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Standards of Excellence: Appendix

Cell Phone Etiquette

  1. In general, personal cell phones should be turned off during work hours. Personal business including calls and text messages should be conducted while on break or off duty.
  2. Let your family and friends know that you cannot take personal calls or texts while on duty, and how to contact you in case of an emergency.
  3. If a personal call or text is necessary, it should be conducted in a non-public area.
  4. For those employees who are authorized to use cellular phones as part of their job duties, remember the following:
  5. Practice professional telephone etiquette. See the Telephone Etiquette Appendix on page 27.
  6. Keep your phone on courtesy mode while in meetings or other work settings.
  7. If you must answer a call, step out of the meeting or into a private location to do so.
  8. Cell phone use while driving any CCH vehicle is prohibited.
  9. Employees who use a personal cell phone to access confidential CCH information must protect the integrity of confidential information per policy.
  10. Lost or stolen cell phones that contain confidential CCH information must be reported to Information Systems as soon as possible.

For more information: Refer to the Telephone Use Policy in Policy Manager and your department specific policy.

Dress Code

The professional, personal appearance of all who are associated with Campbell County Health is vitally important to our relations with patients, residents, the community and one another.

  1. Employees who spend 80% of their work time interacting with patients/residents or customers must wear designated uniform apparel in the Company Store.
  2. Employees are required to wear their CCH Identification Badge at all times while on duty. The badge should be worn on the upper torso with the name and photo visible.
  3. Clothing should fit well and allow for comfortable movement throughout all required work activities without compromising safety or professional image—pants or scrubs should not extend beyond the bottom of the shoe or drag on the floor.
  4. Nail polish and artificial nails are not allowed by any direct patient or resident caregiver.
  5. Perfumes and colognes are strongly discouraged and shall not be worn by employees providing direct patient or resident care.
  6. Visible body piercing(s), other than the ears is unacceptable during the work shift. Tongue piercing(s) and gauges are prohibited. Ear piercings must be limited to three piercing(s) per ear.
  7. Body art that displays suggestive or nude material, profanity, or represents discriminatory or hate messages, or symbolizes death are prohibited and must be covered while on duty. Sleeves (tattoos that cover the whole arm or leg like a sleeve), partial sleeves and large tattoos covering the arms or legs must be covered. Employees who have tattoos and body art that are allowable are encouraged to cover them with clothing or hosiery if possible.
  8. Employees have the option to participate in the Denim Day fundraiser for the GIVE Grant, which allows employees to wear denim on Fridays if appropriate for their department. Denim must be medium-wash, boot cut or straight fit, mid or high rise styles, and without any holes. Employees must maintain a professional appearance at all times. Clothing that incorporates the CCH approved logos may also be worn.
  9. Shirt length is required to ensure coverage of the torso. If wearing leggings or jeggings, the shirt must cover the buttocks—mid-thigh length is appropriate.

For more information: See the Company Store page on the Intranet (Staffnet), or refer to the Uniform Policy, Dress Code Policy and/or Denim Day Policy in Policy Manager, as well as your department specific policy.

Elevator Etiquette

  1. Hold the door open for approaching passengers. Ask others, "What floor do you need?" if you are near the buttons.
  2. Wait until those on the elevator exit before entering.
  3. Step aside or to the back of the elevator to make room for others entering.
  4. Allow guests to enter the elevator first.
  5. Make positive eye contact, smile and speak to fellow passengers.
  6. Safeguard patient confidentiality. Do not have discussions on elevators about patient care.
  7. Do not have personal conversations when a customer is on the same elevator.
  8. Patient transport has the right of way in elevators. If you see a patient being transported in a bed or on a stretcher, step off or wait for another elevator.
  9. When transporting patients, always face them toward the door and exit with care.
  10. Hold the door open for passengers exiting the elevator.

Wellness Tip: When you can, try walking up one flight or down two flights of stairs to avoid using the elevator altogether. You will reduce overall elevator traffic and stay fit at the same time!

Excellence Every Day Terms

In this section, we are outlining the terms from The Studer Group, as well as the quality improvement tools of Toyota LEAN/Six Sigma.

Studer Group Terms

AIDET®: Five Fundamentals of Service: These are five behaviors to use in patient and family encounters to anticipate, meet, and exceed the expectations of the customer and reduce the anxiety of the patient.

  • Acknowledge: Acknowledge the patient by name. Make eye contact, smile, and acknowledge everyone in the room (patient and families).
  • Introduce: Introduce yourself, your skill set, your professional certification, and experience.
  • Duration: Give an accurate time expectation for tests, physician arrival, and identify / communicate next steps. When this is not possible, give a time in which you will update patient on progress.
  • Explanation: Explain step by step what will happen, answer questions, and leave a way to contact you, such as a nurse call button or phone number. Use language a patient can understand.
  • Thank You: Thank the patient. You may thank them for choosing your hospital, and for their communication and cooperation. Thank the family for assistance and being there to support the patient.

Evidence-Based Leadership (EBL): A spinoff of evidence-based medicine, EBL is a strategy centered on using the current "best practices" in leadership—practices that are proven to result in the best possible outcomes. The "evidence," in this context, is the data collected from studies that aim to determine what people really want and need from their leaders.

Hardwire: The process by which an organization, department, team or individual integrates a behavior or action into the daily operations to ensure it becomes a habit and is always done.

Healthcare Flywheel®: A teaching diagram that illustrates the power that Purpose, Passion, To-Do's and Results has in creating momentum in an organization. Studer Group developed the Healthcare Flywheel to help organizations understand the journey in creating great places for employees to work, physicians to practice, and patients to receive care.

highmiddlelow® (hml): A performance management approach for moving organizational performance, through the use of high, middle and low performer conversations.

Key Words at Key Times: Key words at key times are consistent pre-determined messages delivered at certain times in our care delivery to "connect the dots" and help patients, families, and visitors better understand what we are doing. They align our words with our actions to give a consistent experience and message.

Leader Evaluation Manager® (LEM): Studer Group's Leader Evaluation Manager® is a web-based application that automates the goal setting and performance review process for all leaders, while ensuring that the performance metrics of individual leaders are aligned with the overall goals of the organization.

Leadership Development Institute (LDI): Regularly scheduled, two-day leadership training sessions held off-site on a quarterly basis to develop new, current and future leaders in an organization. LDI curriculum aligns to the goals of the organization and focus on the skills and knowledge leaders need to be successful and meet those goals.

Linkage Grid: Action items for the team to complete after training to make sure learning is incorporated over 90 days following the training session.

Manage Up: Positioning others in a positive light. It is a form of communication at all levels that aligns your own skills, your co-workers, other departments and physicians to the goals of your organization. Example: Letting your supervisor know to attend a celebration regarding achievement of results or to pass on positive information regarding an area so that they can be recognized. This makes you and your organization better and aligns everyone to working on the right goals.

Must Haves®: Specific actions and "to-do's" common to organizations achieving exceptional results. These Must Haves® are based on the Nine Principles® and evolved from the Studer Group partnering with hundreds of organizations to identify these actions. The Must Haves® are:

  1. Rounding for Outcomes
  2. Employee Thank You Notes
  3. Selection and the First 90 Days
  4. Discharge Phone Calls
  5. Key Words at Key Times, and
  6. Aligning Leader Evaluations with Desired Behaviors

Nine Principles®: A sequenced step-by-step process and road map to attain desired results and help leaders develop and achieve an excellence-based culture. The Nine Principles® are truths upon which the culture of excellence can be built:

  1. Commit to Excellence
  2. Measure the Important Things
  3. Build a Culture Around Service
  4. Create and Develop Leaders
  5. Focus on Employee Satisfaction
  6. Build Individual Accountability
  7. Align Behaviors with Goals and Values
  8. Communicate at all Levels
  9. Recognize and Reward Success

Ownership: The sense of sharing responsibility for the solution as well as the problem, as in owning a house versus renting it.

Rounding for Outcomes: Communicating with employees, physicians and patients in such a way that there is a specific purpose to walk away with specific outcomes.

Service Recovery: Actions taken when customer expectations have not been met.

Toyota LEAN/Six Sigma Terms

Black Belts: Operate under Master Black Belts to apply Six Sigma methodology to specific projects. They devote 100 percent of their valued time to Six Sigma. They primarily focus on Six Sigma project execution and special leadership with special tasks, whereas Champions and Master Black Belts focus on identifying projects/functions for Six Sigma.

Green Belts: The employees who take up Six Sigma implementation along with their other job responsibilities, operating under the guidance of Black Belts.

Gap Analysis: Method of comparing the current state with the optimal future state and what actions it will take to achieve that future state.

Kaizen: A method for promoting small improvements on a continual basis throughout an organization. A kaizen is a short lived project lasting no more than four or five days, for example, using quick changeover methods to dramatically reduce set up time in an operation. It is the opposite of breakthrough improvements. Kaizen requires no or little investment.

Lean: An approach to improving the delivery of value to customers, through clarifying value-adding versus wasteful actions; and removing the waste.

Muda: a form of waste typically referring to the seven wastes (Overproduction, Inventory, Over processing, Correction, Waiting, Conveyance, Motion).

PDSA: Acronym for Plan-Do-Study-Act; Process of developing, testing, and then rolling out something new.

Root Cause: The originating cause of an event or condition that leads through one (1) or more steps of causality to the immediate cause (e.g., overwork-tiredness-accident).

Sigma: One standard deviation away from the mean.

Six Sigma: A set of techniques and tools for process improvement. It was developed by Motorola in 1986. Six Sigma became famous when Jack Welch made it central to his successful business strategy at General Electric in 1995. Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability in manufacturing and business processes. It uses a set of quality management methods, including statistical methods, and creates a special infrastructure of people within the organization ("Champions", "Black Belts", "Green Belts", "Yellow Belts", etc.) who are experts in the methods. Each Six Sigma project carried out within an organization follows a defined sequence of steps and has quantified value targets, for example: reduce process cycle time, reduce pollution, reduce costs, increase customer satisfaction, and increase profits.

Standardization: Act of standardizing work, processes, documentation, components and materials, and report out activity. An approach to improving the delivery of value to customers, through clarifying value-adding versus wasteful actions; and removing the waste.

Value: The aspects of the service or product that the customer is willing to pay for.

Value Stream: All the activities and steps that occur from the initiation to the final delivery of a product or a process; can be applied to an overall business or a specific sub-process.

Other Terms


  • A – Ask a question
  • R – Request a change
  • C – voice a Concern
  • C – invoke Chain of Command

We each have a responsibility to assure safety in while being respectful. If you have a safety concern, use ARCC. Be assertive but courteous. This tool allows you to start with gentle questions and escalate as needed. We owe it to our patients and each other to question any safety related issues.

  • Ask a question: The best way to question a safety issue is by starting with a question: "Can I ask a clarifying question?" or "I just need to clarify…"
  • Make a request: "I request we stop for a minute and access where we are at."
  • Voice a concern: Be polite but direct: "I have a safety concern."
  • Use the Chain of command: If you still have a concern you feel is not being addressed, take it up the chain of command.

Core Measures: Core Measures are nationally standardized performance requirements. The measures are based on clinical studies that have demonstrated improved patient outcomes. The goal is to lower the risk of surgical complications, lower the risk of mortality and morbidity rates, and implement healthcare standards that will improve the quality of care provided to hospital patients.

PANDA: Handoff effectively using PANDA is to ensure that complete and accurate information is communicated when responsibility for a patient, project, or task transfers from one individual to another.

  • P – Patient, procedure, physician
  • A – Assessment
  • N – Need to know
  • D – Drains and dressings
  • A – Allergies

SBAR: The SBAR tool provides a framework for concise communication between members of the team. This tool can be used for critical conversation and setting expectations.

  • S – Situation – What is the bottom line, immediate problem or concern?
  • B – Background – review pertinent information. What do you know about the concern?
  • A – Assessment – What is happening now? What are the facts and urgency of situation?
  • R – Recommendations – What is next? Suggestions or requests.
  • Questions

Self-Checking Using STAR:

  • S – Stop: Pause for 1 to 2 seconds to focus attention on the task at hand
  • T – Think: Visualize the act and think about what is to be done
  • A – Act: Concentrate and perform the task
  • R – Review: Check for the desired result

When you are about to do something that could potentially cause harm to patients, co-workers or yourself you should self-check using this tool. It only takes a few seconds and has proven to reduce the probability of making an error by a factor of 10 or more.

Value Based Purchasing: Through the Hospital Value-Based Purchasing Program, CMS is changing the way it pays hospitals, rewarding hospitals for the quality of care they provide to Medicare patients, not just the quantity of procedures they perform. Hospitals are rewarded based on how closely they follow best clinical practices and how well hospitals enhance patients' experiences of care. When hospitals follow proven best practices, patients receive higher quality care and see better outcomes. Hospital VBP is just one initiative CMS is undertaking to improve the quality of care Medicare beneficiaries receive.

Service Recovery

The word recovery means to restore to good health or return to normal. Service recovery means that we do whatever we can to return the customer's good feelings when they're angry, or have had a problem.

The majority of customers who seem difficult are not choosing to be difficult; they are frustrated or angry. Our job, as representatives of the organization, is to turn those tense situations into positive impressions. Our job is to become so skilled at service recovery that the customer or patient who started out saying he or she would never come back becomes one who says he or she would never go anywhere else. The starting point in Service Recovery is "Taking the HEAT."

  • H - Hear them out
    Allow the person to vent without interruption.
  • E - Empathize
    For example:
    "I'm sure _____ was upsetting/frustrating."
    "I'd be upset/angry too if _____ happened to me."
    "It must be frustrating/upsetting to see _______."
    "It sounds like you're upset/angry about _______."
  • A - Apologize
    For example:
    "I'm sorry you were inconvenienced."
    "I apologize for the situation."
    "I'm sorry it didn't meet your expectations."
    "I apologize for the confusion."
    "I'm sorry it didn't work out as expected."
  • T - Take responsibility for action
    For example:
    "I'd like to take care of this right away."
    "Let me call my supervisor and get her help."
    "Let's talk about how we can correct this situation."
    "If it's all right with you, I'd like to make a call or two and get back to you with some options."
    "I'll do everything I can to take care of this."

Toolboxes: Located in the vicinity of each department is a toolbox labeled "Service Recovery Toolboxes." Inside, you will find various items, primarily coupons at local restaurants, or a latte or a discount in the Cafeteria, Coffee Shoppe or Gift Shoppe. Every employee at CCH is empowered and encouraged to use these items as a tool to help "make things very right the second time." That is, when a customer is upset in the moment, use the toolbox item along with your apology.

For example, if a patient has waited too long, if we have had to reschedule their test, or if their experience at our facility has been an extremely frustrating one, you may present a coupon and say, "Mr. Smith, I know this long wait has been very frustrating for you. Please accept our apology for the inconvenience and enjoy a latte on your way home courtesy of us."

It is important to remember that Service Recovery is made up of two important elements. We need to focus not only on the tangible element (the item that we are giving the customer as a token of our apology) but also the psychological element. This means that we don't just hand them a coupon and hope it works, but we take the time to focus on our problem-solving (HEAT) skills.

In rare instances, a customer may be someone it seems you cannot satisfy. If a customer is still not approachable, after you have tried taking the HEAT, try getting your manager or supervisor involved, or calling the Patient Advocate.

Always, if you feel the customer is a threat to others, notify Security and try to get the customer to move into a nonpublic space.

Often, if we take the time to get to the bottom of a problem, it is an issue that we can resolve. When we refuse to take the time immediately, we lose the opportunity forever.

Resolving customer dissatisfaction through effective service recovery reinforces to customers that your organization is fully committed to meeting their expectations.

Excellence Every Day Toolkit

Service Excellence

1. AIDET plus the Promise:

  • A – Acknowledge, Eye Contact, Greet
  • I – Introduce, name and role
  • D – Duration: How long will ______ take
  • E – Explanation: Explain the procedure, process, or situation
  • T – Thank: Thank for choosing CCH, allowing us to serve you
  • Promise: Make a personal commitment to engage personally in delivering Excellence Every Day

2. HEAT:

  • H – Hear them out
  • E – Empathize
  • A – Apologize
  • T – and Take responsibility for action


1. SBAR:

  • S – Situation
  • B – Background
  • A – Assessment
  • R – Recommendation
  • Questions


  • P – Patient, procedure, physician
  • A – Assessment
  • N – Need to know
  • D – Drains and dressings
  • A – Allergies

3. Construction Problem Solving Policy

4. Department Visibility Boards


1. Safety Huddles with leadership and in departments

2. Sharing safety stories and messages

3. Rounding for safety


1. Self-Checking Using STAR:

  • S – Stop: Pause for 1 to 2 seconds to focus attention on the task at hand
  • T – Think: Visualize the act and think about what is to be done
  • A – Act: Concentrate and perform the task
  • R – Review: Check for the desired result

Self Checking: The most effective way to avoid slips and lapses. It takes only seconds to do and reduces the probability of making an error by a factor of 10 or MORE!


1. ARCC:

  • A – Ask a question
  • R – Request a change
  • C – voice a Concern
  • C – invoke Chain of Command

Social Media Guidelines for Use

CCH is dedicated to fostering a community of stakeholders that supports the mission and purpose of the healthcare system. In order to accomplish this, we realize the importance of communicating and learning using social and new media channels. CCH employees have access to the following social media sites for educational purposes, or for use on their breaks:

  • Facebook
  • LinkedIn
  • Twitter
  • YouTube / Streaming Media

Accessing these social media and streaming media sites at work should not interfere with your duties at work. We monitor our facilities to ensure compliance with this restriction. Web usage reports for any employee can be accessed by department managers from Information Systems if they believe an employee may be accessing the sites for purposes other than education, or spending too much time on the site when not on a break. These usage reports detail what sites an employee is visiting, as well as how much time they are spending on said sites. If it is determined that the employee is not using the sites for educational purposes, or accessing sites more often than on breaks, the employee will be subject to disciplinary action, up to and including termination.

No generic accounts have access to social media sites. Employees must log on to their personal account for access.

Employees are prohibited from uploading any content to YouTube or other streaming media sites. The only exception is Community Relations or departments with the approval of Community Relations and Information Systems.

Employees are expected to follow the same behavioral standards online as are mandated by CCH Policies and Procedures, including (but not limited to) the Use of Computers and Electronic Media policy, as well as the CCH Social Networking Policy in Policy Manager and the Social Media Standards (outlined below). The same guidelines for interacting online with stakeholders, fellow staff, physicians, or other associates apply as in the workplace.

CCH Social Media Standards

  1. Employees are cautioned that they should have no expectation of privacy while using the Internet. Your postings can be reviewed by anyone, including CCH, CCMH, CCMG, The Legacy Living & Rehabilitation Center (Pioneer Manor) and other organizational entities. CCH reserves the right to monitor comments or discussions about the organization, its employees, patients and the industry, including products and competitors, posted on the Internet by anyone, including employees and non-employees. CCH fully respects the legal rights of our employees, medical staff, and volunteers. Activities in or outside of work that affect your job performance, the performance of others, the privacy of our patients, or our health system's reputation are subject to CCH policies.
  2. The use of social media by CCH employees for professional, work, educational, and personal purposes creates opportunities to communicate in a public forum and with that the potential for conflicts in patient and customer management. To use social media productively and avoid these conflicts, CCH employees who engage in social media activities agree to demonstrate appropriate conduct in accordance with the CCH Social Media Policy. All posts on social media must comply with our policies on confidentiality of patient health information and disclosure of proprietary information. If you are unsure about the confidential nature of information you are considering posting, consult your manager. A good rule of thumb: Only post items that you would want your director, manager or Administration to see.
  3. CCH team members may not use social networking to harass, discriminate, or make disparaging or defamatory statements about the health system or its affiliates; employees; affiliated physicians; other healthcare providers; volunteers; students; patients; guests; vendors and contractors. In other words: BE RESPECTFUL!
  4. Team members should recognize that online communications / activity can impact their personal image and reputation and may be seen by others as a reflection of their character, judgment and values. Posting some types of information or photographs may jeopardize their individual personal and /or professional reputation. By extension, if it is known that an individual is associated in any way with CCH, the health system's reputation can, likewise, be negatively impacted. Should this occur, an employee will be subject to disciplinary action, up to and including termination. It is important to note that information shared online in social media forums lasts forever on the Internet and is available to everyone, including your employer. The bottom line: USE COMMON SENSE!
  5. Personal use of social media must not interfere with your work commitments and the use of social media during assigned work hours and on CCH property must be limited to work-related reasons. Web usage reports for any employee can be accessed by department managers from Information Systems if they believe an employee may be accessing the sites. These usage reports detail what sites an employee is visiting, as well as how much time they are spending on said sites. Employees are expected to follow the same behavioral standards online as are mandated by CCH Policies and Procedures.

Telephone Etiquette

All CCH employees are required to use the CCH Standardized Greeting when answering the telephone.

With the exception of Pioneer Manor, all departments should answer phones with the following standardized statement when answering calls made from outside the organization:

  • "Thank you for calling Campbell County Health, this is , how may I help you?"
  • Or, "Thank you for calling Campbell County Health (Department name), this is , how may I help you?"

For all CCMG Clinics:

  • Thank you for calling Campbell County Medical Group, this is , how may I help you?

When answering calls made from inside the organization, please use:

  • "Department Name, this is ." For example, "Community Relations, this is Felicia."

Greeting the Caller

  • Answer the phone within three (3) rings.
  • Use a pleasant, caring and sincere tone of voice and an unhurried pace.
  • Use the standard greeting outlined above.

Being a Good Listener

  • Listen carefully to understand the caller's words, intent, feelings and needs.
  • Validate what you heard the caller say by repeating it in your own words.
  • When giving information, use easily understood and appropriate language (e.g., no incorrect grammar, slang, medical terminology or abbreviations).
  • Address the caller's needs and take whatever action is necessary. Ask others to help you if necessary.
  • Check for understanding and ask,
  • "Do you need any more information?"
  • "Do you have any more questions?"

Placing a Call on Hold

  • Always ask if the caller is able to hold, and then wait for a response.
  • "Mrs. Jones, would you mind holding while I research that information for you?"
  • Tell callers why you need to put them on hold.
  • Let callers know how long they will be on hold.
  • Check back every 30 seconds, give the status of the call, and see if the caller can continue to wait. If not, ask for the caller's phone number and return the call.
  • Thank the caller for holding.
  • "Mrs. Jones, thank you for holding. Ella is still on the other line. She knows you're holding and expects to be finished in another minute or so. Would you like to continue to hold, or would you like me to have her call you right back?"

Transferring a Call

  • Always ensure that callers understand why they are being transferred.
  • Ask their permission to transfer and wait for a reply.
  • Explain where the call is being transferred and to whom.
  • Give the caller the number for future reference, and in case you are disconnected.
  • Give information about the call to the person receiving the transfer.
  • Remain on the line until a connection is made.
  • "Hello, Mr. Jones, thank you for holding. I spoke to Medical Records. They have your chart and will be happy to help you with your concern. I am going to transfer you. I will stay on the line to make sure you get through, but let me give you their phone number just in case."

Taking a Message

  • Obtain the following information and write it down:
  • Name of person being called.
  • Caller's name and phone number.
  • Time and date of call.
  • Purpose of the call.
  • Restate the message to check for accuracy.
  • Put your initials on the message.
  • Make sure it reaches the appropriate person.

Ending the Call

  • Use an appropriate phrase such as:
  • "Is there anything else I can help you with today?"
  • "Thank you for calling the unit."
  • "If we can be of further assistance, please give us a call."
  • "Have a nice day."
  • "Good bye" (not "Bye-bye").
  • Make certain the caller hangs up before you do. This ensures that the call is over.

For more information: Refer to the Telephone Use Policy in Policy Manager and your department specific policy.

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