ANNUAL REVIEW ONLINE

ANNUAL REVIEW ONLINE

Welcome

Test

Compliance and Confidentiality Form

TB Health Assessment Form

Print out all forms:Complete front and back

SAFETY

SAFETY KDMC Safety Officer: Clyde

Sbravati MSDS SHEET: Material Safety

Data Sheet: This information is now available via phone.

1-800-451-8346 Information will be read for

you or they will FAX the information to you.

MSDS FORM SHOULD HAVE THE FOLLOWING INFORMATION:

Where product come from.

Composition and information on the ingredients.

Physical data. Boiling point Appearance Potential health effects

Emergency and first aid measures.

Fire fighting measures and procedures.

Handling and storage of the chemical.

PPE needed to handle the chemical spill. (The hospital will provide you with the equipment needed.

Should be worn by all employees while at

work.

Never loan your nametag to anyone.

Your Nametag:

Report all unsafe practices, conditions,

defective equipment and or injuries to your supervisor, Safety Committee or Safety Officer.

Use required personal protective equipment in specified areas and on designated job duties.

Operate equipment only after have been authorized and trained to do so, and follow all safety rules, procedures and practices.

Respond to emergency situations in accordance with medical center and departmental polices and procedures.

Be Safety Alert:

SENSITIVE AREAS OF KDMC

Nursery

Medical Records

Back Loading dock

Pharmacy

Emergency Department

Chemical Spills Mercury spill kits are located at each nurses

stations.

There is a big gray barrel with red lettering, located in materials management for chemical spills

Electrical Safety: Unplug Equipment from wall immediately if you notice:

A burning smell. Equipment is hot to

touch. Equipment is

smoking You feel a shock or

tingling feeling.

Report Cords and Wall plugs if you notice: Cracks in insulation Bent or missing AC

plug or prongs Burn marks on AC

plug Warm or Hot power

cords.

An external or internal disaster occurs when an

incident produces casualties of such numbers, that the routine methods for patient care are not adequate.

If a disaster occurs while you are off duty, you will received notice that you are needed at KDMC by phone, radio or TV announcement.

It is your responsibility to respond to any disaster at KDMC. Be sure your home phone and cell phone numbers are up to date in the Human Resources office and with your immediate supervisor.

What is a Disaster or Code Black?

Code Force: Non-medical emergency

Available employees

should report to the location

called.

Code Gray: Tornado Move as many

patients as possible to the hallway.

Move all others away from the windows.

All other employees should move to 1st floor hallway by dietary.

Code Red: Fire Alarm, RACE

R-Remove anyone in the danger area.

A-Alarm, dial 711 and announce the location of the fire.

C-Control fire with extinguisher.

E-Evacuate patients to a safe part of hospital

Code Red: Fire Get Fire extinguisher

and report to area called.

Use Pass for fire extinguisher. P-Pull pin A-Aim Nozzle S-Squeeze handle S-Sweep at the base

of the fire.

Code Pink / Code Adam: Missing baby or missing

child. Report to the nearest exit. No one should be able to leave or enter

the building. Try to obtain a description of child

Age Sex Race Hair and eye color Clothing Type and color of shoes

Code Blue: Cardiac Arrest

Available medical staff, Code Team,

should report to the location called.

SAFE LIFTING& BODY MECHANICS

Proper Sitting: Sit in a chair that has

proper low back support. Keep your feet flat on

the floor. Keep your hips at a 90%

angle. Avoid slumped sitting. Keep your chin tucked in

and avoid head forward posture.

Avoid prolonged sitting. Change positions frequently.

Lifting Safely:Bend your knees,

not your back, and you greatly reduce stress to your low

back. Keep the load close to your body and carry heavy

objects waist high.

1. Plan ahead, rearrange area and get help if needed.2. Bend your knees not your back.3. Keep the load or patient close to your body.4. Use a good wide base of support.5. Pivot your feet when turning-avoid twisting.

5 Key Points of Proper Lifting:

Pushing or Pulling?If you have a choice-

PUSH! Pushing is more

mechanically efficient.

Keep your back straight. Bend as you push.

Reposition your body as you push. Don’t let the load get too far in front of you.

Support the load in two places, side and

bottom.

Hold the load close to your body, keep your back straight.

Carry with a slight bend in your elbows.

If you carrying shopping bag or luggage- split the load and carry a lighter load on each side.

Carrying a Load:

Pace your work and get as close as you can.

Avoid standing on your ‘tip toes’, use a stool or ladder if necessary.

Store frequently used items within easy reach.

Use one hand for extra support if possible.

Avoid prolonged overhead work without breaks.

Reaching:

Lifting with the Back Bent and the leg Straight.

Lift with your legs not your back. Using Fast Jerking Motions.

This adds additional stress on back and joints Bending and twisting at the same time.

This causes maximum stress on the lower back.

Common Mistakes of Body Mechanics:

Load too far away.

Load at arms length weights 7-10 time more.

Poor planning Failure to anticipate needing assistance

Poor communication Let patients know what to expect, they can

help.

Insufficient strength Not strong enough to lift the patient or load.

Common Mistakes Continue:

Remember: Lift with your legs

and not your back.

Keep back straight.

Bend at the legs. Lift your head

before you lift. Maintain natural

sway in lower back.

FALL PREVENTION

Should be completed on every patient.

If your patient does fall:1.Complete Occurrence Report.2.Complete Fall Report in Meditech Nursing3.Place on “High Risk” Fall precautions if not on it already.4.Notify physician and family.

Fall Risk Assessment

“High Risk” Fall Precautions:

Yellow armband and door card.

Room near nurses station.

Possible bed alarm.

4 side rails up. Sitter at bedside. Bed in low

position.

PATIENT RIGHTS

EVERY PATIENT SHOULD RECEIVE A“Patient Rights & Responsibilities”

Hand Book

The Patient Bill of Rights.Each Patient has the Right to:

Be treated with dignity & respect

Expect privacy & confidentiality

Make informed decisions

Participate in all aspects of care

Establish advance directives

Receive impartial access to care

Be given full financial information

Help Them Develop an Advanced Directive

Advising of their right to advance directives. Asking if they have an advance directive. Assisting them in developing advanced

directives. Including the information in their medical

record.

Patient’s Bill of RightsEach patient has the right to:

Know the identity & professional status of all healthcare workers.

Participate voluntarily in research & education projects.

Receive full knowledge of their rights and responsibilities.

Only with a doctors order to include:

The type of restraint to be used. The length of time the restraint is to be used. Reason for the restraint. Document every two hours on restraint sheet

circulation and skin condition. Checked at least every 15 minutes. Signed by physician within 1 hour. New order every 24 hours

Patient RestraintsWhen Are Restraints

Used?

Follow manufactures directions. Use correct size. Fasten straps tight but not constrictive. Do not place over IV Site or wound. Tie knots for easy release. Only trained personnel should apply.

How Are Restraint Used?

Problems That Can OccurFrom Using Restraints:

Increase agitation Circulatory

impairment Asphyxiation D/T

aspiration or restricted respiratory function.

Seizure Pts can suffer fractures or trauma.

Alternative: Have family stay

with patient. Move them out to

the desk. Try to fix what is

bothering them.

National Bereavement SignIf you see this sign on a patient door, it means

there is a “sensitive” situation going on involving possible loss or death. Please be respectful.

Patients have the right to choose who may visit them. They have the right to choose someone who is not related by blood or law. This includes, but is not limited to: A Friend A Domestic partner (any gender) A Neighbor A Significant Other

Visitation Rights

WORKPLACEVIOLENCE

POLICY: KDMC does not tolerate acts ofworkplace violence committed by or

against employees.

If Conflict Occurs:1. Stay Calm

2. Listen attentively

3. Maintain eye contact

4. Be courteous, but maintain your distance

5. Signal for someone to call for help

6. Never try to grab a weapon

Early Warning Signs: Nervous behavior. Loud, over

bearing personality.

Threatening others.

Getting in your face.

Clinched fist. Flashing a

weapon. History of

violence.

If Violence Strikes: Take action to

protect yourself. Call for Code

Force. Remove patients

& visitors to safe area.

Don’t try to take away a weapon.

Don’t try to restrain the person alone.

Don’t leave scalpels or needles unsecured. Obtain history: ask about cuts & bruises. Know way to contact Security.

Overhead page Pager Radio

Safe Practices:

Watch for Signs of Abuseto our Patients:

Physical Indicators: Unexplained bruises

in different stages of healing.

Complains of abuse at home.

Patterned injuries. (Buckles, belts, burns)

Untreated old injuries.

Delay in receiving help.

Attempted suicide.

Provide a safe environment. Interview patient alone. Have Security escort others out of the room if

need. Ask direct, non-threatening, non-judgmental

questions.

Questioning the Suspected Abuse

Patient.

INFECTION CONTROL

Bloodborne Pathogens

What are Bloodborne Pathogens?

They are viruses, bacteria and other microorganisms that:

are carried (borne) in the person’s bloodstream and in certain other body fluids

cause disease

If a person comes in contact with infected blood or certain other body fluids, he or she might become infected too!

revised: 2012

Sweat Saliva Tears Urine Feces Vomitus Nasal secretions

revised: 2012

Non-Infectious Body Fluidsfor Bloodborne Pathogens:

Blood

Fluid around or in an organ

Any body fluid that contains blood

revised: 2012

Infectious Body Fluidsfor Bloodborne Pathogens:

Hepatitis B virus (HBV)Hepatitis C virus (HCV)Human Immunodeficiency Virus (HIV)

revised: 2012

Three of the Most Serious Bloodborne Pathogens

HEPATITIS Hepatitis A

Hepatitis B*

Hepatitis C*

Hepatitis D

Hepatitis E

revised: 2012

The primary symptom of HBV & HCV isjaundice (yellowing of the skin and eyes)

THERE IS NO CURE.

revised: 2012

Symptoms of Hepatitis B & C

HIV = Human Immunodefiency Virus

The virus attacks the body’s ability to fight disease and infection (immune system)

The virus causes AIDS (acquired immune deficiency syndrome)

revised: 2012

HIV

The symptoms of HIV are:

none weakness weight loss fever sore throat dark urine

THERE IS NO CURE.

revised: 2012

Symptoms of HIV Infection

needle-stick injuries or sharps injuries

cut, scrapes, andother breaks in the skin

splashes in the mouth,nose or eyes

revised: 2012

How are these pathogens spread?When infected fluids enter the body through:

Standard precautions (also known as universal precautions) means that you will consider the blood and certain other body fluids of another

person INFECTIOUS at all times

AND

You will use equipment to protect yourself

revised: 2012

STANDARD PRECAUTIONS

You must use certain PPE items to protect yourself. This will place a barrier between you and the potentially infected material. These items include:

gloves masks goggles gowns resuscitation equipment

revised: 2012

Personal Protective Equipment

PPE

revised: 2012

SHARPS!!

Sharps MUST be disposed of

properly!!!! You should dispose of

sharps:

in a labeled sharps container only

without recapping

as soon as they are used

HAZARD SIGNS, LABELS & COLOR CODING

Warning labels and colors help you identify hazardous or regulated

waste!

RED CANS, CONTAINERS, LABELS OR BAGS

MEAN“INFECTIOUS”

revised: 2012

UNIVERSAL BIOHAZARD SIGN

What is an exposure event?

Did I get stuck with a needle or sharp used on another person…

Did I get a splash of blood or *OPIM from another person into my mouth or eyes or up in my nose…

Did the blood or *OPIM from another person enter my body through my non-intact skin (cut, scrape, open wound)...

*OPIM = other potentially infectious material

revised: 2012

HAVE I BEEN EXPOSEDto BLOODBORNE GERMS?

Wash the exposed area thoroughly with soap and running water.

If splashed in the eye or mucous membrane, irrigate with running water for 15 minutes

Report the exposure to your supervisor as soon as possible

Fill out the EOR form provided on the units*

Your supervisor will advise you of the next steps to be taken.

* students, physicians, visitors, contract staff are responsible for their testing costs.

revised: 2012

What if I Am Exposed?

Hepatitis B vaccination is provided to you for free! You should

take the vaccination unless:

you have previously received the vaccination antibody testing reveals you are immune the vaccination is contraindicated (not recommended)

The vaccination process involves a series of 3 injections given in the arm muscle over a 6 month period. That will protect you if you are exposed to the blood or OPIM of someone with Hepatitis B.

HEPTITIS B VACCINATION ONLY PROTECTS YOU FROM HEPATITIS B, NOT ANY OTHER TYPE OF HEPATITIS!

revised: 2012

That’s Why You Should Get Vaccinated!!

RECAPPING NEEDLESRule =

No recapping!

Reality = Sometimes you

have to...sodo it right!

revised: 2012

GlovesNot a choice!!!

revised: 2012

Nursing Staff and/or EMS staff who have

knowledge of their patient having a known or suspected infection must notify the

receiving facility PRIOR to the transport.

revised: 2012

Transfer of Infected Patients

HANDWASHINGHandwashing is the single and most important practice used to prevent

transmission of bloodborne pathogens.

************************

IMPORTANT!

My patient has diarrhea?

Gloves, soap, water and friction!

(no alcohol rubs)

************************

Wash hands after removing gloves!

You touch your eyes, nose & mouth about 300 times/day!

revised: 2012

INFORMATIONSYSTEMS

HIPAA: Health Insurance Portability

and Accountability Act:

HIPAA was signed into law in 1996 by President Clinton. The purpose is to improve portability and continuity of health insurance coverage. It’s also used as an opportunity to improve the efficiency and cost-effectiveness of the healthcare industry. The HHS (Health and Human Services) has established regulations for transmitting data and protecting the security and confidentiality of all type of patient information.

HIPAA REGULATIONS AT KDMC

One of the main focuses is the privacy of information within KDMC. We must take every precautions and measure to ensure the privacy of our patients information. This can be done in many ways, including:

1. Not leaving Medical Charts in an open area for others to see.

2. Being aware of others around you when discussing treatment or condition of patients.

3. Not leaving your computer screen with patient information visible.

4. Not giving out sensitive patient information over the phone.

5. Reporting misuse

HIPAA – Your Responsibilities:

Core members of the HIPAA Committee at

KDMC: Cathy Bridge-HIPAA

Coordinator Carl Smith-

Information Security Officer

Teresa Brown-Privacy Officer

Janet Wesselhoft-TCI Officer (Transactions, Code Sets, Identifiers)

Electronic Security is based on Policy IM 2.5-2.6 and is maintained by our HIPAA Committee. Please review both of these policies. Policy and actions are based on HIPAA regulations, as well as Joint Commission standards on Information Management. Meditech Patient Information Audits are conducted quarterly to determine if any potential violations have occurred. To do this, our committee chooses random employees and observes all patients that a particular employee has accessed. This not only pertains to clinical personnel, but to all employees of King’s Daughters Medical Center. Electronic Security extends beyond the Meditech System. It also relates to Internet access, faxing, email, voice mail, and any other type of electronic information. Access to computerized patient information is handled the same way as a patient’s.

ELECTRONIC SECURITY

Please Review:

1) Policies IM 2.5 & IM 2.62) Non-Acceptable Justifications for

accessing electronic information.3) Notes and Guidelines for Security

Badge Use.If you have any questions, please call Carl

Smith at ex. 9278

Medical Record or Chart. The information is the same, whichever

way you decide to view it.

“This is my child and I have a right to the

data, I am paying the bill.” This is my spouse and he/she asked me to

look up the information.” “I thought it was OK since I already have

access to everyone’s information. I’m a professional and I won’t discuss it with anyone.”

NON – ACCEPTABLE JUSTIFICATION:

“I thought it was OK since I wasn’t going to tell

anyone.” “This is my co-worker and I am very worried

about him/her.” “This is my Mom’s pathology report and I am

really worried about it. I wasn’t going to tell her the results. That’s the doctor’s job.”


‘My co-worker called me from home and asked

me to look up the information about their lab work. I had his/her permission to look at he lab results and tell them the results. They will verify that they gave me permission.”

“I can look at my OWN information when I want to. It’s about me.”


“I go to church with this patient and I may

need to pray for them.” “I know Dr Anderson is not his doctor but he is

on staff and he asked me to look up his father’s x-ray report.”


The new Access Control Door Security System uses Proximity devices to recognize employees who wish to gain access to certain areas. A Proximity device is a small black box which you will see located at employee entrances and certain departments. It recognizes the employee by sensing a computer chip located in the employee’s badge or key-tag.

To gain access to a door, you must simply hold your card in font of the reader until it beeps. The red light on the reader will turn green and the door will be unlocked. The first time you use the card, it will take about a second for it to read it. After that, it will only take a split second.

NOTES & GUIDELINES FOR SECURITY BADGE USE:

This include departments that are sensitive in nature and need controlled access. External doors consist of basically all employee entrances.

Your badge is not a standard generic card. It contains a number that is assigned strictly to you. Do not loan your security badge to anyone.

You must report loss of badge to Human Resources within 24 hours of loss.

No holes may be punched in the badge.

Internal Electronic Doors

Loss or personal destruction of badge will result in a $10 charge for replacement. This may be payroll deducted.

You must turn in your security badge to HR upon termination.

Report misuse of security badge to HR or Security officer immediately.

Violation of these rules will be strictly enforced Under HR 2.2 policies and could result in termination.

Security Badge Continues:

AGE SPECIFIC COMPETENCIES

Age-Specific Competencies

Communication – Speak softly, slowly, and calmly Involve parents

Comfort Keep warm and dry. Infants are prone to hypothermia. Do not separate from parent unless necessary.

Growth and development Dependent Communicates by crying

Safety Keep side rails up. Prone to head injuries from falls. Airways obstruct easily.

Collect data appropriately Furrowed brow, tightly shut eyes are signs of pain. Easily dehydrated with the loss of small amounts of blood, fluid or stool. Compromised with heart rates greater 200 beats per minute Poor gas exchange when congested.

Modify care appropriately Adjust medications and fluids Use distractions Keep parent in baby’s line-of-vision

Communication Communicate at child’s eye level Talk in simple language Give honest explanations Be patient

Growth & Development Clumsy and trips easily Self-centered thinking Has vivid fears and imagination

Comfort Keep familiar things nearby Give praise

Safety Do not leave unsupervised Transport with side rails Use caution around sharp edges

Collect data appropriately Limited vocabulary Be alert for signs of trauma Look for dehydration

Modify care Let child explore and touch equipment May accept procedures performed first on “Teddy” or other toy. Involve parent and child

Communications Do not “talk down” to child Help child to fee useful Explain procedures using correct terminology Encourage child and parents to ask questions Permit child some input in decisions

Growth & Development Active Seeks independence Understands cause & effect

Comfort Make intent of actions clear before touching child Allow child some choices and control

Collect date appropriately Use appropriate-size equipment Include parent & child

Modify care Allow child to make decisions (e.g. “In which arm to do you want to draw blood?”) Adjust fluids and medications for child’s weight

Comfort Permit peer group contracts

as much as possible Maintain privacy; protect

modesty

Safety Transport as adult Help recognize danger

Collect data appropriately Prepare for procedure

separately from parents Explain procedures

completely in adult language

Communication Show acceptance & respect Use adult vocabulary Encourage open

communication

Growth & Development Grows in spurts Maturing physically and

sexually Able to think abstractly Concerned about

appearance Challenges authority

Physical Characteristics Skeletal growth completed at

25 years Coordination & response speed

are at maximum Sensory functions are at their

peak Good problem-solving abilities Violence major cause of death

(MVA, etc.)

Psychosocial Characteristics 20 – 30 Intimacy vs Isolation

Developing interpersonal relationships

Capacity for intimate love Influenced by social & cultural

concerns

30 – 45 Generatively vs. Stagnation Productive Nurtures next generation with care &

concern

Nursing Interventions Assess emotional, financial &

physical support systems Allow patient to set own pace &

be self-directed Encourage participation in care Identify values that may affect

health care.

Physical Characteristic Muscle mass & strength begin to decrease Loss of agility On-set of arthritis Presbyopia occurs Sensory functions decrease Reaction times slow Memory changes occur Cardiovascular disease is major cause of death

Psychosocial Characteristics Generatively vs Stagnation

Care & concern for next generation Gender differences decrease Begin personal freedom & planning for retirement Reverses roles with parents

Nursing Interventions Support patient’s right to make an informed choice Support & affirm coping skills Provide referrals for emotional, financial & physical

support systems Allow patient to set own pace & be self-directed Encourage participation in care Identify values that may affect health care

Communication Show respect and

consideration. Do not patronize patient.

Speak distinctly and slowly Call patient by title and last

name unless patient asks to be called by another name.

If patient is hearing impaired: If patient uses a hearing aid,

make sure it is worn. Check hearing aid batteries

periodically. Look at patient while you

speak. Use a deeper voice, not a

louder voice.

Growth & Development Decreased auditory and visual

acuity Decreased ability to regulate

heat Memory skills begin to decline Increased learning and reaction

times Nutritional needs for

maintenance.

Comfort Keep patient warm (may need

extra blankets) Follow home or nursing home

schedule as much as possible. Maintain adult privileges (e.g.

decision making, privacy, personal habits

Safety Do not rush Keep cords and equipment out of patient’s path Weak or confused patients may need a safety belt while in wheelchair If patient wears glasses

Offer to clean patient’s glasses. Have patient to wear glasses while awake.

Collect data appropriately Perform assessment slowly Ask clear, precise questions – listen carefully Assess for confusion, orientation, and unsteady gait Monitor cardiovascular functions

Modify care Involve patient in decision-making and control pain Use caution with temperature of fluids, bath water, etc. Elderly patients may have complex care requirements Use extra precautions to prevent skin breakdown Maintain hydration and fluid and electrolyte balance.

RISK MANAGEMENT

Risk is the chance of loss or injury

Risk Management is an organized effort to identify, assess, reduce, and eliminate risk

revised: 2012

Risk Management

revised: 2012

How Safe is Healthcare?

revised: 2012

revised: 2012

revised: 2012

revised: 2012

revised: 2012

The public is better informed about healthcare issues now than they ever have been before. Accountability for outcomes is at an all time high. “hospitalcompare.com” is a public website. Facility information available:

What facility left a surgical instrument/sponge in a patient. What facility has the happiest patients. What facility has the most patient falls. What facility gave a patient an infection they did not have

when they came in. And on and on and on…

revised: 2012

Transparency in Healthcare

revised: 2012

Is It Really That Bad?

To improve patient care by being aware, identifying,

correcting, and preventing potential hazards or areas of risk exposures

To investigate and follow-up on incidents that do occur

Claims management

Risk prevention education

revised: 2012

Risk Management ProgramFocus and Objectives

Major tool for the identification of risk is the

“Occurrence Report”

Reporting is the responsibility of each person who provides care, treatment, or a service for a patient or witnesses an event.

Never assume someone else will do it!

revised: 2012

Occurrence Reporting Depends On YOU!!!!

If you are contacted by an attorney about an

occurrence involving KDMC, you are requested not to discuss any information.

If you are approached, please contact me right away.

revised: 2012

Talking to Attorneys

Any Event or Condition Which:

May result or has resulted in an injury to a patient or impairment of patient care

Reflects a major deviation from hospital policy, procedure, or practice

revised: 2012

What Should Be Reported To Risk Management?

revised: 2012

Examples of an Occurrence

Medication Events Patient/Visitor Falls Equipment Malfunction Policy/Procedure Variance

Serious Complaints Behavior Events Property Loss/Damage AMA/Walkouts

Remember the 5 Rights to Medication

Administration: Right Patient Right Drug Right Dose Right Route Right Time

revised: 2012

Medication Events How To Reduce The Risk!

Know the drug:

Use: Why is your patient receiving this drug? Dosage: Did the physician order the correct

dose? Side Effects: Is your patient’s complaint a side

effect? Name: Do you know the drug’s trade and

generic name?

Educate Your Patient and Their Families!

revised: 2012

If You Administer Medication:

An event resulting in an unanticipated death or major

permanent loss of function, not related to the natural course of the patient’s illness or underlying condition.

Sentinel Events must be reported immediately to RM in person or by phone.

revised: 2012

Sentinel Events!!!

revised: 2012

Ten of the Most Common Sentinel Events

Patient Suicide Medication Error Operative or Post-

Operative Complication

Wrong Site Surgery Delay in Treatment

Patient Falls Assault/Rape/Homicide Patient Death/Injury due

to restraints Patient Elopement Transfusion Error

revised: 2012

Completing an Occurrence Report

The employee who was directly involved should complete

Fill out all information correctly, completely, and sign and date the occurrence report

Forward the report to the Risk Manager within 24/48 hours

Do Not Make Copies!

If follow-up is initiated, document findings on the form, return to RM after investigation and documentation is completed

All copies are maintained by the Risk Manager.

COMPLIANCE

Following all local, state and federal laws consistent

with the highest standards of business and professional ethics.

To make sure that happens, KDMC has a COMPLIANCE OFFICER – Cathy Bridge

Privacy Officer – Teresa BrownSecurity Officer – Carl Smith

Compliance Officer reports to the Board of Trustees

revised: 2012

Healthcare Compliance

revised: 2012

Examples ofLaws and Regulations

Anti Kickback Antitrust Billing/Coding Boycotts Competitor Discussions Confidentiality (HIPAA) Conflict of Interest Controlled Substances Credentialing Employment EMTALA False Claims Act Fund Raising Gifts/Tips Hazardous Waste Disposal

Laboratory Mail/Wire Fraud Marketing OSHA Patient Referrals Patient Self Determination Physician Recruitment Political Contributions Purchasing/Bidding Record Retention/Disposal Safe Medical Device Act Securities State Licensure Tax Trade Associations

Read your Compliance Handbook Read the False Claims Act Policy Conduct yourself in a professional and ethical

manner at all times Report any concern or suspected violation(s).

It is your duty!

revised: 2012

Employee Responsibilities

Please read policy LM.1.19

Key Point:

Under no circumstances will patient information, written or visual, be published by a KDMC

employee.

revised: 2012

Social Media

If you suspect it, report it! It is the duty of each employee to

report promptly any concern and/or suspected violation(s)

The following is the mechanism for reporting: Supervisor Compliance officer (835-9175) Hotline (823-5327)

revised: 2012

Duty To Report Concerns And/or Suspected

Violations

Employees who willingly and intentionally

commit acts which are in violation of the law are subject to disciplinary action, including criminal and civil penalties

No disciplinary action will be taken against an employee for asking a question or reporting a concern or suspected violation of KDMC’s code of conduct

Employees are subject to disciplinary action for NOT reporting a concern or suspected violation

revised: 2012

Disciplinary Action

PATIENTSAFETY

Prevent Mistakes in Procedures. Use “Time Out” Before Procedures.

Correct Patient Correct Procedure Consent signed Correct site

marked Diagnostic studies

in room.

COMMUNICATE EFFECTIVELY

1). Get important test results to the Doctor or Nurse on time.2) “Do not use Abbreviations”3) Good “Hand Off” patient reports

Hand off Communication:

SBAR Allow time for

questions and answers about your patient’s:

S-Situation B-Background A-Assessment R-Recommendation

Use Meds Safely1.Label all medicines even during a procedure.

2. Double check doses of blood thinning medicines.

3. Be on alert for: “Look alike” & “Sound alike medicines”

U, u, IU QD or qd QOD or qod MS, MSO4, MgSO4 Trailing zeros (3.0mg) Lack of leading zeros (.3mg)

AVOID !!!!!“Do Not Use Abbreviations”

Reduce Risk of Infection:

Proper hand hygiene is the best defense against spreading germs.

Clean your hands whenever you go into a patients room and before you leave out, Every Time.

Check all Patients Medicines:

Before, during and after hospitalization.

List medicines accurately and completely.

Update medicine list each time patient changes settings.

Check!! Use Medicines Safely.

Help to identify patients at risk for suicide.

Signs of abuse Depression Talk or history of suicide

Identify Patient Safety Risks

Involve Patients In Their Care:

Educate patients and family about safety strategies.

Encourage patients’ active involvement in their own safety.

Provide and communicate the means for patients and families to report concerns about patient safety issues.

Use two ways to identify patients.

Make sure the correct patient gets the correct blood transfusion.

Identify Patients Correctly

REMEMBER: PATIENT SAFETY

IS EVERYONE’S JOB!!!

INAPPROPRIATE CONDUCT

What you must know in today’s workplace.

Discrimination or segregation based on:

Race Color Religion National origin Gender Age or Genetics

What is Inappropriate Conduct?

(Harassment)

How it is defined, and how the courts and the

government apply that definition. What specific steps you can take to ensure

that you are not breaking the law. What behavior can you expect from others.

Three Things about Inappropriate Conduct:

(harassment)

Unwelcome sexual advances, request for sexual favors,

and other verbal or physical conduct of a sexual nature constitutes sexual harassment when: Submission to such conduct is made either explicitly

or implicitly a term or condition of an individual’s employment.

Submission to or rejection of such conduct by an individual is used as the basis for employment decisions effecting such individual or:

Such conduct has the purpose or effect of unreasonably interfering with an individual ‘s work performance or creating an intimidating, hostile, or offensive working environment.

EEOC’S Definition of Sexual Harassment:

The Quick Picture: (THE DANGER ZONES)

The law defines three kinds of conduct that are considered sexually harassing: Unwelcome sexual

advances. Request for sexual

favors. Other verbal or

physical conduct of a sexual nature.

The conduct must be unwelcome. Participation in the conduct is made a term or

condition of employment or is used as the basis for employment decision.

The conduct has the purpose or effect of unreasonably interfering with work performance, or of creating an intimidating, hostile, or offensive working environment.

Defining Harassment:

We must treat Co-workers fair and with

respect. It is unpleasant to work in an

inhospitable environment. It is a violation of Federal Laws. Consider the bottom line.

Lost time and resources Legal fees Possible judgment

WHY YOU MUST KNOW ABOUT HARASSMENT?

GUIDELINES FOR BEHAVIOR

Avoid the danger zone behaviors.

Quid pro quo harassment. (Something for Something)

Hostile environment harassment.

Situations you might not think of : Within your office walls Beyond the office walls Computer, e-mail, and

the web Non-employees

IF YOU FEEL YOU ARE BEING HARASSED:

Ask yourself: Do I feel uncomfortable?

Step #1: Talk to the harasser.Step #2: Tell your supervisor.Step #3:Tell Human Resources.

WHAT WILL HAPPEN???

King’s Daughters Medical Center will take action and investigate.

Cultural Diversity

They’re the skills you use to work well with co-

workers and patients of all cultures. Considering a patients culture when giving care. Relating to each patient & co-worker as an

individual.

What are Cultural Competencies?

Help patients receive more effective care.

Help our organization meet TJC standards.

Improve your job performance.

Why Do We Have Cultural Competencies?

Gaining Self Awareness

Know your own beliefs & practices Think about how

your culture & upbringing affect you. Showing

politeness Expressing pain Appropriate ways

to treat children or older adults

Country of origin Preferred language Communication style Views of health Family & community relationships Religion Food preferences Consider other factors that may affect

care. Age, Gender, Sexual orientation Socio-economic status Presence of a physical or mental disability.

Cultural Factors To Be Aware Of:

Developing cultural competencies does not

mean knowing everything about every cultural group you work with. It does mean: being aware of cultural factors taking appropriate steps to learn about each

individual.

Cultural Competencies

What is a Culture? Religion, Family, Nationality What are Stereotypes? Filters by which We

view & hear others. Mostly negative Where do Stereotypes come from? Developed by groups due to their lack of

knowledge about another group. (Ignorance) Most are taught to us as children by parents,

grandparents, aunts and uncles.

Stereotypes v/s Cultures

Listen to how the patient talks about his or her

condition. Ask indirect questions, if needed. Look for clues. Talk with others who know the patient. Ask for the patient’s views on treatment. Use interpreters effectively.

Communicate Effectively

Use Cultural Knowledge to Improve Patient Care

When staff members make the effort to work well together: Job satisfaction

increases. Patients receive the

best care. Challenge Stereotypes

Ask questions to avoid cultural stereotypes.

Get to know co-worker and patients as individuals rather than as a member of a group.

Change…The One Constant in the

Universe.

We must change to master change.

Lyndon B. Johnson

ALMOST DONE!

After filling out your test packet in it’s entirety,

YOU must turn it in to get credit to:

Kim Bridge or Tammy CalcoteEducation Annex(601) 835-9406

[email protected]

How to completeAnnual Review

Documents

ANNUAL REVIEW ONLINE