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Title: This is the title Author: Mary Lou Faulk Last modified by: DGelsiCollins Created Date: 3/13/2006 9:16:53 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: This is the title


1
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2
Discovery
  • New Team Member
  • Self Learning Packet
  • 2013

3
Self Learning Packet Objectives
  • This self learning packet will discuss
    AtlantiCares
  • Strategy Map
  • Quality Improvement Process
  • Essential Work Requirements (EWRs)
  •   
  • Upon completion of this course, you should be
    able to
  • Describe AtlantiCares Mission, Vision,
    Strategy, and Key Services.
  • Demonstrate AtlantiCares Values and Customer
    Service Standards.
  • Give examples of AtlantiCares 5 Strategic
    Objectives (The 5 Bs).
  • Understand and use AtlantiCares Quality
    Improvement Process.
  • Understand your responsibility in keeping your
    EWRs current.
  • Understand AtlantiCares commitment to the
    safety and well-being of our employees and
    customers through specific policies and
    procedures to ensure the safest possible
    environment.
  • Take the post-assessment for this course.

4
KEEPING ATLANTICARE FIRST
Customer Experience Index
Patients Cared for by Our Physician Network
Employee Engagement
Re-admission Rate
Operating Margin
5
What does the Strategy Map tell us?
  • Starting at the bottom of the map, our mission is
    to deliver health and healing to all people
    through trusting relationships. This is done by
    living our values of safety, teamwork, integrity,
    respect and service (STIRS). By assuring all
    members of the AtlantiCare family act on our
    values, we are able to focus on the performance
    excellence commitments of our 5 Bs. These
    include Best People and Workplace, Best Customer
    Service, Best Quality, Best Growth, and Best
    Financial Performance. Our attention to these
    details will move us closer to our vision of
    building healthy communities.
  • Consider how your work will contribute to these
    commitments.

6
AtlantiCares Values
  • Our Values
  • AtlantiCare has a set of values that guide our
    actions and behaviors.
  •  
  • Safety
  • Safety is our top priority.
  • Teamwork
  • We work together to achieve our goals.
  • Integrity
  • Our behaviors consistently reflect the highest
    ethical standards.
  •  
  • Respect
  • We treat each individual with dignity and
    compassion.
  •  
  • Service
  • We create loyalty by delighting those we serve.

7
Corporate Organization
AtlantiCare
AtlantiCare Regional Health Services
AIT AtlantiCare Information Technology
AtlantiCare Foundation
AtlantiCare Heath Solutions
AtlantiCare Health Services
AtlantiCare Regional Medical Center
AtlantiCare Health Engagement
AtlantiCare Behavioral Health
AtlantiCare Home Care
AtlantiCare Surgery Center LLC
South Jersey Oncology Property LLC
AMI/AtlantiCare Imaging
AtlantiCare Physician Group
AtlantiCare Cape May Surgery Center
Health Care Delivery
Health Engagement
Health Information
Rev 09.12
8
AtlantiCare Overview
  • As the regions largest healthcare organization
    and largest non-casino employer, AtlantiCares
    5,000 employees serve the community at over 65
    locations.
  • AtlantiCare and its business units are governed
    by boards comprised of 70 volunteer community
    leaders.
  • AtlantiCare is not-for-profit, focusing on health
    and wellness in the community.

9
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10
Quality Measures and Organizational Commitments
  • How we benchmark and assess ourselves against
    outside measurements
  • Malcolm Baldrige National Quality Award (2009
    recipient)
  • Magnet Status
  • Medicaid / Medicare (7 in the nation)

11
AtlantiCares Deployment Model for New Processes
Plan Establish a sense of urgency Identify timeline and measures Create communicate the vision
Design Identify best in class processes Involve stakeholders Validate process design w/ impacted areas Communicate change
Measure Collect and display data in a useful format Create linkages to other existing processes Recognize and reward early adopters
Assess Performance Analyze results Prioritize opportunities
Improve Use the PDCA Model for improvement
12
Quality Improvement Process
  • In line with our Strategic Objective of Best
    Quality, AtlantiCare constantly strives to
    improve how we do what we do.  We regularly look
    for ways to save money, reduce waste, increase
    our customer service, and improve clinical
    outcomes etc.  We consistently evaluate our
    performance measurement system for opportunities
    to improve while remaining flexible to change.
  •  
  • The PDCA Cycle
  • We understand that improvement does not happen by
    accident.  That is why we use the PDCA cycle as
    part of our Quality Improvement Process.  The
    PDCA Cycle emphasizes and demonstrates that
    improvement must begin with careful planning,
    followed by specific action and coordinated
    follow-up.

13
AtlantiCares Deployment Model For Existing
Processes
Plan Create a work team Identify improvement needed Produce possible solutions
Do Educate Small tests of change Pilot Communicate
Check Re-measure analyze results Identify barriers to success Discuss with stakeholders
Act Solve for barriers Hardwire improvements Share best practices
14
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15
Exceeding Customer Expectations
  • Excellent customer service is the ability of an
    organization to constantly and consistently
    exceed customers expectations

16
Internal External Customers
  • Customers may be called
  • Patient medical services
  • Client behavioral health services
  • Member LifeCenter services
  • Parents or children AtlantiCare Kids
  • Providers (Physicians, Clinicians etc.)
  • Co-worker in our department and across the
    system

17
Internal External Customers
  • All customers have the same expectations for
    service excellence
  • Professionalism
  • Responsiveness
  • Courtesy
  • Respect
  • Kindness
  • Compassion

18
Customer Loyalty
is driven by the customers experience with
PEOPLE, PRODUCTS and PROCESSES.
  • is greatly impacted by how PEOPLE facilitate
    the PROCESSES to deliver PRODUCTS to the customer.

is built when PEOPLE make emotional connections
while facilitating the PROCESSES to deliver
PRODUCTS to the customer.
19
Key Differences
Loyal Customers
Satisfied Customers
willingly refer other customers to AtlantiCare.
may refer other customers to our competitors.
Referrals
view AtlantiCare as a partner.
view AtlantiCare as a commodity.
Perception
20
Customer Experience Standards
  • Determine how we deliver our service
  • Guide the way we should act when we are providing
    service
  • Support our mission, vision, values and the Five
    Bs of our Performance Excellence Commitments
  • Should be incorporated into all we do

21
I will say please and thank you in all customer
/ co-worker interactions.
  • Greetings and closing set the stage for first
    and last impressions
  • Customers like to feel appreciated.
  • This standard relates to our value of Respect.

22
I will say is there anything else I can assist
you with today at the end of customer/co-worker
conversations.
  • We must be committed to listening attentively to
    our customers to fully understand their needs.
  • This standard supports our organizational values
    of Teamwork, Respect and Service.

23
I will always identify myself, my department and
say may I help you when answering the phone.
  • Our communication, whether in face-to-face or
    over the phone needs to be delivered with
    courtesy, clarity and care.
  • This standard reflects to our values of Respect
    and Service.

24
I will always wear my name badge in a visible
location.
  • Our appearance represents AtlantiCare.
  • Customers what to know who we are, what our role
    is and they can trust us as AtlantiCare
    employees.
  • This standard supports our organizational values
    of Safety, Teamwork, Respect and Service.

25
I will always make eye contact, smile and address
others who are near me.
  • Greeting people customers and co-workers alike,
    will help make them feel welcome and important.
  • This standard reflects to our values of
    Teamwork, Respect and Service.

26
First Impression
  • You only get ONE chance to make a first
    impression.

27
3 Vs of Perception
  • Visual- 55
  • This is what people or customers view about you
    or your business clothes, neatness, hair,
    posture, calm and organized
  • Vocal- 38
  • This is the tone of your voice, pitch of voice,
    volume, rate, pauses, emphasis and emotion.
  • Verbal- 7
  • What we say, words we use and choose, phrasing
    and language.

28
Body Language is Very Important
  • More than 90 of all communication includes
    nonverbal behaviors (voice or body language).
  • Individuals pay close attention to evaluating
    nonverbal communication.
  • Verbal and Nonverbal communication must match
  • The way we carry ourselves can greatly impact
    the first impression that a customer has of us.

29
AIDET Reduces Patient Anxiety
  • AtlantiCare encourages our employees to consider
    the role anxiety plays in patient care and
    customer service. AIDET is a tool we use to
    minimize patient or customer anxiety regarding a
    service they are about to receive, whether it is
    an invasive medical procedure or a more simple,
    non-invasive test.

30
AIDET Process
  • Acknowledge the customer using their name, and
    ask what else you can do for them.
  • Introduce yourself and explain your role and
    expertise. If other departments or staff are
    involved, talk up their expertise.
  • Duration explain how long the wait will be, as
    well as the duration of the procedure itself and
    turn-around time for results.
  • Explain the process thoroughly and ask what
    questions they have about it. Leave your phone
    number for them.
  • Thank the customer and their family for choosing
    AtlantiCare, for their support of the care we
    provided, and for their cooperation and
    communication.

31
Key Words at Key Times
  • Help patients, families and visitors connect the
    dots
  • Align our words with our actions to give a
    consistent experience and message.
  • Use everyday opportunities to maximize our
    potential for improving clinical outcomes while
    generating customer loyalty.
  • Key Words at Key Times are the variables we plug
    into the AIDET formula to make our words both
    efficient and impactful. By taking advantage of
    everyday opportunities to communicate with
    intent, we maximize our potential for improving
    clinical outcomes while generating customer
    loyalty.

32
Key Words at Key Times
  • I am committed to helping you keep your pain
    under control. How is your pain today?
  • Im closing the curtain for your privacy.
  • For your safety, it is important that I verify
    your name and birth date and review your arm band
    before beginning this procedure.
  • I want to make sure you are very satisfied with
    the cleanliness of your room. Have I missed
    anything?

33
Managing Up Co-workers and Departments
  • Speaking positively about coworkers, reduces
    patients anxiety about their next provider of
    care and puts them more at ease with the
    coordination of their care because it suggests
    strong teamwork among providers.
  • Hello Mrs. Woldow. I will be your physician
    today. I see that Mary is your nurse. We will
    be working together to make sure that we deliver
    excellent care. I have worked with her for almost
    10 years. Mary and I will take excellent care of
    you during your stay with us at ARMC

34
Managing Up Co-workers and Departments
  • Managing up also gives your co-workers a head
    start in winning the confidence and trust of the
    patient. If the patient trusts you, they will
    value your opinions regarding other providers.
    Here are some examples of managing up a coworker
    or department at the hospital.
  • Hello Mrs. Woldow. I have ordered a CT today.
    Our radiology department has state of the art
    technology and highly skilled staff . They are
    aware you are coming to their department and will
    take good care of you during your procedure.

35
When we make a mistake Service Recovery Steps
  • Listen to their concern without interrupting
    them. Ask questions for clarification and to
    assure you understand their situation.
  • Recognize Respond by rephrasing what is
    concerning them about the service they received.
  • Apologize no matter who is at fault, and never
    place blame. Ask what we can do to make the
    situation right
  • Correct the Failure - Brainstorm ideas with them,
    and select one that is appropriate and reach
    agreement
  • Appreciate the customer by telling them that
    their honesty in bringing the issue forward gave
    us the opportunity to fix a failure

36
We measure to be sure our behaviors match our
goals
  • Surveys
  • Customer Satisfaction Surveys across the system
  • Focus groups
  • Community surveys

37
What We Know
  • The HCAHPS survey is how CMS measures the Quality
    around a patients experience
  • The Survey is based on a Frequency scale
  • Always, Usually, Sometimes and Never
  • Only Always answers score points we do not
    receive credit for any other answers
  • Survey results are used to calculate a portion of
    our reimbursement from CMS.

38
HCAHPS Measurements
  • Communication with Nurses
  • Communication with Doctors
  • Responsiveness of Hospital Staff
  • Pain Management
  • Communication About Medications
  • Discharge Information
  • Hospital Environment (cleanliness and quietness)
  • Overall Rating of Hospital

39
Corporate and Privacy Compliance
Management of Information
40
Corporate and Privacy Compliance
  • Provides AtlantiCare with system wide services
    with authority to act with respect to all
    entities, subsidiaries and cost centers.
  • Responsibilities require unlimited and
    unrestricted access to all data during audit and
    investigation.
  • Continuous assessments of the effectiveness of
    AtlantiCares compliance and internal control
    environment.
  • Corporate Compliance independent support
    function of AtlantiCare reporting directly to the
    Board and administratively to Corporate Counsel.
  • Privacy Compliance AtlantiCare HIPAA compliance
    reporting directly to Corporate Counsel.

41
Prevalent Laws and Regulations
  • Deficit Reduction Act (DRA) of 2005. Mandates
    that employees and agents be educated about the
  • NJ Conscientious Employee Protection Act (CEPA)
  • Federal False Claims Act
  • Federal Program Fraud Civil Remedies Act of 1986
  • NJ Medical Assistance and Health Services Act
  • State false claims legislation
  • NJ Conscientious Employee Protection Act (CEPA)
  • Whistleblower Act
  • Prohibits an employer from taking any retaliatory
    action against an employee because the employee
    discloses an activity that the employee
    reasonably believes is in violation of a law or
    regulation or constitutes improper quality of
    patient care.
  • Policy distributed

42
HIPAA - Health Insurance Portability and
Accountability Act of 1996
  • Establishes standards for the transmission and
    usage of health care information.
  • Laws and Regulations
  • Administrative Simplification
  • administrative financial data
  • electronic formats, code sets and identifiers
  • Privacy
  • Security

43
Corporate Compliance and HIPAA Governance
  • Mandated by federal, state and local agencies.
  • OIG / OCR / IRS
  • CMS / EEOC / FDA
  • NJDOH / JCAHO
  • Penalties for non-compliance are significant.
  • Civil and criminal penalties for the organization
    and possibly individuals inside the organization,
    resulting in fines, possible termination, and
    prison time.
  • Possible exclusion from Medicaid and Medicare
    programs.

44
Mandatory Compliance
  • Obey all laws and regulations governing business
    conduct.
  • Be honest, fair, and trustworthy in all
    activities and relationships.
  • Avoid all conflicts between business and personal
    affairs.
  • Strive to be a role model for ethical conduct.
  • Strive to create a safe workplace .
  • Do not use AtlantiCare property/systems for
    personal use.
  • Protect the intellectual property of AtlantiCare
    and its vendors.
  • Audits are routine and ongoing, no expectation of
    privacy

45
Conflicts of Interest
  • Not participate in any activity that conflicts or
    appears to conflict with your responsibilities to
    AtlantiCare.
  • A conflict of interest occurs if the activities
    or personal interests appear to or directly
    influence the business or professional decisions
    required by the employee.
  • For example, an employee (or a family member,
    relative) should not
  • receive a financial benefit from any decision or
    action he/she takes
  • have a financial interest in an organization that
    does business or is seeking to do business with
    AtlantiCare
  • accept or solicit gifts or entertainment or
    receive special discounts for the purchase of
    items or services for personal use from any
    outside organization or individual
  • make a decision that results in an improper or
    illegal gain for the employee or a third party or
    is harmful to the interests of AtlantiCare.

46
Information is Protected
  • Maintain confidentiality of all protected health
    information
  • electronically
  • paper
  • verbally
  • Properly dispose of confidential information
    (paper, disk/electronic).
  • Access information on a minimum necessary /need
    to know level for job performance.
  • System access keep user names and passwords
    confidential.
  • Security measures are in place protecting our
    network and information systems.
  • Report suspicious email messages to InfoShare
    Customer Service Help Desk.

47
Patient Care
  • Ensure competency of staff. All licenses are
    kept current.
  • Treat all patients equally in the provision of
    care.
  • Ensure all patients receive appropriate care
    within the scope of AtlantiCare.
  • NOT deny admission/testing for non-elective
    services based on ability to pay.
  • Maintain complete and accurate records of care
    provided.
  • Obtain informed, written consent prior to
    providing care.
  • Properly dispose of medical waste and hazardous
    materials.

48
Potential Violations of Corporate or HIPAA
Compliance
  • Refer to the Guidelines for Reporting Compliance
    /Privacy Complaints/Concerns Policy
  • Compliance/Privacy Phone Line (609 - 407 -7788
    or internally 4-7788) or online
    www.MyComplianceReport.com
  • All are documented and investigated
  • Corporate Compliance Director / Corporate Legal -
    all Corporate Compliance concerns
  • Chief Privacy Officer / Corporate Legal all
    HIPAA concerns
  • Strict confidentiality protections are in place

49
Your Responsibilities
  • At AtlantiCare, everyone must comply
  • Laws, regulatory and accreditation requirements
  • AtlantiCares Policy and Procedures
  • Are on the Intranet for your review
  • Leadership / Compliance / Management of
    Information
  • Understanding your rights and responsibilities is
    the best way to safeguard our patients and
    customers, ourselves and our organization.

50
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51
Harassment Free Workplace
  • Harassment Free Workplace
  • In line with our Strategic Objective of Best
    People / Best Workplace, AtlantiCare is a
    Harassment Free Workplace.  As an organization,
    we prohibit harassment based on any of the
    following
  • Race
  • Creed
  • Color
  • National origin
  • Age
  • Ancestry
  • Gender
  • Citizenship status
  • Sexual orientation
  • Handicap or disability  
  • We also prohibit sexual harassment which includes
    behavior such as unwelcome sexual advances,
    request for sexual favors and other lewd conduct
    such as lewd talk, inappropriate jokes or
    suggestive comments.
  •  
  • If you witness harassment taking place, you can
    file a report with your supervisor, Human
    Resources or any other member of AtlantiCares
    Management team.

52
Harassment Free Workplace
  • What does Harassment mean?
  • To disturb, torment or pester on a persistent
    basis.
  • The most frequent types are verbal, physical, and
    visual.
  • It may be in the form of inappropriate verbal
    comments, the tossing of an object at an
    individual, inappropriate touching, inappropriate
    graphics or stereotyping behaviors.
  • Excuses such as "I dont mean to offend when I
    call you baby, thats just the way I am", are not
    a defense for offending behavior.

53
Harassment Free Workplace
  • What is Sexual Harassment?
  • Sexual harassment includes behavior such as
    unwelcome sexual advances, requests for sexual
    favors, and other verbal or physical conduct of a
    sexual nature, such as name-calling, suggestive
    comments, or lewd talk and jokes.

54
Harassment Free Workplace
  • What is Sexual Harassment?
  • There are two forms
  • Quid Pro Quo harassment ("This for That"
    harassment)
  • This form of sexual harassment involves one party
    using power over another to gain some sort of
    sexual advantage. (i.e. Promotional
    opportunities, increases, etc.)
  • Environmental harassment (hostile work
    environment)
  • This form of sexual harassment conduct is based
    on gender and unreasonably interferes with an
    individuals work performance or has the purpose
    or effect of creating an intimidating, hostile or
    offensive work environment.

55
Safety is Our First Concern
  • You are required to immediately report to
    Human Resources any information that reasonably
    indicates another health care professional has
    demonstrated
  • Impairment
  • Gross incompetence, or
  • Unprofessional conduct

56
Impairment is defined as
  • The condition of being unable to perform as a
    consequence of physical or mental unfitness.

57
Impairment includes
  • Under the influence of drugs or alcohol
  • Mental or emotional illness including dementia
    that precludes a person from safely performing
    the essential functions of their job and
  • Physical disability that precludes a person from
    safely performing the essential functions of
    their job

58
Drug and/or Alcohol Abuse Reasonable Suspicion
  • Employee appears to be under the influence of
    drugs/alcohol, (i.e. slurred speech, inability to
    walk a straight line, etc.)
  • Any other objective factors which raise a
    reasonable suspicion of alcohol or drug use.
  • Recurring or serious problems with job
    performance, attendance, or behavior where no
    other verifiable basis for such a problem exists.

59
Help is Available
  • Human Resources can assist those with
    disabilities by working our reasonable
    accommodations
  • Employee Assistance Program (EAP) can assist
    those with mental, emotional and substance abuse
    through
  • Prevention
  • Intervention
  • Treatment
  • You can reach AtlantiCares EAP by calling
  • 1-800-260-0808

60
For More Information
  • You may use AtlantiCares Starfish, to find the
    policies on
  • Signs of Impairment
  • Drug and Alcohol Free Workplace
  • Harassment Free Workplace
  • If you have any additional questions, please
    contact a representative from Human Resources.

61
Chest Pain and Heart Attacks
  • AtlantiCare's vision of building healthy
    communities applies equally to our employees as
    it does to our external customers.  That is just
    one reason why we think it is important for each
    of us to understand the following information
    about chest pain and heart attacks.  They can
    happen to patients, visitors, family members or
    co-workers at anytime or anywhere.
  • People typically expect a heart attack to include
    crushing chest pain and sudden falls to the floor
    like commonly seen in movies or on television. 
    In reality, heart attacks often begin with vague
    symptoms that slowly intensify with pain that may
    be mild and come and go.  Women tend to delay
    longer than men when it comes to seeking help.

62
Chest Pain and Heart Attacks (Symptoms)
  • Shortness of breath which may or may not come
    with chest discomfort
  • Uncomfortable pressure, fullness, squeezing of
    pain in the center of the chest that lasts a few
    minutes or goes away and comes back
  • Breaking out into a cold sweat, nausea or
    lightheadedness
  • Pain or discomfort in one or both arms, the back,
    the neck, the jaw or the stomach
  • A general feeling of impending doom

63
Chest Pain and Heart Attacks (continued)
  • If you or anybody else experiences these symptoms
    you should do the following
  • If you are in the hospital, dial '0' for the
    operator and tell them that it may be a heart
    attack.  Ask that Security help transport the
    person to the Emergency Department immediately!
  • If you are at any place outside of the hospital
    call 911 and give the operator the relevant
    information needed to request an ambulance.
  • It is important to know that any delay in
    treatment may result in permanent damage to the
    person's heart tissue.  When in doubt call the
    emergency numbers immediately.

64
Chest Pain and Heart Attacks Special Concerns
for Women
  • Women or diabetic's signs and symptoms of a Heart
    Attack can be vague and non specific. They may
    not experience Chest pain at all. They may just
    experience weakness, fatigue, shortness of breath
    or epigastric problems such as nausea and
    abdominal pain.
  • According to the American Heart Association (AHA)
  • Women often delay in seeking treatment for a
    Heart Attack.
  • More women than men die within the first year of
    having a Heart Attack.
  • Women can be less aggressively treated medically
    than men following a heart attack
  • Women may receive less follow up care than men.
  • It is for these reasons that women need to be pay
    extra close attention to their health and how
    their bodies feel.

65

Stroke Awareness Act F-A-S-T!
  • What is F-A-S-T?
  • F-A-S-T is an acronym for recognizing and
    responding to the symptoms of stroke.
  • It stands for face, arms, speech and time, and it
    is used as part of a campaign by the National
    Stroke Association to raise awareness about the
    impact of stroke on women.
  • Additional warning symptoms have been added for
    general public knowledge and to prepare patients
    and families post discharge.

66
Electrical Safety
  • We also want to discuss the importance of
    electrical safety.  Electrical hazards can be
    avoided.  It is important that each of us is
    aware of potential hazards and take actions to
    prevent them from happening.
  • Fires and shocks can occur when electrical cords
    or outlets are damaged.  Damage to these can
    happen when pieces of equipment are unplugged
    improperly.  The following three behaviors should
    be performed to help prevent these events from
    happening
  • ALWAYS unplug electrical equipment by pulling on
    the plug and not the cord.
  • Inspect each piece of equipment on a regular
    basis for damage to the cord or plug.
  • Do NOT use damaged equipment and immediately
    report it.

67
2013 Patient Safety Goals
Clinical Education
68
2013 National Patient Safety Goals
  • Improve the accuracy of patient identification
  • Improve the effectiveness of communication
  • Improve the safety of using high risk medications

69
2013 National Patient Safety Goals
  • Reduce the risk of health care associated
    infections
  • Accurately and completely reconcile medications
    across the continuum of care
  • Improve the accuracy and safety of surgeries and
    procedures
  • Identify patients at risk for suicide

70
Environment of Care JCAHO Policies
  • Storage
  • Doorways
  • Ceiling Tiles

71
Sink Storage
  • The area under a sink is considered a soiled
    environment
  • The following can NOT be stored under sinks
  • Anything wearable
  • Anything ingestible
  • Anything used for treatment
  • Only cleaning supplies can be stored under sinks

72
O2 Tank Storage
  • Unsecured O2 bottles can fall over start a fire
  • Must be secured
  • In a rack
  • Behind a chain
  • In a stretcher mounted tank holder

73
Shelf Storage
  • Nothing can be stored within 18 inches of the
    BOTTOM of sprinkler heads

74
Hallway Storage
  • The hallways cannot be used as storage areas

75
Linen Carts
  • Linen carts must be covered at all times when not
    in use

76
Doorways
  • Wedging a door open
  • In the case of a fire allows smoke fire to
    spread around the building, possibly trapping and
    causing harm to hospital staff, patients
    visitors
  • Prevents certain procedures from being effective

77
Ceiling Tiles
  • Wet ceiling tiles
  • Are breeding grounds for mold
  • Can fall and possible hit people
  • If stained tiles are noticed, please contact
    Facilities to have them replaced

78
Safety Quality of Care Reporting Concerns
  • Any employee who has concerns about the safety or
    quality of care provided in the hospital may
    report these concerns to our Safety Officer,
    Debra Fox at 572-8310.

79
Safety Quality of Care Reporting Concerns
  • You may also contact the
  • Joint Commission
  • Call 1-800-994-6610
  • From 830 am to 5 pm
  • You may contact the New Jersey Department of
    Health directly with complaints
  • Call 1-800-792-9770
  • Or by mail
  • NJ Department of Health
  • PO Box 367 LL
  • Trenton, NJ 08625

80
Your Role in the Event of a Fire
  • Safety is one of AtlantiCares organizational
    values.  With this in mind, we all play a very
    important role when it comes to keeping our work
    environment safe.  In the event of a fire, it
    would be helpful to remember the RACE acronym
  •  
  • Rescue people in immediate danger.
  •  
  • Alarm (pull a fire alarm and follow other
    departmental procedures for reporting an
    emergency).
  •  
  • Confine the fire by closing the appropriate
    doors.
  •  
  • Extinguish the fire (if it is a small one) or
    Evacuate to a safe location.

81
Using a Fire Extinguisher
If it is possible for you to extinguish a fire,
such as a small one in a garbage can, the PASS
acronym should help you remember how to properly
use a fire extinguisher.
  • After taking the fire extinguisher out of its
    holder and setting it onto a flat surface, hold
    it by its neck and
  •  
  • Pull the pin and break the tamper seal
  •  
  • Aim the nozzle at the base of the burning object
  •  
  • Squeeze the handles together releasing the
    extinguisher's chemicals
  •  
  • Sweep the nozzle back and forth to coat the
    burning material.

82
Magnetic Resonance Imaging (MRI) Safety
At AtlantiCare, we use the most cutting edge
equipment to provide exceptional service to our
customers.  One tool in our arsenal is Magnetic
Resonance Imaging (MRI).  Considering the fact
that this piece of equipment is essentially a
very large magnet, there are some very specific
safety practices that must be adhered to while
being around it. 
  • Some of the safety practices are as follows
  •  All patients must be properly screened before
    entering the MRI room
  • All metallic equipment, including hand tools,
    wheelchairs, gas tanks, etc should be checked
    with a hand magnet before entering the MRI room
  • Employees that work directly with the MRI
    machine should know the proper procedures to
    follow in the event of an emergency

83
Safety Codes
Code Red Fire
Code Blue Adult Medical Emergency
Code White Pediatric Medical Emergency
Code Amber Infant/Child Abduction
Code Yellow Bomb Threat
Code Grey Security Emergency / Patient Elopement
Code Silver Hostage Situation
Code Orange Hazmat Situation
Code Triage Disaster Situation
Code Clear Situation Has Cleared
Code Ten Community member injured on premise
Met Team Rapid response to assess patient
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Recent AtlantiCare expansions
  • Recent additions to AtlantiCare include
  • Cape May Courthouse Surgery Center
  • Galloway and Somers Point Urgent Care Sites
  • Hammonton Health Park
  • Multiple physician practices in tri-county area
  • Primary Care and Cardiology campus in Manahawkin
  • Construction on Child Adolescent Mental Health
    Center in EHT
  • Construction on Cape May Cancer Center

86
AtlantiCares Organizational Commitment
  • Equitable Health Care means that every person
    we care for, regardless of their race, culture,
    spoken language, or any other differences,
    receive an equally respectful and quality health
    care experience.

87
Culture
  • We encourage an atmosphere that allows each
    person to
  • have a sense of importance
  • observe and experience our passion in providing
    quality care
  • actively participate in strategies to enhance
    their health.

88
Cross Cultural Services
  • We recognize that the culture of our customer
    population is changing.  We also understand that
    disparities in healthcare delivery exist between
    various races.  In line with our value of Respect
    and our Strategic Objective of Best Community
    Health, AtlantiCare offers the following services
    to help meet the language and cultural needs of
    our customers
  •  
  • Telephonic Interpreter Services through the use
    of Language Line Phones
  • The nurse and the patient can interact with each
    other by using this service.
  •  
  • Contracted Interpreter Services
  • A translator can be requested to be physically
    present to assist in the transfer of information.
    Customer Relations can assist with interpreters
    at no cost to patients.
  •  
  • Translation Services
  • Patient education materials and vital consent
    forms can be translated.
  •   
  • We believe that ALL people should be treated with
    dignity and respect.

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90
Best Financial Performance
Bringing together best in quality, customer
service, workplace/people and community helps us
enrich our profits in a not for profit
organization. Our revenue is invested in the
education of our employees, improvement in
services and the expansion of locations within
AtlantiCare. This commitment creates our
financial success.
91
Best Financial Performance
  • AtlantiCare is a non-profit organization and has
    a triple A bond rating.
  • Financially we are very strong and stable and
    because of this position, we were able to invest
    back into such projects as the new Cancer Center
    in Cape May County.

92
Understanding EMTALA
  • The Emergency Medical Treatment and Active Labor
    Act (EMTALA) is a federal law that was adopted in
    1986 and was originally designed to stop
    hospitals from refusing to treat patients based
    on their ability to pay for services.  This
    legislation deals with various requirements
    around transferring patients and discharge.
  •  
  • Here are some of the important things to know
    about this law
  • EMTALA applies to ALL hospital employees
  • The Emergency Department has been expanded to
    included the entire hospital as well a 250 yard
    perimeter around the hospital, and in hospital
    owned ambulances
  • Every patient is allowed to be screened by a
    physician to determine if there is an emergency
    medical condition or active labor
  • Before a patient is transferred, they are
    entitled to stabilizing treatment
  • Documentation must be completed in the RAAMPS
    format before transferring a patient

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RAAMPS Documentation
  • RAAMPS Documentation
  • The documentation that should go with a patient
    during a transfer is supposed to be in RAAMPS
    format.
  •   
  • Reason for transfer
  • Accompanying equipment
  • Acknowledgement of acceptance of patient by staff
    member
  • Method of transfer
  • Personnel accompanying patient
  • Summary of patients condition
  • This is also known as the NJ Universal Transfer
    Form.  
  • Failure to comply with EMTALA can lead to several
    serious consequences for AtlantiCare including
    negative attention, increased legal scrutiny,
    fines and possibly loss of Medicare/Medicaid
    eligibility.

94
Self Learning Packet Wrap up
  • The information presented in this course and much
    more can be found in your Employee Pocket Guide
    as well as on the AtlantiCare Starfish.
  •  
  • Please be sure you take the time to complete the
    post-test for this course and return it to your
    manager.  Both pieces, viewing this course and
    completing the post-test, are required parts of
    the orientation process.
  •  
  •  
  • Thank you!
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