Transcript 2015_Annual_Required_Trainingx

Texas Children’s Hospital
2015 Annual Required Training
Welcome!
Welcome to the Texas Children’s Hospital 2015 Annual Required
Training course! This course will take approximately one hour to
complete.
Course Navigation
You may only use the NEXT button, as illustrated on this slide, to move
forward through each of the slides. You must go through the slides in
sequential order; however, you may use the PREV button to review
previous slides already viewed.
Back
Forward
Who Is Exempt From This Course
 Texas Children’s new employees (including Texas Children’s
physicians) who were hired after January 1, 2015 are exempt.
 Physicians, Residents, Fellows, Dentists, Podiatrists, and Licensed
Ph.D. Psychologists not employed by Texas Children’s are exempt.
All others not listed in either of the above categories must complete
Annual Required Training.
Course Content
This course consists of twelve modules. After reviewing all of the
information in each of these modules, you must also complete the
Acknowledgements section in HealthStream to receive credit for
completing 2015 Annual Required Training.






Compliance and Ethical Behavior
Patient Privacy
Information Security
Fraud Awareness & Prevention
Language Interpreter Services
Diversity and Inclusion






Substance Abuse
Patient Safety
Quality Improvement
Infection Control
Emergency Response
Environmental Health &
Safety
Objectives
As a result of this course, you will be able to:
 Successfully meet the annual knowledge and safety review
requirements of Joint Commission (JC), the Occupational Safety and
Health Administration (OSHA), and Texas Children’s.
 Respond appropriately to specific emergency and safety situations
that may occur during the course of a work day or shift.
 Maintain a safe and ethical work environment for everyone.
COMPLIANCE AND ETHICAL BEHAVIOR
“Integrity at Work”
Doing What Is Right, Not What Is Easy
Compliance and Ethical Behavior
Texas Children’s develops and maintains an ethical and lawful environment in all
aspects of its operations.
The purpose of the Corporate Compliance program is to:
 Support the mission and vision of Texas Children’s by ensuring compliance program
effectiveness.
 Monitor compliance and regulations.
 Assist the organization in identifying and resolving issues.
 Mitigate organizational risk.
Lance Lightfoot
Vice President & General Counsel
Compliance & Privacy Officer
Your Role
Compliance and Ethical Behavior
Your role is to follow the organization’s Code of Ethical Behavior, including
understanding your job responsibilities and learning to identify and report potential
issues in your area. Everyone at Texas Children’s is responsible for compliance.
We are committed to:
 Following the law, ethical business practices, and Texas Children’s policies and
procedures.
 Avoiding conflicts of interest.
 Reporting inappropriate or unethical conduct or activity.
 Maintaining confidentiality.
 Keeping accurate and complete records.
 Doing what is right, not what is easy!
Lance Lightfoot
Vice President & General Counsel
Compliance & Privacy Officer
Following The Law
Compliance and Ethical Behavior
There are many laws, regulations, and policies our organization must comply with
including:
 Organization-wide policies.
 Entity specific policies.
 Federal and state regulations, for example:
 Fraud and abuse laws.
 HIPAA and privacy laws.
 Medicare/Medicaid coding and billing regulations.
 Employment and labor laws.
Lance Lightfoot
Vice President & General Counsel
Compliance & Privacy Officer
Texas Children’s Policies & Procedures On CONNECT
Compliance and Ethical Behavior
All Texas Children’s workforce members are expected to abide by established
policies and procedures. These may be found on the Texas Children’s
CONNECT intranet site under the Employee Resources heading.
Healthcare Fraud And Abuse
Compliance and Ethical Behavior
Healthcare expenses are under scrutiny from government agencies and private payers.
There are civil and criminal penalties for organizations and individuals involved in
fraudulent, wasteful, and abusive practices.
Fraud is an intentional misrepresentation made to receive unauthorized payments or
benefits. Some examples are:
 Billing for services, procedures, and supplies that were not provided.
 Falsifying information in a patient’s record.
 Using another person’s insurance to receive benefits.
Abuse is an overuse or misuse of services that are inconsistent with sound medical,
business, or fiscal practices. Intent is not required. Some examples of healthcare
abuse are:
 A physician sees a patient more times than is medically necessary.
 The use of more expensive supplies than is medically necessary.
 Ordering lab work and tests that are not medically necessary.
Conflicts Of Interest
Compliance and Ethical Behavior
A conflict of interest occurs when workforce members have a personal or outside
interest that may interfere with their Texas Children’s responsibilities.
Common types of conflicts of interest are:
 Self Dealing – using your official role to secure a personal or financial gain.
 Family or Friend Dealing – using your official role to secure a personal or financial
gain for a family member or a friend.
 Outside Employment – holding a position that competes with, interferes with, or
conflicts with your official role at Texas Children’s.
 Gifts – gifts that have the potential to interfere with the recipient’s objective
judgment.
Conflicts Of Interest (continued)
Compliance and Ethical Behavior
Texas Children’s workforce members must avoid taking part in any activity that may
influence or appear to influence decisions they make on behalf of Texas Children’s.
Appearances matter when it comes to conflicts of interest, so if you suspect there is a
potential for a conflict of interest, you must disclose that to your leader or to the
Compliance and Privacy Office.
Texas Children’s Conflict of Interest Disclosure form is available on CONNECT through
the Forms link.
Conflicts Of Interest – A Second Job
Compliance and Ethical Behavior
Many Texas Children’s workforce members have more than one place of employment.
If you have a second job, it is important to maintain separate roles and not use your
role at Texas Children’s to benefit your other workplace.
For example:
 Do NOT solicit Texas Children’s patients for another business.
 Do NOT use Texas Children’s proprietary information for the benefit of another
business.
 Do NOT use network resources or access physical areas of Texas Children’s
provided to you because of your work to benefit another business.
Gifts
Compliance and Ethical Behavior
All gifts must be scrutinized. Any gift that may interfere with your objective judgment
must be declined. It is never appropriate to solicit or appear to solicit gifts.
Cash (including tips and gratuities) and cash equivalents (such as gift cards and gift
certificates) are always prohibited regardless of whether they are from a patient,
patient family, or vendor.
Gifts (continued)
Compliance and Ethical Behavior
Thank you cards and notes from patients and their families may be accepted, but any
enclosed cash or cash equivalents, regardless of value, must be declined and returned.
Even a $5 Starbucks card is prohibited.
Small, token gifts from a patient or patient family (for example, a box of doughnuts,
candy, or a small flower arrangement) may be accepted, but should be shared with
everyone involved in the patient’s care, to the extent possible.
If a family wishes to recognize Texas Children’s with a donation, they should be
directed to the Office of Development.
Gifts From Vendors
Compliance and Ethical Behavior
It is important to remember that gifts from vendors currently involved in any stage of
the bidding process (RFP, RFI, or RFQ) with any Texas Children’s entity must be
declined.
Vendors, or even potential vendors, may not pay for travel expenses, and may not
sponsor or provide items for departmental parties, such as funds, gift cards, gift
certificates, or raffle prizes. There are a few exceptions made for certain activities.
Vendor Management
Compliance and Ethical Behavior
All vendors must be registered with VendorMate to conduct business with Texas
Children’s.
 Any person working on-campus must have either a Texas Children’s badge or an
appointment-specific badge sticker label indicating that they are an approved
vendor with a pre-scheduled appointment.
 New or unknown vendors should contact Supply Chain Services at 832-824-2122 to
register prior to their visit.
Vendor Management – Kiosk Locations
Compliance and Ethical Behavior
If you see a vendor without the appropriate identification, ask them if they have an
appointment and direct them to a kiosk location to obtain a pre-scheduled
appointment badge.
Kiosk Locations:
 Clinical Care lobby
 Meyer Building lobby
 Feigin Center lobby
 West Tower lobby
 West Tower Operating Room 3rd floor suite
 Pavilion for Women lobby and 3rd floor reception area
 West Campus lobby
TCH Badges
Compliance and Ethical Behavior
Please review and become familiar with the samples on this slide of the types of
Texas Children’s badges you will see across the organization.
Maintaining Confidentiality
Compliance and Ethical Behavior
Ensuring the confidentiality of Texas Children’s records, including our patient’s
protected health information, is a responsibility of all workforce members.
We must take all appropriate measures to safeguard all confidential information. If you
are aware of a situation in which Texas Children’s confidential information has been or
is in jeopardy of being inappropriately accessed, used, or disclosed, then you must
report your concern.
Reporting Concerns
Compliance and Ethical Behavior
You are our organizations eyes and ears. You must report any potential violations of
ethical business standards, policies, or laws.
You can make reports to your leader or any other leader in the organization. If you are
not satisfied with the outcome or do not feel comfortable reporting your concern to a
leader, contact the Compliance and Privacy Office or call the Confidential Hotline.
Whistle-blowers are protected from retaliation by Federal and State laws, as well as
Texas Children’s policies. No workforce member making a report in good faith will be
punished for making the report, no will retaliation be tolerated. If you feel you have
been retaliated against, you can report that concern to the Compliance and Privacy
Office.
Contact Information
Compliance and Ethical Behavior
Compliance and Privacy Office
832-824-2085
Email “Compliance Office”
Confidential Hotline
866-478-9070
www.mycompliancereport.com
(access code: TEX)
Lance Lightfoot
Vice President & General Counsel
Compliance & Privacy Officer
PATIENT PRIVACY
“Their Right, Our Duty”
Privacy and Security Starts With You
Patient Privacy
Everyone working at Texas Children’s has a duty to safeguard the protected health
information (PHI) of all of our patients. Our patients trust us with their confidential
information. We must do everything we can to protect their right to privacy. If you
are aware that PHI has not been properly secured, you have a duty to take immediate
action to safeguard the information.
Texas Children’s “Notice of Privacy Practices” is displayed throughout the campus and
is provided to every patient during their initial contact with Texas Children’s. It serves
to document our commitment to protecting our patient’s PHI. A copy of the notice
must be provided to patients upon request.
Protected Health Information (PHI) Examples
Patient Privacy
Identifying
Information
Contact
Information
Medical Record
Information
Insurance
Information
• Name
• Medical Record Number
(MRN)
• Social Security Number
(SSN)
• Date of Birth
• Address
• Phone Number
• Email Address
• Social History
• Diagnosis and Treatment
Information
• Dates of Service
• Full Facial or Comparable
Photographic Image
• Health Insurance
Beneficiary
Number
Any document or item that contains any of the listed identifiers above is considered
PHI. The majority of confidential information handled at Texas Children’s is PHI.
YOU are the most important safeguard of our patient’s PHI!
Patient Privacy Violations In The News
Patient Privacy
 Blue Cross Blue Shield Tennessee
agreed to pay a $1.5 million
settlement after 59 unencrypted
hard drives with data belonging to
more than one million individuals
were stolen from one of their
facilities.
 A password protected but
unencrypted desktop computer was
stolen from a Sutter Health Facility.
The computer contained PHI for
four million patients. A class action
lawsuit totaling $1 billion was filed
as a result of this breach.
Mobile Devices
Patient Privacy
Be vigilant about your use of mobile devices. These devices are often stolen or lost
and a large volume of data can be stored on these devices. Examples of mobile
devices include: laptops, desktop computers, USB flash drives, cell phones, cameras,
and video cameras.
Do not store documents on a mobile device unless it is password protected and
encrypted. Use secure network drives to store documents that contain any element of
PHI.
Generally, PHI should not be stored on unencrypted devices. If there is a situation
where an unencrypted device, for example a digital camera, must be used to store
PHI, the device must be physically secured, for example in a safe or locked in a storage
cabinet.
Access, Use, And Disclosure
Patient Privacy
Without written authorization, Texas Children’s may only access, use, and disclose
PHI for:
 Treatment - such as continuity of care, referral authorizations, and quality
review.
 Payment - such as to receive payment for services.
 Operations - to perform business functions.
It is wrong to access a patient’s PHI unless it is directly related to your official,
assigned job duty. In fact, it is a crime! Texas Children’s may terminate employees
found to have inappropriately accessed patient information.
Access, Use, And Disclosure (continued)
Patient Privacy
Keep in mind that you may not use your system access, for example EPIC or
PeopleSoft, for activities that are not directly related to your official assigned duties.
Every click within the EPIC system is traceable and the Privacy Office routinely audits
records to make sure access to PHI is appropriate.
Here are some things to remember:
 Do NOT access the records of patients that appear in news stories or television
programs.
 Do NOT access your own records, except for those in MOLI and My Chart.
 Do NOT access the records of your children, relatives, friends, neighbors, former
patients, or co-workers.
 Do NOT click on a patient’s name from the census of a different unit or another
Texas Children’s entity.
Privacy Measures – Sensitive Discussions
Patient Privacy
When you have a sensitive discussion which may contain PHI, keep the following
points in mind:
 Evaluate your surroundings for privacy.
 Keep your voice down.
 Verify identities before releasing information, including during phone calls.
 Verify at least three patient demographic elements, such as name, address, and
date of birth.
Privacy Measures – Using Computers
Patient Privacy
Adhere to proper privacy policies and practices by:
 Locking or logging-off workstations.
 Not sharing your password with anyone.
 Physically securing laptops and other mobile devices.
 Storing documents containing PHI on network drives, and only on mobile devices
when absolutely necessary.
 Only using your Texas Children’s email for work related business.
 Using Securemail when sending emails that contain confidential information
outside of the Texas Children’s or Baylor College of Medicine networks.
 Using the Rights Management Systems to control confidential emails that you
might send to others within Texas Children’s.
Privacy Measures – Handling Documents
Patient Privacy
 When handling documents that contain PHI, be sure to secure all materials. Do not
leave PHI in non-secure areas. Be sure to promptly remove documents from
copiers or fax machines.
 When sending documents containing PHI by mail, email, or fax, be sure to verify
names, addresses, and fax numbers before sending the documents.
Privacy Measures – Document Disposal
Patient Privacy
 When you dispose of documents with confidential information, do not dispose in a
regular trash can or recycling bin. There are locked shredding bins provided
throughout Texas Children’s for disposal of paper products.
 If you need to dispose of non-paper media, such as a CD, tape, or USB flash drive,
contact Records Management at 832-824-2054.
Privacy Measures – Patient Photography
Patient Privacy
 Patient images require the same policy safeguards as other elements of a patient’s
medical records. Texas Children’s Consent for Treatment authorizes photographs and
files related to the care and treatment of the patient.
 Photographs used for treatment purposes must be included in the patient’s medical
records. Any photograph for any other official purpose, for example for marketing
purposes, requires a separate authorization. There are no other means for obtaining
consent for photography.
 Workforce members are prohibited from taking photographs of patients for their own
personal use and may not take photographs of patients on their personal mobile phones
or cameras.
 Remember, cameras and video cameras used to take official photographs must be
properly secured at all times. Digital files must be removed promptly from unencrypted
devices and stored securely.
Privacy Measures – Social Media
Patient Privacy
Social media refers to online interactive tools that enable individuals and organizations
to publish, access, and share information electronically.
Examples include:
 Facebook
 LinkedIn
 MySpace
 Twitter
 YouTube
 Blogs
 Photo sharing services
 Discussion boards
Privacy Measures – Social Media (continued)
Patient Privacy
 It is not appropriate to use Texas Children’s resources, for example computers or
internet connections, for personal social media activity, nor is it appropriate to let
social media interfere with work commitments and responsibilities.
 Patient information, including photographs, should not be posted on a workforce
member’s personal social media sites, for example on Facebook.
 It is not appropriate to use personal communication devices, for example a cell
phone, in the vicinity of or within sight of patients. You should limit your use of
these devices during working hours; you may use them when you are away from
patient care areas, for example during a break time.
Breach Event Reporting Form
Patient Privacy
Texas Children’s has created a CONNECT Breach Event Reporting Form that workforce
members should use to report any instance in which PHI is misdirected, lost, stolen,
or otherwise inappropriately acquired, accessed, disclosed, or used.
This includes:
 Unauthorized acquisition, access, disclosed, or use of protected health
information. For example:
Inappropriate access (without a legitimate work purpose) of patient
records in Texas Children’s electronic medical record system.
As soon as you become aware of a potential privacy breach, you must take steps to
mitigate the breach. If there has been a breach and you are unsure what to do,
contact your leader or the Privacy Office.
Breach Event Reporting Form (continued)
Patient Privacy
Examples of accidental disclosures of protected health information you should
report are:
 Mail that has been sent to the wrong address.
 Faxes that have been sent to the wrong fax number.
 Email sent to the wrong recipients.
 Other documentation mix-ups (for example, handing documents intended
for one patient to another patient).
 Lost hardcopies of documents containing patient identifiable information
(name, MRN, DOB, etc.).
 Stolen or lost information assets containing protected health information
(laptops, desktops, USB storage drives, external hard drives, etc.).
Report Privacy Concerns
Patient Privacy
Your compliance with established policies mitigates the organization’s risk for privacy
incidents.
When workforce members violate our patients’ privacy it can:
 Disrupt patient care.
 Create negative publicity for our organization.
 Create a negative patient perception.
 Open the door to identity theft of patient information.
 Have civil and criminal penalties for individual workforce members and for the
organization.
 Cause disciplinary action to be taken against a workforce member, including
termination, as noted in the “Investigation of Privacy Violations Sanctions Policy”.
Report Privacy Concerns (continued)
Patient Privacy
Texas Children’s is required by law to take action when privacy rules are broken.
Some examples of how we may treat privacy breaches are by:
 Verbal counseling - a discussion with you and your leader. This is usually a
warning.
 Written counseling - a formal document placed in your personnel file.
 Suspension from work - the workforce member is not allowed to work for a period
of time, with or without pay.
 Termination.
If you are aware of any privacy issues, you should report them. You may also report
any concerns you may have about the physical security of your work area or about the
security of the network, a system, or a computing device.
Take a moment and review the chart on the next slide for contact information when
reporting concerns.
Report Privacy Concerns (continued)
Patient Privacy
Concern
Contact Information
General Privacy Concern
Privacy Office
832-824-2091
Confidential Hotline
866-478-9070
Security of a Network, System, or
Computing Device
IS Service Desk
832-824-3512
Physical Security of Work Area
Security Services
832-824-5400
INFORMATION SECURITY
“Protecting Our System”
Information Security Policies
Information Security
Texas Children’s must comply with many laws and regulations regarding the security of
confidential and proprietary information.
These include:
 Health Insurance Portability and Accountability Act of 1996 (HIPAA).
 Joint Commission.
 Payment Card Industry Data Security Standard.
 Many others.
Information Security Policies (continued)
Information Security
We have in place several policies related to information security. Everyone is required
to sign and attest to the guidelines in the Information Security Awareness Agreement
as a condition of employment. On the next few slides we will review the two policies
in bold.
Policy Name
Acceptable Use of Information Assets Policy
Electronic Mail Policy
Password Policy
Disposal of Confidential and Proprietary Information Policy
Handling of Confidential and Proprietary Information Policy
Employee Conduct Policy
Termination Policy
Acceptable Use of Information Assets
Information Security
Texas Children’s provides all employees with the resources to perform their job,
including individual user accounts, email addresses, access to workstations, and the
system network.
The “Acceptable Use of Information Assets Policy” describes the proper use of and
access to Texas Children’s computers, information systems and network resources, and
the proper management of these resources by authorized users. You are responsible
for any activity performed under your individual user account.
Information assets, such as computers, email, and network access are intended for
business use and may be monitored and reviewed anytime by authorized personnel.
User Passwords
Information Security
Passwords play an important role in securing sensitive, proprietary, or otherwise
protected information. The “Passwords Policy” outlines requirements for creating
strong passwords that provide enhanced security and restrict unauthorized access to
information.
Password requirements are as follows:
 Must be at least eight characters long.
 Must change every 90 days, or immediately if breached.
 Must contain at least three of the following character types:
 English uppercase characters (A-Z).
 English lowercase characters (a-z).
 Base 10 digits (0-9).
 Non-alphanumeric characters (!, $, #, %).
User Passwords (continued)
Information Security
Never share passwords with anyone!
 No one at Texas Children’s will ever request your password either verbally or
through email.
 Remember, each Texas Children’s user remains personally responsible for the usage
under his or her user ID and password.
Email Security - Securemail
Information Security
Email to external recipients containing confidential information, including PHI, must be
sent using Texas Children’s Securemail.
To send a message securely through Outlook, Outlook Web Access, or a mobile phone,
type the following in the subject line of the email: an exclamation point, then the
word secure, and then another exclamation point (!secure!), and then send your email
as you normally would. The system will encrypt the message automatically.
The user will receive a notification on how to access the confidential information. The
next slide shows you an example of what a Securemail would look like.
Email Security – Securemail (continued)
Information Security
To view complete instructions regarding how to use Securemail go to the TCH
CONNECT intranet site, then search “securemail”.
Email Security - Phishing
Information Security
You also need to be wary of email that comes from sources you do not recognize. If
you receive a Phishing email, please delete it immediately.
Phishing is a type of spam in which someone fraudulently attempts to acquire
sensitive information such as user names, passwords, or credit card information via
email. Usually the email will appear to come from a trustworthy source like a credit
card company or a bank. If you are not sure about a suspicious email, contact the IS
Service Desk at 832-824-3512 to confirm.
Be cautious about opening attachments within an email message. Phishers or hackers
commonly use attachments in an attempt to compromise Texas Children’s network.
Open attachments only from known and trusted sources.
Internet Usage
Information Security
You may see certain notifications pages when you attempt to visit certain websites.
 Human Resources Notice - displays when the site you are attempting to visit is not
considered to be a legitimate business site. If the site has genuine business value,
and you still want to access it, click on the “continue to site” link.
 Blocked Website Notice – displays when you attempt to visit a site that is blocked
by Texas Children’s policy, you will see a Blocked Category notification page. You
will not be able to access this site, but you may request that this site become
unblocked if you believe that you have received the message in error or that the
site should not be restricted.
 Uncategorized Website Notice – displays when you are attempting to visit a site
that is uncategorized and may pose a security risk. Be cautious about clicking the
“continue” link to access these types of sites.
Other Security Safeguards
Information Security
 Never download software from any outside source. All software must be installed
through the Information Services Department. This is to protect Texas Children’s
from viruses and to ensure compliance with software licensing agreements.
 Texas Children’s information should not be stored on any type of personal mobile
device or portable storage device, such as a Flash drive, as these can easily be lost
or stolen. Flash drives can also introduce viruses to our network. If there is a
special business need for storing information on a storage device, the device must
be encrypted or stored securely.
Reporting Information Security Incidents
Information Security
It is important for all workforce members to report information security incidents.
Information security incidents include but are not limited to:
 A lost or stolen workstation or laptop.
 A stolen user password.
 Suspicious email such as phishing, etc.
If you need to report a lost or stolen workstation or laptop:
 First inform your supervisor or manager immediately.
 Then notify the Security Service Center at 832-824-5488.
 Finally contact the Information Services Service Desk at 832-824-3512.
FRAUD AWARENESS & PREVENTION
“Protecting Our System”
The Fraud Triangle
Fraud Awareness & Prevention
Fraud is the deliberate deception to secure unfair or unlawful gain.
There are three circumstances that lead to fraud, which are known as the fraud
triangle:
1. The incentive to commit fraud.
2. The opportunity to carry out the fraudulent act.
3. The ability to rationalize or justify the fraud.
Examples Of Fraud
Fraud Awareness & Prevention
Asset Misappropriation
• Theft
• Payroll fraud – falsifying overtime, “buddy” clocking for someone else
• False or padded expense reimbursements
• False invoicing
• Upcoding of medical charges for services not performed
Corruption
• Bribes
• Accepting illegal gratuities
• Engaging in conflicts of interest
• Extorting illegal payments from third parties
Financial Statement Fraud
• Intentional misstatement or omission of material information from financial reports
Fraud Warning Signs
Fraud Awareness & Prevention
Warning signs include:
• Odd or irregular transactions
• Missing or altered documents
• Lack of adequate supporting documentation for transactions
• Missing or unverified inventory or physical assets
• No reconciliation or unexplained reconciliation of items
• Shortages in cash on hand
• Abnormal expenditures for external services
• Unauthorized changes to employee time worked
Your Responsibilities
Fraud Awareness & Prevention
The minimization of fraud, waste, and abuse is EVERY employee’s responsibility.
Leaders should:
• Ensure the appropriateness of all requests including from established vendors,
check requests, and expense authorizations
• Frequently review financial information for validity and accuracy
• Encourage an effective internal control environment
• Convey the importance of the Code of Ethical Behavior to all team members
• Be a role model and lead by example
All employees should report:
• Illegal, fraudulent, or suspicious activity
• Financial misstatements
• Accounting or auditing irregularities
• Conflicts of interest, dishonest or unethical conduct
• Violations of the Code of Ethical Behavior
• Violations of other laws, rules, or regulations
Your Responsibilities (continued)
Fraud Awareness & Prevention
The minimization of fraud, waste, and abuse is EVERY employee’s responsibility.
All employees should report:
• If fraudulent activity is suspected, DO NOT confront the person or investigate on
your own.
• Texas Children’s has a no retaliation policy in place for all reports made in good
faith.
• You can report fraudulent activity to:
• Your leader
• The Texas Children’s Compliance Department
• The Texas Children’s Confidential Hotline (866-478-9070)
• Online at www.mycompliancereport.com (Access code: TEX)
LANGUAGE INTERPRETER SERVICES
“Patient’s Rights”
Patient’s Right – Preferred Language
Language Interpreter Services
Communication and Interaction is a vital component of everything we do at Texas
Children’s. The Joint Commission standard RI.01.01.03 states that all patients have the
right to receive communication in their preferred language.
Communicating in the patient’s preferred language helps to reduce potential risks
caused by ineffective or incomplete communication.
Some examples of potential risks that may occur when not communicating in the
patient’s preferred language are:
 An increase in medical errors or events.
 An increase in non-compliance with the treatment plan or follow-up.
 Poor treatment outcomes.
Bi-lingual Competency And Safe Practice
Language Interpreter Services
The Joint Commission standard JC 01.06.01 requires that Texas Children’s as an
organization assess the competency of activities performed by staff as part of their
daily work.
This standard includes all bi-lingual staff who are communicating with or interpreting
for non-English speaking patients and families during medical encounters.
Bi-lingual Competency And Safe Practice (continued)
Language Interpreter Services
In order to be validated to communicate and/or interpret during medical encounters,
you must successfully complete:
 A test that validates language fluency and appropriate use of medical terminology.
 An online training module on the ethics and standards for interpreting.
If you do not complete both of these requirements to be a validated communicator or
interpreter at Texas Children’s, you should not be communicating or providing
interpretation during medical encounters.
If you wish to become a validated interpreter or if you are unsure of the need to be
validated based on your job responsibilities, please contact Language Services at 832824-5200 for assistance.
Language Encounters
Language Interpreter Services
Texas Children’s services a variety of patients including local, national, and
international patients.
For this reason, and because Joint Commission requires staff to know the most
common languages spoken by patients and families at Texas Children’s, the chart on
this slide shows you the most frequently spoken languages, other than English, at our
organization.
Frequently Spoken Languages
(Other Than English)
Percent
Spoken
62%
11%
5%
4%
3%
3%
3%
9%
When To Provide Services
Language Interpreter Services
Helping patients and families receive communication in their preferred language may
trigger the need for interpreter services. At Texas Children’s, interpreter services are
provided in a variety of ways including by telephone, video, and face-to-face,
depending on the need and location.
Interpreter/language services must be provided to patients and families when:
 Patients or families speak some English but are more comfortable communicating
in a preferred language, such as Spanish.
 Medical information needs to be provided.
 Consent for medical treatment is needed or sought.
 Informed consent is required or sought.
In addition, staff should avoid using a patient’s family members as interpreters. Family
members may not understand medical terminology, and may not provide all the
information in an effort to protect the patient from bad news.
When To Provide Services (continued)
Language Interpreter Services
Service
Telephone Interpretation
Best Provided When
• Patient encounters are less than 15 minutes.
• Scheduling or completing an explanation of
benefits is required.
• Discussing consents or completing follow-up
calls, triage, and vitals.
Service Details
Dial *9123 from any TCH phone and
press:
1 - if calling from Pavilion for Women
2 - if calling from Main Campus
3 - if calling from West Campus
(available 24/7 in 200 languages)
Video Interpretation (Martti)
• Other language services, such as sign language,
are not available.
• There are pre-op or follow-up visits.
Located in areas such as the EC,
Critical Care Center, Health Centers,
and some clinics.
Call Language Service if you need a
Martti delivered for a patient
encounter.
(available 24/7 in 39 languages)
TCH Spanish/Arabic Interpreter
(face-to-face)
• Discussing complex medical situations or a new
diagnosis.
• Discussing highly emotional or traumatic
situations.
Call Language Services at 832-8245200 to request a validated
interpreter.
DIVERSITY AND INCLUSION
“Valuing Individuals”
Texas Children’s Values
Diversity and Inclusion
At the heart of Texas Children’s mission is a set of core values that guide us individually
and collectively as an organization. Texas Children’s values bring clarity to our mission
by defining specific positive behaviors that are essential to all of our peer and patient
interactions.
EMBRACE FREEDOM
LEAD TIRELESSLY
LIVE COMPASSIONATELY
AMPLIFY UNITY
Diversity
Diversity and Inclusion
Texas Children’s creates and fosters a work environment that attracts, welcomes,
supports, and develops a diverse organization. A critical part of this is for every
individual to feel valued for their contribution to the mission of Texas Children’s. All of
us are responsible for embracing and nurturing a culture of inclusion in our work
areas.
Some important components of diversity include:
 Maximizing the contributions of individuals from diverse backgrounds, education,
and organizational affiliation by utilizing their capabilities, insights, and ideas to
collaborate effectively.
 Better serving and interacting with our patients and families in ways that
demonstrate an understanding of different cultures, religions, traditions, and
languages.
 Promoting Texas Children’s as the best place to work and receive care.
Dimensions of Diversity
Diversity and Inclusion
It is also important to understand the Dimensions of Diversity, because these
dimensions help to influence our behaviors, attitudes, values, and drive the way we
communicate and interact with each other.
One way to think about Dimensions of Diversity is to understand that some
dimensions are things you can easily see in others, for example a person’s gender,
while other dimensions are not readily recognizable, such as a person’s educational
background or diversity of thought or experience.
Dimensions of Diversity (continued)
Diversity and Inclusion
It is essential to talk to coworkers, and other customers in a respectful manner and to
understand how we may be the same or differ on various dimensions, even if they are
not obvious. To fully embrace our values, we must be respectful with our words and
actions to show we value others.
When we understand these dimensions, we can:
 Better serve our patients, their families, and other customers.
 Understand what is unique and special about others.
 Maximize their contributions to Texas Children’s ongoing success.
 Find value and richness when interacting with co-workers.
Harassment Free Workplace
Diversity and Inclusion
Texas Children’s is committed to providing a workplace free of harassment and
inappropriate and disrespectful conduct. We maintain a strict policy of prohibiting
such conduct and provide reporting mechanisms and processes to address any related
concerns.
It is important to understand that our policy prohibits inappropriate conduct, whether
or not such conduct is sufficient to establish a legal claim of harassment. All workforce
members, both management and non-management, are expected to adhere to this
policy and are responsible for assuring that a workplace free of harassment and
inappropriate and disrespectful conduct is maintained.
Harassment Free Workplace (continued)
Diversity and Inclusion
If you feel like you have been harassed, express your discomfort with the behavior
immediately, regardless of the position held by the individual engaging in the behavior.
You can bring the matter to the attention of your department leader, Employee
Relations, and/or call the Compliance Hotline.
All complaints will be treated seriously and will be promptly and thoroughly
investigated by Employee Relations. Complaints will be treated confidentially to the
extent possible in conducting a thorough and fair investigation.
Following an investigation, Texas Children’s will immediately take any necessary and
appropriate disciplinary action. If you have made a complaint but feel that the action
taken in response has not remedied the situation, you should notify your department
leader, Employee Relations, and/or call the Compliance Hotline. No employee making
a report in good faith will be punished for making the report, nor will retaliation be
tolerated.
Harassment Free Workplace (continued)
Diversity and Inclusion
It is important to understand that our policy prohibits inappropriate conduct, whether
or not such conduct is sufficient to establish a legal claim of harassment.
MID-COURSE REVIEW
SUBSTANCE ABUSE
“What Every Employee Should Know”
What Are The Consequences
Substance Abuse
Substance abusing employees often do not make good employees.
Studies show that, compared with non-substance abusers, they are more likely to:
 Change jobs frequently - individuals who use alcohol are more likely to have
changed employers 3 or more times in the past year.
 Be late to or absent from work - it is estimated that substance abuse causes 500
million lost workdays annually.
 Less productive - a substance abuser will function at about 67% of his or her
capacity.
 Involved in workplace accidents - nearly 40% of fatalities and 47% of injuries can
be linked to alcohol consumption and alcoholism.
 File a workers’ compensation claim - substance abusers are 5 times more likely to
file a workers’ compensation claim, and they cost American businesses over $100
billion annually.
Policy And Procedure
Substance Abuse
Because of the costs and consequences of substance abusing employees, almost every
company in the United States has a substance abuse policy. Texas Children’s policy
reads:
“Texas Children’s is committed to protecting the safety, health, and well-being of
its workforce members, patients, and guests.
Texas Children's recognizes that drug and alcohol abuse pose a direct and
significant threat to this goal, and to the goal of a productive and efficient
working environment in which all workforce members have an opportunity to
reach their full potential. Texas Children's is committed to ensuring a substanceabuse-free working environment for all of its workforce members, and
underscores that commitment through implementation and enforcement of the
Substance Abuse Prevention Policy.”
Policy And Procedure (continued)
Substance Abuse
The rest of the policy explains the who, what, why, and how of substance abuse
prevention at Texas Children’s. You probably received a copy of the policy and signed an
acknowledgement stating such.
Another document that is used whenever making a report of possible impairment due
to substance abuse is the “Substance Abuse Prevention For Cause Observation Report”
and is located in the appendices of the “Substance Abuse Prevention Policy”.
What You Can Do
Substance Abuse
As you read a moment ago, “Texas Children’s is committed to protecting the safety,
health, and well-being of its workforce members, patients, and guests.” We all share
this commitment as employees of Texas Children’s. Reporting your observations
shows that commitment.
 Recognize the signs associated with substance abuse. We will review those on the
next slide.
 Report it to your leader. Many people find it fairly easy to spot the signs and then
find it very difficult to report their observations.
Recognize The Signs
Substance Abuse
There are four categories of signs that treatment professionals use to identify alcohol
and drug abuse problems in employees.
Category
Signs
Physical
Weariness/exhaustion; untidiness; depression/anxiety; blank stares; irritability;
slurred speech; suspiciousness; unsteady walk; emotional instability; apathy;
frequent use of breath mints; dilated pupils; frequent and unusual use of
sunglasses or eye drops.
Absenteeism
Frequent unreported absences from work areas more than usual or necessary;
unusually high incidence of such common ailments such as colds and headaches;
consistently unplanned Monday/Friday absences; frequent use of unscheduled
vacation time; repeated two-to-four day absences.
Work Patterns
Inconsistent work quality; difficulty in recalling instructions; fluctuating periods
of productivity; use of more time to complete work/increased missed deadlines;
poor judgment/more mistakes than normal; increased difficulty in handling
complex situations; shortened attention span.
Personal Relationships
Overreaction to real or imagined criticism; frequent borrowing of money;
avoidance of and withdrawal from peers; domestic complaints from co-workers;
persistent job transfer requests.
Reporting
Substance Abuse
Reporting your observations and suspicions about an impaired employee is everyone’s
responsibility.
Texas Children’s policy states that workforce members must report, in a confidential
manner, to their leader:
 Any individual suspected of being under the influence of drugs and/or alcohol
while on duty.
 Any indications that an individual is not performing job functions in a way that
ensures work safety or performance.
 Any individual suspected of violating the Substance Abuse Prevention Policy.
Having a leader verify your observations helps to make the case for possible
interventions and protects you from misinterpreting the facts.
Remember that when you report your suspicions of an employee abusing substances,
the information is considered confidential and they will not be able to give you
information about what happens.
Reporting Blocks
Substance Abuse
There are primarily two blocks to reporting:
Denial
Enabling
Denial is a person’s refusal
to believe that a problem
exists.
Enabling is when we use our
natural instinct to help, but
end up only making it
possible for the substance
abuser to continue to abuse
substances.
Denial and Enabling block reporting and puts you in danger of not following policy.
The consequences for not reporting can put the patients and families, our coworkers,
TCH, and ourselves in harm’s way.
Reporting Blocks – Denial
Substance Abuse
Denial
Denial is a person’s
refusal to believe that a
problem exists.
The substance abuser uses all kinds of excuses to deny they have a problem and that it
is affecting their work or life despite evidence to the contrary. Coworkers deny there
is a problem by failing to report it. We tend to believe that this couldn’t actually
happen at TCH or to our coworker who knows better. The truth is it does happen.
Remember, Department of Labor statistics indicate that approximately 1 out of every
10 people in the United States abuse substances and the percentage is even higher in
health care.
Reporting Blocks – Enabling
Substance Abuse
Enabling
Enabling is when we use our natural instinct
to help, but end up only making it possible
for the substance abuser to continue to
abuse substances.
Common enabling behaviors are:
 Misdirected compassion - because you don’t want them to get in trouble, lose
their job, or lose their professional license instead of realizing you may be saving a
life - theirs, a patient’s, or maybe yours.
 Giving them “one more chance” - then another and another.
 Ignoring the problem - because they get so defensive when you bring it up or you
hope that it will magically go away.
Reporting Blocks – Enabling (continued)
Substance Abuse
 Avoiding problems - by keeping the peace, believing a lack of conflict will help, or
covering up.
 Repeatedly coming to the “rescue“ - like loaning them money or sending them
home to sleep it off.
 Joining them in the behavior - when you know they have a problem with it.
 Joining them in blaming others - for their own feelings, problems, and
misfortunes.
 Accepting their justifications, excuses and rationalizations - such as "I'm
destroying myself with alcohol because I'm depressed."
 Doing their work or failing to act on promises of consequences.
One possible consequence for failing to report suspected substance abuse or its
effects is termination or other adverse employment actions.
You Can Make A Difference
Substance Abuse
You can help keep TCH safe and help a coworker get the help they need to recover
from their substance abuse. You just need to recognize the signs and report your
observations to a leader. Remember that denial and enabling are blocks to keeping
TCH safe. Don’t let them be blocks that keep you from reporting.
In fact, your actions to report are their best chance to get help. Statistics show that
people are more likely to change addictive behaviors when they have something like
their jobs to lose.
If you are unsure about what to do, you can always call the Employee Assistance
Program (EAP). The EAP has a lot of experience helping people get into treatment. An
employee who voluntarily discloses a substance abuse problem to the EAP will be
given every opportunity to recover and the support to stay clean and sober in the
most confidential manner possible.
Getting Help
Substance Abuse
Employee Assistance Program
Meyer Basement: MB 1201
1919 S. Braeswood Blvd, Suite 1301
Houston, TX 77030
Main: 832-824-2155
Fax: 832-825-2142
Page operator evenings and weekends
West Campus by appointment only
PATIENT SAFETY
“It Takes Everyone”
It Takes Everyone
Patient Safety
It takes everyone – physicians, staff, patients, volunteers, and visitors – to continue to
improve patient safety. It’s everyone’s responsibility.
While medical errors are not new, the issue of patient safety has moved to center
stage both politically and publically, in recent years. No one comes to work planning
on making a mistake. Yet, in spite of our best efforts, mistakes can happen. Patient
safety requires establishing environmental awareness and a workforce that creates
and sustains processes that minimize risks.
Two important ways we can create a culture of safety are to:
• Adhere to proven safety behaviors.
•
•
•
•
Make a personal commitment to safety.
Support a questioning attitude.
Use clear, complete communication.
Report dangerous situations, including near-miss events.
It Takes Everyone (continued)
Patient Safety
One way to make significant improvements in healthcare delivery is to know as much
as possible about events. We urge all employees to pay close attention, actively
respond, and report concerns when they see or hear about dangerous situations.
Here are some key concepts to keep in mind.
It takes everyone. Everyone needs to report dangerous situations, including near-miss
events.
Report problems. Texas Children’s staff can’t improve processes if problems are not
reported and brought to light.
Involve leadership. Staff should report any and all events to their leader, Risk
Management, and/or Patient Safety using the appropriate procedures.
Types Of Events
Patient Safety
Dangerous Situations are errors that reach a patient and may or may not result in
harm. These situations can be classified as:
• Precursor Safety Events – errors that reach the patient and result in minimal or no
detectable harm. For example, a patient is given the wrong medication and
experiences no adverse side effects.
• Serious Safety Events – errors that reach the patient and result in moderate to
severe harm or death. For example, a patient is given an over-dose of a
medication and experiences a serious arrhythmia requiring CPR and the patient
dies.
Near-Miss Events are errors that do not reach the patient but are caught by a
detection barrier or by chance.
–
–
Example of a near-miss caught by a detection barrier – while going through the steps of safe
medication administration, the nurse realized that the label on the medication does not match the
patient’s identification bracelet. She does not administer the drug.
Example of a near-miss caught by chance – the family expresses a concern that the pill looks
different than the pill usually given to the patient. The nurse contacts the pharmacy to double check
the medication. The medication is held.
Sentinel Event
Patient Safety
A Sentinel Event is defined by The Joint Commission as an unexpected occurrence
involving death or serious physical or psychological injury or risk thereof.
Unlike a Serious Safety Event, Sentinel Events do not require that there is a deviation
in the standard of care. For example, an abduction of a patient can occur while there
is no breach in policy or procedure. Therefore, this is a Sentinel Event and not a
Serious Safety Event.
Other examples of Sentinel Events are:
 Discharge of an infant to the wrong family.
 Suicide of any patient receiving care.
 Hemolytic transfusion reaction involving administration of blood.
 Unintended retention of a foreign object after surgery or other procedure.
Reporting Errors Or Concerns
Patient Safety
In order to sustain a culture of safety, every workforce member must be willing to
report errors, near-miss events, and other safety concerns. Only then can everyone at
Texas Children’s work together to learn what happened, why it happened, and what
can be done to prevent a similar event from happening in the future.
Reporting an error or safety concern puts the children and families that we serve first.
To report an error, use one of the following reporting mechanisms:
 Report safety concerns to your leader.
 Complete the online Event Reporting Form (Safety Scoop), which can be found
on CONNECT by clicking on the Event Reporting link under the heading
Employee Resources.
 Call Texas Children’s confidential hotline at 866-478-9070.
 Call Risk Management at 832-824-1220 or Patient Safety at 832-824-1362.
Joint Commission
Patient Safety
Joint Commission requires organizations like Texas Children’s to inform all staff,
including medical staff, that if they have safety or quality of care concerns, they may
report those concerns directly to The Joint Commission either by emailing
[email protected] or calling 800-994-6610.
In addition, the requirement states that the organization will not retaliate or take
disciplinary action against an employee or physician for reporting safety or quality of
care concerns to The Joint Commission. Texas Children’s supports this requirement
through our “Non-Retaliation Protection of Whistleblowers Policy”.
Magnetic Resonance Imaging Safety
Patient Safety
Magnetic Resonance Imaging equipment, or MRI, uses a strong magnetic field and
radio waves to produce diagnostic images. Safety precautions are necessary to ensure
the safety of everyone who enters MRI rooms.
The following safety facts on MRIs are very important to keep in mind:
 All person’s and equipment entering MRI rooms must be screened by an MRI
Technologist to ensure safety.
 All metal brought into the MRI room could cause injury or death due to the strong
magnetic field of the MRI machine.
All of these items have potential to become dangerous projectiles!
 The magnetic field of an MRI scanner could interfere with implants, like pace
makers, as well as move or shift tiny metal fragments in an individual’s body.
Food And Drink In Patient Care Areas
Patient Safety
No staff food is allowed in patient care areas. Drinks that are in non-spillable
containers are allowed. Soda cans, open cups, coffee containers with lids with slits, or
cups with lid/straws are not allowed in patient care areas.
Patient care areas include team communication areas, patient hallways, treatment and
clean utility rooms, and patient rooms. Non-patient care areas are break rooms,
conference rooms, lounges, and offices.
Non-Spillable Containers Allowed
Drink Containers Not Allowed
QUALITY IMPROVEMENT
“Providing Better Outcomes”
Quality Improvement Is For Everyone
Quality Improvement
Quality improvement is a part of the work we do everyday at Texas Children’s. It is the
right thing to do for our patients and patient families.
Each of us has a role in improving our work so that patient care and activities that
support patient care are improved, resulting in better outcomes and excellent
performance.
There are many models for quality improvement. Texas Children’s uses four models:
1. Donabedian’s Framework
2. The Model for Improvement
3. Fishbone Diagram
4. Lean Six Sigma
Donabedian’s Framework
Quality Improvement
The Donabedian’s Framework consists of a structure, process, and outcomes
framework, which helps us think of our work in terms of systems.
Structure – We all work within the Texas Children’s organizational structure and also
within department or clinic structures. Additional structures can include reporting
and accountability structures, for example, organizational chart and committee
structures.
Lance Lightfoot
Vice President & General Counsel
Compliance & Privacy Officer
Donabedian’s Framework (continued)
Quality Improvement
Process – The processes are what we do. Processes are a series of activities that
generate an output. For example, a nurse taking care of a patient obtains the patient
history, assesses the patient, designs the goals for the patient, administers
medications and treatments, and documents the care given. These are all examples of
processes.
Outcomes – The outcomes are generated or influenced by the structures and
processes.
Most problems reside within a system, not with the people within the system. We can
all learn to work on improving the system together to make care better, safer, and give
our patients and families a meaningful experience.
Lance Lightfoot
Vice President & General Counsel
Compliance & Privacy Officer
The Model For Improvement
Quality Improvement
The Model for Improvement provides a
systematic approach for planning, testing,
and implementing change made in systems
and processes. The model focuses on:
• Identifying the problem and targeting the
team’s efforts towards a common aim
• Measuring along the way to obtain
feedback on how effective the change is
in reaching the aim
• Analyzing the data to determine which
changes are making the targeted
improvements
The Plan-Do-Study-Act cycle allows for
learning so that changes can be made
through a data-driven approach, provide
documentation of the improvement, and can
be adapted to many different environments.
Aim
Measure
Change
Cycles of
Improvement
Fishbone Diagram
Quality Improvement
The Fishbone Diagram, also called the Cause and Effect Diagram, is a tool to help us
identify possible causes of problems and relationships between possible causes.
Lance Lightfoot
Vice President & General Counsel
Compliance & Privacy Officer
Fishbone Diagram (continued)
Quality Improvement
Each of the diagonal lines, or bones of the fish, represents a cause, which ultimately
leads to the problem, or the head of the fish.
One example of a problem is the incomplete registration received from the patient
family. There are many factors that can create this problem. For example, the printer
that prints the registration forms can be continuously running out of ink or there may
be too many distractions for the family member and he/she is not able to complete
the necessary forms.
Understanding the possible causes of the problem helps lead to better solutions.
Lance Lightfoot
Vice President & General Counsel
Compliance & Privacy Officer
Lean Six Sigma
Quality Improvement
Lean Six Sigma is a process improvement methodology derived from the principles of
Lean and Six Sigma.
Lean focuses on the continuous elimination of waste to improve flow, productivity,
and customer satisfaction.
Six Sigma concentrates on the reduction of defects and variability within a process to
improve consistency and throughput.
Lance Lightfoot
Vice President & General Counsel
Compliance & Privacy Officer
INFECTION CONTROL
“It’s In Our Hands”
Healthcare Associated Infection
Infection Control
A Healthcare Associated Infection, or HAI, is an infection that a patient acquires while
in our care. It is everyone’s responsibility to keep our patients safe and prevent the
transmission of a HAI.
Everyone can assist in preventing the spread of infections by:
 Following standard precautions in the care of every patient.
 Performing proper hand hygiene before and after every patient contact.
 Providing appropriate equipment and environmental cleaning.
 Initiating isolation – based on symptoms, diagnosis, or history.
REMEMBER a physician’s order is not required to implement isolation.
Multi-Drug Resistant Organisms
Infection Control
Some infections may be resistant to antibiotics that are commonly used for treatment.
These infections are called Multi-Drug Resistant Organisms or MDRO.
Common MDROs include:
 Methicillin Resistant Staph Aureus (MRSA).
 Multiple Drug Resistant Pseudomonas Aeruginosa (MRPA).
 Vancomycin Resistant Enterococcus (VRE).
All patients with a history of having an infection or patients who now have an active
infection with any MDRO, except for VRE, should be placed in Contact Precautions,
which is designated by a pink sign. Patients with VRE should be placed in Special
Contract Precautions
Multi-Drug Resistant Organisms (continued)
Infection Control
In addition to MDROs, there are other resistant organisms which may require
isolation. Your infection Control Practitioner should notify you when you need to
isolate these patients.
The guidelines for the discontinuation of isolation for MDROs can be found in the
“Isolation Precautions Procedure”.
If you have any other questions about discontinuing isolation, please contact Infection
Control.
Hand Hygiene
Infection Control
Keeping your hands clean is the single most important thing you can do to prevent the
spread of infections. If hands are not visibly dirty, an alcohol-based hand rub should
be used for routine decontamination. This is the preferred method for hand hygiene,
unless hands are visibly dirty.
Procedures for using alcohol-based hand rub:
 Dispense a small amount of alcohol-based hand rub into the palm of your hand.
 Rub the hand rub over the entire surface of the hands and between the fingers
until dry.
 Never use a paper towel to dry your hands after using an alcohol-based hand rub.
Hand Hygiene (continued)
Infection Control
Remember, gloves are NOT a replacement for hand hygiene. You should ALWAYS
perform hand hygiene before and after gloving.
Hand Hygiene – Fingernail Policy
Infection Control
All healthcare workers, including volunteers, who care for patients directly must have
short, clean, and natural fingernails. No artificial nails, tips, jeweled insets, nail
shellac, or overlays should be worn by direct patient care providers.
This also applies to healthcare workers who prepare medications or serve food.
Tuberculosis – Signs and Symptoms
Infection Control
Tuberculosis (TB) is an airborne disease that affects the lungs or other organs where
the lymph system may be involved. TB may be transmitted by inhalation or respiratory
secretions from infected individuals.
Generally very young children cannot transmit TB since they cannot cough forcefully
enough to generate sputum; however, adults are more efficient transmitters.
Signs and symptoms of active TB are:
 Fever
 Malaise
 Night sweats
 Cough
 Unexplained weight loss
 Blood in sputum
Tuberculosis – Evaluation Criteria
Infection Control
Pediatric patients with suspected or confirmed TB are evaluated for infection using the
same evaluation criteria as adults. These children must be placed in airborne
isolation.
Because family members are usually the source of infection, parents and other care
givers should do the following:
 Be evaluated for TB as soon as possible.
 Wear surgical masks when in the hospital setting until an evaluation is complete.
Tuberculosis – Engineering (Physical) Controls
Infection Control
There are two types of engineering controls:
 Isolation rooms with special ventilation called “negative pressure airflow”. Patients
suspected or known to have active TB should be placed in these rooms and the
doors are kept closed. Facilities Operations ensures that a room is under “negative
pressure”. To verify that the room is operating properly, call Facilities Operations.
 Airborne isolation procedures should be maintained until the patient is no longer
contagious, as determined by Infection Control. Only the healthcare workers who
have been fit tested with the special N-95 respirator should be providing patient
care to patients with suspected or confirmed TB. Fit testing should be redone
every year.
Tuberculosis – Engineering (Physical) Controls (continued)
Infection Control
Suspected or confirmed pediatric TB patients are only admitted to the following
main campus units:
 7 West Tower (Progressive Care Unit)
 12 West Tower
 14 West Tower
 PICU – Main Campus
 2 and 3 West – West Campus
 Pavilion for Women – any unit with a negative pressure room
Before ruling out TB and discontinuing airborne isolation, clinical staff must first
contact the Infection Control Department.
Tuberculosis – Work Process Controls
Infection Control
All eligible employees may be required to take a tuberculin skin test as frequently as
every year. The frequency is determined by the Infections Committee. This test
determines whether an employee has been infected with Mycobacterium Tuberculosis.
The following work process controls are in use for TB:
 If the TB test is positive, the employee will receive a chest x-ray to rule out active TB.
 Employees will be given an opportunity, if appropriate, to take preventative
medication for at least six months to deter active TB.
 An employee with active TB must not work until drug treatment is started, his or her
cough has subsided, and three sputum samples test “negative” for the disease, as
determined by a physician.
 Employees must be cleared by Employee Health before returning to work.
Bloodborne Pathogens
Infection Control
Bloodborne Pathogens are communicable diseases that are transmitted by blood or
other body fluids, including but not limited to semen and vaginal secretions.
All body fluids visibly contaminated with blood should be considered as potentially
infectious for:
HBV – the virus that causes Hepatitis B.
HCV – the virus that causes Hepatitis C.
HIV – the virus that causes AIDS.
Bloodborne Pathogens – Hepatitis B (HBV)
Infection Control
Hepatitis B (HBV) is a liver disease that is caused by a virus and can alter liver function.
How is HBV spread?
It is spread by contact with an infected person’s blood or other bodily fluids.
Anyone with occupational exposure to blood is at risk of contracting HBV.
What are the signs and
symptoms of HBV?
HBV can make you feel like you have the flu. You might experience fatigue,
nausea, diarrhea, fever, or loss of appetite. Some people who are infected
with HBV produce dark yellow urine and/or light colored stool. They may also
have yellowish eyes and skin.
How can employees protect
themselves from HBV?
The OSHA Standard of Bloodborne Pathogens requires employers to offer the
Hepatitis B vaccination, which is a series of three injections given over a six
month time frame, within the first 10 days of employment.
The vaccine series is free to all employees who may be exposed to blood or
other potentially infectious materials as part of their job duties. Those at risk
should use appropriate Personal Protective Equipment and appropriate safety
devices to protect themselves from HBV.
What if an employee declines
the vaccination?
Employees who decline the HBV vaccination must complete a declination
form which is kept on file. At any time after an employee initially declines the
vaccine, he or she may still take it in the future.
Bloodborne Pathogens – Hepatitis C (HCV)
Infection Control
Hepatitis C (HCV) is an infection of the liver caused by a virus. It is less common than
Hepatitis A or Hepatitis B.
How is HCV spread?
HCV is spread by contact with an infected person’s blood. In rare cases, a
person could get Hepatitis C from sexual contact with an infected person.
Some blood transfusions or organ transplants conducted before 1992 have
resulted in exposure to the virus, since prior to that time, healthcare facilities
did not test to detect Hepatitis C antibodies.
What are the signs and
symptoms of HCV?
Typically Hepatitis C infections have no symptoms for a period of years. Most
cases of HCV are identified when people have liver tests or HCV antibody
tests are done before donating blood. Some people eventually experience
flu-like symptoms with fatigue, nausea, diarrhea, and loss of appetite. They
may have dark yellow urine, light colored stools, or yellowish eyes or skin.
How can employees protect
themselves from HCV?
Currently no vaccine exists to prevent Hepatitis C. Studies have found that
healthcare workers exposed to the virus, through a needle stick or other
injuries that enter the skin, have become infected at an average of 1.8% per
injury. Those at risk should use appropriate Personal Protection Equipment
and appropriate safety devices to protect themselves from Hepatitis C.
Bloodborne Pathogens – Human Immunodeficiency Virus (HIV)
Infection Control
Human Immunodeficiency (HIV) is the virus that causes AIDs. The virus is passed
from one person to another through direct blood to blood contact. HIV kills an
important kind of blood cell, the CD4 T Lymphocyte or T cell. As the T cells die off, the
body becomes more and more vulnerable to other diseases, called opportunistic
infections. When a person with HIV gets those infections, or if their CD4 T cell levels
become too low, they may contract AIDS.
Who is at risk for contracting
HIV?
Employees whose job duties involve potential contact with a patient’s blood
or other hazardous bodily fluids in a healthcare setting are at risk.
How can exposure to HIV
occur?
Exposures can occur through needle sticks, cuts, lacerations, and contact
with non-intact skin or mucous membranes.
Bloodborne Pathogens – Standard Precautions
Infection Control
To protect against exposures to Bloodborne Pathogens, employees should use
Standard Precautions. Complying with these precautions will help to maintain a safe
work environment for everyone.
Some examples of standard precautions are:
 Properly using Personal Protective Equipment (PPE) like respirators, goggles,
gloves, gowns, masks, and safety sharps.
 Removing all contaminated or dirty gloves promptly.
 Disposing of all sharps in designated containers immediately after use.
 Disposing of closed, locked sharps containers when they are 2/3 full in a
designated red bag waste container.
Bloodborne Pathogens – Exposures
Infection Control
If an exposure occurs, employers must provide a free medical evaluation and offer
treatment options to an employee who experiences an exposure incident at work.
Should an exposure occur, please remember to:
 Wash the wound and skin with soap and water.
 Flush the mucous membranes with irrigating solutions.
 Report the exposure immediately to your department manager and to Employee
Health. You can contact Employee Health during the hours of 7:30 am to 4:30 pm
to report the exposure, or if it occurs after hours, contact the page operator and
ask for the Employee Health nurse on call. Employee Health will conduct a
detailed post-exposure evaluation and make recommendations for your
consideration. A copy of those recommendations will be made available to you.
 Complete an online report in the Employee Event Reporting System (EERS).
Bloodborne Pathogens – OSHA Standard
Infection Control
OSHA created a Standard on Bloodborne Pathogens in order to reduce occupational
exposure by healthcare workers. The standard applies to any employee who could
reasonably anticipate contact with blood or other potentially infectious material
during the performance of their employment responsibilities.
OSHA also requires employers to provide direct access to a qualified trainer during the
time that an employee is completing the computer based training on Bloodborne
Pathogens.
Bloodborne Pathogens – OSHA Standard (continued)
Infection Control
Should you have any questions on Bloodborne Pathogens while you are completing
this section of Annual Required Training, please call:
 832-824-2150, during normal business hours Monday through Friday.
 The page operator at 832-824-2099, if after hours, and ask for the Employee
Health nurse on call.
EMERGENCY RESPONSE
“Prepared and Ready”
What Is An Emergency
Emergency Response
An emergency is any event that significantly affects normal operations at any Texas
Children’s facility. The source of an emergency can be either internal or external to
the organization.
Examples of Internal Emergencies
• Flooding within a building due to a pipe
burst.
Examples of External Emergencies
• Hurricane or other severe weather event.
• Mass casualty incident.
• Fire starting within a lab or a kitchen.
• An epidemic.
• An act of violence occurring within a unit
from an angry family member.
Responding To Emergencies
Emergency Response
Although emergencies can affect our organization in varying degrees, the basic
approach for staff is always the same. Everyone is considered essential at Texas
Children’s.
During an emergency, our organization needs all hands on deck to help manage the
incident. If you are at work, you may need to stay at work for an extended period of
time. If you are not at work, you may need to come into work.
The Employee Disaster Roster, or EDR, allows for sufficient staffing levels during
prolonged or anticipated events, like hurricanes. All staff must register in the EDR
system. You can access this system at all times by logging into MOLI, except just
before and during emergencies.
Responding To Emergencies (continued)
Emergency Response
Work with your manager to select which of the teams you should be on. The three
team options are:
 Prep Team - deployed before an event.
 Ride-Out Team - deployed during an event.
 Relief Team - deployed after an event.
Listen to your direct supervisor for additional guidelines and/or information about
responding appropriately to an event. Additional resources available to help you learn
more about responding to emergencies before they happen are:
 The Emergency Management Departmental website on CONNECT.
 The Emergency Response & Recovery portal available on CONNECT.
 The Emergency Preparedness Procedures binder, also known as a Redbook.
 The Department Disaster Plan, if available.
 Training from the Department of Emergency Management for your work area, which
can be requested.
Hospital Codes
Emergency Response
A number of hospital emergency codes exist to alert staff of various types of
emergencies. These codes apply specifically to Main Campus, West Campus, and the
Pavilion for Women.
Types of emergency codes:
 CARLA Alert - expected emergency.
 CARLA - actual emergency.
 Dr. Pyro - suspected fire.
 Code Pink - missing or abducted child.
Reporting Emergencies
Emergency Response
If you witness or experience any type of emergency, it is very important that you alert
others to get help.
Main Campus & West Campus
• In the case of a fire, pull a “pull station” and
dial *9999.
• For a medical emergency, or missing/abducted
child, dial *9999.
• For emergencies involving facilities (i.e.
flooding), dial x4-5000.
• For security related emergencies (i.e. violent
individual), dial x4-5400.
Meyer & NRI Buildings
• In case of a fire, pull a “pull station” and dial
911.
• For a medical emergency, dial 911.
• For emergencies involving facilities (i.e.
flooding), dial x4-5000.
• For security related emergencies (i.e. violent
individual), dial x4-5400.
All Other Facilities
• In the case of a fire, pull a “pull station” and dial 911.
• For emergencies involving facilities (i.e. flooding), dial 832-824-5000.
• For security and medical emergencies, dial 911.
Personal Preparedness
Emergency Response
To make sure you are ready to respond to emergencies in which you may need to stay
at work or report to work, we recommend that you prepare yourself and your family.
It is important to create and store an emergency supplies kit or bag to keep at work
with at least three days worth of supplies.
Recommended Items:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Non perishable food items
Bottled water
Three to four changes of clothes
Medications and vitamins
Sleepwear
Linens and blankets
Towels and washcloths
Small pillow
Phone charger
Non-powered diversion items (book, crossword puzzle, Sudoku puzzle)
Contact lens or spare glasses
Socks and undergarments
Extra pair of shoes
Toiletries (toothbrush, toothpaste, deodorant, shampoo, soap, razor, shaving cream, personal hygiene items,
etc.)
Create A Family Plan For Emergencies
Emergency Response
Help your family, including pets and extended relatives, get ready for emergencies by
creating a plan for when they do occur.
Some questions to address in your plan are:
 How will you communicate if you cannot be reached by cell phone?
 Where will you go if you have to leave the area? What route will you take?
 Who will be responsible for picking up and taking care of children, pets, and/or
other dependents if you are unable to do so?
For help creating a Family Plan for Emergencies, you can visit the various websites
listed on the next slide.
Create A Family Plan For Emergencies (continued)
Emergency Response
Personal and Family Preparedness
•
•
•
•
•
•
www.readyharris.org
www.ready.gov
www.redcross.org
www.redcross.org/tx/houston
www.texasprepares.org
www.houstonoem.org
People With Special Needs
• www.disability.gov/emergency_preparedness
• www.agingcare.com/Articles/ederly-disaster-emergency-preparedness-145628.htm
• www.ready.gov/seniors
Pets
• www.aspca.org/pet-care/disaster-preparedness
• www.ready.gov/caring-animals
ENVIRONMENTAL HEALTH & SAFETY
“Chemical and Fire Safety”
Environment of Care Safety Officer
Environmental Health & Safety
The Joint Commission requires every hospital to “identify an individual(s) to intervene
whenever environmental conditions immediately threaten life or health, or threaten
to damage equipment or buildings.” Texas Children’s Safety Officer is:
Melissa Murrah
Director of Risk Management
[email protected]
832-824-1225 (office)
What Is A Hazardous Chemical
Environmental Health & Safety
The Occupational Safety and Health Administration, or OSHA, requires employers to
inform and train staff on the proper use and handling of hazardous chemicals, and to
provide a safe work environment. Staff has a right to know about hazardous chemicals
and about how to protect themselves from exposures and injuries.
A hazardous chemical is any chemical that is a health or physical hazard. Such
chemicals are used every day in most healthcare settings.
Hazardous chemicals come in several forms, such as:
 Solids
 Liquids
 Gases
 Vapors
 Fumes
 Mists
Chemical Exposures
Environmental Health & Safety
A hazardous chemical may enter a person’s body through:
 Swallowing
 Breathing
 The skin
 Accidental needle stick or “sharps” puncture
Some of the signs and symptoms of a chemical exposure are:
 Dizziness
 Nausea
 Eye irritation
 Headache
 Skin rash
 Wheezing or difficulty breathing
Container Labels
Environmental Health & Safety
By June 1, 2015 a new container label style has
to appear on product labels.
Key Label Elements:
 Product Identification
 Supplier / Manufacturer Identification
 Precautionary Statements
o Recommendations to minimize or
prevent adverse effects resulting from
exposures to hazardous chemicals, or
improper storage or handling
 Hazard Pictograms (example on upcoming
slides)
 Signal Words
o Danger – for more severe hazard
o Warning – for less severe hazard
 Hazard Statements
o Describes the nature and possible
degree of hazard (ex. flammable liquid
and vapor, causes skin irritation, may
cause cancer, etc.
www.osha.gov/Publications/HazComm_QuickCard_Labels.html
Hazard Pictograms (Health Hazards)
Environmental Health & Safety
There are nine label pictograms categorized into two categories, health hazards and
physical hazards. The labels and their meanings are listed on this slide and the next slide.
• Acute Toxicity
(Severe)
• Acute Toxicity
(Less Severe)
• Dermal
Sensitizer
• Narcotic
Effects
• Respiratory
Tract Irritation
• Skin Corrosion
• Serious Eye
Damage/ Eye
Irritation
• Carcinogen
• Respiratory
Sensitizer
• Reproductive
Toxicity
• Target Organ
Toxicity
• Mutagenicity
• Aspiration Hazard
Hazard Pictograms (Physical Hazards)
Environmental Health & Safety
• Gases Under Pressure
•
•
•
•
•
Flammables
Self Reactives
Pyrophorics
Self Heating
Emits
Flammable Gas
• Organic
Peroxides
• Explosives
• Self Reactives
• Organic
Peroxides
• Oxidizer
• Corrosive To Metals
Secondary Container Labels
Environmental Health & Safety
Employees must ensure that when a chemical is
transferred from the original container to a secondary
container that the secondary container is appropriately
labelled. The label should include the following, at a
minimum:
•
Identity of the chemical and words.
•
The primary health and/or physical hazards using
words, pictures, symbols, or a combination thereof.
•
The name and address of the manufacturer,
importer, or other responsible party.
Safety Data Sheets
Environmental Health & Safety
Material Safety Data Sheets (MSDS) are being phased out and replaced with Safety
Data Sheets (SDS) over a period of time ending in late 2015. Employees may
encounter both MSDS and SDS until that time.
Texas Children’s uses a web-based database to store these data sheets. You can access
the database from the CONNECT page under Tools > SDS (MDS).
If you cannot find an MSDS or SDS for a chemical in the database, please contact
Environmental Health and Safety (832-824-1961) for assistance.
Chemical Spills Or Releases
Environmental Health & Safety
Unintentional spills of chemicals and workplace exposures may occur. It is critical you
know how to effectively respond to minimize risk. This chart shows you steps to take
when responding to a chemical spill, release, or exposure.
Released Into The Environment
Exposure To
 Remove people from the immediate area.  Wash or flush the affected area, like the
eyes or skin, immediately with running
 Secure the area by closing doors.
water, or go immediately to an eye-wash
station and perform the same procedures.
 Report the incident to your leader or
supervisor.
 Inform your leader or supervisor
immediately of your exposure and
 Notify On-Call Safety: 832-824-2099.
complete an online Event Report.
 Allow only trained staff to clean up the
hazardous chemical.
 Immediately inform the Employee Health
Department in Human Resources.
Fire Safety – Things To Avoid
Environmental Health & Safety
Fire Safety is every employees responsibility, and is dependent on engineered fire
protection features in a building, safe work practices, and staff responses. Let’s take a
look at some things to avoid.
Nothing should be stored within
18” of the ceiling.
Nothing should interfere with the
function of the door.
Fire Safety
– Things
To Avoid
(continued)
Fire
safety
– Violations
Environmental Health & Safety
No storage in the corridors. Storage
means items that are unattended for
more than 30 minutes.
Power strips should not be plugged
into one another (i.e. no daisychaining).
Fire Safety – Things To Avoid (continued)
Fire safety – Violations
Environmental Health & Safety
Space heaters are prohibited.
Extension cords should never
be used as permanent wiring.
Fire Safety – Preparation and Response
Environmental Health & Safety
To be prepared to respond to a fire emergency, all employees working in Texas
Children’s facilities need to know the following:
 R.A.C.E.
 P.A.S.S.
 The location of:
 Fire alarm pull stations.
 Fire extinguishers. If there are multiple types of extinguishers in your area, you
need to know when to use each type.
 Exit routes. Evacuation route maps are posted in all clinical areas.
 Exit stairwells.
 Adjoining smoke compartments, if present in you area.
Fire Safety – Fire Alarm Pull Stations
Environmental Health & Safety
National fire code dictates where fire alarm pull
stations are required to be located.
Pull stations are at:
• Every emergency stairwell entrance
• Every designated emergency exit leading out of a
building
Additional pull stations are sometimes added and
may be found at nurse’s stations, however, not every
nurse’s station will have a fire alarm pull station.
Fire Safety – R.A.C.E.
Environmental Health & Safety
The acronym R.A.C.E. is used throughout Texas Children’s to remind staff how to
respond to a fire emergency. It is critical that all staff memorize the elements of
R.A.C.E. to ensure an efficient and safe response.
Rescue
Rescue/ remove any person who is in immediate danger before doing
anything else. The safety of any person (patients, visitors, staff, etc.)
comes first.
Alert
Do two things:
1. Pull the fire alarm pull station closest to the fire emergency.
2. Call the hospital operator at extension *9999 to report the fire. (Call
911 at offsite facilities.)
Confine
Confine the fire by closing doors and windows to prevent it from
spreading.
Extinguish
Extinguish a small fire by using the proper fire extinguisher, but only if
your safety can be assured.
Fire Safety – P.A.S.S.
Environmental Health & Safety
If you are attempting to extinguish a small fire by using a fire extinguisher, remember
the acronym P.A.S.S.
Fire Safety – P.A.S.S. (continued)
Environmental Health & Safety
Consider the following when attempting to use a fire extinguisher:
 Identify a safe evacuation path before approaching the fire. Do not allow the fire,
heat, or smoke to come between you and your evacuation path.
 Select the appropriate type of fire extinguisher, if more than one type is present in
your work area.
 Discharge the extinguisher within its effective range, generally 8 – 10 feet, but
check the instruction sticker on the extinguisher.
 Back away from an extinguished fire in case it flames up again.
 Evacuate immediately if:
 the extinguisher is empty and the fire is not out.
 the fire progresses beyond the incipient stage.
Fire Safety – Evacuation
Environmental Health & Safety
Employees should evacuate when in immediate danger or when they are directed to
do so by a member of the fire response team, including the Administrator-On-Call,
Nursing Administrative Coordinator/House Supervisor, or the Houston Fire
Department.
The appropriate evacuation strategy will depend on the type of building in which you
are working. All staff should review the “Fire Response Evacuation Plan Policy” and the
attachment specific for the building in which they work. This resource will outline the
basic fire response and evacuation plan. Please note that your department or unit may
supplement this information; therefore, you will want to review any department or
unit specific plans as well.
Fire Safety – Evacuation Route Map
Environmental Health & Safety
Below is an example of an evacuation route map. These maps identify the location of
the exit stairwells, pull stations, and smoke compartments, if present in your area.
Fire Safety – Evacuation (continued)
Environmental Health & Safety
Evacuation strategies depend on the type of building in which you are working. In the
hospital, there are two approaches – horizontal and vertical.
•
If fire and smoke are confined to one area of a floor, patients and visitors should
be moved horizontally (i.e. on the same floor level) toward an exit and to an area
that places the fire/smoke doors between them and the fire emergency.
•
This is the primary evacuation strategy.
•
If the fire or smoke is out of control and spreading rapidly, it may be necessary to
evacuate the floor or entire building. When vertical evacuation is necessary,
movement will be toward the first floor. The extent of vertical evacuation shall be
determined by the location and size of the fire.
•
Elevators should not be used in the event of a fire emergency unless under the
direction of the Houston Fire Department.
•
Stairwells should be checked prior to entry, and if smoke-filled or obstructed, an
alternate exit should be used.
Horizontal
Vertical
END OF COURSE REVIEW
Course Conclusion
Congratulations! You have successfully
completed the 2015 Annual Required
Training course.
To receive credit for this course, you
must:
1. Click on the EXIT button in the
top right corner of this course
and complete the
Acknowledgements section in
HealthStream.