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Holland Hospital

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Holland Hospital Orientation for students, contractors and temporary employees Welcome! Mission To continually improve the health of the communities we serve in the ... – PowerPoint PPT presentation

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Title: Holland Hospital


1
Holland Hospital
  • Orientation for students, contractors and
    temporary employees

2
Welcome!
  • Mission
  • To continually improve the health of the
    communities we serve in the spirit of hope,
    compassion, respect and dignity.
  • Vision
  • In partnership with our medical staff, to be the
    pre-eminent stand-alone hospital in West Michigan
    as measured by benchmark customer service,
    business growth, financial performance and
    medical quality.
  • Our Core Values
  • Customer Service Be There
  • Commitment Choose Your Attitude
  • Communication Make Their Day
  • Creativity Play

3
Introduction
  • This presentation is intended to familiarize you
    with procedures and expectations while you are at
    Holland Hospital.
  • The presentation will offer reading material on
    HIPAA, Infection Control and Needle Stick Safety.

4
Instructions
  • Immediately following the slides for HIPAA and
    Infection Control, a quiz will be given. Please
    complete the quiz and then print completed quiz
    (please print only the quiz pages).
  • Complete the Non-Employee Workforce Form and
    Non-Employee Service Provider Acknowledgement
    Form on slides at the end of this presentation
    and then print each.
  • Call Human Resources at (616) 394-3780 to
    schedule a time to meet prior to starting your
    assignment at Holland Hospital.
  • Please remember all required documentation for
    your appointment in Human Resources. Without it
    you may NOT begin your assignment. A checklist is
    provided at the end of this presentation to
    ensure you have all required paperwork.

5
HIPAA Training
  • Self-Study Module

6
HIPPA
  • Directions
  • Review the slide presentation.
  • Complete the HIPAA quiz.
  • Sign the HIPAA quiz. Be sure to print and sign
    your name include the date and your department.
  • Thank you!

7
The HIPAA Privacy Rule
  • What You Need to Know

8
HIPAA
  • What are the possible repercussions to the
  • patient, to you, and to the hospital if
  • confidentiality is broken?

9
What is HIPAA?
  • HIPAA stands for Health Insurance Portability
  • and Accountability Act, passed in 1996. Its a
  • federal law imposed on all health care
  • organizations such as
  • Hospitals, physician offices, home health
    agencies, nursing homes and other providers.
  • HMOs, private health plans and public payers such
    as Medicare and Medicaid.

10
HIPAA Components
  • Portability and Accountability
  • Its original goal was to make it easier for
    people to move from one health insurance plan to
    another as they changed jobs or became
    unemployed.
  • This means they would be able to move their
    medical records and information more easily and
    to get the care they needed.
  • The next component of HIPAA is Administrative
    Simplification. What does
  • this mean?

11
HIPAA Components
  • Another component is Administrative
  • Simplification, intended to do the following
  • Standardize formats, codes and IDs for the
    electronic transmission of health information.
  • Protect the security of electronic health data.
  • Protect the privacy of all health information.

12
HIPAA Components
  • Administrative Simplification
  • Before computerized records, it would have been
    difficult to remove many records and make use of
    this information.
  • Today, with e-mail and electronic storage of
    information, thousands of records can be sent
    virtually anywhere in just a few minutes via a
    computer.

13
HIPAA Components
  • Imagine you wanted to identify patients who
  • had an expensive medical condition in order
  • to discriminate against them. It would take
  • countless hours to use paper records, but with a
  • computer and standardized records, its simple to
  • sort out patients who have expensive illnesses
    and
  • potentially use that information to hurt their
    chances
  • at getting jobs or insurance.

14
HIPAA Privacy Rule
  • HIPAA is the first federal law protecting
    patients privacy and it gives patients certain
    rights to view their own medical records and
    restrict who sees their health records.
  • Key concepts to remember
  • HIPAA punishes individuals and organizations that
    fail to keep patient information confidential.
  • HIPAA gives patients federal rights to gain
    access.
  • So what could happen if a patients
  • privacy is violated?

15
Penalties for Breaking HIPAA Privacy Rules
  • Criminal penalties Maximum of 10 years in jail
    and a 250,000 fine for serious offenses.
  • Civil penalties Maximum fine of 25,000 per
    violation.
  • Facility sanctions
  • See HR Policy 15.5.1.2. Confidential
    Information
  • located on Holland Hospitals internal website.
  • (Could result in suspension or termination.)

16
Penalties for Breaking HIPAA Privacy Rules
  • For instance
  • Knowingly releasing patient information in
    violation of HIPAA can result in a one-year jail
    sentence and 50,000 fine.
  • Gaining access to health information under false
    pretenses can result in a five-year jail sentence
    and 100,000 fine.
  • Releasing patient information with harmful intent
    or selling the information can lead to a ten-year
    jail sentence and 250,000 fine.

17
Penalties for Breaking HIPAA Privacy Rules
  • Civil
  • Civil penalties are fines up to 100 for each
    violation of the law per person, up to a limit of
    25,000 for each identical requirement.

18
Section VII Employment Realities
  • Holland Hospital Standards of Conduct
  • I understand that Holland Hospital employees are
    expected to conduct their duties in a manner that
    meets the highest legal and ethical standards. I
    agree that I will comply with all applicable
    laws, regulations, programs requirements and
    standards of ethical conduct as described in the
    HH Standards of Conduct. I also certify that I
    will report any known or suspected violations of
    these Standards of Conduct to the Corporate
    Compliance Officer immediately and without
    concern for retaliation or retribution for doing
    so.
  • Confidentiality
  • I am aware that authorization to access computer
    systems at Holland Hospital also allows me access
    to confidential information. I certify that I
    understand that it is my responsibility to keep
    in strict confidence all information I encounter
    and will not discuss, disclose or disseminate
    such information to unauthorized persons. I
    specifically understand that information
    regarding patients, employees and individuals
    affiliated with Holland Hospital is not to be
    accessed by individuals who do not have a need to
    know this information. I recognize that
    unauthorized release of confidential information
    may make me subject to civil action under the
    provision of state and federal codes and
    regulations governing the confidentiality of
    patient specific health care information. In
    addition, any such breach of confidentiality will
    be reported to licensing and professional
    organizations as appropriate.

19
Myths about HIPAA
  • When the privacy rule was released, many people
  • worried that hospitals would have to take extreme
  • measures to make sure no one overheard any
  • Protected Health Information (PHI). The
  • Department of Health and Human Services has
  • released statements assuring the health care
  • industry that such actions are not necessary.
  • Lets take a closer look at some of these myths.

20
Myths about HIPAA
  • Myth Hospitals cannot put patient names
  • outside their doors or use white boards.
  • White boards and patient nameplates are
    acceptable as long as a patients health
    information isnt in plain view for someone
    passing by. Problems arise when patients names
    are linked to their conditions. If patients
    names are listed next to their condition on a
    white board, the board must be kept away from
    view.

21
Myths about HIPAA
  • Myth Doctors and nurses can go to jail for
  • honest mistakes.
  • There are certainly serious penalties
    including jail times and huge fines for health
    care workers who intentionally violate patient
    privacy by selling information to a marketing
    company or purposely looking up information about
    patients they're not treating. However, mistakes
    such as accidentally grabbing the wrong file will
    not result in serious sanctions.
  • Now lets look at what information is considered
    confidential information.

22
What is Confidential?
  • Its not just one piece of Protected Health
  • Information (PHI) by itself its two or more
  • pieces of information that might identify a
  • person and their health information a key
  • concept to remember.
  • What are acceptable uses of confidential
    information?

23
Acceptable Uses of Confidential Information
  • Health care providers are permitted to share and
  • disclose Protected Health Information (PHI)
  • - For treatment, payment and health care
    operations a key concept to remember
  • - For other reasons if they obtain permission
    from the patient

24
Treatment, Payment and Health Care Operations
  • Health Care Operations Physicians and
  • quality control directors review confidential
  • information to make sure patients are getting
    good
  • care.
  • All members of the workforce at a hospital
    contribute to the quality of care, but that
    doesnt mean everyone needs to see health
    information about patients. This is termed as the
    Minimum Necessary Requirement.
  • Lets review what this KEY phrase means to you.

25
The Minimum Necessary Requirement
  • HIPAA calls on health care workers to use the
  • minimum amount of patient information they need
  • to do their jobs efficiently and effectively a
    key
  • concept to remember.
  • Ask yourself
  • - Do I need this information to do my job and
    provide good patient care?
  • - What is the least amount of information I
    need to do my job?

26
Do You Need to Know?
  • Coders and billers need to look at certain
    portions of records to code and bill correctly.
  • Housekeeping staff do not need to look at patient
    records at all.
  • If its not for treatment, payment, or health
    care
  • operations, patient authorization is necessary
    to use or disclose Protected Health Information.

27
Authorization
  • Facilities must obtain authorization from
  • patients before using or sharing their Protected
  • Health Information (PHI) for reasons other than
  • treatment, payment or health care operations
  • Reasons include
  • - Research - Some types of fundraising
  • - Marketing - Attorney

28
Authorization
  • Its important that patients understand how they
    can
  • protect their own health information and how
  • providers protect their information. Thats why
    the
  • HIPAA rule requires health care providers to post
  • notices telling patients how their information
    will
  • usually be used.
  • Lets take a look at some common sense ways that
    you
  • can protect patients privacy.

29
Protect Patient Privacy
  • Dont leave patient records lying
  • around.
  • It would be easy for a patient or other staff
    member to look at the papers openly lying on a
    desk or counter.

30
Protect Patient Privacy
  • Do close curtains and speak softly when
  • discussing treatments in semi-private
  • rooms.
  • Be aware of who is around when youre discussing
    patient care, and use common sense to protect
    confidentiality by taking simple steps such as
    lowering your voice or moving to a more secluded
    area of a room.

31
Protect Patient Privacy
  • Do log off the computer when youre
  • finished.
  • When using any computer system that contains
    Protected Health Information, log off when you
    are finished. Do not leave the information
    visible on an unattended computer monitor.

32
Rules for Faxing Patient Information
  • When sending a fax
  • Always use a fax cover sheet.
  • Call intended recipient before sending the fax.
    That way, they will be ready for the fax.
  • Double check the fax number before sending it.
    Its critical when faxing PHI that we do
    everything we can to ensure that the fax is going
    to the right person.
  • If ever in question, ask the manager for
    assistance.

33
Rules for Using Computers
  • Keep your passwords a secret. Although computers
  • have greatly improved the efficiency of health
    care
  • delivery, they have also increased the risk that
  • large amounts of private information could be
    sent
  • to the wrong person, computer or website with one
  • keystroke.
  • For instance, a Midwestern university mistakenly
    posted childrens psychiatric records on a public
    website.
  • Another example, a hospital accidentally revealed
    the names of organ donors to the recipients in a
    computer-generated letter.

34
Rules for Using Computers
  • Do not log into the system using someone elses
    password or computer key. Passwords should never
    be given out, and they should not be written
    down.
  • Passwords and other security features are put in
    place to protect patient information. If you
    share passwords, you may be held responsible for
    another workers inappropriate use of records.

35
Rules for Using E-Mail
  • Do not open attached files from unknown sources
    this may open the door for viruses and hackers.
  • Do not use work e-mail for personal matters.

36
Rules for Using E-Mail
  • Double check the address line of the message
    before you send it to make sure its going to the
    right person.
  • Do not use e-mail to send patients Protected
    Health Information (PHI). Only use the internal
    mail system provided by the Protected Health
    Information program.

37
Patient Rights
  • Patients have the right to
  • View and keep a copy of the facilitys Notice of
    Privacy Practices (this notice will be made
    available at the time of registration).
  • Request restrictions on disclosures of PHI for
    treatment, payment and health care operations.
  • Receive an accounting of disclosures not for
    treatment, payment or health care operations.

38
Patient Rights
  • Patients have the right to
  • Inspect and copy their own health information.
  • Request amendments to information in their
    medical record.
  • Request preferred method of contact.

39
Patient RightsNotice of Privacy Practices
  • This notice will be posted in main patient areas,
    off-site locations and on Holland Hospitals
    internal website.
  • It will be offered to all patients at the time of
    registration and will be available to any
    individual who requests one from Patient
    Relations.

40
Patient Rights Request for Restrictions on
Disclosures
  • Patients must agree to let facilities use PHI for
  • treatment, payment and health care operations,
    but
  • patients can request that they limit the use.
  • For example, a patient knows a lot of Holland
    Hospitals staff personally. He/she may request
    that his/her record not be chosen for quality
    review, or could ask that we do not use or
    disclose information about a previous surgery.

41
Patient Rights Viewing and Copying Information
  • Patients have the right to view and copy their
  • Protected Health Information (PHI). This
  • may include information stored on computer
  • (e.g., their medical and business records).
  • Patients may contact Medical Records for a
  • copy.

42
Patient Rights Requests for Amendments
  • Patients may think the information contained
  • in their medical record is incomplete or
  • inaccurate and may request an amendment
  • for as long as the information is kept by or
  • for the hospital.

43
Patient Rights Patient Directory
  • When patients are at the hospital, they are put
    in the
  • directory so that visitors can inquire about
    them. Patients
  • may opt out of appearing in the directory. If
    they have opted
  • out, no information can be given to the visitor
    or caller. For
  • patients who do not opt out, staff can tell
    visitors or callers
  • who ask for the patient by name the following
  • The patients location in the facility.
  • The patients general condition (e.g., stable,
    good, fair).
  • At the time of registration, the patient will be
    given the option
  • to opt out of the directory.

44
Patient Rights Patient Directory
  • Dont
  • Give out a patients location or condition
    without making sure the patient is listed in the
    directory.
  • Disclose patient information other than location
    and general condition.
  • Say anything about a patient who has opted out of
    the directory, including confirming if the
    patient is here or not.
  • If the patients privacy is violated, you may
    direct the patient to Patient Relations
    (394-3742). You may also call Patient Relations
    if you know or suspect breaches of
    confidentiality.

45
Corporate Compliance
  • The main purpose of the program is to create a
    work culture that is
  • compliant with legal and ethical standards and a
    way for you to
  • anonymously report inappropriate activities
    (e.g., The Corporate
  • Compliance Hotline).
  • Standards are set by authorities such as the
    OSHA, CMS, Medicare,
  • Medicaid, Federal (e.g., HIPAA), state, local
    governments and Holland Hospitals
  • own standards and policies (Standards of
    Conduct).
  • An important part of keeping the trust of our
    patients and our
  • community is to follow the laws and guidelines
    established by outside
  • agencies and our own organization.
  • Example Maintaining patient confidentiality
    and reporting breaches
  • in confidentiality.
  • Compliance is the responsibility of ALL staff
    members, regardless
  • of their positions or job responsibilities.

46
Key Concepts to Remember
  • Minimum necessary HIPAA calls on health care
    workers to use the minimum amount of patient
    information they need to do their jobs
    efficiently and effectively (e.g., for treatment,
    payment and/or health care operations).
  • We have a legal and ethical obligation to protect
    patient privacy and rights.

47
Next Step
  • Complete HIPAA quiz on next two slides.
  • Print off your completed quiz and take to Human
    Resources (make sure to only print the pages
    containing the quiz).

48
HIPAA Quiz
  • The criminal penalties for improperly disclosing
    patient health information can be as high as
    fines of 250,000 and prison sentences of up to
    10 years.
  • True or False
  • Confidentiality and privacy are important
    concepts in health care because
  • They help protect hospitals from lawsuits
  • They allow patients to feel comfortable sharing
    information with their doctors and care providers
  • They help establish trust with the organization
  • All the above
  • Which of the following are some common ways that
    employees protect patient privacy?
  • Looking up your neighbors medical information
    because you are curious
  • Lowering voice when needed
  • Logging off the computer when not using
  • b c
  • Confidentiality protections cover not just
    patients health related information, such as the
    reason they are being treated, but also
    information such as address, age, social security
    number and phone number.
  • True or False
  • Any employee or physician who violates the
    hospital privacy policy is subject to punishments
    up to and including firing or termination of work
    privileges.

49
HIPAA Quiz
  • If you suspect someone is violating Holland
    Hospitals Confidentiality policy(s), you should
  • Say nothing its none of your business
  • Watch the individual involved until you have
    gathered solid evidence against him or her
  • Report your suspicions to your supervisor or call
    Holland Hospitals anonymous Compliance Hotline
    (616) 494-4050 and complete an Occurrence Report
    (orange form)
  • Only employees who care for patients need to be
    concerned with protecting patient privacy and
    confidentiality.
  • True or False
  • HIPAA gives patients certain rights to view their
    own medical records and restrict who sees their
    health records.
  • True or False
  • What kind of personally identifiable health
    information is protected by HIPAAs Privacy Rule?
  • Written
  • Electronic
  • Spoken
  • All the above
  • In addition to regulating your own behavior with
    regard to confidentiality, you are responsible
    for monitoring the behavior of others, including
    physicians, co-workers, volunteers, visitors and
    patients.
  • True or False

50
Infection Control
  • Holland Hospital Infection Control

51
Infection Control Objectives
  • Protect our patients
  • Protect ourselves
  • Protect our coworkers
  • Protect our families
  • Protect our visitors

52
Who and Where is Infection Control?
  • Infection Control is under the Quality Department
  • Located at the 24th Street building
  • Infection Control Medical Director Dr. Shannon
    Walko, D.O.
  • Available on-site, Monday-Friday, 800 a.m.-430
    p.m.
  • Amy Lyons, RN, MS, CIC (ext. 4201)
  • Available by pager 24/7
  • 713-0804

53
Infection Control Questions or Concerns?
  • When you are at the hospital
  • Our policies are located on the hospitals
    internal website. The Infection Control section
    of the Hospital Policies and Procedures is
    Chapter 16. This chapter includes
  • The Bloodborne Pathogen (BBP) Exposure Control
    Plan (16.3).
  • Isolation Policies.
  • If you do not have direct access to the internal
    website, please contact your direct supervisor
    for assistance.
  • OR
  • Feel free to contact the Infection Control
    Coordinator (in person 800 a.m.-430 p.m.,
    Monday-Friday, or by pager 24/7).
  • or
  • The Patient Care Coordinators (PCC) are available
    300 p.m.-730 a.m. daily. The PCC pager number
    is 713-0777.

54
History of the Final Standard
  • December 6, 1991 Federal Register is where the
    final standard was originally published.
  • It was created due to complaints of federal
    unions for their health care employees.
  • Michigan OSHA and Federal OSHA BBP
    Standards are both available at any time
    by contacting infection control coordinator.

55
What are Bloodborne Pathogens?
  • Human Immunodeficiency Virus (HIV)
  • Hepatitis B
  • Other bloodborne diseases include
  • Hepatitis C

56
High Risk Fluids for Bloodborne Pathogens
  • Blood
  • Blood by-products
  • Unfixed tissue or organs
  • Semen
  • Vaginal secretion
  • Amniotic fluid
  • Cerebrospinal fluid
  • Peritoneal fluid
  • Pleural fluid
  • Pericardial fluid
  • Synovial fluid
  • Saliva in dental procedures
  • Any body fluid visibly
  • contaminated with blood
  • Any body fluids which are
  • difficult or impossible to
  • differentiate from body fluids

57
Hepatitis B
  • Etiologic agent Hepatitis B virus
  • Clinical Features jaundice, fatigue, abdominal
    pain, loss of appetite, intermittent nausea,
    vomiting
  • Transmission bloodborne, sexual and perinatal

58
Hepatitis C
  • Hepatitis C is a liver disease caused by the
  • Hepatitis C virus (HCV) which is found in the
  • blood of persons who have this disease.
  • The infection is spread by contact with blood
  • of an infected person.

59
How Serious is Hepatitis C?
  • Hepatitis C is unpredictable it can be serious
    for some and not for others.
  • Most people who get infected carry the virus for
    the rest of their lives.
  • Complications from chronic Hepatitis C can
    include cirrhosis, which can lead to liver
    failure later in life.

60
Risk Factors Associated with the Transmission of
HCV
  • Transfusion or transplant from infected donor
  • Injecting drug use
  • Hemodialysis (years on treatment)
  • Accidental injuries with needles and sharps
  • Sexual/household exposure to anti-HCV-positive
    contact
  • Multiple sex partners
  • Birth to HCV-infected mother

61
Hepatitis C Virus is NOT Spread by
  • Breast feeding
  • Sneezing
  • Hugging
  • Coughing
  • Sharing eating utensils or drinking glasses
  • Food or water
  • Casual contact

62
Human Immunodeficiency Virus (HIV)
  • AIDS is caused by the human immunodeficiency
    virus (HIV).
  • As of December 2001, Center for Disease Control
    has received reports of 57 documented cases and
    138 possible cases of occupationally acquired HIV
    infection among health care personnel in the
    United States since reporting began in 1985.
  • The average risk of HIV infection after a
    needle-stick injury or cut exposure to HIV
    infected blood is 0.3 (1 in 300). Stated another
    way, 99.7 of needle-stick/cut exposures do not
    lead to infection.
  • Reference Exposure to Blood from CDC published
    in July 2003

63
HIV Transmission
  • Sexual
  • Perinatal
  • Blood to blood exposure
  • Blood to mucous membrane exposure
  • It is NOT spread by
  • Casual contact or through insect bites or stings

64
Where is the Bloodborne Pathogen Exposure Control
Plan?
  • The Exposure Control Plan is located on
  • the hospitals internal website under
  • Chapter 16.
  • If you do not have direct access to the
  • hospitals internal website, please contact
  • your direct supervisor for assistance.

65
What is Contained in the Exposure Control Plan?
  • Risk classification of all jobs within the
    organization
  • Types of personal protective equipment are to be
    utilized and when
  • Defines standard precautions
  • Blood and body fluid exposure follow-up
  • Biohazard signage or color coding
  • Hand hygiene

66
Hepatitis B Vaccine Did You Know?
  • Three injection series given first injection
    one 30 days later and then five months following
    the second injection.
  • 90 percent will develop serum antibodies.
  • Antibody testing should occur six weeks to three
    months following last injection.
  • If an employee of a health care facility that
    requires Hep B chooses not to participate upon
    employment, they must sign a formal declination
    and may choose later to receive injections.

67
Regulated Waste
  • Medical waste was discovered on the Lake
  • Michigan shore in 1988 which led to the
  • enactment of the Medical Waste Regulatory
  • Act of 1990. This act controls the handling,
  • storage, treatment, transportation and
  • disposal of medical waste from its
  • generation to ultimate disposal.

68
Biohazard Labeling
69
Medical Waste Labeling
  • Warning labels are affixed to containers of
    regulated waste, refrigerators and freezers that
    contain blood body fluids and containers that
    are used to store or transport blood or body
    fluids.
  • Red bags or red containers may be substituted for
    labels.
  • Laundry is NOT medical waste and is never placed
    in a red bag.

70
What to Do in Case Of a Blood or Body Fluid Spill
  • Always wear the personal protective equipment
    appropriate to the size of the spill.
  • Never pick up glass fragments by hand always use
    dustpan and broom or forceps, etc.
  • Absorb fluid with either absorbent towels or
    powders.
  • Area must be disinfected with approved
    disinfectants.
  • Housekeeping will assist during hours 0600 to
    midnight. After hours, a spill kit located in the
    housekeeping closets or soiled utility rooms.

71
Other Information
  • Personal protective equipment
  • Available in clean storage rooms, isolation carts
  • Goggles available in clean storage areas
  • Disinfectant wipes available for reusable
    equipment (stethoscopes, glucometers, etc.)
  • Located on isolation carts and dirty utility rooms

72
Blood or Body Fluid Exposure
  • If you get a needlestick or blood or body fluid
    exposure
  • Wash area with soap and water (exception eyes or
    mouth use only water).
  • Notify the Infection Control Coordinator or
    Patient Care Coordinator
  • Page either the Infection Control Coordinator
    (713-0804) or Patient Care Coordinator
    after-hours (713-0777)
  • Complete necessary paperwork (available through
    Infection Control Coordinator/Patient Care
    Coordinator)
  • Employee illness and injury report (ask
    supervisor for report)

73
What Happens if You Have a Bloodborne Pathogen
Exposure?
  • If we know whose blood you were exposed to
  • Lab draws for HIV/Hepatitis B and C on that
    person (not you).
  • We notify you of their HIV results that day.
  • The hepatitis labwork comes back within a week.
  • If we do not know the source of the blood
  • We will send you to either Med 1 or ED
    (after-hours) immediately for care
  • You may be offered testing
  • Determine risk
  • Consultation on meds and treatment options

74
Our Isolation Procedures
  • Standard Precautions
  • Transmission-Based Precautions
  • Contact
  • Contact-PLUS
  • Droplet
  • Airborne
  • Neutropenic
  • Not CDC based precaution

75
Standard Precautions Use on Every Patient, Every
Time
  • Standard precautions must be followed even
  • if transmission-based (the colored signs)
  • isolation is in place.

76
Our Transmission-Based Isolation Signs
77
Contact Isolation
  • Yellow sign
  • Any contact with patient or objects that patients
    may have contact will spread these organisms
  • Equipment
  • Gloves
  • Gown
  • Diseases
  • C.difficile
  • Scabies
  • Lice

78
Contact Plus
  • Green sign
  • (Not officially a Center for Disease Control
    transmission-based precaution)
  • Other health care facilities will not use this
    term. Specific only to Holland Hospital.
  • Any contact with patient or objects that patients
    may have contact will spread these organisms
  • Equipment needed
  • Gown and gloves
  • Surgical mask if within three feet of the patient
  • Diseases
  • MRSA and VRE

79
Droplet
  • Orange sign
  • Equipment needed
  • Surgical mask within three feet of the patient
  • Diseases
  • Influenza
  • Pertussis
  • Bacterial meningitis

80
Rules for the N-95 Respirator Mask
  • Disposable
  • Can be used up to 8 hours if not soiled or
  • misshapen for TB.
  • Exception use only once and replace during a
    pandemic flu, SARS, etc.
  • Store the mask
  • Paper bag
  • Label with your name on the bag or elastic strap

81
Airborne Isolation
  • Red sign
  • Need a negative-pressure room
  • Both doors (inner and outer) must remain closed.
  • Bioengineering must inspect airflow daily when
    patient present.
  • Equipment needed
  • N-95 respirator mask
  • Diseases
  • Tuberculosis
  • SARS/Avian Flu
  • Chicken Pox/Measles

82
Neutropenic Precautions
  • Neutropenia is a blood condition in which the
    patient white blood
  • cells are abnormally low. Patients with
    neutropenia are more
  • susceptible to bacterial infections.
  • Blue sign (does not state neutropenic since this
    is a diagnosis).
  • A mask is required if you are going to be within
    three feet of the patient.
  • Good hand hygiene!

83
Handwashing
  • Handwashing remains the cornerstone of all
    preventative measures. Our policy Hand Hygiene is
    16.3.3. (If you do not have direct access to the
    hospitals internal website, please contact your
    direct supervisor for assistance.)
  • Our policy is Wash in Wash out!
  • Handwashing with soap and water is ideal
    however, in times when these are not available
    waterless degermers are acceptable.
  • 10-15 seconds of scrubbing in order to be most
    effective.
  • Lots of hand jewelry and very long nails can
    harbor germs, puncture gloves and get in the way
    of good handwashing.
  • Only Holland Hospital hand lotion may be used.

84
Handwashing The 1 Way to Maintain Infection
Control
  • Soap and water
  • Visibly dirty, soiled (with or without gloves)
  • Feel sticky, sweaty or dirty
  • After using the restroom
  • Before eating
  • Alcohol-based waterless hand sanitizer
  • Before/after contact with patients
  • Before/after putting on gloves
  • If moving from a contaminated body area to a
    clean area
  • After touching dirty or contaminated
    environmental surfaces

85
For Questions or Concerns
  • Please contact Infection Control at 494-4201 or
    pager 713-0804 (24/7).
  • After business hours or on weekends, for
    in-person assistance the Patient Care Coordinator
    (PCC) can assist you.

86
Next Step
  • Complete the Infection Control Quiz on next four
    slides.
  • Print off your completed quiz and take to Human
    Resources (make sure to only print the pages
    containing the quiz).

87
Infection Control Quiz
  • Circle the best answer
  • TRUE FALSE Standard precautions apply to all
    patients with any diagnosis.
  • TRUE FALSE Hand washing is not required
    between patient contacts if you wear good quality
    gloves.
  • TRUE FALSE Hand hygiene is the most important
    defense against the spread of infection.
  • TRUE FALSE Infection Control policies and
    procedures are located on Holland Hospitals
    internal website under Policies and Procedures,
    Volume 16.0.
  • TRUE FALSE Patient care equipment can be a
    source of infection for the patient and the staff.

88
Infection Control Quiz (page 2)
  • TRUE FALSE Report an exposure incident at
    least two days after it happens.
  • TRUE FALSE If you dont work directly with
    patients, you dont need to be concerned about
    infection control.
  • TRUE FALSE Report an exposure incident by
    sending an e-mail message to Infection Control.
  • TRUE FALSE Contact precautions prevent the
    spread of pathogens through physical contact.
  • TRUE FALSE Tuberculosis is a disease that
    requires airborne precautions in a negative
    pressure room (a room with an ante-room).

89
Infection Control Quiz (page 3)
  • TRUE FALSE A regular surgical mask can be
    worn when entering a room of a known or suspected
    tuberculosis patient.
  • TRUE FALSE When a TB patient is cared for in
    a negative pressure room, only the inner door of
    the ante-room needs to be kept closed.
  • TRUE FALSE When a patient requires airborne,
    droplet, or contact precautions, you dont need
    to follow standard precautions.
  • TRUE FALSE Lots of hand jewelry and very long
    nails can harbor germs, puncture gloves and get
    in the way of good hand washing.
  • TRUE FALSE Alcohol-based hand rubs can be
    used for hand hygiene instead of soap and water
    hand washing, unless hands are visibly soiled.

90
Infection Control Quiz (page 4)
  • TRUE FALSE Infection Control is everyones
    shared responsibility.
  • Employee Signature_____________________________
  • Date________________
  • Print Name_______________________________________
    _______
  • Department/Job Title_____________________________
    _________

91
Once Slide Orientation is Complete
  • Complete the Non-Employee Workforce Form and
    Non-Employee Service Provider Acknowledgement
    Form on the following slides.
  • Print both of the above documents.
  • Call Human Resources at (616) 394-3780 to
    schedule a time to meet prior to starting your
    assignment at Holland Hospital.
  • Please remember to return all required
    documentation for your appointment to Human
    Resources. Without it you may NOT begin your
    assignment.

92
Non-Employee Workforce Form
  • Name
  • Position
  • Address
  • Phone
  • Licensure or certification type (if applicable)
  • Licensure or certification number (if
    applicable)
  • Department you will be working
  • Reporting to
  • Assignment start date
  • Assignment end date
  • Employer/school
  • Employer/school contact
  • Employer/school phone
  • Please circle type of provider
  • Student/Instructor Contract-Clinical Contract
    Non-Clinical

93
Non-Employee Service Provider Acknowledgement Form
  • Confidentiality Statement
  • I realize that in the course of my work at
    Holland Hospital, I may be exposed to
    confidential patient health information. I
    understand that I have no right or ownership
    interest in any confidential information.
    Additionally, I will limit my exposure to
    confidential patient health information and will
    treat this information, regardless of how it was
    obtained, with utmost discretion.
  • I am required to conduct myself professionally
    and in strict compliance with applicable laws
    including, but not limited to, the Health
    Insurance Portability and Accountability Act of
    1996 and Holland Hospital policies governing
    confidential information. I understand that a
    breach in confidentiality may result in immediate
    discontinuation of our agreement and/or legal
    action against me and/or the business I
    represent.
  • I recognize that unauthorized release of
    confidential information may make me subject to
    civil action under the provisions of State and
    Federal codes and regulations governing the
    confidentiality of patient-specific health care
    information. In addition, any such breach of
    confidentiality will be reported to licensing and
    professional organizations, as appropriate.

94
Non-Employee Service Provider Acknowledgement Form
  • Acknowledgement
  • I have reviewed the Non-Employee Service Provider
    Safety Information Sheet or the "What You Need to
    Know" booklet and agree to comply with all
    Holland Hospital policies and procedures.
  • Service Provider Name (please print your
    name)___________________________________________
  • Department/Unit__________________________________
  • Your signature___________________________________
  • Last four digits of Social Security
    Number_________
  • Print this page and take to Human Resources.

95
IMPORTANT
  • Please take the following with you for your
    appointment in
  • Human Resources. You MUST have all required and
  • completed paperwork prior to starting at Holland
    Hospital.
  • Non-Employee Workforce Form
  • Non-Employee Service Provider Acknowledgement
    Form
  • Completed HIPAA Quiz (print once completed)
  • Completed Infection Control Quiz (print once
    completed)
  • TB test results within one year
  • Immunization records or records of Hepatitis
    History Titer, MMR Titer, Varicella Titer
  • Current CPR for all clinical positions
  • Other documentation may be required for certain
    positions

96
You Are Finished!!
  • Checklist to bring to Human Resources
  • Current TB Test
  • Record of Immunizations
  • CPR (if applicable)
  • Current licensure/certification (if applicable)
  • Printed Non-Employee Workforce Form
  • Printed Non-Employee Service Provider
    Acknowledgement Form
  • Printed HIPAA Quiz
  • Printed Infection Control Quiz
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