AtlantiCare Vendor Orientation 2015

Self-Learning Course

Introduction

Orientation is required for each AtlantiCare vendor. This self-learning course is intended to cover the pertinent information from new employee orientation.

Topics include safety information, strategies for providing excellent customer experiences, cultural diversity and inclusion, Early Heart Attack Care (EHAC), EMTALA, Social Media usage, HIPAA, Corporate Compliance, as well as Harassment and Discrimination information and more.

You must complete the test after this educational section to receive credit for having completed the self-learning course.

Mapping Our Strategy

Our Strategy Map is designed to help each of us understand how our work is organized as well as our focus for the coming year. We cascade our business unit and department goals, and therefore, our individual performance goals based on the 5 Bs. Each of the 5 Bs have a specific “Big Dot” goal, which will be covered in more detail later in the presentation. Our Strategy Map includes our values of Safety, Teamwork, Integrity, Respect and Service (STIRS). AtlantiCare’s Mission and Vision, as well as our Customer Experience Standards are included on the Strategy Map.

Best People/Best Workplace

The Big Dot goal under Best People Best Workplace is to achieve Best In Class scores in our Employee Engagement Survey in the spring of 2015.

Much of our work addresses more than one of the 5 Bs. For this course, the following topics are included under Best People Best Workplace:Essential Work Requirements, Hand Hygiene, Respiratory Etiquette, Fire and Electrical Safety practices, Use of Social Media, Network Security, Stroke Awareness, Early Heart Attack Care and Acute Coronary Syndrome, Organ and Tissue Donation, Communication and Employee Voice, Harassment and Discrimination-Free workplace, Diversity and Inclusion at AtlantiCare.

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Essential Work Requirements

The Big Dot under Best People and Workplace is achieving Best in Class in our surveys, which supports Employee Engagement. You can contribute to our efforts in many ways. Maintaining your certifications is part of that. Continuing your education is also part of being an engaged professional.

Essential Work Requirements:

Essential Work Requirements refer to the minimum licensing, certification and/or education you need to perform your job. These include orientation and any job-specific requirements, such as basic life support, TB surveillance, nursing license, driver’s license, etc.

If any one of your EWRs expires, it can result in the following:• Suspension • Termination

Please talk with your manager if you have any questions about what your Essential Work Requirements are or how to be sure you are current and in compliance with these requirements.

Hand Hygiene – Clean your hands frequently

Respiratory Etiquette to Prevent Seasonal Flu

Hey guys, I think I’m going

to sneeze!

Bad timing!

• Cover your mouth and nose with a tissue when you cough or sneeze

• If you do not have a tissue, cough or sneeze into your upper sleeve, not your hands

• Put used tissue in the trash

• Avoid touching eyes, nose and mouth • Wash your hands frequently,

especially after coughing or sneezing• Get vaccinated annually for seasonal

influenza

FireSafety is one of AtlantiCare’s values. Each of us plays a role in the overall safety of our workplace. In the event of a fire, the acronym RACE reminds us to follow these steps:• Rescue people in immediate danger• Alarm – pull the fire alarm and follow other departmental

procedures for reporting an emergency• Confine the fire by closing the appropriate fire doors• Extinguish the fire (if it is small) or Evacuate to a safe

location

Using a Fire Extinguisher:If it is possible for you to extinguish a fire, such as a small one in a garbage can, the PASS acronym will help you remember how to properly use a fire extinguisher.After taking the fire extinguisher out of its holder and setting it onto a flat surface, hold it by its neck and:• Pull the pin and break the tamper seal • Aim the nozzle at the base of the burning object• Squeeze the handles together, releasing the extinguisher's chemicals• Sweep the nozzle back and forth to coat the surface of the burning

material.

Electrical Safety

Avoid electrical hazards.  Be alert to potential hazards and know how to prevent them. Fires and electrical shocks can occur when electrical cords or outlets are damaged.  Pulling on the cord- rather than the plug – can damage the cord. • ALWAYS unplug electrical equipment by pulling on the plug and not the cord (see photo example). • Inspect each piece of equipment on a regular basis for damage to the cord or plug. • Do NOT use damaged equipment. Immediately report any damaged equipment.

Your attention and actions help keep AtlantiCare safe for our employees and our

customers.

Using Social Media

Hey! Someone keeps mis-tagging me on FaceBook!

Using Social Media

“Social media” describes web-based platforms through which people communicate and interact electronically.

AtlantiCare’s Marketing and Communications Department uses social media as one way to communicate with, and engage our community in the services we provide.

Social Media Policy #4313

Social Media Policy # 4313 applies to all AtlantiCare staff, physicians, Medical Staff, vendors and volunteers. It provides guidance for social media etiquette and is reinforced by the AtlantiCare Employee Handbook. It includes, but is not limited to the following information:

• You are personally responsible for any content (words, images, audio, video) you post.

• In using social media, AtlantiCare employees are expected to adhere to all international, federal and state laws, and all AtlantiCare policies governing employee activity.

• Consider the appropriate use of words, images or video before posting to social media sites.

• There is no expectation of privacy when you post to social media.

• Any posts you make to social media sites could be seen by patients, coworkers, or AtlantiCare leaders, and, as such, may have consequences for your employment with AtlantiCare.

• You may respectfully disagree with company actions, policies or management, but you may not attack members of AtlantiCare’s workforce or leadership.

• If you are posting public comments about AtlantiCare-related issues, clearly identify your business affiliation and include your name and when relevant, your role at AtlantiCare: “I work for AtlantiCare and this is my personal opinion.”

Using Social Media

• Your presence on social media sites can impact your work at AtlantiCare .

• Using social media inside or outside of the workplace has the potential to affect our job performance and/or the performance of others, AtlantiCare’s brand and reputation, and AtlantiCare’s business interests.

• You represent AtlantiCare. The same responsibilities that you have within the walls of AtlantiCare as an employee still apply to any forum outside of the organization if you identify yourself as an AtlantiCare employee. When you engage in social media matters that involve AtlantiCare, you should identify yourself as an employee and indicate that the opinions you express are personal to you and are not those of the organization.

• The profile and content you present on social media should be consistent with the image you present in the workplace.

• Comments you make or content you post should adhere to professional etiquette, should be respectful of others, and should be consistent with AtlantiCare’s privacy policies.

• Per AtlantiCare’s Release of Information to the Media Policy, only authorized users can speak on behalf of the organization. This applies to use of social media.

Using Social Media – What NOT to Post

Inappropriate or offensive images or comments that you would not display in any other public forum.

Sensitive, confidential, and or proprietary information, including, but not limited to:

Anything that identifies a patient, such as that you cared for a Philadelphia Eagles player (even if you do not identify the patient by name), or photos with patient information or patient identifiers/information in the background

Confidential information about AtlantiCare’s partners, staff, clients, suppliers, vendors, partners, technology, business plans, strategic plans, contracts and/or financial information.

General information about the above groups without written permission from AtlantiCare Marketing and Communications

Any material that violates the privacy rights of AtlantiCare patients.

Do not post AtlantiCare logos on social media sites (without written consent from AtlantiCare Marketing and Communications).

Social Media DON’Ts

Do not post any patient identifiers

Do not post that you cared for an Eagles player.

Do not post comments that you would not say in an elevator or any other public forum.

Do not post pictures of yourself at work if patient or business information can be identified by photo manipulation.

Do not speak negatively about your patients or clients

Do not post inappropriate photos

Below are examples of what not to post on social media:

Information Security FBI Warns “Hackers Directly Targeting Health Care

Organizations”. (FBI Flash Alert Warning, August 21, 2014.)

Medical information is worth 10 times more than credit card numbers on the black market – making it a more lucrative target for hackers.

On the black market, a full identity profile contained in a single medical record can bring as much as $500!

The number of healthcare organizations reporting a criminal cyber attack has risen from 20% in 2009 to 40% in 2013.

Boston Children’s Hospital employee’s lost laptop resulted in a data breach of more than 2,000 patient medical records.

A weak password at the Utah Department of Tech Services allowed a hacker to steal 780,000 patient health records.

Chinese hackers exploited an unpatched vulnerability on a Community Health Systems server to steal the personal information of 4.5 million patients.

Phishing For Dollars

When internet fraudsters impersonate a trusted business or individual to trick you into giving out your personal information, it’s called PHISHING.

Phishing attacks directed at specific individuals, roles, or organizations are referred to as “Spear Phishing”. The term “Whaling” is used when those attacks are directed specifically at executive officers or other high-profile targets of an organization.

Phishing attacks use email or malicious websites to solicit personal information often by spoofing the email address of a person within AtlantiCare or some other trusted source.

An attacker may also send email seemingly from a reputable credit card company or financial institution that requests account information, often suggesting that there is a problem. When users respond with the requested information or open an attached document, attackers can use it to gain access to the accounts.

How Do You Avoid Being a Victim? When in doubt, throw it out! Links or attachments in email, tweets,

posts, and online advertising are often the way cybercriminals compromise your computer. If it looks suspicious, even if you know the source, it’s best to delete it or verify the sender via out-of-band communication.

Pay attention to the URL of a link or website. Malicious websites may look identical to a legitimate site, but the URL may use a variation in spelling or a different domain (e.g., .com vs. .net. Be suspicious of URLs hosted in foreign countries (e.g., .ru is Russia, .br is Brazil, .cn is China).

Be suspicious of unsolicited phone calls, visits, or email messages from individuals asking about employees or other internal information. If an unknown individual claims to be from a legitimate organization, try to verify his or her identity directly with the company.

Don’t send sensitive information over the Internet before checking a website’s legitimacy and security.

Information + Security

AtlantiCare and other reputable organizations will never use email or a phone call to request your password, Social Security number, or confidential information.

Be suspicious of any email message that asked you to enter or verify personal or financial information through a web site or by replying to the message itself. NEVER reply to or click the links in a message without verifying the authenticity of the sender.

If you think the message may be legitimate, go directly to the company’s web site (i.e., type the real URL into your browser) or contact the company to see if you really do need to take the action described in the email message.

Do not provide personal information or information about AtlantiCare, including organizational structure or networks, unless you are certain of a person's authority to have the information.

Information Security + You

If you believe you might have revealed sensitive information about AtlantiCare or compromised your account or computer, immediately contact the AtlantiCare Customer Support Center.

Immediately change any passwords you might have revealed. If you used the same password for multiple resources, make sure to change it for each account, and do not use that password in the future.

If you believe your financial accounts or credit cards have been compromised, contact the financial institution immediately and close any accounts or change any cards that may have been compromised. Watch for any unexplainable charges to your account.

What actions should you take if you think you are a victim?

Information Security

Good security practices are an essential part of patient care.

AtlantiCare depends on each and every one of us to be informed, responsible, and on our guard to protect our

network, information, and our patients.

Think before you click!

If you have questions about any information security topic, you may contact the Information Security team at

ITSecurity@atlanticare.org.

Stroke Awareness

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What is F-A-S-T? F-A-S-T is a national stroke association acronym for recognizing and responding to the symptoms of stroke.It stands for face, arms, speech and time,

Be alert! Get help FAST.  It is important for us to know the signs and to teach others.

• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body (Can the person smile? Has his/her mouth or eye drooped?)

• Sudden confusion, trouble speaking or understanding

• Sudden trouble seeing in one or both eyes

• Sudden trouble walking, dizziness, loss of balance or coordination

• Sudden, severe headache with no known cause

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If you witness someone with the symptoms listed in the previous slide, based on where you work, you should call for help using the following numbers:

• Patient care delivery areas, Nursing units (with the exception of Critical Care and Emergency Departments): Call a MET – Dial 1-2222 at the City Campus or 2-2222 at the Mainland Campus

• All other areas of the hospital, for visitors, employees and outpatients: Call a Code 10 - Dial 1-2222 at the City Campus or 2-2222 at the Mainland Campus and tell the operator what you are witnessing.

• All ARMC off-campus areas – Dial 911

Stroke Awareness

Early Heart Attack Care (EHAC) and Acute Coronary Syndrome (ACS)

AtlantiCare Regional Medical Center is a designated Chest Pain Center by the Society of Cardiovascular Patient Care. This content is designed to introduce you to Early Heart Attack Care (EHAC). After learning this information, you will be able to:• Describe risk factors that contribute to ACS.• Distinguish signs and symptoms that patients experience

during Acute Coronary Syndrome.• Support AtlantiCare’s efforts to educate the community in Early

Heart Attack Care. Share this information with family and friends.

Risk Factors

• High Blood Pressure• 1st or 2nd hand

smoke exposure• Diabetes• High Cholesterol• Sedentary lifestyle• Obesity• Prior stroke• Increased age• Family history

Special Considerations

• Diabetics: May not present with pain at all…

•Mostly vague complaints of nausea, vomiting, shortness of breath

• Age: 82 % of people who die of heart disease are over 65 years old.

• Females: More likely to present with nausea, dizziness, and anxiety.

• Males: Greater risk of heart attack than women do, and they have attacks earlier in life.

ACS Beginnings

• Nausea• Pain down one or both arms• Jaw pain• Fatigue• Anxiety• Chest pressure, squeezing,

discomfort• Back pain• Shortness of breath (with or

without exertion)• Feeling full• Feeling of impending doom• Heart burn; indigestion• Breaking out in a cold sweat

Don’t drive! Call 911!

Early Heart Attack Care: What YOU need to do….

First, you need help…

• If you’re at City, dial 1-2222• If you’re at Mainland, dial 2-

2222 • If you’re outside the hospital,

dial 9-1-1

Tell the operator what is happening….

• MET Call- for admitted patients who are in need of immediate medical attention.

• Code 10- for staff and visitors who are in need of immediate medical attention.

• Code Blue- for patients who are in Cardiopulmonary Arrest.

Help will arrive! If the patient is having a heart attack, “ONE CALL” will be activated and the patient will be brought to the Cardiac Cath Lab.

AtlantiCare Vendors are Ambassadors for

Early Heart Attack CareEHAC Oath:

• “I understand that heart attacks have beginnings and on occasion, signs of an impending heart attack may include chest discomfort, shortness of breath, shoulder and/or arm pain, and weakness. These may occur hours or weeks before the actual heart attack.

• I solemnly swear that if it happens to me or anyone I know, I will call 9-1-1 or activate our Emergency Medical Services.”

YOU make a difference!

Organ/Tissue Donation

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More than 95,000 people are waiting for transplants. More than 4,200 of them are NJ residents. Eighteen people die each day while waiting for a transplant.

If there is no designation on your driver’s license or other legal means of donor designation, the final decision about organ and tissue donation will be made by your next of kin.

Your decision to be an organ donor can make a difference in as many as 50 other lives.

Anyone can decide to be a donor. At the time of death, a person’s physical condition, not age, determines potential for organ and tissue donation. In the event of an accident or emergency, physicians and nurses will do everything possible to save your life.  The medical team treating you is always completely separate from the transplant team.

Communication

You are encouraged to share ideas, suggestions, compliments or concerns directly with your leader.

Two-way communication is essential to a strong and successful organization and to encourage professional engagement. Please stay informed about the organization by visiting the intranet, reading newsletters and bulletin board postings, checking in with managers, listening during staff meetings and asking your leader to update you on new initiatives in the organization.

Harassment and Discrimination-Free WorkplaceAtlantiCare is firmly committed to maintaining a work environment that is free from all forms of

discrimination, sexual and other workplace harassment. This is part of our commitment to Best People/Best Workplace. AtlantiCare has a zero tolerance policy for conduct that could be construed as unlawful discrimination or harassment. All employees are required to promptly report any incident they feel may violate this policy.

What is discrimination? Treating someone differently because of their race, skin color, religion, gender, pregnancy, national origin, disability, age, creed, ancestry, marital status, domestic partnership status, affectional or sexual orientation, gender identity or expression, atypical hereditary cellular or blood trait, genetic information, military service, or AIDS and HIV related illnesses – these are referred to as “protected classes”.

What is Harassment? Unwelcome conduct that occurs because of a person’s protected class, in which an employee’s acceptance or rejection of the conduct affects their employment or the environment in which they work.

Failure to comply with EMTALA can lead to several serious consequences for AtlantiCare including:

• Large fines, starting at $50,000. • Increased legal scrutiny. • Negative media attention. • Possible loss of Medicare/Medicaid eligibility. • Loss of confidence in our work by the community we serve.

If you feel as though you are experiencing or have witnessed discrimination or harassment, please immediately report this to your supervisor, Human Resources or any member of AtlantiCare’s management team. Human Resources will promptly investigate and take appropriate action.

ImpairmentAtlantiCare is committed to ensuring nothing interferes with the care, safety and well-being of our customers, vendors and employees.  Impairment is defined as the condition of being unable to perform as a consequence of physical or mental unfitness. If you suspect a co-worker is unable to perform his/her job due to some sort of impairment, you need to act.   Impairment can be the result of the following:

• Being under the influence of drugs or alcohol • Lack of sleep • Psychological ailments such as depression or stress. • Working while sick

Any impairment can impact an employee’s job performance.  When an employee is impaired, his/her ability to adequately react and care for our customers is affected.

If you think a co-worker is working while impaired, it is very important that you report the facts immediately to your immediate supervisor, any member of the leadership team or to Human Resources.

Strategic purpose:To further position AtlantiCare as a leader and trusted partner in the delivery of culturally and community competent respectful health care services to our diverse community.

How we will get there:We will enhance the delivery of our healthcare services for our diverse community.

We will create the best workplace for our staff by fostering an inclusive, collaborative, innovative, and culturally competent environment.

Diversity & Inclusion at AtlantiCare

Building inclusive and healthy communities.

Recruitment & Retention

Ensure we recruit and retain a

diverse workforce reflective of the communities we

serve.

Employee Engagement

Foster a learning environment that values diversity and encourages

employees to reach their full potential.

Customer Experience

Provide customer experiences and

health care services reflective of

beliefs, cultural and community

practices , to foster an environment of inclusion for our patients and their

families.

D&I Strategic Priorities

Employee networks who share a common interest/identity and support the diversity and inclusion strategic priorities through collaborative relationships.

ERGs are open to all employees.

What is an Employee Resource Group (ERG)?

Employee Resource Groups

Must have completed six months of service with AtlantiCare

Manager’s Approval

No disciplinary action in past 6 months.

Membership options:

Core Team Member

Ad Hoc Team Member

Contact diversity@atlanticare.org for more information, or

visit the Diversity & Inclusion Team Page on the Starfish to see more information on our ERGs and membership.

How do I become a member of an ERG?

Best Customer Experience

The Big Dot for Customer Experience is Loyal Customers, and the challenge is to increase our Customer Experience Index score. Loyal Customers rate us as “Excellent”, which means “Good” isn’t good enough. This is critical to our reimbursement formula from Center for Medicare and Medicaid Services (CMS). Low scores means money that could come to us is given to an organization with better scores. Let’s work hard to make sure we knock those scores out of the park in 2015!

Best Customer Experience

AtlantiCare

Starfish Experience Standards

AtlantiCare’s workforce has continued to reinforce our Customer Experience Standards throughout the year. Many of our employees have taken part in the Starfish Experience Lab, designed to help us focus on the behaviors that build loyalty in customers and improve customer experience scores.

The next several slides will focus on Best Customer Experience, starting with our Standards:

• I will say “please” and “thank you” in all customer/co-worker interactions.

• I will ask “is there anything else I can help you with?” at the end of customer/co-worker interactions.

• I will always identify myself, my department and ask “may I help you?” when answering the telephone.

• I will always wear my name tag in a visible location.• I will smile, make eye contact and address others

who are near me.

Narrate the Care

Narrating the care of the patient helps them to understand what you are doing as you are doing it. It gives them the opportunity to ask questions and interact with you. We ask that you meet the patient at their level of health literacy while explaining your care delivery. By narrating the care we:

• Improve patient’s understanding by meeting their health literacy level.

• Reduce the patient’s fear and anxiety.

• Create a relationship between the patient and the care team, thus increasing trust. Key Words At

Key Times

Narrating the Care - AIDET

• Acknowledge the patient – say hello

• Introduce yourself and other team members

• Duration – how long should they expect this procedure or visit to take?

• Explanation – what will happen during this visit?

• Thank the patient for coming to AtlantiCare for their health care needs.

Narrating the Care starts with AIDET. A simple tool to help you give our patients a clear picture of the care being delivered

Narrate the Care -Teach Back

“Teach Back” is used to evaluate the patient’s understanding of information you have shared with them. After you provide instructions, ask the patient (or their representative) to explain it back to you so you can be sure you didn’t leave anything out of your explanation.

“Listen for them to explain specific steps, procedures or timetables that are critical to their care and recovery.

If they miss or confuse any of the information, this is your opportunity to cover that part again and provide any additional support to help them effectively manage their health issues after discharge.

• Remember that we are present during some of our patients best and worst moments of their life.

• Your patient may not be the key learner. Please ensure that you appropriately include your patient’s support person when available.

Narrate the Care - Managing Up

Not only does Managing Up creates a better patient experience, it is also a demonstration of our values of Teamwork and Respect. When we speak positively about co-workers and interactions with other departments we reduce patient anxiety.• Give your co-workers a head start in winning the confidence and trust of the

patient.

• Example: “My shift is ending, but I am leaving you in very capable hands”.

As we Narrate the Care, we must keep in mind that this is the story they will tell when our patients share their experience with others.

If we expect our patients to tell a good story, we should start it off with a great introduction!

Customer Interactions

Customer InteractionsLimit Distractions

Limit distractions during customer interactions. Be sensitive to your impact on the their sense of well being.

EmpathyAddress customer needs of with empathy. What if this was your loved one?

EnvironmentIs it private? Is it safe? Did we effectively communicate?

ProactiveAnticipate our customers needs and look to exceed expectations

• You never know what is happening in the lives of those around us.

• Each exchange with another person is like an emotional transaction. We want to leave a positive balance with each one.

• Each time we interact with a patient or each other keep these interaction concepts in mind.

Sacred Moments

Sacred Moments

Moments of complete focus on the patient.

• At every first interaction with the customers (sitting down)

• Every time a customer asks a question (sitting when possible)

• When someone is leaving

• When you are sharing important information

People may not remember what you say, they may not remember what you do, but they will

always remember the way you made them feel. – Maya Angelou

• Always is the only answer that counts on our patient survey.

• Sacred moments are special opportunities to build stronger relationships between our patients and each other.

• There are many ways that you can take advantage of these moments in your work day. Your response to these moments can be as unique as you are.

• To your right are some great ways to acknowledge some of the more common sacred moments we see each day.

Customer Experience Recovery

• An experience where we have not met our patient’s expectations is an opportunity to perform service recovery.

• Excellent service recovery can lead to even greater customer loyalty.

We use a five-step process to correct customer experience mistakes.

1. Listen to the customer’s problem without interrupting them or making excuses.

2. Recognize and define their problem in simple terms.

3. Apologize for the inconvenience or confusion. Use empathy.

4. Correct the problem or connect them directly to the appropriate Customer Experience Representative who can fix the problem.

5. Thank them for telling you about the problem so you could fix it and improve their AtlantiCare experience.

Impairment

Patient Directed Visitation

Visitation Limitations• Patient Request• Identified infection control issues• Interference with the care of other patients• Patient’s roommate(s) need for rest or privacy• Inpatient substance abuse program• Patient undergoing care intervention• Existing court order restricting contact• Visitor engaging in disruptive, threatening, or

violent behavior of any kind

AtlantiCare will not restrict, limit, or otherwise deny visitation privileges on the basis of race, skin color, marital status, age (except as required for clinical reasons), national origin, nationality, religion, sex, gender identity or expression, sexual orientation or disability. All AtlantiCare patients have the right to receive the visitors they have designated at the time of their preference and may make this request either verbally or in writing. This includes, but is not limited to, a spouse, a domestic partner (including a same‐sex domestic partner), another family member, or a friend. All AtlantiCare patients have the right to withdraw or deny such consent at any time either orally or in writing.

• Children under 14 years of age must be approved by clinical leadership for visitation

• Visitation at AtlantiCare is expected to be patient directed. Limitations to visitation must be according to those listed in our policy #4411.

Best Financial PerformanceThe Big Dot under Financial Performance is sustainability of the organization and the challenge is maintaining a healthy operating margin. The operating margin is what is left over each month after we receive all reimbursements and income, and pay out all that we owe. This year we exceeded our goal for Financial Performance.

As we navigate Health Care Reform, our reimbursement has shifted from “Fee for Service” to “Triple Aim.” Our cost-efficiency, customer experience and our quality contribute to the Triple Aim formula. These scores are key to our future sustainability and our success. Failing to receive the best scores will negatively impact our income, financial operating margin and our overall sustainability.

The term Triple Aim is a trademark of The Institute for Healthcare Improvement.

These three factors are used to determine how CMS reimburses us for our services.

Triple Aim

(Quality)

(Customer Experience Index Score)

(Cost-Efficiency)

Best GrowthThe Big Dot under Best Growth is Keeping AtlantiCare First and having our patients cared for by our physician network. To accomplish this, we have steadily increased our service area, making services available to underserved populations and locations. We have increased our capacity to serve our customers by adding more physician practices throughout Atlantic, Cape May and in Ocean County, so that our customers can be served by our own physicians. Our physician practices include internal medicine, family medicine, and specialty practices. We have grown in other ways, as well. AtlantiCare is proud to have added same day surgery locations in Cape May and Ocean County, and we are partnering with Geisinger in Pennsylvania in 2015.

Best QualityThe Big Dot goal under Best Quality is Comprehensive Care Transitions, with Readmission Rate cited as our challenge. Our impact on these is reflected in the scores calculated into our reimbursement formula from the Centers for Medicare and Medicaid Services (CMS). We exceeded our goals for 2014, so this factored into our Share the Success Bonus by adding $135 to our bonus. To assure our quality remains excellent, we have many policies and procedures in place to guide our daily work. For the purposes of this course, we will include Patient Safety, MRI, Process Improvement, Corporate Compliance, HIPAA, Incident Reporting, Injury Reporting, EMTALA, Language Line and Emergency Codes. These topics help assure we address negative outcomes and take action to prevent recurrences.

Magnetic Resonance ImagingAtlantiCare uses advanced technology for our patients. Our magnetic resonance imaging (MRI) equipment is a strong magnet that requires specific safety practices. Employees who work directly with the MRI machine know the proper procedures to follow in an emergency. Here are some important safety practices:

The magnet is ALWAYS on!

• Screen all patients and personnel before they enter the MRI room. • Check all metallic equipment, including hand tools, wheelchairs, gas tanks, etc. with a hand magnet before they enter the MRI room.

PDMAI/PDCAUse these processes to assure the end users are always involved in the project PLAN, and to prevent rework and wasted time.

PDMAI: PDMAI is an acronym for

the specific process we use to develop new ideas for services.  It stands for the following:

Plan Design Measure Assess Improve

PDCA: PDCA is an acronym for

the specific quality improvement process we use to improve existing programs, services and procedures.  It stands for the following:

Plan Do Check Act

Corporate ComplianceCorporate Compliance 1. Continuously assesses the effectiveness of AtlantiCare’s

compliance and internal control environment. 2. Promotes adherence to laws, regulations, and internal

policies & procedures 3. Advances the prevention of fraud, waste, and abuse4. Furthers the hospital’s mission of providing quality care to

patients

Corporate Compliance is an independent supportfunction of AtlantiCare, reporting directly to our Boardand administratively to Corporate Counsel.

Corporate Compliance activities require unlimited and unrestricted access to all data during audit and investigation. Audits are ongoing and routine – staff have no expectation of privacy with AtlantiCare systems.

It provides AtlantiCare with system-wide services with authority to act with respect to all entities, subsidiaries and cost centers.

Deficit Reduction Act (DRA) of 2005 mandates employees and agents education on:• NJ Conscientious Employee Protection Act (CEPA)

“Whistleblower Act”• Federal False Claims Act (1863)• Federal Program Fraud Civil Remedies Act (1986)• NJ False Claims Act (2009)• NJ Medical Assistance and Health Services Act

Important Government Agencies (not all inclusive):• Office of Inspector General (OIG)• Internal Revenue Service (IRS)• Food & Drug Administration (FDA)• Center for Medicare/Medicaid Services (CMS)• Equal Opportunity Employment Commission (EEOC) • Office on Civil Rights (OCR) • Joint Commission (JCAHO) • NJ Department of Health (NJDOH)

Laws and Regulatory Agencies

Important policies all AtlantiCare employees need to be aware of:• Code of Business Ethics and Corporate Compliance (ID# 403)

• Guidelines for Reporting Compliance/Privacy Issues/Concerns (ID# 3366)

• Education Concerning False Claims Liability, Anti-Retaliation Protections, and Detecting and Responding to Fraud (ID# 3119)

• Guidelines for Employee Acceptance of Vendor Gifts, Meals, Entertainment (ID# 4231)

All policies are available on AtlantiCare’s intranet policy and procedure site and from Human Resources or your manager.

Policies and Procedures

Corporate ComplianceCompliance Line Phone Number: (609) 407-7788 In-house 4-

7788

Compliance Line Website: www.MyComplianceReport.com (Access Code: ATC)

Our reporting system is maintained by a third-party vendor to ensure strict confidentiality. Protections are in place for all callers.

• No retaliation for reporting.• Report any activity that appears to violate

AtlantiCare’s Code of Business Ethics and Corporate Compliance (Code of Conduct) or any other policies and government laws and regulations.

• If you are aware of a violation and fail to report it, you may be subject to corrective or disciplinary action.

• All complaints are documented and investigated.

• You may report anonymously.

HIPAA – Protecting Patient Information

Patient Privacy Laws: What is Protected Health Information (“PHI”)?

PHI is a special term regarding protected health information, based on any information collected during the provision of care that applies to a patient’s health condition, past, present or future. If the health information includes data that would allow someone to identify the patient, it is PHI. A few examples of PHI are…

Name Date of Birth Medical Record #Lab/Test Results Photographs Email addressPrescriptions Billing Records Admit-Discharge DatesX-rays Address FingerprintsTelephone # Insurance Claim # Social Security #

PHI takes many forms, i.e. a prescription label with the patient’s name and the name of the drug, a doctor’s note about a patient, a letter giving patient test results.

PHI must be kept private whether it is in written, spoken or electronic form.

The federal HIPAA law protects the privacy of patients by:• limiting access to and disclosure of PHI • requiring security of records containing PHI whether in paper,

electronic or other forms

A collection of New Jersey laws provide even HIGHER protection for patient information: • based on sensitive diagnoses (i.e., HIV/AIDs, STDs, genetic information)• based on sensitive type of treatment (i.e., drug and/or alcohol

treatment, psychiatric treatment)

Federal and state laws contain significant criminal and civil penalties for individuals and providers who violate these laws.

HIPAA – Protected Health Information Privacy Laws

Red Flag RuleID theft program designed to detect, prevent & mitigate ID theft.

NJ ID Theft Prevention Act (NJITPA)Focus on specific security precautions to prevent ID theft, i.e. use of SS#.• Requires breach notification.

HIPAA (Health Insurance Portability and Accountability Act)Established standards for transmission and usage of health care information.

HITECH (Health Insurance Technology for Clinical Health Act)This builds on HIPAA privacy & security of PHI, with modifications.• Requires breach notification• Increases penalties & enhances enforcement provisions

Additional HIPAA Regulations

Laws to Protect Identity and Privacy

HITECH is The final Omnibus Rule, with an effective date of September 23, 2013.   Some of The Rule’s key provisions include:

Makes business associates and their subcontractors directly liable for compliance with HIPAA/HITECH’s privacy and security rules requirements;

Strengthens the limitations on the use and disclosure of protected health information for marketing and fundraising purposes and prohibits the sale of protected health information without individual authorization;

Expands individuals' rights to receive electronic copies of their health information and to restrict disclosures to a health plan concerning treatment for which the individual has paid out of pocket in full;

Requires modifications to, and redistribution of, a covered entity's notice of privacy practices;

Modifies individual authorization and other requirements to facilitate research and disclosure of child immunization proof to schools and to enable access to decedent information by family members or others;

Enhances the enforcement rule, adding provisions to address enforcement of noncompliance due to willful neglect and incorporating the increased and tiered civil money penalty structure of up to $1.5 million per violation category. 

HIPAAPatient Privacy: Protecting PHI is Important!

Under the Privacy laws, you are prohibited from accessing or disclosing PHI unless:

• you are directly involved with treatment of the patient; or

• you are directly involved with a payment process or health care operation relating the patient’s record, and then with a payment process or health care operation relating the patient’s record, and then you are limited to accessing and/or disclosing only the minimum necessary information needed to complete the task at hand.

• you are limited to accessing and/or disclosing only the minimum necessary information needed to complete the task at hand.

Protecting Patient Privacy is the right, ethical and legal thing to do – federal and state law require it. The Privacy laws apply to us in all settings: at home, on social media websites, in the supermarket, as well as in the hospital –even after we separate from AtlantiCare!

HIPAAPHI Security: Internet, Email & Virus Protection Tips

Do: • limit personal Internet use and only visit appropriate web sites.     • forward unwanted spam emails to spam@atlanticare.org      • lock your computer when not in use: Press “WINDOWS KEY” + L (for “Lock”) or

Press “Ctrl-Alt-Delete” and Lock Your Computer Don't • forward business e-mail to your personal e-mail account.  • click on links contained in emails – they often contain viruses or redirect to

malicious web sites that can damage our healthcare systems or steal your information.

• open an email attachment from anyone you do not know --be wary of email attachments that you are not expecting; contact the sender or information security if you are not sure.

• install any unauthorized programs on your work computer.   

Remember, it is always okay to call or email the AtlantiCare Information Security Department for help or guidance. Phone 609-272-6353 or email iSecurity@atlanticare.org

HIPAAPHI Security: Password and Physical Security Tips

Do:• make strong passwords, including at least 8 characters along with

numbers, upper and lower case letters.  • change your passwords every 90 days, or in accordance with policy.• Know the whereabouts of your laptop at all times – don’t leave it in your

car!• clear your desktop, lock drawers and file cabinets when you leave.• politely challenge anyone who is not displaying an ID badge or a pass.• ensure no one can overhear discussions about patient care. • use shredder bins – never put PHI in regular trash! • turn computer screens containing PHI away from view.

Don't:• share your password with anyone. AtlantiCare representatives will never

ask you for this information.     • display your password where others can view it• hold doors open for people without checking their authorization

HIPAAPatient Privacy – Reporting Violations

If you become aware of a privacy violation, you are required to report it on the Compliance line at 407-7788 or www.MyComplianceReport.com. You may report anonymously.

DO YOUR PART TO PROTECT PHI

Everyone has a role in protecting patient information. Remember, keeping patient health information private is not only a matter of patient satisfaction and Customer Experience – it’s the law. If you have any questions about the Privacy Laws and how they affect your work at AtlantiCare, contact the Privacy Office at (609) 407-2251 or 4-2251.

Incident Reporting with QuantrosAn incident is an unusual occurrence in or around AtlantiCare property. Everyone is responsible for reporting safety information.

Examples of incidents reported through Quantros: • Patient Injury (or near miss) • Visitor Injury• Car Accident• Equipment Malfunction • Facilities Issue• Vandalism • Lost or Damaged Property • Threatening Behavior • Theft and Security Issues

Exception: Employee injuries are reported through the web by clicking the Employee Injury Reporting Site link on the Starfish page under “Tell Us.”

Incident Reporting with QuantrosQuantros Incident Reporting System – How do I begin?:Directions for all reportable incidents:1. Go to Starfish page2. Go down the right side menu and click on Incident

Reporting in the “Tell Us” box 3. User name is your email/ computer access user name

(the one with your first initial and last name, for example jdoe for John Doe) Don’t include the email address “@atlanticare.org”

4. On first login, you will be guided through the steps to create a password.

5. Choose your new password which is a minimum of 8 digits, combine numbers and letters

6. If you need assistance with password, log-in or system issues, please call the help desk (3-7070)

An Event Reporting Tutorial can be accessed through the system.

Employee Injury Reporting

All employee injuries should be reported through the Employee Injury Reporting Site.

1. Go to Starfish page

2. Go down the right side menu and click on Incident Reporting in the “Tell Us” box. There is no required log in, just click on the Employee injury Reporting Site. It will take you directly to the instruction page where you access the form.

3. The Report should include: Who, What, Where, When, Why, and

How

EMTALA

x

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law, adopted in 1986, designed require that hospitals treat patients without discrimination or their ability to pay for services.  This legislation also deals with various requirements for transferring and discharging patients.

Here are some of the important things to know about this law:

• EMTALA applies to ALL hospital employees.

• Every patient must be screened by a qualified medical provider within 4 hours of presenting to the Emergency Department or elsewhere on hospital property to determine if there is an “emergency medical condition” or active labor.

• Medical screening and further stabilizing treatment may not be delayed to inquire about the individual's insurance or payment information.

• Before patients are transferred, they are entitled to stabilizing treatment.

• Document transfers using the Universal Transfer Form.

• EMTALA Policy #566 details specific requirements related to the law

EMTALA – Universal Transfer Form

Failure to comply with EMTALA can lead to several serious consequences for AtlantiCare including:

• Large fines, starting at $50,000. • Increased legal scrutiny. • Negative media attention. • Possible loss of

Medicare/Medicaid eligibility. • Loss of confidence in our work

by the community we serve.

Language LineCulturally Appropriate Services

AtlantiCare is committed to providing culturally and linguistically appropriate healthcare services. Most of our locations have LanguageLine telephone interpreter systems at no cost to patients/families. If you need an on-site medical interpreter to communicate with a limited English proficiency patient or a deaf/hearing impaired patient, please contact Customer Experience (Atlantic City, 1-8193, or Mainland, 2-3444).

EMERGENCY CODES

Code Red – Fire Code Silver – Hostage situation/Active Shooter event

Code Blue – Adult medical emergency Code Orange – Hazmat situation

Code White – Pediatric medical emergency

Code Triage – Disaster/Additional staff needed

Code Amber – Child abduction Code Clear – Situation resolved

Code Yellow – Bomb threat Code 10 – Visitor injured

Code Grey – Security needed

You might hear these codes over the intercom while working at either hospital campus.  It is important that you know what each of these codes means and what to do when one of them is called.   Emergency Codes and other emergency calls are activated by calling the following numbers:City Campus - 1-2222 Mainland Campus - 2-2222 Non-hospital facilities - 911

Please complete the test for our 2015 Self-Learning Orientation course. Passing the

test gives you credit for completing this course.

Thank you!