1 1 Corporate Compliance Program To understand the ethical, professional, and legal obligations we have and our role in meeting these obligations To

11 11

Corporate Compliance ProgramCorporate Compliance Program

To understand the ethical, To understand the ethical, professional, and legal obligations professional, and legal obligations we have and our role in meeting we have and our role in meeting these obligationsthese obligations

To promote honest, ethical To promote honest, ethical behavior in the day to day behavior in the day to day operationsoperations

To identify, correct and prevent To identify, correct and prevent illegal conductillegal conduct

11 22

Principles of CompliancePrinciples of Compliance

As healthcare professionals and As healthcare professionals and providers, we are dedicated to caring providers, we are dedicated to caring for and improving the health and well for and improving the health and well being of the people we serve in the being of the people we serve in the communitycommunity

Compliance means doing what is Compliance means doing what is right, not just what is requiredright, not just what is required

11 33

Benefits of Compliance ProgramBenefits of Compliance Program

Structure to manage compliance with Structure to manage compliance with laws and regulationslaws and regulations

Potentially reduces fines and Potentially reduces fines and penalties if effectivepenalties if effective

Avoidance of negative publicityAvoidance of negative publicity Improve clinical quality and fiscal Improve clinical quality and fiscal

performanceperformance

11 44

Corporate ComplianceCorporate Compliance

Code of conductCode of conduct

Conflict of interestConflict of interest

Documentation and billingDocumentation and billing

Questionable behaviorsQuestionable behaviors

11 55

Questionable BehaviorsQuestionable Behaviors

Discrimination and harassmentDiscrimination and harassment Dishonest communicationDishonest communication Violations of confidentialityViolations of confidentiality Conflicts of interestConflicts of interest Inappropriate giftsInappropriate gifts Stealing/misuse of assetsStealing/misuse of assets Fraud, abuse and false claimsFraud, abuse and false claims Improper lobbying Improper lobbying Misuse of proprietary informationMisuse of proprietary information

11 66

Corporate Compliance ReportingCorporate Compliance Reporting

Report activity to immediate supervisorReport activity to immediate supervisor

Report to higher level managerReport to higher level manager

Report to Corporate Compliance Officer: Report to Corporate Compliance Officer: Anne Mason, 821-4469Anne Mason, 821-4469

CHS Compliance line 1-888-200-5380, CHS Compliance line 1-888-200-5380, 24/7, confidential and, if desired, 24/7, confidential and, if desired, anonymousanonymous

11 77

• LEP Patient = non-English speaking

• An interpreter must be provided to LEP patients emergency - within 10 minutes

non-emergency - within 20 minutes

• CHS has phone interpreter services available 24/7

• Free of charge

• CHS staff may not serve as an interpreter

• Family members under the age of 16 may not be used as interpreters except in emergency situations until an interpreter is contacted

Language Assistance ProgramLanguage Assistance Program

REQUIRED BY LAWREQUIRED BY LAW

1

11 88


Secure an InterpreterSecure an Interpreter•Identify LEP patient

•Determine pt language - wall poster or brochure

•CHS trained staff will contact an interpreter via instructions located at their respective workstations.

•Pt will be notified of FREE interpreter service

Patients who present to security stations or front lobby should be taken to Admissions, Registration, ED, Patient Representative or Nursing Supervisor for further assistance.

2

11 99


Chart DocumentationChart Documentation•Any provision or refusal of LEP services

MUST BE DOCUMENTED in the patient chart.

•Specific documentation guidelines must be followed.

•Documentation guidelines can be found in the Language Assistance for Limited English Proficient (LEP) Persons and Hearing Impaired Policy and Procedure and are located on Compliance 360.

•Staff should always contact an interpreter to ensure quality patient care and to minimize liability to individual staff members as well as the organization.

3

11 1010

New York State Patient Bill Of New York State Patient Bill Of RightsRights

19 Bill of Rights19 Bill of Rights

They are posted in all They are posted in all patient care areaspatient care areas

They are available in They are available in Spanish as well as EnglishSpanish as well as English

If they don’t understand their rights, If they don’t understand their rights, someone needs to explain themsomeone needs to explain them

Receive treatment without discriminationReceive treatment without discrimination Receive considerate and respectful care in a Receive considerate and respectful care in a

clean safe environment free from clean safe environment free from unnecessary restraintsunnecessary restraints

Receive needed emergency careReceive needed emergency care Know the names and positions of people Know the names and positions of people

caring for them, and refuse their treatmentcaring for them, and refuse their treatment Know who the MD is who is in charge of Know who the MD is who is in charge of

your hospital careyour hospital care A non smoking roomA non smoking room Receive complete information about their Receive complete information about their

diagnosis, treatment and progressdiagnosis, treatment and progress Receive all information for informed Receive all information for informed

consentconsent Receive all information to give informed Receive all information to give informed

consent regarding do not resuscitateconsent regarding do not resuscitate Refuse treatment and be informed of effectRefuse treatment and be informed of effect Refuse to take part in researchRefuse to take part in research Privacy in the hospital and confidentiality of Privacy in the hospital and confidentiality of

all information and records of your careall information and records of your care Participate in decision making about their Participate in decision making about their

care, including dischargecare, including discharge Review of their medical recordReview of their medical record Receive an itemized bill with explanation of Receive an itemized bill with explanation of

chargescharges Complain without fear of reprisalComplain without fear of reprisal Authorize family members to visitAuthorize family members to visit Make known your wished regarding Make known your wished regarding

anatomical giftsanatomical gifts

111

Catholic Health SystemCatholic Health System

RISK MANAGEMEN

T

112

What is “Risk Management”?

Risk Management is the systematic review

of events that present a potential for harm and could result in loss for the

hospital system..

113

FOUR ELEMENTS OF RISK MANAGEMENT

Risk Identification

Review Occurrence Reports Review Patient/Visitor Complaints Participate in Root Cause Analysis Review concerns expressed by CHS staff

114

Loss Prevention

Educational Programs through

CHS University Department specific inservices


115


Claims Management

Investigating & reporting occurrences and claims made

Assist with Summons & Complaints and Subpoenas *** REMEMBER TO NOTIFY RISK MANAGEMENT IMMEDIATELY UPON RECEIPT OF SUMMONS OR SUBPOENA

Assist with discovery requests for lawsuits

116


Risk FinancingObtaining & maintaining appropriate

insurance coverage

HPL (Healthcare Professional Liability) GL (General Liability) D&O (Directors & Officers) Property & Casualty Auto CrimeFiduciary (Finance)

117

What is an Occurrence?

An occurrence is an event that was unplanned, unexpected and unrelated to the natural course of a patient’s disease process or routine care and treatment.

118

What is an

Occurrence?

An occurrence is not consistent with the accepted standard of careor the routine operation of a facility and has the potential to or already has had an untoward effect on patient care.

119

What are sources of an

Occurrence?PatientsPatientsVisitorsVisitorsPatient/Family ComplaintsPatient/Family ComplaintsSecurity reportsSecurity reportsEquipment “failure”Equipment “failure”

120

What is an Occurrence Report?

An occurrence report is a factual account of the details of an occurrence. It is

prepared and reviewed for the purpose of enhancing the quality of patient care,

providing a safe environment, and identifying potential liability.

121

Enhance the quality of patient care

Assist in providing a safe environment

Quick notice of potential liability

What is the purpose of an Occurrence Report?

122

Who can complete an Occurrence Report?

Any associate or physician who discovers, witnesses or to whom

an occurrence is reported, is responsible for documenting the event immediately by means of the Occurrence Report. Anyone who requires assistance should

contact the department manager.DO NOT MAKE COPIES OF AN

OCCURRENCE REPORT

123

What happens to the Occurrence Report?

The completed Occurrence Report is to be forwarded

to the Department ManagerWho will investigate the

occurrence and forward to either PI or Security as

indicated in the Risk Management process

124

Risk Management Process

Patient and visitor safety are assessed from both clinical and

environmental perspectives

Notify Performance Improvement of patient occurrences Notify Security of visitor or property occurrences Risk Management will be notified by PI or Security and will participate in evaluation of occurrence Risk management will report occurrences to insurance carrier in cases of potential liabilityRisk Management will manage claim as indicated

125

Documenting an Occurrencein the medical record

•Date (MM/DD/YY) and time (military)•State facts, be clear and concise•Your own observations•If event described to writer, use quotes or “according to…”•Do not place blame in the record•DO NOT REFER TO OCCURRENCE REPORT

26

EMTALA REGULATIONSEMTALA is the Emergency Medical Treatment and Active Labor Act (aka COBRA)EMTALA provides a guideline for safely and appropriately transferring patients in accordance with Federal regulations. The law provides for a medical screening exam (MSE) to all individuals seeking emergency services on hospital property. Hospital property includes the driveway, parking lot, lobby, waiting rooms and areas within 250 yards of the facility.

127

EMTALA REGULATIONSIf an emergency medical condition is found, it will be stabilized within the hospital’s ability to do so, prior to the patient’s transfer or discharge.If a patient does not have an emergency medical condition, EMTALA does not apply.

*** IMPORTANT: NEVER SUGGEST THAT A PATIENT GO ELSEWHERE FOR TREATMENT

128

Catholic Health SystemCatholic Health System

RISK MANAGEMENT

DEPARTMENT Carol Ahrens, RN, BSN 821-4462Director, Risk Management

Joanne Ricotta, RN, BSN 821-4463Risk Management Coordinator

Linda McGavin 821-4467Risk Management Technical Assistant

Valerie Pizarro 821-4468Administrative Assistant

1 29

Violence in the Workplace

1 30

Introduction According to the Bureau of Labor Statistics

(BLS), 2,637 nonfatal assaults on hospital workers occurred in 1999. Rate in hospitals is 8.3 assaults per 10,000

workers *(2000 statistics report increase to 25 per 10,000)

Rate in private sector industry is 2 per 10,000 workers

1 31

Introduction Violence takes place

During times of high activity such as meal time or visiting hours or patient transportation

When service is denied When a patient is involuntarily admitted When limits are set regarding eating, drinking,

tobacco or alcohol use

1 32

What is Workplace Violence?? Wide range from offensive or threatening

language to homicide

NIOSH (National Institute for Occupational Safety and Health) defines workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.

1 33

Examples Threats: Expressions of intent to cause harm,

including verbal threats, threatening body language, and written threats.

Physical assaults: Attacks ranging from slapping and beating to rape, homicide, and use of weapons such as firearms, bombs, or knives.

Muggings: Aggravated assaults, usually conducted by surprise and with intent to rob.

1 34

Case Reports An elderly patient verbally abused a nurse and

pulled her hair when she prevented him from leaving the hospital to go home in the middle of the night.

An agitated psychotic patient attacked a nurse, broke her arm, and scratched and bruised her.

A disturbed family member whose father had died in surgery walked into the E.D. and fired a handgun, killing a nurse and an EMT and wounding a physician.

1 35

Case Reports Workplace violence in general is most often

related to robbery Workplace violence in hospitals usually

results from patients and occasionally from family members who feel frustrated, vulnerable, and out of control.

1 36

Who is at Risk?? Nurses and nursing assistants have the most

direct contact with patients and are at a high risk.

Other hospital personnel includes emergency response personnel, hospital safety officers, and all health care providers.

1 37

Where May Violence Occur?? Anywhere in the hospital but it is most

frequent in the following areas: Psychiatric wards Emergency rooms Waiting areas Geriatric units

1 38

What are the Effects of Violence?? Effects can range in intensity and include:

Minor physical injuries Serious Physical injuries Temporary and permanent physical disabilities Psychological trauma Death

1 39

Effects of Violence Violence can have a negative organizational

outcome reflected by: Low morale Increased job stress Increased worker turnover Reduced trust of management or co-workers Hostile working environment

1 40

Risk Factors Working directly with violent people; those

under the influence of drugs, alcohol or have a history of violence or psychotic diagnosis

Working when understaffed Transporting patients Long wait for service Overcrowded, uncomfortable waiting rooms Working alone

1 41

Risk Factors Poor environmental design Inadequate security Lack of guidelines for preventing and

managing crisis Drug and alcohol abuse Access to firearms Unrestricted movement of the public Poorly lit corridors, rooms, parking lots

1 42

General Prevention Strategies Environmental:

Alarms Security devices Escorts to parking lots at night Good lighting Design waiting areas Staff restrooms and exits Enclosed nurses’ stations

1 43

General Prevention Strategies Administrative controls:

Staffing patterns to prevent personnel from working alone

Prevent patient waiting time Restrict movement of public in hospitals Security personnel alert system

1 44

General Prevention Strategies Behavioral Modifications

recognizing and managing assaults resolving conflicts maintaining hazard awareness

1 45

Dealing with violence Provide open communication Develop written procedures for reporting and

responding to violence Offer and encourage counseling

1 46

Safety Tips Watch for signals of impending violence:

Verbally expressed anger and frustration

Body language such as threatening gestures

Signs of drug or alcohol use

Presence of weapons

1 47

Diffusing Anger Present a calm, caring attitude

Don’t match the threats

Don’t give orders

Acknowledge a person’s feelings

Avoid behavior that may be interpreted as aggressive

1 48

Be Alert Evaluate when you enter a room or begin to

relate to a patient or visitor Be vigilant throughout the encounter Don’t isolate yourself with a potentially

violent person Keep an open path for exiting

1 49

To Diffuse the Situation QUICKLY.. Remove yourself from the situation

Call security for HELP

Report any violent incidents to management

1 50

Strategies that have worked… Metal detector in a Detroit hospital during a 6

month period prevented entry of: 33 handguns 1,324 knives 97 mace sprays

1 51

Strategies that have worked… Violence reporting program in Portland

Oregon identified patients with history of violence in a computer database.

Reduced violent attacks by 91.6% by alerting staff to take additional safety measures when serving these patients

1 52

Strategies that have worked… New York City hospital: Restricted movement of visitors using ID

badges and color-coded passes to limit each visitor to a specific floor

Enforced a limit of two visitors per patient Over 18-months, reduction of reported violent

crimes by 65%

1 53

Summary No universal strategy exists to prevent violence

All hospital workers should be alert and cautious when interacting with patients and visitors

Staff participation in safety programs regarding violence prevention

545411

‘‘The The process of transformingprocess of transforming CHS into an CHS into an

organization with a organization with a superior abilitysuperior ability to to

deliver deliver patient-centeredpatient-centered, quality, , quality,

compassionate healthcare through compassionate healthcare through

outstanding outstanding

professionals and innovative technology.’professionals and innovative technology.’

11 5555

Welcome to EquinoxWelcome to Equinox

• Equinox - Why?– Four Hospitals – “grew-up” with their own

process, culture, technology– Need to establish Electronic Medical Record

• Equinox – How?– Comprehensive system-wide effort to

standardize and improve processes• Standardized Clinical Practices

– Getting the right tools in the hands of our associates – Nurses, Doctors, Administrators

11 5656


• Equinox - When?– Now! Process started in 2004 and is

ongoing– Strategic Alliance with Siemens Medical

Solutions – 10 year agreement

• Equinox – Who?– Everyone – directly and indirectly!

11 5757

• Managing The Process – The TMO– Multidisciplinary Team Dedicated to

Transformation Initiatives (Transformation Management Office)

• Clinicians• Finance/Patient Access• Technology/Project Management• Communications• Administrative Leadership


11 5858

• Function of the TMO Team:– Articulates Existing Processes/Workflows &

Recommends Improvements– Coordinates Disparate & Intersecting

Projects– Collaborates with Siemens – Manages

Strategic Alliance– Communicates With All Stakeholders– Provides Counsel to Stakeholders


11 5959


• Examples of Equinox in Action:– Soarian Clinicals– Clinical Standardization– Financial Process Redesign– St. Joseph Campus Emergency Room

• Process• Culture• Technology

11 6060


• Your Role…– Stay informed– Ask questions– Identify ways to “do it better” always

with the patient in mind– Embrace change!

11 6161


• Questions - contact….

[email protected]

Documents

1 1 Corporate Compliance Program To understand the ethical, professional, and legal obligations we have and our role in meeting these obligations To