welcome. test compliance and confidentiality form tb health assessment form print out all forms:...
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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.”
NON – ACCEPTABLE JUSTIFICATION:
‘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.”
NON – ACCEPTABLE JUSTIFICATION:
“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.”
NON – ACCEPTABLE JUSTIFICATION:
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
How to completeAnnual Review