2016 Annual Education Packet

Rockdale Medical Cente.. 2016 Annual Mandato.-y Education Fo..
Students, Cont..act E....ployees, Othe..s
Naane: ----------------------------
Date: ----------------------------
Please, keep this book fo.. you....efe..ence.
Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
I. Lifepoint Health
Our Mission, Vision and Values:
Lifepoint's facilities across the nation are united by a shared mission, vision and common values.
Mission -Making Communities Healthier.
Our Vision -We want to create a place where:
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•
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People choose to come for healthcare.
Physicians want to practice
Employees want to work.
Core Values­
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Honesty
Integrity
Trustworthiness
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Compassion
Legal/ ethical compliance
Our High Five Guiding Principles Lifepoint was founded with five core guiding principles we call our High Five. These principles guide
our actions and decision making and define what communities can expect from us as a healthcare partner.
•
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Delivering high quality patient care.
Supporting physicians.
Creating excellent workplaces for our employees.
Taking a leadership role in our communities.
Ensuring fiscal responsibility.
Rockdale Medical Center
Rockdale Medical Center is a general medical and surgical hospital in Conyers, GA, with 138
beds. Survey data for the latest year available shows that 57,000 plus patients visited the hospital's emergency
room. The hospital had a total of 8,899 admissions. Its physicians performed 2,356 inpatient and 6,690
outpatient surgeries.
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
Customer Service
Rockdale Medical Center strives for excellent customer service. To accomplish this we have
implemented several initiatives.
• AIDET - This is an acronym for how we come into a room to see a patient. It reminds us to do
the following:
• A - Acknowledge
Take the time to focus completely on the patient. Call them by name.
Smile and make eye contact.
• I - Introduce
Introduce yourself - who are you and what are you doing?
• D - Duration / Timeframe
How long are you going to take?
• E - Explanation
What is it you are doing and why. Use the teach back method (have the
patient tell you in their own words what they understood).
• Thank You
Thank the patient for choosing Rockdale Medical Center for their
healthcare.
• Hourly Rounding - The patient is rounded on hourly. Use the word "rounding" when speaking
to the patient. Techs round on the even hours. Nurses round on the odd hours. When you are
ready to leave be sure you tell the patient you or your tech will be back in about one hour to
check on them.
• The 4 P's -At each "Rounding" visit for the nurse and the tech, address the 4 P's:
):- Pain - Monitor the patient's comfort and pain.
):- Potty - Assist the patient with help to the bathroom.
):- Positioning - Help the patient move or change positions.
):- Personal Needs - Take the time to make sure the patient's personal items are within easy
reach. Be sure the bed in in the lowest position, the bedside table is near the patient, and
their call light is within easy reach. (Ex. Phone, cell phone, books or writing materials).
• Bedside Shift Report - when changing shifts, the off going nurse gives report to the oncoming
nurse at the bedside. This helps to involve patients and family members in their care and allows
them the opportunity to ask questions.
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
• Briefs, Debriefs and Huddles - as a student or contract employee you are expected to
participate in these brief meetings to solidify your role on the team.
~ Brief - A short pause to plan for the day. The purpose of the brief is to ensure a shared
understanding of the plan for the day, goals, established expectations, climate and
anticipate outcomes as well as prepare for likely contingencies.
~ Huddle - called by any member of the team to discuss a change in status from the
original plan.
~ Debrief - a short pause to discuss what went well, what we could improve, and what
lessons can we learn from what happened today.
II. Dress Code
Students are required to dress neat, clean and appropriately:
No shorts, no Capri pants No denim jeans or printed T-shirts No clothing that is revealing or clings to skin (tank tops, low cut blouses, stretch pants, etc.) Hosiery or socks must be worn, no open toe shoes in clinical areas. Minimal amounts ofjewelry - no more than 2 earrings per ear. No cologne or perfume. Your school uniform is appropriate. Students are required to wear their school badge while on property. Nurses are required to wear navy blue and/or white - solid colors. Surgical Services are to wear
appropriate surgical attire for operating and other procedural areas.
III. Safety Management Program
• Everyone has the responsibility for the safety at Rockdale Medical Center (RMC). This includes
volunteers, employees and Medical Staff.
• Everyone should review the Environment of Care (EOC) Manual also called a Safety Manual. This
manual is currently located on the Hospital Intranet in Policy Stat.
• The Risk Management Department reviews all unexpected or accidental events which are reported in
our online incident reporting program, RLSolutions. RLSolutions is located on the Intranet.
• RLSolutions is used to report patient, visitor, and employee incidents. If you are involved in an
occurrence, report it in RLSolutions.
• If a visitor falls, please contact Security at 3838. If you witness a visitor fall, ask the visitor if they
desire medical attention. If they do, the visitor should be escorted to the ED . All visitor falls should
be entered into RLSolutions.
• Encourage patients to be actively involved in their own care as a patient safety strategy.
• If you are stuck with a needle or are otherwise exposed to blood or body fluids, or have an injury
while on campus, please report this immediately to the Employee Health Nurse (extension 3120) or
the House Supervisor (3140) after regular business hours or on weekends. Note the time and exact
location you are in if this should occur. All incidents should be reported in RLSolutions.
• All employees should wear their name badges at all times.
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
• Service representatives, sales people and contractors are required to go through the Materials
Management Department to receive identification through the Reptrax system - a vendor
identification system. Stations are located in Materials Management and the North Tower Lobby.
• Employees who transport newborn infants wear a color coded ID badge. This badge has a royal blue
strip across the top of the tag.
• Direct all lost or found items to the Security Department.
IV. Emergency Preparedness:
•
•
•
•
•
The number to call to report an emergency is 6666.
"MET TEAM" is paged overhead when immediate assessment! treatment is needed in order to
prevent a Code Blue situation from occurring. ANYONE can make a MET TEAM call ­
patients, family, students, etc.
Staff Disaster Line is 678-413-RDMC (7362). Call this to listen to a recorded message about the
disaster.
If you are called in the event of a disaster you will need to enter the hospital through a badge
access entrance. Report to the manpower pool in classroom 3 unless otherwise directed.
If you are already here, report to your assigned department.
Emergency Codes
Code BLUE - Used for Cardiac Arrests anywhere in the building except the NICU and the
Surgical Services Department. A Code BLUE called in the ED is usually followed by "ETA
(estimated time of arrival) _ _ minutes".
Code RED - Used for announcing a fire anywhere in the building. The
announcement will be Code Red followed by the location of the fire.
Life Safety - Fire Management Plan
The acronym for what to do in a Code RED is:
~ R
Rescue
~ A
Alarm
~ C
Contain
~ E
Extinguish or Evacuate
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
The acronym for the use of a fire extinguisher is:
~ P
Pull Pin
~ A
Aim at the base of the fire
~ S
Squeeze the handle
~ S
Sweep at the base of the fire
Interim Life Safety Measures are designated by the Facilities department when Physical Hazards or Fire
Hazards are present during renovation or construction. Frequent Fire Drills may occur.
Code ORANGE - Used to announce the release or spill of any hazardous material,
including radiation, in the hospital environment.
Code ORANGE followed by Code CDC- If the hospital experiences a Bioterrorism Event, a Code
CDC will be announced possibly followed by a SECOND announcement of CODE ORANGE.
Bioterrorism:
• Rockdale Medical Center has a Bioterrorism Plan
• The plan is located on the Intranet in the Emergency Codes Policy.
• Smallpox and anthrax are forms of bioterrorism.
Code GREY - Used to announce a situation that requires the response of Security
Personnel. Examples include bomb threats, combative patients, and unruly family
members.
Code SILVER - There is an active or threatening shooter in the facility. Turn off
any cell phones and hide until the all clear is called. Once called, come out with
your hands open and above your head.
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
..
,. ,..
.'
....:....--=-= =--== Code PINK - Used to announce an abduction - usually an infant but could be an adult. Code
PINK will be followed by "Mother Baby Unit" for a baby or the name of the unit an adult was assigned
if the abduction is an adult.
Your role:
~ All exits are to be manned.
~ No one is allowed to leave the facility until "all clear" is
announced overhead.
Code TRIAGE - Used to activate the hospital disaster plan.
If you are called in the event of a disaster you will need to enter the
hospital through a badge access door.
If you are already in the facility go to your assigned department.
Inclement Weather - Will be announced by the hospital operator. The Safety
Officer/ Administration will instruct the hospital operator. Announcement of any warnings will
be based on advisement from the weather service or local emergency operations center.
BOMB THREAT ­
~ If you
~
~
~
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receive a bomb threat contact Security who will notify the Administrator on
Call(AOC). Do NOT dial 6666. The AOC will notify the operator of any announcements.
and alert the hospital of the bomb threat.
When entering a room, look for a suspicious object.
The search supervisor is responsible for :
Supervising the search in an assigned area.
Receiving reports from others searching that area.
Reporting the results to the COO or designee as soon as possible.
Listed are the things you would complete on a bomb threat reporting form:
,/ Age
,/ Accent
,/ Male or Female Voice
,/ Background noise
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
v. Medical Equipment ­
o The Clinical Engineering Department's role is to ensure operational reliability, assess
special risk and respond to failures of medical equipment and support patient care.
o Defective equipment or any piece of medical equipment that is not functioning properly
should be taken out of service and tagged immediately. Report it to Clinical Engineering
and to the Risk Management Department. RLSolutions is a great tool.
o All medical equipment is inspected and tagged before use at Rockdale
Medical Center.
o All medical and non-medical equipment is inspected at least annually.
VI. Utilities
The Facilities Department monitors the utilities. These Utilities are as
follows:
~ Electrical distribution
~ Emergency power
~ Elevators
~ Heating and air
~ Plumbing
~ Boiler and steam
~ Medical gas
~ Vacuum
• The emergency electrical outlets are red in color.
• If you have any problems with these items, please report them to the
Facilities Department.
-I
.
•
,•
VII. Latex Allergy:
• A person who is allergic to latex has reactions to natural rubber products.
• People who are allergic to avocados, bananas, chestnuts, kiwi fruit or passion fruit may
have a latex allergy.
• A green armband is placed on patients to identify them as latex allergic.
• A green sign is placed on the patient's door to identify them as latex allergic.
• The Latex Allergy Cart is located in Materials Management.
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
Some signs of Latex Allergy are:
./
./
./
./
./
./
./
Skin redness Scratchy throat Hives/Itching Itching eyes Shock Asthma Runny nose VIII. Infection Prevention and Control
• All rooms that are occupied by a patient who needs to be in special isolation will have a
sign posted on the door. This sign tells you what precautions should be followed.
• Follow the directions on the sign to know what Personal Protective Equipment
(PPE's) should be used by all staff and visitors.
• PPE's prevent contact with blood and other body fluids. Always wear gloves when you
may come into contact with blood or body fluids.
• Examples of PPE's are: ~ Gloves ~ Gown ~ Mask • The single most im portant way to prevent infection transmission is by hand washing.
• Cover your cough to help prevent the spread of germs.
• The supervisor and employee health nurse should be contacted immediately when
you have a needle stick.
• You must have a TB test every year.
• When entering the room of a known TB patient, you must first put on a special TB
mask (N-95 Mask) that has been fitted specifically for you.
• Autopsy or surgical tissue specimens, empty blood transfusion bags and urine cups
with no visible blood, should be red bagged for special handling.
• Breast milk is a body fluid and should be stored in a special designated
refrigerator.
• Only hospital approved cleaning disinfectant products are to be used.
• Sharps should be discarded in a sharps container. This includes needles, blades,
scalpels, etc.
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
IX. Ergonomics and Work Safety
• Poor posture, being out of shape or overweight and moving your body incorrectly can cause
lower back pain.
• Lifting is the most common cause of back injury among healthcare workers.
• Always keep loads close to your body and bend your knees, not your back.
• When moving patients or objects, make sure you have adequate help.
• The 3 principles you should use to help prevent problems with your back and wrists are:
~ Keep wrist in neutral position
~ Keep head straight in line with your body
~ Take frequent stretch breaks
• Two attendants should be used when transporting a patient
by stretcher.
X. Patient Rights
• Patient Rights adopted from the American Hospital Association includes: ~ The right to respectful treatment
~ The right to privacy and confidentiality in all forms of
documentation and communication
~ The right to be in communication
~ The right to make informed decisions
~ The right to participate in all aspects of healthcare
~ The right to an advance directive
~ The right to impartial access to care
r
• When a patient is to be restrained, the following are needed: ~ Physician order ~ Patient's behavior documented ~ Alternative measures used • Patients in medical restraints must be checked at least every two hours.
XI. Abuse and Neglect:
• All Rockdale Medical Center employees are mandated (required by law) reporters
of Child Abuse and Elder Abuse. Case Management and the Administrative Supervisor
are the designated liaisons available to represent any concerns.
• Any employee of Rockdale Medical Center is mandated by law to report abuse, neglect or
exploitation. The number to call is 1-855-422-4453 (Child Abuse), 1-866-552-4464 (Adult
Protective Services).
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Hospital Orientation
Annual Mandatory Education
• Types of abuse include
~
Physical
~
Emotional
~
Verbal
~
Neglect
~
Sexual ~
Exploitation (use of another person for one's own advantage) • If you feel you are being sexually harassed at work, report this to the HR Department.
XII. Legibility
• Our goal is legible documentation that fosters patient care and safety.
• Illegibility will be declared whenever two or more staff (one must be licensed or
credentialed) cannot read an entry in the medical record.
• An illegible entry should be copied and forwarded to the director of the department.
XIII. Corporate Compliance
• Rockdale Medical Center has a Corporate Compliance Program because it:
./ Prevents fraud and abuse throughout the organization
./ Demonstrates a strong ethical business
./ Promotes quality patient care
• All employees must report any violations known in the areas of hospital policies,
professional standards and all federal and state laws.
• Rockdale Medical Center does have a Corporate Compliance Officer.
• The Corporate Compliance Officer investigates all reports of violations.
• You should report violations in the order of: Supervisor, Compliance Officer,
Human Resources, and Compliance Hotline (1-877-508-5433).
• The Compliance Hot Line is an anonymous reporting system.
• Failure of employees or students to follow the Code of Conduct set forth by the
hospital may result in written warnings, disciplinary actions, and suspension from
work and/or termination of employment. Students may be asked to leave the facility.
• Rockdale Medical Center does not encourage employees to conduct campaign
activities.
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
These are examples of not following the Corporate Compliance Program:
.:. An employee or student has someone else clock in for him/her so they get
paid for more time than they actually worked .
•:. An employee or student takes home patient supplies for their own
personal use .
•:. An employee or student uses profanity while talking to a patient .
•:. An employee or student tells their friend why a neighbor was in the hospital.
XIV. Impaired Practitioner
• Staff members should notify their Manager, Director or Administrative Supervisor if they suspect a Physician is impaired. • The Manager, Director or Administrative Supervisor will
-\
notify a designated chairperson who is then responsible for ensuring that appropriate and
immediate action is taken.
I
xv.
EMTALA • When any patient presents to the Emergency Department ED (which is defined as
coming to any hospital property), you are required to provide a medical screening
exam to determine the presence of absence of an emergency medical condition,
regardless of the patient's ability to pay.
• If an emergency condition is found, then the hospital is required to stabilize the
patient within the capability of the facility.
• The hospital may transfer the patient only when it is medically necessary or the
patient requests. The medical necessity is defined as when a physician can certify
that the benefits outweigh the risks.
• Medical screening may only be done by a Medical Doctor, or a midlevel provider.
• Triage alone does not constitute a medical screening.
• To transfer a patient, you must expect stabilization to last through the transfer.
• The 250 yard rule is - the ED includes anything that is 250 yards from the main
building, plus off-site, outpatient areas owned by the hospital.
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
XVI. Ethics Process
Rockdale Medical Center has an Ethics Process that can be initiated by calling the operator (dial "0") and asking for an Ethics Consult. Anyone can ask for an Ethics Consult. XVII. Diversity
Diversity is:
• Recognition that our patients, customers, visitors and employees are different.
• An environment where all customers feel and employees feel welcomed regardless of the
differences. Dimensions of Diversity Gender
Culture
Age
Religion
Economic Status
Education
Life-Style Choices
Marital Status
Physical/ Mental abilities or challenges
Race
Sexual Orientation
Political Status
Social Affiliations
Prejudice
• Prejudice is a natural feeling where there is distrust and fear of people that are different
than us.
• To overcome prejudice, visit a different ethnic environment, attend a different place of
worship, dine with people from other cultures, ask questions about healthcare in other
cultures and read about different cultures.
• The Cultural, Ethnic and Religious Reference Manual for Health Care Providers is located
on the Intranet.
Stereotyping
• Applying bias and experiences to an entire group of people.
• To avoid stereotyping, pay attention to the thoughts you have, notice your first reaction to a
patient or other customer and do not make snap decisions about what a customer wants or
needs.
Self-Awareness
• Feelings and beliefs
• Filtered view of the world
Accepting Diversity
• Search for common ground.
• Understand everyone desires to succeed, contribute and be in good health. RR 02/2016 12
Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
• Understand everyone needs to belong, to be understood and to be treated with dignity and
respect.
• Respect is shown through acceptance, tolerance, getting to know the person behind the
difference and practicing the Golden Rule.
XVIII. Fall Prevention
All patients are assessed on admission and daily for fall risk. Patients identified at risk on
admission during their hospital stay will be placed on the fall prevention protocol. They will remain
on the protocol until discharge, unless ordered otherwise by a Physician. Any patient experiencing a
fall will remain on the fall protocol for the remainder of the admission.
•
•
Fall Risk Assessment
Monitor the patient's gait, balance and tolerance during ambulation.
Monitor the patient closely after medication changes for possible side effects such as sedation,
hypotension (low blood pressure), impaired balance, impaired circulation and impaired
reaction time.
•
•
•
•
•
•
•
•
Fall Risk Criteria
History of falls
Multiple medications
Mental status change
Improper footwear
Sensory &/ or auditory deficits
Elimination changes
Communication deficits
History of orthostatic hypotension (low blood pressure when going from a sitting to standing
position).
Fall Prevention Interventions
• Place a yellow armband on the patient.
• Discuss their fall risk with the patient &/or family.
• Keep the bed/stretcher/procedure table in the lowest position, with two side rails up at all
times (if there are no side rails, the patient should not be left unattended.)
• Use the bed alarm system where available.
• Bed should be in the locked position at all times.
• Provide adequate lighting.
• Re-orient the patient to their environment.
• Monitor the patient's environment for potential safety issues.
• Provide non-skid slippers for patients without proper footwear. (Yellow footies)
• Assist the patient with elimination procedures.
• Obtain a walker or cane from home if a patient uses them and assist with ambulation and
transfers from bed to wheelchair, wheelchair to table, etc.
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Rockdale Medical
Hospital Orientation
Annual Mandatory Education
station.
when possible.
,._r'~~'
close to
Documentation
assessment on admission and
the "At Risk for
plan of
placing a sticker outside of
door, and U~'_AAA'~
status to 1Ju.,."....... &/ or family upon initial identification.
Remember, any
physician.
must be reported
should
of
charge
nurse manager. Nursing Supervisor and
into RLSolutions.
Joint
is an
not-for-profit
in the
administers voluntary accreditation programs for
and other
organizations.
The commission develops performance standards
address crucial elements of operation,
such as
care, medication
infection
and consumer rights.
2016
The Joint Commission has
""n'''''''""ri
these areas
hospitals to improve patient
safety:
patients.
At Rockdale Medical
we use two
to identify a patient =~_ Never use
room number to identify the -.-",1''''1>'1''''
Make sure
correct T".,i-,o..,,.
~~""'-"~~~~
the correct blood when they get a blood transfusion.
Improve Staff CommWlication
Get important test results to the right staff person on time.
The lab will only
Critical lab
to a nurse or MD. Inform
doctor of any
critical lab results, positive
or other tests a timely manner
than 5
when
possible,
within one hour.)
Use Medicine Safely
Before a procedure, label medicines that are not labeled.
example,
medicines syringes, cups
basins. Do
in the area where the supplies
extra care with patients who take medicines to thin their blood.
Record and pass
correct information about patients medicines. Find out
what medicines the patient is taking. Compare those medicines to new
medicines
to the patient. Make sure the patient knows which medicines
to take when they are at home. Ten the
it is important to bring their
up-to-date list of medicines every time they visit a doctor.
and update
admission assessment forms and
Medication Reconciliation
upon admission.
sure to
the patient at
about any new
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Medical Center
Hospital Orientation
Annual Mandatory Education
wnrvnn,o
and what
.............,....., improvements to ensure that
responded to on
each shift to ensure compliance and
If possible
when they
to take or
on medical equipment are
alarm fatigue.
the hand cleaning guidelines from the Centers for JUlI;~ot:;ii:l~ot:; and ...A'"A."..... r .." or the World Health Organization. goals for ........."'_~.... ni .....
hand
Use the goals improve hand cle~anllnl~. Wash your
before and after
sanitizer or soap and proven guidelines to prevent infections that are difficult to treat.
Follow
signs and make sure
Infection Control and Prevention Policies.
into the patient's room follows the
on these signs.
everyone
proven guidelines to prevent infection
lines.
Follow
policy for
dressing
blood from ...Aln......·~
use of central
Use proven guidelines to prevent infection after surgery. Follow
Measures - Prophylactic antibiotic within one hour of incision. Blocker given perioperative period and continued
postop day 2
contraindicated (HR less than 50 or
BP less than 100). Antibiotics "'''''..''''..... ,'"..-,'..,
within 24
end of
otherwise
Infection), Timely
prophylaxis
anesthesia
Catheter
Use proven guidelines to
infections of
urinary tract that are
caused by catheters.
Discontinue catheters as directed by MD. If no order
and urinary
not appropriate,
MD and get an
discontinue. (FOLLOW THE SCIP
MEASURES Identify Patient Safety Risks
Find out which patients are
likely to try to commit suicide
Complete
Admission
ask your patient
see a concern.
Prevent Mistakes In Surgery
Make sure that the correct
is done on the correct patient and
the correct
on the patient's body.
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Rockdale Medical Center
Hospital Orientation
Annual Mandatory Education
Mark the correct place on the patient's body where the surgery is to be
done.
Pause before the surgery to make sure that a mistake is not being made.
Follow the Time Out Policy #955882. A Time Out is called before an invasive procedure by
the RN or circulating nurse. All members of the team participate in the Time Out. Follow the steps in
the policy.
xx. Suicide
The Joint Commission suggests the following to detect suicide ideation (thoughts):
);> Review each patient's personal and family medical history for suicide risk
factors. Examples of these risk factors are:
• Mental and emotional disorders such as bipolar disorder or
depression.
• Previous suicide attempts or self-inflicted injury
• History of trauma or loss, abuse as a child, family history of
suicide, bereavement or economic loss.
• Serious illness
• Alcohol or drug abuse
• Discharge from inpatient psychiatric care within the first year but
particularly within the first few weeks and months after discharge.
• Access to lethal means coupled with suicidal thoughts.
);> Screen all patients for suicidal ideation.
);> Review the screening questionnaires before the patient leaves the
appointment or is discharged.
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HIPAA (Health Insurance Portability & Accountability Act of 1996)
Presented by Stephanie Fowler, RHIA,
Director of Health Information Management & Privacy Officer
2016 Orientation to
HIPAA Privacy Rule Compliance
2/29/2016
1
PHI Definition o PHI (Protected Health Information) is
identifiable health information that RMC or
any covered entity has acquired in the
course of serving its patients.
2/29/2016
2
Examples of PHI Data elements that make health
information identifiable include:
A
A
A
A
A
A
A
A
A
2/29/2016
Patient Name
A Social Security #
Address
A Member/Account #
Employer
A License #
Relatives' Names A Fingerprints
Date of Birth
A Photographs
Telephone Numbers
Fax Numbers
E-mail Addresses
Or any other linked number, code or
characteristic
3
HIPAA Provides for Specific Uses of PHI ... o PHI may be used & shared
lNithout authorization for
purposes of:
.• Ireatment - Ongoing Care
:. eayment - Doctors, hospitals,
insurance payers, including
Medicare & Medicaid
:. Qperations - Running the business
of health care
This is explained in the Notice of Privacy Practice 2/29/2016
4
Safeguards to Protecting P D
Refrain from discussing PHI aloud in public
areas of RMC, such as cafeteria, nursing
units, treatment areas, etc.
o Destroy all documentation containing PHI.
Shred-it bins are available on all units. If
small recycle receptacles are used at your
desk, please empty into shred-it bin at end
of shift.
2/29/2016
5
Your Role o If you are made aware of, or suspect a misuse or
improper disclosure of a patient's information,
contact your Privacy Officer immediately
o Do not notify the patient / family yourself
o Be aware of how you utilize patient's health
information in your job and protect the information
from unauthorized disclosure
o Review your facility's privacy and security policies
o If a suspected incident is in question, a full risk
assessment will be conducted internally to determine if
the breach is reportable
o You will not be retaliated against for reporting a
suspected incident in good faith
o Failure to report a suspected incident could result in
disciplinary action
2/29/2016
6
Social Media o Healthcare providers have an obligation
to protect PHI during and following
treatment of a patient and this
obligation does not expire because a
patient discloses their own condition
online through a media source .
o HIPAA Security rules require us to
protect "electronic" PHI
2/29/2016
7
Social Media You may think you are safe as long as you
don't use a patient's name BUT not true:
Someone may be able to determine the
patient's name by other details stated
It is not lawful to even provide the fact
that someone is a patient (mere
existence of the provider/patient
relationship is considered to be PHI)
Reply or discussion on a blog that was
initiated by the patient
Posting a picture of a patient (sad
because my favorite patient died today)
2/29/2016
8
A
2/29/2016 AlI.nIonnadan cancernl.. a present
or former pattent"s care, treatment, clllno­
sis. pr1JInOsls and personal aftalrs is str1cdv
c:ontidenlial and .s to be dl5alssed or
disclosed ontv b¥ authorized penonnel on a
nee~to-know basis.
Whether InbmaIIon concernl", the
patient Is obtained dun.. the COUIH of
one"s replilr ctut;es or accidemaltv
O¥etheard while performl.. work.
emplo'f'Bes must refrain from dl5alssl"l
such Information with unauthorized
persons, .n or out of the hospfta~ .n order
to ensure the patient's riFt to privacy.
VIolatIon of employee/patient
confldenaallty is grounds for disc~line.. up
to and includilll termination.
9