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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

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Page 1: Park Nicollet Health Services Required Education Manual

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

Page 2: Park Nicollet Health Services Required Education Manual

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

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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

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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

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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

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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.

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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

12

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

29

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

Page 8: Park Nicollet Health Services Required Education Manual

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

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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 [email protected]

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

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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

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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 [email protected]

o [email protected]

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

7

12

20

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

29

41

46

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: [email protected]

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: [email protected]

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:_____________