Abbreviated Orientation for Preceptor Students Observers Surgical Shadows

Abbreviated Orientation for Preceptor Students, Observers, Surgical Shadows, Mentorship Students and Other Selected Personnel

There are instances when visitors to CCH need a cursory understanding of some of our legal and safety policies and procedures. Instances of this include: n n Preceptor Students Observers Students shadowing in Surgery Mentorship/Intern students This training and the accompanying forms are intended to give you this understanding.

The following slides will provide information: n Compliance n HIPAA n Hand Hygiene n General Safety n Patient Safety Goals

After exiting this presentation you will need to access, print & complete the following forms: n n n Student/Observer Information Sheet CCH Orientation Competency Hand Hygiene/Safety Certification The completed forms should be returned to: Reye Snitily Education Coordinator Columbus Community Hospital PO Box 1800 Columbus, NE 68602 -1800

Compliance Program

“It Just Makes Good Sense!” Columbus Community Hospital, Inc. (CCH) believes in maintaining a high level of professional and ethical standards in the conduct of its business. We work hard to foster ethical conduct and to provide guidance to each employee for his/her conduct. CCH wants to provide a tool for all employees to use in striving to comply with legal and regulatory requirements, and to seek to prevent and detect unlawful and unethical conduct. An effective Compliance Program is just such a tool, which is reasonably capable of reducing the prospect of unlawful conduct and unethical business practices

What is the CCH Compliance Program? The CCH Compliance Program is a comprehensive process created to ensure that CCH and its employees consistently comply with applicable laws relating to business activities. Many industries have used formal compliance programs for several years -- banking, insurance and the defense industry, to name a few. It is a process and not a document or a bundle of policies and procedures. It has the commitment of the CCH Board of Directors, management and all employees to make it work

Why does CCH need a Compliance Program? CCH has established a Compliance Program because it makes good business sense, and because it is “the right thing to do. ” The complexity of participating in a variety of government and private programs has imposed an extraordinary burden on CCH, and the potential for error is significant. CCH is committed to following appropriate requirements. The ultimate goal of the CCH Compliance Program is to help employees, managers, and governing body simply do a better job, as well as to identify and prevent improper conduct. CCH employees should aggressively attempt to deter, detect, and correct improper conduct by other employees or managers.

What are the benefits of the CCH Compliance Program? Having a Compliance Program at CCH benefits us in many ways. Among the benefits are to: n n n n Demonstrate to employees and to the community our commitment to being an honest, ethical and responsible provider; Identify and prevent criminal and unethical conduct; Improve the quality of patient care; Create a centralized source for distributing information on health care statutes and regulations; Develop a methodology that encourages employees to report potential problems; Develop procedures that allow the prompt, thorough investigation of alleged misconduct; and, Initiate immediate and appropriate corrective action as necessary.

What do I need to do if I suspect improper conduct? CCH expects employees to act in an honest, ethical and responsible manner. But should a dilemma arise, we have developed a process to help guide you if you are ever in doubt about the proper conduct in a given situation. Step 1 n Use existing CCH policies and procedures within your department to resolve the problem yourself, or contact your immediate supervisor. Step 2 n If you are not satisfied with your supervisor’s response, contact your department head. If your immediate supervisor is a department head, then contact the Senior Manager that your department head reports to. Step 3 n If you are not satisfied with the results of Steps 1 or 2, or if you are not comfortable addressing your concerns through those channels, contact the CCH Compliance Officer though a written memo, a telephone call, or in person. The Compliance Officer is the Director of Quality Improvement, Penny Barels, who can be reached by calling 562 -3345. Memos can be sent through interoffice mail to the Quality Improvement Director. Step 4 n If you are not comfortable addressing your concerns through the above channels, you can report your concern anonymously through the Compliance Suggestion Box. The Compliance Suggestion Box is found by the employee information bulletin board outside the cafeteria.

What happens after I identify my concern through the Compliance Suggestion Box? Once you have followed Steps 1, 2 and 3 of the aforementioned process, drop your concern in the Compliance Suggestion Box. The Compliance Officer will retrieve the information and will address the concern(s) identified. The Compliance Officer will conduct an investigation if one is warranted, will compile a report, and when appropriate, ensure corrective action is taken. The status of the investigation will be provided to you by the Compliance Officer, if you choose to identify yourself.

Do I have to give my name? No. You may report suspected violations through the Compliance Suggestion Box without disclosing your identity, if you choose. You must give your name however, if you wish to be contacted by the Compliance Officer regarding the status of your report.

Will I suffer any retaliation for making a report? No employee will be subject to retaliation in any form for reporting a possible noncompliance issue, pursuant to hospital policy. Persons reporting compliance issues will be protected up to the limits of the law and to the extent reasonably possible.

What kind of behavior should I report? You should report any instance in which you are aware of behavior that you suspect is illegal or which violates the CCH Compliance Program or any CCH policy and procedure. Some specific issues that are of special concern to CCH are: n n n n Patient Rights and care issues; Privacy rights and employee and patient records; Health, safety and environmental issues; Medicare/Medicaid fraud and abuse; Harassment/Discrimination issues; Substance abuse; Bribes and kickbacks; n n n n Theft and fraud; Antitrust law violations; Proper accounting and record keeping; Billing; Potential criminal violations; Confidentiality of hospital information; and, Other violations of hospital policy.

How would I respond to a government investigation? Any CCH employee receiving a subpoena, inquiry or other legal document in regard to CCH business, should immediately notify their supervisor and hand carry the document to the CCH Compliance Officer (or in the Compliance Officer’s absence, the hospital President/CEO, or a member of Senior Management). The Compliance Officer will assist you in following the proper procedures for cooperating with the investigation.

HIPAA

Health Insurance Portability and Accountability Act of 1996. Intended to: n “improve the efficiency and effectiveness of health information systems, establish standards and requirements for electronic transmission of health information and protect the confidentiality, integrity and availability of individual health information” n affects many different entities such as physician offices, hospitals, health plans & health care clearinghouses

PRIVACY n Privacy is the individual’s right to control access and disclosure of his or her protected health care information. n Protected Health Information is considered paper, electronic & oral.

PRIVACY NOTICE Must be provided to all Patients regarding the use & disclosure of all individually identifiable patient health information. n Must be made available prior to or at the time of treatment. n Must be posted in a clear & prominent location within the hospital facility service areas. n

CONTENT OF NOTICE n n n Must contain description of uses & disclosure that a hospital will make for treatment, payment & health care operations. Descriptions of other uses & disclosures that a hospital is allowed to make without a patient’s explicit authorization. Statement that other uses & disclosure will be made only with patient’s written authorization & that such authorization can be revoked at any time. n n n Patient may complain to the hospital and to the HHS Secretary if they believe their privacy rights have been violated Notice must contain description of how to file such a complaint with hospital That the patient will not be retaliated against for filing such a complaint Name or title & telephone number of a person to contact for further information Effective dates of the notice

PATIENT RIGHTS n n n The right to confidential communication The right to see medical record The right to obtain a copy of the record The right to amend medical record The right to know who has had access to their records (which requires the hospital to keep an accounting of all disclosures)

HOSPITAL DIRECTORY n Upon Admission, Patient will be asked if they wish to be part of Hospital Directory. If so the hospital: n n May disclose patient’s location in the hospital if asked for by name May disclose general condition to any person who asks about the individual by name May disclose the patient’s name, location, general condition and religious affiliation to members of the clergy If the patient chooses not to be part of the Hospital Directory, the arm band on the patient will be marked with a YELLOW sticker.

TREATMENT, PAYMENTS & HEALTH CARE OPERATIONS CCH may disclose PHI for treatment, payment & health care operations. Treatment: n Furnishing preventative, diagnostic, therapeutic, rehabilitative maintenance or palliative care. Payment: n. Preparing or submitting claims, obtaining certification of enrollment or coverage, obtaining precertification for treatment, pursuing collection through an attorney or collection agency, etc. Health Care Operations: n Quality assessment activities, utilization review, peer review activities, conducting audit functions, medical reviews and business planning.

REQUIRED DISCLOSURES ALLOWED WITHOUT PRIOR AUTHORIZATION We are still required to disclose health information in certain situations without an authorization: n n n State Tumor Registry Birth Certificates Congenital anomalies Public Health Activities Victims of Abuse, Neglect or Domestic Violence Health Oversight Activities Judicial & Administrative Proceedings Law Enforcement Purposes To Avert a Serious threat to Health or Safety About decedents to coroners, medical examiners & funeral directors Cadaveric organ, eye or tissue donation

MINIMUM NECESSARY n n Hospital must implement reasonable procedures to ensure that only the minimum protected health information is used, disclosed or requested when conducting necessary payment activities and health care operations. We have looked at all of our internal and external users and identified all PHI needed for each person to perform their job function and what access they may have. Physicians, nurses and all ancillary services are permitted unrestricted access to protected health information for the purpose of providing patient care. This unrestricted access is only for the time the patient is being treated. All other requests for access must be through the Medical Records Department. n n n § Limited access, with supervision, will be given to departments like admissions, billing, accounts payable, dietary clerks and SPD for billing of implants. Unrestricted access, based on official inquiry, will be granted to Risk Management, QI, CEO & Vice Presidents. UR will have unrestricted access up to 48 hours after discharge. Requests for “any and all records” will not be honored. The requesting party will be contacted to determine the specific information needed. Routine or recurring disclosures are limited to information necessary.

ADMINISTRATIVE REQUIREMENTS The hospital and medical staff has developed an Organized Health Care Arrangement (OCHA) under which we can carry out health care operations such as quality improvement review, utilization review, etc without a Business Associate Contract. n Additionally we have: n n n n Designated a Privacy & Security Officer Designated a contact person or office to receive complaints Provided training for all employees who handle PHI Provided training to each new member of the workforce within a reasonable period of time after start date Documented that the training has been provided Ensured that appropriate administrative, technical and physical safeguards must be in place to protect the privacy of PHI. Provided a process for individuals to make complaints concerning the hospital policies and procedures Documented all complaints received and their disposition

SANCTIONS & REPORTING OF INVESTIGATIONS § Employees who violate CCH’s HIPAA Compliance Plan are subject to discipline administered according to policies adopted by the Personnel Department. The following are considered serious offenses under the HIPAA Plan and may result in immediate discipline, up to and including termination: § § Sharing a password or identity with another person or obtaining information under false pretenses. Accessing or disclosing protected health information contrary to CCH’S policies, for personal gain or for other personal benefit or motive. n n n Disclosing protected health information when the workforce member knew or should have known that he or she had no authority to do so. Failure to make a mandatory report. Retaliating against a patient because the patient or someone on the patient’s behalf has filed a complaint with DHHS Retaliating against a member of the workforce who has made a mandatory or permissive report. Failure to complete and document required training.

Penalties for person who knowingly and in violation of the law obtains or discloses individually identifiable health information: Civil Penalties n $100 per violation, up to $25, 000 per year for all violations of identical requirement. n No Civil Penalty if: n Punishable under criminal provision n Person did not know or by exercising reasonable diligence would not have known, that he or she violated the provision n Failure due to reasonable cause not result of willful neglect and corrected within 30 days Criminal Penalties n Fine $50, 000 and one year prison n If offense committed under false pretenses, fine $100, 000 and five years in prison n If offense committed with intent to sell, transfer or use individually identifiable health information for commercial advantage, personal gain, or malicious harm, fine $250, 000 and ten years in prison n Enforcement will be carried out by the Office of Civil Rights, DHHS.

REPORTING AND INTERNAL INVESTIGATIONS Members of the workforce with first hand knowledge of the facts are required to report their knowledge or belief that: n n There has been a violation of HIPAA or a breach of CCH’s HIPAA Compliance Plan. There has been an improper use or disclosure of protected health information. n n There will be a locked box available by the employee entrance, that concerns may be placed in, if you do not want to report directly to the Privacy Officer. It would be helpful to know who is reporting the concern to help in any investigation that may need to be carried out, but it can be anonymous. No promises will be made by the Privacy Officer, to the workforce member making the report, as to what steps may be taken in response to the report. Any member of the workforce making a report shall be protected from retaliatory action.

CODE WHITE This is a verbal code to be used when an employee observes that an inappropriate discussion is going on in the hallways, cafeteria, etc.

Hand Hygiene

Hand Hygiene Program Essentials n n n Handwashing is essential when hands are visibly soiled Alcohol based hand rubs are effective for routine decontamination Do not wear artificial fingernails in high risk areas (ICU and Surgery) Keep natural nail tips less than ¼ inch long Wear gloves when in contact with potentially infectious material Be alert for educational Hand Hygiene updates

General Safety

We at CCH believe that Safety is the responsibility of each and every employee, student & volunteer The level to which you participate in our Safety Plan determines how safe we are! If you have Safety questions or concerns, please contact – Sara Hough, Risk Manager, 402 -562 -3361 Remember – you are the eyes & ears of the hospital!

Hospital Safety Codes n n n n n CODE BLUE - Patient in arrest STANDBY CODE BLUE – Ambulance en route with patient in arrest CODE BLUE BROSLOW – Pediatric arrest SECURITY TO …. STAT – violent or abusive person in reported area DR. LOUISIANA – A life is being threatened with a weapon, all move to a “safe” area PLAN 100 – Employee Recall DR SEARCH – Missing patient CODE PINK – Baby missing or abducted DR. WATCH – Weather conditions favorable for a tornado TORNADO WARNING – Tornado sighted in Platte County

Paging n To Page – pick up any phone n dial 699 *2 n then n speak into receiver To call Police n Dial 911

What is the code announcement for Fire Drills?

FIRE SAFETY n In the event of a fire “Dr Red …” and an area will be announced three times on the overhead paging system. n During Dr. Red, all employees should be available in their work area. One person from each area should be designated to report (with fire extinguisher if available) to fire area to provide assistance. n All doors and windows should be closed and remain closed until the all clear is given. n Use stairways and NOT ELEVATORS. Only go through fire doors if it seems safe to do so. n

Please remember: n n It takes less than a minute to empty most fire extinguishers You should only attempt to put out small fires if you have been properly trained and have a clear escape route You should know the location of all Oxygen shut off values. Nurses will be responsible for turning off the valves in patient care areas. Always leave yourself a way out! Keep your back to a safe exit.

Remember RACE and PASS n n R – Rescue people in immediate danger A – Activate alarm – pull nearest fire alarm. Alarms are located by each exit. C – Confine the fire – Close all doors and windows E – Extinguish the fire or escape n n P – Pull fire extinguisher pin A – Aim at the base of the fire. S – Squeeze the handle S – Sweep the hose from side to side

Levels of Evacuation: n Out of the immediate area n Horizontally n Vertically – beyond fire doors – floors below fire

RADIATION SAFETY n This is the internationally recognized warning symbol for radiation. Signs with black or magenta printing on a yellow background will be posted in areas where radiation is used or stored. n Packages containing radioactive materials will also have labels with this symbol. n When you see this symbol: n Do not enter the designated room unless you have been trained to do so. n Do not handle a package with this symbol unless you have been trained in how to handle radioactive materials

Tornado Safety DR WATCH n Announced on overhead page three times when weather conditions are favorable for a tornado. Start preparations for evacuation, remember where safe areas are. CCH South and Medical Office Building will be notified of Dr. Watch. Once notified of Dr. Watch, personnel shall turn on radio and listen for updated weather conditions. TORNADO WARNING n n Announced on overhead page three times when a tornado is sighted in the Columbus vicinity. Staff shall immediately move patients and visitors to safe area, close all doors to patient rooms and offices and take cover. If “sheltering in place” is required, patients shall be given a blanket and pillow. Hospital personnel will remain with patients until all clear is given. Available staff should report to patient care areas to assist with evacuation.

Disaster Plan When notice of an event is received. The House supervisor/ER charge nurse will confer with the Pres/VP. A decision may be made to implement the Hospital Emergency Incident Command System. Need for Additional Employees n Every department has a Plan 100 call list to use when additional staff are needed. n Employees must be familiar with the location of their Re- Call List. n After receiving a call, employees must call the next person or continue to call down the list until they contact someone. n Report to the North Employee Entrance with their picture ID name badge as soon as possible.

Disaster Plan n The Plan establishes specific areas for: Disaster Headquarters n Personnel Pool n Entrances n Triage Areas n Treatment Rooms n Family Waiting Area n

BOMB THREAT Procedure for Phone Call Warning: n Document current time n Keep caller on the phone as long as possible n Have co-worker call CEO/Designee immediately from another phone n Listen for and note any identifying background noises n Document any special voice characteristics n Ask and note location of bomb and what time it will go off n Document if caller indicates knowledge of the hospital by description of location

BOMB THREAT Once notified of a Bomb Threat: n n n Unit Director Hospital Administration Columbus Police Department will be notified and appropriate action taken. If suspicious items are noted, n n DO NOT TOUCH THEM, notify Administration and clear the area. Bomb experts will be on their way to assist with the situation. Security or Plant Operations personnel will secure all entrances and restrict entry to only those employees presenting appropriate disaster identification. All Department Heads will report to Administration for information and instructions.

Electrical & Utility Safety n In the event of loss of any utility such as phones, elevator or electricity, dial the operator. The operator will page the on-call plant operations personnel. In the event of electrical failure, all equipment plugged into a red outlet will be supplied power from our Emergency Generators. n ALL ELECTRICAL EQUIPMENT is to be checked and tagged by Plant Operations. (Send Form MA-1 New Equipment Check In Form to Plant Operations. ) n Patient owned electrical devices must also be checked by Plant Operations prior to use. Unacceptable patient equipment should be given to a family member to take home. n Employee owned electrical equipment (coffeepots, cup warmers, radios, etc. ) must also be checked by Plant Operations prior to use

Electrical & Utility Safety TO AVOID BURNS, SHOCKS AND FIRES n Do Keep floors and other patient areas dry n Do Check power cords and plugs for damage BEFORE plugging them in. n Don’t use any equipment that sparks or smells. n Don’t roll equipment over power cords n Don’t use any clinical equipment that has an expired or missing BIOMED Inspection Sticker

Hazardous Materials n Haz. Com, (OSHA’S Hazard Communication n Chemical manufacturers have determined the physical and health hazards associated with each product they make. They label products with this information and supply Material Safety Data Sheets (MSDS). n MSDS information is accessed “on-line” by your department director. Standard) requires employers to provide information, training and equipment to employees to ensure on the job safety. Employees are required to use this information to remain healthy and work safely.

In Case of Chemical Exposure or Accident: n Follow appropriate first aid procedure for type of exposure: n n Splash - Flush eyes with water for 15 minutes. Know where the eye flushing stations closest to you are at. Burn - Remove contaminated clothing immediately, wash exposed skin for at least 15 minutes. Follow-up with immediate treatment in the Emergency Room. Inhalation- move to fresh air immediately Notify a Supervisor ASAP. Contact Occupational Health during business hrs or ER for “on call“ Occ Health staff

Hazardous Material Spills n n n Clear area where spill is located. Locate MSDS for spill. Spill Kits are located: n n Omnicel ACU – west Omnicel ER Dirty Utility Room n n n ACU SNU OB All Housekeeping Carts Pharmacy

Proper Disposal of Hazardous Waste – Red Bags n n n n All items that are blood soaked Amniotic Fluid that surrounds the brain, spine, heart and joints Fluids in the chest and abdomen Vaginal secretions Any other fluids that may contain blood but blood is not visible Hemovac drains and suction canisters Blood bags and tubing Hemodialysis tubing Soiled and/or bloody dressings Bloody syringes without the needle Chest tubes Isolation bagging out

Proper Disposal of Regular Waste n n n n n All items that do not contain blood Boxes Wet diapers Plastic medication bottles Dirty Kleenex Used papers Foley bags Food containers Wrappers IV bags and tubing

What would you dial if you needed immediate assistance?

Security n All employees are required to wear their picture ID and name badge for identification purposes. This is a key element in maintaining security within the buildings and on campus grounds. n A Security Service provides surveillance of the hospital and grounds during their scheduled hours 6: 00 pm to 6: 00 am M - F and 24 hrs on weekends. To contact the guard call #333

Security Sensitive Areas: n Closed circuit cameras are operating 24 hr/day in the following areas: ER, n Front lobby, n South corridor, n Dock, n OB, n Pharmacy n South site. n

“Security To …. STAT” (699*2) n Use the overhead paging system when you need immediate assistance for a combative or abusive patient, visitor or staff member. Employees from specific areas will respond to assist and support. n Dial 911 if you feel the situation is dangerous and police intervention is necessary.

Patient Safety Goals

Thank You! We hope your experience with CCH is a Safe and productive experience! After exiting this presentation please remember to access, print & complete the following forms: n n n Student/Observer Information Sheet CCH Orientation Competency Hand Hygiene/Safety Certification The completed forms should be returned to: Reye Snitily Education Coordinator Columbus Community Hospital PO Box 1800 Columbus, NE 68602 -1800