Abbreviated Orientation for Preceptor Students, Observers, Surgical Shadows, Mentorship Students and Other Selected Personnel - PowerPoint PPT Presentation


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


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

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
  • 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
  • Compliance
  • Hand Hygiene
  • General Safety
  • Patient Safety Goals

  • After exiting this presentation you will need to
    access, print complete the following forms
  • 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

(No Transcript)
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
  • 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
  • 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
  • Having a Compliance Program at CCH benefits us in
    many ways. Among the benefits are to
  • Demonstrate to employees and to the community our
    commitment to being an honest, ethical and
    responsible provider
  • Identify and prevent criminal and unethical
  • Improve the quality of patient care
  • Create a centralized source for distributing
    information on health care statutes and
  • Develop a methodology that encourages employees
    to report potential problems
  • Develop procedures that allow the prompt,
    thorough investigation of alleged misconduct
  • Initiate immediate and appropriate corrective
    action as necessary.

What do I need to do if I suspect improper
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
  • Use existing CCH policies and procedures within
    your department to resolve the problem yourself,
    or contact your immediate supervisor.
  • Step 2
  • If you are not satisfied with your supervisors
    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
  • 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
  • Step 4
  • 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)
  • 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 non-compliance
    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
  • 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
  • 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 Officers absence,
    the hospital President/CEO, or a member of Senior
  • The Compliance Officer will assist you in
    following the proper procedures for cooperating
    with the investigation.

Health Insurance Portability and Accountability
Act of 1996.
  • Intended to
  • 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
  • affects many different entities such as physician
    offices, hospitals, health plans health care

  • Privacy is the individuals right to control
    access and disclosure of his or her protected
    health care information.
  • Protected Health Information is considered paper,
    electronic oral.

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

  • 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 patients
    explicit authorization.
  • Statement that other uses disclosure will be
    made only with patients written authorization
    that such authorization can be revoked at any
  • 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

  • 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)

  • Upon Admission, Patient will be asked if they
    wish to be part of Hospital Directory. If so the
  • May disclose patients 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 patients 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.

CCH may disclose PHI for treatment, payment
health care operations.
  • Treatment
  • Furnishing preventative, diagnostic, therapeutic,
    rehabilitative maintenance or palliative care.
  • Payment
  • 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
  • Quality assessment activities, utilization
    review, peer review activities, conducting audit
    functions, medical reviews and business planning.

  • We are still required to disclose health
    information in certain situations without an
  • 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

  • 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.
  • Limited access, with supervision, will be given
    to departments like admissions, billing, accounts
    payable, dietary clerks and SPD for billing of
  • 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.

  • 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
  • Additionally we have
  • Designated a Privacy Security Officer
  • Designated a contact person or office to receive
  • Provided training for all employees who handle
  • 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
  • Documented all complaints received and their

  • Employees who violate CCHs 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
  • Accessing or disclosing protected health
    information contrary to CCHS policies, for
    personal gain or for other personal benefit or
  • 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 patients 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

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

  • Members of the workforce with first hand
    knowledge of the facts are required to report
    their knowledge or belief that
  • There has been a violation of HIPAA or a breach
    of CCHs HIPAA Compliance Plan.
  • There has been an improper use or disclosure of
    protected health information.
  • 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
  • Any member of the workforce making a report shall
    be protected from retaliatory action.

  • 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
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Hand Hygiene Program Essentials
  • Handwashing is essential when hands are visibly
  • Alcohol based hand rubs are effective for routine
  • 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 Safety Codes
  • 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 WARNING Tornado sighted in Platte

  • To Page pick up any phone
  • dial 699 2
  • then speak into receiver
  • To call Police
  • Dial 911

  • What is the code announcement for Fire Drills?

  • In the event of a fire Dr Red and an area
    will be announced three times on the overhead
    paging system.
  • 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.
  • All doors and windows should be closed and remain
    closed until the all clear is given.
  • Use stairways and NOT ELEVATORS.
  • Only go through fire doors if it seems safe to do

Please remember
  • It takes less than a minute to empty most fire
  • 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
  • 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
  • E Extinguish the fire or escape
  • 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
  • Out of the immediate area
  • Horizontally beyond fire doors
  • Vertically floors below fire

  • 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
  • Packages containing radioactive materials will
    also have labels with this symbol.
  • When you see this symbol
  • Do not enter the designated room unless you have
    been trained to do so.
  • Do not handle a package with this symbol unless
    you have been trained in how to handle
    radioactive materials

Tornado Safety
  • 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.
  • 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
  • Every department has a Plan 100 call list to use
    when additional staff are needed.
  • Employees must be familiar with the location of
    their Re- Call List.
  • After receiving a call, employees must call the
    next person or continue to call down the list
    until they contact someone.
  • Report to the North Employee Entrance with their
    picture ID name badge as soon as possible.

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

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

  • Once notified of a Bomb Threat
  • Unit Director
  • Hospital Administration
  • Columbus Police Department
  • will be notified and appropriate action taken.
  • If suspicious items are noted,
  • 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
  • All Department Heads will report to
    Administration for information and instructions.

Electrical Utility Safety
  • 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.
  • ALL ELECTRICAL EQUIPMENT is to be checked and
    tagged by Plant Operations. (Send Form MA-1 New
    Equipment Check In Form to Plant Operations.)
  • 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.
  • Employee owned electrical equipment (coffeepots,
    cup warmers, radios, etc.) must also be checked
    by Plant Operations prior to use

Electrical Utility Safety
  • Do Keep floors and other patient areas dry
  • Do Check power cords and plugs for damage BEFORE
    plugging them in.
  • Dont use any equipment that sparks or smells.
  • Dont roll equipment over power cords
  • Dont use any clinical equipment that has an
    expired or missing BIOMED Inspection Sticker

Hazardous Materials
  • HazCom, (OSHAS Hazard Communication 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
  • 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).
  • MSDS information is accessed on-line by your
    department director.

In Case of Chemical Exposure or Accident
  • Follow appropriate first aid procedure for type
    of exposure
  • 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
  • Clear area where spill is located.
  • Locate MSDS for spill.
  • Spill Kits are located
  • Omnicel
  • ACU west Omnicel
  • ER
  • Dirty Utility Room
  • ACU
  • SNU
  • OB
  • All Housekeeping Carts
  • Pharmacy

Proper Disposal of Hazardous Waste Red Bags
  • All items that are blood soaked
  • Amniotic Fluid
  • Fluid that surrounds the brain, spine, heart and
  • 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
  • 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

  • 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.
  • A Security Service provides surveillance of the
    hospital and grounds during their scheduled hours
    600 pm to 600 am M - F and 24 hrs on weekends.
    To contact the guard call 333

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

Security To .STAT (6992)
  • 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
  • Dial 911 if you feel the situation is dangerous
    and police intervention is necessary.

Patient Safety Goals
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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
  • 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