Welcome to Student Affiliate Orientation at CHA

Objectives

• To give Clinical Students brief overviews of areas which are required by regulatory agencies, such as the State Board of Health.

• We do not expect you to remember all of this information, but just want to present this material so that you are slightly familiar with the terms and procedures.

Student General Information

•Rules and Regulations

•NRCP-HIPAA-Confidentiality

•Guidelines

Hospital Regulators & Acts• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

• Board of Health (county and State offices)

• HIPAA

• EMTALA

Organizational Chart

Dr. Bill VanNess

President/CEO

John Harris

VP CFO

Keith Trent

Foundation Director/ Community Relations Sherry Sidwell

VP Integrated Services

Lisa Halstead

VP Professional/Ambulatory

Services

Betty Crum

Long Term Care

Steve Majors

VP H.R./Information Services

Beth Tharp

VP Patient Care Services

Jeane Atkinson

Materials/Property Mgmt.

Mission

The mission of Community Hospital is to serve the medical health, and human service needs of the people in Anderson, Madison County, and contiguous counties with compassion, dignity, respect, and excellence. Service, although focused on injury, illness, and disease will also embrace prevention, education, and alternative systems of health care delivery.

SERVE Evaluation Tool

• Service

• Enthusiasm

• Respect

• Value

• Excellence

Who are our customers?

•Patients/Families•Volunteers•Students•Employees•Physicians•Payors

Customer Expectations

Our Job is to Exceed Expectations:RespectCourtesyPrivacyDignityTo be informedRight to RefuseThere are many more

We, the employees of the Community Health Network, see every customer interaction as a genuine opportunity to serve. It is with this

intent in mind that we commit the following to all of our customers and to one another:

We will be caring, compassionate and approachable in all of our customer contacts. (The key characteristics that will demonstrate our positive attitude will include our

genuine smiles, direct eye contact, authenticity, openness, and listening actively). We will greet our customers with

our customer’s name (if possible), with our name, and with the statement, “How may I help you?” We will end

our customer interactions with the question, “Is there anything more that I can do for you?”, and follow through

accordingly.

Attitude

We will respect our customer’s right to privacy and modesty by creating and maintaining a secure and

trusting environment.

Privacy

We will provide excellence in telephone courtesy. Our courtesy will be projected when we:

a. Answer the telephone within three rings

b. State the department reached

c. State our own name

d. Ask “How may I help you?”

We want our customers to hear our “smiles”.

Telephone Etiquette

We will view ourselves through the eyes of our customers. Each of us, along with our facilities, will be

easily identifiable to our customers. Our personal appearance will be professional, clean, tasteful, discrete

and in attractive condition. We will take personal ownership in the appearance of our work environment.

•No “name brand” apparel

•Always have on name tag

Appearance

NO SMOKING

When we see a problem, wherever it is, we will take the necessary steps to fix it --

IMMEDIATELY.

Initiative

We will delight our customers with our personalized attention. We will actively listen when customers ask for directions within one of our facilities, and offer an escort to their destinations. When a customer’s destination is another facility, we will provide a map on which we will mark the directions. We will be courteous, friendly, and

helpful when responding to customer needs.

Customer Acknowledgement

We will recognize that our customers’ time is very valuable. From the moment our customers enter our

service centers or request help, we will greet and provide them with prompt service. If customers have to

wait longer than 10 minutes, we will let them know when they can expect the service, and we will update

them every 10 minutes.

Customer Waiting

We will provide customers with the expert information they need to make informed, positive, personal, or

professional choices. We will do what it takes to ensure information is presented to our customers in a clear,

understandable manner. We will use an interdisciplinary approach to customer education.

Customer Information and Education

Continuous Quality Improvement•Plan Do Check Act

•Tools

Process Improvement Teams

Re-engineering Teams

Others

•Total Quality = Clinical Quality + Service Quality

Community Hospital Anderson “notes”

• 130-150 patient rooms “beds”

• 2nd floor: OB, Pediactric, ICU

• 3rd floor: 3E and 3N Med/Surg

• 4th floor: Extended Care/ InPatient Therapy

• 5th floor: Short Stay/ Quick Trip, Lab

Network Responsibility and Compliance Program

&HIPAA

&Patient Rights

Network Responsibility & Compliance Program (NRCP)

• Helps us achieve quality by ensuring that we comply with various Federal and State laws, rules and regulations, accreditation and certification standards, network policies and ethical standards. Doing the right thing and acting with integrity!

Ethics• The watchword of hospital ethics is discretion. Anything you hear or see

should be considered confidential.

• Example: Reception desk personnel are obligated not to discuss information on the patient’s admitting papers.

• Example: Volunteers are not to check the files to see who is in the hospital, or read admitting papers while taking a patient to the laboratory.

• It is a BREECH OF ETHICS to discuss patient information INSIDE OR OUTSIDE the hospital.

• When acquaintances come to the hospital, do not question them concerning their reasons for being there. Never discuss a patient’s illness with him/her.

Ethics• Information concerning the care of a

patient is always personal in nature

and; therefore any information about

his/her condition, care, treatment or

personal data is absolutely

confidential and must not be

discussed with anyone other than

those directly responsible for his/her

care and treatment.

• Only designated employees of the

hospital may release information

about patients.

• Please be discreet in your

conversations. A violation of

confidential information is a violation

of hospital ethics.

Code of Conduct• Treat all of our customers fairly, ensuring equal opportunity

and freedom from discrimination, harassment or violence of any kind.

• Appearance of misconduct or impropriety can be very damaging to the Network’s reputation and our ability to service our customers is critical.

Confidentiality

HIPAA: Health Insurance Portability and Accountability Act of 1996

Protecting Confidential Patient Information in Any Form Is

Everyone’s Responsibility !!

Confidentiality

Patient Confidentiality• New Federal Regulations under

HIPAA require more protections for patient medical information and records.

• Severe penalties will be imposed for non-compliance (civil fines of $100/violation up to $25K/yr; Criminal penalties $250K & 10 yrs prison if for personal gain, malicious harm or commercial benefit).

We should do the following:• Properly dispose of any notes, documents,

labels and any items that contain Patient Information.

• This includes: Patient Name, Address, Phone No., Account No., Hospital Room No., Diagnosis, DOB, and any other identifying information

We should do the following:• ALL trash with Patient

information on it should be placed in the Shred Containers located in the patient care office and lounge areas. These are marked “Shred it”

HIPPA Highlights: • Does the HIPPA Privacy Rule allow health care providers to transmit

protected health information (PHI) in e-mails?

• E-mailing PHI must be done with the utmost caution. While the HIPAA Privacy Rule does not specifically address e-mailing of PHI, WE are ultimately responsible for our patients’ PHI in any format. There is a very big risk of violating patients’ privacy when you e-mail PHI over the Internet. Why?

1. Email messages sent outside the Network, through the Internet is not secure.

2. Information included in these messages could be intercepted and read, just like a postcard.

It is our Network’s policy that PHI MAY NOT be sent out unprotected over the Internet

HIPAA HIGHLIGHTS:• You should be equally careful when putting patients’ PHI in e-

mail messages sent within our Network.

• It is just too easy to forward e-mail messages

Things you can do to reduce the risk of violating HIPAA:• Eliminate any patient information in e-mail.

• When forwarding or responding to e-mails; delete previous messages and

subject lines containing PHI.

• Reduce the amount of PHI in the e-mail.

• Do not use Patient names in e-mail.

• Password protect files when attaching files containing PHI.

• Consider alternatives: Fax or Snail/Regular Mail

• Contact IS Security of assistance in finding secure electronic means to share

PHI with other providers.

Key Points To RememberAll employees during their employment and thereafter, have a moral as well as legal obligation to keep all information concerning patients in the strictest confidence.Access to patient information should begin when you are directly involved in providing some portion of the care they receive.The federal government has issued new privacy regulations called HIPPA (Health Insurance Portability and Accountability Act) which ALL Healthcare Providers MUST comply with (effective April 2003).

The following instructions are to find “patient’s rights on the Inside Anderson Link (CHA Intranet):

CLICK:

Departments>Nursing>Patient Rights

Patient Rights• Each patient has rights, which are founded in our tradition

and history, our moral and ethical standards, and federal and state laws, rules and regulations.

• Key Patient Rights Include:

• Access to care by qualified caregivers

• Respect of personal values, beliefs and civil rights

• Informed participation in care

• Privacy and confidentiality

Patient Rights Continued…

• Key patient rights include:

• Expression of opinions/complaints and receipt of resolution

• Holistic care at the end of life

We provide access to care and make clinical judgments and decisions based solely upon what is in the best interests of the patient, without respect to the patient’s ability to pay.

When each of us observe and conduct ourselves in accordance with these guidelines every day, in everything we do, we build and reinforce our commitment to excellence, and we contribute to fulfilling CHA’s mission of “making a difference”.

5 minute break…

Disaster Codes & Safety

DISASTER CODES

DIAL 66CODE RED - FIRE

CODE BLUE - CARDIAC/RESP. ARREST

CODE 7 - CALL FOR ASSISTANCE

CODE PINK - CARDIAC/RESP. ARREST (OB/NURSERY ONLY)

CODE I - INFANT ABDUCTION

CODE EXTERNAL - EXTERNAL DISASTER EMERGENCY

CODE INTERNAL - INTERNAL DISASTER EMERGENCY

CODE GREEN - HAZARDOUS MATERIAL/WASTE SPILL

EXTERNAL CODE GREEN - TOXIC CLOUD

WEATHER WATCH - SEVERE WEATHER, POSSIBLY TORNADO WATCH

WEATHER WARNING - TORNADO WARNING

CODE B – BOMB THREAT

CODE E – EARTHQUAKE

CODE H – HOSTAGE/WEAPON (Security & Administrative Reps. Only)

For further information, refer to your Red Safety Manual

To report a Disaster

•Student and Patient Safety first, then…

•Dial 66

•Give type and location of the

In Case of a Fire- Pull the nearest fire alarm.

- Dial 66

- Switchboard will page “Code Red” (and location, if known) four times over the public address system.

Special Instructions

A. DO NOT use any elevators until the “All Clear” is announced.

B. All visitors are to remain either in the patient rooms, cafeteria or main lobby. They are not to move from one area to another.

C. Students and patients already on elevators enroute to a specified area should be taken to the intended destination and placed in the care of the person in charge of the department.

D. Students are to stay with a patient they are transporting and other volunteers are to return to their assigned area via the stairway.

E. When working weekends or evenings, since offices are closed, a worker should go to the front door. Do not allow anyone to leave or enter until “All Clear” is heard.

Special Instructions continued…

Code Blue

•Cardiac/ Respiratory Arrest

Code Pink

•Cardiac/

Respiratory Arrest (OB/Nursery Only)

Code 7

Call for Assistance

Code I

•Infant /Abduction• Screen all persons leaving.

• Carefully observe suspicious behavior and note physical description.

• If abduction occurs from O.B./Nursery:

“Code I” will be called.

• If abduction occurs from Pediatric Unit:

“Code I” along with the age of the child will be called.

Two types of Disasters

•External

•Internal

Code External • External Disaster Emergency are emergencies which occur outside

the hospital which results in large numbers of patients arriving in a short period of time that cannot effectively be taken care of in the Emergency Room.

• The switchboard operator will announce over the public address system “Code External” four times.

• Volunteers should report to their assigned areas for further instructions.

Code Internal• An internal disaster is a disaster stemming from a

fire, explosion, tornado, etc.

• The switchboard operator will announce “Code Internal” four times over the public address system.

• Volunteers should report to their assigned areas for further instructions.

Code Green

• If a Hazardous Material/Waste spill occurs in the area you are working

1. Dial 66 and report a “Code Green”

• Determine nature of spill• Level 1 – Self clean• Level 2 – HazMat Team• Level 3 – Outside assistance

External Green Code• Hazardous substance spill, toxic

cloud, or a fire/explosion that causes

a hazardous release which could

threaten human health outside the

facility.

• If a “Code Green” is called over the

public address system, return to

your assigned area immediately.

Weather Watch• The National Weather Service

determines a Tornado Watch (conditions are right for a tornado).

• Switchboard operator will announce “Weather Watch” four times over public address system.

• Secure flashlights and any necessary items and place them in an easily accessible location.

• Be prepared for further instructions.

Weather Warning• The National Weather Service determines

a Tornado Warning (Tornado sighting has been confirmed).

• Switchboard operator will announce “Weather Warning” four times over the public address system.

• Students should move to an inside corridor away from windows.

• Switchboard operator will announce “All Clear” over public address system when cancelled.

Code B

Bomb Threat

Code E

Earthquake

Code H

•Hostage/ Weapon

Safety

Infection Control

• If you have ANY questions contact:

• Linda Robinson, HEALTH/INFECTION CONTROL, OCC HEALTH CLINICAL

• Phone:2985322

• Ext:85322

• Pager:6081780

• Email:Linda.Robinson@ecommunity.com

Infection Control• Students will comply with annual tuberculosis screening.

• Students will not report for duty with any symptoms of communicable disease.

• Thorough hand hygiene is very important, especially before and after direct contact with patients or specimens.

• Students should only enter a patient’s room that has been designated an isolation room if they have been trained in transmission –based precautions and have knowledge of the organism that has been identified for isolation.  The student’s instructor must approve the assignment.

Hospital Manuals:

• Safety Manual--“Red” Safety Manuel

• MSDS Manual (Materials Safety Data Sheet)--“Yellow with Black stripes”

• Each Department will have an individual “policies and procedures” manuals

Safety Manual• Red Manual located within each department.

MSDS Manual• Master MSDS Manuals, which contain information on any

chemical/hazardous material used in the anywhere in the hospital, are located in:

- Safety Officers Office (Sherry Sidwell)

- Storeroom

- Emergency Dept.

Incident Reporting:

• What to do:

• If first Aid is necessary, do this first

• Tell Supervisor, manager, and or instructor that there has been an injury

• Contact Security to fill out an “Midas Incident Report”

Standard Precautions

• Treat all patients as though they are infectious by using Standard Precautions.

• Standard Precautions means to use P.P.E. (Personal Protective Equipment) with all patients. The kind of P.P.E. depends on the situation.

• P.P.E. includes things such as gloves, gowns, eye shields, etc.

Federal Law which requires the reporting of all incidents of death,

serious illness, or injuries sustained by a patient due to a faulty medical device.

In such a case, you must report the incident to the Nursing Supervisor and

Bio-Med IMMEDIATELY!

The device in question should not be touched until it has been inspected.

Telecommunications device for the hearing impaired are provided at Community Hospital Anderson

TDD Devices are located in the the following areas:

“The Life Safety Program provides guidelines to insure that the buildings and grounds of the hospital are constructed and

maintained in such a manner as to provide safety to patients, visitors,

employees and physicians.”

Systems testing includes:

The program is assured through periodic testing of building systems and employee competency

Employee competency includes:

When requirements for fire protection or environment and grounds safety are affected by construction, interim life safety measures are instituted to compensate for hazards

posed by existing deficiencies.

•Additional fire extinguishers

•Assurance of fire alarm operation

•Hospital-wide safety education

•Increased surveillance

EMTALA

E.M.T.A.L.A.

Emergency Medical Treatment

And

Active Labor Act

E.M.T.A.L.A.• Guidelines apply to:

• Any hospital that participates in Medicare

• Any facility perceived as hospital property• Entire main hospital campus• 1601 Building• Business Office• Parking lots, sidewalks, driveways, etc.

• Any hospital-operated off-site facility operating under the same Medicare Provider number as a department of the hospital:

• Physician offices• Immediate Med Center• Procare @ 10th Street• Nursing Homes (Elwood, Summitville, CNCC,)

• Any hospital-owned/-operated ambulance or helicopters, whether or not on hospital premises

E.M.T.A.L.A.

• Any individual who presents to the hospital/remote locations (as defined above) who requests emergency care, regardless of their ability to pay is entitled to:

• A medical screening to determine the presence of an emergency medical condition

• No delay in examination or treatment in order to inquire about the individual’s method of payment

• The following, if an emergency medical condition or labor exists:

– Stabilizing treatment within capabilities of hospital

– Transfer to another facility ONLY with patient consent

EMTALAEMTALA does not apply to patients without an emergency medical condition

E.M.T.A.L.A.Medical Screening Exam

• Guaranteed

• Regardless of ability to pay

• For any person, present anywhere on hospital or affiliated property

• By qualified personnel

• Must include all diagnostics & testing necessary to determine an emergency medical

condition

E.M.T.A.L.A.Emergency Medical Condition

• Broad, legal definition

• If present, patient must be treated and stabilized

• If necessary, must transfer for specialty care by appropriate transfer

• Patients may not be transferred to a less acute level of care (ie., Emergency Room to

physician office)

WOMAN IN LABOR MAY NOT BE TRANSFERED

Student Parking

Because of our commitment to customer

service it is very important that all

students park in the designated student

parking lot.

Parking for students is located in the West parking lot near the 1601 Building (see map next slide).Look for Entrance #6 on the 1210 Building’s West side entrance, this is the nearest entrance to the hospital and these doors do not require a “card-key” access to enter. You may use Entrance 5 and 4 as alternatives.

STUDENT PARKING

Age Specific Criteria• Handout

• The one thing that is universal for all ages is “Introduce yourself”.

• Each age group has different needs for communication, comfort, and safety.

Latex Allergy• Latex is a natural substance made from the sap of rubber trees. Natural

rubber latex is found in most latex gloves and many medical, household and other consumer products.

• Latex allergy is a reaction to certain proteins in latex rubber.

• The amount of exposure needed to produce a reaction is not known, however, increasing the exposure increases the risk of developing allergic symptoms.

• Most common reaction, which is not a true allergy, is dry, itchy areas that develop, usually on the hands. It is caused by irritation from using gloves and other chemicals. There may be other causes of a rash on the hands. If you develop a rash and suspect you may have a latex allergy and are in an area where you need to wear gloves, let a staff member know that you need latex-free gloves.

• See handout.

GRAND TOUR:

Questions

Please feel free to ask?????

Complete Paperwork

Thank you for your time.