Welcome to St. Luke’s-Roosevelt Hospital Center
SLRHC Mission, Description and History
Volunteer Department Mission and Organization
SLRHC Core Competencies
Fire Safety
Emergency Management and Codes
9 - 10
Infection Control
Hand Hygiene/Washing
Patient Rights
Cultural Competency
Language Services
Advance Directives
Privacy and Confidentiality
Accident Reporting
Standards of Customer Care
Volunteer Policies and Procedures
Responsibilities of Volunteers
Personal Conduct
Smoking Policy
Personal Use of Cell Phones & Electronics
Transport/Escort of Patients
Non-Discrimination and Anti-Harassment Policy
24 -26
Dress Code & Hygiene
Reporting Illnesses and Absences
Health Assessment
Performance Assessment
Letter of Service
Exit Interview
Welcome to St. Luke’s-Roosevelt Hospital Center. We are delighted to have you apply
to the Volunteer Department. Our hard-working and dedicated volunteers play an
important role at the Hospital Center and enrich the lives of our patients. Whether it is
helping an office worker or spending time with patients, each volunteer makes a
valuable contribution.
Opportunities for volunteers exist throughout St. Luke’s- Roosevelt. Some of the
assignments involve patient contact, while others entail office support. We will try to
place you in a position that will reflect a combination of your skills and interests with the
needs of the Hospital Center. Remember – whatever service you perform is vital to the
total care received by our patients. We hope that you find your volunteer experience
personally fulfilling and derive satisfaction from helping the Hospital Center provide the
highest quality care to its patients.
St. Luke’s – Roosevelt Hospital Center is committed to assuring that all staff members
and Volunteers are highly competent and consistently provide quality services to our
patients and our community. This handbook has been designed as a resource to help
volunteers develop and maintain their competence. Topics have been selected because
of their importance to our patients and our institution. It is essential that you carefully
review the Handbook at the time of your application and during each calendar year
thereafter. This is an institutional requirement that will help us to meet the mandates of
regulatory agencies such as The Joint Commission, the Occupational Safety and Health
Administration (OSHA) and the New York State Department of Health (NYSDOH).
If you have any questions about the content of the handbook and how it applies to you
and your assignment, be sure to discuss these issues with the volunteer administrator
for him/her to review with you.
After reviewing the handbook, please complete the test related to the content. Of
course, you may refer to the handbook to check for the accuracy of your answers. Give
your completed test to the volunteer administrator for him/her to review with you.
Please remember to continue to incorporate the information that you have reviewed into
your everyday practice.
You are very special to us. Thank you for your time and interest in joining the St.
Luke’s-Roosevelt Hospital volunteer team.
Kathleen Dalton, Director of Volunteer Services
The mission of St. Luke's Roosevelt Hospital Center is threefold
 Provide outstanding health care
 Provide the highest quality education to health care professionals
 Further research medical knowledge and develop excellence in health care
Our vision is to become the provider of choice for Manhattan's West Side communities.
St. Luke's-Roosevelt Hospital Center is a 1,076-bed, full-service community and tertiary
care hospital. We are centers of clinical excellence for cardiology, neurology, oncology
and much more. Plus, we are leaders in caring for the elderly, treating breast cancer,
and providing physical rehabilitation.
St. Luke's-Roosevelt Hospital Center consists of two separate locations - St. Luke's
Hospital at 1111 Amsterdam Avenue and Roosevelt Hospital at 1000 Tenth Avenue.
The St. Luke's and Roosevelt Hospitals were established in 1846 and 1871,
respectively. St. Luke's-Roosevelt was formed in 1979 by a merger of St. Luke's
Hospital, adjacent to the campus of Columbia University, and The Roosevelt Hospital,
located two blocks west of Columbus Circle.
We are part of Continuum Health Partners, which also includes Beth Israel, Long Island
College Hospital, and New York Eye and Ear Infirmary.
We Care about Community
Throughout our history St. Luke's-Roosevelt has placed strong emphasis on responding
with compassion and sensitivity to the unique needs of the communities we serve,
including areas whose residents have multiple social and economic challenges.
The Hospital Center's ability to serve these populations is enhanced through
relationships with groups including the William F. Ryan Community Health Center and
the Council Health Center, as well as through school-based clinics at area high schools.
St. Luke's-Roosevelt initiates and supports a wide range of community health-focused
activities and maintains an extensive network of relationships with churches and
community groups throughout the West Side and Upper Manhattan.
It is the mission of the Volunteer Department to provide St. Luke’s Roosevelt Hospital
Center (SLRHC) with highly competent volunteers who consistently provide quality
services to our patients to enhance the mission of the Hospital.
It is the philosophy of the Department to provide the Hospital with volunteers who are
committed to enhance patient care. It is the function of the Department to provide
qualified volunteers where needed in both patient and non-patient areas through
recruitment, orientation and training. Therefore, we do not have volunteer positions for
shadowing or observing physicians.
Volunteer support is available to most departments in the Hospital however, volunteers
in no way replace paid employees.
The Volunteer Services Department has two offices, one at the St. Luke’s site and one
at the Roosevelt site.
Janice Connolly
AVP Administration
Kathleen Dalton
Director Volunteer Services
Elizabeth Gillander
Assistant Director (SL)
Heather Brancatelli
Volunteer Coordinator (RH)
 Wear and conspicuously display, your hospital Identification (ID) badge at all
times while on premises
 Secure your personal belongings
 Safeguard patient, hospital, personal property
For immediate security response due to threatening, aggressive or violent behavior
For Security Emergencies at St. Luke’s and Roosevelt - Dial 4444
Inform the operator of a security emergency
the hallways
Security representatives are available 24 hours/day:
St. Luke’s: 212-523-1000
Roosevelt: 212-523-7512
Provide your name and location of the incident
Describe the nature of the incident
Provide information and description
 Stay Alert – observe who is in front of you and who is behind you. Don’t be
distracted by diversions
 Remain calm
 Without being obvious, take notice of details: clothing, behavior, means of
escape, unique features of persons
 Exhibit confidence
 When possible, let someone know where you are going and when you expect to
 Remember anyone can be a victim of crime at any time
 TRUST YOUR INSTINCTS – If you feel uncomfortable, walk away, consider your
options and notify security or seek other help
“Fire Code Word” - Never yell “fire” - it can cause fear and panic. Use the
phrase “Code Red” at St. Luke’s-Roosevelt Hospital Center when discovering a
fire or smoke situation.
Fire Alarms - When fire alarms are sounded, remember to check the fire alarm
code chart (located at the stairwells) to find the location of the fire.
Elevators - Never use elevators during a fire alarm situation. Use elevators only
when directed by the Fire Department.
Smoke / Fire Barrier Doors - Designated cross-corridor hallway doors close
automatically when there is a fire alarm activation. All room doors are closed by
staff. Please provide a quick reassuring word of explanation to patients when
closing their room doors.
Horizontal Evacuation or Area of Refuge - The first mode of evacuation is
moving patients horizontally, to the other side of smoke barrier doors or a
designated area of refuge on the same floor.
Vertical Evacuation - Moving patients vertically can be dangerous and should
only be considered as a last resort. This type of evacuation will be completed
only when ordered by Fire Department personnel or the hospital administration.
Evacuate personnel at least two floors below the fire/smoke affected area.
Storage – Do not store anything within 18 inches of the top of a sprinkler head.
In the Event of a Fire: Ambulatory patients are evacuated first.
Whenever a fire alarm is activated, remember to implement:
R - RESCUE persons in danger
A - ALARM; yell out CODE RED, pull the alarm, dial 4444
C - CONTAIN fire by closing doors
E - EXTINGUISH fire if possible with an extinguisher
Please ask your manager/supervisor to explain or provide information on your
department’s specific fire response. When you are located on your unit or department,
please walk around and become familiar with the location of important fire prevention
Manual fire alarm pull stations
Fire alarm code charts (know your area’s fire alarm code and the general building
Portable fire extinguishers (determine the type of extinguisher for your area, and
read the directions on the side of the extinguisher)
Smoke and fire barrier doors
Medical gas shut off valves and note the area or room(s) they control
(remember medical valves can only be shut upon the direction of unit’s
To use a fire extinguisher you – PASS
Pull the pin. The pin is in place to prevent the accidental discharge of the fire
extinguisher. Check its location on the extinguisher.
Aim the nozzle. The nozzle is usually clipped to the side of the extinguisher. In
the event of a fire, aim the nozzle at the base of the fire.
Squeeze the handle. Use firm pressure and squeeze the two handles located on
top of the extinguisher.
Sweep the extinguisher nozzle from side to side. Holding the nozzle and
pointing at the base of the fire, the person activating the fire extinguisher should
try to move nozzle in a sweeping motion.
An event is determined a disaster if the event has an effect on St. Luke’s - Roosevelt
Hospital Center’s ability to maintain a ‘safe environment of care’ for patients and staff.
Any event that threatens that ability can trigger SLRHC to activate our emergency
response plans (Code D plan.)
SLRHC categorizes a disaster/emergency in one of two ways: Internal (fire inside the
hospital) or external (a blizzard that hampers staff’s ability to report to work; or a
pandemic influenza outbreak.)
The Code D is activated by senior administration on duty and the staff and volunteers
are notified by:
 a series of four fire alarm bells followed by,
 an overhead announcement: ‘Code D is activated’
If VOLUNTEERS are on assignment when a Code D is activated:
 Report to your supervisor for direction
 End all telephone calls that are not an emergency
If VOLUNTEERS are home, and hear about the event on the media call the Continuum
Prepares Hotline: 1-877-518-1878 and call the Volunteer Office for further instruction.
In the event that a newborn, infant, or child is discovered missing from the maternal
infant care or pediatric unit, a Code Pink will be activated. The following announcement
will be made over the public address system 3 times:
“Code Pink, (state location), all personnel must report to their assigned
When a Code Pink is announced, all staff in the hospital should go “on alert” and
notify Security immediately of anyone acting suspiciously. Be especially aware of
persons carrying large bags or transporting an infant in arms instead of in a
Depending on where you work, you may be assigned to check bathrooms or
rooms or monitor an egress. Check with your supervisor about what your role is
when a Code Pink alert is announced.
It is important to remember that all employees and volunteers are the eyes
and ears for the Security staff. Notify Security if you see anyone or anything
What is Code Green? Code green is a response to Non–Life Threatening Medical
Emergencies. Code Green assures that non life-threatening medical emergencies that
occur on and off Hospital campus will be responded to in an appropriate manner,
without putting the patient in danger.
What to do in the event of a Non-Life Threatening emergency on campus:
Once you have identified that another person, (a patient, staff member or visitor)
requires emergency medical assistance but is still alert, pick up the nearest
phone and dial 4444.
Inform the operator that this is a Code Green, indicating that medical intervention
is required but that the person needing assistance appears alert.
The operator calls a Code Green on the overhead paging system to the
identified location.
Someone should remain with the patient at all times, providing support and
The respective Emergency Department responds.
The Department of Transportation responds to the site with a stretcher.
Once the patient is transported, complete an occurrence report and forward it
to Hospital Administration.
Using Standard Precautions reduces the risk of transmission of microorganisms from
both recognized and unrecognized sources of infection. In hospitals Standard
Precautions apply to:
-all body fluids, secretions and excretions, except sweat, regardless of whether
or not they contain visible blood
-non-intact skin
-mucous membranes
You follow Standard Precautions if and when you:
-practice hand hygiene after touching bodily fluids, blood… whether or not gloves
are worn
-use protective equipment to reduce the risk of exposure
-report all needle injuries and mucous membrane exposures as an incident
-use approved hospital disinfectants to clean up and decontaminate spills of
blood and body fluids
Hand hygiene remains the single most important way to prevent the spread of
infection for patients, associates and volunteers.
The Hand Hygiene Guidelines developed by the Centers for Disease Control and
Prevention (CDC) recommend that healthcare workers use an alcohol-based hand
wash to routinely clean their hands between patient contacts, as long as their hands are
not visibly soiled.
You should always wash your hands:
-after touching patient care equipment or environmental surfaces
-when hands are visibly contaminated or soiled with blood or body fluids
-when caring for a patient with C. difficile, wash with soap and water
-after leaving a patient’s room
-after removing gloves
-after blowing your nose
-after handling garbage
-before and after eating
-after using alcohol based hand rubs 6 times in a row
Hand washing with soap and water is most effective if it’s done for at least 10-15
Fingernail Length and Artificial Nails
As per SLRHC dress code policy nail length should be short enough to allow for
thorough cleaning underneath the nails and not cause gloves to tear.
Volunteers with direct patient contact may not wear artificial fingernails or extenders
since they are proven risk factors for colonization of organisms of the hand.
Personal Protective Equipment
PPE is primarily described as items worn to protect the skin, eyes, nose and through of
associates from pathogens, blood and other bodily fluids. This includes: gloves, mask,
eyewear and gowns.
Transmission Based Precautions
Transmission Based Precautions are designed for patients documented or suspected to
be infected with a highly transmissible pathogen for which additional precautions
beyond Standard Precautions are needed to interrupt spread of the infections.
Types of precautions include: Airborne (e.g. TB Measles); Droplet (e.g. influenza) and
Contact (e.g. draining wounds, diarrhea.)
When patients are on precaution, the type of isolation/precaution is identified by a sign
on the door to alert all associates, volunteers and visitors.
As a patient in a hospital in New York State, you have the right, consistent with
law, to:
 Understand and use these rights. If for any reason you do not understand or you
need help, the hospital MUST provide assistance, including an interpreter.
 Receive treatment without discrimination as to race, color, religion, sex, national
origin, disability, sexual orientation or source of payment.
 Receive considerate and respectful care in a clean and safe environment free of
unnecessary restraints.
 Receive emergency care if you need it.
 Be informed of the name and position of the doctor who will be in charge of your
care in the hospital.
 Know the names, positions and functions of any hospital staff involved in your
care and refuse their treatment, examination, or observation.
 A no smoking room.
 Receive complete information about your diagnosis, treatment and prognosis.
 Receive all the information that you need to give informed consent for any
proposed procedure or treatment. This information shall include the possible
risks and benefits of the procedure or treatment.
 Receive all the information you need to give informed consent for an order not to
resuscitate. You also have the right to designate an individual to give this
consent for you if you are too ill to do so. If you would like additional information,
please ask for a copy of the pamphlet “Do Not Resuscitate Orders - A Guide for
Patients and Families.”
 Refuse treatment and be told what effect this may have on your health.
 Refuse to take part in research. In deciding whether or not to participate, you
have the right to a full explanation.
 Privacy while in the hospital and confidentiality of all information and records
regarding your care.
 Participate in all decisions about your treatment and discharge from the hospital.
The hospital must provide you with a written discharge plan and written
description of how you can appeal your discharge.
 Review your medical record without charge. Obtain a copy of your medical
record for which the hospital can charge a reasonable fee. You cannot be denied
a copy solely because you cannot afford to pay.
 Receive an itemized bill and explanation of all charges.
 Complain without fear of reprisals about the care and services you are receiving
and to have the hospital respond to you and if you request it, a written response.
If you are not satisfied with the hospital’s response, you can complain to the New
York State Health Department. The hospital must provide you with the Health
Department telephone number.
 Authorize those family members and other adults who will be given priority to visit
consistent with your ability to receive visitors.
 Make known your wishes in regard to anatomical gifts. You may document your
wishes in your health care proxy or on a donor card, available from the hospital.
The workforce of St. Luke’s-Roosevelt Hospital Center and the patient population we
serve represent many nationalities, races, religious and cultural beliefs. These
differences can impact the quality of our communication, the quality of our work
environment and the quality of patient care.
Every volunteer is expected to develop a basic level of cultural competency, enabling
him or her to work effectively in cross-cultural situations.
Workplace diversity refers not only to the different characteristics of associates and
volunteers such as life experience, age, gender, sexual orientation, and physical
abilities but also work experience, job title, union affiliation, seniority and other
workplace related differences. To create an inclusive work environment, one which
enables all associates to make a full contribution to the success of St. Luke’s-Roosevelt
Hospital Center, all associates and volunteers are encouraged to:
Show respect for one another
Engage in open discussions about cultural, racial or other differences
Constructively address misunderstandings and conflict
The St. Luke’s – Roosevelt Hospital Charter for Diversity is to create a multicultural
environment that works for everyone, to value and respect each other’s contribution to
the workplace.
Keep in mind that while it is helpful to learn about different cultures, we do not
treat cultures; we treat individuals.
It is Continuum’s policy to provide our patients with free, trained medical interpreters to
eliminate language as a barrier to quality health care. This policy is part of our mission
to provide excellent medical care for the communities we serve.
Each institution has developed its own Language Assistance resources.
Resources include:
 Staff interpreters
 Trained medical interpreters
 Independent contractors
 The Language Line (telephone interpretations)
 Language cards and posters
 ASL Videoconference rovers
How do I know if a patient needs an interpreter? Appropriate phrasing to determine
patient’s needs should be utilized at all times. Statements such as: “in which language
do you prefer to communicate” are correct. DO NOT ASK: “Do you speak English?”
What is the procedure to get an interpreter?
Monday through Friday between 9:00 AM and 5:00 PM at SL call:
 For Spanish Interpreters only page 3-3853
 For other languages call extension 23-2187
Monday through Friday between 9:00 AM and 5:00 PM at RH call:
 For Spanish Interpreters only page 3-7155
 For other languages call extension 23-2187
At all other times or if the interpreter is not available
 Call the Language Line at extension 36-5096 and give SLRHC ID #
What services are available for hearing impaired patients?
Monday-Friday 9:00 AM to 5:00 PM, to schedule an ASL interpreter (at least 24
hours in advance) or for emergency and walk-in requests call 23-2187.
All other times call 23-5678
The ASL Videoconference rovers are located at the ED and at the Admitting
EVERY patient who enters the St. Luke’s-Roosevelt Health Care System must
receive information and counseling, if needed, concerning use of ADVANCE
As part of the admission process, the patient is given a packet containing the booklet,
Your Rights as a Hospitalized Patient, which contains the NY State Healthcare Proxy
(This is available on every patient care unit). Out-patients receive a packet with the
Patients’ Bill of Rights and the Health Care Proxy. The information in this booklet is
reviewed with the patient and the patient is then given an opportunity to discuss their
questions and concerns with a staff member.
When we ask patients if they have an Advance Directive, what exactly do we
An advance directive is a mechanism through which patients can articulate their
treatment preferences in the event they lose the capacity to make decisions. Patients
can select an authorized surrogate decision-maker in advance of a time when they may
no longer be able to make their wishes known. Advance directives can be used to clarify
what treatments patients do want as well as what treatment they do not want.
Examples of Advance Directives include:
 Health Care Proxy: A document in which a patient appoints a legally authorized
surrogate decision-maker, called the health care agent, in the event the patient
loses the ability to make his/her wishes known.
 Living Will: A document patients can use to express their treatment preferences
to be followed when they have lost their ability to be involved in the treatment
decision-making process.
 Oral Advance Directive: A spoken statement made by the patient, prior to loss
of decision-making capacity, which clearly reflects the patient’s preferences
about specific treatment options. Any oral statements made by a patient during
their hospitalization must be fully documented in the medical record.
 Do Not Resuscitate (DNR) Order: Patients and their surrogate decision makers
also have the right to ask for a DNR order if they would not want
cardiopulmonary resuscitation attempted in the event they experience a cardiac
or pulmonary arrest. Consent for a DNR order is given by the patient, health care
proxy agent or next of kin when a patient has lost decision-making capacity. This
consent for the DNR order is obtained by the attending physician, and must be
reassessed every 7 days while a patient is hospitalized. A non-hospital DNR can
be obtained for discharged patients.
All hospital personnel and volunteers have the responsibility to protect patients’
confidentiality at all times. The Patients’ Bill of Rights ensures patient confidentiality.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is an important
federal law that rules how hospitals and caregivers must strive to protect a Patients’
Health Information. Each patient in a hospital in New York State has rights under the
law (the full list of a Patient Bill of Right’s is listed above AND POSTED ON THE
PATIENT UNITS). Patients have a right to expect that any information about their
medical history, condition or treatment will be held in the strictest confidence.
Volunteers must respect this right and must never share information about the patient
inside or outside the hospital.
Protected Health Information (PHI) is any information associated with a patient: SSN,
address, DOB, condition….
Do not discuss any patient information with:
 Other patients, relatives, friends or visitors of patients
 Visitors to the hospital
 Representatives of the news media
 Other staff, except when in a conference
 Your own relatives, friends, or neighbors
Discard paper with patient information in locked receptacles.
All volunteers who are injured while at work are required to report the incident to
their supervisor.
If the injury is serious or a blood-borne pathogen exposure, i.e. contaminated
sharps injury (needle stick with a dirty needle), then the volunteer should also
seek medical attention at the hospital emergency room. After seeking
emergency treatment for any injury, then the volunteer must contact his
supervisor to complete an employee accident report.
Employee Accident Report Forms completed by volunteer, supervisor, and ED
doctor (if applicable) must be sent to Human Resources, Worker’s Compensation
If a volunteer refuses medical treatment for an injury, an accident report must still
be completed indicating that the volunteer refuses medical treatment.
CMS, or Medicare, has developed the hospital CAHPS (HCAHPS) survey to provide a
standardized instrument and data collection methodology for measuring patient
satisfaction with hospital care. CMS has required that all hospitals who receive
Medicare reimbursement to participate in the HCAHPS survey and to have their scores
reported publicly on the internet.
The survey is mailed to discharged patients by a third party which also accumulates and
reports the scores for each patient unit. It includes seven themes that are measured:
1. Nurse communication
2. Doctor communication
3. Cleanliness and quiet of the hospital environment
4. Responsiveness of hospital staff
5. Pain management
6. Communication about medication
7. Discharge information
Two overall rating questions are also measured:
1. The patients are asked to rank the hospital on a scale of worst to best
2. Indicate if they would recommend the hospital to friends and family
SLRHC is committed to having the highest scores possible on the HCAHPS survey so
that patients will choose to come to our facilities.
Use the acronym ‘AIDET’ to remember the five fundamentals of service:
Address the patient by name
Eye contact
Stop whatever you are doing so the patient knows that they are important
Introduce yourself by name and title
State why you are there and how long you will be on the unit
Offer your assistance to help them with anything they might need (e.g. a blanket,
water, magazine…)
Inform the patient that you will get back to them and then do it (e.g. finding an
NA to help with toileting)
Offer to answer any questions, or get the answers for them
Say ‘thank you’ and ask if there is anything else you can do for the patient before
leaving their room.
Standard #1: We will make our patients and their families feel welcomed.
 Introduce ourselves using name and title, and explain to the patient our role in
his/her care
 Wear our hospital ID badge with name and picture visible
 Greet patients and families with a smile
 Respond promptly to inquiries or problems
 Offer assistance to individuals
Standard #2: Whenever we have a patient or associate interaction, we will act in a
professional manner and we will dress professionally to communicate that
 Greet a patient using his/her formal name, unless invited to call him/her
 Always knock before entering a room and ask permission to enter
 Identify ourselves to associates and patients by name and department
Standard #3: We will maintain a peaceful, calm and healing environment.
 Speak in a quiet tone of voice
 Offer assistance when needed and possible
 Ask “Is there anything else I can do for you?” when leaving a patient room
Standard #4: We will keep our personal frustrations separate.
 Keep staff gossip and personal matters out of a patient’s hearing
 Help others with our “know how” and ask for help when we need it
 Always link problem identification with problem solving suggestions
Standard #5: We will relieve the fears and anxieties of our patients by listening,
answering questions and explaining procedures.
 Repeat a patient’s request or concern so he/she knows we understand
 Communicate in a clear, esy to understand manner
 Maintain eye contact when talking and listening
 Always try to go that ‘extra step’
Standard #6: We will acknowledge when we have failed to meet their
expectations and apologize sincerely for inconveniences.
 Apologize for all delays- even though we may not be responsible for them
 Recognize and stay calm when a patient is upset and ask what we can do to help
 Remain calm with an angry patient/visitor; the most important thing we can do is
Volunteers must be at least 15 years of age. Before you are accepted into the program
and given an assignment, you must:
complete an application
receive medical clearance from Employee Health Service
provide references and photo ID
pass a core competency exam
be interviewed by volunteer department staff
All volunteers will be recruited and assigned in accordance with SLRHC's equal
opportunity, affirmative action, and labor relations policies without regard to sex, race,
religion, national origin, age, physical disability, or martial status.
Volunteer assignments will be made in accordance with your interests, abilities, and
vocational goals and in accordance with the needs of the Hospital, which will be the
ultimate determining factor. Volunteer assignments will be made only upon the request
and agreement of the department to which the volunteer is assigned.
Upon acceptance into the volunteer program, you must agree to:
Sign a Volunteer Agreement
Commit to a 150-hour annual minimum service
Sign in and out every time you volunteer
Accept and abide by the policies of SLRHC and the Department of Volunteer
Be in good health
Orientation for new volunteers is given periodically and includes general institutional
and departmental rules and regulations with special emphasis on Infection Control, Fire
Safety, Security and Volunteer policies. In addition, information will be provided on
most volunteer programs.
St. Luke’s-Roosevelt Hospital Center expects its volunteers to maintain a high standard
of conduct and work performance to make sure the hospital maintains its good
reputation with patients and families. Good personal conduct contributes to a good work
environment for all.
This involves all volunteers:
 observing all policies and procedures
 treating colleagues with courtesy and respect
 treating patients in a professional and courteous manner at all times
 working safely at all times
St. Luke’s-Roosevelt Hospital Center Center is a no smoking facility. There is no
smoking permitted inside the facility or on hospitals property.
Personal use of cell phones and other electronic devices (Blackberry, MP3 players)
during assignment in patient care and public areas of the Hospital is prohibited. The
purpose of this restriction is to improve patient safety, patient satisfaction and promote a
quality work environment. Volunteers who violate this policy are subject to termination.
 While on assignment, the cell phone/electronic device must be on vibrate or
silent mode.
 Headphones are not to be worn during a volunteer’s assignment.
 Cameras are not permitted under any circumstances unless authorized by the
All patients transported to procedural/diagnostic areas and/or between patient care units
will have a safe transport/transfer by a hospital employee.
Volunteers can transport a patient only at the time when the patient is being discharged
from the hospital. Transferring a patient within the hospital from one procedure to
another is not permitted by volunteers, nor is transporting a patient to run errands to the
ATM machine, admitting, etc.
At the direction of nursing staff the volunteer may transport discharged
patients via wheelchair to their departing destination, one of the main lobbies
of the hospital center.
Nursing personnel will assist transferring the patient into a wheelchair.
When the patient is in the wheelchair ask the patient if they are comfortable.
During transport remain attentive to the patient and let them know of any
obstacles or bumps when you get on or off the elevator.
All your attention should be focused on the patient.
Never transport a patient beyond the main entrance.
Keep the patient company while waiting for pick up by family or taxi.
Volunteers will participate in wheel chair transport training during orientation.
SLRHC prohibits and will not tolerate any discrimination or harassment on the basis of
race, color, national origin, religion, sex, age, disability, citizenship, marital status,
creed, sexual orientation or any other characteristic protected by law.
Therefore SLRHC expects that all relationships among persons in the workplace will be
business like and free of bias, prejudice and harassment.
The Volunteer Department will abide by the St. Luke’s-Roosevelt Hospital Center
Administrative policy for Non-Discrimination and Anti-Harassment with the
understanding that the policy applies to all volunteers. The SLRHC policy follows:
St. Luke’s-Roosevelt Hospital Center is committed to a work environment in which all
individuals are treated with respect and dignity. Each individual has the right to
volunteer in a professional atmosphere that promotes equal employment opportunities
and prohibits discriminatory practices, including harassment. Therefore the Hospital
Center expects that all relationships among persons in the workplace will be businesslike and free of bias, prejudice and harassment.
It is the policy of St. Luke’s –Hospital Center to ensure equal employment/volunteer
opportunity without discrimination or harassment on the basis of race, color, national
origin, religion, sex, age, disability, citizenship, marital status, creed, sexual orientation
or any other characteristic protected by law. St. Luke’s-Roosevelt Hospital Center
prohibits and will not tolerate any such discrimination or harassment.
Definition of Harassment
Sexual harassment constitutes discrimination and is illegal under federal, state and local
laws. Sexual harassment has been defined by government regulations as unwelcome
sexual advances, requests for sexual favors, and other verbal or physical conduct of a
sexual nature when: (1) submission to such conduct is either explicitly or implicitly made
a term or condition of an individual’s assignment; (2) submission to or rejection of such
conduct is used as the basis for decisions affecting such individual; or (3) such conduct
has the purpose or effect of unreasonably interfering with the individual’s performance
or creating an intimidating, hostile, or offensive environment.
Sexual harassment may include a range of subtle and not so subtle behaviors and may
involve individuals of the same or different gender. Depending on the circumstances,
these behaviors may include, but are not limited to: unwanted sexual flirtation,
advances or requests for sexual favors; subtle or overt pressure for sexual favors;
sexual or sexist jokes, innuendoes, advances or propositions; verbal abuse of a sexual
nature; commentary about an individual’s body, sexual habits, sexual prowess or
sexual deficiencies; leering, whistling, touching, pinching, assault or coerced sexual
acts; suggestive, insulting or obscene comments or gestures: display or circulation,
including through e-mail, in the workplace of sexually suggestive material, objects or
pictures; or other physical, verbal or visual conduct of a sexual nature.
Harassment on the basis of any other protected characteristic is also strictly prohibited.
Under this policy, harassment is verbal or physical conduct that denigrates or shows
hostility or aversion towards an individual because of his/her race, color, religion, sex,
national origin, age, disability, citizenship, marital status, creed, sexual orientation, or
any other characteristic protected by law, or that of his/her relatives, friends or
associates, and that (1) has the purpose or effect of creating an intimidating, hostile or
offensive environment; (2) has the purpose or effect of unreasonably interfering with an
individual’s performance; or (3) otherwise adversely affects an individual’s opportunities.
Harassing conduct includes, but is not limited to: epithets, slurs or negative
stereotyping; threatening, intimidating or hostile acts; denigrating jokes and display
or circulation in the workplace (including through e-mail) of written or graphic
material that denigrates or shows hostility or aversion towards an individual or
These lists are for purpose of illustration and are not intended to be exhaustive.
Individuals and Conduct Covered
This policy applies to all volunteer applicants, to all personnel, supervisory and nonsupervisory, and to all members of the medical and dental staff, and prohibits
harassment, discrimination and retaliation whether engaged in by fellow employees, by
a supervisor or manager or someone not directly connected to St. Luke’s Roosevelt
Hospital Center (e.g. an outside vendor, consultant or customer).
Managers and other supervisory personnel and directors of service are
responsible for doing all they can to ensure that no volunteer or employee is
subject to conduct which constitutes discrimination or harassment.
Retaliation is Prohibited
Retaliation against an individual who reports discrimination or harassment or
provides information relevant to such reports is strictly prohibited and will be treated
as a serious violation of this policy.
Complaint Procedure:
Volunteers who believe they have experienced or witnessed discrimination or
harassment have an obligation to bring their complaints to the attention of their
immediate supervisor or Department Head. The Hospital Center urges the prompt
reporting of complaints. Complaints will be investigated promptly and thoroughly.
The availability of this complaint procedure does not preclude individuals who
believe they are being subjected to harassing conduct from promptly advising the
offender that his or her behavior is unwelcome and requesting that it be
Any individual found to have engaged in discrimination, harassment, or retaliation
will be disciplined as appropriate, up to and including discharge.
Confidentiality will be maintained to the extent permitted by law and consistent with
the Hospital Center’s obligations to investigate complaints and take appropriate
corrective action.
Complaints about discrimination and harassment committed by non-employees (for
instance, independent contractors or outside vendors) against Hospital Center
personnel may be brought in the same manner. The Hospital Center will investigate
such complaints and take appropriate action. If a volunteer believes that this policy is
not being adhered to or perceives a lack of appropriate response to complaints through
the process described above, that volunteer may address his or her complaints directly
to the President’s office.
If you have any questions about this policy, please contact the Human Resources
Department. Your queries will be answered promptly.
Consensual Personal Relationships
When two employees involved in a consensual personal relationship work as supervisor
and subordinate, the supervisor should promptly inform his or her immediate superior of
the personal relationship. The supervisor should notify the Human Resources
Department. In order to eliminate any appearance of, or actual, partiality, the Hospital
center may change the reporting relationship between the individuals. Failure to give
proper notice to the supervisor’s immediate superior may result in a denial of legal
representation and indemnification by the Hospital Center, if such benefits would
otherwise be provided, in the event that a lawsuit is filed in connection with the
relationship. Although the obligation to make the report is on the supervisor, the other
party to the relationship may make the disclosure as well. For the purpose of this
policy, a ‘consensual personal relationship’ shall include marriage, cohabitation,
engagement, dating and other ongoing relationships of an intimate or close personal
nature, but shall not include purely social friendships.
Hospital Center volunteers are required to maintain a high standard of personal
appearance, hygiene and grooming at all times. Clothes must be in good condition and
acceptable for the job. All volunteers must wear their SLRHC Identification badges, with
picture facing out, at all times while on Hospital Center property. Volunteers who are
inappropriately dressed may, at the supervisor’s discretion, be sent home.
For those instances in which the Hospital Center requires volunteers to wear uniforms, the
Hospital Center will provide uniforms and the volunteer will provide a $10 deposit to be
returned when the uniform and volunteer ID badge are returned. The volunteer will assume
responsibility for the servicing including laundering, mending and replacement. Lab coats
are restricted to attending medical staff, medical professionals with patient contact,
pharmacy personnel and technical staff in laboratory, therapy and radiology areas.
The following clothing is considered inappropriate for volunteers and may not be worn by
any volunteer while on duty:
 Low back, backless or strapless dresses and tops
 See through or sheer blouses, shirts, pants, skirts or dresses
 Tank tops, T-shirts with offensive or suggestive slogans/logos
 Shorts
 Nylon athletic suits or sweatshirts or sweatpants
 Head coverings of any type with the exception of those worn for religious reasons
 Slippers, house shoes
 Spandex, leggings, or any other tight fitting clothing
 Eyebrow, lip rings or tongue studs
 Open toed shoes
 Minimal jewelry, no long, dangling earrings, bracelets or necklaces
 Long hair is to be pulled back
In addition, nail length should be short enough so as to allow the individual to thoroughly
clean underneath nails and not cause glove tear.
The Department of Volunteer Services of SLRHC will make every effort to protect the
patients, employees, volunteers and visitors to the extent possible from transmitting and
acquiring any infectious disease. Further, the Department wishes to ensure that
volunteers are physically able to perform their duties without risk to their own well being
or the well being of others.
Volunteers need to maintain an agreed upon schedule and ‘sign in and out’ in the
Volunteer Office
Never report to an assignment with any communicable infection; notify the
Volunteer Department
Notify the office when taking a vacation, going on leave or terminating an
If a volunteer has three absences or more the Volunteer Department maintains
the right to replace the volunteer with another
All volunteers are required to receive medical clearance from the hospital's Employee
Health Service prior to their initial assignment and to have a reassessment of their
health status annually. Volunteers are not charged for these clearances or
Each year, you will receive a notice from the Department of Volunteer Services
informing you of the need for an annual health update at the Employee Health Service.
For your protection, and the protection of others at the hospital, it is essential that you
receive a health assessment promptly. Please notify the Volunteer Office if there are
any reasons this assessment cannot be completed.
The formal performance assessment system is designed to:
 Maintain or improve each volunteer’s job satisfaction and morale by letting
him/her know that the supervisor and volunteer office are interested in his/her job
progress and personal development.
 Assist in determining and recording special talents, skills, and capabilities that
might otherwise not be noticed or recognized.
 Provide an opportunity for each volunteer to discuss job problems and interests
with his/her supervisor.
An Evaluation Form will be completed for each volunteer annually. This is a joint effort
between the Volunteer Services Department, the volunteer, and his/her immediate
supervisor. After completion by the volunteer’s supervisor, the form should be returned
to the Volunteer Services Department and retained in the volunteer file.
Letters of Service are provided to those volunteers who have completed the 150 hour
service requirement. If the volunteer requests verification of service after the service
requirement is met, we will be happy to supply a letter for you.
All SLRHC Volunteers must adhere to requirements and policies of the Volunteer
Department and hospital policy as stated in the Volunteer Core Competency Handbook.
Failure to adhere to policies may result in termination.
Other reasons for termination include, but are not limited to:
 the commission by the Volunteer of any act which would constitute a crime under
federal, state or local law;
 any act or omission by the Volunteer resulting or intended to result in personal
gain at the expense of SLRHC;
 the engaging by the Volunteer in fraud, misconduct or negligence injurious to
 the improper disclosure by the Volunteer of proprietary information or trade
secrets of SLRHC;
 the performance by the Volunteer of his duties in an unsatisfactory
 misconduct by the Volunteer including, but not limited to insubordination, theft,
violent acts or threats of violence, or possession of alcohol or controlled
substances on the property of SLRHC;
 failure to comply with time and attendance rules
Prior to leaving volunteers are asked to participate in an exit interview. Volunteer
Services is responsible for conducting this exit interview. As part of this process, the
volunteer is asked to return their hospital ID badge, uniform and provide feedback on
their volunteer experience at SLRHC. The uniform deposit of $10 will be returned at
this time.
The care of our patients is a team effort:
We all make important contributions to
the well-being of those who place
themselves in our care.
To see how we can improve the way we
treat our patients, put yourself in the
patient’s place and ask:
“Is this how I would want to be treated?”

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