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Policy & Procedure for Visiting a DUHS & PDC Facility
Policy & Procedure for Visiting a DUHS Facility
Scheduled Review Date:
DUH Procurement of Patient Care Equipment and Supplies Policy
TJC HR Standards
Unauthorized Entry of Patient Care Equipment Task Force
Director, Procurement & Supply Chain Management
Policy applies to all DUHS entities.
To provide guidance, which will assist the clinical staff and physicians in providing high quality, uninterrupted patient care, and to maintain the highest degree of patient confidentiality. All Vendor Representatives will adhere to Duke Health System Procedures, and will abide by the laws and regulations of the State of North Carolina, federal government, The Joint Commission (TJC), AORN, HIPAA Privacy Rule, and other regulatory standards of practice.
All vendor representatives will adhere to Duke Health System Procedures, and will abide by the laws and regulations of the State of North Carolina, federal government, The Joint Commission (TJC), AORN, HIPAA Privacy Rule, and other regulatory standards of practice. Prior to coming to a Duke Medicine entity for business purposes, vendor representatives will register with Vendormate for Duke Medicine, providing evidence of competency for desired/required level.
Purpose: To provide guidance, which will assist the clinical staff and physicians in providing high quality, uninterrupted patient care, and to maintain the highest degree of patient confidentiality. All vendor representatives will adhere to Duke Health System Procedures, and will abide by the laws and regulations of the State of North Carolina, federal government, The Joint Commission (TJC), AORN, HIPAA Privacy Rule, and other regulatory standards of practice.
Note: vendor representatives who visit multiple departments within Duke Medicine will be registered at their maximum competency level as determined by Duke Medicine. Competency levels as outlined in the Addendum of this policy.
Prior to first visit:
Prior to coming to a Duke Medicine entity for business purposes, vendor representatives will:
- Register with Vendormate for Duke Medicine, providing evidence of competency for desired/required level.
- Complete the required training and paperwork (see addendum for requirements). Vendormate will maintain the evidence of compliance with the requirements.
**Vendor representatives who are not in compliance with the requirements will not be able to obtain a Vendormate ID nametag, and therefore will not be permitted to conduct business at any Duke Medicine entity.
Check in procedure for Hospital Representatives:
Upon arrival to any entity, in order to obtain a nametag, vendor representatives will:
- Sign into Vendormate.
- If the vendor representative has not registered with Vendormate, then they are to go to the Procurement Office at 310 Trent Drive Suite 154 at the Duke University campus in Duke NC.
a. Allowance to enter the premises for purposes of representing a company will be determined on a case by case basis at Procurement. For purposes of this policy, no grace entry will be allowed.
- Vendor representatives will be issued a nametag at check in, which will serve as a pass for the time period of the scheduled appointment. The nametag serves as a photo ID and includes area to be visited, the date, and their company.
- The nametag should be prominently displayed above the waist, along with their company issued name nametag. Vendor representatives must wear the nametag and their company badge at all times while in the facility.
- The nametag will indicate which area the representative is allowed to visit.
DUHS Check in Locations & Procedure
Duke Hospital: Vendormate Kiosk locations (includes Duke Medical Pavilion & Duke Cancer Center)
OR: Elevator alcove on the 3rd floor opposite the entrance to the Main OR.
Cardiology: Staff Lounge in Cardiac Cath Lab, floor 7.
Radiology: Children’s Health Center corridor 1901X – around the corner from Radiology.
ASC: Front desk, Ambulatory Surgery Center North Pavilion
Eye Center: Front desk in the Wadsworth Eye Center for non-Operating Room representatives.
For representatives who are designated by competency and Vendormate registration to go into the Operating rooms will sign in at the kiosk outside of the Eye Center Operating rooms.
Procurement: Vendors not visiting any of the above areas will sign in at the Procurement Office
Duke South Clinics on Trent Drive: Vendormate Kiosk location: 2nd floor before bridge to parking garage.
Duke Regional Hospital: Vendormate Kiosk locations
MM: Resource Distribution, basement DRH
OR: Information desk in the Lobby of DRH
Davis Ambulatory Surgery Center: Vendormate Kiosk location
Main Lobby: Business office after reporting to the front desk.
Duke Raleigh Hospital:
Off the main lobby: Vendors will register at the computer which is located in the first hallway to the right, past the main elevators.
Offsite Duke Raleigh Hospital Locations – Check in at front desk (see DPC below)
Duke Cancer Institute at Macon Pond
4101 Macon Pond Rd. Raleigh, NC 27607
Duke Cancer Institute at Cary-Radiation Oncology
300 Asheville Ave, Suite 110, Cary NC, 27518
Duke Cancer Institute at Cary-Medical Oncology
216 Asheville Ave, Suite 20, Cary NC 27518
Note: Exceptions to normal business hours shall be coordinated with the appropriate person applicable to the business transaction or visit.
Vendormate computers are property of DUHS and any activity is regulated to comply with DUHS DHTS policy. Vendor representatives will access computers only for obtaining a nametag for that particular location. Any activity other than the foregoing will be construed as a breach in policy and may result in dismissal from marketing in any DUHS facility.
Duke Primary Care (DPC) (previous known as Duke University Affiliated Physician Practices) (DUAP)
- and -
Duke Private Diagnostic Clinics (PDC) and Duke Community Private Diagnostic Clinics (CPDC):
Check in Procedure:
- Vendor representatives will check in upon entering the clinic at the front desk.
- Upon verifying full compliance as indicated by “PASS” under documents the Vendormate profile, a badge will be printed on 8x10 paper with instructions for proper folding.
Extended Care and DME Representative Check in Procedure:
Representatives of Extended Care Companies at Duke University Hospital:
Representatives of Extended Care companies, who have been granted on-site review access by the Department of Patient Resource Management, will have their names and companies maintained on file in Vendormate.
- Prior to signing in, the Extended Care Representative must have prior approval from a PRM and must confirm this with the receptionist at Procurement, who will retain the list of approved representatives for that day.
- They will check in at the Vendormate kiosk in Procurement and will be issued a nametag for that day.
Representatives of Extended Care Companies at Duke Regional and Duke Raleigh Hospitals will use Vendormate exclusively.
DME Vendors Duke University Hospital will:
- Register with Vendormate in the category that indicates patient contact because patient contact occurs in the normal course of job performance.
DME vendors will not have to check in with each visit to Duke University Hospital.
DME VENDORS Duke Regional and Duke Raleigh Hospitals:
DME vendors who make deliveries to DRAH will:
- Check in using Vendormate with each visit. Due to the nature of their job performance, they must register in the category that indicates patient contact.
ADDITIONAL GUIDELINES AND PROCEDURES TO BE FOLLOWED BY FORMULA REPRESENTATIVES.
In compliance with the World Health Organization code, Duke Hospital does not permit the distribution, advertisement or free samples (to include diaper bags) of infant formula to patients, staff or families.
THE ONLY ALLOWABLE NAMETAG FOR DUHS IS THE VERTICAL PREMIUM MEMBERSHIP TAG.
Each Duke Facility, or specific departments within each facility, may have additional Vendor Policies and Procedures. Vendor representatives shall receive such information from the department representative, upon their initial visit and periodically thereafter, and will be expected to abide by the specific area’s policy.
DUHS Gifts and Courtesies Policy: The policy generally prohibits the acceptance of gifts or courtesies from actual or potential patients or other consumers of DUHS services, healthcare providers or vendors of goods or services. Under the policy:
- DUHS locations: any food paid by vendors is prohibited, including food provided during educational sessions.
- Off-site locations: DUHS staff and medical staff may not accept a meal where vendors are paying for the meal including during educational programs.
To report an unauthorized vendor or a breach in policy, call Procurement and Supply Chain Management at 681-5900 or 684-4010. Simply furnish the representative's name, and/or company so that follow up can occur.
Failure to comply with these Procedures shall result in the loss of Vendor’s privileges, and exclude the Vendor representative from further transactions with Duke Medicine. Length and duration of privilege loss will be determined on a case by case basis by the Director of Clinical Resource Management, in consultation with the Associate VP Procurement & Supply Chain Management and other departments within DUHS as appropriate.
Any exception to the foregoing will occur on a case by case basis by the designated administrator for that area.
NOTE: All vendors must be accompanied by a staff member at all times within any patient care area or interacting with any patient anywhere in Duke University Health System.
- While the vendor representative may be present at the point of care, if so designated, they are not to open any sterile product. Product is to be given to the appropriate Duke Staff member to open.
Vendor representatives will not retrieve tissue or blood at any time.
Vendor representatives will not remove inventory at any time, unless their company’s inventory is consigned. In that case, notification of the appropriate personnel is required prior to restocking or removing inventory.
- Dress Code: Vendor representatives will dress professionally. VENDOR REPRESENTATIVES IN ALL PROCEDURAL AREAS (OR, IR, CARDIOLOGY AND ANYWHERE STERILE TECHNIQUE DICTATES) WILL WEAR A RED BOUFFANT CAP AS A DESIGNATION OF VENDOR STATUS.
- Should a sales representative be found visiting departments within the facility without first signing in and obtaining a nametag, or if they have an expired nametag as evidenced by the appearance of the stop sign, he/she will be asked to obtain a nametag through Vendormate. If the vendor representative isn’t registered, then they will be asked to leave the premises. In addition, the incident will be reported to the Asst. Vice-President, Procurement and Supply Chain Management for appropriate action.
- Passes are good for the pre-scheduled appointment only. Should the need arise to visit another department after signing in; an additional pass will need to be issued by signing in with Vendormate.
- All meetings should be held in accordance with the policy or guidelines of that specific area.
- Vendor representatives may be present in common areas of the facilities. However initiating unsolicited contact with clinicians and facility employees is prohibited, and may result in suspension of visitation privileges.
- Vendor representatives’ access to patient-specific information in any clinical setting shall be managed in accordance with the HIPAA Privacy Rule.
- Vendor representatives may visit in patient care areas only when an appointment has been scheduled. Vendor Rep may be asked for verification of appointment at any time while on the premises.
- Two Vendor representatives per company will be permitted to visit a patient care area at one time; however, more than two representatives per company may visit when support is required for pre-approved trials, or in-service training is needed.
- Vendor representatives are prohibited from displaying company advertisements, without prior permission from appropriate clinical staff and approval from Associate VP Procurement & Supply Chain Management.
- Vendor representatives must park their private or company vehicles in appropriate visitor parking areas. Vehicles parked in unauthorized areas will be towed at the expense of the drivers.
- The vendor is responsible for timely notification to Vendormate in the event a vendor representative is terminated, voluntarily leaves the company, or transfers within the company and/or if the competency changes for any reason.
- All Non FDA approved Investigational Devices (Class A or B) must have Duke IRB approval and a FDA IDE/HDE number and a Duke Material (SAP) number. (Refer to Use and Reimbursement for Non-FDA-Approved Investigational Devices Procedure)
- Investigators who plan to study or use non-FDA approved devices will assure clinical staff competency in the proper and safe use of the device, the identification and immediate management of any complications that might arise in connection with the device, and will educate involved clinical staff as to the procedures of the study. Such competency validation and education will occur before the research is initiated in the patient care setting. In addition, investigators will comply with all IRB requirements regarding the use of non-FDA approved devices.
- All incoming products and equipment must be covered by a Duke University and Duke University Health System Purchase Order, which is issued by Procurement & Supply Chain Management. Medical Equipment must be inspected and approved by Clinical Engineering prior to use. Vendors will assume all responsibility of the equipment on loan or evaluation for proper operation or suitability. Vendor Representatives may not introduce products to any facility prior to meeting with the appropriate Procurement & Supply Chain Management representative and/or Duke Committee liaison. Products and equipment that are delivered without a valid purchase order may be considered a donation to Duke, or may be returned at the vendor’s expense.
The clinical settings (hospitals, clinics and community-based care of Duke University Health System), billing operations (Patient Revenue Management Organization, LLC) and the academic and research entities (School of Medicine and School of Nursing) as well as the Private Diagnostic Clinic, LLC.
An individual associated with a company that does business with Duke Medicine.