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0 Volunteer Services

Policies and Procedures Handbook May 2018

St. Michael’s Hospital

Volunteer Services Handbook May 2018 - 2 -

Welcome to St. Michael’s

Thank you for your donation of volunteer time. St. Michael’s relies on the dedication of people like you to ensure our patients, families and visitors receive the service they deserve. We trust you will find your volunteer experience to be interesting as well as enjoyable and rewarding. This handbook will help you to become familiar with the policies and procedures for volunteers.

For additional information, please refer to your volunteer

orientation at tinyurl.com/SMHVolunteerOrientation

The Volunteer Role Every volunteer position has a specific set of tasks and duties. Volunteers must always work within this role definition and within the boundaries that are set out during volunteer orientation or that are explained by the staff in your area. The unit staff or an experienced volunteer in your placement area will provide an orientation and training to your new area. If you are unsure whether a duty you have been asked to perform is within the guidelines for a volunteer, discuss it with your supervisor and let them know your concern (see Volunteer



Boundaries on pg 13). Direct communication with staff is the most efficient way to address any problems and avoid them in the future. If you are uneasy about your duties, please discuss the issue with Volunteer Services. It is always best to address your concerns early to ensure a successful placement for you and the team you are working with. Your Placement Supporting volunteers at St. Michael’s is a shared responsibility between the Volunteer Services Department and the individual units or service areas. Building a relationship with the staff team and maintaining an open line of communication is the most effective way to approach your volunteer role, and address any concerns or questions that may come up during your volunteer placement. Attendance When you commit yourself to do volunteer work at a specific time, the patients and staff are counting on you to be there. Therefore, it is important to be punctual and conscientious in your responsibilities as a volunteer. Volunteers must be regular and prompt in reporting to their placement area and remaining for the entire shift. Signing In



Volunteers need to sign in and sign out every time they volunteer. The Attendance Computer is located on the counter in Volunteer Services. This record is necessary to comply with hospital reporting policies, in case we need to find you in the hospital and to confirm your hours of service for recognition purposes. Planned Absences If you cannot attend your volunteer shift for any reason or you wish to take time off (for vacation, etc), please notify your placement area and Volunteer Services as soon as possible. Volunteers, for legitimate reasons, may also request to be placed on a leave of absence (LOA). If LOA is granted, we cannot guarantee your placement/time will be available when you return. Unreported Absences If you do not sign in for three (3) consecutive weeks without contacting Volunteer Services or if your attendance shows a pattern of infrequent volunteering, the Hospital reserves the right to determine terminated your service and we may discontinue your placement. Statutory Holidays The statutory holidays are as follows:



New Year’s Day, Victoria Day, Labour Day, Boxing Day, Family Day, Canada Day, Thanksgiving, Good Friday, Civic Holiday (August), Christmas Day. The Volunteer Services Office is closed during the above statutory holidays. If a volunteer chooses to come in for their volunteer shift, they should first check if their placement unit is open for the holiday. Volunteer Services Lounge can be opened using the door code. There are also two additional hospital holidays specific to St. Michael’s (one in November and one in June). Volunteer Services will remain open for these two holidays. Terms of Volunteer Service Volunteers in the regular program complete a minimum of 125 hours over a 12 month period and volunteers in the student program complete 70 hours in either an academic year or over the summer. If you would like a change of placement or schedule, you should get in touch with Volunteer Services who will gladly discuss this with you. Changing your Placement Volunteers may apply to change to another area or to another kind of volunteering. All such changes will be approved by Volunteer Services. Normally, such transfers will not be permitted until three months have been completed.



Resignation

While we hope that you will continue to benefit from your volunteering, we realize that it may become necessary for you to leave your position. If you anticipate having to resign your position, you are expected to complete the following steps:

1. Notify Volunteer Services at least 2 weeks prior to end date 2. Notify the staff of the placement area 3. Return uniform and ID badge before leaving (and get a

deposit refund) 4. Verify mailing address with Volunteer Services Department Performance

Volunteer Services is committed to providing the best possible volunteer service to the units and areas we serve. Where a volunteer’s performance does not meet the required standards, reasonable efforts will be made to assist the volunteer to succeed. Standards and expectations will be clearly outlined so that the volunteer is given a meaningful chance to improve. The unit staff and the Director, Volunteer Services will set up a meeting with the volunteer to discuss any performance concerns. Wherever possible, a progressive approach will be taken wherein the volunteer will be given concrete suggestions for change, opportunities for additional orientation or training, and timelines for improvement. This may also include a change in volunteer placement.

When a volunteer fails to meet required standards after being given this opportunity the volunteer may be dismissed. Dismissal



of volunteers is the responsibility of the Director, Volunteer Services. Breach of Policy

Volunteers who are found to be in breach of Hospital rules, policies or approved conduct will be given a reasonable opportunity to explain their behaviour. There may also be a review or investigation of the events. The Director, Volunteer Services maintains the right to suspend a volunteer while a final determination is made. If the determination is made to dismiss the volunteer, the dismissal of volunteers is the responsibility of the Director, Volunteer Services.

In rare cases where the breach is substantial, the Hospital reserves the right to impose an immediate dismissal.

When a dismissal occurs, the volunteer will be required to turn in their ID badge and exit the Hospital immediately. The volunteer will also be restricted from applying to volunteer with St. Michael’s Hospital in the future and no letters of reference will be provided.

Health and Safety Health Screening All volunteers must participate in the mandatory Health Screening process in the Corporate Health and Safety Services. All screening requirements must be completed with 30 days of initial volunteer registration.



Flu Shot Policy The hospital has a policy that requires staff, physicians, students and volunteers to either get a flu vaccination or wear a mask when they are in patient care areas of the hospital during influenza season. The hospital will provide flu shots each year at no cost. If you receive your flu shot from another source, you must provide the hospital with proof of vaccination. Illness or Accident If you feel ill before coming to the Hospital, notify your area and Volunteer Services that you will not be coming to your placement. If you are unsure about coming in, call the Corporate Health and Safety Services at 416-864-5013 for advice. Once you arrive at the Hospital and you feel ill or have an accident:

Minor accidents or illness

Notify the staff and then report to Corporate Health and Safety Services (2 Shuter)

The staff will complete an Incident Report

If you feel ill and are going home, Volunteer Services can provide you with an emergency TTC token or a taxi chit.

Major accidents or illness (i.e. bleeding, needle stick)

You should go directly to the Emergency Department.

The staff will complete an Incident Report. Please note that Corporate Health is only open Monday to Friday from 7am to 4pm. At all other times, please report to your



supervisor for advice on minor incidents and go directly to Emergency for serious incidents. ID Badges Every volunteer will be issued a St. Michael’s photo ID badge. The badge remains the property of the Hospital and must be reported immediately if lost or stolen. For the safety of everyone that works or visits the Hospital,

the badge must be worn at all times while you are in the hospital.

the badge will be worn in a manner which allows your name to be visible.

In certain cases, ID badges will be permitted to have first name and last initial (Jane B) where requested for safety reasons.

Insurance Volunteers are covered under the Hospital's liability insurance for the duties that they perform on behalf of St. Michael's Hospital and as outlined in their volunteer role. If a volunteer engages in activities outside of their role, they will not be covered by this policy. In the case of personal injury, volunteers are not covered by Workplace Safety and Insurance Board (WSIB) coverage. Therefore, all volunteers must have OHIP, other provincial coverage or private insurance. Co-op students are covered by



WSIB through their school board and must provide proof of coverage before the start of their co-op. Please also note that the Hospital is not responsible for lost, stolen or damaged personal property. The Hospital is not liable for any personal belongings stored in the Hospital. Emergency Codes The Hospital uses a series of coloured Emergency Codes to alert staff to incidents. Each colour represents a specific type of incident. As a volunteer, you will hear these codes on the Hospital speaker system, so please review them. Please note that during any type of “code”, volunteers have no responsibility to perform any duties or tasks. In the event of any emergency, volunteers should simply stay out of the way of the staff responding to the incident and follow any instructions given to them by the staff. Red* Fire Orange External Emergency Black Bomb Threat Brown Hazardous Spill Green Evacuation White Violent Person Yellow Missing Patient Blue Medical Emergency Pink Neonatal Medical Emergency Code OB Pregnant Patient Medical Emergency Amber Missing Infant Grey Internal Emergency



* during Code Red, all Hospital elevators will be disabled and all hallway doors will close automatically. Food and Beverage Policy St. Michael’s staff, physicians and volunteers cannot store or consume any food or beverage in patient care areas such as a patient room, an exam rooms or a workstation. Each unit will have an established “Designated Refreshment Area” in which you may eat and drink. These areas will be clearly identified with signage. Infection Control and Handwashing All members of the hospital community, including volunteers, play a role in controlling the spread of infection. Handwashing is the most important basic hygiene measure for preventing the spread of infection. Please follow the infection control and handwashing guidelines as outlined in Volunteer Orientation, and always obey the isolation and precaution signs posted on patient rooms. The signs are on, or near, the door to the patient’s room. If you encounter an isolation or precaution room, do not enter.

From time to time, individual hospital units may also identify that they have higher than normal incidents of a specific infection among the patients. Three of the most common are MRSA (methicillin resistant staphylococcus aureus), CDiff (Clostridium Difficile)



and VRE (Vancomycin-Resistant Enterococcus). If any such infection rate is declared on your unit, the unit may choose to suspend volunteering, as well as limit visiting, for a period of time until the infections have been eliminated.

Volunteer Conduct General Conduct St. Michael's Hospital is committed to the highest standards of conduct in our relationships with each other, and with the patients, and visitors to the Hospital. This means performing our work in accordance with all applicable policies, procedures, regulations and laws, and it also means being committed to follow the spirit (and not just the letter) of those principles and rules. As a volunteer at St. Michael’s, it is essential that your actions always reflect the St. Michael’s mission and values and promote a work environment that upholds St. Michael's commitment to providing compassionate patient care, to honesty and integrity, to dedication to our work, and to earning and maintaining the respect and trust of our colleagues. Refer to Appendix – Volunteer Service Agreement Volunteer Role Boundaries Please note that volunteers are not permitted to take on any tasks or responsibilities that can only legally be performed by a



member of a licensed or regulated profession (physician, pharmacist, physiotherapist, laboratory technician, etc.) or by a unionized employee. Volunteers must always be aware of their boundaries and ensure that they do not:

duplicate the work of paid staff

overlap with unionized positions

engage patients in clinical or medical conversations

offer medical advice

lift, touch or feed patients (even if asked or directed to by staff)

express religious, political or other personal beliefs

engage in any clinical activities (taking temperature, blood pressure, etc.)

perform any tasks or responsibilities that can only legally be performed by a member of a licensed or regulated profession

serve as a “patient bed sitter”

transport patients outside of the hospital

violate any Hospital privacy or confidentiality guidelines

sign anything or serve as a witness

borrow or accept money or gifts from patients

attend any clinical observation or medical procedure If you have any questions about your role or if you at any time you feel uncomfortable about a task, please contact Volunteer Services.

Dress Code



Another aspect of good customer service is presenting yourself in a professional manner. The volunteer uniform consists of a volunteer jacket or vest (or in some cases, a volunteer lanyard). Blue jeans should not be worn (except on Fridays) and shoes should be closed at the toes. Please also keep your uniform clean by taking it home to wash or by putting it into the Hospital laundry service (there is a drop box in Volunteer Services). Volunteers must also wear their ID badge at all times. Scent

Due to increased environmental sensitivities of our patients and visitors, volunteers should refrain from wearing perfumes, colognes, aftershaves or scented lotions. Harassment & Workplace Violence St. Michael's Hospital is committed to providing a work environment that is free from violence and harassment and where the dignity and self-esteem of every employee is respected. The Hospital considers workplace violence and/or harassment a serious offence that will not be tolerated or condoned. The Hospital also provides a confidential means to report and remedy any incidents should they occur. Please



contact Volunteer Services for more information or to report a concern. Computer Usage Access to Hospital information systems or computers will only be granted in exceptional circumstances and only with the approval of the unit Manager (not Volunteer Services). No volunteer may use a computer without the permission and agreement of the person to which that computer and/or workstation is assigned. The volunteer must log-in using their own hospital user ID and password.

Gifts and Solicitation Patients and families are often very grateful for the assistance and service provided by volunteers. However, it is inappropriate for volunteers to accept money or gifts. If a patient or family expresses a desire to give money or gifts, thank them and encourage them to make a donation to St. Michael's Hospital Foundation. Also, you may not promote or solicit your own charity, fundraiser, business enterprise, political agenda or religious beliefs while volunteering with us. Confidentiality and Discretion

As a volunteer of St. Michael’s Hospital, you may have access to information that is private and confidential. Anything you hear,



see or learn about any patient in the hospital must not be repeated. If you have a concern, you can share information with staff that are directly involved in that patient’s care. Further, volunteers should always be aware that as representatives of the Hospital, they have a duty to make our patients and visitors feel welcome. Volunteers should always show discretion in their public conversations. Conversations about clinical or medical subjects should be avoided, even if a specific patient is not the subject. You never know who may hear what you say. If you do need to share information or observations about a patient with staff, this should always take place in a confidential manner. Discussions about patients and their families are not appropriate in hallways, elevators and other public spaces.

In addition, if your volunteer role requires use of patient lists or surgery lists, it is your responsibility to maintain possession of that information during your shift and to destroy it at the end of your shift (using the approved shredding boxes on each floor). You must never take this information out of the Hospital. Inpatient Privacy If you are asked by a visitor or family member to help them find a patient on your floor, please direct them to the nursing station to speak to the staff. Do not use your patient list (census) to direct them to the patients' room because the census does not indicate whether or not the patient has requested to be "anonymous" or if they have any restrictions on who may visit. Our patients's have the right to restrict who may visit with them, but your lists will not give you this information so please send all visitors and family over to the nursing station.



Relationships with Patients or Families Outside of the Volunteer Role Volunteers will provide a respectful and caring support to our patients and their families/visitors. Volunteers must also remain within the appropriate ethical boundaries of a professional relationship. Volunteers must not engage in personal friendships or relationships with patients or their families/visitors. There must be no contact between the volunteer and patients/families outside of the hospital and outside of the volunteer relationship (this would include attending funerals of patients). Viewing Patient Exams or Procedures Volunteers are not members of the health care team and are not permitted to attend surgeries or other patient procedures. Under no circumstances should volunteers make their own arrangements to view a surgery or procedure. Coop Students may be granted special permission to observe as part of their coop curriculum, provided they abide by the appropriate policy and procedures.



Volunteer Agreement This agreement represents the general terms and conditions that govern my volunteer placement at St. Michael’s Hospital:

I have completed all sections of the Volunteer Orientation (in class or online) and I have received my Volunteer Services Handbook.

I understand that it is my responsibility to read and abide by the policies and rules as stated in the Volunteer Handbook, including but not limited to conduct, attendance, role boundaries, dress code, and safety.

I understand that I have a proactive responsibility to immediately disclose to St. Michael’s if I am convicted of a criminal offense after the date of my most recent volunteer criminal records check.

I know the hospital will have great trust and confidence in my conduct as a volunteer and I will always act in a manner to preserve that trust and confidence. I am committed to upholding a high standard of conduct in my relationships with both my St. Michael’s colleagues and with the patients and visitors to the Hospital.

All personal health information [i.e. information identifying an individual and relating to the provision of health care to that individual] and/or confidential information [i.e. information relating to the business of the Hospital] that I have access to or learn through my volunteering is to be treated as strictly private and confidential.

I will attend my regularly scheduled volunteer shifts and will notify my unit and/or Volunteer Services if I am unable to do so.

I will report to my shift in uniform and with my photo ID clearly visible.

I will record my daily attendance as a volunteer (or submit monthly by email where permitted).

I will notify Volunteer Services of any changes to my contact information.

At the end of my volunteer service, I will notify Volunteer Services at least two weeks in advance of my last date. The volunteer uniform and photo ID badge are the property of St. Michael’s and they will be returned at the end of my volunteer service.

I understand that Volunteer Services reserves the right to discontinue my volunteer status as a result of any of the following: a) failure to comply with the Hospital’s rules and regulations; b) unsatisfactory attitude, work, or appearance; c) absences without notification; d) poor attendance pattern, e) violation of the hospital conduct or harassment policies; f) any other circumstances which, in the judgment of the Hospital, would make my continued service as a volunteer contrary to the mission and values of St. Michael’s.



Contact Information

St. Michael's Hospital

30 Bond Street

Toronto, Ontario

M5B 1W8

416-360-4000

www.stmichaelshospital.com

Volunteer Services

416-864-5859 (tel)

416-864-6081 (fax)

Corporate Health and Safety Services

416-864-5013

Form No. 70411

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