Transcript Annual Education Presentation for Vendors, Students and Volunteers

Welcome
to
Meadowlands Hospital
New Hire Orientation
Please sign in & take a packet
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
PATIENT RELATIONS
VOLUNTEER
SERVICES
Sabina Sanchez
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Patient Satisfaction and Customer Service
Definition of customer service:
Wikipedia states that “Customer Service is the provision of
service to customers before, during and after a purchase.
Customer Service is a series of activities designed to enhance
the level of customer satisfaction-that is, the feeling that a
product or service has met the customer’s expectation. A
customer service experience can change the entire perception
a customer has of the organization”
MEADOWLANDSHOSPITAL.ORG
How can our team provide excellent
customer service?
-Give everyone a “warm welcome”! Greet patients/visitors
with a smile. Maintain eye contact. Make customer service a
priority!
-Respond in a timely manner. You may not have the answer
to a request-but you have the power to contact the
appropriate department/person who has the answer! Give the
patient/visitor a time frame. Follow up to ensure request
was fulfilled!
-Way finding Accompany patients or visitors to their
destination or ask someone else to assist.
-Take ownership! Resolve the problem or issue or involve a
colleague who can.
MEADOWLANDSHOSPITAL.ORG
-Show you care! Demonstrate sincerity, enthusiasm
and warmth in delivering care and in communicating
with patients, visitors and fellow team members!
-Take pride in your appearance! Dress in compliance
with MHMC Dress Code Policy. Wear the appropriate
uniform. ID badges are always worn at eye level.
Remember you are the face of our facility!
-Be positive! Leave your personal issues and concerns at
home! Be wary of your body language and tone of voice.
We never look good by making other people look bad!
If you encounter a situation with a patient, visitor or team
member that you feel you need assistance with-contact
supervisor/manager/director for guidance.
MEADOWLANDSHOSPITAL.ORG
What is a service failure?
-A service failure is any patient’s perception of
interruption of service or the lack thereof.
-Service failure could be perceived differently by each
patient.
-Research has shown that patients (customers) who have
had a service failure resolved quickly and properly are
more loyal than are patients who have never had a service
failure.
-Hospitals with high patient satisfaction are also the
facilities with high patient concerns/complaints-it is how
they resolve the concerns that make them great!
MEADOWLANDSHOSPITAL.ORG
The Three “A”s of Service Failure
-Acknowledge-Recognizing that the patient/visitor/team member has
experienced a “service failure” and actively listening to the
concern/complaint.
-Apologize- Voicing your sincere regret for the concern even if you
were not responsible or aware of the failure relays to the patient that
you care. A simple “I am sorry for your inconvenience” goes a long
way.
-Amend-Making amends for the service failure could be as easy as
picking up the phone to contact the appropriate person or
department to resolve the problem. All employees have the power to
make amends for a service failure! The patient or visitor may request
to speak to a Clinical Director, Nursing Supervisor, Patient Advocate
or member of Administration.
MEADOWLANDSHOSPITAL.ORG
Effective patient complaint resolution is a
GUARANTEE for high patient satisfaction.
HCAHPS-Hospital Consumer Assessment
of Healthcare Providers and Systems
The HCAHPS Survey is the first national, standardized, publicly
reported survey of patient’s perceptions of hospital care. It is a 32
question survey instrument and data collection methodology for
measuring patient’s perceptions of their hospital experience. Since
2008, HCAHPS has allowed valid comparisons to be made across
hospitals locally, regionally and nationally.
Adult patients who are admitted on Med/Surg, Telemetry, ICU and
Maternity can complete an HCAHPS survey. MHMC surveys 100%
of discharged patients in these areas.
 MHMC utilizes Press Ganey for survey distribution and data
collecting.
 HCAHPS scores are based on consecutive quarters of patient
surveys and are publicly reported on
www.medicare.gov/hospitalcompare
 A portion of CMS reimbursement to hospitals is based on
HCAHPS data


ADVANCE DIRECTIVES
What is an Advance Directive for Health Care?
-It is a written document which gives direction regarding your health care
in case you are no longer able to make your wishes known. An Advance
Directive may be a living will, a durable power of attorney for health care
or a combination of both. It is an effective means of maintaining control
over your care, if you become incompetent to make decisions. The
document also states specific directions regarding life-prolonging
treatments and the conditions under which you would or would not
want such treatments to be carried out.
-All admitted MHMC patients over the age of 18 are asked if they have
or would like an Advance Directive-regardless of why they are in the
hospital.
-Patient Advocate or Nursing Supervisor can assist in completing
Advance Directive.
MEADOWLANDSHOSPITAL.ORG
Sabina Sanchez
Patient Advocate,Volunteer and
Community Services Coordinator
201-392-3397
Monday through Friday 9-5

Thank you and good luck!
Workplace Etiquette &
Professional Conduct
Marat Rysmendiev,
Director Marketing, Communications,
PR & Protocol
MEADOWLANDSHOSPITAL.ORG
Workplace etiquette and professionalism is about conducting yourself
respectfully and courteously. You are the ambassador of the business. When
you start a new job, you need to make a good impression on your employer
and co-workers. Below are some etiquette concepts that should be
remembered and followed at a workplace.
MEADOWLANDSHOSPITAL.ORG
- The Art of Appreciation and Being Polite and Friendly
- Attitude is Everything
- On Your feet!
- Write It Right Emails And Not Using Spellcheek (Oops!)
- Please Listen Carefully...
- Call Back
MEADOWLANDSHOSPITAL.ORG
- Play the Game by the Rules
- Say My Name!
- Reciprocate with Others
- An Unprofitable Mix
- Rescue Rangers Beware!
- Don't Sneeze on It and Personal Hygiene
MEADOWLANDSHOSPITAL.ORG
- FU Manners
- Cell Phone Etiquette
- Check Your Attire!
- Hay is for Horses
- Watch the Clock
- An Invitation That Gets a Yes
MEADOWLANDSHOSPITAL.ORG
- Are You A Brain-Picker?
- Don't Be a Mailing List Abuser
- Be Authentic!
- "The Interrupter" Are You One?
- Show Up or Call
- Brutally Honest or Just Brutal
MEADOWLANDSHOSPITAL.ORG
- Don't Turn Your Back
- The Power of the Written Word!
- Say No to the Lambada at Work
- Watch What You Say and Where You Say it!
- Multi-Culturalism IQ
- Common Courtesy and Common Sense
MEADOWLANDSHOSPITAL.ORG
TEAMSTEPPS
JANINE MALAVE, NURSE MANAGER
MATERNAL CHILD HEALTH
TEAMSTEPPS-J MALAVE, RN
COMMUNICATION
Effective communication skills are vital for
patient safety
 Enables team members to effectively relay
information
 The mode which most strategies and
tools are executed

COMMUNICATION IS …
◦ The process by which information is
exchanged between individuals,
departments, or organizations
◦ The lifeline of the Core Team
◦ Effective when it permeates every aspect of
an organization
STANDARDS OF EFFECTIVE
COMMUNICATION
COMPLETE
Communicate all relevant
CLEAR
Convey information that is plainly
understood
Brief
Communicate the information a concise manner
Timely
Offer and request information in an appropriate
timeframe
Verify authenticity
Validate or acknowledge information
SBAR PROVIDES………

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
A framework for team members to effectively
communicate information to one another
Communicate the following information:
Situation: What is going on with the patient?
Backround: What is the clinical backround or
context?
Assessment: What do I think the problem is?
Recommendation: What would I recommend?
HANDOFF IS………….

The transfer of information during
transfers in care across the continuum

Includes an opportunity to ask questions,
clarify, and confirm
Handoff Consists of……
Transfer of responsibility and
accountability
 Clarity of information
 Verbal communication of information
 Acknowledgment by receiver
 Opportunity to review


“I PASS THE BATON”
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Nancy Brobeck,
Director
INFECTION
CONTROL
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Infection Prevention and Control
Infection Prevention and Control Program Goal:
to reduce the risk and prevent the spread of infection.
Hospital Acquired Infections in the US:
• Are estimated 2 million per year
• Account for nearly 100,000 deaths.
• Cost estimated at $10 billion
It is estimated that 30% of these infections can be
prevented by following standard and transmission based
precautions.
MEADOWLANDSHOSPITAL.ORG
What are some examples
of things everyone can do
to prevent the spread of
infections?
Standard Precautions
•
•
•
•
•
Consider all blood and body fluids as infectious
for all patients regardless of diagnosis
Hand hygiene before and after donning gloves.
When there is a risk of splashing of body fluids,
wear gloves, gowns, masks, and eye goggles or
mask with shield.
Dispose sharps in proper receptacles.
Lab samples transported in appropriate containers
in biohazard bags.
MEADOWLANDSHOSPITAL.ORG
Donning and Doffing Personal Protect Equipment
Must do in the correct order!
Donning (bottom up standing with hands above your head):
1st Gown
2nd Mask
3rd Goggles
4th Gloves
Doffing (alphabetical):
1st Gloves
2nd Goggles
3rd Gown
4th Mask
Standard Precautions (continued):
•
•
•
•
•
•
Do not wear Personal Protective Equipment in
the hallway.
Blood Spills - remove large amounts with blood
spill kit
Soiled Linen- wear gloves / avoid contact with
your clothing.
Single patient use means only for 1 patient
Single use vials are for one patient one time use,
They do not have a preservative and must be
discarded immediately after use.
Bacteria and spores can survive for days and
months on equipment and surfaces.
Which do you think are greater
the number of human cells in
our body, or the number
bacteria in our body?
Know your opponents:
“We exist in the bacterial world,
not bacteria in ours. Unfortunately,
we believe that we can rid ourselves
of bacteria when, in fact, we
cannot.”
Transmission Based Precautions:
Contact, Droplet , and Airborne
•
•
•
•
•
•
These are based on mode of disease transmission
We follow the 2007 CDC guidelines for isolation
precautions for healthcare facilities.
Determines type and duration of isolation
Located on our intranet in Infection Control
Policy Manual
Compliance is monitored with isolation
precautions and hand washing.
Noncompliance reports to employee’s manager
Education will be done
For repeated events disciplinary actions per HR
policy.
MEADOWLANDSHOSPITAL.ORG
Contact Precautions
• For known or suspected infections.
• Infections can be transmitted by patient contact or with
their environment. Use single patient use items when
possible (disposable thermometer, stethoscope, BP cuff
etc.).
• Clean equipment appropriately between patient use.
• Direct Contact person to person transmission.
• Indirect Contact transmission with contaminated objects.
• Wear gloves and gowns when entering the room
• Discard PPE before exiting the room.
• Examples: C- difficile, MRSA (Multi-drug Resistant
Staphylococcal Aureus infections.
Droplet Precautions
•
•
•
•
•
•
Prevents transmission of microorganisms in
mucus membranes by coughing, sneezing,
talking, and suctioning.
Droplets can travel 3-6 feet of the patient
Examples: meningitis, influenza, pertussis,
mumps, and pneumonia.
Wear mask prior to entering the room.
Remove mask without touching front of mask.
Patient wears mask when leaving the room.
MEADOWLANDSHOSPITAL.ORG
Airborne Precautions
• Diseases with very small microorganisms can travel
long distances on air currents and be inhaled
• Requires a negative pressure room with doors closed
• Ball in the wall device alert for functioning of negative
pressure
• Examples: Tuberculosis, Varicella (chicken Pox),
Measles, and Disseminated Herpes Zoster (Shingles).
• Requires N 95 particulate respirator mask and
annual fit test
• Patients wear a surgical mask when leaving the room.
Hand Washing
Most effective deterrent to the spread of infection
• Instruct patients, family, and visitors about
hand hygiene and to remind their
healthcare providers to wash their hands if
they do not see them do so
• Let the patient see you wash your hands
• We follow CDC guidelines with 20 second hand
wash
• Fingernails for direct care givers• No artificial nail products.
• Keep well manicured and length < ¼” above
finger tip.
Sometimes Seen as a Difficult Conversation
Don’t be Shy!
What do you say to someone if
you know they did not wash
their hands when they should
have?
When to wash your hands
•
•
•
•
•
•
Before and after glove application
Before and after touching a patient
After touching patient environment
Before and after a clean / aseptic procedure
After body fluid exposure
When you enter and exit the room.
Soap and Water
• For visibly soiled hands and C- difficile precautions
• Wet hands, apply soap, and wash all surfaces of your
hands for 20 seconds; dry with towel, then rinse (sing
(Happy Birthday) twice).
•Use paper towel to turn off water.
Alcohol Based Gel (Purell)
• Routine decontamination of hands
• When no hand washing facilities are available
• Directions- Apply alcohol based gel to the palm of
one hand and rub hands together covering all
surfaces until it is dry
C- difficile Precautions (Deadly Diarrhea):
•Use contact precautions
•Pink sign to cover alcohol based gel dispenser,
stating not to use this product, advising to use soap
and water
• Alcohol based gel has no effect on c-difficile
• Call EVS for terminal cleaning with Yanex Machine
for air and surface disinfection
• Spores live for months on surfaces
Cleansing of Equipment: Always use dedicated equipment for isolation rooms
when possible. All equipment (including stethoscopes) going from patient to patient
should be cleaned and decontaminated after each patient use. Always follow
manufactures recommended disinfection chemicals/agents and wear gloves.
PDI Sani-Cloth Germicidal wipes.
Contact time – is the amount of time the surface is wet when wiping equipment. The
amount of contact time is printed on the label. Bacteria and viruses are being killed
during the drying time.
Super Sani Cloth Germicidal Disposable Wipe (Purple top)
Disinfects in 2 minutes contact time (wet time) .
Ideal for daily use fast-paced environments that require the shortest contact time.
High touch surfaces such as bed rails, countertops and carts
Effective against 27 microorganisms
Sani Cloth Bleach Germicidal Disposable Wipe (Orange top) for Glucometer ,
norovirus, MDROs and CDI
Disinfects in 4 minutes contact time (wet time) .
Sani Cloth AF3 (Grey Color) is ALCOHOL FREE
Use for computers
Contact time 3 Minutes
Latex Allergy
•Skin reactions to latex can start as an irritant dermatitis
• Can develop into severe life threatening allergic reaction.
• Read labels on products
• Medical products that may have latex: Ace bandages,
airways, bite blocks, BP cuffs, breathing bags, electrode pads,
and stethoscope tubing etc.
•Non-medical products containing latex: Adhesive tape, air
mattress, balloons, chewing gum, condoms, telephone cords,
and pacifiers.
Employee Blood/Body Fluid Post Exposure Resource Guide
If an exposure occurs, immediately wash the area, notify your supervisor
and go report to the ED.
Labs to be done:
EMPLOYEE:
Rapid HIV
CBC with differential
Syphilis Screen
Hep B Ag
Total Cholesterol Hep B surface Ab
Triglycerides
Hep C Ab
UA
CMP
UCG (females)
SOURCE PATIENT:
Rapid HIV (If source is positive, complete on misc slip HIV resistance test to
Truvada and Insentress; genotype and phenotype viral load.
Hep B Ag, Hep C AB, and Syphilis Screen
Must follow up with employee health nurse for all injuries / incidents The
employee health nurse will follow up with any pending results not completed
at the time of your ED evaluation.
QUIZ TIME
How long do we wash
our hands for?
20 Seconds
What do you do
after any
employee injury?
1.
2.
3.
4.
Go directly to the Emergency
Department
Complete an Employee Injury Report
Notify your supervisor
Call / Visit the employee health nurse
the next day office is open
Patients entrust their
lives in our hands,
MAKE SURE THEY ARE
CLEAN!!!!
THANK YOU!!!!
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Vision, Mission & Value
Evidence Based Management,
Organizational Structure,
ISO, Quality Mgmt, DNV &
Document Control
Felicia Karsos, CEO
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
VISION
To be the destination of choice when your
loved one needs care in the Hudson/
Meadowlands region.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
MISSION
To provide exceptional patient outcomes
through our commitment to safety. We
do this with service excellence and
sophisticated information technology to
bring evidence-based medicine and
evidence-based best practices to our
patients.
MEADOWLANDSHOSPITAL.ORG
Evidence Based Management
Using the current, best evidence in
management and decision-making.
 MHMC promotes a evidence based
management culture.
 We communicate using facts, data and
evidence.

Drama drains our energy
Drama reduces innovation
Drama depletes our passion for
our work
Drama contributes to disease
MEADOWLANDSHOSPITAL.ORG
MHMC wants engaged employees
MHMC wants evidence, not
emotion
CONNECT instead of BLAME
CREATE instead of COMPLAIN
COACH instead of CRITICIZE
of
MEADOWLANDSHOSPITAL.ORG
Organizational Structure
Governing Board
Quality Mgt Oversight Comm.
Patient Safety & Quality Comm.
Felicia Karsos, CEO
Stanley Galichenko, Safety Officer
-Ancillary Depts
M. Bellifemine, CMO
-Marketing
-General Counsel
E Garrity, VP, HR
-Finance
-HR
-Revenue Cycle
-Food & Nutrition
Stanley Galichenko, VP
-Environmental Services
D. Ortiz, CNO
-Security
- Nursing units
-Facilities
- Infection Control, Emp Health
Dr. Alan Rimmer
- Pharmacy, Respiratory
-Lab
-EMS
-Emergency Department
-Registration
Alexis Joseph, Dir. of Patient Safety Quality& Compliance
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
MEADOWLANDSHOSPITAL.ORG
ISO 9001:
International Organization for
Standardization
 ISO
standards – are generic
standards (can be applied to all types
of industries)

Give the requirements for what the
organization must do to manage
processes affecting quality of its products
and services (delivering healthcare).
Quality Management
 Quality
management: what the
hospital does to ensure that its products
or services satisfy the customer's
quality requirements and comply with
any regulations applicable to those
products or services.
 enhance customer satisfaction, and
 achieve continual improvement of its
performance.
DNV: Det Norske Veritas

DNV is the hospital’s accreditation
body.

Uses ISO 9001 standards and NIAHO
standards during their annual survey visit
for accreditation.

DNV uses both standards as a way to
check that the hospital is following
hospital policy and the
standards/regulations in everyday
functions.
NIAHO:
National Integrated Accreditation for
Healthcare Organizations

NIAHO standards – are more specific, only
for healthcare.

NIAHO standards - based upon the
Centers for Medicare and Medicaid Services
(CMS) Conditions of Participation and State
Operations Manual Regulations.
Document Control

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The process to ensure all documents are the
most up to date including policies, forms,
consents etc.
The intranet contains the most up-to-date
version of all policies and procedures.
All policies printed from the intranet are
verified as the most current version.
Once a policy is printed, it is considered an
“uncontrolled document” and is no longer
considered the most current version.
Workplace Etiquette & Professional Conduct
Patient Safety
Dona Ortiz
Chief Nursing Officer
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Patient Safety
Actions undertaken by individuals and
organizations to protect healthcare recipients
from being harmed by the effects of healthcare
services.
MEADOWLANDSHOSPITAL.ORG
Patient Safety
•
Increase Focus on the Human Factors:
• Memory lapse,
• Failure to communicate,
• Poorly designed Equipment,
• Exhaustion, Ignorance,
• Noisy working conditions,
•
•
other personal and environmental factors.
GOALS
• Design safer process- Barriers or safeguards can prevent untoward
events.
• Reduce Harm Caused By Mistakes- People must be able to quickly
recognize the adverse event and take action.
MEADOWLANDSHOSPITAL.ORG
Implementing a Patient Safety Program
•Consider
safety improvement recommendations
made by external groups (DNV, CDC, IOM,
HRET)
•Share safety improvement ideas.
•Focus attention on high-risk processes
•Incident reports and other information are used
to identify risk-prone patient care processes
MEADOWLANDSHOSPITAL.ORG
Implementing a Patient Safety Program
•Redesign
our processes so that simple mistakes
don’t end up harming patients
•Eliminate opportunities for errors – Failure
Modes and Effects Analysis (FMEA)
-is a step by step approach for identifying possible failures or
safety issues in a new program or process
-is used to proactively identify and assess the severity of risks
and prioritize actions
MEADOWLANDSHOSPITAL.ORG
Implementing a Patient Safety Program
•
•
Build better safeguards to catch and
correct errors before they reach the
patient
Establish a Culture of Safety
Safe Patient Handling

“Safe Patient Handling Act” N.J.S.A. 26:2H-14.8 et. seq.,
requires hospitals to minimize unassisted patient handling by utilizing
assistive patient handling technology.
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Safe patient handling program
Assessment of patient’s need for assisted
patient handling
Evaluation of assistive devices available within
the facility
Education and Training of Personnel
Review of work related injuries
MEADOWLANDSHOSPITAL.ORG
Risk Management
•Incident: any
unusual occurrence or mishap
•Incident reports: Tool used to track and trend
incidents
•Health Care Incident Report: Patient/visitor incident
•Employee Incident Reports: For EMPLOYEES ONLY
•Examples of Incidents: Accidents, Lost/Damaged
Property, Equipment (Damage/Malfunction), Exposure to
Infectious/Hazardous Material, Medication Error
MEADOWLANDSHOSPITAL.ORG
Abuse/Neglect
•Abuse:
physical, sexual, or psychological attack or
assault on the elderly or vulnerable adult/child.
•Vulnerable: Any adult/child who, due to physical or
mental incapacitation, is at risk for abuse/neglect
•Neglect: Any omission of care which results in harm to
the health or welfare or risk of harm to the elderly or
vulnerable adult/child.
•Exploitation: Financial or material gain as a result of
acts of trickery, threat or in any way taking advantage of
an elderly or vulnerable adult.
MEADOWLANDSHOSPITAL.ORG
Indicators of Abuse/Neglect
Neglect Indicators: Malnutrition, Dehydration,
lack of personal hygiene, clothing, lack of medical
equipment (hearing aids, eyeglasses, diapers)
 Indicators of Medical Abuse/Neglect:
Withholding or improperly administering prescribed
or over the counter medications
Withholding necessary medical treatment
 Psychological Abuse: Isolation from friends, family
or religious community Threats of physical abuse,
insult
 Exploitation: Misuse of a person’s income or
resources

MEADOWLANDSHOSPITAL.ORG
Signs of Sexual Abuse

Difficulty Walking, and/or Sitting

Torn-strained clothing

Evidence of blood on underclothing

Pain, Swelling in the Genitalia Area

Bruises, bleeding, laceration or discharge

Poor sphincter tone

Childhood Pregnancy
MEADOWLANDSHOSPITAL.ORG
Behavioral Indicators of Child
Abuse/ Neglect
•
Extreme Behavior
•
Precocious Maturity
•
Wary of Physical Contact/ shrinks away from touch or overly
looking for attention and kindness
•
Appears Frightened
•
Verbalizes he/she deserves punishment
•
Won’t report parents for fear of loss of security
“A bad parent is better than no parent”
 NJ State Law mandates that any person having a reasonable
cause to believe that a child has been subjected to abuse must
report this information immediately to DYFS.
•
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
CORPORATE COMPLIANCE
PROGRAM
Alexis Joseph, Quality & Compliance
Officer
MEADOWLANDSHOSPITAL.ORG
Compliance Program

The Compliance Program provides an
overview of key legal and regulatory
requirements.

System that lays the foundation of ethical
behavior composed of:
◦ Individuals
◦ Polices and procedures
◦ processes
Compliance Program
 MHMC
is committed to providing high quality
care in compliance with all applicable laws, rules,
regulations and standards.
 Employee: act
with the highest level of integrity
 Management: support/carry
out objectives
 Compliance
Officer: ensures that compliance program is
being properly operated and implemented
 Governing
Board: provides vision, guidance, and support
Combating Fraud and Abuse

Medicare Fraud: making false statements or
representations to material facts to obtain
some benefit or payment for which no
entitlement exists

Medicare Abuse: occurs when doctors or
suppliers do not follow good medical practices
that lead to
◦ unnecessary costs to Medicare
◦ improper payment
◦ services that are not medically necessary
HIPAA (Health Insurance
Portability and Accountability Act)
•
Patient confidentiality
– ALWAYS protect/secure paper & electronic health information
– Only accessible through need-to-know basis
– Can only be released upon written consent from patient
•
PHI (Protected Health Information)
–
–
–
–
Demographic information/insurance info
Medical condition/records
Account handling/Hospital billing
The Privacy Rule protects all individually identifiable health
information.
EMTALA (Emergency Medical
Treatment & Labor Act)

Ensures public access to emergency services
regardless of ability to pay.

Requires hospitals to provide an
examination and needed stabilizing
treatment without consideration of
insurance coverage/ability to pay.
Whistleblowing
Federal Whistleblower rule allows anyone
who knows about a person or entity
submitting false claims to bring a lawsuit
on behalf of the government.
 NJ Law-Conscientious Employee
Protection Act (CEPA)
 You are protected by law from retaliation
relating to any report made in good faith.

Chain of Command

It is the employee’s duty to report
suspected wrongdoing or misconduct.

You can report wrongdoing to the
Compliance Office, Human Resources
dept or your supervisor.
Chain of Command
 Compliance
Office is located on the 2nd
floor of MHMC in the Administration suite.
 Compliance
Office phone #: 201-392-3262
 Anonymous
Compliance Hotline: 201-392-
3191
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Stanley Galichenko,
Director of
Safety and Security
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Who is the Safety
Officer?
Stanley Galichenko
MEADOWLANDSHOSPITAL.ORG
EMPLOYEE SAFETY
RESPONSIBILITIES:
Safety at Meadowlands Hospital is every employee’s
responsibility.
Every employee is expected to follow hospital safety
policies. Policies can be found on the Intranet under Main
Manuals
Employees are expected to make recommendations for
safety improvements.
Familiarize yourself with policies
related to CODES & DRILLS
88
Protective measures
◦ Report anything suspicious to your Supervisor and/or
Security immediately.
◦ Avoid direct contact with suspicious items
◦ Do not use cell phones or radios in close proximity to
suspicious items, it can trigger the explosion
◦ Move patients and staff away and contain the affected area
by closing doors.
◦ Ask your supervisor for further actions
89
REPORTING SAFETY PROBLEMS:

A life threatening situation requires immediate
action.

Report any safety issue or incidents/occupational
injuries to your Supervisor or, if after hours, the
Nursing Supervisor on duty.

Dial 8 for any emergency
90
Prevention of Injury

Bending and Lifting
◦ Avoid lifting when possible, use patient
handling equipment
safe
◦ Bend your knees to let your legs do the work ,keep
abdominal muscles tightened
◦ Store heavy objects at waist level
◦ Ask for help when necessary.

Pushing and Pulling
◦ Push rather than pull, avoid leaning over the object and
move with the object
◦ Use whole body to push and not just your arms, and get
help when you need it.
91
You work on a
SMOKE FREE CAMPUS!
Emergency Preparedness
HOSPITAL WIDE DRILLS
The purpose of disaster planning and drills is to prepare
all personnel and members of the medical staff to cope
with real incidents when they occur.

We conduct 2 drills per year
Drills help us to assess our effectiveness in the case of
a disaster.
 Check with your Supervisor for your assigned duties
during a drill.

In case of emergency situation, the Incident Command
Center (ICS) is set up in the 2 Center Conference Room
93
Emergency Codes
Code Triage - External Mass Casualties/Internal
Emergency
Code Red – Fire
Code Blue – Adult Medical Emergency/Cardiac Arrest
Code White – Pediatric Medical Emergency
Code Amber - Infant/Child Abduction
Code Yellow- Bomb/Bomb Threat
Code Gray –Patient Elopement
Code Silver –Threat of Violence (Active Shooter)
Code Orange – Hazmat Situation/Decon-Needed
Code 9 – Utility Failure
Code Clear – The Situation/Emergency is now cleared
Emergency - Dial 8
94
Protective measures
◦ Report anything suspicious to your Supervisor and/or
Security immediately.
◦ Avoid direct contact with suspicious items
◦ Do not use cell phones or radios in close proximity to
suspicious items, it can trigger the explosion
◦ Move patients and staff away and contain the affected area
by closing doors.
◦ Ask your supervisor for further actions
95
Emergency Situation
Personnel and Tools
◦ Trained staff for
decontamination procedures
is always present
◦ Personal protective equipment and detection equipment
◦ Decon tent & trailer for showers-back of the hospital

Emergency Backup
Communications Systems
◦
◦
◦
◦
Portable radios
State Police radio system
Cell phones
EMS dispatch center-4th fl
96
Security Management
The Overall Goals of the Security Management Plan are to:
◦ Safeguard hospital and personal property from damage or theft.
◦ Maintain an environment conducive to the health and safety of patients,
visitors, and employees.
◦ Identify and correct security and safety hazards.
◦ Maintain order throughout Meadowlands Hospital and prevent disruptions
to the hospital’s operations by persons or groups behaving in an improper
manner.
IDENTIFICATION
◦ All employees and volunteers are required to wear identification badges
issued by the Security Department.
◦ Wear your identification badge where patients and visitors can see it.
◦ We expect all of our employees to introduce themselves when
communicating with patients or visitors.
97
Employee Responsibilities
Wear your identification badge at all times
Maintain patient confidentiality
Secure patient valuables, & your personal
valuables
Report all security incidents to Ext. 3269
Dial “8” for all emergencies!!!
Practices to Promote Safety
 Limit access to facility (direct all visitors and
vendors to Security desk when accessing the
building)
 We conduct 1 fire drill/month. Your
supervisor will assign your duties.
 Have your code card attached to ID at all
times so you know your responsibility.
 See something; say something (such as
unattended bags/packages or suspicious
objects/persons) report to ext 3269.
99
Life Safety Fire / Evacuation
Plan

Fire Alarm System Activation
◦ Use the pull station to activate the fire alarm during smoke or
a fire condition .
◦ Dial “8” to notify Customer Services to announce the Code
for a fire (CODE RED)
◦ Close the doors & Clear the corridors

Compartmentation
◦ Fire & smoke doors close automatically.
◦ Close all patient room doors

Employee Responsibility
◦ Complete required education & Attend drills
◦ Know locations for pull station; fire extinguishers; & fire and
smoke doors. Contact your manager for these locations.
100
At the Scene of the Fire (RACE)
In the event of a fire emergency or a drill, Meadowlands
Hospital used the R.A.C.E. procedure, which stands for:
◦ Rescue/move to a safe area
◦ Alarm: pull Alarm AND notify Operator
by dialing “8” to provide location of fire
◦ Confine by closing all doors
◦ Extinguish (extinguish small fires)
101
Evacuation
◦ Horizontal/Initial Evacuation:
From one fire compartment to another
compartment (through the fire doors).
◦ Vertical Evacuation: Going from
one floor to the floor below and is only
done when a horizontal evacuation is
not possible.
◦ IMPORTANT!
Know the location of your
department's oxygen shut-off
valve
These are clearly labeled in each
patient care area.
102
EMPLOYEE RESPONSIBILITIES FOR FIRE
DRILLS OR EMERGENCIES
Patients, visitors, & others will be looking for you for
guidance and direction.
 Make sure all doors, windows and fire doors are closed in
the area you leave behind.
 Listen for instructions over PA system or directly from
your supervisor.
 Do not use the elevators. Restrict travel of visitors and
staff (moving through doors allows smoke through).
 Remove all guests or visitors from the corridors
immediately and return patients to their rooms.
 Keep all corridors clear for emergency personnel.
 Evacuate patients horizontally from the area in their beds
and disconnect all mechanical devises.

103
FIRE Extinguishers
TYPES OF FIRE EXTINGUISHERS
◦ Class A – ordinary combustibles (ash)
◦ Class B – flammable liquids (boiling liquids)
◦ Class C – electrical fires (current)
◦ Type K
(Portable Extinguisher for Cooking Hoods)
FIRE EXTINGUISHER OPERATION (PASS)
◦ P
Pull the Pin
◦ A
Aim the extinguisher at the base of the flames
◦ S
Squeeze the trigger while holding the extinguisher upright
◦ S
Sweep the extinguisher from side to side
104
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Gary Patterson
Director of
Environmental
Services
MEADOWLANDSHOSPITAL.ORG
Hazardous Materials/Waste
Management (Right-to-Know)


This section covers health risks, routes of entry
with exposure, and procedures for clean-up
related to hazardous materials.
Hazard Communications
◦ OSHA Requirements
 Written plan by employer, labeling by manufacturer
 Labeling by employee, training and education

Types of Hazards
◦ Flammables, Corrosives, Toxins, Reactive
Hazardous Materials/Waste
Management

RECOGNIZE HAZARDOUS SUBSTANCES BY THEIR:
◦ Signs (to an area)
◦ Color Coding (usually red or yellow)
◦ Container Labels (always read the label BEFORE using a hazardous
substance)

ROUTES OF ENTRY:
◦
◦
◦
◦

Inhalation (lungs)
Absorption (skin)
Ingestion (digestive system)
Injection (puncture or open wound)
HEALTH HAZARD:
◦ Acute = immediate effect
◦ Chronic = long term effect
HAZARDOUS MATERIALS/WASTE
MANAGEMENT - SPILLS
WHAT DO I DO IF THERE IS A HAZARDOUS MATERIAL SPILL?

Should an incident occur that involves the spill of a hazardous substance, your first concern will
be for the protection of yourself, your co-workers in the area, patients or visitors. “Isolation
and evacuation of the immediate area by all persons who are in danger should be your
first priority”

After evacuation, refer to your Material Safety Data Sheets/MSDS to determine the hazards
present, and PPE/personal protective equipment. Report spill by calling the hospital emergency
line. Dial 8 and explain to the operator that you are reporting a possible CODE ORANGE

Additionally, a hospital or employee incident report will be completed and forwarded to Risk
Management or Employee/Occupational Health respectively.

For large hazardous materials spills you should contact the Operator at *8 and report a
CODE ORANGE. Specify the hazardous material that was spilled and the exact location.
Role of Safety Data Sheets in
the Harmonized System - SDS
Safety Data Sheets (SDS)
Safety Data Sheets are an essential component of the GHS and are intended to provide comprehensive information
about a substance or mixture for use in the workplace chemical management.
Minimum Information for an SDS
1. Identification of the substance or mixture and of the supplier
a)
GHS Product Identifier
b)
Other means of Identification
c)
Recommended use of the chemical and restrictions on use
d)
Supplier’s details (including name, address, phone number etc.)
e)
Emergency phone number
2. Hazard identification
8. Exposure controls/personal protection
3. Composition/information on ingredients
9. Physical and chemical properties
4. First aid measures
10. Stability and reactivity
5. Fire-fighting measures
11. Toxicological information
6. Accidental release measures
12. Ecological information
7. Handling and storage
13. Disposal information
14. Transport information

What is the Globally Harmonized System (GHS)?

GHS stands for the Globally Harmonized System of Classification and Labelling of Chemicals. GHS defines and classifies the hazards of
chemical products, and communicates health and safety information on labels and safety data sheets). The goal is that the same set of
rules for classifying hazards, and the same format and content for labels and safety data sheets (SDS) will be adopted and used around
the world. An international team of hazard communication experts developed GHS.

SDS FORMS ARE AVAILABLE ON THE HOSPITAL INTRANET. MAIN SECURITY DESK, and ED
Why is global harmonization
necessary?

Currently many different countries have different systems for classification
and labelling of chemical products. In addition, several different systems can
exist even within the same country. This situation has been expensive for
governments to regulate and enforce, costly for companies who have to
comply with many different systems, and confusing for workers who need
to understand the hazards of a chemical in order to work safely.

GHS promises to deliver several distinct benefits. Among them are:
Promoting regulatory efficiency.
Facilitating trade.
Easing compliance.
Reducing costs.
Providing improved, consistent hazard information.
Encouraging the safe transport, handling and use of chemicals.
Promoting better emergency response to chemical incidents.
Reducing the need for animal testing.








What is a pictogram?

Pictograms are graphic images that immediately show the
user of a hazardous product what type of hazard is present.
With a quick glance, you can see, for example, that the
product is flammable, or if it might be a health hazard.

Most pictograms have a distinctive red "square set on one of
its points" border. Inside this border is a symbol that
represents the potential hazard (e.g., fire, health hazard,
corrosive, etc.). Together, the symbol and the border are
referred to as a pictogram. Pictograms are assigned to
specific hazard classes or categories.

The graphic below shows hazard pictograms. The bold type is
the name given to the pictogram; the words in the brackets
describe the hazard.
Personal Protective Equipment

EYES
Safety Glasses

Splash Goggles
SKIN
Gloves

Face Shield
Boots
Protective Apron
Full Suit
Respiratory
Dust Respirator
Vapor Respirator
Mask or Hood
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Michael Acquaviva
Facilities Supervisor
MEADOWLANDSHOSPITAL.ORG
Utility Systems


Utilities
◦ Electric
◦ Water
◦ HVAC (Heating/Ventilation/Air Conditioning)
User Failure Plan
◦ Notify Plant Operations/Emergency Operator if
failure occurs
◦ In the case of a power failure, use emergency
electrical outlets (in red)
115
Electrical Safety

Emergency Power
◦ Automatic within 10 seconds.
◦ Daisy chains are prohibited on
Hospital property.
◦ Power will only be provided by the RED outlets.
Essential lighting in main corridors and patient care
areas will remain lit.
◦ Always use Emergency outlets RED for critical
patient care equipment (you cannot predict an
outage).
116
Medical Equipment

Safety Considerations
◦ All medical equipment must be inspected prior to use & with a current sticker
◦ Never use equipment without proper inservicing
◦ Use three prong/grounded equipment only & avoid use of extension cords
◦ When unplugging grasp the body of the plug to prevent damage to the prongs
◦ All electrical equipment brought by employees, vendors or physicians must be
checked for electrical safety by the Biomedical Engineering Department before
use.
◦ Do not touch patients while touching medical or electrical devices.

Employee Responsibilities
◦ Ensure all equipment is checked and tagged prior to use
◦ Remove malfunctioning equipment from service
◦ Complete incident report for and report problem to Supervisor
117
Facilities Dept-Landport

Landport is a work order management system that was implemented to provide a more efficient way
to send and monitor maintenance requests. ALL maintenance requests are to be submitted through
Landport and will be addressed within 2 days.


1. Go to the company intranet page: Select Landport work order log-in icon. The main login page should
appear


2. Type in your user ID and password:



User ID: mead-staff
Password: mead2013


3. Press the "Login" button to access your personal account.


4. Click the link "Create Request" and follow the directions to describe and submit your maintenance
request.


It's easy to use. You may track maintenance request progress at any time by simply logging in.


If you have any questions or need help, I can be reached at [email protected] or
extension 3162.
WHAT TO DO IF EQUIPMENT
MALFUNCTIONS:

Immediately remove the equipment from service.

Fill out a healthcare incident report and report to the Nursing
Manager/Supervisor.

Tag the equipment so that anyone can identify that the equipment
cannot be used.

Essential equipment that is needed, and not functional for patient care
during off hours, can be handled by having the operator contact the
Biomedical Engineering Technician on-call, who is available 24 hours a
day by dialing 0.
119
Medical Equipment
EMPLOYEE OR PATIENT HARM BY A
MEDICAL DEVICE:
◦ A device that has been identified as causing patient harm, or in
some way brings into play the “Safe Medical Devices Act of 1990:
must be handled in the following manner:
 Immediately respond to the individual’s clinical needs.
 Remove the equipment from service, saving all attachments, and tag
the equipment with a service tag or label.
 Notify your supervisor immediately. If an incident occurs after
normal working hours, notify the Nursing Supervisor or
Administrator-On-Call who will contact the appropriate individuals.
120
UHS BIOMED 360
Biomedical Engineering Department
For Non Emergency

Current Office Room:- 406

Phone Extension:- 800-328-8077 or Ext. 3149

Standard Hours at Hospital :- 8am – 5pm

Week Days :- 8.30 AM to 5.00 PM

Time is Flexible based on the need.

After Office Hours On Call for Emergency Needs.

For Emergency needs contact Hospital Switch

Board. They will reach him on his mobile.

Response Time :- 2.00 Hours.
121
EMERGENCY PREPAREDNESS
&EVACUATION CHAIR TRAINING
Hantz Ricot
Why Evacuate?

Structural Integrity of the Building (following
an impact such as an explosion).

Emergency/Life Threatening Conditions i.e.,
fires, chemical releases.

Inability to ensure a safe environment (Flood,
hurricane, power outage w/out back up
generators, bomb threat)
TYPES OF EVACUATION
A.
HORIZONTAL EVACUATION (safe area same
level, a fire/smoke barrier door(s) to the other
side)
B.
VERTICAL EVACUATION (up or down / stairs)
C.
HOLDING AREA/ REFUGE(designated by
incident commander)
D.
OUTSIDE EVACUATION (parking lot / field)
E.
EVACUATION OF THE FACILITY (off-site)
When to evacuate

The order to evacuate is given by Administration or the
Public Safety Official (Fire or Police) Incident Commander.

Your supervisor or manager informs you that the area is
being evacuated.

Each patient must be registered by nurse manager 
name, MR#, dob, time + mode of Evac- refuge location.
How to evacuate



Follow instructions by Fire Dept. or Administration
The Fire Department or Administration will identify a safe
area of refuge
Evacuate patients in immediate danger first:
AMBULATORY PATIENTS/RESIDENTS first to
leave.
NON-AMBULATORY PATIENTS/RESIDENTS
(disabled, life support systems, PERI-OP) will be
evacuated by staff per instructions.
 Personnel assigned to the patients will remain with them
until “all clear” and responsibility has been reassigned.

Stryker Emergency Evacuation Chair
•Essential for NON-AMBULATORY
PATIENTS/RESIDENTS
•Located at every stair case exit in MHMC
•Can be used for all types of evacuation
•227kg or 500 lbs. MAXIMUM
Transferring the patient
on and off the chair
1) Place the chair beside the patient
2) Inform patient of intended actions
3) Apply wheel locks to prevent chair movement
4) Open the restraint straps
5) Transfer using approved techniques
6) Secure patient using the restraint straps
7) Disengage wheel locks before attempting to transport
Stryker chair set up
To unfold the chair
1) Stand behind the chair
2) Apply the wheel locks (optional)
3) Pull the backrest and the lower
extension handles apart
4) The automatic locking
mechanism will engage when
FULLY separated
WARNING
An unlocked chair can fold during
use, causing injury to the patient or
operator. Always make sure the chair
is locked in the unfolded position
before use
Horizontal Evacuation
A- Pull upper handles until they
lock
B- Press Red buttons to
release bottom handles
C- 4 sets of restraining straps
- Across the chest
- Across the lap (hands can be under)
- Across legs
- Head strap optional
Vertical Evacuation Downstairs
A-
Release the upper control
handle by pulling on the release
cable
B- Squeeze the red track
release bar to release the
Stair-Tread (downstairs only)
C- 2 Operators
Do not attempt more than you
can safely lift
D- TILT chair prior to
descent
TRAINING VIDEO ON MHMC
WEBSITE
GO ON MHMC HOMEPAGE
SHARED DOCUMENTS(left column)
CLICK ON EVACUATION CHAIR
LENGTH: ONLY 6 MIN
REQUIRED FOR ALL STAFF
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
HUMAN RESOURCES
Liz Garrity
Vice President, HR
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
Rules of Conduct
MHMC provides a safe environment for employees, patients and visitors
The following are examples of behaviors that will not be permitted:
Theft
Falsification of information
Destruction of property
Insubordination
Disclosing confidential information
Being under the influence of alcohol or illegal drugs while at work
Smoking on Hospital property
Violence in the Workplace
Please see the HR Rules of Conduct Policy for additional information and details.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
ANTI - HARASSMENT POLICY
MHMC is dedicated to providing a workplace that is free of all forms of employment discrimination,
including sexual and other unlawful harassment.
Any conduct that creates an intimidating, hostile or offensive work environment is not tolerated.
Some examples of sexual harassment are unwelcome behaviors such as:
Sexual advances, propositions, off color jokes, touching, bullying, physical assault, sexually explicit
conversations ,suggestive pictures, etc.
Some examples of other forms of harassment are:
Verbal or physical conduct relating to an individual’s race, religion, creed, color, national origin,
citizenship, disability, age, military status, marital status, sexual orientation, ancestry, or veteran
status.
Please see the HR Anti Harassment Policy for additional information and details.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
DRESS CODE
All employees are expected to dress appropriately and professionally.
Employees whose position requires that they wear a uniform must wear the correct uniform and
footwear.
Employees working in other areas of the hospital must dress in a professional business manner.
Examples of inappropriate items of clothing are flip flops, shorts, jeans, tee shirts, halter tops,
leggings, hats, etc. These items are NOT permitted.
Please see the HR Dress Code Policy for additional information and details.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
ATTENDANCE POLICY
It is vital that all employees are at work on their scheduled times and dates.
It is every employee’s responsibility to adhere to their schedules.
It is also every employee’s responsibility to find out what their own department’s policy is when
calling in an absence ,or lateness., how much time prior to the beginning of their shift is required
and who to contact .
Excessive ( three or more occurrences in a three month period) absences or lateness may lead to
disciplinary action up to and including termination of employment.
No call no shows, excessive missed clock ins/outs, or forgotten clock ins/outs and patterned
absences will be reviewed and may lead to disciplinary action up to and including termination of
employment.
Please see the HR Attendance Policy for additional information and details.
MEADOWLANDSHOSPITAL.ORG
MEADOWLANDS HOSPITAL MEDICAL CENTER
55 Meadowlands Parkway, Secaucus, NJ 07094
HR SERVICES
HR Online – Information System for Employees
•View
and Print Paystubs, W2 forms, change demographic information, etc.
MystaffingPro – Applicant Tracking
•View
and apply for open positions via hospital website/careers section
Benetrac – Online Benefits System
•Enroll, or
waive benefit coverage and view and manage your personal benefit plans
Kronos – Timekeeping system
•Manage
your time at work online and submit time off requests
MEADOWLANDSHOSPITAL.ORG