SLRH

SAINT LOUISE REGIONAL HOSPITAL
Organization-Wide Manual
PC
Original Date: 8/02
Revised Date: 9/07, 4/09, 10/12
Reviewed Date: 07/13
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SUBJECT: PLAN FOR THE PROVISION OF PATIENT CARE

PURPOSE
The purpose of the Saint Louise Regional Hospital Plan for the Provision of Patient Care is to establish a framework
for leadership, staff and providers to respond to community and patient needs, provide for patient safety and improve
health outcomes. The plan serves as a basis to:
Identify existing and potential new patient care services

Plan for health care services
Direct and integrate patient care and support services throughout the organization
Implement and coordinate services among departments
Demonstrate improvement in patient care services provided
Direct and support comparable levels of patient care throughout the medical center
Provide care based on the principles of patient safety.
INTRODUCTION
The leadership of Saint Louise Regional Hospital recognizes its role in providing the framework for planning,
directing, coordinating, providing and improving health services that are responsive to community and patient needs.
Leadership also provides for patient safety initiatives that result in positive patient health outcomes. The Leadership
further recognizes that the hospital organization that delivers multiple acute care services and ambulatory services is
complex, composed of many professional disciplines, each of which brings a unique expertise to patient care. The
coordination and integration of each of these disciplines is embodied in the leadership process defined for Saint
Louise Regional Hospital.
DESCRIPTION OF ORGANIZATION
Saint Louise Regional Hospital is a not-for-profit facility, owned and operated by Daughters of Charity Health
Systems. Located in Gilroy California, Saint Louise Regional Health Center is a 93-bed licensed acute care hospital
offering a wide range of services to residents of Santa Clara and San Benito counties. The Hospital is accredited by
The Joint Commission and is a Joint Commission Certified Primary Stroke Center.
The population utilizing healthcare services of Saint Louise Regional Hospital consists of newborn to geriatric
patients. Community-based healthcare is provided in a tertiary (or non-tertiary) setting. All patients requiring high
risk care and services are referred or transferred to a healthcare facility where these needs can be met.
Saint Louise Regional Hospital employees 550 Associates and has over 200 medical staff members. Key services
offered by the Hospital include general medical services, surgical services, maternal-child health services, critical
care services and emergency services. An Urgent Care Center provides support to the general community.
SAINT LOUISE REGIONAL HOSPITAL SCOPE OF SERVICES

In determining the scope of services to be provided at Saint Louise Regional Hospital, consideration has been given
to the needs and expectations of the community, patient, families, and surrogate decision-makers. Specific systems
have been designed to assure patients/families receive care to meet identified needs within the scope and at the
level of care required in a timely and safe manner. The design of patient care services provided throughout the
organization is specified in each departments scope of service.
The hospital monitors changes in the environment and community needs, emerging treatment modalities, significant
patient and staff needs and changing regulatory requirements. Priority for design attention is placed on those
processes that affect a large percentage of the patient population, place patients at risk, and are problem prone.
Plan for the Provision of Patient Care -2013
PLAN FOR THE PROVISION OF PATIENT CARE
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HOSPITAL MISSION, VISION AND VALUES:

Mission:
In the spirit of our founders, St. Vincent de Paul, St. Louise de Marillac, and St. Elizabeth Ann Seton, the Daughters
of Charity Health System is committed to serving the sick and the poor. With Jesus Christ as our model, we advance
and strengthen the healing mission of the Catholic Church by providing comprehensive, excellent healthcare that is
compassionate and attentive to the whole person: body, mind, and spirit. We promote healthy families, responsible
stewardship of the environment, and a just society through value-based relationships and community based
collaboration.
Vision
In the context of our Mission and Vincentian Values, Saint Louise Regional Hospital is to be the center for health
and healing for our communities and to nurture the spiritual and physical well being of all.
Values
The Charity of Christ urges us to:
Respect
Recognizing our own value and the value of others.
Compassionate Service
Providing excellent care with gentleness and kindness.
Simplicity
Acting with integrity, clarity and honesty.
Advocacy for the Poor
Supporting those who lack resources for a healthy life and full human development.
Inventiveness to Infinity
Being continuously resourceful and creative.
ORGANIZATIONAL RESPONSIBILITIES
St. Louise Regional Hospital Board of Directors
The Board of Directors is the governing body of St. Louise Regional Hospital, responsible for conducting the affairs of
the organization, establishing policy, and providing oversight of operations and patient care outcomes through review
of quality and performance improvement data. The Board of Directors duty is to ensure that the organization
provides quality service to the organizations patients in a safe, efficient and cost-effective manner.
The Board of Directors delegates the responsibility for the provision of patient care, treatment and services to the
President/Chief Executive Officer (CEO), Ministry Market Leader for Santa Clara County.
President/Chief Executive Officer
The Saint Louise Regional Hospital Board of Directors appoints the President/CEO, Ministry Market Leader for Santa
Clara County, of Saint Louise Regional Hospital. The Hospital President/CEO, Ministry Market Leader for Santa
Clara County, is the person who is responsible for carrying out the policies established by the Board of Directors.
He/she is responsible to the Board of Directors for the management of the hospital, including the efficient operation
of all departments within the hospital. The President/CEO, Ministry Market Leader for Santa Clara County, is the
liaison coordinating the Medical Staff, Board of Directors, contracted services, and the hospital.
In carrying out his/her management responsibility, the President/CEO, Ministry Market Leader for Santa Clara
County, may delegate major functions to the Executive Management Team which includes but is not limited to the
Chief Operating Officer, the Chief Nurse Executive, the Chief Financial Officer and the Vice President Quality and
Risk Management
Chief Nurse Executive
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The Chief Nurse Executive (CNE) is ultimately responsible and accountable for the provision of patient care. The
CNE is a registered nurse in the State of California and is qualified by advanced education and experience. The
CNE is vested with the authority and responsibility to address the following functions:
Developing organization-wide patient care programs.

Developing patient care policies and procedures
Developing and implementing the organizations plan for providing care to patients
Participating with governing body, management, medical staff, and clinical leaders in the organizations
decision-making structure and processes
Implementing an effective ongoing program to measure, assess and improve the quality of patient care
delivered to patients.
Department Directors
Department Directors are responsible for planning, implementing and evaluating the functions and processes of their
departments. They assure that department functions are successfully integrated so as to provide a continuous and
comparable level of care, treatment and service to the patient in a safe and effective manner.
Hospital Associates
Each staff member of Saint Louise Regional Hospital is responsible for supporting the organizations functions and
processes through the proper performance of their respective job. Associates are encouraged to submit ideas for
performance improvement/patient safety and to participate in performance improvement activities in order to achieve
the highest level of patient care.
Medical Staff
As part of their responsibility for the functions and processes of the Hospital, the Medical Staff, through the Medical
Executive Committee (MEC), are responsible for providing input and guidance to hospital leadership. MEC has the
authority and is accountable for all medical staff systems, processes and functions related to the provision of patient
care.
PLANNING FOR PATIENT CARE

The Hospital Plan for Provision of Patient Care is linked to the Mission, Vision and Values, the hospitals planning
process and considers the following:
Patient/customer needs, expectations, and satisfaction
Determination of patient care services necessary to meet the needs of the patient population taking into
consideration patients with all types of disabilities.
Planning for the provision of those essential services, either directly, or through referral or contract.
Adherence to regulatory standards and a focus on patient safety
Ability to recruit, retain and/or develop appropriate staff
Relevant information from staffing variance reports
Patients with comparable needs receive the same standard of care, treatment, and services throughout the
hospital.
Opportunities to improve processes in the design and delivery of patient care, treatment, and services,
including the efficient flow of patients throughout the hospital.
The planning process at Saint Louise Regional Hospital is a collaborative process with leadership and the Medical
Staff to define strategic and operational plans, budgets, allocation of resources, and policies.
DIRECTING SERVICES
The leadership team at Saint Louise Regional Hospital provides daily oversight of the services provided. Leaders
support the Hospitals mission, vision and values, and develop an organizational culture that focuses on continuously
improving performance. Principles of participative decision making are inherent in the organization to promote
participative decision making, invest directors with the authority and responsibility to direct and guide assigned
departments, foster staff involvement and assure current standards of practice.
COMMUNICATION
Leadership is responsible for communicating the hospitals mission, vision and values throughout the organization in
order to guide the day-to-day activities of its associates. The communication process begins in hospital orientation
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and continues in leadership forums, CEO employee meetings, publications and the interdisciplinary work teams on
an on-going basis. Appropriate committees are appointed as well as to ensure interdepartmental collaboration on
issues of mutual concern that require multidisciplinary input.
Leaders of the Medical Staff communicate with their members through the established Medical Staff Committee
structure and through written memorandum. The Medical Staff Leadership meets at least monthly with the Medical
Center Administration. Representatives from Administration attend Medical Staff meetings and keep members
informed of hospital happenings.
BUDGET PROCESS
Saint Louise Regional Hospital develops and monitors an annual operating budget and long term capital expenditure
plan. The annual budget review process includes consideration of the appropriateness of the organization's plan for
providing care to meet patient needs, improve patient safety and achieve outcomes of care. Responsibility for
budget development and implementation is delegated to each department director. Physician input is solicited via
department directors, committee structure and in the budgetary planning processes. The budgeting process takes
into consideration the following:
Information from the strategic planning process, reflecting hospital goals and objectives
Physician input
Proposed innovation/improvements
Comparable level of care issues
Performance improvement and risk management activities, utilization review, patient safety and other evaluation
activities
Budget/Staffing variance information
Community standards of patient care
Organization's ability to attract, develop and retain staff
Feedback received from patient/families regarding expectations, involvement, and satisfaction with care
Feedback from staff/providers regarding employee satisfaction
Regulatory requirements
The Saint Louise Regional Hospital President/CEO, Ministry Market Leader for Santa Clara County, has overall
responsibility for the budget implementation and performance.
STAFFING FOR PATIENT CARE

Patient care services are organized, directed, and staffed in a manner commensurate with the scope of services
offered. Associates are assigned clinical and managerial responsibilities based on educational preparation,
applicable licensing laws and regulation, and assessment of current competence.
Staffing plans are department-specific and developed based on:
Level and scope of care provided
Age and developmental functioning of patients
Diagnoses and co-occurring conditions
Average acuity of patients
Workload standards
The physical design of the environment
Regulatory requirements
The number, scope of practice and competencies of the staff that can most appropriately provide the care
needed, while meeting the minimum staffing requirements mandated by state law.
The acuity system is reviewed and evaluated at least annually by the nursing staff.
RECRUITMENT, RETENTION AND STAFF EDUCATION

Programs to promote recruitment, retention, development, and continuing education of staff members are provided to
enhance and promote patient care. Recruitment and retention is the responsibility of the department director with
assistance from the Human Resources Department. Recognition programs exist to honor personal or team
recognition. There are ongoing feedback mechanisms that are utilized to solicit employee feedback with respect to
job satisfaction.
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Directors consider the following factors when developing programs that promote the recruitment, retention,
development, and continuing education of staff members:
The Mission
Case mix of patients
Services provided and the complexity of the patient population
Needs of family/significant others
Technology used in the patient care provided
Expectations of the organization, the medical staff, the patients, the families/significant others of patients for
the type and degree of patient care provided
The stated, inferred or otherwise identified learning needs of staff members
Mechanism designed for recognizing the expertise and performance of staff members engaged in patient care
Issues identified or stated by staff members that influence their decision to maintain employment with the
organization.
All employees receive a formalized orientation based on the scope of responsibilities defined by their job description
and the patient population they will be assigned to provide care. In addition, systems are in place to provide
mandatory annual training to employees. Each department within the organization has developed standards for
identifying, demonstrating, and documenting staff competence. Regular and routine department-focused education
and training is conducted by each department. Human Resources and the Educators coordinate regular educational
programs.
Clinical facilities are provided for nursing and allied health students of affiliated institutions. This association is based
on commitment to community, patient care, education, and research. Formal written agreements are in place for
each affiliated school or Institution.
DEFINITION OF PATIENT CARE SERVICES

Patient care services at Saint Louise Regional Hospital are provided through an organized and systematic process.
Patient care encompasses the recognition of disease and health, patient education and advocacy, and the unique
physical, emotional and spiritual needs of each person. It is designed to ensure the delivery of safe, effective and
timely care and treatment in an atmosphere that promotes respect and caring.
The provision of patient care requires specialized knowledge, judgment and skill derived from the principles of
physical, biological, behavioral, psychosocial and medical sciences. As such, patient services will be planned,
coordinated, provided, delegated, and supervised by professional healthcare providers. A registered nurse will
assess each patient's need for nursing care in all settings in which nursing care is to be provided. A cohesive unit is
formed with organizational administrative leaders, medical staff, nursing staff and other healthcare professionals
functioning collaboratively as a multidisciplinary team to achieve positive patient outcomes.
Professional health care staff provides key patient care functions to support the patients achievement of optimal
health or a dignified dying process. Policies and procedures and medical staff bylaws, rules and regulations provide
guidelines for the following key functions:
Initial assessment within 24 hours of admission and defined periodic reassessments
Plan of care development, prioritization, revision and problem resolution
Care of patient during hospitalization
Patient/family education
Medication administration and management
Application of patient safety principles
Documentation (accurate and timely) of patient care provided, orders, care plan and support documents
PROFESSIONAL PRACTICE OF NURSING

The professional practice of nursing includes accountability for coordination of the multidisciplinary team in the
provision of patient care. This is achieved by applying the nursing process which involves the ongoing assessment,
planning, implementation, and evaluation of care from admission to post-hospitalization. Saint Louise Regional
Hospital supports the philosophy that nursing is a scientific discipline that takes a holistic approach to the diagnosis
and treatment of potential and actual responses to illnesses. The goal of nursing is to lessen the effects of illness,
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promoting comfort and healing and assisting patients to achieve an optimum state of health or a dignified death.
Nursing will:
Strengthen nursing practice through a commitment to innovation and research-based theories.
Accept professional accountability to patients, families, and the communities.
Believe that patient care is best provided through collaboration with other health care professionals treat
and advocate for those who need nursing care.
Recognize the uniqueness and cultural diversity of each person, and respect, protect, and advocate for the
individual's right to self-determination, self-expression, confidentiality and dignity.
Value the relationships that have an inherent capacity to promote health, healing and wholeness.
Commit to support, acknowledge and nurture one another, thereby creating an environment of mutual
respect and caring.
INTEGRATION AND FUNCTIONAL RELATIONSHIPS OF PATIENT CARE SERVICES

The leadership of Saint Louise Regional Hospital strives to ensure systems are in place to promote the integration of
services that support the patients continuum of care needs in a way that promotes patient and family understanding.
The importance of a collaborative multidisciplinary team approach, which takes into account unique knowledge,
judgment, and skills of a variety of disciplines in achieving desired outcomes, serves as a foundation for the plan for
provision of patient care. Medical staff, registered nurses, and allied healthcare professionals function collaboratively
as part of a multidisciplinary team to achieve positive patient outcomes. Open, ongoing lines of communication are
established between all departments providing patient care in the hospital, and as appropriate with community
agencies to ensure efficient, effective patient care.
In caring for patients across the continuum, linkages are supported between the ambulatory care departments, the
acute care hospital departments and the post-hospitalization setting. These linkages are maintained through case
management activities and the partnerships with physicians.
Each department is integrated into the overall functioning of the hospital to better understand the role and purpose of
other services and how they complement each others patient care activities. The leaders of the hospital are
responsible for coordinating and integrating its services with those of other services, and to continuously improve the
services. Positive interdepartmental communications are encouraged as part of our customer focused philosophy.
CONTRACT SERVICES
In order to meet the ongoing needs of patients at Saint Louise Regional Hospital, it is necessary to contract with
agencies external to the hospital. The contract includes language that requires the agency to remain independently
in compliance with Joint Commission and other regulatory agencies such as Department of Public Health Services,
CMS and OSHA.
Saint Louise Regional Hospital has overall responsibility and authority for services furnished under a contract. The
business and patient care aspects of the contracts are monitored by the appropriate leader in the organization. An
evaluation by Leadership and Medical Staff of services provided are communicated on an annual basis to the
Medical Staff for approval. The Medical Staff collaborates with hospital leadership regarding the sources of clinical
services to be provided by contractual arrangements.
PATIENTS ENTERING SAINT LOUISE REGIONAL HOSPITAL

Patients enter Saint Louise Regional Hospital by:
Self-referral, referral from an ambulatory care setting, referral from physician, transfer from other institutional
health care settings.
Scheduled surgeries or admissions.
Emergency admissions.
Patients seeking acute medical care are referred to the Emergency Department.
o Women in labor may present to the Emergency Department or directly to the labor and delivery
department.
o Patients arriving via ambulance are seen in the Emergency Department unless a direct admission
has been arranged in advance by the physician
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PATIENT CARE DEPARTMENTS
Breast Care Center

Cardiopulmonary Services
Clinical Laboratory
Critical Care Unit
Diagnostic Radiology/Imaging Services
Emergency Department
Food and Nutritional Services
Maternal Child Health Services
Medical Surgical Pediatrics
Pathology
Pharmacy
Rehabilitation Services (Physical Therapy, Occupational Therapy, Speech Therapy)
Surgical Services
Urgent Care
Wound Care and Hyperbaric Medicine
PATIENT SUPPORT DEPARTMENTS
Admitting
Case Management
Central Processing
Communications/PBX
Environmental Services
Infection Prevention and Control
Materials Management
Medical Records/Health Information Management
Pastoral Care
Plant Maintenance and Operations Services and Biomedical Engineering
Safety and Security
Social Services
Volunteers
ADMINISTRATIVE SUPPORT DEPARTMENTS
Administration
Employee Health Services
Financial Operations
Human Resources
Information Systems
Marketing/Public Relations
Medical Staff Office
Nursing Education
Quality Management
Risk Management
PATIENT CARE PERFORMANCE IMPROVEMENT ACTIVITIES

All departments are responsible for participating in the organization's Performance Improvement Program. Data
collection, analysis and action planning in response to the data are focused on clinical outcomes, clinical processes
and quality control activities that are new, high risk, problem prone and/or low volume. Included in monitoring
activities are patient/customer satisfaction and financial indicators. Saint Louise Regional Hospital utilizes the PlanDo-Check-Act (PDCA) and Rapid Cycle methodologies for focused performance improvement activities. Various data
analysis tools are used to provide analysis for developing action plans in response to the data. These include data
dashboards, graphs, run charts, root cause analysis, etc.
The Performance Improvement Committee receives periodic reports of performance improvement activities. This
committee reports to the Medical Executive Committee who receives, considers, and acts on reports of the clinical
services, medical staff monitoring functions and pertinent hospital-wide activities.
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EVALUATION OF PLAN AND SERVICES

The organizations plan for the provision of patient care and the department specific scope of service are reviewed
and revised, at a minimum, every year or whenever patient care needs change, or prioritization findings from
performance improvement activities, risk management, case management and/or staffing plan variance suggest the
need for review and revision.
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Saint Louise Regional Hospital

Scope of Services
Direct Patient Care Departments
Breast Care Center
Department Description
The Breast Care Center provides services to a specific patient population to include outpatients, primarily women.
The Breast Center provides mammography procedures which include diagnostic mammography, breast ultrasound
and biopsies. The department provides care to adolescent, adult and geriatric populations.
Key Functions
Key functions of the Breast Care Center include patient assessment, patient/family education, medical imaging and
invasive procedures with local anesthesia.
Hours of Operation
The Breast Care Center is routinely open from 8:30am to 4:30pm, Monday through Friday except holidays.
Staffing
Saint Louise Regional Hospital Breast Care Center is routinely staffed with Radiologists, Technologists and Clerical
staff. Minimally, each shift is staffed with one Technologist and one Clerk. Staffing schedules are developed based
on historical analysis of patient exams and procedures. Staffing is adjusted based on the current days scheduled
exams.
Staff Qualifications
The Breast Care Center is staffed with appropriately qualified personnel. The specific qualifications are outlined in
staff job descriptions, which can be found in the Human Resources Personnel Files.
Staff performance and competency are evaluated at least annually and documented in a performance appraisal and
competency tools.
Professional Practice Guidelines
The Breast Care Center works closely with Physicians to develop population-specific policies based on American
College of Radiology recommendations, the Mammography Quality Standards Act, California Title 17 and Joint
Commission. Policies and procedures within the Administrative Policy Manual and the Department-specific Policy
Manual provide guidelines and structure for consistent and safe care to the patient.
Integration of Services
The Breast Care Center works closely with a multidisciplinary team of health care providers specific to the patients
needs to facilitate diagnostic treatment.
Communication
Various modes of communication are used to provide continuity of patient care and communication of key
information. Focus of communication is on identification, condition, care requirements, recent or anticipated changes
and safety. Communication focuses on prospective care planning by staff, as well as coordinated care follow-up with
specialists as determined by the outcome of the diagnostic test.
Performance Improvement
The Breast Care Center participates in hospital-wide and department-specific performance improvement activities.
Data is collected for analysis and action planning as needed. Results and action plans are communicated to staff
within the department.
Annually and as opportunities present, performance improvement initiatives are identified and prioritized.
Department involvement in performance improvement initiatives is related to the scope of service of the Breast Care
Center.
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Cardiopulmonary Services
Cardiopulmonary Services provides services to a broad patient population to include outpatients and inpatients with a
goal of maintaining optimum physiological maintenance of the cardiac and respiratory systems. Cardiopulmonary
Services personnel provide quality conscious, cost effective and competent care with respect for life and dignity at
every state of the human experience. The Cardiopulmonary Department provides special procedures to include
mechanical ventilator support, bronchoscopy assistance, pulmonary function testing oximetry, EKG, EEG,
Echocardiography, Holter monitoring, pulmonary function testing, pulmonary rehabilitation, peak flow analysis,
treadmill stress testing, ventilator care and breathing treatments and arterial blood gases. The department provides
care to neonatal, pediatric, adolescent, adult and geriatric populations.
Key Functions
Key functions of Cardiopulmonary Services include patient assessment, treatments, patient/family education,
medication management, application and monitoring of medical gases, ventilator care and management and artificial
airway care.
Hours of Operation
The Cardiopulmonary Department is open 24 hours per day/7 days per week.
Staffing
Cardiopulmonary Services is routinely staffed with:
Licensed Respiratory Care Practitioners
24 hours/7 days
EKG Tech
ECHO Tech
EEG Tech
minimally two/shift
Monday-Friday 7am to 3:30pm

One/shift
During off-hours, EKG completed by RCP
Monday and Friday 8am to 12pm One/shift
During off-hours, on-call Tech available
On-call
Staffing is adjusted based on the current days census and expected admissions, transfers and discharges.
Additional staff can be obtained through overtime, per diem staff or agency staff.
The Cardiopulmonary Department is staffed with appropriately qualified personnel. Respiratory Care Practitioners
must possess a current state RCP license and current certification of ACLS, BLS and NRP. Clinical Service
Representatives must possess current BLS certification. Cardiac Sonographers must possess a current ARDCS or
CCI certification as well as BLS certification. The specific qualifications are outlined in staff job descriptions, which
can be found in the Human Resources Personnel Files or in the agency staff files.
Staff performance and competency are evaluated at least annually and documented in a performance appraisal tool.
The Cardiopulmonary Department works closely with Physicians to develop population-specific policies based on
recommendations from Respiratory Care Board of California.
Policies and procedures within the Administrative Policy Manual and the Department-specific Policy Manual provide
guidelines and structure for consistent and safe care to the patient.
The Cardiopulmonary Department works closely with a multidisciplinary team of health care providers specific to the
patients needs to develop and implement an individualized patient plan of care that is updated as the patients
condition changes.
Communication
and safety. Communication methods include:
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Shift to shift report between caregivers completed through department report.

Verbal or written communication provided when the patient receives care off of the unit.
The Cardiopulmonary Department participates in hospital-wide and department-specific performance improvement
activities. Data is collected for analysis and action planning as needed. Results and action plans are communicated
to staff within the department.
Department involvement in performance improvement initiatives is related to the scope of service of
Cardiopulmonary Department.
Clinical Laboratory
The Clinical Laboratory Department provides comprehensive testing and immunohematology services for all patients
utilizing the facility. The department is accredited by the Joint Commission and is registered under the Department of
Health Services for CLIA. The department participates in proficiency testing through the College of American
Pathologists.
Relationships with outside reference laboratories allow for completion of any laboratory test in a timely manner via
computerized interface. All outside reference laboratories are approved by the medical staff.
Key Functions
Clinical laboratory personnel, as members of the health care delivery team, are responsible for assuring reliable and
accurate laboratory test results which contribute to the diagnosis, treatment, prognosis, and prevention of
physiological and pathological conditions.
Quality clinical laboratory testing is evidenced by: performing the correct test, on the right person, at the right time,
producing accurate test results, with the best outcome, and in the most cost-effective manner. This is accomplished
by:
Ensuring that appropriate laboratory tests are ordered.
Procuring laboratory test samples in an efficient, timely manner.
Producing accurate laboratory test results.
Correlating and interpreting laboratory test data.
Disseminating laboratory test information to clinicians and patients in a timely manner.
Evaluating the outcome of clinical laboratory testing for each individual patient and the entire health care
system.
Hours of Operation
The Clinical Laboratory is open 24 hours per day/7 days per week.
Staffing
Saint Louise Regional Hospital Clinical Laboratory is routinely staffed with Clinical Laboratory Scientists as well as
support staff. Staffing levels vary by shift. Minimally each shift is staffed with a Clinical Lab Scientists and a Lab
Assistant / Phlebotomist. Staffing schedules are developed based on historical analysis of workload volumes.
Staffing is adjusted based on the current days workload. Additional staff can be obtained through overtime, per diem
staff or contract staff.
The Clinical Laboratory is staffed with appropriately qualified personnel to include staff state licensed in medical
technology and certified in phlebotomy. All personnel have evidence proficiency with the Laboratory computer
system. All personnel have an understanding and are able to demonstrate knowledge of the laboratory specific
safety and infection control policies and procedures, as well as, the organizational safety management. The medical
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director of the Clinical Laboratory is board certified in Clinical Pathology. The specific qualifications are outlined in
staff job descriptions, which can be found in the Human Resources Personnel Files or in the agency staff files.
CLIA and Joint Commission standards and CMS regulations provide a basis from which practice guidelines are
developed or revised.
guidelines and structure for consistent and safe care to the patient. Additionally, a service-specific clinical text book
provides guidelines for basic care procedures.
The Laboratory works closely with a multidisciplinary team of health care providers specific to the patients needs to
facilitate diagnostic treatment.
Communication
Verbal or written communication provided to nursing staff when critical values are called to the unit which is
caring for the patient.
The Laboratory participates in hospital-wide and department-specific performance improvement activities. Data is
collected for analysis and action planning as needed. Results and action plans are communicated to staff within the
department.
Department involvement in performance improvement initiatives is related to the scope of service of the Laboratory.
Critical Care Unit

The Critical Care Unit is an 8-bed multi-disciplinary unit that provides specialized intensive care primarily to acutely ill
and postoperative patients. Other populations served include cardiac care patients. The Unit provides care for adult
and geriatric populations. The Critical Care Unit department population will include the developmental groups of
adults, geriatrics and adolescent patients greater than 14 years of age. The types of diagnosis managed in the
Critical Care department include:
Suspected, impending or established myocardial infarction
Post-cardiac or respiratory arrest
Cardiac arrythmias or conduction disturbances
Severe pneumonia or patients with significant respiratory disease or compromise
Pulmonary edema and acute Congestive Heart Failure
Multi-system organ failure
Single system organ failure with instability
Septic syndromes
Severe Diabetic Ketoacidosis with metabolic acidocis
Post-surgical care of moderately complex to complex surgical cases
Low Cardiac Output syndrome
Thrombolytic Agent therapy
Medical or Surgical patients who require:
o Direct Cardiac monitoring
o Mechanical ventilation
o Intensive observation
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Medical and Emotional Management for patients on 72-hour hold while awaiting psychiatric care
transfer
Patients who require post-anesthesia recovery for after hour service
Intracranial Monitoring
Key Functions
Key functions of the Critical Care Unit include patient assessment and care planning, patient/family education,
medication management, pain management, post-operative recovery, ventilator management, physiological
monitoring, and sedation with invasive procedures.
Hours of Operation
The Critical Care Unit is open 24 hours per day/7 days per week.
Staffing
The Critical Care Unit is staffed by a minimum of 2 licensed nursing personnel whenever open. When there are no
patients, a Critical Care Nurse remains on site with a back-up licensed nurse on-call. A Registered Nurse may be
kept on call during a shift when potential admissions could warrant the need for additional nursing staff. The Critical
Care Unit complies with the California State Staffing Ratios, which is minimally 1 RN: 2 patient ratio, although patient
acuity is taken into consideration, potentially requiring additional staff above the ratio.
Additional staff can be obtained through overtime, qualified float staff, per diem staff or agency staff.
Registered nurses trained in critical care nursing are employed in the Critical Care Unit. These nurses have received
training in critical care nursing theory, EKG recognition, ACLS/PALS certification, and have completed an orientation
and preceptor-ship in Critical Care nursing. The specific qualifications are outlined in staff job descriptions, which
can be found in the Human Resources Personnel Files or in the agency staff files.
The American Association of Critical Care Nurses is the recognized authority and resource for the practice of Critical
Care Nursing at Saint Louise Regional Hospital. Publications by the AACN are kept on the Critical Care Unit for
scientific and theoretical reference. Publications endorsed by the AACN are also used as references for the Critical
Care staff. The Critical Care Unit also relies on the California State Department of Health Services Title 22, CMS
and The Joint Commission for standards and guidelines used to establish and update patient care delivery
methodology and practice.
guidelines and structure for consistent and safe care to the patient. Additionally, a service-specific clinical textbook
The Critical Care Unit works closely with a multidisciplinary team of health care providers specific to the patients
needs to develop and implement an individualized patient plan of care that is updated as the patients condition
changes.
Communication
Shift to shift report between caregivers completed through bedside rounds.
Fax or verbal report provided for patients who are admitted from the Emergency Room.
Fax or verbal report provided for patients who are transferred between levels of care or from other nursing
care departments.
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Whenever a patient is being transferred to another unit for care, the name of the key care provider and department
extension is provided to facilitate communication of additional information if needed.
The Critical Care Unit participates in hospital-wide and department-specific performance improvement activities.
within the department and to the Performance Improvement Committee.
Department involvement in performance improvement initiatives is related to the scope of service of Medical Surgical
Intensive Care Unit.
De Paul Urgent Care

The De Paul Urgent Care provides outpatient services to a broad patient population that includes: pediatric, adult and
geriatrics. The department provides care to pediatric, adolescent, adult and geriatric populations.
Key Functions
Key functions of the De Paul Urgent Care include basic patient assessment, minor treatments and/or splinting and
patient/family education for ongoing follow-up care.
Hours of Operation
The De Paul Urgent Care is open 7 days per week; M-F from 3pm-11pm and Saturday and Sunday from 11am
7pm. Hours are adjusted and posted on Holidays.
Staffing
De Paul Urgent Care is staffed with a Physician, a Medical Assistant and a Radiology Technician during all open
business hours.
The De Paul Urgent Care is staffed with appropriately qualified personnel. The specific qualifications are outlined in
staff job descriptions, which can be found in the Human Resources Personnel Files or in the agency staff files.
The De Paul Urgent Care works closely with Physicians to develop population-specific policies based on
recommendations from Joint Commission and CDPH.
guidelines and structure to assure consistent and safe care to the patient. Additionally, a service-specific clinical
book provides guidelines for basic care procedures.
The De Paul Urgent Care is a clinic from hospital that provides outpatient care to the patients that present for basic
level care.
Diagnostic Imaging
Diagnostic Imaging provides services to a broad patient population to include: inpatients and outpatients, Emergency
Services and Urgent Care. The department provides special procedures to include: diagnostic radiology, CT, MRI,
Ultrasound, Mammography, and Nuclear Medicine. The department provides care to: neonatal pediatric, adolescent,
adult and geriatric populations.
Key Functions
Key functions of Diagnostic Imaging include diagnostic medical imaging, patient assessment, treatments, and
patient/family education.
Hours of Operation
Page 15 of 48
Diagnostic Imaging is open 24 hours per day/7 days per week for diagnostic and CT services. Diagnostic Imaging
provides some services during closed hours via an on-call schedule that covers evenings, nights and weekends.
When a need arises during closed hours, on-call staff can be reached by contacting the Diagnostic Imaging
department. On-call staff include: Radiologists, Nuclear Medicine Technologists, Ultrasound Technologists, MRI
Technologists, and Radiologic Technologists.
Staffing
Saint Louise Regional Hospital Diagnostic Imaging department is routinely staffed with Radiologists, Nuclear
Medicine Technologists, Radiologic Technologists, Ultrasound Technologists, MRI Technologists, Mammographic
Radiologic Technologists, and clerical staff. Minimally each shift is staffed with a Radiology Technologist. Staffing
schedules are developed based on historical analysis of patient treatments. Staffing is adjusted based on current
days expected patient treatments. Additional staff can be obtained through overtime, on-call and per diem staffing.
Diagnostic Imaging is staffed with appropriately qualified personnel. The specific qualifications are outlined in staff
job descriptions, which can be found in the Human Resources Personnel Files.
Staff performance is evaluated at least annually and documented in performance appraisal tool. Staff competency is
evaluated at least annually and documented in competency files located in the Department personnel files.
Diagnostic Imaging works closely with Physicians to develop population-specific policies based on recommendations
from The American College of Radiology.
Diagnostic Imaging works closely with a multidisciplinary team of healthcare providers specific to the patients needs
to facilitate diagnostic treatment.
Communication
Various modes of communication are used to assure continuity of patient care and communication of key
and safety.
Communication methods include:
Verbal or written communication provided by caregiver when a patient is transferred between departments.
Information transmitted through an electronic medical record.
Diagnostic Imaging participates in hospital-wide and department-specific performance improvement activities. Data
is collected for analysis and action planning as needed. Results and action plans are communicated to staff within
the department. Annually and as opportunities present, performance improvement initiatives are identified and
prioritized. Department involvement in performance improvement initiatives is related to the scope of service
Diagnostic Imaging.
Emergency Department
The Emergency Department consists of five (5) patient care areas and nine (9) beds. The beds are designated for
care of critically ill or injured patients, orthopedic patients, general examination of adult and pediatric patients,
OB/GYN patients, eye patients and fast track care.
All patients presenting to the Emergency Department will be triaged according to approved Triage Policy and
Procedures. Patients admitted to the Emergency Department will be assessed by a licensed nurse. Data collected
from this assessment will be utilized as the basis for problem identification and subsequent patient care planning.
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The Emergency Department refers for a higher level of care, patients such as critically ill newborns or pediatrics,
C.N.S. and major trauma requiring surgical intervention, cardiac disorders requiring invasive procedures or surgery,
pediatric psychiatric illness, and other psychiatric illness requiring more than emergency intervention for drug and
alcohol abuse. Burn care is provided on a very limited basis for those patients whose injuries are not severe-all
major burns are transferred to a Burn Center. The Emergency Department will provide stabilization care to these
patients while arrangements are being made for their transfer to a higher level of care. The Emergency Department
will follow the COBRA guidelines in treatment of patients.
Key Functions
Key functions of the Emergency Department include providing emergency medical screening examinations, patient
assessment and care planning, patient/family education, medication management, pain management, physiological
monitoring, ventilatory care, sedation and invasive procedures.
All patients presenting to the Emergency Department will be triaged according to approved Triage Policy and
Procedures (see Triage and Medical screening exam policies). Patients admitted to the Emergency Department will
be assessed by a licensed nurse, using the Emergency Record/Outpatient procedure. Data collected from this
assessment will be utilized as the basis for problem identification and subsequent patient care planning.
Hours of Operation
The Emergency Department is open 24 hours per day/7 days per week.
Staffing
The department is staffed with Registered Nurses and a Unit Clerk.
The Emergency Department complies with the California State Staffing Ratios, which is minimally;
Emergency Department Patients 1 RN: 4 patients
ICU Patients
1 RN: 2 patients
Trauma Patients
1RN:1 patient
Patient acuity is taken into consideration, potentially requiring additional staff above the ratio.
Staffing schedules are developed based on historical analysis of patient census. Staffing is adjusted based on the
current days census and expected admissions, transfers and discharges. Additional staff can be obtained through
overtime, qualified float staff, per diem staff or agency staff.
The Emergency Department is staffed with appropriately qualified personnel. Advanced Cardiac Life Support
(ACLS), Pediatric Advanced Life Support (PALS) and Basic Cardiac Life Support (BCLS) certifications are mandatory
for all RNs in the Emergency Department. It is recommended that the Emergency Department RNs take the CEN
exam for Specialty certification. All Emergency Department clerks must be BCLS certified.
All nursing staff in the Emergency Department must complete and pass competencies (both general and department
specific). The specific qualifications are outlined in staff job descriptions, which can be found in the Human
Resources Personnel Files or in the agency staff files.
The Emergency Department works closely with Physicians and Physician Assistants to develop population-specific
policies based on recommendations from American College of Emergency Physicians, Emergency Nurses
Association, Joint Commission and CMS.
guidelines and structure for consistent and safe care to the patient. Additionally, a service-specific clinical textbook
The Emergency Department works closely with a multidisciplinary team of health care providers specific to the
condition changes.
Communication
Page 17 of 48
Shift to shift report between caregivers
Fax or verbal report provided for patients who are admitted from the Emergency Department as an inpatient.
The Emergency Department participates in hospital-wide and department-specific performance improvement
Department involvement in performance improvement initiatives is related to the scope of service of Emergency
Department.
Food and Nutrition Services Department

The Food and Nutrition Services Department provides services to staff, visitors, volunteers, physicians and a broad
patient population including inpatients and outpatients. Services are performed in an environment that promotes
personal responsibility and growth, teamwork, and continuous improvement. Success is measured by customer
satisfaction surveys, quality performance improvement monitoring and financial performance. The department
provides care to neonatal, pediatric, adolescent, adult and geriatric populations.
Key Functions
Key functions of the Food and Nutrition Services Department include:
Inpatient meal service providing nutritionally appropriate patient meals
Patient assessment and medical nutrition therapy recommendation
Patient/family education
Out-patient nutrition counseling
Employee, physician and visitor meal service
Catering services
Meal on Wheels
Hours of Operation
The Food and Nutrition Services Department is open 7 days per week, provided from 6:00am to 7:30pm. This
service includes meal service for breakfast, lunch and dinner snacks and beverages are available between meals.
During hours when the department is closed, food is available to patients through pantry stock provided to the
nursing units and from a Patient Late Tray Refrigerator.
Employee, physician and guests, food service is available 7 days per week. Vending services are available 24 hours
per day, seven days per week.
Staffing
Food and Nutrition Services Department is routinely staffed as follows:
Director
Dietitian
Dietetic Technician
Chef
Cook
Purchasing Assistant
7:00 a.m. 4:00 p.m. Monday Friday

8:00 a.m. 4:30 p.m. Monday through Saturday (On call on Sundays)
7:00 a.m. 11:00 a.m. Saturday & Sunday
5:30 a.m. 2:00 p.m. Monday through Friday
5:30 a.m. 7:00 p.m. Sunday through Saturday
10:30 a.m. 7:00 p.m. Monday, Tuesday, Thursday, and Friday
8:00 a.m. 4:30 p.m. Wednesday
Cafeteria Lead
Food Service Assistant
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6:00 a.m. 2:30 p.m. Monday through Friday

5:30 a.m. 9:30 p.m. Sunday through Saturday
Clinical Nutrition Services, including patient screening, assessment, intervention and counseling are available 8
hours daily, 7 days/week. If a nutrition question arises outside of these hours, the Food Service Assistant calls a
Dietitian at home. If a patient is being discharged and a Dietitian is not on site to provide diet instruction, the Dietitian
contacts the patient by phone and/or the patient can return for outpatient instruction, or Nursing may provide
educational materials.
Staffing is adjusted based on the current days census and expected admissions and discharges and on requested
catered meals. Additional staff can be obtained through the use of supplemental staff, overtime or staff from other
local DCHS hospitals.
The Food and Nutrition Services Department is staffed with appropriately qualified personnel. The specific
qualifications are outlined in staff job descriptions, which can be found in the Human Resources Personnel Files.
competency tools.
The Food and Nutrition Services Department works closely with Physicians to develop policies based on
recommendations from the Academy of Nutrition & Dietetics, the Academy of Nutrition and Dietetics Nutrition Care
Manual, American Society for Eternal and Parenteral Nutrition, and U.S. Public Health Service FDA Food Code
Book, U.S. Department of Health and Human Services.
The Food and Nutrition Services Department works closely with a multidisciplinary team of health care providers
specific to the patients needs to develop and implement an individualized patient plan of care that is updated as the
patients condition changes.
Communication
Documentation in the patient medical record
Verbal communication with the multi-disciplinary team
The Food and Nutrition Services Department participates in hospital-wide and department-specific performance
improvement activities. Data is collected for analysis and action planning as needed. Results and action plans are
communicated to staff within the department.
Department involvement in performance improvement initiatives is related to the scope of service of the Food and
Nutrition Services Department.
Maternal Child Health

The Maternal Child Health Department provides the community with services for the Perinatal, Gynecological, and
Newborn needs and provides the following services:
Antepartum Observation and testing
Labor & Delivery in a Level I capacity
Newborn Nursery in a Level I capacity
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Postpartum Patients in a Mother-Baby Unit

Non-Newborns under eight weeks old
The Maternal Child Health Department refers for higher levels of care. These patients are considered for transport
based upon criteria including risks/benefits of transport, stability of the patient, gestational age and underlying
medical problems. The Maternal Child Health Department follows the COBRA guidelines in treatments of patients.
Specialty consultation is available to the medical staff, generally within 30 minutes.
The Maternal Child Health Department consists of three separate patient care areas as follows:
Labor and Delivery (LD)
Two Labor Deliver Recover (LDR) Suites
Two Labor Rooms
One Recovery Room
One Delivery/Cesarean Delivery room that may be used for patients such as those with high risk
vaginal deliveries, multiple gestation deliveries, or planned cesarean deliveries.
These rooms are used for patients such as those here for ante partum observation, in labor or
suspected labor, and deliveries.
Mother/Baby Unit
16 beds, including 2 private rooms
This area provides care for postpartum patients, and newborns, including transition after birth,
stabilization, and discharge with family.
Nursery
Main Nursery 2 beds

Well Nursery 4 beds
The Newborn Nursery provides care for stable newborns. Resuscitation and stabilization of critically
ill neonates is also provided until a Neonatal Intensive Care Unit transport team arrives to assume
care for the patient.
Key Functions
Key functions of the Maternal Child Health Department include patient assessment; care planning, patient/family
education, medication management, analgesia and anesthesia pain management, ante partum and intra partum
management, surgical care for cesarean sections, post-surgical care, physiological monitoring and neonatal
stabilization.
Hours of Operation
The Maternal Child Health Department is open 24 hours per day/7 days per week.
Staffing
The Saint Louise Regional Hospital Maternal Child Health Department complies with the California State Staffing
Ratios. The Family Birth Center complies with the Perinatal Guidelines recommended staffing ratios. These
guidelines are supported by the Association of Womens Health, Obstetric and Neonatal Nursing, American College
of Obstetricians, and American Academy of Pediatrics.
The minimal staffing for labor and delivery is 2 RNs. for postpartum is 1 RN and in the nursery 1 RN. Staffing is
adjusted based on the current days census and expected admissions, transfers and discharges. Staffing schedules
are developed based on historical analysis of patient census. Additional staff can be obtained through overtime,
qualified float staff, per diem staff or agency staff.
The Maternal Child Health department is staffed with appropriately qualified personnel. RNs hold certificates in
ACLS, BLS and Fetal Monitoring. Staff is encouraged to become certified in Inpatient Obstetrical Nursing. The
specific qualifications are outlined in staff job descriptions, which can be found in the Human Resources Personnel
Files or in the agency staff files.
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The Maternal Child Health department works closely with Physicians to develop population-specific policies based on
recommendations from The Guidelines for Perinatal Care, AWHONN, ACOG, AAP, AORN, Joint Commission, CMS
and California DPHS.
The Maternal Child Health department works closely with a multidisciplinary team of health care providers specific to
the patients needs to develop and implement an individualized patient plan of care that is updated as the patients
condition changes.
Communication
The Maternal Child Health department participates in hospital-wide and department-specific performance
Department involvement in performance improvement initiatives is related to the scope of service of Maternal Child
Health.
Medical Surgical Pediatrics Department

The Medical-Surgical-Pediatrics Department is a 43 bed unit that provides care to medical, surgical and pediatric
patients. Other populations served include patients requiring hemodialysis, cardiac monitoring, wound care,
pulmonary care, chemotherapy and any of the various types of isolation. The department provides care to infant,
pediatric, adolescent, adult and geriatric populations.
Key Functions
Key functions of the Medical Surgical Pediatrics Department includes patient assessment and care planning,
patient/family education, medication management, pain management, initial rehabilitation and telemetry monitoring
Hours of Operation
The Medical-Surgical-Pediatrics Department is open 24 hours per day/7 days per week.
Staffing
The Medical-Surgical-Pediatrics Department complies with the California State Staffing Ratios, which is minimally 1
RN: 5 patients, however, patient acuity is also taken into consideration, potentially requiring additional staff above the
ratio.
The Medical-Surgical-Pediatrics Department is routinely staffed with Registered Nurses, Licensed Vocational Nurses,
Nursing Assistants, and a Ward Clerk. Minimally each shift is staffed with 2 Licensed Nurses (RNs and LVNs).
Additional staff can be obtained through overtime, qualified float staff, per diem staff or agency staff.
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The Medical-Surgical-Pediatrics Departments staffed with appropriately qualified personnel. RNs providing
chemotherapy treatments to cancer patients are chemotherapy certified. RNs caring for pediatric patients are PALS
certified. The specific qualifications are outlined in staff job descriptions, which can be found in the Human
Resources Personnel Files or in the agency staff files.
The Medical-Surgical-Pediatrics Department works closely with Physicians, including Pediatricians to develop
population-specific policies based on recommendations from professional evidence-based literature, professional
association recommendations, Joint Commission, CMS and the American Academy of Pediatrics.
guidelines and structure for consistent and safe care to the patient. Additionally, service-specific clinical text books
provide guidelines for basic care procedures.
The Medical-Surgical-Pediatrics Department works closely with a multidisciplinary team of health care providers
specific to the patients needs to develop and implement an individualized patient plan of care that is updated as the
patients condition changes.
Communication
care departments.
The Medical-Surgical-Pediatrics Department participates in hospital-wide and department-specific performance
Department involvement in performance improvement initiatives is related to the scope of service of the MedicalSurgical-Pediatrics Department.
.
Pathology
Pathology provides for examination, diagnosis and description of all human tissue and cytology specimens received
in the department for both inpatients and outpatients. Services are provided to all patient populations of Saint Louise
Regional Hospital and include infants, pediatrics, adolescents, adults and geriatrics.
Key Functions
Key functions of Pathology tissue and specimen analysis and autopsies.
Hours of Operation
Pathology is open from 8am to 5pm Monday to Friday. Pathology staff and the Pathologist are availablevia
exchange beeper during closed hours.
Staffing
The Pathology Department operates under the direction of a physician licensed in anatomical and clinical pathology.
In addition there is a certified Histotechnologist.
Page 22 of 48
The Pathology Department is staffed with appropriately qualified personnel. The pathologist is credentialed and
privileged by the Medical Staff. Privileges can be found in the credential file or online. The Histotechnologist is
licensed by the American Society of Clinical Pathologists Board of Registry.The specific qualifications are outlined in
the job description, which can be found in the Human Resources Personnel Files.
The Pathology Department works closely with the Pathologist and Administration to develop population-specific
policies based on recommendations from the College of American Pathologists, Joint Commission and CMS.
The Pathology Department works closely with Physicians and all clinical care departments to facilitate diagnostic
treatment.
Communication
Verbal and written communications to Physicians and clinical care units
care departments.
The Pathology Department participates in hospital-wide and department-specific performance improvement activities.
Department involvement in performance improvement initiatives is related to the scope of service of the Pathology
Department.
Pharmacy
The Pharmacy provides dispensing and clinical pharmacy services to a broad patient population including both
inpatients and outpatients. The department provides care to neonatal, pediatric, adolescent, adult, and geriatric
populations.
Key Functions
Key functions of the Pharmacy Department include:
1. All aspects of medication management: selection, storage, ordering and prescribing, dispensing, administration,
and monitoring.
2. Dispensing of pharmaceuticals in accordance with federal and state regulations
3. Inventory and Formulary maintenance functions
4. Drug monitoring and record keeping
5. Provision of drug information
6. Provision of patient, physician and staff education
7. Serves in an advisory capacity through the Pharmacy & Surveillance Committee and the administrative leaders
to insure the development, coordination and review of all professional standards, procedures, policies and
controls relating to procurement, storage, dispensing and safe use of medications.
8. Patient care services in collaboration with other health-care professionals to optimize medication therapy for
patients.
9. Pharmacist participation in the prospective evaluation and development of an individualized treatment plan
Page 23 of 48
10. Participation on multidisciplinary teams

11. Written and oral consultations regarding medication selection and management.
th
12. Education and teaching of both 4 year pharmacy students through clinical rotations and Pharmacy Practice
Residents through the ASHP accredited residency program (IPPE & APPE).
Hours of Operation
The Pharmacy Department is open during the hours of 7:30 AM through 8:00 PM, Monday through Friday, 8:00 AM
through 4:00 PM, Saturday and Sunday; with a pharmacist available on-call 24-hour per day. The nursing supervisor
may access medications from department PYXIS machines or the Night Locker when the Pharmacy Department is
closed.
Staffing
The Pharmacy Department is staffed with registered pharmacists and pharmacy technicians. Minimally each shift is
staffed with one registered pharmacist and one registered pharmacy technician when the Pharmacy is open. Staffing
schedules are developed based on historical analysis of patient census and department need. Staffing is adjusted
based on the current days census and expected admissions, transfers and discharges. Additional staff can be
obtained through the use of per diem staff or with overtime.
Pharmacists are registered and licensed in accordance with the regulations of the State Board of Pharmacy, with
training and experience that emphasizes an acute care hospital environment. Technician personnel meet the
licensing/certification requirements of the State Board of Pharmacy. All personnel are provided with regular
continuing education and training to maintain proficiency and competence. Technicians and Pharmacists are
required to demonstrate active participation in continuing education courses as required by the State Board of
Pharmacy by providing documentation of attendance.
The Pharmacy Department is staffed with appropriately qualified personnel. The specific qualifications are outlined
in staff job descriptions, which can be found in the Human Resources Personnel Files.
Staff performance and competency are evaluated at least annually and documented in a performance appraisal or
competency tools.
The Pharmacy Department works closely with the medical staff to develop population-specific policies based on
recommendations from evidence-based medicine, as well as standards from Joint Commission, CMS and the
American Society of Health-System Pharmacists (ASHP).
The Pharmacy Department works closely with a multidisciplinary team of health care providers to develop and
implement an individualized patient plan of care that is updated as the patients condition changes.
Communication
Shift to shift report between Pharmacy staff completed through verbal reporting.
Written communication provided when there are patient-specific issues that require follow-up.
The Pharmacy Department participates in hospital-wide and department-specific performance improvement
to staff within the department and reported to the Quality Management Committee as appropriate.
Page 24 of 48
Department involvement in performance improvement initiatives is related to the scope of service of the Pharmacy
Department.
Rehabilitation Services
Rehabilitation Services is an exclusive contract service providing physical therapy, occupational therapy and speech
therapy to inpatients at the bedside, in the nursing units or in the Physical Therapy Department, and outpatients.
Rehabilitation Services provides services to primarily adults and geriatric patient populations with orthopedic,
neurological, or general medical diagnoses. Occasionally, pediatric and adolescent populations are served.
Physical therapy and occupational therapy services are provided to individuals with physical dysfunction secondary
to disability, disease or injury in accordance with professional standards of practice, departmental policies and
procedures and organizational standards.
Speech Therapy provides prescribed bedside therapies/evaluations for the inpatient population at Saint Louise
Regional Hospital. Speech Therapy delivers comprehensive services to individuals with speech and language
dysfunction and dysphasia secondary to disability, disease or injury in accordance with professional standards of
practice, departmental policies and procedures and organizational standards
Key Functions
Key functions of Rehabilitation Services includes patient assessment/reassessment, development of treatment
plans/care plans, treatment, discharge planning, patient/family education and consultation designed to restore,
improve, or maintain the patient's optimal level of functioning, self-care, self-responsibility, independence, and quality
of life.
Hours of Operation
Rehabilitation Services are scheduled during specified hours at the acute hospital level of care. In the event of an
emergency or high-risk situation, the routine hours of operation may be flexed as needed. Service hours are 8am to
4:30pm as census requires. During closed hours, referrals are coordinated between the House Supervisor and the
contract service.
Outpatient Rehabilitation Services are scheduled at Saint Louise Regional Hospital on Wednesdays and Fridays
from 9am to 3pm.
Staffing
Rehabilitation Services is routinely staffed with Physical, Occupational, and Speech Therapists.
Daily staffing is based upon anticipated amount (number of hours) and type (evaluation or treatment and acuity) of
patient volume, as well as department operations activities pre-scheduled to occur that day.
As needed, additional staff may be obtained by the regular contract staff overtime.
Rehabilitation Services is staffed with appropriately qualified and licensed personnel. The specific qualifications are
outlined in staff job descriptions, which can be found in the contract staff files.
Rehabilitation Services adheres to the State of California Practice Acts, laws and regulations for Physical,
Occupational, and Speech Therapy. Rehabilitation Services references professional standards and practices of the
American Physical Therapy Association (APTA) American Speech-Language-Hearing Association (ASHA), the
American Occupational Therapy Association (AOTA), the Joint Commission and CMS.
Page 25 of 48
Rehabilitation Services works closely with a multidisciplinary team of health care providers specific to the patients
needs to develop and implement an individualized patient plan of care.
Communication
and safety. Communication methods include verbal or written communication between caregivers.
Verbal and written communication between Therapists
Verbal communication with clinical department RN caring for patient
Rehabilitation Services participates in hospital-wide and department-specific performance improvement activities.
Department involvement in performance improvement initiatives is related to the scope of service of Rehabilitation
Services.
Department of Surgical Services

The Saint Louise Regional Hospital Department of Surgery provides care on a 24 hour basis to inpatients and
outpatients requiring surgical intervention by the Saint Louise Regional Hospital Medical Staff. The patient
population consists of pediatric, adolescent, adult and geriatric. Services include, but not limited to ENT, general,
gastrointestinal endoscopies, urology, gynecology, ophthalmology, orthopedic, podiatry, dental, oral maxillo-facial,
endovascular, neurosurgery, plastic and thoracic. Patient care is delivered by Registered Nurses, Certified Surgical
Technicians, Surgical Technicians, and Surgical Aides.
The Department of Surgical Services consists of a pre-admissions service, 3 operating rooms, a 5 bed preoperative/holding unit, a 5 bed post-operative unit and a special procedures room for endoscopy procedures.
Key Functions
Key functions of the Surgery Department include patient assessment and care planning, patient/family education,
medication management, pain management, physiological monitoring, anesthesia, sedation, surgery, invasive
procedures, and recovery.
Hours of Operation
The Surgery Department is open 24hours/7 days per week. Elective procedures can be scheduled Monday-Friday
from 7:30a, to 3pm.
Staffing
The Department of Surgery complies with the recommendations from AORN, which are minimally one Circulating RN
and one ORT/RN scrub for each procedure performed in the operating room and Special Procedures. Recovery
patients are staffed according to California State Staffing Ratios which is 1 RN: 2 patients. Additionally, patient acuity
is taken into consideration, potentially requiring additional staff above the ratio.
The Department of Surgery is routinely staffed with Registered Nurses, Certified Surgical Technicians, Surgical
Technicians, Surgical Aides and a surgery scheduler. Staffing schedules are developed based on volume of surgical
cases scheduled.
The Operating Room is staffed with appropriately qualified personnel. Clinical staff must have BLS and/or PALS with
PACU staff maintaining certification in ACLS and PALS. The specific qualifications are outlined in staff job
descriptions, which can be found in the Human Resources Personnel Files or in the agency staff files.
The Department of Surgery works closely with Physicians to develop population-specific policies based on
recommendations from ASA, ACOS, AORN, Title 22, Joint Commission and CMS.
Page 26 of 48
The Department of Surgery works closely with a multidisciplinary team of health care providers specific to the
condition changes.
Communication
Universal protocol to include the pause and identification requirements at all levels of care within the
perioperative departments.
Hand off report between caregivers.
Fax or verbal report provided for patients who are transferred to the next level of care.
The Department of Surgery participates in hospital-wide and department-specific performance improvement
Center for Wound Care and Hyperbaric Medicine

The Center for Wound Care and Hyperbaric Medicine is a fully integrated, outpatient system for the management of
acute and chronic wounds. Evaluation, diagnostic testing and therapeutic intervention are delivered for all
appropriate diagnoses according to orders written by The Centers physicians. Hyperbaric Oxygen Therapy is also
provided. Patient access to The Center includes, but is not limited to self-referral, referral from primary care
physicians, specialty care physicians, or referral from another health-care facility. The department provides care to
the following: pediatric, adolescent, adult and geriatric populations.
Key Functions
The Center provides patient evaluation as required including complete patient assessment of systemic and local
factors affecting wound healing and peripheral vascular testing to assess the blood flow to the extremities.
Based on the identification of underlying causes of poor wound healing, the Center provides specific wound
management as indicated to include:
An aggressive program of conventional wound care and clinical wound debridement.
Lower extremity edema control.
Adjunctive hyperbaric oxygen (HBO 2 ) treatment to correct tissue hypoxia.
Skin grafting with bioengineered skin products.
Negative Pressure Wound Therapy.
Patient education.
Photographs and measurements of patients' wound(s) on initial and follow-up visits.
Recommendation of off-loading and specialized orthotics to assist in initial healing of plantar ulcers and to
prevent recurrence.
Hyperbaric Oxygen Therapy is provided as either the primary method of treatment or a significant adjunctive
treatment for acute peripheral arterial insufficiency, preparation and preservation of compromised skin grafts, chronic
refractory osteomyelitis and certain diabetic wounds, diabetic wound classified as Wagner grade III or higher and has
Page 27 of 48
failed an adequate course of standard wound therapy.

Hours of Operation
The Center for Wound Care and Hyperbaric Medicine department is open from 7am to 4:30pm, Monday through
Friday.
Staffing
The Center for Would Care and Hyperbaric Medicine is staffed with the following personnel on a daily basis:
Program Director who leads the department and provides operational support services to the Medical Director,
staff and patients.
Registered Nurses.
Certified Hyperbaric Technicians who can function as a Chamber Console Operator, and perform daily
chamber system maintenance.
Clerical Personnel who can function as a Contact Person, a Medical Records Coordinator, and perform basic
Certified Nursing Assistant and Wound Technician functions.
Certified Nursing Assistant OR Wound Technician who can function as Wound Care Assistant, and assist
clerical personnel as needed.
The Center will safely adjust staffing levels by consideration of volume, needs, and acuity of the population served.
.
The Hyperbaric and Wound Care department is staffed with appropriately qualified personnel. The specific
The Center for Would Care and Hyperbaric Medicine works closely with Physicians to develop population-specific
policies based on recommendations from the Undersea Hyperbaric Medicine Society, Joint Commission and CMS.
The Center for Wound Care and Hyperbaric Medicine works closely with a multidisciplinary team of health care
providers specific to the patients needs to develop and implement an individualized patient plan of care that is
updated as the patients condition changes.
Communication
Written communication with patients
Verbal or written communication with physicians.
The Center for Wound Care and Hyperbaric Medicine participates in hospital-wide and department-specific
performance improvement activities. Data is collected for analysis and action planning as needed. Results and
action plans are communicated to staff within the department.
Department involvement in performance improvement initiatives is related to the scope of service of The Center for
Wound Care and Hyperbaric Medicine.
Page 28 of 48
Patient Support Departments

Admitting Department
The Admitting Department provides registration of patients for the entire hospital in order for the patient to receive
care prescribed by their admitting/referring physician. Patient registration can occur in the Emergency Department,
Admitting Department or at the bedside according to the assessed needs of the patient. The responsibilities of the
department include preregistration and registration of patients to the acute hospital, Emergency Department,
Outpatient Surgery and outpatient ancillary services.
Key Functions
The Admitting Department provides the following:
Pre-admission and admission services
Obtaining demographic information, insurance verification
Patient information on PSDA, Conditions of Admission, patient rights, financial responsibilities
Translation services as needed
Hours of Operation
The Admitting Department is open 24 hours/7 days.
Staffing
The department is routinely staffed with Admitting Clerks.
Additional staff can be obtained through overtime or agency staff.
The Admitting Department personnel must possess an accurate understanding of applicable state and federal
requirements, insurance verification and requirements, organizational policy including patient rights and a thorough
knowledge of the computerized registration system. The specific qualifications are outlined in staff job descriptions,
which can be found in the Human Resources Personnel Files.
guidelines and structure to for consistent and safe care to the patient.
The Admitting Department works closely with all departments providing patient care to carry out the key functions of
the department and meet the departments goals.
Communication
Communication between shifts passes information regarding the patients admission process. Communication also
occurs with the House Supervisor on a routine basis to assure patients are appropriately placed. Communication is
verbal.
The Admitting Department participates in hospital-wide and department-specific performance improvement activities.
Department involvement in performance improvement initiatives is related to the scope of service of the Admitting
Department.
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Case Management
The Case Management Department provides a significant support role in coordinating discharge planning and
appropriate post-hospitalization care arrangements for patients. Utilization is assessed and managed on an on-going
basis during hospitalization
Key Functions
The RN Case Manager concurrently facilitates the coordination of services and care designed to move the patient
through inpatient care in a timely, cost-effective manner with desired outcomes. This is accomplished through:
Identify and monitor the appropriate level of care and intensity of service per INTERQUAL criteria.
Provide medically necessary cost effective care
Collaborate with other members of the health care team to develop and implement continued care plans based
on medical diagnosis and on the identified needs and goals of the patient
Determine a target length of stay based on medical diagnosis
Evaluation of responses to treatments as related to discharge planning and utilization review.
Effective intervention and communication with the patient, their family, physician, caregivers and payers in
assessing patient needs
Provide a process for responding to questions or appeals, denials, one day length of stays and
authorizations in hospitals.
Provide education to physicians and hospital staff regarding utilization findings and performance
Fulfill the regulatory and contractual requirements related to utilization review
Case Management provides assessment of the biopsychosocial needs and financial resources of the patient and
collaborates with all disciplines appropriate for the patient's care to develop an interdisciplinary care plan that
smoothly moves the patient through the continuum of services and connects them to programs, services and
resources that exist in the community.
Hours of Operation
Case Management is available Monday through Friday 8am to 5pm, excluding holidays.
Staffing
Staffing is fixed, meaning each day starts out with a full complement of staff. The standard is based on volume of
each fiscal year and correlates with the budget. Staffing assignments are made at the beginning of each day. The
assignment will vary and will be agreed upon by the staff on duty.
Staffing adjustments are made when the census changes enough to require more or less staff. The department
director makes the changes as necessary with authorization from Administration.
The Director of Case Management is a licensed RN with applicable certification and experience. The Case
Managers are licensed RNs with special training in Utilization Review and Discharge Planning. The specific
INTERQUAL criteria is utilized by Case Managers to provide guidelines for appropriate treatments and length of stay.
Joint Commission and CMS standards guide the department in collaboration with evidence-based medicine.
provides guidelines for basic care procedures
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Central Processing
Central Processing is directed by the Materials Management Department who assumes oversight responsibility for all
Central Processing functions.
Key Functions
Key functions of Central Processing include:
Routine stocking of inpatient units with supplies.
Filling of requests for sterilized non-chargeable and chargeable items and equipment.
Pick up of reusable equipment/supplies from patient care units that need to be decontaminated and
sterilized.
Clean, decontaminate and sterilize all reusable instruments, assemble reusable instrument sets and
crash carts,
Central Processing provides and routinely stocks inpatient units with certain items, as well as fills requests for
sterilized non-chargeable and chargeable items and equipment. Patient care personnel are responsible for placing
reusable dirty supplies in appropriate containers or areas within the dirty utility rooms. Central Processing personnel
make daily rounds to areas to pick up reusable equipment/supplies that need to be decontaminated and sterilized.
Patient care units are restocked by par levels. Central Processing is responsible for assembly of reusable instrument
sets, assembly of crash carts and clean, decontaminate and sterilize all reusable instruments
Hours of Operation
Central Processing provides supply services 24 hours per day/7 days per week.
Staffing
Central Processing is routinely staffed with Technicians. Staffing schedules are developed based on historical
analysis of patient census/procedures and is adjusted based on the current days census and expected admissions,
transfers and discharges. Additional staff can be obtained through overtime.
Central Processing is staffed with appropriately qualified personnel. The specific qualifications are outlined in staff
job descriptions, which can be found in the Human Resources Personnel Files.
Central Processing develops policies based on recommendations from AAMI (American Association of Medical
Instrumentation), ASHCSP (American Society of Hospital Central Service Personnel), Infection Control guidelines,
Joint Commission and CMS.
Central Processing works closely with the Materials Management department, operating rooms, emergency
department, inpatient and ancillary areas to carry out the key functions of the department and meet the departments
goals.
Communication
information. Communication methods include shift to shift report between staff and communication throughout the
shift to assure patient care needs are met.
Central Processing participates in hospital-wide and department-specific performance improvement activities. Data
is collected for analysis and action planning as needed. Results and action plans are communicated to staff within
the department.
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Communications/PBX
The Communications/PBX Department is responsible for the operation of the organization's communication system.
Key Functions
Communications/PBX Department staff is responsible for:
Answering all incoming calls in a timely and professional manner and to accurately disperse all calls to their
final destination.
Activating the facility's overhead paging system.
Activating internal and external pocket pager system.
Monitoring all of the organization-wide emergency systems Key functions of the Telecommunications
Department.
Hours of Operation
The Communications/PBX department provides services 24 hours per day/7 days per week.
Staffing
The Communications/PBX department is routinely staffed with telecommunications operators. Staffing schedules are
developed based on historical analysis of patient census. Staffing is adjusted based on the current days census and
expected admissions, transfers and discharges. Additional staff can be obtained with the use of per diem staff.
The Communications/PBX department is staffed with appropriately qualified personnel. The specific qualifications
are outlined in staff job descriptions, which can be found in the Human Resources Personnel Files.
The Communications/PBX department works closely with all departments to carry out the key functions of the
department and meet the departments goals.
Communication
Various modes of communication are used to assure continuity of patient care and communication of key information
to various departments and physicians. This includes, telephone communication, overhead paging and beeper
paging. Communication methods include a verbal shift to shift report.
The Communications/PBX department participates in hospital-wide and department-specific performance
As opportunities present, performance improvement initiatives are identified and prioritized. Department involvement
in performance improvement initiatives is related to the scope of service of Communications/PBX department.
Environmental Services
The Environmental Services Department provides routine cleaning of patient care and public areas. As well, linen
services are provided to patient care units to include pick-up, cleaning and stocking of linen.
Key Functions
Key functions of the Environmental Services Department include:
Cleaning and disinfecting patient and non-patient areas according to policies and procedures.
Removing regular and bio-hazardous waste.
Removing soiled linen and restocking clean linen on patient care units.
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Completing any unscheduled or emergency housekeeping service that falls under the routine scope of services
of the Environmental Services Department or that is considered necessary for the health and safety of patients,
employees, visitors or medical staff (i.e., cleaning up spills or flooding).
Setting up rooms for special functions and meetings.
Evaluating and monitoring the interior of the hospital for areas or items needing repair/replacement (i.e., floor
tiles, carpet or paint), safety concerns and reporting items to the appropriate department.
Hours of Operation
The Environmental Services Department provides services 24 hours per day/7 days per week.
Staffing
Saint Louise Regional Hospital Environmental Services Department is routinely staffed housekeepers and a Lead
housekeeper on the day shift Monday through Friday. At least one Housekeeper is staffed weekends, evenings and
nights with House Supervision. Staffing schedules are developed based on historical analysis of patient census and
adjusted discharges. Staffing is adjusted based on the current days census and expected admissions, transfers and
discharges. Additional staff can be obtained through the use of supplemental staff and overtime.
The Environmental Services Department is staffed with appropriately qualified personnel. The specific qualifications
are outlined in staff job descriptions, which can be found in the Human Resources Personnel Files.
competency tools.
The Environmental Services Department develops policies based on recommendations from ASHES/The American
Society for Healthcare Environmental Services and from facility infection control practitioners.
The Environmental Services Department works closely with all departments to carry out the key functions of the
Communication
Various modes of communication are used to assure continuity of work flow and needs of the departments.
Communication methods include shift-to-shift report between staff completed through department report.
The Environmental Services Department participates in hospital-wide and department-specific performance
Department involvement in performance improvement initiatives is related to the scope of service of the
Environmental Service Department.
Infection Prevention and Control

Infection Prevention and Control provides consultative services to prevent and control infection throughout the
hospital, including outpatient facilities. Populations served include neonatal, pediatric, adolescent, adult and
geriatric.
Key Functions
Key functions of the Infection Control Department include epidemiology, surveillance, reporting, consultation,
education, and policy formation relative to infection prevention, control and emerging pathogens.
The organizational Infection Prevention and Control Plan and infection control policies serve as guidelines for all
infection prevention and control activities.
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The Pharmacy and Surveillance Committee serves as the gatekeepers for infection prevention and control activities,
including policy review and approval and approval of all infection prevention and control programs. The committee
includes appropriate Department Directors and Physicians.
Hours of Operation
The Infection Control Department provides services 8am to 5pm, Monday through Fridays, except holidays. The
Infection Preventionist is available via pager during closed hours.
Staffing
Infection Prevention and Control is routinely staffed with an Infection Control Practitioner who works in concert with a
physician specializing in Infectious Disease.
The Infection Control Department is staffed with a certified Infection Preventionist. The specific qualifications are
outlined in staff job descriptions, which can be found in the Human Resources Personnel Files.
Staff performance and competency is evaluated at least annually and documented in a performance appraisal tool.
Infection Prevention and Control develops policies based on recommendations from the CDC, APIC, OSHA, AORN,
DHS, Joint Commission, CMS and the county DPHS.
Infection Prevention and Control works closely with Nursing, Plant Operations, Risk Services, Quality Management,
Environmental Services, Food and Nutrition Services and Employee Health Services to carry out the key functions of
the department and meet the departments goals.
Communication
and safety. Communication methods include one-on-one discussion, staff meetings, committee minutes, visual aids
(posters, flyers, etc.), and e-mail.
Infection Prevention and Control participates in hospital-wide and department-specific performance improvement
to staff within the departments individually or through the specific department leadership.
Department involvement in performance improvement initiatives is related to the scope of service of the Infection
Prevention and Control.
Materials Management
Materials Management provides and distributes patient care supplies to a centralized location in each clinical
department.
Key Functions
Key functions of Materials Management include:
Stocking of patient care supplies to departments
Assessing dates of sterile supplies maintained in the central locations on each patient care unit.
Patient charges of supplies
Hours of Operation
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Materials Management provides supply services 24 hours per day/7 days per week.
Staffing
Materials Management is routinely staffed with department technicians and office staff. Staffing schedules are
developed based on historical analysis of patient census/procedures and is adjusted based on the current days
census and expected admissions, transfers and discharges. Additional staff can be obtained through overtime.
Materials Management is staffed with appropriately qualified personnel. The specific qualifications are outlined in
Materials Management develops policies based on recommendations from AAMI (American Association of Medical
Instrumentation) and ASHCSP (American Society of Hospital Central Service Personnel).
guidelines and structure for consistent and safe care to the patient. Additionally, a service-specific clinical book
provides guidelines for service-specific procedures.
Materials Management works closely with the operating rooms, emergency department, inpatient and ancillary areas
to carry out the key functions of the department and meet the departments goals.
Communication
information. Communication methods include shift to shift report between staff and communication throughout the
shift to assure patient care needs are met and telephonic communication with patient care units to meet special
supply needs.
Materials Management participates in hospital-wide and department-specific performance improvement activities.
Medical Records/Health Information Management Department

Medical Records/Health Information Management is responsible for overseeing the timely processing, completeness,
and retrieval of all patient medical records. Services provided by Medical Records/Health Information Management
are based upon a collaboration and information sharing format to enhance patient care. Medical records services
are provided to all areas of the organization, as appropriate to need and security levels.
Key Functions
Key functions of Medical Records/Health Information Management include:
Provision of an accurate patient record
Record abstracting, analysis and coding
Transcription of dictation for the medical record
Correspondence/Release of Information
Record retrieval, filing and storage
Accessibility of the medical record at all times to those authorized persons requesting use for patient care;
Hours of Operation
Hours of Operation
Medical Records/Health Information Management is open from 8am to 4:30pm Monday through Saturday. The
House Supervisor has access to the department and all medical records and is available during closed hours.
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Staffing
Medical Records/Health Information Management is routinely staffed with a Department Director, a lead technician, ,
a coding supervisor Medical Records, Technicians, coders and clerks. Staffing on each shift is constant with a set
number of employees on each shift including one staff member on the night shift.
Medical Records/Health Information Management is staffed with appropriately qualified personnel. The specific
Medical Records/Health Information Management develops policies based on recommendations from the American
Health Information Management Association, California Health Information Management Association, Joint
Commission, California Code of Regulations Title 22, CMS and applicable federal and state law regarding
confidentiality and handling of patient medical records including the Health Insurance Portability and Accountability
Act (HIPAA).
guidelines and structure to for consistent and safe care to the patient.
Medical Records/Health Information Management works closely with several departments to carry out the key
functions of the department and meet the departments goals. These departments include but are not limited to:
Patient Registration, Emergency Department, Quality Management Department, Medical Staff Services, Case
Management, inpatient and outpatient care units and Administration.
Communication
information. Focus of communication is on continued customer service in providing records for patient care in a
timely and efficient manner. Communication methods include department meetings and minutes, in-service training,
memos and e-mail.
Medical Records/Health Information Management Department participates in hospital-wide and department-specific
Department involvement in performance improvement initiatives is related to the scope of service of Medical
Records/Health Information Management Department
Spiritual Care Services

Spiritual Care Services works collaboratively with patient care staff to meet the spiritual needs of inpatients,
outpatients, family and staff, representing diverse spiritual and religious perspectives. Any patients expressing desire
for care from various denominations are afforded timely contact with those religious/spiritual leaders through referral
and contact by members of the Spiritual Care Department. Spiritual Care Services provides care to neonates,
pediatrics, adolescents, adults and geriatric patients and their families/friends.
Spiritual Care is available to all persons in the facility regardless of religious affiliation. Spiritual care is provided from
community resources and can be initiated by the patient, family, hospital personnel or Spiritual Care Department
members. All patients are visited by members of the Spiritual Care Department to assess need for spiritual care and
comfort.
Key Functions
Key functions of Pastoral Care include
Assessment of spiritual practices and distress
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Crisis intervention and family support

Grief assessment and interventions,
Patient/family education regarding Advance Directives and bereavement resources
Prayer/scripture and sacramental/ritual support
Spiritual/emotional counsel and support.
Hours of Operation
Spiritual Care is available Monday through Saturday during regular work hours by Spiritual Care staff. Catholic
priests are available on call during the night or off hours in the event of an emergency should the family request this.
Staffing
Spiritual Care is routinely staffed with trained chaplains. Minimally one chaplain is staffed. Staffing schedules are
developed based on historical analysis of patient census/treatments. Staffing is adjusted based on the current days
census and expected admissions, transfers and discharges.
Spiritual Care is staffed with appropriately qualified personnel. The specific qualifications are outlined in staff job
descriptions, which can be found in the Human Resources Personnel Files.
Spiritual Care works to develop population-specific policies based on recommendations from the National
Association of Catholic Chaplains.
Spiritual Care Services works closely with a multidisciplinary team of health care providers specific to the patients
needs to facilitate diagnostic treatment and support of the care plan. The Spiritual Care team works closely with
Department Leadership during times of staff crisis.
Communication
Shift to shift report between chaplains.
Verbal report provided for patients who are transferred between levels of care or from other nursing care
departments.
Spiritual Care participates in hospital-wide and department-specific performance improvement activities. Data is
department. Annually and as opportunities present, performance improvement initiatives are identified and prioritized.
Department involvement in performance improvement initiatives is related to the scope of service of Spiritual Care.
Medical Records/Health Information Management Department participates in hospital-wide and department-specific
Department involvement in performance improvement initiatives is related to the scope of service of Medical
Records/Health Information Management Department
Plant Maintenance & Operations Services Department & Biomedical Engineering

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The Plant Maintenance & Operations Services Department &Bio-Medical Engineering Department is responsible for
the organization's equipment management program, condition of the physical plant; including all grounds and
equipment.
Key Functions
Key functions of the Plant Maintenance & Operations Services Department &Bio-Medical Engineering Department
include:
Inspection and maintenance of all equipment in accordance with the equipment preventive maintenance
system, either directly through the Plant Maintenance & Operations Services Department &Bio-Medical
Engineering Department or via outside vendor contracting.
Oversight responsibility for the safety and security of the organization, including the Safety Management
Program, physical condition of the plant and grounds and security of patients, personnel and visitors. is
responsible for the organization's equipment management program. The program assesses and controls the
clinical and physical risks of fixed and portable equipment used for the diagnosis, treatment, monitoring and
care of patients. will ensure the safety of patients and maintain life safety equipment. Provide reliable utility
system; maintain specialty equipment systems unique to the Hospital such as med gas, vacuum, etc.
The Plant Maintenance & Operations Department systems that maintain a normal hospital environment are supplied
or maintained and recorded on an individual basis within the system. Inspection, maintenance and repair of the
following categories of equipment and documentation thereof is the responsibility of the following departments:
Imaging equipment
Radiology/Imaging Services
Laboratory testing equipment
Laboratory
Anesthetic delivery equipment (including analyzers)
Surgery
Computer terminal equipment
Data Processing/Information Systems
Communication lines
PBX/Business Office
Personal computers
Desktop Publishing/Data Processing/
Information Systems
Telecommunications equipment
PBX/Business Office
Verification oxygen purity & nitrous oxide at the point of patient delivery Cardiopulmonary
Hours of Operation
The Plant Maintenance & Operations Services Department &Bio-Medical Engineering Department provides services
24 hours per day/7 days per week.
Staffing
Plant Maintenance & Operations Services Department & Bio-Medical Engineering Department is routinely staffed
with Engineers, Technicians, Painters, Clerical staff, and Management. Minimally each shift is staffed with 1
Engineer in Plant Maintenance & Operations. Bio-med is staffed with one Engineer Monday through Friday 7:00 am
3:30 pm. After hours is staffed by an Engineer on-call. Staffing schedules are developed based on the need to
keep the generators, boilers & associated utilities in working order. Staffing is adjusted based on preventative
maintenance & inspection schedules. Additional staff can be obtained through overtime, part-time or per diem staff.
Plant Maintenance & Operations Services Department &Bi- Medical Department staff possess the skill level in order
to provide safe, competent and accurate services. Personnel must possess knowledge of safety program policies
and procedures including a thorough understanding of the "Safe Medical Device Act of 1990."The specific job
Plant Maintenance & Operations Services Department & BioMedical Engineering Department develops policies and
management plans that are based on Joint Commission Standards, and Federal, State and County regulations.
guidelines and structure
.
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Plant Maintenance & Operations Services Department & BioMedical Engineering Department works closely with all
departments to carry out the key functions of the department and meet the departments goals.
Communication
Various modes of communication are used to assure communication of key information. Focus of communication is
on identification and mitigation of issues that may affect the safety of staff, visitors and patients. Communication
methods include shift-to-shift report between staff completed through verbal and written report, work orders and
telephonic communication methods with departments.
The Plant Maintenance & Operations Services Department &Bio-Medical Engineering Department participates in
hospital-wide and department-specific performance improvement activities. Data is collected for analysis and action
planning as needed. Results and action plans are communicated to staff within the department.
Department involvement in performance improvement initiatives is related to the scope of service of Plant
Maintenance & Operations Services Department &Bio-Medical Engineering Department.
Safety and Security

Safety and Security Departments maintain a safe and secure environment for patients, visitors and hospital
personnel.
Key Functions
Key functions of Safety and Security include:
Risk assessments through the multidisciplinary Safety Committee
Monitoring of sensitive areas
Serve as a resource for security/safety information, equipment, supplies and training.
Random hospital and ground patrol
Provides escorts and directions
Access control to hospital facilities
Response to calls for assistance in assault/combative behavior incidents,
After hours visitor control
Response to all codes with the exception of Code Blue
Hours of Operation
The Safety and Security Department is staffed 24 hours/day 7 days per week.
Staffing
The Safety and Security Department is routinely staffed with the Safety/Security Supervisor and Security Officers.
Additional resources are available through Hospital Administration approval.
The Safety and Security Department is staffed with appropriately qualified personnel. The specific qualifications are
outlined in staff job descriptions, which can be found in the Human Resources Personnel Files or in agency staff files.
The Safety and Security Department develops policies based on recommendations from the Safety Committee and
regulatory commissions.
Policies and Procedures within the EOC manual, specifically the Safety and Security sections, provide guidelines and
structure for the services provided to patients, visitors and staff. Policies and procedures within the Administrative
Policy Manual provide additional guidelines and structure.
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The Safety and Security Department works closely with all departments to carry out the key functions of the
Communication
on site condition, recent or anticipated changes and safety. Communication methods include attendance and/or
transcripts of various committees, interdepartmental meetings, emails and telephonic communications with
departments.
The Safety and Security Department participates in hospital-wide and department-specific performance improvement
Department involvement in performance improvement initiatives is related to the scope of service of the Safety and
Security Department.
Social Services
The Social Services Department provides clinical services to patients in all areas of the hospital. Special patient
populations include Emergency Department, Maternal/Child Health and Pediatrics patients which have specific
requirements for social services as defined by federal, state or regulatory requirements. The department provides
care to all ages of the hospital population, including: neonatal, pediatric, adolescent, adult and geriatric populations.
Key Functions
Referrals for all Social Services are accepted from physicians, hospital personnel, patients, families, outside
agencies and other healthcare professionals as appropriate. Referrals may be made in person, by telephone or
written contact. The Social Worker works closely with the interdisciplinary teams to develop a holistic plan of care for
the patient.
Key functions of Social Services include
Patient assessment
Development of a care plan
Staff consultation
Discharge planning
Collaboration with external agencies
Referrals to community resources
Hours of Operation
Social Services staff are available onsite 8am to 5pm Monday through Friday, except holidays. During closed hours,
Social Services staff is contacted through the nursing supervisor.
Additional staff can be obtained through use of overtime, per diem staff or contracted agency staff.
The Social Services Department is staffed with appropriately qualified personnel. The specific qualifications are
outlined in staff job descriptions, which can be found in the Human Resources Personnel Files or in the agency staff
files. All staff receive specialized training and are certified as designated individuals to apply for 5150 involuntary
holds. Social workers are licensed or certified.
The Social Services Department works closely with Physicians to develop population-specific policies based on
recommendations from Title 22, NASW Ethics, Joint Commission, CMS, California Consent Manual and Standards of
Practice.
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Volunteers
The Volunteers of Saint Louise Regional Hospital provide various assistance to patients, visitors, staff and
physicians. Volunteers staff the information desk and patient services desk to assist family with directions, run
errands for various hospital departments, and provide customer service to all visitors and patients. Other
departments include the gift shop, emergency department, and other departments as needed.
Key Functions
The key function of the Volunteers is to provide volunteer services throughout the hospital. Delivering flowers,
messages and locating patients for their visitors as well as walking them to their destination are but a few of their
services. Many volunteers work within various departments and work as directed by staff.
Hours of Operation
The Volunteers provide services during the day and evening hours. Each volunteer signs up for his or her scheduled
hours each month.
The Volunteers are staffed with appropriately qualified personnel. The specific qualifications are outlined in the
Volunteer job descriptions, which can be found in the Volunteer Department.
Volunteers receive orientation and in-Service training on an annual basis, to keep them up-to-date with hospital
policies and protocol.
The Volunteer Department works closely with several departments to provide service assistance as requested.
Communication
on identification of a need and completing the process to resolve the need within the scope of the Volunteer.
Communication methods include communication between individual volunteers, meetings, memos, and quarterly
newsletters.
Administrative Support Departments

Administration
The Administration department of Saint Louise Regional Hospital provides ongoing operational and administrative
support to the entire organization.
Key Functions
Key functions of the Administration department are administrative oversight and support to department personnel in
the entire hospital.
Hours of Operation
The Administration department provides services Monday through Friday 8:00am to 5:00pm. The Hospital President
or a designated representative will be available at all times to provide administrative support to personnel of the
organization. In the absence of the Hospital President, the administrator on-call will be fully responsible for the
medical center and will act in consultation with other senior leaders as indicated/available. When a need arises
during closed hours, the Hospital President or Administrator on-call can be reached by contacting the House
Supervisor.
Staffing
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The Administration Department is routinely staffed with Administrators and administrative assistants.
The Administration Department is staffed with appropriately qualified personnel. The specific qualifications are
The Administration Department works closely with all departments to carry out the key functions of both
Administration and the hospital departments and meet established hospital goals.
Communication
and safety. Communication methods include daily communication between Administrators, the House Supervisor,
Administrator on-call, and other Administrators completed through daily reports and conference calls throughout the
day.
The Administration Department participates in hospital-wide performance improvement activities. Data is collected
for analysis and action planning as needed. Results and action plans are communicated to staff within the
department.
Department involvement in performance improvement initiatives is related to the scope of service of Administration.
Employee Health Services

Saint Louise Regional Hospital Employee Health Services provides for and delivers health and safety services to
associates, physicians and volunteers. The practice focuses on promotion and restoration of health, prevention of
illness and injury, and protection from work-related and environmental hazards.
Key Functions
Key functions of Employee Health Services include:
Performing annual health requirements of Tuberculosis skin testing and Respirator Fit testing
New hire physical examinations and medical clearance
Assessment of ill/injured associates
Yearly biometrics review
Workers compensation injury/risk management
Ergonomic evaluation
Transitional work management
Yearly influenza vaccination program, insuring compliance with local, state, and Federal regulations.
Hours of Operation
The Employee Health Services department is open and provides services Monday through Friday from 8:00 AM to
4:00 PM. If an emergency arises during off hours, associates, physicians and volunteers should be assessed and
treated in the Emergency Department. Non-emergent injuries/illnesses should be seen in Employee Health Services
the next business day.
Staffing
Saint Louise Regional Hospital Employee Health Services is routinely staffed with an Occupational Health Nurse.
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The Employee Health Services department is staffed with appropriately qualified personnel to include a Registered
Nurse certified as required. The specific qualifications are outlined in staff job descriptions, which can be found in the
Human Resources Personnel Files.
The Employee Health Services department develops policies based on recommendations from the California Nursing
Practice Act, American Association of Occupational Health Nurses Standards of Occupational and Environmental
Health Nursing, and the Core Curriculum for Occupational and Environmental Health Nursing, Third Edition, Joint
Commission, CMS and local, state, and Federal regulations.
guidelines and structure to assure consistent and safe care to associates, physicians and volunteers.
The Employee Health Services department works closely with Infection Control, Patient Care units, Human
Resources and all other departments of the organization,
Communication
Various modes of communication are used to assure continuity of associate, physician and volunteer health, care
and communication of key information. Communication methods include emails of work-related injury status and
other vital information within the strictures of patient confidentiality and verbal communication by telephone and in
person.
The Employee Health Services department participates in hospital-wide and department-specific performance
communicated to those with a need to know.
Department involvement in performance improvement initiatives is related to the scope of service of Employee
Health Services.
Financial Operations
Financial Operations is responsible for providing all financial functions of the organization to leadership and focus
performance improvement teams.
Key Functions
Key functions of Financial Operations include:
Accounts receivable
Accounts payable, including patient refunds, payroll, financial statements, budgeting, financial regulatory
reporting, including OSHPD and cost reports.
Support to all patient care providers throughout the organization for all data-related to the financial operation of
specific units and how this interrelates with the organizational mission and values.
Hours of Operation
The Financial Operations Department provides services 8am to 5pm, Monday through Friday, except holidays.
Staffing
The Financial Operations department is routinely staffed with qualified individuals in each of the major department
functions.
The specific qualifications for each job are outlined in staff job descriptions, which can be found in the Human
Resources Personnel Files.
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The Financial Operations department develops policies based on recommendations from CMS and published best
practices.
guidelines and structure to assure consistent and safe care to the patient.
The Financial Operations department works closely with all organization departments and the System Finance
Department.
Communication
Various modes of communication are used to assure communication of key information. Communication methods
include financial reports, both routine and as needed, email and verbal/telephonic conversations.
The Financial Operations department participates in hospital-wide and department-specific performance
Department involvement in performance improvement initiatives is related to the scope of service of Financial
Operations.
Human Resources
The Human Resources department provides support services to the hospital in the following key areas: employment
on boarding, recruitment, benefits administration, workforce planning, policy development and review,
employee/labor relations, training, reward and recognition programs, associate safety program and performance
management.
Key Functions
Key functions of the Human Resources department are administrative oversight and management of the human
capital assets of the hospital.
Hours of Operation
The Human Resources department provides services Monday through Friday 8:30am to 5:00pm. The Hospital Vice
President of Human Resources or a designated representative will be available to provide services to personnel at
the medical center. In the absence of the Hospital Vice President, the Human Resources Generalist (s) can be
responsible for the human resources services and act in consultation with other senior leaders as indicated/available.
When a need arises during closed hours, the Hospital Vice President or Administrator on-call can be reached by
contacting the Administrative Nursing Supervisor.
Staffing
Saint Louise Regional Hospital Human Resources Department is routinely staffed with one Administrator and two
Human Resources Generalists. The Human Resources Staffing ratio to employees is .78 (HR FTE x EE FTE x100 =
ratio).
The Human Resources Department is staffed with appropriately qualified personnel. The specific qualifications are
Human Resources Practice Guidelines
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Policies and procedures within the Human Resources Policy umbrella of responsibilities provide guidelines and
structure to for consistent application of various employment and regulatory requirements to ensure safe care to the
patient and minimize liabilities. Additionally, the staff is tasked to source, track, monitor, and enforce key compliance
requirements for the following: licensure, certification, OIG, background checks, performance evaluation,
competencies, and policy adherence as prescribed by Joint Commission and Department of Public Health.
The Human Resources Department works closely with all departments to carry out the key functions of Human
Resources to assist and meet established hospital goals.
Communication
on recruitment and selection, on boarding employment process, working with Employee Health for screenings and
drug testing, licensure/certification source verification and all background check requirements, performance
management tracking, employee assistance communications, benefit and retirement fairs and updates, payroll, union
negotiations, recognition awards, and wellness initiatives. In addition, any substantial changes or new employment
law regulations that may impact operations. Communication methods may include daily communication between
Human Resources and key stakeholders (associates, directors, executives, system office, and union
representatives). Communication vehicles include attending department staff meetings, fairs, emails, walk-ins, and
phone.
The Human Resources Department participates in hospital-wide performance improvement activities. Data is
department.
Department involvement in performance improvement initiatives is related to the scope of service of Human
Resources and what they are responsible for relative to Joint Commission HR standards, Department of Public
Health, and other Federal and State law provisions governing the work.
Information Systems Department

The Information Systems Department provides for the software, hardware and support needs of the patient care
providers, as well as office automation. The Department is a critical component of the organization-wide information
management system.
Key Functions
Key functions of the Information Systems Department include:
Installation of new software systems, along with the hardware and training necessary to utilize such systems
Ongoing maintenance of current hardware and repair of such hardware.
The Information Systems Department is an important part of the decision team used in making selections of
appropriate software systems to provide support in short and long-term planning for the patient care information
needs of the organization.
Hours of Operation
The Information Systems Department is open from 8am to 5pm, Monday through Friday, except holidays.
The Information Systems Department provides services during closed hours via service desk 24/7.
Staffing
Information Systems Department is routinely staffed with Information Systems Technicians. Department staffing is
constant.
Page 45 of 48
The Information Systems Department is staffed with appropriately qualified personnel. The specific qualifications are
The Information Systems Department develops policies based on recommendations from evidence-based
information, Joint Commission standards and state and federal regulations.
The Information Systems Department works closely with all departments to accomplish the goals of the department
and organization.
Communication
Various modes of communication are used to convey key information. Communication methods include
verbal/telephonic communications, emails and ARCIS education.
The Information Systems Department participates in hospital-wide and department-specific performance
Department involvement in performance improvement initiatives is related to the scope of service of Information
Systems Department.
Medical Staff Office

The Medical Staff Office provides liaison services between Saint Louise Regional Hospital and the medical staff.
Key Functions
Key functions of Medical Staff Office include:
Coordinates medical staff credentialing and privileging, to include proctoring, and for medical staff
reappointments.
Coordinates OPPE and FPPE with other departments.
Advises the Medical Staff Leadership on the appropriateness of actions under consideration with respect of
the Medical Staff Bylaws, Rules and Regulations, and other regulatory bodies.
Provides administrative support and functional guidance to the medical staff committees relative to the medical
staff responsibilities.
Provides support for ad hoc meetings, peer review and coordinating actions as needed.
Acts as a vehicle of communication of policies and other documents through the appropriate medical staff
committees.
Hours of Operation
The Medical Staff Office provides services from 8:30am to 5pm, Monday through Friday, except holidays.
The Medical Staff Office provides services during closed hours via the House Supervisor with respect to physician
privileges online. The Hospital Administrator On-Call provides additional support during closed hours.
Staffing
The Medical Staff Office is routinely staffed with a Medical Staff Office Director and a Credentialing Coordinator.
Staffing is flexed to support medical staff meetings and medical staff functions as needed.
Page 46 of 48
The Medical Staff Office is staffed with appropriately qualified personnel. The specific qualifications are outlined in
The Medical Staff Office implements processes based on the Medical Staff Bylaws, Rules and Regulations, Joint
Commission and CMS regulations.
guidelines and structure for consistency.
The Medical Staff Office works closely with clinical departments, Medical Records, Quality Management and
Administration to carry out the key functions of the department.
Communication
information. Emails, faxes, committee meetings and posters are conduits of information generated for the medical
staff. Urgent communications are accomplished via telephone and email modes.
The Medical Staff Office participates in hospital-wide and department-specific performance improvement activities.
Data is collected for analysis and action planning as needed. Results and action plans are communicated to the
medical staff within the department via the medical staff department chairs.
Department involvement in performance improvement initiatives is related to the scope of service of the Medical Staff
Office.
Quality Improvement Department

The Quality Improvement Department coordinates the organization-wide performance improvement program, which
is designed to establish, support, maintain and document the improvement of patient care and service. The
members of the department facilitate compliance with all regulatory standards regarding performance improvement
through a variety of activities, including support of medical staff and hospital committees that focus on improvement
of systems and processes. The department gathers data and provides reports as necessary to the leadership, and
provides education to medical staff and associates regarding performance improvement. The members serve as a
resource to the hospital in matters of performance improvement.
Key Functions
Key functions of Quality Improvement Department include:
Coordinating, conducting, monitoring and reporting quality control and performance improvement information
Coordination of regulatory and accreditation surveys and provision of interpretation of regulation and standard.
Policy and procedure management
Hours of Operation
The Quality Improvement Department is open from 8am-5pm, Monday through Friday, excluding holidays.
The Vice President of Quality and Risk Management is available during closed hours via the nursing supervisor.
Staffing
The Quality Improvement Department is staffed with licensed RNs with applicable certification and experience.
The Policy and Procedure Project Manager provides support for leadership regarding the formatting, routing and
posting of hospital policies. The department is accountable to the Vice-President of Quality and Risk Management.
Page 47 of 48
The Quality Management Department is staffed with appropriately qualified personnel. The specific qualifications are

Policies and procedures within the Administrative Policy Manual provide guidelines and structure to assure
consistent and valid data reported. Additionally, a measure/study-specific abstraction guideline provides direction for
core-specific abstractions.
The Quality Improvement Department works closely with Risk Management, Health Information Management,
Medical Staff Office, Administration and other hospital departments to facilitate timely abstraction and reporting of
data. Additionally, the department works with various departments, physicians and teams on quality initiatives.
Communication
Various modes of communication are used to assure accuracy and timeliness of data abstraction and communication
of key information. Focus of communication is on identification of cases/events, abstraction requirements, accuracy,
recent or anticipated changes and timeliness. Communication methods include electronic and paper reports and
memos, phone calls and meetings.
The Quality Improvement Department coordinates hospital-wide and department-specific performance improvement
Department involvement in performance improvement initiatives is related to the scope of service of the Quality
Improvement Department.
Risk Management
Risk Management provides assessment and identification of risk issues and works with leadership, medical staff and
staff to mitigate identified problems.
Key Functions
Key functions of Risk Management include:
Assessment and identification of loss potential
Development and measurement of the effectiveness of loss prevention programs
Provide educational activities to increase the knowledge of the governing body, administration, associates,
medical staff, volunteers and visitors with regard to risk potential and mitigation
Act as hospital liaison to corporate risk management, attorneys, insurance and claims management entities
Manage the incident reporting and grievance tracking system in collaboration with the Patient Advocate
Patient Safety
Assists hospital leadership and medical staff in tracking and trending risk data related to patient care and
operations.
Hours of Operation
Risk Management is available 9a-5pm, Monday through Friday except holidays.
The Director of Risk Management is available during closed hours via pager and cell phone. When a need arises
during closed hours, the Risk Director can be reached by contacting the Hospital Operator.
Staffing
Saint Louise Regional Hospital Risk Management department is routinely staffed with one Director of Risk
Management. Additional staff can be obtained through per diem staff.
Page 48 of 48
Risk Management is staffed with a certified Risk Manager. The specific qualifications are outlined in staff job
descriptions, which can be found in the Human Resources Personnel Files.
Risk Management develops policies based on recommendations from the California Consent Manual, Joint
Commission standards, CMS regulations and evidence-based clinical practice guidelines.
Risk Management works closely with Daughters of Charity corporate office, attorneys, insurance departments,
hospital leadership, physicians, and all hospital departments to facilitate quality of care, and a safe environment.
Communication
Various modes of communication are used to communicate key information. Communication methods include
memos, emails and educational presentations.
Risk Management participates in hospital-wide and department-specific performance improvement activities. Data is
department.
Department involvement in performance improvement initiatives is related to the scope of service of Risk
Management.
REPLACES:
APPROVED BY
Administration
Medical Executive Committee
Board
DATE APPROVED
11/16/12, 07/13
07/24/13
09/05/13

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SAINT LOUISE REGIONAL HOSPITAL

SUBJECT: PLAN FOR THE PROVISION OF PATIENT CARE

Identify existing and potential new patient care services

SAINT LOUISE REGIONAL HOSPITAL SCOPE OF SERVICES

Plan for the Provision of Patient Care -2013

PLAN FOR THE PROVISION OF PATIENT CARE

HOSPITAL MISSION, VISION AND VALUES:

Plan for the Provision of Patient Care -2013

PLAN FOR THE PROVISION OF PATIENT CARE

Developing organization-wide patient care programs.

PLANNING FOR PATIENT CARE

PLAN FOR THE PROVISION OF PATIENT CARE

STAFFING FOR PATIENT CARE

RECRUITMENT, RETENTION AND STAFF EDUCATION

PLAN FOR THE PROVISION OF PATIENT CARE

DEFINITION OF PATIENT CARE SERVICES

PROFESSIONAL PRACTICE OF NURSING

PLAN FOR THE PROVISION OF PATIENT CARE

INTEGRATION AND FUNCTIONAL RELATIONSHIPS OF PATIENT CARE SERVICES

PATIENTS ENTERING SAINT LOUISE REGIONAL HOSPITAL

Scheduled surgeries or admissions.

Plan for the Provision of Patient Care -2013

PLAN FOR THE PROVISION OF PATIENT CARE

PATIENT CARE DEPARTMENTS

Breast Care Center

PATIENT SUPPORT DEPARTMENTS

ADMINISTRATIVE SUPPORT DEPARTMENTS

PATIENT CARE PERFORMANCE IMPROVEMENT ACTIVITIES

PLAN FOR THE PROVISION OF PATIENT CARE

EVALUATION OF PLAN AND SERVICES

Plan for the Provision of Patient Care -2013

PLAN FOR THE PROVISION OF PATIENT CARE

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PLAN FOR THE PROVISION OF PATIENT CARE

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PLAN FOR THE PROVISION OF PATIENT CARE

Shift to shift report between caregivers completed through department report.

Procuring laboratory test samples in an efficient, timely manner.

Producing accurate laboratory test results.

Correlating and interpreting laboratory test data.

Disseminating laboratory test information to clinicians and patients in a timely manner.

PLAN FOR THE PROVISION OF PATIENT CARE

Critical Care Unit

PLAN FOR THE PROVISION OF PATIENT CARE

Plan for the Provision of Patient Care -2013

PLAN FOR THE PROVISION OF PATIENT CARE

De Paul Urgent Care

PLAN FOR THE PROVISION OF PATIENT CARE

Plan for the Provision of Patient Care -2013

PLAN FOR THE PROVISION OF PATIENT CARE

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Food and Nutrition Services Department

7:00 a.m. 4:00 p.m. Monday Friday

Plan for the Provision of Patient Care -2013

PLAN FOR THE PROVISION OF PATIENT CARE

6:00 a.m. 2:30 p.m. Monday through Friday

Maternal Child Health

PLAN FOR THE PROVISION OF PATIENT CARE