Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
River Region Health System STUDENT ORIENTATION & COMPLIANCE 2100 Highway 61 North Vicksburg, Mississippi 39183 (601) 883-5000 MISSION & VISION The Mission of River Region Health System is to improve and deliver quality, compassionate healthcare aligned with the needs of the communities we serve. The Vision of River Region Health System is to be the health system of choice by patients, physicians, employees, and will be nationally recognized as a premier healthcare provider. BASIC PRINCIPLES OF CUSTOMER SERVICE Attitude Greet all customers with a smile Introduce yourself by name and position Address customers by their last name Rudeness is NEVER acceptable Make eye contact Always meet customer needs immediately or find someone who can. Appearance Always dress professionally. Badges Must Be Worn by All Students and Faculty Members at Eye Level and Must Be Visible at All Times. BADGES are not to be attached to LANYARDS. Practice good personal hygiene and grooming. Comply with your school’s dress code. Anticipate the Needs of our Customers Ask “How can I help” Understand the needs of the customer Communicate during waits Apologize when a delay occurs Ask, “Is there anything else I can do for you?” Maintain a Safe & Clean Environment Keep the environment clean Pick up any litter you find Put things back in their place Keep hallways free of clutter Know safety codes and respond appropriately Report needed repairs. Privacy & Confidentiality Always knock before entering Keep all patient information confidential Discuss patient information in a confidential setting Close doors when possible Provide a robe or extra gown for patients in public places. Elevator Etiquette Always smile and speak to fellow passengers When transporting patients, face them toward the door Make room for others Allow our guests to enter the elevator first. Sense of Ownership Take pride in River Region Be an ambassador inside and outside of the facility Follow policies and procedures Do the right thing. The Basics of Patient Safety Background to Patient Safety 1999 IOM report: medical errors kill up to 98,000 hospital patients per year. Medical Errors occur in 2.9% to 3.7% of Hospital Admissions; 8.8% to 13.6% of error lead to death. Recent Studies reveal - 2% of hospital admissions have a preventable adverse drug event resulting in: • Increased LOS of 4.6 days • Increased hospital costs of $4,7000 per admission. Patient Safety is part of Performance Improvement here at River Region. The PI Council is the interdisciplinary group that oversees patient safety. At admission, all River Region patients receive patient safety education. The RRHS patient handbook has an entire section dedicated to safety. Each patient satisfaction survey includes questions on safety. We embrace a culture that recognizes human error and strives to learn from our mistakes by providing a safe reporting environment. We contain errors through Analysis to understand the cause behind the event so we can make changes that will promote safer care for our patients. Since 1996, the JCAHO have required organizations to investigate Sentinel Events. A Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury. They are considered sentinel because they signal a need to investigate and respond immediately. Who Reports? All employees and students are responsible for reporting a Sentinel Event. Why Report? To have a positive impact on improving patient care. National Patient Safety Goals Identify Patients Correctly Patient Identifiers at River Region: Name and Date of Birth Improve Staff Communication LISTEN, WRITE DOWN, and READ BACK all verbal/telephone orders/results. Verbal orders taken when the physician is on the unit areacceptable only in emergency situations! Clarify any physician order containing an unapproved abbreviation. LISTEN, WRITE DOWN, and READ BACK critical lab values. Document accordingly in the nurses notes and on the critical lab value form. Notify the physician immediately! Hand Off Communication Guidelines (Giving Report) Patient demographics Diagnoses & present code status Current vital signs & abnormal trends Critical lab values Recent tests, surgeries, procedures, & radiology reports Medications including IV fluids & recent pain medications Use Medications Safely TWO NURSES : Before administration of insulin, heparin, and chemotherapy The second nurse must watch preparation & document on the MAR. Label all medications, medication containers. (for example, syringes, medicine cups, basins) Prevent Infection Scrub hands for 15 seconds with soap and water or use alcohol foam before, between, and after contact with patients/patients’ environments. Fingernails are to be kept short and clean. Artificial nails and/or acrylic overlays are prohibited. Check Patient’s Medicines Find out what medicines each patient is taking. Make sure that it is OK for the patient to take any new medicines with their current medicines. Step 1: With patient’s involvement, create a complete list of the patient’s current medications at admission/entry (Medication Reconciliation Form). Step 2: The medications ordered for, administered to, or dispensed to the patient while under the care of the organization are compare to those on the list. Step 3: Resolve any discrepancies. Give a list of the patient’s medicines to their next caregiver or to their regular doctor before that patient goes home. Give a list of the patient’s medicines to the patient and their family before they go home. Explain the list. Prevent Patients From Falling Fall Prevention Tips: -Assist elderly patients to toilet -Keep call light within patients’ reach -Assign rooms close to the nurses’ station -Monitor demented patients closely -Ensure adequate lighting -Offer toileting regularly -Keep side rails up -Keep bed locked and in low position -Instruct patients to call before getting out of bed -Monitor patients on diuretics and narcotics frequently -Identify fall precaution patients with yellow sticker & armband clip Prevent Patients From Getting The Flu and Pneumonia Assess the older adults’ risk status for the flu and pneumonia. Take action through educating the patient on the diseases and offer vaccinations to protect against them. Use Influenza and Pnuemococcal order sets to access risk factors. Always vaccinate if there is a question whether the patient has received previous vaccinations. Reduce the Risk of Surgical Fires OR staff must know how to control heat sources, how to manage fuels while maintaining enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes. -Fire safety video housed in Surgical Services -Mock fire drills conducted in Surgical Services Help Patients To Be Involved In Their Care Tell each patient and their family how to report their complaints about safety. Encourage active patient participation & use of the PI Line (Patient Intervention Hotline). The Patient Advocate gives pamphlets to all patients. Educate on methods to report unsafe practices: The Joint Commission – (630) 792-5000 The MS State Dept of Health – (866) 458-4948) Prevent Hospital Acquire Pressure Ulcers Assess and periodically reassess each resident’s risk for developing pressure ulcers and take action to address any identified risks. Rules of Thumb: -All patients are to be assessed for high risk for pressure ulcer development on admission and every 12 hours afterward. -A total body assessment should be completed in the first 24 hours to identify a pressure ulcer on admission (POA). -If a patient is identified with a pressure ulcer or having a high risk status, protocols should be implemented within an 12 hour period. -Identify ancillary consults to impact healing process. Identify Patient Safety Risks Find out which patients are most likely to try to kill themselves. Perform suicide risk assessment and reassessment, address immediate safety needs, and provide crisis hotline information. Tips to Identify Patients at Risk for Suicide: -Sudden changes in mood and behavior -Drug/Alcohol impairments -Change in level of consciousness (LOC) -History of suicide attempts, violent behavior -Recent change in stressors, loss of coping skills and/or support systems -Patients at risk for flight -Patient’s admitted for treatment of emotional or behavioral disorder -Patient’s admitted for court-ordered evaluation Watch Patients Closely For Changes In Their Health & Respond Quickly Activate the Rapid Response Team by calling the Hospital Operator. -Systolic BP < 90 mmHg -Heart Rate < 40 or > 130 beats per minute -Respiratory Rate < 8 or > 28 per minute -O2 Saturation < 90% despite O2 -Abnormal Temperature -Urine Output < 50 mL in four hours -Change in Level of Consciousness -Intuition tells you something is wrong Universal Protocol & Implementation Guidelines Conduct a preoperative verification process as described in the Universal Protocol. Surgical Procedure: Pre-operative & Verification Checklist Mark the operative site as described in the Universal Protocol. The physician marks the surgical site. Check the marked site against the History and Physical, consent, and ask the patient to verify. Conduct a “time out” immediately before starting the procedure as described in the Universal Protocol. Time Out = Physicians & Nurses Agree Site Patient Procedure CULTURAL DIVERSITY What are Cultural Competencies? They are skills you use to work well with PATIENT’S of all CULTURES. Those skills consider every patient’s culture when giving care and treating every patient as an individual. WHY LEARN ABOUT CULTURAL COMPETENCIES ? TO HELP PATIENTS RECEIVE MORE EFFECTIVE CARE. TO HELP OUR FACILITY MEET THE JCAHO STANDARDS. TO IMPROVE JOB PERFORMANCE. CULTURAL FACT CULTURE IS… Customs Morals How people are raised to live their lives. Belief Habits CULTURAL FACT DIVERSITY IS… Socioeconomic status Race Gender Age Sexual Orientation Preferred Language Views of Health All the differences that define each of us as individuals. Food Preferences Nationality Religion Physical or Mental Disability CULTURAL FACT STEREOTYPING IS… Pushing another into a “category” without considering the uniqueness of individuals, groups, or events. CULTURAL FACT PREJUDICE IS… Prejudging someone before you know all the facts. CULTURAL DIVERSITY BENEFITS REDUCES CONFLICT INCREASES MORALE AND DECREASES TURNOVER DECREASES DISCRIMINATION CLAIMS IMPROVES COMMUNICATION IMPROVES UNDERSTANDING OF OUR CUSTOMERS AND PATIENTS DO THE RIGHT THING! CULTURAL COMPETENCIES REQUIRE… Self-Awareness Time to Learn About the Patient Effective Communication •Know your own cultural beliefs and practices. •Ask questions to avoid cultural stereotypes. •Listen to how the patient talks about his or her condition. •Be aware of the culture of health care in the U.S. •Learn the patient’s views about health. •Look for clues. •Show respect. •Talk with others who know the patient. •Understand relationships. •Ask for the patient’s views on treatment. •Consider privacy needs. •Use interpreters effectively. What is Infection Control? Surveillance Prevention Control of Infections What’s the #1 way to prevent infection? HANDWASHING Many studies have shown that the bacteria that cause hospital acquired infections are most frequently spread from one patient to another on the hands of healthcare workers. CDC reports 2 million people get hospital acquired infections every year and 90,000 of these result in death. Although handwashing has been proven to reduce the spread of germs, healthcare workers often do not wash their hands when recommended. In 34 studies of handwashing, workers washed their hands only 40% of the time. Healthcare workers can get 100s or 1000s of germs on their hands by doing simple tasks: Pulling patients up in the bed Taking a blood pressure or pulse Touching a patient’s hand Touching the patient’s gown or bed sheet Touching equipment like bedside rails, bedside tables, IV pumps/poles and wheelchairs We now have made it easier for healthcare workers to comply with CDC Hand Hygiene Guidelines: Use of Alcohol based Hand Gel/Foam It only takes 15 seconds compared to 60 seconds for handwashing They can be placed in convenient locations, making it readily available They are more effective in reducing the number of live germs on your hands Cause less skin irritation. When do you wash your hands? Before and after using the bathroom After using computer/phone After patient contact/care After sneezing After coughing. Before and after eating After removing gloves. What is a hospital acquired infection? An infection that was not present or incubating at the time a patient was admitted. How to prevent & control infections? Develop good hand hygiene techniques Follow infection control policies and procedures Implement those policies and procedures. Types of Isolation Airborne Contact Door Sign and Color Example: MRSA Modified Contact Door Sign and Color Example: Vancomycin Resistant Enterococcus (VRE) Door Sign and Color Example: TB Droplet Door Sign and Color Example: Meningitis Isolate the disease NOT the patient! Choose the correct isolation category Follow directions that are on the sign Provide Teach the same care the family and visitors. When is isolation necessary? When a patient has a diagnosed infectious disease Before a definite diagnosis can be made (suspected) Immunosupressed patients If you have any questions regarding any statistical data presented or Infection Control Questions – please contact the Infection Control Coordinator at 601-883-5576. Bloodborne Pathogens Approximately 5.6 million workers in health care and other facilities are at risk of exposure to bloodborne pathogens such as human immunodeficiency virus (HIV – the virus that causes AIDS), the hepatitis B virus (HBV), and the hepatitis C virus (HCV). OSHA’s Bloodborne Pathogens standard prescribes safeguards to protect workers against the health hazards from exposure to blood and other potentially infectious materials, and to reduce their risk from this exposure. Implementation of this standard not only will prevent hepatitis B cases, but also will significantly reduce the risk of workers contracting AIDS, Hepatitis C, or other bloodborne diseases Who is covered by the standard? All employees who could be “reasonably anticipated” as the result of performing their job duties to face contact with blood and other potentially infectious materials. “Good Samaritan” acts such as assisting a coworker with a nosebleed would not be considered occupational exposure. Some Workers Who are at Risk Physicians, nurses and emergency room personnel Orderlies, housekeeping personnel, and laundry workers Dentists and other dental workers Laboratory and blood bank technologists and technicians Medical examiners Morticians Law enforcement personnel Firefighters Paramedics and emergency medical technicians Anyone providing first-response medical care Medical waste treatment employees Home healthcare workers STUDENTS How does exposure occur? Most common: needlesticks Cuts from other contaminated sharps (scalpels, broken glass, etc.) Contact of mucous membranes (for example, the eye, nose, mouth) or broken (cut or abraded) skin with contaminated blood Universal Precautions Treat all human blood and certain body fluids as if they are infectious Must be observed in all situations where there is a potential for contact with blood or other potentially infectious materials Engineering & Work Practice Controls These are the primary methods used to control the transmission of HBV and HIV. When occupational exposure remains after engineering and work practice controls are put in place, personal protective equipment (PPE) must be used. Engineering Controls These controls reduce employee exposure by either removing the hazard or isolating the worker. Examples: - Sharps disposal containers - Self-sheathing needles - Safer medical devices - Needleless systems - Sharps with engineered sharps injury protections Safer Medical Devices Needless Systems: a device that does not use needles for the collection or withdrawal of body fluids, or for the administration of medication or fluids Sharps with Engineered Sharps Injury Protections: a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident Work Practice Controls These controls reduce the likelihood of exposure by altering how a task is performed. Examples: - Wash hands after removing gloves and as soon as possible after exposure - Do not bend or break sharps - No food or smoking in work areas Personal Protective Equipment Specialized clothing or equipment worn by an employee for protection against infectious materials Must be properly cleaned, laundered, repaired, and disposed of at no cost to employees Must be removed when leaving area or upon contamination Examples of PPE Gloves Gowns Face shields Eye protection Mouthpieces & resuscitation devices Housekeeping Work surfaces must be decontaminated with an appropriate disinfectant: After completion of procedures When surfaces are contaminated At the end of the work shift Regulated Waste Must be placed in closeable, leak-proof containers built to contain all contents during handling, storing, transporting or shipping and be appropriately labeled or color-coded. Laundry Handle contaminated laundry as little as possible and use PPE Must be bagged or containerized at location where used No sorting or rinsing at location where used Must be placed and transported in labeled or color-coded containers What to do if an exposure occurs? Wash exposed area with soap and water Flush splashes to nose, mouth, or skin with water Irrigate eyes with water or saline Report the exposure Direct the worker to a healthcare professional Biohazard Warning Labels Warning labels required on: - Containers of regulated waste - Refrigerators and freezers containing blood and other potentially infectious materials - Other containers used to store, transport, or ship blood or other potentially infectious materials Red bags or containers may be substituted for labels SAFE LIFTING: Avoiding a Painful Back The Five Leading Back Injury Factors: -Poor Posture -Poor Physical Condition -Improper Body Mechanics -Incorrect Lifting -Jobs That Require High Energy The Spine‘s Basic Functions: -Provide Support -Protect the Spinal Cord -Provide Flexibility to Allow Bending and Rotating · · STANDING POSTURE Keep Your Spinal Column Aligned in Its Natural Curves Prop One Foot up on a Stool to Reduce Stress in Your Lower Back. · · · · STRETCH OFTEN & SHIFT POSITIONS Change (Shift) Your Posture Often Stretch Frequently Throughout the Day Keep Your Body Flexible (Not Rigid or Fixed) Don’t Force Your Body to Conform to Its Workspace. LIFT WITH COMMON SENSE! · · · Assess the Situation Do You Need Help? Remember- No Single Technique Will Work in All Circumstances. · · · THE SAFE LIFTING ZONE The Safe Lifting Zone Is Between the Knees and Shoulders Below Knee Level? Bend With Your Knees and Lift With Your Legs Above Your Shoulders? Use a Stool or Ladder. PREPARING TO LIFT OR MOVE · · · Have You Stretched Your Muscles or Warmed up Before Lifting? Are You Wearing Slip Resistant Shoes? Have You Cleared a Pathway Before You Move the Item? WHEN YOU LIFT DO · · · · · · · · Plant Your Feet Firmly- Get a Stable Base Bend at Your Knees- Not Your Waist Tighten Your Abdominal Muscles to Support Your Spine Get a Good Grip- Use Both Hands Keep the Load Close to Your Body Use Your Leg Muscles As You Lift Keep Your Back Upright, Keep It in Its Natural Posture Lift Steadily and Smoothly Without Jerking. WHEN YOU LIFT DO NOT · · · · · · · Lift From the Floor Twist and Lift Lift With One Hand (Unbalanced) Lift Loads Across Obstacles Lift While Reaching or Stretching Lift From an Uncomfortable Posture Don’t Fight to Recover a Dropped Object. EXERCISE FOR LOW BACK PAIN · · · Keeps Body Flexible Helps Prevent Injury Do Not Overdo-- Follow Doctor’s Instruction Carefully. REMEMBER! · · · Your Work Day Is One Third of Your Total Day Plan Your Tasks Carefully to Avoid a Painful Back Managing Your Back Is Your Responsibility. Environment of Care Security Update Seven Management Programs Of EOC Safety Management Security Management Hazardous Materials & Waste Management Emergency Management Life Safety Management Equipment Management Utility Management Making it all work: Have a Plan Implement the Plan Evaluate how it went Hazardous Materials & Waste Reduce and minimize the use of hazardous materials & waste in the hospital. Identification of materials in your department. Moderate to Large Spills - “Code Orange” Hazardous Materials & Waste What is on a Material Safety Data Sheet – aka MSDS? Product Data Ingredient Information Physical Properties Fire and Explosion Hazard Reactivity Data Health Hazard Data Safe Handling Precautions Special Protection Special Precautions Housekeeping Housekeeping is everyone’s job - Small spills are to be taken care of by employees – that would be us. - Black marks on floors – rub them out. - Restrooms, sinks – wipe them down. Testing your housekeepers – “I’ve been looking at that spot/trash all morning to see if anyone would clean it up.” WEAPONS IN THE WORKPLACE No Weapons allowed. This includes all property, facilities, buildings, work area, or vehicles owned, operated, leased, or under the control of the facility. The only exception is to private vehicles parked on premises. No one should have Possession of a weapon; this includes one’s personal effects or in one’s custody or control. Weapon: Interment designed or reasonably believed to be intended infliction of injury to or intimidating another person. (firearms, knives, ballistics, explosives, ammunition or other incendiary devices) The only exception to this rule are those who are acting in an official capacity and who are licensed to possess a weapon acting in that capacity (law enforcement). A student maybe required, upon a supervisor’s request, to submit to an inspection of personal property including, but not limited to: any pocket, package, purse, lunchbox, or other container brought onto the facility premises. Also included are any desk, file cabinet, personal locker, or other container provided by the facility. WORK PLACE VIOLENCE Any act or threats of violence by any employee or student against any other employee, patient, visitor, student, or any person on hospital or affiliated premises, or during employee working hours, are forbidden. Any employee or student who engages in any threatening behavior or acts of violence or who uses obscene, abusive or threatening language or gestures will be subject to disciplinary actions. Life Safety Management Fire Warning & Safety Systems R.A.C.E. = Rescue, Alarm (Code Red), Confine and Extinguish - Building functions P.A.S.S. = Pull, Aim, Squeeze and Sweep - Duration and capabilities of fire extinguishers Other Components - Exit doors and means of egress - Exit lights Codes Fire – Code Red Altercation – Code Strong Patient Elopement – Code Blacktop Inter/External Disaster – Code Aster Emergency Resuscitation – Code Blue Tornado Watch/Warning – Code Gray Chemical, Radiation Spill – Code Orange Assist with Patient (not Altercation) – Code Assist Infant/Child Abduction – Code Pink with age/sex/race Special team to help prevent Code Blue – Rapid Response For more information check the EMERGANCY PREPARDNESS MANUAL Security Personnel Locations & how to contact them…. Security Office at River Region is located in the Ambulance Entranceextension 35118. Their Net Work Phone extension is 36272. Security Office at West Campus is located on 3rd Floor across from the elevators-extension 33064. In an emergency dial “O” and have security paged to your extension or location. Any concerns dealing with Security please call Jason Acreman Security Coordinator directly at 35881. Tobacco Policy All RRHS campuses are Tobacco free. – No smoking in the facility - PERIOD. – Tobacco is prohibited on River Region property and adjacent walkways & roads. – Employees using tobacco will be subject to disciplinary action. – You are responsible for ensuring that patients and family members know that there is no tobacco use allowed. River Region Main Campus Students and Faculty are to park in the Pink Shaded areas ONLY. River Region West Campus Back of Building Front of Building Students and Faculty are to park in the Red Shaded areas ONLY. The Compliance Department of Community Health Systems presents General Compliance Training and the Code of Conduct “CHS is committed to operating with the highest standards of integrity and behavior.” Wayne T. Smith, Chairman, President and CEO The CHS Compliance Program The Code of Conduct Corporate Compliance Officer Written Policies and Procedures Training and Education Auditing and Monitoring Confidential Disclosure Program Periodic Reports to the CHS Board of Directors What is the Code of Conduct? The Code of Conduct (the “Code”) is designed to provide all CHS employees and affiliates with guidance to perform their daily activities in accordance with all federal, state and local laws, rules and regulations. The Code is an integral part of the CHS Compliance Program, and reflects our commitment to achieve our goals within the framework of the law, through a high standard of business ethics and compliance. The Code is a collection of policy statements. Most sections of the Code of Conduct refer to a broader policy covered in various department policy manuals. These policies are referenced within the body of the Code of Conduct. The Code of Conduct and You Every CHS colleague is required to comply with the Code of Conduct. Each individual is expected to perform his/her daily activities with the highest standards and compliance. All CHS colleagues are required to notify the Ethics and Compliance Officer (the facility ECO), the Corporate Compliance Officer (Carol Hendry) or the Confidential Disclosure Program of any violations of law, the Code of Conduct, or Compliance Policy. Examples of Topics in the Code of Conduct: Patient Privacy Confidential Information Coding and Billing Financial Reporting Confidentiality of Patient Information When a patient enters a CHS Facility, a large amount of personal, medical, and insurance data is collected and used to satisfy varying information needs, including the ability to make decisions about a patient’s care. CHS CONSIDERS PATIENT INFORMATION HIGHLY CONFIDENTIAL. CHS colleagues must never disclose or release patient information in a manner that violates the privacy rights of a patient. Patient information may only be discussed or released in accordance with release of information laws that normally require the express written authorization of the patient. CHS colleagues should not have access to or use any patient information unless it is necessary to perform his/her job. Coding & Billing If you are responsible for coding or billing of services, you must not knowingly cause or permit false or fraudulent claims, and must adhere to all official coding & billing guidelines. Furthermore, CHS colleagues shall not engage in any intentional deception or misrepresentation intended to influence any entitlement or payment under any federal healthcare benefit program. Claims must be submitted only for services ordered, appropriately documented, and actually provided. The Compliance Department will audit & monitor claims on a regular basis to verify their validity. When appropriate, the hospital or CHS will return any overpayment amounts. Confidential Information, Electronic Media, Records, & Documents Inside information is non-public information and is confidential. This includes acquisition plans, financial data, marketing plans, or other business material that an employee may become aware of in the normal course of business. Use of this information for personal gain is strictly prohibited. In case of termination, you may not take, retain, copy or direct any other person to take, retain, or copy without prior written permission, any documents or confidential information of any kind belonging to the Company. Disposal or destruction of CHS records and files is not discretionary with any of us, including the originator of the record. Legal and regulatory guidelines require retention of various types of records. Each facility has policies governing accuracy, retention, and disposal of documents and records. Training & Education CHS and each affiliated entity offer a variety of training programs. Training includes this lesson and in some instances specific lessons for certain job codes and descriptions. Auditing & Monitoring Auditing and Monitoring topics are selected annually by the Corporate Compliance Workgroup. Auditing and monitoring is routinely performed in an effort to prevent and detect inappropriate activities. The results of these activities are used to determine future training topics. Financial Reporting All accounts and financial records must be maintained in accordance with generally accepted accounting principles and all SEC rules and regulations. Compliance with the Code of Conduct The Code of Conduct is a mandatory policy of the Company. All colleagues will sign a form indicating they have received a copy of the Code, have read it, and understand it. In addition, all colleagues will reaffirm these actions on an annual basis. Compliance with the Code of Conduct and other policies will be considered in annual employee evaluations and decisions regarding promotion and compensation for all CHS employees. The Code of Conduct is a unilateral statement of policy by CHS. Nothing in the Code is intended to create enforceable employee contract rights. Compliance Officer Privacy Officer The CHS Corporate Compliance & Privacy Officer is Andi Bosshart. Written Policies and Procedures CHS has many written policies and procedures in the area of compliance. Your facility ECO can answer questions concerning those policy and procedures. It is your job to have an awareness of those policies and procedures. Confidential Disclosure Program CHS has established a Confidential Disclosure Program for all colleagues to report known or suspected violations of the Code of Conduct, written policy, or any federal, state or local laws, rules and regulations. This program may also be used for individuals who are uncertain whether an action is a violation and would like to communicate with the Compliance Officer on a confidential basis. Grievance Resolution If an individual is concerned about a personnel action that does not involve any violation of law, the Code of Conduct, or Compliance Policy, he/she may file a grievance at the CHS entity where he/she is employed. The facility Human Resources Department can provide a grievance resolution form and assistance in preparing and presenting a grievance. Information regarding employee grievances is held in strict confidence. Confidential Disclosure Program Hotline Hotline number is 1-800-495-9510 Retribution or retaliation against any person reporting suspected violations of the Code, law, or policy will not be tolerated. Reporting Questions or Concerns Questions or concerns about potential compliance violations may be addressed to any of the following: Your Supervisor or Department Head Any Supervisor or Department Head The Ethics and Compliance Officer The Confidential Disclosure Program Hotline @ 1-800-495-9510 It is recommended to first report concerns through your local facility management. Reporting Violations Failure to report a known violation of the law, Code of Conduct, or any Compliance Policy could subject an individual to disciplinary action. Any colleague who attempts to divert or discourage reporting shall be subjected to severe discipline, up to and including discharge. Investigation of Violations Once contact is made via the Confidential Disclosure Program, a prompt, appropriate, confidential investigation will be undertaken. The Corporate Compliance Officer will coordinate findings from the investigation and recommend corrective and/or disciplinary actions. When appropriate, CHS will return any overpayment amounts, notifying the correct governmental agency of the overpayment situation. Periodic Reporting The CHS Compliance Officer periodically reports the activities of the Compliance Program to the CHS Management Compliance Committee and to the CHS Board of Directors. This concludes your Student Orientation and Compliance for River Region Health System. Please PRINT, READ, and SIGN the Certificate of Completion. You will be given a Code of Conduct book from your instructor. Please READ the book in completion then SIGN the Last Page. Submit BOTH the Certificate of Completion & Last Page of the Code of Conduct Book to your instructor. Welcome to River Region Health System!