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Occupancy Manual
YOUR GUIDE TO THE NEW MISSION BERNAL CAMPUS

Information deemed reliable through March 2019
© Sutter Health June 2018

Occupancy Manual | ii

Welcome to the
New Mission Bernal Campus
We hope you are as excited as we are to begin work at Mission Bernal campus! This detailed Occupancy Manual
is designed to be your “go-to guide” to help orient you to our new campus.

Retaining the “heart” of what we do
The opening of the new Mission Bernal campus is the culmination of years of hard work, commitment and
anticipation. It will continue the legacy of being the neighborhood hospital in the Mission District and retain the
“heart” that has made St. Luke’s special for patients, staff, physicians and volunteers 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.
Mission Bernal Campus will open on August 25, 2018. 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

Occupancy Manual | iii

Table of Contents
General Building Information

Safety and Security

Telephone Numbers. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2
Hours of Operation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3
Visitor Badges .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4
Personnel Identification Badges.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4
Elevators .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5
Staff Lockers .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5
Shared Spaces .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5
Conference Rooms .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6
Departments and Divisions by Floor. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6
Sustainability .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14
Building Reminders .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14

Security Awareness.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Security Station.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Door Alarms and Stairwell Access.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Emergency Department Team.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Crash Carts . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Automated External Defibrillator (AED).  .  .  .  .  .  .  .  .  .  .  .  .  .
Emergency Management.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Communications in a Disaster.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Hospital Command Center. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Standardized Emergency Codes.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Medical Alerts .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Fire Safety .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
MRI Suite Safety. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Reporting an Injury. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Workplace Violence Reporting.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Hand Hygeine .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
ADA Information.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Service Dogs.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

Transportation and Parking
Public Transportation and CPMC Shuttles.  .  .  .  .  .  .  .  .  .  . 16
Parking .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17

Support Services
Volunteers .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Spiritual Care and Chaplaincy Services.  .  .  .  .  .  .  .  .  .  .  .  .
Department Telephone Directory.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Patient Relations .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Interpreter Services .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Newborn Connections .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Respiratory Etiquette Stations .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Wheelchairs and Gurneys .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Lost and Found .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

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Equipment and Furnishings
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Building Amenities
Information Desks .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Waiting Areas.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Restroom Locations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Lactation Lounge.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Room Reservations . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Bicycle Storage .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Water Cooler / Bottle Filling Stations .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Dining Services .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Catering Services . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Patient Entertainment / Education.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Ambassador Services Suite.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Guest Internet Access (Wi-Fi) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
How to Use Pillow Speaker .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

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Ergonomics .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Office Spaces .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Kronos Time Clocks. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Multi-function Printers .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
VOIP Telephones .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Fax Machines. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
PBX/Phone Operating System.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Vocera.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Nurse Call System .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
HIPAA—Confidential Document Containers.  .  .  .  .  .  .  .  .  .
Sustainable Waste Removal. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Temperature Monitor .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Pneumatic Tube System. . . . . . . . . . . . . . . . . . . . . . . .
Patient Lift System and Mobile Lifts.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

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Restocking Supplies
Loading Dock. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Supply Chain Overview .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Supply Chain and Medical Gas Area .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Supply Chain Stat Requests .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Pharmacy. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Asset Management .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Equipment Cleaning. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Staff Duress.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Durable Medical Equipment (DME). .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Linen .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
How to Order Stationery, Forms & Brochures .  .  .  .  .  .  .  .

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Occupancy Manual | iv

GENERAL BUILDING
INFORMATION

Telephone Numbers
Emergency.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6625
Main Hospital.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-6000
Security .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-0837

General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

Abuse Hotline (Adult). .  .  .  .  .  .  .  .  .  .  .  . 800-814-0009
Abuse Hotline (Child). .  .  .  .  .  .  .  .  .  .  .  . 800-856-5553
Admitting.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6951
Administration.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6536
Ambassador Suite.  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-2600
Bed Control.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-850-7123
Breast Health. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6545
Cashier .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-3333
Cardiac Catheter Lab .  .  .  .  .  .  .  .  .  .  .  . 415-600-5990
Cardiology (Non-Invasive).  .  .  .  .  .  .  .  . 415-641-6570
Case Management .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6534
Central Distribution.  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6626
Chaplain .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6527
Clinical Lab .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6533
CT .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6545
Diabetes Center. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-0506
Dialysis (in-patient) .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-3427
Emergency. . . . . . . . . . . . . . . . . . . . . 415-641-6625
ER Registration.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6698
Food and Nutrition .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6594
Hospitalists .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-912-8469
Imaging .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6545
Information/Lobby.  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6512
Information Services.  .  .  .  .  .  .  .  .  .  .  .  . 888-888-6044
Interpreter Services.  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-1077
Main Hospital .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-6000
Medical Staff Office.  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-6285

Medical Records.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6515
MRI .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6545
Newborn Connections. . . . . . . . . . . . 415-600-2229
Nursing Admin. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6536
Occupational Therapy.  .  .  .  .  .  .  .  .  .  .  . 415-641-6560
Outpatient Surgery .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6889
Parking Office .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-1986
Patient Relations.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-6634
Pharmacy .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6505
PT/OT/ST. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6560
Respiratory Therapy .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6565
Safety Department .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-4620
Security.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-0837
Support Services. .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-600-7900
Volunteer Services. .  .  .  .  .  .  .  .  .  .  .  .  .  . 415-641-6490
Nursing Stations
3rd Floor ACU.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
3rd Floor OR .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
3rd Floor PACU.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
4th Floor ICU.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
4th Floor PCU .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
5th Floor Med Surg.  .  .  .  .  .  .  .  .  .  .  .  .  .
6th Floor Med Surg.  .  .  .  .  .  .  .  .  .  .  .  .  .
7th Floor L&D .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
7th Floor Nursery. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
7th Floor Postpartum .  .  .  .  .  .  .  .  .  .  .  .

415-641-6889
415-641-6635
415-641-6638
415-641-6612
415-641-6610
415-641-6690
415-641-6710
415-641-6630
415-641-6655
415-641-6650

Need to dial an extension?
641 numbers use 8 plus last four digits
600 numbers use 6 plus last four digits
ie. 415-600-0837 = 60837
Occupancy Manual • General Building Information | 2

Hours of Operation
Cesar Chavez Entrance

7am–7pm every day

Badge after hours

27th St. Plaza Entrance

24 hours a day

Open every day

Emergency Entrance

24 hours a day

Open every day

Cafeteria
1st Floor

6:30am–6:30pm Monday–Friday

Closed on weekends
Closed after hours

Mail Room
1912 Building

24 hours a day

Open every day

Peet’s Coffee Cart
Monteagle Building

7:30am–3pm Monday–Friday

Closed on weekends

Walgreens Pharmacy
Monteagle Building

9am–6pm Monday–Friday

Closed on weekends

Newborn Connections
Monteagle Building

9am–6pm Monday–Thursday
9am–4pm Friday

Closed on weekends

Loading Dock/
Delivery Hours

5am–8pm Monday–Friday

Other hours by appointment only

Cesar Chavez Blvd
Valencia St

Plaza

Guerrero St

General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

Main Hospital
1970 Building
1957 Building
1580 Valencia St
1912 Building
Monteagle Building

27th St

Hartzell Building
Parking Garage
ADA Entrance
Entrance
ER Entrance
Public Transit
Occupancy Manual • General Building Information | 3

Visitor Badges

Personnel Identification 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 2nd Floor.

Providers, staff and volunteers must wear their
hospital identification badge while on campus. Badges
are required for identification and to gain access to
non-public areas and devices.

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.

Staff must tap their badge to the respective device, to
activate the corresponding system.

Patients/visitors going to appointments in the Medical
Office Building will not require a badge.

If someone needs assistance to
enter the building
Should an individual arrive after hours at the Cesar
Chavez Street entrance and need assistance (ADA
accommodation), he/she should use the phone at the
entrance to contact Security. A security officer will
then assist the individual into the building.

General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

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, please go to the Security
Desk 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
Bicycle Storage
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

Occupancy Manual • General Building Information | 4

Elevators

Staff Lockers

Shared Spaces

There are two sets of elevators on the campus. Please
yield to patients being transported.

Lockers are available for staff use in department areas
(see table below).

Mission Bernal is designed as a shared work space.

Four public (green) elevators are available for patients
and visitors. Badge access is not required.

All lockers will be day use only, unless otherwise
designated by management.

Three transport/service (orange) elevators are for
staff, volunteers and patient transport. Badge access is
required to activate elevator.

Lockers accept padlocks and are two or three high.
Department managers are responsible for handling
locker buddy assignments and distribution.
Department Lockers

Cesar Chavez
Entrance

Public
Lobby

Service
Elevators

Public Elevators
General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

Location

Pharmacy

Floor 1

Kitchen

Floor 1

Materials Management, EVS,
Biomed, Engineering

Floor 1

Emergency Department

Floor 2

Imaging

Floor 2

Surgery, Prep/Recovery,
PACU, CSPD

Floor 3

Lab

Floor 3

ICU

Floor 4

Med/Surg

Floors 4, 5, 6

Respiratory Therapy

Floor 4

Labor and Delivery

Floor 7

Multi-disciplinary workrooms are conferencestyle rooms on patient care floors. These rooms
accommodate 10 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 workstations 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 conversations 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 two On-Call rooms, 5361 or 5359, available
for scheduling. Contact Support Services at 415-6007900 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 the hospital operator or the Nursing
Supervisor.
Staff lounges are for non-physician staff. Nursing staff
is responsible for cleaning the coffee maker.

Occupancy Manual • General Building Information | 5

Conference Room Reservations

Conference Rooms

There are conference rooms on the 1st and 2nd floors, available for
hospital and public use: Conference Rooms A & B (1st floor) and
Room 2910 (2nd Floor). To reserve a conference room, go to the online room scheduling portal at http://dcpwdbs405/virtualems/.

Conference rooms are available on the patient care floors for patient
care team use.

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.

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 Mission Bernal Campus is a seven-story, 120-bed, full-service medical center with an emergency department and supporting services,
including imaging services, and laboratory. The building is thoughtfully designed to enhance patient comfort, be environmentally
conscience, be seismically safe, and support current and future technologies.
A department phone directory is on page 2.
Floor 7

Postpartum (14)

LDRP (6)

C-Section (2)

Nursery

Floor 6

Med-Surg (34)

Non-invasive Cardiology (IP)

Floor 5

Med-Surg / ACE (34)

PT/OT/SP

Floor 4
General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

Antepartum (2)

ICU (10)

Floor 3

Surgery (5)

PACU(8)

Floor 2

ED (16)

Patient
Access

Floor 1

Loading Dock /
Materials Managment

EVS, Plant Ops,
Biomed

Med-Surg (20)
ACU (12)

Clinical Lab

Meditation Area
Pharmacy

Conference
(24/24, seated)

Nursing Admin

Ambassador Suite

Imaging [CT (1), MRI (1), U/S (2),
Xray (2)/Fluoro (1)]
Physician Dining

Kitchen/Cafeteria

Occupancy Manual • General Building Information | 6

First Floor Main Areas
Bicycle Storage
Biomed
Cafeteria
Cesar Chavez Entrance
Central Distribution
Conference Rooms A & B
EVS
Loading Dock
Locker Rooms & Showers
Pharmacy
Physicians Dining/Lounge

Conference
Room B

Conference
Room A

Cesar Chavez
Entrance

Security
Loading Dock

Volunteer
Public
Lobby

Central
Distribution

Public

PBX

Public Elevators

Morgue

Limited
Guest Restroom

Cafeteria

Staff Restroom
Water Fountain
General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

Food & Nutrition
Services

Pharmacy

KRONOS
Service Elevators
Public Elevators

EVS

Engineering

Biomedical
Engineering

Lockers &
Showers

MD
Dining
Lounge

Bike

Occupancy Manual • General Building Information | 7

Second Floor Main Areas
Admitting/Cashier/Request of Information
27th Street Entrance
ER Entrance
Ambulance Entrance
Imaging
Information Desk
Meditation Room
Vending Machines

Conference
Room

Ultra
Sound
Rad

Gown Wait

Radiology
Rad/Fluoro
Nurse Work
Area
Patient
2C
Holding

Reception
MRI

CT Scan
Equip
Storage

Emergency
Water

Meditation
Room

Waiting
Area

Staff
Lounge
Treatment

Equip

Public

Office

Limited
Guest Restroom
Staff Restroom

Nourish
Treatment

Cardiac

Water Fountain
General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

KRONOS

Trauma

Service Elevators
Public Elevators
Decon
Shower

Physcn
Wr Rm
Equip
Storage

Nurse
Station
2B

Soiled
Wk Rm

Nurse
Station
2A
Treatment

Clean
Storage
Med
Prep
Physician
Charting

Infection
Isolation

Vending Public Elevators
Info
Desk

Admitting/
Cashier/ROI

Peds
Treatmnt

Waiting
Area

Triage
27th St Plaza
Entrance

Security
Desk
Ambulance
Entrance

Emergency

ER
Entrance

Occupancy Manual • General Building Information | 8

Third Floor Main Areas
Ambulatory Care Unit (ACU)
Operating Rooms
Post Anesthesia Care Unit (PACU)
Sterile Processing
Nursing Administration
Ambassador Services
Clinical Lab/Blood Bank

PACU

Staff
Lounge

ACU

Nurse
Station 3A
Soiled
Med Work Room
Prep
Clean
Storage

Nurse
Station 3B
Nurse
Station
3C

ACU

Equip
Room

ACU

Equip
Room
Staff Lounge

Operating
Room 1

Staff Lockers
Nurse
Control
Check-in

Operating
Room 2

Public
Limited
Guest Restroom

Anesthesia
Operating
Room 3

Staff Restroom
Water Fountain
General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

Staff Lockers

Operating
Room 4

ACU
Waiting Area

Equip
Room
Minor
Procedure

Pathology
Freezer
Section

Nursing
Admin
Offices

KRONOS
Service Elevators

Operating
Room 5

Ambassador
Services Suite

Public Elevators

Decontamination
Cart Staging
Prep/Pack

Clinical Lab /
Blood Bank

Occupancy Manual • General Building Information | 9

Fourth Floor Main Areas
Intensive Care Unit (ICU) - 10 Beds
Progressive Care Unit (PCU) - 20 Beds
Respiratory Care

Conf.
Room

Patient Rm
ICU

Call
Room
Nurse Station
4E

Patient Rm
ICU

Public

Patient Rm
ICU,
Airborne

Limited
Guest Restroom

Patient Rm
PCU

Nurse
Station
4C
Respiratory
Care

PCU Wait
Room

Conf.
Room

KRONOS

Public Elevators

Work
Room
Nourish Soiled
Work Rm

Technology
Room

Water Fountain

Service Elevators

Clean
Storage

ICU Wait
Room

Staff Restroom

General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

Nurse
Station
4D

Staff
Lounge

Work
Room

Nurse
Station
4A

Staff
Lounge
Patient Rm
PCU

Patient Rm
PCU
Nourish
Soiled
Consult
Nurse Med
Clean
Equip
Station 4B Prep
Storage
Storage

DME
Patient Rm
PCU
Occupancy Manual • General Building Information | 10

Fifth Floor Main Areas
Med/Surg - 34 Beds
PT/OT Exercise Room
Dialysis Workroom

Conf.
Room

Patient Rm
M/S

Patient Rm
M/S Airborne

Nurse
Station
5B
Patient Rm
M/S

Work
Room

Offices
Dialysis
Work
Room
Patient Rm
M/S

Lockers
Equip
Room

Public

PT/OT
Exercise Room

Nourish
Med
Prep

Staff
Lounge

Activity
Room

Limited
Guest Restroom

Wait Room

Staff Restroom
Gurney
Shower On Call
Rooms

Water Fountain
General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

KRONOS

Nurse
Station
5A
Lactation
Lounge

Service Elevators
Public Elevators
Patient Rm
M/S

Physician
Workroom Soiled
Workroom

Equip
Storage

Clean
Storage
Equip
Room

Nourishment Patient Rm
M/S

DME

Patient Rm
M/S
Occupancy Manual • General Building Information | 11

Sixth Floor Main Areas
Med/Surg - 34 Beds
Non-Invasive Cardiology (Inpatient)

Ante
Room

Ante
Room
Airborne
Infection

Tech
Stress WkRm
Test
Office
Dietitian
Non-Invasive
Cardiology

Nourish
Med
Prep

Work
Room
Nurse
Bed
Station
Storage
Soiled
6B
Work
Room
Patient Rm
M/S

Equip
Storage

Patient Rm
M/S

Lockers
Equip
Room

Public

Conf.
Room

Patient Rm
M/S

Staff
Lounge

Conf.
Room

Limited
Guest Restroom

Nurse
Station 6A

Staff Restroom
Water Fountain
General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

Wait
Room

Work
Room

KRONOS

Med
Prep
Clean
Storage

Service Elevators
Public Elevators
Patient Rm
M/S

Physician
Workroom

Soiled
Workroom

Equip
Room

Nourish

Patient Rm
M/S

DME
Equip
Storage

Patient Rm
M/S
Occupancy Manual • General Building Information | 12

Seventh Floor Main Areas
Antepartum/Postpartum - 16 Beds
C-Section
Labor and Delivery - 6 Beds
Special Care - 4 Beds
Well Baby Nursery - 4 Beds

Conf.
Room

Patient Rooms
Postpartum

Nurse
Station
7C

Patient
Rooms
Postpartum

Lactation
Consulting

Nursery
& Special Care

Nurse
Station
7D
Equip
Storage
Soiled
Workroom
Patient
Rooms
Postpartum

OB Triage
Antepartum
Testing

Public
Limited

Nurse
Station 7A

Guest Restroom
Staff Restroom
Water Fountain
General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

KRONOS

Patient
Rooms
LDRP

Nurse
Station
7B

Staff
Lounge
Equip
Storage

Med Nourish
Prep

Call
Rooms

Call
Rooms

Service Elevators
Public Elevators

C-Section
Room

C-Section
Room
Staff
Locker
Rooms

C-Section
Recovery

Anes.
Work
Room
Occupancy Manual • General Building Information | 13

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 29).

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.

General Information
Telephone Numbers
Hours & Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Depts. & Divs.
LEED
Reminders

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 2nd Floor Security Desk to
pick up food. Food delivery will not be allowed
to come to the care department

A new pedestrian plaza is designed to be an urban
oasis with shade trees and plantings and to help with
water drainage. Approximately 360,000 gallons of
storm water will annually be diverted from the city’s
water system. In addition, about 50,000 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 31) and the
sustainable waste removal program (page 36) are
other examples of ongoing sustainable processes.

Occupancy Manual • General Building Information | 14

TRANSPORTATION
AND PARKING

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
Mission Bernal 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 Mission
Bernal Campus to 24th Street Mission BART station is
available for staff, physicians, volunteers, patients and
their families.
To connect with other CPMC campuses, additional
shuttles are available. In general, shuttle service is
available approximately every 30 minutes, Monday–
Friday, 6am to 6pm. For more specific times and pickup information, go to:
cpmc.org/visiting/shuttle.html

Shuttle Routes
B

Civic Center BART to
Pacific Campus

C

California Campus to
Pacific Campus

D

Davies Campus to
Pacific Campus

JG

Japantown Garage to
Pacific Campus

K

Kabuki Hotel to
Pacific Campus

MBC

Mission Bernal Campus to
Davies Campus

MBC24

Mission Bernal Campus to
24th Street Mission BART

SAC

1825 Sacramento to
Civic Center BART

Patients and visitors may also obtain additional
information on public transportation and shuttle
timetables at the Information Desks. Staff and
providers may visit our Intranet for additional public
transportation and shuttle service information.
Transportation
Public Transit
CPMC Shuttles
Parking

Ask your shuttle driver about courtesy stops.

Occupancy Manual • Transportation and Parking | 16

Parking
Parking is limited, so please take public transportation
whenever possible.

MISSION ST

Payment machines are on Level 1, by the elevators.
Payment machines accept cash and credit cards. Please
pay before exiting; cashiers are not stationed at the exit
gates.

24th St Mission
GUERRERO ST

Level 1 has van accessible spaces and spaces for
oversized vehicles. Vehicle charging stations are
located in the garage on Level 1.

Staff Parking
In addition to the Cesar Chavez Street Garage, two
other off-site parking lots have been made available to
provide more parking spaces during business hours.
These parking lots are within five minutes’ walking
distance to the hospital.

Visitor Parking
Visitor parking is available for patients and their
families. The entrance to the parking structure is on
San Jose Avenue.

CESAR CHAVEZ
MISSION
BERNAL

P
3115 Mission St

JOS

E AV

E.

P

SAN

Security escorts are available if needed. The Cesar
Chavez Street Garage is available to staff after hours
and on weekends.

101

199 Tiffany Ave

P
Transportation
Public Transit
CPMC Shuttles
Parking

Bernal
Heights Park

Occupancy Manual • Transportation and Parking | 17

SUPPORT SERVICES

Support Services are composed of CPMC departments
such as Environmental Services, Facilities,
Engineering, Biomedical Engineering, Materials
Management, and Nutrition & Food Services. At
Mission Bernal, they are located on the First Floor, see
“First Floor Main Areas” on page 7.

Volunteers
At the Mission Bernal Campus, volunteers help at
the Information Desks, provide hospitality, escort
patients, and help with selected non-clinical patient
care activities. CPMC offers volunteer opportunities to
students and adults.
The Mission Bernal Volunteer Office is located in the
1912 Building. See page 15. The telephone number is
415-641-6490.

Spiritual Care and Chaplaincy
Services
The CPMC Spiritual Care Team provides spiritual care
to patients, families and staff inclusive of all religious
traditions, cultural backgrounds and spiritual
expression. The Spiritual Care Team offers
or arranges for the practice or experience
Support Services
of religious sacraments and rituals such as
Volunteers
baptism, blessings, communion, sacrament of
Spiritual Care
Patient Relations
sick, confessions, chanting, and more.
Telephone Directory
Interpreter Services
Newborn
Connections
Respiratory
Etiquette Stations
Wheelchairs &
Gurneys
Lost & Found

Department Telephone Directory

Patient Relations

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.

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 415-600-6634 or ask a Nursing Supervisor.

Use the advanced search on the address book for quick
lookups.
A list of important department phone numbers in the
Mission Bernal Campus can be found on page 2.

The Patient Relations Team can do the following:
Assist with lost patient items (coordinate an
investigation, 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 (facilitate trainings and
in-services to help staff improve the experience)

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 415-641-6527 to request a chaplain visit.

Occupancy Manual • Support Services | 19

Interpreter Services
Our Interpreter Services Program offers the following
services:
In-person interpreting by professionally 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
415-600-1077.

Newborn Connections
Newborn Connections is a community resource
new to the Mission Bernal Campus that offers
support and education from pregnancy through early
parenting. Located in the Monteagle Building, the
program includes prenatal classes, massage services,
breastfeeding support, and support groups, as well as
breastfeeding, baby and lactation supplies.
Support Services
Telephone Directory
Volunteers
Spiritual Care
Patient Relations
Interpreter Services
Newborn
Connections
Respiratory
Etiquette Stations
Wheelchairs &
Gurneys
Lost & Found

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.

Lost and Found
Lost and Found is located in the 1912 Building on the
3rd Floor. Please contact Security at 415-600-0837 if
you have a missing item that cannot be located.

Hours are Monday–Thursday, 9am–6pm, Friday,
9am–4pm. Closed Saturday and Sunday. The telephone For patient lost and found items, please direct them to
Security or contact Patient Relations at 415-600-6634.
number is 415-600-2229.

Occupancy Manual • Support Services | 20

SAFETY AND SECURITY

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 suspicious 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 415-600-0837.
Safety and Security
Security Awareness
Security Station
Door Alarms and
Stairwell Access
Emergency
Department Team
Crash Carts
Automated External
Defibrillator (AED)
Emergency
Management
Communications in a
Disaster
Hospital Command
Center
Standardized
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Reporting an Injury
Workplace Violence
Reporting
Hand Hygeine
ADA Information
Service Dogs

Security Station

The main Security Station for the Mission Bernal
Campus is located on the 2nd Floor at the 27th
Street main entrance / Emergency Department (ED)
entrance. 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 to
include the ED and loading dock
Staff Duress buttons on Aeroscout RFID tags worn
by staff

Emergency Department Team
The ED Team will respond to all non-patient
emergencies in the main hospital—for example, if a
visitor collapses in the cafeteria.

Crash Carts
Crash carts are strategically located throughout the
Mission Bernal Campus in the event of a medical
emergency for patients, visitors or staff.

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 emergency 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 reenter 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.

Automated
External
Defibrillator
(AED)
AEDs are in two locations
on the 1st Floor of the
campus:
Outside Conference
Rooms A and B
Outside the cafeteria

Occupancy Manual • Safety and Security | 22

Emergency Management /
Emergency Operations Plan
Emergencies, disasters and other catastrophic events
pose a significant 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
organization-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.
Safety and Security
Security Awareness
Security Station
Door Alarms and
Stairwell Access
Emergency
Department Team
Crash Carts
Automated External
Defibrillator (AED)
Emergency
Management
Communications in a
Disaster
Hospital Command
Center
Standardized
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Reporting an Injury
Workplace Violence
Reporting
Hand Hygeine
ADA Information
Service Dogs

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
Resources and assets
Safety and security
Staff responsibilities
Utilities management
Patient clinical and support activities
The full plan is located on the CPMC Intranet
at
http://mysutter/bay/CPMC/Resources/
Safety/Pages/EmergencyManagement.aspx

Communications in a Disaster

Hospital Command Center

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.

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.

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.

If Code Triage is initiated, the Hospital Command
Center (HCC) will be activated; it is located on the
1st Floor in Conference Rooms A and B. If additional
resources are needed to manage the event, the Labor
Pool will be activated; it is located in the hospital
cafeteria.

Hospital
Command Center
Conference
Room B

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.

Cesar Chavez
Entrance

Conference
Room A

Security
Volunteer
Public
Lobby

First Floor

Please direct questions regarding Everbridge to the
Safety Department at 415-600-4620 or email
sforzok@sutterhealth.org.

Occupancy Manual • Safety and Security | 23

Standardized Emergency Codes

Code Team

Code

Definition and Announcement

Blue

Cardiac or respiratory arrest

Gray

Combative Person

Orange

Hazardous Material Spill

The Code Team will respond to all patient medical
emergencies in the main hospital and will respond
to non-patient emergencies only if requested Code
Blue (5-5555) is called. The Code Team is multidisciplinary, made up of ICU physicians, nurses,
respiratory therapists, security and a Nursing
Supervisor.

Pink

Infant Missing or Abducted (up to the age of 2)

Purple

Child/Adult Missing or Abducted (over age 2)

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.”

Patient care areas should also use the Code Blue alarm
system and alert the hospital operator by dialing
5-5555.

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

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.

Sepsis

Patient is in septic shock and needs emergent attention

Yellow

Bomb Threat / Suspicious Device

“Code Blue (Adult, Maternity, Neonate, Pediatric, or V.A.D.) - location”
“Code Gray - location”
“Code Orange - Hazardous Materials Spill/Release - location”
“Code Pink last seen - location [insert description, age, gender, race, clothing, and description of individual
that may be with, if available.”
“Code Purple (child or adult) - last seen - location and description.”

“Code Lime - initiate (EPIC, PACS, other) downtime procedures.”
“Code Sepsis - location.”

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, immediately seek medical-nursing
assistance by calling for help—and by dialing 5-5555
from a hospital phone.

Outside of the Hospital
For patient and non-patient emergencies in 1912
or Monteagle Buildings, call 911.

“Code Yellow - location.”

Disaster/MCI/Patient Surge event. Activate Emergency Operations.
Triage,
Internal/External, Plan for internal or external incident.
“Code Triage Internal/External -Alert - describe situation.” OR “Code Triage Internal/External -Activate
Alert/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.

Occupancy Manual • Safety and Security | 24

Code Gray

Code Pink

Code Purple

Initiated for any event with aggressive, hostile,
combative or potentially combative behavior from a
patient, visitor or staff member, without the display of
weapons.

Initiated when an infant or child less than 2 years of
age is discovered missing or has been abducted.

Initiated when a child/adult over the age of 2 is
discovered missing or has been abducted.

Staff response to a 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:

Staff should initiate a Code Purple when the
missing child/adult:
Is a minor

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.

Safety and Security
Security Awareness
Security Station
Door Alarms and
Stairwell Access
Emergency
Department Team
Crash Carts
Automated External
Defibrillator (AED)
Emergency
Management
Communications in a
Disaster
Hospital Command
Center
Standardized
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Reporting an Injury
Workplace Violence
Reporting
Hand Hygeine
ADA Information
Service Dogs

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 applicable, 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.

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 department’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.

May have been removed from the facility against
their will
Has a central line, IV, PICC Line, catheter, etc.
Is awaiting Psychiatric Emergency Service
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)
(Continued on Next Page)

Occupancy Manual • Safety and Security | 25

Staff response to a Code Purple
announcement:
Immediately stop all non-critical work and proceed
to your department’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.
Safety and Security
Security Awareness
Security Station
Door Alarms and
Stairwell Access
Emergency
Department Team
Crash Carts
Automated External
Defibrillator (AED)
Emergency
Management
Communications in a
Disaster
Hospital Command
Center
Standardized
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Reporting an Injury
Workplace Violence
Reporting
Hand Hygeine
ADA Information
Service Dogs

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.

Medical Alerts
Alerts

Definition and Telephone Operator Announcement

C-Section A pregnant patient needs an emergent C-Section
“Medical Alert: C-Section - location”

ECMO

A patient needs an emergent extracorporeal life support
“Medical Alert: ECMO (infant, child, or adult) - location”

Imminent A pregnant patient in advanced stages of labor cannot be transported to the Labor & Delivery
Delivery Unit prior to delivery and needs emergent attention
“Medical Alert: Imminent Delivery - location”

Massive
Blood

A patient emergently needs a massive blood transfusion
“Medical Alert: Massive Blood Transfusion - location”

A patient with early signs of clinical deterioration needs emergent attention to prevent
Rapid
Response respiratory 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”

Occupancy Manual • Safety and Security | 26

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
Safety and Security
if you feel heat when opening the door.
Security Awareness
Security Station
If the corridor is clear, proceed with
Door Alarms and
evacuation.
Stairwell Access
Emergency
Department Team
Crash Carts
Automated External
Defibrillator (AED)
Emergency
Management
Communications in a
Disaster
Hospital Command
Center
Standardized
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Reporting an Injury
Workplace Violence
Reporting
Hand Hygeine
ADA Information
Service Dogs

If you are caught in smoke or heat, stay
low until you reach a safe area such as
another smoke compartment.

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.

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

Confine—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.

Pull the pin
Aim nozzle at
base of fire

Squeeze
grips

Sweep
nozzle side
to side

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?

Occupancy Manual • Safety and Security | 27

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

Safety and Security
Security Awareness
Security Station
Door Alarms and
Stairwell Access
Emergency
Department Team
Crash Carts
Automated External
Defibrillator (AED)
Emergency
Management
Communications in a
Disaster
Hospital Command
Center
Standardized
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Reporting an Injury
Workplace Violence
Reporting
Hand Hygeine
ADA Information
Service Dogs

Workplace Violence Reporting
Effective April 1, 2017, employees working in inpatient
and outpatient 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 20, 2016, were required to maintain
a log of all incidents of workplace violence by April 1,
2017.

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 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.

The MRI suite has a special designated EVS closet
with non-metallic supplies and equipment. Regardless,
EVS staff should never enter the MRI suite without
supervision from an MRI technologist.

In addition, if an employee is injured in a workplace
violence incident, they must complete an Electronic
Report of Injury (eROI) Form AND a Workplace
Violence Incident Report.

Finally, to ensure all zone protocol is followed, always
check with an MRI tech before entering the suite.

If a patient is injured, the employee must go to the
Hospital Midas Tools Page and complete a patient
injury form.

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.

Safety, Security, Human Resources, Risk Management,
and Operations Management will coordinate a postincident investigation.

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.
Occupancy Manual • Safety and Security | 28

Hand Hygiene

ADA Information

Service Dogs

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:

Assistance for the hearing, listening, visually and
speech impaired is available, and contact information
can be found below:

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:

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.

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 1-800-975-8150
For Assistive Listening Systems (Pocket Talkers), call
campus security at 415-600-0837.
For an Amplified Telephone Handset,
call 888-888-6044.

Safety and Security
Security Awareness
Security Station
Door Alarms and
Stairwell Access
Emergency
Department Team
Crash Carts
Automated External
Defibrillator (AED)
Emergency
Management
Communications in a
Disaster
Hospital Command
Center
Standardized
Emergency Codes
Medical Alerts
Fire Safety
MRI Suite Safety
Reporting an Injury
Workplace Violence
Reporting
Hand Hygeine
ADA Information
Service Dogs

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.

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 appointment 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 415-600-4620 with any questions or concerns.
Occupancy Manual • Safety and Security | 29

BUILDING
AMENITIES

Information Desks

Bicycle Storage

The Mission Bernal Campus Information Desks are
located on the first and second floors off the Plaza
Entrance. The Information Desk staff provides the
following services:

Bicycle parking is available on a first come, first served
basis. The bicycle storage is located on the 1st Floor
in Room 1388, accessible via 1st Floor 27th Street or
Cesar Chavez front entrance (through the conference
center corridor).

General information
Directions and wayfinding
Shuttle schedule information
Taxi and transportation services information

Waiting Areas
Waiting areas and lobbies are available throughout the
hospital. See General Building Information, page 7.
For safety reasons and to prevent accidental blocking
of the retractable fire doors, do not rearrange furniture
in the waiting areas.

Badge access is required.
Reserved bicycle space may be available. Contact the
Parking Office, 415-600-1986 to register to use this
facility and to program your badge for access.
First floor lockers are available—however only while
utilizing the shower facilities. Day use lockers are
available on department floors.
Additional bicycle racks are available at the 27th
Street and Cesar Chavez entrances.

Building Amenities
Information Desks
Waiting Areas
Restroom Locations
Lactation Lounge
Room Reservations
Bicycle Storage
Bottle Fill Stations
Dining Services
Catering Services
Patient Education
Ambassador
Services Suite
Guest Wi-Fi

Public
Lobby

To reserve a room, complete the Online
Conference Room Request form,
http://dcpwdbs405/virtualems/

Ice makers are available in patient nourishment rooms
(not in staff lounges).

Dining Services

Catering Services
All catering requests must be submitted to the Food
and Nutrition Services Department three days in
advance of the meeting or event.

Public Elevators

Use Catertrax, the ordering platform to order food for
meetings. Place catering orders at:
www.cpmc-stlukes.catertrax.com

Cafeteria

Food &
Nutrition
Services

Room Reservations

Plumbed coffee makers with hot water dispensers are
available on certain floors.

Snack and beverage vending machines are located on
the 2nd Floor near the public elevators.

Security
Volunteer

Lactation Lounge
A dedicated lactation lounge for staff and
physicians only is located on the Fifth Floor,
Room 5357 (page 11). Badge access is
required.

The Mission Bernal Campus is a sustainable and LEED
certified building. To reduce the use of disposable
bottles, water fountains are available on each floor
near the elevators. Bottle filling locations are in the
Emergency Department, Cafeteria, and Surgical
Waiting Room.

Several choices for food and beverages are available
during regular business hours. The Cafeteria and Grab
and Go are on the 1st Floor, to the left of the elevators
and are open Monday–Friday, from 6:30am–6:30pm.
They are closed after hours and on weekends.

Cesar
Chavez
Entrance

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.

Water Cooler/
Bottle Filling Stations

Lockers &
Showers

MD
Dining
Lounge

27th St
1st Floor

For training on Catertrax, go to:
https://catertrax-1.wistia.com/medias/ojoa2vlyhm#

Bike Storage
Occupancy Manual • Building Amenities | 31

Patient Entertainment/Education
(Powered by Sonifi)
Rooms are equipped with a multi-purpose media
system capable of providing patient education,
communication and entertainment features:

HOW TO USE

Pillow Speaker

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

Ambassador Services Suite
The Ambassador Services Suite is a hospitality space
located on the 3rd Floor near Nursing Administration.
It is our way of saying “thank you” to our most
generous philanthropic donors, as well as volunteers
with 500 or more hours of service per year to CPMC.

Building Amenities
Information Desks
Waiting Areas
Restroom Locations
Lactation Lounge
Room Reservations
Bicycle Storage
Bottle Fill Stations
Dining Services
Catering Services
Patient Education
Ambassador
Services Suite
Guest Wi-Fi

Guest Internet Access
(Wi-Fi)
The Mission Bernal 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.”

Occupancy Manual • Building Amenities | 32

EQUIPMENT AND
FURNISHINGS

Ergonomics

Kronos Time Clocks

Telephone System

Ergonomic chairs and keyboard trays are fully
adjustable. For assistance on proper chair and
keyboard adjustment, please contact the Safety
Department at 415-600-4620 or email sforzok@
sutterhealth.org. They will send materials regarding
self-assessments and if needed will direct you to
complete the online ergonomic assessment.

New InTouch wall clocks are located throughout the
campus, conveniently positioned near:

Cisco Voice over IP (VoIP) phones are used at the
Mission Bernal 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:

Equipment
Ergonomics
Office Spaces
Kronos Time Clocks
Multi-function
Printers
VOIP Telephones
Fax Machines
Phone Operators
Vocera
Nurse Call System
HIPAA Containers
Sustainable Waste
Temperature Monitor
Pneumatic Tube
Patient Lift

Office 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

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 7) 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).

Cisco Unity voicemail
Connection to the Vocera badge application,
allowing calls to be made between telephones and
Vocera badges.
Informacast for paging and broadcast messaging
Emergency red phones will be installed in key
locations.

For copier and printer support, call Sutter Health
Information Services at 888-888-6044 or go to:
is.sutterhealth.org

Occupancy Manual • Equipment and Furnishings | 34

Fax Machines
Most faxing will be done using RightFax. There will be
a limited number of traditional 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.

PBX/Phone Operating System
Hospital operators will be located at both the Van Ness
and Mission Bernal Campuses. Hospital operators will
have Nurse Call and other alarm panels to assist in
routing alerts.

Vocera

The Vocera badge delivers hands-free, real-time voice
communication between the wearer and other staff
Vista Point Enterprise Operator Services System
members. This communication system weighs less
(phone console) will support the hospital operator
than two ounces, allowing users to keep their hands
workflows and assist in the management of call queues,
free without the burden of carrying a smartphone.
routing and call handling statistics.

Nurse Call System
Equipment
Ergonomics
Office Spaces
Kronos Time Clocks
Multi-function
Printers
VOIP Telephones
Fax Machines
Phone Operators
Vocera
Nurse Call System
HIPAA Containers
Sustainable Waste
Temperature Monitor
Pneumatic Tube
Patient Lift

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:

HIPAA—Confidential 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
415-600-7900 to arrange for EVS assistance.
Mission Bernal is dedicated to being a green facility, so
please remember to “think before you ink.”

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 entertainment and education.
Occupancy Manual • Equipment and Furnishings | 35

Sustainable Waste Removal

Temperature Monitoring

Pneumatic Tube System

Mission Bernal is designed to be a green hospital. This
includes recycling, composting, red-bag (biohazard),
pharmaceutical and toxic waste management and
medical equipment reuse.

The Mission Bernal 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.

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”
functionality, which will only allow appropriately
licensed staff to send and receive medication and blood
products.

In office spaces and public areas, receptacles are
provided for co-mingled recycling (blue) and regular
trash (black). In the staff lounges and
Equipment
conference rooms there are receptacles for
Ergonomics
co-mingled recycling (blue), regular trash
Office Spaces
(black), and composting (green).
Kronos Time Clocks
Multi-function
Printers
VOIP Telephones
Fax Machines
Phone Operators
Vocera
Nurse Call System
HIPAA Containers
Sustainable Waste
Temperature Monitor
Pneumatic Tube
Patient Lift

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.

Patient Lift System and
Mobile Lifts

When a device’s temperature goes out of range when
the department is closed, primary and secondary alerts Patient lift systems are available in med/surg and ICU
patient rooms. Patient lifts are a safety feature to assist
are sent to Plant Operations.
in patient mobility and reduce the risk of associated
employee injuries.
Where ceiling lifts are not available, mobile lifts can
assist with patient mobility.

Occupancy Manual • Equipment and Furnishings | 36

SUPPLIES AND
RESTOCKING

Loading Dock
The Mission Bernal Campus loading dock is located
off Cesar Chavez Street on Level 1. Interior access is
adjacent to the service elevator.

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.
Restocking Supplies
Loading Dock
Supply Chain
Overview
Supply Chain &
Medical Gas Area
Supply Chain Stat
Requests
Pharmacy
Asset Management
Equipment Cleaning
Staff Duress
DME
Linen
How to Order
Stationery, Forms &
Brochures

Supply Chain and
Medical Gas Area
The Supply Chain area is located on the 1st Floor,
Room 1522, adjacent to the loading dock. Staff,
supplies and receiving will be staged here to support
a Low Unit of Measure (LUM) Just in Time (JIT)
distribution model.

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.

The Supply Chain Team is responsible for the
replenishment of medical gases, housed in the Medical
Gas storage room on Level 1, accessed directly off the
loading dock in Room 1518.

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.

The Code Blue Cart quick reference guide can be
found here: tinyurl.com/CPMC-CrashCart

Asset Management

A Broselow quick reference guide can be found here:
tinyurl.com/GuideCrashCart

Supply Chain Stat Requests
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 staff will be on-site between the hours
of 7am and 4:30pm, Monday–Friday. For supply needs
during evening and weekends, follow current process
and contact the Nursing Supervisor who has access to
the distribution storage area.
Central Distribution, normal business hours:
415-641-6626
Receiving, normal business hours:
415-641-6901
Supply Chain Intranet requests: http://
apps.insidecpmc.org/CPMC_SRQ/servlet/
LoginServlet?cpmc_role_id=180

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 children (HUGS System)
PCA pumps
Portable imaging machines
SCD
Vital sign monitors
Wheelchairs

Occupancy Manual • Supplies and Restocking | 38

Equipment Cleaning

Staff Duress

There is a central medical equipment cleaning process
for the following types of equipment

Staff will be able to silently notify Security for
assistance. Security will be able to locate the staff in
need, via the RFID tag.

PCA pumps
Feeding pumps
Sequential compression devices
Infusion pump modules
Infusion pump control units
Seizure pads

AeroScout Tag and Who
Wears It?
The categories of caregivers who
wear the tag will be identified by
the Operations Group.

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
Restocking Supplies
Loading Dock
Supply Chain
Overview
Supply Chain &
Medical Gas Area
Supply Chain Stat
Requests
Pharmacy
Asset Management
Equipment Cleaning
Staff Duress
DME
Linen
How to Order
Stationery, Forms &
Brochures

If a department was responsible for completing their
own equipment cleaning, that work will remain within
the department; however, the department must follow
the new cleaning standards that are compliant with
regulatory standards.
“Clean Sticker”
Clean equipment is to be tagged
and identified with a “Clean” sticker.

The badge is used for Staff
Duress, and it works in
conjunction with Vocera.

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 2334), OR/PACU (Room 3201) and Inpatient
Units (Rooms 4334, 5334 and 6334). DMEs will be
replenished by our DME partner Pacific Medical.

N

CLEA

Occupancy Manual • Supplies and Restocking | 39

Linen
Linen will be managed and delivered by EVS at the
Mission Bernal Campus just as it has been managed
at St. Luke’s. Clean linen will be stored in Room 1404,
next to the Materials Management area adjacent to the
loading dock.
Soiled linen will be stored in Room 1308 and will
exit the building through the designated “Soiled” exit
pathway as shown in the diagram below.
Clean linen will enter through the “Clean” entrance as
shown below.
Cesar Chavez
Entrance

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).

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.

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.

Clean
Dock

Specify your quantity and complete your order for
approval.
Soiled
Dock
Central
Distribution

Clean
Linen
Rm 1404

Soiled
Linen
Rm 1308

Occupancy Manual • Supplies and Restocking | 40

Index
27th St. Plaza Entrance, 3
Alerts, Medical 26
Ambassador Services Suite, 32
Asset Management, 38
Automated External Defibrillator (AED), 22
Bicycle Storage, 31
Building Amenities, 31
Building Reminders, 14
Cafeteria, 3
Catering Services, 31
Cesar Chavez Entrance, 3
Code Team, 24
Codes, 24
Code Blue, 24
Code Gray, 25
Code Pink, 25
Code Purple, 25
Conference Room, 6
Reservations, 6
Crash Carts, 22
Departments and Divisions
by Floor, 6
Lockers, 5
Telephone Directory, 19
Dining Services, 31
Door Alarms and Stairwell Access, 22
Durable Medical Equipment (DME), 39
Elevators, 5
Emergency Code Definition and Announcement, 24
Emergency Department Team, 22
Emergency Entrance, 3
Emergency Management / Emergency
Operations Plan, 23
Equipment and Furnishings, 33
Equipment Cleaning, 39
Ergonomics, 34

General Building Information, 1
Guest Internet Access (Wi-Fi), 32
HIPAA—Confidential Document Containers, 35
Hospital Command Center, 23
Hours of Operation, 3
How to Order Stationery, 40
How to Use Pillow Speaker, 32
Infant/Child Security, 25
Information Desks, 31
Interpreter Services, 20
Kronos Time Clocks, 34
Lactation Lounge, 32
Linen, 40
Loading Dock, 3, 38
Loading Dock / Delivery Hours, 3
Lost and Found, 20
Mail Room, 3
Medical Alerts, Definition and Telephone Operator
Announcements, 26
Medical Gas Area, 38
Multi-function Printers (Scan, Print, Copy), 34
Newborn Connections, 3, 20
Nurse Call System, 35
Office Spaces, 34
Parking, 17
Patient Entertainment/Education (Powered by Sonifi), 32
Patient Lift System and Mobile Lifts, 36
Patient Relations, 19
PBX/Phone Operating System, 35
Peet’s Coffee Cart, 3
Personnel Identification Badges, 4
Pharmacy, 38
Pneumatic Tube System, 36
Public Transportation and CPMC Shuttles, 16

Respiratory Etiquette Stations, 20
Restocking, 37
Restricted Area Examples, 4
Restroom Locations, 31
Room Reservations, 31
Safety and Security, 21
Second Floor Main Areas, 8
Security Awareness, 22
Security Station, 22
Seventh Floor Main Areas, 13
Shared Spaces, 5
Shuttle Routes, 16
Sixth Floor Main Areas, 12
Sonifi, 32
Spiritual Care and Chaplaincy Services, 19
Staff Duress, 39
Staff Lockers, 5
Standardized Emergency Codes, 24
Stairwell Access, 22
Supplies and Restocking, 37
Supply Chain and Medical Gas Area, 38
Supply Chain Overview, 38
Supply Chain Stat Requests, 38
Support Services, 18
Sustainability, 14
Sustainable Waste Removal, 36
Telephone Numbers, 2
Telephone System, 34
Temperature Monitoring, 36
Third Floor Main Areas, 9
Transportation and Parking, 15
Visitor Badges, 4
Vocera, 35
Volunteers, 19
Waiting Areas, 31
Walgreens Pharmacy, 3
Water Cooler/Bottle Filling Stations, 31
Wheelchairs and Gurneys, 20

Fax Machines, 35
Fifth Floor Main Areas, 11
First Floor Main Areas, 7
Floor Maps, 6
Fourth Floor Main Areas, 10
Occupancy Manual • Supplies and Restocking | 41

18-CPMC-Occupancy Manual 06/07/18 © Sutter Health 2018
revise content: eric@ericgrossdesign.com



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