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OIC Ed.1-19-18 1
Park Nicollet Health Services
Required Education Manual
This manual includes the following:
Required education based on your role at Park Nicollet Health Services
Required Education and Compliance Agreements Acknowledgement Form
OIC Ed.1-19-18 2
Table of Contents
Table of Contents ............................................................................................................................................... 2
Welcome to Park Nicollet! ................................................................................................................................. 5
Head + Heart, Together: Our culture, our way, our mantra .............................................................................. 6
Required Education ............................................................................................................................................ 7
Orientation to our Code of Conduct, Privacy, Security and Compliance Program ............................................... 8
Code of Conduct .............................................................................................................................................. 8
Privacy and Confidentiality ............................................................................................................................... 8
Information Security ........................................................................................................................................ 9
Use of Internet and Social Media ................................................................................................................... 10
Gifts, Entertainment, Favors and Meals ......................................................................................................... 10
Fraud Waste and Abuse (FWA) ...................................................................................................................... 10
Report concerns or violations of the Code of Conduct ................................................................................... 11
Emergency Management ................................................................................................................................. 12
Safety and Security Department and what to report ................................................................................... 12
Park Nicollet's Emergency Management Plan .............................................................................................. 13
Facility Alert: Fire .......................................................................................................................................... 13
Evacuation procedures ................................................................................................................................. 14
Emergency Alert: Mass Influx ....................................................................................................................... 14
Facility Alert: Severe Weather ...................................................................................................................... 15
Severe weather safe area ............................................................................................................................. 15
Severe weather: What do you do? ............................................................................................................... 15
Threat Assessment and Response Protocol .................................................................................................. 16
Weapons policy ............................................................................................................................................. 17
Security Alert: Active Security Threat ........................................................................................................... 18
Security Alert: Missing Person ...................................................................................................................... 18
The Hospital Incident Command System (HICS) ........................................................................................... 19
Harassment, Offensive and Disruptive Behavior, and Workplace Violence .................................................... 20
What is sexual harassment? ......................................................................................................................... 20
What about consensual relationships between coworkers at PNHS? .......................................................... 20
What is non-sexual harassment? .................................................................................................................. 20
What is not considered harassment? ........................................................................................................... 21
Disruptive behaviors ..................................................................................................................................... 21
Workplace violence ....................................................................................................................................... 21
OIC Ed.1-19-18 3
Harmful intent versus harmful impact .......................................................................................................... 26
Who is covered by these policies? ................................................................................................................ 26
Reporting violations ...................................................................................................................................... 27
Reporting an incident .................................................................................................................................... 27
Additional Required Education for Patient Care Roles .................................................................................... 28
Advanced Corporate Compliance for the Patient Revenue Cycle ................................................................... 29
The Revenue Cycle Process ........................................................................................................................... 29
Registration, scheduling and check in ........................................................................................................... 29
Clinicians and coding ..................................................................................................................................... 31
Pre- and post-adjudication (e.g., Claims/Billing) .......................................................................................... 35
Abuse, fraud, and auditing ............................................................................................................................ 37
You can make a difference ............................................................................................................................ 40
Hazardous Waste for Healthcare Workers ...................................................................................................... 41
Managing hazardous waste requirements ................................................................................................... 41
Why manage hazardous waste? ................................................................................................................... 41
Hazardous waste management resources .................................................................................................... 41
Infectious waste ............................................................................................................................................ 42
DEA-controlled substances (narcotics) waste ............................................................................................... 42
IV solutions (without medications) waste .................................................................................................... 43
P-listed pharmaceutical waste ...................................................................................................................... 44
Do NOT dispose of this waste in the black MEDS box .................................................................................. 44
What do I do with a dropped pill? ................................................................................................................ 45
General hazardous waste ............................................................................................................................. 45
Patient Safety ................................................................................................................................................... 46
Patient safety error reduction plan .............................................................................................................. 46
Speak up ........................................................................................................................................................ 46
Involving the patient ..................................................................................................................................... 47
Joint Commission National Patient Safety Goals .......................................................................................... 47
Other standards related to patient safety .................................................................................................... 49
BEST Care Reporting ..................................................................................................................................... 51
Right to Know and Infection Prevention .......................................................................................................... 51
What is 'Right to Know'? ............................................................................................................................... 51
Safety data sheet (SDS) ................................................................................................................................. 51
Container labeling ......................................................................................................................................... 52
Product labels: NFPA diamond ..................................................................................................................... 52
OIC Ed.1-19-18 4
Product labels: Signal words ......................................................................................................................... 53
Product labels: Hazard and precautionary statements ................................................................................ 53
Harmful physical agents ................................................................................................................................ 53
Personal protective equipment (PPE) ........................................................................................................... 54
What to do if splashed with a chemical ........................................................................................................ 54
Cytotoxic drugs ............................................................................................................................................. 54
Healthcare-acquired infections? ................................................................................................................... 55
Bloodborne pathogens ................................................................................................................................. 55
Reporting exposures: Time is of the essence ............................................................................................... 55
Tuberculosis (TB) ........................................................................................................................................... 55
Standard Precautions .................................................................................................................................... 56
Transmission-based precautions .................................................................................................................. 56
Safe injection practices ................................................................................................................................. 57
Preventing back pain ..................................................................................................................................... 58
Park Nicollet Health Service Required Education and Compliance Agreements Acknowledgement Form .... 59
Workplace Violence Prevention....................................................................................................................... 60
OIC Ed.1-19-18 5
Welcome to Park Nicollet! At Park Nicollet, we never forget why we’re here. We believe outstanding healthcare is delivered when we
merge the science and intellect of medicine with the compassion, spirit and humanity of our hearts. We
refer to this as "Head + Heart, Together," and it exists to inspire constant improvement and lasting success.
We achieve this by partnering with patients and families in everything from care decisions to service and
facility design. As we work together as a unified team, we engage patients, families and the community, and
put them at the center of everything we do.
Mission – why we’re here
Improve health and well-being in partnership with our members, patients and community.
Vision – where we’re headed
Health as it could be, affordability as it must be, through relationships built on trust.
Values – what guides our actions
Excellence: we strive for the best results and always look for ways to improve.
Compassion: we care and show empathy and respect for each person.
Partnership: we are strongest when we work together and with those we serve.
Integrity: we are open and honest and keep our commitments.
We are committed to living our values. That means you can expect certain things from each of us.
You can expect us to be your partner and treat you with dignity and respect. You can expect us to listen carefully and give you good, timely information. You can expect us to do our best to provide affordable, coordinated, high-quality care and services that are easy to find and simple to use. You can expect safe, clean spaces. And we will do our very best to earn your trust by being open and honest, and keeping our word.
If we ever fail to live up to our values, please tell us so we can work to make it better.
Strategies – what we do
We approach our work and create our work plans by focusing on four dimensions.
People – Health – Experience - Stewardship
OIC Ed.1-19-18 6
Head + Heart, Together: Our culture, our way, our mantra Head + Heart, Together exists to inspire constant improvement together with patients, families, team
members and the community.
Head (IQ) – Evidence-based medicine (clinical quality, science, business)
+ Heart (EQ) – Healing relationships with compassionate care (human, spiritual) Together – Engage with patients, families, teams and communities
Your responsibility
Head + Heart, Together defines and sets expectations for how we do our work and treat each other, our
patients and their families. By aligning our behavior to Head + Heart, Together, we strengthen the core of
our culture - putting patients and families at the center of everything we do.
OIC Ed.1-19-18 7
Required Education Park Nicollet Health Services (PNHS) must meet various regulatory agency guidelines for mandatory
education. On an annual basis, managers and supervisors are responsible for ensuring team members and
non-employees are provided training applicable to their job function.
Your required education is based on your role. Please identify your role on the table below and complete
the associated tasks.
Non-patient Care: Sections 1 and 3
Patient Care: Sections 1, 2, and 3
Section If your role is…. Task Page
1. Patient care or
Non-patient care
Read required education:
Orientation to our Code of Conduct, Privacy, Security and Compliance program
Emergency Management
Harassment, Offensive and Disruptive Behavior, and Workplace Violence
7
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20
2. Patient care Additional required education for Patient Care roles:
Advanced Corporate Compliance for the Patient
Revenue Cycle
Hazardous Waste for Healthcare Workers
Patient Safety
Right to Know and Infection Prevention
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41
46
51
3. Patient care or
Non-patient care
Sign Acknowledgement Forms and return to leader 60
4. Patient care or
Non-patient care
Complete additional Integrity & Compliance courses
OIC Ed.1-19-18 8
Orientation to our Code of Conduct, Privacy, Security and
Compliance Program
Code of Conduct
Among the most important commitments we make at our organization is the commitment to do the
right thing for our patients, members and the community. That's how we earn trust, impact the lives of
others and ultimately achieve our mission. Our culture of Head+Heart, Together is a strong foundation.
It, along with our values of Compassion, Excellence, Integrity and Partnership are the basis for our Code
of Conduct, which is an important guide to doing our work with integrity.
It’s your resource for finding answers to important questions and doing the right thing. It applies to
every person who represents us, including non-employees. You are expected to follow our Code of
Conduct. You have been provided with “Your guide to the Code of Conduct,” a resource brochure that
gives you general information about the Code of Conduct and useful resources to use if you have
questions or concerns.
Access or download the complete Code of Conduct from myPartner or Facets or from your
organization’s external website under the “About” or “About Us” section. Ask your leader if you need
help locating the Code of Conduct.
The material in this packet covers some of the topics most relevant to you as a non-employee.
Privacy and Confidentiality
As a non-employee, you will come into contact with confidential information. It may be related to our
business, our patients or our members. For example, the patient or member information you may see
might be related to patient/member name, diagnosis, demographic or family information. Any and all
patient or member information must remain confidential, which means:
Only access, use or share it if necessary to do an assigned task
Only access, use or share it at the time that it is needed to do an assigned task
Only access, use or share it to those who have a business, job‐related need to know
Only access, use or share the minimum amount of information you need to do your assigned
task
Ask yourself: Do I have a business need to know? Do I need to access, use or share this information to do
my assigned task? If the answer is “no,” then don’t access, use or share the information.
If someone you know is a patient or member, it is important for you to separate your role as a non-
employee from your friend or family relationship. This means that you should not use the information
or the access that you have because of your role to snoop or give information to family members or
friends.
Never discuss patients or members with others unless it is part of your assigned task. Respect patient
and member privacy while you are at work and outside of work. This means you should not discuss
patients or members with other non-employees, volunteers, visitors or with family or friends, even after
your assignment ends.
If a patient or member asks about how to exercise their individual privacy rights (example: getting a copy of
OIC Ed.1-19-18 9
their record, or changing something in their record) talk to the supervisor in your area to get them the information they need. Review the Notice of Privacy Practices for more information on privacy rights.
Other sensitive information: You may learn business confidential information about our organization or the people who work here during your temporary assignment. You need to keep this information private as well and not use it for any outside purpose or personal use.
Some ways you can protect patient and member information:
Don’t talk about patients or member in public areas where others may overhear, such as
elevators, hallways or the cafeteria.
Don’t heave confidential, patient or member information on computer screens, printers, fax
machines or other places where people may see it.
Don’t take business, patient or member information outside of our work premises.
Properly dispose of information using the confidential destruction bins located throughout our
facilities when it is appropriate to dispose of it.
Access only the information that you are asked to work on.
Don’t give out patient or member information without proper authorization. Ask your
supervisor if you are unsure.
Make sure you have the right patient identified, and don’t share information until you’ve
confirmed ID according to the organization’s established policies and procedures
Never take a picture or make an audio recording of a patient.
Following all organizational policies and privacy standards. These are available on myPartner or
Facets.
A special note about the hospital directory: Sometimes patients ask for an additional level of privacy
protection during their hospital stay. They ask that their name NOT be included in the hospital directory.
You must respect this request. You must not reveal that this person is a patient in our facility. Not being
in the directory means that visitors who check at the admissions or information desks should NOT be
given any information about that patient, no callers should be transferred to the patient’s room and no
flowers or other items may be delivered to the room. Say, “I do not see this person in our directory.”
Answers are not always clear. Rules can’t always tell you what to do in every situation. If you have any
doubts or wish to report a concern, please contact the supervisor in your area or contact one of the
areas below:
Your leader
Human Resources for your organization
The Office of Integrity and Compliance integrityandcompliance@healthpartners.com
The Integrity and Compliance Hotline 1‐866‐444‐3493
Failure to comply with these rules and the Confidentiality of Patient/Member Information – Employee
Access and Use policy may be dismissed from the organization.
Information Security
Create strong passwords
Don’t share passwords or log on sessions
OIC Ed.1-19-18 10
Don’t open emails, attachments or links from unknown senders
Keep computers locked when stepping away
Do not leave mobile devices unattended or unlocked
Never email patient or member information except as necessary to perform an assigned task.
Never email patient or member information to or from a personal email account
Report suspected security incidents, suspicious activity, stolen/lost laptops and smart‐phones to the IS&T Support Center (952‐967‐7000) immediately
Use of Internet and Social Media
When using the internet, be aware of your surroundings, even if you are on break. Who can see
your screen? Think about the perception you are giving to patients or members in the area
Never post anything about patients or members on any social media, like Facebook or Twitter,
even if you don’t use their names and think you have removed all identifiers
We discourage “friending” or following patients or members whom you’ve met through your
assignment at Park Nicollet via social media
Make it clear that your opinions are your own when commenting on topics related to our
organization
Don’t use threatening or hateful language
Gifts, Entertainment, Favors and Meals
Our workforce, including our non-employees, must avoid the influence or appearance of
influence in our relationships with patients, members, patients and member’s family and
friends and vendors - companies that provide or want to provide supplies or services to our
organization.
You may not accept the following from patients, members, their family and friends or vendors:
o Gifts such as food, cash, discounts or gift cards, services or entertainment, including tickets to events, company swag (e.g. pens, pads of paper)
You may not participate in any activity that could potentially influence decision‐making at work
If you have questions, talk to your supervisor; they will engage Human Resources and Integrity
and Compliance as necessary.
Fraud Waste and Abuse (FWA)
We are committed to preventing, detecting and correcting fraud, waste and abuse, which includes:
• Stealing (e.g., taking home excess supplies)
• Making false statements in documents about patients or members
• Identity fraud (Attempting to use a false identity or someone else’s name/date of birth/social
security number)
• Prescription fraud and drug theft
OIC Ed.1-19-18 11
If you’re aware of or suspect conduct that could be fraudulent, wasteful or abusive, report your
concerns immediately using one of the methods described below.
Report concerns or violations of the Code of Conduct
To your leader, or any leader
To the Human Resources team
To Integrity and Compliance
o integrityandcompliance@healthpartners.com
o privacy@healthpartners.com
o Integrity and Compliance hotline: 1‐866‐444‐3493 (you may be anonymous)
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Emergency Management Park Nicollet's Emergency Management Plan ensures we continue to provide effective patient care when an emergency
affects our facilities. The goal of this section is to provide information for responding to situations that may affect the
health and safety of you, your coworkers, patients, and visitors.
Safety and Security Department and what to report
The Safety and Security Department serves to support a safe and secure environment in which our team members and
customers experience exceptional service.
What to report
All team members, regardless of the PNHS location at which they work, should report the following to Safety and
Security for support, response and/or reporting purposes:
Thefts or diversion of corporate or personal property
Suspicious people or events, unusual activity
Property damage or vandalism
Situations that could have an impact on personal safety or security to the facility, personal belongings, and
corporate resources and equipment
Harassment
Falls/injuries in work areas or public areas (at St Louis Park campuses)
Vehicle accidents or abandoned vehicles
How to report
To call in a report of an emergency event, please use the process below to assure an effective information exchange.
Methodist Hospital and
Park Nicollet Clinic –St. Louis Park campuses
Ambulatory clinic and office locations
outside of St. Louis Park
Call 1-1-1
(PNHS Safety and Security)
Call 9-1-1
(local emergency responder)
Note: After, report event to PNHS Safety and Security at 952-
993-5101
Provide the following information:
• building name and address
• floor
• department or unit name
• a brief description of the emergency event
• your name and call back number
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Security badge
Security badges (photo IDs) are used to verify that a team member, volunteer, or contractor has business in a PNHS
facility. These badges are your corporate name tag while working on PNHS properties. The Human Resources Personal
Appearance policy requires that all team members wear this visible identification while on duty.
Park Nicollet's Emergency Management Plan
Where to find emergency preparedness resources
The resources listed below are used throughout PHNS as emergency management guides.
Emergency Management Procedures Quick Reference
Locate it: Facets>Departments>Emergency Preparedness>Quick Clicks sidebar>Emergency Management
Procedures Quick Reference
Emergency Management Card
Obtain from your area leader or calling Safety and Security.
Emergency Quick Reference Guide
Locate it: available in your department
Utility Systems Failure Response Placard
Locate it: Facets>Departments>Real Estate>Quick Clicks sidebar>Utility Systems Failure Response
Facility Alert: Fire
Facility Alert: Fire is the PNHS emergency procedure enacted when there is evidence of a fire (smoke or flame). When a
Facility Alert: Fire is announced, follow the Fire Emergency Plan's 4-point procedure. Check with your area leader to
understand your work area’s plans and location of alarms, extinguishers, and exits.
1. Step 1: Rescue
Move those in immediate danger, including yourself, to safety before doing anything else.
2. Step 2: Alert
Pull the alarm and call the emergency number
Activate the nearest fire alarm
Dial the emergency phone number for your facility
o 111 for Methodist Hospital campus and Park Nicollet Clinic (St. Louis Park campus)
o 911 for Melrose Institute, ambulatory clinics and office sites
Identify yourself and specify your department, location and type of fire. Do not hang up the phone.
Contact must be maintained with the switchboard and fire dispatcher if flames or smoke are reported.
3. Step 3: Contain the fire
Close all windows and doors
At Methodist Hospital, Melrose Institute, & 3900 Ambulatory Surgery:
i. Move visitors into rooms & instruct them to stay with patients
At Clinics and Office Sites:
i. Move visitors into the next compartment
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Remain calm and reassure patients and visitors
Mark empty rooms to determine checked areas
Clear hallways and entrances
Do not use elevators
Step 4: Extinguish
Do not place yourself in danger.
If you are a trained emergency responder, use available equipment to extinguish the fire until help
arrives.
If you are NOT a trained emergency responder, do NOT attempt to extinguish the fire.
Attempt to extinguish the fire only if it is safe to do so.
Fire out
A “fire out” is any sign that a fire has occurred. Some examples include burned linens, scorched electrical plugs and,
everyone's favorite, burnt popcorn. Report the "fire out" to Safety and Security immediately so the appropriate
response measures can be taken.
Evacuation procedures
In the event of a fire or non-fire emergency that requires evacuation, follow evacuation procedures outlined below.
Patients should be evacuated in the following order:
1. Persons in greatest danger
Those nearest the fire or source of smoke
2. Ambulatory patients
Those who can walk out on their own and follow instructions
3. Semi-ambulatory patients
Those using walking devices, crutches, or walkers, or who need physical support and guidance
4. Bedridden hospital patients
Those who cannot ambulate or help themselves
Keep in mind the following:
Depending on the type of building and location of the fire, evacuations should first take place horizontally, or
on the same floor as the fire. If the fire continues to spread, evacuations should then take place vertically using
stairs (not elevators), or on neighboring floors.
Elevators are not to be used in the event of a fire.
Hospital team members should know their route of egress. Ambulatory clinic and office site team members
must identify an external meeting location to account for the safety of team members, patients, and visitors.
Emergency Alert: Mass Influx
Emergency Alert: Mass Influx prepares Methodist Hospital to receive a large influx of patients in from an external or
internal disaster.
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An external disaster is one that occurs in the community and may result in a sudden influx of patients to
Methodist Hospital Emergency Center.
An internal disaster, such as structural damage from severe weather, may result in an influx of patients into
other areas of the hospital.
Facility Alert: Severe Weather
Park Nicollet’s Severe Weather Plan is designed to direct team members in an established severe weather response.
How will you be notified of potential severe weather?
Methodist Hospital, Melrose Institute, and Park Nicollet
Clinic – St. Louis Park campuses
Ambulatory clinic and office locations
outside of St. Louis Park
Weather conditions are monitored by Safety and Security
Officers who will notify the site administrator of any
change.
Site administrator arranges for monitoring of weather
conditions and alerting team members to changing
conditions. Prepare at least three people at each
ambulatory and office site to be responsible for
monitoring weather conditions specific to that facility.
Severe weather safe area
When instructed, seek shelter in safe areas during severe weather.
Safe areas are located throughout PNHS facilities and have the
following characteristics:
Interior room: a room not located along the exterior walls
of the building.
Latching door
No windows
Small ceiling span: a smaller room is generally better than a larger room, although there are exceptions to this
rule, such as some of the meeting rooms at the Heart and Vascular Center.
Severe weather: What do you do?
When severe weather occurs, follow these directions in order to maintain the safety of our patients, visitors, and staff.
Always (all weather conditions)
Be aware of safe areas.
Severe thunderstorm watch
Monitor weather conditions.
Severe thunderstorm warning and/or tornado watch
o Keep calm and reassure patients and visitors.
o Close all patient room and hallway doors.
o Close window blinds and curtains.
o Move visitors from waiting areas with windows.
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o Clear hallways of equipment and supplies.
o Refresh your memory on where safe areas are located.
o Pay special attention to further overhead announcements.
o At offsite locations, continue to monitor your weather radio for warnings in your geographical area.
o Report any problems to your supervisor.
“Take cover” announcement
o Move patients away from windows (patient care areas).
o Limit or avoid use of elevators.
o Stand by for further instructions or announcements.
o At offsite locations, continue to monitor your weather radio for warnings in your geographical area.
“All clear” announcement
o Ensure patient safety.
o Account for all staff.
o Return patients and visitors to regular locations.
o Report any damage to facilities.
Threat Assessment and Response Protocol
The PHNS Threat Assessment Response Protocol provides a standardized process for identifying, investigating and
resolving threats which have the potential for harm to persons on PNHS properties and/or disruption of business
operations or continuity of our systems and infrastructure.
What is a threat?
A threat refers to any verbal or physical behavior, communication or device that could be interpreted as
communicating or conveying any one of the following:
intent to cause emotional or physical harm or injury to persons
intent to interrupt business services or continuity
intent to cause damage to property
Examples of types of threats
Personal threat: for example, a person threatens the safety of another person on PNHS property.
Bomb threat
Weapons threat: for example, a person threatens they will use a gun on PNHS property.
Infrastructure threat: for example, threats to take down the computer network or contaminate the ventilation
system.
Who should you notify?
Depending on the threat, you may alert any of the following (an immediate response into the reported event will be
initiated):
• your supervisor or manager
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• Safety and Security
• Human Resources
• Risk Management
Weapons policy
PNHS bans weapons on all PNHS owned or leased properties, which includes inside buildings, surrounding grounds, and
parking lots. The ban covers all individuals on PNHS property, but the ban does not apply to on-duty law enforcement.
Individuals finding themselves on PNHS properties with a weapon are expected to comply with this ban by one of the
following means:
• Leave the property
• Secure the weapon in a secure lockbox or trunk in their vehicle
• Turn it over to Safety and Security to be stored in the departmental lockbox
You encounter or become aware someone with a weapon. What do you do?
Advise your department or area leader of your observation.
IF there is no immediate threat or danger, consider approaching the individual and advising them of the
corporate ban on weapons.
IF there is an immediate threat to safety, team members are expected to move anyone in danger as is
reasonable, without risk of bodily harm and contact the appropriate response provider based on location.
Methodist Hospital, Melrose Institute and Park Nicollet Clinic–St. Louis Park campuses
Promptly provide all pertinent information.
• Call Safety and Security (3-5101) or
• Call the campus emergency number (1-1-1)
Ambulatory clinic and office locations outside of St. Louis Park
• Call local law enforcement (9-1-1)
• Call Safety and Security (3-5101) for support and response as needed.
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Security Alert: Active Security Threat
For a person actively or attempting to actively harm others. In the event of an active security threat in your area,
choose the option that will best increase your chance of survival and safety.
Safest response options
1. Run
If there is an escape path, take it, bring patients, visitors and others with you if you can, leave
belongings behind, call 9-1-1 when it’s safe to do so
2. Hide
Find a lockable room, and lock/block the door, silence your cell phone, pager, and all electronics, turn
off the lights if you can, and remain quiet, hide behind large, solid objects that could protect you
3. Fight
If you have no other options, fight back! Throw objects, yell and distract the attacker, improvise
weapons, commit to your actions.
Follow police direction at all times
Follow all instructions by law enforcement. Keep hands visible at all times. Law enforcement’s top priority is stopping
the threat; help for the injured is on the way.
Security Alert: Missing Person
For a missing vulnerable adult, minor, child or infant
Don’t wait to alert others:
Your supervisor, manager, and/or other team members in your immediate area can assist in gathering additional help
and making the necessary emergency notifications.
Make Emergency Notifications:
Methodist Hospital Campus and St. Louis Park Clinic Campus:
-Dial 111 to immediately notify a Switchboard Operator
All other PNHS locations:
-Make overhead and face-to-face notifications to alert others and get help
-Diale 9-911 to notify your local police department at your site leader’s direction.
Contact Safety & Security directly at 952-993-5101
Site leaders will evaluate the need to contact family members of missing person.
Search for the person
Watch exits and hallways to ensure that the missing person does not leave.
-Search your department and immediately adjoining areas
-if the missing person is a minor (under 18), post someone at all department exits as able and ask everyone
to remain where they are until an all clear announcement is made.
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-request assistance from Safety & Security and/or law enforcement if that person is found and unwilling to
cooperate.
Don’t lose site of a suspicious person
Gather as much information as possible from a safe distance
-physical appearance of the suspect and victim
-what they are wearing
-vehicle description, license plate number and direction of travel
Don’t put yourself in danger by attempting to stop someone by yourself.
The Hospital Incident Command System (HICS)
In an emergency, agencies such as hospitals, law enforcement, medical transportation, local governments, and fire
departments can communicate more efficiently when all agencies follow the same command structure. This structure is
called the Incident Command System (ICS). ICS customized for hospitals is called the Hospital Incident Command
System (HICS).
In large emergency events, PNHS may activate the Hospital Command Center (HCC), using HICS to assign roles and
responsibilities. The HCC will coordinate the emergency response from a central location and will work with the
community partners such as the fire department or EMS, as well as other hospitals.
HICS model
The HICS model defines a chain of command for managing Park Nicollet's emergency response and ongoing operations.
In a disaster, the Incident Commander (IC) is the person responsible for giving overall direction for hospital or clinic
operations during the emergency situation. The person assuming the role of Incident Commander will vary depending
on who is on duty and the nature of the emergency. The IC is the only position that is always activated in HICS.
Other HICS positions will be assigned as necessary based on what is required to respond to the event. These positions
include:
• Safety Officer
• Public Information Officer
• Liaison Officer
• Section Chiefs for Operations, Logistics, Planning, and Finance/Administration
Each position has a job action sheet that acts as checklist of responsibilities and accountability, and to prompt specific
actions for that job duty. The most qualified person will be assigned to a position, not necessarily the most senior
person.
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Harassment, Offensive and Disruptive Behavior, and Workplace Violence This section was developed as part of Park Nicollet's commitment to providing a safe, healthy, and productive work
environment. In order to achieve such an environment, it must be free from intimidation, hostility, discrimination,
violence, retaliation, and other inappropriate behavior. All Park Nicollet tem members have the right to work in a
professional setting, free from harassment or violence, where they are treated with respect and dignity.
What is sexual harassment?
Sexual harassment includes sexual advances, requests for sexual favors, and other verbal or physical conduct of a
sexual nature.
Sexual harassment can result in:
• Creating an intimidating, hostile, or offensive environment
• Interfering with an individual's ability to perform his or her job
• Adversely affecting an individual's employment opportunities
Any type of sexual harassment is prohibited at Park Nicollet.
What about consensual relationships between coworkers at PNHS?
Park Nicollet recognizes that consensual relationships exist between team members that are, or have the potential to
become, sexual in nature. These relationships are often problematic because conduct that is consensual during the
course of the relationship can become unwelcome if the relationship ends. Although Park Nicollet doesn’t prohibit
these types of relationships at work, the issues that these relationships can create need to be considered.
Park Nicollet strongly discourages intimate relationships between leaders and their direct reports.
What is non-sexual harassment?
Non-sexual harassment is harassment that is not sexual in nature. Park Nicollet prohibits this and any type of
harassment.
Non-sexual harassment can result in:
Creating an intimidating, hostile, or offensive environment
Interfering with an individual's ability to perform his or her job
Adversely affecting an individual's employment opportunities
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PNHS prohibits non-sexual harassment based on:
Race
Color
Creed
Age
Gender
Gender identity
Disability
Religion
National origin
Marital status
Sexual orientation
Status with regard
to public
assistance
What is not considered harassment?
Although Park Nicollet encourages team members to report all suspected cases of harassment, reports are occasionally
made for situations that, although unpleasant or uncomfortable, don't meet the criteria for harassment.
Following are some examples of behavior that are NOT considered harassment:
Monitoring or tracking of absenteeism and performance by a leader
Administering disciplinary action either by warning or suspension for failure to meet expectations
Receiving constructive feedback on a performance appraisal from coworkers or a leader that may be negative
in nature
Denying a vacation request due to a business need
Being asked to supply a medical doctor’s note to Employee Occupational Health & Safety (EOHS) for a missed
day due to illness
Disruptive behaviors
Sexual and non-sexual harassment are examples of disruptive behaviors. Disruptive behaviors can threaten the
performance of teams. For example, disruptive behavior can foster medical errors, contribute to poor patient
satisfaction, contribute to preventable adverse outcomes, and ultimately increase the cost of care. Safety and quality
patient care is dependent on teamwork, communication, and a collaborative work environment.
Workplace violence
Our organization-wide workplace violence prevention team is working to create a safe environment for everyone.
What is workplace violence? Violence refers to a broad range of behaviors including (but not limited to) physical violence, intimidation and/or behavior disruptive to the environment generating concern for personal safety of others (visitors, patients, individuals, clients, students and others who are present in the facility every day). High Risk Factors
Be aware of high-risk factors and signs will help you recognize the potential for incidents of workplace violence:
History of Violence
Substance Abuse
Poor Coping Skills
Cognitive Disorders
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Verbal signs
Paying close attention to what people are saying can help you know if someone may become violent. People often
show their anger through words and tone of voice. In fact, this is often one of the most obvious early warning signs of
aggression.
You can see an example of each of these verbal signs of violence below.
DISRESPECTFUL BEHAVIOR: The individual starts to raise their voice, become louder and disrespectful; starts
swearing.
THREAT: “I will come down there and find that nurse and punch them!”
INTIMIDATION: “If I don’t get a meeting with that leader today, then I will have you fired.”
Non-verbal signs
In many cases, people may not tell you they are angry or frustrated. That is why non-verbal warning signs are
important.
Review below to see what these warning sign looks like.
BODY LANGUAGE: An individual’s body language can tell you a lot. Examples of body language that may be a
sign of increasing aggression include pacing, clenched fists or jaws, arms held across the chest and heavy
breathing.
THREATENING GESTURES: Threatening gestures are a more obvious warning sign. These gestures include
pointing fingers, shaking fists or moving too close to you.
HOW A PERSON LOOKS AT YOU: How a person looks at you can also be a sign. They may look away from you or
avoid you, or they may narrow their eyes and stare at you. If you perceive a threat from the person’s eye
contact or lack of eye contact, take it seriously.
BODY MOVEMENT: And finally, there may be a change in the way the person moves their body. They may look
like they are going to run away, stretch their muscles, or even come at you.
Other signs
Here are a few other warning signs of violence:
THEATS OF SELF HARM: “If you can’t make this bill go away, I will kill myself.”
THREATENS OF HARMING OTHERS: “If one more person tells me I can’t smoke here, I am going to throw
something.”
WEAPONS IN THE WORKPLACE: A person says “I’m angry” and then grabs scissors from a table and holds it in a
threatening manner.
SIGNS THE INDIVIUDAL IS UNDER THE INFLUENCE OF ALCOHOL OR DRUGS: The person is calm one moment and
all the sudden becomes loud and threatening.
How to respond: Know the stages of aggression
Knowing the stages of aggression can help you determine how to respond. Remember, the goal is to recognize signs as
early as possible and respond before a situation gets worse (escalates).
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ANXIETY: Anxiety may look like irritability, inability to sit or stand still, discourteous or disrespectful
communication.
AGITATION: Agitation may appear as extreme nervousness, pacing, hostility, harassment or bullying.
ACTING OUT: Acting out is when the person verbally threatening, calling names, throwing items or striking out.
How do you respond?
Next we will look at different ways you can encourage someone’s behavior to de-escalate (to reduce the intensity of a
conflict or potentially violent situation), when it is safe to do so – and when you should call for help.
Communication
How you interact with someone can make a big impact on their mood and how they respond to you.
BODY LANGUAGE: Adjust your body language. Just as someone else's body language can trigger a warning sign
for you, how you present yourself can do the same for them. Stand with your arms at your side, hands hanging
downward and use appropriate eye contact; do not stand with your hands on hips.
TONE OF VOICE: Maintain the appropriate tone of voice. A caring tone can help calm the environment and the
person. The tone of your voice can either calm the incident or cause the incident to escalate.
SIMPLE LANGUAGE: Speak in an even rhythm and use simple language as much as possible. Using “big” or
uncommon words can increase frustration. When giving instructions, try doing it in three words, such as
“Please follow me” or “Please sit down.”
VOLUME: Adjust the volume of your voice. Speaking in a soft volume that can still be heard easily can help
someone relax. Do not match the volume of the person.
Active Listening
Many of our patients and members just want to be heard – they want us to really listen to them. Active listening can
help de-escalate behavior.
• JUST LISTEN: Listen. Silence is a powerful tool.
• ASKE QUESTIONS: Ask simple questions. Take some time to allow the patient to express their concerns, or tell
you what they need. Use simple, open-ended questions such as, “How can I help?”
• VALIDATE CONCERNS: Validate the concerns of the person you are talking with. This shows them that you are
listening, that you understand – and that you care.
• USE “I” STATEMENTS: Try using “I” statements. Without turning the focus on yourself, respond to the person
with how you would like to help. Focus on the problem – not the person. An example of this is, “When you talk
so quickly, I can’t hear you.” Or, “I’m sorry that experience happened to you. I want to help. What can I do
now?”
• GIVE TIME: Give people time to think. If you find that an individual is not responding to your questions, try
“Taking 5” with them and ask questions about their personal life. Or, take a break and let them know that you
will come back later. Giving them time to process information can help future conversations.
Call for help if you feel uncomfortable or unsafe
If you feel uncomfortable or unsafe in a situation, leave and call for help – before a situation gets worse (escalates).
Immediate on-site resources are available if you are experiencing an unsafe or threatening situation.
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Call for assistance: when additional resources are needed
Call for help: when concerned about active security threats or bodily harm
Call for assistance: Contact your department or site leader
Call PNHS Emergency Number (111)
Call for help: Methodist and St. Louis Park Clinic Campuses call PNHS Emergency Number (111)
All other sites call 911
What to report
Reporting violence is important in helping create a safer workplace. Your role in reporting events is critical.
Please report:
VERBAL OR WRITTEN THREATS: One example - Your patient begins calling you names, yelling and/or
threatening you for any reason.
VERBAL ABUSE: One example -The caller on the phone swears at you and threatens you.
PHYSICAL ASSAULTS: One example - Your patient with dementia or brain injury starts hitting, spitting, kicking
and biting you during care or interventions.
ANY PERCEIVED ACTS THAT CAUSE FEAR OR HARM: One example - Frustrated visitor in the waiting room
throws magazines at the front desk attendant.
Where to document events
Best Care Reporting System
Recognize and respond to an Active Security Threat
What is an Active Security Threat?
An active security threat describes a situation when a person or persons are being harmed, or are at immediate risk for
harm.
Responding to an Active Security Threat
Events involving weapons are rare and unlikely, but it’s important to plan to protect ourselves, our patients, and others.
“Run, Hide, Fight” is short and simple plan that offers the best chance of survival.
Run -Try to escape, with our patients & visitors as able
Hide - Seek cover if escape is not possible
Fight - Only as a last resort
RUN: Escape if possible
When another person is harming or attempting to harm others in the area, and a safe escape path is available, RUN.
• We should help our patients and visitors as much as possible; however, don’t delay your escape for someone
refusing to leave.
• Have a basic plan in mind, along with a plan for what to do when leaving the area or building.
• When you run, leave your belongings behind. Stuff can always be replaced; you can’t be. Remember to keep
your hands visible at all times when running, and do not return until you receive an “All Clear” announcement.
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HIDE: Stay hidden until “All Clear”
When the exact location of the threat or suspect is unknown, or escape isn’t possible, hiding may be your safest option.
When you hide:
• Make sure your hiding spot is out of view.
• Encourage patients and others to hide with you. Assist them if possible
• Block entry to your hiding spot, and lock doors if you can.
• Hide behind large, solid objects that will help protect you.
• Silence all electronics such as cell phones and pagers.
• Remain completely quiet and as calm as possible. If others are with you, tell them to do the same.
• Remain hidden until the announcement of “All Clear” has been made.
FIGHT: Use objects in your area
• Fight back when you have no other options or when you are faced with a life-threatening event.
• You must fight as though your life depended on it, because it does.
• You cannot hesitate or delay your actions.
• Throw items at the suspect, hit them with solid objects, or punch and kick them if you are close enough.
Calling for help
Call for help when it’s safe
Report only what you know
If an Active Security Threat happens, call for help as soon as it is safe to do so. A work phone may help identify where
you are. When you call for help, there is important information you can provide, if you can. This includes:
• The location of the threat
• The number of suspects
• Physical descriptions of the suspect(s): clothing type, skin color, hair color, visible scars or tattoos, or anything
else that makes them stand out.
• The type of weapon used or held by the suspect, such as “handgun,” “long gun,” “knife,” “baseball bat,” etc.
• The number of victims in your area.
Panic or duress buttons
If panic or duress buttons are available at your location, press them if it’s safe to do so. When able, provide responders
with information about the situation.
If safe to do so, provide responders with additional information
Call your site support response team
Know the policies and procedures for your location
Responders to an alarm may take several minutes to arrive, take action as needed while waiting
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Announcements
If you hear an announcement similar to “May I have your attention please: Active Security Threat. Methodist Hospital,
second floor lab,” figure out what you will do with that information.
• Act immediately -- Do not delay your actions.
• Do not call for additional information.
• Call only if there is an emergency in your area (and it is safe to do so) or if you have information that can help
responders.
Epic Aggression Flag
What is the Epic Aggression Flag?
The Epic Aggression Flag is a next step in providing a safe and healing environment for everyone.
The Aggression Flag is like other patient chart advisories found in Epic.
Its purpose is to alert us to a situation we should be aware of regarding a patient in our care.
When is an Epic Aggression flag placed?
A patient’s behavior determines the use of the Aggression Flag. The flag indicates a patient has demonstrated one or
more of the following:
• Physical assault
• Physical actions with the intent to intimidate or cause physical harm
• Verbal or written threats with the intent to cause physical harm
Once the flag is placed, its purpose is to raise awareness about a patient who may have the potential to harm others
and to remind us to implement safety measures as necessary.
Discuss with your leader the process and who is responsible for placing an aggression flag on a patient chart.
Want a more in-depth refresher course?
Talk to your leader about additional courses that may be available in your area including:
• Workplace Violence Prevention Level 1
• Activity Security Threat
• Epic Aggression Flag
• Other site or role specific training
Harmful intent versus harmful impact
Individuals accused of harassment or violent conduct may argue that their behavior was not intended to be offensive or
threatening. However, lack of intent is NOT a defense against these acts. The offense does not need to be intentional in
order to be considered harassment or violent conduct.
Who is covered by these policies?
All PNHS team members, patients, visitors, independent contractors, volunteers, students, vendors, and employment
applicants.
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These policies apply to any work-related setting
These policies extend beyond the immediate workplace. Conduct prohibited by these policies is also unacceptable in
any work-related setting outside of the workplace, including but not limited to business trips, business meetings, and
work-related social events.
Reporting violations
Addressing the offender
Park Nicollet encourages team members that feel they are being subjected to harassment or violent behavior to first
advise their offender that the behavior is unwelcome and to make a demand for it to stop.
If for any reason the individual does not feel comfortable addressing the offender or if such action does not cause the
offensive behavior to stop immediately, report the incident using the resources described in this section.
Reporting an incident Park Nicollet encourages the reporting of all perceived incidents of discrimination, harassment, violence, or retaliation.
This applies regardless of the offender’s identity or position within the organization.
Individuals who believe that they are the victim or witness of such conduct should immediately discuss their concerns
with their leader. In the event that your leader is the offender, notify the next level leader within your department.
Ways to report a violation
Contact your leader
Use Quality Tracking on Facets if you have access
Call Employee Relations at 952-993-1699
Call the Compliance Hotline at 952-993-2320
Call Safety and Security at 952-993-5101
Call the Employee Assistance Program at 800-383-1908
Anti-retaliation statement
As part of Park Nicollet’s commitment to a healthy, harassment free environment, team members can be assured that they can bring complaints forward in good faith without risk of negative consequences. Retaliation against an individual for bringing forward an allegation or for participating in an investigation of harassment or violence is a violation of Park Nicollet’s policy. Such conduct will result in corrective action up to and or including termination of employment.
If your role at Park Nicollet Health Services does not involve patient care,
STOP here and proceed to:
Page 60: Sign Acknowledgement Forms and return to leader
Complete Additional Integrity & Compliance Courses
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Additional Required Education for Patient Care Roles If you are in a patient care role, please complete the tasks listed in the table below. Please note that patient care roles
require additional education which will begin on the next page (38).
If your role is…. Task Page
Patient care or
Non-patient care
Read required education:
Orientation to our Code of Conduct, Privacy, Security and Compliance program
Emergency Management
Harassment, Offensive and Disruptive Behavior, and Workplace Violence
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Patient care Additional required education for Patient Care roles:
Advanced Corporate Compliance for the Patient Revenue Cycle
Hazardous Waste for Healthcare Workers
Patient Safety
Right to Know and Infection Prevention
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51
Patient care or
Non-patient care
Sign Acknowledgement Forms and return to leader 60
Patient care or
Non-patient care
Complete additional Integrity & Compliance courses
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Advanced Corporate Compliance for the Patient Revenue Cycle This section is designed to provide you with a review of basic Corporate Compliance requirements, concepts and
policies, and to describe how they apply to Park Nicollet team members who are involved in the Revenue Cycle.
Following guidelines to produce timely and accurate claims and patient bills helps us achieve our mission and ensures
that we are in compliance with the laws and regulations that govern our business.
The Revenue Cycle Process
A great number of team members at PNHS are involved in the revenue cycle process. Due to the number of
departments involved in the revenue cycle, teamwork is essential.
Understanding the work of the departments and how patient data flows in the revenue cycle is the key to compliance.
The revenue cycle is one integrated process in which all players must understand their role and how they influence the
whole.
The pieces of the revenue cycle are Registration, scheduling, and check in; Clinicians and coding; and Billing and
payment.
Registration, scheduling and check in
Team members in registration, scheduling, and check in roles perform several major tasks that are vital to the efficiency
and financial welfare of our organization.
These key tasks include:
• registering and scheduling patients
• confirming patient identity
• verifying insurance information
• obtaining copayment and deductibles (if applicable)
• obtaining completion of the patient consent form
• obtaining the Medicare Secondary Payer Questionnaire
These major tasks help our patients get their claims paid correctly by their insurance coverage the first time.
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Task 1: Register and schedule patients
Registering patients is an important part of the patient revenue cycle. If patients are not registered correctly, there are
implications throughout the cycle, including wrong address, wrong age, wrong social security number, etc.
Information must be gathered from the patient during the registration process such as the patient's address, telephone
number, next of kin, and date of birth.
After registration is scheduling. Scheduling also has implications for the patient revenue cycle, including the potential
for coding to be incorrect by the clinician. Scheduling too soon may mean a visit may not be covered by insurance.
Scheduling the wrong type of appointment may cause patients to be upset when clinicians do not have enough time to
spend with them for multiple issues.
Task 2: Confirm patient identity
The check-in process can set the tone for the rest of the patient’s visit. When our patients are welcomed, put at ease,
and have a timely check in, they can be roomed more quickly, which can enhance their overall experience.
One of the first elements of check in is to confirm patient identity by checking the photo ID in accordance with the
Identity Theft Prevention, Detection and Mitigation (ID Theft) policy.
Mistakes in patient information can carry over to the claim form causing claim rejects, delays in processing, and even
denials. These mistakes cause more work and can be quite costly for our organization.
Report any discrepancies and potential cases of ID theft using the process and form included in the policy.
Task 3: Verify insurance information
Patient's insurance information should be scanned at the patient's visit and verified at each patient visit to ensure
accuracy and to make any necessary changes.
The pieces of information that we need to pay close attention to and collect from the patient are:
• exact legal name of patient
• relationship to subscriber (name/date of birth)
• name and address of insurance company
• type of coverage
• policy/group and ID number
The accuracy and verification of insurance information is extremely important because that information will be used on
many claim forms and medical documentation materials throughout the patient's history.
Task 4: Obtain copayment and deductibles
Team members in frontline and registration roles are responsible for collecting patient copayments. Park Nicollet
Health Services collects copayments, prepayments, or other amounts owed by a patient (or his/her legal
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representative).
PNHS team members shall not routinely waive copayments or deductibles. Waivers of copayments in cases of indigency
shall be made only in accordance with applicable law, payer contracts, and the PNHS Collection and Charity Care
policies.
Task 5: Obtain the Patient Consent form
Another crucial compliance task that takes place in this phase of the patient revenue cycle is obtaining the Patient
Consent form.
Park Nicollet designed Patient Consent forms for Methodist Hospital and Park Nicollet Clinics, including TRIA, to meet
Minnesota state requirements, assignment of benefits requirements, and HIPAA requirements.
It is important to make sure the patient understands the information on the form.
Once the consent form is completed, dated, and signed, it should be sent to Health Information Management
(HIM) to be scanned into the consent section of the patient's chart.
Task 6: Obtain MSPQ
Front Line and Registration team members are responsible for obtaining the Medicare Secondary Payer Questionnaire
(MSPQ or Medicare Questionnaire). Medicare uses the term Medicare Secondary Payer when Medicare is not
responsible for paying the claim first. Registration is responsible for determining if a patient's Medicare coverage is
primary or secondary to any other insurance coverage. Team members are required to conduct admission interviews
using a questionnaire to determine if Medicare is primary or secondary.
The Medicare Secondary Payer questions will help you determine if the beneficiary is:
• covered by another policy or government program.
• potentially eligible for coverage by a different insurer due to an accident or injury that makes a third party
liable for medical expense.
• eligible for coverage of all expenses over the amount Medicare covers.
Medicare Secondary Payer questions must be asked of every Medicare hospital patient and recorded in the electronic
medical record. The Medicare Secondary Payer Questionnaire is located in the electronic medical record. Performing
these steps correctly protects Medicare funds and ensures that Medicare does not pay for services that are the
responsibility of private insurance plans or other programs.
Clinicians and coding
In this phase of the Patient Revenue Cycle, clinicians and coders ensure that documentation and codes are accurate.
Medical documentation must be maintained to support the diagnosis codes and services reported.
A responsibility of clinicians that greatly affects the patient revenue cycle is documentation and coding. Proper
diagnosis coding involves identifying the appropriate codes for the patient's conditions or symptoms. Clinicians are also
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responsible for coding correctly for items and services provided. The patient records are then used as the basis for
reimbursement on claims.
Documentation
One important consideration for compliance with documentation guidelines at PNHS is to be timely in the dictation and
signing of medical charts. As so many parties are involved in and affected by documentation, delays can occur many
places in the patient revenue cycle, leading to claim denials and inaccurate patient bills.
To support our commitment to timely and accurate documentation, PNHS has policies regarding timely completion and
authentication of records.
Diagnostic tests, such as X-rays, lab or other diagnostic tests, must be ordered by a physician or appropriate
practitioner. Errors may occur in billing if the clinic or hospital documentation does not clearly indicate the physician
who ordered the diagnostic tests. It is wrong to list one person as ordering a test when, in fact, another person ordered
the test.
Some common errors that occur, causing unnecessary delays in the overall Patient Revenue Cycle, are insufficient
documentation, missing or no documentation, unsigned documentation, insufficient accident information, and/or
undated or incorrectly dated documentation.
Timely dictation and signing of charts
Every healthcare provider is required to document the clinical services performed on behalf of individual patients. This
includes services at hospitals, physician offices, clinics, home care, hospice, and ambulatory settings. Healthcare
providers include licensed practitioners such as physicians, nurses, psychologists, allied health professionals, clinical
social workers, case managers, and licensed independent practitioners (for example, physician's assistants).
Accreditation and regulatory standards require healthcare providers to create and maintain a separate record for each
individual patient that is treated. Specific data elements are required.
Health Information Management's (HIM) purpose at Park Nicollet Health Services is to manage paper and online clinical
documentation that is generated and used for patient care.
HIM is responsible for the following processes: managing clinical documentation for patient care, release of
information, transcription, document imaging, and chart completion.
Documentation: Patient care
A major responsibility of clinicians is documentation of the services that they provide. Although providers are
responsible for the bulk of documentation in medical records, it is the responsibility of every authorized PNHS team
member providing patient care to include any necessary documentation to a patient chart.
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A medical record is only accurate if all services provided and items used or ordered are documented. Correct and timely
documentation must take place in order to comply with Corporate Compliance policies, but documentation is
important for many other reasons as well, including:
• Charges submitted to payers are based on documentation.
• Documentation is the legal record for malpractice claims and payer audits.
• Management decision making uses documentation to determine the type and level of care.
• Communication and continuity of care among physicians and other healthcare professionals is essential.
• Providers must sign their dictations. This is a requirement.
Physician order for diagnostic tests
An order is a communication from the treating physician/practitioner requesting that a diagnostic test be performed
for a beneficiary. The medical record and/or the request itself must clearly document the physician's intent for the
diagnostic test to be performed.
The following are examples of acceptable documentation:
• An order, signed by the physician
• A signed requisition/Medical Service Record (MSR)
Note: A requisition/MSR, or order, not signed by the physician does not support physician's intent for the
test to be performed
• A notation in the patient's medical record documenting the need for or the intent to obtain a specific test,
signed by the physician
• A verbal or telephone order - documented at both the treating physician's office and the testing facility - and
placed in the beneficiary's medical record
Note: Must be signed within the time frame specified by the state
• An email from the physician that may be verified
• Another type of electronic requisition transmitted from the treating physician to the testing facility that
requires a password, with proof of the process in writing (e.g., attestation)
Charge entry
At Park Nicollet Clinics, the providers initiate charges by entering Current Procedural Terminology (CPT) and diagnosis
codes out of Computerized Provider Order Entry (CPOE).
At Methodist Hospital, the task of charge entry can take place across a number of different departments.
Regardless of the setting, we are able to promote accurate charges being entered by keeping correct and complete
documentation.
A critical aspect of this task is that the charge is entered for the correct patient, with the correct date of service, and the
correct provider identification number/billing number.
Coding: Introduction
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Professional clinic coding: For Park Nicollet Clinicians providing services at a clinic, clinicians are expected to
select appropriate ICD-9 diagnosis and CPT procedure codes for all services performed during that visit. The
documentation must reflect these services.
Professional coding in the hospital: Park Nicollet clinicians are also expected to assign CPT and diagnostic codes
for their hospital evaluation and management visits and some procedures using the Navigator. Charges are sent
to professional coders via the Charge Router and checked for accuracy.
Hospital facility coding
For hospital inpatient and outpatient claims, Methodist Coding Department converts clinician documentation, including
operative reports, discharge summaries, and narrative diagnoses, into diagnosis and procedure codes in accordance
with nationally recognized ICD-9-CM and CPT-4 guidelines.
After patient records are coded and entered, the Coding Department extracts information from the medical record to
meet Uniform Discharge Data Set guidelines. This data is then used for compiling, running and analyzing research study
requests.
Coding as part of the patient revenue cycle
Just as documentation serves as the primary communication engine between all of the PNHS parties that are involved
in patient care, coding serves as the means for PNHS to communicate with our third party payers.
The process is Patient Care > Coding > Billing.
ICD-9-CM and CPT-4 codes ensure that we are speaking the same "language,” whereas non-standardized, narrative
explanations leave room for interpretation. Precise coding is essential to submitting compliant claims and thus being
correctly compensated for the services we provide. Coders must follow nationally recognized coding guidelines.
The Coding Department can only code what is documented in the chart. If a charge is present, but no documentation
exists, the Coding Department cannot code the charge. Therefore, it is extremely important that clinicians document
with sufficient detail for the coders. The Coding Department must have access to the necessary documentation to code
from before the claim can be released for billing.
If documentation is in question, you may need to query the clinician. If there is no documentation to substantiate the
charge, the charge should be removed after discussing with your leader.
Coding: Special considerations
Coding practice is the transformation of descriptions of diseases, injuries, conditions, and procedures from words in the
medical record to alphanumerical designations for billing purposes.
Coders must be able to assign codes to all codable information. Information used to assign codes must be part of the
official health record, not part of an unofficial document such as a surgery log or registration list.
Coding responsibilities
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All PNHS professionals and others involved in the revenue cycle shall:
• Adhere to the ICD-9-CM, ICD-9-CM Official Guidelines for Coding and Reporting, coding conventions, official
coding guidelines, the CPT rules, established by the AMA, and any other official coding rules and guidelines
established for use with mandated standard code sets.
• Only assign and report codes that are clearly and consistently supported by physician documentation in the
health record.
• Not change codes or the narratives of codes so that the meanings are misrepresented. Diagnoses or procedures
should not be inappropriately included or excluded because the payment or insurance policy coverage
requirements will be affected.
• Assist and educate physicians and other clinicians by advocating proper documentation practices, further
specificity, re-sequencing, or inclusion of diagnoses or procedures when needed to more accurately reflect the
acuity, severity, and the occurrence of events.
• Strive for the optimal payment to which the facility is legally entitled, remembering that it is unethical and
illegal to maximize payment by means that contradict regulatory guidelines.
• Code all documented conditions that coexist at the time of the encounter and require or affect the patient’s
treatment or care management. Do not code conditions that have been treated in the past but no longer exist.
Pre- and post-adjudication (e.g., Claims/Billing)
The Pre- and Post- Adjudication Departments (e.g., Claims/Billing) submit PNHS‘ charges to primary and secondary
payers. They ensure that claims are created and submitted in compliance with government regulations and third-party
contracts. They correct errors found prior to claim submission through system edits and manual review and also correct
errors after denial by the payer.
Not only is Pre- and Post-Adjudication responsible for correcting errors found prior to claim submission, but they must
also perform this task to get the claim submitted within timely filing limits. As you may imagine, many of the errors that
have taken place in other places in the patient revenue cycle become visible in this process.
Some of the challenges for team members involved in billing are using correct provider billing numbers, correct place of
service codes, and recognizing and adhering to the different Medicare and Medicaid billing rules.
Claim submission standards of conduct
• Claim documentation: Claims should be submitted only when appropriate documentation supports the claims
and when such documentation is maintained and available for audit and review.
• Un-bundled charges: It is not appropriate to un-bundle charges to inappropriately enhance payment. Use of separate billing codes for services that have an aggregate billing code is abusive. It is not acceptable as it may violate anti-kickback statutes.
• Billing discrepancies: In the event a discrepancy is discovered subsequent to the submission of the claim, all attempts to rescind the original claim submitted must be made in order to submit the correct claim for the services. If we have already received reimbursement, an adjusted claim will be submitted to the payer. Any member of the billing staff who identifies potential billing or reimbursement discrepancies with respect to claims already submitted to government or private payers is required to report immediately those discrepancies either to their leaders or to the Compliance Officer.
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• Records: Billing staff will not falsify, destroy or withhold records relating to any portion of the billing and claims submission function.
• Billing inconsistencies: Billing staff should immediately report to their leaders, or compliance, any billing instruction received from Payers which is inconsistent with current billing policies and procedures.
• Provider numbers: All billable providers' entered into the Billing System must have their own provider numbers (National Provider Identifiers). The billable provider who rendered the services and his/her provider number must be reported in the claim. No other provider number in the system will be used for another provider. It is fraudulent to misrepresent the provider. Any questions regarding who provided the service should be forwarded to Coding and/or the Compliance Department.
• 3-day window policy: Per the patient accounting 3-day window policy, all outpatient services connected with an inpatient stay will be bundled.
• Duplicate billing: Submitting more than one claim for the same services or submitting the same claim to more than one primary payer is prohibited. Duplicate billing can occur due to simple error. Knowing about duplicate billing, which is sometimes evidenced by systematic or repeated double billing, can create liability under criminal, civil or administrative law, particularly if any overpayment is not promptly refunded. When a claim needs to be resubmitted, Billing staff will submit an adjusted/replacement claim to avoid duplicate claims.
• Orders/medical necessity: Claims should only be submitted for services that the hospital has reason to believe are medically necessary and that were ordered by a physician or other appropriately licensed individual.
Payment: Two potential outcomes
The desired outcome of the patient revenue cycle is that we are appropriately reimbursed for the services we have
provided. The other possible outcome of claim submission, however, is that the claim is denied for any number of
possible reasons, returned to PNHS, and routed to the appropriate party before resubmitting the claim. In some cases,
denials are not payable and Park Nicollet loses the reimbursement.
Common reasons for denials include:
• incorrect insurance was billed
• Medicare Secondary Payer denials
• insufficient accident information
• codes don't support service provided
• lack of medical necessity
• timely filing
• doesn't meet HIPAA transaction requirements
Payment and reimbursement
It is unethical and fraudulent to make changes to a returned claim that is not supported in the documentation for the
sole purpose of reimbursement. We can only claim what is accurately documented in the patient record.
For example, if a patient calls to complain that their insurance denied a claim for a preventive visit, you can't change
the visit coding to that of a problem visit if that isn't the documented reason the patient was seen.
You can't charge for anything that isn't documented (e.g., drugs, durable medical equipment, and therapy sessions).
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Credit balances and bad debt
PNHS treats credit balances and bad debt in compliance with applicable law and regulations. PNHS endeavors to
accurately track, report, and refund credit balances.
Patient Financial Services team members shall monitor credit balances and refund them in a timely and appropriate
manner. If a payment results in a credit balance (overpayment) and is an improper or excessive payment made, the
credit balance will be researched and if appropriate, expeditiously returned to the source.
Abuse, fraud, and auditing
Given the complexity and interdependent relationships of the departments in the revenue cycle, proper coordination
and supervision of the revenue cycle process is important. Those involved in the revenue cycle must also protect the
organization against Medicare fraud and abuse.
Medicare abuse
The legal definition of abuse is abuse may result, directly or indirectly, in unnecessary costs to the Medicare or
Medicaid program, or improper payment for services that fail to meet professionally recognized standards of care or
are medically unnecessary.
Individuals who are guilty of Medicare abuse unintentionally follow practices that violate the guidelines of the
Medicare program and may result in unnecessary costs to Medicare.
Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has
not knowingly or intentionally misrepresented facts to obtain payment.
Medicare fraud
The legal definition of fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to
defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representation, or
promises, any of the money or property owned by or under the custody of any healthcare benefit program.
Individuals who commit Medicare fraud intentionally obtain, or attempt to obtain, money or property owned by
Medicare through false or fraudulent pretenses.
Medicare may consider a healthcare provider fraudulent if the provider identifies inappropriate actions or behaviors
against the Medicare program but fails to remedy them. Medicare expects all healthcare providers who participate in
the program to furnish and report services in accordance with the established regulations and policies.
Healthcare providers should correct any billing or reporting errors that they identify. If the errors result in
overpayments, the healthcare provider is required to return the overpaid amounts to Medicare.
The most common types of Medicare fraud are:
• billing for services that were not rendered
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• misrepresenting as medically necessary non-covered or screening services, by reporting covered
procedure/revenue codes
• signing blank records or certification forms, or falsifying information on records or certification forms for the
sole purpose of obtaining payment
• consistently using procedure/revenue codes that describe more extensive services than those actually
performed
Penalties for fraud and abuse
Law enforcement agencies investigating and prosecuting for fraud can choose between criminal or civil prosecution.
Criminal prosecution: The U.S. Attorney's Office may use a series of federal statutes to indict and prosecute
individuals or entities involved in fraud. Those found guilty may be subject to:
substantial penalties
fines
restitution
imprisonment
Civil prosecution: In lieu of criminal prosecution, the U.S. Attorney's Office may decide that the interests of the
Medicare program are best served through the civil courts. In these cases, individuals or entities face substantial
penalties for each violation of program rules, including repayment of up to three times the amount of damages to
the Medicare program and large fines.
Recovery Audit Contractors
Recovery Audit Contractors (RACs) are private companies contracted by the Centers for Medicare and Medicaid
Services, tasked to identify Medicare overpayments and underpayments and return Medicare overpayments to the
Medicare Trust Funds.
RACs review claims submitted by hospitals and health systems, physicians/clinicians, and other healthcare providers
and suppliers in an attempt to identify improper payments. They are highly motivated to identify overpayments and
other improper payments, as they are compensated on a contingency-fee basis, based upon the principal amount
collected from and/or returned to Medicare providers or suppliers resulting from improper payments.
Type of
Review
Medical Records
Required
Target Areas
Complex
Reviews
Medical records
requested
DRGs, coding errors, medically unnecessary setting (billed an inpatient
and should have been outpatient or observation), durable medical
equipment, drugs given and documentation to support units of
service, renal dialysis, etc.
Automated
Reviews
Review of claims
data only. No medical
records requested.
Duplicate billing for the same service, medically unnecessary services,
discharge disposition codes.
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PNHS has created a multidisciplinary group to work on RAC related items - Park Nicollet Health Services RAC Committee
and RAC Response Team.
The Compliance and Contracting website has information dedicated to RAC activities, called the Recovery Audit
Contractors (RAC) Program. This page provides the latest information on the RAC program expansion and Park
Nicollet's efforts and educational activities.
Many people play key roles in the RAC process at PNHS. In general, the following departments and individuals play
major roles in the RAC process:
• Ordering/treating physician
• Patient Admitting/Registration
• Charge master/Finance
• HIM
• Coding
• Case Management
• Patient Financial Services
• Denial Management/Appeals
• Compliance
• Clinical Departments
Complete, accurate, and timely documentation of the patient's clinical condition is critical in order to ensure that
patients receive the appropriate level of care in the setting that the clinical condition requires, and that the hospital
receives the appropriate Medicare reimbursement for the level of care provided.
If you or your department is contacted regarding a RAC request, please know that these requests should receive
priority attention. It is essential that all our responses to the RAC inquiries be timely and complete, and there is a
complete record of documentation to support the services charged.
CMS has identified the following areas for targeted review, among others:
• Place of service errors
• Evaluation and Management ("E/M") services
• Medical Necessity
• "Incident to" billings
• Pharmaceutical injectables
• Injection billing of units based on HCPCS Code descriptions
• Medically unnecessary setting (billed as inpatient and should have been outpatient or observation) for some of
the following admissions (not an all inclusive list):
• medical back problems
• chest pain
• gastrointestinal hemorrhage
• heart failure and shock
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• kidney and urinary tract infections
• renal failure
• COPD
Government inspections and investigations
Park Nicollet may be audited by an external source, such as Medicare/Medicaid, Recovery Audit Contractors (RACs) or
the Office of Inspector General (OIG). These reviews test the effectiveness of our Compliance Program and our
compliance with government and provider regulations.
Regarding Government Inspections, it is Park Nicollet policy that:
• All government inspections or requests for interviews or documents be referred to the Chief Compliance
Officer or legal counsel for review.
• Park Nicollet team members cooperate promptly and fully regarding possible civil or criminal violations of the
law.
You can make a difference
To ensure the financial health of PNHS, it is critical that compliance is practiced, by all team members, throughout the
patient revenue cycle. From the beginning of the revenue cycle to the completion, each successful step in the process
minimizes the hospital's Accounts Receivable days and improves cash flow.
All of the following requirements can create an overwhelming amount of overhead and responsibility:
• compliance with laws and regulations
• providing necessary care
• accurately documenting each patient's hospital experience
• generating clean claims for payment
These measures are necessary to maximize the efficiency of our revenue cycle process, protect our financial welfare
and reputation, and maintain compliance with the law.
Everyone has a role to play. All of us benefit by working together.
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Hazardous Waste for Healthcare Workers This section presents hazardous waste management training required by U.S. regulatory agencies for those involved
with hazardous waste at Park Nicollet Health Services.
Hazardous waste is waste that is dangerous or potentially harmful to our health or the environment. Park Nicollet
generates hazardous waste that must be controlled in several areas. This section covers the basic hazardous waste
management requirements for medical and general waste.
Managing hazardous waste requirements
The Federal Government's Resource Conservation and Recovery Act (RCRA) gave the Environmental Protection Agency
(EPA) the authority to control hazardous waste from "cradle-to-grave." This includes the generation, transportation,
treatment, storage, and disposal of hazardous waste. RCRA also defines a framework for the management of non-
hazardous wastes.
The law was enacted in 1976 to protect our environment. It applies to businesses, schools and hospitals,
including Park Nicollet.
The RCRA requires that Park Nicollet facilities (including Methodist Hospital and Park Nicollet Clinics) follow
specific rules and procedures for disposal of hazardous waste. It also requires mandatory and documented
training for those who come in contact with hazardous waste.
In addition to the EPA, other regulatory bodies that monitor Park Nicollet’s hazardous waste management include the
Minnesota Pollution Control Agency as well as the metropolitan counties of Hennepin, Carver, Dakota, and Scott.
Why manage hazardous waste?
It is not only important to manage hazardous pharmaceutical waste properly because it's the law, but proper
management is also good stewardship.
Hazardous waste management resources Clean Harbors
Clean Harbors is the environmental management company contracted by PNHS to help Methodist Hospital and all Park
Nicollet Clinics and facilities dispose of our hazardous waste and reach full compliance with the EPA's Resource
Conservation and Recovery Act requirements.
Clean Harbors is responsible for:
inspecting and replacing hazardous waste containers
arranging for secure storage and shipment of hazardous waste off-site
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Contacting Clean Harbors
If you have questions about how to handle hazardous waste, contact your leader or contact Clean Harbors via
phone: (952) 993-5116 (Methodist office)
(507) 263-0200 (Main office)
email: medswaste@parknicollet.com
Resources on Facets
Hazardous waste management policies, standards, and procedures are available on the Environmental Services
department page on Facets. You may also contact your area leader for information.
You may access this information at a later time via this path:
Facets>Departments>Environmental Services>Waste Management
Infectious waste
Definition
Soft or sharp medical materials that have been in contact with blood or body fluids (BBFs).
Examples
Soft infectious materials: bandages and sponges saturated and/or dripping with blood or bodily fluids
Sharp infectious materials: empty used needles, syringes, and broken glass
Disposal procedures
Soft infectious materials: place in red biohazard-labeled bag (often referred to as a "red bag") and then dispose
of in the infectious waste container
Sharp infectious materials: dispose of in the sharps waste container
DEA-controlled substances (narcotics) waste
Definition
Drugs regulated by the Federal Drug Enforcement Agency (DEA).
Examples
Narcotics such as Demerol, morphine, Nembutal, Percocet, etc.
Disposal procedures
1. Dispose of leftover DEA-controlled substances by draining them down a sink or toilet in front of a witness.
The DEA has recommended this procedure as the best way to securely manage narcotics.
2. Empty ampules, needles and/or syringes: dispose of in sharps waste container
Empty vials, cassettes, IV bags: dispose of in regular waste container
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IV solutions (without medications) waste
Definition
This type of waste includes intravenous solution materials and IVs containing total parenteral nutrition (TPN). It does
not include IVs with medications.
Examples
IVs containing salts, sugars or lipids, such as K+, Na+, dextrose, amino acids, potassium, calcium, or magnesium
IV solutions without medications
Disposal procedures
In 2012 the process to dispose of IV bags with no pharmaceutical waste is changing.
Unless they contain pharmaceutical waste, IV bags labeled with patient information should be disposed of in special IV
bag containers located on the hospital nursing floors. The content of these bins is incinerated.
Starting in April 2012, PNHS will be making the following changes to this process to further protect patient privacy:
1. Empty IV into sink or drain, if needed.
2. If there is a patient label on the bag, remove label and black out name with a marker.
3. Dispose empty IV bags in the regular waste container.
Note: Do not dispose of partial IVs with medications such as insulin or epinephrine in the general trash. Place them in the
hazardous waste container (black MEDS box) instead.
Pharmaceutical waste Definition
Pharmaceutical waste is any medication waste within partially full bottles, vials, IV bags, tubing, or other containers.
Examples
Any partially used medication:
partially used vials, bottles, syringes
partially used IV bags and tubing with medicine additives such as TPN with insulin or epinephrine
loose pills, tablets, capsules
partially used aerosol inhalers & cans
partially full containers of creams, ointments, and medicated shampoos
partially full/dripping wet containers of patient prep solution (alcohol)
Disposal procedures Dispose all unused medications and medicated IV bags in the hazardous waste container (black MEDS box) and then close the container.
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Important notes
Make sure you follow proper procedures for disposing of partially used DEA-controlled drugs before placing the empty containers in the regular trash.
Keep black MEDS box closed at all times unless actively adding waste to it.
Disposing of items in the hazardous waste container (black MEDS box) ensures patient confidentiality because the container and contents are ultimately incinerated.
P-listed pharmaceutical waste Definition Pharmaceuticals that are characterized as being acutely toxic because small amounts may cause severe health effects. Examples
Arsenic trioxide
Nicotine
Phentermine
Physostigmine
Physostigmine salicylate
Warfarin/Coumadin
Disposal procedures
P-listed pharmaceutical waste must be disposed of with special care by following the steps below:
1. Place empty or partially used vials, wrappers or packaging of P-listed drugs in a plastic zip-top bag.
2. Dispose of the zip-top bag in a hazardous waste container (black MEDS box).
3. Close the container.
Dual waste Dual waste is hazardous waste that is both hazardous and infectious. Examples
Drug waste contaminated with blood or body fluids
IV with medication tubing contaminated with blood
Partially used syringes with medication still contained
Pitocin IV (if the catheter is left on)
Does not include sharps such as needles or metals
Disposal procedures
Place dual waste in a red biohazard-labeled bag (often referred to as a "red bag").
Place the red bag in the hazardous waste container (black MEDS box).
Close the container.
Do NOT dispose of this waste in the black MEDS box There have been cases at Park Nicollet where waste has been improperly disposed of in the hazardous waste container
(black MEDS box). Improper disposal can increase waste management costs as well as lead to potential injury to waste
handlers. Please review the list below; this waste should not be disposed of in the black MEDS box—the appropriate
disposal method is listed.
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Type of waste Disposal method
Empty needles Empty needles should be disposed of in the sharps waste
container.
DEA-controlled substances (narcotics) Dispose of by draining down a sink or toilet in front of a
witness.
Soft infectious materials saturated and/or dripping with
blood or bodily fluids
Place in red biohazard-labeled bag and then dispose of in
the infectious waste container.
IV solutions and TPNs (without medications) Empty IV contents into sink if needed; if there is a patient
label on the bag, remove label and black out name with a
marker; lastly, dispose bag in regular waste container.
Bandage with a small amount of dried blood Dispose of in regular waste container.
What do I do with a dropped pill?
A pill is dropped on the floor. What do you do now? DEA-controlled pill Dispose of down a sink or toilet in front of a witness. Unknown type of pill Dispose of in hazardous waste container (black MEDS box) and then close the container.
General hazardous waste Even if you and/or your department are not involved with patient care, you may generate general hazardous waste. This type of waste includes:
aerosol cans (expired or unused)
cleaning chemicals (expired or unused)
fluorescent light bulbs
non-alkaline batteries (lithium, nickel cadmium, and lead acid) Note: Place tape over the battery terminals before disposal.
Disposal options at PNHS
The hazardous waste disposal options for these items depend on your location. Some examples on how to dispose are
listed below.
If your facility has a hazardous waste storage area and you can safely transport the item, you may move the
waste to this area.
If you can safely move the waste, place the items next to a hazardous waste container (black MEDS box) with a
label or note indicating that the items are "hazardous waste.”
If you cannot safely move the waste, place a note next to a hazardous waste container (black MEDS box) that
provides the following information: location of the waste, description of the waste, and your contact
information.
Note: If the above disposal options are not available at your facility, please contact Clean Harbors for assistance.
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phone: (952) 993-5116 or (507) 263-0200 email: medswaste@parknicollet.com
Patient Safety Park Nicollet is committed to providing patients the best and safest care possible. The purpose of this section is to
inform you of the processes in place for reporting, evaluating, and correcting patient safety concerns of team members,
patients and family members.
Patient safety error reduction plan
At Park Nicollet, the Patient Safety Error Reduction Plan outlines our organization's commitment to providing safe
patient care by doing the following:
recognizing risks to patient safety and taking action to reduce those risks
encouraging individuals to report errors
focusing on system failure rather than individual blame
involving patients in their care
educating team members about healthcare errors and safety enhancement strategies
Speak up
Patients' involvement is essential to provide the best healthcare possible. The phrase "nothing about me without me"
means we encourage patients to become actively involved by asking questions, voicing concerns, and participating in all
decisions about their treatment.
The Joint Commission and Medicare launched a national campaign that encourages individuals to become active
participants of the healthcare team. To prevent healthcare errors, patients are urged to speak up in the ways described
below.
Speak up if they have questions or concerns. If they do not understand something, expect them to ask again.
It's their body, and they have a right to know.
Pay attention to the care they are receiving and make sure they are getting the right treatments and
medications.
Educate themselves about their diagnosis, the medical tests they are receiving, and medications.
Ask a trusted family member or friend to be their advocate.
Know what medications they take and why. Medication errors are the most common healthcare mistakes.
Use a hospital, clinic, surgery center, or other type of healthcare organization that has undergone an on-site
evaluation against established quality and safety standards, such as those provided by the Joint Commission.
Participate in all decisions about their treatment. They are the center of the healthcare team.
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Involving the patient
Healthcare providers are responsible for keeping patients and their families informed about all outcomes of care. At
times, patient care outcomes are unanticipated outcomes or clinical consequences of a medical accident.
PNHS policy provides the following guidelines for working with patients and families in such situations:
Provide a prompt and compassionate explanation of what happened.
Assure the patient and their family that a full analysis of the situation will take place.
Discuss any changes being made based on the analysis.
Offer an apology and acknowledgment of accountability.
Joint Commission National Patient Safety Goals
The purpose of the Joint Commission's National Patient Safety Goals is to promote specific improvements in patient
safety.
Goal 1: Improve the accuracy of patient identification
Requirement .01.01.01
Use at least two (2) patient identifiers (neither being the patient's room number) when:
administering medication or blood products
collecting blood samples and other specimens for clinical testing
providing any other treatment or procedure
Label containers used for blood specimens and other specimens in the presence of the patient.
Requirement .01.03.01
Eliminate transfusion errors related to patient misidentification.
1. Before initiating a blood or blood component transfusion:
Match the blood or blood component to order
Match the patient to blood or blood component
Use two patient identifiers
2. One individual conducting the identification verification must be the person who will administer the
blood component to the patient. The second person must be qualified to participate in the process.
Goal 2: Improve effectiveness of caregiver communication
Requirement .02.03.01
Park Nicollet must measure and assess, and if appropriate, take action to improve the timeliness of reporting
critical results and diagnostic procedures to the responsible licensed caregiver.
1. As an organization, we need to determine the following:
a. Critical values (frequently called panic values) of laboratory and diagnostic tests.
b. Turnaround time between availability of critical test results and receipt by the care giver.
2. Then monitor timelines:
Develop a method of tracking the timeliness of reporting and receipt of those critical test results, to
allow analysis and improvement in these areas if necessary.
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Goal 3: Improve the safety of using medications
Requirement .03.04.01
All medications, medication containers (for example, syringes, medicine cups, basin), or other solutions
are labeled unless administered immediately.
Only label one medication/solution at a time.
When the individual preparing the medication is not the individual who will be administering the
medication, all labels must be verified verbally and visually by two (2) qualified persons.
Discard any unlabeled medications.
Documentation on the label includes:
o name of the medication /solution
o strength of the medication/solution
o quantity
o amount if not apparent from the container
o expiration date, when not used within 24 hours
o expiration time when expiration will occur in less than 24 hours
Keep in mind:
An immediately administered medication is one that a qualified staff member prepares or obtains,
takes directly to the patient, and administers without any break in the process.
Medications/solutions must be labeled even if only one medication or solution is being used.
Medications not administered must be reviewed by oncoming and outgoing staff at change of shifts
or breaks.
Goal 7: Reduce the risk of healthcare associated infections
Comply with the CDC hand hygiene guidelines to reduce the transmission of infectious agents by staff to
patients, thereby decreasing the incidence of healthcare-associated infections.
When using soap and water, be sure to wash for a minimum of 15 seconds.
Requirements .07.03.01, .07.05.01, .07.06.01
use best practices or evidence-based guidelines to prevent central-line associated bloodstream
infection
implement best practices for preventing surgical-site infections
establish evidence-based practices to prevent healthcare associated infections due to multiple
drug-resistant organisms
implement evidence-based practices to prevent indwelling catheter-associated urinary tract
infections
Follow the Universal Protocol
Follow the Universal Protocol to prevent wrong site, wrong procedure, wrong person.
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Requirement UP .01.01.01
Implement a pre-procedure process to verify the correct procedure, for the patient, at the correct site.
Note: The patient is involved in this verification process when possible.
Requirement UP .01.02.01
Identify those procedures that require marking of the incision or insertion site.
Mark procedure site before procedure is performed and, if possible, with the patient involved.
The procedure site is marked by a licensed independent practitioner who is ultimately
accountable for the procedure and will be present when the procedure is performed.
The method of marking the site and the type of mark is unambiguous and is used consistently
throughout the organization.
A written, alternative process is in place for patients who refuse the site marking or when it is
technically or anatomically impossible or impractical to mark the site (e.g., mucosal surfaces ).
Other standards related to patient safety
Medication Management .01.02.01
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and
take action to prevent errors involving the interchange of these drugs.
Common actions that have been taken include:
Separation of stock shelf to differentiate
Special alerts in the automated medstation (Pyxis) or unique packaging (epinephrine ampules)
Information Management .02.02.01
Park Nicollet has a list of abbreviations, acronyms, and dose designations that are not to be used.
The DO NOT use list applies to all orders and all medication-related documentation when handwritten
or entered free text into a computer.
The DO NOT use list may not be used on PN preprinted forms.
Provision of Care .01.02.08
Reduce the risk of patient harm resulting from falls.
The organization establishes a fall reduction program.
The program includes an evaluation, as appropriate to the patient population, of the settings where
services are provided.
The plan includes interventions to reduce patient fall risk factors.
Staff have been educated and trained on the fall reduction program.
The patient and patient's family are educated on the fall reduction program and any individualized fall
reduction strategies.
The fall reduction program is evaluated to determine effectiveness.
Provision of Care .02.01.03
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While taking verbal or telephone orders or reports or critical test results by telephone, you must verify the
complete order or test result following these steps:
Writing down the complete order or test result (or entering the information into the computer).
Reading it back, and
Receiving confirmation that it is accurate from the individual who gave the order or test result.
Provision of Care .02.02.01
As an organization, we must implement a standardized approach to "hand-off" communications that includes
an opportunity to ask questions and respond to those questions and also to read back or repeat back patient
information, if appropriate.
Accurate information regarding the patient's care, treatment, and services.
Current patient's conditions
Any recent or anticipated changes in the patient's condition
Opportunity for the receiver to review patient historical data regarding care, treatment, or services as
applicable
All information should be presented in a clear, concise manner
Hand-off communication is interactive, meaning there is opportunity to ask questions between giver
and receiver of information
Healthcare professionals should be allotted enough time for hand-off communications with minimal
interruptions. It is hoped this will lessen the amount of information that may be forgotten or simply not
conveyed.
Provision of Care .02.03.01
Define and communicate the means for patients and their families to report concerns about safety and
encourage them to do so. This includes information on how to send a complaint to Joint Commission.
Methods of communication may include:
Information packet given at time of admission
Information posted throughout the facility
Information on the PNHS external website
Precautions taken to prevent infections (e.g., hand hygiene)
Precautions taken to prevent adverse events during procedures (e.g., use of two patient identifiers and
site marking)
Provide patients and families education encouraging active involvement in the patient's care.
Patient/family education should include:
Reporting unexpected changes in their conditions
Asking questions about their condition, treatments, procedures, and diagnostic test results
Asking questions when they do not understand what they have been told about their care and what
they are expected to do
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Reporting any concerns or errors they observe
Discussing the importance of managing medications
BEST Care Reporting
All team members have a responsibility to patient safety and patient experience. BEST Care Reporting gives team
members a robust tool to document and report patient safety events and patient feedback. PNHS encourages and
supports anonymous reporting to improve the care we provide to our patients.
Staff in the Patient Safety/Quality Assessment department review all patient safety events and concerns reported
through BEST Care Reporting daily.
A Quality Alert E-Page system is also available for more urgent concerns. You can access a Quality Alert E-Page simply
by typing “quality" in the Phonebook search field at the top of the FACETS home page and clicking the "GO" button. The
E-Page phone number will appear.
Right to Know and Infection Prevention
What is 'Right to Know'?
OSHA: Individuals have a 'right to know'
The Occupational Safety and Health Administration’s (OSHA) Hazard Communication Standard is based on the concept
that individuals have a ‘right to know’ the hazards they are exposed to.
Minnesota Employee Right to Know Act
In 1983, the Minnesota legislature expanded OSHA’s standard and named it the Minnesota Right to Know Act (ERTK).
To comply, employers must identify hazardous substances (chemicals), harmful physical agents, and infectious agents
in the workplace and provide training to individuals who are exposed to them.
Park Nicollet’s Safety Management Plan
The purpose of the Safety Management Plan is to establish, maintain, and promote safety at Park Nicollet. PNHS
recognizes that an effective Safety Management Plan can reduce the number of job-related injuries, illnesses, and
fatalities by managing workplace safety and health as well as ensuring compliance with regulatory standards.
Safety data sheet (SDS)
What is an SDS? A safety data sheet (SDS) contains detailed information for a specific product written by the manufacturer. They are intended to provide workers with information they need in order to safely work with chemical products.
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Products determined to be hazardous by the manufacturer must be included in the Damarco SDS database where they can be assigned to your location/department inventory list. A paper copy of a chemical inventory in your department is not required, but may be appropriate in some cases (e.g., housekeeping).
Keep in mind:
When locating an SDS, make sure it is the sheet for the correct manufacturer.
SDSs will soon need to follow a standard format to include all safety and health information required by OSHA.
Important examples of chemicals to be aware of are liquid nitrogen and cytotoxic drugs.
Accessing SDSs In order to ensure staff has access to current SDSs, our SDS inventory is maintained electronically by an external vendor, Damarco Solutions. Damarco Solutions provides access 24 hours a day, 365 days a year to SDSs. This service can be accessed most efficiently online via Facets. Note: To access SDS information over the phone, call the 24-hour toll-free hotline at 1-877-451-6919.
More information on SDSs When working with SDSs, contact your area leader or the Safety Manager at 952-993-3957 or the Safety Assistant at 952-993-6663 for assistance in the following situations:
You are unable to locate an SDS.
You are no longer using a chemical listed in your department's hazardous chemical inventory.
Your department obtained a new chemical.
Container labeling
The manufacturer's label on incoming containers of hazardous chemicals is PNHS's primary labeling system. Labels on
incoming containers must not be removed or defaced.
Secondary container labels
If chemicals are transferred into other containers for storage or use throughout the day (i.e. soaking bins, sinks, bottles,
liquid nitrogen dewers, etc.), these containers must be labeled using secondary labels. Labels for secondary containers
must be legible and prominently displayed on, above, or adjacent to the container and include:
the name of the chemical
the appropriate hazard warning, such as the NFPA diamond or words that convey the same (flammable, causes
lung damage, etc).
Product labels: NFPA diamond
The National Fire Prevention Association (NFPA) diamond is a hazard
warning commonly used on labels. As illustrated the NFPA diamond is
divided into four sections, each having a color and code: fire, health,
reactivity, and special.
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Product labels: Signal words
Product labels will start containing a signal word which indicates the relative degree of severity of an immediate
hazard. For uniformity, signal words are associated with specific colors.
DANGER
Indicates a hazardous situation which, if not avoided, will result in death or serious injury.
This signal word is to be limited to the most extreme situations.
WARNING
Indicates a hazardous situation which, if not avoided, could result in death or serious injury.
CAUTION
Indicates a hazardous situation which, if not avoided, could result in minor or moderate injury.
NOTICE
This is the preferred signal word to address practices not related to personal injury. The safety alert symbol is not be
used with this signal word.
Product labels: Hazard and precautionary statements
Signal words on product labels are paired with hazard and precautionary statements.
Hazard statements
Hazard statements are intended to form a set of standardized phrases about the physical, health, and environmental
hazards of chemical substances and mixtures.
Precautionary statements
Precautionary statements are intended to form a set of standardized phrases giving advice about the correct handling
of chemical substances and mixtures.
Harmful physical agents
If a physical hazard is present in work environment above permissible exposure limit, PNHS must label equipment or
work areas with name of physical agent and appropriate hazard warning. Four harmful physical agents:
1. Occupation noise exposure
2. Heat/cold
3. Ionization radiation
4. Non-ionization radiation
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Personal protective equipment (PPE)
Personal protective equipment (PPE) includes any specialized clothing or equipment worn for protection against health
and safety hazards. Personal protective equipment is designed to protect many parts of the body, e.g., eyes, head, face,
hands, feet, and ears.
Store PPE where it is easily accessible or used; it should not be locked up.
A red or white personal protective equipment sign (shown at right) should be used on the outside of cabinet
and drawers containing PPE.
REMOVE your PPE before leaving patient care or other work areas.
OSHA's Personal Protective Equipment standard requires that employers must provide personal protective equipment
for individuals based on an assessment of the hazards in their job.
What to do if splashed with a chemical
If a chemical is splashed into the eyes or on the skin, individuals should:
Rinse the skin or eye out with generous amounts of water
Report to Employee Occupational Health and Safety for evaluation
Cytotoxic drugs
If you have direct patient contact, you may be caring for patients who receive cytotoxic drugs (also known as
antineoplastic drugs). Cytotoxic drugs are used in chemotherapy to kill cancer cells and are therefore labeled with
orange chemotherapy labels. These drugs are also used for non-cancer treatments, including Crohn's disease, multiple
sclerosis, and rheumatoid arthritis.
Healthcare professionals with frequent exposure to cytotoxic drugs may be at risk of developing cancer or showing DNA
changes. To minimize these risks, training regarding safe handling is required for individuals who dispense or administer
cytotoxic drugs.
Safe handling of cytotoxic drugs
Up to 72 hours after cytotoxic drug administration, a patient may still be excreting some of the drug in their body fluids
and is considered to be under Chemo Precautions.
When caring for these patients, the following should be done:
Follow Standard Precautions to protect yourself.
Wash contaminated surfaces three times with soap and water.
Place glassware or other contaminated reusable items in a plastic bag, transport them to the dirty utility room,
and wash them three times using soap and water.
Place any linen contaminated with cytotoxic drugs in a linen bag labeled "chemotherapy," then place the bag in
a second linen bag.
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Healthcare-acquired infections?
Healthcare-acquired infections are infections that patients get during the course of treatment within a healthcare
facility. For every 100 patients admitted to US hospitals each year, 4.5 will get a healthcare-acquired infection. These
infections cause or contribute to the deaths of nearly 100,000 people each year. You will review the following
infectious agents that are causing problems in healthcare setting (including home care).
Bloodborne pathogens
Tuberculosis (TB)
MRSA
Clostridium diffcile
Other multi-drug-resistant organisms (MDROs)
Bloodborne pathogens
Bloodborne pathogens (BBPs) are microorganisms in blood that can cause disease.
Examples of bloodborne pathogens:
Hepatitis B virus (HBV)
Hepatitis C virus (HCV)
Human immunodeficiency virus (HIV)
In a healthcare setting, workers are at risk for bloodborne pathogen infections if they:
are stuck with a needle or sharp object (referred to as a "sharp") that was used on an infected person
are splashed with infected blood or body fluids on broken skin, or in the eyes, nose or mouth
Healthcare workers who know they are infected with a bloodborne pathogen are responsible for reporting the
infection to EOHS by calling 952-993-5080.
Reporting exposures: Time is of the essence
If you are EVER exposed to blood or body fluids through a needle stick or a splash to the eyes, nose, mouth or broken
skin, you must do the following IMMEDIATELY.
1. Wash the exposed area.
2. Call the Blood and Body Fluid (BBF) pager (952-231-5223).
3. Ask a department supervisor or charge nurse to help you with the exposure reporting process (which includes
completing some paperwork). Your shift supervisor can also arrange coverage of your responsibilities so you
can take care of yourself.
Tuberculosis (TB)
TB is an infection caused by Mycobacterium tuberculosis bacteria. TB bacteria are airborne-transmitted. If someone
inhales TB bacteria, they can become infected with TB. TB bacteria usually affect the lungs, but they can infect any body
site.
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People who work in healthcare facilities can be at risk for being exposed to patients with active TB. Airborne and Standard Precautions must be used when caring for a patient with active TB.
Standard Precautions
Standard Precautions are practices that are used with all patients at all times and include:
Hand hygiene
Using barriers like gloves and gowns to prevent exposure to body fluids
Standard Precautions also protect your patients from being exposed to germs that cause healthcare-acquired infections
by preventing healthcare workers from carrying germs from patient to patient.
Hand hygiene
Healthcare workers must clean their hands:
Before patient care contact
After patient care or contact with the patient's environment
After touching body substances, mucous membranes or open skin
After removing gloves
Before invasive procedures and touching invasive devices like IV or urinary catheters
Before handling or preparing medications
Between "dirty" (for example, assisting a patient in the bathroom) and "clean" tasks (for example,
administering medication) to prevent cross contamination
Before eating and after using the bathroom
Here are two strategies to help you perform hand hygiene before and after patient contact 100% of the time:
1. Clean hands as you enter and leave a “patient space” (which is the exam room, cubicle, and area around bed).
2. Foam in, foam out.
What should I use for hand hygiene?
Use alcohol hand rub (AHR) for routine hand hygiene.
Use soap and water when hands are visible soiled or when caring for a patient suspected to have infectious
diarrhea.
Transmission-based precautions
Transmission-based precautions, also known as isolation precautions, are practices needed in addition to standard
precautions to prevent transmission of certain infectious diseases. Transmission-based precautions are based on how
an organism is transmitted.
1. Contact precautions
a. When used: Use when patients are known or suspected to have infections spread by direct contact.
b. Examples of infections requiring: MRSA, VRE, ESBL, CRE
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c. Signage: At Methodist Hospital, a contact isolation sign on the door of a patient’s room means that
healthcare workers must use contact precautions during patient care. Follow all instructions on
isolation signs.
2. Enteric precautions
a. When used: Use when patients are known or suspected to have infections spread by direct contact.
b. Examples of infections requiring: Clostridium difficile (C. diff.) diarrhea
c. Signage: At Methodist Hospital, an enteric isolation sign on the door of a patient’s room means that
healthcare workers must use enteric precautions during patient care. Follow all instructions on
isolation signs.
3. Droplet precautions
a. When used: When patients are known or suspected to have infections spread by large droplets
released through coughing or sneezing and that travel short distances (about 3-6 feet) before settling
on surfaces.
b. Examples of infections requiring: Influenza, Pertussis, and Neisseria meningitidis
c. Signage: At Methodist Hospital, a droplet isolation sign on the door of a patient’s room means that
healthcare workers must use droplet precautions during patient care. Follow all instructions on
isolation signs.
4. Airborne precautions
a. When used: When patients are known or suspected to have infections spread through tiny airborne
particles.
b. Examples of infections requiring: Tuberculosis, chickenpox, measles
c. Signage: At Methodist Hospital, a droplet isolation sign on the door of a patient’s room means that
healthcare workers must use droplet precautions during patient care. Follow all instructions on
isolation signs.
5. Full barrier precautions
a. When used: When patients have infections that are spread through multiple modes of transmission.
b. Examples of infections requiring: Smallpox, Avian Influenza, Severe Acute Respiratory Syndrome
(SARS)
c. Signage: A full barrier Isolation sign on the door of a patient’s room means that healthcare workers
must use full barrier precautions during patient care. Follow all instructions on isolation signs.
Safe injection practices
Don’t contaminate sterile injection equipment. If contamination accidentally occurs, dispose of equipment
properly and use new equipment.
Don’t administer injectable solutions from one syringe to multiple patients, even if the needle on the syringe is
changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another
patient or to access a medication or solution that might be used for a subsequent patient.
Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only
and dispose appropriately after use. Consider a syringe or needle/cannula contaminated after it has been used
to enter or connect to a patient’s intravenous infusion bag or administration set.
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Preventing back pain
What can you do to prevent back injury?
Eliminate or reduce manual lifting and moving of patients
Assess your patient before lifting or moving them
Use assist (lift and transport) devices
Exercise regularly
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Park Nicollet Health Service Required Education and Compliance
Agreements Acknowledgement Form By signing this form, you acknowledge you have read the following education and will abide by the following
compliance agreements. Please complete this form and return to your area leader.
Required education To ensure Park Nicollet Health Services (PNHS) meets the various regulatory guidelines/standards in the areas of
integrity & compliance, emergency management, and other requirements, I do hereby acknowledge that I have read
the following required education sections in this manual.
Non-patient Care Roles Patient Care Roles
Orientation to our Code of Conduct, Privacy,
Security & Compliance
Emergency Management
Harassment, Offensive and Disruptive Behavior,
and Workplace Violence
Advanced Corporate Compliance for the Patient
Revenue Cycle
Orientation to our Code of Conduct, Privacy,
Security & Compliance
Emergency Management
Harassment, Offensive and Disruptive Behavior,
and Workplace Violence
Hazardous Waste Awareness for Healthcare
Workers
Patient Safety
Right to Know and Infection Control
Take action, show your commitment Please take a moment now to show your commitment to doing the right thing. When you complete this form, you acknowledge the information you received today and confirm your commitment to your Code of Conduct.
I know where to find my Code of Conduct
I will act according to the Code of Conduct
I will immediately report any concerns and ask questions about activities that I think may violate the Code of Conduct.
Print name:
Signature:
Organization/Department:
Date:
Give this completed form to your leader at your organization.
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Workplace Violence Prevention Annual Training Completion
I have reviewed the Workplace Violence Prevention Annual Training and I am able to:
• Define workplace violence, recognize warning signs and know how to respond
• Define Active Security Threat and know how to respond
• Describe how and where to get help and how to report incidents of workplace violence
• Know what the Epic Aggression Flag is and when it is placed in a patient chart
Give this completed form to your supervisor. This form must be retained by your supervisor for regulatory tracking.
Print Name: ____________________________________
Signature:______________________________________
Date:_____________
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