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Monroe County Hospital New Employee Orientation MCH Personnel Policies Managed by: Debra K. Flowers, PHR Director, Human Resources Extension 209 Annual Policy Review • Each employee should be familiar with all policies and procedures. • Policies and any related forms are posted on the web site for your convenience: – Employee Documents – Type in monroe as password – Click on document you would like to review/print • This is short review; please go to the web site to review the complete policy. Annual Updates • Annual recertification/updates are mandatory for all employees. Requirements include: – PPD Skin Test (or Chest X-Ray if history of positive skin test) – Passing score on annual update chapters (via the web) (90% or higher) – Any required license renewal to include CPR and ACLS Attendance • It is essential that all employees work the hours they are scheduled to work. • MCH requires employees to provide adequate notice, as well as justifiable reason, for absenteeism and tardiness. • Excessive absenteeism and/or tardiness can result in disciplinary action, up to and including, termination. Confidentiality • It is the responsibility of all employees to safeguard MCH information. – Never share patient information with strangers or anyone without prior consent from the patient. – Never discuss confidential patient information where others can overhear your conversation. – Never reveal any information to the media or other public source; refer questions to your supervisor. • Safeguarding patient information is every employee’s obligation. Direct Deposit • All employees are required to sign up for direct deposit for all payroll checks. Donation of Paid Days Off (PDO) • An employee may donate his/her accrued PDO hours to another employee. – Transfer of PDO is on an hour-for-hour basis. – Recipient’s PDO balance must be below 24 hours. – Donating employee must have at least 48 hours accrued in his/her PDO account. – PDO hours are not recoverable. – All PDO donation hours are approved by Administration prior to transfer. Dress Code • Administrative Staff: – Business casual is required. – No jeans. – A neat, well-groomed appearance is required. – Socks or hose will be worn. – Hair must be neat and clean. – Fridays are “casual” days; denim jeans and shorts are not allowed. – ID badge will be worn at all times. Dress Code • Clinical Staff: – Scrubs will be worn. – White nursing shoes (including clogs w/o holes) or tennis shoes may be worn. No open toe shoes are allowed. – Socks or hose will be worn. – Hair should be neat and clean. – Excessive jewelry is not allowed. – No artificial nails are allowed. – ID badge will be worn at all times. Educational Assistance Program • MCH will provide financial assistance to current employees wishing to enter a program of study in a field which the Hospital Authority identifies as beneficial to the hospital. All such requests/ applications for financial assistance will require approval by the Hospital Authority. Employee Benefits • Once a full-time employee has successfully completed their introductory period (90 days), they are eligible for the following benefits: – – – – – – – Group Health Insurance (eligible after 30 days) Dental Insurance Long Term Disability Life Insurance Supplemental Insurance through AFLAC ING Retirement Plan Vision Insurance Employee Classifications • Full Time: – An individual that is scheduled to work a minimum of 36 hours or more per week. • Part Time: – An individual that is scheduled to work less than 36 hours per week. • PRN (As needed): – An individual that is scheduled to work based on prevailing workload. Employee Wellness Physical • As an added benefit to MCH employees, all employees are eligible to receive a wellness physical free of charge. The physical may include the following: – Comprehensive Metabolic Panel – Complete Blood Count – Prostrate Specific Antigen – Chest X-Ray – Mammogram Employee Wellness Physical • The following govern the program: – Employees must complete the Employee Wellness Physical form and take it to radiology or lab. – Employees are responsible for their own appointments. Coordinate appointments with supervisor. – All lab work ups will be completed at MCH lab. – All chest x-rays and mammograms will be completed at MCH radiology department. Employee Wellness Physical – Only one wellness check per year per employee. – Only one chest x-ray and mammogram per year per employee. – All results are sent directly to primary care physician. – Employee Wellness Physical form must be returned to Human Resources when completed. Equal Employment Opportunity • MCH will provide equal opportunity regardless of race, color, sex, religion, national origin, age, or disability. • MCH will provide promotion and advancement in a non-discriminatory fashion. • MCH will not permit employees to engage in discriminatory practices. Extended Illness Bank • • • • • • • All full-time employees are eligible. Accrual rate is 2.154 hours per pay period. Maximum accrual is 960 hours (120 days). EIB starts on the 4th day of illness unless admitted to the hospital. Outpatient surgery will qualify for EIB use; diagnostic procedures do not. MCH reserves the right to verify illness at any time during benefit period. EIB is forfeited upon resignation, termination, or retirement. Family Medical Leave Act (FLMA) • MCH provides 12 weeks of unpaid leave to eligible employees each calendar year. – Applies to employees who have worked one year and for at least 1250 hours over the previous 12 months. • Leave is granted for birth of child, serious health • • condition of employee or family member. Employee is required to complete FMLA documentation and provide certification from attending physician. Return to work authorization is required prior to employee’s return to duties. Grievance Procedure • MCH wishes to cultivate clear and open communications between employees and supervisors. • If an employee cannot resolve a specific concern with his or her supervisor, the employee should follow these procedures: – Initiate grievance to next higher level of supervision – If not resolved in 5 days, put grievance in writing and forward to department director Grievance Procedures cont… – If grievance is still not resolved, it will be forwarded to HR director who will act as mediator between employee and supervisor. – If appropriate action has note been taken with 5 days, the problem should be presented to CEO. – Upon review of information, CEO will determine course of action to be taken. Jury Duty • Employees will be compensated for lost time • • • • from work. Any payment received from courts will be turned in to the Business Office. Employee must report to work when it does not conflict with jury obligations. Employees are responsible for keeping their supervisor informed about amount of time required for jury duty. Time spent on jury duty does not count as overtime. New Employee Orientation • All employees are required to complete the New Employee Orientation. • This orientation is done on your first day of work. • Department Managers are responsible for introducing new employees to co-workers and department managers. Paid Days Off (PDO) • All full-time employees are eligible for PDO. • PDO days are days off which include vacation, holidays, bereavement leave, and short term illness. – Holidays are: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Day • Employees start to accrue PDO on date of hire, • but cannot use it until they have satisfactorily completed the 90-day introductory period. Employees are paid PDO upon proper resignation; if terminated PDO will be forfeit. Performance Evaluations • MCH has a merit-based evaluation system. • Evaluations are done at the 90-day point and annually on anniversary date of hire. • Salary increases are neither automatic nor periodic. Salary is reviewed and increases are based on performance and overall fiscal goals of MCH. • Performance evaluations are a permanent part of an employee’s personnel file. Progressive Discipline • All employees are expected to abide by the general rules of good conduct. Should it become necessary for disciplinary action the following is usually taken: – Oral Warning – Written Warning – Suspension – Termination • If the severity of the infraction is sufficiently serious, one or more of these steps may be bypassed. Rehire of Former Employees • An employee involuntarily terminated by MCH, regardless of reason, is ineligible for reemployment. • HR Director will review former employee’s personnel records prior to re-hire. • Former employees who quit without notice are ineligible for re-hire. Safety • All employees are required to report any incident or accident or any unsafe practice. • Follow these guidelines: – Notify your supervisor – Complete the Accident Report Form and Lab Request Form – Escort employee to ER to be examined by ER doctor – Escort employee to lab for drug screen – Return to work, if released by ER physician – Forward Accident Report Form to HR Sexual Harassment • Defined as: – Unwelcome sexual advances, request for sexual favors, and other verbal or physical contact of a sexual nature constitutes sexual harassment. • This is strictly prohibited. • Appropriate action will be taken against any • employee who violates this policy, up to and including termination. Retaliation against employees who complain about sexual harassment is strictly prohibited. Smoke Free Facility • No smoking or other tobacco products is permitted inside the hospital or patients rooms. • Employees may only smoke in designated area: – Area outside of South Wing entrance, first floor, known as the “loading dock.” • Failure to comply with this regulation may result in disciplinary action, up to and including termination. Substance Abuse • It is a a violation of MCH policy to use, possess, sell, trade, offer for sell, or offer to buy illegal drugs or otherwise engage in the illegal use of drugs on or off the job. • It is a violation for employees to report to work under the influence of illegal drugs or impaired by alcohol. • It is a violation for employees to use prescription drugs illegally. Termination/Resignation • An employee desiring to terminate employment • • • • with MCH is asked to give a minimum 2 weeks notice; managers are asked to give 30 days notice. If employee provides proper notice, any accrued PDO will be paid. All terminations will be treated in a confidential and professional manner. Employees terminated by MCH will receive all earned pay and any expenses due at the time of the next regular paycheck. If an employee is terminated, all PDO is forfeit. Test 1. Are you required to wear your MCH ID badge at all times? a. Yes b. No 2. When do you receive your first evaluation? a. 90 days after employment. b. 1 year after employment. c. Whenever your supervisor thinks it is necessary. 3. What are the guidelines for an accident/incident? The Core Values Managed by: Presented by: Kay Floyd Chief Executive Officer Extension 211 Guiding Statements • Mission Statement: – We will be the hospital of choice in our service area and will be guided by our core values of caring, quality, integrity, and respect to those we serve and to our employees, medical staff, volunteers, and partners. • Vision Statement: – To be an independent community hospital that is an asset to its community Core Values • The Value of Caring – the common thread that runs through our hearts. • The Value of the Person – we are all equal in God’s sight. • The Value of Quality – we always do the very best we can. • The Value of Integrity – we will always do what we said we would do. Core Value Test 1. What core value is the first and most important? a. Person b. Caring c. Integrity d. Quality 2. Why are Core Values so important? a. Because my grandmother has these values. b. Because we act the way we think and believe. c. I’ll get 10% off at the grocery store if I rattle them off to the cashier. d. Because I’ll look foolish if I don’t know them. Quality Management Program Presented by: Kathy Louth Director, Quality Management Extension 215 Why is Quality Improvement (QI) done? • The goal of QI is to continuously improve patient health outcomes. A hospital’s performance affects its patients outcomes, the cost to achieve these outcomes, and the perception of its patients and their families about the quality and value of its services. How is QI done? • Our hospital’s approach to QI consists of process design, performance measurement, performance assessment, and performance improvement. The methodology used is the PDCA method PLAN DO CHECK ACT PDCA Cycle at MCH • Each department is responsible to monitor any critical processes within that department. This includes any monitors set forth by regulatory agencies such a Joint Commission. Cycle at MCH (con’t) • Each department collects the data needed to report on these critical processes. The data is graphed on a statistical control chart –run chart- and turned in monthly to the Director of Quality. Cycle at MCH (con’t) 25 20 15 Error 10 5 0 Jan Feb Mar Apr May Jun Cycle at MCH (con’t) • The Director of Quality Management, Kathy Louth, analyzes the graphs and determines the trend, range, and cause on each critical process graphed. Trend is the direction the graph is going. This can be negative, positive, stable, or unstable. The range is the difference from one point to another point. This can be increasing, decreasing, stable, or unstable. Cause is what actually made the graph the way it is. This can be normal or special. Cycle at MCH (con’t) • All graphs with special causes or increasing ranges for consecutive quarters are reported at the Quality Council (QC) meeting held quarterly. The QC has members from the Hospital Authority, Administration, QI, Nursing Administration, and Medical Staff. These members channel the information to the rest of the Medical Staff, Hospital Authority, Department Managers, and Staff. Cycle at MCH (con’t) • A performance improvement (PI) team is set up for any problems that need attention based on this data. Teams are prioritized based on a criteria set forth by the organization. The team uses the Cause and Effect Diagram (a.k.a. the Fishbone Diagram) to help solve the problem. Cause & Effect (Fishbone Diagram) PLANT PEOPLE PROBLEM POLICY PROCEDURE External Quality Programs • Healthcare Research & Medical Evaluation System (HERMES) • Collaborative Approach to Research Effectiveness (CARE) Program • Hospital Quality Alliance (HQA) • Georgia Medical Care Foundation (GMCF) Healthcare Research & Medical Evaluation System (HERMES) • CARE 2 – Patient care outcomes and QI • Med Eval – Physician costs and performance • High Risk – High risk patient safety and reportable events • CARE Core – Clinical processes and The Joint Commission Submission Hospital Quality Alliance (HQA) • Pneumonia (PNE) Georgia Medical Care Foundation (GMCF) • Quality Initiatives • Right Care to the Right Person Everytime PATIENT SAFETY HISTORY • 1999 Institute of Medicine report: “To Err is Human: Building a Safer Health System” *Estimated 44,000- 98, 000 medical error deaths annually *More than from highway accidents, breast cancer, or AIDS HISTORY (Continued) • Medical errors are responsible for injury in 1 out of every 25 hospital patients • The problem is not new, but in the past, may not have gotten the widespread attention it deserved. THE PUBLIC FEARS • Awareness of the issue has been growing • Americans have a very real fear of medical errors • 51 percent of Americans followed closely the release of the IOM report on medical errors HOW MUCH DO THESE ERRORS COST? • Medical errors carry a high financial cost • According to the IOM report, preventable healthcare-related injuries cost the economy over $17 billion annually. IT’S A SYSTEMS PROBLEM • Most errors are not attributable to individual negligence or misconduct • Healthcare professionals are human, and like everyone else, they make mistakes • System improvements can reduce the error rates REGULATORY INTEREST • The Joint Commission (TJC) has implemented patient safety standards July 2001 • TJC has implemented national patient safety goals/recommendations January 2003 • Georgia Hospital Association has created Partnership for Health and Accountability (PHA) PATIENT SAFETY AT MCH • Programs previously addressing patient safety (before 2000) – QI (Quality Management Program) – Environment of Care – Risk Management – Infection Control PATIENT SAFETY AT MCH (CONTINUED) • 2000 and beyond – MCH Patient Safety Program – Partnership for Health & Accountability (PHA) – Sentinel Event Alerts – TJC’s National Patient Safety Goals – Changing the Culture of Safety MCH Patient Safety Program • Plan • Commitment to Patient Safety • Staff Survey (annually) • Education • State, Federal, TJC, OSHA Regs • State reporting of events • Patient Safety Rounds MCH Patient Safety Program (con’t) • Health Research & Medical Evaluation System (HERMES) • Collaborative Approach to Research Effectiveness (CARE) Program • Hospital Quality Alliance (HQI) • Georgia Medical Care Foundation (GMCF) Commitment to Patient Safety Monroe County Hospital Commitment to Safety Monroe County Hospital is committed to providing a safe environment for patients, visitors, and staff. Our staff and Medical Staff strive to deliver excellent care in a complex environment. While systems are in place to decrease the risk of error, no system can wholly prevent errors from occurring. We share the goal of continuous learning from routine daily events as well as any mishaps that occur to reduce the chance of errors. Commitment (continued) To meet our responsibility to provide a safe environment for patients, their families and our staff, we are committed to the following principles: • We will work continuously to foster a non-punitive, trusting environment where errors, adverse consequences of care, and "near misses" can be reported confidentially. • Each employee plays a critical role in identifying, reporting, and developing solutions to conditions that pose potential hazards to patients or staff. Actions include sharing problems and solutions with others, and reporting problems to supervisors responsible for ensuring resolution. Commitment (continued) • All events, or potential events, that compromise patient • • • or staff safety provide an opportunity to learn how to prevent future occurrences. New information or changes in process resulting from analysis of current processes will be communicated to staff in a timely manner. Information systems, medication delivery systems and other technologic advances play a critical role in providing care to patients. We will use these technologies to improve patient and staff safety and prevent errors. We take pride in our hospital and work hard every day to ensure the safety of all that visit. Partnership for Health & Accountability (PHA) Safe Medication Use – Medication Error Reduction Project Patient Safety Issues – Fall Reduction Project Patient Safety Awards Information and resources Event Reporting Data published in PHA Insights annually Partnership for Health & Accountability (con’t) Hospital Quality Index (HQI) – Process- Pneumonia (PNE) – Outcomes-Length of Stay (LOS) Inpatient Mortality Clinical Core Measures: PNE Culture of Patient Safety Survey (COPS) Community Outreach Serving on Accountability & Health Safety Committee and Collaborative Approach to Research Effectiveness (CARE) Technical Advisory Committee Sentinel Events Alerts • 44 Sentinel Event Alerts issued by TJC as of January 26, 2010 • Review each one and determine what improvements can be made TJC National Patient Safety Goals 2010 • Goal 1 – Improve the accuracy of patient identification. – A. Use of Two Patient Identifiers (NPSG.01.01.01) – C. Eliminating Transfusion Errors (NPSG.01.03.01) TJC National Patient Safety Goals 2010 (con’t) • Goal 2 – Improve the effectiveness of communication among caregivers. – C. Timely Reporting of Critical Tests and Critical Results (NPSG.02.03.01) TJC National Patient Safety Goals 2010 (con’t) • Goal 3 – Improve the safety of using medications. • • D. Labeling Medications (NPSG.03.04.01) E. Reducing Harm from Anticoagulation Therapy (NPSG.03.05.01) TJC National Patient Safety Goals 2010 (con’t) • Goal 7 – Reduce the risk of health care– associated infections. • A. Meeting Hand Hygiene Guidelines • • • (NPSG.07.01.01) C. Preventing Multidrug-Resistant Organism Infections (NPSG.07.03.01) D. Preventing Central Line–Associated Blood Stream Infections (NPSG.07.04.01) E. Preventing Surgical Site Infections (NPSG.07.05.01) TJC National Patient Safety Goals 2010 (con’t) • Goal 8 – Accurately and completely reconcile medications across the continuum of care. • A. Comparing Current and Newly Ordered Medications • • • (NPSG.08.01.01) B. Communicating Medications to the Next Provider (NPSG.08.02.01) C. Providing a Reconciled Medication List to the Patient (NPSG.08.03.01) D. Settings in which Medications Are Minimally Used (NPSG.08.04.01) TJC National Patient Safety Goals 2010 (con’t) • Universal Protocol • A. Conducting a Pre-Procedure Verification • • Process (UP.01.01.01) B. Marking the Procedure Site (UP.01.02.01) C. Performing a Time-Out (UP.01.03.01) CHANGE TO A CULTURE OF SAFETY • SPEAK UP Program – TJC sponsored program which encourages patients be involved in their healthcare – Supported by Centers for Medicare & Medicaid Services (CMS) – Research shows that patients involved in their healthcare achieve better outcomes Speak Up Initiatives • • • • • • • Help Prevent Errors in Your Care Help Avoid Mistakes in Your Surgery Information for Living Organ Donors Five Things You Can Do to Prevent Infection Help Avoid Mistakes With Your Medicines What You Should Know About Research Studies Planning Your Follow-up Care Speak UP Initiatives (con’t) • Help Prevent Medical Test Mistakes • Know Your Rights • Understanding Your Doctors and Other • • • • Caregivers What You Should Know About Pain Management Prevent Errors in Your Child’s Care Stay Well and Keep Others Well (a coloring book for children) Tips for Your Doctor’s Visit CHANGE TO A CULTURE OF SAFETY • Staff and Physicians must – Be receptive to questions asked by patients – Be ready to answer or find the answer KEEPING INFORMED • Department/Manager’s Meetings • Orientation/Annual Update • Contact Kathy Louth 478-994-2521, ext 215 or [email protected] Quality Management Test 1) The goal of Quality Improvement is to: A. Study why other departments are causing problems with patient care. B. Continuously work with the physicians to improve nursing care. C. Continuously study and adapt functions and processes within the hospital to achieve improved patient care and services outcomes. 2) What model/process is utilized by MCH in our cycle of quality improvement? A. PDCA–Process, Determine, Cause, Analyze B. PDCA–Plan, Do, Check, Act C. PDCA–Performance, Develop, Communicate, Associate 3) A Performance Improvement Team uses this quality tool to give them a visual representation of all the various causes that contribute to a single effect: A. Control Diagram B. Fishbone Diagram C. Task Diagram Patient Safety Test 1. 2. 3. MCH uses two patient identifiers; name and date of birth when: a. b. c. d. Administering medications. Administering blood products. Taking blood samples and other specimens for clinical testing. All of the above. a. True a. b. c. d. Public Health Activity Partnership for Health and Accountability People’s Health Administration Peach Health Act Only the clinical staff at MCH need to be involved in the Patient Safety program? b. False MCH is involved with a statewide patient safety effort with the Georgia hospital Association called PHA which stands for: Bloodborne Pathogens Training Managed By: Jean Riley, RT Director, Respiratory Services Extension 249 OSHA’s Bloodborne Pathogens (BBP) Standard • Occupational Exposure to Bloodborne Pathogens • • • (29 CFR§1910.1030) Originally published December 1991; revised in January 2001 Covers all occupational exposure to blood and other potentially infectious material (OPIM) Healthcare workers (HCWs) are entitled to a copy of the standard Major Provisions of the BBP Standard • Defines terms such as exposure incident and engineering controls • Requires an exposure control plan • Discusses methods of compliance • Hepatitis B virus (HBV) vaccination and postexposure follow-up • Labeling and training • Record keeping Important Definitions • Other Potentially Infectious Material (OPIM) – includes semen; vaginal secretions; cerebrospinal fluid; body fluids; saliva and any body fluid visibly contaminated with blood; unfixed tissue or slides; cell, tissue, or organ cultures; blood or organs from experimental animals Other Important Definitions • Occupational Exposure – reasonably anticipated • • skin, eye, mucous membrane, or parenteral contact with blood or OPIM as a result of performing your job Parenteral—piercing mucous membranes or the skin barrier through such events as needlesticks, bites, cuts, and abrasions Universal Precautions – an approach to infection control that considers all blood and OPIM to be infectious Bloodborne Pathogen • A disease-causing microorganism found in blood, blood products, and other body fluids. For example: – Human immunodeficiency virus (HIV), the virus that causes AIDS – Hepatitis B virus (HBV) – Hepatitis C virus (HCV) – Other pathogens, such as those causing malaria or syphilis Usual Exposure Routes of HCWs • Sharps injuries (e.g., needlesticks, scissor or scalpel cuts and nicks) • Splashes or splatters of blood or OPIM into eyes, mouth, or nose • Open skin contact with a source of blood or OPIM (e.g., cut, abrasion) Bloodborne Illnesses • HBV and HCV • Acquired immune deficiency syndrome (AIDS) • Others (depending on patient population) BBP Transmission • Occupational – Sharps injuries – Mucous membrane or open-skin contact with blood or OPIM • Nonoccupational – – – – Sexual contact with infected person Sharing needles or syringes Infected mother to infant Blood transfusion (rarely in the United States since screening introduced) Hepatitis Facts • Caused by a virus that affects the liver, causing inflammation and damage – There are at least six strains (A, B, C, D, E, and G) – All except A and E are bloodborne – B and C are of most concern from occupational exposure standpoint • All strains cause similar symptoms, including anorexia, weakness, nausea, vomiting, headache, chills, fever, and jaundice HBV Infection • 6% to 30% of the estimated 800,000 to 1,000,000 sharps injuries per year will cause HBV infection • 50% of HBV-infected individuals are unaware • Individuals can be infected with more than one viral strain at a time HBV Prevention • Hepatitis B vaccination is 95% effective in preventing HBV infections • The vaccine is safe and provided free to exposed employees • Employees can be vaccinated when they start work or at a later time • The vaccine is a series of three shots over a six-month period of time HCV Infection • Approximately 1% of hospital workers have • • • • evidence of HCV-infection (CDC 1998) Seroconversion after percutaneous exposure to HCV-positive source averages 1.8% 75% to 85% of infected individuals develop chronic HCV infection if untreated Often causes no symptoms initially No vaccine, but treatment is available HIV Infection • HIV infection causes AIDS, a life-threatening • illness that suppresses the immune system, placing individuals at risk for other diseases, such as tuberculosis and cancer Early symptoms of AIDS include flulike symptoms, such as fever, diarrhea, headache, joint or muscle pain, rash, and nausea HIV Infection • As of June 2001, CDC documented 57 cases of seroconversion following documented occupational exposures • CDC is aware of an additional 137 other cases with presumed occupational exposure • Most documented cases suffered needlestick injuries How HIV is Not Transmitted • Contact with doorknobs, toilet seats, etc. • Casual contact HIV Transmission • Average risk after percutaneous injury is 0.3%. Hollow-bore needles and high viral titer affect risk • Average risk after mucous membrane exposure is 0.1% • Nonintact skin exposure risk is < 0.1% • There is no vaccine available Exposure Control Plan (ECP) • Required for all employers who have employees with potential occupational exposure • Describes specific measures used to control BBP exposures • Must be reviewed and, if necessary, updated annually Copies of the ECP • The ECP is maintained by: The Safety Officer and Infection Control Dept. • Employees are entitled to a copy of the plan • Copies of the ECP are available in: The Safety Manual and our website Purpose of the ECP • The ECP provides facility-specific policies and procedures to: – Help prevent accidental exposures, – Provide means to report exposure incidents, – Perform postexposure follow-up and appropriate treatment, and – Identify labels and signs indicating infectious materials HCW Jobs with BBP Exposure Potential • Clinical personnel (e.g., doctors, nurses, technicians) • Housekeeping and maintenance • Laundry • First aid providers • Others: ER Registration Staff Examples of Procedures with Exposure Potential • • • • • • Performing vascular access procedures Handling or removing contaminated waste Handling contaminated equipment or laundry Analyzing blood or OPIM specimens Cleaning blood or body fluids in common areas Rendering first aid How to Minimize Exposure • Follow standard precautions • Use engineering and work-practice controls • Use appropriate personal protective equipment (PPE) What are Universal Precautions? • Universal precautions (UP) is the practice of • • • assuming that all blood and OPIM are infectious Standard precautions as recommended by CDC incorporate UP and go one step further by assuming all blood and body fluids are infectious All HCWs must use UP whenever there is a chance of exposure to blood or OPIM, according to OSHA Handwashing is key! What Are Engineering Controls? • OSHA defines an engineering control as a control that isolates or removes the hazard from the workplace – some examples include sharps containers, biological hoods, sharps with engineered sharps injury protections, and needleless systems Facility-Specific Engineering Controls • Sharps containers for disposal of used needles, • • lancets, scalpels, etc. Sharps with engineered sharps injury protections (i.e., needlestick prevention devices) Limitations: They reduce but do not eliminate the potential for sharps injury Sharps with Engineered Sharps Injury Protections • Also known as Needlestick Prevention Devices (NPDs) • Types – Needleless systems – Shielded needles – Plastic capillary tubes • Needless IV tubing NPD Selection and Evaluation • NPD evaluation process – Nonmanagerial worker participation • NPD evaluation criteria • Appoint a Sharps Review Committee periodically to review new devices Work-Practice Controls • Measures that reduce the likelihood of exposure by altering the way you perform a task or job • Examples: – Minimizing splashing – Sharps handling and disposal in sharps containers – Containerizing and labeling specimens Prohibited Work Practices • No eating, drinking, or applying cosmetics in an area with blood or OPIM • No food in areas where blood or OPIM may be present • No recapping of needles • No mouth pipetting Work-Practice Limitations • Work practices must be used correctly and consistently by all employees to be effective in reducing the likelihood of BBP and sharps exposures. What is PPE? • PPE (personal protective equipment) includes items such as gloves, fluidresistant masks, eyewear, face shields, gowns, and other items a person wears to protect him/herself against exposure to blood and OPIM Facility-Specific PPE Practices • PPE is provided free to employees for use while working • PPE is chosen to fit the task and the worker(s) who will be using it • PPE supplies are generally kept in each department, in patient rooms • If you need items, contact Robin Spence When Do I Use PPE? • Wear PPE anytime you may come in contact with infectious material (including contaminated equipment) • Wear PPE if you are doing a task that may cause blood or OPIM to splash or splatter • When in doubt, USE IT! Types of PPE • Gloves • Goggles and face shields • Disposable gowns • Additional items can be ordered as needed – contact your department manager Gloves • There are a variety to choose from, including latex-free gloves • Check for small holes, puncture marks, etc., before using. These are big enough to allow a virus to pass through! • Double gloving is a practice that reduces but does not eliminate the occurrence of needlestick injuries Goggles and Face Shields • Protects surrounding skin and mucous membranes of the eyes, nose, and mouth from exposure during procedures that may generate splashes of blood or OPIM Gowns • When required, put them on before starting to work • Don’t remove them wearing “dirty” gloves or if hands are dirty • Choose an appropriately sized gown to maximize comfort and protection Removing PPE • Remove contaminated PPE immediately after use • If any area on your body has blood or OPIM on it after removing PPE, wash with soap and water • Generally speaking, gloves should always be considered contaminated After Removing PPE • Always wash hands after removing gloves and other PPE • All contaminated PPE should be disposed of into biohazardous-waste containers Limitations of PPE • Does not eliminate the exposure source • Must be worn correctly and at all times in work • • • • • tasks where exposures may be encountered Must be the right type and fit Must be changed whenever soiled May be uncomfortable to the user May affect task performance May impede communications Biohazardous Waste • Biohazardous waste is material contaminated • • with blood or OPIM. Biohazardous waste is disposed of in labeled biohazardous-waste bags/containers For example, sharps go into sharps disposal containers and PPE, paper towels, and other contaminated waste that will not puncture a bag goes into biohazardous-waste bags. Biohazardous-Waste Bag/Container • Is red or orange-red in color Or • Has the word “BIOHAZARD” printed on it Or • Has the “BIOHAZARD” symbol on it This is the biohazard symbol Biohazardous-Waste Containers at This Facility • Large closed containers with biohazard labels located: in each clinical department • Small closed containers, also with labels on them, located: clinical depts • Biohazard bags, located: each clinical department • Sharps containers in all clinical areas Blood or OPIM Decontamination and Cleanup Procedures • Clean equipment or surface according to • • established procedures which are outlined in your department Use an approved disinfectant according to manufacturers’ directions or a fresh 1:10 chlorine bleach solution (made within 24 hours of use) Contact: Tim Allen ext 156 Environmental Survival • Outside the body, HIV and HCV are weak viruses that are easily killed with chemical disinfectants • HBV is somewhat hardier and can survive for at least one week in dried blood or on contaminated surfaces, needles, or instruments Laundry • Contained or bagged • Requirements for laundry bags or containers: – Color coded or labeled biohazard – Prevent leaking • No sorting or rinsing • No home laundering Prevention of BBP Infection • Hepatitis B vaccine • Incident Reporting • Postexposure follow-up Hepatitis B Vaccine • Offered free to potentially exposed staff • Given before assignment to tasks involving • • • occupational exposure to HBV Administered according to the latest CDC guidelines Given at: Emergency Room Signed waiver required for vaccine refusal Exposure Incident: • An exposure incident has occurred if: – Blood or OPIM (not your own) has come into direct contact with your eyes, mouth, mucous membranes, or open wounds or – You have punctured your skin with a contaminated sharp object What to Do After an Exposure Incident • WASH the affected area(s) with plenty of soap and water immediately following exposure • REPORT the exposure immediately. Prompt evaluation is important Reporting an Exposure Incident • Report all exposures to: Your Supervisor • Your supervisor or will provide you with the necessary paperwork and will help document the exposure After an Exposure Incident • You will be sent for a free medical evaluation • Any necessary treatment will be provided for you • • free of charge Any test results, medical recommendations, or other information will be shared with you The incident will be recorded on the Sharps Injury Log maintained by: Christa Garner Sharps Injury Log Information • Includes details of all exposure incidents: – Type and brand of device involved – Where incident occurred – Description of how incident occurred • Maintains employee confidentiality (Personal identification is not recorded) Postexposure Follow-Up • Medical evaluation • Postexposure prophylaxis (PEP), if clinically indicated • Physician’s written opinion Postexposure Evaluation Requirements • Follow latest CDC requirements for postexposure evaluation and prophylaxis – Document route of exposure – Identify source – Test source blood – Make test results available to HCW – Upon consent, test HCW’s blood Evaluation Requirements • If no consent for HIV tests, save blood for 90 days • Advise HCW to seek medical attention • Provide counseling • Evaluate test results to offer treatment if needed Types of Prophylaxis • HBV – Vaccine, Hepatitis B immunoglobulin • HIV – Zidovudine – Lamivudine (3TC) – Expanded regimen: Indinavir (IDV) or similaracting agents when increased risk • HCV – None Physician’s Written Opinion • Employer obtains within 15 days and provides copy to HCW • Contains: – Limited medical information – Documentation that HCW was informed of results and exposure-related conditions Record keeping • What records are kept? – Medical and training records – OSHA Illness and Injury, Sharps Log(s) • How long are they kept? – Medical: employment plus 30 years – Training: 3 years – OSHA Log(s): 5 years • Medical records kept confidential • Access to records: employee, OSHA Remember: • Avoid all contact with blood or OPIM • Handwashing is key to preventing infection • Use PPE as required • Get vaccinated against HBV: HBV vaccine is free and eliminates a potential risk • Report any exposure incident that occurs as soon as possible Bloodborne Pathogen Video • Now you must watch the video on blood borne pathogens. • The next section is about Tuberculosis. Tuberculosis • The hospital has one isolation room for TB patients and that is room 274. Before you enter the room, there is a small area that contains all masks and gowns. Tuberculosis • Our hospital does not receive many TB patients. • If you notice a patient: coughing a lot and spitting up blood, you may request that patient wear a surgical mask until they can be evaluated by a physician. • Always give coughing patients a tissue to cover their mouth. Tuberculosis • Please watch the video on TB now. After the video, go to the next slide to take a short test. Test 1. The best way to prevent the spread of infection is by: a. Washing your hand. b. Staying away from people. c. Keeping your eyes closed. d. Not talking. 2. The location of our TB room is: a. In the ER. b. Room 274. c. In the hallway. d. In the Maintenance Department. 3. Our exposure control plan: a. Tells you what to do if you fall. b. Details your paycheck. c. Tells you what to do if you are stuck by a needle or splashed by blood or OPIM. d. Is not important. Health Care-Associated Infection and Hand Hygiene Improvement Managed by: Jean Riley, RRT Director, Respiratory Services Infection Control Officer Extension 249 Definition • Health Care-associated Infection (HCAI) – Also referred to as “nosocomial” or “hospital” infection • “An infection occurring in a patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the health-care facility but appearing after discharge, and also occupational infections among health-care workers of the facility” HCAI: The worldwide burden – Estimates are hampered by limited availability of reliable data – The burden of disease both outside and inside health-care facilities is unknown in many countries – No health-care facility, no country, no healthcare system in the world can claim to have solved the problem Estimated rates of HCAI worldwide – At any time, hundreds of millions of people worldwide are suffering from infections acquired in health-care facilities – In modern health-care facilities in the developed world: 5–10% of patients acquire one or more infections – In developing countries the risk of HCAI is 2–20 times higher than in developed countries and the proportion of patients affected by HCAI can exceed 25% – In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44% The impact of HCAI • HCAI can cause: – more serious illness – prolongation of stay in a health-care facility – long-term disability – excess deaths – high additional financial burden – high personal costs on patients and their families Prevention of HCAI – Validated and standardized prevention strategies have been shown to reduce HCAI – At least 50% of HCAI could be prevented – Most solutions are simple and not resourcedemanding and can be implemented in developed, as well as in transitional and developing countries SENIC study: Study on the Efficacy of Nosocomial Infection Control Relative change in NI in a 5 year period (1970–1975) – >30% of HCAI are preventable 26% 30 20 10 % 0 14% 19% 18% 9% LRTI SSI UTI BSI Total With infection control -10 -20 -30 -40 Without infection control -27% -35% Haley RW et al. Am J Epidemiol 1985 -31% -35% -32% Hand transmission – Hands are the most common vehicle to transmit health careassociated pathogens – Transmission of health care-associated pathogens from one patient to another via health-care workers’ hands requires 5 sequential steps 5 stages of hand transmission one two three four five Germs present on patient skin and immediate environment surfaces Germ transfer onto healthcare worker’s hands Germs survive on hands for several minutes Suboptimal or omitted hand cleansing results in hands remaining contaminated Contaminated hands transmit germs via direct contact with patient or patient’s immediate environment Why should you clean your hands? – Any health-care worker, caregiver or person involved in patient care needs to be concerned about hand hygiene – Therefore hand hygiene concerns you! – You must perform hand hygiene to: – protect the patient against harmful germs carried on your hands or present on his/her own skin – protect yourself and the health-care environment from harmful germs The “My 5 Moments for Hand Hygiene” approach How to clean your hands – Handrubbing with alcohol-based handrub is the preferred routine method of hand hygiene if hands are not visibly soiled – Handwashing with soap and water – essential when hands are visibly dirty or visibly soiled (following visible exposure to body fluids)1 1 If exposure to spore forming organisms e.g. Clostridium difficile is strongly suspected or proven, including during outbreaks – clean hands using soap and water How to handrub To effectively reduce the growth of germs on hands, handrubbing must be performed by following all of the illustrated steps. This takes only 20–30 seconds! How to handwash To effectively reduce the growth of germs on hands, handwashing must last 40–60 seconds and should be performed by following all of the illustrated steps. Hand hygiene and glove use – The use of gloves does not replace the need to clean your hands! – You should remove gloves to perform hand hygiene, when an indication occurs while wearing gloves – You should wear gloves only when indicated (see the Pyramid in the Hand Hygiene Why, How and When Brochure and in the Glove Use Information Leaflet) – otherwise they become a major risk for germ transmission Compliance with hand hygiene – Compliance with hand hygiene differs across facilities and countries, but is globally <40%1 – Main reasons for non-compliance reported by health-care workers2: – – – – 1Pittet 2Pittet Too busy Skin irritation Glove use Don’t think about it and Boyce. Lancet Infectious Diseases 2001; D, et al. Ann Intern Med 1999 Time constraint = major obstacle for hand hygiene • Adequate handwashing with water and soap requires 40–60 seconds • Average time usually adopted by health-care workers: <10 seconds • Alcohol-based • handrubbing: 20–30 seconds Health Care-Associated Infection and Hand Hygiene Improvement Test Adequate handwashing with water and soap requires: a. 5 minutes b. 20-30 seconds c. 40-60 seconds 2. Hands are the most common vehicle to transmit health care-associated pathogens? a. True b. False 3. Why is it important to wash your hands? a. Protect the patient against harmful germs carried on your hands or present on his/her own skin. b. Protect yourself and the health-care environment from harmful germs. c. An infection can cause a prolonged stay in the hospital or even death. d. All of the above. Safety Management Program Managed by: Tim Allen Director, Environmental Services Extension 156 Safety Management Program • Safety Committee – Meets bi-monthly – Conducts 2 safety surveys per year – Report any unsafe condition you become aware of immediately • Incidents/Accidents – Report incidents/accidents immediately to your supervisor or the Charge Nurse – Complete the Incident/Accident report – Report to emergency room for exam – Report to Lab for drug screen – Return Incident/Accident Form to HR Safety Management Program • Accident Review Committee – Will convene at least 5 days after an incident/accident is reported – Accident will be reviewed, employee interviewed, and steps initiated to help prevent accident from occurring again Safety • Safety Drills are conducted quarterly and can occur at any time. You may be asked to be an evaluator and to write down what you observed during the drill. • If you have any safety concerns related to patients or employees please call Tim Allen at ext 156. Safety Manual • Book of policy & procedures related to safety issues: Fire Plan, Bomb Threat, Weather Safety, Hazardous Material, Weapons of Mass Destruction, Security, Employee Safety, and Utilities • Located in every department Safety Manual • Please take time to read your safety manual and sign the acknowledgment form in the front of the notebook. • Your supervisor will be able to tell you about department specific plans. Material Safety Data Sheets (MSDS) • A sheet designed to provide workers with proper procedures for handling or working with a particular substance. • Every chemical you work with has a MSDS and is located in your department. • The ER has the Master MSDS with all chemicals located in the hospital. Security Management • Hospital Codes – – – – – – – – – Code Grey – Security Incident Code Orange – Hazardous Materials & Waste Code Triage – Emergency Preparedness Code Weather – Severe Weather Conditions Code Red – Life Safety (Fire) Code Yellow – Trauma Patient Code Pink – Infant Abduction Dr. Atlas – Physical Help Needed Code Blue – Cardiac Arrest Security Management • Medical Equipment Management – All electrical equipment checked at least one time per year – Report any equipment outages to the Safety Officer (Tim Allen) immediately • Utility Management – We have backup generator in case of power outage – Generator operates light in corridors, outlets, boiler, and all critical care equipment Safety Management Test 1. The code for Security is Code Grey. a. True b. False 2. A urine drug screen must be done if an employee has an accident. a. True b. False 3. How many surveys does the Safety Committee conduct each year? a. One b. Two c. Three MRI Safety Managed By: Megan Randall, ARRT Director, Radiology Services Ext 160 What is MRI? • MRI stands for Magnetic Resonance Imaging • MRI is one of the most diagnostic imaging tools in Radiology today. • MRI does not use radiation in any form to image the body. Interesting Fact about MRI • Most MRI scanners have a magnetic field strength of about 20,000 times greater than the magnetic force of the Earth. Important things to Know about MRI • The magnet is ALWAYS • • on!! Never enter the scan room without first being screened for metal by the MRI technologist. ALWAYS unload pockets and remove metal objects prior to entering the scan room. • NEVER ASSUME that an • • object is safe to enter into the scan room. If something is questionable, the technologist can screen the object with a magnet. In MRI, ANY unscreened object could be a potential danger. MRI Warning Signs THINGS THAT ARE MRI PROHIBITED • Pacemakers • Defibrillators • Intra-cranial Aneurysm • • • • • • Clips Knives/guns Credit cards Watches Scissors Cell phones/beepers Implanted devices or pumps • • • • • • • Metal Oxygen Tanks Metal IV poles and Pumps Crash Cart Metal Stretchers Wheelchairs Chairs containing metal Telemetry boxes or EKG wire • Bullets in the body THINGS THAT ARE MRI PROHIBITED • Jewelry • Hair pins,bobby pins, • • • • • • barrettes, and clips Partial dental plates Hearing Aids Eyeglasses Cochlear (ear) implants Keys Ventilators • Body piercing objects • Aluminum backed • • • • • medicinal patches (Nitroglycerin,Nicotine) Prosthetics (artificial limbs) Certain Heart Valves and stents Metal in eyes Lighters Fire extinguishers WHEN IN MRI: • Always check equipment • for MRI compatibility information. This is usually present in sticker form on most pieces of medical equipment. REMEMBER THAT…. • ALL METAL OBJECTS should be screened before • • entering the MRI scan room. ALL PEOPLE should be thoroughly screened before entering the scan room. MRI can be a dangerous place if the rules and guidelines are not respected and followed! MRI Screening Form CODE in MRI • If a code occurs in MRI, the patient should be removed from the scan room in order to allow emergency equipment access to the patient. Oxygen Tanks can be LETHAL Missiles in MRI OXYGEN TANKS cont… Danger of METAL IV poles Dangers of METAL chairs in MRI INFORMATION ABOUT MCH’s MRI UNIT • MCH’s MRI unit is equipped with a non- ferrous (non-magnetic) Oxygen tank, fire extinguisher, and stretcher. • MCH has a portable MRI compatible ventilator if needed. IN CONCLUSION….. • Flying metal objects pose • a life threatening risk to employees and patients. In the event that an object has to be removed from the MRI unit, the cost of turning the magnet off for repair is around $46,000. QUESTIONS? • Always assume that an item is “UNSAFE” until it has been screened by MRI technologist. • THERE IS NO SUCH THING AS A DUMB QUESTION IN MRI!!!!! • ASK QUESTIONS!! MRI Safety Test 1. The magnet is only on when a MRI is being done. a. True b. False 2. All metal is prohibited in MRI. a. True b. False Information Management Principles Managed by: Donna Hogg, RHIT, CHP Director, Medical Records Extension 229 Notice of Privacy Practices • MCH will provide notice to all patients upon first • • • • date of service Will provide notice ASAP after emergency Will provide hard copy of notice to patient Notice will describe patient rights regarding Protected Health Information (PHI) Notice will describe the patients’ right to file a complaint with MCH or Office of Civil Rights Right of Patients • The patient has a right to: – Confidential communications including providing us with an alternate address or phone number – Request a restriction on how we use their PHI – Inspect and copy their record – Request an amendment of their record – Request a listing of when and to whom we release PHI Rights of Patients • Hospital directory and individuals accompanying patients to hospital: – Patient must be given the opportunity to object to being listed on the directory (census, morning report, etc.) – Unless patient objects, the patient’s name and location may be given to members of the clergy or persons who ask for the patient by name – The patient must be given the opportunity to object to disclosures to persons involved in their care including relative, caregiver, or someone who accompanies them to the hospital Rights of Patients • Words of Caution – Do not assume the patient wants his personal health information discussed in front of other people. Use professional judgment, and if unsure, ask the patient when possible about their wishes. Marketing & Fundraising • The Privacy Rule will not allow us to share PHI • • with other companies for their marketing without patient authorization Never use patient pictures without written authorization We can use limited information to notify patient about services we provide – We must allow the patient an opportunity to opt out of this service Protected Health Information for Treatment, Payment, and Healthcare Operations (TPO) • Permits the Hospital to use PHI (protected health • • • information) for treatment, payment and healthcare operations. Treatment: We may use PHI to treat the patient as well as share information with other healthcare facilities who are involved in the patient’s care. Payment: We may use PHI to be reimbursed for our services according to the Minimum Necessary Rule. Operations: We may use PHI to carry out hospital business such as to improve quality of care and utilization management according to the Minimum Necessary Rule. Minimum Necessary Rule • MCH must use or disclose only the minimum • amount of information necessary to accomplish the purpose of the use or disclosure Exceptions to Minimum Necessary Rule – Disclosure for treatment – Disclosure to patient or upon written authorization from patient – Disclosure required by law or privacy rule Minimum Necessary Rule –Need to Know • The Privacy Rule requires the hospital to have • • policies in place to limit the use of PHI to only the minimum amount of information to get our jobs done Access to patient information is therefore determined by what your responsibilities are Do not view or attempt to access PHI outside your job responsibility Disclosure of PHI • Disclosure: The release, transfer, or access to, or divulging information to an entity or person outside the hospital • All requests for patient information are handled by the Medical Records Department – The Release of Information function is governed by federal and state laws. If someone is requesting records or other patient information (example: attorney, law enforcement, spouse, relative) they must be referred to Medical Records • All patients or patient representatives are required to have ID for verification Incidental Disclosures • The Privacy Rule is not intended to prohibit providers • • from talking to each other or to their patients in a treatment setting The Privacy Rule recognizes that in a healthcare setting, incidental disclosures are impossible to always avoid. In other words, someone who would not normally have access to information, may overhear or see information because of the setting. These “incidental disclosures” are not considered a violation of the Privacy Rule as long as the hospital has implemented reasonable safeguards to limit this from happening CAUTION An “incidental disclosure” may NOT be considered incidental if it could have been prevented Safeguards • Limited access and information in general locations • Never throw away anything with the patient’s name or • • • • information that identifies a patient – use the shred bins Password protocols should be used for all electronic systems Fax numbers should be verified and receipt information confirmed Do not send PHI via e-mail If you become aware of privacy violations, notify the Privacy Officer – You may also file an anonymous complaint using the Compliance Complaint Process Common Privacy Mistakes • Discussing PHI in public places (hallways, elevator, • • • • • • • cafeteria, outside the hospital) Using or disclosing PHI without written authorization Leaving PHI on desk, printer, or fax machine Leaving PHI in a public area Leaving computer screens on while away from your area Disclosing or sharing your password or workstation E-mailing PHI Discussing PHI with friends and family Workforce Responsibilities How to avoid a “HIPAA SLIPPA” • Keep PHI out of sight! • Use common sense on the phone: avoid being • • • • • • • overheard Create privacy in the admitting areas Confine patient discussions to patient care areas only Use available safeguards in your area Program fax numbers to prevent dialing wrong numbers & remember to notify the other party who will receive the information Do not post anything containing patient information Always shred Always log out of computer when not in use Privacy Complaint Process • MCH is required to have a process in place to allow patients to make • • • • complaints about the Hospital’s compliance with its privacy policies The patient should be directed to the Privacy Officer (Donna Hogg, ext 229), or if they wish they may contact the Office of Civil Rights The Hospital must complete a written complaint as well as investigate the incident. All action taken must be documented Any person, including a family member or employee, can file a complaint on behalf of a patient The Hospital has a policy in place that prohibits intimidating, threatening, coercing, discriminating against, or taking other retaliatory action against any person who files a privacy complaint Violations of Patient Confidentiality •Compromise patient care because patients keep information from their caregivers •Could be the basis for disciplinary action, ranging from counseling to a warning to termination •Could be subject an individual to civil and criminal penalties, including fines and imprisonment •Could subject our hospital to criminal and civil penalties, including fines •Is inconsistent with our Hospital’s mission HIPAA Privacy Training • If you have any questions, please contact Donna Hogg at ext 229 • Now please watch the video on Privacy: – Privacy Fundamentals and Clinical • NOTE: for Admission Clerks, please view the Registration video also. Test 1. The Privacy Rule does not allow the hospital to use PHI to carry out hospital operations. a. True b. False 2. The “Minimum Necessary Rule” allows employees to access PHI needed to accomplish their jobs. a. True b. False 3. The hospital must implement reasonable safeguards to limit incidental disclosures. a. True b. False HIPAA Security Compliance/Hospital Ethics Managed by: Becky Firster, CPA Chief Financial Officer Extension 104 HIPAA Security Training • What is HIPAA – first federal law passed to • protect the privacy and security of patient’s health information Why is HIPAA Security mission critical? – Patient trust is vital to our mission – Respect for patient privacy is vital to our mission – Security of patient medical information goes hand-inhand with patient privacy HIPAA Security Training • What is the scope of the Security Rule? – EPHI – Electronic Protected Health Information • PHI that is transmitted or stored in electronic format • Electronic means is used to exchange information • Security rule does not cover paper records, verbal communications, PHI on paper to paper faxes, PHI transmitted by telephone, PHI in voice mail, video conferencing HIPAA Security Training • What does the Security Rule require of the hospital? – Ensure confidentiality, integrity, and availability of all ePHI created, received, maintained, or transmitted – Protect against any reasonably anticipated uses or disclosures – Ensure compliance with Security Rule by workforce HIPAA Security Training – Designate a Security Officer (Becky Firster, ext 104) • Security Officer must work with Privacy Officer, Compliance Officer, and Risk Manager • Develop and maintain ePHI policies and procedures • Accept and investigate complaints or concerns about ePHI security breaches HIPAA Security Training • Key Security Policies – Sanctions for Security Breaches – Transmitting PHI by Fax, E-Mail, Internet – Security Incident Procedures – Workstation Use and Security – Unique User Identification – Access Control – Use of Network Applications and Internet Key Security Training • Sanctions for Security Breaches – Employees must report known or potential violations to Security Officer – If violation occurs, it will be handled according to Compliance program disciplinary process – Disciplinary actions would depend on the nature and severity of the incident – The law prevents retaliation again an employee in any way for filing a complaint or participating in a compliant investigation Key Security Training • Transmitting PHI by Fax, E-mail, or Internet – Use reasonable measures to verity fax number to which sent and confirm receipt of fax by authorized person – PHI may be transmitted by e-mail only if approved by manager, and then only if a secure application is used to encrypt the information – PHI is to be transmitted via internet only if encryption is used and both the sender and recipient are know to each other and authorized to receive and decrypt the ePHI Key Security Training • Security Incident Procedures – Security incidents • unauthorized access, use, disclosure, modification or destruction of ePH • Interference with hospital information system • Improper network activity • Misuse of data Key Security Training • Security Incident Procedures – Examples • Service disruption caused by natural disaster, power outage, virus or worm, theft of ePHI, hacking, unauthorized use of system for processing, transmitting, or storing data, or business associate security incident Key Security Training • Security Incident Procedures – Security incidents must be report by employee to Security Officer – An employee found to have caused a security incident will be dealt with under the Sanctions for Security Breaches policy Key Security Policies • Workstation Use and Security – Access to system workstations are limited to authorized users – Workstations should be positioned to minimize unauthorized viewing of ePHI – Unauthorized personnel should not be left alone in areas containing workstations Key Security Policies • Unique User Identification – Each system user will have a unique number and password for identifying and tracking the identity of the user in the healthcare information system – Access to health information system must be authorized by manager/human resources and activated by Security Officer Key Security Policies • Unique User Identification – Sharing of passwords is prohibited – Passwords must be complex (combination of letters and numbers) and will expire/change every 60 days – Lost or compromised passwords must be reported to Security Officer so they can be reset Key Security Policies • Access Control – Health information system access is defined based on user’s job position – Access is audited on a periodic and random basis, or anytime a security discrepancy is suspected Key Security Policies • Use of Network Applications and Internet – Network access is limited to authorized users based on job position – Use of network resources, e-mail, and internet must be limited to hospital-related purposes only • E-mail must be legitimate, legal, and relevant to the business affairs of the hospital and must be written in acceptable styles of business communication and etiquette • Access of the internet on the hospital’s information system for purely personal reason or for persona gain is STRICTLY PROHIBITED HIPAA Security Training • Common Security Mistakes – Using or disclosing ePHI without prior authorization – Not logging off computer – Inappropriate or unintentional uses through e-mail, internet, fax – Posting passwords on computer – Loaning passwords to others – Failing to follow Minimum Necessary Rule HIPAA Security Training • Consequence of Security Violations – Compromise patient care – Disciplinary actions; could include termination – Government enforcement • Department of Health and Human Services enforces • Criminal and civil penalties to include fines and imprisonment Corporate Compliance Program Hospital Ethics • What is Corporate Compliance – Following correct coding and billing rules – EMTALA rules for treating emergency patients regardless of their ability to pay – Following HIPAA privacy and security rules – Proper disposal of hazardous materials Corporate Compliance Program Hospital Ethics • Why should I care about compliance? – Puts hospital and jobs at risk – Can be viewed as fraud and abuse – Can be subject to government investigations, penalties, including exclusion from Medicare and Medicaid programs Corporate Compliance Program Hospital Ethics • Who keeps track? – Department of Health and Human Services – Office of Inspector General – US Department of Justice – FBI – Center for Medicare and Medicaid – Office of Civil Rights Corporate Compliance Program Hospital Ethics • What is fraud? • The crime of willfully and intentionally acting to gain something that is unfair or unlawful (cheating) • What is abuse? • An unjust or wrongful practice that can result in unnecessarily increasing healthcare costs, unfair or unreasonable pricing, restricting patient choice, or restricting competition Corporate Compliance Program Hospital Ethics • Laws that apply: – False Claims Act – Social Security Act – Anti-kickback statute – Civil Monetary Penalties Act – Stark II – Physician self-referral law Corporate Compliance Program Hospital Ethics • Fraudulent or abusive billing practices – Billing for medically unnecessary services – Duplicate billing – Billing lab panels individually and at a higher rate – Billing for non-covered services or services not provided – Medicare cost reports Corporate Compliance Program Hospital Ethics • Other Risk Areas – Patient dumping – EMTALA – Financial arrangements between physicians and hospitals – HIPAA violations – Environmental waste disposals – Promotional inducements from vendors – “Moonlighting” Corporate Compliance Program Hospital Ethics • What is our Code of Ethics? – We do not market to attract patients for services we cannot render – Decisions to admit, treat, transfer or discharge patients are not based on financial reasons – Our billing and collection practices are fair – We seek to avoid conflicts of interest Corporate Compliance Program Hospital Ethics • What is our hospital doing? – Workforce training – Non-retaliatory policies – Anonymous reporting procedures – Compliance committee works on risk areas – Careful screening of applicants HIPAA Security Test 1. HIPAA is the first state law passed to protect the privacy and security of patient’s health information? a. True b. False 2. EPHI is Electronic Protected Health Information? a. True b. False 3. The key Security policies an employee should know are: Sanctions for Security Breaches, Policy on Transmitting PHI, Policy on Security Incident Procedures, Policy on Workstation Uses, and Policy on Unique User ID? a. True b. False 4. Network access is available to all hospital employees. a. True b. False 5. Employees are not required to report potential security violations; that is the responsibility of the Security Officer. a. True b. False Compliance Test 1. You shouldn’t report compliance issues because you may lose your own job for doing so? a. True b. False 2. It isn’t important to report compliance problems because nothing will be done about it anyway. a. True b. False 3. The “EMTALA” law requires every emergency room patient to receive an adequate medical screening prior to being asked about payment? a. True b. False Compliance Test 4. It is a compliance problem if procedures/ medications administered to the patient are not properly documented in the chart? a. True b. False 5. Compliance issues can cost the hospital a lot of money? a. True b. False Customer Service Managed by: Debra K. Flowers, PHR Director, Human Resources Extension 209 Customer Service Objectives • Define quality customer service • What does quality customer service look like? • What is your role in providing quality customer service? • How do you stay committed to your customers? What is Customer Service? • Not based on quantitative outcomes • It is a combination of the “Golden Rule” and how the customer perceives the service you are providing MCH Customer Service Creed • We Care enough to give you a smile. • We Care enough to go the extra mile. • We Care enough to listen. • We Care enough to be informed. • We Care enough to follow through. • We Care enough to say “thank you.” The MCH Motto •Commitment •Attitude •Respect •Empathy Customer Service Includes: • How well the staff works together to take care of the customer • Overall cheerfulness/friendliness • Response to concerns/complaints • Amount of attention paid to special needs • The staff’s ability to keep the customer informed • Skill level of the employee Customer Service Includes: • The anticipation of the customer’s needs • Teamwork • Responding with care and compassion • Responding in an adequate timeframe to customer needs The Role of the Employee • Communicate within your team regarding customer needs, concerns, etc. • Communicate with your supervisor regarding your ideas on how to address customer needs, concerns, etc. • Clear communication is of vital importance to your team when providing quality customer service The Role of the Employee • If you are struggling with your skill level for a • • • task you have been given, ask for assistance Continually ask yourself how YOU can improve and add value to the organization You can assist in creating an atmosphere of excellence with your department and overall organization You make the difference! Customer Service Pitfalls • Body language – lack of eye contact, tone of • • • • • voice, closed off, etc. Poor attitudes Lack of training Poor response rate or lack of anticipation of customer needs Forgetting that there are internal and external customers Not knowing your competition Your Competition • Your competition is anyone the customer compares your organization to • A customer judges their overall experience by his/her perceptions – something that is subjective and cannot be verified by outcomes Quality Customer Service Starts With You • Never pass another person in the hallway • • without giving them a smile! Judge yourself against the standards set by the nicest people giving services anywhere (i.e., Disney) Compassion, caring, and empathy are the three qualities that correlate most with overall satisfaction and most certainly loyalty Questions for you as an Employee • Have you given your input to your team regarding ways to assist your organization in providing quality customer service • If yes, how have you done so? • If no, why have you failed to do this? How Do You Stay Committed? • Remember the promises you make to your customers • Anticipate their needs • Deliver your services with a caring, compassionate attitude • Use the “Golden Rule” • Teamwork will always be successful Customer Service Test 1. What is the MCH Motto? 2. Who is your competition? a. The Medical Center of Central Georgia. b. Anyone the customer compares our organization to. c. The hospitals in Atlanta. Cultural Sensitivity Managed By: Debra K. Flowers, PHR Director, Human Resources Ext 209 Diversity in the Workplace • What do we want to do: – Raise the level of awareness about the important of sensitivity to diversity of health care workers – Provide language around topics of diversity – Learn tools to work effectively with a diverse customer base What Exactly is “Diversity”? • Diversity refers to all the ways that individuals are unique and differ from one another • Broken down into PRIMARY and SECONDARY characteristics Examples of Diversity • • • • • • • • Age Race Martial Status Education Profession Religion Gender Language • • • • • • • • Lifestyle Life Experiences Geographic Location Eye Color Sexual Orientation Disability Economic Status Likes/Dislikes Primary Characteristics: • Qualities we are born with: – Gender – Eye color – Hair color – Race – Birth Defects Secondary Characteristics: • Religion • Educational Level • Parental Status • Geographic Location • Socioeconomic Status What Exactly is “Culture”? • Patterns of daily living by a group of people • Learned consciously or unconsciously Examples of Culture • • • • • • • Language Practices Customs Food Clothing Religion Superstitions • • • • • • • Architecture Holiday Celebrations Family Unit Dating Rituals Art Governing Music Barriers to Accepting Others • Perceptions • Bias • Prejudice • Stereotypes Perceptions • Thoughts resulting from a feeling. Based on opinions, likes, dislikes, attitudes, beliefs, values, and rationalizations. Bias • An inclination – either for or against – an individual or group that interferes with impartial judgment. Prejudice • Pre-judging a person or group without sufficient knowledge. • Frequently based on stereotypes. Stereotype • An oversimplified generalization or mental picture about a person or group without regard for individual differences. Components of Communication • Tone of Voice • Body Language • Spoken Language What Makes the Impression? Spoken Language – 7% Tone of Voice – 38% Body Language – 55% Foundations of Communication • Showing Respect • Demonstrating Empathy • Being Genuine Respect • Accepting people without necessarily agreeing with them. • Genuinely valuing and supporting without patronizing. Empathy • Accurately understanding people’s feelings. • Recognizing an individual’s needs. • Showing sensitivity to the content, nature, and intent of people’s concerns. Being Genuine • Being sufficiently aware of yourself to behave in ways that are aligned with inner feelings and thoughts. • Being aware of your own limitations in interacting with others. Bridging Diversity • Learn about other cultures • Be willing to accommodate • Be open and flexible • Challenge perceptions • Practice active listening • Avoid judging • Be patient Bridging Diversity cont… • Practice effective communication skills • Look for similarities • Show respect • Understand your biases • Avoid slang • Embrace differences • See diversity as a STRENGTH! Cultural Sensitivity Test 1. List three (3) examples of diversity. 2. What is Culture? 3. What are the four (4) barriers to accepting others? Emergency Preparedness Managed by: Tim Allen Director, Environmental Services Ext 156 Why Emergency Management Began During the 1970’s there were many wildfires in California. Information released concerning the weaknesses in response time was attributed to lack of communication, unclear chain of command and conflicting codes and terminology. In response to the findings, the Incident Command System was developed. A poorly managed incident response can be devastating. The Incident Command System allows us to effectively manage our response efforts. September 11, 2001 – 911 What impact did it have on Emergency Management After the attacks on September 11, President George W. Bush issued Homeland Security Presidential Directive 5 (HSPD – 5) in February 2003. This called for a National Incident Management System (NIMS) and identified steps for improved coordination of Federal, State, local and private agencies and organizations. National Incident Management System (NIMS) In March 2004, NIMS was established by the Department of Homeland Security. One key feature of NIMS is the Incident Command System. Compliance with NIMS is a condition for any healthcare organization receiving federal assistance, including grants and contracts from such agencies as the Human Resources Services Administration (HRSA), the Agency for Healthcare Research and Quality (AHRQ) and the center for Disease Control (CDC). Hospitals are required to integrate the “Six Components of NIMS” 1. Command and Management 3. Resource Management 5. Supporting Technology 2. Preparedness 4. Communication and Information Management 6. Ongoing Management and Maintenance NIMS compliance involves a series of activities aimed at improving institutional preparedness and integration with a community-based response system. Incident Command System (ICS) ICS is part of the organization’s all-hazard emergency management program that includes mitigation (including prevention), preparedness, response and recovery activities. ICS is used to manage the response and recovery activities. ICS is: • A proven time management system based on successful business and military practices. • The result of decades of lessons learned in the organization and management of emergency incidents. ICS is designed to: • Meet the needs of incidents of any kind or size. • Allow personnel from variety of agencies and organizations to meld rapidly into a common management structure. • Provide logistical and administrative support to operational staff. • Be cost effective by avoiding duplication of efforts. ICS COMMAND AND GENERAL STAFF AGENCY EXECUTIVE LOGISTICS SECTION CHIEF INCIDENT COMMAND PUBLIC INFORMATION OFFICER LIAISON OFFICER SAFETY AND SECURITY OFFICER MED/TECH SPECIALIST PLANNING SECTION CHIEF FINANCE SECTION CHIEF OPERATIONS SECTION CHIEF Incident Commander • He/she has overall responsibility for managing the incident. • He/she should be fully briefed and have written delegation of authority. In addition to having overall responsibility for managing the incident, the IC is specifically responsible for: • He/she has the authority to assign positions, regardless of the positions/rank they hold within their respective organizations. • • • Ensuring incident safety Providing information services to internal and external stakeholders Establishing and maintaining liaison with other organizations participating in the incident. The Incident Commander has 4 Officers and 5 Section Chiefs that report to him/her. OFFICERS: LIAISON , PUBLIC INFORMATION, SAFETY/SECURITY and MED/TECH SPECIALIST SECTION CHIEFS: LOGISTICS, PLANNING, FINANCE, and OPERATIONS Additional positions are filled as needed Monroe County Hospital’s Incident Command Structure INCIDENT COMMAND SYSTEM STRUCTURE Agency Executive (CEO) Incident Commander Logistics Section Public Information Officer Liaison Officer Safety and Security Officer Med/Tech Specialist Planning Section Finance Section Situation Status Unit Leader Time Unit Leader Communications Unit Leader Labor Pool Unit Leader Procurement Unit Leader Materials Supply Unit Leader Medical Staff Unit Leader Claims Unit Leader Nutritional Supply Unit Leader Nursing Unit Leader Cost Unit Leader Facility Unit Leader Patient Tracking Officer Operations Chief Medical Care Director Medical Staff Director In-Patient Area Supervisor Surgical Services Unit Leader ICS ACTIVATION TIERS # 1 – Will be activated all emergencies Patient Information Officer Critical Care Unit Leader General Nursing Unit Leader Ancillary Services Director Laboratory Unit Leader Treatment Area Supervisor Triage Unit Leader Immediate Treatment Unit Leader Delayed Treatment Unit Leader #2 – Will be activated in most emergencies Minor Treatment Unit Leader #3 – Will be activated as needed Discharge Unit Leader Morgue Unit Leader Radiology Unit Leader Pharmacy Unit Leader Cardiopulmonary Unit Leader At Monroe County Hospital all employees are essential during an emergency or disaster So what should you do in an emergency or disaster? 1. Return to or stay in your department. 2. Notify your supervisor that you are present. Clinical staff – once you report to your supervisor – provide the necessary care to our patients. Non-clinical with a pre-assigned position – once you report to your supervisor – proceed to this location immediately. 3. Your supervisor will call the Labor Pool, usually Human Resources. Your Department Director will inform HR that you are accounted for and what skills/training you can provide or if you have a pre-assigned job. All correspondence with the Labor Pool will be done via the telephone - E – mail will not be checked at this time If electronic systems are down – runners will be utilized. 4. After the Labor Pool Unit Leader assesses the available staff, employees will be assigned to duties in other areas. 5. When the disaster or emergency situation is over or contained, return to your department. You will be notified when you can leave the premises. The Labor Pool Unit Leader only can authorize an employee to leave the premises during a disaster/emergency. If a situation arises and you feel you must leave, your Department Director will contact Human Resources for authorization. Emergency Preparedness Test 1. There are six components of NIMS? 1. True 2. False 2. We must be in compliance with NIMS to receive federal assistance and grants after a disaster or emergency? 1. True 2. False 3. NIMS compliance involves a series of activities aimed at improving institutional preparedness and integration with a community-based response system? 1. True 2. False 4. Your department director can grant permission to leave the premises during or after an emergency or disaster? 1. True 2. False Congratulations! • You have now completed the New Employee Orientation for Monroe County Hospital. • Please take your test worksheet to Human Resources to be checked. • Please sign the Employee Acknowledgment form and return to Human Resources