What is Gaylord Hospital Gaylord Specialty Healthcare is a not-for- profit, long-term acute care hospital that specializes in the care and treatment ofmedically complex patients, rehabilitation and sleep medicine. Our mission is to preserve and enhance a person’s health and function.
Our Vision and Our Valuesis to promote patient • Clinical excellence, compassion, integrity,functionality through the respect and accountabilitybest clinical services, most are the values which guideadvanced and effective all of our actions.treatment protocols, and • As an organization we will excel in every aspect of ourdocumented outcomes for service delivery whileour patients. honoring the public trust. As professionals we hold ourselves accountable for our actions.
I CARE Program– an employee recognition award based on nominations from patients, their family members, hospital staff– Awards are given quarterly at a breakfast event– Quarterly recipients become eligible for the Employee of the Year Award in May– Underscores the importance of the Gaylord Values among all employees each and every day
I is for INTEGRITYC is for COMPASSIONA is for ACCOUNTABILITYR is for RESPECTE is for EXCELLENCE
What is an LTACH?LTACH stands for:Long-Term Acute Care Hospital.As an LTACH, Gaylord Hospital is staffed and equippedto handle the specific needs of acutely ill orchronically disabled patients who require a hospitallevel of care.Gaylord Hospital is also able to treat those who needrehabilitation for illnesses or injuries related to braininjury, stroke, spinal cord injury, neurologicalrehabilitation and orthopedics.
State LicensureGaylord is licensed by the State ofConnecticut as a 137-bed chronicdisease hospital.
Service LinesGaylord consists of 3 Service Lines to manageprogramming for our patients and referralsources more efficiently: – Inpatient Service Line – Outpatient Service Line – Sleep Medicine Service Line
Gaylord Locations Trumbull Wallingford Guilford Glastonbury North HavenMain Campus Outpatient Centers Sleep CentersGaylord Hospital North Haven Glastonbury/HartfordGaylord Farm Road Wallingford GuilfordP.O. Box 400 North HavenWallingford, CT Trumbull06492
Social Accountability• Not-for-profit health care organizations must show federal, state and local government that they fulfill their mission of community service to meet their charitable tax- exempt status.• Gaylord does this through annual Social Accountability reporting of programs and activities conducted by the hospital and our employees: – Education for health care professionals – Community health education – Counseling/support services – Clinical research – Participation in professional/community organizations – Financial and volunteer contributions – In-home services
GENERAL SAFETY Gaylord Specialty Healthcarestrives to provide a safe environment and to reduce risks for patients, visitors, employees, volunteers and students.
ELECTRICAL SAFETY POLICIES The Facilities Department must check ALL electrical equipment before placing it into service. YOUR RESPONSIBILITIES:Remove damaged electrical equipment from service.Report damaged electrical equipment to your supervisor.Do not attempt to repair electrical equipment.Do not bring in personal electrical equipment for your use or for patient use.
EQUIPMENT MANAGEMENT PROGRAMMaintains a current inventory of all Hospital equipment.Provides periodic preventive inspection, testing and maintenance.Reports and investigates equipment problems, failures, abuse and/or user error.Monitors performance to identify trends and implement improvements.
HAZARD COMMUNICATIONS• OSHA established the HAZARD COMMUNICATIONS STANDARD to protect employees who use hazardous materials on the job.• The standard states that companies who use or produce hazardous materials must provide their employees with information and training on the proper use and handling of these materials.• Your immediate Supervisor is responsible for appropriate training and educational materials.
YOU HAVE “A RIGHT TO KNOW”You have a right to know about thehazardous materials used in yourworkplace and the potential effects ofthese materials upon your health andsafety.
MSDS: MATERIAL SAFETY DATA SHEETSManufacturer is required todetermine, record and distribute hazardinformation for each product in the form ofthe MSDS.Gaylord Specialty Healthcare maintains a file of all MSDS to which workers might be exposed.
INFORMATION IN THE MSDS YOUR RESPONSIBILITIES:Product ID Know what hazardousHazardous ingredients chemicals are used in yourPhysical data work area.Fire and explosion hazard Know where MSDS sheets data are located.Health hazard data Know how to read anEmergency and first aid MSDS sheet. proceduresReactivity dataSpill, leak and disposal procedures Remember:Personal protection MSDS Sheets are available information on the Gaylord intranet.
BUILDING SECURITYYou must wear your ID badge at all times while on duty. Your badge is to be worn in a conspicuous place between your collar and your heart. Your badge is to be worn with the employee name and picture visible.
SMOKING POLICY• Gaylord Specialty Healthcare is a non- smoking/tobacco-free facility.• No smoking is permitted anywhere or by anyone on hospital property.
KNOW THE CODES!CODE RED: Fire emergencyCODE BLUE: Medical EmergencyCODE GREEN: Any situation which interrupts our ability to conduct business as normal
KNOW THE CODES!DR. STRONG: Help is needed when someone is a threat to himself, others, or property.SIGNAL 1: Help is needed to locate patient who is unaccounted for.SIGNAL 5: To inform staff when computernetworks are non-operational.RAPID RESPONSE: To provide intervention for a patient with acute change of condition.FALLS RESPONSE: To provide assistance to a patient who has fallen.
CODE LOCKDOWNThis code will be used to announce a situation ofpotential extreme violence, up to and including anarmed intruder/active shooter.The instinctive response is to flee – but the correctresponse is to remain in place.You must act and you must act quickly.CEASE ALL TRAVEL THROUGHOUT THE HOSPITAL.
CODE LOCKDOWN• Patient units: take all patients into a room, turn off the lights, close the door.• Therapy areas: patients are to remain with staff and to seek refuge in offices or other low visibility areas. Close and lock doors if possible, turn off lights.• All other areas: remain in the area, taking refuge in closets or offices. Lock doors, turn off lights.• Seek whatever cover is available.DO NOT CALL THE SWITCBOARD FOR INFORMATION.DO NOT CALL THE MEDIA VIA PERSONAL CELL PHONE.
CODE LOCKDOWN• Response time for Wallingford Police and/or State Police is expected to be in the 7 -10 minute range.• Listen for and follow all instructions from law enforcement personnel.• DRILLS will be held, as the only way to prepare for this scenario is through education and training.
EMPLOYEE PARKING The lots at the Jackson Building are reserved for patients, visitors and medical staff.Employees are to park only inareas designated as employeeparking and to observerestrictions for specified shifts.
NO PARKING! DO NOT park in FIRE LANES or in front of building entrances. YOU WILL BE TOWED! Use of handicapped-accessible parking is restricted to those with State of CT issued tags.
SLIPS, TRIPS AND FALLSAll workers are at risk ofdangerous slips, tripsand falls.If you experience a slip/tripor fall, you must report it toyour Supervisor who willcomplete an EmployeeInjury Report.
YOUR RESPONSIBILITIES Wear proper footwear Watch where you are walking Keep work areas clean and orderly Report or clean up spills immediately Report hazards
Given the right conditions, fire can happen anywhere …In order for a fire to occur, the following are needed: Fuel Oxygen HeatA fire will break out whenever theseitems come together in the rightamounts.
Fire Prevention Strategies at Gaylord SPECIALTY HEALTHCARE All new employees are required to attend New Employee Orientation which includes an in-depth review of fire safety issues and procedures. Environmental rounds are performed regularly to identify deficiencies, hazards, and unsafe practices. Fire drills are conducted regularly to assess readiness for response to a fire emergency.
Prevention is the best defense against fire! Gaylord Hospital is a Smoke Free, tobacco-product free campus. Smoking is prohibited anywhere on hospital grounds. Remove damaged equipment from service. Ask for training before using equipment.
R.A.C.E.Rescue and/or assist in the rescue of patients, visitors, staff.Activate the nearest alarm; dial x3399 and give the location of the fire.Contain the fire by closing all doors.Evacuate and/or Extinguish if you have been trained in the use of a fire extinguisher.
Fire ResponseDO keep a cool headDO think before you actDO wait for the “All Clear” AnnouncementDO NOT shout, run or panicDO NOT use elevatorsDO NOT open fire/smoke doorsDO NOT block exits or stairwells
P.A.S.S. Using a fire extinguisher• Pull the pin on the extinguisher handle• Aim the nozzle at the base of the fire• Squeeze the handle to discharge the retardant• Sweep the base of the fire with the retardant
EvacuationThe decision to evacuate is based on whether patients are indanger. Evacuation in a healthcare facility is an action of “LastResort.”Horizontal evacuation: movement is made horizontally(connected floor to connected floor) beyond the fire doors tothe next smoke compartment.Vertical evacuation: people are moved to a lower floor of thehospital using stairwells.
Your Responsibilities Know the location of fire alarm pull stations See Gaylord Hospital Know the location of Policy 2-100.7 fire extinguishers for additional information. Know exit locations Keep exits and smoke and fire doors clear Know your role in the event of an emergency
Remember!Fires can be prevented and contained when everyone focuses on SAFETY.
EMERGENCY PREPARATION PLANNINGPlanning ensures that systems are:• established ahead of time• practiced• evaluated and changed as necessary
Purpose of Gaylord SPECIALTY HEALTHCARE’S Emergency Management Plan To attend promptly and efficiently to all individuals requiring medical attention in an emergency situation; To provide maximum safety and to protect patients, visitors, and staff from injury; To respond quickly and appropriately to the community’s disaster plan; To protect property, facilities, and equipment.
Emergency Incident Command System The Emergency Incident Command System (EICS) is a management system designed to assist hospitals in the management of minor and major disasters. Specific personnel responsibilities, clear reporting channels and common nomenclature are detailed in the plan.
CODE GREENGaylord Hospital’s Emergency Operations Plan isreferred to as “Code Green.”The plan will be activated based on authorizationof the Administrator-on-Call or designee, or afterhours by the Nursing Shift Coordinator.
WHAT IS A DISASTER? A DISASTER OCCURS WHEN EVENTS:• overload the capacity and/or ability of any area of the hospital to provide care,• cause significant disruption to normal hospital operations, or• arise in the community, leading to requests for support from Gaylord Specialty Healthcare.
EVENTS THAT COULD TRIGGER A CODE GREENFires/explosions Natural gas leaks orFloods/high winds chemical spillsEarthquakes Acts of terrorismHurricanes/other storms Civil disturbancesLoss of telephones Emergencies within the organizationLoss of powerLoss of water Emergencies within the community
PROCEDURESA CONTROL CENTER will be establishedin the Neubig Board Room.A PERSONNEL POOL will be set up in theBrooker Lecture Hall.If additional staffing is necessary, theDisaster Officer will activate Recall Rosters.Evacuations may be deemednecessary, depending on the nature of theevent and the extent of damage.
NOTIFICATIONWhen a Code Green is called, the switchboardoperator will announce: “Code Green”three times in a row and every 5 minutes forthe first 15 minutes, and then every 15minutes until the code is secured.
KNOW YOUR ROLE!REVIEW POLICY 2-100.9 AND BE SUREYOU KNOW YOUR ROLE IN THE EVENT OFA CODE GREEN.
DID YOU KNOW? Healthcare workers have the highest incidence of back injuries. Up to 80% of Americans will suffer back pain at some point in their lives. Back injuries cost American companies 100 million lost workdays. Nursing personnel lose an average of 750,000 workdays per year as a result of back injury.
BACK PAIN CAN BE PREVENTED!Most back pain comes from softtissue injuries, including strains andsprains of muscles, ligaments, andtendons.These injuries can be prevented by: Good posture Regular exercise Use of lifting devices Proper body mechanics
STRUCTURE OF THE SPINEThe vertebrae of the spineare aligned to create fournatural curves: an inward curve at the neck an outward curve at the ribcage an inward curve at the low back an outward curve at the base of the spine
GOOD POSTURE Aligns the curves of the spine Centers the head, chest, and lower body over one another Balances the weight of the body
REGULAR EXERCISE: Can help you keep the muscles of your back and stomach strong and flexible. Can help you maintain a healthy weight to avoid excessive stress and strain on your back. Be sure to include: Cardiovascular conditioning Stretching and strengthening exercises
GOOD BODY MECHANICS Size up the load – look it over; decide if you can handle it or will need help. Determine best lifting technique for the height and location of the load. Ask for help if you need it. Inspect your intended path for obstacles or other hazards. Place your feet in a position that gives you a wide, balanced base of support. Tighten your stomach muscles prior to performing a lift.
GOOD BODY MECHANICS DON’T BEND Use your legs, don’t bend at your waist. Let your leg muscles do the work since they are stronger and more durable. DON’T REACH Keep the load close to your body. DON’T TWIST Move your feet when you change directions; do not twist your upper body while carrying the load.
USE PATIENT LIFTING EQUIPMENT To limit manual lifting, motorized lifts and assistive transfer devices are available. These devices should be used when a patient: is not willing or able to transfer is not able to maintain balance while standing is unpredictable, uncooperative, or aggressive
IT’S UP TO YOU!Know yourself and know your limits.Know how to move people IF YOU SUSPECT A WORK-RELATED and objects. INJURY, CONTACTKnow when to YOUR SUPERVISOR get help. IMMEDIATELY!
ERGONOMICS The study of how human beings relate to their work environment The science of fitting the job to the person, rather than making the person fit the job. Goals: increased effectiveness, improved work quality, greater health and safety, and increased job satisfaction.
CUMULATIVE TRAUMA DISORDERSCumulative trauma disorders aremusculoskeletal conditions thatdevelop gradually over a periodof time. Do not typically result from a instantaneous event. Caused by repetitive wear and tear on tendons, muscles, related nerves and bones.
POTENTIAL SYMPTOMS Numbness or tingling in the arm or hand Weakened grip Reduced range of motion Swelling Weak or painful hands, arms, wrists, neck, shoulders, back
INJURY PREVENTIONChange work area organization or layoutChange environment, e.g. lightingReduce or avoid repetitive motionsReduce the amount of force needed to perform the taskReduce awkward movements, reaches, or stretches
INJURY PREVENTION Use tools that are lighter, easier to grip Keep wrists straight and keep elbows at right angles Use a chair with back support, adjustable height and arm rests Use an appropriate foot rest, if necessary
INJURY PREVENTION Use padded wrist rests when typing or using a computer mouse to minimize contact pressure Use a document holder placed at eye level when typing Use proper posture for standing, sitting, and sleeping Change jobs or tasks frequently
If you suspect a work-relatedinjury, contact your supervisor immediately!
ERGONOMICS INFORMATION ON SHAREPOINTGo to the Intranet (Sharepoint)Click on “Departments”Click on “Human Resources”On the left side, under “Documents” you will find Ergonomic Resources.
ERGONOMIC REFERRAL PROCESS1. Employee notifies Supervisor2. Employee and Supervisor complete the Self- Assessment Form.3. If assessment reveals workstation complexity or additional modifications, a request form is sent to Human Resources to arrange an evaluation by the Ergonomics team.4. Evaluation is completed.
ERGONOMIC REFERRAL PROCESS5. Recommendations of the Ergonomics Team are given to the employee, the Supervisor and Human Resources.6. Equipment modifications and requisition of recommended equipment must be made by supervisor.7. Follow up completed within 30 days to ensure proper modifications and equipment use.8. Human Resources sends 90 day follow-up as above.
LEGAL DEFINITION The law defines sexualharassment as unwelcomesexual advances, requests forsexual favors, and other verbaland physical conduct of a sexualnature when:
LEGAL DEFINITION, cont. Employment decisions such as hiring, firing, work assignments, promotions or pay rises depend upon the victim’s response, or The conduct interferes with the victim’s job performance, or The conduct creates an intimidating, hostile or offensive workplace.
UNWELCOME BEHAVIORRefers to any behavior which the recipientdoes not invite or encourage or which therecipient regards as undesirable oroffensive, such as obscene gestures orsounds, persistent pressure fordates, deliberate blocking of physicalmovement, and/or the display of sexuallyexplicit or suggestive material.
TYPES OF SEXUAL HARASSMENT QUID PRO QUOHOSTILE WORK ENVIRONMENT
QUID PRO QUO Means “this for that”. Usually involves supervisor & employee. Supervisor makes unwanted sexual advances or engages in unwelcome sexual behavior and states or implies that the employee must accept in order: to keep his/her job to avoid transfer, demotion, or firing to receive a raise or promotion
HOSTILE WORK ENVIRONMENT Requires unwelcome verbal, physical, orgraphic conduct of a sexual nature which: reasonably interferes with the employee’s work performance, or Creates an environment which is intimidating, hostile, or offensive.
EFFECTS OF SEXUAL HARASSMENT Decreased productivity/morale. Increased rates of employee turnover, transfer and absenteeism. Increased legal fees and other costs. Increased rates of workers’ compensation and unemployment claims. Ruined lives, families, and careers.
THINGS YOU SHOULD KNOW ABOUT SEXUAL HARASSMENT Harassers may be respected, talented and well-liked. Many who engage in offensive conduct stop when asked to stop. To be harassment, the behavior must be unwanted or unwelcome. Certain behaviors would be harassment to some, but not to others. The courts ask “how would it look to a reasonable person?”
EMPLOYEES’ RESPONSIBILITIES If you think you have been sexually harassed, REPORT IT. If you observe sexual harassment, REPORT IT. If you are making suggestive comments or behaving in ways that could make someone uncomfortable, STOP IT.
YOU SHOULD KNOW THAT: confidentiality at the time of reporting an infraction is assured on a need-to-know basis, and retaliation against any employee for complaining about harassment is prohibited.
Gaylord Hospital is firmly committed to providing anenvironment that is free of any form of sexual harassment.
Diversity is more than differences in race, gender, ethnicity and age. Diversity includes differences in:Income Military experienceEducation PersonalitySexual Orientation Learning StyleReligious Beliefs Working StyleMarital Status LanguageDisability
Culture is more than differences in patterns of daily living. Culture includes differences in:Language ReligionCustoms SuperstitionsHolidays FoodArt MusicClothing
“The Melting Pot” and “The Salad Bowl” The Melting Pot implied a blending of many cultures into one American culture. Immigrants gave up traditions and values to become American.
“The Melting Pot” and “The Salad Bowl” In the Salad Bowl, the focus is on retaining unique ethnic and cultural values and traditions.
Culturally Competent HealthcareCulturally competent healthcare requires acommitment from clinicians and othercaregivers to understand and be responsiveto the different health beliefs, practicesand needs of diverse patient populations.
Why is it so important?• To improve quality of care, outcomes, patient satisfaction, and productivity.• To meet legislative, regulatory and accreditation mandates.• To gain a competitive edge in the marketplace, and decrease the likelihood of liability/malpractice claims.
Characteristics of Culturally Competent Healthcare• Understanding different attitudes, values, verbal cues, and body language.• Respecting patients’ beliefs and values• Interacting with patients in a culturally appropriate and sensitive manner
Culture and Co-WorkersYou may work with people from manycultures. When staff members make an effortto work well together:• Job satisfaction increases• Patients receive the best care
To learn more about other cultures:• The Tremaine Library has a collection of books which describe different cultures and their perceptions of health and illness.• The Tremaine Library website has links to resources that describe the health perspectives of a variety of populations.
Diversity Different Individuals Valuing Each otherRegardless of Skin, Intellect, Talent, or Years
Identifying and Reporting Suspected Abuse and Neglect What to look for What to do
There are many forms of maltreatment• Physical abuse • Financial abuse• Physical neglect • Financial neglect• Self-neglect • Psychological• Sexual abuse abuse • Psychological neglect
What to look for• Recurring marks or bruises on the body• Contradictory or implausible stories regarding injuries• Sudden or increasing isolation from others• Constant presence of caregiver
What to look for• Patient is not willing or is not permitted to speak for him/herself• Resentment, denial, withdrawal, or anger when questioned about obvious facts, including medical treatment• Compromised nutritional status, either overeating or malnourished
Screening Conduct screening for abuse and/or neglect in PRIVATE!The following people SHOULD NOTbe present: the primary caregiver any other possible abuser
If the patient denies abuse• Respect his or her right not to disclose• Inform the patient of your ongoing support and availability• Offer information about resources that are available• Reassess the patient at appropriate intervals
Legal issuesThe State of Connecticut mandatesthe reporting of suspected physicalor sexual abuse or neglect.
Mandated ReportersCertain individuals are required to report cases ofsuspected abuse or neglect involving children, theelderly, or clients of the Department ofDevelopmental Services.Mandated reporters include: Physicians Nurses Pharmacists Social workers Therapists Psychologists Clergy Physician assistants
Reporting vs. ConfidentialityReporting requirements can provide an ethicalconflict for healthcare providers. The patientmay not want the provider to make a report.In this case: • explain that the law may require you to report, and • work to keep a positive relationship with the patient.
How to reportFor individuals under the age of 18 years,contact: Department of Children and Families 1-800-842-2288For individuals 60 years of age and older,contact: Protective Services for the Elderly 1-888-385-4225
ReportingFor all DDS clients, regardless of age, contact: Office for the Protection and Advocacy for Persons with Disabilities at: 1-800-842- 7303There are no reporting requirements for disabled or non-disabled adult victims of abuse between the ages of 18 and 59 years. See Social Services Department for assistance.
Effective Communication with Words that Work RELATE
Communication60% of medical and 58% of surgicalsafety errors are related tocommunication issues.
Words that Work Not just words – it’s an attitude Planned communication Positive body language Pleasant facial expression NOT mechanical or robotic NOT just for clinical staff
Step One: REASSUREMany of our customers are experiencing highstress levels as a result of their situation. It is ourresponsibility to reduce their stress and makethem feel that they are in good hands.Project a professional image; smileOffer an appropriate greeting; introduce yourselfSeek and maintain eye contactOffer reassurances about Gaylord and the staff.
Step Two: EXPLAINMost people will be patient and understandingif they know what to expect.oExplain in clear and understandable terms what is going on, why there is a delay or what they should expect to happen next.oSpeak clearly and at a level that is easy to understand.oMake eye contact and maintain it.
Step Three: LISTENSome people will question why they need to dosomething or why they have to wait. We must remaincalm and patient , especially when the customerbecomes challenging.oListen carefully for questions and concernsoEmpathize with feelingsoBe sure you understand what the person is telling you; ask clarifying questions
Step Four: ANSWER Be positive and calm. Your answer needs to be non-threatening. Remember, we are trying to reassure the customer and explain what he/she should expect.oSummarize using the customer’s wordsoCheck for understanding
Step Five: TAKE ACTION Do what you said you were going to do.o If there is a change in the process, stop and explain.o Keep your customer informed.
Step Six: EXPRESS APPRECIATIONNow is the time to sincerely thank thecustomer for coming to Gaylord. If you arehanding off the customer to another employee,it is appropriate to thank both parties.Also, provide information about the nextperson the customer will see. o “Is there anything else I can do for you before I leave? I have time.” o “This is John. He will take good care of you.”
The Patients’ Bill of Rights has 3 goals:• Strengthen consumer confidence that the health care system is fair and responsive to consumer needs;• Reaffirm the importance of a strong relationship between patients and health care providers;• Reaffirm the critical role consumers play in safeguarding their own health.
PATIENTS HAVE A RIGHT TO: INFORMATIONPatients have a right to accurate andeasily understood information about theirhealth plan, health careprofessionals, and health care facilities.If the patient speaks another language, orhas a mental or physicaldisability, assistance must be provided inorder for the patient to make informedhealth care decisions.
PATIENTS HAVE A RIGHT TO: BE A FULL PARTNER IN HEALTH CARE DECISIONSPatients have a right to know theirtreatment options and to participate indecisions about their care.Parents, guardians, family members orother individuals can be named as asurrogate to represent the patient whenthe patient is unable to make his/herown decisions.
PATIENTS HAVE A RIGHT TO: RESPECT AND NONDISCRIMINATIONPatients have a right to respectful andnondiscriminatory care from theirdoctors, health planrepresentatives, and other health careproviders.
PATIENTS HAVE A RIGHT TO: CONFIDENTIALITY OF HEALTH INFORMATIONPatients have a right to speak inconfidence with health care providersand to have their health careinformation protected. Patients alsohave the right to review and copy theirown medical record and to request thatthe physician change the record if it isnot accurate.
PATIENTS HAVE A RIGHT TO: SPEEDY COMPLAINT RESOLUTIONPatients have a right to a fair, fast andobjective review of any complainthe/she has against doctors, thehospital or other health care personnel.
PATIENTS HAVE A RESPONSIBILITY TO: Collaborate with health care providers in order to achieve the best possible health care and treatment outcomes.
PATIENTS HAVE A RESPONSIBILITY TO: PROVIDE ADVANCE DIRECTIVESPatients have a responsibility forensuring that the health care institutionhas a copy of his/her written advancedirective if one has been written.
PATIENTS HAVE A RESPONSIBILITY TO: SEEK INFORMATION Patients have a responsibility to ask for information about their health status or treatment if they do not understand the information or instruction provided.
• 52 million people in the U.S. speak a language other than English at home.• 95 million people in the U.S. have literacy levels below that required to understand basic written health information, such as how to take medication.
Limited English ProficientAn individual who does not speak English as their primary language or who has a limited ability to read, speak, write or understand English is considered to be Limited English Proficient (LEP).Federal law requires all federally funded health care providers to provide meaningful health care access to LEP persons.
Our Policy• LEP or deaf/hard of hearing patients will have services provided to them during the delivery of all significant healthcare services.• Services will be provided within a reasonable time and at no cost to them.• The provision of interpretation services extends to surrogate decision-makers.
Identification of Need for Interpretation Services Begins before Admission Documented in the EMR Patient or surrogate decision-maker will be asked: “Do you speak another language at home?” “How well do you speak English?” “In what language do you prefer to receive your medical services and your written materials?”
Specific Situations for Interpretation Services • Obtaining medical history • Obtaining informed consent • Explaining diagnosis and • Providing medication treatment plan information • Discussing mental health • Explaining discharge issues instructions • Explaining changes in • Discussing issues at patient condition conference • Discussing Advance Directive • Explaining tests and procedures • Discussing end of life decisions • Explaining patient rights and responsibilities • Obtaining financial and insurance information
Use of Family Members or Staff as Interpreters Staff must beFamily members or certified as languageother individuals interpreters.accompanying the Non-certified staffpatient may be used may be used toto interpret NON- interpret NON-MEDICAL MEDICALinformation only. information only.
Interpretation Telephones Telephones are located on all Nursing Units, Inpatient Therapy, Medical Services, Outpatient Therapy in Wallingford and North Haven, and all Sleep Medicine locations.
Interpretation Services• Directions on use of interpretation phones are attached to each device.• Clinicians can also direct dial CyraCom for assistance. The number is on the device.• TTY phones are available for hearing impaired patients or surrogate decision-makers.• Face-to-face interpreters will be used in special circumstances.
INFECTION PREVENTION AND CONTROL PROGRAM The goal of the InfectionPrevention and Control Program isto improve patient care practicesand thus preserve and enhance aperson’s health and function bypreventing the acquisition ofhospital-acquired infections.
PROGRAM COMPONENTS Infection prevention and control strategies Surveillance in patients and personnel Communication and reporting Education Employee Health Program Environment and Community controls
HANDWASHINGTHE SINGLE MOST EFFECTIVEMETHOD OF PREVENTING THESPREAD OF INFECTION ISHANDWASHING.
WASH YOUR HANDS: Before and after patient contact After removing gloves and other Personal Protective Equipment (PPE) After using the rest room or any personal grooming After coughing/sneezing/blowing nose Before preparing, serving, eating food When arriving at work and before leaving work
HANDWASHING TECHNIQUES Use water and plenty of soap Work up a good lather Scrub well; pay attention to nails, between fingers, and up to your wrists Lather for AT LEAST 15 seconds Rinse well; let the water run off your fingers Dry your hands well; use paper towels to turn off the faucet and open the door
AN ALTERNATIVE TO SOAPAND WATER: ALCOHOL RUBS Use when handwashing is called for EXCEPT when hands are visibly soiled or when the patient has C Difficile. Hand rubs: offer good protection, are convenient to use, and less drying to the skin than repeated soap and water washing. Apply enough to cover the surfaces of both hands and rub hands until dry. Do not rinse.
FINGERNAIL POLICYThe following applies to all staff whohave direct patient contact, as well asstaff who handle, prepare or processpatient items. Artificial nails are prohibited. Fingernails may not exceed ¼ inch from the tip of the finger. Nail polish must be intact.
LATEX ALLERGY Definition: a sensitized response to latex, a natural rubber product. Transmission: latex antigen can be transmitted by air or by contact with latex rubber products. Reaction: can range from dermatitis to anaphylaxis (shock). Signs and symptoms: rash, redness, hives, difficulty breathing.
LATEX ALLERGYEMPLOYEES WHOEXPERIENCE OR SUSPECTA LATEX REACTION MUSTREPORT THIS TO THEIRDEPARTMENT MANAGER ASSOON AS POSSIBLE.
TUBERCULOSIS TB is a disease Symptoms caused by bacteria; the Productive, persi lungs are stent cough affected. Bloody sputum or TB Spreads phlegm through the air Fever after an infected person Weight loss speaks, coughs, s Night sweats neezes, or sings. Loss of appetite
UNIVERSAL/STANDARD PRECAUTIONS Standard Precautions are work practices that help prevent the spread of infectious diseases. Standard Precautions help protect patients and every member of the health care team. Standard Precautions can help prevent illness and can help save lives – including your own!
UNIVERSAL/STANDARD PRECAUTIONSTREAT ALL BODY FLUIDS ASPOTENTIALLY INFECTIOUS ATALL TIMES.Universal Precautions stress that all bodyfluids should be assumed to be infectiousfor bloodborne diseases. The greatestrisks are from HIV, Hepatitis B, andHepatitis C.
COVER YOUR COUGH ALWAYS COVER YOUR COUGH OR SNEEZE. USE TISSUE OR SLEEVE TO COVER. CLEAN YOUR HANDS AFTER COUGHING OR SNEEZING. IF YOU ARE ILL – STAY HOME!
BLOODBORNE PATHOGENS Bloodborne pathogens are microorganisms present in human blood that can cause disease in humans. Bloodborne pathogens can enter the body if infected blood or other potentially infectious material touches a body opening or break in the skin.
PROTECT YOURSELF! Get vaccinated! Hepatitis B vaccine is available to employees free of charge. Do not eat, drink, apply cosmetics, or handle contact lenses in areas where exposure is likely. Do not store food, beverages, or personal items in refrigerators or places where potentially infectious material is stored.
PROTECT YOURSELF! Practice proper hand hygiene. Prevent injuries from sharps. Practice proper handling of contaminated materials. Use Personal Protective Equipment (PPE) if blood or potentially infectious material exposure is anticipated.
PERSONAL PROTECTIVE EQUIPMENT [PPE]PPE should be appropriate for thetype of procedure being performedand the type of exposure anticipated.GLOVES are to be worn when thereis potential for contact withblood, potentially infectiousmaterial or items/surfacescontaminated with these materials.
PERSONAL PROTECTIVE EQUIPMENT [PPE]EYE & MOUTH GOWNS are toSHIELDS are to be worn whenbe used if there there is theis a risk of potential forspraying or splashing ofsplashing body blood or bodyfluids. fluids.
PERSONAL PROTECTIVE EQUIPMENT [PPE]POCKET MASK or BARRIERVENTILATORY MASK is to beworn when giving CPR.
SHARPS Take precautions to prevent injuries caused by needles, scalpels and other sharp instruments or devices. Get help before using sharps around confused or uncooperative patients. Utilize safety engineered mechanisms. Needles should NOT be recapped, removed from disposable syringes, or manipulated by hand.
SHARPS Sharps must be properly disposed of in a marked container as soon as you have finished with them. Do not put a used sharp down and never throw sharps in the trash. Never overfill a sharps container. Containers should be replaced at ¾ full.
BIOMEDICAL WASTE Biomedical waste includes: Blood, blood bags, blood products Items soaked or caked with blood Contaminated laboratory waste, pathology waste Isolation waste from rare, highly communicable diseases
BLOOD & BODY FLUID EXPOSURES Can be a needle stick/puncture wound, mucous membrane exposure (splash), contact with open chapped skin, or a bite. GIVE YOURSELF FIRST AID IMMEDIATELY. WASH EXPOSED SKIN WITH SOAP AND WATER OR FLUSH EYES UNDER RUNNING WATER. AFTER FIRST AID, NOTIFY YOUR SUPERVISOR IMMEDIATELY.
TRANSMISSION BASED PRECAUTIONS ALL PRECAUTIONS ARE IN ADDITION TOSTANDARD PRECAUTIONS – FOR ALL PATIENTS.
AIRBORNE PRECAUTIONS Examples: Tuberculosis, Chickenpox, Measles Use when there are organisms that remain suspended in the air and can be dispersed by air currents within a room or over a long distance. Transfer suspected patient to negative-pressure room ( M115, M215 and L102 or Exam Room 9 in Outpatient) Keep door closed. N95 respirators or PAPR Hoods must be applied prior to entering room. Fit testing of N95 mask is required Pt must wear a surgical mask if leaving the room.
CONTACT PRECAUTIONS Examples: MRSA, VRE, ESBL shingles, scabies, impetigo Use when there are organisms that are transmitted by direct contact with patient. Gowns and gloves are to be used for direct contact with the patient, the environment or equipment. Masks are to be used if within 3 feet of the patient if the infected site is respiratory.
DROPLET PRECAUTIONS Examples: Influenza, Pertussis, Mumps Use for organisms transmitted by droplets generated during coughing, sneezing, or talking. Masks are indicted if within 3 feet. Gowns and gloves are indicated if touching infected materials or if soiling is likely. Patient must wear a mask if leaving room.
ENTERIC PRECAUTIONS Use for patients with C Difficile Diarrhea. Gloves and gowns are to be used when in contact with the patient or the patient’s environment. Alcohol-based hygiene products are not effective against C Difficile spores. Utilize soap and water only. Therapy warded until diarrhea free x48hrs. Disinfect equipment with hospital approved bleach solution.
Protective Environment Precautions Examples: bone marrow transplant, chemotherapy Use when patient has an absolute neutraphil count is below 500 Thoroughly wash hands before entering patient’s room Wear a surgical mask if you are experiencing a respiratory infection. Patient should wear a surgical mask when leaving the room if determined by their physician.
EMPLOYEE HEALTH Pre-employment 2-step PPD skin test and annual PPD for all employees and volunteers Employee Education Vaccination program: Hepatitis B, Chicken Pox, Measles, German Measles, Mumps and Flu. Employee exposure reporting and follow-up.
For your information: The Infection Control, Isolation and EmployeeHealth Manual is available on the Gaylord Intranetunder “Infection Control.”
QUESTIONS?If you have questions about any ofthe Infection PreventionInformation presentedhere, contact:Susan Paxton RN CICDirector of Infection PreventionBrooker 108, x3278203-412-2475 beeper
INFLUENZA• Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than 200,000 persons in the United States each year.• Influenza is PREVENTABLE.• Influenza vaccination is recommended for all healthcare workers to prevent influenza disease and it’s complications , including death.• The influenza virus can be spread from asymptomatic carriers.
Flu Symptoms• Fever• Chills• Cough• Sore throat• Headache, body aches, fatigue• Diarrhea and vomiting in some cases.• Symptoms may be mild or severe
How is the Influenza Virus Spread?• Spread is mainly through coughing and sneezing.• People may become infected by touching something with flu virus on it and then touching their mouth and nose.
Who is at risk?Anyone who has contact with an infectedperson may be exposed.
PREVENTION• Get vaccinated!• Wash your hands often and well• Cover coughs and sneezes• Eat well and get plenty of rest• Avoid contact with sick individuals• Frequently disinfect high touch items such as keyboards, phones, doorknobs)• Have tissue and Purell readily available• Don’t share community food, drinks etc.• Follow travel alerts• If sick, stay home!
If you are sick….• Stay home! Notify your supervisor that you are experiencing flu symptoms. Your supervisor will report this to Infection Prevention ext 3278.• Employees are to remain out of work until fever free for 24 hours without the use of Motrin, Tylenol or medications containing fever reducing ingredients, such as Theraflu.• Call your doctor. Anti viral medication may be indicated.• Avoid close contact with others and cover your cough.• Rest, drink plenty of fluids.• Warning! Do not give aspirin to children or teenagers who have the flu. This can cause a rare but serious illness called Reye’s syndrome.
Helpful Tips when caring for some one at home with Influenza• Social distancing: Avoid close contact (less than 6 ft) with the sick person. Avoid being face to face with the sick person.• When holding small children who are sick, place their chin on your shoulder so that they will not cough in your face.• Wash your hands after every contact with the ill person or the ill person’s things.• Reduce visitors and keep sick person in a room separate from the common area of the house.• If possible designate a bathroom for the ill person.• Talk to your care giver about antiviral medication.• Monitor yourself for signs and symptoms.
Protect Our Patients• Please do your part• Vaccinate yourself and your family• It’s the right thing to do!• Joint Commission targets a 75% Health Care worker’s vaccination compliance rate this year• A signed declination is required for all employees who refuse vaccination, as well as a documented reason why• FYI: Mandatory vaccination has been passed in some states (NY and West Virginia)• More to come as the season evolves….
Risk ManagementRisk Management is a proactive approach toimprove safety and reduce risk forpatients, visitors, and employees.Key steps: • Identify the risk • Assess frequency/severity of the risk • Reduce or eliminate the risk
Risk Management Tools– Employee Injury Report Form– Occurrence Forms • Medication • Falls • Wound • General/All Other OccurrencesThese confidential forms are available on theGaylord Hospital Sharepoint site. Paper copies areavailable in each department.
In the event of an employee, visitor or patient occurrence• Respond to the needs of the person• Obtain a form and provide a brief, factual description of the event• Give the completed form to your supervisor by the end of the shift during which the event occurred• Do not make copies of the form• Do not note in patient’s chart that an occurrence report has been written• For employee occurrences, obtain care, notify your supervisor and have him/her complete a form
Who to Contact• In the case of serious events, contact your supervisor and the Outcomes Management Director• Share information with only those who need to know• Maintain confidentiality
If a patient/family member has questions/concerns about care• Try to answer the question/concern yourself or if not possible, contact your supervisor or the responsible director• Inform the patient about the Patient Advocate at Ext. 3000 • (Only when unsuccessful in responding to the concern)• Provide contact information for the CT Department of Public Health or The Joint Commission as appropriate
PERFORMANCE IMPROVEMENT• Performance Improvement is a process for improving organizational performance.• The overall goal is the provision of safe, high quality, sustainable health services.• Gaylord Hospital is committed to the process of Performance Improvement to help us achieve our mission.
PERFORMANCE IMPROVEMENTPerformance Improvement is driven by themission, vision, values and strategic plan ofGaylord Hospital.Performance Improvement goals arefocused in 3 areas: – Safety and Quality – Patient Satisfaction – Outcomes
PERFORMANCE IMPROVEMENT Hospital Wide Patient SatisfactionThe gap between the height of the monthly bar and the red goal line represents thedifference between the performance we want (the goal) and the performance wehave achieved. We want that gap to be as small as possible. When it appears insuccessive months, eg, March and April, we use a Performance Improvement Plan (PIPlan) to close the gap.
GAYLORD’S PI PROGRAM• Monitored by the Organizational Excellence Committee• Carried out collaboratively with a hospital-wide approach• Involves hospital staff at all levels
Gaylord’s PI Plan Methodology FOCUS PDCAFind an opportunity to Plan an intervention that improve responds to the analysisOrganize the study and of the data identify the team Do a pilot of the interventionClarify the knowledge of the Check the effect of the process interventionUnderstand the data Act on the results of theSelect an intervention based intervention on the data
Examples of 2012 PI Monitors All Service Lines Likelihood of Recommending Gaylord Patient Satisfaction with Gaylord InpatientNumber of Central Line Associated Blood Stream Infections Outpatient Percent of patients reporting Improvement in Function Sleep Percent of patients who Comply with CPAP treatment
Why focus on PI?• To improve quality of care• To enhance safety for patients/staff• To improve patient satisfaction• To save time and money
OUR COMMITMENTTO INFORMATION SECURITY Gaylord is committed to protecting information and information systems, maintained in any medium, from improper use, alteration or disclosure, whether accidental or deliberate.
WHAT IS INFORMATION SECURITY?Information Security encompasses all of theprotections in place to ensure that ProtectedHealth Information [PHI] is: kept confidential not improperly altered or destroyed readily available for those who are authorizedWhat is PHI? PHI isconfidential, personal, identifiable healthinformation about individuals.
WHY IS INFORMATION SECURITY NECESSARY? Protecting patient information is an essential part of quality health care. Creating an environment where patients can trust us to protect their private information is the responsibility of every employee. Information security policies and procedures are required by The Joint Commission, HIPAA and other state and federal laws and accreditation standards.
WHEN CAN WE SHARE PHI?For Treatment of the patientFor PaymentFor Healthcare OperationsWith Business Associates: individual or entity who performs a function on behalf of Gaylord Hospital with whom we share PHI.
E-MAIL Not all of electronic mail sent outside of Gaylord is encrypted. Encryption scrambles the data so that it cannot be read by anyone who does not have the key to read it. In an un-encrypted state, if someone intercepts the e-mail, it can easily be read or hacked. Do not send PHI outside of the Gaylord Hospital network. Best Practice: Use the minimum necessary information at all times.
MINIMUM DISCLOSURE NECESSARY An organization must make reasonable efforts to disclose ONLY the amount of health information needed to accomplish the intended purpose. The Medical Provider CAN disclose the entire record to another health care provider for treatment.
UNAUTHORIZED HARDWARE/SOFTWARE Do not install any hardware or software without the approval of Gaylord’s IT Department Certain software can disable your computer, threaten our network, or contain malicious software or coding. Digital cameras, jump drives and CD’s from home or other outside sources may contain viruses malware or spyware that may also do harm to our systems. Please contact the IT Helpdesk at x2222 if you have any questions about hardware and/or software.
USER IDs AND PASSWORDS User ID’s and Passwords are the most effective way to protect access to electronic PHI. Properly manage your ID and password: do not share your ID and/or password with anyone, and never use anyone else’s ID or password. Choose a strong ID and password, one that is not easily guessed. See Gaylord Hospital policy 2-200-48 for more information on password management.
KEEP THIS IN MIND! If you let someone else use your personal ID or password or use a computer where you are still signed in, you are risking YOUR REPUTATION, YOUR PROFESSIONAL CREDENTIALS AND YOUR JOB!
IN THE EVENT OF VIOLATIONS Violations of Information Security policies will result in corrective action, up to and including termination of employment.Policy violations that also violate HIPAA could result in fines and prison sentences.
WHO TO CONTACT? Gerald Maroney, Chief Information Officer x 2120 or firstname.lastname@example.org Susan Hostage, Director of Outcomes Management x 2747 or email@example.com
COMPLIANCE AT GAYLORD HOSPITALGaylord Hospital is committed toconducting its business in an ethical andlawful manner. We will comply withboth the letter and spirit of all applicablelaws, regulations, policies and procedures.
Gaylord Hospital’s Compliance Program Written standards of conduct (Code of Ethics and Privacy/Security Statement) A Compliance Officer and a Compliance Committee Training and education of employees Written policies and procedures Investigation/ corrective action for detected problems/disciplinary action as appropriate Ongoing monitoring and auditing to assess the effectiveness of the program
Written Standards of Conduct The Code of Ethics provides guidance toensure that our work is done in an ethical andlegal manner. It contains standards of ethicalbehavior for all staff in their professionalrelationships with colleagues, patients, otherorganizations, state and federal governmentagencies, donors, the community and societyas a whole.
Examples of Organizations/Laws Requiring Compliance• The Joint Commission• Commission on Accreditation of Rehabilitation Facilities (CARF)• American Academy of Sleep Medicine• Centers for Medicare and Medicaid (CMS) Conditions of Participation• CT Department of Public Health Code• Fraud and Abuse Laws
Examples of Non-Compliance Accessing patient information without a business need to know Documenting incorrectly Billing for services or supplies not actually provided Sharing passwords Failing to maintain patient confidentiality and privacy
Fraud and AbuseGaylord Hospital will investigate allallegations of fraud and/or abuse, takenecessary corrective actions after athorough investigation, and reportconfirmed misconduct to theappropriate parties.
Definitions of Fraud and Abuse FRAUD: ABUSE:an intentional deception provider practices thator misrepresentation are inconsistent withmade with the sound business, fiscal orknowledge that the medical practices, anddeception could result in result in unnecessary costsome unauthorized to health programs, or inbenefit to him/herself or reimbursement forsome other person. services that are not medically necessary.
Federal Deficit Reduction Act Requires development of policies and education relating to false claims, whistleblower protections, and procedures for detecting and preventing fraud and abuse. False Claims Act: those who knowingly submit, or cause another person or entity to submit false claims are liable for damages plus civil penalties.
Reporting Violations• Discuss the issue with your supervisor, or• Contact the Compliance Officer Susan Hostage, or• Contact the Compliance Hotline.• You may also refer to the Code of Ethics and specific policies for additional guidance.
Compliance Hotline: 203-679-3537 The Compliance Hotline can be used to report something you believe is, or may be, a compliance violation. You do not speak directly to anyone; you simply leave a recorded message. You do not have to identify yourself.
Consequences For the hospital: Monetary fines Exclusion from federal healthcare programs (Medicare or Medicaid) Possible criminal penalties For the individual employee: Disciplinary action Possible termination
Employees’ Responsibilities Read compliance-related materials such as the Code of Ethics Know the type of conduct that is expected of you and what is prohibited Follow all policies and procedures that apply to your job Share concerns/questions you have regarding potential compliance issues with your supervisor.
Questions and/or Concerns?? Non-Retaliation PolicyNo action will be taken against a staff memberfor asking questions or raising concerns in goodfaith about the Code of Ethics or for reportingpossible improper conduct.All employees are strictly prohibited fromretaliating against anyone who reports aviolation or a concern.
WHAT IS HIPAA? HIPAA is an acronym for the Health Insurance Portability & Accountability Act of 1996. HIPAA consists of three separate parts: 1) Privacy, 2) Security, and 3) Electronic Data Exchange Privacy Security Electronic Data Interchange
THREE AREAS OF PRIVACY Use and disclosure of protected health information (PHI) Patient rights related to their PHI Security of PHI Administrative Physical
WHAT IS PROTECTED HEALTH INFORMATION?Protected HealthInformation, also knownas PHI: any individuallyidentifiable informationincluding demographicinformation which iscollected from anindividual.
PHI PHI is created, received, maintained or transmitted by a healthcare provider. Relates to the past, present or future physical or mental health or conditions of an individual and the provision of healthcare to an individual. PHI can be found in electronic, paper or oral formats. PHI either identifies the individual, or contains information through which the individual could be identified.
PHI INCLUDES THESE PATIENT IDENTIFIERS:• Names • Any dates related to• Medical Record Numbers any individual (date of• Social Security Numbers birth)• Account Numbers • Telephone numbers• Vehicle Identifiers/Serial • Fax numbers numbers/License plate • Email addresses numbers • Biometric identifiers• Internet protocol including finger and addresses voice prints• Health plan numbers • Any other unique• Full face photographic identifying images and any number, characteristic comparable images or code
WHAT DOES THE PRIVACY RULE MEAN FOR PATIENTS?• Enables patients to find out how their info may be used.• Enables patients to find out what disclosure of their info has been made.• Limits release of info to the minimum reasonable needed for the purpose of the disclosure.• Gives patients right to examine and obtain copy of their own health records and request corrections.
WHEN CAN WE SHARE PHI?For Treatment, Payment, and Healthcare Operations (TPO)A doctor may access the patient’s medical file to treata patient.We may send PHI to an insurance company to pay ahospital bill.We may use PHI for operations such as qualityimprovement, case management or trainingprograms.
Minimum Necessary An organization must make reasonable efforts to disclose ONLY the amount of health information needed to accomplish the intended purpose. Medical provider CAN disclose entire record to another health care provider for treatment (referrals, etc.)
Minimum Necessary and Need to Know• Only staff members who “need to know” a patient’s PHI to perform their job should access the information• HIPAA requires healthcare workers to use or share only the “minimum necessary” information needed to perform their job function.
Ask yourself the following questions before accessing or viewing any patient information:• Do I need this information to perform my job?• Do I have an immediate business need to obtain this information?• What is the least amount of information that I need to perform my job?
HIPAA ComplianceUnder HIPAA we are required to:• Conduct random security audits to ensure that only staff members who need to know PHI are accessing it.• Ensure that only the minimum information necessary to perform the job are being accessed.• An employee who inappropriately accesses PHI is subject to disciplinary action. Refer to Policy # 2-600- B-23 Compliance Investigations and Associated Disciplinary Action
Do your part to protect PHI…Clean It Up Retrieve documents that contain PHI immediately from printers and fax machines. Secure all files or documents with PHI out of sight when you leave your desk. Minimize PHI and lock your computer when leaving your workstation for any reason. Place all papers or documents that contain PHI in appropriate shred-bin for proper destruction.
THE SECURITY RULEEnsures the confidentiality, integrity and access of all electronicProtected Health Information which Gaylordcreates, receives, maintains, or transmits.Safeguards electronic system use by providing employeesindividual passwords that are not shared, and allowing accessto the systems based on job description.Protects against any reasonably anticipated uses or disclosuresof information that is not permitted by educating staff andperforming routine and ongoing audits of system use andaccess.
SECURITY ALSO APPLIES TO Email Social Networking Handheld devices and laptops Unauthorized hardware & software
SECURITY REMINDERS• Select passwords that are hard to guess and include alpha and numeric characters• Do not share your password with anyone• Do not send email containing PHI outside of the Gaylord network (gaylord.org)• Do not save PHI directly to your computer• Do not remove PHI from the hospital• Secure laptop and portable devices
THE HITECH ACT OF 2009 Expands the protection under HIPAA with increased focus on Privacy & Security Increased civil penalties and potential for criminal penalties Breach Notification – the mandatory requirement to report the unauthorized access of protected health information
THE BREACH RULEA breach is the unauthorized acquisition, access, use or disclosure of unsecured PHI that compromises the security or privacy of such information.The hospital is required to provide notice to each patient affected by a breach within 60 days of the occurrence.The hospital must submit an accounting of all reportable breaches to the Department of Health & Human Services each year.**Not every HIPAA violation is a “reportable” breach but should be reported to a compliance officer.
WHAT HAPPENS IF …a Privacy or Security policy is violated? Organization-specific sanctions Right to file a complaint Civil and criminal penalties
WHAT SHOULD YOU DO? Follow all Confidentiality and HIPAA policies 2-300-06 Use and Disclosure of Protected Health Information 2-800-07 Breach Notification Policy 2-800-20 Notice of Privacy Practices 2-800-02 Minimum Necessary for Use & Disclosure of PHI Additional Privacy & Security policies can be found on SharePoint Report all potential breaches immediately to the Privacy Officer (Ext 3303), regardless of its significance. When in doubt, contact the Privacy or Security Officer Privacy Officer: Tracey Nolan ext. 3303 Security Officer: Gerry Maroney ext. 2120 Compliance Officer: Susan Hostage ext. 2747