Catholic Health Orientation for New Associates
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Catholic Health Orientation for New Associates



New associates are required to view this presentation before attending orientation.

New associates are required to view this presentation before attending orientation.



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Catholic Health Orientation for New Associates Catholic Health Orientation for New Associates Presentation Transcript

  • This material must be reviewed prior to attending your General Orientation class.Please ask any related questions at your General Orientation class. 1
  • 2
  • Together we can prevent and reduce the risk of infection in healthcare for ourpatients, associates, families and visitors. 3
  • The Infection Control Program is designed with expertprevention strategies…Evidence based guidance is primarily from: Center for Disease Control Society for Healthcare Epidemiology New York State Health Department Association for Practitioners in Infection Control Joint Commission 4
  • Infections occur person to person, based on the typeof infection it is. Respiratory infections are transmitted through coughing, sneezing and talking by someone who is ill Other infections may occur from: Direct skin to skin contact Touching something contaminated Hand washing is the KEY to prevention! 5
  • Hand WashingTraditional Hand Washing Use running water and soap. Remember to keep the water temperature comfortable. 15-20 seconds is needed for effective hand washing. Sing “Happy Birthday!!” Apply friction to all surfaces. Rinse and dry. Turn off faucets with a paper towel. THAT’S IT!! 6
  • Hand Washing - continuedHand Hygiene Waterless hand sanitizer is available and is just as effective as soap and water, except when taking care of patients with C-diff. Waterless hand sanitizer dispensers are conveniently located throughout the building. Waterless hand sanitizer should not be used when your hands are visibly soiled because you need the mechanics of hand washing. Artificial fingernails of any kind ARE NOT to be worn in clinical areas. 7
  • InfluenzaTransmitted through respiratory secretionIncludes seasonal, H1N1 and othersPractice respiratory etiquette – cover your cough,use tissues and meticulous hand hygiene isessentialConsider obtaining the flu vaccine for protection 8
  • Associate HealthAssociates should not work while illPrior to returning to work after illness, associatesmust be fever free for 24 hours and off antipyreticsAnnual Health Assessment/PPDObtain vaccines (e.g. Influenza, Hepatitis B)Report any potential communicable illnessexposure (e.g. Chicken Pox) for appropriateguidance 9
  • Emergency PreparednessTwo plans exist: Pandemic BioterrorismBoth are addendums to the EmergencyManagement Plan Information available at: Compliance360/Emergency Management/ Surge Capacity 10
  • Find us on “Click on the Bug” …from the main Catholic Health website for information Includes: Infection Control policies IC staff contact information Staff, patient, family and visitor information General communicable disease information 11
  • Anne MasonCompliance &Privacy Officer 12
  • To prevent, find and correct violations of CHSstandards, governmental laws, regulations andrulesTo promote honest, ethical behavior in theday-to-day operationsTo understand the ethical, professional, and legalobligations associates have and our role inmeeting those obligations 13
  • As healthcare professionals and providers, we are dedicated to caring for and improving the health and well being of the people we serve in the community Compliance means “doing the right thing” 14
  • Attain compliance by: Embracing our Mission and Values Adherence to Policies and Procedures Found in Compliance 360 Maintaining high standards of business and ethical conduct Delivering high quality patient care 15
  • Standards of Conduct & Ethical Conduct Deal openly and honestly with others Maintain high standards of conduct in accordance to the CHS Mission, directives of the Catholic Church, and applicable federal, state and local laws and regulationsConflict of Interest We have a responsibility to act on the best interests of Catholic Health. We need to avoid situations that lead to actual or perceived conflicts of interestDocumentation and Billing Must be accurate and complete 16
  • Associate Compliance Guidebook Provides information on the Standards of Conduct and is available on CHS website. An observation of failure to follow Standards of Conduct, Policies or Procedures, or observation of an error requires reporting. Associates can face disciplinary action and even termination for failure to report such events. 17
  • All associates are expected to follow standards for Legal and Regulatory Compliance Business Ethics Conflict of Interest Appropriate Use of Resources Confidentiality Professional Conduct Responsibility And follow the Code of Ethics 18
  • Enhance the Patient Experience Have a questioning attitude Pay attention to details Follow the rules Be accountable for your actions Providing high quality services and upholding patient rights supports the Compliance Program. 19
  • Compliance policies and procedures are available onCompliance 360 (or in an on-site reference manual)and apply to all CHS associates.Additional compliance policies are also applicable to: Home Care Clinical Laboratory Physician Practices Nursing Facilities Coding and Billing Home Health Agency PACE Program 20
  • It is fraudulent to either document services that werenot performed or to submit claims for services withoutappropriately documenting those services Missing clinical notes (dates, signatures, orders, care or service rendered) or test results Incomplete or illegible documents Improper billing and coding can be interpreted as fraud or abuse and lead to a false claim with the government resulting in penalties Reimbursement can only be sought for services or items that have been provided and appropriately documented. If it’s not documented, it’s not done. 21
  • It is a crime to knowingly make a false record, file, orsubmit a false claim with the government for payment.A false claim can include billing for service that: Was not provided or documented Was not ordered by a physician Was of substandard quality Improperly coded or billedIt is also unlawful to improperly retain overpayments. Allows for Qui Tam Relator – notification togovernment with protection (Whistleblower provision) 22
  • Government Sanctions Individuals or entities can be excluded from participation in Medicare and Medicaid programs. CHS must not submit any claims to Medicare and/or Medicaid in which a sanctioned individual or entity provided care or services. If an associate/provider is sanctioned, he/she must provide notification immediately to the Compliance Officer. 23
  • If working on behalf of CHS, do your actions or activitiesresult in personal gain or advantage, potential adverseeffect for CHS or the potential to interfere with professionaljudgment, objectivity or ethical responsibilities?Potential Conflicts of Interest Relationships includefinancial relationship for yourself or your immediate familymember or secondary employment Consultant Speakers’ Bureau Advisory Panel Administrative positions with Pharm or DME Third Party Payor Other entities doing business with CHS All potential Conflicts of Interest must be reported. 24
  • Associates may NOT accept any cash gifts orcash equivalent gifts (gift cards) from any personor business conducting or seeking to conductbusiness with CHSPrior to receiving work-relatedGiftsSocial or entertainment eventsFree mealsAssociates must consult with their supervisor. See CHS Policy for further information. 25
  • Ensures that limited English proficiency or hearingimpaired persons utilizing CHS services are ableto understand and communicate with CHSassociates and physiciansProvided FREE of charge to the patientMandatory service by lawDocumentation is vital to complianceLanguage Assistance Program Policy is found in Compliance 360 26
  • HEALTHINSURANCEPORTABILITYACCOUTABILITYACT and HITECHHealth/Information Technology for Economic andClinical Health Act Privacy and Security Policies are found in Compliance 360 27
  • Individually identifiable health information Also known as Protected Health Information (PHI) Transmitted or maintained in any form or medium 28
  • Names Biometric IdentifiersFull face photos Geographic subdivisionsMedical Record Number smaller than a stateHealth Plan Number All elements of datesAccount Numbers related to birth date, admission, discharge, orCertificate/License date of death, ages over 89Numbers Telephone and faxVehicle Identifiers numbersE-mail and web Social Security Numberaddresses Any other unique identifying data 29
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  • Be aware of surroundings Be conscious of who is in the immediate area when discussing sensitive patient information or at your computer terminal (lower your voice)Secure area when not attended Close out of computer screens containing PHI before leaving the area Close medical records/chart when not in use Do not allow other associates to utilize your ID and password Report theft or loss of computer devices immediatelyCorrect Disposal of PHI (shred bin) 31
  • Telephones Be careful with phone call pertaining to patient informationFax Machines and Scanners Pick up faxed or printed PHI immediately Use fax cover sheet, verify # and receipt Scan PHI only to CHS e-mail accountsE-Mail Make sure to encrypt if being sent outside CHS Careful forwarding and replyingMail Double check name/address and material prior to sending 32
  • Curiosity can be a normal human trait …However accessing health information on yourself,family members, friends, co-workers, persons ofpublic interest or any others that you are not involvedin the care of orDisclosing PHI inappropriately Are … VIOLATIONS of HIPAA Individuals do NOT have the right to look up their own health records. Your computer use can be monitored. 33
  • Fraud and AbuseFraud Defined: An intentional deception ormisrepresentation that could result in someunauthorized benefit to a person or CatholicHealthAbuse Defined: Practices that are inconsistentwith sound fiscal, business, or medical practices,and result in unnecessary cost, or inreimbursement of services that are not medicallynecessary or that fail to meet professionallyrecognized standards for health care 34
  • Documentation issuesImproper billing and codingOffering or receiving kickbacks, bribes, or rebatesThe service has not been rendered by theidentified provider, to the identified person, or onthe identified date 35
  • Lack of integrity Ethical incidents Theft or misuse of services Improper political activity Breech of corporate confidentiality Improper use of proprietary information Environmental health and safety issues Dishonest communication (spoken or documents) Improper business arrangements Failure to follow Record Retention policy Receipt of incentives for patient referralsThe Associate Guidebook or your supervisor can provide additional info. 36
  • Immediate supervisor or appropriate department Higher level manager Compliance Officer Anne Mason 821-4469 Also available 24/7 Compliance Line 1-888-200-5380 Confidential and Anonymous (if desired) 37
  • Behavior issuesHuman Resource policy violationsUnion contract matters… Should be reported to Human ResourcesPolicies on Compliance 360 include: Corrective Action Fair Treatment Review 38
  • Protects associates from adverse action whenthey do the right thing and report a genuineconcernReckless or intentional false accusations by CHSassociates are prohibitedReporting the possible violation does not protectthe constituent from the consequences of theirown violation or misconduct Associates have a duty to report HIPAA/Compliance concerns 39
  • Upholding CHS Mission and ValuesAdhering to Code of Conduct, Policies andProcedures and the LawCompleting education and employmentrequirementsConstant monitoring for concernsDuty to report concerns and support non-retaliationDuring an investigation Be truthful Preserve documentation or records relevant to ongoing investigations 40
  • For associate and CHSmanagers/supervisors/administrators Fines and Prison sentences Corrective action - Includes termination of employment for violations or failure to report concernsFor Catholic Health System Exclusion from government funded insurance programs (Medicare/Medicaid) Fines 41
  • Putting words into action …“We judge ourselves based on our intentions … Others judge us based on our actions.” Adhere to the CHS code of conduct, policies and procedures, and other standards 42
  • Duty to report Compliance/HIPAA concerns assoon as aware of situationDo the right thing … Apply ethical decision makingIf uncertain … Always Seek Knowledge (A.S.K.) Use Associate Booklet on CHS website as a reference 43
  • Compliance/HIPAA Privacy Officer Anne Mason 821-4469CHS HIPAA Hotline 862-1790Compliance Hotline 1-888-200-5380 (available 24/7) All reports are confidential. 44
  • 45
  • Risk Management is thesystematic review of eventsthat present a potential for harm and could result in loss for the system. 46
  • Review IdentificationReview Occurrence ReportsReview Patient/Visitor ComplaintsParticipate in Root Cause AnalysisReview concerns expressed by CHS staff 47
  • Loss PreventionEducational programs through CHS UniversityDepartment specific in-services 48
  • Claims ManagementInvestigating and reporting occurrences andclaims made to insurance carriersAssist with discovery requests for lawsuitsProcess Summons, Complaints and Subpoenas ** NOTIFY RISK MANAGEMENT IMMEDIATELY UPON RECEIPT OF A WORK RELATED SUMMONS OR SUBPOENA 49
  • Claims Management - Continued Within CHS, a process server is to be directed to Administration of the facility in order to serve a Summons or Subpoena.(HIM may accept subpoenas for hospital records.) *** INDIVIDUAL DEPARTMENTS SHOULD NOT ACCEPT, EVEN IF IT IS FOR SOMEONE IN THE DEPARTMENT. 50
  • Risk Financing Obtaining and maintaining appropriate insurance coverage:HPL (Healthcare Professional Liability)GL (General Liability)D&O (Directors and Officers)Property and CasualtyAutoCrimeFiduciary (Finance) 51
  • An occurrence is an event thatwas unplanned, unexpected andunrelated to the natural course of a patient’s disease process or routine care and treatment. 52
  • Patient harm/potential harm like falls, medicationerrorsVisitor injuryPatient related equipment “failure”Security issues like elopement, crime, altercationsLost or damaged property 53
  • Enhance the quality of patient careAssist in providing a safe environmentQuick notice of potential liability 54
  • Any associate or physician who discovers,witnesses or to whom an occurrence is reported, is responsible for documenting the event immediately by means of the Occurrence Report.Anyone who requires assistance should contact the department manager. DO NOT MAKE COPIES OF AN OCCURRENCE REPORT. 55
  • The completed Occurrence Report is to be forwarded to the Department Manager who will investigate the occurrence and forward to Quality & Patient Safety Department who will forward to Risk Management. 56
  • Patient and visitor safety are assessed from both clinical and environmental perspectivesNotify Quality & Patient Safety of patientoccurrencesNotify Security of visitor or property occurrencesRisk Management will be notified and willparticipate in evaluation of occurrenceRisk Management will report occurrences toinsurance carrier in cases of potential liabilityRisk Management will manage claim as indicated 57
  • Date (MM/DD/YY) and time (military)State facts, be clear and conciseYour own observationsIf event described to writer, use quotes or“according to …”Do not place blame in the recordDO NOT REFER TO OCCURRENCE REPORT INTHE MEDICAL RECORD 58
  • EMTALA is the Emergency Medical Treatment andActive Labor Act (aka COBRA)EMTALA provides aguideline for safely andappropriatelytransferring patients inaccordance withFederal regulations. 59
  • The law provides for a medical screening exam (MSE) to allindividuals seeking emergency services on hospital property. Hospital property includes the driveway, parking lot, lobby, waiting rooms and areas within 250 yards of the facility. If an emergency medical condition is found, it will be stabilized within the hospital’s ability to do so, prior to the patient’s transfer or discharge.If a patient does not have an emergency medical condition, EMTALA does not apply. *** IMPORTANT: NEVER SUGGEST THAT A PATIENT GO ELSEWHERE FOR TREATMENT 60
  • Fair and Accurate Credit Transactions Act of 2003 or “RED Flag Rules”Hospitals that maintain covered accounts must develop and implement writtenpolicies and procedures to identify, detect, prevent, and mitigate identity theft. 61
  • Alerts, notifications, warningsPresentation of suspicious informationSuspicious activityNotice from patient, law enforcement, etc. ** Patient Access, Health Information, Finance, I.T. departments primarily involved. 62
  • You can help reduce opportunities for Identity Theft by keeping PHI confidential and out of public view. If you believe someone is presenting suspicious documents or acting in asuspicious manner, notify your supervisor who will notify Risk Management. 63
  • Carol Ahrens, RN, BSN 821-4462Director, Risk ManagementJoanne Ricotta, RN, BSN 821-4463Risk Management CoordinatorLinda McGavin 821-4467Risk Management Technical AssistantAmy Maurer 821-4468Legal Services Administrative Assistant 64
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  • NIOSH (National Institute for Occupational Safetyand Health) defines workplace violence as violentacts (including physical assaults and threats ofassaults) directed toward persons at work or onduty. 66
  • Threats:Expressions of intent to cause harm, includingverbal threats, threatening body language, andwritten threats.Physical Assaults:Attacks ranging from slapping and beating to rape,homicide, and use of weapons such as firearms,bombs, or knives.Muggings:Aggravated assaults, usually conducted bysurprise and with intent to rob. 67
  • Workplace violence in hospitals usually resultsfrom patients and occasionally from familymembers who feel frustrated, vulnerable,and out of control. 68
  • Violence takes place During times of high activity such as meal time or visiting hours or patient transportation When service is denied When a patient is involuntarily admitted When limits are set regarding eating, drinking, tobacco use or alcohol use 69
  • Hospital personnel having direct contact withpatients and families are at increase risk. 70
  • An elderly patient verbally abused a nurse andpulled her hair when she prevented him fromleaving the hospital to go home in the middle ofthe night.An agitated psychotic patient attacked a nurse,broke her arm, and scratched and bruised her.A disturbed family member whose father had diedin surgery walked into the E.D. and fired ahandgun, killing a nurse and an EMT andwounding a physician. 71
  • Anywhere in the hospital, but it is most frequent inthe following areas: Emergency Departments Any Critical Care area Waiting Rooms Geriatric Units 72
  • Violence can have a negative effect on anorganization as reflected by: Low morale Increased job stress Increased worker turnover Reduced trust of management or co-workers 73
  • Contact with violent people or those with history ofviolenceContact with those under the influence of drugsand/or alcoholContact with people having psychotic diagnosesContact while transporting patientsContact with people perceiving a long wait forserviceWorking alone 74
  • Watch for signals of impending violence: Verbally expressed anger and frustration Body Language such as threatening gestures Signs of drug or alcohol use Presence of weapons 75
  • Assess current demeanor when you enter a roomor begin to relate to a patient or visitorBe vigilant throughout the encounterDon’t isolate yourself with a potentially violentpersonKeep an open path for exiting 76
  • Present a calm, caring attitudeDon’t match the threatsAvoid giving commandsAcknowledge a person’s feelingsAvoid behavior that may be interpreted asaggressive 77
  • Remove yourself from the situationCall Security for HELP if neededReport any potential or actual violent incidents toyour department manager 78
  • No universal strategy exists to prevent violenceAll hospital workers should be alert and cautiouswhen interacting with patients and visitorsStaff need to be aware of polices and proceduresrelating to violence prevention 79
  • 19 Rights in the Patient Bill of RightsThey are posted in all patient care areasThey are available in Spanish as well as English 80
  • If they don’t understand their rights, Receive all information to give informedsomeone needs to explain them consent regarding do not resuscitateReceive treatment without Refuse treatment and be informed ofdiscrimination effectReceive considerate and respectful Refuse to take part in researchcare in a clean safe environment freefrom unnecessary restraints Privacy in the hospital and confidentiality of all information andReceive needed emergency care records of your careKnow the names and positions of Participate in decision making aboutpeople caring for them, and refuse their care, including dischargetheir treatment Review of their medical recordKnow who the MD is who is in chargeof your hospital care Receive an itemized bill with explanation of chargesA non smoking room Complain without fear of reprisalReceive complete information abouttheir diagnosis, treatment and Authorize family members to visitprogress Make known your wished regardingReceive all information for informed anatomical giftsconsent 81
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  • It is a focused approach toidentify, evaluate and improvestrategic clinical processes to realize our overall goals ofimproving patient safety and clinical outcomes. 83
  • Improving the Patient ExperiencePreventing FallsPreventing Pressure UlcersReducing Medication ErrorsPreventing Associate InjuriesReducing Hospital Infections – (Central LineInfections, Urinary Tract Infections from Catheters,MRSA, Surgical Site)Disease Specific Measures (Heart Failure,Pneumonia, Acute MI, Stroke)Reducing Readmissions 84
  • Establish multi-disciplinary teams at site and /orsystem level (Associates are often asked toparticipate)Set target / goals that are reported up to the BoardCollect and analyze dataUtilize national best practicesStandardize practices / policiesProvide educationMonitor the changes and obtain feedback fromend users 85
  • At CHS we believe that the patients and associatessafety are our main concern. As a result we havefocused our efforts to strengthen our Culture ofSafety with the ultimate goal of eliminating medicalerrors to our patients and injuries to our associates.How? By raising our expectations of our Board,Leaders, Physicians and Associates. 86
  • We expect every ASSOCIATE,LEADER and PHYSICIAN to:Pay Attention to DetailsCommunicate Clearly and Directly and PerformEffective HandoffsHave a Questioning AttitudeWork Together With Your TeamFollow the RulesInteract Respectfully and CompassionatelyDemonstrate a Positive AttitudeDemonstrate Accountability for your Actions 87
  • Use STAR to Self Check and focus on the details of the taskPay Attention To Details: Stop for just a second Think about the task – is everything correct Act Do the task safely Review Is the outcome as expected Use SBAR to make sure we include all the important information in our communication of aCommunicate Effectively: situation SITUATION BACKGROUND ASSESSMENT RECOMMENDATION or REQUEST Escalate Your Concerns If you see something unsafeWork Together with Your Team: let someone know Offer to Help / Ask for Help Say Thank You 88
  • If it doesn’t seem right or you are uncertainHave a Questioning Attitude: stop and ask Know the policies and procedures and follow them.Follow the Rules: If there is a reason a policy can not be followed let your manager or supervisor know so it can be corrected 89
  • The Catholic Health System fully endorses andsupports the Joint Commission (JC) standardswherein any employee who has concerns about thesafety or quality of care provided in the hospitalmay report these concerns to the JC. Furthermore,CHS demonstrates it’s commitment by taking nodisciplinary action against any associate whoreports a safety or quality of care concern to theJC. Any employee can also feel free to reportthese concerns to the Quality and Patient SafetyDepartment in their facility. 90
  • Obesity: Understanding,Awareness, and Sensitivity Catholic Health Orientation 2012 91
  • Consequences of ObesityPsychological and Social Well-Being Negative Self-Image Discrimination Can be difficult to maintain personal hygiene Depression Turnstiles, cars, and sitting may be too small Diminished sexual activity 92
  • Social Discrimination Studies show society has a low respect for morbidly obese May have limited number of friends May experience social rejection Have poor quality in relationships 93
  • Weight Bias in Healthcare What assumptions do I make based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors Could my assumptions impact my ability to care for these patients? Do I only look at their weight problem, and not other health related issues? 94
  • Challenge the Bias Lead by example: influence peers and others to demonstrate patient sensitivity, become a good role model. Don’t tolerate behind-the-back whispers, jokes, even in private. If no one questions obesity bias, what will ever stop it? 95
  • Strategies for Healthcare Consider that patients may have had negative experiences with other healthcare professionals regarding their weight; approach patients with sensitivity. Recognize that many patients have tried to lose weight repeatedly. Acknowledge the difficulty of lifestyle changes. 96
  • Our Role We need to care for both physical and emotional needs. Support and encouragement are so important. Compassion and empathy must be conveyed. Communication and listening skills are essential. Smile, look at the person, do not ignore a patient because of their obesity. 97