east jefferson general hospital standing out...post discharge care hcahps categories confidential...
TRANSCRIPT
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East Jefferson General Hospital
Standing Out STANDING STRONG
Welcome!EJGHExperience
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CONFIDENTIAL
OurServiceStatement
Providingcareandcomfortisourhighestmission...
Wepledgetoourguestsandeachother:
v Thefinestinpersonalservicev Courtesyandrespectv Asatisfyingexperience
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CONFIDENTIAL
Senior Leadership
RubyBrewer,RN,MSN,MBASeniorVicePresidentChiefQualityOfficer/ChiefNurseOfficer
RaymondDeCorte,M.D.ChiefMedicalOfficer
JamesHritz,MPH,JDSeniorVicePresident
ComplianceandLegalServices
ValerieEngladeSeniorVicePresidentCommunityAffairs
RobHinyub,Jr.,JDVicePresidentLegalServices
GeraldPartonPresident/ChiefExecuDveOfficer
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CONFIDENTIAL
• HistoryofEastJeffersonGeneralHospital• Mission,Vision,Values• OurServiceStatement
• InfecDonControl• HIPAA• HospitalStandards
Takeaways
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CONFIDENTIAL
• OpenedonFebruary14,1971• Louisiana’sfirstNurseMagnethospital• MemberoftheMDAndersonCancerNetwork• ACommunityHospital,butreceivesnotaxsupport
A Proud History
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CONFIDENTIAL
Our Mission Statement
EastJeffersonGeneralHospital,community-owned,providesthehighestquality,compassionatehealthcaretothe
peopleweserve.
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CONFIDENTIAL
EastJeffersonGeneralHospitalwillbetheregion'shealthcareleaderprovidingthe
highestqualitycarethroughinnovaKonandcollaboraKonwithourteammembers,
medicalstaff,andcommunity.
Our Value Statement
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CONFIDENTIAL
• Quality• Integrity• CollaboraDon• ConDnualImprovement• Compassion• Stewardship
Our Values
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CONFIDENTIAL
Wecommittoqualityineverythingthatwedo,throughachievementandinnovaKon,alwayscontribuKngtoexcellentcareandpaKentsaKsfacKon.
Quality
Weupholdthehigheststandardsofbehaviorencompassingfairness,trust,respect,andethicalpracKces.
Integrity
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CONFIDENTIAL
Teamworkisthekeytooursuccess.Workingtogether,weensureeveryonebenefitsfromourcollecKvewisdom.
Collaboration
WeembraceandencouragecreaKvityandinnovaKon,aswellason-goingself-evaluaKonofourprocessesand
outcomes.
Continual Improvement
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CONFIDENTIAL
Byourthoughts,words,anddeeds,wecreateandmaintainacaring,compassionateenvironment.
Compassion
WeareaccountabletomakewiseuseofKme,skills,andresources.
Stewardship
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CONFIDENTIAL
Distinctions in Quality
12
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CONFIDENTIAL
• CancerCare• CardiovascularCare• Pulmonology• StrokeCare-Neurosciences• WomanandChildServices• DiagnosDcImaging
EJGH Services
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CONFIDENTIAL
“Thecareandwell-beingofourpaKentsshoulddriveeverydecisionwemake.”
• PaDentSaDsfacDonSurveys–theopportunityforourpaDentstogiveusfeedbackandhelpusimprove
• PaDentHandbook–orientpaDentsandfamilymemberstoourfacilityandsettheexpectaDonofexcellence
• GuestServicesDepartment–assistwithpaDentandfamilyconcerns• PaDentandFamilyAdvisoryCouncil–theVOICEofourpaDentsandfamilymembers
• TeamMembersandPhysicians–weareanadvocateforthepaDentandtheirfamily
• PaDentCenteredCare–creaDnganorganizaDonfocusedonpaDents
The Patient’s Perspective
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CONFIDENTIAL
HCAHPS(HospitalConsumerAssessmentofHealthcareProvidersandSystems)
• Federallymandatedsurveycreatesvalidcomparisonsacrosshospitalslocally,regionallyandnaDonally
• AlladultinpaDentstays(exceptforpsych)areeligibletobesurveyed• Hospitalsmustuseapprovedvendorsforthesesurveys–EJGHusesPressGaney,anaDonallyregardedhealthcareresearchprovider
• Publiclyreportedathospitalcompare.gov• Scoreseffectthehospital’sMedicarePayments–fundswithheldforpoorscores
Patient Satisfaction
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CONFIDENTIAL
1. CommunicaDonwithNurses2. CommunicaDonwithDoctors3. ResponsivenessofstafftopaDents’needs4. ManagementofPain5. CommunicaDonAboutMedicines6. DischargeinformaDon7. Environment–Cleanliness8. Environment-Quietness9. PaDents’overallraDngofthehospital10. Willingnesstorecommendhospital11. PostDischargeCare
HCAHPS Categories
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CONFIDENTIAL
East Jefferson General Hospital, community-owned, provides the highest quality, compassionate healthcare to the people we serve.
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CONFIDENTIAL
PaKent-CenteredCareModel
EveryJobGeneratesHarmony
EJGH Patient Experience
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CONFIDENTIAL
Itisourhopethatthroughourefforts,patients,familymembers,andvisitorswillhaveapositiveexperience.ThegoalforeverypatientatEastJeffersonGeneral
Hospitalisexcellence.
Focus on Service Excellence
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CONFIDENTIAL
• AIDET:5FundamentalsofPaDentCommunicaDon– Acknowledge– Introduce– DuraDon– ExplanaDon– ThankYou
Exceptional Patient Experience
UseAIDET…EveryDay
EveryEncounter
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CONFIDENTIAL
Exceptional Patient Experience
• “Goodmorning/a>ernoon,_______(PaBent’sname)”A–Greetpeoplewithasmileandusetheirname.UseSirorMa’amifyoudonothaveopportunitytolearnname.
• “Mynameis_____andIworkintransport.Iamheretobringyoutoyourprocedure.”
I–Introduceyourself–Whoyouareandhowyouaregoingtohelpthem.
• “Itwilltake_____minutestoreachyourdesBnaBon.”D–KeepintouchtoeasewaiDngDme.Includewhereyouareinstatusofprocedure.
• “Iwilltransportyouvia______(gurney/wheelchair).Onceyouhavecompletedyourprocedure,Iwilltakeyoubacktoyourroom.”
E–Explainprocedure/process.Whotocontactiftheyneedassistance.
• “______(PaBent’sname),thankyouforyourpaBenceandforchoosingEastJefferson.LetmeknowifIcanassistyouinanyotherway.”
T–ThankthepaDent.FosteraitudeofgraDtude.
21
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CONFIDENTIAL
• ParkingislocatedintheEsplanadeGarageonthe3rdfloorandup.
• IDBadgesaretobewornatallDmesandabovethewaist.
Hospital Policies
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CONFIDENTIAL
• Uniformsshouldbeinwrinklefreeandingoodrepair
• Haircolorshouldbefromnature(Blue,purple,pink,etc.notallowed)
• TaloosshouldbecoveredatallDmes• Piercingsareonlyallowedinearlobes
– Limit2perear
Hospital Policies
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CONFIDENTIAL
Infection Control & Hand Hygiene
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CONFIDENTIAL
• Patient Quality • Improved Care • Patient Expectations • National Patient Safety Goals • Comparison to National Benchmarks • Increased Cost
Why Infection Control?
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CONFIDENTIAL
Cornerstones of Infection Control
• Hand Hygiene – Alcohol Foams – Soap & Water – No Artificial Nails – Appropriate Glove Usage – Hand Hygiene Champion
Program – Two-Hands-Up Reminder
Symbol
• Containment – Environmental Cleaning –
Who Cleans What – Infectious Waste
• Isolation – Standard Precautions – 4 Types of Isolation –
Airborne, Droplet, Contact, Enteric
– Isolation Rooms/Caddies
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CONFIDENTIAL
Cornerstones of Infection Control
• Hand Hygiene – Alcohol Foams – Soap & Water – No Artificial Nails – Appropriate Glove Usage – Hand Hygiene Champion
Program – Champion Oath – Two-Hands-Up Reminder
Symbol
• Containment – Environmental Cleaning –
Who Cleans What – Infectious Waste
• Standard Universal Precautions • Isolation Precautions
– 5 Types of Isolation – Airborne, Droplet, Contact, Enteric & Strict Isolation
– Isolation Rooms/Caddies
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CONFIDENTIAL
Corporate Compliance
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CONFIDENTIAL
Standards of Conduct Major Sections
Introduction
1. Quality of Care
2. Privacy, Security and Confidentiality of Information
3. Compliance with Laws and Regulations
4. Safeguarding Property & Interest
5. Maintaining a Safe Healthcare Environment
6. Proper Consideration of Human Resources
7. Billing and Coding Outlined in the EJGH Experience Handbook on page 6
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CONFIDENTIAL
Confidential Ethics and Compliance Hotline
TheEJGHEthicsCommileeprovidesnon-bindingadvisoryopinionstoassistinmanagingethicalissuesconcerningpaDentcare.The
commileereviewscasesbyrequestofphysicians,paDents,familymembersorsurrogateorhospitalstaffmembers.
•CallsaretakenbyanindependentcompanywithoperatorstrainedinHotlineprotocol•Callsareneverrecordedortraced•CalleranonymityandconfidenDalitywillbeprotectedtothelimitofthelaw•EJGHhasapolicyofnon-retribuDonagainstanyonewhocallstheHotline•AllinformaDonisthoroughlyinvesDgated
TollFreeCall1-877-631-0016
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CONFIDENTIAL
HIPAA q HIPAA"isanacronymfortheHealthInsurancePortability&AccountabilityActof1996,whichisafederallawaffecDngallparDcipantsinthecountry'shealthcaresystemandthatincludesEJGH.
q HIPAAPrivacyregulaDonswererequiredforcomplianceinAprilof2003toprotectpaDentconfidenDality.
q HIPAASecurityregulaDonswererequiredforcomplianceinAprilof2005.
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CONFIDENTIAL
HIPAA Privacy & Security
HIPAAPrivacy&SecurityOfficer•RobHinyub–Legal&ComplianceDepartment
Responsibletoensure..
Policies&proceduresaredocumentedtoprotectconfidenDality,integrity,andavailabilityofinformaDonsystemsandePHI(electronicprotectedhealthinformaDon)
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CONFIDENTIAL
HIPAA Privacy & Security
ThereisadirectrelaKonshipbetweenprivacyandsecurity:Privacyis‘what’willbeprotectedPHI(paDenthealthinformaDon)and‘why’weprotectPHISecurityis‘how’toprotectePHI(electronicpaDenthealthinformaDon)Procedurally,physically&technically
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CONFIDENTIAL
EJGH Work Stations or Electronic Media
•PROTECTACCESS–Lockorlog-offworkstaDonwhenlerunalendedorwhenshiriscomplete.
–WhenacommonID/passwordisusedbyseveralmembersoftheworkforce(toshareadevice),logoutofapplicaDonsaccessingePHI(electronicpaDenthealthinformaDon)inaddiDontolockingtheworkstaDon.
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CONFIDENTIAL
EJGH Work Stations or Electronic Media
•PHYSICALPROTECTION–Takereasonablepre-cauDonstophysicallyprotectePHIandbusinessconfidenDalinformaDon.
•posiDondisplayscreenssuchthattheycannotbereadilyviewedbyothers.•physicallylocatedevicestominimizetheriskofunauthorizedaccess.
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CONFIDENTIAL
HIPAA Compliance
WhatYouShouldDoToBeHIPAASecurity/PrivacyCompliant
–DON'Taccessdataunlessitisrequiredtoperformyourjob–DOprotectdevices(posiDonscreens,passwords,physicallysecure).–DON’Tdownloadsorware(astheycouldhavevirusesthatinfectsystems&data).–DOrecognizehoaxe-mails&don'topene-mailoralachments.–DOhaveanD-virussorwareonalldevicesyouuse.–DOreportrisksandsecurityincidents.♦ReportHIPAAsecurityincidentsasquicklyaspossibletoTheHIPAASecurityofficerorthroughtheconfidenDalhotline.
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CONFIDENTIAL
HIPAA Compliance
DisposalofDocumentsContainingConfidenKalInformaKon
q Disposeofdocumentsinrecyclebinslocated
withinthedepartment.
q Alwaysaskforassistanceifnotsurewheretodisposeproperly.
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CONFIDENTIAL
HIPAA Security Violations
DisciplinaryacDons,uptoterminaDon,ifyouareaccessingoralempDngtoaccessePHI(electronicprotectedhealthinformaDon)whennotauthorizedorimproperdisclosure.
CompletetheNon-TeamMemberReceiptofUnderstandingForm
(Step4ofEJGHExperiencehomepage)
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CONFIDENTIAL
Sexual Harassment
Sexualharassmentisagainstthelaw!–VerbalAbuse–Jokingorkiddingthatissexuallyorientedandconsideredunacceptableandoffensive
ForaddiDonalinformaDon,requestacopyofthepolicy
–Reportimmediately–AppropriateacDonwillbetaken
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CONFIDENTIAL
The Joint Commission
•Isavoluntary,non-governmentalorganizaDonthatestablishesstandardsfortheoperaDonofhospitalsandnursinghomes.
•CompliancewithJointCommissionisrecognizedbytheissuanceofcerDficatesofaccreditaDon.
•AccreditaDonallowsMedicarereimbursement.
Visitsareunannounced!
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CONFIDENTIAL
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CONFIDENTIAL 42
WateronfloorElevatormalfuncDonVisitorfallLostItemsThersVehicleAccidentsVandalismTripHazardsBurnedoutlightsDefecDvedoorsImproperLiringTechniques(BackSafety)
Safety Hazards, Incidents, or Accidents
ReportimmediatelytoSafety&Securityatextension4059
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CONFIDENTIAL
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CONFIDENTIAL
Workplace Violence
Ifyouhearadirectorimpliedthreat,reporttosupervisorwhothencallsSecurityatextension4059Ifimminentdangertolife,call911,security,andthennoDfysupervisor
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CONFIDENTIAL
Next Steps…
• PleasereporttoworkwiththeHIPAAagreementsignedanddated.
• Alsobringthecompletedquizwithyou.
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CONFIDENTIAL
EastJeffersonGeneralHospital
great people… …doing great things!