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Mandatory Education This booklet has been prepared to educate and familiarize non-employees with the mandatory requirements for Atlantic Health System. Please review and complete the test, return to The Department Manager Atlantic Health System Mandatory Education for Non-Employees 2014 1 Atlantic Health System VISION: Atlantic Health System will be recognized as one of the nation’s best health care systems. MISSION: Deliver high-quality, safe, affordable patient care within a healing culture Educate, in an exemplary manner, present and future health care professionals Innovate through leadership Improve the health status of the communities we serve Patient Rights: Patient Rights are posted in every patient room, waiting areas and other departments where care is provided. Patient rights include, but are not limited to the following: Privacy, Confidentiality, Right to Information, Informed Consent, Pain Management, Participation in Care Decisions, Advance Directives, Restraints and Seclusion, Abuse and Neglect, Patient Complaints. Cultural Awareness: Cultural awareness refers to the understanding that our patients, employees, physicians, and visitors may have different cultural, spiritual, or religious beliefs than our own. Direct patient care providers are expected to identify and support the cultural or spiritual needs of every patient, respecting the customs and traditions of other people. Risk Management: Atlantic Health provides risk management services 24 hours/7 days a week. Check the Risk Manager Web oncall director for the covering individual on evenings, nights, weekends and holidays. An electronic Quantros Report (occurrence report) is completed for any unusual occurrence involving patients, visitors, damage to equipment or property. Occupational Safety and Health Administration (OSHA) Training Bloodborne Pathogens and TB The Occupational Safety and Health Administration (OSHA) “Bloodborne Pathogens Standard” was issued in 1991 and was designed to protect healthcare personnel (HCP) at risk for occupational exposure to the Atlantic Health System Mandatory Education for Non-Employees 2014 2 hepatitis B (HBV) and C (HCV) and the Human Immune Deficiency (HIV) viruses. The Atlantic Health Exposure Control Plan is available to all hospital personnel on the hospital Infection Control intranet site or in hard copy in the libraries of the hospitals, Infection Prevention Offices, and Occupational Medicine Service (OMS). HBV is a disease of the liver with an incubation time of 6 weeks to 6 months. Symptoms may be so mild that a person does not know that they have been infected, moderate in intensity, or so severe that hospitalization is required. HBV may become a chronic illness leading to cirrhosis, liver cancer and at times death. The good new is that it can be prevented with a vaccine that has been available since the early 1980’s. HCV is also a disease of the liver and also has an incubation time of 2 weeks to 6 months. Symptoms of HCV are similar to those of HBV but often milder. It has risks and complications similar to HBV. Unfortunately there is no vaccine available for HCV. HIV is the virus that causes the Acquired Immune Deficiency Syndrome (AIDS). It attaches the body’s immune system and has an incubation period of weeks to months. There is also no vaccine available for HIV. Potentially Infected Body Fluids and Routes of Transmission Bloodborne pathogens (BBP) are found in the following body fluids of an infected individual; blood; cerebrospinal, amniotic, synovial, pleural, and peritoneal fluid; semen and vaginal secretions; and any body fluid visibly contaminated with blood. Exposure to a BBP occurs through: Sharps injury from needles, scalpel, or anything than can pierce, puncture, or cut your skin. Exposure to non-intact skin (open cuts, sores or nicks in skin). Exposure to mucous membranes (splashes or sprays of blood to your eyes, nose or mouth). Methods to Prevent Exposure Include: Following standard precautions Following work practices: These are procedures that you must follow to reduce your and your co-workers risk of exposure. For example: Promptly dispose of needles and sharps in appropriate containers, do not recap Atlantic Health System Mandatory Education for Non-Employees 2014 3 needles or eat or drink in patient care areas. Always wash your hands before and after patient contact and when they are visibly soiled. Wearing appropriate personal protective equipment (PPE) will reduce exposure risks. Wear the following PPE when you may have contact with body fluids: Gloves to protect your skin. Fluid resistant gowns to protect skin and clothing. Masks to protect your nose and mouth from splashes and sprays of body fluids. Protective eyewear to protect your eyes from splashes and sprays of body fluids. Put on and remove PPE correctly in order to prevent infections. The Care Environment To keep your environment free of hazards: Clean all equipment and work surfaces as soon as possible after contact with body fluids. Clean up contaminated broken glass using a dust pan and brush, not your hands. Handle linens as little as possible. Confine and contain trash in plastic bags by keeping them closed. Dispose of body fluids that may be contaminated with potentially infectious materials into a liquid regulated medical waste (RMW) located in soiled utility rooms. Non liquid items soiled with bodily fluids go into red bag containers. A biohazard symbol indicates a potentially infectious material. Procedures to Follow with Exposure to a Potentially Infectious Body Fluid 1. Wash the affected area immediately with soap and water. If exposure is to your eyes, nose, or mouth; flush with large amounts of water or saline. 2. Immediately report the exposure to whoever is in charge of the department. Contact the “Off Shift Supervisor” as there may be a need to complete an incident report. 3. Proceed to the Emergency Department (ED) for an evaluation. Take the name of the source patient with you to the ED, if possible. 4. A report of the incident may be required. For guidance on procedures to follow you may contact the hotline numbers at each facility: Atlantic Health System Mandatory Education for Non-Employees 2014 4 Chilton Medical Center: 973-831-5116 Morristown Medical Center: 973-971-5819 Newton Medical Center: 973-579-8577 Overlook Medical Center: 908-522-5304 If you have questions regarding bloodborne pathogens contact one of the following resources for assistance: Infection Control Department, CMC phone: 973-831-5150 Infection Control Department, MMC on call cell phone: 973-294-0512 Infection Control Department NMC on-call cell phone: 973-222-4933 Infection Control Department OMC on-call cell phone: 973-294-0645 Occupational Medicine Service pager: 877-595-7143 Tuberculosis: Control Measure for TB Patients Follow airborne precautions when a patient is or may be infected with TB disease. This includes: Placing the patient in a negative air pressure isolation room (NPIR). Contact unit resources for proper procedures. Particulate respirators (N95) must be worn when entering patient rooms. Anyone caring for TB patients must be fit-tested annually in order to use these respirators. When caring for patients with or who may have TB disease – o Minimize the transportation of patients; when they must leave their isolation room, when possible, have them wear a surgical mask. o Keep patients on airborne precautions until three (3) negative sputum tests are confirmed. o Discontinue airborne precautions only when an infectious disease specialist, pulmonologist, or the Infection Prevention Department approves it. All Caregivers are required to have an annual tuberculin skin test (TST) except those with proof of the following: A documented positive TST Adequate treatment for TB disease or preventive therapy for TB infection A medical contraindication Atlantic Health System Mandatory Education for Non-Employees 2014 5 Infection Prevention What is Infection Prevention? Infection Prevention addresses factors related to the spread of infections with the healthcare setting. This practice improves patient safety by reducing risk of infection. It requires the commitment of every healthcare worker to achieve this goal. Hand Hygiene (washing or using alcohol rubs) is the number one way to prevent the spread of infections. Information Resource: Infection Prevention website contains all pertinent policies, procedures, guidelines, forms and links for information. Contact Information: Office Morristown 973-971-4003 Overlook 908-522-2912 Newton 973-579-8372 Chilton 973-831-0515 Off Shift Cell 973-294-0512 973-294-0645 973-222-4933 973-831-5000 (Nursing Supervisor) Hand Hygiene: The practice of hand hygiene measures is required before and after handling patients. Using medical equipment on patients, before giving medications, contact with patient skin, contact with body fluids or excretions, wound dressing, removing gloves, or in the patient’s environment are all examples of when hand hygiene is a requirement to ensure patient safety, and to protect against cross-contamination. The process of hand washing requires – wetting the hands first with water, applying soap and rubbing hands together for at least 15 seconds, covering all surfaces of the hands and fingers, rinsing with water and drying thoroughly. Use a paper towel to turn off the faucet upon completion. Alcohol-based rubs can be used when your hands are not visibly soiled or contaminated with fluids. Do not use alcohol-based rubs with caring for patients with C. difficile. When applying this product ensure that all surfaces of hands and fingers, including under fingernails have been covered. Continue rubbing until product dries – at least 15 seconds. Atlantic Health System Mandatory Education for Non-Employees 2014 6 Fingernails and Lotions: Natural nails kept to one-fourth inch long. No artificial nails are permitted for healthcare workers who: provide direct patient care, supervise direct patient care, or have contact with patient care supplies, equipment or food. Only hospital-approved, non-glycerin based lotion is permitted and available for use at Atlantic Health. Healthcare Acquired Infections (HAI) are infections a patient acquires while receiving treatment for a condition. It is one of the top 10 leading causes of death in the United States. These infections: Urinary Tract, Bloodstream, Ventilator Associated Pneumonia, Surgical Site, and Multidrug Resistant Organisms can be acquired through patient medical equipment, tubes used to administer IV fluids, machines that help a patient breathe, body parts where surgery took place, and from medications, the environment, and your hands. National Patient Safety Goal #7 refers to improving patient safety by reducing the risk of healthcare acquired infections. Complying with hand hygiene, following hospital protocols, as well as personal protective equipment (i.e. gloves) complies with this safety goal and reduces this risk. Isolation Precautions: Regardless of a patient diagnosis, there are standard as well as different types of precautions designed to protect you from getting specific types of diseases. Make sure you follow all instructions on posted signs and wear appropriate personal protective equipment (gowns, gloves, or masks). Please remember that many of the patients in our hospitals are recovering from severe illnesses and/or have poor immune systems. Infections with organisms like influenza can lead to very serious illness and even death. To ensure safe patient care, do not come to hospital if you have an upper respiratory tract infection with a fever, or diarrhea or vomiting. When handling patient equipment, follow responsible care and cleaning between patients. Supplies or equipment labeled as single use must be disposed of after use on a patient. Contact Sterile Processing or Infection Prevention for any cleaning questions. Influenza (“Flu”) Seasonal flu usually occurs in the Fall through early Spring. It most severely affects the very young, the elderly and those with chronic illnesses. Symptoms include: fever, headache, fatigue, dry cough, sore throat, runny or congested nose, muscle aches, and can include diarrhea, vomiting and nausea. Atlantic Health System Mandatory Education for Non-Employees 2014 7 On average 5% to 20% of the U.S. population contracts the flu. More than 114,000 are hospitalized and approximately 36,000 people die from this virus. The annual shot is the most effective method to prevent infection with this virus. The CDC recommends the following precautions for healthcare workers: practice hand hygiene before and after patient contact; follow standard precautions; wear a surgical mask when working within 3 feet of the patient; and get the flu vaccine. A “pandemic” is an epidemic that occurs in many parts of the world at the same time. For an influenza pandemic to occur, a new strain of the virus must emerge and spread easily from person to person. The 2009 H1N1 was classified as a pandemic with increased risk for serious flurelated complications. The precautions recommended by the CDC have been standard, respiratory, airborne, as well as wearing respiratory protection such as the N95 respirator which requires fit-testing. In the event of a pandemic, visitors may be restricted. In a serious pandemic, it may be necessary to close most facility entrances and to post security at the open entrances. Staff and visitors may need to be screened for flu-like symptoms. Occupational Medicine Services asks that all staff, volunteers, visitors, and physician are aware of the symptoms. They ask that individuals experiencing symptoms go home, and if needed, follow up with your physician. Hazardous Materials and Waste Hazardous materials and waste in use at Atlantic Health include: several EPA listed chemotherapy drugs, xylene; mercury, solvents, various chemicals, reagents, and spill clean-up materials. Regulated Medical Waste (RMW) classes of materials or products at Atlantic Health include needles, syringes, and sharps, human blood, blood products and pathological waste, isolation waste, cultures and stocks of infectious agents and associated biological. Sharps including needles, pipettes, test tubes, vacutainers, cultures/stocks and glass sides are to disposed of in the approved rigid containers. Nonsharps including bloody gauze pads, empty feeding bags and tubing, and empty suction canisters are disposed of in “Red Bag Receptacles.” Liquid RMW are disposed of in “red and biohazardous liquid receptacles.” All articles and containers with free-flowing RMW must be placed into liquid receptacles to comply with the US Department of Transportation. Atlantic Health System Mandatory Education for Non-Employees 2014 8 Unless IV Bags or tubing has been contaminated with blood or regulated body fluids, they are not considered RMW and can be disposed of in regular waste. All batteries, lamps, mercury containing devices and consumer electronics must be collected and handled separately. Emergency Management The Atlantic Health System Emergency Operations Plan is available on the Atlantic Health intranet under Forms and Policies then Safety Manual and Emergency Management. Each department has a role in emergency management and department specific plans/policies are defined. The Atlantic Health System Emergency Operations Plan addresses the four phases of Emergency Management: Mitigation, Preparedness, Response and Recovery. Refer to manuals for further guidance. A Hazard Vulnerability Analysis is done as a risk assessment. Emergency Management exercises are conducted a minimum of twice a year for Internal and External Disasters, ensuring preparedness, response and protocols to follow. Further reference includes the EM Quick Reference Guide posted throughout the facilities, as well as Communications Matrices available in the Biological, Chemical and Radiological Response Plans. The Incident Command Center (ICS) is a standardized all-hazard incident management system that enables hospitals and others to organize resources, staff, and facilities in order to remain operational during an emergency and promote the restoration of day-to-day operations. Communications are maintained through a variety of methods including email, internet/intranet, dedicated call-in lines, department snowball lists, faxes, emergency telephones, handheld radios and information sharing with the state. Atlantic Health System Mandatory Education for Non-Employees 2014 9 Atlantic Health has standardized Emergency Codes: Homeland Security Advisory System (HSAS) disseminates information regarding the risk of terrorist acts, and provides warnings in the form of a set of graduated “Threat Conditions” that increase as the risk of the threat increases. To access Atlantic Health HSAS interventions online on the intranet – select Departments, then Protection and Security Services, then the HSAS picture in left sidebar. Medical Equipment Management The Clinical Engineering/BioMed Department at Morristown Medical Center: MMC: call 973-971-5634 Located on the C level of the Meade building. Hours are 7:00am to 4:00pm Mon-Fri. Atlantic Health System Mandatory Education for Non-Employees 2014 10 The Clinical Engineering/BioMed Department at Overlook Medical Center: OMC: call 908-522-2903 Located on the 3rd Floor. Hours are 8:00am to 4:30pm Mon-Fri. The Clinical Engineering/BioMed Department at Newton Medical Center: NMC: call 973-579-8573 Located Ground Level, Administration Building. Hours are 8:00am to 4:30pm Mon-Fri. The Clinical Engineering/BioMed Department at Chilton Medical Center: OMC: CMC:call call908-522-2903 973-845-7589 Located on the 3rd Level Floor. Located Ground Hours are 7:00am to 4:00pm Inspects and repairs all medical equipment throughout hospital. All medical equipment must be inspected prior to use; and all medical equipment requiring repair should be taken out of service and reported to the Clinical Engineering/Biomed department. In addition, all medical equipment must have an inspection sticker. If the “Inspection Due” date has expired, do not use the device, return it to the Clinical Engineering/BioMed department at the facility. Utility Management Plant Engineering/Maintenance is responsible for the maintenance and operation of all electrical, water, heating, ventilation, and AC systems. Red power outlets are used for emergency backup power systems. Only critical emergency medical equipment should be plugged into the red emergency power outlets serviced by the hospital’s emergency backup power system. Safety Management In addition to Atlantic Health System’s concern for the health and safety of our staff, many of our programs are driven by the requirements of Joint Commission, the Occupational Health and Safety Administration (OSHA) and the NJ Department of Environmental Protection (NJDEP). Our Atlantic Health System Mandatory Education for Non-Employees 2014 11 hospitals have a multidisciplinary group serving as the Occupational Health and Safety Committee which represents the interests of all departments and services the hospital. They are responsible to do environmental tours periodically to inspect both patient and non-patient areas. There are two Safety Officers at each hospital, one is the Occupational Safety Officer and the other is the Public Safety Officer. To contact the OSO or the PSO at MMC, call extension X5779 for OSO or beeper #866-586-4189, or X5697 for the PSO. To contact the OSO or the PSO at OMC, call extension X5318 for the OSO or X5308 for the PSO. To contact to OSO at NMC, call extension 773-971-5250 or the PSO at 973660-3122. The Occupational Health and Safety (O&ES) Inquiry Form is used to formally report and get answers about potentially unsafe conditions. Right to Know About Chemical Hazards in Your Work Environment or the HazCom Standard communicates information about hazardous chemicals used in our work environment by ensuring container labeling, the written program is available online on the O&ES web page. Material Safety Data Sheets (MSDS) are information sheets available in the Safety Management Program located in online through the O&ES webpage, or in the library at both hospitals. Chemical Spills require notification to Environmental Services Department at X5030 at MMC and X2169 at OMC and X8304 at NMC so that they may ensure proper clean-up. Be sure to call and give information on what, where, and how much was spilled. Certain clinical activities involve potential exposure to ionizing radiation. These include X-ray imaging, radioactive materials to diagnose and treat, and certain radioactive materials to irradiate blood samples. People working in these areas are required to participate in radiation monitoring and will be provided a radiation badge they are required to wear. Only people approved for this area may work there. If you are injured while working at one of the facilities, you need to report your injury using an incident report and seek medical attention. If you are not an employee of Atlantic Health, being treated at an Atlantic Health facility may be subject to your own medical insurance. Life Safety Although rare, fires do happen in healthcare facilities. Life and Fire Safety Guidelines require everyone to know that oxygen enriched environments Atlantic Health System Mandatory Education for Non-Employees 2014 12 enhance the spread of fire, can generate large volumes of toxic gas, and intense heat. In the event of a fire be sure to follow the steps in the R.A.C.E. acronym when responding: Rescue those in immediate danger and conduct a systematic search for others in the area. Alarm the nearest fire alarm pull station and then dial extension 8888 at MMC, X777 at OMC and X8888 at NMC to report the location of the fire. Contain the fire by closing ALL doors and windows. Extinguish the flames using a fire extinguisher if it’s a small fire just getting started, or evacuate to behind the nearest fire doors. When using the fire extinguisher, use the P.A.S.S. acronym to remember how to use the extinguisher: Pull the pin from the handle of the fire extinguisher. Aim at the base of the fire. Squeeze the handle of the fire extinguisher to activate and discharge the extinguisher on the fire. Sweep the base of the fire until it’s out or the extinguisher is empty. There are three different classes of fire we deal with and fire extinguishers are divided into various categories based on the different type of fire: Class A: Ordinary combustible or fibrous materials. Examples: wood, paper, cloth, rubber, and some plastics. Class B: Flammable or combustible liquids. Examples: alcohols, xylene, gasoline, kerosene, paint and paint thinner, and propane. Class C: Energized electrical equipment. Examples: appliances, switches, panel boxes and power tools. The label on a fire extinguisher will tell you what class of fire it covers. Approximately 90% of the fire extinguishers used at Atlantic Health are ABC (universal/dry chemical) extinguishers. Be sure to follow the proper steps in evacuating from a fire area. Step 1 – move horizontally to next smoke zone; Step 2 – move vertically – down two flights. Compartmentalization allows us to isolate the smoke and fire to the unit where the fire occurs minimizing the amount of evacuation necessary. Things to Remember: Do not use the elevators. Follow exit signs. In patient care areas, place diagonal piece of tape on room doors that have already been swept/clear to eliminate duplicating efforts. Security The Protection and Security Services departments at the hospitals are a 24/7 department. The department is located on Simon B level in MMC, Atlantic Health System Mandatory Education for Non-Employees 2014 13 with a telephone number of 973-971-5555. At OMC, the Security Command Center is located on the 5th Floor with a phone number of 908522-5529, at NMC on 973-383-2121. This department is responsible for the physical safety of the hospitals and its sites, as well as issuing ID badges and parking decals. Other services include monitoring security sensitive areas, investigating, responding to various codes, providing support for employee escorting, and maintaining a constant security presence throughout the hospital. All staff, volunteers, students, physicians and vendors must wear ID badges when present in the facility. If you observe unusual or suspicious activity, please report it to the Security Command Center at X5555 (MMC) or X5529 (OMC), at X8888 (NMC). Code Pink/Code Adam: When these codes are announced all departments adjacent to entryways, exits, stairwells and elevators are required to “Adopt an Exit.” Monitoring these accesses is important to ensure all suspicious activity is reported immediately. Code Lockdown: This code is enacted when there is a “potential or active shooter.” If involved in a code lockdown at the point of origin, Dial “9-then 9-1-1, and the internal emergency number X8888 (MMC) or X7777 (OMC), X8888 (NMC) as soon as possible, advise telecommunications from the nearest safe area. Stay on line if possible to provide further information. Seeking safe shelter within the building, assisting patients and visitors, as necessary, are what all employees are instructed on. An “All Clear” will only be called by the Security Department. Workplace Violence There are three regulatory agencies that require Atlantic Health to work to prevent workplace violence: OSHA, Joint Commission, and NJDHSS. Workplace Violence is defined as any physical assault, threatening behavior, or verbal abuse occurring in the work setting. Atlantic Health has a policy on Workplace Violence that prohibits conduct that includes threats, threatening language, or other any aggressive behavior including verbal or physical harassment. Disciplinary actions up to and including termination may be initiated after investigation of a claim of workplace violence. Also, any employee who makes false accusations will be subject to similar disciplinary actions. Atlantic Health completes an annual risk assessment, analyzes reportable incidents, and does workplace violence training. All incidents of workplace violence should be reported to security. Atlantic Health System Mandatory Education for Non-Employees 2014 14 With regard to patients and patient families, a Code White should be called when the caregiver feels a patient’s behavior presents an imminent danger to self, others and/or property. Call X8888 (MMC) or X7777 (OMC), X8888 (NMC) to issue a Code White. Mandatory Education Review 1. The Atlantic Health Exposure Control Plan is available to all hospital personnel on the hospital Infection Control intranet site or in hard copy in the libraries of the hospitals. TRUE__________ FALSE__________ 2. Bloodborne Pathogens (BBP) exposure can occur through sharps injury, scalpel, or anything that can pierce the skin. TRUE__________ FALSE__________ 3. Following standard precautions includes washing your hands and personnel protective equipment (PPE) to reduce exposure risks. TRUE_________ FALSE__________ 4. Contaminated body fluids may be disposed of in regular medical waste containers. TRUE__________ FALSE__________ 5. Particulate respirators must be worn when entering patient rooms on airborne precautions. TRUE__________ 6. FALSE__________ Caregivers are not required to have an annual tuberculin test. TRUE__________ FALSE__________ 7. Hand washing or using alcohol rubs is the number one way to prevent the spread of infection. TRUE__________ FALSE__________ Atlantic Health System Mandatory Education for Non-Employees 2014 15 8. Isolation precautions are only required to be followed by employees. TRUE__________ FALSE__________ 9. Only Security has a role in the Atlantic Health’s Emergency Management Plan. TRUE___________ 10. FALSE__________ Match the following codes: Fire Emergency Bomb Threat Cardiac Arrest Unruly Patient/Visitor Emergency Mgmt Plan Medical Emergency Missing Child Infant Abduction Green Blue Red Black Purple White Pink Adam 11. Clinical Engineering maintains and inspects all electrical, water, heating, ventilation and AC systems. TRUE__________ FALSE__________ 12. The MSDS information sheet is available in the Safety Management Program located on the intranet, or in the library at MMH. TRUE__________ FALSE__________ 13. Environmental Services Department (X5030) should be notified in the event of a chemical spill. TRUE__________ 14. R.A.C.E. stands for Rescue, Alarms, Contain and Extinguish. TRUE__________ 15. FALSE__________ FALSE__________ P.A.S.S. stands for: a. Pass, Aim, Switch, and Spread b. Pull, Aim, Squeeze, Sweep Atlantic Health System Mandatory Education for Non-Employees 2014 16 NAME:__________________________________ DATE:________________________ (To review the answers to this quiz, please see the following page) Atlantic Health System Mandatory Education for Non-Employees 2014 17 Answers to Quiz Mandatory Education Review 1. The Atlantic Health Exposure Control Plan is available to all hospital personnel on the hospital Infection Control intranet site or in hard copy in the libraries of the hospitals. TRUE____X______ FALSE__________ 2. Bloodborne Pathogens (BBP) exposure can occur through sharps injury, scalpel, or anything that can pierce the skin. TRUE_____X_____ FALSE__________ 3. Following standard precautions includes washing your hands and personnel protective equipment (PPE) to reduce exposure risks. TRUE_____X____ FALSE__________ 4. Contaminated body fluids may be disposed of in regular medical waste containers. TRUE__________ FALSE____X______ 5. Particulate respirators must be worn when entering patient rooms on airborne precautions. TRUE____X______ 6. FALSE__________ Caregivers are not required to have an annual tuberculin test. TRUE__________ FALSE____X______ 7. Hand washing or using alcohol rubs is the number one way to prevent the spread of infection. TRUE_____X_____ 8. Isolation precautions are only required to be followed by employees. TRUE__________ 9. FALSE__________ FALSE____X______ Only Security has a role in the Atlantic Health’s Emergency Management Plan. TRUE___________ FALSE_____X_____ Atlantic Health System Mandatory Education for Non-Employees 2014 18 10. Match the following codes: Fire Emergency Bomb Threat Cardiac Arrest Unruly Patient/Visitor Emergency Mgmt Plan Medical Emergency Missing Child Infant Abduction ANSWERS RED BLACK BLUE WHITE GREEN PURPLE ADAM PINK 11. Clinical Engineering maintains and inspects all electrical, water, heating, ventilation and AC systems. TRUE__________ FALSE____X______ 12. The MSDS information sheet is available in the Safety Management Program located on the intranet, or in the library at MMH. TRUE____X______ FALSE__________ 13. Environmental Services Department (X5030) should be notified in the event of a chemical spill. TRUE_____X_____ 14. R.A.C.E. stands for Rescue, Alarms, Contain and Extinguish. TRUE_____X_____ 15. FALSE__________ FALSE__________ P.A.S.S. stands for: a. Pass, Aim, Switch, and Spread b. Pull, Aim, Squeeze, Sweep Atlantic Health System Mandatory Education for Non-Employees 2014 19 ATLANTIC HEALTH SYSTEM INFORMATION SECURITY AWARENESS Introduction – Welcome to the Atlantic Health System, Information Security Awareness training module. This mandatory training course has been designed primarily for non Full time, Part time or Per Diem workforce members. Examples of who are required to complete this training include (but are not limited to); business partners, nursing students, volunteers and contractors or consultants. This would include anyone with electronic access to Atlantic Health Systems either on the property of one of our facilities or someone requiring remote access to Information Resources. At the end of the course you will be required to agree to a “Statement of Understanding” assuring that you have viewed the course and understand your responsibilities in assuring we maintain a secure environment. Technology Device Usage – If you will be using a non Atlantic Health System (AHS) issued device such as a laptop computer you will only have access to the AHS “Guest” wireless network At no time will you be permitted to plug a non-AHS issued/managed laptop into our “wired” network or connect to the AHS wireless business network. If necessary you will be provided an AHS loaner laptop if deemed a requirement during your engagement. This should be discussed with the Manager you will be reporting to prior to beginning your assignment. If a non-AHS issued laptop is used to store any type of proprietary AHS data it must have full disk encryption installed. In addition all security updates must be current and Anti-Virus software must be installed with the most recent virus definitions. Removable media such as CD’s, DVD’s, flash drives or portable hard drives are utilized to store any AHS proprietary data they must be encrypted. Laptops – Laptops and other mobile devices are expensive and small making them good targets for theft. Some surveys indicate over 10,000 laptops are lost every week in US airports alone. A missing laptop with unencrypted sensitive information is a data Atlantic Health System Mandatory Education for Non-Employees 2014 20 breach with the potential for grave reputational, financial, and often legal consequences. Laptops with sensitive information or the ability to access secure systems must be encrypted and securely managed to ensure loss or theft does not result in a data breach. Any missing laptop, including those with secure encryption and management, must be reported immediately. Studies indicate the cost associated with a lost or stolen laptop containing sensitive information can cost an organization in excess of eight million dollars not to mention reputational damage that is hard to quantify. Appropriate Use – Limited incidental personal use of Atlantic Health System information systems, including the telephone is permissible provided that the usage is De minimis – so little that there is no impact on AHS systems Does not interfere with job performance, Does not impact or affect other Users’ access to the system assets, Does not incur significant costs and Cannot be reasonably carried out during non-working hours with non-Atlantic Health System Information Assets. You should have no expectation of privacy when using the Atlantic Health System network. All Activity is monitored and logged. Network activity is automatically monitored and audited for security purposes. Audit trails include websites visited, time spent on websites, email monitoring and application access. Inappropriate or excessive Internet use is reported to Human Resources and/or Protection and Security Services. Some examples of appropriate use include limited access to view news articles, weather forecasts and personal banking. Examples of inappropriate use include: Conducting a personal business or performing work for another client while being paid by AHS Atlantic Health System Mandatory Education for Non-Employees 2014 21 Interfering with Atlantic Health System business Illegal activities Visiting websites that are sexually oriented, allow gambling, or promote negative beliefs such as hate language, harassment, or threats. Using Atlantic Health System computing devices to complete paid surveys. Any inappropriate use of computing equipment is a reportable incident. All activity performed while utilizing the AHS wired or Guest network is monitored and logged. There should be no expectation of privacy when using the AHS network. All activity is monitored and logged by Information Security personnel. Remote Access Atlantic Health System maintains multiple technologies to provide remote access Services such as LogMeIn, GoToMyPC and Webex are not allowed for remote access into AHS systems Work with your AHS manager to have proper remote access setup File Transfer FTP/SFTP – FTP should never be used to transmit any AHS proprietary data as it is sent un-encrypted SFTP is an acceptable solution for configuring automated transfers Atlantic Health System employs ShareFile for sending or receiving files securely. If you need access to ShareFile please contact the Customer Support Center at 973-971-7272 E-Mail Security If you are issued an AHS email account all outbound messages to recipients who are not part of the AHS domain will be automatically encrypted if they contain PHI or PII. Personal email accounts must never be used to conduct AHS business. Only secure email platforms shall be used for email communications. Any email containing PHI/PII/PCI information must be encrypted. User Accounts and Password Security – Atlantic Health System Mandatory Education for Non-Employees 2014 22 Any form of a generic account is prohibited for accessing AHS systems. All accounts must be a unique naming convention that links a specific individual to their activity All passwords must be complex to include the use of upper and lower case letters, numbers and at least one special character. At no time should your credentials be shared with anyone. Your computer must be configured to automatically lock the system after fifteen minutes of inactivity. When you step away from your computer the screen shall be manually locked to prevent unauthorized access. Internet Security – AHS employs content filtering so not all websites will be accessible. All internet activity is monitored and logged Protecting Information – With proper authentication and a mobile device, access to sensitive information is available almost anywhere. Personnel with remote access have a responsibility to support our Information Security policies by protecting access to information from outside threats. Follow these rules to protect sensitive information: Encrypt any sensitive information while in transit. This includes transit on physical devices, which are easily lost or stolen such as CDs, thumb drives, and backup disks. Email containing sensitive or protected information must use authorized encryption. Contact the ISS Customer Support Center at 973-971-7272 if you need assistance. Never use a personal email account to send or receive any Atlantic Health System business. Policies are clear that you may only use your Atlantic Health System email for conducting Atlantic Health System business. Authenticate requestors of sensitive information, or refer them to designated employees. Do not retain sensitive information longer than needed and dispose of hardcopies using authorized means such as a ShredEx bin. Report any suspicious attempt to obtain patient, Atlantic Health System, or employee information. AHS automatically encrypts anything copied to removable media such as a flash drive, CD or DVD from an Atlantic Health System owned and managed Information Asset. Depending on your role, you may have specific procedures for Atlantic Health System Mandatory Education for Non-Employees 2014 23 handling Atlantic Health System and patient information, and you may be required to take additional training. Incident Reporting – Incident Reporting is a critical element of an effective Information Security program. Reporting what you believe is a small incident may prevent a loss of Atlantic Health System or patient information that can prove costly and cause reputational damage. Workforce Members who receive a report of identity theft from a customer must immediately notify Corporate Compliance in writing or e-mail about the report and provide details and any background documentation in support of same. Be vigilant, and report any suspicious incident immediately such as missing, lost, or stolen equipment, suspicious visitors, inappropriate requests for information, inappropriate access to sensitive information, or misuse of computing equipment. You Make a Difference Everyone with access to Atlantic Health System information systems has a responsibility to follow and enforce Information Security policies and act in a manner that protects information assets. To protect sensitive information, your responsibilities include: Log off or Lock your computer when it is unattended. Report suspicious events and security incidents quickly. Never share passwords with anyone. Use your Atlantic Health System computer and IT assets appropriately. Use best practices to protect Atlantic Health System and patient information. Comply with all Atlantic Health System Information Security, Corporate Compliance, Protection and Security Services, HR and ISS policies, which can be found on the intranet. Information Security is a responsibility we all must share. Please sign the attestation on the next page and submit it to the AHS manager you will be reporting to. Atlantic Health System Mandatory Education for Non-Employees 2014 24 Atlantic Health System Information Security Awareness Training Please complete the following and submit to manager: DATE____________________ NAME:__________________________________________________ (Print clearly) DEPARTMENT/LOCATION:________________________________ EMPLOYEE ID #:_________________________________________ As a user with access to Atlantic Health System computer systems or data, I understand that I am required to comply with all AHS policies (including Information Security policies)s as well as the information I have reviewed above and report the misuse, loss, abuse, or unauthorized access of Atlantic Health Information Systems. Information Security policies are available via our intranet. Please ask the person you are reporting to for the specific location. SIGNATURE:_______________________________________ DATE:____________________ Manager/Supervisor you report to: ___________________________________________ Atlantic Health System Mandatory Education for Non-Employees 2014 25