Transcript RIVER REGION HEALTH SYSTEM

River Region Health System
STUDENT ORIENTATION & COMPLIANCE
2100 Highway 61 North
Vicksburg, Mississippi 39183
(601) 883-5000
MISSION & VISION
The Mission of River Region Health System is to improve
and deliver quality, compassionate healthcare aligned
with the needs of the communities we serve.
The Vision of River Region Health System is to be the
health system of choice by patients, physicians,
employees, and will be nationally recognized as a premier
healthcare provider.
BASIC PRINCIPLES OF
CUSTOMER SERVICE
Attitude

Greet all customers with a smile

Introduce yourself by name and position

Address customers by their last name

Rudeness is NEVER acceptable

Make eye contact

Always meet customer needs immediately or find someone
who can.
Appearance

Always dress professionally.

Badges Must Be Worn by All Students
and Faculty Members at Eye Level and
Must Be Visible at All Times.

BADGES are not to be attached to
LANYARDS.

Practice good personal hygiene and
grooming.

Comply with your school’s dress code.
Anticipate the Needs of our Customers

Ask “How can I help”

Understand the needs of the
customer

Communicate during waits

Apologize when a delay occurs

Ask, “Is there anything else I
can do for you?”
Maintain a Safe & Clean Environment

Keep the environment clean

Pick up any litter you find

Put things back in their place

Keep hallways free of clutter

Know safety codes and respond
appropriately

Report needed repairs.
Privacy & Confidentiality

Always knock before entering

Keep all patient information confidential

Discuss patient information in a confidential setting

Close doors when possible

Provide a robe or extra gown for patients in public places.
Elevator Etiquette

Always smile and speak to fellow
passengers

When transporting patients, face them
toward the door

Make room for others

Allow our guests to enter the elevator first.
Sense of Ownership

Take pride in River Region

Be an ambassador inside and outside of the facility

Follow policies and procedures

Do the right thing.
The Basics of Patient Safety
Background to Patient Safety
1999 IOM report: medical errors kill up to 98,000 hospital patients per year.
Medical Errors occur in 2.9% to 3.7% of Hospital Admissions; 8.8% to 13.6% of error lead to death.
Recent Studies reveal - 2% of hospital admissions have a preventable adverse drug event resulting in:
•
Increased LOS of 4.6 days
•
Increased hospital costs of $4,7000 per admission.

Patient Safety is part of Performance Improvement here at River Region.

The PI Council is the interdisciplinary group that oversees patient safety.

At admission, all River Region patients receive patient safety education.

The RRHS patient handbook has an entire section dedicated to safety.

Each patient satisfaction survey includes questions on safety.
We embrace a culture that recognizes human error and strives to learn from our
mistakes by providing a safe reporting environment. We contain errors through
Analysis to understand the cause behind the event so we can make changes that
will promote safer care for our patients.
Since 1996, the JCAHO have required organizations to investigate Sentinel
Events. A Sentinel Event is an unexpected occurrence involving death or
serious physical or psychological injury. They are considered sentinel because
they signal a need to investigate and respond immediately.
Who Reports?
All employees and students are responsible for reporting a Sentinel Event.
Why Report?
To have a positive impact on improving patient care.
National Patient Safety Goals
Identify Patients Correctly
Patient Identifiers at River Region:
Name and Date of Birth
Improve Staff Communication
 LISTEN, WRITE DOWN, and READ BACK all verbal/telephone
orders/results.
Verbal orders taken when the physician is on the unit areacceptable only in
emergency situations!
Clarify any physician order containing an unapproved abbreviation.
LISTEN, WRITE DOWN, and READ BACK critical lab values.
Document accordingly in the nurses notes and on the critical lab value form.
Notify the physician immediately!
Hand Off Communication Guidelines
(Giving Report)
Patient demographics
Diagnoses & present code status
Current vital signs & abnormal trends
Critical lab values
Recent tests, surgeries, procedures, & radiology reports
Medications including IV fluids & recent pain medications
Use Medications Safely
TWO NURSES :
Before administration of insulin, heparin, and chemotherapy
The second nurse must watch preparation &
document on the MAR.
Label all medications, medication containers.
(for example, syringes, medicine cups, basins)
Prevent Infection
Scrub hands for 15 seconds with soap and water or use
alcohol foam before, between, and after contact with
patients/patients’ environments.
Fingernails are to be kept short and clean.
Artificial nails and/or
acrylic overlays are prohibited.
Check Patient’s Medicines
Find out what medicines each patient is taking. Make sure that it is OK for the
patient to take any new medicines with their current medicines.
Step 1: With patient’s involvement, create a complete list of the patient’s
current medications at admission/entry (Medication
Reconciliation Form).
Step 2: The medications ordered for, administered to, or dispensed to
the patient while under the care of the organization are compare
to those on the list.
Step 3: Resolve any discrepancies.
Give a list of the patient’s medicines to their next caregiver or to their regular
doctor before that patient goes home.
Give a list of the patient’s medicines to the patient and their family before they
go home. Explain the list.
Prevent Patients From Falling
Fall Prevention Tips:
-Assist elderly patients to toilet
-Keep call light within patients’ reach
-Assign rooms close to the nurses’ station
-Monitor demented patients closely
-Ensure adequate lighting
-Offer toileting regularly
-Keep side rails up
-Keep bed locked and in low position
-Instruct patients to call before getting out of bed
-Monitor patients on diuretics and narcotics frequently
-Identify fall precaution patients with yellow sticker & armband clip
Prevent Patients From Getting
The Flu and Pneumonia

Assess the older adults’ risk status for the flu and
pneumonia. Take action through educating the patient on
the diseases and offer vaccinations to protect against them.

Use Influenza and Pnuemococcal order sets to access risk
factors.

Always vaccinate if there is a question whether the patient
has received previous vaccinations.
Reduce the Risk of Surgical Fires

OR staff must know how to control heat sources,
how to manage fuels while maintaining enough time
for patient preparation, and establish guidelines to
minimize oxygen concentration under drapes.
-Fire safety video housed in Surgical Services
-Mock fire drills conducted in Surgical Services
Help Patients To Be Involved In Their
Care
Tell each patient and their family how to report their complaints about safety.
Encourage active patient participation & use of the PI Line (Patient
Intervention Hotline).
The Patient Advocate gives pamphlets to all patients.
 Educate on methods to report unsafe practices:
The Joint Commission – (630) 792-5000
The MS State Dept of Health – (866) 458-4948)
Prevent Hospital Acquire
Pressure Ulcers
Assess and periodically reassess each resident’s risk for developing
pressure ulcers and take action to address any identified risks.
Rules of Thumb:
-All patients are to be assessed for high risk for pressure ulcer
development on admission and every 12 hours afterward.
-A total body assessment should be completed in the first 24 hours to
identify a pressure ulcer on admission (POA).
-If a patient is identified with a pressure ulcer or having a high risk status,
protocols should be implemented within an 12 hour period.
-Identify ancillary consults to impact healing process.
Identify Patient Safety Risks


Find out which patients are most likely to try to kill themselves.
Perform suicide risk assessment and reassessment, address immediate
safety needs, and provide crisis hotline information.
Tips to Identify Patients at Risk for Suicide:
-Sudden changes in mood and behavior
-Drug/Alcohol impairments
-Change in level of consciousness (LOC)
-History of suicide attempts, violent behavior
-Recent change in stressors, loss of coping skills and/or support systems
-Patients at risk for flight
-Patient’s admitted for treatment of emotional or behavioral disorder
-Patient’s admitted for court-ordered evaluation
Watch Patients Closely For
Changes In Their Health
& Respond Quickly
Activate the Rapid Response Team by calling the Hospital Operator.
-Systolic BP < 90 mmHg
-Heart Rate < 40 or > 130 beats per minute
-Respiratory Rate < 8 or > 28 per minute
-O2 Saturation < 90% despite O2
-Abnormal Temperature
-Urine Output < 50 mL in four hours
-Change in Level of Consciousness
-Intuition tells you something is wrong
Universal Protocol &
Implementation Guidelines
Conduct a preoperative verification process as described in the Universal
Protocol.
Surgical Procedure: Pre-operative & Verification Checklist
Mark the operative site as described in the Universal Protocol.
The physician marks the surgical site. Check the marked site against the
History and Physical, consent, and ask the patient to verify.
Conduct a “time out” immediately before starting the procedure as
described in the Universal Protocol.
Time Out = Physicians & Nurses Agree
 Site
 Patient  Procedure
CULTURAL DIVERSITY
What are Cultural Competencies?
They are skills you use to work well with PATIENT’S of all CULTURES.
Those skills consider every patient’s culture when giving care and treating
every patient as an individual.
WHY LEARN ABOUT
CULTURAL COMPETENCIES ?
TO HELP PATIENTS RECEIVE MORE EFFECTIVE CARE.
TO HELP OUR FACILITY MEET
THE JCAHO STANDARDS.
TO IMPROVE JOB PERFORMANCE.
CULTURAL FACT
CULTURE IS…
Customs
Morals
How people are
raised to live their
lives.
Belief
Habits
CULTURAL FACT
DIVERSITY IS…
Socioeconomic
status
Race
Gender
Age
Sexual
Orientation
Preferred
Language
Views
of
Health
All the differences that
define each of us as
individuals.
Food
Preferences
Nationality
Religion
Physical
or Mental
Disability
CULTURAL FACT
STEREOTYPING IS…
Pushing another into a
“category” without
considering the
uniqueness of individuals,
groups, or events.
CULTURAL FACT
PREJUDICE IS…
Prejudging someone
before you know all
the facts.
CULTURAL DIVERSITY BENEFITS
REDUCES CONFLICT
INCREASES MORALE AND DECREASES TURNOVER
DECREASES DISCRIMINATION CLAIMS
IMPROVES COMMUNICATION
IMPROVES UNDERSTANDING OF OUR CUSTOMERS AND PATIENTS
DO THE RIGHT THING!
CULTURAL COMPETENCIES REQUIRE…
Self-Awareness
Time to Learn
About the Patient
Effective
Communication
•Know your own
cultural beliefs and
practices.
•Ask questions to
avoid cultural
stereotypes.
•Listen to how the
patient talks about his
or her condition.
•Be aware of the
culture of health
care in the U.S.
•Learn the patient’s
views about health.
•Look for clues.
•Show respect.
•Talk with others who
know the patient.
•Understand
relationships.
•Ask for the patient’s
views on treatment.
•Consider privacy
needs.
•Use interpreters
effectively.
What is Infection Control?

Surveillance
 Prevention
 Control of Infections
What’s the #1 way to prevent infection?
HANDWASHING
Many studies have shown that the bacteria that cause
hospital acquired infections are most frequently spread
from one patient to another on the hands of healthcare
workers.
CDC reports 2 million people get hospital acquired
infections every year and 90,000 of these result in death.
Although handwashing has been proven to reduce the
spread of germs, healthcare workers often do not wash
their hands when recommended. In 34 studies of
handwashing, workers washed their hands only 40% of
the time.
Healthcare workers can get 100s or 1000s of germs
on their hands by doing simple tasks:

Pulling patients up in
the bed

Taking a blood pressure
or pulse

Touching a patient’s
hand

Touching the patient’s
gown or bed sheet

Touching equipment
like bedside rails,
bedside tables, IV
pumps/poles and
wheelchairs
We now have made it easier for healthcare workers to
comply with CDC Hand Hygiene Guidelines:

Use of Alcohol based
Hand Gel/Foam

It only takes 15 seconds
compared to 60 seconds
for handwashing

They can be placed in
convenient locations,
making it readily
available

They are more effective
in reducing the number
of live germs on your
hands

Cause less skin
irritation.
When do you wash your hands?

Before and after using
the bathroom

After using
computer/phone

After patient
contact/care

After sneezing

After coughing.

Before and after eating

After removing gloves.
What is a hospital acquired infection?
An infection that was not present or incubating
at the time a patient was admitted.
How to prevent & control infections?

Develop good hand hygiene techniques

Follow infection control policies and procedures

Implement those policies and procedures.
Types of Isolation
 Airborne
 Contact
Door Sign and Color
 Example: MRSA
 Modified
Contact
Door Sign and Color
 Example: Vancomycin
Resistant Enterococcus
(VRE)
Door Sign and Color
 Example: TB
 Droplet
Door Sign and Color
 Example: Meningitis
Isolate the disease NOT the patient!
 Choose
the correct isolation category
 Follow
directions that are on the sign
 Provide
 Teach
the same care
the family and visitors.
When is isolation necessary?

When a patient has a diagnosed infectious disease

Before a definite diagnosis can be made (suspected)

Immunosupressed patients
If you have any questions regarding any statistical data presented or Infection Control Questions –
please contact the Infection Control Coordinator at 601-883-5576.
Bloodborne Pathogens

Approximately 5.6 million workers in health care and other
facilities are at risk of exposure to bloodborne pathogens
such as human immunodeficiency virus (HIV – the virus
that causes AIDS), the hepatitis B virus (HBV), and the
hepatitis C virus (HCV).

OSHA’s Bloodborne Pathogens standard prescribes
safeguards to protect workers against the health hazards
from exposure to blood and other potentially infectious
materials, and to reduce their risk from this exposure.

Implementation of this standard not only will prevent
hepatitis B cases, but also will significantly reduce the risk
of workers contracting AIDS, Hepatitis C, or other
bloodborne diseases
Who is covered by the standard?

All employees who could be “reasonably
anticipated” as the result of performing their job
duties to face contact with blood and other
potentially infectious materials.

“Good Samaritan” acts such as assisting a coworker with a nosebleed would not be considered
occupational exposure.
Some Workers Who are at Risk













Physicians, nurses and emergency room personnel
Orderlies, housekeeping personnel, and laundry workers
Dentists and other dental workers
Laboratory and blood bank technologists and technicians
Medical examiners
Morticians
Law enforcement personnel
Firefighters
Paramedics and emergency medical technicians
Anyone providing first-response medical care
Medical waste treatment employees
Home healthcare workers
STUDENTS
How does exposure occur?

Most common: needlesticks

Cuts from other contaminated sharps (scalpels, broken
glass, etc.)

Contact of mucous membranes (for example, the eye,
nose, mouth) or broken (cut or abraded) skin with
contaminated blood
Universal Precautions

Treat all human blood and certain body fluids as if
they are infectious

Must be observed in all situations where there is a
potential for contact with blood or other
potentially infectious materials
Engineering & Work Practice Controls

These are the primary methods used to control the
transmission of HBV and HIV.

When occupational exposure remains after
engineering and work practice controls are put in
place, personal protective equipment (PPE) must
be used.
Engineering Controls
These controls reduce employee
exposure by either removing the
hazard or isolating the worker.
Examples:
-
Sharps disposal containers
- Self-sheathing needles
- Safer medical devices
- Needleless systems
- Sharps with engineered sharps injury protections
Safer Medical Devices

Needless Systems: a device that does not use needles for
the collection or withdrawal of body fluids, or for the
administration of medication or fluids

Sharps with Engineered Sharps Injury Protections: a
non-needle sharp or a needle device used for withdrawing
body fluids, accessing a vein or artery, or administering
medications or other fluids, with a built-in safety feature
or mechanism that effectively reduces the risk of an
exposure incident
Work Practice Controls
These controls reduce the likelihood
of exposure by altering how a task is
performed.
Examples:
- Wash hands after removing gloves
and as soon as possible after exposure
- Do not bend or break sharps
- No food or smoking in work areas
Personal Protective Equipment

Specialized clothing or equipment
worn by an employee for protection
against infectious materials

Must be properly cleaned, laundered,
repaired, and disposed of at no cost
to employees

Must be removed when leaving area
or upon contamination
Examples of PPE

Gloves

Gowns

Face shields

Eye protection

Mouthpieces &
resuscitation devices
Housekeeping
Work surfaces must be decontaminated with an
appropriate disinfectant:

After completion of procedures

When surfaces are contaminated

At the end of the work shift
Regulated Waste
Must be placed in closeable,
leak-proof containers built to
contain all contents during
handling, storing, transporting or
shipping and be appropriately
labeled or color-coded.
Laundry

Handle contaminated laundry as
little as possible and use PPE

Must be bagged or containerized at
location where used

No sorting or rinsing at location
where used

Must be placed and transported in
labeled or color-coded containers
What to do if an exposure occurs?

Wash exposed area with soap and water

Flush splashes to nose, mouth, or skin with water

Irrigate eyes with water or saline

Report the exposure

Direct the worker to a healthcare professional
Biohazard Warning Labels
 Warning labels required on:
- Containers of regulated waste
- Refrigerators and freezers containing
blood and other potentially infectious
materials
- Other containers used to store,
transport, or ship blood or other
potentially infectious materials
 Red bags or containers may be
substituted for labels
SAFE LIFTING:
Avoiding a Painful Back
The Five Leading Back Injury Factors:
-Poor Posture
-Poor Physical Condition
-Improper Body Mechanics
-Incorrect Lifting
-Jobs That Require High Energy
The Spine‘s Basic Functions:
-Provide Support
-Protect the Spinal Cord
-Provide Flexibility to Allow Bending and Rotating
·
·
STANDING POSTURE
Keep Your Spinal Column Aligned in Its Natural Curves
Prop One Foot up on a Stool to Reduce Stress in Your Lower Back.
·
·
·
·
STRETCH OFTEN & SHIFT POSITIONS
Change (Shift) Your Posture Often
Stretch Frequently Throughout the Day
Keep Your Body Flexible (Not Rigid or Fixed)
Don’t Force Your Body to Conform to Its Workspace.
LIFT WITH COMMON SENSE!
·
·
·
Assess the Situation
Do You Need Help?
Remember- No Single Technique Will Work in All Circumstances.
·
·
·
THE SAFE LIFTING ZONE
The Safe Lifting Zone Is Between the Knees and Shoulders
Below Knee Level? Bend With Your Knees and Lift With Your Legs
Above Your Shoulders? Use a Stool or Ladder.
PREPARING TO LIFT OR MOVE
·
·
·
Have You Stretched Your Muscles or Warmed up Before Lifting?
Are You Wearing Slip Resistant Shoes?
Have You Cleared a Pathway Before You Move the Item?
WHEN YOU LIFT DO
·
·
·
·
·
·
·
·
Plant Your Feet Firmly- Get a Stable Base
Bend at Your Knees- Not Your Waist
Tighten Your Abdominal Muscles to Support Your Spine
Get a Good Grip- Use Both Hands
Keep the Load Close to Your Body
Use Your Leg Muscles As You Lift
Keep Your Back Upright, Keep It in Its Natural Posture
Lift Steadily and Smoothly Without Jerking.
WHEN YOU LIFT DO NOT
·
·
·
·
·
·
·
Lift From the Floor
Twist and Lift
Lift With One Hand (Unbalanced)
Lift Loads Across Obstacles
Lift While Reaching or Stretching
Lift From an Uncomfortable Posture
Don’t Fight to Recover a Dropped Object.
EXERCISE FOR LOW BACK PAIN
·
·
·
Keeps Body Flexible
Helps Prevent Injury
Do Not Overdo-- Follow Doctor’s Instruction Carefully.
REMEMBER!
·
·
·
Your Work Day Is One Third of Your Total Day
Plan Your Tasks Carefully to Avoid a Painful Back
Managing Your Back Is Your Responsibility.
Environment of Care
Security Update
Seven Management Programs Of EOC

Safety Management
 Security Management
 Hazardous Materials & Waste
Management
 Emergency Management
 Life Safety Management
 Equipment Management
 Utility Management
Making it all work:
 Have a Plan
 Implement the Plan
 Evaluate how it went
Hazardous Materials & Waste
 Reduce and minimize the use of hazardous
materials & waste in the hospital.
 Identification of materials in your department.
 Moderate to Large Spills - “Code Orange”
Hazardous Materials & Waste
What is on a Material Safety Data Sheet –
aka MSDS?









Product Data
Ingredient Information
Physical Properties
Fire and Explosion Hazard
Reactivity Data
Health Hazard Data
Safe Handling Precautions
Special Protection
Special Precautions
Housekeeping
 Housekeeping is everyone’s job
- Small spills are to be taken care of by employees – that would be us.
- Black marks on floors – rub them out.
- Restrooms, sinks – wipe them down.
 Testing your housekeepers – “I’ve been looking at that
spot/trash all morning to see if anyone would clean it
up.”
WEAPONS IN THE WORKPLACE

No Weapons allowed. This includes all property, facilities, buildings,
work area, or vehicles owned, operated, leased, or under the control of
the facility. The only exception is to private vehicles parked on
premises.

No one should have Possession of a weapon; this includes one’s
personal effects or in one’s custody or control.

Weapon: Interment designed or reasonably believed to be intended
infliction of injury to or intimidating another person. (firearms, knives,
ballistics, explosives, ammunition or other incendiary devices)
The
only exception to this rule are those who are acting in an official
capacity and who are licensed to possess a weapon acting in that
capacity (law enforcement).
A student
maybe required, upon a supervisor’s
request, to submit to an inspection of personal
property including, but not limited to: any pocket,
package, purse, lunchbox, or other container
brought onto the facility premises. Also included
are any desk, file cabinet, personal locker, or other
container provided by the facility.
WORK PLACE VIOLENCE
 Any act or threats of violence by any employee or student against
any other employee, patient, visitor, student, or any person on hospital
or affiliated premises, or during employee working hours, are
forbidden.

Any employee or student who engages in any threatening behavior or
acts of violence or who uses obscene, abusive or threatening language
or gestures will be subject to disciplinary actions.
Life Safety Management
Fire Warning & Safety Systems
 R.A.C.E. = Rescue, Alarm (Code Red), Confine and
Extinguish
- Building functions
 P.A.S.S. = Pull, Aim, Squeeze and Sweep
- Duration and capabilities of fire extinguishers
 Other Components
- Exit doors and means of egress
- Exit lights
Codes
Fire – Code Red
Altercation – Code Strong
Patient Elopement – Code Blacktop
Inter/External Disaster – Code Aster
Emergency Resuscitation – Code Blue
Tornado Watch/Warning – Code Gray
Chemical, Radiation Spill – Code Orange
Assist with Patient (not Altercation) – Code Assist
Infant/Child Abduction – Code Pink with age/sex/race
Special team to help prevent Code Blue – Rapid Response
For more information check the
EMERGANCY PREPARDNESS MANUAL
Security Personnel Locations &
how to contact them….

Security Office at River Region is located in the Ambulance Entranceextension 35118. Their Net Work Phone extension is 36272.

Security Office at West Campus is located on 3rd Floor across from the
elevators-extension 33064.

In an emergency dial “O” and have security paged to your extension or
location.

Any concerns dealing with Security please call Jason Acreman
Security Coordinator directly at 35881.
Tobacco Policy
All RRHS campuses are Tobacco free.
– No smoking in the facility - PERIOD.
– Tobacco is prohibited on River Region property and adjacent walkways &
roads.
– Employees using tobacco will be subject to disciplinary action.
– You are responsible for ensuring that patients and family members know that
there is no tobacco use allowed.
River Region Main Campus
Students and Faculty are to park in the
Pink Shaded areas ONLY.
River Region West Campus
Back of Building
Front of Building
Students and Faculty are to park in the
Red Shaded areas ONLY.
The Compliance Department of
Community Health Systems
presents
General Compliance Training
and the Code of Conduct
“CHS is committed to operating
with the highest standards of
integrity and behavior.”
Wayne T. Smith, Chairman, President and CEO
The CHS Compliance Program

The Code of Conduct
 Corporate Compliance Officer
 Written Policies and Procedures
 Training and Education
 Auditing and Monitoring
 Confidential Disclosure Program
 Periodic Reports to the CHS Board of Directors
What is the Code of Conduct?

The Code of Conduct (the “Code”) is designed to provide all CHS
employees and affiliates with guidance to perform their daily
activities in accordance with all federal, state and local laws, rules
and regulations.

The Code is an integral part of the CHS Compliance Program, and
reflects our commitment to achieve our goals within the framework
of the law, through a high standard of business ethics and
compliance.

The Code is a collection of policy statements. Most sections of the
Code of Conduct refer to a broader policy covered in various
department policy manuals. These policies are referenced within
the body of the Code of Conduct.
The Code of Conduct and You

Every CHS colleague is required to comply with
the Code of Conduct.

Each individual is expected to perform his/her
daily activities with the highest standards and
compliance.

All CHS colleagues are required to notify the
Ethics and Compliance Officer (the facility
ECO), the Corporate Compliance Officer
(Carol Hendry) or the Confidential Disclosure
Program of any violations of law, the Code of
Conduct, or Compliance Policy.
Examples of Topics in the
Code of Conduct:
Patient Privacy
Confidential Information
Coding and Billing
Financial Reporting
Confidentiality of Patient Information
When a patient enters a CHS Facility, a large amount of personal, medical,
and insurance data is collected and used to satisfy varying information
needs, including the ability to make decisions about a patient’s care.
CHS CONSIDERS PATIENT INFORMATION HIGHLY CONFIDENTIAL.
CHS colleagues must never disclose or release patient information in a
manner that violates the privacy rights of a patient. Patient information
may only be discussed or released in accordance with release of information
laws that normally require the express written authorization of the patient.
CHS colleagues should not have access to or use any patient information
unless it is necessary to perform his/her job.
Coding & Billing

If you are responsible for coding or billing of services,
you must not knowingly cause or permit false or
fraudulent claims, and must adhere to all official coding
& billing guidelines.

Furthermore, CHS colleagues shall not engage in any
intentional deception or misrepresentation intended to
influence any entitlement or payment under any federal
healthcare benefit program.

Claims must be submitted only for services ordered,
appropriately documented, and actually provided.

The Compliance Department will audit & monitor claims
on a regular basis to verify their validity. When
appropriate, the hospital or CHS will return any
overpayment amounts.
Confidential Information,
Electronic Media, Records,
& Documents

Inside information is non-public information and is confidential.
This includes acquisition plans, financial data, marketing plans,
or other business material that an employee may become aware
of in the normal course of business. Use of this information for
personal gain is strictly prohibited.

In case of termination, you may not take, retain, copy or direct
any other person to take, retain, or copy without prior written
permission, any documents or confidential information of any
kind belonging to the Company.

Disposal or destruction of CHS records and files is not
discretionary with any of us, including the originator of the
record. Legal and regulatory guidelines require retention of
various types of records. Each facility has policies governing
accuracy, retention, and disposal of documents and records.
Training & Education
CHS and each affiliated entity offer a variety of
training programs. Training includes this lesson
and in some instances specific lessons for
certain job codes and descriptions.
Auditing & Monitoring
Auditing and Monitoring topics are selected
annually by the Corporate Compliance
Workgroup. Auditing and monitoring is
routinely performed in an effort to prevent
and detect inappropriate activities. The
results of these activities are used to
determine future training topics.
Financial Reporting
All accounts and financial records must
be maintained in accordance with
generally accepted accounting principles
and all SEC rules and regulations.
Compliance with the Code of Conduct

The Code of Conduct is a mandatory policy of the Company. All
colleagues will sign a form indicating they have received a copy of
the Code, have read it, and understand it. In addition, all colleagues
will reaffirm these actions on an annual basis.

Compliance with the Code of Conduct and other policies will be
considered in annual employee evaluations and decisions regarding
promotion and compensation for all CHS employees.

The Code of Conduct is a unilateral statement of policy by CHS.
Nothing in the Code is intended to create enforceable employee
contract rights.
Compliance Officer
Privacy Officer
 The
CHS Corporate Compliance &
Privacy Officer is Andi Bosshart.
Written Policies and Procedures
CHS has many written policies and procedures in the
area of compliance. Your facility ECO can answer
questions concerning those policy and procedures. It is
your job to have an awareness of those policies and
procedures.
Confidential Disclosure Program
CHS has established a Confidential Disclosure Program for all
colleagues to report known or suspected violations of the Code of
Conduct, written policy, or any federal, state or local laws, rules and
regulations. This program may also be used for individuals who are
uncertain whether an action is a violation and would like to
communicate with the Compliance Officer on a confidential basis.
Grievance Resolution
If an individual is concerned about a
personnel action that does not involve any
violation of law, the Code of Conduct, or
Compliance Policy, he/she may file a
grievance at the CHS entity where he/she is
employed. The facility Human Resources
Department can provide a grievance
resolution form and assistance in preparing
and presenting a grievance. Information
regarding employee grievances is held in
strict confidence.
Confidential Disclosure Program Hotline
Hotline number is 1-800-495-9510
Retribution or retaliation
against any person
reporting suspected
violations of the Code,
law, or policy will not be
tolerated.
Reporting Questions or Concerns

Questions or concerns about potential compliance
violations may be addressed to any of the
following:

Your Supervisor or Department Head

Any Supervisor or Department Head

The Ethics and Compliance Officer

The Confidential Disclosure Program Hotline @
1-800-495-9510

It is recommended to first report concerns
through your local facility management.
Reporting Violations
Failure to report a known violation of
the law, Code of Conduct, or any
Compliance Policy could subject an
individual to disciplinary action. Any
colleague who attempts to divert or
discourage reporting shall be subjected
to severe discipline, up to and
including discharge.
Investigation of Violations

Once contact is made via the Confidential Disclosure Program,
a prompt, appropriate, confidential investigation will be
undertaken.

The Corporate Compliance Officer will coordinate findings
from the investigation and recommend corrective and/or
disciplinary actions.

When appropriate, CHS will return any overpayment amounts,
notifying the correct governmental agency of the overpayment
situation.
Periodic Reporting
The CHS Compliance Officer periodically
reports the activities of the Compliance
Program to the CHS Management
Compliance Committee and to the CHS
Board of Directors.
This concludes your Student Orientation and Compliance for River Region Health System.

Please PRINT, READ, and SIGN the Certificate of Completion.

You will be given a Code of Conduct book from your instructor.
Please READ the book in completion then SIGN the Last Page.

Submit BOTH the Certificate of Completion & Last Page of the
Code of Conduct Book to your instructor.
Welcome to River Region Health System!