Transcript Monroe County Hospital

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:
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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
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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
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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
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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,
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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
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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
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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
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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.
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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
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(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
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(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
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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
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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
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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
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(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
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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
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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
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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
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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,
•
•
•
•
•
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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
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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
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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
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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
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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
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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
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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
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Age
Race
Martial Status
Education
Profession
Religion
Gender
Language
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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
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Language
Practices
Customs
Food
Clothing
Religion
Superstitions
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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.
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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