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Occupancy Manual | i
Occupancy Manual
YOUR GUIDE TO THE NEW MISSION BERNAL CAMPUS
i | Occupancy Manual
Information deemed reliable thru March 2019
© Sutter Health June 2018
Occupancy Manual | ii
We hope you are as excited as we are to begin work at Mission Bernal campus! is 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
e 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, sta, physicians and volunteers alike.
Balancing safety, comfort and sustainability
e new building balances the safety and technical needs of sta, physicians, and volunteers with the comfort
and safety of our patients. e modernized campus is seismically safe and certied as Leadership in Energy and
Environmental Design (LEED), a globally-recognized symbol of sustainability.
e layout of the building is built with a front of house (on stage) and back of the house (o stage) concept.
Front of the house refers to all areas that patients and visitors will see, and where we are “on stage” and help
create a positive environment for our patients and visitors. Back of house includes sta only hallways and
elevators. is 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 healthcare services for San Francisco.
-Your CPMC Leadership and New Hospital Transition Team
Welcome to the
New Mission Bernal Campus
iii | Occupancy Manual
General
Important Contacts ........................X
Building Hours and Entrances ...............X
Badges .................................X
Elevator Usage ...........................X
Staff Lockers .............................X
Shared Spaces ...........................X
Conference Room Reservations ..............X
Conference Rooms ........................X
Department and Divisions by Floor ...........X
LEED ...................................X
Building Reminders ........................X
Parking & Transportation
Public Transportation ......................X
CPMC Shuttle Schedule and Routes ..........X
Parking .................................X
• Staff Parking ...........................X
• Visitor Parking ..........................X
Services
Support Services .........................X
Department Phone Directory ................X
Volunteers ...............................X
Spiritual Care and Chaplaincy Services ........X
Interpreters ..............................X
Respiratory Etiquette ......................X
Wheelchairs and Gurneys ...................X
Lost and Found ...........................X
Patient Relations ..........................X
Newborn Connections .....................x
Safety and Security
Security .................................X
Emergency Department ....................X
Door Alarms & Stairwell Access .............X
Crash Carts .............................X
Automated External Defibrillator (AED) .........X
Crisis Management .......................X
Emergency Operations Plan (EOP) ...........X
Hospital Command Center ..................X
Communications in Disaster .................X
Fire Safety ...............................X
Emergency Codes .........................X
Injuries ..................................X
Workplace Violence .......................X
MRI Safety ...............................X
ADA Information ..........................X
Hand Hygiene ............................X
Service Dogs .............................X
Amenities
Information Desks .........................X
Waiting Areas ............................X
Restrooms ...............................X
Bicycle Locker & Showers ..................X
Water Bottle Refilling Stations ...............X
Dining Services ...........................X
Catering Services .........................X
Room Reservation. . . . . . . . . . . . . . . . . . . . . . . . .X
Patient Entertainment ......................X
Lactation Lounges ........................X
Ambassador Services Suite .................X
Guest Internet Access ......................X
Equipment and Furnishing
Ergonomics ..............................X
Office Space & Furniture ....................X
Kronos ..................................X
Telephone ...............................X
Multi-Function Printers .....................X
Fax .....................................X
PBX and Telephone Operating System .........X
HIPAA – Confidential Document Containers ....X
Sustainable Waste Removal ................X
Wayfinding ...............................X
Vocera ..................................X
Nurse Call System .........................X
Temperature Monitoring ....................X
Patient Lift System and Mobile Lifts ...........X
Pneumatic Tube System ....................X
Supplies and Restocking
Loading Dock / Deliveries ...................x
Supply Chain .............................x
Supply Chain and Medical Gas Area ..........x
Supply Chain Stat Request ..................x
Pharmacy ...............................x
Equipment Cleaning .......................x
Aeroscout Asset Management ...............x
Staff Duress .............................x
Durable Medical Equipment (DME) ............x
Linen Services ............................x
How to Order Forms and Brochures ...........x
Table of Contents
Occupancy Manual • General Building Information | 1
GENERAL BUILDING
INFORMATION
2 | Occupancy Manual • General Building Information
General Information
Telephone Numbers
Hours and Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Department Divisions
LEED
Reminders
Telephone Numbers
Emergency ....................415-641-6625
Main Hospital ..................415-600-6000
Security ......................415-600-0837
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 Cath 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 & 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
Patient Relations ................415-600-6634
Pharmacy .....................415-641-6505
PT/OT/ST ......................415-641-6560
Respiratory Therapy .............415-641-6565
Security .......................415-600-0837
Support Services ................415-600-7900
Volunteer Services ...............415-641-6490
Nursing Stations
3rd Floor ACU ..................415-641-6889
3rd Floor OR ...................415-641-6635
3rd Floor PACU .................415-641-6638
4th Floor ICU ...................415-641-6612
4th Floor PCU ..................415-641-6610
5th Floor Med Surg ..............415-641-6690
6th Floor Med Surg ..............415-641-6710
7th Floor L&D ..................415-641-6630
7th Floor Nursery ................415-641-6655
7th Floor Postpartum ............415-641-6650
Occupancy Manual • General Building Information | 3
Hours of Operation
Cesar Chavez Entrance 7am–7pm Everyday Badge after hours
27th St. Plaza Entrance 24 hours a day Open Everyday
Emergency Entrance 24 hours a day Open Everyday
Cafeteria
1st Floor
6:30am–6:30pm Monday–Friday Closed on weekends
Closed after hours
Mail Room
1912 Building
24 hours a day Open Everyday
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
ENTRANCE
ADA ENTRANCE
PUBLIC TRANSIT
EMERGENCY
Cesar Chavez Blvd
27th St
Plaza
Main Hospital
1970 Building
1957 Building
1580 Valencia St
1912 Building
Monteagle Building
Hartzell Building
Parking Garage
ADA Entrance
Entrance
ER Entrance
Public Transit
Guerrero St
Valencia St
4 | Occupancy Manual • General Building Information
General Information
Telephone Numbers
Hours and Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Department Divisions
LEED
Reminders
Visitor Badges
Visitors and vendors who are coming to the hospital
will be required to wear Visitor Badges between 8 pm
and 7 am. ey may sign-in and receive badges at the
Security Desk on Floor 2
Photo identication 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.
Patients/visitors going to appointments in the Medical
Oce Building will not require a badge.
If someone needs assistance to enter
the building
Should an individual arrive aer hours at the Cesar
Chavez St. entrance and need assistance (ADA
accommodation), he/she should use the phone at the
entrance to contact Security. A security ocer will
then assist the individual into the building.
Personnel Identification Badges
Providers, sta and volunteers must wear their hospital
identication badges while on campus. Badges are
required for identication and to gain access to non-
public areas and devices.
Sta must tap their badge to the respective device, to
activate the corresponding system.
Registry sta 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 shi.
Internal stairwells may be used for exiting the
building; however badge access is required on the
ground oor for re-entry.
You will need your badge if you are moving from
one oor 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.)
Multidisciplinary / Conference Rooms
Consult Rooms
Bicycle Storage
Locker Rooms
Emergency Department
Imaging Entrance
Patient Floors
(unless otherwise specied)
Service elevators
Restricted Area Examples:
Badge Clearance Required
Administrative Suite
Admitting
Biomedical Engineering
Clean/Soil Utility Room
Clinical Lab
Food & 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 | 5
Elevators
ere are two sets of elevators on the campus. Please
yield to patients being transported.
Four public (green) elevators are available for patients
and visitors. Badge access is not required.
ree transport/service (orange) elevators are for
sta, volunteers and patient transport. Badge access is
required to activate elevator.
Staff Lockers
Lockers are available for sta use in department areas
(see table below).
All lockers will be day use only, unless otherwise
designated by management.
Lockers accept padlocks and are two or three high.
Department managers are responsible for handling
locker buddy assignments and distribution.
Department Lockers Location
Pharmacy Floor 1
Kitchen Floor 1
Materials Mgmt, 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 erapy Floor 4
LDR Floor 7
Shared Spaces
Mission Bernal is designed as a shared work space.
Multi-disciplinary workrooms are conference-
style type rooms on patient care oors. ese rooms
accommodate ten people sitting around a rectangular
conference table and may be used for small group
meetings, education sessions, and so forth. e
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 specic individual use. Practice shared workspace
etiquette; keep the volume down, no eating and clean
up aer yourself.
Consult rooms are designed for providers to have
private conversations with patient family member(s)
and signicant others. Rooms may be locked; request
keys from the charge nurse. Please clean the room aer
every use.
Family rooms are public areas for family members to
sit and gather, outside the patient room.
ere are two On-Call rooms, 5361 or 5359, available
for scheduling. Contact Support Services at 415-600-
7900 or use the Online Room Scheduling Portal at
http://dcpwdbs405/virtualems/ to reserve a room up
to a week in advance. Same day or aer-hours requests
can be directed to the hospital Operator or the Nursing
Supervisor.
Sta Lounges are for non-physician sta. Nursing sta
is responsible for cleaning the coee maker.
Public Elevators
Service
Elevators
Cesar Chavez
Entrance
Public
Lobby
6 | Occupancy Manual • General Building Information
General Information
Telephone Numbers
Hours and Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Department Divisions
LEED
Reminders
Department and Divisions by Floor
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. e building is thoughtfully designed to enhance patient comfort, be environmentally
conscience, seismically safe, and support current and future technologies.
A department phone directory is on page 2.
Floor 7 Post Partum (14) Antepartum (2) 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 ICU (10) Med-Surg (20)
Floor 3 Surgery (5) PACU(8) ACU (12) Clinical Lab Nursing Admin Ambassador Suite
Floor 2 ED (16) Patient
Access Meditation Area Imaging [CT (1), MRI (1), U/S (2),
Xray (1)/Fluoro (1), Dexa (1)]
Floor 1 Loading Dock / Mat
Mngt
EVS, Plant Ops,
Biomed Pharmacy Conference
(24/24, seated) Physician Dining Kitchen / Cafeteria
Conference Room Reservations
ere are conference rooms on the 1st and 2nd oors, available for
hospital and public use. Conference Rooms A & B (1st oor) and
Room 2910 (2nd oor).To reserve a conference room, go to the
online room scheduling portal at http://dcpwdbs405/virtualems/.
Each room is equipped with large monitors and teleconferencing.
Rooms will be locked aer hours, by Security, and re-opened by
Security. ere will be video displays outside of these rooms that will
provide meeting schedules.
Conference Rooms
Conference rooms are available on the patient care oors for patient
care team use.
Floor conference rooms are dedicated to the oor. Oversight and
scheduling of these rooms lie with the Nurse Manager. In general,
these can be used for small classes, inservices, and department
meetings.
Occupancy Manual • General Building Information | 7
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
Public
Limited
Guest Restroom
Staff Restroom
Water Fountain
KRONOS
Service Elevators
Public Elevators
Food & Nutrition
Services
Lockers &
Showers
Bike
Pharmacy
Morgue
EVS
Engineering Biomedical
Engineering
Central
Distribution
Loading Dock
Conference
Room A
Cafeteria
MD
Dining
Lounge
Conference
Room B
Cesar Chavez
Entrance
Public Elevators
PBX
Public
Lobby
Security
Volunteer
8 | Occupancy Manual • General Building Information
Public
Limited
Guest Restroom
Staff Restroom
Water Fountain
KRONOS
Service Elevators
Public Elevators
Second Floor Main Areas
Admitting/Cashier/Request of Information
27th Entrance
ER Entrance
Ambulance Entrance
Imaging
Information Desk
Meditation Room
Vending Machines
Public Elevators
Ambulance
Entrance
Waiting
Area
Waiting
Area
Info
Desk
Vending
Admitting/
Cashier/ROI
Meditation
Room
Equip
Storage
Reception
Staff
Lounge
CT Scan
Equip
Nurse
Station
2B
Nourish
Soiled
Wk Rm
Clean
Storage
Med
Prep
Physician
Charting
Nurse
Station
2A
Office
Nurse Work
Area
2C Patient
Holding MRI
Conference
Room
Rad/Fluoro
Gown Wait
Rad
Radiology
Ultra
Sound
Emergency
Water
Treatment
Treatment
Treatment
Triage
Trauma
Cardiac
Infection
Isolation
Peds
Treatmnt
Decon
Shower
Emergency ER
Entrance
Security
Desk
27th St Plaza
Entrance
Equip
Storage
Physcn
Wr Rm
General Information
Telephone Numbers
Hours and Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Department Divisions
LEED
Reminders
Occupancy Manual • General Building Information | 9
Public
Limited
Guest Restroom
Staff Restroom
Water Fountain
KRONOS
Service Elevators
Public Elevators
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
Staff Lounge
Cart Staging
Prep/Pack
Decontamination
Clinical Lab /
Blood Bank
Ambassador
Services Suite
Offices
Nursing
Admin
Staff Lockers
Staff Lockers
Equip
Room
Equip
Room
Nurse
Station 3B
Nurse
Control
Soiled
Work Room
Clean
Storage
Med
Prep
Nurse
Station 3A
Minor
Procedure
ACU
Waiting Area
Check-in
Anesthesia
Equip
Room
Nurse
Station
3C
Staff
Lounge
PACU ACU
ACU
ACU
Operating
Room 1
Operating
Room 2
Operating
Room 3
Operating
Room 4
Operating
Room 5
Pathology
Freezer
Section
10 | Occupancy Manual • General Building Information
Public
Limited
Guest Restroom
Staff Restroom
Water Fountain
KRONOS
Service Elevators
Public Elevators
Fourth Floor Main Areas
Intensive Care Unit (ICU) - 10 Beds
Progressive Care Unit (PCU) - 20 Beds
Respiratory Care
General Information
Telephone Numbers
Hours and Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Department Divisions
LEED
Reminders
Nurse
Station
4A
Equip
Storage
Consult
Nurse
Station 4B
Nurse Station
4E
Nurse
Station
4C
Nurse
Station
4D
Work
Room
Work
Room
Nourish
Nourish
Clean
Storage
Soiled
Med
Prep
Respiratory
Care
Call
Room
Staff
Lounge
Patient Rm
PCU
PCU Wait
Room
Patient Rm
PCU
Patient Rm
PCU
Patient Rm
PCU
Clean
Storage
ICU Wait
Room
Conf.
Room
Staff
Lounge
Technology
Room
Patient Rm
ICU
Patient Rm
ICU,
Airborne
Patient Rm
ICU
Conf.
Room
Soiled
Work Rm
DME
Occupancy Manual • General Building Information | 11
Public
Limited
Guest Restroom
Staff Restroom
Water Fountain
KRONOS
Service Elevators
Public Elevators
Fifth Floor Main Areas
Med/Surg - 34 Beds
PT/OT Exercise Room
Dialysis Workroom
Offices
Lockers
Nourish
Med
Prep
PT/OT
Exercise Room
Dialysis
Work
Room
On Call
Rooms
Nurse
Station
5A
Lactation
Lounge
Nourishment
Equip
Room
Soiled
Workroom
Physician
Workroom
Clean
Storage
Nurse
Station
5B
Work
Room
Staff
Lounge
Conf.
Room
Activity
Room
Wait Room
Equip
Room
Equip
Storage
Gurney
Shower
Patient Rm
M/S
Patient Rm
M/S
Patient Rm
M/S
Patient Rm
M/S Airborne
Patient Rm
M/S
Patient Rm
M/S
Patient Rm
M/S
DME
12 | Occupancy Manual • General Building Information
Sixth Floor Main Areas
Med/Surg - 34 Beds
Non-Invasive Cardiology (Inpatient)
General Information
Telephone Numbers
Hours and Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Department Divisions
LEED
Reminders
Equip
Storage
Non-Invasive
Cardiology
Lockers
Nourish
Med
Prep
Tech
WkRm
Stress
Test
Bed
Storage
Office
Dietitian
Nurse
Station 6A
Work
Room
Nourish
Equip
Room
Soiled
Workroom
Physician
Workroom
Clean
Storage
Med
Prep
Nurse
Station
6B
Work
Room
Soiled
Work
Room
Staff
Lounge
Conf.
Room
Conf.
Room
Wait
Room
Equip
Room
Equip
Storage
DME
Patient Rm
M/S
Patient Rm
M/S
Patient Rm
M/S
Airborne
Infection
Patient Rm
M/S
Patient Rm
M/S
Patient Rm
M/S
Ante
Room
Ante
Room
Public
Limited
Guest Restroom
Staff Restroom
Water Fountain
KRONOS
Service Elevators
Public Elevators
Occupancy Manual • General Building Information | 13
Public
Limited
Guest Restroom
Staff Restroom
Water Fountain
KRONOS
Service Elevators
Public Elevators
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
Post Partum
Patient
Rooms
Post
Partum
Patient
Rooms
Post
Partum
Patient
Rooms
LDRP
Staff
Lounge
Call
Rooms
Call
Rooms
C-Section
Room
C-Section
Room
C-Section
Recovery
Staff
Locker
Rooms
Antepartum
Testing
OB Triage
Nurse
Station 7A
Nursery
& Special Care
Lactation
Consulting
Nurse
Station
7C
Nurse
Station
7B
Anes.
Work
Room
Equip
Storage
Med
Prep
Nourish
Nurse
Station
7D
Soiled
Workroom
Equip
Storage
14 | Occupancy Manual • General Building Information
Sustainability
e campus is Leadership in Energy and Environmental
Design (LEED) certied, a globally recognized symbol
of sustainability. e building is constructed to lower
greenhouse gas emissions by reducing the use of
energy and water.
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 rooop cooling towers.
Bottle water relling stations (pg. X) and the
sustainable waste removal program (pg. X) are other
examples of ongoing sustainable 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 “on stage” 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 of any kind will be permitted,
with the exception of service animals (pg. xxx)
Personal packages will no longer be accepted at
the campus. Materials Management will not sign
for it.
Ordering food for delivery—Staff are responsible
to come down to the second floor Security
Desk to pick up food. Food delivery will not be
allowed to come to the care department.
General Information
Telephone Numbers
Hours and Entrances
Badges
Elevators
Lockers
Shared Spaces
Conference Rooms
Department Divisions
LEED
Reminders
Occupancy Manual • Transportation and parking | 15
TRANSPORTATION
AND PARKING
16 | Occupancy Manual • Transportation and parking
Public Transportation
and CPMC Shuttles
CPMC encourages visitors and sta to follow San
Francisco’s Transit First policy and use alternative
modes of transportation whenever possible. e
Mission Bernal Campus is easily accessible by a combi-
nation 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 families.
Complimentary shuttle services to and from Mission
Bernal Campus to 24th St. Mission BART station is
available for sta, 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, 6:00 a.m. to 6:00 p.m. For more specic times,
and pick-up information go to:
cpmc.org/visiting/shuttle.html.
Patients and visitors may also obtain additional infor-
mation on public transportation and shuttle timetables
at the Information Desks. Sta and providers may visit
our Intranet for additional public transportation and
shuttle service information.
Ask your shuttle driver regarding courtesy stops.
Shuttle Routes
BCivic Center BART station to Pacific
Campus
CCalifornia Campus to Pacific Campus
DDavies Campus to Pacific Campus
KKabuki Hotel to Pacific Campus
MBC Mission Bernal Campus to Davies
Campus
JG Japantown Garage to Pacific Campus
SAC 1825 Sacramento to Civic Center
BART station
MBC24 Mission Bernal Campus to 24th St.
Mission BART Station
Transportation
Public Transit
CPMC Shuttes
Parking
Occupancy Manual • Transportation and parking | 17
Parking
Parking is limited, so please take public transportation
whenever possible. Level 1 has van accessible spaces
and spaces for oversized vehicles. Vehicle charging
stations are located in the garage on Level 1.
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.
Staff Parking
In addition to the Cesar Chavez Street Garage, two
other osite parking lots have been made available to
provide more parking spaces during business hours.
ese parking lots are within ve minutes walking
distance to the hospital. However they are only avail-
able to sta who currently hold monthly permits.
Security escorts are available if needed. e Cesar
Chavez Street Garage is available to sta aer hours
and on weekends.
Visitor Parking
Visitor parking is available for patients and their
families. e entrance to the parking structure is on
San Jose Ave.
MAPS Staff Parking
18 | Occupancy Manual • Support Services
SUPPORT SERVICES
Occupancy Manual • Support Services | 19
Support Services
Support Services are comprised of CPMC depart-
ments 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
page 6.
Department Telephone Directory
e Microso Outlook Address Book is an application
to access the Employee Department Phone Direc-
tory for all CPMC and Sutter Health campuses. e
standard process for adding / changing sta locations
will synchronize with the address book to keep the
directory accurate without additional administrative
work. 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
Mission Bernal Campus can be found on page 2.
Volunteers
At the Mission Bernal Campus, volunteers help at the
Information Desk, provide hospitality, escort patients,
and help with selected non-clinical patient care activi-
ties. CPMC oers volunteer opportunities to students
and adults.
e Mission Bernal Volunteer Oce is located in the
1912 Bldg. See page 3. e telephone number is
415-641-6490.
Spiritual Care and
Chaplaincy Services
e CPMC Spiritual Care Team provides spiritual care
to patients, families and sta inclusive of all religious
traditions, cultural backgrounds and spiritual expres-
sion. e Spiritual Care Team oers or arranges for
the practice or experience of religious sacraments and
rituals such as baptism, blessings, communion, sacra-
ment of sick, confessions, chanting..
In addition, the team is available to support’ families
and loved ones. e Spiritual Care Team is available to
visit patients 24/7 on all four campuses.
Call 415-641-6527 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. ey may also contact Patient
Relations at 415-600-6634 or ask a nursing supervisor.
e Patient Relations team can address:
Lost patient items (coordinate an investigation,
conduct a follow-up, facilitate reimbursement)
Assist with dicult 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)
Patient experience (facilitate trainings and
in-services to help sta improve the experience)
Support Services
Telephone Directory
Volunteers
Spiritual Care
Patient Relations
Interpreter Services
Respiratory
Etiquette Stations
Wheelchairs and
Gurneys
Lost and Fount
Newborn
Connections
20 | Occupancy Manual • Support Services
Support Services
Telephone Directory
Volunteers
Spiritual Care
Patient Relations
Interpreter Services
Newborn
Connections
Respiratory
Etiquette Stations
Wheelchairs and
Gurneys
Lost and Fount
Interpreter Services
Our Interpreter Services Program oers 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
ese services are available to all departments at no
cost. Please access Interpreter Services by calling
x61077 or 415.600-1077.
Newborn Connections
Newborn Connections is a community resource new
to Mission Bernal campus that oers support and
education from pregnancy through early parenting.
Located in the Monteagle Building, the program
includes prenatal classes, massage services, breast-
feeding support, and support groups, as well as breast-
feeding, baby, and lactation supplies.
Hours are Monday – ursday, 9 a.m. to 6 p.m., Friday,
9 a.m. – 4 p.m. Closed Saturday and Sunday. e
telephone number is 415.600-2229.
Respiratory
Etiquette
Stations
To prevent the transmission
of respiratory infections,
complimentary respira-
tory etiquette stations with
gloves, antibacterial gel, and
masks are available in the
main registration areas and
on each oor.
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 aer each
patient use by clinical or transport sta.
Lost and Found
Lost and found is located in the 1912 building on the
3rd oor. Please contact Security at 415-600-0837 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 415-600-6634.
Occupancy Manual • Safety and Security | 21
SAFETY AND SECURITY
22 | Occupancy Manual • Safety and Security
Safety and Security
Security Station
Security Awareness
ED Team
Door Alarms &
Stairwell Access
Crash Carts
Automated External
Debrillator (AED)
Emergency
Management EOP
Hospital Command
Center
Communications in a
Disaster
Fire Safety
Standardized
Emergency Codes
Code Team
Workplace Violence
MRI Suite Safety
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, brief-
cases 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.
Security Station
e main Security Station for the Mission Bernal
Campus is located on the second oor at the 27th
Street main entrance / Emergency Department (ED)
entrance. Security enhancements include:
A metal detector at the ED entrance.
Panic alarms are located in identied high risk areas;
when activated, a silent alarm is sent to Security
Dispatch.
Security stations are located at key main entrances to
include the ED and loading dock.
Sta Duress buttons on Aeroscout RFID tags worn
by sta
Door Alarms & Stairwell Access
e new hospital has public and sta only areas. In the
event of a re, all persons in the building must be able
to exit the building by the emergency stairwells. ere-
fore, we cannot lock interior doors, but we can alarm
doors to notify security when a person has entered
an authorized hospital sta only area. Signs reading
“Authorized Hospital Sta 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 oor from the stairwell, sta must hold their
employee ID badge to a card reader located on the
door.
On the women and children oor, the stairwell doors
have a sign which reads “KEEP PUSHING. THIS
DOOR WILL OPEN IN 15 SECONDS. ALARM WILL
SOUND”. Only specic authorized sta, can use their
employee ID badge to deactivate these alarms. ese
doors are part of our infant security system. In case of
re, push on door and it will open in 15 seconds.
Emergency Department Team
e 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 sta.
Automated External
Defibrillator (AED)
AEDs are in two locations on the rst oor of the
campus:
Outside the Conference
Rooms A and B
Outside the Cafeteria
Occupancy Manual • Safety and Security | 23
Emergency Management /
Emergency Operations Plan
Emergencies, disasters and other catastrophic events
pose a signicant 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 a mass casualty incident.
e All-Hazards Emergency Operations Plan is an
organization-wide program that incorporates all
services and sites of care under the CPMC license.
is plan applies to sta, licensed independent practi-
tioners, contract workers, volunteers and others as
appropriate and indicated throughout this document.
e All-Hazards Emergency Operations Plan complies
with the elements of the National Incident Manage-
ment 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
Sta responsibilities
Utilities management
Patient clinical and support activities
e full plan is located on the CPMC Intranet
Communications in a Disaster
Sutter Health aliates use Everbridge Mass Notica-
tion System to communicate to all sta simultaneously
in an emergency. Everbridge has been implemented to
improve the eciency and eectiveness of communi-
cations. e system-wide notication system enables
CPMC sta to receive and respond to critical safety
and business impact information in a timely manner.
Everbridge allows CPMC to communicate with sta
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
on the link provided in the email, or “press 1” if
the message is received via phone.
e purpose of conrming the message is so that
CPMC knows 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 conrm your personal contact information is
correct. Having accurate personal contact information
is critical for Everbridge to work eectively and sta to
receive emergency information. Everbridge pulls from
Lawson and if information is inaccurate you may not
receive emergency notications.
Please direct questions regarding Everbridge to the
Safety Department at 415-600-4620 or email
sforzok@sutterhealth.org.
Hospital Command Center
e hospital uses the Hospital Incident Command
Structure (HICS) to manage emergency events and if
the situation warrants the Emergency Operations Plan
would be activated via Code Triage.
If Code Triage is initiated, the Hospital Command
Center (HCC) will be activated and is located
on the rst oor in Conference Room A and B.
If additional resources are needed to manage
the event, the Labor Pool will be activated
and is located in the hospital cafeteria.
Conference
Room A
Conference
Room B
Cesar Chavez
Entrance
Public
Lobby
Security
Volunteer
Hospital
Command Center
First Floor
24 | Occupancy Manual • Safety and Security
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 rearm 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.”
Ye l l o w 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. e 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 brieng.”
* NOTE: Plain language should be used to describe the situation.
Code Team
e 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. e Code Team is a multi-disci-
plinary, made up of ICU physicians, nurses, respiratory
therapists, security, and a nursing supervisor.
Code Blue or Other
Medical Emergency
If you witness a patient, visitor or sta 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.
Patient care areas should also use the Code Blue alarm
system and 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,
provide nature of emergency, your name and location.
Outside of the Hospital
For patient and non-patient emergencies in 1912
or Monteagle Buildings, call 911.
Occupancy Manual • Safety and Security | 25
Code Gray
Will be initiated for any event with aggressive, hostile,
combative, or potentially combative behavior from a
patient, visitor, or sta member, without the display of
weapons.
Response Procedures
At the rst indication of a perceived Code Gray:
Dial the emergency number 4-4444
Describe the incident to the operator, including the
specic location
Security will determine when an “All Clear” will be
announced.
Post Incident
Security will conduct a post investigation debrieng.
You will be interviewed to gather incident specic
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
ere 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.
Code Pink
Code pink is initiated when an infant or child less
than 2 years of age 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 conrmed 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.
e 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 ees, do not forcibly restrain
them. If safe to do so, follow them taking note of their
appearance, what they are wearing and how the 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.
Code Purple
Is 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 Emergency Service
evaluation.
Poses a danger to themselves or others as
documented by physician.
Is on a conservatorship.
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 conrmed 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.
e 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).
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. (Continued on Next Page)
26 | Occupancy Manual • Safety and Security
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 ees, do not forcible restrain them. If
safe to do so, follow them taking note of their appear-
ance, 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
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”
Massive
Blood
Transfu-
sion
A patient emergently needs a massive blood transfusion
“Medical Alert: Massive Blood Transfusion - 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”
Safety and Security
Security Station
Security Awareness
ED Team
Door Alarms &
Stairwell Access
Crash Carts
Automated External
Debrillator (AED)
Emergency
Management EOP
Hospital Command
Center
Communications in a
Disaster
Fire Safety
Standardized
Emergency Codes
Code Team
Workplace Violence
MRI Suite Safety
ADA Information
Hand Hygiene
Service Dogs
Occupancy Manual • Safety and Security | 27
Fire Safety
General Fire Safety
Never block access to pull stations, fire extin-
guishers and medical gas value boxes. Corridors
should be clear except for crash cards, 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 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 re alarm pull station, then
call 4-4444 and/or 911.
Confine – Conne re and smoke by closing all doors
in the area.
Extinguish or Evacuate – extinguish a small re by
using a portable re extinguisher or use to escape from
a large re. Evacuate the building ONLY upon order of
the Incident Commander or the Fire Department.
How to Use a Fire Extinguisher
MRI Suite Safety
For security and safety reasons, access to MRI suite
is limited to MRI personnel and security and is
controlled. e MRI spaces are zoned to protect sta,
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.
e MRI suite has a special designated EVS closet with
non-metallic supplies and equipment. Regardless, EVS
sta should never enter the MRI suite without supervi-
sion from an MRI technologist.
Finally, to ensure all zone protocol is followed, always
check with MRI technologist 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
shi in which the injury or illness occurred. e 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.
28 | Occupancy Manual • Safety and Security
Safety and Security
Security Station
Security Awareness
ED Team
Door Alarms &
Stairwell Access
Crash Carts
Automated External
Debrillator (AED)
Emergency
Management EOP
Hospital Command
Center
Communications in a
Disaster
Fire Safety
Standardized
Emergency Codes
Code Team
Workplace Violence
MRI Suite Safety
ADA Information
Hand Hygiene
Service Dogs
Workplace Violence Reporting
Eective 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.
Adopted on October 20, 2016, certain health care
facilities as dened by the new Cal/OSHA Workplace
Violence Prevention Plan standards, Section 3342,
California Code of Regulations Title 8, are required to
maintain a log of all incidents of workplace violence by
April 1, 2017.
e 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 workplace
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.
Hand Hygiene
rough our Aeroscout Hand hygiene system, we
will be able to monitor and record our hand hygiene
events, including number of hand washing and
location in patient care areas over Wi-Fi. Hand hygiene
benets:
Enables Infection Control and Process Improvement
sta to focus on compliance, education and data
analysis.
Does not disrupt routine patient care workows.
Providing automated data collection and reporting.
Drives accountability down to the caregiver level.
ADA Information
Assistance for the hearing, listening, visually and
speech impaired are available and contact information
can be found below:
MySutter Portal: Interpreter Services & Multilin-
gual Resources http://mysutter/SHWBR/CPMC/
Resources/MoreResources/Pages/InterpreterSer-
vices.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 or ext. 60837.
For an Amplied Telephone Handset, call 74000 or
888-888-6044.
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.
Occupancy Manual • Safety and Security | 29
Service Dogs
Service dogs don’t require proof of certication or
medical documentation to enter public patient care
areas. If you are unsure if the 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 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 aer all options are
exhausted.
Please contact ADA Coordinator or Safety Ocer at
415-600-4620 with any questions or concerns.
30 | Occupancy Manual • Building Amenities
BUILDING
AMENITIES
Occupancy Manual • Building Amenities | 31
Information Desks
e Mission Bernal Campus Information Desk is
located on the rst and second oors o the Plaza
Entrance. e Information Desk sta provides the
following services:
General information
Directions and waynding
Shuttle schedule information
Taxi and transportation services information
Waiting Areas
Waiting areas and lobbies area available throughout the
hospital. See General Building Information page 6.
For safety reasons and to prevent accidental blocking
of the retractable re doors, do not rearrange furniture
in the waiting areas.
Restroom Locations
Public restrooms and water fountains are located
on every oor near the public elevators. Sta Only
restrooms require badge access and are generally near
sta lockers, lounges and conference rooms.
Lactation Lounge
A dedicated lactation lounges for sta and physicians
only is located on the Fih Floor, Room 5357 (page
11). Badge access is required.
Room Reservations
To reserve a room, complete Online Conference Room
Request form, http://dcpwdbs405/virtualems/
Bicycle Storage
Bicycle parking is available on a rst come, rst serve
basis. e bicycle storage is located on the rst oor
in room 1388, accessible via rst oor 27th Street
or Cesar Chavez front entrance (through conference
center corridor).
Badge access is required.
Reserved bicycle space may be available. Contact the
Parking Oce, 415-600-1986 to register to use this
facility and to program your badge for access.
First oor lockers are available, however only while
utilizing the shower facilities. Day use lockers are
available on department oors.
Additional bicycle racks are available at the 27th St.
and Cesar Chavez entrances.
Water Cooler/Bottle
Filling Stations
Mission Bernal Campus is a sustainable and LEED
certied building. To reduce the use of disposable
bottles, water fountains are available on each oor
near the elevators. Bottle lling locations are in the
Emergency Department, Cafeteria, and Surgical
Waiting Room.
Plumbed coee makers with hot water dispensers are
available on certain oors.
Ice makers are available in patient nourishment rooms
(not in sta lounges).
Dining Services
Several choices for food and beverages are available
during regular business hours. e Cafeteria and Grab
and Go are on the rst oor, to the le of the elevators
and are open Monday – Friday, from 6:30 a.m. – 6:30
p.m. ey are closed aer hours and on weekends.
Snack and beverage vending machines are located on
the second oor near the public elevators.
Catering Services
All catering requests must be submitted to
the Food & 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 on www.cpmc-stlukes.catertrax.
com. For training on Catertrax, go to
https://catertrax-1.wistia.com/medias/
ojoa2vlyhm#.
Food &
Nutrition
Services
Lockers &
Showers
Cafeteria
MD
Dining
Lounge
Cesar
Chavez
Entrance
27th St
1st Floor
Public Elevators
Security
Volunteer
Public
Lobby
Bike Storage
Amenities
Information Desk
Waiting Areas
Restroom Locations
Lactation Lounge
Room Reservations
Bicycle Storage
Bottle Fill Stations
Dining Services
Catering Services
Patient Education
Ambassador
Service Suite
Guest Wi-Fi
32 | Occupancy Manual • Building Amenities
Amenities
Information Desk
Waiting Areas
Restroom Locations
Lactation Lounge
Room Reservations
Bicycle Storage
Bottle Fill Stations
Dining Services
Catering Services
Patient Education
Ambassador
Service Suite
Guest Wi-Fi
Patient Entertainment /
Education (Powered by Sonifi)
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
Ambassador Services Suite
e Ambassador Services Suite is a hospitality space
located on the third oor near Nursing Administra-
tion. 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.
Guest Internet
Access (Wi-Fi)
Mission Bernal Campus oers compli-
mentary internet access. To connect,
select “SHGUESTNet” as the wireless
network. Follow the prompts on the device,
including accepting the “Terms and Condi-
tions of Use.”
EQUIPMENT AND
FURNISHING
34 | Occupancy Manual • Equipment and Furnishing
Equipment
Ergonomics
Ofce Spaces
Kronos Time Clocks
Multi-Function
Printers
VOIP Telephones
Fax Machines
Phone Exchange
Vocera
Nurse Call System
HIPPA Containers
Sustainable Waste
Temperature Monitor
Pneumatic Tube
Patient Lift
Ergonomics
Ergonomic chairs and keyboard trays are fully adjust-
able. For assistance on proper chair and keyboard
adjustment, please contact Safety Department at
415-600-4620 or email sforzok@sutterhealth.org.
ey will send materials regarding self-assessments
and if needed will direct you to complete the online
ergonomic assessment.
Office Spaces
Oce 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
Lab & Pharmacy
Some Sta Lounges
Web App will also be available for some users
Refer to Floorplans (page 6) for specic 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 workows will default to
specic printers (such as in the ED).
For copier and printer support, call Sutter Health
Service Desk at 888-888-6044 or by going to
is.sutterhealth.org
Telephone System
Cisco Voice over IP (VoIP) phones are used at Mission
Bernal Campus, including desk, wall and wireless
phones. In addition to the standard features of tradi-
tional phones (hold, speaker phone, call forwarding,
conferencing, muting), the Cisco phones oer:
Cisco Unity voicemail
Connects to the Vocera badge application, allowing
calls can be made between telephones and Vocera
badges.
Informacast for paging and broadcast messaging
Emergency red phones will be installed in key
locations.
Fax Machines
Most faxing will be done using RightFax. ere 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 workows.
Occupancy Manual • Equipment and Furnishing | 35
PBX/Phone Operating System
Hospital Operators will be located at both the Van
Ness and Mission Bernal Campuses. Hospital Opera-
tors 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
workows and assist in the management of call queues,
routing and call handling statistics.
Vocera
e Vocera badge delivers hands-free, real-time voice
communication between the wearer and other sta
members. is communication system weighs less
than two ounces, allowing users to keep their hands
free without the burden of carrying a smartphone.
Nurse Call System
e Nurse Call Rauland Responder 5 system is an
application which allows the patient to alert sta from
the bedside, among other patient locations. Identied
alerts will integrate with other applications in order to
produce hospital-wide communications and noti-
cation acknowledgement and generates a number
of reports. e 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 & security.
It provides a patient alert-communication system
(for hospital sta) which assists patients and allows
for increasingly ecient hospital operations.
It interacts with other systems to provide access to
patient entertainment and education.
HIPAA - Confidential
Document Containers
Condential 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 “ink before you ink.”
Sustainable Waste Removal
Mission Bernal is designed to be a green hospital. is
includes recycling, composting, red-bag (biohazard),
pharmaceutical and toxic waste management and
medical equipment reuse.
In oce spaces and public areas, receptacles are
provided for co-mingled recycling (blue) and regular
trash (black). In the sta lounges and conference
rooms there are receptacle for co-mingled recycling
(blue), regular trash (black), and composting (green).
36 | Occupancy Manual • Equipment and Furnishing
Equipment
Ergonomics
Ofce Spaces
Kronos Time Clocks
Multi-Function
Printers
VOIP Telephones
Fax Machines
Phone Exchange
Vocera
Nurse Call System
HIPPA Containers
Sustainable Waste
Temperature Monitor
Pneumatic Tube
Patient Lift
Temperature Monitoring
Mission Bernal Campus uses a combination of two
systems to monitor and alert if an equipment tempera-
ture 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
e pneumatic tube system will assist with trans-
porting medications, lab specimens and blood
products to/from patient care areas, to expedite patient
care. e system has an enhanced “secure send”
functionality which will only allow appropriately
licensed sta to send and receive medication and blood
products.
Patient Lift System
and Mobile Lifts
Patient li systems are available in med/surg and ICU
patient rooms. Patient lis are a safety feature to assist
in patient mobility and reduce the risk of associated
employee injuries. In addition, mobile lis are avail-
able for use in patient care areas, to assist with patient
mobility, where ceiling lis are not available.
SUPPLIES AND
RESTOCKING
38 | Occupancy Manual • Supplies and Restocking
Supplies/Restocking
Loading Dock/
Unloading
Supply Chain
Overview
Supply Chain &
Medical Gas Area
Supply Chain Stat
Requests
Pharmacy
Asset Management
Equipment Cleaning
Staff Duress
Durable Medical
Equipment
Linen
How to Order
Forms, Stationery &
Brochures
Loading Dock / Unloading
e Mission Bernal Campus loading dock is located o
Cesar Chavez St. on Level 1. Interior access is adjacent
to the service elevator.
Supply Chain Overview
Supply chain sta will monitor supply levels and the
automated supply system will generate rell requisi-
tions 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 specic
and are non-standard storage options some
departments use. Supply Chain does not
manage or replenish supplies on these
carts.
Supply Chain & Medical Gas Area
e supply chain area is located on Level 1, room
number 1522, adjacent to the loading dock. Sta,
supplies, and receiving will be staged here to support a
Low Unit of Measure (LUM) Just in Time (JIT) distri-
bution model.
e Supply Chain team is responsible for the replen-
ishment of medical gases, housed in the Medical Gas
storage room on Level 1, accessed directly o the
loading dock in room 1518.
e Code Blue Cart quick reference guide can be
found here: tinyurl.com/CPMC-CrashCart
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 Sta
will manage the restocking and storage of Code Blue/
Broselow resuscitation and isolation carts.
Supply Chain sta will be onsite between the hours of
7 a.m. to 4:30 p.m., 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.
Normal Business Hours Central Distribution:
x86626
Normal Business Hours Receiving: x86901
Supply Chain Intranet requests: http://apps.
insidecpmc.org/CPMC_SRQ/servlet/LoginServ-
let?cpmc_role_id=180
Pharmacy
e Pyxis Supply management system will be used in a
combination of locked and unlocked cabinets.
Pharmacy sta will make twice daily medication deliv-
eries to inpatient units, and once daily deliveries to
ancillary departments, including new Pyxis Anesthesia
carts.
Controlled substances are mostly lled in Pyxis, but
may be picked up at the Pharmacy by Nursing for
one-time medications. Pharmacy sta will make daily
rounds to remove discharged orders.
Asset Management
AeroScout is the chosen RFID (Radio Frequency
Identication) 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
Debrillators
EKG machines
Gurneys
IV pump brains & modules
Other infusion pumps (mobile)
Patients, infants or child (HUGS System)
PCA pumps
Portable imaging machines
SCD
Vital sign monitors
Wheelchairs
Occupancy Manual • Supplies and Restocking | 39
Equipment Cleaning
ere is a central medical equipment cleaning process
for the following types of equipment
PCA Pumps
Sequential Compression Devices
Infusion pump modules
Infusion pump control units
Seizure pads
Feeding pumps
Equipment will be preliminarily wiped down by EVS
before leaving the patient room, and temporarily
placed in the soiled utility room. e medical equip-
ment cleaning team will round on oors and follow
the process outlined here:
1. Single Patient Use
2. Clinical Sta takes equipment to soiled hold
3. AM clean delivery rounds to stock to par levels
(scan)
4. AM Soiled Pick Up rounds (scan)
5. Put on PPE at each location / Pre-soak / Bag
Equipment and place on cart
6. Central cleaning location
7. Clean / Operational test / Send to Biomed for
PMs (scan)
8. PM Delivery rounds (scan)
9. PM soiled pick-up rounds (scan)
10. Cleaning at central location / Repeat cycle next
day (scan)
Staff Duress
Sta will be able to silently notify Security for assis-
tance. Security will be able to locate the sta in need,
via the RFID tag.
AeroScout Tag and
who wears it?
e categories of caregivers who
will wear the tag will be identied
by the Operations Group.
e badge is used for Sta Duress
and it works in conjunction with
Vocera.
Durable Medical
Equipment (DME)
e 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 replen-
ished by our DME partner Pacic Medical. 
Linen
Linen will be managed and delivered by EVS at
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.
“Clean Sticker”
Clean Equipment is identified with a
“Clean” Sticker
CLEAN
Central
Distribution
Cesar Chavez
Entrance
Clean
Dock
Soiled
Linen
Rm 1308
Clean
Linen
Rm 1404
Soiled
Dock
40 | Occupancy Manual • Supplies and Restocking
Supplies/Restocking
Loading Dock/
Unloading
Supply Chain
Overview
Supply Chain &
Medical Gas Area
Supply Chain Stat
Requests
Pharmacy
Asset Management
Equipment Cleaning
Staff Duress
Durable Medical
Equipment
Linen
How to Order
Forms, Stationery &
Brochures
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, enter your requesting location (sa ve
digit number).
Go to Find/Shop icon, then OneSource; scroll down
to Standard Register.
See icons on top – click on browse catalog icon and
nd 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.
Occupancy Manual • Supplies and Restocking | 41
Occupancy Manual | i
18-CPMC-Occupancy Manual © Sutter Health 2018

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