Transcript Slide 1

Welcome to the 2014
Catholic Health System
Online Orientation Component
This material must be reviewed prior to attending
your General Orientation class.
Please ask any related questions at your General Orientation class.
1
Leonardo
Sette‐Camara, Esq
Compliance &
Privacy Officer
2
To prevent, find and correct violations of CHS
standards, governmental laws, regulations and
rules
To promote honest, ethical behavior in the
day-to-day operations
To understand the ethical, professional, and
legal obligations associates have and our role
in meeting those obligations
3
As healthcare professionals and providers,
we are dedicated to caring for and
improving the health and well being
of the people we serve in the community
Compliance means
“doing the right thing”
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Attain compliance by:
Embracing our Mission and Values
Adherence to Policies and Procedures
Found in Compliance 360
Maintaining high standards of business and
ethical conduct
Delivering high quality patient care
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Standards of Conduct & Ethical Conduct
Deal openly and honestly with others
Maintain high standards of conduct in
accordance to the CHS Mission,
directives of the Catholic Church, and applicable
federal, state and local laws and regulations
Conflict of Interest
We have a responsibility to act on the best
interests of Catholic Health. We need to avoid
situations that lead to actual or perceived conflicts
of interest
Documentation and Billing
Must be accurate and complete
6
Associate Compliance Guidebook
Provides information on the Standards of
Conduct and is available on CHS website.
An observation of failure to follow Standards
of Conduct, Policies or Procedures, or
observation of an error requires reporting.
Associates can face disciplinary action and
even termination for failure to report such
events.
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All associates are expected to follow standards for
Legal and Regulatory Compliance
Business Ethics
Conflict of Interest
Appropriate Use of Resources
Confidentiality
Professional Conduct
Responsibility
And follow the Code of Ethics
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Enhance the Patient Experience
Have a questioning attitude
Pay attention to details
Follow the rules
Be accountable for your actions
Providing high quality services
and upholding patient rights
supports the Compliance Program.
9
Compliance policies and procedures are available
on
Compliance 360 (or in an on-site reference
manual)
and apply to all CHS associates.
Additional compliance policies are also applicable
to:
Home Care
Clinical Laboratory
Physician Practices
Nursing Facilities
Coding and Billing
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It is fraudulent to either document services that were
not performed or to submit claims for services without
appropriately documenting those services
Missing clinical notes (dates, signatures, orders,
care or service rendered) or test results
Incomplete or illegible documents
Improper billing and coding
can be interpreted as fraud or abuse and lead to a
false claim with the government resulting in
penalties
Reimbursement can only be sought for services or items
that have been provided and appropriately documented.
If it’s not documented, it’s not done.
11
It is a crime to knowingly make a false record, file,
or
submit a false claim with the government for
payment.
A false claim can include billing for service that:
Was not provided or documented
Was not ordered by a physician
Was of substandard quality
Improperly
coded
or billed retain overpayments.
It is
also unlawful
to improperly
Allows for Qui Tam Relator – notification to
government with protection (Whistleblower provision)
12
Government Sanctions
Individuals or entities can be excluded from
participation in Medicare and Medicaid
programs.
CHS must not submit any claims to Medicare
and/or Medicaid in which a sanctioned
individual or entity provided care or services.
If an associate/provider is sanctioned,
he/she must provide notification immediately
to the Compliance Officer.
13
If working on behalf of CHS, do your actions or
activities
result in personal gain or advantage, potential adverse
effect for CHS or the potential to interfere with
professional
judgment, objectivity or ethical responsibilities?
Potential Conflicts of Interest Relationships include
financial relationship for yourself or your immediate
family
member or secondary employment
Consultant
Speakers’ Bureau
Advisory Panel
Administrative positions with Pharm or DME
Third Party Payor
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Associates may NOT accept any cash gifts or
cash equivalent gifts (gift cards) from any
person or business conducting or seeking to
conduct business with CHS
Prior to receiving work-related
Gifts
Social or entertainment events
Free meals
Associates must consult with their supervisor.
See CHS Policy for further information.
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Ensures that limited English proficiency or
hearing impaired persons utilizing CHS
services are able to understand and
communicate with CHS associates and
physicians
Provided FREE of charge to the patient
Mandatory service by law
Documentation is vital to compliance
Language Assistance Program Policy is found in
Compliance 360
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HEALTH
INSURANCE
PORTABILITY
ACCOUTABILITY
ACT
and HITECH
Health/Information Technology for Economic
and Clinical Health Act
Privacy and Security Policies are found in
Compliance 360
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Individually identifiable health
information
Also known as
Protected Health Information (PHI)
Transmitted or maintained in
any form or medium
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Names
Full face photos
Medical Record Number
Health Plan Number
Account Numbers
Certificate/License
Numbers
Vehicle Identifiers
E-mail and web
addresses
Biometric Identifiers
Geographic subdivisions
smaller than a state
All elements of dates
related to birth date,
admission, discharge, or
date of death, ages over 89
Telephone and fax
numbers
Social Security Number
Any other unique identifying data
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Only for:
Treatment, Payment or
Health Care Operations
Access or Disclose
minimum necessary
related to your job function and
those of the other person’s job function
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Be aware of surroundings
Be conscious of who is in the immediate area when
discussing sensitive patient information or at your
computer terminal (lower your voice)
Secure area when not attended
Close out of computer screens containing PHI before
leaving the area
Close medical records/chart when not in use
Do not allow other associates to utilize your ID and
password
Report theft or loss of computer devices immediately
Correct Disposal of PHI (shred bin)
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Telephones
Be careful with phone call pertaining to patient
information
Fax Machines and Scanners
Pick up faxed or printed PHI immediately
Use fax cover sheet, verify # and receipt
Scan PHI only to CHS e-mail accounts
E-Mail
Make sure to encrypt if being sent outside CHS
Careful forwarding and replying
Mail
Double check name/address and material prior to
sending
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Curiosity can be a normal human trait …
However accessing health information on yourself,
family members, friends, co-workers, persons of
public interest or any others that you are not involved
in the care of or
Disclosing PHI inappropriately
Are … VIOLATIONS of HIPAA
Individuals do NOT have the right to
look up their own health records.
Your computer use can be monitored.
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Fraud and Abuse
Fraud Defined: An intentional deception or
misrepresentation that could result in some
unauthorized benefit to a person or Catholic
Health
Abuse Defined: Practices that are inconsistent
with sound fiscal, business, or medical practices,
and result in unnecessary cost, or in
reimbursement of services that are not medically
necessary or that fail to meet professionally
recognized standards for health care
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Documentation issues
Improper billing and coding
Offering or receiving kickbacks, bribes, or rebates
The service has not been rendered by the
identified provider, to the identified person, or on
the identified date
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Lack of integrity
Ethical incidents
Theft or misuse of services
Improper political activity
Breech of corporate confidentiality
Improper use of proprietary information
Environmental health and safety issues
Dishonest communication (spoken or documents)
Improper business arrangements
Failure to follow Record Retention policy
Receipt of incentives for patient referrals
The Associate Guidebook or your supervisor can provide additional info.
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Immediate supervisor or appropriate department
Higher level manager
Compliance Officer
Nancy Sheehan, Esq.
821-4469
Also available 24/7
Compliance Line 1-888-200-5380
Confidential and Anonymous (if desired)
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Behavior issues
Human Resource policy violations
Union contract matters
… Should be reported to Human Resources
Policies on Compliance 360 include:
Corrective Action
Fair Treatment Review
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Protects associates from adverse action when
they do the right thing and report a genuine
concern
Reckless or intentional false accusations by CHS
associates are prohibited
Reporting the possible violation does not protect
the constituent from the consequences of their
own violation or misconduct
Associates have a duty to report
HIPAA/Compliance concerns
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Upholding CHS Mission and Values
Adhering to Code of Conduct, Policies and
Procedures and the Law
Completing education and employment
requirements
Constant monitoring for concerns
Duty to report concerns and support non-retaliation
During an investigation
Be truthful
Preserve documentation or records relevant to ongoing
investigations
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For associate and CHS
managers/supervisors/administrators
Fines and Prison sentences
Corrective action - Includes termination of
employment for violations or failure to report
concerns
For Catholic Health System
Exclusion from government funded insurance
programs (Medicare/Medicaid)
Fines
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Putting words into action …
“We judge ourselves based on our intentions …
Others judge us based on our actions.”
Adhere to the CHS code of conduct,
policies and procedures, and other standards
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Duty to report Compliance/HIPAA concerns as
soon as aware of situation
Do the right thing …
Apply ethical decision making
If uncertain …
Always Seek Knowledge (A.S.K.)
Use Associate Booklet on CHS website
as a reference
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Compliance/HIPAA Privacy Officer
Leonardo Sette – Camara 821-4469
CHS HIPAA Hotline
862-1790
Compliance Hotline
1-888-200-5380 (available 24/7)
All reports are confidential.
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Risk Management is the
systematic review of events
that present a potential for
harm and could result in
loss for the system.
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Review Identification
Review Occurrence Reports
Review Patient/Visitor Complaints
Participate in Root Cause Analysis
Review concerns expressed by CHS staff
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Loss Prevention
Educational programs through CHS University
Department specific in-services
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Claims Management
Investigating and reporting occurrences and
claims made to insurance carriers
Assist with discovery requests for lawsuits
Process Summons, Complaints and Subpoenas
** NOTIFY RISK MANAGEMENT
IMMEDIATELY UPON RECEIPT
OF A WORK RELATED
SUMMONS OR SUBPOENA
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Claims Management - Continued
Within CHS, a process server is to be
directed to Administration of the facility
in order to serve a Summons or Subpoena.
(HIM may accept subpoenas for hospital records.)
*** INDIVIDUAL DEPARTMENTS
SHOULD NOT ACCEPT, EVEN IF IT IS
FOR SOMEONE IN THE DEPARTMENT.
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Risk Financing
Obtaining and maintaining appropriate
insurance coverage:
HPL (Healthcare Professional Liability)
GL (General Liability)
D&O (Directors and Officers)
Property and Casualty
Auto
Crime
Fiduciary (Finance)
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An occurrence is an event that
was unplanned, unexpected and
unrelated to the natural course of
a patient’s disease process or
routine care and treatment.
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Patient harm/potential harm like falls, medication
errors
Visitor injury
Patient related equipment “failure”
Security issues like elopement, crime, altercations
Lost or damaged property
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Enhance the quality of patient care
Assist in providing a safe environment
Quick notice of potential liability
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Any associate or physician who discovers,
witnesses or to whom an occurrence is reported,
is responsible for documenting the event
immediately by means of the
Occurrence Report.
Anyone who requires assistance should contact
the department manager.
DO NOT MAKE COPIES OF AN
OCCURRENCE REPORT.
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The completed Occurrence Report
is to be forwarded to
the Department Manager
who will investigate the occurrence
and forward to Quality & Patient
Safety Department who will
forward to Risk Management.
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Patient and visitor safety are assessed from
both clinical and environmental perspectives
Notify Quality & Patient Safety of patient
occurrences
Notify Security of visitor or property occurrences
Risk Management will be notified and will
participate in evaluation of occurrence
Risk Management will report occurrences to
insurance carrier in cases of potential liability
Risk Management will manage claim as indicated
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Date (MM/DD/YY) and time (military)
State facts, be clear and concise
Your own observations
If event described to writer, use quotes or
“according to …”
Do not place blame in the record
DO NOT REFER TO OCCURRENCE REPORT IN
THE MEDICAL RECORD
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EMTALA is the Emergency Medical Treatment and
Active Labor Act (aka COBRA)
EMTALA provides a
guideline for safely and
appropriately
transferring patients in
accordance with
Federal regulations.
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The law provides for a medical screening exam (MSE) to all
individuals seeking emergency services on hospital property.
Hospital property includes the driveway, parking lot, lobby,
waiting rooms and areas within 250 yards of the facility.
If an emergency medical condition is found, it will be
stabilized within the hospital’s ability to do so, prior to the
patient’s transfer or discharge.
If a patient does not have an emergency medical condition,
EMTALA does not apply.
*** IMPORTANT: NEVER SUGGEST THAT
A PATIENT GO ELSEWHERE FOR TREATMENT
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Fair and Accurate Credit
Transactions Act of 2003
or
“RED Flag Rules”
Hospitals that maintain covered accounts
must develop and implement written
policies and procedures to identify, detect,
prevent, and mitigate identity theft.
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Alerts, notifications, warnings
Presentation of suspicious information
Suspicious activity
Notice from patient, law enforcement, etc.
** Patient Access, Health Information,
Finance, I.T. departments primarily involved.
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You can help reduce opportunities
for Identity Theft by keeping
PHI confidential and out of public view.
If you believe someone is presenting
suspicious documents or acting in a
suspicious manner, notify your supervisor
who will notify Risk Management.
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Carol Ahrens, RN, BSN
Director, Risk Management
821-4462
Joanne Ricotta, RN, BSN
Risk Management Coordinator
821-4463
Linda McGavin
821-4467
Risk Management Technical Assistant
Amy Maurer
821-4468
Legal Services Administrative Assistant
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Violence can have a negative effect on an
organization as reflected by:
Low morale
Increased job stress
Increased worker turnover
Reduced trust of management or co-workers
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Contact with violent people or those with history of
violence
Contact with those under the influence of drugs
and/or alcohol
Contact with people having psychotic diagnoses
Contact while transporting patients
Contact with people perceiving a long wait for
service
Working alone
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Watch for signals of impending violence:
Verbally expressed anger and frustration
Body Language such as threatening gestures
Signs of drug or alcohol use
Presence of weapons
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Assess current demeanor when you enter a room
or begin to relate to a patient or visitor
Be vigilant throughout the encounter
Don’t isolate yourself with a potentially violent
person
Keep an open path for exiting
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NIOSH (National Institute for Occupational Safety
and Health) defines workplace violence as violent
acts (including physical assaults and threats of
assaults) directed toward persons at work or on
duty.
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Threats:
Expressions of intent to cause harm, including
verbal threats, threatening body language, and
written threats.
Physical Assaults:
Attacks ranging from slapping and beating to rape,
homicide, and use of weapons such as firearms,
bombs, or knives.
Muggings:
Aggravated assaults, usually conducted by
surprise and with intent to rob.
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Workplace violence in hospitals usually results
from patients and occasionally from family
members who feel frustrated, vulnerable,
and out of control.
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Violence takes place
During times of high activity such as meal time
or visiting hours or patient transportation
When service is denied
When a patient is involuntarily admitted
When limits are set regarding eating, drinking,
tobacco use or alcohol use
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Hospital personnel having direct contact with
patients and families are at increase risk.
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An elderly patient verbally abused a nurse and
pulled her hair when she prevented him from
leaving the hospital to go home in the middle of
the night.
An agitated psychotic patient attacked a nurse,
broke her arm, and scratched and bruised her.
A disturbed family member whose father had died
in surgery walked into the E.D. and fired a
handgun, killing a nurse and an EMT and
wounding a physician.
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Anywhere in the hospital, but it is most frequent in
the following areas:
Emergency Departments
Any Critical Care area
Waiting Rooms
Geriatric Units
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Violence can have a negative effect on an
organization as reflected by:
Low morale
Increased job stress
Increased worker turnover
Reduced trust of management or co-workers
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Contact with violent people or those with history of
violence
Contact with those under the influence of drugs
and/or alcohol
Contact with people having psychotic diagnoses
Contact while transporting patients
Contact with people perceiving a long wait for
service
Working alone
68
Watch for signals of impending violence:
Verbally expressed anger and frustration
Body Language such as threatening gestures
Signs of drug or alcohol use
Presence of weapons
69
Assess current demeanor when you enter a room
or begin to relate to a patient or visitor
Be vigilant throughout the encounter
Don’t isolate yourself with a potentially violent
person
Keep an open path for exiting
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Present a calm, caring attitude
Don’t match the threats
Avoid giving commands
Acknowledge a person’s feelings
Avoid behavior that may be interpreted as
aggressive
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Remove yourself from the situation
Call Security or 911 for HELP if needed
Report any potential or actual violent incidents to
your department manager
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No universal strategy exists to prevent violence
All hospital workers should be alert and cautious
when interacting with patients and visitors
Staff need to be aware of polices and procedures
relating to violence prevention
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Obesity: Understanding, Awareness,
and Sensitivity
Catholic Health
Orientation
2013
74
Consequences of Obesity
Psychological and Social Well-Being
Negative Self-Image
Discrimination
Can be difficult to maintain personal hygiene
Depression
Turnstiles, cars, and sitting may be too small
Diminished sexual activity
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Social Discrimination
Studies show society has a low respect for
morbidly obese
May have limited number of friends
May experience social rejection
Have poor quality in relationships
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Weight Bias in Healthcare
What assumptions do I make based only on
weight regarding a person’s character,
intelligence, professional success, health
status, or lifestyle behaviors
Could my assumptions impact my ability to
care for these patients?
Do I only look at their weight problem, and
not other health related issues?
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Challenge the Bias
Lead by example: influence peers and
others to demonstrate patient sensitivity,
become a good role model.
Don’t tolerate behind-the-back whispers,
jokes, even in private.
If no one questions obesity bias, what will
ever stop it?
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Strategies for Healthcare
Consider that patients may have had
negative experiences with other healthcare
professionals regarding their weight;
approach patients with sensitivity.
Recognize that many patients have tried to
lose weight repeatedly.
Acknowledge the difficulty of lifestyle
changes.
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Our Role
We need to care for both physical and emotional
needs.
Support and encouragement are so important.
Compassion and empathy must be conveyed.
Communication and listening skills are essential.
Smile, look at the person, do not ignore a patient
because of their obesity.
80
Catholic Health Systems
Employee Breastfeeding
Support
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Catholic Health Systems
Employee Breastfeeding Support
Overview
Support of Breastfeeding is a
Priority
1
Reduced
Risk
for
Infants
with
Exclusive
Breastfeeding
2
Obesity
Ear Infections
Respiratory Infections
Asthma
Gastrointestinal Infections
Atopic Dermatitis
Type 1 & Type 2 Diabetes
Leukemia
Sudden Infant Death Syndrome
Necrotizing Enterocolitis
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Public Health Case
Breastfeeding is the standard for infant feeding
and protects infants and children from many
significant infectious and chronic diseases.
$13 billion of direct pediatric health-care costs and
more than 900 lives would be saved annually if
90% of women were able to breastfeed exclusively
for six months as recommended.2
Women who breastfeed have a reduced risk of
breast and ovarian cancer, type 2 diabetes,
postpartum depression, and cardiovascular
disease.3-5
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Work Remains a Barrier to
Breastfeeding6-10
Full-time employment decreases
breastfeeding duration by an average of
more than eight weeks.
Mothers are most likely to wean their infants
within the first month after returning to work.
Only 10% of full-time working women
exclusively breastfeed for six months.
Catholic Health is a leader in supporting
breastfeeding moms in the workplace.
85
If a mother chooses to breastfeed, she
needs to pump breast milk during the
workday in order to maintain her milk
supply.
Missing even one needed pumping
session can lead to decreased milk
production and other undesirable
consequences.
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Women Need Worksite Lactation
Support11
Breaks for lactation are similar to other work
breaks for attending to physical needs:
Time to eat/drink, restroom breaks, accommodation for health
needs (e.g., diabetes)
When mother and child are separated for more
than a few hours, the woman must express milk.
Missing even one needed pumping session can
have undesirable consequences:
Discomfort – Leaking – Inflammation
Infection – Decreased Milk Production
Breastfeeding Cessation
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How to Support Breastfeeding
Employees
In general, women need 30 minutes (15 to
20 minutes for milk expression, plus time to
get to and from a private space and to wash
hands and equipment) approximately every
2 to 3 hours to express breast milk or to
breastfeed.
Needs may vary from woman to woman and
over the course of the breastfeeding period.
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Business Case11
Lactation programs are cost-effective, showing a
$3 return for every $1 invested.
By supporting lactation at work, employers can
reduce turnover, lower recruitment and training
costs, cut rates of absenteeism, boost morale and
productivity, and reduce health-care costs.
Lactation accommodation is not one-size-fits-all.
Flexible programs can be designed to meet the
needs of both the employer and employee.
89
Breastfeeding = Increased Productivity11
Breastfeeding reduces illness of the baby = fewer
absences of parent employees = immediate return on
investment.
Breastfeeding support in the workplace helps families meet
their breastfeeding and childrearing goals = higher job
satisfaction, increased loyalty, increased ability to focus on
job responsibilities, higher return to work postpartum, and
lower turnover = immediate return on investment.
Breastfeeding prevents chronic disease in women who
breastfeed and contributes to a healthier future workforce
through reduction of obesity and chronic disease = longterm payoff that keeps on giving.
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Legal Basis
Fair Labor Standards Act
Section 7 of the Fair Labor Standards Act was amended effective
March 2010:
Employers are required to provide “reasonable break time for
an employee to express breast milk for her nursing child for 1
year after the child’s birth each time such employee has need
to express the milk.”
Employers are also required to provide “a place, other than a
bathroom, that is shielded from view and free from intrusion
from coworkers and the public, that may be used by an
employee to express breast milk.”
91
Common Concerns of Breastfeeding
Mothers 11
Modesty
Time and social constraints
Lack of support
Making enough milk for their babies
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Resources
What resources are available for managers?
Catholic Health Policy on Lactation (Compliance 360)
Identify location within your department for your associate
– talk with your manager about a room for your use
Direct associates with specific breastfeeding/personal
advice regarding lactation can call 862-1939
What resources are available for employees?
Baby Café at Sisters
Mercy and Sisters Hospital Lactation Department
Educational materials, professional support.
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References (1-6)
1.
2.
3.
4.
5.
6.
Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. (TuftsNew England Medical Center Evidence-based Practice Center). Breastfeeding
and maternal and infant health outcomes in developed countries. Evidence
Report/Technology Assessment No. 153. Rockville, MD: Agency for Healthcare
Research and Quality; 2007 Apr. AHRQ Publication No. 07-E007. Contract Nu.
290-02-0022. 415 pp. Available from: http://www.ahrq.gov/Clinic/tp/brfouttp.htm
American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and
the use of human milk. Pediatrics. 2012;129(3):e827-41.
Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the in the
United States: A pediatric cost analysis. Pediatrics. 2010;125(5): e1048-56.
Schwarz EB, Ray RM, Stuebe AM, Allison MA, Ness RB, Freiberg MS, Cauley JA.
Duration of lactation and risk factors for maternal cardiovascular disease. Obstet
Gynecol. 2009;113(5):974-82.
Gunderson EP, Jacobs DR, Chiang V, et al. Duration of lactation and incidence of
the metabolic syndrome in women of reproductive age according to gestational
diabetes mellitus status: A 20-year prospective study in CARDIA—The Coronary
Artery Risk Development in Young Adults Study. Diabetes. 2010;59(2):495-504.
Fein B, Roe B. The effect of work status on initiation and duration of breastfeeding. American Journal Public Health. 1998:88(7): 1042-46.
94
References (7-12)
7.
Cardenas R, Major D. Combining employment and breastfeeding: Utilizing a
work-family conflict framework to understand obstacles and solutions. J Bus
Psychol. 2005; 20(1): 31-51.
8. Galtry J. Lactation and the labor market: Breastfeeding, labor market changes,
and public policy in the United States. Health Care Women Int. 1997;18(5): 46780.
9. Texas Department of State Health Services. WIC Infant Feeding Practices Survey,
2009.
10. United States Breastfeeding Committee. Workplace Accommodations to Support
and Protect Breastfeeding. Washington, DC: United States Breastfeeding
Committee; 2010. Available from:
http://www.usbreastfeeding.org/Portals/0/Publications/Workplace-Background2010-USBC.pdf
11. Department of Health and Human Services (U.S.). The Business Case for
Breastfeeding. Steps for Creating a Breastfeeding Friendly Worksite: Bottom
Line Benefits [Kit]. US Department of Health and Human Services, Health
Resources and Services Administration (HRSA), Maternal and Child Health
Bureau. 2008. HRSA Inventory Code: MCH00254. Available from:
http://www.womenshealth.gov/breastfeeding/programs/business-case/index.cfm
12. US Department of Labor. Break Time for Nursing Mothers. [Online]. 2010.
Available from: http://www.dol.gov/whd/nursingmothers
95
Social Media Policy Review
Social Media is defined as user generated content
that is shared over the internet via technologies
that promote engagement, sharing and
collaboration. It includes, but is not limited to
social networking sites such as Facebook,
LinkedIn, Flickr and Twitter, personal websites,
news forums and chat rooms.
Catholic Health recognizes social media as an
avenue for self-expression. Associates must
remember that they are personally responsible for
the content they contribute and should use social
media responsibly. Catholic Health’s human
resources policies – including its equal
employment opportunity and sexual
harassment/non-harassment policies – and its
policies on patient confidentiality/HIPAA, apply to
associates’ on line conduct.
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Social Media Policy Review, cont.
1. Follow Catholic Health values, Code of Conduct and policies in all
social media usage.
Know and follow the Catholic Health code of conduct, which is available online
at http://www.chsbuffalo.org/AboutUs/Policies/Standards and the Catholic
Health Conduct Principles and Corrective Action Policy. Behavior related to
social media must comply with all Catholic Health policies, including any
Confidentiality Agreements, HIPAA policies and rules of practice, discrimination
and harassment policies, computer use policies and any other policies that
govern the content or manner of your social media usage.
2. Carefully consider what you post.
You are personally responsible for the content you publish on blogs, wikis or
any other form of user-generated media. Be mindful that what you publish may
be public for along time. If you're about to publish something that makes you
even a little uncomfortable, reconsider whether the publication is a good idea
and whether it violates any Catholic Health rules. If you are unsure or have
questions, discuss it with your manager or Human Resources prior to posting
the information. Ultimately, you have sole responsibility for what you post and
publish in any form of online social media. If your social media activity shows
that you have exercised poor judgment in such activities, or if your activities in
social media violate any Catholic Health policies, Catholic Health take legal or
disciplinary action against you.
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Social Media Policy Review, cont.
3. Representation of Catholic Health on any social
media site is subject to approval.
Anyone creating a presence on any social media outlet for
the purpose of representing an entity of Catholic Health
should first gain approval from the Communications and
Marketing Department. This will ensure that the
organization as a whole is aware of all official
communication efforts of its facilities, departments, and
associates. No Catholic Health associate or stakeholder
should create any presence (user or group), or post
material to any website as a representative of any Catholic
Health entity without authorization.
4. Affiliation with Catholic Health must be disclosed.
Every website, “fan page” or other online destination that is
controlled by Catholic Health must make that fact known to
users and must be authorized according to internal
protocols
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Social Media Policy Review, cont.
5. Identify your opinions as your own and not those of
Catholic Health.
Associates must use appropriate disclaimers when using
social media. If you choose to identify yourself as affiliated
with Catholic Health, or if you identify your role at Catholic
Health, you should write in the first person. You must make
it clear that you are speaking for yourself and not on behalf
of Catholic Health. Use a disclaimer such as “The postings
on this site are my own and don't necessarily represent
Catholic Health’s positions, strategies or opinions."
6. Do not disclose private, confidential or proprietary
information.
Do not provide confidential information regarding Catholic
Health, our business, patients, associates or affiliates.
Know and follow the Catholic Health privacy policy.
7. Abide by federal and state laws.
Do not violate federal and state laws, including
discrimination, harassment, bullying, copyright, fair use
and financial disclosure laws.
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Social Media Policy Review, cont.
8. Be respectful.
Associates must not use any form of social media to
harass, bully, coerce, intimidate or retaliate against other
Catholic Health associates or anyone affiliated with
Catholic Health. Associates must not post anything that is
false, obscene, defamatory, libelous, threatening or
abusive whether in word, images or audio, about Catholic
Health or anyone affiliated with the organization including
other associates. Lastly, speak respectfully about our
current, former and potential customers, partners,
associates, and competitors.
9. Be professional.
If you choose to identify yourself as a Catholic Health
associate or affiliated person, ensure that your profile and
related content is consistent with how Catholic Health
requires you to represent yourself when interacting with
colleagues and clients. If you have joined Catholic Health
recently, be sure to update your social profiles to reflect our
code of conduct guidelines.
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Social Media Policy Review, cont.
10. Do not engage in solicitation.
Do not advertise for a third party on Catholic Health’s
social media pages or when referencing Catholic Health.
See also Catholic Health’s Solicitation policy, HR 106,
which applies to activity in relation to social media.
11. Associates may not use any Catholic Health social
media site to gain access to contact lists or names to be
used for any purpose that would violate federal or state
laws or any Catholic Health policy.
12. Do not post photographs taken on Catholic Health
property without the consent of the individuals in the
photos or if the information in the photos is confidential,
patient information, proprietary, offensive as outlined in
Catholic Health’s Media Policy, CHS CM 001.
13. Do not post malignant materials.
Do not post materials that contain software viruses,
worms, disabling code, or any other computer code, files or
programs designed to interrupt, destroy or limit the
functionality of any computer software or hardware or
telecommunications equipment.
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Social Media Policy Review, cont.
14. Think twice before “connecting.”
Carefully consider whether connecting to other Catholic Health
associates, customers, donors, medical staff, volunteers, board
members, independent contractors, affiliates, vendors, business
partners, or competitors via social media is appropriate for your level,
position, and responsibilities. Not everyone wants to be your “friend,”
and it may be awkward to refuse to “friend” or to “unfriend” a coworker, customer or business associate or to learn overly personal
information about such people (or for them to learn overly personal
information about you). To the extent that you do connect via social
media with people affiliated with Catholic Health, consider using
available privacy filters or settings to block any inappropriate,
unprofessional, or overly personal information about you from such
people. Associates in supervisory or managerial roles should be
especially mindful of appropriate boundaries.
15. Use of Catholic Health e-mail address.
Associates should not use their CH e-mail addresses to register for
social media unless use of social media on behalf of Catholic Health is
required by or directly related to the associate’s job. Associates may
reference their Catholic Health employment and contact information on
professional networking sites, such as LinkedIn.
Access to social media is prohibited for non-exempt associates during
work time unless job related.
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Social Media Policy Review, cont.
Catholic Health reserves the right to host or sponsor internal or external social
media sites for its own business purposes. Unauthorized access to or editing
of any Catholic Health sponsored social media site is strictly prohibited.
By posting content on any Catholic Health social media site, you grant to
Catholic Health the right to reproduce, distribute, or publish such content and
the right to create derivative works from your content, edit or modify such
content and use such content for any Catholic Health purpose.
Associates have no right to privacy with respect to any information sent,
received, created, accessed, obtained, viewed, stored or otherwise found at
any time on Catholic Health’s computer network or using Catholic Health’s
electronic equipment. Conduct that violates other policies would also be
prohibited through social media. Associates are encouraged to report known or
suspected violations of any policy to their supervisor or Human Resources.
Human Resources will investigate a claim in the same fashion as if the
associate made a complaint directly to HR. See also Discrimination and
Harassment policy, HR 016. Associates who violate this policy will be subject
to corrective action, up to an including termination of employment. See also
HR 011, Conduct Principles and Corrective Action. Catholic Health may
monitor any social media activity of individuals covered by this policy if there is
reason to believe that a policy or legal violation has occurred as well as in
connection with Human Resource investigations. Catholic Health reserves the
right to edit or remove posts that violate this policy.
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The Uninsured Expected Payment
and Healthcare Assistance Policy
104
Policy
The policy divided is into three distinct
sections that grant different rights to patients
based on the following Catholic Health
ministries:
Acute Care
Continuing Care
Home Healthcare
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Acute Care
All uninsured patients of Catholic Health receiving
treatment at one of the Catholic Health’s acute care
facilities who are residents of New York State, a contiguous
State or the state of Ohio, excluding the following services:
- Non-Medically Necessary Elective Services (e.g. cosmetic
surgery),
- Long term level of care services (Sub-Acute or Skilled
Nursing),
- Physician services other than Catholic Health primary care
physician services, and
- Medical equipment and supplies
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Continuing Care
Continuing Care:
All residents of Catholic Health receiving treatment
at one of the Catholic Health’s Long Term Care
facilities (Hospital and Non Hospital Based) that
are subject to insurance co-payments or
deductibles and Adult Home residents may
be eligible for charity care.
107
Home Healthcare
Home Healthcare:
All patients that receive services within the
Catholic Health Home Care division
(Certified Agencies, Licensed Agencies, and
Infusion Pharmacy) may be eligible for
Charity Care.
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Acute Care Section
Policy and Procedures
All patients registered as uninsured (i.e., those
without insurance, also often referred to as self
pay) will automatically be enrolled in the
Healthcare Assistance Program. An optional
application form will be offered at time of
registration, but failure to complete the application
will not exclude enrollment. As such, uninsured
patients presenting for care at a Catholic
Healthcare acute care facility need do nothing
to apply for healthcare assistance.
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