student orientation 2010 mission statement cartersville medical center is committed to treating all...

Student Orientation 2010Student Orientation 2010

Mission StatementMission Statement

Cartersville Medical Center is committed to treating Cartersville Medical Center is committed to treating all of our patients with compassion, kindness, and all of our patients with compassion, kindness, and dignity. We will collaborate with our stakeholders to dignity. We will collaborate with our stakeholders to continuously improve patient care, evaluate and continuously improve patient care, evaluate and establish services beneficial to our community, and establish services beneficial to our community, and position our hospital as the preferred health care position our hospital as the preferred health care provider and a desirable business partner.provider and a desirable business partner.

Welcome to Welcome to Cartersville Medical CenterCartersville Medical Center

An Overview of An Overview of Cartersville Medical CenterCartersville Medical Center

960 Joe Frank Harris ParkwayCartersville, GA 30120(770) 382-1530

Hospital opened September 1, 1985112 Total Beds14 Intensive Care88 Med/Surg10 OB/Maternity beds18 Beds in the Emergency Department8 Operating Rooms

Personnel750 Employees160 Physicians

Volume (FY 2009)6,402 Admissions 48,514 ER Visits 9,280 Surgeries1,031 Births 67,376 Outpatient Visits

Cartersville Medical CenterCartersville Medical CenterExecutive Management TeamExecutive Management Team

Keith Sandlin, Chief Executive Officer

Lori Rakes, Chief Operating Officer

Benny McDonald, Chief Financial Officer

Miriam Eide, Chief Nursing Officer

Rebecca Battle, Associate Administrator

VisionVision

At Cartersville Medical Center, building on aAt Cartersville Medical Center, building on a

foundation of strong physician and communityfoundation of strong physician and community

support, we will continue providing top-quality,support, we will continue providing top-quality,

patient-centered health care and remain thepatient-centered health care and remain the

preeminent hospital in Bartow County.preeminent hospital in Bartow County.

Customer Service and Customer Service and HCAHPSHCAHPS

Walking the TalkHCAHPS

ObjectivesObjectives Increase awareness of HCAHPS and its impact on

facility

Discuss how patient loyalty impacts satisfaction

Apply HCAHPS initiatives in your work setting to help “move the bar” on current results

What is HCAHPS?What is HCAHPS?Hospital Consumer Assessment of Healthcare

Providers and Systems

The nation’s first standardized, publicly reported survey of patients’ perspectives of hospital care.

Cliff Notes: It’s what our patients think about us after they leave our hospital.

Why is HCAHPS Important?Why is HCAHPS Important?The HCAHPS survey asks patients who have stayed atour hospital (inpatients) 27 questions, including 18 itemsabout key aspects of their hospital experience. These are broken down into the following domains: Communication with nurses and doctors The responsiveness of hospital staff Cleanliness and quietness of hospital environment Pain management Communication about medicine Discharge information Overall rating of the hospital And recommendation of the hospital

Caring BehaviorsCaring BehaviorsIt’s all about the things we doIt’s all about the things we do

Our collective acts of all hospital staff have important

consequences for patients, and directly affect their

perceptions of the quality of care they received.

IICCAARREE

Introduce yourself; explain your role

Call the patient by his/her preferred name

Appropriate touch

Review care with patient daily or purpose of visit, sitting at eye-level with patient

Each day compliment another caregiver/co-worker to the patient

T.E.A.M.T.E.A.M.T- TogetherE- Excellence andA- AttitudeM- Matters

“… Cartersville Medical Center is committed to treating all our patients with compassion, kindness, and dignity.”

Customer ServiceCustomer Service and and

HCAHPS continued HCAHPS continued

Welcome to

The Multi-Language Workplace

Learning ObjectivesLearning Objectives Describe the impact of the multi-language workplace on

our facility Identify your responsibility to respect different cultures

in our organization and patient base Identify your responsibility in ensuring that we do not

exclude others just because English is not their first language

Describe how to apply a commonsense approach for addressing situations in which language might tend to exclude others

Identify other ways in which our behaviors might exclude others and strategies for demonstrating respectful, inclusive behaviors

Core Concepts and Core Concepts and DefinitionsDefinitions

Respect Showing appreciation and regard for the rights, values, and beliefs of others

Culture A system of shared beliefs, values, customs, and behaviors

Diversity The similarities and differences among all groups that make up HCA

Core Concepts and Core Concepts and DefinitionsDefinitionsContinuedContinued

Cultural Diversity The differences and unique characteristics of the various groups that make up our business environment

Workforce Diversity The differences that are created by HCA’s own structure and culture

Cultural Competence Having the knowledge and ability to recognize and respond appropriately to our similarities and differences and use that knowledge and understanding to make better decisions

Ethics and ComplianceEthics and ComplianceCartersville and HCA have a comprehensive, valuesbased Ethics and Compliance Program, which is a vitalpart of the way we conduct ourselves. Because theProgram rests on our Mission and Values, it has easily become incorporated into our daily activities andsupports our tradition of caring – for our patients, ourcommunities, and our colleagues. We strive to deliverhealthcare compassionately and to act with absoluteintegrity in the way we do our work and the way welive our lives. All work must be done in an ethical andlegal manner. It is your responsibility and yourobligation to follow the code of conduct and maintainthe highest standards of ethics and compliance.

Ethics and ComplianceEthics and ComplianceContinuedContinued

If you have questions or encounter any situation which you believe violates the provisions of the code of conduct or the corporate integrity agreement, you should immediately consult your supervisor, another member of the management team, the VP of HR(Robbie Tatum ext 1141), the Ethics and Compliance Officers (Benny McDonald ext 1134 and Rebecca Battle ext 2206), or the HCA Ethics Line (1-800-455-1996).

Each employee and volunteer is required to attend two hours of initial code of conduct training and a one hour annual refresher training session. Leaders and individuals in key jobs have additional annual education requirements.

Georgia False Claims LawsGeorgia False Claims Laws There is a federal False Claims Act, and there are also

Georgia laws that address fraud and abuse in the Georgia Medicaid program.

Any person or entity that knowingly submits a false or fraudulent claim for payment of funds is liable for significant penalties and fines.

The False Claims Act has a “qui tam” or “whistleblower” provision. This allows a private person with knowledge of a false claim to bring a civil action on behalf of the US Government. If the claim is successful, the whistleblower may be awarded a percentage of the funds recovered.

For additional information please see the Georgia False Claims Statutes Policy.

Infection PreventionInfection Prevention Our goal is to identify and reduce risks of healthcare

associated infections in patients, visitors, and healthcare workers.

Hand washing is the single most effective way to prevent the spread of infection. Routine hand washing involves a rigorous rubbing together of well lathered hands for 15-20 seconds followed by a thorough rinsing under running water. Must use soap and water if hands are visibly soiled.

Hand hygiene with an alcohol based product is acceptable as long as the hands are not visibly soiled. (Always wash hands with soap and water if the patient you are caring for has C. Difficile).

IC Champions monitor hand washing in our facility. The use of gloves does not eliminate the need for good hand washing.

Hand HygieneHand Hygiene Wash hands at least in the following situations:

◦ Before donning sterile gloves when inserting a central intravascular catheter

◦ Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure

◦ After contact with a patient’s intact skin (e.g. when taking a pulse or blood pressure, and lifting a patient)

◦ After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings

◦ If moving from a contaminated body site to a clean body site during patient care

◦ After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient

◦ After removing gloves◦ Before eating and after using the restroom

Hand Hygiene ComplianceHand Hygiene ComplianceA comprehensive hand hygiene program involving

the patient.

Signs have been placed in patient rooms “It’s OK to Ask”. Patients have a right to ask if you washed your hands before you take care of them

Goal for Hand Hygiene is 100%

Artificial NailsArtificial NailsArtificial Nails, extenders, wraps, tips, etc. can not

be worn by employees providing any services to a patient in accordance with the Center for Disease Control (CDC) guidelines.

Chipped nail polish should be immediately removed. Nails should be well-kept in appearance.

Ways Surgical Staff Help Ways Surgical Staff Help Prevent Surgical Site Prevent Surgical Site

InfectionsInfectionsAll healthcare workers wash hands before and

after contact with patientAppropriate skin prepClip hair instead of shaving hairAntibiotics are given in timely manner for

appropriate durationSurgical team wears mask, cap, gown and

gloves during surgeryMonitor for signs and symptoms of infectionControl of blood sugarSurgical hand scrubs before procedure

Ways Cartersville Staff Help Ways Cartersville Staff Help Prevent Blood Stream Prevent Blood Stream

InfectionsInfectionsWash hands prior to inserting line

Wash hands prior to touching line or giving medication through line

Follow bundle best practices for line insertion:◦ Special skin prep, wear gown, mask, gloves, and

cap when inserting line, remove line when no longer needed, choose safe site for insertion, evaluate necessity of line daily.

Ways Cartersville Staff Help Prevent the Ways Cartersville Staff Help Prevent the Transmission of Multi-Drug resistant Transmission of Multi-Drug resistant

organisms like MRSA, VRE, and C organisms like MRSA, VRE, and C DifficileDifficile

Hand washing before and after contactUse contact precautions when caring for patient

with history of these conditions (wear gown and gloves on entry to room)

Special room assignmentsScreen patients at high risk when they are admittedPatient EducationCarefully clean hospital equipment

Ways Cartersville Staff Help Prevent Ways Cartersville Staff Help Prevent Urinary Tract Infections caused by a Urinary Tract Infections caused by a

Foley CatheterFoley Catheter

Hand washing prior to inserting foley catheterCatheters are inserted only when necessary and

removed when no longer neededOnly properly trained staff insert cathetersSterile technique used while inserting foleySkin prep prior to insertionThe foley bag is kept below the level of the bladder

to prevent urine back flowThe foley bag is emptied regularly

Ways Cartersville Staff Help Ways Cartersville Staff Help Prevent Ventilator Associated Prevent Ventilator Associated

PneumoniaPneumoniaHand hygiene prior to careMouth care every two hoursFollow the bundle best practices:

◦ Head of bed up 30 degrees unless contra-indicated

◦ Evaluate daily need of ventilator◦ Peptic Ulcer Disease Prophylaxis◦ Deep Venous Thrombosis Prophylaxis

Personal Protective Personal Protective EquipmentEquipment

Personal Protective Equipment (PPE) is provided at no cost to the associate

Worn when there is a chance of contact with blood or other potentially infectious body material (OPIM).

PPEs include, but are not limited to: gloves, gowns, goggles, pocket masks, and shoe coverings. PPEs are available in each department.

Wear gloves when it can be reasonably anticipated that there may be hand contact with blood or OPIM and when handling and touching contaminated items or surfaces. Replace them if torn or punctured or if their ability to function as a barrier is compromised.

Gloves must be removed before leaving the room. Hands must be washed after glove removal.

Personal Protective Personal Protective EquipmentEquipmentContinuedContinued

Wear appropriate face and eye protection when splashes, sprays, splatters, or droplets of blood or OPIM may pose a hazard to the eye, nose, or mouth.

Remove immediately, or as soon as feasible, any garment contaminated by blood or OPIM.

PPEs may be disposed of in the regular trash unless contaminated with blood or other OPIM, if contaminated they must be disposed of in red biohazard bags.

Each department has a list of tasks and what PPE is recommended or mandatory to wear while performing those tasks. Ask your leader about this list.

Standard PrecautionsStandard Precautions Standard Precautions apply to all blood or body fluid which

is considered potentially infectious. Very important to wear appropriate PPE when dealing with blood or body fluids.

By using standard precautions you will substantially reduce your risk of infection with a blood borne pathogen.

In addition to standard precautions, there are three types of transmission based precautions (isolation precautions) used for patients with documented or suspected transmissible pathogens that require more than standard precautions.

Isolation PrecautionsIsolation PrecautionsAirborne (wear N 95 Mask)

Droplet (wear regular mask)

Contact (wear gown, gloves, sometimes mask)◦ Add sign “Wash hands with soap and water if

patient has C difficile”

Contact PrecautionsContact Precautions

◦ Used in addition to standard precautions ◦ Bacteria transmitted by direct patient contact or

by indirect contact by touching environmental surfaces.

◦ Isolation gowns and gloves must be worn and sometimes a mask.

◦ Private room for patient or placed with patient with the same bacteria.

◦ Patients should wear an isolation gown and wash hands before leaving the room.

◦ Environmental services should be notified on patient discharge to terminal clean room.

Airborne PrecautionsAirborne Precautions◦ Used in addition to standard precautions for illnesses

transmitted by airborne droplets.◦ Patient is placed in a negative air flow room. ◦ If patient must leave room, they are given a mask to

wear. ◦ Staff must be fit tested for an N 95 mask before

entering this type of isolation room. Staff members who have not been fit tested may not go in this room.

◦ Visitors are taught by the nurse how to wear the mask.

◦ Persons not immune to measles or varicella (chicken pox or disseminated varicella) should not enter the room of patients with these illnesses.

Droplet PrecautionsDroplet Precautions◦ Used in addition to standard precautions for illnesses

transmitted by large droplets.

◦ A regular mask is worn in this room.

◦ Patient must be placed in a private room.

◦ If the patient needs to leave the room, they are given a mask to wear.

◦ For patients with suspected H1N1, wear N 95 mask for aerosol generating activities (enhanced droplet precautions)

Examples of Multi-Drug Examples of Multi-Drug Resistant Organisms Resistant Organisms

(MDRO’s)(MDRO’s)1. Methicillin-Resistant StaphAureus (MRSA)

◦ Staph aureus are bacteria commonly found on the skin of healthy people.

◦ MRSA can be present without causing disease. When there is no associated disease, we call their presence colonization. If MRSA is causing disease such as fever or pneumonia, we call it infection.

◦ MRSA is spread by contact (direct contact with the pt or indirect contact with their environment) thus contact precautions are implemented (gown and gloves)

◦ Good hand washing is the best prevention for the spread of MRSA.

2. Clostridium Difficile

◦ Causes severe diarrhea

◦ Can be spread by contact with patient or environment

◦ Contact precautions upon entry to room

◦ Good hand washing with soap and water

3. VRE

◦ High risk patients are screened on admission

◦ Most patients are colonized with VRE which means it is colonized (not bothering them)

◦ Contact precautions upon entry to room

For all MDRO’sFor all MDRO’s Use disposable equipment, such a B/P cuffs as much as possible. Any equipment taken in to the room must be disinfected prior to

removing it from the room. Education is given to patient/visitors by the nurse. The visitor may

decide for themselves whether or not to wear a gown or gloves. If the visitor will be visiting other patients during this visit, they must

wear a gown and gloves Notify receiving department that the patient is on contact

precautions. If possible, schedule procedures when there are fewer patients in

the area. The patient should wear an isolation gown and wash hands prior to

transport. Have the area where the patient has been terminally cleaned by

Environmental Services

Screening for MRSAScreening for MRSA Certain high risk populations are screened for MRSA on

admission by having a nasal swab screening completed. If they have MRSA in their nose, they are placed on

contact precautions to reduce the risk of MRSA to others. You may have noticed more patients on isolation

precautions because of this process. Patients who already have MRSA on admission to our

facility have Community Acquired MRSA. This is different from MRSA acquired in a healthcare setting.

Usually it is a skin infection or MRSA colonization in the nose.

Community MRSA is increasing throughout the US.

Tuberculosis (TB) UpdateTuberculosis (TB) Update Spread from person-to-person through the air droplets from

someone who has TB Symptoms of TB include: greater than three weeks of cough,

unexplained fever, weight loss, and night sweats. Infection is usually detected by a positive PPD skin test and

an abnormal chest x-ray. Patients suspected of having active tuberculosis are placed

on airborne precautions in a private room with negative air flow. The door must remain closed at all times except when entering and exiting the room

A person can also have the TB germ which is dormant (not active TB). This person has a positive skin test but they are not ill.

They cannot spread the bacteria to others, however they do have an increased risk of eventually acquiring active TB.

Tuberculosis (TB) UpdateTuberculosis (TB) UpdateContinuedContinued

Upon hire, associates are required to have a PPD skin unless they have ever had a positive skin test.

CMC is a low risk facility for TB. This means we do not have to have annual skin testing except in histology, microbiology and the bronchoscopy department

Associates with active tuberculosis will be placed on a work furlough until cleared by the health department as no longer being a risk of transmission to others and healthy enough themselves to perform the tasks of their occupation.

Special masks (N 95) are worn by healthcare personnel when entering the room.

Contact Employee Health Services if your facial structure changes or your mask does not fit for any reason, or if you have problems wearing the mask. Personnel should fit check the mask before entering the patient’s room. The mask must be discarded if it becomes soiled or at the end of your shift. Masks are stored in the ante room.

How would the hospital How would the hospital handle an influx of infectious handle an influx of infectious

patients?patients? If a large number of infectious patients suddenly

presented to the hospital, we would activate our emergency preparedness plan.

This plan addresses staffing, supplies, and other issues that might occur as a result of the increased patient load.

Blood Borne PathogensBlood Borne Pathogens A copy of our plan is available to any associate. The plan explains the processes we have in place to

minimize exposures, and what we do if there is an exposure to a blood borne pathogen.

The following fluids are considered to be potentially infectious: blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, or any other fluid that is visibly contaminated with blood and all body fluid where it is difficult or impossible to differentiate, saliva in dental settings, tissue and organs that are not fixed other than intact skin (from any human living or dead), HIV containing cell or tissue cultures or organs, and tissue from experimental animals infected with blood borne pathogens.

What is Hepatitis B (HBV)?What is Hepatitis B (HBV)?◦ Hepatitis B is a serious liver disease. ◦ Symptoms include jaundice, fatigue, fever, nausea and

abdominal pain. ◦ It can be transmitted by contact with infected blood and

body fluids.◦ HBV is much easier to transmit than HIV and lives on

surfaces for longer periods of time. ◦ You can help protect yourself from acquiring Hepatitis B if

you practice infection control guidelines and get vaccinated.

◦ The Hepatitis B vaccination is given free of charge to associates. Generally people have few side effects from the vaccine. If you previously declined the vaccination, you may notify Employee Health Services if you choose to begin this series.

What is Hepatitis C (HCT)?What is Hepatitis C (HCT)?

◦ Hepatitis C is a disease that attacks the liver.

◦ It is transmitted by contact with an infected person’s blood or blood products which enters the body of a person who is not infected.

◦ HCV infection often occurs without symptoms or with mild symptoms. The symptoms are very similar to those of Hepatitis B.

◦ There is no vaccine that offers protection from Hepatitis C.

What is HIV?What is HIV?◦ Human Immunodeficiency Virus (HIV) is the virus that

causes the disease Acquired Immune Deficiency Syndrome (AIDS).

◦ HIV damages the immune system and makes a person with AIDS more likely to get serious infections and other diseases.

◦ To become infected with HIV, the virus must get into your body and enter your bloodstream.

◦ Many people who are infected with HIV do not have symptoms for years. Persons who are HIV infected (with or without symptoms, diagnosed with AIDS, or recently exposed with a negative HIV antibody test) can spread HIV to others.

◦ It may be transmitted by contact with an infected person’s blood or body fluids which enter the body of a person that is not infected.

How to Reduce Transmission How to Reduce Transmission of Blood Borne Pathogensof Blood Borne Pathogens

Observe engineering controls; needle-less systems, safety devices, sharps disposal containers, biohazard waste containers, needle boxes at appropriate height.

Observe work practices; never recap needles, perform hand hygiene, use appropriate PPEs, do not bend or break needles, do not eat or drink in areas where there is potential for exposure, do not store food or drinks in a refrigerator that is used to store blood or other potentially infectious material (OPIM), use red biohazard bags for disposal of infectious wastes.

Know the job tasks in your department that may involve exposure to blood or OPIM and wear appropriate PPEs.

What is an Exposure?What is an Exposure? Contact with another person’s blood or OPIM such as in needle

sticks/sharps exposures, mucus membrane exposure, or exposure to non intact skin.

If you are exposed to blood or OPIM, you should clean the skin injury site with soap and water. If it is a mucous membrane exposure, flush the area with water.

Inform your supervisor or the designated charge person and go to Employee Health Services (may go to the Emergency Room during other hours) to be evaluated.

Complete occurrence form. You will receive risk information, be evaluated by the ER physician or the

Nurse Practitioner in Employee Health Services, be informed of recommendations of treatment, and receive care.

You should follow up after your initial evaluation the next day with Employee Health Services.

You will receive a written opinion for any future recommended follow up in approximately 15 days.

Prevent Blood Borne Prevent Blood Borne Pathogen ExposuresPathogen Exposures

Use appropriate barriers such as gloves, eye protection, or gowns when contact with blood is expected.

Wash your hands with soap and warm running water as quickly as possible after contact with blood or potentially infectious materials.

Don’t eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses in area with possible exposure to bloodborne pathogens.

Do not store food in refrigerators, freezers, cabinets, shelves, or on countertops where blood or other body fluids are present.

Blood Borne Pathogen Blood Borne Pathogen ExposureExposure

Report to Employee Health Services or the E.R. immediately after a Bloodborne Pathogen Exposure. If you go the E.R., then follow-up with Employee Health Services as soon as the office opens.

Following a bloodborne pathogen exposure, the risk of infection may vary with factors such as these

the pathogen involved the type of exposure the amount of blood involved in the exposure the amount of virus in the patient’s blood at the time of

exposure The following factors were associated with an increased risk of

HIV seroconversion: deep injury (deep puncture wound) visible blood on source patient device causing injury procedure involving needle placed in a vein or artery of

source patient endstage AIDS in source patient

Questions OSHA might ask Questions OSHA might ask about Blood Borne Pathogensabout Blood Borne Pathogens

What is standard precautions? All blood and body fluids are treated as if potentially infectious by wearing appropriate PPE when dealing with them.

What do you do when there is a blood spill? Wear PPE, locate spill kit, follow directions, dispose of properly in red bag and disinfect area where spill occurred.

What do you do with contaminated sharps and laundry? Used sharps go in designated sharps containers made of hard plastic that are puncture resistant, soiled linen goes in a blue linen bag inside a soiled linen hamper and held inside the soiled utility room.

Have you been offered the hepatitis B vaccination free of charge? Yes by employee health services (all employees have opportunity to receive the vaccine)

Where is the Blood borne pathogen plan? On the intranet under IC policies, in the nursing office or can be obtained through employee health services

Infection Control Infection Control Contact InformationContact Information

If you have any questions about Infection Prevention or Blood Borne Pathogens, you may contact Infection Control ext 8194 (8:00 – 4:30 Monday through Friday)

If the Infection Control Department is not available, contact your Department Leader or the Nursing House Supervisor

What Can You Do To Prevent What Can You Do To Prevent Sharps Injuries?Sharps Injuries?

Be PreparedComplete your Hepatitis B vaccine series and titer

in Employee Health Services free of charge.Organize your work area with appropriate sharps

disposal containers within reach.Receive training on how to use sharps safety

devices.Wear gloves if you expect to come in contact with

blood or body fluids.


Be AwareKeep the exposed sharp in view.

Be aware of people around you. Stop if you feel rushed or distracted.

Focus on your task.

Avoid hand-passing sharps and use verbal alerts when moving sharps.

Watch for sharps in linen, beds, on the floor, or in waste containers.


Follow PoliciesDon’t recap needles.

Never use needles with the needleless IV system.

Be responsible for every device you use.

If you identify a sharps without a safety device, discuss this with your supervisor and/or Employee Health Services.


Dispose of Sharps with CareDon’t remove contaminated sharps with your hands

unless medically required (i.e. caps off used needles, scalpel blades). If necessary, use a mechanical device or forceps.

Always activate safety devices immediately after using a sharp. Never remove safety devices. Keep your hands behind the needle at all times.


Disposal of Sharps With CarePlace all used sharps in biohazard containers, see

policy HIC-16.Securely close biohazard containers when ¾ full

and notify Environmental Services to change the sharps container.

Do Not overfill sharps containers.Do Not reach by hand into containers where sharps

are placed.

Additional Sharps Injury Additional Sharps Injury Prevention for the ORPrevention for the OR

Use a neutral zone when passing sharps instruments. Pass sharps on a tray, not directly to another individual. Use verbal alerts when moving sharps.

When suturing, use blunt sutures for muscle and fascia.

Stay focused on your task. Stop if you feel rushed or distracted.

Use mechanical devices such as tongs to handle contaminated reusable sharps. Do Not use your hands.

Needle Stick/Sharps InjuryNeedle Stick/Sharps InjuryWhat is the risk of infection after exposure?

HBV◦ Healthcare personnel who have received

hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection.

◦ For a susceptible person, the risk from an exposure can range from 6 – 30% and depends on the status of the source individual.


HCV◦ The average risk for infection after a needle stick

exposure to HCV infected blood is approximately 1.8%.

◦ There is a small risk associated with exposure to the eye, mucous membranes, or non-intact skin.


HIV◦ The average risk of infection after a needle stick

exposure is 0.3% (or about 1 in 300).

◦ The risk after exposure of the eye, nose, or mouth is about 0.1% (1 in 1, 000).

◦ The risk after exposure to non-intact skin is less than 0.1%.

Needle Stick/Sharps InjuryNeedle Stick/Sharps InjuryTreatment for the Exposure

HBV◦ Hepatitis B vaccine for all healthcare personnel

who have a reasonable chance of exposure to blood or body fluids.

◦ Hepatitis B immune globulin (HBIG) alone or in combination with vaccine (if not previously vaccinated or no immunity developed after vaccination).

Needle Stick/Sharps InjuryNeedle Stick/Sharps InjuryTreatment for the Exposure

HCV◦ There is no vaccine against hepatitis C and no

treatment after exposure that will prevent infection.

◦ Following recommended control practices to prevent percutaneous injuries is imperative.

Needle Stick/Sharps InjuryNeedle Stick/Sharps InjuryTreatment for the ExposureHIV

◦ There is no vaccine against HIV.◦ Post-exposure prophylaxis (PEP) with retroviral

drugs is recommended for certain occupational exposures that pose a risk of transmission of HIV.

◦ PEP is not recommended for exposures with low risk for transmission of HIV.

◦ PEP should be started as soon as possible after exposure, preferably within 2 hours.

Latex AllergiesLatex Allergies Latex allergies pose a serious problem for nurses, other health care

workers, and for 1% to 6% of the general population. Anaphylactic reactions to latex can be fatal.

Health care workers’ exposure to latex has increased dramatically since universal precautions against blood borne pathogens were mandated in 1987. Latex can trigger three types of reactions: irritant contact dermatitis, allergic contact dermatitis, and immediate hypersensitivity.

Many medical devices contain latex that might trigger serious systemic reactions by cutaneous (skin) exposure, (i.e. ECG electrodes, masks, bandages, catheters, gloves, and tape.)

There are some diagnostic tests to determine if a person has an

allergy to latex. If a patient tells you they are allergic to latex, notify

Materials Management and they will provide a cart with latex-free

products. Need more information? Contact the Nursing House

Supervisor at ext. 6910. For associates with latex allergies, contact

Employee Health Services ext. 2129.

Cartersville Medical CenterCartersville Medical CenterEmployee HealthEmployee Health

Employee Health Employee Health Body MechanicsBody Mechanics

Consider using mechanical help when possible

Ask for help if neededRemember to push, not

pullBend your kneesAvoid twisting

Potential HazardPotential HazardIncreased potential for employee

injury exists with awkward

postures with include: Twisting while lifting Bending over to lift Lateral of side bending Back hyperextension or flexion

Forces on the spine increaseWhen lifting, lowering or handlingobjects with the back bent ortwisted. This occurs because themuscles must handle your bodyweight in addition to the weight ofthe object being lifted. This is unsafe lifting

back posture.

CMC is a Drug Free CMC is a Drug Free WorkplaceWorkplace

CMC drug screens for the following:

◦ Pre-Placement drug screen

◦ Reasonable Suspicion drug screen

◦ Any time you have an injury at work you will have to complete a post accident urine drug screen as soon as possible prior to the end of your shift.

Ergonomic SafetyErgonomic Safety Ergonomic Safety is adapting the equipment, procedures and

work areas to fit the person in order to help prevent injuries and improve efficiency. Musculoskeletal disorders (MSDs) affect muscles, nerves, tendons, ligaments, joints or spinal discs. Injuries can include strains, sprains, and repetitive motion injuries.

Signs and symptoms: pain, tingling, numbness, swelling, stiffness, burning sensation, etc. May experience decreased gripping strength, range of motion, muscle function, or inability to do everyday tasks. Risk factors: repetition, forceful exertions, awkward postures, contact stress, and vibration. Common MSDs: Carpal tunnel syndrome, rotator cuff syndrome, trigger finger, tendonitis, herniated spinal disc, and back pain.

Ergonomic SafetyErgonomic Safety Apply these tips to your job: Adjust chair height and

backrest (feet should be flat on the floor, knees level with hips, and lower back supported). Sit an arm's length away from the computer screen. Keep wrists straight and elbows at right angles. Alternate tasks. Use proper body mechanics when lifting, transferring, etc. Avoid reaching and stretching overhead.

You may recommend ways to reduce the chance of developing musculoskeletal disorders to your supervisor. Report signs, symptoms, illnesses ,and injuries to your supervisor, complete an occurrence report, and obtain medical treatment in Employee Health Services.

12 Principles of Ergonomics12 Principles of ErgonomicsKeep everything in easy reachWork at proper heightsReduce excessive forcesWork in good posturesReduce excessive repetitionMinimize fatigueMinimize direct pressureProvide adjustability and change of positionProvide clearance and accessMaintain a comfortable environmentEnhance clarity and understanding Improve work organization

Ergonomics: The “Do Nots”Ergonomics: The “Do Nots” Upper Extremity

◦ Shoulder Reaching over 90 degrees (vertical flexion) External rotation of greater than 45 degrees

◦ Elbow Avoid static hold time of flexion

Lower Extremity◦ Sitting position

The hip, knee, and ankle should be placed at 90 degrees

Body positions to avoid Deep knee bends Constant standing in hip and knee extension Walking with feet externally rotated

ErgonomicsErgonomicsSelf Care

◦ Ice THEN heat◦ Stretch regularly◦ Use good posture◦ Exercise!!!!!◦ Work smart◦ Play smart

Ergonomic TipsErgonomic TipsThe best way to avoid the discomfort of MSDs is:

◦ Change body positions frequently/Set up work stations to fit your body/Stretch every 45 minutes to an hour/Perform stretches that are designed to decrease discomfort for job specific tasks

•Decrease Fatigue•Warm-up exercises•Interrupt sustained postures•Proper ergonomics•Appropriate work methods•Limited overtime

•Increase Recovery•Physical Fitness•Proper nutrition•Good sleeping postures•Ice after activities•Avoid smoking•Alternative job placement

Performance ImprovementPerformance ImprovementContinual Quality Continual Quality

ImprovementImprovementWhat is PI?

◦ PI is a work philosophy that encourages every employee to find new and better ways of doing things. All accredited healthcare organizations are required to have an improvement program. Cartersville is accredited by The Joint Commission.


ImprovementImprovement Excellent organizations make sustained and continuous

efforts to improve their care and services. Healthcare, our business, is constantly changing; what made us successful last year may no longer be appropriate. Even if we think today's solution is perfect, tomorrow will teach us that it wasn't perfect; it was just the best that we could do at the time

Even though a process may appear to work most of the time, we are challenged to look at the process and ask ourselves, "Is there a better way to do this?" or "Why are we doing this?” Because we live in a rapidly changing environment that is fast-paced and stressful, change brings many opportunities to improve our care and services.

Performance ImprovementPerformance ImprovementContinual Quality Continual Quality ImprovementImprovement

Key Points to RememberCustomers come first.Every employee is important.Communication is essential.Tasks (processes) are streamlined whenever

possible.Ongoing improvement is crucial.Improvement should be maintained.

We want to improve everything we do! We owe

this to our ultimate customer ~ the patient.


ImprovementImprovement What does this mean to me?◦ Management provides support and guidance, and

they bear ultimate responsibility, but the best improvement ideas come from people who work providing care and services for our customers. Continually improving one’s own performance and their own job processes are essential for producing great patient outcomes. Within your department, you have the responsibility to think about your “daily work life” to determine if there are processes that can be improved. At the department level, the organization has determined that the Pillars of Excellence should be continually improved. There are five pillars: Service, Quality, People, Growth, and Finance.


ImprovementImprovement What does this mean to me?

◦ You can make suggestions for improvement to your supervisor by expressing the idea and asking if an improvement team could be organized to work on the project. There is also an “Improvement Suggestion Form” in your department’s PI Manual (or posted on your department’s Communication Center); you can fill out the form and turn in to your supervisor. If the idea only relates to your job, your supervisor may ask you to “just do it.” You may be asked to serve on an improvement team or lead an improvement project; you should accept this as an honor.

2010 National Patient Safety 2010 National Patient Safety Goals for HospitalsGoals for Hospitals

The purpose of the National Patient Safety Goals is to improve patient safety.

The Goals focus on problems in health care safety and how to solve them.


Improve the accuracy of patient identification◦ Use at least two ways to identify patients. For

example, use the patient’s name and hospital account number. This is done to make sure that each patient gets the medicine and treatment meant for them.


Improve the effectiveness of communication among caregivers◦ Provide timely reporting of critical tests and critical

results◦ Read back and verify spoken or phone orders to the

person who gave the order.◦ Create a list of abbreviations and symbols that are not

to be used.◦ Quickly get important test results to the right staff

person.◦ Create steps for staff to follow when sending patients to

the next caregiver. The steps should help staff tell about the patient’s care. Make sure there is time to ask and answer questions.


Improve the safety of using medications◦ Create a list of medicines with names that look

alike or sound alike. Update the list every year.◦ Label all medicines that are not already labeled.

For example, medicines in syringes, cups and basins.

◦ Take extra care with patients who take medicines to thin their blood.


Reduce the risk of health care-associated infections◦ Use the hand cleaning guidelines from the Centers for

Disease Control and Prevention.◦ Report death or injury to patients from infections that

happen in hospitals.◦ Use proven guidelines to prevent infections that are

difficult to treat, such as multidrug-resistant organism infections.

◦ Use proven guidelines to prevent infection of the blood, these infections may be associated with central lines.

◦ Use safe practices to treat the part of the body where surgery was done.


Accurately and completely reconcile medications across the continuum of care

◦ Find out what medicines each patient is taking. Make sure that it is OK for the patient to take any new medicines with their current medicines.

◦ Provide a list of the patient’s medicines to their next caregiver or to their regular doctor before the patient goes home.

◦ Provide a list of the patient’s medicines to the patient and their family before they go home. Explain the list.

◦ Some patients may get medicine in small amounts or for a short time. Make sure that it is OK for those patients to take those medicines with their current medicines.


Reduce the risk of patient harm resulting from falls◦ Find out which patients are most likely to fall. For

example, is the patient taking any medicines that might make them weak, dizzy or sleepy? Take action to prevent falls for these patients.


Prevent health care-associated pressure ulcers◦ Initiate prevention methods to reduce

occurrences of pressure ulcers.

Identify patient safety risks◦ Find out which patients are most likely to commit

suicide.


Establish a universal protocol for preventing wrong site, wrong procedure, and wrong person surgery◦ Conduct a pre-procedure verification process.

Create steps for staff to follow so that all documents needed for surgery are on hand before surgery starts.

◦ Mark the part of the body where the surgery will be done. Involve the patient in doing this.

◦ Conduce a time-out prior to beginning procedure.

Patient RightsPatient Rights We believe that most patients want to understand and

participate in their care. Therefore, it is important that each patient understand his or her rights and responsibilities while at Cartersville. It is also necessary as healthcare workers that we understand patient rights and responsibilities to ensure that quality care is provided.

How are patients informed of their rights?◦ Upon admission, each patient is given a handbook,

which includes a list of patient rights and responsibilities. This patient bill of rights tells a patient and his or her family what they can expect of caregivers and what caregivers expect of them.

Patient RightsPatient Rights What is your role in patient rights?

◦ Everyone is involved in protecting the rights of patients, not just those involved in direct patient care. For example, the right to confidentiality means not telling your friends and/or relatives when someone you know has been a patient. Also, you provide privacy for patients by making sure you always knock before entering a patient’s room or any room where a patient might be having a procedure.

◦ Patients have a right to a secure environment, which means you should know how to respond during a disaster or fire in the building. Patients are informed of their right to establish advance directives.

◦ Patients also have a right to file a grievance. You can assist with the investigation and response by contacting Risk Management (Clair Williams) at ext. 1004 or Administration at ext. 8161 should you have a question.

Patient RightsPatient RightsWhere can you find a list of patient rights?

◦ In facility Policy HW362 Rights and Responsibilities of Patients, the Patient Handbook, posted beside the elevator in the front lobby and at outpatient services and on Cartersville’s Intranet site.

Patient RightsPatient RightsAccess the Ethics and Compliance Officers at

770-606-2206 or 770-387-8183Access the grievance process. Express complaints

or concerns regarding care or services, including discharge. Facility contact: 770-606-2206Corporate Ethics Line: 1-800-455-1996

Reportable EventsReportable Events State (Georgia) Reportable Events:

◦ The following type events should be reported to the State of Georgia Office of Regulatory Services: 1. Any unanticipated patient death not related to the natural

course of the patient’s illness or underlying condition; 2. Any surgery on the wrong patient or the wrong body part of

the patient; 3. Any rape of a patient which occurs in the hospital.

◦ Cartersville Medical Center’s employees and the medical staff should report to the appropriate department leader and Risk Management at 1004 or Regulatory Compliance at 3038 in the event that any of the above situations occur to a patient at Cartersville. A multidisciplinary group will review the situation, complete the State forms, and provide them to the Office of Regulatory Services within 24 hours of knowledge that the event meets one of the State definitions.

Recognizing Abuse and Recognizing Abuse and NeglectNeglect

Signs of Abuse◦ History inconsistent with nature and extent of

injury◦ Delay in seeking medical treatment◦ Frequent Emergency Room visits ◦ Accident prone◦ Discrepancy in patient’s and family’s story◦ Bruises in various stages of healing◦ History of previous trauma in patient or sibling

Recognizing Abuse and Recognizing Abuse and NeglectNeglect

Signs and Symptoms of Neglect◦ Failure to thrive◦ Poor hygiene◦ Dehydration◦ Malnutrition◦ Poor social skills

Reporting AbuseReporting Abuse Nursing Interventions:

◦ Routinely screen during each patient encounter. ◦ Screen one-on-one in a private environment. ◦ Assess patient’s immediate safety. ◦ Listen with a non-judgmental attitude. ◦ Document in the medical record the following: abuse

history (subjective and objective), results of safety assessment, authorities notified, family notified, treatment given, and any safety instructions provided.

The person suspecting the abuse should notify Social Services during weekday hours and the House Supervisor at night and on weekends to inform them of the situation. These resource persons will assist with the notification of the authorities.

Reporting AbuseReporting Abuse Reporting Responsibilities:

◦ Notify the MD. ◦ Notify DFACS or Adult Protective Services (APS)

of the possibility and the appropriate authorities. ◦ GA has general mandatory reporting laws. MUST

report to law enforcement the following: injuries resulting from general violence and injuries inflicted by gun, firearm, knife, or other sharp object.

Resources: Department of Family and Children Services (DFACS): (770) 720-3610/ Police Dept: 911 / Battered Woman/Domestic Violence Hotline: 1-800-334-2836 / Prevent Child Abuse GA: 1-800-532-3208

Adult Protective Services: 1-888-774-0152

Occurrence ReportingOccurrence ReportingCompleted in the Meditech Module

Initiated by the person with the most knowledge

Used for tracking, trending, mandatory reporting and system Performance Improvement

Risk Assessment: Prevent/Limit harm to the patient

Non-Punitive “Just” Culture

Occurrence Reporting FactsOccurrence Reporting FactsNever print report!

Never document in the record that an occurrence report has been completed

Never write statements that point fingers◦ “Just the facts Ma’am” Sgt. Joe Friday- Dragnet

Be factual, brief, and objective

Tell the end of the story if known

What should I report?What should I report? Patient, visitor, and employee falls or injury Sentinel Events Medication events and near misses, ADRs* Equipment and supply related events Lost/damage to personal belongings Adverse surgical/procedural outcomes Behavioral issues-

◦ Against Medical Advice, Left Without Being Treated, Refusal of treatment, Elopement

◦ Other events that may result in injury or potential unfavorable outcome such as disruptive behavior

◦ Complaints regarding patient care or treatment

Occurrence ReportingOccurrence Reporting3 Types

◦ Patient: All patients◦ Non Patient: Visitors, Contractors, Students,

Physicians◦ Employee: CMC Employees

Completed ASAP prior to the end of your shiftDiscoverability and AdmissibilityRisk/Safety/Quality Connection

Environment of CareEnvironment of Care

Safety and SecurityFire SafetyHazardous Materials

and WasteMedical EquipmentUtilitiesOther Physical

Environment Requirements

Safety and SecuritySafety and SecurityEC.02.01.01, EC.02.01.03 The hospital manages safety and security risks The hospital identifies safety and security risks Electrical Safety Incident/Accident and Near Miss Reporting Infection Control Precautions Storage (medical gas, supplies ETC.)

Your Role Includes…Your Role Includes… Wearing Proper ID

Knowing the Location of Emergency Plans and your role in them

How to Respond to and Document Incidents/Accidents

Access Control

How to obtain an MSDS

Floors & Walking SurfacesFloors & Walking SurfacesDry, Level, Clear of Obstructions / DebrisWell LitAppropriate Mat Placement Condition of CarpetWalk to Center or RightWatch IntersectionsKeep hallways clear of clutter

Environment of CareEnvironment of Care

What is an MSDS?

Material Safety Data Sheets Material Safety Data Sheets (MSDS)(MSDS)

The MSDS is used by The MSDS is used by chemical manufacturers chemical manufacturers and vendors to convey and vendors to convey hazard information to hazard information to users. users.

MSDS’s should be MSDS’s should be obtained when a obtained when a chemical is purchased.chemical is purchased.

A chemical inventory list, A chemical inventory list, and MSDS, for each and MSDS, for each chemical are required to chemical are required to be maintainedbe maintained

Hazardous Materials Hazardous Materials ManagementManagement

OSHA Hazard Communication Standard Right-to-Know (R2K)

Material Safety Data Sheets (MSDS’s)Training and Labeling RequirementsStorage, Handling and Disposal of Hazardous

Materials Jeff Barwick 770-382-8190

Kelly Proctor 770-387-8168

Cartersville Medical Center Cartersville Medical Center CommunicationCommunication

Telephone use:Dial “0” for the PBX

operatorDial “9” for outside lineDial “66” for emergency

phoneDepartments located

outside the main hospital building must call 911 for emergencies.

Medical EquipmentMedical EquipmentAvoid use of extension

cords If you don’t know how to

safely use equipment, don’t.

Make sure all electrical equipment has been inspected by the biomed department before use.

Make sure all Medical Equipment has a current inspection sticker

Hazardous Materials and Hazardous Materials and WasteWaste

Radiation Safety ◦ International radiation symbol

will be used near sources of radiation

◦ Radiation used in x-rays is known to cause harm at large doses.

◦ If you work in an area where x-rays are being performed, you should wear all required PPE

◦ The use of radioactive material is overseen by the Radiation Safety Officer and the Radiation/Laser Committee

◦ Frank Homiller – 678-721-5580


Biohazard Waste - Standard Precautions◦ Use gloves, masks, shoe

coverings, eye protection, fluid resistant gowns when appropriate.

◦ Sharps must be discarded in sharps containers.

◦Seal and discard sharps containers when ¾ full


Biohazard Waste◦ Biohazard waste that

cannot be disposed of in the Municipal Waste System must be discarded in leak proof, break resistant containers

◦ Red Bags – What can and cannot go in them

◦ Needle boxes – What can and cannot go in them

Utility SystemsUtility Systems

Code White ◦ Utility system failure◦ Power◦ Water◦ Communication

systems◦ HVAC System

Utility SystemsUtility Systems Emergency Electrical

Power System ◦ provides electrical

power after the hospital’s normal electrical system has failed or interrupted.

◦ Emergency power is provided by generators in 5-10 seconds.

◦ Only the red power receptacles will work under the emergency power

Utility SystemsUtility SystemsHeating, ventilation, air

conditioning systems (HVAC)

◦ Cooling towers◦ Chillers◦ Boilers◦ Thermostats◦ P.I.U.’s

Utility SystemsUtility Systems

◦ Water – In the event the hospital looses its main water supply, Plant Operations will:

◦ The hospital will follow the loss of water plan

◦ Plant Operations will activate the emergency well

◦ Emergency water supply

Utility SystemsUtility SystemsMedical Gases

◦ Provides oxygen ◦ compressed breathing

air for patients ◦ specialty gas systems

in surgical suitesKnow location of shut off

valves in your department.

Only Plant Operations and the fire department can authorized medical gas shut off

Utility SystemsUtility Systems Communications includes:

◦ Telephone systems◦ Beepers/pagers◦ Nurse call systems◦ PA system◦ 2-way radios◦ Cell phones◦ Civil defense radio◦ EMS communication◦ Fire alarm systems◦ Emergency

Preparedness communication systems

SecuritySecurity Security of the hospital

requires a cooperative effort and is a responsibility of each employee.◦ Wear ID badges at work◦ Secure valuables and

belongings◦ Be alert. Report any

suspicious activity◦ Assure secured areas

stay that way

Environment of CareEnvironment of CareSecurity- Code GraySecurity- Code Gray

Security staff are employees of the hospital

Security staff are present 24/7

In a security emergency, dial “66” and ask PBX operator to page “Code Gray” to your location

If additional support is needed, dial 911 and ask for law enforcement response.

Fire Safety Fire Safety RACE Fire Response PlanRACE Fire Response Plan

Remove Anyone in immediate danger

Alarm Pull closest alarm; Dial “7777”

Confine Close doors and windows

Turn off air moving equipment

Extinguish Use closest proper extinguisher

Fire Extinguisher BasicsFire Extinguisher BasicsPULL the safety pin at the top

of the extinguisher

AIM the nozzle, horn or hose at the base of the flames (from 6-8 feet away )

SQUEEZE or press the handle

SWEEP from side to side at the base of the fire until it goes out

Fire SafetyFire SafetyCode RedCode Red

Using a fire extinguisher: P-A-S-S

◦ Pull the retaining pin◦ Aim the fire

extinguisher at the base of the fire

◦ Squeeze the handle to release contents

◦ Sweep the nozzle from side to side

Code BlueCode BlueCardiopulmonary Arrest

(adult or child) – Code Blue

Dial “66” and tell the PBX operator to page “Code Blue” to your location

Code Blue response team: Charge nurse from ICU, ER, 2N, 2C, PCU, respiratory therapy, and the ED MD.

Other personnel will be called if needed

Code NeonateCode NeonateCardiopulmonary Arrest

(neonate) – Code Neonate

Dial “66” and tell the PBX operator to page “Code Neonate” to your location

Code Neonate response team: Charge nurse from ER and 2C, respiratory therapy, and the ER MD.

Other personnel will be called if needed

Code PinkCode Pink

Infant/Child AbductionAll hospital staff on alertDial “66” to reportSecure all exits and

entrancesAdvise leaving staff,

visitors, and contractorsDo not physically stop

anyone

Code TriageCode Triage

External Disaster – Code Triage:

Code Triage Standby: employees will be notified and called to hospital as needed

Code Triage Activate: employees will immediately activate disaster plan

Code Triage StandbyCode Triage Standby

External Disaster – Code Triage Standby

Dial “66” and have the PBX operator page “Code Triage Standby”

Evaluate department situation and staff and prepare for influx of patients

Code Triage ActivateCode Triage Activate

External Disaster – Code Triage Activate

Dial “66” and have the PBX operator page “Code Triage Activate”

Prepare for immediate influx of patients and accept change of assignments

Code WeatherCode Weather

Sighting of Tornado: Code Weather

Notification by civil defense radio, 911, or weather channel.

Administration will notify and ask PBX to page “Code Weather”

Move visitors into internal hallways or patient rooms.

Reassure and calm patients

Updates will be communicated by Administration via PBX

Code RunnerCode RunnerPatient Elopement

-“flight risk” patient is missing ◦ “Flight Risk” is defined

as any patient who is assessed to be confused, disoriented, or demented and mobile

◦ Dial “66” and tell the PBX operator to call Code Runner

Code OrangeCode Orange

Chemical or large biohazard spill or event.

Dial “66” and ask the PBX operator to call Code Orange

Secure the area

Code MedicCode Medic

Visitor or employee injury or severe illness

Dial “66” and ask PBX operator to page Code Medic.

ED RN and security will respond

Information SecurityInformation Security Cartersville Medical Center relies heavily on computers to meet its

operational, financial, and informational requirements. The computer systems, related data files, and the derived information are important assets of the company. Cartersville has established a system of internal controls to safeguard these valuable assets by processing information in a secure environment. As a Cartersville employee, you are expected to share the responsibility for the security, integrity, and confidentiality of this information.

Policy Enforcement

Any employee who has knowledge of a violation of the IT & S Security

policy must immediately report the violation to his/her supervisor.

Anyone who violates the policy is subject to:◦ Suspension◦ Termination◦ Civil and/or criminal prosecution◦ Other Disciplinary action

Secure your workstation at all times!

Information SecurityInformation Security CMC standards and policies include information about:

◦ Individual accountability for the use of any computing and network resources

◦ The authentication process to allow access to, and use of, systems and networks

◦ Audit trails of sensitive security events◦ A means to ensure the integrity of systems, networks,

and processes◦ The design and implementation of security controls with

adequately met identified risks ◦ The controls necessary to interface Carterville

computer systems/networks with foreign computer systems/networks

Please refer to policies IS.SEC.001 – 005 for additional information.

Information SecurityInformation Security Workstation Security

◦ Protection of the workstation and its equipment is each employee’s responsibility. Control your work area fully so that ALL your equipment and information is kept secure.

Secure Workstations◦ When not in use, hard copy information is kept in a secure place◦ Information on any screen or paper is shielded from casual public view◦ Terminals are not left active or unlocked and unattended◦ Short (5-20 minutes) Screensaver “time-out” settings◦ Company approved anti-virus software actively checks files and

documents◦ Only company approved, licensed, and properly installed software is

used◦ “Shareware” or downloaded Internet programs are not permitted◦ User ID and Passwords are not written down and physically displayed◦ “Log Off” and “Shut Down” your PC before leaving work each day

Information SecurityInformation SecurityElectronic CommunicationsElectronic Communications

Promote effective and efficient business communication Use e-mail and the Internet in a productive manner Transmit information only to individuals that are

authorized to see it Do not bypass system security mechanisms Do not automatically forward messages using mailbox Do not access or distribute obscene, abusive, libelous,

or confidential information Do not conduct any type of personal solicitation

Maintain and enhance the hospital’s public image

*Do not use electronic communication for any purpose which is illegal, against company policy, or contrary to

the company’s best interest

Information SecurityInformation SecurityElectronic CommunicationsElectronic Communications

Send only relevant information to people who need it

Do not use publicly accessible areas of the Internet to transmit or display info

Use e-mail and the Internet for highly limited personal use

Do not distribute chain lettersRules to e-mail addresses outside hospitalDo not address another persons e-mailDo not transmit unsecured patient identifiable or

other sensitive and offensive material

Information SecurityInformation SecuritySocial EngineeringSocial Engineering

“Social Engineers” are individuals who attempt to gain access to systems of confidential information through the manipulation of others. Using a combination of basic knowledge about a given business with some personal information or details that the “victim” will recognize, the Social Engineer converses with, wins the trust of, and extracts information from an employee.

To combat social engineering:◦ Limit your conversations in public areas◦ Be aware of your surroundings and who listens to

your conversations◦ Identify as fully as possible anyone asking you for

information

HIPAA & HIM-Health HIPAA & HIM-Health Information ManagementInformation Management

“Medical Records”

Kim Hicks, HIM Director, FPO, x 1413

Angel Shellhorse, HIM Supervisor, x 1106

PurposePurposeProtect patient privacy, confidentiality, and security

of Protected Health Information (PHI) and provide methods in which to accomplish the above.

Information protected under HIPAA includes oral, written, and electronic communications.

HIPAA Privacy PoliciesHIPAA Privacy PoliciesPolicies can be located on Cartersville’s Intranet

1. Notice of Privacy Practices 2. Patient’s Right To Opt Out of Facility Directory 3. Right to Request Confidential Communications 4. Patient’s Right To Access 5. Patient’s Right To Amend

PHI (Protected Health PHI (Protected Health Information)Information)

Information is obtained on a “need to know” basisFollow appropriate access guidelinesEmployees only have access to what they need to

know to perform their job

***Employees are not allowed to access their own information

PHI, ContinuedPHI, ContinuedMinimum necessary information is released to fulfill

the intended purposePHI must be disposed of properly in Re-cycle binsFines for HIPAA violations for facility start at

$10,000 up to $250,000 and/or 10 years imprisonment.

Practicing PrivacyPracticing Privacy

1. Treat all information as if it were about you or your family

2. Access only those systems you are officially authorized to access

3. Use only your own User ID & Password to access system(s)

4. Access only the information you need to do your job

Practicing Privacy ContinuedPracticing Privacy Continued

5. Only share sensitive & confidential information with others that have a “need to know”

6. Refrain from discussing patient info in public places

7. Create “hard to guess” passwords & never share them

8. Log-off when finished

External Faxing GuidelinesExternal Faxing GuidelinesLimit when possibleVerify fax numberUtilize preset numbers when applicableLocate fax machine in secure locationAlways use cover sheet with confidentiality

statement for transmittalsHighly sensitive information should NEVER be

faxed (HIV status, abuse records, etc.)

Thank you!!!

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