Transcript Slide 1

Principles of
Corporate Compliance
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Promotes Ethical, Professional, and
Legal conduct
“Doing what is right”
Defines Responsibility/Accountability
Supports CHS Standards
Assurance of Quality Care
Catholic Health System
Standards
Attain Compliance by:
• Embracing our Mission and Values
• Following the Code of Conduct
• Avoiding Conflicts of Interest
• Upholding Patient Rights
• Adherence to Policy and Procedures
Found in Compliance 360
• Maintaining High Standards of
Business and Ethical Conduct
False Claims Act
It is a crime to knowingly make a false record,
file, or submit a false claim with the
government for payment
A false claim can include billing for service that:
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was not provided or documented
not ordered by a physician
was of substandard quality
It is also unlawful to improperly retain
overpayments
Allows for Qui Tam Relator
(Whistleblower protection)
Language
Assistance Program
• Ensures that limited English proficiency, or
hearing impaired persons utilizing CHS
services are able to understand and
communicate with CHS associates and
physicians
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Provided FREE of charge to the patient
Language
Assistance Program
Needs to be utilized with Hearing Impaired or
Limited English Proficient patient:
• upon initial contact
• each and every time medical information is
being provided
Language
Assistance Program
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Mandatory service by law
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Family may NOT routinely interpret
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Documentation is vital to compliance
If it’s not documented, it’s not done.
See Policy for additional information
HIPAA
HEALTH
INSURANCE
PORTABILITY
ACCOUNTABILITY
ACT
Privacy and Security Policies are in
Compliance 360
What is Protected by HIPAA?
Individually identifiable health information
Also known as
Protected Health Information (PHI)
Transmitted or maintained in any
form or medium
Protected Health
Information (PHI)
 Biometric Identifiers
 Names
 Full face photos
 Geographic subdivisions
smaller than a state
 Medical Record Number
 Health plan Number
 Account Numbers
 Certificate/License
Numbers
 Vehicle identifiers
 Any other unique
identifying data
 E-mail and web addresses
 All elements of dates
related to birth date,
admission, discharge, or
date of death, ages over
89
 Telephone and fax
numbers
 SSN
What Information Can
Providers Share?
• To provide continuity of care
• To others based on need for the information
• Disclose minimum necessary
• Use professional judgment to share
information with a patient’s family and
friends
• May provide necessary health information
with licensing and credentialing agencies
(Dept of Health & JACHO)
Minimum Disclosure Necessary of
Protected Health Information (PHI)
Associates must:
• ID persons who need to access PHI
• Only access portions of PHI necessary to carry
out their duties or fulfill request
• Maintain reasonable efforts to restrict access
to PHI in accordance with above
• Disclose on “need to know basis” the minimum
necessary for your job function
(review HIPAA policy PRIV-24 for additional information)
Consent and Authorization
• Consent is obtained from the patient upon
presenting for treatment and allows disclosure
for treatment, payment & healthcare
operations.
(Consent and Financial Agreement)
• Authorization from the patient is needed for
disclose of health information that exceeds the
Privacy Rule (release for treatment, payment &
healthcare operations)
Disclosure Restrictions
The following types of information are protected by
federal and/or state statute and may not be faxed or
photocopied without specific written patient
authorization, unless required by law.
Must obtain signed authorization prior to disclosure
with family & friends for restrictions noted below.
(see HIPAA policy PRIV-02)
Disclosure restrictions for:
• HIV information
• Psychotherapy notes (mental health)
• Drug and alcohol treatment
HIPAA Safeguards
• Be aware of surroundings
– Be conscious of who is in the immediate area when
discussing sensitive patient information or at your
computer terminal
• Secure area when not attended
– Close out of computer screens containing PHI
before leaving the area
– Close medical records/chart when not in use
– Do not allow other associates to utilize your ID and
password
– Don’t leave papers with PHI in plain view
HIPAA Concerns can lead to
• Privacy & Security violations
• Identity Theft
The World Privacy Forum 2008 estimates
between 250,000-500,000 people
have their medical identities stolen every
year
UNAUTHORIZED ACCESSING AND
DISCLOSURE OF PATIENT
INFORMATION
Curiosity can be a normal human trait
• However accessing health information on yourself,
family members, friends, co-workers, persons of
public interest or any others that you are not involved
in the care of is a …
...VIOLATION of HIPAA
• Disclosing PHI inappropriately is also a violation
• Individuals do NOT have the rights to look up their
own health records
Your Computer Usage
can be monitored
Information Technology is able to audit all
associate’s internet usage.
Associates should have no expectations of
privacy while using CHS computer resources.
Compliance Concerns
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Lack of integrity and improper billing (coding & billing)
Conflicts of Interest
Ethical concerns
Theft or misuse of services
Inappropriate Gifts/Services
Improper Political Activity
Breech of Corporate Confidentiality
Improper use of Proprietary Info.
Environmental Health and Safety Issues
Dishonest Communication (spoken, or documents etc.)
Improper Business Arrangements
Failure to follow Record Retention policy
Documentation Concern (false or lacking documents)
Example of
Compliance Concern of
Fraud & Abuse
“If you bill these
services
individually, the
hospital will
receive more
reimbursement”
Example of
Improper Use of Proprietary
Information Compliance Concern
Jack, I have a list of the patients
that were seen at the hospital. I am
sure these names would be helpful
for your pharmaceutical company
mailing list.
Example of HIPAA VIOLATION
Faxing PHI to the Incorrect
Physician or Office
“…let’s see there are four
different MD’s with the
same name… I’m sure the
first one must be the right
one, if not I’m sure they
will forward it to the right
office…
Example of HIPAA VIOLATION
Unauthorized Access
of Medical Record
“Joe, I just thought I’d
give you a call and let
you know that our
neighbor Mrs. Smith
had heart surgery last
week – I am looking at
her record now. You
might want to go over
and check on her
later.”
Example of HIPAA VIOLATION
Inappropriate Computer Blogs &
Face Book Entries Regarding
Events at Work
“…a guy came
into the lab
today and stole
one of the
laptops with
patient
information
from the
workstation.
The guards
were unable to
find him...”
“…at our nursing
home a confused
patient got
dressed and
wandered out of
the building…it
took the staff 4
hours to find her –
she was 10 blocks
away...”
Example of HIPAA and Compliance VIOLATION
Sale of Patient Information to
Outside Vendor
“…thank you for
supplying that
list of pregnant
patients...we
would be happy
to send them
information on
our new child
care products”
“…It was no
problem...anytime
you need this
information I’ll
provide it … of
course I’m
assuming you’ll still
be providing me $5
for every referral”
Associate’s Responsibility
• Upholding CHS mission and values
• Adhering to code of conduct,
policies & procedures, and the law
• Constant monitoring for concerns
• Duty to Report Concerns
3 Step process of Reporting
• During an investigation
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be truthful
participate in good faith with investigators
preserve documentation or records
relevant to ongoing investigations
3 Steps for Reporting
Compliance Concerns
Immediate supervisor or appropriate department
Higher level manager
Compliance Officer
Also available 24 hours a day/ 7days a week
Compliance Line
1-888-200-5380
Non-Retaliation Policy
• Protects associates from adverse action
when they do the right thing and report a
genuine concern
• Reckless or intentional false accusations by
CHS associates are prohibited
• Reporting the possible violation does not
protect the constituent from the consequences
of their own violation or misconduct
Possible Consequences
for Non-Compliance
• For the Associate and CHS Managers/Supervisors/Administrators
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Fines and Prison sentences
Corrective Action (including possible
termination of employment) for
violations or failure to report concerns
• For Catholic Health System
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Exclusion from government insurance
funded programs
Fines
Things to Remember
• Adhere to CHS code of conduct,
policies & procedures, and other standards
• Duty to report Compliance/HIPAA concerns
as soon as aware of situation
• Do the right thing
apply ethical decision making
• If uncertain…
Use Corporate Compliance Booklet as a
reference and … Always Seek Knowledge
(A.S.K.)
CHS Corporate Compliance
Contacts
Compliance/HIPAA Privacy Officer
Anne Mason 821-4469
HIPAA Security Analyst
Sally O’Brien 862-1938
CHS HIPAA Line
862-1790
Corporate Compliance Line
1-888-200-5380
All calls are confidential
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
anatomical gifts
Catholic Health
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.
FOUR ELEMENTS OF
RISK MANAGEMENT
Risk Identification
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Review Occurrence Reports
Review Patient/Visitor Complaints
Participate in Root Cause Analysis
Review concerns expressed by CHS
staff
FOUR ELEMENTS OF
RISK MANAGEMENT
Loss Prevention
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Educational Programs through
CHS University
Department specific inservices
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
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.
What are sources of an
Occurrence?
Patients
Visitors
Patient/Family
Complaints
Security reports
Equipment “failure”
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.
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
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
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 Quality & Patient Safety
Dept or Security as indicated in the
Risk Management process
Risk Management Process
Patient and visitor safety are assessed from both
clinical and environmental perspectives
Notify Quality & Patient Safety of patient occurrences
 Notify Security of visitor or property occurrences
 Risk Management will be notified by QPS 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 IN
THE MEDICAL RECORD
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
IDENTITY THEFT
Fair and Accurate Credit Transactions
Act of 2003
or
“RED Flag Rules”
In effect January, 2008
to be enforced November 1, 2009
Hospitals that maintain covered accounts must
develop and implement written policies and
procedures to identify, detect, prevent, and mitigate
identity theft.
IDENTITY THEFT
“RED FLAGS”
•Alerts, Notifications, Warnings
•Presentation of Suspicious
information
•Suspicious Activity
•Notice from patient, law
enforcement, etc
**Patient Access, Health Information,
Finance, IT Depts primarily involved
Catholic Health
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
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
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
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.
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.
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.
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.
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.
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
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
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
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
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
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
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
General Prevention Strategies
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Behavioral Modifications
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recognizing and managing assaults
resolving conflicts
maintaining hazard awareness
Dealing with violence
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Provide open communication
Develop written procedures for reporting and
responding to violence
Offer and encourage counseling
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
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
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
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
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
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
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%
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
‘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.’
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
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!
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
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
Welcome to Equinox
• Examples of Equinox in Action:
– Soarian Clinicals
– Clinical Standardization
– Financial Process Redesign
– St. Joseph Campus Emergency Room
• Process
• Culture
• Technology
Welcome to Equinox
• Your Role…
– Stay informed
– Ask questions
– Identify ways to “do it better” always
with the patient in mind
– Embrace change!
Welcome to Equinox
• Questions - contact….
[email protected]