Orientation Brochure - Christiana Care Health System

Medical‐Dental Staff Services Department

302‐623‐2507

[email protected]

1

Welcome

Christiana Care's Medical‐Dental staff includes nearly 2000 physicians,

surgeons, podiatrists, dentists, and other healthcare providers representing

every medical practice and specialty. We celebrate and recognize the

contributions of each of our members.

We are excited to have you as part of our team and hope you find the

information contained in this brochure helpful.

Please feel free to contact Physician Relations for additional information at

302‐623‐0595.

Mike Cinkala

Director, Provider Relations

Christiana Care Health Services

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ORIENTATIONGUIDEContents

CHRISTIANA CARE WAY ...................................................................................................................................... 4

ADMISSION PREFERENCES .................................................................................................................................. 4

CLINICAL DOCUMENTATION/CODING ................................................................................................................. 4

CLINICAL GUIDELINES AND PROTOCOLS ............................................................................................................. 4

CLINICAL TRIALS ................................................................................................................................................. 4

CODE OF CONDUCT ............................................................................................................................................ 4

COMMUNICATION ............................................................................................................................................. 5

COMPLIANCE ..................................................................................................................................................... 5

COMPUTER ASSISTANCE .................................................................................................................................... 6

CONTINUING MEDICAL EDUCATION (CME) ......................................................................................................... 6

CREDENTIALING/PRIVILEGING ............................................................................................................................ 6

CULTURE OF RESPONSIBILITY ............................................................................................................................. 6

EMPLOYEE ASSISTANCE PROGRAM .................................................................................................................... 6

EXECUTIVE HEALTH RESOURCES ......................................................................................................................... 7

FIRE SAFETY AND EMERGENCIES ........................................................................................................................ 7

FITNESS CENTERS ............................................................................................................................................... 7

FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE) ................................................................................... 7

FOOD OFFERINGS ............................................................................................................................................... 7

HOSPITALIST SERVICES ....................................................................................................................................... 7

ID REPLACEMENT & BADGE ACCESS................................................................................................................... . 7

INFECTION PREVENTION ................................................................................................................................... . 7

LOUNGES ........................................................................................................................................................... 8

MEDICAL EXECUTIVE COMMITTEE (MEC) ............................................................................................................ 8

MEDICAL LIBRARIES ........................................................................................................................................... 8

ONGOING PROFESSIONAL PRACTICE EVALUATIONS (OPPE) ................................................................................ 8

PARKING ............................................................................................................................................................ 8

PATIENT IDENTIFICATION ................................................................................................................................... 9

PATIENT RELATIONS ........................................................................................................................................... 9

PRIVACY (INFORMATION SECURITY) ................................................................................................................... 9

PUBLIC WEBSITE PROFILE & REFERRALS .............................................................................................................. 9

RAPID RESPONSE TEAM (RRT) ............................................................................................................................ 9

QUALITY PARTNERS…………………………………………………………………………………………………………………………………………...9

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QUALITY & SAFETY ............................................................................................................................................ 10

SENTINEL EVENTS .............................................................................................................................................. 10

TOURS .............................................................................................................................................................. 11

APPENDIX A: KEY CONTACTS ............................................................................................................................. 12

APPENDIX B: CODE OF CONDUCT ..................................................................................................................... .13

APPENDIX C: CULTURE OF RESPONSIBILITY ........................................................................................................ 14

APPENDIX D: MEDICAL LEADERSHIP ROSTER ..................................................................................................... 15

APPENDIX E: PARKING MAP .............................................................................................................................. 16

APPENDIX F: FIRE, EMERGENCY AND SAFETY INFORMATION ............................................................................. 17

APPENDIX G: GUIDELINES AND POLICIES FOR YOUR REVIEW: CODE OF ORGANIZATIONAL ETHICS, INFORMATION

SECURITY, PHYSICIAN HEALTH, PAIN MANAGEMENT, RESTRAINT AND SECLUSION, OPPE AND FPPE, DISCLOSURE,

PEER REVIEW AND PROCTORING ....................................................................................................................... 20

All Phone Numbers are located on Page 12

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CHRISTIANA CARE WAY

"We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating

innovative, effective, affordable systems of care that our neighbors value." To understand more

about the Christiana Care Way, please visit our site. http://www.christianacare.org/way

ADMISSION PREFERENCES

Christiana Care provides Primary Care, Internal Medicine, & Pediatric physicians with the option of

having admission preferences on file. Contact Physician Relations at 302‐623‐0595 or

[email protected] for more information.

CLINICAL DOCUMENTATION/CODING

Clinical documentation is vital to the quality and safety of patient care. As you are performing this

important function, please keep these points in mind and contact the Case Management team at

302‐733‐2222 CHR or 302‐320‐4941 WILM for more information. The CCHS Rules and Regulations

outline all documentation requirements.

PowerChart is the system we use for Computerized Provider Order Entry. Completion of training is

required prior to use of the system. While some training is available on our external site, you may

complete additional training with an instructor or via PowerPoint. Click here for training or contact

the PowerUp Team at 302‐733‐1777.

CLINICAL GUIDELINES AND PROTOCOLS:

Our guidelines are based on systematic review of clinical evidence and are designed to assist

practitioners in the care of their patients. Many of our guidelines are embedded in our electronic

record. Please note: the following link is located on our Inet and will not be accessible until after

you are credentialed and receive access.

http://intranet/sites/QualityAndSafety/clinicalresources/SitePages/ClinicalResources.aspx

CLINICAL TRIALS

Christiana Care participates in clinical research programs of high quality and may invite patients or

members of our community to join with us. For more information please visit:

www.christianacare.org/clinicaltrials

CODE OF CONDUCT

Expectations for members are outlined in the CCHS Medical‐Dental Staff Bylaws. Please take the

time to review Appendix B.

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COMMUNICATION

It is a requirement of Medical‐Dental Staff Members as well as APNs and PAs to supply the Medical‐

Dental Staff Services office with an alpha beeper and/or text capable cell phone number. This

information is placed on the Physician Portal to help facilitate communication among

providers.

SBAR Paging Form ‐ Our non‐physician staff will use this standardized online paging system to notify you of many clinical conditions, to include but not limited to: uncontrolled pain, GI bleed, medication order clarification as well as other conditions and requests.

Web Paging ‐ You may choose to set up your cell phone or pager in our web paging system. For questions or to get set up, please contact Physician Relations. Keeping Current – Email is utilized to communicate important announcements and to gather your feedback. It is extremely important that you provide us with an email address that is frequently checked. For the latest news and information relevant to you and your practice, please visit: www.christianacare.org/forphysicians

Updating Your Information – Please contact either Medical‐Dental Staff Services at 302‐

623‐2597 or [email protected] or Physician Relations at 302‐623‐0595 or

[email protected] when your contact information changes.

COMPLIANCE Christiana Care’s mission is to serve our community. Our community expects us not only to provide excellent patient care, but also to do it in a way that is commercially reasonable and ethical. In the spirit of commercial reasonableness and ethics, we need to go beyond the excellent

care we provide and ensure that everyone in our organization complies with the laws, regulations,

and rules set by Medicare, Medicaid, and commercial insurers that affect the claims development

and submission process. As healthcare providers, we have a responsibility to make sure that we are

doing things the right way when it comes to billing, accounting, purchasing, and making business

transactions and vendor selections. Following the requirements of our Code of Organizational Ethics

helps every one of us do it. You will be asked to complete an initial compliance training and

annually thereafter.

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COMPUTER ASSISTANCE

For questions or assistance regarding your computer access and training needs, please use the

following resources:

Powerchart/Dragon: PowerUpTeam ‐ 302‐733‐1777 CPOE Set up and Assistance: Janet McCrossen, IT Physician Liaison‐ 302‐327‐3386

General computer issues & questions: IT Customer Service Center – 302‐327‐3637

CONTINUING MEDICAL EDUCATION (CME)

There are many opportunities for CME at Christiana Care. For more information please contact the

Office of Continuing Physician Professional Development at 302‐623‐5588.

CREDENTIALING/PRIVILEGING

Christiana Care requires all providers to be credentialed through the Medical‐Dental Staff Services

department prior to the delivery of any care or treatment. Credentialing appointments last for a

period of two years, at which time you will need to apply for renewal. For questions regarding this

process, contact Medical‐Dental Staff Services at 302‐623‐2597 or [email protected].

CULTURE OF RESPONSIBILITY

The concept of Just Culture is becoming a critical component of Christiana Care’s approach to

patient safety. The four (4) areas of focus within the Culture of Responsibility are to create a

learning culture; an open and fair culture, design safe systems; and manage behavioral choices.

Please see Appendix C for more information.

EMPLOYEE ASSISTANCE PROGRAM

All members of Christiana Care’s Medical‐Dental Staff, both employed by Christiana Care as well as

those not employed by Christiana Care, and members of their household are eligible to use this

voluntary assistance program at no cost. The program provides confidential support, resources, and

information to get through life’s challenges. Please call the HR Service Center at 302‐327‐5555 for

more information.

EXECUTIVE HEALTH RESOURCES (EHR)

Christiana Care has partnered with Executive Health Resources (EHR), a physician led and operated

organization to help you and Christiana Care place your patients who are being admitted in the

appropriate status. On rare occasions, when your input is needed due to your superior knowledge

of the patient, you may be asked by our Case Management department to speak with one of EHR's

physician advocates. It is very important that you answer these calls and work with the EHR

physician.

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FIRE SAFETY AND EMERGENCIES

As a Safety First organization, Christiana Care endeavors to provide a safe environment for our

patients, visitors, and staff. We look to partner with our LIP colleagues in this effort. Knowing what

to do in an emergency or when you see a safety hazard can help make Christiana Care a safer

place. See Appendix F for information.

FITNESS CENTERS

Along with 24–hour access on both Christiana and Wilmington campuses, the fitness centers offer

group exercise classes. To schedule an appointment or request more information, please stop by

the fitness center in the basement of the E Tower at Christiana Hospital.

FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE)

FPPE is required by the Joint Commission. This assessment of competence is applicable to all new

members as well as current members requesting additional privileges. FPPE is expected to be

completed within 6 months. For more information please contact the Medical‐Dental Staff

Services Department at 302‐623‐2597 or [email protected].

FOOD OFFERINGS The following is a list of places offering food in each facility. Please visit each location for hours and menu:

Christiana Hospital – Cafeteria, Au Bon Pain, Brew HaHa (Main Lobby & E Tower) Wilmington Hospital – Cafeteria, Au Bon Pain Cancer Center – Lakeview Café

HOSPITALIST SERVICES

There are two groups of hospitalists that provide adult patient care for those physicians choosing

not to serve as the attending for their admitted patients. Please contact Physician Relations at 302‐

623‐0595 or [email protected] for more information.

ID REPLACEMENT & BADGE ACCESS

For any ID replacement needs or badge access issues, please contact Security at 302‐733‐1247 CHR

or 302‐320‐2937 WLM. The Security offices are located in the basement level at Christiana Hospital

and on the right hand side of the emergency entrance at Wilmington Hospital.

INFECTION PREVENTION

Christiana Care has two priorities when patients come into the hospital: to fix whatever it is that's

bringing them in and to keep them safe while we're doing it. We have a robust Infection Prevention

program and patients and family members are encouraged to speak up when they notice someone

has not washed their hands. Additionally, we have a hand hygiene observation program in clinical

areas. We also have numerous initiatives targeting CLABSI and C. Difficile.

Please visit our Infection Prevention program for specific information about precautions and hand

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hygiene, as well as other critical patient care information. Available on our Inet:

http://inet/InfCont/Home%20Page.htm

LOUNGES

The Medical‐Dental staff lounges are accessible 24/7 and are located in the lower level (E tower

section) of Christiana Hospital, room LE51, and on the first floor of Wilmington Hospital, room 1E91.

Computer workstations, printers, phones, faxes, lockers, coffee, couches, and cable television are

provided for your convenience.

MEDICAL EXECUTIVE COMMITTEE (MEC)

The MEC is the primary governance committee for the medical staff and is the only committee that

the Joint Commission requires. With your input, this committee carries out important staff

functions, such as credentialing and privileging, quality improvement initiatives and adopting and

implementing policies. This committee manages the process for approving and amending the

medical staff bylaws and rules and regulations. See Appendix D for the Medical Staff Leadership

Roster.

MEDICAL LIBRARIES

Christiana Care operates four medical libraries for you and your patients’ convenience. In addition

to a wide variety of journals and medical texts, library staff is available to conduct literature

searches at your request.

ONGOING PROFESSIONAL PRACTICE EVALUATION (OPPE)

Ongoing Professional Practice Evaluation (OPPE) is designed to continuously evaluate a

practitioner’s performance. Additionally OPPE identifies practice trends that impact on quality of

care and patient safety, as well as to inform decisions about whether a practitioner is competent to

maintain existing privileges. You may be asked to undergo a period of focused review for those

privileges that are infrequently exercised.

PARKING

Christiana Hospital – Physician parking is located in lots “C” (near the Delaware Academy of

Medicine Entrance in the E Tower) and the “E” lot directly across the street, in front of the

Emergency Department. OB/GYN and Oncology physicians should check with their sections for

specific parking instructions. See map in Appendix E.

Wilmington Hospital – There are reserved parking spots for physicians on the first floor of the

visitor parking garage on Jefferson Street. You must have a red parking tag to park in these spots.

You should have received your tag with your ID Badge, if not please call the Public Safety Office at

302‐733‐3742.

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PATIENT IDENTIFICATION

Patient Identification – A National Patient Safety Goal (NPSG) since 2003, requires that all providers

use at least two identifiers when providing care, treatment and services. Please

Introduce yourself to the patient. Ask the patient to state his/her full name and date of

birth. Always check the patient ID band to verify the identifiers. This process should be used for all

encounters.

PATIENT RELATIONS

Christiana Care has a Patient Relations team to assist patients and families with questions related to

their care. Members of this department may occasionally reach out to you for supporting

information related to the investigation of a case. Please contact Patient Relations at 302‐733‐

1340 CHR or 302‐320‐4608 WLM for more information.

PRIVACY (INFORMATION SECURITY)

Christiana Care is committed to protecting individual’s right to privacy of their health information.

Providers with any questions regarding the policies or procedures related to privacy should

contact the Privacy Office at 302‐623‐4468 or [email protected].

PUBLIC WEBSITE PROFILE & REFERRALS

As a member of our Medical‐Dental Staff, Christiana Care offers you the opportunity to include a

brief biography and photograph in our public medical directory for patients and families.

Furthermore, you will receive referrals based on your specialty and any other privileged skills you

have from this website and our telephone referral service. For more information, please contact

External Affairs at 302‐327‐3300.

RAPID RESPONSE TEAM (RRT)

The Rapid Response Team (RRT) is composed of a critical care RN, respiratory therapist, and

physician at Wilmington and Christiana Hospitals. This team assists the patient caregiver in

assessing and stabilizing the patient’s condition and organizing information to be communicated to

the patient’s physician. The nurse may activate this team or in some cases the patient or family

member may request activation of the team. The Attending physician is notified when a RRT has

been activated.

QUALITY PARTNERS

Christiana Care Quality Partners is a clinically integrated network of health care for employees.

Community physicians are invited to become part of the network. For more information click here

or call Mike Cinkala at 302‐623‐7950.

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One of the ways we demonstrate our commitment to patient safety is through our Sentinel Event

Policy. In addition to performing a root cause analysis (RCA) on the events above, we routinely look

at other events that result in harm or could result in harm to your patients.

Our RCA process has adopted techniques from such high hazard industries as Aviation and Nuclear

Power Industry. Our physician led teams are multidisciplinary and the recommendations are

evidence‐based. Leadership commitment to explore and integrate system level strategies has

resulted in the implementation of technology such as the Smart Pump. We have consulted with

external experts such as Human Factor Consultants to assess and modify such processes as the

“sponge count”. We collaborate with vendors to change packaging design.

Moreover, the support of our staff and members is a significant part of the process. Our Post Event

Debrief Process is a forum for staff to express themselves in a safe, supporting, learning

environment. Initial discussions help members understand what happened, why it happened, what

would normally occur and what we might do differently in the future. This interdisciplinary

roundtable enhances open discussion and assists in supporting the disclosure process.

TOURS

To schedule a tour of any of our facilities, please contact Physician Relations at 302‐623‐0595 or

[email protected].

Please contact Physician Relations at 302‐623‐0595 with any questions.

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APPENDIX A:

Christiana Wilmington Admitting 302‐733‐1259 302‐320‐6801 Bed Control

302‐733‐1275

302‐320‐2241

Case Management/Social Work

302‐733‐2222

302‐320‐4941

Compliance Hotline

1‐877‐737‐6780

CME :Continuing Physician Professional Development

302‐623‐5588

ED Triage 302‐733‐1620 302‐733‐4180

HIMS (Medical Records) 302‐733‐1111 302‐733‐2212

Human Resources Service Center 302‐327‐5555

IT Help Desk 302‐327‐3637

IT Physician Liaison (for help with PowerChart) 302‐327‐3386 Laboratory/Pathology Results

302‐733‐3615

Medical‐ Dental Staff Services (credentialing) 302‐623‐2507

Operator Services 302‐733‐1000

Patient Relations

302‐733‐1340

302‐320‐4608

Physician Relations 302‐623‐0595

Pharmacy

302‐733‐3160 302‐320‐2366

Radiology Services Films: Reports:

302‐733‐1747 302‐733‐1800

302‐320‐2144 302‐320‐2251

Rehabilitation, Center for

302‐332‐0886 302‐733‐1029

Security

302‐733‐1247

302‐320‐2937

Visiting Nurse Association (VNA) 302‐327‐5200

Wound Care & Hyperbaric Medicine 302‐765‐4132

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APPENDIX B: CODE OF CONDUCT The Christiana Care Medical‐Dental Staff has adopted the principles of the Christiana Care Way to guide and, the Culture of Responsibility to evaluate the conduct of its’ members.

Members of the Staff are expected to: (1) Provide care in accordance with accepted standards of medical practice.

(2) Physicians generally shall not treat themselves or members of their immediate

families.

(3) Display courtesy and professionalism in all interactions with patients, employees

and peers.

(4) Maintain appropriate behavior, avoid offensive or demeaning language, and

verbal abuse in all interactions with patients, hospital employees, and peers.

(5) Respect confidentiality in discussing protected health information as well as other

sensitive matters, or potentially controversial issues.

(6) Request assistance/consultation when appropriate.

(7) In emergency situations, provide assistance/consultation when requested by a

member of the Staff.

(8) Display professionalism in personal appearance and behavior while acting in a

professional capacity.

(9) Maintain effective communication with patients and their families, hospital staff,

other members of the health care team, and peers.

(10) Maintain an environment that promotes the dignity and trust of those who are

under our care.

(11) Comply with federal and state laws and regulations. Adhere to Christiana Care

policies including but not limited to those relating to discrimination/harassment,

emergency medical treatment (EMTALA), fraud and abuse, prescribing practices,

government reporting, and privacy.

(12) Not discriminate when accepting or treating patients on the basis of any protected

class, or insurance.

(13) Participate and cooperate with Hospital’s charitable mission and reasonably

attend to patients who do not have the ability to pay for their medical care.

(14) Cooperate with the Medical‐Dental Staff, Departments, and Hospital by

participating in peer review and by attending interviews and/or providing

information necessary for evaluation of his/her credentials or resolution of any issues or concerns

regarding patient care and/or professional interactions

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14

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15

APPENDIX D: MEDICAL‐DENTAL STAFF LEADERSHIP

ADMINISTRATIVE LEADERSHIP

Janice E. Nevin, MD, MPH President & CEO

Kenneth L. Silverstein, MD, MBA Chief Clinical Officer

Edmondo J. Robinson, MD, MBA, FACP Sr Vice President, Executive Director Wilmington

Associate Chief Medical Office

Thomas L. Corrigan Executive Vice President and Chief Financial Officer

Neil B. Jasani, MD Chief Learning Officer, Chief Academic Officer and

Vice President of Medical Affairs

Anand Panwalker, MD Associate Vice President, Medical Affairs

Terri H. Steinberg, MD Chief Medical Information Officer

MEDICAL‐DENTAL STAFF OFFICERS

James T. Hopkins, MD President

Brian E. Burgess, MD Past President

Joseph J. Bennett, MD President Elect

Neil G. Hockstein, MD Secretary‐Treasurer

DEPARTMENT CHAIR/SERVICE LINE LEADERS

Mark Schneider, MD Anesthesiology

Linda J. Lang, MD Behavioral Health

Nicholas J. Petrelli, MD Cancer

Charles L. Reese, IV, MD Emergency Medicine

David M. Bercaw, MD Family Medicine

Timothy J. Gardner, MD Heart & Vascular

Virginia U. Collier, MD Hugh R. Sharp Jr., Chair of Medicine/Acute Medicine

Matthew K. Hoffman, MD, MPH Obstetrics and Gynecology

Daniel J. Meara, MD, DMD Oral & Maxillofacial Surgery & Hospital Dentistry

Brain J. Galinat, MD Orthopaedic Surgery/Musculoskeletal Health

Gary B. Witkin, MD Pathology & Laboratory Medicine

David A. Paul, MD Pediatrics/Women’s & Children’s

Omar A. Khan, MD, MHS Primary Care and Community Medicine

Adam Raben, MD Radiation Oncology

Kert F. Anzilotti, MD, MBA Radiology/Neurosciences

Gerard J. Fulda, MD Surgery

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APPENDIX E: PARKING MAP – CHRISTIANA CAMPUS

17

APPENDIX F: FIRE, EMERGENCY AND SAFETY INFORMATION

DIAL 9‐1‐1 FOR ALL EMERGENCIES (Christiana, Wilmington, Riverside, PMRI, HCCC)

Fire/Safety, Security/Police, Chemical Spills, Unusual Odors, Trauma Codes, Trauma Alerts, All Code Blues, and Medical Emergencies.

FIRE

CODE RED = FIRE

IN THE EVENT OF FIRE – RACE

R ‐ Rescue anyone threatened by fire. A ‐ Alarm by dialing 9‐1‐1, Activate a fire alarm pull station. C ‐ Contain fire and smoke by closing all doors. E ‐ Extinguish the fire if you are comfortable doing so.

Other duties:

Reassure patients and visitors in the hospitals and surgicenters that there is no need to evacuate unless directed. Business occupancies (MAP2, HFG Cancer Center East Building, HCCC, Wilm. Annex, Riverside MAC) must evacuate. In areas adjacent to an alarm, begin clearing the corridors of equipment. In the area of the alarm origination, look for signs of smoke or fire. If fire is found, initiate RACE procedure. Assist staff with horizontal evacuation of patients and visitors to the adjacent smoke/fire compartment (beyond the fire/smoke doors).

TO OPERATE A FIRE EXTINGUISHER P – Pull the pin. A – Aim the nozzle at the base of the fire. Stand 8‐10 feet from the fire. S – Squeeze the handle. S – Sweep the extinguisher from side to side.

SECURITY

Christiana Care I.D. must be worn at all times on property. Familiarize yourself with departmental specific security procedures in areas such as the Women’s

Health Building and the Emergency Department. CODE YELLOW means Infant Abduction. Monitor exits and call 9‐1‐1 if an individual is observed

carrying an infant from the facility.

HAZARDOUS MATERIALS

Safety Data Sheets (SDS) provide health and safety information for a specific chemical. Available on the Portal under Systemwide. Click on Workplace Chemical List and search.

18

If a hazardous material spill or exposure occurs:

Evacuate a safe area and provide first aid.

Dial 9‐1‐1 and report the emergency.

Prevent others from entering the spill area.

Provide details of the spill/exposure to the HAZMAT team.

Know the location of eyewashes and safety showers in your work area.

UTILITIES

Red electrical outlets are supplied by emergency power. Life sustaining equipment such as ventilators should always be plugged into red outlets.

Medical gas alarm panels monitor the pressure of medical gasses and alarm in the event of an excessive increase or decrease in pressure.

Oxygen zone valves can only be shut off with the approval of the charge nurse.

MEDICAL EQUIPMENT

Check equipment for current inspection tag prior to placing in service. Report any equipment that is not working properly. If a device is involved in an event, make sure all

disposables potentially associated with the problem are saved.

EMERGENCY MANAGEMENT

CODE DELTA – Term used to notify staff that more resources are needed than currently available to treat victims from a mass casualty incident. INTERNAL EMERGENCY – Term used to notify staff that an event has occurred or will occur that will have

a significant impact upon hospital operations. Examples: utility interruption, snow storm, or a bomb

threat.

Planning for emergencies and disasters is critical in today’s world. As a member of Christiana Care’s

Medical‐Dental Staff, we want to share with you possible steps Christiana Care could take and to

request your assistance during an emergency.

Emergencies take many forms. Mass casualty incidents, public health events and other

circumstances – such as the loss of a major utility, flood or blizzard – could significantly and

adversely affect Christiana Care’s operations.

Regardless of the type or duration of an emergency, Christiana Care must maintain its ability to

provide basic services to patients and the community. To continue its mission to serve the

community during an emergency, Christiana Care could:

Request you discharge patients earlier than anticipated to accommodate the need for additional beds.

Request you transfer patients to a lower acuity unit.

19

Reduce the level and types of services it provides to the community, such as elective surgery or outpatient testing and procedures.

See a far greater number of patients than even our maximum capacity. In these circumstances, managing more patients through your office rather than referring to the Emergency Department would provide valuable support.

If Christiana Care needs your assistance responding to an emergency, Christiana Care’s Chief Clinical

Officer, your department chair or their designate will contact you.

In addition, it is highly recommend that you register with the Delaware Division of Public Health to

receive health alerts, advisories, updates and other health information to keep you informed in the

timeliest manner possible of any possible emergency situations that can affect our operations. The

Delaware Health Alert Network (DHAN) is part of a nationwide network of public health agencies

that communicates important information about state and federal public health threats via e‐mail

or fax. To register: http://www.dhss.delaware.gov/main/mailforms/dph_hanform.aspx)

Please contact 733‐6181 if you have questions or need additional information.

*For non‐emergency safety, security, and fire issues, contact PUBLIC SAFETY OFFICE AT 733‐3740**

20

APPENDIX G

The following pages include important Guidelines and Policies for your review:

Chain of Command

Code of Organizational Ethics

Disclosure

Informed Consent

Information Security

Medication Reconciliation

FPPE and OPPE POLICIES

Pain Management

Physician Health Policy

Peer Review

Restraint and Seclusion

Providers and EHR

1

CHRISTIANA CARE HEALTH SERVICES POLICY

POLICY TITLE: Chain of Command

LAST REVISION/REVIEW DATE: July 7, 2016

DATE OF ORIGIN: June 3, 2009 POLICY: Christiana Care is committed to the resolution of administrative/operational, clinical, and/or patient care concerns in a prompt, timely, and respectful manner. PURPOSE: To provide guidelines for implementing a hierarchy of authority to assist in resolving administrative/operational, clinical, and/or patient care concerns until satisfactory resolution is achieved. SCOPE: Christiana Care Health Services and the Medical–Dental Staff. DEFINITIONS: For the purposes of this policy, the following definitions apply: Administrative/Operational: Relates to hospital functions, including but not limited to, facility operations, resource needs, and overall management of the organization. Clinical: Relates to the observation, care, treatment, and services of a patient Unprofessional Behavior not consistent with Christina Care Way or Code of Conduct which may include: behavior that is perceived by others to represent or which constitutes acts of anger, degradation, intimidation, or threat of harm; disrupts the orderly operations of the hospital and/or patient care; interferes with and/or impairs the ability of others to accomplish their work safely and competently; creates a hostile work environment and/or; interferes with an individual’s own ability to function in a safe and competent manner. Impairment: Physical and/or mental condition that may compromise the delivery of patient care. Patient Care Concern: Concern related to the care or condition of a patient. OB Emergency Rapid Response Team (OBERT): OBERT provides a core team of health care providers to the bedside of an obstetrical patient experiencing an acute change in obstetrical condition that may alter maternal or fetal outcome.

2

Rapid Response Team (RRT): The RRT is composed of a critical care RN, respiratory therapist and resident at Wilmington and Christiana Hospitals. This team assists the caregiver in assessing and stabilizing the patient’s condition and organizing information to be communicated to the patient’s physician. RRT also takes on the role of educator and support to the staff. GUIDING PRINCIPLES: Members of the healthcare team are encouraged and empowered to intervene to facilitate resolution of administrative/operational, clinical, and/or patient care concerns. PROCEDURE: I. For an emergent clinical condition:

A. Initiate appropriate emergency response for immediate intervention if there is an emergent clinical situation involving a deteriorating patient or the patient becomes, or is, unstable (eg, Code Blue, RRT, OBERT).

II. For administrative/operational and non-emergent clinical or patient care concerns:

A. Implement the chain of command when any member of the healthcare team is unable to resolve concern(s) (Refer to Chain of Command Communication Process Flow). Bypass a step or steps in the chain of communication hierarchy if determined to be in the best interest of the patient or staff. This flow is not intended to replace or override clinical judgment.

B. Facilitate collaborative two way communication. Ongoing communication is essential in attaining resolution.

C. Utilize Unit Based and/or Departmental Management to assist with resolution if appropriate. D. Utilize the following list as examples of when the chain of command should be initiated. This

list is not intended to be comprehensive or to replace or override clinical judgment. 1. Unavailability or unresponsiveness of a member of the healthcare team. If there is an

emergent clinical situation involving a deteriorating patient or the patient becomes, or is, unstable initiate appropriate emergency response for immediate intervention (eg. Code Blue, RRT, OBERT.)

2. Unresolved concern regarding patient assessment 3. Unresolved concern and/or disagreement regarding the patient’s plan of care 4. Unclear or potentially unsafe orders, after the ordering clinician has been asked for

clarification 5. Reckless/unprofessional behavior that may jeopardize patient care or staff safety and

requires immediate assistance 6. Suspected impairment of a member of the healthcare team 7. Clinical situations where a member of the healthcare team needs additional guidance

or knowledge regarding a patient’s care 8. Unresolved administrative/operational concerns, including but not limited to, resource

needs and/or safety concerns.

E. Utilize the hierarchy of clinical and administrative/operational decision making lines of authority to facilitate the process for flow of communication and information.

F. Attempt to resolve concerns at each step in the hierarchy of clinical and/or administrative/operational decision making lines.

3

DOCUMENTATION: If the chain of command concern relates to the clinical care, treatment, or services provided to a patient, document the following information in the patient’s medical record: date, time, facts of patient assessment and observation, names of individuals contacted, measures taken, orders received and carried out, and patient response. REFERENCES:

Consortium Management LLC & McNeary, Inc, Compass navigating Today’s Healthcare Risks & Liabilities Chain of Command, March 2004, Volume 2, Issue 2 HCR Risk Analysis, risk and quality management strategies 19; Chain of Command, September 2004 The Joint Commission Perspectives in Patient Safety, Effectively using chain-of-command policies, January 2005, Volume 5, Issue 1 The Joint Commission Comprehensive Accreditation Manuel for Hospitals 2016 Patient Safety Systems (PS) chapter

Patient care orclinical issue?

Initiate appropriateemergency responseeg: Code Blue, RRT,

OBERT

Chain ofCommunication

Contact Manager orSupervisor

Emergent?Is the patient

unstable?

Contact DepartmentChairman

Contact

Contact President &Chief Executive Officer

Contact NursingCoordinator or

DepartmentSupervisor

ContactResponsible

Physicianconsider contacting

Unit Based /Department

Manager

Implement strategies toresolve issue

ContactAdministrator on-

call

Contact Seni

Resolved?

Resolved?

Resolved?

Resolved?

Resolved?

Resolved?

Resolved?

Chain of Command

If resolution has not been achieved, utilize thefollowing Clinical and Administrative/operational

Clinical Chain of Command as a guide until resolutionis achieved

No

No

Yes

No

Yes

No

No

Clinical Chain

No

No

Yes

Yes

Yes

YesNo

Yes

Administrative/operational

Chain

Yes

No

Yes


http://depts/policies/WebPolicies/Docs/CodeofOrganizationalEthics.htm[12/11/2015 2:45:45 PM]

CHRISTIANA CARE HEALTH SYSTEM POLICY POLICY TITLE: Code of Organizational EthicsLAST REVIEW/REVISION DATE: December 16, 2013DATE OF ORIGIN July 1, 1996

POLICY:Christiana Care Health Services (“CCHS”), its Board of Directors, Medical-Dental Staff, Administration, employeesand agents are committed to providing patient care and conducting business operations in an ethical manner consistentwith CCHS’s mission, core values, strategic plan, regulatory requirements, and policies. PURPOSE:This Code was created to guide CCHS personnel at all levels of decision making so that sound legal and ethicalprinciples will be applied in day to day business and operational decisions. CCHS has adopted many policies andprocedures to promote compliance with ethical principles, which policies/procedures may not be described in thisCode. Nothing contained in this Code, however, is intended to substitute for, or diminish any staff member’sresponsibility to adhere to the particular requirements of those policies/procedures. SCOPE:The CCHS Compliance Program and the requirements of this Code of Organizational Ethics are applicable to allCCHS directors, officers, employees, contractors, and active medical staff members (sometimes referred to as “CCHSpersonnel”, “staff members” or “providers”) and to CCHS affiliates and subsidiaries. ORGANIZATIONAL STANDARDS OF PRACTICE:

1. QUALITY OF CARE Standard: All CCHS facilities and providers will provide quality health care in a manner that is appropriate, reasonable andmedically necessary. Policy Overview:a. CCHS patients will be provided with high quality clinical services without regard to race, religion, sex, national

origin, age, disability, veteran status, sexual orientation or any other status constituting an illegal basis fordiscrimination.

b. CCHS promotes clinical excellence and patient safety by continually evaluating provider competency through itscredentialing and performance review processes, and monitors the quality and efficiency of services providedthrough its Performance Improvement and Utilization Management programs.

c. Situations may arise where a staff member’s religious, ethical or moral beliefs may conflict with his/her duty toprovide/participate in certain aspects of patient care. In these situations, staff members are permitted to requestexclusion from those aspects of patient care. However, exclusion may not be permitted if the result couldcompromise patient care.

d. To the extent possible, providers will involve patients and family members in decisions regarding care/treatmentand will follow CCHS standards regarding communication with patients or representatives. There is a process inplace that permits staff, patients and families to address and resolve ethical issues related to patient care. The rightof each patient to make choices about his/her own care, or to refuse treatment, is recognized.

e. The physician or knowledgeable designee will discuss with the patient the therapeutic alternatives and risksassociated with the treatment contemplated and obtain the informed consent of the patient or representative. To theextent possible, this information will be provided in a language that the patient can understand.

f. Decisions relating to resource allocation and utilization management are for the purpose of determining appropriate



care and will not limit services for financial reasons. Medically appropriate and covered services may not bewithheld from patients based on payment methodology.

g. Under EMTALA law, any person presenting on the main campus of a CCHS hospital requesting, or appearing toneed, emergency care must be screened and evaluated for an emergency medical condition regardless of ability topay for the services rendered. The term “main campus” includes the parking lots, sidewalks and driveways directlyserving either of the two main hospitals. Any patient with such a condition shall be stabilized within thecapabilities of the hospital and/or transferred to another facility if the hospital lacks sufficient stabilizationcapabilities.

h. EMTALA is applicable to any physician/provider responsible for the screening, stabilization, and/or transfer of anindividual with an emergency medical condition, including any physician assigned to provide on-call specialtycoverage to the Emergency Department, and that physician must come to the ED for such purpose if requested bythe ED physician. An on-call specialist must respond to all calls from the Access Center or ED physician withoutregard to a patient’s sex, race, ethnicity, religion, national origin, citizenship, age, preexisting medical condition,physical or mental handicap, insurance status or ability to pay for medical services.

2. CODING, BILLING AND MEDICAL NECESSITY Standard:CCHS submits claims for payment to government and commercial insurers only for services or items that aremedically reasonable and necessary to diagnose or treat a patient’s medical condition. CCHS providers or otherpersonnel responsible for documentation, coding, billing, and/or accounting for services/items shall comply with allapplicable federal/state laws and regulations and with CCHS claims development and submission policies/procedures.Cost Reports shall be prepared in accordance with CMS guidelines and costs shall be supported by documentation. Policy Overview:a. CCHS and its providers will bill government and commercial payers only for services/items actually provided

and/or delivered, and determined to the best of our knowledge, to be covered and medically necessary.Misrepresentations or presumptions in coding and/or billing are prohibited. “Unbundling” of claims, i.e. separatebilling of charges that are required to be billed together pursuant to payer rules, is prohibited. CCHS will maintainappropriate edits in its billing systems to prevent duplicate billing.

b. Supporting medical record documentation must be generated for all services/items ordered or provided, anddocumentation shall support medical necessity for every service/item billed. All diagnosis and procedure codingshall be supported by appropriate medical record documentation. “Upcoding”, i.e. assignment of a higher payingcode than is justified by documentation, for either inpatient or outpatient services, is prohibited. Medical necessityfor any outpatient/inpatient test or procedure subject to a local medical review policy or national coveragedetermination must be verified against those standards prior to performance of the test/procedure.

c. Services provided shall be accurately and completely coded to the highest specificity, with attachment ofappropriate modifiers, and submitted to the proper primary and then secondary payers. Federal/state regulationsregarding proper claims development and submission practices shall be followed, and CCHS policies/proceduresshall be analyzed for consistency with these regulations. Professional coding and documentation shall beconsistent with the standards developed by the CCHS Departments of Compliance, Patient Finance, HealthInformation Management, and applicable clinical department.

d. Decisions with respect to assignment of patients to inpatient, observation or outpatient status (accommodationcoding) will be made in accordance with medical necessity standards, payer rules, and the requirements of federalregulations. Claims shall not be submitted for procedures designated by Medicare as “inpatient only” if performedon an outpatient basis.

e. All patients must be consistently and uniformly charged based on category. Discounts will be appropriatelyrecorded and items consistently described so that comparability may be established among payers. Governmentpayers will not be charged in excess of CCHS’s usual and customary charges for hospital and/or professionalservices or health care items.

f. Billing and collections shall be recorded in appropriate accounts. Credit balances will be processed and returned ina timely manner. Any overpayments from payers discovered in the monitoring/audit process will promptly beinvestigated, calculated, disclosed and refunded to payers in a timely and appropriate manner. Corrective actionwill be implemented to prevent recurrence of any incorrect billing practices.



g. In some cases, a provider may determine that services/items are medically necessary or appropriate, but thepatient’s health plan may not cover those services/items. In the case of commercial insurance, the patient shouldbe directed to his/her her health plan administrator for information about the process for determining coveredbenefits. Patients are provided with information regarding charges for which they are personally responsible.

h. Medicare/Medicaid patients may request outpatient or inpatient services/items that are not covered benefits. Suchservices/items may be provided so long as the patient signs an advance beneficiary notice, or notice of non-coverage, in which the patient agrees to pay for the services/items if the payer denies the claim. In these cases, thepatient may request the submission of a claim anyway to protect his or her appeal rights or to determine the extentof coverage.

i. CCHS personnel responsible for coding, documentation and billing will be knowledgeable about CCHS policiesand procedures as well as federal/state regulations regarding the claims development/submission process. CCHSmanagers are individually responsible for those parts of the process under their control. Regular audits and trainingwill be provided for all personnel/providers for whom coding and documentation are part of their responsibilities,and also for those responsible for the submission of charge or billing data. All managers shall maintain appropriateprocesses in their departments to evaluate whether such personnel/providers understand and adhere to correctprocedures in this regard.

j. An accurate and timely billing structure and medical records system is critical to ensure that CCHS personnel caneffectively implement and comply with established claims development and submission processes. Lapses ordeficiencies discovered in the information and/or billing systems infrastructure will be remedied in a timelymanner.

k. In the preparation of Cost Reports, costs will be properly classified, allocated to the correct cost centers, andsupported by verifiable and auditable data. Cost Reports will be submitted in a timely manner in accordance withpayer requirements. Any Cost Report errors or omissions discovered shall be corrected in a timely manner and, ifnecessary, procedures shall be clarified and remedial education provided to prevent recurrence.

l. The cost of drugs, devices and supplies, as well as any discounts offered by vendors, shall be properly reportedand accounted for. Acceptance of educational, research or other grants or gifts from vendors given in lieu of adiscount is prohibited.

m. In order for charges to be processed, chart documentation shall always support the level of services provided. It isa serious violation of law to knowingly submit, or direct anyone else to submit, a claim that is not properlysupported by chart documentation. Submission of a claim in reckless disregard or deliberate ignorance of the truthor falsity of the information, or of the requirements of federal/state regulations or payer rules is, under the FalseClaims Act, equivalent to doing so “knowingly.”

n. A provider or any other person may not alter a bill for services rendered so as to identify services covered by thepatient’s insurance instead of the services actually provided.

o. In certain teaching settings, if a teaching physician is on-site and generally available for consultation, residents ortrainees may be permitted to treat patients without one-to-one supervision. Generally, a teaching physician maynot submit charges for services rendered to patients unless he/she was involved in providing the key or criticalportions of those services. Billing rules relating to the services of attending physicians in the teaching setting arevery complex and care should be taken in the preparation of such claims.

p. Records of transactions should be created in accordance with generally accepted accounting principles and CCHSpolicy. Any accounting staff member who receives instruction appearing to be inconsistent with these principlesshall raise the issue with his/her manager and they shall attempt to correct the situation. If they are unable to agreeon a resolution, the issue shall be elevated to a manager or higher until a satisfactory resolution is reached.

q. Any staff member reviewing an official report in which some financial data appears incorrect shall immediatelyraise the issue with his/her manager. If an official statement is published with incorrect information, there may beserious consequences for the organization as a whole and, in particular, those responsible for preparation of theinformation.

3. IMPROPER REFERRALS, KICKBACKS AND CONFLICTS OF INTEREST Standard: CCHS personnel may never accept, solicit or offer, for themselves or the organization, anything of value in exchangefor the referral of healthcare business or the referral of patients. Subject to certain exceptions, Federal law andregulations prohibit referral of a patient to any entity in which a physician has a financial interest.



Policy Overview:a. Federal law prohibits anyone from offering anything of value to a Medicare, Medicaid or TRICARE beneficiary

that is likely to influence their decision in the selection of a particular provider.b. CCHS personnel may not receive, solicit or offer anything of value as an inducement for the referral of business or

patients to or from any healthcare provider or vendor. This includes the offering of incentives directly tofederal/state health plan beneficiaries, such as routine waiver of copayments or forgiveness of debt, withoutdetermination of financial need.

c. Federal law prohibits the exchange of anything of value that could immediately or eventually exert an influence ona provider’s clinical decisions, increase costs, or lead to over or under utilization of services. The prohibitionregarding exchange of goods or money to induce referrals extends to receipt of gifts by any CCHS personnel.

d. CCHS providers that prescribe/order drugs or other items must be particularly cautious in their interactions withdrug or device industry representatives, and in serving in an advisory capacity to industry, to ensure that grants orother compensation do not actually, or are not perceived as, influencing clinical or purchasing decisions.

e. Providers may not accept payments from drug/device companies for consulting or advisory roles, or to serve on aspeakers bureau, that are in the aggregate in excess of fair market value for legitimate and commercially reasonableservices provided.

f. CCHS providers shall not engage in purely commercial marketing or promotional efforts for drug/device companyproducts in return for compensation in any form. Assisting a drug/device company in the promotion of a productfor an off-label use is a direct violation of the False Claims Act.

g. Outside of the medical conference setting, a CCHS provider shall not attempt to influence CCHS colleagues to useor prescribe the products of a drug/device company in which that provider has a financial interest or othercompensation relationship.

h. Research grants from commercial sponsors must be for legitimate and scientifically necessary research and notaccepted if the purpose is to promote a product after FDA approval has already been obtained. Research oreducational grants initiated by the marketing or sales departments of a commercial sponsor shall not be accepted.The methods used for the conduct of clinical trials or basic research, including the gathering of data andinterpretation of results, shall be scientifically sound and unbiased and remain free from the influence ofcommercial sponsors that may compromise the scientific integrity of the results.

i. A CCHS provider may not accept compensation from a drug/device company for attending a seminar sponsored bythat company unless the provider performs a legitimate service such as speaking or preparing learning material. Accepting gifts or payment for exotic travel, expensive hotels, or lavish meals, or for prolonged leisure orrecreational activities, even as part of a legitimate scientific or medical conference, is prohibited because of theappearance of a conflict of interest.

j. A CCHS provider who serves on a drug/device company speakers bureau may be reasonably compensated forhis/her services but the content of the presentation shall have legitimate scientific or medical value or be based onhis/her personal clinical experience with the products discussed, rather than serve merely as a venue for marketingor promoting the products of the company. This also applies to the authorship of scientific articles. The amount ofsuch compensation may be subject to certain annual limits set by CCHS from time to time within its solediscretion. Acceptance of honorary authorship of scientific articles is strictly prohibited.

k. The advantages and disadvantages of the use of a product for an off-label indication may be discussed in apresentation at a legitimate scientific or medical conference, so long as the conference is free from industrysponsorship and the presentation does not promote the use of the product for an off-label indication.

l. CCHS does not endorse drug/device company products, nor does it accept compensation in any form for the use ofits name, logo, or image, whether in picture or narrative form, in the endorsement of such products. However,statements about the use of a particular product by CCHS providers may be included in promotional literature ifapproved by the Department of External Affairs. Any conference or media presentation amounting to a productendorsement, for which a CCHS provider is compensated, may not connect the provider’s name with CCHS.

m. Subject to certain statutory or regulatory exceptions, Federal law prohibits a physician from referring a patient forcertain health services to a facility where that physician (or a family member) has a financial interest or a non-employment financial relationship.

n. Offers of discounts on products from manufacturers or wholesalers may be accepted in certain circumstances inaccordance with CCHS policy but must be accounted for and disclosed to any government payers that reimburseCCHS for such products.



o. Any arrangement/agreement between CCHS and any of its non-employed providers or vendors, especially wherethat provider/vendor is in a potential or actual position to refer, or be the recipient of, referrals of patients or otherhealthcare business to or from CCHS or its providers, must be carefully reviewed by Corporate Counsel and/or theCompliance Office, to ensure that the arrangement/agreement does not violate the prohibitions of the federal Antikickback Statute or Stark Law (or any state equivalent) which prohibit incentivization of referrals forservices/items covered by government healthcare payers.

4. CONFLICTS OF INTEREST Standard:CCHS personnel will avoid potential or actual conflicts of interest whenever possible in undertaking clinicalenterprises or personal business. Policy Overview:a. No CCHS staff member may use the authority of his/her office to influence a decision affecting the organization

relating to a transaction in which he/she has an outside interest.b. No CCHS staff member may offer or accept gifts, gratuities, loans or other items of value from third parties

potentially or actually doing business with CCHS except as permitted by CCHS policy. Such third parties mayinclude customers, patients, vendors, suppliers, competitors, payers, carriers and fiscal intermediaries.

c. Any use of CCHS facilities equipment or other resources for other than organizational related activities is a misuseof those resources. In particular, staff members may not use the CCHS name or image to promote non-CCHSproducts or services for pecuniary gain.

d. Organizational funds may not be used to contribute to a political party, committee, organization or candidate inconnection with a federal, state or local campaign. Personal contributions of private funds may be made to thecampaigns of political candidates but such contributions are not reimbursable by the organization.

e. Generally, CCHS avoids contracting for goods or services with family members of employees. Staff membersshould not engage in any activity that may create the impression that they are attempting to influence a CCHSpurchasing decision in favor of a family member. Purchasing decisions made through appropriate committees inwhich conflicts of interest are disclosed may be made in favor of family members if the interested party does nottake part in the decision making process.

f. Certain types of invitations from vendors may be accepted if they are within the bounds of the law, good taste,moderation and common sense. Participation in such activities shall adhere to the requirements of CCHS policyand avoid creating even the appearance of impropriety. If the acceptance of such an invitation has the potential toinfluence a purchasing decision, it is prohibited.

g. Any member of the CCHS formulary committee (P&T Committee), or any other CCHS purchasing committee, isprohibited from involvement in any decision as to the purchase or use of the products of a drug or devicecompany, if that member has any financial interest in, or compensation relationship with that company. Theindividual shall recuse him/herself from the decision making process in accordance with the requirements of CCHSConflicts of Interest Policies. Additionally, any CCHS staff member who advocates for the placement of any drugon the CCHS formulary, or who advocates for any other purchasing committee decision favorable to the purchaseof a drug or device, must disclose in detail any financial interest in, or compensation relationship with, thecompany that sells the drug or device.

h. Vendors and suppliers are selected solely on the basis of quality, cost-effectiveness and appropriateness ofservices/items offered. Purchasing decisions are complex and usually controlled through a formal process withsubstantial oversight. It is legal for a vendor/supplier to offer certain incentives to group purchasing entities inwhich CCHS participates. However, if it is suspected that any purchasing arrangement provides a single vendor/supplier with an unfair advantage, or that a vendor/supplier has improperly incentivized purchasing, ordering, orprescribing decision makers within the organization, the matter should be raised with a supervisor or theCompliance Officer.

i. Any CCHS marketing materials must accurately represent the hospital and the care, treatment or other servicesprovided by the hospital, either directly or through contractual arrangement.

5. PERSONAL AND CONFIDENTIAL INFORMATION



Standard: All efforts shall be made to protect the personal and confidential health information of CCHS patients and informationrelating to CCHS business and practices. CCHS abides by Federal HIPAA Privacy and Security Regulations andapplicable state laws. Policy Overview:a. The CCHS Notice of Privacy Practices explains to patients how CCHS will protect and treat their confidential

health information. CCHS personnel may not disclose confidential patient information other than at the patient’srequest or as authorized by law. Approval for use of patient information for research purposes must be obtainedfrom the Institutional Review Board.

b. CCHS personnel are trained about privacy and security law/regulations as applicable to their job function. Confidential patient information may be discussed with, or disclosed to, other CCHS personnel on a limited, “needto know basis” and only for reasons related to treatment, payment or organizational operations. The HIPAA“minimum necessary standard” for disclosure is always applicable.

c. At no time may confidential patient information be discussed with, or disclosed to, non-CCHS personnel otherthan family members or persons assuming responsibility for the patient, except as permitted under HIPAA or otherapplicable law. Personnel and/or trainees who have questions regarding patient confidentiality should refer toCCHS policies or consult with the Privacy Officer.

d. Breach of patient confidentiality warrants corrective and/or disciplinary action up to and including, termination ofemployment. Breach of confidentiality can occur in many ways, some more subtle than others. These can includelooking at identifying information in documents other than the medical record or informal discussions withcolleagues.

e. Information system passwords may never be shared. Confidential information stored on company or personal datadevices shall be protected at all times and deleted when no longer needed.

f. In general, patients may request and are entitled to receive copies or summaries of their medical records, if suchrequests are made in writing, with the exception of minors and some other patients in cases where access is limitedfor the patient’s protection or as otherwise limited by state law.

g. CCHS personnel may not disclose CCHS proprietary or trade secret information to any unauthorized or non-CCHSpersons. Such proprietary information may relate to CCHS’s business affairs or those of a CCHS vendor orcontractor.

h. CCHS personnel may not disclose to any third party confidential Medical Staff or peer review information.State/federal law grants special privileges to the proceedings and minutes of certain organized committees of theMedical Staff and peer review bodies.

i. Personnel records are considered confidential. Access to personnel files is limited to management, humanresources staff, and internal auditors. These persons are held accountable for protecting the privacy of personnelrecords.

j. Viewing the medical records of other employees is a serious violation of federal law and will usually result indisciplinary action for the offender up to and including termination. The offender could also be subject to privatelegal action for damages by the party whose information was wrongfully accessed. Corrective action bymanagement in response to a breach may require modification of internal procedures or computer systems.Knowledge of a breach should be reported immediately to a supervisor, the Privacy Officer or the HumanResources Department.

k. Trainees such as residents may not retain personally identifiable information on patients except as required byrecognized training oversight organizations. If copies of records otherwise need to be retained by trainees, theinformation shall be de-identified.

l. Information concerning employee performance requested by a subsequent employer is sensitive and may beconfidential. Refer any such requests to the Human Resources Department.

m. Generally, CCHS owns all information (e.g. computer programs, training materials, processes, marketingstrategies) created or developed by employees while on the job or through the use of CCHS resources. Suchinformation constitutes the “intellectual property” of CCHS. Proceeds received by CCHS for permitting third partyuse of such information may be shared with the employee or his/her department under certain circumstances. Thisis a complex legal area and a supervisor, technology transfer personnel, or Corporate Counsel should be consultedon such matters.



6. CREATION AND RETENTION OF RECORDS Standard: All medical and institutional records found on the premises of CCHS facilities are the property of CCHS. Thoseresponsible for the preparation and retention of patient and/or institutional records will determine that those records areaccurately prepared and maintained in a manner and location as dictated by law, regulations, or CCHS policies. Policy Overview:a. The complete and accurate preparation and maintenance of all paper or electronic records by CCHS physicians or

other providers is of the utmost importance in providing quality care and conducting CCHS business. Accuraterecords are essential to the maintenance of licensure and/or accreditation of CCHS facilities and providers.

b. Knowingly creating records that contain any false, fraudulent, fictitious, deceptive or misleading information is aserious violation of law. It is a violation of the False Claims Act to knowingly make false or misleading entries inmedical records. The Act includes in its definition of “knowingly” making entries with reckless disregard ordeliberate ignorance of the truth or falsity of the information.

c. An entry in a medical record may never be deleted. Medical records may be amended and material added toenhance the comprehensiveness and accuracy of the record but only in accordance with medical recorddocumentation policy and procedures. Any amendment to a medical chart must indicate that the entry is anaddition or correction to the original record and reflect the actual date the amendment was made.

d. Placing the signature or initials of another person on a record is prohibited. Electronic signatures and signaturestamps may be used in limited circumstances in accordance with CCHS policy. Use of such devices is limited tothe individual whose signature is recorded and access to such devices is strictly controlled.

e. Unless authorized by CCHS policy, at no time may records be destroyed, altered after the fact, or removed fromthe premises. CCHS record retention and destruction policies set applicable time periods for retention, andprocedures for destruction, based on the category of record involved. The premature destruction of records couldbe misinterpreted as an effort to destroy or conceal evidence which can have serious legal consequences.

f. Only orders heard personally may be recorded by an individual. A supervisor may not authorize a subordinate tosign the name or initials of any other person. Any such request must be reported to a manager or higher.Retaliation against employees who resist or report attempts to falsify records will not be tolerated.

g. An entry into a chart should never be placed next to a note written at a previous time unless the actual date of theadditional note is included. Such an entry may be interpreted by a payer as an attempt to fraudulently generate acharge when one is not justified. The entry should explain that it is applicable to a prior date of service rather thanthe date of the additional note. Any person witnessing a violation of this rule shall report it to a supervisor.

7. CLINCAL RESEARCH Standard:The rights of research study participants and their safety and privacy are protected by CCHS policies which reflectfederal and state regulations governing ethical practices in the conduct of human subject research and clinical trials. Policy Overview:a. CCHS policies provide guidance for compliance with federal/state standards regarding the integrity of research

programs. These policies address conflict of interest situations, regulatory non-compliance, scientific misconductand procurement integrity. They are disseminated to all staff, students, volunteers and contractors involved inCCHS research programs. Additionally, procedures have been established to permit individuals to elevate concernsabout suspected non-compliant research practices.

b. Protection of the rights, safety and privacy of research subjects, and of the integrity of research, is assured throughan Institutional Assurance filed with the Federal Office of Human Research Protections and through ongoinginteraction with federal/state research oversight agencies. The activities of the Institutional Review Board includeprotocol review, the informed consent process, clinical trials monitoring, and review of unexpected serious adverseevents occurring in a research study.

c. The CCHS Office of Research and Grants Administration oversees the process through which governmentalfunding is obtained for research purposes. Other CCHS departments provide the fiscal oversight needed todetermine that research budgets and cost allocation practices comply with federal regulations and commercial



industry sponsor agreements. CCHS billing systems incorporate processes to determine that research costs areappropriately charged to sponsors and/or to third party payers.

d. The cost of performing clinical trials conducted for a commercial sponsor must be fully funded by the sponsor andmay not be supported in whole or in part by other funds including third party reimbursement, grants or charitabledonations. Wherever possible, coverage of medical expenses for any patient injured in a clinical trial should benegotiated with a commercial sponsor. Clinical trial protocols initiated by the marketing or sales departments of acommercial sponsor shall not be considered for implementation.

e. Under certain circumstances, Medicare/Medicaid will cover the routine costs of care for subjects participating in aclinical trial, and sometimes the costs associated with the diagnosis and treatment of conditions arising out of thesubject’s participation in the trial.

f. Items and services relating to research are procured in a fair and competitive manner in accordance with CCHSpolicy which prohibits conflicts of interest in this process. Educational or research grants received fromcommercial sponsors may not influence procurement decisions.

g. It is the responsibility of the Principal Investigator to respond to patient questions regarding research proceduresand safety as part of the informed consent process. The patient should always be informed that he/she maywithdraw from study participation at any time and this will not compromise his/her medical care.

h. It is illegal and unethical to exert improper pressure on, or to provide excessive financial incentives to, patients toconvince them to participate in a particular research study or to undergo an experimental procedure.

i. It is considered a conflict of interest for the Principle Investigator, or any other participant, to have a financialinterest in the outcome of a research study. The methods used for the conduct of clinical trials, including theinformation gathering process and interpretation of results, must be scientifically sound and unbiased, and freefrom consideration of the financial interests of the sponsor or any other inappropriate commercial influences thatmay compromise the scientific integrity of the results. Any concerns in this regard should be reported to theCompliance Officer.

j. The CCHS Notice of Privacy Practices explains that an investigator may apply to the IRB to get permission toexamine the charts of patients with specified diagnoses to determine if a study is feasible of if there are patientsavailable to enroll.

8. GOVERNMENT REQUESTS FOR INFORMATION Standard:CCHS personnel shall cooperate with investigations and audits by appropriately authorized government enforcementagencies as outlined below (Joint Commission and State agency quality of care surveys are addressed in a separatepolicy). Policy Overview:a. CCHS policy will provide more detailed guidance on how to respond to requests from federal or state enforcement

agencies or agents for information or records. Any recipient of such a request should delay any response untilhe/she has reviewed the policy.

b. If an investigator from a federal or state enforcement agency requests information during or after work hours, theinvestigator should be directed to a supervisor, the Compliance Officer, or Corporate Counsel. Before consent isgiven for an interview, positive identification should be obtained from the investigator and information should berequested on the nature of the investigation and the subject of the interview. If the request is made in a telephoneconversation, call-back information should be obtained so that the identity of the investigator may be verified.

c. The staff member has the legal right to consult with his/her supervisor or other CCHS personnel, such as theCompliance Officer or Corporate Counsel, before answering any questions. Under law, such consultation may notbe interpreted by the government as an unwillingness to cooperate with an investigation. CCHS personnel areentitled and strongly encouraged to have one of these individuals with them during any interview, which can bearranged by a supervisor.

d. If the investigator wants to conduct a search of a CCHS facility or records, a search warrant should be requested.In any case, a supervisor, the Compliance Officer or Corporate Counsel should be immediately notified.

e. A staff member may not provide an investigator with any confidential patient information, personnel records, orany other records—either in written or verbal form, without first consulting with a supervisor, the ComplianceOfficer or Corporate Counsel. CCHS documents or records may never be destroyed or altered in anticipation of a



government request for records.f. A staff member should never attempt to persuade other personnel to make false or misleading statements to a

government investigator or to alter/destroy records.g. FBI agents have the legal authority to visit CCHS personnel at home to ask about activities at work. CCHS may

not prohibit personnel from talking to government investigators if they wish to do so. However, personnel mayconsult with Corporate Counsel or their personal attorney before answering any questions. Asking to speak withlegal counsel before answering questions is always one’s right and is always prudent. Notes should be madesummarizing any conversation with an investigator. A supervisor, the Compliance Officer or Corporate Counselshould always be notified regarding a home visit.

9. ADHERENCE TO ANTITRUST LAWS Standard: CCHS will comply with applicable federal and state antitrust laws. Policy Overview: a. CCHS personnel shall not participate in the following activities which may violate antitrust laws:

i. agreement or negotiation with a competitor to artificially set prices or salaries;ii. division of markets, restriction of output, or blocking new competitors from the market;iii. sharing pricing information with competitors that is not normally available to the public, which could be

considered by a court as an effort to fix fees or limit competition.iv. Arbitrary denial of medical staff privileges to physicians or other practitioners for reasons unrelated to

clinical competence or the legitimate business interests of the organization.v. participation in a boycott of government programs, insurance companies, or of particular drugs or products.

b. Any discussion with competitors regarding conditions in the marketplace including pricing policy, profit margins,

or credit and billing practices should be avoided. Competitors are at risk when they discuss these issues at tradeshows or professional conferences, including conversations at informal gatherings (e.g., lunch or dinner after themeeting has concluded). CCHS personnel shall not engage in unauthorized business discussions with competitors. Questions regarding antitrust liability should be directed to Corporate Counsel.

10. PATIENT’S FREEDOM OF CHOICE Standard: In the referral of patients for post-discharge care to home health agencies, medical equipment or home drug suppliers,or long-term care and rehabilitation facilities, the rights of patients to choose their own providers should be respected. Policy Overview:a. It is improper to consistently direct patients to a particular agency, supplier or facility for post-discharge care to

the exclusion of others, especially where CCHS has a financial interest in the provider. However, CCHS maydevelop a list of recommended providers based on legitimate beliefs about quality of care. If the patient/family isstill unable to choose after receiving the list, CCHS may recommend a provider in which it has a financial interest.

b. It is improper to permit a discharge planning coordinator representing any outside provider to maintain officespace, or regularly occupy any other designated area, directly on the property of any CCHS facility used for thecare of patients. Likewise, it is improper to favor any particular provider in the grant of regular access to CCHSpatients for the purpose of soliciting referrals for post-discharge services.

c. Insurance coverage may limit a patient’s choice of provider if it is expected that the insurer will cover the cost ofcare. A patient may choose providers not covered by insurance if he/she is willing to pay for non-covered care.

d. A physician may consistently direct his/her patients to a particular provider based on legitimate beliefs aboutquality of care. Nonetheless, it is not improper to raise a question about the propriety of any financial arrangementbetween the physician and a favored provider.



11. FAIR TREATMENT OF PERSONNEL Standard: In accordance with CCHS Human Resources policy, CCHS prohibits discrimination in any employment relateddecision on the basis or race, color, national origin, religion, sex, physical or mental disability, medical condition(cancer-related or genetic characteristics) ancestry, marital status, age, sexual orientation, citizenship, or status as aveteran. CCHS is committed to providing equal employment opportunity and a work environment in which eachemployee is treated with fairness, dignity, and respect. Policy Overview:a. Reasonable accommodation will be made by the organization to the known physical and mental limitations of

otherwise qualified individuals with disabilities. If any individual requires special accommodation or assistance asthe result of handicap, he/she should contact the Human Resources Department.

b. Harassment or discrimination of any employee based on diverse characteristics or cultural background is strictlyprohibited as is any form of workplace violence or sexual harassment. All personnel should be familiar withHuman Resources policies in this regard. Anyone who observes or experiences any form of discrimination,harassment, or violence in the workplace should immediately report the incident to his/her supervisor or the HumanResources Department.

c. Promotions and assignments are based solely on one’s ability and accomplishments as compared to fellowworkers. If a supervisor cannot explain his/her decisions in this regard to the satisfaction of an employee, theemployee should consult with a manager or Human Resources. Retaliation for raising such issues will not betolerated. Nonetheless, the employee has an obligation to accept reasonable supervisory decisions and work toimprove his/her performance to advance his/her career.

12. REPORTING POTENTIAL ERRORS OR SUSPECTED VIOLATIONS Standard: All personnel are required to report any actual or suspected compliance violations directly to a supervisor, theCompliance Officer or through the Anonymous Compliance Hotline. Compliance policy establishes procedures forinvestigating known or suspected compliance violations. Corrective action, remediation, and/or disciplinary measuresfor improper conduct will be imposed uniformly for all levels of staff without regard to position or influence. Theorganization does not tolerate retaliation against any individual for reporting, in good faith, an actual or suspectedviolation even if the allegation is never substantiated. However, the Compliance Officer will investigate situations inwhich there is reason to suspect that the motive for making a compliance report is other than honorable and in goodfaith. Refer to the CCHS Compliance Enforcement Policy for more detail. 13. CORRECTIVE ACTION AND DICIPLINARY PROCEDURES Standard: Appropriate corrective action will be taken with any CCHS personnel who fail to comply with CCHS policies orfederal/state regulations relating to the subjects above. Corrective action may take many forms and is designed tochange behavior or practices, provide remedial education or training, abate an offending practice, make financialrestitution to payers, or put systems into place to prevent recurrence of non-compliant practices or conduct. Correctiveaction may or may not include disciplinary action depending on the severity of the violation and whether themisconduct was intentional. Refer to the Compliance Enforcement Policy for more detail. RESPONSIBILITYResponsibility for enforcement of this Code is assumed by the Compliance Officer and other members of theCompliance Steering Committee as may be applicable. Notwithstanding it is the responsibility of each individual staffmember to comply with the provisions of: 1. all applicable law and regulations related to his/her job responsibilities; 2. the standards and requirements of this code;



3. the requirements of other CCHS compliance policies. Attachment 1 ETHICAL PRACTICE QUESTIONS & ANSWERS:While every possible ethical situation cannot be addressed in this policy, the following questions are intended toclarify application of this policy in every day practice. I am not sure if we are billing correctly for some of the supplies we use in my department. You are encouraged to talk to your supervisor first. However, if for any reason you do not feel comfortable talking toyour supervisor or if your supervisor did not answer the question or address the problem to your satisfaction, you dohave other options. You should speak with someone else in management, contact the Compliance Officer, or call the24-hour compliance hotline (1-800-863-8567 ). Will I get in trouble if my suspicion turns out to be wrong?As long as you have an honest concern, you will not get in trouble. Employees may be subject to discipline if theywitness something but do not report it. The only time someone will be disciplined for reporting misconduct is if theyknowingly and intentionally report something that they know to be false or misleading in order to harm someone else. What if I tell my supervisor, but they say not to worry about it and to do it anyway because we have alwaysdone it that way?If you know something is wrong, you must not do it. You should report the situation to the Compliance Officer. While conducting chart reviews, my supervisor told me to fill in missing information for my co-workers. Can Ido this?No. It is wrong to document information other than your own. A patient who receives services frequently wants to give you a tip for taking such good care of her. Is thisacceptable?No. Cash gifts or other gratuities are not to be accepted from patients. Refer to Christiana Care Employee Handbook,section on “Gifts and Gratuities”. A health care worker sometimes requests medical records, whether he is involved in the patient’s care or not. Ishe allowed to do this?No. Christiana Care is responsible for protecting patient information from anyone not involved in the patient’s care. Employees should report such inappropriate requests to their supervisor. I have strong religious beliefs and feel I have a duty to teach others. May I pass out my religious flyers atwork?No. Employees may not solicit for any reason or distribute literature or other materials during work time or inworking areas or patient care areas. People not employed by Christiana Care may not, at any time, solicit or distributeliterature for any purpose on Christiana Care property. My brother works for a company that is currently proposing to provide services to Christiana Care. Is that aconflict of interest?Possibly. If your brother is seeking to provide services to Christiana Care, you must not use your position atChristiana Care or information that you obtain at work to influence the negotiation process in any way. You shouldmake your supervisor aware of the situation so that even the appearance of favoritism is avoided. What do I do if I am asked to participate in an aspect of patient care that feels ethically wrong?Christiana Care recognizes that there may be situations where conflict may arise related to an employee's religious orethical beliefs and cultural or moral values that impact on their willingness to participate in certain aspects of patientcare. When such conflicts arise, employees may request to be excluded from certain aspects of patient care. There is



no guarantee that the request can be granted as patient care will not be compromised. Christiana Care must ensure thatpatient care is continued and not compromised by such a request. Whenever possible, employees should notify theirsupervisor or department head in advance and in writing about their concerns and request to be excused fromparticipating in a particular aspect of treatment or care. Can employees really get dismissed for violating this Code of Organizational Ethics?Yes. Christiana Care takes this Code seriously and will enforce it. The standards apply to everyone. Any employee –no matter what his or her level in the organization – who has violated the standards outlined will receive correctiveaction in an appropriate and consistent manner ranging from coaching to termination of employment.

CHRISTIANA CARE HEALTH SYSTEM POLICY

POLICY:Christiana Care is committed to maintaining communication with the patient or designated decision maker and, if appropriate, the family, by providing information to enable informed decisions.Disclosure communication includes but is not limited to unanticipated outcomes related to adverse events or medical errors.

PURPOSE:To establish guidelines for providing information about unanticipated outcomes, including outcomes related to adverse events and medical errors.

SCOPE:Christiana Care Health Services and the Medical–Dental Staff

DEFINITIONS: For the purposes of this policy, the following definitions apply:

Adverse Event:A safety event that resulted in harm.

Communication Coach:An individual trained to support the provider in preparing for the disclosure communication.

Decision Maker: When the patient no longer has decision-making capacity then a decision maker will act on the patient’s behalf. Where applicable and available, the decision maker will be a court-appointed guardian, a patient-selected agent (durable power of attorney for healthcare/person named in an advancedirective), or a patient-selected surrogate decision maker. If the patient has none of these, the descending order of priority in decision-making will be:

A. Spouse including civil unions, unless a petition for divorce has been filedB. Adult children - Equally (18 years or older)C. Parents (any age)D. Adult siblings – Equally (18 years or older)E. Adult grandchildren – Equally (18 years or older)F. Adult niece or nephew – Equally (18 years or older)G. Adult aunt or uncle – Equally.

Any member of the same decision-making level who can be contacted may makethe decision on the patient’s behalf.

Note: Individuals specified in this subsection are disqualified from acting as a surrogate if the patient has filed a petition for a Protection from Abuse order against the individual or if the individual is the subject of a civil or criminal order prohibiting contact with the patient.

H. If an adult patient has none of the individuals eligible to act as a surrogate as listed above reasonably available, an adult, other than a paid caregiver, who has exhibited special care and concern for the patient, who is familiar with the patient's personal values and who is reasonably available may make health care decisions to treat, withdraw or withhold

POLICY TITLE: Disclosure: Communication of Unanticipated Patient Event/Outcome

LAST REVISION/REVIEW DATE: June 13, 2016 DATE OF ORIGIN: April 29, 2002

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treatment on behalf of the patient. Such person shall provide an affidavit to the health care facility or to the attending or treating physician which includes statements that he or she:

i. is a close friend of the patient;

ii. is willing and able to become involved in the patient's health care; and

iii. Has maintained such regular contact with the patient as to be familiar with the patient's activities, health, personal values and morals.

The affidavit must also recite facts and circumstances that demonstrate such person's familiarity with the patient.

Patients with Decision Making Capacity:An individual with the ability to understand the significant benefits, risks and alternatives to proposed health care and to make and communicate a health-care decision

Medical Error:An unintentional act either of omission or commission. An error occurs when either a correct action is not executed properly or an incorrect action is executed.

Patient /Family Liaison:an individual who is designated to be the primary patient and or family contact

Unanticipated Outcome: A result that differs significantly from what was anticipated to be the result of a treatment or procedure

GUIDING PRINCIPLES: � The Christiana Care Way� The patient’s attending physician or his/her designee, when necessary, has the responsibility of

timely disclosure.� Disclosure should be confidential, face-to-face and take place in an appropriate setting. � The intent of the disclosure is to honor the patient’s autonomy and right to be informed about

outcomes of care including unanticipated outcomes related to adverse events or medical error. � Discussions are patient-centered, respecting patient preference and cultural considerations.

COMMUNICATION OF UNANTICIPATED OUTCOME OF CARE/TREATMENT RELATED TO ADVERSE EVENT OR MEDICAL ERRORPROCEDURE:I. Responsibilities of Attending Physician or his/her Designee if necessary:

Note: After discussion with the Attending Physician/designee, a resident may proceed with initial disclosure in exceptional and urgent situations.

A. Develop a plan for initial communication of facts known regarding a suspected unanticipated outcome related to an adverse event or medical error.1. Collaborate with Risk Management, Communication Coach, Patient Relations and administrative

leadership for disclosure support. 2. Involve the Manager of the involved unit /department, as appropriate.3. Perform initial communication as soon as possible, preferably within 24 hours of the event.4. Include the following in the disclosure discussion:

a. Facts known at the time of discussion



b. Offer an apology that the unanticipated outcome occurredc. Inform patient of immediate changes if any regarding the plan of cared. Explain that a review will be undertaken, anticipated date of completion of the Review and that

we will share the outcome of the reviewe. Allow time to address patient and family concerns f. Identify the Christiana Care individual who will act as the Patient Liaison , should there be

additional questions. Provide the name and phone number of the Patient Liaison to the patientand or family. The Patient Liaison should keep in contact with the patient/family until thereview is complete.

5. Document the disclosure discussion in the medical record, including the following: factsknown, date and time of disclosure, who was present for the conversation, what information was conveyed, and the follow-up plan or next steps.

B. Develop a plan for final disclosure to share additional facts learned, if indicated:1.Collaborate with Risk Management, Communication Coach, Patient Relations to prepare

for the final disclosure meeting (add link to Guidelines for Patient/Family Meetings)2. Involve the Manager/Leadership of the involved unit /department, as appropriate3. Share additional facts learned and outcome of review4. Share actions which will be taken to prevent similar events, if applicable.5. Allow time to address patient and family concerns6. Final disclosure discussion may be documented in the Patient Relations record or the medical

record. Include date and time of meeting, who was present for the conversation and the information shared.

REFERENCES: • ASHRM: American Society for Healthcare Risk Management: Disclosure of Unanticipated

Outcome Information• CCHS Safety First Learning Report: Event Reporting Policy and Procedure• CCHS Sentinel Event • ECRI Institute: Disclosure of Unanticipated Outcomes: Supplement A, January 2008• Joint Commission Standards 2015 • Quality and Safety Health Care, McDonald, T. B. Responding to patient safety incidents: the “seven

pillars”, (2009)




POLICY:Christiana Care is committed to obtaining informed consent from the patient or their decision maker prior to invasive procedures.

PURPOSE:To outline the responsibilities and procedures for obtaining informed consent from patients or their decision maker before invasive medical or surgical procedures, including blood product transfusions.

SCOPE:Christiana Care Health System, The Medical-Dental Staff, Christiana Care Health Initiatives, and Christiana Care Home Health & Community

DEFINITIONS: For the purpose of this policy, the following definitions apply:

Informed Consent:An agreement or permission accompanied by a full notice about care, treatment or services that is the subject of the consent. A patient will be apprised of the nature , risks, benefits and alternatives of a medical procedure or treatment before the physician or other healthcare professional begins any course of treatment. After the patient receives this information then either a consent to, or refusal for such procedures or treatment can be made.The elements of informed consent include:

1. the diagnosis;2. the nature and purpose of the procedure;3. benefits, significant risks and alternatives;4. an assessment of the likelihood that the procedure will accomplish the desired objective(s);

Note: The consent form documents the patient’s request and consent to undergo the specified procedure but does not replace the informed consent process. Consents remain valid as long as there is no change in the patient’s condition which would change the risks and benefits of the planned procedure. A re-consenting process would be required with a material change in risks and benefits.

Note: For patients participating in a Christiana Care Institutional Review Board approved research or clinical trials, informed consent will be obtained by the principal investigator or designee when applicable in conformance with IRB requirements.

Capacity: An individual's ability to understand the significant benefits, risks and alternatives to proposed health care and to make and communicate a consistent decision. Capacity should be assessed with each health care decision. Many factors contribute to fluctuating capacity including hemodynamic factors, pain, medications and environment. The level of capacity required for a health care decision depends on the severity of consequences for the decision. For example, a low level of capacity would be required to accept sequential compression boots as prophylaxis for DVT; a high level of capacity would be required to refuse life-saving surgery.

Patients without Decision Making Capacity: Patients who never or can no longer demonstrate the

POLICY TITLE: Informed ConsentLAST REVISION/REVIEW DATE: August 16, 2016DATE OF ORIGIN: January 14, 1972

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ability to reason, to consider relevant information and to evaluate risks, benefits and alternatives to proposed health care. The consent process for these patients, including minors, will take place with their decision maker.

Decision Maker: When the patient no longer has decision-making capacity then a decision maker will act on the patient’s behalf. Where applicable and available, the decision maker will be a court-appointed guardian, a patient-selected agent (durable power of attorney for healthcare/person named in an advancedirective), or a patient-selected surrogate decision maker. If the patient has none of these, the descending order of priority in decision-making will be:

A. Spouse including civil unions, unless a petition for divorce has been filedB. Adult children - Equally (18 years or older)C. Parents (any age)D. Adult siblings – Equally (18 years or older)E. Adult grandchildren – Equally (18 years or older)F. Adult niece or nephew – Equally (18 years or older)G. Adult aunt or uncle – Equally.

Any member of the same decision-making level who can be contacted may makethe decision on the patient’s behalf.

Note: Individuals specified in this subsection are disqualified from acting as a surrogate if the patient has filed a petition for a Protection from Abuse order against the individual or if the individual is the subject of a civil or criminal order prohibiting contact with the patient.

H. If an adult patient has none of the individuals eligible to act as a surrogate as listed above reasonably available, an adult, other than a paid caregiver, who has exhibited special care and concern for the patient, who is familiar with the patient's personal values and who is reasonably available may make health care decisions to treat, withdraw or withhold treatment on behalf of the patient. Such person shall provide an affidavit to the health care facility or to the attending or treating physician which includes statements that he or she is:

i. A close friend of the patient;

ii. Is willing and able to become involved in the patient's health care; and

iii. Has maintained such regular contact with the patient as to be familiar with the patient's activities, health, personal values and morals.

iv. The affidavit must also recite facts and circumstances that demonstrate such person's familiarity with the patient.

Minor: Patients less than 18 years of age, who are not pregnant or married.

Emergency:A medical emergency exists when immediate treatment is necessary to preserve the patient’s life or prevent serious, permanent injury or impairment

Witness:Any adult with decision making capacity who observes the signature of the consenting person.



Designee:A healthcare practitioner trained and qualified to inform the patient of the nature of the procedure including benefits, risks, and alternatives. Staff nurses and technicians employed by Christiana Care may not be a designee.

PROCEDURE:I. PROCESS OF INFORMING

A. The healthcare practitioner or designee authorized to perform medical and surgical invasive procedures or the healthcare practitioner authorized to monitor the administration of blood products will include a discussion about the potential benefits, risks, side effects and alternatives to the patient’s proposed care, treatment, and services and the likelihood of the patient achieving his or her goals and potential problems that might occur during recuperation.This discussion will provide the patient with the information necessary to make an informed decision, answer any questions the patient may have, and when possible shall obtain the patient’s or decision maker’s signature on the consent form.

1. Patients who are at least18 years old and who have decision making capacity may consent to their own procedure(s).

2. Consents for patients without decision making capacity will be obtained from the decision maker.

3. Pregnant or married patients under the age of 18 who have decision making capacity may consent for themselves.

4. When the patient is a minor: a. A parent or guardian will consentb. A minor parent will consent for his/her child

B. Documentation1. The healthcare practitioner or designee will utilize Christiana Care Health

Services approved consent forms. Where available, pre-printed, procedurespecific forms should be utilized.

2. The informed consent contains documentation of a patient and practitioner’s mutual understanding of, and agreement for care, treatment, and or services through written signature, electronic signature, or when a patient is unable to provide a signature, documentation of the verbal agreement by the patient or surrogate decision maker.

3. The following information will be provided in the designated areas of the consentform prior to the procedure being performed:

a. patient labelb. name of doctor or practitioner performing the procedurec. patient’s full named. procedure to be performed (the complete name of the procedure including

appropriate side if indicated)e. patient’s initials where indicated f. signature of patient or decision maker with date, time, and relationship to

patient (by signature, the patient or decision maker is documenting that they have been informed)

g. signature of doctor or practitioner with date and time (by signature, the healthcare practitioner is documenting that the patient has been informed)

h. signature of witnesses with date and time (by signature, the witness is



documenting that the person whose name appears has signed the consent form)

4. Whenever possible for non-hospitalized patients, the informed consent should be obtained in the physician’s office.

5. The informed consent will be obtained and documented before invasive medical or surgical procedures are performed, and prior to blood product administration.

6.The consent form is placed in the patient’s medical record prior to the procedure, except in emergencies:If there are concerns regarding completeness of the consent form or the patient/decision maker’s understanding or unwillingness to sign the consent form, the healthcare practitioner(s) performing the procedure(s), or designee, will be notified.

C. Emergency Situations1. In emergency situations as defined in this policy, emergent treatment may be provided

without informed consent. The medical record will reflect the nature of the emergency, the treatment provided, and the reason informed consent was unable to occur.

D. If the patient has a Do Not Resuscitate Order or Decision to Limit Treatment:1. The informed consent process addresses the current plan of care to limit treatment and

determine if the DNR order should be suspended for the administration of anesthesia, moderate sedation or analgesia for the proposed procedure.

2. The attending physician or designee will review treatment limitations and/or any existing DNR order and the impact of the procedure and anesthesia, moderate sedation or analgesia with the patient or decision-maker or parent/guardian (if a minor) prior to the procedure. This dialog will be documented in a progress note in the patients’record.

3. The physician (surgeon) performing the procedure will review treatment limitations and/or any existing DNR order with the patient or decision-maker or parent/guardian (if a minor) prior to the procedure. This dialog will be documented in a progress note in the patients’ record.

4. The anesthesiologist or designee if applicable will review treatment limitations and/or any existing DNR order and implications of administration of anesthesia with the patient or decision-maker or parent/guardian (if a minor) prior to the procedure. This dialog will be documented in a progress note in the patients’ record.

5. The physician (surgeon) performing the procedure and anesthesiologist will document the discussion and any changes applicable only to the procedure and immediate recovery period with a notation in the ‘special instructions’ section of the Treatment Limitations/DNR Order.

E. Special Considerations:1. For patients with communication disabilities, special assistance will be provided. Refer to

Communication and Language Services for Patients who Require Communication Assistance or Accommodation.

2. For non-English speaking patients Refer to Communication and Language Services for Patients who Require Communication Assistance or Accommodation. To avoid errors in translation, informed consent forms should be translated professionally and provided for the patient in the language of their preference whenever possible and then, if necessary, read aloud by the interpreter.

3. If the patient is unable to sign his/her name in the signature area, any mark made by the patient will be accepted.

4. If the patient is unable to indicate with a mark but still has decision making capacity, the



healthcare practitioner will note this in the progress notes and the signature line will remain blank. The witness will sign the form indicating the person has consented to the procedure.

5. Telephone consents will be accepted when the decision maker is unable to be present. If the nurse is available while the healthcare practitioner or designee is informing the decision maker, he/she should listen and sign the form as a witness. If the telephone consent was based on a prior conversation between the healthcare practitioner and the decision maker, the nurse will obtain the telephone consent in the presence of another nurse and both will sign the consent as witnesses.




POLICY:

Information that is the property of Christiana Care or which has been entrusted to Christiana Care for use and safekeeping must be protected from unauthorized access, modification, destruction, or disclosure, whether accidental or intentional. This protection is provided through appropriate handling procedures, equipment and software used to access, process, store, and transmit information. Use of Christiana Care information resources is subject to ethical standards, federal and state regulations and laws, and other applicable Christiana Care policies.

PURPOSE:

The purpose of this policy is to provide guidance regarding the access, use and disclosure of paper and electronic information. The intent is to balance the need to provide information, effectively and efficiently, while minimizing the risk of misuse of information.

SCOPE:

This policy applies to Christiana Care Health Services, Inc., the Medical-Dental Staff, Christiana Care Health Initiatives, and Christiana Care Home Health & Community Services, and Christiana Care Health & Welfare Benefits Plan, as applicable.

This policy applies to information (electronic, paper, or other), created, collected, stored, or processed by Christiana Care throughout the information life cycle (origination, entry, processing, distribution, storage, and disposal).

DEFINITIONS:

For the purpose of this policy, the following definitions will apply:

Classification of Information

a. Confidential – Protected Health Information (PHI)Individually identifiable health information (oral, electronic, paper, or other), including demographic information that is created or received by a health care provider, health plan, employer or health care clearinghouse and relates to the past, present or future physical or mental condition of an individual, the provision of health care to an individual, or the past, present or future payment for the provision of health care to an individual, that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual. Identifiers of Protected Health

b. Confidential – Business InformationInformation that must be protected from access by anyone other than those specifically authorized to have access based upon need-to-know to perform one’s job. Examples include,

POLICY TITLE: Privacy & Information Security – A Master Policy on Information Security

LAST REVISION/REVIEW DATE: March 10, 2016DATE OF ORIGIN: March 2, 1998

Page 1 of 6Privacy & Information Security - A Master Policy on Information Security

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but are not limited to, PCI or payment card data, payroll and other types of human resource information associated with employees.

c. Private InformationInformation that is internal to the organization which is available to workforce members within the organization. Examples include, but are not limited to, Christiana Care policies and procedures.

d. Public InformationInformation that is available to anyone outside the organization. Examples include, but are not limited to, directions and maps; phone numbers for Christiana Care locations; and physician listings.

E-mail or Electronic Mail Often referred to as E-mail, is a paperless form of communication. Regardless of whether the system used is based on local area networks (LANs), mainframe computers, or some their party commercial value-added network, e-mail allows messages and documents to be sent from one computer to another, much like postal mail is sent from one location to another.

Encrypt(ing) Means the use of an algorithmic process to transform data into a form in which there is low probability of assigning meaning without the use of a confidential process or key. Christiana Care’s standard encryption mechanism for web browsing is Secure Sockets Layer (SSL).

Information Access Administrator (Information Administrator) Information Administrators are responsible for providing access to information (as directed by the Information Owner), as well as protecting and securing, programs and data in accordance with information security policies, standards, and procedures.

Information Security SteerPolicy provides senior leadership oversight to Christiana Care data security functions. This Steer also provides structure for continuous security and confidentiality improvements, and approves information security policies

Information Owner Information Owners are responsible for particular sets of data. These are typically department heads, division chairs, or principal investigators on research projects who are knowledgeable about contents of the data sets. Information Owners approve access to the data sets for which they are responsible.

WorkforceWorkforce means employees, volunteers, trainees, and other persons whose conduct in the performance of work for a covered entity or business associate is under the direct control of such entity or business associate whether or not they are paid by the covered entity or business associate. For example, workforce includes: employees on payroll, residents, medical and other students, volunteers, Junior Board, members of the Medical/Dental Staff, and other temporary, agency or contract persons whose conduct, in the performance of work for Christiana Care, is under the direct control of Christiana Care.



PROCEDURE:

A. Information Confidentiality and Security AgreementWorkforce members are required to review, and acknowledge agreement with, Christiana Care’s Confidentiality and Security Agreement as required in the workforce members’ Department Orientation List, and annually thereafter. Workforce members with access to online Christiana Care education may acknowledge their agreement electronically. Others that do not have access to on-line education may manually sign the agreement. Members of the Medical/Dental staff will sign a Confidentiality and Security Agreement upon appointment, and bi-annually thereafter during the re-credentialing process. Managers will need to secure a signed Information Confidentiality and Security Agreement from parties such as agents, contractors, vendors and others being provided access to confidential information, and the party does not meet the definition of a Business Associate.

B. Access, Use, and Disclosure of Confidential and Private InformationAccess to confidential and private information is limited to that which is reasonably necessary for workforce members to carry out their duties. Workforce members may access, use or disclose information for the purpose for which their access was authorized. Access to confidential and private information must be approved by the Information Owner as well as the workforce member’s supervisor prior to being provided access to the information. The Information Administrator providing the individual with access will maintain a record of the approval for a minimum of six years.

Christiana Care will enter into a Business Associate Agreement with a person, or entity, when they are required to access, use, and/or disclose PHI on behalf of Christiana Care. See the policy, Privacy & Information Security – Business Associates and Contractors with Incidental Contact with Protected Health Information, for additional guidance on this topic.

The workforce needs to be aware of and sensitive to communicating confidential and private information in public places.

C. Electronic Access to Confidential InformationTo establish individual accountability, workforce members will have a unique identifier (or login ID) and password for use in logging into information systems where confidential information will be accessed. Workforce members are responsible for their use of their individual account and should keep their passwords confidential. They are not authorized to sync their CCHS passwords with ASP’s or any systems outside of the CCHS processing environment.

Passwords are required to include the following controls at a minimum:

� Mixture of letters and numbers including at least 2 alpha and 2 numeric; � Minimum length of six, maximum password length is 255; � No words found in the dictionary in any language(best practice, not

required);� Passwords will lockout after 5 invalid attempts;� Users can change their passwords at any time;� Password lockout will be at least 30 minutes;� Passwords expiration will be in intervals of 180 days or less; and� The new password cannot be the same as the last four passwords.



Password expiration intervals, length and characteristic requirements will be reviewed on an annual basis and modified if appropriate. Employees, who cannot comply, for any reason, with the password requirements for a specific system or application, see section O - Deviations to Policy.

In addition to password requirements, specific requirements exist for login IDs. These requirements are defined for user, vendor and daemon accounts.

Workstations connected to the Christiana Care network, both hard-wired and wireless, which may be used to access confidential and private information, will be deployed by individuals in Information Technology authorized to do so. Further guidance regarding computer workstation use and security can be found in the Privacy & Information Security – Computer Workstation Use and Security Policy. See the Privacy & Information Security - Wireless Security Policy for further information on the use of wireless devices.

All user accounts must be reviewed at least annually.

D. Remotely Accessing the Christiana Care Computer NetworkWorkforce members may be granted remote access to the Christiana Care network as needed.Approval for remote access to applications with confidential information shall be obtained from the workforce member’s supervisor before it is provided. Further guidance regarding remote access requirements can be found in the Privacy & Information Security - Computer Workstation Use and Security Policy.

E. Transmitting Confidential Information Outside of Christiana CareConfidential information shall not be transmitted in an e-mail, in an attachment to an e-mail, or in a file outside of the Christiana Care network without proper authorization and consulting Information Technology for a method to secure the transmission. Guidance on the transmission of electronic confidential information can be found in the Privacy & Information Security -Computer Workstation Use and Security Policy and the Privacy & Information Security -Electronic-Mail (E-mail) Access and Usage Policy.

F. Faxed Patient Information

� Clinical areas will not accept faxed patient information that does not contain the patient’s first and last name and birth date.

� In the event, the facsimile does not contain the appropriate identification, the receiving clinical area shall contact the sender and request patient identification be documented and the facsimile resent.

G. WEB Forms� Application developed WEB forms that contain confidential or PHI data should not expose

clear text and should be encrypted. The form results should be contained in a secured file using Windows OS permissions. These permissions should be audited routinely by the department owner of the form to ensure that the membership access is valid.

� WEB Forms built using the CCHS custom tool, WEB Form Builder, should only be used internally and should not contain confidential or PHI data. This tool does not provide encryption and distributes the response via clear text.



� WEB Forms built using MOSS 2007 Surveys should only be used internally and should not contain confidential or PHI data. This tool does not provide encryption and distributes the response via clear text.

� WEB Forms built using ASP Vendor solutions (ex. Survey Monkey) that does not provide encryption should only be used for non- confidential and non-PHI information.

H. Maintaining Proper Storage, Back-up, and Integrity of Confidential InformationConfidential information, whether in paper or electronic form must be stored in a secure location.Confidential information can be secured in a variety of ways however, but must be stored in a locked or badge restricted area to limit access to only authorized individuals based on a need-to-know basis. If confidential information is restricted by a badge, the department manager is responsible for determining which personnel should have access to the secured area based on job responsibilities and care of services provided in the department.

Electronic confidential information should be stored on a server (F: drive or common directory) designated by Information Technology, rather than saved to a computer’s hard drive (the C: drive). Confidential information stored on portable media such as a CD, UBS or laptop must be protected with encryption. See the Privacy & Information Security - Portable Media and Computing Device Security Policy for further information.

Other specific user responsibilities with respect to the safeguarding of electronic confidential information can be found in the Privacy & Information Security - Computer Workstation Use and Security Policy.

Software and other material can be downloaded to Christiana Care equipment as long as it is consistent with the acceptable uses as defined in the Privacy & Information Security - Internet Access and Usage Policy and Privacy & Information Security - Computer Workstation Use and Security Policy.

I. Audit Trail for Systems Containing Confidential InformationAll systems containing confidential information, including but not limited to PHI must have an audit trail.

J. Disaster Recovery/ Continuity of Operations PlanInformation Technology shall provide guidance for determining back-up strategies for the Information Owner who will approve back-up requirements of the program and data files.Regular schedules for making backup copies of data files stored on computer systems will be maintained and performed by Information Technology. Back-up of data files stored on other electronic media is the responsibility of the department head.

A disaster recovery plan to maintain electronic information on computer systems for use in the event of a natural disaster, vandalism, or system failure will be defined by Information Technology.

A continuity of operations plan detailing for a department to either continue to operate at normal capacity, operate at a reduced capacity or, or suspend operations will be defined by each department head.



K. Disposal of Confidential and Private InformationDisposal of confidential and private information on printed documents, CDs, diskettes, and other electronic media should be rendered unreadable and unusable by other parties. See the Privacy & Information Security Disposal of Confidential and Private Information Policy for guidance on how to dispose of confidential and private information.

L. Reporting Security ProblemsIt is the responsibility of Christiana Care workforce to report any suspected or validated security issue (e.g. information lost or disclosed to unauthorized parties, sharing or stealing passwords, tampering with access control mechanisms) to their direct supervisor, the Information Technology Service Center and/or the Privacy Office.

M. Training of the WorkforceChristiana Care requires that workforce members be trained initially on security and privacy practices, and again annually.

N. Standards and ProceduresAll standards and procedures will be documented and stored in the related directory for the policy.

O. Deviations to PolicyAny deviations to this policy or its associated standards and procedures will be reviewed and approved by IT management and the Chief Information Security Officer.

P. Penalties/Enforcement of Information Security PracticesViolation of information security practices will be grounds for disciplinary action as outlined in the Christiana Care Positive Discipline in a Culture of Responsibility Policy A-7.

Workforce members violating information security practices may be subject to disciplinary action up to and including termination of employment as well as civil and criminal liability under applicable law.

Q. Retention of Policies, Procedures, and other Related DocumentationInformation Security Policies, procedures, and other related documentation will be retained for a minimum of six years.




POLICY:

Christiana Care Health Services is committed to providing safe medication practices through obtaining a medication history and reconciling medications.

PURPOSE:

To provide guidelines for obtaining and communicating a medication history and reconciling a patient’s medications at Christiana Care Health Services.

SCOPE:

Christiana Care Health Services and the Medical-Dental Staff

DEFINITIONS:

For the purposes of this policy, the following definitions apply:

Medication History:The record of medications a patient is taking at the time of hospital admission or presentation.

� Complete Medication History:The name, dose, route and frequency of all medications a patient is known to be taking at the time the history is obtained.

� Complex Medication History:A medication history that meets defined criteria used to identify high risk patients.

� Partial Medication History:A documented medication history which contains at minimum the name(s) of the medication(s) the patient is taking, and may include other available information such as route, dose, or frequency.

Medication:Includes prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medication, respiratory therapy treatments, parenteral nutrition, blood derivatives, intravenous solutions, and any product designated by the FDA as a drug.

Medication Reconciliation:A process for comparing the patient’s medications to new medications that are ordered to identify and resolve any discrepancies.

Non-24 Hour Settings:Emergency Departments (treated and released), Primary Care offices, Ambulatory Surgery, Diagnostic,

POLICY TITLE: Medication Management –Medication History and Reconciliation

LAST REVISION/REVIEW DATE: August 16, 2016DATE OF ORIGIN: March 16, 2006

Page 1 of 5Medication Management - Medication History and Reconciliation

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and Outpatient settings.

Procedural Area:Diagnostic Testing and Outpatient Procedure Areas

Providers:Physicians, Physician Assistants, and Advanced Practice Nurses

GUIDING PRINCIPLES:

� A good faith effort to collect a complete medication history should occur early in the patient encounter. The patient’s medication history is a prerequisite for performing comprehensive Medication Reconciliation.

� Medication reconciliation is an ongoing process intended to identify and resolve discrepancies and may involve the patient and/or family.

� Medication reconciliation is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions, contraindications, interactions, and the need to continue current medications. The types of information that providers use to reconcile medications may include but is not limited to:medication name, dose, route, frequency, and purpose.

� Medication reconciliation shall occur as soon as possible and within 24 hours of admission, as well as prior to discharge. It is also recommended upon transfer into or out of the intensive care unit (ICU) and with a transfer from one level of care to another.

� Patient care areas with Computerized Provider Order Entry (CPOE) shall perform admission, transfer (when applicable) and discharge medication reconciliation electronically in PowerChart.

� Patient care areas without CPOE shall perform medication reconciliation on paper.

� The process for obtaining a medication history and the performance of medication reconciliationmay vary based upon services provided and whether the patient has a complex medication history.

PROCEDURE:

I. Medication History and Reconciliation process by roleA. Emergency Department (ED) nurse obtains and documents a partial medication history on

ED patients if medication history is not completeB. Inpatient Unit nurse obtains and documents a complete medication history on admitted patients if medication history is not completeC. Procedural Area staff obtains and documents a medication history on pre-procedural patients D. Medication History Technician obtains and documents a complete medication history on

admitted ED patients, prioritizing patients with complex medication histories, as resourcedE. ED Pharmacist:

1. Obtains and documents a complete medication history on ED patients, as resourced

F. Inpatient Unit Pharmacist assists the inpatient unit nurse in documenting a complete medication history on admitted patients, prioritizing patients with complex medication



historiesG. Provider:

1. Completes medication reconciliation as appropriate upon admission, transfer and discharge2. May obtain medication history if not done by another discipline

II. Medication Reconciliation for Admitted PatientsA. Medication History

1. Nurse, Pharmacist, Medication History Technician, or Provider will:a. Obtain a Medication History as early in the admission as possible.b. Utilize the following as a primary source for obtaining the medication

history:i. Patient/family interview ii. Medication List from a transferring facility

c. Utilize the following additional secondary sources during the patient and family interview to assist with the collection of medication history. These sources require verification by the patient or family prior to adding to the medication history:

i. Review of a patient medication listii. A faxed list from the Primary Care Provider’s office or other

healthcare organization iii. External Prescription (Rx) Historyiv. Home medication list from a previous Christiana Care Health

Services encounterv. Medication list from History and Physical or previous Discharge

Summaryvi. Conversation with community pharmacist or designee vii. conversation with Primary Care Provider or designeeviii. Information from prescriptions bottles if available

d. Obtain and document the medication name, dose, route, and frequency. e. Communicate to provider information deemed relevant related to

medication compliance.f. Review medication purpose if available with patient and communicate to

the Provider pertinent information related to patient report of medication purpose.

g. Attempt to obtain additional medication history information if the medication history is known to be a partial medication history.

h. Record any additional information related to home medications in the medication history as it becomes available. Notify the Provider as appropriate.

B. Admission Medication Reconciliation1. The Provider will:

a. Complete and document within 24 hours of admission. b. Compare the medication history to medication orders.c. Resolve any medication order discrepancies including but not limited to

duplications, omissions, contraindications, unclear information, changes, interactions, and the need to continue current medications.

C. Transfer Medication Reconciliation for ICU Patients1. The ICU Provider shall:

a. Complete medication reconciliation when a patient transfers into or out of the ICU.



b. Compare the medication history, current medications, and new medication orders.

c. Resolve any medication order discrepancies including but not limited to duplications, omissions, contraindications, unclear information, changes, interactions, and the need to continue current medications.

D. Medication Reconciliation for Non-ICU Patients with Transfer of Service1. The Transferring Provider shall:

a. Complete medication reconciliation when a patient transfers to a different service.

b. Compare the medication history, current medications, and new medication orders.

c. Resolve any medication order discrepancies including but not limited to duplications, omissions, contraindications, unclear information, changes, interactions, and the need to continue current medications.

E. Discharge Medication Reconciliation1. The Provider will:

a. Compare the medication history, current medications, and medications the patient will be prescribed upon discharge.

b. Resolve any medication order discrepancies including but not limited to duplications, omissions, contraindications, unclear information, changes, interactions, and the need to continue current medications.

2. The Nurse will:a. Verify that discharge medication reconciliation has been completed.b. Notify Provider if discharge medication reconciliation is not complete. c. Collaborate with Provider to facilitate completion of discharge medication

reconciliation. Note: If unable to facilitate completion of discharge medication reconciliation, implement Chain of Command to assist in resolution.

d. Provide the patient and/or family or facility with the discharge medication list that they should be taking when discharged from the hospital. The list shall include the medication name, dose, route, and frequency.

e. Review and verbally explain the purpose of the medication to the patient and/or family.

f. Educate the patient and/or family about the importance of managing medication information including but not limited to instructing the patient to give a list to his or her primary care or other Providers; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations.

g. Maintain a copy of the patient’s discharge medication list for the patient’s medical record.

III. Medication Reconciliation for Non Twenty-Four Hour Setting PatientsA. Medication History

1. Collect partial medication history anytime a patient enters a non-twenty-four hour setting if medications (including diagnostic

and contrast agents) are to be used, or the patient’s response to the treatment or service could be affected by the medications

that the patient has been taking.2. Review medication purpose if available with patient and communicate to the Provider



pertinent information related to patientreport of medication purpose.

3. Place the medication history in a visible location in the patient’s medical record.B. Medication Reconciliation

1. Compare the medication history to medication orders as appropriate before treatment, test, or procedure. The Medication Reconciliation

process generally does not apply to outpatients seeking physical therapy, laboratories services and most routine imaging services that

do not involve administration of contrast media or other medications.2. Resolve any medication order discrepancies including but not limited to duplications,

omissions, contraindications, unclear information,changes, interactions, and the need to continue current medications.

3. Provide the patient and/or family written information at the end of the encounter including the name, does, route, and frequency of

medication when new medications are prescribed or medications are changed by the provider.

4. Review and verbally explain the purpose of the new medication to the patient and /or family.

Note: When the only additional medications prescribed are f a short duration, the medication information may include only those

medications.5. Educate the patient and/or family about the importance of managing education information.

REFERENCES:

http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf

Inpatient Medication Reconciliation Process



Maintained by: Rosemary Ellis Mar 10, 16, 9:00 AM

CHRISTIANA CARE HEALTH SERVICES MEDICAL-DENTAL STAFF POLICY

POLICY TITLE: Proctoring and Focused Professional Practice Evaluation

LAST REVISION/REVIEW DATE; March 2016

DATE OF ORIGIN: November 7, 2013

POLICY:

It is the policy of the Christiana Care Medical-Dental Staff to properly evaluate the professional competency and qualifications of all new appointees and current members requesting additional privileges.

PURPOSE:

To define the proctoring process as identified in CCHS Credential Policy § 3.B.2 Focused Professional Practice Evaluation and Christiana Care Medical-Dental Staff Policy: Ongoing and Focused Professional Practice Evaluation SCOPE:

Medical-Dental Staff with clinical privileges and Credentialed Health Care Providers

DEFINITIONS: (For the purposes of this policy, the following definitions apply)

Focused Professional Practice Evaluation (FPPE): FPPE allows for focused evaluation of a specific aspect of a practitioner’s performance. This process is time- or volume limited and evaluates a practitioner's competency in a specific privilege. FPPE may consist of more than one (1) type (s) of proctoring. Practitioners: Includes members of the Medical-Dental Staff with clinical privileges and Credentialed Healthcare Providers Proctoring: The evaluation of a practitioner’s clinical competence by a proctor (who holds the same privilege- unrestricted) who represents and is responsible to report his/her evaluation to the Medical-Dental staff. Proctoring takes both cognitive and procedural abilities into account and may be considered FPPE. (See next page for types of proctoring). Proctor: Individual evaluating a practitioner’s clinical competence, either by directly observing clinical care being administered or reviewing care previously provided by the subject practitioner.


Types of Proctoring

Concurrent Proctoring (previously known as “direct supervision”): Proctor observes the practitioner during either a procedure or patient interaction.

External Proctoring: May be utilized when the patient is located outside of CCHS or a proctor is not on staff at CCHS:

Patient located at another facility or a non-CCHS practice

Proctor not on CCHS Staff

• Both the proctor and the individual undergoing FPPE must be on staff at CCHS as well as the other facility.

• Used only when approved by department chair.

• A proctor who is not on staff at Christiana Care, but who has expertise in the privilege/ procedure/equipment being reviewed, may serve as a CCHS proctor.

• Under most circumstances an external proctor is used when there are no CCHS attending staff members who have the required privileges, knowledge and expertise to perform the proctoring.

• The responsibilities of an external proctor shall be detailed in a letter agreement

• See section V for requirements

Prospective Proctoring: Review by a proctor of either the patient’s medical record or the

patient and plan of care before treatment. May be used to assess the appropriateness of planned care if the indications for a particular procedure are difficult to determine or if the procedure is particularly risky. Retrospective Proctoring: Retrospective review of the patient’s medical record by the proctor. This term replaces the previously used term “indirect supervision.”

Teleproctoring: The evaluation of the practitioner remotely using technology. The teleproctor is in one location and the practitioner is in another. Teleproctoring may be prospective, concurrent or retrospective.

Simulation: Evaluation of competency utilizing simulation may be used in conjunction with prospective, concurrent, or retrospective proctoring unless the Department Chair determines that the sole use of simulation may be sufficient to determine competency.


PROCEDURE:

I. PRACTITIONERS TO BE PROCTORED include the following: A. New practitioners; B. Current practitioners requesting additional privileges, which may include the use of new

technology, techniques or procedures; C. Practitioners moving from Ambulatory or Pediatric Courtesy Category to Attending

Category with inpatient privileges D. Practitioners returning from an extended leave of absence; E. Practitioners requesting renewal of privileges performed so infrequently that assessment

of current competence is not feasible; and F. Any practitioner for whom specific monitoring or assessment of current competence has

been recommended by the department or organizational peer review committee(s). When this occurs, the process will be managed via the Medical-Dental Staff Peer Review Policy. This may include but not be limited to the concepts defined in this policy.

II. PROCTORING PROCESS

A. Each department will identify either the time period and/or the required number of cases

for completion of the FPPE plan. Generally, unless otherwise approved by the Department Chair, the FPPE process will be completed within a period of six (6) months.

B. For new privileges, the FPPE plan may take into account the previous experience of the individual including recent graduation from a CCHS training program.

C. The Department Chair or designee may modify the requirement based on the practitioner’s experience or demonstrated competency.

D. The Department Chair or designee shall be responsible for determining the appropriate proctor.

E. If an external proctor is used, the Department Chair must approve after reviewing the credentials of the External Proctor. The use of an external proctor will also be noted on the FPPE Forms.

F. The Department Chair must approve the use of a non-CCHS site or facility for external proctoring.

G. The proctor may be a member of the same practice group as the practitioner being proctored. In such cases, however, the proctor is responsible to the Medical-Dental Staff and is required to report his/her findings to the Department Chair.

H. The Department Chair shall determine the appropriate process for FPPE of low volume practitioners, which may include but not be limited to: direct observation, peer references, surveys obtained from patients, evidence of maintenance of certification, simulation, external proctoring at a non-CCHS site and concurrent proctoring of an admission or procedure.

III. ROLE AND RESPONSIBILITY OF THE PROCTOR

A. As defined in Medical-Dental Staff Bylaws 3.A.3. (3) Ongoing Responsibilities and requirements, every member specifically agrees to accept committee assignments, emergency call obligations, care of unassigned patients, consultation requests, participation in quality improvement and peer review activities, and such other reasonable duties and responsibilities as assigned by the department chair.

B. The proctor (except for an external proctor) must be a member in good standing in the Attending Category of the Medical-Dental Staff.


B. If performing concurrent proctoring for surgery/invasive procedures, the proctor must hold unrestricted privileges to perform the procedure to be proctored, and the proctoring must include direct observation of at least the key portions of the procedure.

C. If completing a retrospective review of the medical record following discharge, the review should be completed on approved CCHS forms.

D. The proctor shall maintain confidentiality of the proctoring results and forms. E. Unless agreed by the Department Chair, the proctor shall return a completed

proctoring form to the Medical-Dental Staff Services Department within two (2) weeks of review.

IV. RESPONSIBILITIES OF THE PRACTITIONER UNDERGOING FPPE FOR INITIAL REVIEW OF

PRIVILEGES. A. It is the responsibility of the practitioner to:

1. obtain an acceptable proctor for each procedure/privilege requiring proctoring (unless previously designated by the Department Chair), before the admission/procedure except for emergency cases; a. in the event of an emergency, a retrospective review may be

completed by the proctor; B. Notify the chair if he or she has difficulty finding a proctor(s)

2. keep a record of the cases and the practitioner (s) who have served as proctors; 3. notify the assigned proctor in sufficient time for each case to be proctored; 3. inform the proctor of any unusual incident in any way associated with the patient; 4. complete the FPPE within the defined time frame; and 5. comply with the number of cases to be proctored.

A. Failure to complete FPPE for requested cognitive and procedural privileges within one (1)

year will result in automatic relinquishment of the applicable clinical privilege(s).

V. EXTERNAL PROCTOR (NOT ON STAFF) REQUIREMENTS A. When external proctoring is required for specific monitoring and assessment of current

competence or for new privileges/procedures/equipment, it is the responsibility of the Practitioner to: 1.Forward the names and contact information of the proctors to CCHS Legal Office for the

development of consulting and business agreement(s); 2.Forward the names and contact information of the proctors to CCHS Medical-Dental Staff

Services to arrange for the following information to be submitted: a. Copy of curriculum vitae (CV); b. State in which applicant is licensed or copy of foreign medical License 1; c. Social security number and date of birth; d. Copy of malpractice certificate; e. Name(s) of procedure or new equipment; f. Name of CCHS attending physicians of record; and

1 Please note: Per the Board of Medical Licensure and Discipline Title 24, 1700, Section 6.0 Consulting Physician Consultation may be done telephonically, electronically or in person. Consultation shall ordinarily consist of a history and physical examination, review of records and imaging pathology or similar studies. Consultation includes providing opinions and recommendations. An active Delaware certificate is required of any out of state physician who comes into Delaware to perform a consultation more than twelve (12) times per year. A physician who comes into Delaware to perform consultations must be actively licensed in another State or country on a full and unrestricted basis. Any consultations done for teaching and/or training purposes may include active participation in procedures and treatment, whether surgical or otherwise, provided a Delaware licensed physician remains responsible as the physician of record, and provided the patient is not charged a fee by the consultant.


g. As applicable, name of patient(s). B. All External Proctors must be approved by the Department Chair.

VI. DOCUMENTATION OF FPPE AND THE PROCTORING PROCESS

A. For Practitioners listed in paragraph I(A) – (E): 1. CCHS Proctoring forms will be supplied to the practitioner and/or collaborative/supervising physician by the Medical-Dental Staff Services Department. It shall be the responsibility of the practitioner to provide the proctor with the forms. 2. When the proctoring process is completed, the proctor forms will be forwarded to the department chair or designee as well as the Medical- Dental Staff Services Department. 3. The Department Chair or designee will recommend either to extend or remove the practitioner from FPPE. The recommendation may be reflected through documentation of such in the department credentialing meeting minutes. 4. After successful completion of FPPE, performance will be monitored through the Ongoing Professional Practice Evaluation (OPPE) process as defined by the department.

B. For practitioners listed in paragraph (IF) above: 1. The proctor process shall be determined in accordance with the Medical- Dental Staff Peer Review Policy.

VII. ADVERSE RECOMMENDATION OR ACTION

A. Issues identified in FPPE may be addressed through an extension of FPPE or the Peer review process.

VIII. CONFIDENTIALITY AND DOCUMENT RETENTION A. The proctor shall maintain strict confidentiality.

IX. The original proctoring report shall be filed in the practitioner’s credential file. REFERENCES:

American Academy of Family Physicians. Clinical Proctoring. http://www.aafp.org/online/en/home/policy/policies/c/clinicalproctor.html Title 24 Regulated Professions and Occupations, Delaware Administrative Code, Department of State, Division of Professional Regulation, 1700 Board of Medical Licensure, Section 6.0 Consulting Physician Ilese J. Smith, Editor The Medical Staff Handbook: A Guide to Joint Commission Standards, Second Edition, 2004 Livingston, Edward H. & J. D. Harwell, The medicolegal aspects of proctoring, The American Journal of Surgery 184 (2002) 26-30 Marder, Robert J. & M.A. Smith, Proctoring and FPPE: Strategies for Verifying Physician Competence, Second Edition, Greeley, HCPRO, Medical Staff Institute Smith Mark A & Sally Pelletier, Assessing the Competency of Low-Volume Providers, Second Edition, Greeley, HCPRO, Medical Staff Institute

MEDICAL-DENTAL STAFF SERVICES POLICY POLICY TITLE: Ongoing Professional Practice Evaluation

(OPPE) LAST REVISION/REVIEW DATE: January 2016

DATE OF ORIGIN: January 2010

POLICY:

The Medical-Dental Staff is committed to the provision of safe, quality patient care through the ongoing evaluation of privileged providers.

PURPOSE: To provide guidance to Clinical Departments regarding the selection of measures, review of measures, and utilization of the information.

SCOPE: Credentialed providers with clinical privileges at Christiana Care Health Services

DEFINITIONS: For the purposes of this policy, the following definitions apply: Annual Operating Plan (AOP): Annual tactical goals related to quality and safety of care

Ongoing Professional Practice Evaluation (OPPE): OPPE is the ongoing process to assess clinical competence and professional behavior.

PROCEDURE: 1. Under the direction of the Medical Executive Committee, each Clinical Department

Chair will define the criteria used for ongoing professional practice. Selected metrics should support the tactical goals of the AOP and the Service Lines (as applicable)

2. In addition to quantitative measures, members of the Medical Dental Staff and Credentialed Healthcare providers will be evaluated on their communication and interactions with patients, family members, each other, hospital employees and trainees consistent with the expectations set forth in the Code of Conduct, Article I, Medical-Dental Staff Bylaws.

3. OPPE is conducted a minimum of every six to nine months and as applicable renewal data may be substituted for the OPPE time period immediately prior to current renewal

4. The Department Chair or his/her designee are provided with practitioner specific

data relative to the measures outlined in Attachment A.

5. The Department Chair/designee is responsible for identifying the relevant leader(s) and or committee(s) who will be accountable for reviewing the information, and identifying any areas of concern which in turn are communicated to the Department Chair.

6. Departments that routinely collect and review data on the performance of their practitioners may submit evidence of that review in order to satisfy OPPE requirements. This data should be readily available for review if requested.

7. Information obtained about members or credentialed health care providers during OPPE will factored into the decision to maintain or revise existing privileges or revoke an existing privilege at the conclusion of OPPE or at the time of the practitioner’s next reappointment as applicable.

8. Indicators/triggers for focused professional practice evaluation will include but not be limited to the following:

a. Occurrences (including Patient Relations and Safety First Learning Reports) that meets the initial indicators/triggers as defined by the Medical-Dental staff (may be rule based or rate based)

b. Any Sentinel Event c. Any event referred by the Department Chair or Service Line Leader

9. Adverse decisions made as a result of OPPE will be managed as outlined in the the

Fair Hearing Process as delineated in Medical-Dental Staff Bylaws Article 3.D.4 Fair Hearing Procedures.

Revised: March 2015, January 2016 Approved by Medical Executive Committee: February 1, 2010, October 7, 2013

ATTACHMENT A

OPPE MEASURES All credentialed providers with clinical privileges are reviewed for clinical judgement/competence as well as professionalism/patient complaints. Departments may use their own metrics or hospital data that will be provided from University HealthSystem Consortium (UHC).

Group Metrics All Departments/Sections (Medical Staff and Credentialed Healthcare Providers)

Number of validated patient/staff complaints related to professionalism Collaborative/Supervising Physician Evaluation (Please note: forms not

returned within 30 days, may result in administrative suspension of privileges until the completed evaluation is submitted to Medical-Dental Services).

Anesthesiology Attendings and CRNAs

Volume to support Age Group and Specialty Appropriate classification

Emergency Medicine Focused case review

Family & Community Medicine Medicine Obstetrics & Gynecology Orthopaedic Surgery Pediatrics Psychiatry Radiology: Interventional and Neurointerventional Surgery

As appropriate to practice: Inpatient/Outpatient Cases Length of stay Mortality Cost Complications (AHRQ) Blood Utilization Cost per adjusted disharge

Number of consultations Re‐admissions within 7 days for

same diagnosis/problem Medical record suspensions Timeliness of operative notes

(where applicable)

Psychology Record review (2) of any combination of diagnostic interview, patient assessment or consultation)

Oral & Maxillofacial Surgery and Hospital Dentistry

Resident feedback/Faculty Evaluation Oral and Maxillofacial Surgeons: Cases, LOS, Complications, etc. as above

Pathology and Laboratory Medicine

Anatomic Pathology o Turn Around time (TAT) as appropriate o Random Case Review

Clinical Pathology o Timely sign-off on procedure o Laboratory Accreditation/Inspection Results

Radiation Oncology Treatment summaries (compliance with ACR standard for Communication)

Radiology

Diagnostic Nuclear Medicine

Automated Imaging Report Review (2/session) Quality Management Program/Reports

CHRISTIANA CARE HEALTH SERVICES

POLICY:

Christiana Care is committed to respecting patient rights with the appropriate assessment and management of pain.

PURPOSE: To provide guidelines for the assessment, treatment, and management of pain.

SCOPE:Christiana Care Health Services and the Medical–Dental Staff

DEFINITIONS:

For the purpose of this policy, the following definition will apply:

Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain includes not only the perception of an uncomfortable stimulus, but also the response to that perception.

PROCEDURE:

I.Inpatient/Emergency Department

A. Assessment

1. Screen patient for the presence of pain. Observe for nonverbal signs of discomfort, including moaning/groaning, failure to rest/sleep, reluctance for physical therapy, ambulation or daily activities, irritability, muscle tenseness, and/or inability to focus on conversation. Evaluation of psychological functioning (e.g., depression, anxiety, coping ability) may also provide valuable nonverbal clues to one’s comfort level.

2. Perform and document a routine pain assessment upon admission and on an 8 hour basis. Pain will also be assessed and documented with any complaint of pain, following surgery, and pain producing procedures.

3. Perform a pain assessment when pain is present. The pain assessment shall include pain severity, location, and characteristics of pain. An evaluation of signs and symptoms, and physical and psychological assessment shall also be performed, if deemed appropriate.

4. Assess the patient’s pain utilizing the patient’s self-report as the primary source of assessment. The following patient self-report pain scales shall be utilized for the patient's self-report of pain:

a. Numeric Pain Intensity Scale (0 – 10) where 0 represents “no pain” and 10 represents “worst pain imaginable.”

POLICY TITLE: Pain Management LAST REVIEW/REVISION DATE: January 13, 2016DATE OF ORIGIN: November 1, 2006

Page 1 of 4Pain Management

9/8/2016http://depts/policies/WebPolicies/Docs/Pain%20Management.htm

b. The Wong-Baker Faces Pain Rating Scale for children or for patients with communication/language barriers.

5. Assess patients who are not able to self-report by verbally/cognitively describing pain with the appropriate non-verbal pain assessment based upon behavior; facial expression, and physiologic signs. The following non-verbal pain assessment tool shall be utilized as appropriate:

a. Pain Associated Behaviors

b. Neonatal Pain, Agitation, and Sedation Scale (NPASS)

c. Faces, Legs, Activity, Cry, Consolability Scale (FLACC)

d. Critical Care Pain and Observation Tool (CPOT)

6. Treat pain if appropriate based upon the presence of a known painful condition or a pain producing procedure in the event that the patient is unable to self-report and the non-verbal pain assessment tool cannot be utilized, for example if a patient is unconscious or chemically paralyzed.

7. Assess obstetrical patients in labor on admission and at intervals as labor progresses. The pain of labor, not amenable to treatment by non-pharmacologic means, will be treated according to guidelines established by the department of OB/GYN and Anesthesia. Patient requests for analgesia of any type, including epidural, will be communicated to the Obstetrical provider.

B. Reassessment

1. Reassess the patient following pain medication administration to determine the degree of pain relief once sufficient time has passed for the treatment to reach peak effect. Reassessment is dependent on route of medication administration.

2. Reassess the patient using an appropriate pain assessment and achievement of the desired effect. If the desired effect is not achieved, consider additional interventions as deemed appropriate.

3. Pediatric/ neonates respond to pain in ways that may differ from adults although the physiologic responses and effects on recovery are similar.

(CPG: Pain Management (Neonatal/Infant Pre-Verbal Patient)

C. Prescribing and Dosing Guiding Principles

1. Determine and treat the cause of pain.

2. Consider non-pharmacologic techniques for pain management for patients experiencing pain. Techniques that may be used for non-pharmacologic management of pain could include the following: repositioning and cognitive-behavioral interventions such as relaxation breathing, distraction, imagery, prayer, or other population specific strategies (e.g., swaddling).

3. Consider choosing the analgesic based on the severity and type of pain using the following as a guide. This may vary based on patient condition, history, and type of pain, for example surgical patients may require opioids for mild pain:

a. non-opioids or low dose opioids for mild pain (rating 1-3)



b. opioid often in combination with non-opioids, for moderate pain (rating 4-6)c. opioids (long and short acting) for moderate to severe pain (rating 7-10)

4. Administer analgesics orally whenever possible. Degree of pain relief is equivalent to intravenous opiates at equianalgesic doses. Avoid intramuscular injections (Intravenous route preferred to IM).

5. Administer sustained-release analgesics for constant/chronic pain rather than as needed (PRN). Scheduled dosing maintains serum levels and provides constant relief.

a. Utilize breakthrough and adjuvant treatments as needed. Each breakthrough dose is approximately 10-20% of the continuous daily dose and this should be ordered as a PRN for breakthrough pain.

6. Dose escalation or discontinuation of opioid therapy may require gradual titration of the dose. When dealing with titration (especially when titrating a patient down from an opioid), watch for signs/symptoms of physical withdrawal which may include nausea, vomiting, diaphoresis, and chills.

7. Manage symptoms or side effects that are associated with analgesics as part of the patient’s pain management plan.

8. Upon initiation of a scheduled opioid regimen, the patient should be placed on a stimulant laxative protocol if appropriate. It is often beneficial to co-administer a bowel regimen on a scheduled basis. As the narcotic is titrated, the bowel regimen should be titrated if appropriate.

9. Take special caution in determining dosing regimens for the following patients:�Pediatric/ neonate

�Patients new to narcotics (opioid naive),

�Geriatric patient populations

�Patients with Obesity Hypoventilation (OHV), Obstruction Sleep Apnea (OSA), or other hypercarbic respiratory failure conditions

�When patient is prescribed other sedative medications

�Patients with substance dependence

10. Consider local anesthesia and/or sedation for painful procedures.

11. Refer to CCHS Formulary for prescribing and dosing information.

D. Patient Education

1. Educate patients/families that pain management is an important part of their care. Provide patient and family education on use of the appropriate pain assessment tool as needed based on the patient’s plan of care for pain.

2. Provide education to patients and families regarding their roles in managing their pain as well as the potential limitations and side effects of pain treatments when appropriate. Individual cultural, spiritual, and/or ethnic beliefs, will be considered when communicating with patients and families regarding pain management as an important part of their care.



3. Utilize Exit Care® for patient education materials.

E. Continuum of Care

1. Provide pain management through the continuum of care in inpatient, transitional care, and outpatient/community settings. Include the patient/family in the planning and implementation of the patient’s pain management care plan.

2. Provide for continuation of care based on the patient’s assessed pain management needs at the time of discharge.

F. Resources

1. Utilize pain management resources to assist in management of patients with pain. Resources include but are not limited to: Clinical pharmacists, Clinical specialists, and patient educational material.

2. Refer to Lippincott’s Nursing Procedure and Skills for Pain Management

3. Consult Pain and Palliative Care Service for assistance in pain management if needed.

Section II CCHS Community Physician OfficesA. Screen patients seen in the CCHS Community Physician office practices at the time of the rooming

procedure. As appropriate to the complaint of pain, further assessment, treatment and referral will take place by licensed personnel and according to guidelines established by The Medical Group of Christiana Care. (Updated 2/28/13)Pain Management Guideline: CCHS Community Physician Office Practices

Section III OutpatientA. Patients seen in the CCHS Ambulatory sites of care that are non-Medical Group entities will have a

pain screen completed and documented as appropriate to the type of care provided. Complaint(s) of pain may require further assessment and treatment which may be provided at the current location of care or necessitate a referral to an appropriate resource.



CHRISTIANA CARE HEALTH SYSTEM POLICY POLICY NUMBER/TITLE: Provider Fitness to Practice Policy

LAST REVISION DATE: (Formerly known as the Impaired Physician

Policy – January 8, 2007), August 29, 2016

DATE OF ORIGIN: February 2013

POLICY:

The Medical-Dental Staff of Christiana Care demonstrates its commitment to its members through the prompt recognition, referral and treatment of those who are unable to practice medicine skillfully and safely because of physical or mental illness.

PURPOSE:

The purpose of this policy is to protect patient safety while at the same time attempting to rehabilitate members of the Medical-Dental Staff and Advanced Practice Clinicians (APC) impaired by addictive, psychiatric, emotional, physical, or neurocognitive conditions. SCOPE: This policy applies to all members of the Christiana Care Medical-Dental Staff and Advanced Practice Clinicians. DEFINITIONS: Advanced Practice Clinicians: Advanced practice registered nurses, physician assistants, optometrists and other health care providers who are not members of the Medical-Dental Staff but who are credentialed by the Medical-Dental Staff. Impaired Physician: The American Medical Association defines the impaired physician as one

who is “unable to practice medicine with reasonable skill and safety to patients because of a

physical or mental illness, including deterioration through the aging process or loss of motor

skill, or excessive use or abuse of drugs, including alcohol.”a Because the term “impaired

physician” includes a variety of conditions, the procedures below will not be suitable in every

circumstance.

Physician Health Services (PHS): : An external program contracted by Christiana Care to

provide necessary resources to evaluate and/or address conditions that impact the provider’ss

ability to safely perform professional medical activities.

Medical-Dental Staff Provider’s Health Committee: An ad hoc committee comprised of the

provider’s department chair, CCO or designee, President of the Medical Staff, and, as

applicable, other relevant clinicians.

Provider: This term includes both Medical-Dental Staff Members and APCs

PROCEDURE: Education regarding recognizing and reporting impaired providers shall be provided to all licensed practitioners credentialed and privileged through the Medical-Dental Staff Services Department, and pertinent professionally licensed employees of Christiana Care Health Services. See Appendix A for potential signs of impairment. 1. Mechanism for Reporting

The individual who suspects the provider of being impaired must give a report that describes the incident(s) that led to the belief that the provider might be impaired. The individual making the report does not need to have proof of the impairment, but must state the facts or behaviors identified that led to the suspicions. The report should be provided to an appropriate clinical

leader who will notify the provider’s department chair and/or the CCO. In the event the provider

who is suspected of being impaired is a department chair, the report may be made directly to the CCO. If the CCO is the physician suspected of impairment, the report may be made directly to the CEO. Providers who recognize that they have a mental or physical health issue that could have an adverse effect on patient care shall self-report to the applicable Department Chair and/or CCO and/or CEO. 2. Investigation

If, after discussing the incident(s) with the individual who filed the report, the Department Chair and/or CCO (or CEO as provided above) believes there is enough information to warrant an investigation, he/she shall inform the CCO and the President of the Medical-Dental Staff. The

Department Chair and/or CCO (or CEO as provided above) shall meet with the provider in question. To maintain confidentiality and support a culture of safety, the provider need not be told who filed the report and does not need to be told the specific incidents contained in the report, but should be informed of the nature of the concern. When warranted, the Department Chair or CCO or CEO may refer the provider to the PHS or an alternative provider approved by the Department Chair and/or CCO/CEO to obtain a mandatory evaluation and report. The Department Chair or CCO (or CEO as provided above) may provide information regarding the concerns or reports of incidents to facilitate the evaluation. The CEO or physician designee and/or the CCO or designee may impose restrictions on the

provider’s practice, including, if appropriate, a summary suspension of the provider’s privileges,

until the evaluation, and rehabilitation if indicated, have been accomplished. The provider may be afforded the option to agree to restrict his/her practice or privileges or take a leave of absence until the evaluation and/or rehabilitation have been completed. 3. Failure to Cooperate

If the provider fails to cooperate with the referral to the PHS or with other efforts to protect patients, or is noncompliant with the treatment recommendations or after-care monitoring, the Medical-Dental Staff may take corrective action in accordance with Article 6 of the Credentials Manual and/or Christiana Care Human Resources Coaching and Positive Discipline Policy if applicable. 4. Documentation and Confidentiality

The original complaint and report from PHS or other approved provider shall be filed in the confidential Peer Review file kept in the Medical Staff Services office. 5. Rehabilitation

If the evaluation indicates the provider has an impairment that affects his or her practice, the provider may be required to follow the recommendations for treatment made by the PHS as a condition of continued Medical Staff membership and clinical privileges. The provider will provide the PHS with the required consent for the PHS to provide the Department Chair or CCO or CEO with information including evaluations, recommendations and progress in evaluation or therapy. If the provider fails to comply with the referral for an evaluation and/or any recommended treatment, the CCO or CEO shall refer such matter to the Medical Executive Committee for consideration and/or action.

6. Reinstatement and Monitoring

If the provider has been suspended, has been granted a leave of absence, or has had a restriction of his/her privileges, the provider may request reinstatement when his/her treating provider indicates it is safe for the provider to resume his/her privileges. When considering a provider for

reinstatement, the Provider’s Health Committee and Medical-Dental Staff leadership shall

consider the effect of the provider’s resuming privileges on patient and staff safety and health

care operations.

The provider shall provide a release so the Provider’s Health Committee may obtain the

following information from the PHS or other approved provider: • Whether the provider is participating in the rehabilitation program; • Whether the provider is in compliance with all of the terms of the program; • Whether the provider attends program meetings regularly (if appropriate);

• To what extent the provider’ behavior and conduct are monitored;

• Whether, in the opinion of the rehabilitation program physicians, the provider is rehabilitated;

• Whether an after-care program has been recommended to the provider and, if so, a description of the after-care program; and

• Whether, in the provider’s opinion, the provider is capable of resuming, or continuing,

medical practice and providing continuous, competent care to patients and the basis for that opinion.

If the Provider’s Health Committee determines that the physician is capable of resuming patient

care, the provider’s request to resume privileges shall be processed in accordance with the

Medical-Dental Staff governance documents and implemented only after approval by the Board.

The Provider’s Health Committee may impose the requirement of additional monitoring or other

precautions as a condition for restoring clinical privileges. These precautions may include the requirement that the provider submit periodic reports from his/her treating provider stating that the provider is continuing treatment or therapy as appropriate and that he or she is able to treat

and care for patients in accordance with accepted standards of practice. If the provider’s

impairment is related to substance or alcohol abuse, the provider shall, as a condition for reinstatement, agree to submit to random alcohol or drug screening tests.

If the provider does not agree with the recommendation or fails to comply with the Provider’s

Health Committee recommendations, the CCO and/or CEO shall refer such matter to the Medical Executive Committee for consideration and/or action in accordance with the Medical-Dental Staff bylaws. 7. Other

a. Christiana Care employed providers will also comply with applicable employment policies.

b. If at any time it becomes apparent that the matter cannot be handled internally or jeopardizes the safety of patients, the provider or others, the CCO in consultation with the President of the Medical Staff and the Chief Executive Officer may contact law enforcement authorities or other governmental agencies.

c. If required by law, the CCO or CEO shall report to the Delaware Board of Medical Licensure and Discipline on behalf of Christiana Care and its employees and providers.

8. References

a. American Medical Association Policies related to Physician Health: http://www.ama-assn.org/resources/doc/physician-health/policies-physician-health.pdf (document last updated Feb. 2011)

b. 24 Del. Admin. Code 1700 (Final regulations of the Delaware Board of Medical

Licensure and Discipline)(“Impairment is a condition which renders the licensee

unable to practice medicine with reasonable skill or safety. Impaired licensees are not only at risk of causing patient harm but are also at risk of causing significant personal endangerment. Impairments include drug abuse, alcohol abuse, and mental or

physical conditions that impede the licensee’s ability to practice with reasonable skill

and safety”) c. Ross, S. Clinical Pearl: Identifying the impaired physician, Ethics Journal of the

American Medical Association. Dec. 2003;5:12. Joint Commission on Accreditation of Healthcare Organizations, 2013 Hospital Accreditation Standards. Oakbrook Terrace, IL.: Joint Commission on Accreditation of Healthcare Organizations, Standard: Medical Staff 11.01.01.(The medical staff implements a process to identify and manage matters of individual health for licensed independent practitioners which is separate from actions taken for disciplinary purposes.)

Appendix A The impaired health care professional- physician, nurse, ancillary provider- is one who is unable to practice his or her profession with reasonable skill, care and diligence as well as safety to patients because of an emotional disorder, substance abuse or some other impairment. Signs and Symptoms of Potential ImpairmentC. The impaired professional will exhibit subtle personality changes as the problem or disorder worsens. Mood swings may be common ranging from irritability to outbursts of anger. Substance use disorders commonly affect several domains in an individual’s life, especially his or her ability to function at work and at home and often job performance is the last dimension to suffer. Work-related symptoms:

Late to appointments; increased absences; unknown whereabouts Unusual rounding times, either very early or very late Increase in patient complaints Increased secrecy Decrease in quality of care; careless medical decisions Incorrect charting or writing or prescriptions Decrease in productivity or efficiency Increased conflicts with colleagues Increased irritability and aggression Smell of alcohol; overt intoxication; needle marks Erratic job history

Problems at home:

Withdrawal from family, friends, and community Legal trouble (i.e. driving while under the influence) Increase in accidents Increase in medical problems and number of doctor’s visits Increased aggression, agitation, and over conflict Financial difficulties Deterioration of personal hygiene Emotional disturbances such as depression, anxiety, and mood instability

MEDICAL-DENTAL STAFF

PEER REVIEW POLICY

1

PEER REVIEW POLICY TABLE OF CONTENTS

1. OBJECTIVES, SCOPE, AND STATEMENT

OF MUTUAL EXPECTATIONS

1.A Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.B Scope of Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.C Statement of Mutual Expectations. . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.C.1 Expectations for Practitioners . . . . . . . . . . . . . . . . . . . . . . . . 1

1.C.2 Expectations for Medical Staff Leaders and Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2. PEER REVIEW PRINCIPLES

2.A Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2.B Impartial Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2.C Protection for Peer Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2.D Collegial Efforts and Progressive Steps. . . . . . . . . . . . . . . . . . . . . . 3

2.E Findings and Recommendations Supported by Evidence-Based Research/Clinical Protocols or Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.F System Process Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.G Tracking of Peer Review Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3. MEDICAL-DENTAL STAFF PEER REVIEW COMMITTEE (MDSPRC)

3.A. Composition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3.B. Duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

4. PEER REVIEW PROCESS

4.A Cases for Review by Office of Quality and Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

4.B Office of Quality/Patient Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

4.B.1 Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2

4.B.2 Incomplete Medical Records. . . . . . . . . . . . . . . . . . . . . . . . 5 4.B.3 Determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

4.C Department Chair Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . 5

4.C.1 Review of Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 4.C.2 Assignment of Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4.C.3 Internal Review/Investigative Procedure. . . . . . . . . . . . . . . 6 4.C.4 External Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4.C.5 Determination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4.C.6 Development of a Performance Improvement Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

4.D MDSPRC Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

4.D.1 Consultation on Cases and Issues Regarding Practitioner Performance . . . . . . . . . . . . . . . . . . . . . . . . . . .10 4.D.2 Cases Referred for Approval of a Performance Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4.D.3 Cases Referred Back to Department Chair. . . . . . . . . . . . . 10

5. PEER REVIEW REPORTS

5.A Reappointment/Privileging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

5.B Reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

5.C Reports of “Unprofessional Conduct” . . . . . . . . . . . . . . . . . . . . . . . 11

Exhibit A: PEER REVIEW ACTIVITY CONFIDENTIALITY AGREEMENT

1

PEER REVIEW POLICY

1. OBJECTIVES, SCOPE, AND STATEMENT OF MUTUAL EXPECTATIONS 1.A. Objectives.

The primary objectives of Christiana Care Health Services peer review process are to:

(1) Evaluate a provider’s performance in accordance with defined expectations for patient

care and safety through patient care protocols, guidelines, standards of care recommended by applicable societies, and nationally accepted standards of care and

evaluate a provider’s performance in accordance with established quality indicators

facilitating a meaningful review of the care provided; (3) Effectively, efficiently, and fairly evaluate the quality, appropriateness, and safety of

care provided, comparing it to established patient care protocols, guidelines, and nationally accepted standards of care whenever possible;

(4) Evaluate a provider’s performance in accordance with defined expectations for

professional behavior in accordance with Christiana Care Health Services Code of Conduct, Bylaws, and policies;

(5) Adhere to “Culture of Responsibility” principles that recognize the existence of human

fallibility and the organization’s responsibility to provide systems to support

practitioners in providing high quality and safe care while establishing expectations for personal accountability; and,

(6) Provide constructive feedback and education to practitioners regarding the quality, appropriateness, and safety of care they provide; their professional interactions and communications; and opportunities for improvement and learning.

1.B. Scope of Policy.

This policy applies to all credentialed practitioners who provide patient care services in Christiana Care Health Services. For purposes of this policy, a "practitioner" is defined as a member of the Medical-Dental Staff or a credentialed health care provider who has been granted clinical privileges or a scope of practice.

1.C. Statement of Mutual Expectations 1.C.1 Expectations for Practitioners.

Practitioners are expected to meet the standards set in the Medical-Dental Staff Bylaws Code of Conduct. (Link)

1.C.2 Expectations for Medical Staff Leaders and Christiana Care Administration. Practitioners can expect Medical-Dental Staff leaders and Christiana Care Administration to:

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(a) Devote resources to research and development of clinically sound protocols and

guidelines and systems (see § 2.F);

(b) Openly communicate -- within the confines of peer review confidentiality principles --with practitioners regarding their cases that are being reviewed;

(c) Develop mechanisms for sharing credible comparative data on an ongoing basis; (d) Use collegial, educational methods to address administrative, behavioral and/or patient

care concerns when, in the discretion of the Medical-Dental Staff leaders and Christiana Care Administration, such methods are consistent with patient and employee safety, quality patient care, and effective and/or efficient administration of hospital operations;

(e) Provide a reasonable opportunity for a practitioner to have input into the development of a performance improvement plan to which he or she will be subject; and

(f) Complete the review process in a timely and efficient manner. 2. PEER REVIEW PRINCIPLES 2.A. Confidentiality.

Maintaining confidentiality is a fundamental and essential element of an effective peer review process. All individuals directly involved in performing peer review shall sign the Peer Review Activity Confidentiality Agreement (See Exhibit A) and shall be charged with maintaining strict confidentiality. Individuals who are not directly involved in the Peer Review process may not seek and shall not be provided with information pertaining to peer review matters.

2.B. Impartial Reviews.

In order to protect the integrity of the peer review process, any individual who: (1) does not believe he or she can be impartial (whether bias is for or against the subject

practitioner); (2) is an immediate family member (such as spouse/domestic partner, parent, child, or sibling)

of the practitioner whose care is being reviewed; (3) raised the concern that triggered the review; or (4) whenever possible, has a financial relationship shall not participate in a review except to provide information. If any such individual is a member of the Departmental Review or Peer Review Committee, that individual shall not be present during the portion of the meeting when the case is considered and shall not participate in the deliberations or recommendation concerning the case.

2.C. Protection for Peer Reviewers.

It is the intention of Christiana Care and the Medical-Dental Staff that the peer review process outlined in this policy be considered patient safety, professional review, and peer review activities within the meaning of the Patient Safety Quality Improvement Act of 2005, the federal Health Care Quality Improvement Act of 1986, and Delaware law. In addition to the protections offered to individuals involved in professional review activities under those laws, such individuals shall also be indemnified by Christiana Care Health Services to the extent permitted by law when they act in good faith within the scope of their duties as outlined in this policy and function on behalf of Christiana Care.

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2.D. Collegial Efforts and Progressive Steps.

This policy encourages but does not mandate the use of collegial efforts and progressive steps to address issues that may be identified in the peer review process. The goal of those efforts is to arrive at voluntary, responsive actions by the practitioner. Collegial efforts and progressive steps may include, but are not limited to, coaching (including informal discussions, education, mentoring), letters of counsel or guidance, sharing of comparative data, and performance improvement plans as outlined in this policy. All collegial efforts and progressive steps are part of Christiana Care's confidential ongoing professional practice evaluation (OPPE), focused professional practice evaluation (FPPE), and peer review activities.

2.E. Findings and Recommendations Supported by Evidence-Based Research/Clinical

Protocols or Guidelines.

Whenever possible, the findings of Department Chairs and or designees (including Departmental Peer Review Committees), assigned peer reviewers and the MDSPRC shall be supported by evidence -based research, clinical protocols, guidelines, and nationally accepted standards of care.

2.F. System Process Issues.

Quality of care and patient safety depend on many factors in addition to practitioner performance. If, at any level of the review, a case is thought to involve system processes or procedures either within or outside of the department reviewing the case that may have adversely affected, or could adversely affect, outcomes or patient safety, the case shall be referred to the Office of Quality and Patient Safety for follow-up with appropriate departments and personnel.

2.G. Tracking of Peer Review Cases.

The Office of Quality and Patient Safety will support the MDSPRC by tracking the processing and disposition of all cases reviewed pursuant to this policy. Department Chairs and the MDSPRC shall promptly notify the Office of Quality and Patient Safety of their determinations and dispositions regarding each case.

3. MEDICAL-DENTAL STAFF PEER REVIEW COMMITTEE (MDSPRC) 3.A. Composition.

The MDSPRC shall be comprised of key clinical Medical- Dental Staff Members including Department Chairs or designees, all four elected Medical-Dental Staff Officers or designees, the Vice President of Medical Affairs, and/or Members at Large. The CMO shall be a member of the MDSPRC. The Associate Vice-President of Medical Affairs shall be a permanent member of the committee. The MDSPRC shall be chaired by the President of the Medical-Dental Staff. Members of the MDSPRC shall be appointed by the President of the Medical-Dental Staff upon commencement of his/her first term.

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3.B. Duties. The MDSPRC shall: (1) Provide advice and support to the department chairs and Chief Medical Officer on

individual peer review matters and other issues related to peer review. (2) Oversee the three areas of provider performance (administrative, clinical and

behavioral) covered under the Peer Review Process; (3) Resolve clinically related interdepartmental performance improvement opportunities as

necessary; (4) Identify those quality concerns which do not require physician review but for which the

Chair of the MDSPRC may send an educational letter to the practitioner involved in the case;

(5) Review cases referred to it as outlined in this policy; (6) Assist the chairs and/or their designees in the development or review, as needed, of

performance improvement plans for practitioners; (7) Submit reports of its recommendations to the Department Chairs, Medical Executive

Committee, and Board as needed; and (8) Review the effectiveness of this policy and the peer review process on a continuous

basis and recommend revisions or modifications as may be necessary. 4. PEER REVIEW PROCESS 4.A. Cases for Review by Office of Quality and Patient Safety.

Cases to be reviewed by the Peer Review Process may be identified by or referred to the Office of Quality and Patient Safety by any practitioner, Christiana Care employee or committee. The types of cases that will be reviewed include, but are not limited to, the following:

(1) Referrals from any practitioner, Christiana Care employee or Medical-Dental Staff

Committee with concerns related to the care provided to a patient or the professional conduct of a practitioner;

(2) Patient complaints/grievances referred by the Patient Relations Office; (3) Cases in which a quality concern is present; including cases identified through focused

reviews, clinical registries, and mortality reports;

(4) Referrals of “Workplace Concerns” – reports of provider behavior concerns;

(5) Referrals from external Agencies/Payors: (6) Cases identified by a Safety First Learning Report; (7) Cases involving noncompliance with Christiana Care, Medical-Dental Staff, and or

Department governance documents (Bylaws, Rules and Regulations and/or policies); and (8) Cases identified as litigation risks by the Risk Management Department;

4.B Office of Quality and Patient Safety

4.B.1 Review. The Office of Quality and Patient Safety shall review all cases referred to it. The review may include, but is not limited to, the following: (1) the medical record; (2) discussions with Christiana Care employees, practitioners, and others who may have

relevant information;

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(3) consultation with relevant Medical-Dental Staff or Christiana Care personnel; and (4) review of relevant documentation.

4.B.2 Incomplete Medical Records.

One of the objectives of this policy is to review matters and provide feedback to practitioners in a timely manner. Therefore, if a case referred for peer review involves a medical record that is incomplete, the Health Information Management Department is authorized to release incomplete Medical Records to the Office of Quality and Patient Safety. If it is determined that incomplete documentation by the practitioner is critical to the review, a letter is sent from the MDSPRC requesting that the practitioner complete the required documentation within 10 days of receipt of the letter. Any non-compliance with this requirement will be referred to the MDSPRC for further action.

4.B.3 Determination. After conducting its review, the Office of Quality and Patient Safety shall make one of the following determinations based on established Departmental and Peer Review Committee criteria:

(1) No Further Review Required. If the Office of Quality and Patient Safety determines

that no issue is presented in the case and no further action or review is required, it shall notify the chair of the pertinent department and the matter shall be closed or trended.

(2) System or Quality Issue(s) Identified. Case referred to appropriate Clinical Department(s) or Committee(s) to address the issues.

(3) Potential Physician Performance Issue. If the Office of Quality and Patient Safety determines that a case may involve a potential physician performance issue, it shall prepare the case for review by the pertinent Clinical Department. Preparation of the case may include, but is not limited to, the following: (a) completion of the appropriate portions of the applicable review form; (b) pertinent extracts of medical records; (c) preparation of a time line or summary of the care provided; (d) identification of relevant patient care protocols or guidelines; and (e) identification of relevant literature.

The prepared case shall be forwarded to the appropriate Department Chair for further review and disposition of the case. 4.C. Department Chair Responsibilities:

4.C.1 Review of Matters The Department Chair or designee or applicable departmental Peer Review Committee shall review all cases referred by the Office of Quality and Patient Safety along with all supporting documentation. The Department Chair or designee will also review any other matter involving the clinical performance, administrative functions, or behavior of providers credentialed in his/her Department. The Department Chair or designee shall also participate in the review of any interdepartmental issues when requested. The Department Chair or designee may request additional information or input from the practitioner whose care is being reviewed or from any

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other practitioner or Christiana Care employee with personal knowledge or clinical expertise pertinent to the matter. If possible, the Department Chair or designee will attempt to resolve issues through discussion with the practitioner.

4.C.2 Assignment of Review. When necessary to obtain the facts or the clinical expertise, the Department Chair may assign the review to another practitioner or committee in the Department or refer the matter for investigation by an established Department Committee for Peer Review, or a Morbidity/Mortality Forum. The findings from this review/investigation will be forwarded to the Department Chair and/or designee. The Chair must assure that the practitioner involved in the case has an opportunity to provide information and/or input regarding the matter under review 4.C.3. Internal Review/Investigation Procedure (1) The Department Chair, his/her designee or Departmental Peer Review Committee

(“reviewer”) investigating the matter shall, when pertinent, review the relevant

documents, consider outside materials (including relevant literature and clinical practice guidelines), observe the provider, and interview individuals with relevant information or knowledge.

(2) The provider shall be informed of the general issues being investigated and will be given a chance to explain the circumstances surrounding the issues. The reviewer will make a reasonable effort to complete the review or investigation and issue its report within 30 days of the commencement of the investigation.

(3) At the conclusion of the investigation, the reviewer shall prepare a report with the findings, conclusions and recommendations of the review and provide the report to the Department Chair. The reviewer will apply Culture of Responsibility principles and determine whether there was no issue, human error, at-risk behavior or reckless behavior.

(4) In making its recommendations, the reviewer will consider: (a) relevant literature and clinical practice guidelines as appropriate; (b) relevant documentation and information pertaining to the matter;

(c) observation of the provider’s practice at a Christiana Care facility;

(d) all of the opinions and views that were expressed throughout the review; and/or (e) any information or explanations provided by the subject provider.

4.C.4 External Review.

(1) If the Department Chair determines that additional clinical expertise is needed to adequately identify and address concerns relating to a practitioner, he/she may arrange for an external review.

(2) An external review may be appropriate if:

(a) there are ambiguous or conflicting findings by internal reviewers;

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(b) the clinical expertise needed to conduct a review is not available on the Medical-Dental Staff; or

(c) an outside review is advisable to prevent allegations of bias, even if unfounded.

(3) The external review shall consist of any methodology that may permit evaluation of

a practitioner’s practice, including but not limited to: proctoring of the practitioner’s

procedures, review of charts, and/or the provision of a second opinion. (4) If a decision is made to seek an external review, the practitioner involved shall be

notified of that decision and the nature of the external review. Prior to conclusion of the review, the subject practitioner shall be offered an opportunity to meet with the reviewer to provide his/her perspectives on the issues under review.

(5) At the end of the external review, the reviewer will prepare a full report and

recommendations. This report shall be provided to the Department Chair.

(6) After the Reviewer has reached a conclusion, the provider may request reconsideration in writing or may prepare a statement of disagreement, which will be placed in his/her file.

4.C.5 Determination.

Following review of the case, the Department Chair shall determine and document an

appropriate response to the incident or issue. Within the “Culture of Responsibility” framework,

the practitioner’s actions will be supported when they are determined to be justified.

Additionally, the practitioner will be consoled when his/her actions are determined to be a result of human error. The Department Chair shall consider any previous peer review reports concerning the provider that relate to the current incident or issue in order to identify patterns of administrative, clinical or behavioral issues. Appropriate determinations/actions, depending upon the circumstances, may include but are not limited to the following:

(1) No Further Review or Action Required. If the Department Chair determines that no

further review or action is required, the Department Chair shall record his or her findings on the appropriate review form and, if pertinent, close the case by sending the determination to the Office of Quality/Patient Safety.

(2) Address Through Coaching. If the Department Chair determines that the goal of

enhancing quality of care and improving patient safety would be advanced by informal coaching, the Department Chair or designee will have a discussion with the practitioner and no additional details need to be forwarded to the MDSPRC or the Office of Quality/Patient Safety.

(3) Address Through Collegial Intervention. If the Department Chair determines that the

goal of enhancing quality of care and improving patient safety would be advanced by a collegial intervention (such as proctoring or mentoring) with the practitioner involved, the Department Chair will facilitate timely collegial intervention.

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(4) Address through the Physician Health Policy Process. If the matter may relate to a health issue, the Department Chair may address the matter through the Physician Health Policy.

(5) Address Through Performance Improvement Plan. If the Department Chair

determines that a Performance Improvement Plan is required, the Department Chair will inform MDSPRC and may request a consultation in regard to the formulation of the Performance Improvement Plan. After the plan has been developed by the Department Chair and/or the pertinent department peer review committee, the Performance Improvement Plan may be forwarded to the MDSPRC .

(6) Address Through Corrective/Remedial Action. If the Department Chair determines that

a matter cannot be adequately addressed through coaching, collegial intervention or a performance improvement plan, or if a corrective or remedial action is indicated, the Department chair, and/or, if applicable, department credentials committee, shall initiate the Corrective/Remedial Action process as set forth in the Medical-Dental Staff Bylaws and Credentials Policy by submitting a report with recommendations to the Staff Credentials Committee.

(7) Address Through Disciplinary Action such as a Letter of Reprimand or a Letter of

Admonition, setting forth the basis for the action. Such documentation shall be placed

in the Practitioner’s Peer Review File and reviewed at the time of reappointment or

considered should a pattern of at risk behavior arise. (8) Address Through Suspension. When failure to take action may result in imminent

danger to the health and/or safety of any individual or may seriously interfere with the orderly operation of CCHS, the President of the Medical-Dental Staff, a department chair, the CMO or designee (VPMA), the Board Chair, or the Medical Executive Committee will each have authority to impose an immediate precautionary suspension. If the Chair imposes the suspension, he/she shall refer the matter promptly to the Chief Medical Officer and the Medical Executive Committee who shall determine whether to continue, modify or terminate the suspension.

(9) Other Peer Review Action. Based on the circumstances of the matter, the Department Chair may determine that another peer review action is warranted.

4.C.6 Development of a Performance Improvement Plan

A Performance Improvement Plan shall be for a defined time period or defined number of cases, and should specify how the practitioner's compliance with the recommended action and performance issue will be monitored and evaluated. The practitioner shall have an opportunity to provide input into the development and implementation of the Performance Improvement Plan but the decision of the chair is final. A Performance Improvement Plan may consist of one or a combination of practitioner requirements, including, but not limited to the following:

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(1) Additional Education/CME - which means that, within a specified period of time, the practitioner must acquire, at his or her own expense, education or CME of a duration and type specified by the Chair. The educational activity/program chosen by the practitioner must be approved by the Chair. If necessary, the practitioner may be granted an educational leave of absence while undertaking such additional education/CME.

(2) Focused Professional Practice Evaluation and Mentoring, which means

that a certain number of the practitioner's future cases or evaluations of a particular type will be reviewed (e.g., review of the next 10 similar cases performed or managed by the practitioner). This review may be accomplished through various methodologies, including but not limited to proctoring activities such as retrospective chart review, concurrent chart reviews or direct observation/participation.

(3) Second Opinions/Consultations, which means that before the practitioner

proceeds or continues with a particular treatment plan or procedure, he/she agrees to obtain a second opinion or consultation from Medical-Dental Staff member(s) specified by the pertinent department chair. The practitioner providing the second opinion/consultation must complete a Second Opinion/Consultation Report form.

(4) Additional Training, which means that, within a specified period of time, the

practitioner must acquire, at his or her own expense, additional training of a duration and type specified by the Chair. The training program must be approved by the Chair. The practitioner must then successfully complete the training within another specified period of time. The director of the training program or appropriate supervisor must then provide an evaluation of the practitioner's current competence, skill, judgment and, if applicable, technique to the Chair. If necessary, the practitioner may be granted an educational leave of absence while undertaking such additional training.

(5) Refraining from Exercising Privileges While Obtaining Additional

Training, which means that the practitioner voluntarily agrees to refrain from exercising all or some of his/her clinical privileges until the required education/CME, formal evaluation/assessment program or additional training is completed.

(6) Educational Leave of Absence, which means that the practitioner voluntarily

agrees to a leave of absence during which time the practitioner completes an education/training program of a duration and type specified by the Chair. The education/training program must be approved by the Chair. The practitioner must then successfully complete the training within another specified period of time. The director of the training program or other appropriate supervisor must then provide an evaluation of the practitioner's current competence, skill, judgment and technique to the Chair.

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(7) Behavioral Plan, which means that the practitioner voluntarily agrees to monitoring of behavior, submission to psychological or mentoring services by a mutually agreed-upon practitioner, or participation in a behavior management program. The practitioner shall be requested to permit the department chair or designee to discuss the reasons for the plan and to allow the counselor to submit written progress reports and/or a summary report at conclusion of the plan.

(8) Entry into a Written Agreement to Resolve Administrative Issues, which

may include alternative citizenship responsibilities, entry into a written coverage agreement, or a performance plan for Emergency Department call.

4.D MDSPRC Review

4.D.1 Consultation on Specific Cases and Issues Regarding Practitioner Performance and Behavior

At the request of the Department Chair, the MDSPRC may provide a

consultation on specific cases or issues relating to the performance or behavior of practitioners. The MDSPRC may take note of the matter for future review, provide input or recommendations, or may refer issues to the Staff Credentials Committee, Medical Executive Committee or Chief Medical Officer for further action. The MDSPRC shall also consider whether there has been a thorough, unbiased and complete review of the physician performance issue, adequate communication and dialogue with the involved physician, and an effort to resolve the performance collegially.

Department Chairs are strongly encouraged to consult with the MDSPRC when a physician has engaged in repetitious behavioral patterns or a single episode of egregious behavior.

4.D.2 Review of the Effectiveness of Peer Review The MDSPRC will review and suggest measures to increase the effectiveness and consistency of the peer review process throughout the Medical-Dental Staff. From time to time, the MDSPRC may invite individual departments to describe their processes and to demonstrate how they analyze selected matters. The MDSPRC shall also monitor the implementation of this policy.

4.D.3 Cases Referred Back to Department for Corrective/Remedial Action

If the practitioner involved in the case refuses to participate in the development and/or implementation of a performance improvement plan, or if the MDSPRC determines that a performance improvement plan may not be adequate to address the issues identified in a particular case, or if a pattern has developed despite prior attempts at collegial intervention or prior participation in a performance improvement plan, the MDSPRC shall refer the matter to the Department Chair so that he/she may recommend initiation of corrective/remedial action to the departmental, if applicable, or the Staff Credentials Committee under the Medical-Dental Staff Bylaws and Credentials Policy.

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5. PEER REVIEW REPORTS

5.A Reappointment/Privileging. The Office of Quality and Patient Safety shall prepare reports for use in the ongoing professional practice evaluation (OPPE), reappointment and reappraisal of practitioners, comparing individual practitioner performance to performance by other practitioners in the same specialty or Department on specific quality concerns. Such reports shall be prepared at least semi-annually and shall be forwarded to the appropriate Department Chair who shall share them with the department credentials committee and individual practitioners and consider them in the reappointment process and in the granting of clinical privileges.

5.B Reports. The Office of Quality and Patient Safety shall prepare reports on a regular

basis to the MDSPRC, Chief Medical Officer, and Medical Executive Committee. These reports shall include the aggregate number of cases reviewed through the peer review process and the dispositions of those cases. In addition, the Office of Quality and Patient Safety shall prepare reports as requested by the Department Chairs, MDSPRC Committee, the Medical Executive Committee, and the Chief Medical Officer.

5.C. Reports of “Unprofessional Conduct.” When required by statute (Click here), the

Chief Medical Officer of Christiana Care Health Services, or designee shall submit reports on behalf of the facility and physicians involved in the peer review process regarding the unprofessional conduct of a physician or other covered practitioner to the Delaware Board of Medical Licensure and Discipline.

APPROVED: Medical Executive Committee: April 6, 2015

http://dpr.delaware.gov/boards/medicalpractice/index.shtml

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Exhibit A PEER REVIEW ACTIVITY CONFIDENTIALITY AGREEMENT

I have been asked to participate in a peer review proceeding. As a peer reviewer and/or a member of a peer review committee conducting this proceeding, I understand and agree to the following responsibilities:

• I will use the information provided in this peer review proceeding only for the performance of my duties as a peer reviewer and/or member of the Peer Review Committee.

• I will not discuss or disclose any information regarding the matter, the discussion, or even the fact of the proceeding to any person or entity except (1) during this or a subsequent peer review proceeding; or (2) as specifically authorized by the Administration of Christiana Care Health Services, Inc; or (3) as required by law.

• I will return any and all documents, including any personal notes, to the Chair of the Department at the end of this proceeding.

• If I receive any request or demand for release of information related to this proceeding, I will

immediately notify the Christiana Care Legal Department and cooperate with the Hospital’s

efforts to resist, narrow the requested disclosure, or obtain a court order to protect this information.

• I will not attempt to identify, contact, or take any action against any individual who I believe or know to have been involved in the matter under review.

• I will participate in this peer review proceeding in good faith, will make reasonable efforts to obtain the facts of the matter, and will assure that all my actions in this proceeding are in furtherance of quality health care.

• Conflict of Interest: If I feel, at any time that I cannot, in good faith, meet my obligations, I will inform the Chief Medical Officer and/or my Department Chair and I will excuse myself from further involvement in the review. In particular, I will recuse myself from a peer review if:

(1) I am an immediate family member or close personal friend of the practitioner whose care or behavior is being reviewed; (2) I raised the concern that triggered the review; (3) I have a direct financial relationship with or directly compete with the

practitioner whose care or behavior is being reviewed; (4) I have a real or apparent bias for or against the practitioner.

Accepted and Agreed: ____________________________________ Date:__________________ Signature

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POLICY TITLE: Restraints, Guidelines for Use, Non-Violent or

Non-Self-Destructive Behavior

LAST REVISION/REVIEW DATE: September 1, 2016

DATE OF ORIGIN: October 13, 1993

POLICY:

Christiana Care is committed to promoting patient safety, rights, dignity and well-being by protecting

patients from unnecessary restraints.

PURPOSE:

To provide guidelines for the safe application, use, monitoring and discontinuation of restraints for the

non-violent, non-self-destructive patient.

Note: For use of restraints and seclusion for violent and self-destructive behavior refer to the policy on: Restraints and Seclusion, Guidelines for Use, Violent or Self-Destructive Behavior

SCOPE

Christiana Care Health Services and the Medical-Dental Staff

DEFINITIONS

For the purposes of this policy the following definitions apply:

Designee of attending physician:

A licensed independent practitioner involved in the ongoing care of the patient: Resident, Advanced

Practice Nurse, or Physician Assistant.

Licensed independent practitioner:

An attending physician, Resident, Advanced Practice Registered Nurse, or Physician Assistant.

Non-physical interventions:

Alternatives to restraints that are least restrictive measures effective in maintaining patient safety and

well-being. Examples of non-physical interventions can be found in Altered Mental Status:

Delirium/Confusion/Agitation Care Management Guideline

Qualified RN:

A Registered Nurse who has completed education and training for use of restraints.

Restraint:

Any manual method (chemical, physical or mechanical device, material, or equipment) that immobilizes

or reduces the ability of a non-violent, non-self-destructive patient to move his or her arms, legs, body, or

head freely that cannot be removed easily by the patient; or a drug or medication when it is used as a

restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a

standard treatment or dosage for the patient’s condition.

Restraint Episode:

Time from when the restraint is initiated until the time the restraint is removed.

http://depts/policies/Docs/RestraintsandSeclusionGuidelinesforUseViolentorSelfDestructiveBehavior.htm

http://inet/CareMgmt/PatientSafety/Delirium-CMA.pdf

http://inet/CareMgmt/PatientSafety/Delirium-CMA.pdf

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Examples of Restraints vs Alternative

Inclusions:

Hand Mitts used in conjunction with wrist restraints that are tied to a fixture or in which finger

or hand movement is restricted.

Limb restraints

Side Rails: The use of 4 side rails is considered a restraint except for their use in specialty beds

that function for the provision of specific therapy, or those that require 4 sides up to operate.

Lap belt, lap buddy and chair wedge if they limit movement or cannot be released by the

patient.

The application of force to physically hold a patient, in order to administer a medication

against the patient’s wishes is considered a restraint. For the purposes of this regulation, a

staff member picking up, redirecting, or holding an infant, toddler, or preschool-aged child to

comfort the patient is not considered a restraint.

Exclusions:

This policy does not apply to the use of devices that are associated with medical, dental,

diagnostic, surgical or security procedures: Mechanisms used to temporarily immobilize or

limit mobility related to medical, dental, diagnostic, or surgical procedures and the related

post-procedure care processes.

IV arm boards used to stabilize an IV line is generally not considered a restraint.

Recovery from anesthesia that occurs when the patient is in recovery room or an ICU is

considered part of the surgical procedure and restraint order is not required. Forensic Restrictions. Forensic restraints such as handcuffs, shackles, or other restrictive

devices applied by law enforcement do not constitute restraints.

Adaptive device. Mechanisms intended to permit a patient to achieve maximum normative

bodily functioning (e.g., postural support, orthopedic appliances, braces etc.).

Medical protective device. Mechanisms intended to compensate for a specific physical

deficit or to prevent safety incidents. (e.g., helmet, splints, side rail pads used for seizure

precautions, etc.).

Hand Mitts generally are not considered restraints unless they meet criteria defined in restraint

section above.

Special Beds. The use of four side rails in beds that function for the provision of specific

therapy and those that require four sides up to operate. All other use of 4 side rails (e.g. on

patient beds) constitutes a restraint.

Raised side rails on stretchers. In areas such as the emergency department and when

transporting patients, these are not considered restraint, rather a prudent safety intervention.

Age or developmentally appropriate protective safety interventions (such as stroller safety

belts, raised crib rails, crib covers, high chair lap belts) utilized for safety and to protect an

infant, toddler or preschool-aged child would not be considered as restraints

http://depts/policies/WebPolicies/Docs/Restraints%20vs%20Alternative.pdf

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Guiding Principles for Restraints:

Non-physical interventions are preferred alternatives to restraints.

Orders for restraints are initiated only after non-physical measures have failed or safety

concerns require an immediate physical response.

Restraints are used to protect the immediate physical safety of the non-violent, non-self-

destructive patient.

Standing orders or PRN (as needed) orders are prohibited.

Restraints will not be used as retaliation, discipline, coercion, or staff convenience.

The patient and family will be included in the explanation of the need for restraints, when able.

Assess and monitor the patient on an ongoing basis to determine when restraints can be safely

discontinued.

Unsupervised “Trial releases” are not permitted.

A temporary, directly-supervised release, however, that occurs for the purpose of caring for a

patient’s needs (e.g., toileting, feeding, or range of motion exercises) is not considered a

discontinuation of the restraint or seclusion intervention. As long as the patient remains under

direct supervision, the restraint is not considered to be discontinued because the staff member

is present and is serving the same purpose as the restraint or seclusion. Restraints will be

discontinued as soon as safely possible.

An order must be obtained for each new restraint episode.

Performance Improvement initiatives will be utilized to evaluate ways to prevent, reduce and

strive to eliminate the use of restraints.

PROCEDURE:

I. Restraint Episode Orders

A. Obtain an order for restraints when clinically justified for the physical safety of the patient.

1. Licensed independent practitioners are authorized to write orders for restraint. This includes:

attending physician, resident physician, advanced practice nurse (APRN), physician assistant

(PA).

2. In an emergency situation only, the registered nurse (RN) may initiate restraints in order to

protect the safety of the patient, staff or others. An order will be obtained from the physician

or designee as soon as possible after initiation. B. Restraint orders include time, date, type, and reason for restraint.

II. Monitoring

A. The RN will document initiation of restraints and non-physical restraint alternatives that were

ineffective, resulting in the need for restraint.

B. The following will be monitored and documented at 2-hour interval minimum:

1. Observed behaviors.

2. Routine activities of daily living (ADL) checks which includes nutrition, hydration, hygiene and

elimination.

3. Safety monitoring checks which includes integrity of restraints, skin integrity, providing range

of motion, checking circulation, and sensation of restrained extremities.

C. The following will be monitored and documented at 8-hour intervals minimum:

1. RN assessment of changes in patient’s behavior or clinical condition regarding the need for

continued restraints.

2. Vital signs

4

III. Discontinuation of restraints by the RN

A. Discontinue the use of restraints based on observation and assessment that determines the patient

no longer needs the restraints.

B. Document the discontinuation of restraint in the medical record.

IV. Training and competency

A. Physicians, Physician Assistants and Advanced Practice Nurses will review the

policy at the time of initial credentialing.

B Education will be conducted on a 2 year basis or as needed for staff participating in the

application, assessment and monitoring of restraints on results obtained by knowledge or skills

assessments, introduction of new equipment, or performance improvement data.

5

Appendix A: CCHS Training Requirements: Restraints

Discipline/Role Attending

Physician

Resident

Physician

Advance

Practice

Nurse

Physician

Assistant

Registered

Nurse

Licensed

Practice

Nurse

Patient Care

Technician

Safety

Compa

nion

Security

Policy

Requirements

X X X X X X X X X

One-hr. face to

face

X X X X X X

Environmental

triggers,

Nonphysical

Intervention

X X X X X

Non Physical/Least

Restrictive

Intervention, Safe

application of a

restraint.

X X X X X X X

Discontinuing

Restraints Meeting

Behavior Criteria

X X X X X X X X X

Monitoring,

Assessment, and

Reassessment

including Pt.

Family Education

X X X X

Recognition of

Distress

X X X X X X X X X


POLICY:

Christiana Care is committed to promoting patient safety, rights, dignity and well-being by protecting patients from unnecessary restraints, in accordance with applicable Federal and State regulations.

PURPOSE:

To provide guidelines for the safe application and use of violent/self-destructive restraints or seclusion, including monitoring and assessment during use and to provide guidance to promote the discontinuation of seclusion or restraint at the earliest possible time, as soon as is safely possible.

SCOPE:

Christiana Care Health Services and the Medical-Dental Staff where violent/self-destructive restraint/seclusion is used. This policy is not applicable to the Center for Comprehensive Behavioral Health areas such as Rosenblum and the Adult Day Program. (Refer to Department Specific Policy)

DEFINITIONS:

For the purpose of this policy the following definitions apply:

Licensed independent practitioner (LIP):An attending physician, Resident, Advanced Practice Nurse involved in the ongoing care of the patient.

Qualified RN:Registered Nurse (RN) trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and provision of care for a patient in restraint or seclusion.

Restraint Any method, chemical, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely that cannot be removed easily by the patient; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.

Seclusion: Seclusion is the involuntary confinement of a patient alone in a room or area, for any period of time, from which the

patient is physically prevented from leaving. Seclusion may be used only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of thepatient, a staff member, or others.

POLICY TITLE: Restraints and Seclusion, Guidelines for Use, Violent or Self-Destructive Behavior

LAST REVISION DATE/REVIEW DATE April 21, 2014DATE OF ORIGIN October 13, 1993

Page 1 of 5RestraintsandSeclusionGuidelinesforUseViolentoSelfDestructiveBehavior

9/8/2016http://depts/policies/WebPolicies/Docs/RestraintsandSeclusionGuidelinesforUseViolentorSe...

GUIDING PRINCIPLE:

Our philosophy includes the following key considerations:

� Restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others.

� Non-physical and least restrictive alternatives are the first choice and preferred intervention, unless safety demands an immediate physical response.

� Restraint and/or seclusion will not be used as retaliation, punishment, discipline, coercion, or staff convenience

� Orders for and initiation of restraint will be used based on individual patient assessment when there is an imminent risk of the patient harming himself or herself or others including staff.

� Devices used for restraint will be secured to allow for easy release.� The patient and/or family will be involved in the decisions and activities related to the use of

restraint or seclusion as appropriate.� Restraints and/or seclusion will be discontinued as soon as safely possible, at the earliest

possible time.� Performance Improvement initiatives will be utilized to continually explore ways to prevent,

reduce and strive to eliminate the use of restraint and seclusion.� The restraint and seclusion procedures used will protect the patient’s health and safety while

preserving the patient’s dignity, rights and well-being.

PROCEDURE:

ORDERS FOR RESTRAINT/SECLUSION FOR VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR

A. INITIAL AND RENEWAL1. Obtain orders for restraint and/or seclusion only when it is clinically justified or when

warranted by patient behavior that threatens the physical safety of the patient, staff, or others.2. Contact the licensed independent practitioner responsible for the ongoing care of the patient

to write orders for restraint/seclusion. 3. Inform the patient’s attending physician or designee of the action as soon as possible if they

are not the person initiating the restraint or seclusion order.4. Enter orders via Computer Physician Order Entry (CPOE). 5. Standing orders or PRN (as needed) orders for restraint or seclusion are prohibited.6. Orders for restraint/seclusion for violent or self-destructive behavior are limited to and

may be renewed according to the time limits below:a. 4 hours for ages 18 years and older,b. 2 hours for ages 9-17 years, c. 1 hour for patients under 9 years

7. If assessment indicates the need for continued intervention, beyond 24 hours, a face-to-face reassessment will be performed by the LIP, prior to writing a new order for restraint or seclusion.

8. If the physician or LIP provides an order to continue the use of restraints, the medical record must contain supporting documentation of the clinical needs of the patient and the continued use of restraints or seclusion.



B. AUTHORITY TO INITIATE, MONITOR AND DISCONTINUE RESTRAINT OR SECLUSION1. In an emergency situation only, the Qualified RN may initiate restraint and/or seclusion in

order to protect the safety of the patient, staff or others. A verbal or written order will be obtained from the physician or designee immediately (within a few minutes) after the initiation of the emergency intervention.



2. The Qualified RN is responsible for: a. Obtaining a telephone verbal or written order immediately from an LIP (within a few

minutes) after initiation of the emergency intervention.

b. Monitoring, assessment and reassessment of the patient in restraint or seclusion. c. Discontinuation of the restraint or seclusion as soon as safely possible.

C. FACE TO FACE EVALUATION REQUIREMENTS 1. A face-to-face evaluation within one hour is to be completed by an authorized licensed

independent practitioner at initiation of restraint or seclusion to determine if other factors, such as drugs, medication interactions, electrolytes imbalances, hypoxia, sepsis, etc. are contributing to the patient’s violent or self-destructive behavior.

2. Documentation of the face to face in the medical record shall include:a. Description of the patient’s behavior and intervention usedb. Least restrictive interventions attemptedc. Patient response to the interventiond. Complete medical examination with review of symptoms e. Need for continued restraint or seclusion (renewal)

3. Face-to-face reassessment will be performed and documented every 24 hours by the LIP, prior to writing a new order for restraint or seclusion.

D. MONITORING, ASSESSMENT AND REASSESSMENT BY RN, APN OR PA1. Assess the patient immediately after the initiation of restraint and/or seclusion.2. Monitor the patient for the need for continuation of restraint according to age-specific, time-

intervals as outlined in section “A” and document the assessment on theProgress Record for Behavior Management Restraint/Seclusion Form

3. Assess and re-assess on an ongoing basis as follows: a. Continuous observation and documentation of behavior on every 15 minutes basis. b. Assess and document circulation, skin integrity, release/range of motion, elimination needs,

nutritional needs, level of distress and agitation, mental status, neurological status and cognitive functionality on every 2 hours basis. c. Document vital signs (temperature, respirations, pulse, and blood pressure) on every four hours

basis.4. Initiate the Supplemental Plan of Care -Restraints- Behavioral within 8 hours of application of

restraint or seclusion and document expected outcomes every 24 hours. Supplemental Plan of Care-Restraints

E. DISCONTINUATION OF RESTRAINTS1. Discontinuation of the use of restraints by the RN is based on observation and assessment

that determines that the patient no longer needs the restraint to protect self or others, the unsafe situation has ended.

2. Document the discontinuation of restraint in the progress record.

3. Obtain a new order from the LIP if the restraint is terminated and assessment indicates

violent or self-destructive behavior.

F. TRAINING AND COMPETENCY1. Physicians, Physician Assistants and Advanced Practice Nurses will complete training at the

time of initial credentialing.



2. Education will be conducted biannually or as needed for staff participation in the application, assessment and monitoring of restraints on results obtained by knowledge or skills assessments, introduction of new equipment, or quality assurance/performance improvement data.



Maintained by: Rosemary Ellis 07/07/14

CHRISTIANA CARE HEALTH SERVICES POLICY Medical-Dental Staff Policy POLICY TITLE: Electronic Health Record LAST REVISION/REVIEW DATE: DATE OF ORIGIN: New July 2014 POLICY:

It is the policy of Christiana Care Health Services Medical-Dental Staff to support safe and effective communication of patient health information through the utilization of the electronic health record (EHR). PURPOSE:

To establish the requirement for consistent use of EHR when available SCOPE:

This policy applies to Christiana Care Health Services Medical-Dental Staff and Credentialed Healthcare Practitioners when providing care in a Christiana Care Health Services facility.

DEFINITIONS: For the purposes of this policy, the following definitions apply:

Electronic Health Record: EHR is a comprehensive electronic system utilized for patient management that may include but not be limited to electronic order entry, electronic progress notes, electronic discharge process, patient education, brief operative notes and applicable integrated procedure documentation modules. I. New Providers

1. Education is required in the applicable systems prior to the provision of care a. Education can be located in the Education Center or on the Physician’s Portal b. Education and training for integrated procedure documentation modules are

available through the applicable clinical areas c. Please contact Physician Relations for any assistance required.

II. Current Providers

1. Unless unavailable, the electronic medical record must be used to document the patient’s episode of care. 2. Please contact Physician Relations for assistance.

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