2016 Self-Learning Packet

Self-Learning Course
Orientation is required for each AtlantiCare vendor. This
self-learning course is intended to cover the pertinent
information from new employee orientation.
Topics include safety information, strategies for
providing excellent customer experiences, cultural
diversity and inclusion, Early Heart Attack Care
(EHAC), EMTALA, Social Media usage, HIPAA,
Corporate Compliance, as well as Harassment and
Discrimination information and more.
You must complete the test after this educational
section to receive credit for having completed the selflearning course.
Our Strategy Map is designed to help each of us
understand how our work is organized as well as our
focus for the coming year. We cascade our business
unit and department goals, and therefore, our
individual performance goals based on the 5 Bs.
Each of the 5 Bs have a specific ―Big Dot‖ goal, which
will be covered in more detail later in the
presentation. Our Strategy Map includes our values
of Safety, Teamwork, Integrity, Respect and Service
(STIRS). AtlantiCare’s Mission and Vision, as well as
our Customer Experience Standards are included on
the Strategy Map.
The Big Dot goal under Best People Best Workplace is to
achieve Best In Class scores on our Employee
Engagement Survey in the spring of 2016.
Much of our work addresses more than one of the 5 Bs. For this course, the following
topics are included under Best People Best Workplace:
• Essential Work Requirements
• Hand Hygiene
• Respiratory Etiquette
• Fire and Electrical Safety practices
• Use of Social Media
• Network Security
• Stroke Awareness
• Early Heart Attack Care
• Organ and Tissue Donation
• Communication and Employee Voice
• Harassment and Discrimination-Free workplace
• Diversity and Inclusion
The Big Dot under Best People and Workplace is achieving Best in Class on our
surveys, which supports Employee Engagement.
You can contribute to our efforts
x
in many ways. Maintaining your certifications is part of that. Continuing your
education is also part of being an engaged professional.
Essential Work Requirements:
Essential Work Requirements refer to the minimum licensing, certification
and/or education you need to perform your job. These include orientation and
any job-specific requirements, such as basic life support, TB surveillance,
nursing license, driver’s license, etc.
If any one of your EWRs expires, it can result in the following:
• Suspension
• Termination
Please talk with your manager if you have any questions about what your Essential
Work Requirements are or how to be sure you are current and in compliance with
these requirements.
• Cover your mouth
and nose with a
tissue when you
cough or sneeze
• If you do not have
a tissue, cough or
sneeze into your
upper sleeve, not
your hands
• Put used tissue in
the trash
Hey guys, I
think I’m going
to sneeze!
Bad
timing!
• Avoid touching eyes, nose and mouth
• Wash your hands frequently,
especially after coughing or sneezing
• Get vaccinated annually for seasonal
influenza
Safety is one of AtlantiCare’s values. Each of us plays a role in
the overall safety of our workplace. In the event of a fire, the
acronym RACE reminds us to follow these steps:
• Rescue people in immediate danger
• Alarm – pull the fire alarm and follow other departmental
procedures for reporting an emergency
• Confine the fire by closing the appropriate fire doors
• Extinguish the fire (if it is small) or Evacuate to a safe
location
Using a Fire Extinguisher:
If it is possible for you to extinguish a fire, such as a small one in a garbage can, the
PASS acronym will help you remember how to properly use a fire extinguisher.
After taking the fire extinguisher out of its holder and setting it onto a flat surface, hold it
by its neck and:
•
•
•
•
Pull the pin and break the tamper seal
Aim the nozzle at the base of the burning object
Squeeze the handles together, releasing the extinguisher's chemicals
Sweep the nozzle back and forth to coat the surface of the burning
material.
Avoid electrical hazards. Be alert to potential
hazards and know how to prevent them. Fires
and electrical shocks can occur when electrical
cords or outlets are damaged. Pulling on the
cord- rather than the plug – can damage the
cord.
• ALWAYS unplug electrical equipment by
pulling on the plug and not the cord (see photo
example).
• Inspect each piece of equipment on a regular
basis for damage to the cord or plug.
• Do
NOT
use
damaged
equipment.
Immediately report any damaged equipment.
Your attention and actions help keep
AtlantiCare safe for our employees and our
customers.
Social & Digital Media Include
•
Social networking (Facebook,
MySpace, Google Plus, Twitter)
•
Forums, discussion boards, and
groups
•
Professional networking (LinkedIn)
•
Media sharing (YouTube, Flickr, )
•
Content production (blogs [Tumblr,
Blogger] and microblogs [Twitter])
•
Knowledge/information aggregation
(Wikipedia)
•
Virtual reality and gaming
environments (Second Life)
AtlantiCare’s Social Media Policy #4313
Social Media Policy # 4313 applies to all AtlantiCare staff, physicians, Medical Staff, vendors and
volunteers. It provides guidance for social media etiquette and is reinforced by the AtlantiCare
Employee Handbook. It includes, but is not limited to the following information:
•
You are personally responsible for any content (words, images, audio, video) you post.
•
In using social media, AtlantiCare employees are expected to adhere to all international, federal
and state laws, and all AtlantiCare policies governing employee activity.
•
Consider the appropriate use of words, images or video before posting to social media sites.
•
There is no expectation of privacy when you post to social media.
•
Any posts you make to social media sites could be seen by patients, coworkers, or AtlantiCare
leaders, and, as such, may have consequences for your employment with AtlantiCare.
•
You may respectfully disagree with company actions, policies or management, but you may not
attack members of AtlantiCare’s workforce or leadership.
•
If you are posting public comments about AtlantiCare-related issues, clearly identify your business
affiliation and include your name and when relevant, your role at AtlantiCare: ―I work for
AtlantiCare and this is my personal opinion.‖
Using Social Media
•
Your presence on social media sites can impact your work at AtlantiCare .
•
Using social media inside or outside of the workplace has the potential to affect our job
performance and/or the performance of others, AtlantiCare’s brand and reputation, and
AtlantiCare’s business interests.
•
You represent AtlantiCare. The same responsibilities that you have within the walls of
AtlantiCare as an employee still apply to any forum outside of the organization if you identify
yourself as an AtlantiCare employee. When you engage in social media matters that involve
AtlantiCare, you should identify yourself as an employee and indicate that the opinions you
express are personal to you and are not those of the organization.
•
The profile and content you present on social media should be consistent with the image you
present in the workplace.
•
Comments you make or content you post should adhere to professional etiquette, should be
respectful of others, and should be consistent with AtlantiCare’s privacy policies.
•
Per AtlantiCare’s Release of Information to the Media Policy, only authorized users can speak
on behalf of the organization. This applies to use of social media.
AtlantiCare uses
social and digital
media to
• Listen to and learn from
customers
• Identify and respond to
compliments, concerns,
and issues in real-time
• Enhance brand
awareness
• Promote our programs
and services
•
Listen to and learn from customers
•
Identify and respond to
compliments, concerns, and issues in
real-time
•
Enhance brand awareness
•
Promote our programs and services
Examples of
AtlantiCare’s use of
social & digital media
Examples of
AtlantiCare’s use of
social & digital
media
Using Social Media – What NOT to Post
 Inappropriate or offensive images or comments that you would not display in any other
public forum.
 Sensitive, confidential, and or proprietary information, including, but not limited to:
 Anything that identifies a patient, such as that you cared for a Philadelphia
Eagles player (even if you do not identify the patient by name), or photos with
patient information or patient identifiers/information in the background
 Confidential information about AtlantiCare’s partners, staff, clients, suppliers,
vendors, partners, technology, business plans, strategic plans, contracts
and/or financial information.
 General information about the above groups without written permission from
AtlantiCare Marketing and Communications
 Any material that violates the privacy rights of AtlantiCare patients.
 Do not post AtlantiCare logos on social media sites (without written consent from
AtlantiCare Marketing and Communications).
Social Media DON’Ts
Below are examples of what not to post on social media:
Do not post any
patient identifiers
Do not post pictures of yourself at
work if patient or business
information can be identified by
photo manipulation.
Do not post that you
cared for an Eagles
player.
Do not speak
negatively about your
patients or clients
Do not post comments that you
would not say in an elevator or
any other public forum.
Do not post
inappropriate photos
Information Security
 FBI
Warns
“Hackers
Directly
Targeting
Health
Organizations”. (FBI Flash Alert Warning, August 21, 2014.)
Care
 Medical information is worth 10 times more than credit card numbers on
the black market – making it a more lucrative target for hackers.
 On the black market, a full identity profile contained in a single medical
record can bring as much as $500!
 The number of healthcare organizations reporting a criminal cyber
attack has risen from 20% in 2009 to 40% in 2013.
 Boston Children’s Hospital employee’s lost laptop resulted in a
data breach of more than 2,000 patient medical records.
 A weak password at the Utah Department of Tech Services
allowed a hacker to steal 780,000 patient health records.
 Hackers exploited an unpatched vulnerability on a Community
Health Systems server to steal the personal information of 4.5
million patients.
Phishing For Dollars
 When internet fraudsters impersonate a trusted business or individual to
trick you into giving out your personal information, it’s called PHISHING.
 Phishing attacks directed at specific individuals, roles, or organizations are
referred to as ―Spear Phishing‖. The term ―Whaling‖ is used when those
attacks are directed specifically at executive officers or other high-profile
targets of an organization.
 Phishing attacks use email or malicious websites to solicit personal
information often by spoofing the email address of a person within
AtlantiCare or some other trusted source.
 An attacker may also send email seemingly from a reputable credit card
company or financial institution that requests account information, often
suggesting that there is a problem. When users respond with the requested
information or open an attached document, attackers can use it to gain
access to the accounts.
How Do You Avoid Being a Victim?
 When in doubt, throw it out! Links or attachments in email, tweets, posts,
and online advertising are often the way cybercriminals compromise your
computer. If it looks suspicious, even if you know the source, it’s best to
delete it or verify the sender via out-of-band communication.
 Pay attention to the URL of a link or website. Malicious websites may look
identical to a legitimate site, but the URL may use a variation in spelling or a
different domain (e.g., .com vs. .net. Be suspicious of URLs hosted in
foreign countries (e.g., .ru is Russia, .br is Brazil, .cn is China).
 Be suspicious of unsolicited phone calls, visits, or email messages from
individuals asking about employees or other internal information. If an
unknown individual claims to be from a legitimate organization, try to verify
his or her identity directly with the company.
 Don’t send sensitive information over the Internet before checking a
website’s legitimacy and security.
Information + Security
 AtlantiCare and other reputable organizations will never use email or a
phone call to request your password, Social Security number, or
confidential information.
 Be suspicious of any email message that asked you to enter or verify
personal or financial information through a web site or by replying to the
message itself. NEVER reply to or click the links in a message without
verifying the authenticity of the sender.
 If you think the message may be legitimate, go directly to the company’s
web site (i.e., type the real URL into your browser) or contact the company
to see if you really do need to take the action described in the email
message.
 Do not provide personal information or information about AtlantiCare,
including organizational structure or networks, unless you are certain of a
person's authority to have the information.
Information Security + You
What actions should you take if you think you are a victim?
 If you believe you might have revealed sensitive information
about AtlantiCare or compromised your account or computer,
immediately contact the AtlantiCare Customer Support Center.
 Immediately change any passwords you might have revealed. If
you used the same password for multiple resources, make sure
to change it for each account, and do not use that password in
the future.
 If you believe your financial accounts or credit cards have been
compromised, contact the financial institution immediately and
close any accounts or change any cards that may have been
compromised. Watch for any unexplainable charges to your
account.
Information Security
Good security practices are an essential part of patient care.
AtlantiCare depends on each and every one of us to be
informed, responsible, and on our guard to protect our
network, information, and our patients.
Think before you click!
If you have questions about any information security topic,
you may contact the Information Security team at
ITSecurity@atlanticare.org.
What is F-A-S-T?
F-A-S-T is a national stroke
association acronym for
recognizing and responding
to the symptoms of stroke.
It stands for face, arms,
speech and time
Be alert! Get help FAST. It is important for us
to know the signs and to teach others.
•
•
•
•
•
Sudden numbness or weakness of the
face, arm or leg, especially on one side of
the body (Can the person smile? Has
his/her mouth or eye drooped?)
Sudden confusion, trouble speaking or
understanding
x
Sudden
trouble seeing in one or both
eyes
Sudden trouble walking, dizziness, loss of
balance or coordination
Sudden, severe headache with no known
cause
Stroke Awareness
If you witness someone with the
symptoms listed in the previous slide,
based on where you work, you should call
for help using the following numbers:
• Patient care delivery areas, Nursing
units (with the exception of Critical Care
and Emergency Departments): Call a
MET – Dial 1-2222 at the City
Campus or 2-2222 at the Mainland
Campus
x
• All other areas of the hospital, for
visitors, employees and outpatients:
Call a Code 10 - Dial 1-2222 at the
City Campus or 2-2222 at the
Mainland Campus and tell the
operator what you are witnessing.
• All ARMC off-campus areas – Dial 911
 Every 43 seconds someone in the United States has a myocardial
infarction commonly called a heart attack
 A heart attack occurs when the blood flow that brings oxygen to the heart
muscle is severely reduced or cut off completely.
 AtlantiCare Regional Medical Center is the only health system in Atlantic
and Cape May counties to provide full service care for heart attacks.
 The Heart Institute at ARMC has low door to balloon (D2B) times

D2B is measured in minutes from when the heart attack is first identified to time
treatment is delivered
 Current best practice is less than 90 minutes
 ARMC has D2B times less than 60 minutes at City and Mainland
Understand Risk Factors
•
•
•
•
•
•
•
•
•
High Blood Pressure*
1st or 2nd hand smoke exposure*
Diabetes*
High Cholesterol*
Sedentary lifestyle*
Obesity*
Prior stroke
Increased age
Family history
*Risk factors that can be modified, controlled, or treated by changing
lifestyle or taking medication
Heart Attack Warning Sings
•
•
•
•
•
•
•
•
•
•
•
•
Nausea
Pain down one or both arms
Jaw pain
Fatigue
Anxiety
Chest pressure, squeezing,
discomfort
Back pain
Shortness of breath (with or
without exertion)
Feeling full
Feeling of impending doom
Heart burn; indigestion
Breaking out in a cold sweat
Don’t drive!
Call 911!
The American Heart Association recommends that heart disease
prevention begins early in life.
This means assessing your risk factors and working to keep them low.
Learn the ABCs of heart attack prevention
x
Live better with Life’s Simple Seven:
Manage blood pressure
Control cholesterol
Reduce blood sugar
Get active
Eat Better
Lose Weight
Stop Smoking
To Activate Care for a Heart Attack
Initiate treatment promptly
 At ARMC City Campus call 1-2222
 At ARMC Mainland Campus call 2-2222
 Outside of the hospital campuses call 911
In house, tell the operator what is happening
 MET call—for admitted in patients
 Code 10—for outpatients, visitors or staff
 Code Blue/Code Blue 10—for patient who is in
Cardiopulmonary Arrest
More than 95,000 people are waiting for
transplants. More than 4,200 of them are NJ
residents. Eighteen people die each day while
waiting for a transplant.
If there is no designation on your driver’s license
or other legal means of donor designation, the
final decision about organ and tissue donation
will be made by your next of kin.
Your decision to be an organ donor can make a
difference in as many as 50 other lives.
x
Anyone can decide to be a donor. At the time of
death, a person’s physical condition, not age,
determines potential for organ and tissue
donation. In the event of an accident or
emergency, physicians and nurses will do
everything possible to save your life. The
medical team treating you is always completely
separate from the transplant team.
Two-way communication is essential to a strong and successful
organization and to encourage professional engagement. Please
stay informed about the organization by visiting the intranet,
reading newsletters and bulletin board postings, checking in with
managers, listening during staff meetings and asking your leader
to update you on new initiatives in the organization.
You are encouraged to share ideas,
suggestions, compliments or concerns
directly with your leader.
Harassment and Discrimination-Free Workplace
AtlantiCare is firmly committed to maintaining a work environment that is free from all forms of
discrimination, sexual and other workplace harassment. This is part of our commitment to Best
People/Best Workplace. AtlantiCare has a zero tolerance policy for conduct that could be construed
as unlawful discrimination or harassment. All employees are required to promptly report any incident
they feel may violate this policy.
What is discrimination? Treating someone differently because of their race, skin color, religion, gender,
pregnancy, national origin, disability, age, creed, ancestry, marital status, domestic partnership status,
affectional or sexual orientation, gender identity or expression, atypical hereditary cellular or blood
trait, genetic information, military service, or AIDS and HIV related illnesses – these are referred to as
―protected classes‖.
What is Harassment? Unwelcome conduct that occurs because of a person’s protected class, in which
an employee’s acceptance or rejection of the conduct affects their employment or the environment in
which they work.
Failure to comply with EMTALA can lead to several serious consequences for AtlantiCare including:
•
Large fines, starting at $50,000.
•
Increased legal scrutiny.
•
Negative media attention.
•
Possible loss of Medicare/Medicaid eligibility.
•
Loss of confidence in our work by the community we serve.
If you feel as though you are experiencing or have witnessed discrimination or harassment, please
immediately report this to your supervisor, Human Resources or any member of AtlantiCare’s
management team. Human Resources will promptly investigate and take appropriate action.
AtlantiCare is committed to ensuring nothing interferes with the care, safety and
well-being of our customers, vendors and employees. Impairment is defined as
the condition of being unable to perform as a consequence of physical or mental
unfitness. If you suspect a co-worker is unable to perform his/her job due to
some sort of impairment, you need to act. Impairment can be the result of the
following:
•
•
•
•
Being under the influence of drugs or alcohol
Lack of sleep
Psychological ailments such as depression or stress.
Working while sick
Any impairment can impact an employee’s job performance. When an employee
is impaired, his/her ability to adequately react and care for our customers is
affected.
If you think a co-worker is working while impaired, it is very important that you
report the facts immediately to your immediate supervisor, any member of the
leadership team or to Human Resources.
Diversity & Inclusion at
AtlantiCare

Strategic purpose:
To further position AtlantiCare as a leader and trusted partner in the
delivery of culturally and community competent respectful health care
services to our diverse community.
How we will get there:
We will enhance the delivery of our healthcare services for our diverse
community.
We will create the best workplace for our staff by fostering an
inclusive, collaborative, innovative, and culturally competent
environment.
D&I Strategic Priorities
Employee Engagement
Recruitment &
Retention
Foster a learning, and inclusive
environment that values diversity
and encourages employees to
reach their full potential.
Ensure we recruit
and retain a diverse
workforce
reflective of the
communities we
serve.
Building inclusive
and healthy
communities.
Customer
Experience
Provide customer
experiences and
health care services
reflective of
beliefs, cultural and
community
practices to foster
an environment of
inclusion for our
patients and their
families.
What is an Employee
Resource Group (ERG)?

Employee networks who share a common interest/identity
and support the diversity and inclusion strategic priorities
through collaborative relationships.
ERGs are open to all employees.
Employee Resource Groups
How do I become a member
of an ERG?

 Must have completed six months of service with AtlantiCare
 Manager’s Approval
 No disciplinary action in past 6 months.
Membership options:
Core Team Member
Ad Hoc Team Member
Contact diversity@atlanticare.org for more information, or
visit the Diversity & Inclusion Team Page on the Starfish to see
more information on our ERGs and membership.
Best Customer Experience
The Big Dot for Customer Experience is Loyal Customers, and
the challenge is to increase our Customer Experience Index
score. Loyal Customers rate us as ―Excellent‖, which means
―Good‖ isn’t good enough. This is critical to our reimbursement
formula from Center for Medicare and Medicaid Services
(CMS). Low scores means money that could come to us is
given to an organization with better scores. Let’s work hard to
make sure we knock those scores out of the park in 2016!
The next several slides will focus on
Best Customer Experience.
The foundation to the starfish experience is our customer experience standards.
Customer Experience Standards
I will say ―please‖
and ―thank you‖
I will ask ―is there
anything I can do
for you‖
I will always
introduce myself
I will always wear
my name tag in a
visible location.
I will smile, make
eye contact and
greet those near
me.
Starfish Experience
Narrate the Story
Trusting Interactions
Sacred Moments
AtlantiCare’s workforce has continued to reinforce our
Customer Experience Standards throughout the year.
Many of our employees have taken part in the Starfish
Experience Lab, designed to help us focus on the
behaviors that build loyalty in customers and improve
customer experience scores.
The next several slides will focus on Best Customer
Experience, starting with our Standards:
• I will say ―please‖ and ―thank you‖ in all customer/coworker interactions.
• I will ask ―is there anything else I can help you with?‖
at the end of customer/co-worker interactions.
• I will always identify myself, my department and ask
―may I help you?‖ when answering the telephone.
• I will always wear my name tag in a visible location.
• I will smile, make eye contact and address others who
are near me.
Narrating the care of the patient helps them to
understand what you are doing as you are doing it. It
gives them the opportunity to ask questions and interact
with you. We ask that you meet the patient at their level
of health literacy while explaining your care delivery. By
narrating the care we:
• Improve patient’s understanding by meeting their
health literacy level.
• Reduce the patient’s fear and anxiety.
• Create a relationship between the patient and the care
team, thus increasing trust.
Key Words At
Key Times
• Connect to make a great first impression
•
•
•
Narrating the Care starts with
CICARE. A simple tool to
help you give our patients a
clear picture of the care being
delivered
•
•
and to create a sacred moment.
Introduce yourself, your role, and other
team members.
Communicate what your are going to do.
Explain who, what, when, where, why,
and how.
Ask for permission & Anticipate their
needs, questions and concerns.
Respond to patients’ and colleagues’
requests/needs promptly and positively.
End with Excellence by closing the loop
for the patient and thanking the patient or
colleague with a warm, friendly and
genuine tone.
Narrate the Care -Teach Back
―Teach Back‖ is used to evaluate the
patient’s understanding of information
you have shared with them. After you
provide instructions, ask the patient (or
their representative) to explain it back
to you so you can be sure you didn’t
leave anything out of your explanation.
• Remember that we are present
during some of our patients best
and worst moments of their life.
Listen for them to explain specific steps,
procedures or timetables that are critical to their
care and recovery.
• Your patient may not be the key
learner. Please ensure that you
appropriately include your patient’s
support person when available.
If they miss or confuse any of the information,
this is your opportunity to cover that part again
and provide any additional support to help them
effectively manage their health issues after
discharge.
As we Narrate the Care, we must keep
in mind that this is the story they will tell
when our patients share their
experience with others.
If we expect our patients to tell a good
story, we should start it off with a great
introduction!
Not only does Managing Up create a better patient experience, it is also a
demonstration of our values of Teamwork and Respect. When we speak
positively about co-workers and interactions with other departments we reduce
patient anxiety.
•
Give your co-workers a head start in winning the confidence and trust of the
patient.
•
Example: “My shift is ending, but I am leaving you in very capable hands”.
Customer Interactions
Limit Distractions
Limit distractions during customer
interactions. Be sensitive to your
impact on the their sense of well being.
Empathy
Address customer needs with empathy.
What if this was your loved one?
Environment
Is it private? Is it safe? Did we
effectively communicate?
Proactive
Anticipate our customers needs and
look to exceed expectations
• You never know what is
happening in the lives of those
around us.
• Each exchange with another
person is like an emotional
transaction. We want to leave a
positive balance with each one.
• Each time we interact with a
patient or each other keep these
interaction concepts in mind.
People may not remember what you say, they may
not remember what you do, but they will always
remember the way you made them feel.
– Maya Angelou
• Always is the only answer that counts on our
patient survey.
• Sacred moments are special opportunities to build
stronger relationships between our patients and
each other.
• There are many ways that you can take
advantage of these moments in your work day.
Your response to these moments can be as
unique as you are.
• To your right are some great ways to
acknowledge some of the more common sacred
moments we see each day.
Sacred Moments
Moments of complete focus on
the patient.
•
•
•
•
At every first interaction
with the customers (sitting
down)
Every time a customer
asks a question (sitting
when possible)
When someone is leaving
When you are sharing
important information
Customer Experience Recovery
We use a five-step process to correct
customer experience mistakes.
1.
Listen to the customer’s problem
without interrupting them or making
excuses.
2.
Recognize and define their problem in
simple terms.
3.
Apologize for the inconvenience or
confusion. Use empathy.
4.
Correct the problem or connect them
directly to the appropriate Customer
Experience Representative who can
fix the problem.
5.
Thank them for telling you about the
problem so you could fix it and
improve their AtlantiCare experience.
• An experience where we have
not met our patient’s
expectations is an opportunity
to perform service recovery.
• Excellent service recovery can
lead to even greater customer
loyalty.
Patient Directed Visitation
AtlantiCare will not restrict, limit, or otherwise deny visitation privileges on the basis of race, skin
color, marital status, age (except as required for clinical reasons), national origin, nationality,
religion, sex, gender identity or expression, sexual orientation or disability. All AtlantiCare
patients have the right to receive the visitors they have designated at the time of their
preference and may make this request either verbally or in writing. This includes, but is not
limited to, a spouse, a domestic partner (including a same‐sex domestic partner), another family
member, or a friend. All AtlantiCare patients have the right to withdraw or deny such consent at
any time either orally or in writing.
•
•
•
•
•
•
•
•
Visitation Limitations
Patient Request
Identified infection control issues
Interference with the care of other patients
Patient’s roommate(s) needs rest or privacy
Inpatient substance abuse program
Patient undergoing care intervention
Existing court order restricting contact
Visitor engaging in disruptive, threatening, or
violent behavior of any kind
•
Children under 14 years of age
must be approved by clinical
leadership for visitation
•
Visitation at AtlantiCare is
expected to be patient directed.
Limitations to visitation must be
according to those listed in our
policy #4411.
The Big Dot under Financial Performance is sustainability of the
organization and the challenge is maintaining a healthy
operating margin. The operating margin is what is left over each
month after we receive all reimbursements and income, and pay
out all that we owe. This year we exceeded our goal for
Financial Performance.
As we navigate Health Care Reform, our reimbursement has
shifted from ―Fee for Service‖ to ―Triple Aim.‖ Our cost-efficiency,
customer experience and our quality contribute to the Triple Aim
formula. These scores are key to our future sustainability and
our success. Failing to receive the best scores will negatively
impact our income, financial operating margin and our overall
sustainability.
Triple Aim
(Quality)
(Customer
Experience
Index Score)
(CostEfficiency)
The term Triple Aim is a trademark of
The Institute for Healthcare Improvement.
These three factors are used to determine how
CMS reimburses us for our services.
The Big Dot under Best Growth is Keeping AtlantiCare Strong
and having our patients cared for by our physician network. To
accomplish this, we have steadily increased our service area,
making services available to underserved populations and
locations. We have increased our capacity to serve our
customers by adding more physician practices throughout
Atlantic, Cape May and Ocean Counties, so that our customers
can be served by our own physicians. Our physician practices
include internal medicine, family medicine, and specialty
practices.
Among our many growth strategies in 2015,
AtlantiCare opened the Rothman Pavilion at ARMC Mainland
Campus, the Surgery Center in Little Egg Harbor and the
LifeCenter at the Tropicana in Atlantic City. We also officially
become a member of the Geisinger Health System.
The Big Dot goal under Best Quality is Comprehensive Care
Transitions, with Readmission Rate cited as our challenge. Our
impact on these is reflected in the scores calculated into our
reimbursement formula from the Centers for Medicare and
Medicaid Services (CMS). To assure our quality remains
excellent, we have many policies and procedures in place to
guide our daily work. For the purposes of this course, we will
include Patient Safety, MRI, Process Improvement, Corporate
Compliance, HIPAA, Incident Reporting, Injury Reporting,
EMTALA, Language Line and Emergency Codes. These topics
help assure we address negative outcomes and take action to
prevent recurrences.
2016 NPSGs
The magnet is ALWAYS on!
AtlantiCare uses
advanced technology for
our patients. Our
magnetic resonance
imaging (MRI) equipment
is a strong magnet that
requires specific safety
practices. Employees
who work directly with the
MRI machine know the
proper procedures to
follow in an emergency.
Know these important
safety practices:
• Screen all patients and personnel before they
enter the MRI room.
• Check all metallic equipment, including hand
tools, wheelchairs, gas tanks, etc. with a hand
magnet before they enter the MRI room.
Use these processes to assure the end users are always involved in
the project PLAN, and to prevent rework and wasted time.
PDMAI
PDMAI is an acronym for
the specific process we use
to develop new ideas for
services. It stands for the
following:
 Plan
 Design
 Measure
 Assess
 Improve
PDCA
PDCA is an acronym for the
specific quality improvement
process we use to improve
existing programs, services
and procedures. It stands
for the following:
 Plan
 Do
 Check
 Act
Corporate Compliance
1. Continuously assesses the effectiveness of AtlantiCare’s
compliance and internal control environment.
2. Promotes adherence to laws, regulations, and internal
policies & procedures
3. Advances the prevention of fraud, waste, and abuse
4. Furthers the hospital’s mission of providing quality care to
patients
Corporate Compliance is an independent support
function of AtlantiCare, reporting directly to our Board
and administratively to Corporate Counsel.
Corporate Compliance activities require unlimited and
unrestricted access to all data during audit and investigation.
Audits are ongoing and routine – staff have no expectation of
privacy with AtlantiCare systems.
It provides AtlantiCare with system-wide services with
authority to act with respect to all entities, subsidiaries and
cost centers.
Laws and Regulatory Agencies
Deficit Reduction Act (DRA) of 2005 mandates employees and
agents education on:
• NJ Conscientious Employee Protection Act (CEPA)
―Whistleblower Act‖
• Federal False Claims Act (1863)
• Federal Program Fraud Civil Remedies Act (1986)
• NJ False Claims Act (2009)
• NJ Medical Assistance and Health Services Act
Important Government Agencies (not all inclusive):
• Office of Inspector General (OIG)
• Internal Revenue Service (IRS)
• Food & Drug Administration (FDA)
• Center for Medicare/Medicaid Services (CMS)
• Equal Opportunity Employment Commission (EEOC)
• Office on Civil Rights (OCR)
• Joint Commission (JCAHO)
• NJ Department of Health (NJDOH)
Policies and Procedures
Important policies all AtlantiCare employees need to be
aware of:
• Code of Business Ethics and Corporate Compliance (ID# 403)
• Guidelines for Reporting Compliance/Privacy Issues/Concerns (ID#
3366)
• Education Concerning False Claims Liability, Anti-Retaliation
Protections, and Detecting and Responding to Fraud (ID# 3119)
• Guidelines for Employee Acceptance of Vendor Gifts, Meals,
Entertainment (ID# 4231)
All policies are available on AtlantiCare’s intranet policy and
procedure.
Compliance Line Phone Number: (609) 407-7788 In-house 4-7788
Compliance Line Website: www.MyComplianceReport.com (Access
Code: ATC)
Our reporting system is maintained by a third-party vendor to
ensure strict confidentiality. Protections are in place for all
callers.
• No retaliation for reporting.
• Report any activity that appears to violate
AtlantiCare’s Code of Business Ethics and Corporate
Compliance (Code of Conduct) or any other policies
and government laws and regulations.
• If you are aware of a violation and fail to report it, you
may be subject to corrective or disciplinary action.
• All complaints are documented and investigated.
• You may report anonymously.
Patient Privacy Laws: What is Protected Health Information “PHI”)?
PHI is a special term regarding protected health information, based on any
information collected during the provision of care that applies to a patient’s health
condition, past, present or future. If the health information includes data that would
allow someone to identify the patient, it is PHI. A few examples of PHI are…
Name
Lab/Test Results
Prescriptions
X-rays
Telephone #
Date of Birth
Photographs
Billing Records
Address
Insurance Claim #
Medical Record #
Email address
Admit-Discharge Dates
Fingerprints
Social Security #
PHI takes many forms, i.e. a prescription label with the patient’s name and the name
of the drug, a doctor’s note about a patient, a letter giving patient test results.
PHI must be kept private whether it is in written, spoken or electronic form.
HIPAA – Protected Health Information Privacy Laws
The federal HIPAA law protects the privacy of patients by:
• limiting access to and disclosure of PHI
• requiring security of records containing PHI whether in paper,
electronic or other forms
A collection of New Jersey laws provide even HIGHER protection
for patient information:
• based on sensitive diagnoses (i.e., HIV/AIDs, STDs, genetic
information)
• based on sensitive type of treatment (i.e., drug and/or alcohol
treatment, psychiatric treatment)
Federal and state laws contain significant criminal and civil
penalties for individuals and providers who violate these laws.
Additional HIPAA Regulations
Red Flag Rule
ID theft program designed to detect, prevent & mitigate ID theft.
NJ ID Theft Prevention Act (NJITPA)
Focus on specific security precautions to prevent ID theft, i.e. use of Social
Security numbers.
• Requires breach notification.
HIPAA (Health Insurance Portability and Accountability Act)
Established standards for transmission and usage of health care information.
HITECH (Health Insurance Technology for Clinical Health Act)
This builds on HIPAA privacy & security of PHI, with modifications.
• Requires breach notification
• Increases penalties & enhances enforcement provisions
Laws to Protect Identity and Privacy
HITECH is The final Omnibus Rule, with an effective date of September 23, 2013. Some of
The Rule’s key provisions include:

Makes business associates and their subcontractors directly liable for compliance with
HIPAA/HITECH’s privacy and security rules requirements;

Strengthens the limitations on the use and disclosure of protected health information for
marketing and fundraising purposes and prohibits the sale of protected health
information without individual authorization;

Expands individuals' rights to receive electronic copies of their health information and to
restrict disclosures to a health plan concerning treatment for which the individual has
paid out of pocket in full;

Requires modifications to, and redistribution of, a covered entity's notice of privacy
practices;

Modifies individual authorization and other requirements to facilitate research and
disclosure of child immunization proof to schools and to enable access to decedent
information by family members or others;

Enhances the enforcement rule, adding provisions to address enforcement of
noncompliance due to willful neglect and incorporating the increased and tiered civil
money penalty structure of up to $1.5 million per violation category.
HIPAA
Patient Privacy: Protecting PHI is Important!
Under the Privacy laws, you are prohibited from
accessing or disclosing PHI unless:
• YOU are directly involved with treatment of the patient; or
• YOU are directly involved with a payment process or
health care operation relating the patient’s record, and
then with a payment process or health care operation
relating the patient’s record, and then you are limited to
accessing and/or disclosing only the minimum necessary
information needed to complete the task at hand.
• YOU are limited to accessing and/or disclosing only the
minimum necessary information needed to complete the
task at hand.
Protecting Patient Privacy is the right, ethical and legal thing
to do – federal and state law require it. The Privacy laws
apply to us in all settings:
at home, on social media
websites, in the supermarket, as well as in the hospital –
even after we separate from AtlantiCare!
PHI Security: Internet, Email & Virus Protection Tips
Do:
• limit personal Internet use and only visit appropriate web sites.
• forward unwanted spam emails to spam@atlanticare.org
• lock your computer when not in use: Press ―WINDOWS KEY‖ + L (for ―Lock‖)
or Press ―Ctrl-Alt-Delete‖ and Lock Your Computer
Don't
• forward business e-mail to your personal e-mail account.
• click on links contained in emails – they often contain viruses or redirect to
malicious web sites that can damage our healthcare systems or steal your
information.
• open an email attachment from anyone you do not know --be wary of email
attachments that you are not expecting; contact the sender or information
security if you are not sure.
• install any unauthorized programs on your work computer.
Remember, it is always okay to call or email the AtlantiCare Information
Security Department for help or guidance. Phone 609-272-6353 or email
iSecurity@atlanticare.org
PHI Security: Password and Physical Security Tips
Do:
• make strong passwords, including at least 8 characters along with
numbers, upper and lower case letters.
• change your passwords every 90 days, or in accordance with policy.
• Know the whereabouts of your laptop at all times – don’t leave it in your
car!
• clear your desktop, lock drawers and file cabinets when you leave.
• politely challenge anyone who is not displaying an ID badge or a pass.
• ensure no one can overhear discussions about patient care.
• use shredder bins – never put PHI in regular trash!
• turn computer screens containing PHI away from view.
Don't:
• share your password with anyone. AtlantiCare representatives will never
ask you for this information.
• display your password where others can view it
• hold doors open for people without checking their authorization
Patient Privacy – Reporting Violations
If you become aware of a privacy violation,
you are required to report it on the
Compliance
line
at
407-7788
or
www.MyComplianceReport.com. You may
report anonymously.
DO YOUR PART TO PROTECT PHI
Everyone has a role in protecting patient
information. Remember, keeping patient
health information private is not only a
matter of patient satisfaction and Customer
Experience – it’s the law. If you have any
questions about the Privacy Laws and how
they affect your work at AtlantiCare,
contact the Privacy Office at
(609) 407-2251 or 4-2251.
An incident is an unusual occurrence in or around
AtlantiCare property. Everyone is responsible for
reporting safety information.
Examples of incidents reported through Quantros:
• Patient Injury (or near miss)
• Visitor Injury
• Car Accident
• Equipment Malfunction
• Facility Issues
• Vandalism
• Lost or Damaged Property
• Threatening Behavior
• Theft and Security Issues
Exception: Employee injuries are reported through
the web by clicking the Employee Injury Reporting
Site link on the Starfish page under ―Tell Us.‖
Quantros Incident Reporting System – How do I begin?:
1. Go to Starfish page
2. Go down the right side menu and click on Incident Reporting in the ―Tell Us‖
box
3. User name is your email/ computer access user name (the one with your first
initial and last name, for example jdoe for John Doe) Don’t include the email
address “@atlanticare.org”
4. On first login, you will be guided through the steps to create a password.
5. Choose your new password which is a minimum of 8 digits, combine numbers
and letters
6. If you need assistance with password, log-in or system issues, please call the
help desk (3-7070)
An Event Reporting Tutorial can be accessed through the system.
Employee Injury Reporting
All employee injuries should be reported through the
Employee Injury Reporting Site.
1. Go to Starfish page
2. Go down the right side menu and click on Incident
Reporting in the ―Tell Us‖ box. There is no required log
in, just click on the Employee injury Reporting Site. It
will take you directly to the instruction page where you
access the form.
3. The Report should include:
Who, What, Where, When, Why, and How
The Emergency Medical Treatment and Active
Labor Act (EMTALA) is a federal law, adopted in
1986, designed require that hospitals treat
patients without discrimination or their ability to
pay for services. This legislation also deals
with various requirements for transferring and
discharging patients.
Here are some of the important things to know
about this law:
•
EMTALA applies to ALL hospital employees.
•
Every patient must be screened by a qualified medical provider within 4 hours of presenting
to the Emergency Department or elsewhere on hospital property to determine if there is an
―emergency medical condition‖ or active labor.
•
Medical screening and further stabilizing treatment may not be delayed to inquire about the
individual's insurance or payment information.
•
Before patients are transferred, they are entitled to stabilizing treatment.
•
Document transfers using the Universal Transfer Form.
•
EMTALA Policy #566 details specific requirements related to the law
x
EMTALA – Universal Transfer Form
Failure to comply with EMTALA can lead to several
serious consequences for AtlantiCare including:
•
•
•
•
•
Large fines, starting at $50,000
Increased legal scrutiny
Negative media attention
Possible loss of Medicare/Medicaid eligibility
Loss of confidence in our work by the community we
serve
AtlantiCare is committed to providing culturally and
linguistically appropriate healthcare services. Most of our
locations have LanguageLine telephone interpreter
systems at no cost to patients/families. If you need an
on-site medical interpreter to communicate with a limited
English proficiency patient or a deaf/hearing impaired
patient, please contact Customer Experience (Atlantic
City, 1-8193, or Mainland, 2-3444).
EMERGENCY CODES
Code Red – Fire
Code Silver – Hostage
situation/Active Shooter event
Code Blue – Adult medical
Code Orange – Hazmat situation
emergency
Code White – Pediatric medical
emergency
Code Triage –
Disaster/Additional staff needed
Code Amber – Child abduction
Code Clear – Situation resolved
Code Yellow – Bomb threat
Code 10 – Visitor injured
Code Grey – Security needed
You might hear these codes over the intercom while working at either hospital
campus. It is important that you know what each of these codes means and
what to do when one of them is called.
Emergency Codes and other
emergency calls are activated by calling the following numbers:
City Campus - 1-2222 Mainland Campus - 2-2222
Non-hospital facilities - 911