St. Mark's Hospital - July 01, 2017

The Hospital policy for individuals who seek to observe clinical care was updated in May. The purpose of the policy is to assure that we avoid problems that have occurred in other hospitals:

  1. HIPAA violations by observers disclosing healthcare protected information (HPI) to others.
  2. Patient complaints about not being given the opportunity to decline permission to be observed.
  3. Observer interference with delivery of patient care.
  4. Transmission of infections from observers.
  5. Injury or transmission of infection to observers.

In order to accomplish these objectives, please collaborate to follow the provisions of this policy.

Non-affiliated licensed healthcare professionals over 18 years of age must register online at least 30-days in advance at stmarkshospital.com/professionals/observing-shadowing.dot. Documentation of influenza vaccination (during influenza season) and tuberculosis screening within the prior 12 months are required. An online orientation is required, as is a signed attestation by the sponsor that he/she will provide direct supervision of the observer at all times. Completed registrations are routed to a senior leader for approval.

The director of the patient care unit(s) involved in the observation will be notified once a complete application is received and again at approval. A hospital-issued name badge must be worn at all times during the observation period. On the day of observation, all patients must be informed of the observer’s presence and be given the opportunity to decline. Written patient permission for an observer is required prior to observation of all procedures.

Please do not expect on-site registration on the day of observation, because it is rarely feasible to complete all of the requirements on the spot.

Students are not considered to be observers and have different requirements. The educational program for each health professions student, resident or fellow must have an affiliation agreement in place with St. Mark’s prior to the student’s involvement with patients. Most local programs likely have an affiliation agreement already in place. To verify, please call Rory Ukena in the Medical Staff Office at (801) 268-7003. If no affiliation agreement is in place, Rory can guide the process.

Vendors must be registered through eDHP. If you have questions about bringing in a vendor, please contact the Human Resources Office at (801) 268-7776.

If you have questions about someone’s presence in a clinical area, please ask the hospital leaders of that area. If you have questions about the Observer Policy, please contact Robin Phillips RN, Assistant Chief Nursing Officer at robin.phillips2@mountainstarhealth.com or at (801) 268-7132.


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