Sutter Health CPMC Van Ness Hospital Occupancy Manual 18 0012632 Nov16

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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
Ofce 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 Ofce ...........................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 ..............................415-600-3232
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 Ofce 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
Stafng
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
Imaging
Emergency
Drop Off
3A
3B
3D
3C
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
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 Ofce
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.
Ofce
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
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 Ofces
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
Stafng
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, Pacic
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.
Conne—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. They are closed after hours and on weekends.
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 Ofces
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
Stafng
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.
Ofce 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
Ofce 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—Condential
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
Ofce 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
Ofce 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
identied 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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18-CPMC-0012632-CPMC Van Ness Occupancy Manual © Sutter Health 2018

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