Transcript CHS University

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