Welcome to Student Affiliate Orientation at CHA

1. Welcome to Student Affiliate Orientation at CHA

2. Objectives • To give Clinical Students brief overviews of areas which are required by regulatory agencies, such as the State Board of Health. • We do not expect you to remember all of this information, but just want to present this material so that you are slightly familiar with the terms and procedures.

3. Student General Information • Rules and Regulations • NRCP-HIPAA-Confidentiality • Guidelines

4. Hospital Regulators & Acts • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) • Board of Health (county and State offices) • HIPAA • EMTALA

5. Organizational Chart John Harris VP CFO Keith Trent Foundation Director/ Community Relations Lisa Halstead VP Professional/Ambulatory Services Sherry Sidwell VP Integrated Services Dr. Bill VanNess President/CEO Steve Majors VP H.R./Information Services Beth Tharp VP Patient Care Services Betty Crum Long Term Care Jeane Atkinson Materials/Property Mgmt.

6. Mission The mission of Community Hospital is to serve the medical health, and human service needs of the people in Anderson, Madison County, and contiguous counties with compassion, dignity, respect, and excellence. Service, although focused on injury, illness, and disease will also embrace prevention, education, and alternative systems of health care delivery.

7. SERVE Evaluation Tool • Service • Enthusiasm • Respect • Value • Excellence

8. Who are our customers? • Patients/Families • Volunteers • Students • Employees • Physicians • Payors

9. Customer Expectations • Our Job is to Exceed Expectations: • Respect • Courtesy • Privacy • Dignity • To be informed • Right to Refuse • There are many more

10. A NETWORK STANDARDS We, the employees of the Community Health Network, see every customer interaction as a genuine opportunity to serve. It is with this intent in mind that we commit the following to all of our customers and to one another:

11. Attitude We will be caring, compassionate and approachable in all of our customer contacts. (The key characteristics that will demonstrate our positive attitude will include our genuine smiles, direct eye contact, authenticity, openness, and listening actively). We will greet our customers with our customer’s name (if possible), with our name, and with the statement, “How may I help you?” We will end our customer interactions with the question, “Is there anything more that I can do for you?”, and follow through accordingly.

12. Privacy We will respect our customer’s right to privacy and modesty by creating and maintaining a secure and trusting environment.

13. Telephone Etiquette • We will provide excellence in telephone courtesy. Our courtesy will be projected when we: • a. Answer the telephone within three rings • b. State the department reached • c. State our own name • d. Ask “How may I help you?” • We want our customers to hear our “smiles”.

14. Appearance • We will view ourselves through the eyes of our customers. Each of us, along with our facilities, will be easily identifiable to our customers. Our personal appearance will be professional, clean, tasteful, discrete and in attractive condition. We will take personal ownership in the appearance of our work environment. • No “name brand” apparel • Always have on name tag

15. NO SMOKING

16. Initiative When we see a problem, wherever it is, we will take the necessary steps to fix it -- IMMEDIATELY.

17. Customer Acknowledgement We will delight our customers with our personalized attention. We will actively listen when customers ask for directions within one of our facilities, and offer an escort to their destinations. When a customer’s destination is another facility, we will provide a map on which we will mark the directions. We will be courteous, friendly, and helpful when responding to customer needs.

18. Customer Waiting We will recognize that our customers’ time is very valuable. From the moment our customers enter our service centers or request help, we will greet and provide them with prompt service. If customers have to wait longer than 10 minutes, we will let them know when they can expect the service, and we will update them every 10 minutes.

19. Customer Information and Education We will provide customers with the expert information they need to make informed, positive, personal, or professional choices. We will do what it takes to ensure information is presented to our customers in a clear, understandable manner. We will use an interdisciplinary approach to customer education.

20. Continuous Quality Improvement • Plan Do Check Act • Tools • Process Improvement Teams • Re-engineering Teams • Others • Total Quality = Clinical Quality + Service Quality

21. Community Hospital Anderson “notes” • 130-150 patient rooms “beds” • 2nd floor: OB, Pediactric, ICU • 3rd floor: 3E and 3N Med/Surg • 4th floor: Extended Care/ InPatient Therapy • 5th floor: Short Stay/ Quick Trip, Lab

22. Network Responsibility and Compliance Program&HIPAA&Patient Rights

23. Network Responsibility & Compliance Program (NRCP) • Helps us achieve quality by ensuring that we comply with various Federal and State laws, rules and regulations, accreditation and certification standards, network policies and ethical standards. Doing the right thing and acting with integrity!

24. Ethics • The watchword of hospital ethics is discretion. Anything you hear or see should be considered confidential. • Example: Reception desk personnel are obligated not to discuss information on the patient’s admitting papers. • Example: Volunteers are not to check the files to see who is in the hospital, or read admitting papers while taking a patient to the laboratory. • It is a BREECH OF ETHICS to discuss patient information INSIDE OR OUTSIDE the hospital. • When acquaintances come to the hospital, do not question them concerning their reasons for being there. Never discuss a patient’s illness with him/her.

25. Information concerning the care of a patient is always personal in nature and; therefore any information about his/her condition, care, treatment or personal data is absolutely confidential and must not be discussed with anyone other than those directly responsible for his/her care and treatment. Only designated employees of the hospital may release information about patients. Please be discreet in your conversations. A violation of confidential information is a violation of hospital ethics. Ethics

26. Code of Conduct • Treat all of our customers fairly, ensuring equal opportunity and freedom from discrimination, harassment or violence of any kind. • Appearance of misconduct or impropriety can be very damaging to the Network’s reputation and our ability to service our customers is critical.

27. Confidentiality HIPAA: Health Insurance Portability and Accountability Act of 1996

28. Confidentiality Protecting Confidential Patient Information in Any Form Is Everyone’s Responsibility !!

29. Patient Confidentiality • New Federal Regulations under HIPAA require more protections for patient medical information and records. • Severe penalties will be imposed for non-compliance (civil fines of $100/violation up to $25K/yr; Criminal penalties $250K & 10 yrs prison if for personal gain, malicious harm or commercial benefit).

30. We should do the following: • Properly dispose of any notes, documents, labels and any items that contain Patient Information. • This includes: Patient Name, Address, Phone No., Account No., Hospital Room No., Diagnosis, DOB, and any other identifying information

31. We should do the following: • ALL trash with Patient information on it should be placed in the Shred Containers located in the patient care office and lounge areas. These are marked “Shred it”

32. HIPPA Highlights: • Does the HIPPA Privacy Rule allow health care providers to transmit protected health information (PHI) in e-mails? • E-mailing PHI must be done with the utmost caution. While the HIPAA Privacy Rule does not specifically address e-mailing of PHI, WE are ultimately responsible for our patients’ PHI in any format. There is a very big risk of violating patients’ privacy when you e-mail PHI over the Internet. Why? • Email messages sent outside the Network, through the Internet is not secure. • Information included in these messages could be intercepted and read, just like a postcard. • It is our Network’s policy that PHI MAY NOT be sent out unprotected over the Internet

33. HIPAA HIGHLIGHTS: • You should be equally careful when putting patients’ PHI in e-mail messages sent within our Network. • It is just too easy to forward e-mail messages

34. Things you can do to reduce the risk of violating HIPAA: • Eliminate any patient information in e-mail. • When forwarding or responding to e-mails; delete previous messages and subject lines containing PHI. • Reduce the amount of PHI in the e-mail. • Do not use Patient names in e-mail. • Password protect files when attaching files containing PHI. • Consider alternatives: Fax or Snail/Regular Mail • Contact IS Security of assistance in finding secure electronic means to share PHI with other providers.

35. Key Points To Remember • All employees during their employment and thereafter, have a moral as well as legal obligation to keep all information concerning patients in the strictest confidence. • Access to patient information should begin when you are directly involved in providing some portion of the care they receive. • The federal government has issued new privacy regulations called HIPPA (Health Insurance Portability and Accountability Act) which ALL Healthcare Providers MUST comply with (effective April 2003).

36. The following instructions are to find “patient’s rights on the Inside Anderson Link (CHA Intranet): CLICK: Departments>Nursing>Patient Rights

37. Patient Rights • Each patient has rights, which are founded in our tradition and history, our moral and ethical standards, and federal and state laws, rules and regulations. • Key Patient Rights Include: • Access to care by qualified caregivers • Respect of personal values, beliefs and civil rights • Informed participation in care • Privacy and confidentiality

38. Patient Rights Continued… • Key patient rights include: • Expression of opinions/complaints and receipt of resolution • Holistic care at the end of life We provide access to care and make clinical judgments and decisions based solely upon what is in the best interests of the patient, without respect to the patient’s ability to pay.

39. When each of us observe and conduct ourselves in accordance with these guidelines every day, in everything we do, we build and reinforce our commitment to excellence, and we contribute to fulfilling CHA’s mission of “making a difference”.

40. 5 minute break…

41. Disaster Codes & Safety

42. DISASTER CODES DIAL 66 CODE RED - FIRE CODE BLUE - CARDIAC/RESP. ARREST CODE 7 - CALL FOR ASSISTANCE CODE PINK - CARDIAC/RESP. ARREST (OB/NURSERY ONLY) CODE I - INFANT ABDUCTION CODE EXTERNAL - EXTERNAL DISASTER EMERGENCY CODE INTERNAL - INTERNAL DISASTER EMERGENCY CODE GREEN - HAZARDOUS MATERIAL/WASTE SPILL EXTERNAL CODE GREEN - TOXIC CLOUD WEATHER WATCH - SEVERE WEATHER, POSSIBLY TORNADO WATCH WEATHER WARNING - TORNADO WARNING CODE B – BOMB THREAT CODE E – EARTHQUAKE CODE H – HOSTAGE/WEAPON (Security & Administrative Reps. Only) For further information, refer to your Red Safety Manual

43. To report a Disaster • Student and Patient Safety first, then… • Dial 66 • Give type and location of the

44. In Case of a Fire • Pull the nearest fire alarm. • Dial 66 • Switchboard will page “Code Red” (and location, if known) four times over the public address system.

45. Special Instructions • DO NOT use any elevators until the “All Clear” is announced. • All visitors are to remain either in the patient rooms, cafeteria or main lobby. They are not to move from one area to another. • Students and patients already on elevators enroute to a specified area should be taken to the intended destination and placed in the care of the person in charge of the department.

46. Special Instructions continued… • Students are to stay with a patient they are transporting and other volunteers are to return to their assigned area via the stairway. • When working weekends or evenings, since offices are closed, a worker should go to the front door. Do not allow anyone to leave or enter until “All Clear” is heard.

47. CodeBlue • Cardiac/ Respiratory Arrest

48. Code Pink • Cardiac/ Respiratory Arrest (OB/Nursery Only)

49. Code 7 Call for Assistance

50. Code I • Infant /Abduction • Screen all persons leaving. • Carefully observe suspicious behavior and note physical description. • If abduction occurs from O.B./Nursery: “Code I” will be called. • If abduction occurs from Pediatric Unit: “Code I” along with the age of the child will be called.