Transcript HIPAA Island - Columbus Community Hospital | We are an

Abbreviated Orientation for
Preceptor Students, Observers, Surgical
Shadows, Mentorship Students and Other
Selected Personnel
There are instances when visitors to CCH need a
cursory understanding of some of our legal and
safety policies and procedures. Instances of this
include:
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Preceptor Students
Observers
Students shadowing in Surgery
Mentorship/Intern students
This training and the accompanying forms are
intended to give you this understanding.
The following slides will provide
information:
Compliance
 HIPAA
 Hand Hygiene
 General Safety
 Patient Safety Goals
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After exiting this presentation you will need
to access, print & complete the following
forms:
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Student/Observer Information Sheet
CCH Orientation Competency
Hand Hygiene/Safety Certification
The completed forms should be returned to:
Reye Snitily
Education Coordinator
Columbus Community Hospital
PO Box 1800
Columbus, NE 68602-1800
Compliance Program
“It Just Makes Good
Sense!”
Columbus Community Hospital, Inc. (CCH) believes
in maintaining a high level of professional and
ethical standards in the conduct of its business.
We work hard to foster ethical conduct and to
provide guidance to each employee for his/her
conduct.
CCH wants to provide a tool for all employees to use
in striving to comply with legal and regulatory
requirements, and to seek to prevent and detect
unlawful and unethical conduct.
An effective Compliance Program is just such a tool,
which is reasonably capable of reducing the
prospect of unlawful conduct and unethical
business practices
What is the CCH
Compliance Program?
The CCH Compliance Program is a comprehensive
process created to ensure that CCH and its
employees consistently comply with applicable
laws relating to business activities.
Many industries have used formal compliance
programs for several years -- banking, insurance
and the defense industry, to name a few.
It is a process and not a document or a bundle of
policies and procedures.
It has the commitment of the CCH Board of
Directors, management and all employees to make
it work
Why does CCH need a
Compliance Program?
CCH has established a Compliance Program because it makes
good business sense, and because it is “the right thing to
do.”
The complexity of participating in a variety of government and private
programs has imposed an extraordinary burden on CCH, and the
potential for error is significant.
CCH is committed to following appropriate requirements.
The ultimate goal of the CCH Compliance Program is to help employees,
managers, and governing body simply do a better job, as well as to
identify and prevent improper conduct.
CCH employees should aggressively attempt to deter, detect, and correct
improper conduct by other employees or managers.
What are the benefits of the
CCH Compliance Program?
Having a Compliance Program at CCH benefits us in many
ways. Among the benefits are to:
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Demonstrate to employees and to the community our
commitment to being an honest, ethical and responsible
provider;
Identify and prevent criminal and unethical conduct;
Improve the quality of patient care;
Create a centralized source for distributing information on health
care statutes and regulations;
Develop a methodology that encourages employees to report
potential problems;
Develop procedures that allow the prompt, thorough
investigation of alleged misconduct; and,
Initiate immediate and appropriate corrective action as
necessary.
What do I need to do if I
suspect improper conduct?
CCH expects employees to act in an honest, ethical and
responsible manner. But should a dilemma arise, we have
developed a process to help guide you if you are ever in
doubt about the proper conduct in a given situation
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Step 1
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Use existing CCH policies and
procedures within your
department to resolve the
problem yourself, or contact
your immediate supervisor.
Step 2
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If you are not satisfied with
your supervisor’s response,
contact your department head.
If your immediate supervisor is
a department head, then
contact the Senior Manager
that your department head
reports to.
Step 3
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If you are not satisfied with the results of Steps 1 or
2, or if you are not comfortable addressing your
concerns through those channels, contact the CCH
Compliance Officer though a written memo, a
telephone call, or in person. The Compliance Officer
is the Director of Quality Improvement, Penny
Barels, who can be reached by calling 562-3345.
Memos can be sent through interoffice mail to the
Quality Improvement Director.
Step 4
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If you are not comfortable addressing your concerns
through the above channels, you can report your
concern anonymously through the Compliance
Suggestion Box. The Compliance Suggestion Box is
found by the employee information bulletin board
outside the cafeteria.
What happens after I identify my
concern through the Compliance
Suggestion Box?
Once you have followed Steps 1, 2 and 3 of the
aforementioned process, drop your concern in the
Compliance Suggestion Box.
The Compliance Officer will retrieve the information
and will address the concern(s) identified.
The Compliance Officer will conduct an investigation
if one is warranted, will compile a report, and
when appropriate, ensure corrective action is
taken.
The status of the investigation will be provided to
you by the Compliance Officer, if you choose to
identify yourself.
Do I have to give my name?
NoYou may report suspected violations
through the Compliance Suggestion Box
without disclosing your identity, if you
choose.
You must give your name however, if you
wish to be contacted by the Compliance
Officer regarding the status of your
report.
Will I suffer any retaliation for
making a report?
No employee will be subject to retaliation
in any form for reporting a possible noncompliance issue, pursuant to hospital
policy.
Persons reporting compliance issues will
be protected up to the limits of the law
and to the extent reasonably possible.
What kind of behavior should I
report?
You should report any instance in which you are aware of behavior
that you suspect is illegal or which violates the CCH Compliance
Program or any CCH policy and procedure. Some specific issues
that are of special concern to CCH are:
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Patient Rights and care issues;
Privacy rights and employee and
patient records;
Health, safety and environmental
issues;
Medicare/Medicaid fraud and
abuse;
Harassment/Discrimination issues;
Substance abuse;
Bribes and kickbacks;
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Theft and fraud;
Antitrust law violations;
Proper accounting and record
keeping;
Billing;
Potential criminal violations;
Confidentiality of hospital
information; and,
Other violations of hospital
policy.
How would I respond to a
government investigation?
Any CCH employee receiving a subpoena,
inquiry or other legal document in regard
to CCH business, should immediately notify
their supervisor and hand carry the
document to the CCH Compliance Officer
(or in the Compliance Officer’s absence,
the hospital President/CEO, or a member of
Senior Management).
The Compliance Officer will assist you in
following the proper procedures for
cooperating with the investigation.
HIPAA
Health Insurance Portability and
Accountability Act of 1996.
Intended to:
 “improve the efficiency and effectiveness of
health information systems, establish
standards and requirements for electronic
transmission of health information and
protect the confidentiality, integrity and
availability of individual health information”
 affects many different entities such as
physician offices, hospitals, health plans &
health care clearinghouses
PRIVACY
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Privacy is the individual’s right to
control access and disclosure of his or
her protected health care information.
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Protected Health Information is
considered paper, electronic & oral.
PRIVACY NOTICE
Must be provided to all Patients
regarding the use & disclosure of all
individually identifiable patient health
information.
 Must be made available prior to or at
the time of treatment.
 Must be posted in a clear &
prominent location within the hospital
facility service areas.
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CONTENT OF NOTICE
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Must contain description of
uses & disclosure that a
hospital will make for
treatment, payment & health
care operations.
Descriptions of other uses &
disclosures that a hospital is
allowed to make without a
patient’s explicit authorization.
Statement that other uses &
disclosure will be made only
with patient’s written
authorization & that such
authorization can be revoked
at any time.
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Patient may complain to the
hospital and to the HHS
Secretary if they believe their
privacy rights have been
violated
Notice must contain
description of how to file such
a complaint with hospital
That the patient will not be
retaliated against for filing
such a complaint
Name or title & telephone
number of a person to contact
for further information
Effective dates of the notice
PATIENT RIGHTS
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The right to confidential
communication
The right to see medical record
The right to obtain a copy of the
record
The right to amend medical record
The right to know who has had access
to their records (which requires the hospital to
keep an accounting of all disclosures)
HOSPITAL DIRECTORY
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Upon Admission, Patient will be asked if they wish
to be part of Hospital Directory. If so the hospital:
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May disclose patient’s location in the hospital if asked for
by name
May disclose general condition to any person who asks
about the individual by name
May disclose the patient’s name, location, general
condition and religious affiliation to members of the
clergy
If the patient chooses not to be part of the
Hospital Directory, the arm band on the
patient will be marked with a YELLOW
sticker.
TREATMENT, PAYMENTS &
HEALTH CARE OPERATIONS
CCH may disclose PHI for treatment, payment & health care
operations.
Treatment:
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Furnishing
preventative,
diagnostic,
therapeutic,
rehabilitative
maintenance
or palliative
care.
Payment:
Preparing
or
submitting claims, Health Care
obtaining
Operations:
certification of
 Quality assessment
enrollment or
coverage,
activities, utilization
obtaining
review, peer review
precertification for
activities, conducting
treatment,
audit functions, medical
pursuing collection
through an
reviews and business
attorney or
planning.
collection agency,
etc.
REQUIRED DISCLOSURES ALLOWED
WITHOUT PRIOR AUTHORIZATION
We are still required to disclose health information in
certain situations without an authorization:
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State Tumor Registry
Birth Certificates
Congenital anomalies
Public Health Activities
Victims of Abuse, Neglect or Domestic Violence
Health Oversight Activities
Judicial & Administrative Proceedings
Law Enforcement Purposes
To Avert a Serious threat to Health or Safety
About decedents to coroners, medical examiners &
funeral directors
Cadaveric organ, eye or tissue donation
MINIMUM NECESSARY
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Hospital must implement reasonable
procedures to ensure that only the
minimum protected health information
is used, disclosed or requested when
conducting necessary payment
activities and health care operations.
We have looked at all of our internal
and external users and identified all
PHI needed for each person to perform
their job function and what access they
may have.
Physicians, nurses and all ancillary
services are permitted unrestricted
access to protected health information
for the purpose of providing
patient care. This unrestricted
access is only for the time the patient
is being treated.
All other requests for access must be
through the Medical Records
Department.
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Limited access, with supervision, will
be given to departments like
admissions, billing, accounts payable,
dietary clerks and SPD for billing of
implants.
Unrestricted access, based on official
inquiry, will be granted to Risk
Management, QI, CEO & Vice
Presidents.
UR will have unrestricted access up to
48 hours after discharge.
Requests for “any and all records” will
not be honored. The requesting party
will be contacted to determine the
specific information needed. Routine or
recurring disclosures are limited to
information necessary.
ADMINISTRATIVE REQUIREMENTS
The hospital and medical staff has developed an
Organized Health Care Arrangement (OCHA) under
which we can carry out health care operations such
as quality improvement review, utilization review, etc
without a Business Associate Contract.
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Designated a Privacy & Security Officer
Designated a contact person or office to receive complaints
Provided training for all employees who handle PHI
Provided training to each new member of the workforce within
a reasonable period of time after start date
Documented that the training has been provided
Ensured that appropriate administrative, technical and physical
safeguards must be in place to protect the privacy of PHI.
Provided a process for individuals to make complaints
concerning the hospital policies and procedures
Documented all complaints received and their disposition
SANCTIONS & REPORTING OF
INVESTIGATIONS
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Employees who violate CCH’s
HIPAA Compliance Plan are
subject to discipline
administered according to
policies adopted by the
Personnel Department. The
following are considered
serious offenses under the
HIPAA Plan and may result in
immediate discipline, up to
and including termination:
 Sharing a password or
identity with another person
or obtaining information
under false pretenses.
 Accessing or disclosing
protected health information
contrary to CCH’S policies, for
personal gain or for other
personal benefit or motive.
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Disclosing protected health
information when the
workforce member knew or
should have known that he or
she had no authority to do so.
Failure to make a mandatory
report.
Retaliating against a patient
because the patient or
someone on the patient’s
behalf has filed a complaint
with DHHS
Retaliating against a member
of the workforce who has
made a mandatory or
permissive report.
Failure to complete and
document required training.
Penalties
for person who knowingly and in violation of the
law obtains or discloses individually identifiable
health information:
Civil Penalties
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$100 per violation, up to $25,000
per year for all violations of
identical requirement.
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No Civil Penalty if:
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Punishable under criminal
provision
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Person did not know or by
exercising reasonable diligence
would not have known, that he or
she violated the provision
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Failure due to reasonable cause
not result of willful neglect and
corrected within 30 days
Criminal Penalties
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Fine $50,000 and one year prison
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If offense committed under false
pretenses, fine $100,000 and five
years in prison
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If offense committed with intent
to sell, transfer or use individually
identifiable health information for
commercial advantage, personal
gain, or malicious harm, fine
$250,000 and ten years in prison
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Enforcement will be carried
out by the Office of Civil
Rights, DHHS.
REPORTING AND INTERNAL
INVESTIGATIONS
Members of the workforce with first hand knowledge of the
facts are required to report their knowledge or belief that:
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There has been a violation of HIPAA or a breach of CCH’s
HIPAA Compliance Plan.
There has been an improper use or disclosure of protected
health information.
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There will be a locked box available by the employee entrance, that
concerns may be placed in, if you do not want to report directly to
the Privacy Officer.
It would be helpful to know who is reporting the concern to help in
any investigation that may need to be carried out, but it can be
anonymous.
No promises will be made by the Privacy Officer, to the workforce
member making the report, as to what steps may be taken in
response to the report.
Any member of the workforce making a report shall be
protected from retaliatory action.
CODE WHITE
This is a verbal code to be used
when an employee observes
that an inappropriate
discussion is going on in the
hallways, cafeteria, etc.
Hand Hygiene
Hand Hygiene Program
Essentials
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Handwashing is essential when hands are visibly
soiled
Alcohol based hand rubs are effective for routine
decontamination
Do not wear artificial fingernails in high risk areas
(ICU and Surgery)
Keep natural nail tips less than ¼ inch long
Wear gloves when in contact with potentially
infectious material
Be alert for educational Hand Hygiene updates
General Safety
We at CCH believe that Safety is the
responsibility of each and every employee,
student & volunteer
The level to which you participate in our
Safety Plan determines how safe we are!
If you have Safety questions or concerns,
please contact – Sara Hough, Risk
Manager, 402-562-3361
Remember – you are the eyes & ears of
the hospital!
Hospital Safety Codes
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CODE BLUE - Patient in arrest
STANDBY CODE BLUE – Ambulance en route with patient
in arrest
CODE BLUE BROSLOW – Pediatric arrest
SECURITY TO …. STAT – violent or abusive person in
reported area
DR. LOUISIANA – A life is being threatened with a
weapon, all move to a “safe” area
PLAN 100 – Employee Recall
DR SEARCH – Missing patient
CODE PINK – Baby missing or abducted
DR. WATCH – Weather conditions favorable for a tornado
TORNADO WARNING – Tornado sighted in Platte County
Paging
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To Page – pick up any phone
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dial 699 *2
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speak into receiver
To call Police
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Dial 911
What is the code
announcement for Fire
Drills?
FIRE SAFETY
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In the event of a fire “Dr Red …” and an area will be
announced three times on the overhead paging system.
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During Dr. Red, all employees should be available in their
work area. One person from each area should be
designated to report (with fire extinguisher if available) to
fire area to provide assistance.
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All doors and windows should be closed and remain closed
until the all clear is given.
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Use stairways and NOT ELEVATORS.
Only go through fire doors if it seems safe to do so.
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Please remember:
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It takes less than a minute to empty most
fire extinguishers
You should only attempt to put out small
fires if you have been properly trained and
have a clear escape route
You should know the location of all Oxygen
shut off values. Nurses will be responsible
for turning off the valves in patient care
areas.
Always leave yourself a way out! Keep
your back to a safe exit.
Remember RACE and PASS
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R – Rescue people in
immediate danger
A – Activate alarm –
pull nearest fire alarm.
Alarms are located by
each exit.
C – Confine the fire –
Close all doors and
windows
E – Extinguish the fire
or escape
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P – Pull fire
extinguisher pin
A – Aim at the base of
the fire.
S – Squeeze the
handle
S – Sweep the hose
from side to side
Levels of Evacuation:
 Out
of the immediate area
 Horizontally
 Vertically
– beyond fire doors
– floors below fire
RADIATION SAFETY
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This is the internationally recognized warning
symbol for radiation. Signs with black or magenta
printing on a yellow background will be posted in
areas where radiation is used or stored.
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Packages containing radioactive materials will also
have labels with this symbol.
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When you see this symbol:
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Do not enter the designated room unless you have
been trained to do so.
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Do not handle a package with this symbol unless you
have been trained in how to handle radioactive
materials
Tornado Safety
DR WATCH
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Announced on overhead page three times when weather conditions
are favorable for a tornado. Start preparations for evacuation,
remember where safe areas are. CCH South and Medical Office
Building will be notified of Dr. Watch. Once notified of Dr. Watch,
personnel shall turn on radio and listen for updated weather
conditions.
TORNADO WARNING
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Announced on overhead page three times when a tornado is
sighted in the Columbus vicinity. Staff shall immediately move
patients and visitors to safe area, close all doors to patient rooms
and offices and take cover. If “sheltering in place” is required,
patients shall be given a blanket and pillow. Hospital personnel will
remain with patients until all clear is given.
Available staff should report to patient care areas to assist with
evacuation.
Disaster Plan
When notice of an event is received. The House supervisor/ER
charge nurse will confer with the Pres/VP. A decision may
be made to implement the Hospital Emergency Incident
Command System.
Need for Additional Employees
 Every department has a Plan 100 call list to use when
additional staff are needed.
 Employees must be familiar with the location of their Re- Call
List.
 After receiving a call, employees must call the next person or
continue to call down the list until they contact someone.
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Report to the North Employee Entrance with their picture ID
name badge as soon as possible.
Disaster Plan
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The Plan establishes specific areas
for:
Disaster Headquarters
 Personnel Pool
 Entrances
 Triage Areas
 Treatment Rooms
 Family Waiting Area
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BOMB THREAT
Procedure for Phone Call Warning:
 Document current time
 Keep caller on the phone as long as possible
 Have co-worker call CEO/Designee immediately
from another phone
 Listen for and note any identifying background
noises
 Document any special voice characteristics
 Ask and note location of bomb and what time it
will go off
 Document if caller indicates knowledge of the
hospital by description of location
BOMB THREAT
Once notified of a Bomb Threat:
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Unit Director
Hospital Administration
Columbus Police Department
will be notified and appropriate action taken.
If suspicious items are noted,
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DO NOT TOUCH THEM, notify Administration and clear the
area.
Bomb experts will be on their way to assist with the situation.
Security or Plant Operations personnel will secure all
entrances and restrict entry to only those employees
presenting appropriate disaster identification.
All Department Heads will report to Administration for
information and instructions.
Electrical & Utility Safety
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In the event of loss of any utility such as phones, elevator or
electricity, dial the operator. The operator will page the on-call
plant operations personnel. In the event of electrical failure, all
equipment plugged into a red outlet will be supplied power from
our Emergency Generators.
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ALL ELECTRICAL EQUIPMENT is to be checked and tagged by
Plant Operations. (Send Form MA-1 New Equipment Check In Form
to Plant Operations.)
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Patient owned electrical devices must also be checked by Plant
Operations prior to use. Unacceptable patient equipment should
be given to a family member to take home.
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Employee owned electrical equipment (coffeepots, cup warmers,
radios, etc.) must also be checked by Plant Operations prior to
use
Electrical & Utility Safety
TO AVOID BURNS, SHOCKS AND FIRES
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Do Keep floors and other patient areas dry
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Do Check power cords and plugs for damage
BEFORE plugging them in.
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Don’t use any equipment that sparks or smells.
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Don’t roll equipment over power cords
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Don’t use any clinical equipment that has an
expired or missing BIOMED Inspection Sticker
Hazardous Materials
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HazCom, (OSHA’S Hazard Communication
Standard) requires employers to provide
information, training and equipment to employees
to ensure on the job safety. Employees are
required to use this information to remain healthy
and work safely.
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Chemical manufacturers have determined the
physical and health hazards associated with each
product they make. They label products with this
information and supply Material Safety Data
Sheets (MSDS).
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MSDS information is accessed “on-line” by your
department director.
In Case of Chemical Exposure or
Accident:
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Follow appropriate first aid procedure for type of
exposure:
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Splash - Flush eyes with water for 15 minutes. Know
where the eye flushing stations closest to you are at.
Burn - Remove contaminated clothing immediately,
wash exposed skin for at least 15 minutes. Follow-up
with immediate treatment in the Emergency Room.
Inhalation- move to fresh air immediately
Notify a Supervisor ASAP. Contact Occupational
Health during business hrs or ER for “on call“ Occ
Health staff
Hazardous Material Spills
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Clear area where spill is located.
Locate MSDS for spill.
Spill Kits are located:
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Omnicel
ACU – west Omnicel
ER
Dirty Utility Room
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ACU
SNU
OB
All Housekeeping Carts
Pharmacy
Proper Disposal of Hazardous
Waste – Red Bags
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All items that are blood soaked
Amniotic Fluid
Fluid that surrounds the brain, spine, heart and joints
Fluids in the chest and abdomen
Vaginal secretions
Any other fluids that may contain blood but blood is not
visible
Hemovac drains and suction canisters
Blood bags and tubing
Hemodialysis tubing
Soiled and/or bloody dressings
Bloody syringes without the needle
Chest tubes
Isolation bagging out
Proper Disposal of Regular
Waste
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All items that do not contain blood
Boxes
Wet diapers
Plastic medication bottles
Dirty Kleenex
Used papers
Foley bags
Food containers
Wrappers
IV bags and tubing
What would you dial if you needed
immediate assistance?
Security
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All employees are required to wear their picture ID
and name badge for identification purposes. This
is a key element in maintaining security within the
buildings and on campus grounds.
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A Security Service provides surveillance of the
hospital and grounds during their scheduled hours
6:00 pm to 6:00 am M - F and 24 hrs on
weekends. To contact the guard call #333
Security Sensitive Areas:
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Closed circuit cameras are operating
24hr/day in the following areas:
ER,
 Front lobby,
 South corridor,
 Dock,
 OB,
 Pharmacy
 South site.
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“Security To ….STAT”
(699*2)
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Use the overhead paging system
when you need immediate assistance
for a combative or abusive patient,
visitor or staff member. Employees
from specific areas will respond to
assist and support.
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Dial 911 if you feel the situation is
dangerous and police intervention is
necessary.
Patient Safety Goals
Thank You!
We hope your experience with CCH is a Safe and
productive experience!
After exiting this presentation please remember to
access, print & complete the following forms:
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Student/Observer Information Sheet
CCH Orientation Competency
Hand Hygiene/Safety Certification
The completed forms should be returned to:
Reye Snitily
Education Coordinator
Columbus Community Hospital
PO Box 1800
Columbus, NE 68602-1800