Sutter Health CPMC Van Ness Hospital Occupancy Manual 18 0012632 DIGITAL V2
User Manual:
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Page Count: 27
- Telephone Numbers
- ADA Information
- Ambassador Services Suite
- Asset Management
- Bicycle Storage
- Building Amenities
- Building Reminders
- Catering Services
- Code Blue or Other Medical Emergency
- Code Gray
- Code Pink - Infant/Child
- Code Purple
- Code Team
- Communication Operations (formerly PBX) / Phone Operating System
- Conference Rooms
- Crash Carts
- Departments and Divisions by Floor
- Dining Services
- Door Alarms and Stairwell Access
- Durable Medical Equipment (DME)
- Elevators
- Emergency Management / Emergency Operations Plan
- Equipment and Furnishings
- Equipment Cleaning
- Ergonomics
- Fax Machines
- Fire Safety
- General Building Information
- Guest Internet Access (Wi-Fi)
- Hand Hygiene
- HIPAA—Confidential Document Containers
- Hospital Command Center
- Hours of Operation
- Infant/Child Security
- Information Desks
- Interpreter Services
- Kronos Time Clocks
- Lactation Lounge
- Linen
- Loading Dock
- Lost and Found
- Medical Alerts
- Medical Gas Area
- MRI Suite Safety
- Multi-function Printers (Scan, Print, Copy)
- Newborn Connections
- Notes
- Nurse Call System
- Office Spaces
- Parking
- Patient Entertainment/Education (Powered by Sonifi)
- Patient Lift System and Mobile Lifts
- Patient Relations
- Personnel ID Badges
- Pharmacy
- Pneumatic Tube System
- Public Transportation and CPMC Shuttles
- Respiratory Etiquette Stations
- Restroom Locations
- Safety and Security
- Security
- Service Dogs
- Shared Spaces
- Spiritual Care and Chaplaincy Services
- Staff Duress
- Staff Lockers
- Standardized Emergency Codes
- Supplies and Restocking
- Supply Chain
- Support Services
- Sustainability
- Sustainable Waste Removal
- Telephone Numbers
- Telephone System
- Temperature Monitoring
- Transportation and Parking
- Visitor Badges
- Vocera
- Volunteers
- Waiting Areas
- Water Cooler/Bottle Filling Stations
- Wheelchairs and Gurneys
- Workplace Violence Reporting

Occupancy Manual
YOUR GUIDE TO THE VAN NESS CAMPUS

 ii |  Occupancy Manual     Occupancy Manual   |  iii 
Photo at left: Van Ness Hospital Entryway 
by Bill Posner. Above: Render of Van Ness 
Hospital and Medical Office Building.
Information deemed reliable through 
March 2o19 © Sutter Health
We hope you are as excited as we are to begin work at Van Ness 
campus! This manual is designed to be your “go-to guide” to help 
orient you to our new facility. 
Retaining the “heart” of what we do
The opening of the new Van Ness campus is the culmination of 
years of hard work, commitment and anticipation. It will continue 
the legacy of being the neighborhood hospital in San Francisco 
and retain the “heart” that has made our California and Pacific 
campuses special for patients and staff alike. 
Balancing safety, comfort and 
sustainability
The new building balances the safety and technical needs of staff, 
physicians, and volunteers with the comfort and safety of our 
patients. The modernized campus is seismically safe and certified 
by Leadership in Energy and Environmental Design (LEED), a 
globally recognized sustainability program.
The layout of the building employs a front of the house (onstage) 
and back of the house (offstage) concept. Front of the house 
refers to all areas that patients and visitors will see, and where 
we are “onstage,” and helps create a positive environment for our 
patients and visitors. Back of house includes staff-only hallways and 
elevators. This design will help us put our best foot forward.
Van Ness campus will open on March nd, 2o19. We are so pleased 
to be able to create the next generation in health care services for 
San Francisco.
—Your CPMC Leadership and New Hospitals Transition Team
Welcome to the  
Van Ness Campus

 iv |  Occupancy Manual  
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General Building Information
Telephone Numbers .................2
Hours of Operation ..................3
Badges & Access ...................4
Elevators  .........................5
Shared Spaces  ....................5
Staff Lockers ......................5
Conference Rooms  .................6
Departments and Divisions by Floor .....6
Floor Plans ......................7-15
Sustainability  .....................16
Building Reminders  ................16
Transportation and Parking
Transportation and CPMC Shuttles ....18
Parking  .........................19
Support Services
Department Telephone Directory ......21
Volunteers  .......................21
Spiritual Care and Chaplaincy Services . 21
Patient Relations  ..................21
Interpreter Services ................22
Newborn Connections   .............22
Respiratory Etiquette Stations  ........22
Wheelchairs and Gurneys  ...........22
Lost and Found ...................22
Safety and Security
Security Awareness ................24
Crash Carts  ......................24
Security .........................24
Door Alarms and Stairwell Access .....24
Emergency Management EOP ........25
Communications in a Disaster ........25
Hospital Command Center ...........26
Code Team  ......................26
Standardized Emergency Codes ......26
Medical Alerts  ....................29
Fire Safety  .......................30
MRI Suite Safety ...................31
Injury Reporting ...................31
Workplace Violence Reporting ........31
ADA Information ...................32
Hand Hygiene  ....................32
Service Dogs .....................33
Building Amenities
Information Desks  .................35
Waiting Areas .....................35
Restroom Locations ................35
Lactation Lounge ..................35
Water Cooler / Bottle Filling Stations  ...35
Dining Services  ...................35
Catering Services ..................35
Room Reservations  ................35
Guest Internet Access (Wi-Fi)  ........35
Bicycle Storage  ...................36 
Ambassador Services Suite ..........36
Patient Entertainment / Education .....36
How to Use Pillow Speaker  ..........36
Equipment and Furnishings
Ergonomics ......................39
Ofce Spaces  ....................39
Kronos Time Clocks ................39
Multi-function Printers  ..............39
VOIP Telephones ..................39
Fax Machines .....................40
Phone Operators ..................40
Vocera ..........................40
Nurse Call System .................40
HIPAA Containers  .................40
Patient Lift .......................40
Sustainable Waste .................41
Temperature Monitor ...............41
Pneumatic Tube ...................41
Supplies and Restocking
Loading Dock .....................43
Supply Chain .....................43
Medical Gas Area ..................43
Durable Medical Equipment (DME) .....43
Pharmacy ........................43
Linen  ...........................43
Equipment Cleaning ................44
Asset Management  ................44
Staff Duress ......................44
Stationery, Forms, and Brochures .....45
Table of Contents
GENERAL BUILDING 
INFORMATION

 02 |  Occupancy Manual • General Building Information   Occupancy Manual• General Building Information | 03 
Hours of Operation
Van Ness Entrance (L1) 7am–7pm Everyday Badge after hours
Driveway (L2) 5am–8pm Mon-Fri
7am–7pm Sat-Sun
Open every day
Post Street Stairs (L2) 24 hours a day Staff & Badge only
Post Street (L2) 7am–7pm Badge after hours
Geary Street (L2) 24 hours a day Staff & Badge only
Emergency (L3 24 hours a day Open every day
Chuck Williams Café (L2) 6:30am–6:30pm Mon–Fri
6:30am–2:30pm Sat–Sun
Closed after hours
Coffee Shop (L2) 6:00am–6:00pm Mon–Fri
6:30am–2:30pm Sat–Sun
Closed after hours
Loading Dock (L3) 
off Franklin Street
5am–8pm Mon–Fri Other hours by appointment only
Mailroom (L1) 
Room No. 111A
24 hours a day Open everyday  
Badge required
Newborn Connections 
1100 Van Ness
10am–4pm Mon–Fri
10am–2pm Sat
Closed on Sunday
Walgreens Pharmacy
1301 Franklin Street
9am–9pm Mon–Fri
9am–5pm Sat
10am–6pm Sun
CVS Pharmacy
1285 Sutter Street
9am–7pm Mon–Fri
10am–5pm Sat–Sun
Walgreens Pharmacy
1100 Van Ness
Coming Soon
Telephone Numbers
Emergency ............................415-600-3333
Emergency Pediatrics ...................415-600-4444
Main Hospital ..........................415-600-6000
Security  ..............................415-600-0837
Admitting ..............................415-600-3676
Administration  ..........................415-600-1458
Ambassador Suite  .......................415-600-2600
Bed Control ............................415-600-1233
Biomed Engineering ......................415-600-7900
Biomed Eng Internal ......................415-600-8653
Cardiology (Non-Invasive) ......................415-600-8970
Case Management .......................415-600-3504
Cashier ................................415-600-8860
Central Distribution .......................415-600-2740
Chaplain ...............................415-600-3741
Child Life Srvs  ..........................415-600-0710
Clinical Lab .............................415-600-2200
Clinical Lab Internal  ......................415-600-8770
CT  ...................................415-600-3232
CT Internal .............................415-600-8752
Dialysis (in-patient) .......................415-600-3273
Discharge Lounge  .......................415-600-9425
Emergency .............................415-600-3333
Emergency Pediatrics .....................415-600-4444
ED Registration ..........................415-600-3248
Food & Nutrition .........................415-600-3222
Food & Nutrition Internal ...................415-600-3224
Graduate Medical Education ................415-600-3324
Interpreter Services .......................415-600-2070
Loading Dock ...........................415-600-8990
Main Hospital ...........................415-600-6000
MRI  ..................................415-600-3674
MRI Internal  ............................415-600-8751
Newborn Connections ....................415-600-2229
Nursing Administration ....................415-600-6509
Nursing Supervisor .......................415-600-1169
Parking Ofce ...........................415-600-1804
Patient Access ..........................415-600-3676
Patient Advocates  .......................855-711-9450
Patient Advocates Internal. .................415-600-8866
Patient Relations .........................415-600-3280
Pharmacy ..............................415-600-3202
Pharmacy NICU .........................415-600-2110
Plant Operations .........................415-600-7900
Plant Operations Internal  ..................415-600-6390
PT/OT/ST ..............................415-600-3399
Radiology ..............................415-600-3232
Radiology Internal ........................415-600-8755
Respiratory .............................415-600-6589
Security  ...............................415-600-0837
Surgical Services  ........................415-600-3288
Transport  ..............................415-600-4700
VNC Command Center ....................415-600-9400
VNC Executive Command Center ............415-600-9410
VNC Patient Transition IS Command Center ....415-600-9500
VNC Patient Transition Issue Tracking .........415-600-9510
Volunteer Services  .......................415-600-3402
Nursing Stations
3 Floor Emergency Adult  ..................415-600-3333
3 Floor Emergency Ped  ...................415-600-4444
4 Floor ACU Pod 1 .......................415-600-3480
4 Floor ACU Pod 2 .......................415-600-8980
4 Floor GI/IES (control desk) ................415-600-3478
4 Floor GI/IES ...........................415-600-3570
4 Floor IR/CCL/EP (cntrl)  ..................415-600-8900
4 Floor OR .............................415-600-3288
4 Floor PACU ...........................415-600-3482
5 Floor Antepartum Testing .................415-600-6232
5 Floor Labor and Delivery .................415-600-6242
5 Floor NICU  ...........................415-600-6211
6 Floor ICU .............................415-600-3363
7 West ................................415-600-8870
7 East .................................415-600-0740
7 PICU ................................415-600-0720
8 Floor Nursery ..........................415-600-6434
8 Floor Post Partum ......................415-600-6437
9 Floor East Med/Surg ....................415-600-8910
9 Floor West Med/Surg  ...................415-600-8930
9 Floor TICU ............................415-600-8920
10 Floor East Med/Surg ...................415-600-8810
10 Floor West Med/Surg  ..................415-600-8830
Need to dial an extension?
600 numbers use 6 plus last four digits 
ie. 415-600-0837 = 60837
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
Main Hospital
Medical Ofce Building
Tunnel (Parking Level 3)
Entrance
ER Entrance
POST ST
GEARY ST
VAN NESS
FRANKLIN
2, 3, 76X
38, 38R
ENTRANCE
ADA ENTRANCE
PUBLIC TRANSIT
EMERGENCY
Main Hospital Medical  
Office Building

 04 |  Occupancy Manual • General Building Information   Occupancy Manual• General Building Information | 05 
Visitor Badges
Visitors and vendors who are coming to the hospital will be 
required to wear a visitor badge between 8pm and 7am. They may 
sign-in and receive badges at the Security Desk on the 3rd Floor 
Emergency Entrance.
Photo identification is required for those 18 years and older. 
Children without an ID will also receive a badge as long as they are 
accompanied by an adult.
If someone needs assistance 
to enter the building
Should an individual arrive after hours at the Van Ness or Post 
Street entrance and need assistance (ADA accommodation), he/she 
should use the video phone at the entrance to contact Security. A 
security officer will then assist the individual into the building.
Personnel ID Badges
Providers, staff and volunteers must wear their hospital identifica-
tion badge while on campus. Badges are required for identification 
and to gain access to non-public areas and devices.
Staff must tap their badge to the respective device, to activate 
the corresponding system.
• Registry staff is required to show registry ID before 
being issued a badge. Hospital issued badges must be 
return to the charge nurse at the end of the shift.
• Internal stairwells may be used for exiting the building; however, 
badge access is required on the ground floor for re-entry.
• You will need your badge if you are moving 
from one floor to another.
• Do not let anyone use your badge.
• Pay attention to your surroundings when badging 
in, and ensure that no one enters behind you.
• If you forgot your badge, go to the Security Office 
on 1st Floor for a temporary badge.
General Entry Examples: 
Badge Access
All exterior doors with card readers
All back of house space (hallways, etc.)
Multi-disciplinary / Conference Rooms
Consult Rooms
Locker Rooms
Emergency Department
Imaging Entrance
Patient Floors 
(unless otherwise specified)
Service Elevators 
Restricted Area Examples: 
Badge Clearance Required
Administrative Suite
Admitting
Biomedical Engineering
Clean/Soil Utility Room
Clinical Lab
Food and Nutrition Area
Materials Mgmt/Supply Chain
Medical Equipment Rooms
Medrooms
Morgue
MRI Suites
Nourishment Rooms
Nursery/SCN
PBX
Pharmacy
PT/OT Area
Security
SPD, OR, PACU/ACU
Elevators
There are three sets of elevators on the campus. There are six 
public elevators, requiring no badge. Staff, volunteers and 
physicians can use the four service elevators. Finally, there are 
four to five dedicated patient transport elevators, only use these 
elevators when transporting a patient.
Shared Spaces
Van Ness is designed as a shared work space.
Multi-disciplinary workrooms are conference-style rooms on 
patient care floors. These rooms accommodate ten people sitting 
around a rectangular conference table and may be used for small 
group meetings, education sessions and so forth. The rooms are 
equipped with a large wall monitor and teleconferencing.
Inter-disciplinary workrooms are individual computer worksta-
tions in a shared workroom environment. Workstations are not to 
be “claimed” for any specific individual use. Practice shared work 
space etiquette; keep the volume down, no eating and clean up after 
yourself.
Consult rooms are designed for providers to have private conver-
sations with patient family member(s) and significant others. 
Rooms may be locked; request keys from the charge nurse. Please 
clean the room after every use.
Family rooms are public areas for family members to sit and 
gather, outside the patient room.
There are six On-Call rooms, 5344, 5362, 5364, 6433, 6515 and 
653o (ADA), available for scheduling. Contact Support Services at 
415-6oo-79oo or use the Online Room Scheduling Portal at  
http://dcpwdbs405/virtualems/ to reserve a room up to a week 
in advance. Same-day or after-hours requests can be directed to 
security.
Staff lounges are for non-physician staff. Nursing staff is respon-
sible for cleaning the coffee maker.
Staff Lockers
Lockers are available for staff use in department areas.
• All lockers will be day use only.
• Lockers accept standard padlocks.
• Department managers are responsible for distribution.
Department Lockers  Location
Central Sterile 2273, 2275
Clinical Lab 1427, 1428
Emergency Dept 3374
Engineering 2302, 2304
Environmental Service 2251, 2253
Food Service/ Kitchen 1530, 1632
ICU 6053, 6055
Imaging 3540, 3542
Interpreters 2856
Invasive Services / Surgery 4202, 4204
Labor & Delivery 5030, 5172, 5174
Med Surg / Acute Care 9063, 10063
Pathology 1322
Patient Transport 1206
Pediatrics 7063
Pharmacy 1629
Postpartum 8300A
PT/OT 9067
Residents C610A
Respiratory Therapy 6210B
Security 1303B
Volunteers 1651
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability

 06 |  Occupancy Manual • General Building Information   Occupancy Manual• General Building Information | 07 
Conference Room Reservations
There are conference rooms on the 1st, 2nd and 3rd floors, available 
for hospital and public use:
Room (Max. Capacity, Joined Capacity)
110 A (20) 312 A (10)
110 B (75) 312 B/C (120/120, 240)
270 A/B (40/40, 80) 3180 (10)
To reserve a conference room, go to the on-line room scheduling 
portal at http://dcpwdbs405/virtualems/.
Each room is equipped with large monitors and teleconferencing. 
Rooms will be locked after hours, by Security, and reopened by 
Security. There will be video displays outside of these rooms that 
will provide meeting schedules.
Conference Rooms
Conference rooms are available on the patient care floors for 
patient care team use.
Floor conference rooms are dedicated to the floor. Oversight and 
scheduling of these rooms lie with the Nurse Manager. In general, 
these can be used for small classes, in-services and department 
meetings.
Departments and Divisions by Floor
The Van Ness Hospital is a 11-story, 274-bed, full-service medical 
center with an emergency department and supporting services, 
including imaging services, and laboratory. The building is thought-
fully designed to enhance patient comfort, be environmentally 
conscience, be seismically safe, and support current and future 
technologies. The department phone directory is on page 02.
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
Post-Partum (44) Well Baby Nursery (4o)
 1o West (32) Med/Surg  
Transplant/Complex GI Therapy Gym EEG Workroom
1o East (28) Med/Surg 
Cardiovascular
7 West (13): Pediatrics PICU (8)Child Life
7 East (12): Pediatrics
ICU (36) On-Call Rooms
Respiratory Therapy /  
Pulmonary Function
9 West (28):Med/Surg TICU(9) PT/OT/SP9 East (23):Med/Surg/Oncology
Executive  
Administration Medical Staff Services
Graduate Medical  
Education Ambassador Suite Nursing Admin
LDR (2o) Ante-Partum (6)C Section (3) NICU (35) Antepartum Testing
ED (32 & 4 holding) Loading Dock
Imaging [MRI(2), CT(3), 
XRay(2), Fluoro(2), US(5), Nuc Med(3)] Conference Rooms Physician Lounge
OR (13) CCL/EP/IR (6)Non-Invasive 
Cardiology (3)
GI / IES (7) PACU (31) ACU (39)
Support  
Services*
Conference 
Rooms Retail Patient Access 
Services
Patient Relations/ 
Interpreter Services
SPD Cafeteria Meditation
Pharmacy Dialysis 
Workroom Kitchen Security 
Services Morgue
Nurse  
Staffing
Media 
Services
Lab/
Pathology Discharge  Conference 
Room
  Floor 11
   Floor 6
   Floor 
   Floor 
  Floor 1o
   Floor 
   Floor 8
   Floor 
   Floor 
   Floor 2
   Floor 1
First Floor
Bicycle Storage
Blood Transfusion
Emergency Command Center
Food Prep
Morgue
Volunteer Offices 
Emer. 
Command 
Center
110B
Media 
Services
v
Pharmacy
Lobby
Volunteer
Clinical 
Lab
Transfusion
Nurse 
Stafng
Patient 
Discharge
Mail 
Room
Work 
Room
Emergency 
Food
Dish 
Room
Dialysis
Kitchen
Food & Nutrition 
Administration
Food 
Storage
Autopsy
Security 
/ PBX 
Operators
Morgue
Bicycle 
Storage
Pathology
Delivery 
Parking
Patient 
Discharge 
Parking
ER Parking
Motorcycle 
Parking
Ramp Down to P2, P3 
Motor
bikes
Staff 
Lounge
Staff 
Lounge
Med  
Pickup
Technology 
Room
Parking 
Services
P1 Parking
Ramp Up to  
Post Street Exit Patient 
Transport
Patient  
Transport 
Elevators
Service 
Elevators
Shuttle Elevators to Level 
1, 2, Parking 2, 3
Shuttle Elevators to 
Level 3, Parking 2, 3

 08 |  Occupancy Manual • General Building Information   Occupancy Manual• General Building Information | 09 
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
Second Floor
Bed Repair
Biomedical Engineering
Cafeteria
Cart Case Staging
Conference Rooms
Main Lobby
Physician Dining
Third Floor
Ambulance Parking
Conference Rooms
Imaging
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
Ambulance 
Parking / Drop Off
Emergency 
Drop Off
Staff 
Lockers
Staff 
Lounge
Biomedical 
Engineering
Sterile 
Processing 
Decontam 
Entrance
Sterile 
Processing 
Clean 
Entrance
Conference 
Rooms 
270A   270B
Patient Relations /
Physician Relations
Grab and 
Go
Cafe
Security 
Desk
Information
Health & 
Healing 
Center (Gift 
Shop)
Public 
Elevators
Food 
Prep
Admitting 
Adult
Birthing 
& Child 
Admitting
Main Entry 
Lobby
Reception
Cashier
Central 
Distribution
Patient  
Transport 
Elevators
Service 
Elevators
Supply 
Chain
Receiving 
Clean 
Linen
Environmental 
Services
Bed Storage
Cart 
Staging
Meditation
Physician 
Dining
Chuck 
Williams 
Cafe
Bed 
Repair
Engineering
Elevators to 
Parking
Ramp Down to P1, P2, P3 
Hot  
Lab
Surgical Services 
Administration
Imaging 
Administration
Main  
Conference 
Room
312B
Physician  
Lounge
Holding  
Soiled Linen
Loading 
Dock
Receiving
Storage Med 
Gas
Waste 
Management
PsychPsych
Lockers
/ Lounge
Trauma 
Cardiac
Treatment
Treatment
XRay
CT 
Scan
CT 
Scan
CT 
Scan
Gamma
PET / 
CT
Spect / 
CT
MRI
MRI
XRay
Fluoroscopy
Staff 
Lounge
Staff 
Lockers
Fluoroscopy
Technician  
Work Rooms
Stress 
Test
Soiled
Clean
Treatment
Treatment
Treatment
Waiting  
Gowned
Hold 
Patient
Vascular
Imaging
Reception
Play Area 
Peds
Hold 
Patient 
Dosed
Nuclear 
Medicine
Treatment 
Peds
Wait Room 
Pediatrics
Vending
Trauma 
Ortho/
Cast
Conf  
Room 
312A
Results 
Waiting
Triage
Airborne 
Isolation
EMS
Security
Adult 
Waiting 
Room
Ultrasound 
Suite
Patient  
Transport 
Elevators
Service 
Elevators
312C
3180
Nurse 
Education 
3140
Public 
Elevators
Emergency
Imaging
3A
3B
3D
3C

 10 |  Occupancy Manual • General Building Information   Occupancy Manual• General Building Information | 11 
Fourth Floor
Interventional Services
Cardiovascular
Endoscopy
Transplant
Fifth Floor
Birthing Center
OB Triage
Rooftop Garden
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
Shell 
Space
OR 
Transplant
6
OR Cardio
7
OR Cardio
8
Cardio Prep Anesthesia 
Storage
Anesthesia 
Workroom
Med 
Equipment
Imaging
Imaging
Service 
Line Ofce
Med 
Equipment
Soiled
Sterile 
Core
Sterile 
Core Sterile   Core
OR 
Transplant
9
Operating Rooms
3 2 1
ACU C
GI / IES / Motility
Cath / IR/ EP
Non-Invasive 
Cardiology
ACU B
IES 4 IES 5
IES 7IES 3
GI 1
GI 6
GI 2
OR 
General
5
PACU
A
Shell 
Space
Staff 
Lounge
Waiting 
Room
Public 
Elevators Public 
Elevators
Reading 
Room
Staff Lockers, 
Female
Staff Lockers, 
Male
Staff 
Lounge
Anes.
Ofce
OR 
General
10
OR 
General
4
OR Hybrid
14
OR 
General
12
OR 
General
11
Cath
1
Cath
6
IR
2
EP
5
IR
3
EP
4
4A
4C 4G
4F
4B
4D
4E
Patient  
Transport 
Elevators
Service 
Elevators
Lounge
Outdoor Patio
accessible
Garden
Patient Rooms
Cesarean 
Recovery
Nurse 
Station
Exam 
OB 
Triage
Nurse 
Station
Antepartum 
Testing
Family 
Lounge
Staff 
Lounge
Pharm 
Satellite
Formula 
Prep
Reception
Female 
Lockers
Family 
Room
Cesarean 
Section 
OR
Staff 
Lounge
Multi 
Purpose
Storage 
Med 
Equipment
Family 
Waiting
Patient 
Room
LDR 
Patient 
Rooms
LDR
Patient 
Rooms
Patient 
Rooms
Patient 
Rooms
Patient Rooms
Airborne
Infection
Sleep 
Attending
Sleep 
Rooms 
Attending
Patient Rooms
LDR Patient 
Rooms
Patient Rooms
Lactation
Resuscitation
Female 
Lockers
Male 
Lockers
5K
5J
5H5G
5F
5E
5D
5C 5B 5A
Roof Top 
Vegetation
Roof Top 
Vegetation
Shell
Patient  
Transport 
Elevators
Service 
Elevators
NICU
Labor and 
Delivery
Cesarean
OB Triage
Antepartum 
Care Unit

 12 |  Occupancy Manual • General Building Information   Occupancy Manual• General Building Information | 13 
Sixth Floor
Intensive Care Unit
On-Call Rooms
Respiratory Therapy
Seventh Floor
Pediatrics
PICU
Eighth Floor
Well Baby Nursery
Women and Infants
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
Staff 
Lounge Staff 
Lounge
Female 
Lockers
Male 
Lockers Public 
Elevators
Lounge
Patient Rooms
Patient Rooms
Critical 
Care
Patient Rooms
Airbone
Lounge
Airbone
Patient Rooms
Airborne  
Infection
Lounge
Roof Top 
Garden
(view only)
Roof Top 
Garden
(view only)
Lounge
Resident 
Lounge
Resident 
Mailbox & 
Lockers
6B
6A
6C
6E 6F
6D
6 East ICU
6 West ICU
Respiratory 
Therapy
On-Call 
Rooms
Patient Transport 
Elevators
Service 
Elevators
7A
7B
N
7 East 
Pediatrics
Patient Rooms
Family 
Area
Family 
Room
Family 
Room
Family 
Room
Exercise 
Room
Child 
Life Patient 
Rooms
Patient 
Rooms
Patient 
Rooms
Patient 
Rooms
Patient 
Rooms
Procedure 
Room
Shell
Shell
Lounge
Lockers
Sleep 
Room
Storage
Transport 
Elevators
Service 
Elevators
PICU
7 West
7E 7F
7C7D
Public 
Elevators
Family 
Area
Shell
Shell Well Baby 
Nursery
Well Baby 
Nursery
Staff 
Lounge & 
Lockers
Airborne
Airborne
Family 
Area
Family 
Room
Patient Rooms
Patient Rooms
Patient Rooms
8A
8B8C8D
8E 8F
8G
8H
Transport 
Elevators
Service 
Elevators
Women 
and Infants
Public 
Elevators

 14 |  Occupancy Manual • General Building Information   Occupancy Manual• General Building Information | 15 
Tenth Floor
Med/Surg Patient Rooms
Ninth Floor
Med/Surg Patient Rooms
TICU
Eleventh Floor
Ambassador Services Suite
Board Room
Executive Administration
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
Family 
Area
N
N
Patient Rooms
Patient 
Rooms
Patient Rooms
Rehab 
Gym
Airborne
Patient Rooms
9G
9D 9B
9A
9C
9H9F
9E
Transport 
Elevators
Service 
Elevators
9 West
9 East
9 TICU
Staff 
Lockers
Staff 
Lounge
Public 
Elevators
Patient Rooms
Staff 
Lounge
Staff 
Lockers
Rehab 
Gym
Airborne
Airborne
Family 
Area
Family 
Room
Patient Rooms
Patient Rooms
Patient Rooms
10A
10B10D
10E
10F 10G 10H
10C
Transport 
Elevators
Service 
Elevators
10 West
10 East
Public 
Elevators
Board 
Room Conference 
Room
Shell Space
Staff  
Lounge
Medical 
Staff
Graduate Medical Education
Nursing Administration
Executive Administration
Ambassador
Transport 
Elevators
Service 
Elevators
Public 
Elevators

 16 |  Occupancy Manual • General Building Information
General Information
Telephone Numbers
Hours & Entrances
Badges and Access
Elevators
Shared Spaces
Lockers
Conference Rooms
Departments
Floor Plans
Sustainability
Sustainability
The campus is Leadership in Energy and Environmental Design 
(LEED) certified, a globally recognized symbol of sustainability. 
The building is constructed to lower greenhouse gas emissions by 
reducing the use of energy and water.
New roof top gardens are designed to be an urban oasis which help 
with water drainage. Approximately 36o,ooo gallons of storm water 
will annually be diverted from the city’s water system. In addition, 
about 5o,ooo gallons of rainwater will be diverted to help dissipate 
heat from the heating, ventilation and air conditioning (HVAC) 
system at the building’s rooftop cooling towers.
Bottle water refilling stations (page 35) and the sustainable waste 
removal program (page 41) are other examples of ongoing sustain-
able processes.
Building Reminders
Help us create a positive environment for our patients and 
visitors. Please remember that we are moving into a brand new 
hospital that we want to keep as beautiful and tidy as the day we 
move in.
Remember you are “onstage” in front of house 
areas (areas that patients and visitors will see).
No moving furniture or equipment in the building.
No hanging things on the wall (art and 
bulletin boards provided).
No fish or pets will be permitted, with the 
exception of service animals (page 33).
Personal packages will no longer be accepted  
at the campus. Materials Management 
will not sign for them.
Ordering food for delivery—Staff are responsible 
to come down to the 3rd Floor Security Desk at 
Emergency Department to pick up food. Food delivery 
will not be allowed to come to the care department.
TRANSPORTATION 
AND PARKING

 18 |  Occupancy Manual • Transportation and Parking   Occupancy Manual• Transportation and Parking | 19 
Transportation
CPMC Shuttles
Public Transit
Parking
CPMC Shuttle Routes
BCivic Center BART to  
Van Ness Campus
DDavies Campus to  
Van Ness Campus
JG Japantown Garage to  
Van Ness Campus
KKabuki Hotel to  
Van Ness Campus
MBC Mission Bernal Campus to  
Davies Campus
MBC24 Mission Bernal Campus to  
24th Street Mission BART
SAC 1825 Sacramento to  
Civic Center BART
Public Transportation and CPMC Shuttles
CPMC encourages visitors and staff to follow San Francisco’s 
Transit First policy and use alternative modes of transportation 
whenever possible. The Van Ness Campus is easily accessible by a 
combination of rail, bus, shuttle, ferry and/or bicycle. Visit 511.org 
for a comprehensive list of transit options to spare the air and keep 
our campuses safer for you and your family.
Complimentary shuttle services to and from Van Ness Campus to 
Civic Center BART station is available for staff, physicians, volun-
teers, patients and their families.
To connect with other CPMC campuses, additional shuttles are 
available. In general, shuttle service is available approximately every 
3o minutes, Monday–Friday, 6am to 6pm. For more specific times 
and pick-up information, go to: 
cpmc.org/visiting/shuttle.html.
Patients and visitors may also obtain additional information on 
public transportation and shuttle timetables at the Information 
Desks and Kiosks located in lobbies. Staff and providers may visit 
our Intranet for additional public transportation and shuttle service 
information. Ask your shuttle driver about courtesy stops.
At the time of this publication additional shuttle routes are still 
being determined. Check the website for the most up to date 
information: cpmc.org/visiting/shuttle.html
Transportation
CPMC Shuttles
Public Transit
Parking
Parking 
Parking is limited, so please take public transportation whenever 
possible. For parking, public transportation, WageWorks and other 
related information please contact the CPMC parking office at  
415 6oo-18o4 or email cpmcparking@sutterhealth.org
Level P1 has van accessible spaces and spaces for oversized vehicles.
Payment machines are on Level P1, P2, P3 by the elevators. Payment 
machines accept cash and credit cards. Please pay before exiting; 
cashiers are not stationed at the exit gates.
Staff Parking
Decisions for additional lots, have not yet been resolved. More 
information to follow. 
Visitor Parking
Visitor parking is available for patients and their families. The 
entrances to the parking structure are on both Geary Street and 
Post Street.
Van Ness Campus
101
82
Broadway
Market St.
Van Ness
Post St.
Bush St.
Geary
Guerrero St.
Cesar Chavez
Mission Bernal
80
POST ST
GEARY ST
VAN NESS
FRANKLIN
2, 3, 76X
38, 38R
ENTRANCE
ADA ENTRANCE
PUBLIC TRANSIT
EMERGENCY
Main Hospital Medical  
Office Building
CPMC SHUTTLE STOP

  Occupancy Manual• Support Services | 21 
SUPPORT SERVICES
Support Services are composed of CPMC departments such as 
Security, Transport, Environmental Services, Facilities, Engineering, 
Biomedical Engineering, Materials Management, and Nutrition 
& Food Services. At Van Ness, they are located on the First and 
Second Floors, see page 07.
Department Telephone Directory
The Microsoft Outlook Address Book is an application to access 
the Employee Department Phone Directory for all CPMC and 
Sutter Health campuses. The standard process for adding/changing 
staff locations will synchronize with the address book to keep the 
directory accurate without additional administrative work. The 
Department Phone Directory by campus is located in our Intranet. 
Use the advanced search on the address book for quick lookups.
A list of important department phone numbers in the Van Ness 
Campus can be found on page 02.
Volunteers
At the Van Ness Campus, volunteers help at the Information 
Desks, provide hospitality, escort patients, and help with selected 
non-clinical patient care activities. CPMC offers volunteer opportu-
nities to students and adults. 
The Volunteer Office is located on the 1st Floor (page 07). The 
telephone number is 415-6oo-34o2. 
Spiritual Care and Chaplaincy Services
The CPMC Spiritual Care Team provides spiritual care to patients, 
families and staff inclusive of all religious traditions, cultural back-
grounds and spiritual expression. The Spiritual Care Team offers or 
arranges for the practice or experience of religious sacraments and 
rituals such as baptism, blessings, communion, sacrament of sick, 
confessions, chanting, and more.
In addition, the team is available to support families and loved 
ones. The Spiritual Care Team is available to visit patients 24/7 on 
all four campuses. 
Call 415-6oo-3741 to request a chaplain visit.
Patient Relations
Patients are at the center of everything we do. If a patient or a 
family member has a question or concern about their hospital stay, 
they are encouraged to tell their care team. They may also contact 
Patient Relations at 415-6oo-328o or ask a Nursing Supervisor.
The Patient Relations Team can do the following:
• Assist with lost patient items (coordinate an investiga-
tion, conduct a follow-up, facilitate reimbursement)
• Assist with difficult patient/family incidents
• Coordinate patient grievance issues to 
align with regulatory standards
• Coordinate ADA concerns
• Meet with patients/families to de-escalate 
issues before they become grievances 
• Round on patients (in addition to nursing leadership rounds)
• Enhance patient experience (facili-
tate trainings and in-services to help 
staff improve the experience)
Support Services
Telephone Directory
Volunteers
Spiritual Care
Patient Relations
Interpreter Services
Newborn Connection
Respiratory Etiquette 
Stations
Wheelchairs & 
Gurneys
Lost & Found

 22 |  Occupancy Manual • Support Services
Support Services
Telephone Directory
Volunteers
Spiritual Care
Patient Relations
Interpreter Services
Newborn Connection
Respiratory Etiquette 
Stations
Wheelchairs & 
Gurneys
Lost & Found
Interpreter Services
Our Interpreter Services Program offers the following services:
• In-person interpreting by trained medical interpreters
• Video interpreting via an iPad
• Telephonic interpreting via a dual handset phone system 
A dual handset interpreter phone is stored in the nurse server in 
every Med/Surg patient room.
These services are available to all departments at no cost. Please 
access Interpreter Services by calling 415-6oo-2o7o.
Newborn Connections 
Newborn Connections is a community resource in the Van Ness 
Campus that offers support and education from pregnancy through 
early parenting. Located in the Medical Office Building, 11oo Van 
Ness Ave, the program includes prenatal classes, massage services, 
breastfeeding support, and support groups, as well as breastfeeding, 
baby and lactation supplies.
Hours are 1oam–4pm Monday–Friday, 1oam–2pm Saturday. The 
telephone number is 415-6oo-2229.
Respiratory Etiquette 
Stations
To prevent the transmission of 
respiratory infections, complimentary 
respiratory etiquette stations with 
gloves, antibacterial gel and masks are 
available in the main registration areas 
and on each floor.
Wheelchairs and 
Gurneys
Wheelchairs and gurneys are available for general patient use and 
are tagged with Aeroscout RFID (GPS tracking devices) to facilitate 
ease of location for patient use. Equipment will be cleaned after 
each patient use by clinical or transport staff. Wheelchairs are 
located at the entrances of the ER, Level 2 Driveway, and Discharge 
Lounge.
Lost and Found
Lost and Found is located in Security on the 1st Floor. Please 
contact Security at 415-6oo-o837 if you have a missing item that 
cannot be located.
For patient lost and found items, please direct them to Security or 
contact Patient Relations at 415-6oo-328o.
SAFETY AND 
SECURITY

 24 |   Occupancy Manual • Safety and Security   Occupancy Manual• Safety and Security | 25 
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
Security Awareness
• Be aware of your surroundings.
• If you see something, say something.
• For emergency situations (other than Code Blue) dial 4-4444.
• Keep your personal property, especially purses, 
briefcases and bags, locked and secure.
• Pay attention to person(s) who look suspi-
cious or look like they don’t belong.
• Make sure vendors have a vendor badge.
• Wear your hospital badge.
• Be alert when you are in areas or around 
people that are unfamiliar to you.
For general security concerns or for an escort to your vehicle, 
contact Security Dispatch at 415-6oo-o837.
Crash Carts 
Crash carts are strategically located throughout the Van Ness 
Hospital in the event of a medical emergency for patients,  
visitors or staff.
Security
Security Desks are located on 2nd floor (Main Lobby) and 3rd floor 
(Emergency Room). Security enhancements include:
• A metal detector at the ED entrance 
• Panic alarms located in identified high-risk areas; when 
activated, a silent alarm is sent to Security Dispatch
• Security stations located at key main entrances 
including the ED, loading dock, and drive through
• Staff Duress buttons on Aeroscout RFID tags worn by staff
• HUGS Infant Security & Adult patient elopement
Door Alarms and Stairwell Access
The new hospital has public and staff only areas. In the event of a 
fire, all persons in the building must be able to exit by the emer-
gency stairwells. Therefore, we cannot lock interior doors, but 
we can alarm doors to notify Security when a person has entered 
an authorized hospital staff only area. Signs reading “Authorized 
Hospital Staff Only, Alarm Will Sound” and “Emergency Exit Only, 
Alarms Will Sound” are posted on doors that alarm when entered. 
To prevent the alarm from sounding, hold your employee badge 
up to a card reader located near the door.
Stairwells are “exit only” to the public. In order to re-enter a floor 
from the stairwell, staff must hold their employee ID badge to a 
card reader located on the door.
On the Women’s and Children’s floor, the stairwell doors have a 
sign which reads “KEEP PUSHING. THIS DOOR WILL OPEN IN 15 
SECONDS. ALARM WILL SOUND”. Only specific authorized staff, 
can use their employee ID badge to deactivate these alarms. These 
doors are part of our infant security system. In case of fire, push on 
door and it will open.
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
Emergency Management / 
Emergency Operations Plan
Emergencies, disasters and other catastrophic events pose a signif-
icant threat to the ability of a health care organization to maintain 
operational capability and provide care, treatment and services to 
its community.
CPMC has implemented a comprehensive All-Hazards Emergency 
Operations Plan to respond to the medical needs of the community 
in the event of an emergency, disaster situation or mass casualty 
incident. 
The All-Hazards Emergency Operations Plan is an organiza-
tion-wide program that incorporates all services and sites of 
care under the CPMC license. This plan applies to staff, licensed 
independent practitioners, contract workers, volunteers and others 
as appropriate and indicated throughout this document.
The All-Hazards Emergency Operations Plan complies with the 
elements of the National Incident Management System (NIMS), 
incorporates the Hospital Incident Management System (HICS), 
and addresses the six critical areas mandated by Joint Commission 
standards:
• Communications
• Patient clinical and 
support activities 
• Resources and assets
• Safety and security
• Staff responsibilities
• Utilities management
The full plan is located on the CPMC Intranet at 
http://mysutter/bay/CPMC/Resources/Safety/Pages/
EmergencyManagement.aspx
Communications in a Disaster
Sutter Health affiliates use Everbridge Mass Notification System 
to communicate to all staff simultaneously in an emergency. 
Everbridge has been implemented to improve the efficiency and 
effectiveness of communications. The system-wide notification 
system enables CPMC staff to receive and respond to critical safety 
and business impact information in a timely manner. 
Everbridge allows CPMC to communicate with staff via multiple 
contact paths including home phone, email, mobile phones and 
other communication devices during an emergency event.
What to do when a notification is received: 
Read (when received via email) or listen to 
the message carefully for directions.
“Confirm the Message” when asked by clicking 
the link provided in the email, or press 1 if 
the message is received via phone.
Confirming the message lets CPMC know that you have received 
the message.
How to update your personal contact information:
Check the Lawson e-Self Service site on the Intranet portal to 
confirm that your personal contact information is correct. Having 
accurate personal contact information is critical for Everbridge to 
work effectively and staff to receive emergency 
information. Everbridge pulls from Lawson and 
if information is inaccurate you may not receive 
emergency notifications.
Please direct questions regarding Everbridge to 
the Safety Department at 415-6oo-462o or email  
sforzok@sutterhealth.org.

 26 |  Occupancy Manual • Safety and Security   Occupancy Manual• Safety and Security | 27 
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
Hospital Command Center
The hospital uses the Hospital Incident Command Structure 
(HICS) to manage emergency events, and if the situation 
warranted, the Emergency Operations Plan would be activated  
via Code Triage.
If Code Triage is initiated, the Hospital Command Center (HCC) 
will be activated; it is located on the 1st Floor in Conference Room 
#11oB. If additional resources are needed to manage the event, the 
Labor Pool will be activated; it is located in the hospital cafeteria.
Code Team
The Code Team will respond to all medical emer-
gencies in the main hospital and will respond 
to non-patient emergencies. The Code Team is 
multi-disciplinary, made up of ICU providers, nurs-
es, respiratory therapists, security and a Nursing 
Supervisor. 
Code Blue or Other Medical Emergency
If you witness a patient, visitor or staff member who is in cardiac 
and/or respiratory distress, or having a medical emergency, imme-
diately seek medical assistance by calling for help—and by dialing 
5-5555 from a hospital phone. 
Patient care areas should also use the Code Blue alarm system or 
alert the hospital operator by dialing 5-5555. 
For other types of urgent medical situations (Rapid Response) and 
non-medical emergencies (Code Red, Code Gray, etc.), dial 4-4444 
from an in-house phone and provide the nature of the emergency, 
and your name and location. 
Code Gray
Initiated for any event with aggressive, hostile, combative or poten-
tially combative behavior from a patient, visitor or staff member, 
without the display of weapons.
Response Procedures
At the first indication of a perceived Code Gray:
Dial the emergency number 4-4444.
Describe the incident to the operator, 
including the specific location.
Security will determine when an “All Clear” will be announced.
Post Incident
Security will conduct a post investigation debriefing. You will be 
interviewed to gather incident specific information.
Complete the Workplace Violence Incident Report and, if appli-
cable, an electronic Report of Injury (eROI), Patient Safety Report 
(PSR) and Quality Risk Assessment. 
Infant/Child Security
There is an Infant Security System installed in Women’s and Infant 
Center (Labor & Delivery, Nursery) to protect our infants and 
prevent infant abductions. Code Pink and Code Purple are used in 
the event of a missing infant or child.
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
Code Purple
Initiated when a child/adult over the age of 2 is discovered  
missing or has been abducted.
Staff should initiate a Code Purple 
when the missing child/adult:
• Is a minor
• May have been removed from the facility against their will
• Has a central line, IV, PICC Line, catheter, etc.
• Is awaiting psychiatric evaluation
• Poses a danger to themselves or others 
as documented by physician
• Is on a conservatorship
A Code Purple should also be initiated anytime a clinician has 
concerns with the patient leaving the facility.
Staff response to a missing or abducted  
child/adult:
Call the emergency number the moment a child/adult is  
confirmed missing or abducted.
State a child/adult is missing or abducted and provide:
Your name and the location where the  
child/adult was last seen
The child’s/adult’s name and physical  
description (age, gender, race, etc.)
Any additional details about the abduction or  
absence (e.g., description of the abductor)
If response to a Code Purple announcement:
Immediately stop all non-critical work and proceed to your depart-
ment’s pre-assigned area(s) to observe stairwell doors, elevator 
areas and exit doors. If outside of your department, monitor the 
nearest exit. Continue monitoring until “Code Purple—All Clear” is 
announced.  
Identify anyone matching the description of the missing  
child/adult and call the emergency number.
Respectfully engage anyone who is carrying a child or may be 
concealing a small child. Explain the situation and request to 
inspect small objects.
Identify anyone in obvious distress (struggling, needing assistance, 
appearing lost/confused, etc.) and call emergency number.
If the suspect flees, do not forcibly restrain them. If safe to do so, 
follow them, taking note of their appearance, what they are wearing 
and how they exited the building.
If the suspect abductor reaches the parking lot and attempts to 
leave by car, take note of the vehicle’s make, model, color and 
license plate. 
Code Pink - Infant/Child
Initiated when an infant or child less than 2 years of age is  
discovered missing or has been abducted.
Staff response to missing or abducted infant/child:
Call the emergency number 4-4444 the moment an infant/child is 
confirmed missing or abducted. State an infant/child is missing or 
abducted and provide:
Your name and the location where the infant/child  
was last seen
The infant/child’s name and physical description  
(age, gender, race, etc.)
Any additional details about the abduction or absence  
(e.g., description of the abductor)
Staff response to a Code Pink announcement:
Immediately stop all non-critical work and proceed to your depart-
ment’s pre-assigned area(s) to observe stairwell door, elevator areas 
and exit doors. If outside of your department, monitor the nearest 
exit. Continue monitoring until “Code Pink—All Clear.”
Identify and report suspicious individual(s) to the 
emergency number 4-4444.
Respectfully engage anyone who is carrying an 
infant or may be concealing an infant. Explain the 
situation and request to inspect objects.
If the suspected abductor flees, do not forcibly 
restrain them. If safe to do so, follow them, taking 
note of their appearance, what they are wearing 
and how they exit the building.
If the suspect abductor reaches the parking lot and 
attempts to leave by car, take note of the vehicle’s 
make, model, color and license plate.
• Bicycle Storage
• Blood Transfusion
• Emergency Command Center
• Food Prep
• Morgue
• Volunteer Ofces 
First Floor
Public
Limited
Guest  
Restroom
Staff Only  
Restroom
Water Fountain
KRONOS
Service  
Elevators
Public  
Elevators
Media 
Services
Staff 
Conference 
110A
Pharmacy
Lobby
Volunteer
Clinical 
Lab
Trans-
fusion
Nurse 
Stafng
Patient 
Discharge
Mail 
Room
Work 
Room
Emergency 
Food
Dish 
Room
Dialysis
Kitchen
Food & Nutrition 
Administration
Food 
Storage
Autopsy
Security 
/ PBX 
Operators
Morgue
Pathology
Delivery 
Parking
Patient 
Discharge 
Parking
ER Parking
Motorcycle 
Parking
Ramp Down to P2, P3 
Motor
bikes
Staff 
Lounge
Staff 
Lounge
Med  
Pickup
Technology 
Room
Parking 
Services
P1 Parking
Ramp Up to  
Post Street Exit Patient 
Transport
Patient  
Transport 
Elevators
Service 
Elevators
Shuttle Elevators to 
Level 1, 2, Parking 2, 3
Shuttle Elevators to 
Level 3, Parking 2, 3
Outside of the Hospital
For patient and non-patient emergencies 
in the Medical Ofce Building, Pacic 
Campus (after March 2nd), or California 
Campus (after March 3rd), call 911.
Command 
Center

 28 |  Occupancy Manual • Safety and Security   Occupancy Manual• Safety and Security | 29 
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
Standardized Emergency Codes
 Code Definition and Announcement
Blue Cardiac or respiratory arrest
“Code Blue (Adult, Maternity, Neonate, Pediatric, or V.A.D.) - location”
Gray Combative Person
“Code Gray - location”
Orange Hazardous Material Spill
“Code Orange - Hazardous Materials Spill/Release - location”
Pink Infant Missing or Abducted (up to the age of 2)
“Code Pink last seen - location [insert description, age, gender, race, clothing, and description of individual 
that may be with, if available.”
Purple Child/Adult Missing or Abducted (over age 2)
“Code Purple (child or adult) - last seen - location and description.”
Red Fire “Code Red - location”
Silver Person with a Non-Firearm Weapon or Hostage Situation
“Code Silver - location. A security threat exists at location. All persons should immediately move away 
from that location if it is safe to do so. If it is not safe to move away, seek shelter or remain in a room 
with the door closed until an all clear has been announced.”
Silver - 
Active Shooter
“Code Silver - active shooter - location. A security threat involving a firearm exists at location. All 
persons should immediately move away from that location if it is safe to do so. If it is not safe to move 
away, seek shelter or remain in a room with the door closed until an all clear has been announced.”
Lime Electronic Health Record is down
“Code Lime - initiate (EPIC, PACS, other) downtime procedures.”
Sepsis Patient is in septic shock and needs emergent attention
“Code Sepsis - location.”
Yellow Bomb Threat / Suspicious Device
“Code Yellow - location.”
Triage,  
Internal/External,  
Alert/Activate
Disaster/MCI/Patient Surge event. Activate Emergency Operations.  
Plan for internal or external incident.
“Code Triage Internal/External -Alert - describe situation.” OR “Code Triage Internal/External -Activate 
- describe situation. The emergency operations plan has been activated.” When applicable, the following 
should be added to the announcement: “Incident management team members should proceed to the 
location for a briefing.”
* NOTE: Plain language should be used to describe the situation.
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
Medical Alerts
 Alerts Definition and Telephone Operator Announcement
C-Section A pregnant patient needs an emergent C-Section 
“Medical Alert: C-Section - location”
Imminent 
Delivery
A pregnant patient in advanced stages of labor cannot be transported to the Labor & Delivery 
Unit prior to delivery and needs emergent attention
“Medical Alert: Imminent Delivery - location”
Rapid 
Response
A patient with early signs of clinical deterioration needs emergent attention to prevent respira-
tory or cardiac arrest 
“Medical Alert Rapid Response - location and description.”
Sepsis A patient has severe sepsis and needs urgent attention  
“Medical Alert: Sepsis - location”
STEMI A patient with myocardial infarction and ECG evidence of ST elevation needs emergent 
percutaneous coronary intervention 
“Medical Alert: STEMI - location”

 30 |  Occupancy Manual • Safety and Security   Occupancy Manual• Safety and Security | 31 
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
Fire Safety
General Fire Safety
Never block access to pull stations, fire extinguishers and 
medical gas value boxes. Corridors should be clear except 
for crash carts, isolation carts or “in use equipment.” If 
the fire alarm is activated, make sure corridors are clear.
During an actual fire or smoke event, do not use elevators. 
Follow exit signs to the nearest, safest exit stairwell.
Do not open doors if they are hot to touch, or if you can see 
smoke. If you become trapped in a room and cannot exit 
safety, keep the door closed and seal off any cracks. Call 
hospital operator at 4-4444 and report your exact location.
If a door feels cool to the touch, open it cautiously. Be 
prepared to slam the door shut if the corridor is full 
of smoke or if you feel heat when opening the door. 
If the corridor is clear, proceed with evacuation.
If you are caught in smoke or heat, stay low until you 
reach a safe area such as another smoke compartment.
Fire Safety Guidelines
Smoking is prohibited in all buildings  
and vehicles.
Check cords and equipment.
Report problems.
Know where pull stations and  
fire extinguishers are located.
Know evacuation routes—stop and look: 
Where are the exit signs?
Fire Response = RACE
Rescue—Rescue/remove person(s) from the immediate danger.
Alarm—Active the nearest fire alarm pull station, then call 4-4444 
and/or 911.
Conne—Confine fire and smoke by closing all doors in the area.
Extinguish or Evacuate—Extinguish a small fire by using 
a portable fire extinguisher or use to escape from a large 
fire. Evacuate the building ONLY upon order of the Incident 
Commander or the Fire Department. 
How to Use a Fire Extinguisher = PASS
Pull—Pull the pin
Aim—Aim the nozzle at the base of the fire 
Squeeze—Squeeze the grips
Sweep—Sweep nozzle side to side
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
MRI Suite Safety
For security and safety reasons, access to the MRI suite is limited  
to MRI personnel and security and is controlled. The MRI spaces 
are zoned to protect staff, patients and families. Zoning is noted  
as follows:
Zone II: Unscreened MRI patients, personnel and visitors
Zone III: Screened MRI patients, personnel and visitors
Zone IV: Screened MRI patients, personnel and visitors under 
constant supervision of trained MR personnel
Any metallic, electronic, magnetic or mechanical implants, 
devices, or objects are hazardous in the MRI Suite and cannot be 
allowed in the area. Follow and respect instructions from the MRI 
technologist.
The MRI suite has a special designated EVS closet with non-me-
tallic supplies and equipment. Regardless, EVS staff should never 
enter the MRI suite without supervision from an MRI technologist. 
Finally, to ensure all zone protocol is followed, always check with 
an MRI tech before entering the suite. 
What to Do if You Get injured?
Employees are required to report all work related injuries and/or 
illnesses to their supervisor or the on-duty supervisor immediately 
and complete an Electronic Report of Injury Form (eROI) by the 
end of shift in which the injury or illness occurred. The forms are 
located on the CPMC intranet under Frequently Reviewed Forms—
Environment of Care. 
Upon completion and submission of the form, an incident analysis 
will be completed by the employee’s manager to determine what 
caused the incident and actions needed to be taken to prevent the 
incident from reoccurring. 
Workplace Violence Reporting
Effective April 1, 2o17, employees working in inpatient and outpa-
tient settings and clinics on hospital licenses are required to report 
workplace violence incidents into the Midas Workplace Violence 
Incident Report.
Certain health care facilities as defined by the new Cal/OSHA 
Workplace Violence Prevention Plan standards, Section 3342, 
California Code of Regulations Title 8, adopted October 2o, 2o16, 
were required to maintain a log of all incidents of workplace 
violence by April 1, 2o17.
The purpose of the new standard is to protect 
employees, physicians, volunteers and contracted 
personnel from aggressive and violent behavior—
for example, physical and/or verbal assault, sexual 
assault, threats, and violation of a restraining 
order.
In addition, if an employee is injured in a work-
place violence incident, they must complete an 
Electronic Report of Injury (eROI) Form AND a 
Workplace Violence Incident Report.
If a patient is injured, the employee must go to the 
Hospital Midas Tools Page and complete a patient 
injury form.
Safety, Security, Human Resources, Risk 
Management, and Operations Management will 
coordinate a post-incident investigation.
Pull the pin
Aim nozzle at 
base of fire
Squeeze 
grips
Sweep nozzle 
side to side

 32 |  Occupancy Manual • Safety and Security   Occupancy Manual• Safety and Security | 33 
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
ADA Information
Assistance for the hearing, listening, visually and speech impaired is 
available, and contact information can be found below:
MySutter Portal: Interpreter Services & Multilingual Resources 
http://mysutter/SHWBR/CPMC/Resources/MoreResources/Pages/
InterpreterServices.aspx 
For American Sign Language Interpreter Services, (sign language 
only, not languages such Spanish, Chinese, etc.), to schedule an 
ASL interpreter:
Use the Online Interpreter Scheduling system or 
Call our ASL vendor at 1-800-975-815o
For Assistive Listening Systems (Pocket Talkers), call campus 
security at 415-6oo-o837. 
For an Amplified Telephone Handset,  
call 888-888-6o44.
Closed caption decoders—Closed captioning feature is available 
on all TVs in patient areas. In patient rooms, closed captioning 
can be activated by pressing the Pillow Speaker “CC” button. 
For a braille, large print or audio format provider, call LightHouse 
for the Blind and Visually Impaired at 415-694-7358 (braille) and 
415-694-7312 (audio) or by email at ais@lighthouse-sf.org.
Hand Hygiene
Through our Aeroscout Hand hygiene system, we will be able to 
monitor and record our hand hygiene events, including number 
of hand-washings and locations in patient care areas over Wi-Fi. 
Benefits of the hand hygiene system:
• Enables Infection Control and Process Improvement staff 
to focus on compliance, education and data analysis.
• Does not disrupt routine patient care workflows.
• Provides automated data collection and reporting.
• Drives accountability down to the caregiver level.
Safety & Security
Security Awareness
Crash Carts
Security
Door Alarms & 
Stairwell Access
Emergency 
Management EOP
Communications 
in a Disaster
Hospital Command 
Center
Code Team
Standardized 
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Injury Reporting
Workplace Violence
ADA Information
Hand Hygiene
Service Dogs
Service Dogs 
Service dogs don’t require proof of certification or medical 
documentation to enter public patient care areas. If you are unsure 
if an animal is a service dog, you may ask the following:
1. Is the dog required because of a disability?
2. What work or tasks has the dog been trained to  
 perform?
No other questions about a person’s disability or the dog are 
permitted.
Remember
• Always ask permission to approach the service dog.
• Address the person directly.
• Do not draw unnecessary attention to the 
person with the service dog.
• Ask how to accommodate the dog during the medical appoint-
ment or hospital stay. If necessary, ask who is designated to care 
for the dog during the medical procedure or hospital stay. 
In an Emergency
If the patient can communicate, ask who they want to care for their 
dog to determine how best to care for the patient and service dog.
If the patient is unable to communicate:
• Look for identifying information on the dog’s harness or 
collar to determine if the dog came from a school or training 
program. Contact the school or training program.
• If no information is available, contact family members or friends.
• Contact animal control after all options are exhausted.
Please contact the ADA Coordinator or Safety Officer at  
415-6oo-462o with any questions or concerns.

  Occupancy Manual• Building  Amenities | 35 
BUILDING 
 AMENITIES
Information Desks
The Van Ness Campus Information Desks are located on the 2nd 
floor of the Main Lobby. The Information Desk staff provides the 
following services:
• General information
• Directions and wayfinding 
• Shuttle schedule information
• Taxi and transportation services information
Waiting Areas
Waiting areas and lobbies are available throughout the hospital. 
Check the floor plans (pages 7–15).
For safety reasons and to prevent accidental blocking of the retract-
able fire doors, do not rearrange furniture in the waiting areas.
Restroom Locations
Public restrooms and water fountains are located on every floor 
near the public elevators. Staff Only restrooms require badge access 
and are generally near staff lockers, lounges and conference rooms. 
Lactation Lounge
A dedicated lactation lounge for staff and physicians only is located 
on the First Floor, Room 1118. Badge access is required.
Water Cooler/Bottle Filling Stations
The Van Ness Campus is a sustainable and LEED certified building. 
To reduce the use of disposable bottles, water fountains are avail-
able on each floor near the elevators. Bottle filling locations are in 
the Emergency Department, Cafeteria, and Surgical Waiting Room.
Plumbed coffee makers with hot water dispensers are available on 
certain floors.
Ice makers are available in patient nourishment rooms (not in staff 
lounges).
Dining Services
Several choices for food and beverages are available during regular 
business hours. The Chuck Williams Café and Grab and Go are on 
the 2nd Floor and are open 6:3oam–6:3opm M–F, 6:3oam–2:3opm 
Sat–Sun.
Snack and beverage vending machines are located on the 3rd Floor 
near the Emergency room.
Catering Services
All catering requests must be submitted to the Food and Nutrition 
Services Department three days in advance of the meeting or event. 
Use Catertrax, the ordering platform to order food for meetings. 
Place catering orders at:  
www.cpmc-stlukes.catertrax.com
For training on Catertrax, go to:  
https://catertrax-1.wistia.com/medias/ojoa2vlyhm#
Conference Room Reservations 
To reserve a room, complete the Online Conference Room Request 
form, http://dcpwdbs405/virtualems/, more information about 
Conference Rooms and Patient Care Conference Rooms on page 
06.
Guest Internet Access (Wi-Fi) 
The Van Ness Campus offers complimentary internet access.  
To connect, select “SHGUESTNet” as the wireless network. 
Follow the prompts on the device, including 
accepting the “Terms and Conditions of Use.”
Amenities
Information Desks
Waiting Areas
Restroom Locations
Lactation Lounge
Bottle Fill Stations
Dining Services
Catering Services
Room Reservations
Guest Wi-Fi 
Bicycle Storage
Ambassador  
Services Suite
Patient Education

 36 |  Occupancy Manual • Building  Amenities   Occupancy Manual• Building  Amenities | 37 
Bicycle Storage
Bicycle parking is available on a first come, first served basis. The 
bicycle storage is located on the 1st Floor in Room 1218, accessible 
via Parking Level 1. Cyclist should enter the building off Post or 
Geary and proceed down car ramp.
• Badge access is required.
• Reserved bicycle space may be available. Contact the Parking 
Office, 415-6oo-1804 to register to use this facility and to program 
your badge for access. 
• Day lockers are available—as well as bathroom & showers.
Additional bicycle racks are avaivable at Van Ness entrance. 
Ambassador Services Suite
The Ambassador Services Suite is a hospitality space located on 
the 11th Floor near Nursing Administration. It is our way of saying 
“thank you” to our most generous philanthropic donors, as well as 
volunteers with 5oo or more hours of service per year to CPMC.
Patient Entertainment/Education 
(Powered by Soni)
Rooms are equipped with a multi-purpose media system capable 
of providing patient education, communication and entertainment 
features:
• Access the full complement of TV programming
• Review assigned educational content 
• Complete questionnaires 
• Order patient meals 
• View care team information
• Access patient medical schedule
• Interact with their care team
• Use convenient controls and volume integrated  
into Pillow Speaker
Amenities
Information Desks
Waiting Areas
Restroom Locations
Lactation Lounge
Bottle Fill Stations
Dining Services
Catering Services
Room Reservations
Guest Wi-Fi 
Bicycle Storage
Ambassador  
Services Suite
Patient Education
HOW TO USE  
Pillow Speaker
Amenities
Information Desks
Waiting Areas
Restroom Locations
Lactation Lounge
Bottle Fill Stations
Dining Services
Catering Services
Room Reservations
Guest Wi-Fi 
Bicycle Storage
Ambassador  
Services Suite
Patient Education
• Bicycle Storage
• Blood Transfusion
• Emergency Command Center
• Food Prep
• Morgue
• Volunteer Ofces 
First Floor
Public
Limited
Guest  
Restroom
Staff Only  
Restroom
Water Fountain
KRONOS
Service  
Elevators
Public  
Elevators
Media 
Services
Staff 
Conference 
110A
Pharmacy
Lobby
Volunteer
Clinical 
Lab
Trans-
fusion
Nurse 
Stafng
Patient 
Discharge
Mail 
Room
Work 
Room
Emergency 
Food
Dish 
Room
Dialysis
Kitchen
Food & Nutrition 
Administration
Food 
Storage
Autopsy
Security 
/ PBX 
Operators
Morgue
Pathology
Delivery 
Parking
Patient 
Discharge 
Parking
ER Parking
Motorcycle 
Parking
Ramp Down to P2, P3 
Motor
bikes
Staff 
Lounge
Staff 
Lounge
Med  
Pickup
Technology 
Room
Parking 
Services
P1 Parking
Ramp Up to  
Post Street Exit Patient 
Transport
Patient  
Transport 
Elevators
Service 
Elevators
Shuttle Elevators to 
Level 1, 2, Parking 2, 3
Shuttle Elevators to 
Level 3, Parking 2, 3
Bike 
Storage

  Occupancy Manual• Equipment and Furnishings | 39 
Ergonomics
Ergonomic chairs and keyboard trays are 
fully adjustable. For assistance on proper 
chair and keyboard adjustment, please 
contact the Safety Department at 415-6oo-
462o or email sforzok@sutterhealth.org. 
They will send materials regarding self-as-
sessments and if needed will direct you to 
complete the online ergonomic assessment.
Ofce Spaces 
Office spaces include the following:
• Ergonomic chairs
• Ergonomic keyboard trays
• Electric sit/stand desks
• Monitor arms 
• Electrical outlets on the desktop  
for device charging 
• Mobile personal storage—keys will be  
provided for assigned locations
• Task lighting
Kronos Time Clocks
New InTouch wall clocks are located 
throughout the campus, conveniently 
positioned near: 
• Elevator lobbies
• Main corridors
• The Lab and Pharmacy
• Some staff lounges
Web App will also be available for some 
users. Refer to the floor plans (page 07) for 
specific locations.
Multi-function Printers  
(Scan, Print, Copy)
Multi-function networked printers are 
located throughout the facility and can 
function as copiers, scanners and printers. 
Print jobs can be retrieved by tapping your 
badge on the sensor located on the printer 
of your choice. Some workflows will default 
to specific printers (such as in the ED). 
For copier and printer support, call Sutter 
Health Information Services at 888-888-
6o44 or go to: is.sutterhealth.org
VoIP Telephone System
Cisco Voice over IP (VoIP) phones are used 
at the Van Ness Campus, including desk, 
wall and wireless phones. In addition to 
the standard features of traditional phones 
(hold, speaker phone, call forwarding, 
conferencing, muting), the Cisco phones 
offer:
• Connection to the Vocera badge 
application, allowing calls to be made 
between telephones and Vocera badges.
• Informacast for paging and 
broadcast messaging
• Cisco Unity voicemail
Emergency red phones will be installed in 
key locations.
EQUIPMENT AND 
FURNISHINGS
Equipment
Ergonomics
Ofce Spaces
Kronos Time Clocks
Multi-function 
Printers
VoIP Telephones
Fax Machines
Phone Operators
Vocera
Nurse Call System
HIPAA Containers
Patient Lift
Sustainable Waste
Temperature Monitor
Pneumatic Tube

 40 |  Occupancy Manual • Equipment and Furnishings   Occupancy Manual• Equipment and Furnishings | 41 
Fax Machines
Most faxing will be done using RightFax. 
There will be a limited number of tradi-
tional fax machines on the campus in areas 
where electronic faxing is not possible.
Faxes will be received into an electronic 
inbox, can be read online, and can be saved 
or printed. Use the RightFax application 
to send faxes by scanning and sending. 
Sutter EHR will fax records automatically as 
required by clinical workflows.
Communication Operations 
(formerly PBX) / Phone 
Operating System
Hospital operators will be located at the Van 
Ness Campus. Hospital operators will have 
Nurse Call and other alarm panels to assist 
in routing alerts.
Vista Point Enterprise Operator Services 
System (phone console) will support the 
hospital operator workflows and assist in 
the management of call queues, routing and 
call handling statistics.
Vocera
The Vocera badge delivers hands-free, 
real-time voice communication between 
the wearer and other staff members. This 
communication system weighs less than 
two ounces, allowing users to keep their 
hands free without the burden of carrying a 
smartphone. 
Nurse Call System
The Nurse Call Rauland Responder 5 system 
is an application that allows the patient to 
alert staff from the bedside, among other 
patient locations. Identified alerts will 
integrate with other applications in order 
to produce hospital-wide communications 
and notification acknowledgment, and it can 
generate a number of reports. The system 
utilizes devices at the bedside and in the 
patient room to accomplish three primary 
functions:
• It serves as a code required system for 
patient  
safety and security.
• It provides a patient alert-communication 
system (for hospital staff) that assists 
patients and allows for increasingly 
efficient hospital operations. 
• It interacts with other systems to 
provide access to patient enter-
tainment and education. 
HIPAA—Condential 
Document Containers
Confidential document containers are 
located throughout the hospital and are 
emptied every two weeks by the shredding 
company.
If the containers need to be emptied prior 
to the regularly scheduled pick-up, call 
Support Services  
415-6oo-79oo to arrange for EVS assistance.
CPMC is dedicated to being a green facility, 
so please remember “think before you ink.”
Patient Lift System and  
Mobile Lifts
Patient lift systems are available in  
med/surg and ICU/PICU patient rooms. 
Patient lifts are a safety feature to assist 
in patient mobility and reduce the risk of 
associated employee injuries. 
Where ceiling lifts are not available, mobile 
lifts can assist with patient mobility.
Sustainable Waste Removal
Van Ness is designed to be a green hospital. 
This includes recycling, composting, red-bag 
(biohazard), pharmaceutical and toxic waste 
management and medical equipment reuse. 
In office spaces and public areas, receptacles 
are provided for co-mingled recycling 
(blue) and regular trash (black). In the staff 
lounges and conference rooms there are 
receptacles for co-mingled recycling (blue), 
regular trash (black), and composting 
(green).
Temperature Monitoring
The Van Ness Campus uses a combination 
of two systems to monitor and alert if an 
equipment temperature goes out of range—
the AeroScout system (in the refrigeration 
units) and the MobileView system.
When a device’s temperature goes out 
of range during department hours of 
operation:
• A primary alert is sent to the 
department through MobileView
• A secondary alert is sent 
to Plant Operations. 
When a device’s temperature goes out 
of range when the department is closed, 
primary and secondary alerts are sent to 
Plant Operations. 
Pneumatic Tube System
The pneumatic tube system will assist with 
transporting medications, lab specimens 
and blood products to/from patient care 
areas, to expedite patient care. The system 
has an enhanced “secure send” function-
ality, which will only allow appropriately 
licensed staff to send and receive medica-
tion and blood products.
Equipment
Ergonomics
Ofce Spaces
Kronos Time Clocks
Multi-function Printers
VoIP Telephones
Fax Machines
Phone Operators
Vocera
Nurse Call System
HIPAA Containers
Patient Lift
Sustainable Waste
Temperature Monitor
Pneumatic Tube
Equipment
Ergonomics
Ofce Spaces
Kronos Time Clocks
Multi-function Printers
VoIP Telephones
Fax Machines
Phone Operators
Vocera
Nurse Call System
HIPAA Containers
Patient Lift
Sustainable Waste
Temperature Monitor
Pneumatic Tube

  Occupancy Manual• Supplies and Restocking | 43 
SUPPLIES AND 
RESTOCKING
Loading Dock
The loading dock is located off Franklin Street on Level 3. Interior 
access is adjacent to the service elevators.
Supply Chain Overview
Supply Chain staff will monitor supply levels, and the automated 
supply system will generate refill requisitions to order inventory.
Supply Chain will receive delivery from our primary distributor at 
8pm Monday through Friday.
Supply Chain will remove corrugated cardboard at the loading dock 
as per infection control policies and deliver supplies to the Pyxis 
and supply cart areas throughout the hospital.
Nurse Server carts are department specific and are non-standard 
storage options some departments use. Supply Chain does not 
manage or replenish supplies on these carts.
Supply Chain
The Central Distribution area is located on the 2nd floor, Room 
22oo, adjacent to the services elevators. Staff, supplies and receiving 
will be staged here to support a Low Unit of Measure (LUM) Just in 
Time (JIT) distribution model.
Supply Chain will utilize two points of entry for supplies and 
deliveries: The Loading Dock, and a Receiving Office–Room 14oo, 
located on Level P1. The receiving area on Level P1 will be for 
Fed-Ex, UPS, florist, Lab carriers, Blood Bank, Pharmaceuticals, etc.
Central Distribution will operate 7 days/week on 3 shifts:  
7:ooa–3:3op, 3:oop–11:3op, and 1:ooa–9:3op. For supplies needed 
between 11:3op–1:ooa, contact the Nursing Supervisor who has 
access to the Central Distribution area, Room 22oo.
Par Levels for supplies on the units will be calculated for four days 
of inventory on hand. Supply Chain staff will manage the restocking 
and storage of Code Blue/Broselow resuscitation and isolation 
carts.
Supply Chain Intranet requests: http://apps.insidecpmc.org/
CPMC_SRQ/servlet/LoginServlet?cpmc_role_id=180 
The Code Blue Cart quick reference guide can be found here: 
tinyurl.com/CPMC-CrashCart
A Broselow quick reference guide can be found here:  
tinyurl.com/GuideCrashCart
Medical Gas Area
The Supply Chain Team is responsible for replenishment of medical 
gases, housed in the Medical Gas Storage room on Level 3, accessed 
directly off the loading dock in Room 3214.
Durable Medical Equipment (DME)
The DME process will be the same as currently in place, with 
consigned inventory available in certain closets near patient care 
areas in the ED (Room 3317), ACU (4227), OR and Inpatient Units 
(Rooms 9349, 1o335 and 1o135). DMEs will be replenished by our 
DME partner Pacific Medical.
Pharmacy
The Pyxis supply management system will be used in a combination 
of locked and unlocked cabinets.
Pharmacy staff will make twice daily medication deliveries to 
inpatient units, and once daily deliveries to ancillary departments, 
including new Pyxis Anesthesia carts.
Controlled substances are mostly filled in Pyxis, but may be picked 
up at the Pharmacy by Nursing for one-time medications. Pharmacy 
staff will make daily rounds to remove discharged orders.
Linen
Linen will be managed and delivered by Supply Chain. Clean linen 
will be stored in Room 2216, next to the Central Distribution area 
adjacent to the service elevators.
Soiled linen will be stored in Room 32o5 located at the loading 
dock.
Supplies & Restocking
Loading Dock
Supply Chain
Medical Gas Area
DME
Pharmacy
Linen
Equipment Cleaning
Asset Management
Staff Duress
Stationery, Forms & 
Brochures

 44 |  Occupancy Manual • Supplies and Restocking   Occupancy Manual• Supplies and Restocking | 45 
Equipment Cleaning
There is a central medical equipment cleaning process for the 
following types of equipment
• PCA pumps
• Feeding pumps
• Sequential compression devices
• Infusion pump modules
• Infusion pump control units
• Seizure pads
Process Overview
Support Services will oversee a centralized equipment cleaning 
process, seven days/week, for work that was done formerly by 
Pharmacy and/or Supply Chain.
• Clinical staff will bring soiled equipment to the soiled 
holding room, after preliminary wipe down.
• Equipment cleaning team will make 
rounds twice a day (am & pm).
• Support Services will stock equipment to par levels
• Support Services will pick up soiled equipment
If a department was responsible for completing their own equip-
ment cleaning, that work will remain within the department; 
however, the department must follow the new cleaning standards 
that are compliant with regulatory standards.
Asset Management
AeroScout is the chosen RFID (Radio Frequency Identification) 
equipment location system.  
Essential equipment that moves will be targeted for RFID tracking.
Items that will have RFID locating include but are not limited to:
• Beds
• Bladder scanners
• Defibrillators
• EKG machines
• Gurneys
• IV pump brains and modules
• Other infusion pumps (mobile)
• Patients, infants or chil-
dren (HUGS System)
• PCA pumps
• Portable imaging machines
• SCD
• Vital sign monitors
• Wheelchairs
Staff Duress
Staff will be able to silently notify Security for 
assistance. Security will be able to locate the 
staff in need, via the RFID tag.
AeroScout Tag and Who Wears It?
• The categories of caregivers who wear the tag 
will be identified by the Operations Group. 
• The badge is used for Staff Duress, and 
it works in conjunction with Vocera.
How to Order Stationery, Forms, 
and Brochures on the Intranet
For customized stationery and Rx pads: 
Order through SmartWorks. 
For forms:
Order forms through Standard Register, which you can access 
through Lawson. Here are the steps:
Go to All Services, then Requisition Center, Shopping, and enter 
your requesting location (a five digit number).
Go to Find/Shop icon, then OneSource; scroll down to Standard 
Register.
See icons on top—click on browse catalog icon and find Sutter 
CPMC forms. Or, for quick search, enter the form number and/
or name.
Specify your quantity and complete your order for approval.
For brochures and various marketing materials:
Order brochures, fact sheets, folders, marketing materials, logos, 
photos, artwork, etc., from Sutter Health through Workamajig.
Go to the Sutter Intranet marketing page (mysutter/marketing)
Fill out the Workamajig request form
If you don’t have a Workamajig account, send an email to linten@
sutterhealth.org.
Supplies & Restocking
Loading Dock
Supply Chain
Medical Gas Area
DME
Pharmacy
Linen
Equipment Cleaning
Asset Management
Staff Duress
Stationery, Forms & 
Brochures
“Clean Sticker”
Clean equipment is to be tagged and 
identied with a “Clean” sticker.
CLEAN
Supplies & Restocking
Loading Dock
Supply Chain
Medical Gas Area
DME
Pharmacy
Linen
Equipment Cleaning
Asset Management
Staff Duress
Stationery, Forms & 
Brochures

 46 |  Occupancy Manual • Supplies and Restocking   Occupancy Manual• Supplies and Restocking | 47 
ADA Information 32,  
Assistance to enter the building 04
Ambassador Services Suite 36
Asset Management 44
Bicycle Storage 36
Bottle Filling Stations (water) 35 
Building Amenities 34
Building Reminders 16
Catering Services  35
Chaplaincy Services 21 
Codes 26 
Blue 26, Gray 26, Pink 27, Purple 27,  
Other Medical Emergency 26
Code Team 26
Communication Operations, Phone System 40
Conference Rooms 06
Crash Carts  24
Departments and Divisions by Floor 06
Department Telephone Directory 02, 21
Dining Services 35
Door Alarms and Stairwell Access 24
Durable Medical Equipment (DME) 43
Elevators 05
Emergency Management, Emergency Plan 25
Equipment and Furnishings 38
Equipment Cleaning 44
Ergonomics 39
Fax Machines 40
Fire Safety 30
Floor Plans 07
General Building Information 01
Guest Internet Access (Wi-Fi)  35
Hand Hygiene 32
HIPAA, Document Containers 40
Hospital Command Center 26
Hours of Operation 03
Infant/Child Security 26
Information Desks 35
Injured at work 31
Interpreter Services 22
Kronos Time Clocks 39
Lactation Lounge 35
Linen 43
Loading Dock 43
Lockers 05
Lost and Found 22
Medical Alerts 29
Medical Gas Area 43
Mobile Lifts 40 
MRI Suite Safety 31
Multi-function Printers 39
Newborn Connections  22
Notes 47
Nurse Call System 40
Office Spaces  39
Order Stationery, Forms, and Brochures 45
Parking  19
Patient Entertainment/Education 36
Patient Lift System 40
Patient Relations 21
PBX 40
Personnel ID Badges 04
Pharmacy 43
Pillow Speaker 37
Pneumatic Tube System 41
Public Transportation and CPMC Shuttles 18
Respiratory Etiquette Stations 22
Restroom Locations 35
Safety and Security 23
Security 24
Service Dogs  33
Shared Spaces 05
Sonifi 36
Spiritual Care 21
Staff Duress 44
Staff Lockers 05
Standardized Emergency Codes 28
Supplies and Restocking 42
Supply Chain 43
Support Services 20
Sustainability 16
Sustainable Waste Removal 41
Telephone Numbers 02
Telephone System 39
Temperature Monitoring 41
Transportation 17
Visitor Badges 04
Vocera 40
Volunteers 21
Waiting Areas 35
Water Fountains 35
Wheelchairs and Gurneys 22
Workplace Violence Reporting 31
Index Notes
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