected health information.
3. Residents, medical students or contracted employees may not
serve as sponsors.
4. Patients who may be observed must be informed of the observer’s
presence and purpose. Patients must be given the option to refuse
to have the observer present and must be given the option without
the presence of the observer in the patient’s room/clinical area.
D. Responsibilities
1. It is the responsibility of the Department of Hospital Training
to:
provide application packets to persons requesting a job
shadowing/observer experience
ensure that all elements and requirements are completed prior
to the beginning of the observation experience
implement the requirements of this policy
ensure compliance with the procedures outlined within this
policy
issue an official ILH “Observer” identification badge to the
observer.
2. It is the responsibility of the sponsor to:
agree to accept responsibility for the actions of the observer
while at ILH
remain with the observer at all times while at ILH
minimize the amount of protected health information to which
the observer is exposed
notify the Director of Hospital Training or designee when the
observer experience has ended.
3. It is the responsibility of the observer to:
submit the completed application packet to the Director of
Hospital Training or designee at least one (1) week before the
expected job shadowing/observation experience is to occur.
Incomplete application packets will result in a delay of the job
shadowing/observation experience.
agree to the terms and conditions outlined within the Statement
of Agreement and Acknowledgement of Roles and
Responsibilities form (See Exhibit II)Policy 0077
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provide his/her most current immunization status. If found to
be insufficient, the observer must agree to obtain the required
immunizations at his/her own expense.
wear the official ILH “Observer” identification badge at all times
while on ILH premises
return the ILH “Observer” identification badge to the
Department of Hospital Training when the observer experience
has ended.
V. ENFORCEMENT
Failure of an observer to adhere to the intent and procedures of this
policy will result in an end of the observer experience.
Failure of an employee to adhere to the intent and procedures of this
policy will result in disciplinary action up to and including termination.
Failure of a physician to adhere to the intent and procedures of this
policy will result in appropriate action by the Chief Medical Officer or
designee.OBSERVER APPLICATION FORM
Personal Information
Full Name Date of Birth Gender Social Security #
Female
Address
City State Zip/Country e-Mail Phone
Emergency Contact Relationship Phone
Student Information - To be completed only if applicant is a student
Name of Educational Institution High School Grade or Year in College
Name of Teacher or Professor (*attach letter from teacher outlining Curriculum
curriculum requirements)
Professional Information - To be completed if applicant is a healthcare professional
LA license, if applicable: Home State Licensure, if applicable:
Number: Exp. Date: State: Number: Exp Date:
Licensed as: Type of Visa, if applicable:
Degree(s) Field of Practice
Observership/Job Shadowing Request (attach additional sheet(s) if needed)
Purpose of Visit
Observation in conjunction with an educational lecture
Participation in educational rounds
Professional Development
Part of High School curriculum
Other: ___________________________________________________________________________
Anticipated Date(s) of Visit Requested Activities/Duties/Responsibilities During Visit:
Start Date: End Date:
Requested Dept/Unit/Specialty Where Observation will occur? Sponsor
Health Requirements
Requirements Verification Date(s):
A negative TB skin test or negative chest x-ray (within past 12 months)
If born prior to 1/1/1957, proof of 1 MMR vaccine or positive Rubella titer
If born after 1/1/1957, proof of 2 MMR vaccines or positive Rubella titer
Proof of varicella vaccine or year of chicken pox
Proof of influenza vaccine (within past 12 months, if observership falls between December 15–March 31)
I certify that the information in this document and any attached documents are true, correct, and complete. I
understand and agree that any misrepresentation, misstatement, or omission from this application may lead to
termination of my participation in the Observer Program.
_________________________ _______________ _____________________________ _____________
Observer Signature Date If minor, signature of parent/guardian DateObserver: ___________________________
Statement of Agreement and Acknowledgement of Roles and
Responsibilities
Observer Acknowledgement
Agreement- ILH has agreed to allow the undersigned Observer to observe patient care or hospital services
after meeting the established requirements and under the supervision of a designated sponsor. In
consideration of the undersigned Observer being allowed the opportunity at ILH, the undersigned
Observer, hereby agrees to the following:
Confidentiality- The Observer agrees that any information or knowledge acquired or received during the
course of the observation at ILH including but not limited to patient care information and information
contained in patient care records, shall be treated as confidential and shall not, unless required by law or
otherwise permitted by ILH, be disclosed or used during or after termination of the Observer placement at
ILH without the prior written consent of ILH.
Release/Indemnification- The undersigned Observer agrees to and hereby does release, indemnify and
hold harmless ILH, its members, directors, officers, employees, and representatives from any and all
responsibility and obligation, and agrees not to hold ILH liable for any or all injuries, losses, damages or
expenses which may occur as a result of any act or omission of ILH, its members, directors, officers,
employees, or representatives, or which may arise for the Observer’s participation in the Observer
Program.
Illness- The undersigned Observer hereby forever releases and shall discharge all claims and causes of
action whatsoever, present and future, against ILH, its directors, officers, employees, and agents, related
to or arising out of any illness, disease, or health condition the individual may contract, develop or come
into contact with while on the premises of ILH.
Medical Treatment- ILH shall provide or refer for outpatient treatment to Observers while in the facility
for the Observer Program in the case of an accident or illness. However, under no circumstances shall ILH
bear the cost of the treatment.
Hospital Policy- The Observer agrees to conform to all policies and procedures including those related to
safety, patient care, non-discrimination, Code of Ethics, The Joint Commission, CMS, and Occupational
Safety and Health Administration (OSHA) requirements.
Clinical Conduct- The Observer agrees to not participate in any direct clinical action, nor perform any task
that would normally be performed by a healthcare worker. The Observer understands they may not
observe invasive examinations or procedures. The Observer agrees to not document in the patient’sObserver: ___________________________ medical record or any other depository of patient information. The Observer understands there may be restrictions in the areas of observation and their sponsor may be required to obtain special permission from ILH Administration for observations in the Emergency Room. Observations may not be performed in the mental health unit or mental health clinic or infectious disease clinics. Patient Consent- The Observer understands that they may not observe patient care without the patient first consenting to the observing. ___________________________________________ _____________________ Observer Signature Date ___________________________________________ _____________________ If minor, signature of parent or legal guardian Date
Observer: ___________________________ Sponsor Acknowledgement Responsibility- The Sponsor understands that the Observer must observe within the limitations established by this Agreement, the Confidentiality Agreement, the policies and procedures of ILH. The Sponsor agrees that he or she is responsible for the Observer during the Observer’s time at this Facility. The Sponsor agrees that he or she is solely responsible for the supervision of the Observer, and that the responsibility cannot be transferred to someone else without the knowledge and permission of the facility. Residents and medical students may not serve as sponsors. Sponsors may not allow observers to begin observation until the entire registration process is completed and the sponsor is notified that the Observer is cleared to observe. This observer has completed all of the required elements to participate in this experience. I have read the Observer’s policy, specifically the limitations of observers and the confidentiality requirements, and agree to abide by the policy, and all terms of this agreement. ___________________________________________ _____________________ Sponsor Signature Date ___________________________________________ ______________________ Department Director (for non-physician sponsor Date if Department Director is not the Sponsor)
Observer: ______________________
R Observer Confidentiality Agreement
Name of Observer: _____________________________________ Date: ____________
Confidentiality
I agree that I will not at any time during or after my observation period with ILH, disclose any patient
information, including demographic, medical, or other confidential information.
I understand that ILH is committed to protecting patient privacy and confidentiality. I understand that the
information that I as an observer am exposed to, is presented to me in a variety of media such as medical
records, claims, computer systems, logs, and conversations.
I understand I may not take pictures of/audio record/video record any patients or of any documents
during or after my observation experience.
I understand that medical records and other forms of medical information may not be removed from the
hospital.
I share the commitment of ILH to protect patient confidentiality and by my signature on this document,
pledge compliance with the terms of the Confidentiality Policy and Confidentiality Agreement. I
understand that a person may be subject to civil or criminal legal sanctions when such violations occur.
I have read and had a chance to ask questions regarding this agreement. I understand the terms of this
agreement and agree to adhere to them.
_____________________________ __________ ______________________________ _________
Observer Signature Date Sponsor Signature DateExhibit IV
Policy 0077
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Corporate Compliance Attestation
Statement
I have reviewed the mandatory Corporate Compliance training for
all new employees of the Interim LSU Hospital (ILH). I
understand that I am responsible for being familiar with the
Corporate Compliance Program as it relates to my position and to
the facility as a whole. I understand that I am responsible for
following the Corporate Compliance policies and procedures as
well as other policies and procedures of the facility.
I understand that I am responsible to conduct myself in the
manner consistent with the Code of Ethical Behavior and the Core
Values of the Interim LSU Hospital.
I understand that I am responsible for reporting any suspected
fraud and abuse practices within this facility.
If I have any questions regarding compliance, I am to contact my
supervisor or the ILH Corporate Compliance Department as soon
as possible.
____________________________________________________
Signature of Employee/Observer Date
____________________________________________________
Please print your name and your departmentGeneral Orientation Key Elements CheckList
I nitial each space in the left column as you complete the topic.
Service Excellence/Serving With Spirit
Health Literacy
Core Values (ILH Specific)
E-Mail Etiquette
Telephone Etiquette
American with Disabilities Act
Ethics
Risk Management
Prisoner Care
Incident Reports
Key Elements: Common Policies
Appearance
Performance Improvement
Employee Health/Infection Control & Prevention
Hand Hygiene
Bloodborne Pathogens
TB & Viral Screenings
Emergency Preparedness & Safety
Emergency Codes (including Bad Weather, Fire, and other Hazards)
Safe Medical Device Act
Hazardous Materials
Slips, Trips and Falls
Security
Sexual Harassment
Prevention of Violence in the Workplace
Ergonomics, Back Safety
Compliance
Compliance Overview
Security, Privacy (HIPAA Regulations)
Federal False Claims Act
Advocacy in Healthcare/Patient's Rights
Healthcare Advocacy
Patient's Rights (including Pain Management & Population Specific Care) & Responsibilities
Identification and Manditory Reporting of Abuse and Neglect
National Patient Safety Goals
I have completed the ILH General Orientation where the above content was presented along with information about how
to access policies online at anytime. I was given the opportunity to ask questions about these materials and I understand
all key elements. I will abide by this institution's rules and policies.
Print Name Signature Department Date
revised 07/26/2013Instructions for accessing the General
Orientation Key Elements lesson in WILMA:
https://www.webinservice.com/ilh
1. Select View by the My eLearning Lessons:
2. Select the name of the lesson (it’s a hyperlink to the power point presentation).
3. Select Start the Lesson.4. Review the entire Power Point. Then close the window. Select the lesson title/name hyperlink again. 5. Now select Take the Test. 6. Read the instructions. Then select TAKE TEST in the upper right corner of the screen. 7. You have one question to answer which is an attestation. Select YES and then SUBMIT TEST.
8. You will see your score. Select PERSONAL PAGE from the upper right corner of your
screen.
9. When you’re back on your eLearning screen, you will see no assigned
lessons. However, if you select ALL ASSIGNMENTS from the Available Filters drop
down menu, you will see the completed lesson: 2013 General Orientation Key
Elements (Non-Employees). Note: The reason there is an extra lesson in the screenshot below is
because this is one of my “test” end users.
10. Please email Shaquila Dubois (sdubo3@lsuhsc.edu) when you have completed the
lesson.You can also read
