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Corporate Compliance ProgramCorporate Compliance Program
To understand the ethical, To understand the ethical, professional, and legal obligations professional, and legal obligations we have and our role in meeting we have and our role in meeting these obligationsthese obligations
To promote honest, ethical To promote honest, ethical behavior in the day to day behavior in the day to day operationsoperations
To identify, correct and prevent To identify, correct and prevent illegal conductillegal conduct
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Principles of CompliancePrinciples of Compliance
As healthcare professionals and As healthcare professionals and providers, we are dedicated to caring providers, we are dedicated to caring for and improving the health and well for and improving the health and well being of the people we serve in the being of the people we serve in the communitycommunity
Compliance means doing what is Compliance means doing what is right, not just what is requiredright, not just what is required
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Benefits of Compliance ProgramBenefits of Compliance Program
Structure to manage compliance with Structure to manage compliance with laws and regulationslaws and regulations
Potentially reduces fines and Potentially reduces fines and penalties if effectivepenalties if effective
Avoidance of negative publicityAvoidance of negative publicity Improve clinical quality and fiscal Improve clinical quality and fiscal
performanceperformance
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Corporate ComplianceCorporate Compliance
Code of conductCode of conduct
Conflict of interestConflict of interest
Documentation and billingDocumentation and billing
Questionable behaviorsQuestionable behaviors
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Questionable BehaviorsQuestionable Behaviors
Discrimination and harassmentDiscrimination and harassment Dishonest communicationDishonest communication Violations of confidentialityViolations of confidentiality Conflicts of interestConflicts of interest Inappropriate giftsInappropriate gifts Stealing/misuse of assetsStealing/misuse of assets Fraud, abuse and false claimsFraud, abuse and false claims Improper lobbying Improper lobbying Misuse of proprietary informationMisuse of proprietary information
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Corporate Compliance ReportingCorporate Compliance Reporting
Report activity to immediate supervisorReport activity to immediate supervisor
Report to higher level managerReport to higher level manager
Report to Corporate Compliance Officer: Report to Corporate Compliance Officer: Anne Mason, 821-4469Anne Mason, 821-4469
CHS Compliance line 1-888-200-5380, CHS Compliance line 1-888-200-5380, 24/7, confidential and, if desired, 24/7, confidential and, if desired, anonymousanonymous
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• LEP Patient = non-English speaking
• An interpreter must be provided to LEP patients emergency - within 10 minutes
non-emergency - within 20 minutes
• CHS has phone interpreter services available 24/7
• Free of charge
• CHS staff may not serve as an interpreter
• Family members under the age of 16 may not be used as interpreters except in emergency situations until an interpreter is contacted
Language Assistance ProgramLanguage Assistance Program
REQUIRED BY LAWREQUIRED BY LAW
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Language Assistance ProgramLanguage Assistance Program
Secure an InterpreterSecure an Interpreter•Identify LEP patient
•Determine pt language - wall poster or brochure
•CHS trained staff will contact an interpreter via instructions located at their respective workstations.
•Pt will be notified of FREE interpreter service
Patients who present to security stations or front lobby should be taken to Admissions, Registration, ED, Patient Representative or Nursing Supervisor for further assistance.
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Language Assistance ProgramLanguage Assistance Program
Chart DocumentationChart Documentation•Any provision or refusal of LEP services
MUST BE DOCUMENTED in the patient chart.
•Specific documentation guidelines must be followed.
•Documentation guidelines can be found in the Language Assistance for Limited English Proficient (LEP) Persons and Hearing Impaired Policy and Procedure and are located on Compliance 360.
•Staff should always contact an interpreter to ensure quality patient care and to minimize liability to individual staff members as well as the organization.
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New York State Patient Bill Of New York State Patient Bill Of RightsRights
19 Bill of Rights19 Bill of Rights
They are posted in all They are posted in all patient care areaspatient care areas
They are available in They are available in Spanish as well as EnglishSpanish as well as English
If they don’t understand their rights, If they don’t understand their rights, someone needs to explain themsomeone needs to explain them
Receive treatment without discriminationReceive treatment without discrimination Receive considerate and respectful care in a Receive considerate and respectful care in a
clean safe environment free from clean safe environment free from unnecessary restraintsunnecessary restraints
Receive needed emergency careReceive needed emergency care Know the names and positions of people Know the names and positions of people
caring for them, and refuse their treatmentcaring for them, and refuse their treatment Know who the MD is who is in charge of Know who the MD is who is in charge of
your hospital careyour hospital care A non smoking roomA non smoking room Receive complete information about their Receive complete information about their
diagnosis, treatment and progressdiagnosis, treatment and progress Receive all information for informed Receive all information for informed
consentconsent Receive all information to give informed Receive all information to give informed
consent regarding do not resuscitateconsent regarding do not resuscitate Refuse treatment and be informed of effectRefuse treatment and be informed of effect Refuse to take part in researchRefuse to take part in research Privacy in the hospital and confidentiality of Privacy in the hospital and confidentiality of
all information and records of your careall information and records of your care Participate in decision making about their Participate in decision making about their
care, including dischargecare, including discharge Review of their medical recordReview of their medical record Receive an itemized bill with explanation of Receive an itemized bill with explanation of
chargescharges Complain without fear of reprisalComplain without fear of reprisal Authorize family members to visitAuthorize family members to visit Make known your wished regarding Make known your wished regarding
anatomical giftsanatomical gifts
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What is “Risk Management”?
Risk Management is the systematic review
of events that present a potential for harm and could result in loss for the
hospital system..
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FOUR ELEMENTS OF RISK MANAGEMENT
Risk Identification
Review Occurrence Reports Review Patient/Visitor Complaints Participate in Root Cause Analysis Review concerns expressed by CHS staff
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Loss Prevention
Educational Programs through
CHS University Department specific inservices
FOUR ELEMENTS OF RISK MANAGEMENT
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FOUR ELEMENTS OF RISK MANAGEMENT
Claims Management
Investigating & reporting occurrences and claims made
Assist with Summons & Complaints and Subpoenas *** REMEMBER TO NOTIFY RISK MANAGEMENT IMMEDIATELY UPON RECEIPT OF SUMMONS OR SUBPOENA
Assist with discovery requests for lawsuits
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FOUR ELEMENTS OF RISK MANAGEMENT
Risk FinancingObtaining & maintaining appropriate
insurance coverage
HPL (Healthcare Professional Liability) GL (General Liability) D&O (Directors & Officers) Property & Casualty Auto CrimeFiduciary (Finance)
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What is an Occurrence?
An occurrence is an event that was unplanned, unexpected and unrelated to the natural course of a patient’s disease process or routine care and treatment.
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What is an
Occurrence?
An occurrence is not consistent with the accepted standard of careor the routine operation of a facility and has the potential to or already has had an untoward effect on patient care.
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What are sources of an
Occurrence?PatientsPatientsVisitorsVisitorsPatient/Family ComplaintsPatient/Family ComplaintsSecurity reportsSecurity reportsEquipment “failure”Equipment “failure”
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What is an Occurrence Report?
An occurrence report is a factual account of the details of an occurrence. It is
prepared and reviewed for the purpose of enhancing the quality of patient care,
providing a safe environment, and identifying potential liability.
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Enhance the quality of patient care
Assist in providing a safe environment
Quick notice of potential liability
What is the purpose of an Occurrence Report?
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Who can complete an Occurrence Report?
Any associate or physician who discovers, witnesses or to whom
an occurrence is reported, is responsible for documenting the event immediately by means of the Occurrence Report. Anyone who requires assistance should
contact the department manager.DO NOT MAKE COPIES OF AN
OCCURRENCE REPORT
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What happens to the Occurrence Report?
The completed Occurrence Report is to be forwarded
to the Department ManagerWho will investigate the
occurrence and forward to either PI or Security as
indicated in the Risk Management process
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Risk Management Process
Patient and visitor safety are assessed from both clinical and
environmental perspectives
Notify Performance Improvement of patient occurrences Notify Security of visitor or property occurrences Risk Management will be notified by PI or Security and will participate in evaluation of occurrence Risk management will report occurrences to insurance carrier in cases of potential liabilityRisk Management will manage claim as indicated
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Documenting an Occurrencein the medical record
•Date (MM/DD/YY) and time (military)•State facts, be clear and concise•Your own observations•If event described to writer, use quotes or “according to…”•Do not place blame in the record•DO NOT REFER TO OCCURRENCE REPORT
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EMTALA REGULATIONSEMTALA is the Emergency Medical Treatment and Active Labor Act (aka COBRA)EMTALA provides a guideline for safely and appropriately transferring patients in accordance with Federal regulations. The law provides for a medical screening exam (MSE) to all individuals seeking emergency services on hospital property. Hospital property includes the driveway, parking lot, lobby, waiting rooms and areas within 250 yards of the facility.
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EMTALA REGULATIONSIf an emergency medical condition is found, it will be stabilized within the hospital’s ability to do so, prior to the patient’s transfer or discharge.If a patient does not have an emergency medical condition, EMTALA does not apply.
*** IMPORTANT: NEVER SUGGEST THAT A PATIENT GO ELSEWHERE FOR TREATMENT
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Catholic Health SystemCatholic Health System
RISK MANAGEMENT
DEPARTMENT Carol Ahrens, RN, BSN 821-4462Director, Risk Management
Joanne Ricotta, RN, BSN 821-4463Risk Management Coordinator
Linda McGavin 821-4467Risk Management Technical Assistant
Valerie Pizarro 821-4468Administrative Assistant
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Introduction According to the Bureau of Labor Statistics
(BLS), 2,637 nonfatal assaults on hospital workers occurred in 1999. Rate in hospitals is 8.3 assaults per 10,000
workers *(2000 statistics report increase to 25 per 10,000)
Rate in private sector industry is 2 per 10,000 workers
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Introduction Violence takes place
During times of high activity such as meal time or visiting hours or patient transportation
When service is denied When a patient is involuntarily admitted When limits are set regarding eating, drinking,
tobacco or alcohol use
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What is Workplace Violence?? Wide range from offensive or threatening
language to homicide
NIOSH (National Institute for Occupational Safety and Health) defines workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.
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Examples Threats: Expressions of intent to cause harm,
including verbal threats, threatening body language, and written threats.
Physical assaults: Attacks ranging from slapping and beating to rape, homicide, and use of weapons such as firearms, bombs, or knives.
Muggings: Aggravated assaults, usually conducted by surprise and with intent to rob.
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Case Reports An elderly patient verbally abused a nurse and
pulled her hair when she prevented him from leaving the hospital to go home in the middle of the night.
An agitated psychotic patient attacked a nurse, broke her arm, and scratched and bruised her.
A disturbed family member whose father had died in surgery walked into the E.D. and fired a handgun, killing a nurse and an EMT and wounding a physician.
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Case Reports Workplace violence in general is most often
related to robbery Workplace violence in hospitals usually
results from patients and occasionally from family members who feel frustrated, vulnerable, and out of control.
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Who is at Risk?? Nurses and nursing assistants have the most
direct contact with patients and are at a high risk.
Other hospital personnel includes emergency response personnel, hospital safety officers, and all health care providers.
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Where May Violence Occur?? Anywhere in the hospital but it is most
frequent in the following areas: Psychiatric wards Emergency rooms Waiting areas Geriatric units
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What are the Effects of Violence?? Effects can range in intensity and include:
Minor physical injuries Serious Physical injuries Temporary and permanent physical disabilities Psychological trauma Death
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Effects of Violence Violence can have a negative organizational
outcome reflected by: Low morale Increased job stress Increased worker turnover Reduced trust of management or co-workers Hostile working environment
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Risk Factors Working directly with violent people; those
under the influence of drugs, alcohol or have a history of violence or psychotic diagnosis
Working when understaffed Transporting patients Long wait for service Overcrowded, uncomfortable waiting rooms Working alone
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Risk Factors Poor environmental design Inadequate security Lack of guidelines for preventing and
managing crisis Drug and alcohol abuse Access to firearms Unrestricted movement of the public Poorly lit corridors, rooms, parking lots
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General Prevention Strategies Environmental:
Alarms Security devices Escorts to parking lots at night Good lighting Design waiting areas Staff restrooms and exits Enclosed nurses’ stations
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General Prevention Strategies Administrative controls:
Staffing patterns to prevent personnel from working alone
Prevent patient waiting time Restrict movement of public in hospitals Security personnel alert system
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General Prevention Strategies Behavioral Modifications
recognizing and managing assaults resolving conflicts maintaining hazard awareness
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Dealing with violence Provide open communication Develop written procedures for reporting and
responding to violence Offer and encourage counseling
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Safety Tips Watch for signals of impending violence:
Verbally expressed anger and frustration
Body language such as threatening gestures
Signs of drug or alcohol use
Presence of weapons
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Diffusing Anger Present a calm, caring attitude
Don’t match the threats
Don’t give orders
Acknowledge a person’s feelings
Avoid behavior that may be interpreted as aggressive
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Be Alert Evaluate when you enter a room or begin to
relate to a patient or visitor Be vigilant throughout the encounter Don’t isolate yourself with a potentially
violent person Keep an open path for exiting
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To Diffuse the Situation QUICKLY.. Remove yourself from the situation
Call security for HELP
Report any violent incidents to management
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Strategies that have worked… Metal detector in a Detroit hospital during a 6
month period prevented entry of: 33 handguns 1,324 knives 97 mace sprays
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Strategies that have worked… Violence reporting program in Portland
Oregon identified patients with history of violence in a computer database.
Reduced violent attacks by 91.6% by alerting staff to take additional safety measures when serving these patients
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Strategies that have worked… New York City hospital: Restricted movement of visitors using ID
badges and color-coded passes to limit each visitor to a specific floor
Enforced a limit of two visitors per patient Over 18-months, reduction of reported violent
crimes by 65%
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Summary No universal strategy exists to prevent violence
All hospital workers should be alert and cautious when interacting with patients and visitors
Staff participation in safety programs regarding violence prevention
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‘‘The The process of transformingprocess of transforming CHS into an CHS into an
organization with a organization with a superior abilitysuperior ability to to
deliver deliver patient-centeredpatient-centered, quality, , quality,
compassionate healthcare through compassionate healthcare through
outstanding outstanding
professionals and innovative technology.’professionals and innovative technology.’
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Welcome to EquinoxWelcome to Equinox
• Equinox - Why?– Four Hospitals – “grew-up” with their own
process, culture, technology– Need to establish Electronic Medical Record
• Equinox – How?– Comprehensive system-wide effort to
standardize and improve processes• Standardized Clinical Practices
– Getting the right tools in the hands of our associates – Nurses, Doctors, Administrators
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Welcome to EquinoxWelcome to Equinox
• Equinox - When?– Now! Process started in 2004 and is
ongoing– Strategic Alliance with Siemens Medical
Solutions – 10 year agreement
• Equinox – Who?– Everyone – directly and indirectly!
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• Managing The Process – The TMO– Multidisciplinary Team Dedicated to
Transformation Initiatives (Transformation Management Office)
• Clinicians• Finance/Patient Access• Technology/Project Management• Communications• Administrative Leadership
Welcome to EquinoxWelcome to Equinox
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• Function of the TMO Team:– Articulates Existing Processes/Workflows &
Recommends Improvements– Coordinates Disparate & Intersecting
Projects– Collaborates with Siemens – Manages
Strategic Alliance– Communicates With All Stakeholders– Provides Counsel to Stakeholders
Welcome to EquinoxWelcome to Equinox
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Welcome to EquinoxWelcome to Equinox
• Examples of Equinox in Action:– Soarian Clinicals– Clinical Standardization– Financial Process Redesign– St. Joseph Campus Emergency Room
• Process• Culture• Technology
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Welcome to EquinoxWelcome to Equinox
• Your Role…– Stay informed– Ask questions– Identify ways to “do it better” always
with the patient in mind– Embrace change!