EXHIBIT 6

2:15-cv-12101-DML-DRG Doc # 24-7 Filed 08/27/15 Pg 1 of 4 Pg ID 628
HFHS Surgical Attire —EHR075 Page 1 of 3 

PRINTED VERSIONS OF THIS DOCUMENT ARE NOT CONTROLLED AND ARE FOR REFERENCE ONLY.

THE USER IS RESPONSIBLE TO CHECK THE DOCUMENT CONTROL SYSTEM TO VERIFY THE CURRENT VERSION PRIOR TO USE.

Henry Ford 

Health System 

Policy Name/Subject: Tier 1: HFHS Surgical Attire Policy No: EHR075 

Document includes: þ Policy  ̈ Procedure  ̈ Other:

Applies to: þ All HFHS  ̈ Business Unit:  ̈ Service Line:  ̈ Dept: 

Category: Clinical Current Approval Date: August 2013 

Owner (Title): HFHS CNO Approver (Title): OR Executive Council

Last Revision Date & Key Change(s): August 2013

Key Word(s): Surgical Attire

Policy: 

Appropriate attire and personal protective equipment will be worn in the semi restricted and restricted 

areas of surgical services by all staff, physicians and visitors. 

Procedure: 

A. The 2013 AORN Perioperative Standards and Recommended Practices for Surgical Attire should be 

referred to for further detail related to the following policies. 

B. Clean surgical attire, including shoes, head covering, masks, jackets, and identification badges 

should be worn in the semi-restricted and restricted areas of the surgical or invasive procedure 

setting. 

C. Identification badges should be worn by all personnel in the peri-operative setting and be secured on 

the surgical attire top, be visible, and be cleaned if they become soiled. 

D. Facility approved, clean and freshly hospital laundered surgical attire should be donned in a 

designated dressing area of the facility upon entry or reentry to the facility. 

E. Scrubs worn into the hospital from the outside should be changed before entering semi restricted or

restricted areas. 

F. Personnel should change into street clothes whenever they leave the health care facility or when 

traveling between buildings located on separate campuses. 

G. Surgical attire made of reusable woven fabric or single use non-woven fabric that is low-linting should 

be worn. 

H. The top of the scrub suit should be secured at the waist, tucked into the pant, or fit close to the

body. 

I. Surgical attire should be changed daily and whenever visibly soiled, contaminated or wet. 

J. All non-scrubbed personnel should wear a freshly hospital-laundered or single-use long sleeved 

warm-up jacket snapped closed with the cuffs down to the wrists when in the semi-restricted or 

restricted areas. 

K. All personal clothing should be completely covered by the surgical attire (eg. Undergarments such as 

T-shirts with a V-neck, which can be contained underneath the scrub top may be worn; cloth head 

covers contained under a disposable bouffant head cover). 

L. Personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire 

should not be worn. 

2:15-cv-12101-DML-DRG Doc # 24-7 Filed 08/27/15 Pg 2 of 4 Pg ID 629
HFHS Surgical Attire —EHR075 Page 2 of 3 

PRINTED VERSIONS OF THIS DOCUMENT ARE NOT CONTROLLED AND ARE FOR REFERENCE ONLY.

THE USER IS RESPONSIBLE TO CHECK THE DOCUMENT CONTROL SYSTEM TO VERIFY THE CURRENT VERSION PRIOR TO USE.

M. Head and facial hair, including sideburns and the nape of the neck, should be covered when in the 

semi-restricted and restricted areas with a clean, low-lint surgical head cover or hood that confines all 

hair and covers scalp skin. Religious headwear must be covered by a hood in the semi restricted and 

restricted area. 

N. Reuseable hats will be completely covered by a disposal head covering or hood. 

O. All individuals entering restricted areas should wear a mask when open sterile items and equipment 

are present that covers both mouth and nose and be secured in a manner that prevents venting. 

P. A fresh, clean surgical mask should be worn for every procedure and replaced and discarded 

when it becomes wet or soiled. 

Q. Masks should not be worn hanging down from the neck and should be discarded after each 

procedure. 

R. Masks should be removed by carefully handling only the ties, followed by hand hygiene. 

S. Jewelry (including earrings, necklaces, watches, and bracelets) that cannot be contained or confined 

within the surgical attire should be removed before entry into the semi-restricted and restricted areas. 

(Refer to HFHS HR policy number 5.06 Personal Appearance Standards for further information). 

T. Shoes worn within the surgical environment should be clean, have closed toes and backs, low heels, 

non-skid soles, and must meet OSHA and the health care organization’s safety requirements. 

U. Shoe covers are optional and if worn, should be changed whenever they become torn, wet, or soiled 

and should be removed and discarded in a designated container before leaving the surgical area. 

V. No personal bags should be taken into the semi restricted or restricted areas of the perioperative 

suite. 

W. Persons entering the semi-restricted or restricted areas of the operating room for a brief time for a 

specific purpose (eg. Law enforcement officers, parents, biomedical engineers) should cover all head 

and facial hair and don either freshly laundered surgical attire; single-use attire; or a single-use 

jumpsuit (eg. Coveralls, bunny suits) designed to completely cover outside 

X. Lab coats are prohibited in the semi restricted or restricted areas. 

Y. Masks along with protective eyewear will be worn whenever eye, nose, or mouth contamination can 

be reasonably anticipated such as: splashes, spray, or splatter of potentially infectious/hazardous 

materials. 

Z. Scrubbed personnel will wear a mask and an eye shield when scrubbing in any procedure. 

AA. Protective eyewear will be discarded or decontaminated after every procedure or exposure. 

BB. Any Surgical Services personnel that care or come into contact with an isolation patient will 

wear Personal Protective Equipment (PPE) appropriate for the type of isolation (i.e. cover 

gown, gloves, and mask with eye shield, if applicable).

Definition(s) 

Semi-restricted-Includes the peripheral support areas of the surgical suite and has storage 

areas for sterile and clean supplies, work areas for storage and processing instruments, and 

corridors leading to the restricted areas of the surgical suite. 

2:15-cv-12101-DML-DRG Doc # 24-7 Filed 08/27/15 Pg 3 of 4 Pg ID 630
HFHS Surgical Attire —EHR075 Page 3 of 3 

PRINTED VERSIONS OF THIS DOCUMENT ARE NOT CONTROLLED AND ARE FOR REFERENCE ONLY.

THE USER IS RESPONSIBLE TO CHECK THE DOCUMENT CONTROL SYSTEM TO VERIFY THE CURRENT VERSION PRIOR TO USE.

Restricted area-Includes the operating room (OR) and procedure room, the clean core, and the 

scrub sink areas. People in this area are required to wear full surgical attire and cover all head 

and facial hair, including sideburns, beards, and necklines. 

Unrestricted Area: A central control point that is established to monitor the entrance of patients, 

personnel 

and materials where traffic is not limited and street clothes are permitted. 

Reference(s)/Source(s): 

AORN Perioperative Standards and Recommended Practices for Inpatient and Ambulatory 

Settings 2013 Edition 

2:15-cv-12101-DML-DRG Doc # 24-7 Filed 08/27/15 Pg 4 of 4 Pg ID 631